Every finding on record at Millennium Post Acute Rehabilitation

Based on review of facility policy, observation, interview, and record review, the facility failed to (1.) ensure linen and resident clothing was washed at appropriate temperatures or with proper disinfection to prevent the potential spread of infection and or diseases, in 1 of 1 laundry room. Specifically, the washing machine failed to maintain adequate hot water temperature. Additionally, the facility failed (2.) to ensure that medications were administered to residents utilizing proper hand hygiene and use of Personal Protective Equipment (PPE) while performing medication pass, for 2 of 2 residents reviewed. Findings include: 1. Review of the facility policy titled Infection Control Prevention and Control Program with a revised date of 09/2017, revealed, II. GOALS The goals of the infection Control Program are to: . c. Identify the correct problems relating to infection control practices. d. Ensure compliance with state and federal regulations relating to infection control. III. SCOPE OF THE INFECTION CONTROL PROGRAM C. PREVENTION OF INFECTION Staff and resident education are done to identify risk of infection and promote practices to decrease risk. Policies, procedures and aseptic practices are followed by personnel in performing procedures, linen handling and disinfection of equipment. Review of the facility policy titled Housekeeping and Laundry Safety Procedures and Policy with a reviewed date of 2025, revealed, Laundry Sanitizing Methods Use one of the following methods based on the product label, washer programming, fabric type and the Infection Preventionist's guidance. 1. Chemical sanitizing: Use LL3000 bleach or Clothesline sanitizer at the label dose to reach the required parts per million in the cycle. These products may be used with hot or warm water as directed by the label. 2. High temperature sanitizing. Program a wash that maintains 165 degrees Fahrenheit for at least 25 minutes. During an observation and interview on 03/16/26 at 9:08 AM, of the laundry process with Laundry Assistant, revealed there are 5 collection rooms, one on each hall. Soiled/dirty laundry are transported in covered blue bins. The Laundry Assistant properly collected laundry using the proper PPE. Laundry was taken to the laundry room and loaded in an industrial washing machine. During the wash cycle the washing machine thermometer reading was 62 - 65 degrees Fahrenheit, this thermometer reading was verified by the Laundry Assistant. The Laundry Assistant was asked the proper hot water temperature for laundry, he stated he was not sure. The laundry assistant also revealed there has been a problem with the laundry room boiler. Further observation of the laundry room revealed laundry products sitting on a wooden pallet with hoses coming out from them into a automatic dispense system into the washing machine, which included: Spartan Chemical Co. Clothesline Fresh, Chlorine Bleach Drum, Clothesline Fresh Sour/Softener Drum, Clothesline Fresh Liquid Alkali Drum, and Clothesline Fresh Laundry Detergent Drum. During an interview on 03/16/26 at 9:20 AM, the Director of Housekeeping/Laundry was made aware that the washing machine thermometer temperature was 62 – 65 degrees Fahrenheit. The Director stated that maintenance is aware and a new boiler has been ordered. The Director stated that Oxi-Clean Versatile Stain Remover has been used in the laundry since the boiler been down. Review of a [NAME] Order Form dated 01/27/2026 revealed 7 lbs of OxiClean Stain Remover was ordered. Review of an email, between a sales consultant and the facility, with the subject line Cold Water for Laundry dated 03/16/26 at 12:45 PM, revealed, the sales consultant stated that between the chemicals as they are, the water (assuming that it's somewhere around 70 degrees, preferably higher), and a dry cycle, the pathogens that exist on the materials would still be neutralized. During an observation and interview on 03/16/26 at 9:30 AM, the Maintenance Assistant in the laundry boiler room revealed the boiler is leaking water from the bottom of the tank, the riser thermometer gauge reading was 64 degrees Fahrenheit, and the water heater thermometer gauge was 65 degrees Fahrenheit. The Maintenance Assistant stated they are waiting for the new boiler to come in; they have ordered 2 to have as a backup. During an interview on 03/16/26 at 10:00 AM, the Maintenance/Life Safety Director revealed the boiler has been malfunctioning from time to time. A new boiler was ordered. The current boiler been malfunctioning for about 2.5 weeks. The boiler will be changed out next week when the new boiler comes in. When the current boiler works the temperature is between 140-160 degrees Fahrenheit. That boiler supplies hot water to the laundry room only. During an interview on 03/16/26 at 11:00 AM, the Administrator revealed he is aware the boiler has been out and stated another boiler has been ordered. During an interview on 03/16/26 at 4:25 PM, the Laundry Attendant revealed she has been using 1.5 - 2 cups of Oxi-Clean Versatile Stain Removal in each laundry load since the boiler had been malfunctioning. During an interview on 03/17/26 at 7:03 PM, the Infection Preventionist revealed she was made aware of the laundry room boiler being out of order a few weeks ago. She was not aware the boiler was still out of order. She doesn't know off the top of her head what is the proper hot water temperature for the washing machine. The Infection Preventionist further stated she does know the water temperature has to be at a certain degree along with using sanitizer. Her expectation is if there is any change or break in the infection control process, maintenance and the IP need to be notified to get back in compliance. Infection control education is done daily. She was not aware of Oxi-Clean Stain Versatile Remover being used. 2. Review of the facility policy titled, Infection Control Policy Related to Medication Administration states, Policy Statement: The Skilled Nursing Facility (SNF) is committed to preventing the transmission of infection during all aspects of medication administration. This policy establishes standardized infection control practices to ensure the safety of residents, staff, and visitors during the preparation and administration of medications, including oral, topical, ophthalmic (eye drops), injectable medications, and insulin therapy. Purpose: To reduce the risk of infection and cross-contamination by outlining proper hand hygiene, medication handling, administration techniques, and equipment use in accordance with infection prevention and control standards applicable to skilled nursing facilities. Scope: This policy applies to all licensed nurses and other authorized personnel involved in medication preparation and administration within the facility. General Infection Control Principles for Medication Administration: Hand hygiene should be performed before and after every medication administration encounters potential contact. 1. Standard precautions must be followed at all times. 2. Gloves may be worn when there is potential contact with blood, body fluids, mucous membranes, or non-intact skin. 3. Medications must be prepared in a clean, designated medication preparation area free from contamination. 4. Single-use supplies must never be reused between residents. Hand Hygiene: 1. Hand hygiene must be performed: Before preparing medications. Before and after resident contact. Before aseptic procedures. After contact with blood, body fluids, or contaminated surfaces. After removing gloves. 2. Acceptable hand hygiene methods include: Alcohol-based hand sanitizer when hands are not visibly soiled. Soap and water when hands are visibly soiled, after toileting assistance after exposure to bodily fluids. Review of the facility policy titled, Medication Administration: Hand Hygiene states, Policy Statement: It is the policy of PruittHealth Pharmacy Services that partners will use appropriate during medication administration. Appropriate hand hygiene reduces the spread of decreases the spread of infections. Scope: This policy applies to all licensed healthcare staff at a healthcare center and assisted serviced by PruittHealth Pharmacy Services. Definition: Hand Hygiene: The cleansing of hands by using the organization-approved, alcohol-base sanitizer or by washing hands with soap and water. Procedure: 1. During medication administration, use hand hygiene before and after touching a pa immediately before performing a clean or aseptic procedure, immediately after an exposure risk to body fluids, before moving from a soiled body site, after touching patient's immediate surroundings, and before and after glove removal. During an observation on 12/18/2024 at 8:00 AM, during medication administration revealed, R81 on Enhanced Barrier Precautions (EBP) as recognized by a sign on the resident's room door. Licensed Practical Nurse (LPN)1 prepared the by mouth medications for R81, she noticed the EBP sign on the door and went to the nurses desk to get a Personal Protective Equipment cart. She returned with the cart and stated, I do not need to use the gown and gloves just to give oral medications. She entered the room, went over to the resident and called her name. She sat down the medications on the bedside table and with bare hands took the bed control and elevated the head of the bed. LPN1 then placed her bare hand on the side of the resident's face and head and tried to straighten her head up to take her medications by mouth. She administered the medications one at a time, and then took the remote control in hand and lowered the head of the bed. LPN1 did not wear gloves to position the resident's head or when elevating the head of the bed. During an observation on 03/16/26 at 9:19 AM, during medication administration revealed, R62 on Enhanced Barrier Precautions (EBP) as recognized by a sign on the resident's room door. LPN1 practiced hand hygiene and donned a gown and gloves before entering the resident's room. LPN1 administered residents first eye drops. She did not remove her gloves or practice hand hygiene before giving R62 his oral medication. After administering R62's oral medication, LPN1 removed her gloves and donned a new pair of gloves, without practicing hand hygiene and administered a second eye drop to R62. During an observation on 03/17/26 at 8:45 AM, during medication administration revealed, LPN2 applied gloves before entering R123's room to administer his medication. LPN2 was preparing to administer NovoLog Flex Pen 100 UNIT/ML Solution pen-injector inject 5 unit subcutaneously with meals for DM and Lantus Solostar 100 UNIT/ML solution pen-injector Inject 15 unit subcutaneously in the morning for DM. LPN2 pulled the privacy curtains and closed the resident's room door with her gloves on. She did not remove her gloves and perform hand hygiene before administering the insulin injection to the resident. During an interview on 03/17/2026 at 10:30 AM, LPN1 revealed that she failed to remove her gloves, perform hand hygiene, and put on a new pair of gloves after administering eye drops. During an interview on 03/17/26 at 11:30 AM, LPN2 revealed that she closed the privacy curtains and the resident's room door with gloves on. LPN2 verified that she did not remove her gloves and perform hand hygiene before administering insulin to R123. During an interview on 03/17/26 at approximately 11:45 AM, the Director of Nursing (DON) revealed, I expect our nurses to practice good infection control while administering meds. I cannot defend the nurse touching environmental surfaces and giving insulin with the same gloves. As far as the eye drops, it is the same resident I am not sure of the infection control risk there. The resident does not have an eye infection. During an interview on 03/17/2026 at 8:02 PM, the Infection Preventionist revealed, When the nurses are preparing the medication, they can wear gloves to open capsules, but the gloves should be removed, and hand hygiene should be performed before entering the resident's room. The nurse did not practice proper protocol by wearing gloves and not practicing hand hygiene before and after administering eye drops. The nurse should maintain a clean med pass even when administering medications to the same resident. The nurse should also obtain a new eye drop ampule before administering the second drop. Nurses should practice hand hygiene before entering the room and after closing the privacy curtains and the resident's room door. Also, practice hand hygiene anytime they remove gloves. The nurse should also wash their hands after touching any environmental surface and before administering medication to a resident.

Based on record review and interview, the facility failed to complete the Preadmission Screening and Resident Review (PASARR) assessment tool for Residents (R)84 and R108, prior to their admission to the facility, for 2 of 7 residents reviewed. Findings Include:The facility does not have a policy related to PASARR assessments.Review of R84's Face Sheet revealed she was admitted to the facility on [DATE], with diagnoses including, but not limited to, chronic respiratory failure, type 2 diabetes mellitus, major depressive disorder, and anxiety disorder.Review of R84's PASARR Level 1, revealed it was completed on 01/02/25, by the facility.Review of R108's Face Sheet revealed she was admitted to the facility on [DATE], with diagnoses including, but not limited to, rheumatoid arthritis, mood (affective) disorder, anxiety disorder, schizophrenia, and major depressive disorder.Review of R108's PASARR Level 1, revealed it was completed on 06/04/25 by the facility.During an interview on 03/16/26 at 5:20 PM, the Social Services Director (SSD) revealed that she is checking all PASARR Level 1's, as they have not been completed correctly. She included the department is having to redo the PASARRs, and they have been getting pushback from the hospitals to have them completed, so her department has been correcting them by reviewing the hospital records and receiving information from the resident and/or the family. The SSD also stated that a licensed social worker or a nurse can complete a Level 1, but a Level 2 has to be completed with a physician.During an interview on 03/17/26 at 5:18 PM, the Director of Nursing (DON) revealed that he understands that Level 1 PASARRs are required for entry into the facility and Level 2's are required if they had a recent psychiatric stay or diagnosis. He included that Level 1 PASARRs can be completed by any licensed social worker. The DON stated that if the facility did not receive a Level 1 prior to entry, then the facility social worker can complete it or they would try to get one from the hospital or community as well.

Based on record review, interview and observation, the facility failed to ensure Resident (R)1's adaptive equipment was clean, for 1 of 4 residents reviewed.Findings include: The facility did not have a policy and procedure regarding the cleaning/maintenance of wheelchairs. Review of R1's Face Sheet revealed R1 had an admission date of 07/22/24, with diagnoses including, but not limited to, muscle wasting atrophy, unsteadiness on feet, pain in left hip, stiffness of joint, muscle weaknesses, and difficulty in walking. Review of R1's Quarterly Minimum Data Sheet (MDS) with an Assessment Reference Date (ARD) of 12/15/25, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating R1 was cognitively intact. Further review of the MDS revealed R1 uses a wheelchair. During an observation on 03/15/26 at 11:43 AM, revealed R1's wheelchair leaf, had turned brown and there were white stains visible on the back of the wheelchair and on the wheels. During an observation on 03/16/26 at 8:45 AM, revealed R1's wheelchair leaf, was still brown and the white stains were still visible on the back of the wheelchair and on the wheels. During an interview on 03/17/26 at 9:20 AM, Licensed Practical Nurse (LPN)1 revealed that housekeeping cleans wheelchairs and to her knowledge the wheelchairs are cleaned at least once a month. If the wheelchairs need to be cleaned before the next scheduled cleaning, then a request can be made to housekeeping for them to be cleaned or a CNA will clean the wheelchair as needed. During an interview on 03/17/26 at 9:24 AM, 9:40 AM and 10:06 AM, the Director of Housekeeping and Laundry Services revealed that the wheelchairs are sanitized every day if there is nothing in the chair. The chairs are rinsed with water, then a sanitizer then with water again. There is a schedule for the month of March and previous months for when all the chairs in the facility are cleaned twice a month. The wheelchairs are labeled by physical therapy to identify which resident the chair belongs to. During an interview on 03/17/26 at approximately 2:54 PM, the Director of Housekeeping and Laundry Services revealed that she observed how the wheelchairs have visible debris and the last time the chairs were cleaned was on 03/10/26. She stated the wheelchairs would be cleaned by housekeeping to remove the debris on 03/17/26. During an interview on 03/17/26 at 3:07 PM and 3:15 PM, the Director of Nursing (DON) revealed that if a wheelchair is soiled, then the chair will be cleaned even if it has recently been cleaned and if necessary, he would clean it himself. The DON observed that R1's wheelchair was visibly dirty and will be cleaned on 03/17/26.

Based on record review and interviews, the facility failed to employ a full-time qualified Licensed Medical Social Worker (LMSW), as required for facilities with more than 120 certified beds. 130/130 certified beds, all of which are potentially affected by the lack of a full-time LMSW to provide necessary psychosocial support and services.Findings include:Review of facility staff list revealed there is no Licensed Medical Social Worker employed in the facility. Review of the facility census dated 9/9/25 revealed the facility was certified for 132 beds. During an interview with the Social Services Assistant (SSA) on 09/09/25 at 1:29 PM revealed the facility's Social Services Director, who was a Social Worker (SW) left the facility around Mid-August of 2025. SSA revealed the facility has been without a SW since that time and that she has done her best to fill in the role since her departure. SSA revealed that there is a Corporate liaison that she can call if she needs help, but she is unaware of her official title or role. SSA revealed her background is that of a Certified Nursing Assistant (CNA).During an interview with the Administrator (LNHA), Director of Nursing (DON), and Assistant Director of Nursing (ADON) on 9/10/25 at 3:30 PM revealed, Social workers at the facility are responsible for scheduling care plans, handling grievances, assisting with discharge planning, and coordinating discharge and home health services. The full-time LMSW left the facility in mid-August, and the facility has been without an LMSW since that time. The LNHA stated that the facility is currently posting and interviewing for the position, with a candidate scheduled to complete a facility walk-through on Friday, 9/12/25. The DON reported that the facility currently has a resource supporting the SSA. A subsequent interview revealed that this resource is an RN, not an LMSW, and confirmed that the facility is currently without a licensed medical social worker.

Based on facility policy review, observation, and interviews, the facility failed to ensure the confidentiality and security of resident Protected Health Information (PHI) for two of two residents (R)3 and R4) observed for resident rights. Specifically, a resident's code status document containing PHI was observed uncovered and unsecured in a clear wall-mounted mailbox, located in a hallway accessible to staff, residents, and visitors. Additionally, a staff member left a computer unattended in a common area with the screen displaying a resident face sheet, which included personally identifiable information such as the resident's name, photograph, and medical details.Findings include:Review of the undated facility document titled, HIPAA Privacy and Security Operational Guide, revealed: The everyday definition of breach is an infarction or violation of a law, obligation, or standard. HIPAA defines breach as the acquisition, access, use or disclosure of protected health information which compromises the security or privacy of the PHI. PHI is defined by this document as Protected Health Information. Examples of PHI as determined by the facility document includes but is not limited to: Information doctors, nurses, therapists, consultants, and other health care providers document in the medical record; both on paper and electronically. Document also reveals that an example of a breach in PHI includes but is not limited to, Unsecured documents (not shredded, left open/unlocked).Observation of Hall 100 Computer on Wheels (COW) on 9/9/25 at approximately 12:37 PM revealed the computer on wheels was unattended by a staff member. The computer was observed to be on, displaying a resident face sheet and picture displayed on the unattended screen. The Assistant Director of Nursing (ADON) was then observed taking away the COW and closing down the resident's chart.An observation of the Social Services clear mailbox on the 100 hallway, on 9/9/25 at 1:05 PM revealed, Protected Health Information (PHI) was inappropriately exposed and left unsecured. Documentation left exposed included Millennium Post Acute Advance Directives for Resident (R)3, and R4, and R4's signed document for Emergency Medical Services Do Not Resuscitate Order.An interview with the Social Services Assistant (SSA) on 9/9/25 at 1:29 PM revealed that the PHI stored uncovered and exposed should not have been left out in the open, the way it was. SSA revealed, PHI that need to be stored in her mailbox need to be placed in a folder and should be secured and covered. If there is no folder available, then the expectation is for staff to slide PHI underneath her door.During a group interview conducted on 9/10/25, at 3:30 PM with the Administrator (LNHA), Director of Nursing (DON), and ADON confirmed that it is their clear expectation for all staff to protect residents' PHI and comply with the Health Insurance Portability and Accountability Act (HIPAA). The leadership emphasized that PHI must not be left visible or unattended, should not be discussed in open or public areas, and must not be shared with individuals who are not directly involved in the resident's care. Additionally, they stated that when computers on wheels (COWs) are left unattended, screens displaying resident information must be properly secured to prevent unauthorized access. The leadership team acknowledged that staff failed to follow facility policy and expectations regarding the safeguarding of PHI. They confirmed that a resident's electronic health record was left open and unattended, exposing PHI in violation of HIPAA regulations and facility policy. Furthermore, leadership acknowledged that documents containing PHI were inappropriately left unsecured in the SSA's clear mailbox, which does not align with the facility's standards for protecting confidential information.

Based on review of the facility policy, record review, observations, and interviews, the facility failed to ensure the call bell was within reach for one of one resident (R)2) reviewed for physical environment, which resulted in a delay in care. Specifically, R2 was observed in bed with the call bell positioned out of reach, on the opposite side of the bed. During the observation, R2 stated they were unable to call for assistance and had waited over 30 minutes to request pain medications. Findings include:Review of the facility policy titled, CALL LIGHTS - ACCESSIBILITY AND TIMELY RESPONSE-POLICY, with a last update date of 10/31/24 revealed: The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response.Review of R2's face sheet revealed a diagnosis of muscle weakness and history of cerebral infarction.Review of R2's Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/31/25 revealed resident is dependent on staff for self-care and mobility. R2's MDS also reveals resident has impairment on both lower extremities (hip, knee, ankle, foot).During an observation of R2 on 9/9/25 between 1 PM and 1:20 PM revealed R2 was lying in bed, on her right side, supported by positional wedges on her left. The call light was located approximately 6 inches from the ground on the left side of the bed, out of the resident's reach. The resident attempted to access the call light, but was unsuccessful due to her current position. Subsequent interview with R2 revealed she cannot reach her call light and needs to talk to the nurse because she is in pain. R2 rated the pain 8/10 and stated the pain is all over her body. R2 revealed she has been attempting to get a hold of staff for the past 15 minutes.During an observation with Licensed Practical Nurse (LPN)1 completed on 9/9/25 between 1:20 PM and 1:35 PM, the surveyor called LPN1 to R2's room. LPN1 acknowledged the placement of the call bell and confirmed that it was out of the resident's reach. While speaking with R2, the resident requested her pain medication. LPN1 promptly notified the nurse responsible for R2's care, regarding the resident's request for pain management. In a subsequent interview, LPN1 confirmed that the facility's expectation is for call bells to always be within residents' reach. Staff are trained to conduct regular rounding as needed and at least every two hours to ensure that residents have access to their call bells at all times. Additionally, staff are instructed to verify that call bells are within reach before leaving a resident's room. LPN1 acknowledged that failure to ensure call bell accessibility can lead to negative patient outcomes and admitted that R2's call bell should have been positioned within the resident's reach.Review of R2's Electronic Medication Administration Record (EMAR) for 9/9/25 at 1:39 PM, documentation revealed that the resident was administered Hydrocodone-Acetaminophen 5-325 mg in response to a reported pain level of 9 out of 10.During an interview with the Administrator (LNHA), Director of Nursing (DON), and Assistant Director of Nursing (ADON) on 9/10/25 at 3:30 PM, revealed the leadership team expects staff to respond to call bells as promptly as possible when available. However, response times may vary during high demand periods such as meal service or when staff are assisting other residents. Regardless, residents must always have an assistive call device within reach. For residents with mobility limitations or other specific needs, the Interdisciplinary Team (IDT) addresses these concerns through individualized care planning, ensuring appropriate devices such as blow calls, pressure pads, or standard call bells are provided based on the resident's capabilities. Leadership staff conduct routine Angel Rounds to ensure expectations are being met and to support resident care directly on the floor. All staff are expected to round on residents at least every 2 to 3 hours and as needed to maintain safety and accessibility. In the incident observed, the call bell was noted to be on the wrong side of the bed, leadership team reveals the call bell should have been positioned on the side accessible to the resident to ensure timely assistance and compliance with facility standards. Leadership team reveals in this instance, the facility staff did not follow their expectations.

Based on review of the facility policies, Resident [NAME] of Rights, record review, observations and interviews, the facility failed to ensure the nutritional well-being of Resident (R)5,while respecting an individual's right to make choices about their diet. Findings include: Review of the Resident's [NAME] of Rights (South Carolina Code of Laws, Section 44-81-20 et. Seq., revealed under personal treatment, to be treated with respect and dignity. Review of the facility's Heart Healthy Precautions, copyright 2022, revealed indications for use are for the individual desiring to reduce their risk of developing heart disease or minimize further complications from heart disease .A less restrictive diet is shown to increase intake, enjoyment, and palatability of the meal. Nutritional Adequacy revealed with the proper selection of foods, the Heart Healthy Precautions meets the current Dietary Reference Intakes/Recommended Dietary Allowances/Adequate Intakes, Food and Nutrition Board, Institute of Medicine, National Academy of Science, 2011 for individuals ages 31 years and older. Review of the facility's Heart Precautions Educational Handoutcopyrighted 2022, revealed well balanced, nourishing meals include the following component daily: · 6 ounces of protein – one ounce is equivalent to one ounce cooked meat or fish, one ounce cheese, ¼ cup cottage cheese, one egg or ½ cup of cooked beans. Review of R5's Face Sheet revealed that R5 was admitted to the facility on [DATE] with diagnoses including but not limited to: chronic respiratory failure, tracheostomy status, chronic obstructive pulmonary disease, and hypertensive heart disease without heart failure. Review of R5's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/08/25, revealed R5 had a Brief Interview for Mental Status (BIMS) score of 14, indicating an intact cognitive response. Review of R5's Care Plan with a start date of 01/02/2025 documented, “R5 has a nutritional problem or potential nutritional problem, PEG use related to (r/t) dysphagia, type 2 diabetes mellitus, heart failure, gastroesophageal reflux disease (GERD), congestive heart failure (CHF) with weight fluctuations expected resident and family are non-compliant with the ordered diet. Further review of the Care Plan revealed the following approach, “Diet as ordered by the physician, RD to evaluate and make diet change recommendations as needed (PRN), risk versus benefit to resident and family for appropriate diet for resident.” Review of R5's Treatment Administration Record (TAR), revised 08/29/2025 revealed Consistent Carbohydrate Diet (CCHO), regular texture, thin liquids consistency, no concentrated sweets/no fried foods/large protein portions. During an interview on 09/10/2025 at 09:12 AM, R5 stated, “They have me on a strict diet. I am tired of chicken. I eat chicken every day. They gave me two tortillas with salsa with no meat. It is days they don't give me meat. I really don't know much about the Heart Healthy diet. During an interview on 09/10/2025 at 10:30 AM, the Long-Term Care (LTC) ombudsman stated, “When I went out to speak with R5. I was informed that R5 is on a diet. The plan was for R5 to lose weight. But then R5 started complaining that they were not giving R5 enough to eat, and the food is not good.” During an interview on 09/10/2025 at 04:17 PM, Dietary Assistant Supervisor stated, “We get a diet form from the nursing station that tell us what the diet is so they write it on a preference slip. We then try to find out what they like. We go through the meats, milks, drinks, vegetable that we have at Millennium. On the dietary slip, it also let us know what their food allergies are. She never request more food. I know she has to have skinless meat for her heart healthy meal. Our diet slip breaks it down to what our meals are and what they can have and what they can't have. We follow up their preferences as much as possible. R5 can also reach out to the CNA or the Nurse if they want to request a change of diet selections. If the tray is already out, we will make the changes in the system or reprint the ticket or scratch it off. If it's something they can't have I have to have permission to change their diet. We offer salads and hamburger patties. She has an alternate menu posted in her room. I posted it myself. It is under her meal plan she has. They can call on their phone to us directly to change their menu selection. It is in front of her bed. She verified she can see the Menu. We have a cook after hours. I stay till six.” During an observation on 09/10/2025 at 04:39 PM, the surveyor had difficulty reading the weekly menu on the resident's wall. During an interview on 09/10/2025 at 04:39 PM, R5 stated, “I am unable to read the menu on the wall.” During an interview on 09/10/2025 at 05:03 PM, the Dietary Assistant Supervisor stated, “My boss had a conversation with her recently. If we ask if she is ok, R5 says she is ok. I cannot speak on extra portions for her meals because I was not here. We do try our best to see if R5 enjoys their meal.” During an observation on 09/10/2025 at 05:00 PM, the Dietary Assistant Supervisor stated, “She could not see the menu on the wall.” During an observation on 09/10/2025 at 05:00 PM, the Dietary Assistant Supervisor provided the surveyor with a menu for week 2. On Wednesday (Day 11), for dinner, the menu revealed cheese enchiladas, refried beans, pico salad, fresh grapes, sugar cookies, and milk/beverage. During an interview on 09/10/2025 at 05:05 PM, the Dietary Assistant Supervisor provided the surveyor with a menu that was changed out for Wednesday (Day 11). The menu revealed cheese quesadilla- 1 cup, carrots-4 ounce (oz), pico salad #8 scp, fresh grapes-4oz, sugar cookie-1, skim milk/beverage-1 cup. She could not confirm the portion sizes. During an interview on 09/10/2025 at 07:15 PM, the Administrator stated, “R5's Resident Representative (RR) will send food that is not on her heart-healthy diet. We have educated the RR to adhere to her diet, fluid-restricted, low-sodium. The problem is getting her to follow her diet. We are fighting that battle with what she is eating. She DoorDash. A Registered Dietitian (RD) is here weekly. The RD may say she has had her allotted protein for the day. The RD tracks the daily and weekly menu.

Based on facility policy review, record review, observations and interviews, the facility failed to ensure medications were properly stored and secured for one of one resident (R)1, observed for pharmacy services. Specifically, a cup containing Guaifenesin (Robitussin) was observed left unattended on R1's bedside table without documentation of a self-administration assessment or physician authorization.Findings include:Review of the facility policy titled, Medication Administration: General Guidelines, with a last review date of 7/28/25 revealed: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Policy further reveals, Medications are administered at the time they are prepared. Medications are not pre-paired/pre-set/pre-crushed. Only one patient/resident's medications are prepared and administered at a time.An observation of R1's bedside table on 9/9/25 at 11:50 AM revealed R1 had a medication cup in her bed side table with a red liquid. During a subsequent interview, R1 revealed it was a cough medicine that a night shift nurse gave her 2 nights ago.An observation and interview with Licensed Practical Nurse (LPN)2 on 9/9/25 at 1:38 PM revealed a loose white pill tablet that had H-49 engraved on the back of the pill. H-49 Imprint is identified as Sulfamethoxazole and Trimethoprim 800 mg [milligrams] / 160 mg, commonly used to treat various bacterial infections. LPN2 revealed she does not know what the pill is, where it came from, or who it is for. LPN2 denies pulling it for R1. LPN2 was observed wasting medication.Record review of R1's orders revealed no PRN [as needed] and or one time order for cough medication, or Sulfamethoxazole and Trimethoprim in the past 3 days.Record review of R1's electronic health record reveals no self-medication administration assessment completed on file nor was there a provider order for R1 to self-administer medication.During an interview with LPN1, completed on 9/10/25 at 3:37 PM, revealed the facility has standing orders for all residents from the Provider for common symptom relief, among these medications is Guaifenesin/Robitussin: 10ml/po every 8 hours as needed which is a medication used to treat a common cough/cold like symptoms. Subsequent record review was completed with LPN1 of R1's orders revealed no standing orders for cough medication. Further review of R1's electronic health record indicated no one time order or note indicating that the resident was ordered for and received cough medication. Observation was then made with LPN1 of unknown red substance in the medication cup. LPN1 was able to identify the substance as Guaifenesin/Robitussin. LPN1 acknowledged that the resident should have had an order or at least a progress note indicating the use and need for the cough medication.During an interview with the Administrator (LNHA), Director of Nursing (DON), and Assistant Director of Nursing (ADON) on 9/10/25 at 3:30 PM, revealed the leadership team has emphasized that, in accordance with safe medication administration practices, nursing staff must first verify that a resident has a valid provider order for any medication. The medication must be active on the Medication Administration Record (MAR), and provider instructions must be carefully followed prior to administration. Following this, staff are expected to document whether the resident took the medication and record the outcome in the resident's Electronic Health Record (EHR). The leadership team further clarified that residents should never have medications at their bedside, particularly medications that have not been prescribed. In this case, the leadership acknowledged, the nurse who administered the cough medication failed to obtain a provider order and did not adhere to the established protocols, thereby not meeting leadership's expectations for safe and compliant medication practices.

Based on review of the facility policy, observations, and interviews, the facility failed to ensure proper tracheostomy care, in relation to documentation and changing the tracheostomy neck tie, according to professional standards of practice for 1 of 1 resident reviewed.Findings include:Review of a facility policy titled Trach Tie Change dated 01/2025, revealed Policy: The respiratory care provider should use accepted practices to change trach ties.Frequency: Every seven days, after showers or when visibly soiled.A review of the admission record revealed that the facility admitted Resident (R)4 on 09/05/2025, with diagnoses that included, but were not limited to, chronic respiratory failure with hypoxia, dependence on respiratory [ventilator] status, functional quadriplegia, and persistent vegetative state.A review of R4's Respiratory Administration Record (RAR) dated 07/01-31/2025 revealed an order to change the trach ties weekly on Thursday (Thurs) and as needed every day shift every Thurs.During a review of R4's August Medication Administration Record (MAR), the review did not reveal an order to change the tracheostomy ties.A review of R4's Care Plan, initiated 03/13/2025, revealed that R4 has a tracheostomy related to (r/t) chronic respiratory failure. The resident also has Chronic Obstructive Pulmonary Disease (COPD). The interventions further revealed tracheostomy care per facility protocol.A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/20/2025, revealed R4 had a Brief Interview for Mental Status (BIMS) that was not scored.During an observation on 09/09/2025 at 01:00 PM, the RAR did not reveal the changing of tracheostomy ties, weekly.During an interview on 09/09/2025 at 01:06 PM, Licensed Practical Nurse (LPN)4 stated, My new nursing orientation training was for 30 days. They are responsible for changing the tracheostomy neck ties. Respiratory does everything associated with the R4's tracheostomy.During an interview on 09/09/20025 at 01:15 PM, Respiratory Therapist (RT)1 stated, I've worked here for 3 years. We change his tracheostomy ties every Thursday and as needed. He lays on his side and drools a lot, so we may have to change it a little more than once a week.During an interview on 09/09/2025 at 01:36 PM, the Director of Respiratory stated, If they have skin breakdown proximity to the stoma site, the wound nurse changes the dressing. When R4 was in and out of the hospital, the order fell off for changing the tracheostomy ties. I realized his tracheostomy ties were not being changed once I observed there was no documentation for it.During an interview on 09/09/2025 at 02:29 PM, the Director of Respiratory stated, We do not have any documentation on trach changes for August.During an interview on 09/10/2025 at 05:22 PM, the Director of Nursing (DON) stated, They get checked off on changing the neck ties. It is one of the things we do during our annual skills fair.

Based on record review, interviews, and facility policy review, the facility failed to ensure that clinical records were complete and contained accurate documentation for one of 22 residents (Resident (R)75) whose records were reviewed. This had the potential for the resident not to receive accurate care. Findings include: Review of a facility policy titled, Physician Orders, Telephone Orders and Recapitulation Process . Documentation in Long Term Care Record, dated 08/2016, indicated, . This policy ensures that the hybrid record during the transition to the EHR (electronic health record) is managed in accordance with the requirements for maintaining the designated record set. It is the policy of this facility to ensure accuracy of the physician orders, as much as possible, in accordance with the state and federal regulations.Physician's orders shall be obtained prior to the initiation of any medication or treatment . Review of R75's Face Sheet, located under the Profile tab of the electronic medical record (EMR), indicated the resident was admitted to the facility on [DATE]. Review of R75's Physician Orders, located under the Orders tab and dated 01/23/25, indicated the resident was ordered Mighty Shakes (nutritional supplement) with meals. Review of R75's Medication Administration Record, located under the Orders tab of the EMR and for the months of 01/2025, 02/2025, and 03/2025, indicated the order for the Mighty Shake was transcribed into the MAR section and revealed documentation the resident received his physician order Mighty Shake with each meal since 01/23/25. Two observations were conducted of R75. An observation was conducted on 03/10/25 at 12:35 PM, and the resident did not have Mighty Shake on his lunch tray. An observation was conducted on 03/11/25 at 8:32 AM, and there was not a Mighty Shake on his breakfast tray. The resident stated he was to have a Mighty Shake on his trays but did not receive it. During an interview on 03/11/25 at 8:37 AM, Licensed Practical Nurse (LPN)1 stated the process for ordering the Mighty Shake was to complete a diet slip and send it to the kitchen. LPN1 was shown her documentation from 03/10/25 and 03/11/25, and she stated she was to make sure that the resident actually drank the Mighty Shake and typically will ask the Certified Nurse Aide (CNA) if the Mighty Shake was consumed by the resident. LPN1 stated she needed to actually verify that the resident drank a Mighty Shake or not. During an interview on 03/12/25 10:02 AM, LPN8 stated the Mighty Shakes came from the kitchen. LPN8 stated she would ask the CNA if the resident drank the shake and then document this information in the MAR. During an interview on 03/12/25 at 2:47 PM, the Director of Nursing (DON) stated that it was stressed with all clinical staff to enter accurate information into the clinical records and denied that all nurses documented fraudulently. The DON stated it was an issue with LPN1.

Based on interviews, record reviews, and facility policy review, the facility failed to monitor target behaviors for the use of Risperidone (an antipsychotic medication) for one of five sampled residents (Resident (R) 33) reviewed for unnecessary medications out of a total sample of 22. This had the potential to cause the resident to receive unnecessary antipsychotic medications. Findings include: Review of R33's undated Resident Face Sheet, found in the electronic medical record (EMR) under the Continuity of Care (CCD) tab, indicated the resident was re-admitted to the facility on [DATE] with diagnoses including schizoaffective disorder. Review of R33's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/03/24 and located under the MDS tab in the EMR -, indicated a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated R33 was moderately cognitively impaired. The assessment indicated the resident was not exhibiting any behavioral symptoms during the assessment period. It also indicated that the resident used antipsychotic medications during the assessment period. Review of R33's Physician Order Report, dated 10/04/23 and found in the EMR under the Orders Tab, indicated R33 was to receive risperidone 0.5 milligrams (mg), one tablet by mouth twice daily for schizoaffective disorder as evidenced by delusions, yelling out, and sexual comments. Review of R33's Medication Administration Record (MAR), dated February and March 2025 and found in the EMR under the Orders tab, revealed no documented evidence to show which specific behaviors were associated with the administration of the resident's antipsychotic medications and required routine monitoring. During an interview on 03/11/25 at 5:35 PM, Licensed Practical Nurse (LPN)7 stated staff documented monitoring of target behaviors on a resident's medication MAR. She stated she was unsure what specific behaviors were associated with the risperidone for R33. She stated R33 had not had any sexual behaviors that she was aware of, but he did yell out. She stated he did not have any delusions, but she had not communicated that with anyone. She stated she had not reported that to psychiatric physician or the nurse practitioner. LPN7 stated staff should be notifying one of them if they were not seeing behaviors specific to the medications being prescribed. During an interview on 03/12/25 at 9:59 AM, LPN6 stated staff document behavior monitoring on a resident's MAR. She stated she was unsure of what the behaviors were that staff should be monitoring in relation to R33's risperidone. During an interview on 03/12/25 at 12:02 PM, LPN5, who was a unit manager, stated she would expect to see monitoring of the targeted behaviors for R33's antipsychotic medications. LPN5 stated it would need to be added to the MAR since it was not indicated on there. During an interview on 03/12/25 at 3:18 PM, the Director of Nursing (DON) stated staff should be documenting they are monitoring targeted behaviors for R33's risperidone.

Based on observations, record review, and staff interviews, the facility failed to ensure adequate interventions were provided to establish proper nutrition for one of five residents (Resident (R) 75) reviewed for nutrition in a total sample of 22. The facility failed to provide the resident with a dietary supplement as per physician order. This placed the resident at risk for further weight loss. Cross Reference: F842 Findings include: Review of the facility's policy titled, Dietary Services, dated 05/2014, indicated . The RD [Registered Dietician] or designee will document the specific interventions used and determine a monitoring system to evaluate the success of the interventions initiated (i.e. weekly eights, food/fluid intake studies, etc.) . Review of R75's Face Sheet, located under the Profile tab of the electronic medical record (EMR), indicated the resident was admitted to the facility on [DATE]. Review of R75's Care Plan, located under the Care Plan tab of the EMR and dated 05/18/22, indicated the resident had the potential for weight loss and would refuse being weighed at times. The goal identified on the care plan was to provide a physician ordered diet. Review of R75's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/21/24 and located in the ASPEN MDS viewer, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated the resident was moderately cognitively impaired. The assessment indicated the resident did not sustain any significant weight loss. Review of R75's Physician Orders, located under the Orders tab of the EMR and dated 01/23/25, indicated the resident was identified with significant weight loss, and the medical provider ordered to add Mighty Shakes (nutritional supplement) with meals. During an interview on 03/10/25 at 11:51 AM, R75 stated he was aware that he was losing weight, but he was unsure why. During an observation on 03/10/25 at 12:35 PM, R75 had his meal tray on his bedside table and there was no Mighty Shake on his tray. At 1:14 PM, Certified Nurse Aide (CNA)1, pulled the resident's tray from the meal cart, and confirmed that the resident did not receive a Mighty Shake. During an observation on 03/11/25 at 8:32 AM, R75's meal tray was observed and there was no mighty shake on his tray. The resident's meal ticket was reviewed during this observation, and there was no Mighty Shake listed on his meal ticket. During an interview on 03/11/25 at 8:33 AM, CNA2 stated the Mighty Shakes came from the kitchen, and if the resident was ordered the shake, it would be on his tray. During an interview on 03/11/25 at 8:36 AM, CNA3 stated R75 did not receive a Mighty Shake with his meals, and it would be on his meal ticket if he did. During an interview on 03/11/25 at 10:09 AM, Licensed Practical Nurse (LPN) 2, who was the unit manager for [NAME] and Camillia units, stated when the medical providers ordered Mighty Shakes, a diet slip was created and taken to the kitchen. During an interview on 03/11/25 at 10:11 AM, the Dietary Manager (DM) stated the kitchen supplied the Mighty Shakes for the residents and confirmed that she had never received an order from the nurses for R75. During an interview on 03/12/25 at 10:50 AM, the RD stated the medical provider did order R75 Mighty Shakes since he was losing weight. The RD stated the process was for her to make the recommendation, an order was written, and a report was sent to the DM in addition to the order. The RD stated the DM missed her communication for the Mighty Shake for R75.

Based on interview, record review, and facility policy review, the facility failed to ensure all medications were appropriately administered on dialysis days for one of one resident (Resident (R)34) reviewed for dialysis out of a total of 22. Findings include: Review of R34's Admission Record, found in the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] and last readmitted on [DATE]. R34 was admitted with diagnoses including end stage renal disease and type 2 diabetes. Review of R34's quarterly Minimum Data Set (MDS), located in the MDS tab in the EMR and with an Assessment Reference Date (ARD) of 12/05/24, revealed R34 had a Brief Interview for Mental Status (BIMS) score of 03 out of 15, which indicated significant cognitive impairment. R18 was documented to receive hemodialysis while a resident. Review of R34's EMR under the Orders tab revealed an order, dated 01/02/25, for the resident to attend hemodialysis Tuesday, Thursday, and Saturday at 11:00 AM. Further review revealed orders dated 01/21/25 for a mighty shake at meals for decreased appetite, and dated 01/02/25 for Midodrine 10 milligrams (mg) 1 tablet by mouth before meals and Sevelamer carbonate oral packet 2.4 grams 1 packet by mouth with meals in 4-6 ounces of liquid for ESRD (end stage renal disease). Review of R34's Care Plan, located in the Care Plan tab of the EMR and initiated 05/06/22, revealed a focus related to the need for dialysis related to renal failure. The interventions included for the resident to attend dialysis on Tuesday, Thursday and Saturday and to administer medications as ordered. Review of R34's Medication Administration Record (MAR), located under the Orders tab, revealed for January, February and March 2025, the mighty shake, midodrine and the sevelamer were not being regularly administered on Tuesday, Thursday and Saturday at 11:30 AM. During an interview on 03/11/25 at 5:35 PM, Licensed Practical Nurse (LPN)7 stated the resident's blood pressure medication was scheduled before each meal but that R34 would always miss the 2nd dose on the days she went to dialysis. She also stated they were not giving her the 2nd mighty shake, and she did not receive it after she returned from dialysis. She stated she did not notify the physician about the missed medications because she had never thought about it that way. During an interview on 03/12/25 at 11:41 AM, the Nurse Practitioner (NP) stated that it was understood that dialysis residents did not receive medications prescribed during dialysis times but agreed the orders should indicate that. The NP confirmed the current orders did not. During an interview 03/12/25 at 3:19 PM, the Director of Nursing (DON) was unable to provide any information or her expectation on ensuring staff following physician orders and administration medications per the orders. She stated she would need to review R34's medical records before answering but did not provide any additional information by the end of the survey.

Based on record review, interview, and policy review, the facility failed to ensure one of two residents (Resident (R)109) reviewed for falls out of a total sample of 22 had adequate supervision, which resulted in a fall from bed. In addition, the facility failed to ensure there was an accurate root cause analysis which identified the events which led to R109's fall and the corrective action taken as a result. This had the potential to cause harm. Findings include: Review of a facility policy titled, Fall Management Systems, dated 07/24, indicated, . This facility is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards and possible. Each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident with adequate supervision, assistive devices, and functional programs appropriate to prevent accidents . Review of the fall incident will include investigation to determine probable causal factors . Review of R109's titled Face Sheet, located under the Profile tab of the electronic medical record (EMR), indicated R109 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure with hypoxia and nontraumatic intracerebral hemorrhage (stroke). Review of R109's Care Plan, located under the Care Plan tab of the EMR and dated 10/09/24, indicated the resident had a tracheostomy. The care plan indicated the resident was unable to voice her needs and was totally dependent on staff for activities of daily living. It was recorded that the resident had no history of falls. Review of R109's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/15/25 and located in the ASPEN MDS viewer, indicated the staff were unable to determine the resident's Brief Interview of Mental Status (BIMS) score. The assessment indicated the resident was totally dependent on staff for all activities of daily living. Review of R109's Progress Notes, located under the Prog (Progress) Notes tab of the EMR and dated 01/30/25, indicated the resident coughed and slid off the bed. It was recorded the resident landed on her right side and was identified with swelling and some redness on her face. The provider was notified and ordered the resident to be sent to the emergency room for evaluation and treatment. Review of R109's hospital CT [computed tomography] Head Without Contrast, dated 01/30/25 and provided by the facility, indicated the resident did not sustain any head or neck injury and was returned back to the facility. Review of R109's IDT [Interdisciplinary Team], located under the Prog Notes of the EMR and dated 01/31/25, indicated IDT reviewed the resident's fall on 01/30/25. The IDT determined the resident had no acute findings. A new intervention was to place fall mats on each side of the resident's bed. Review of a document provided by the facility and titled Fall, dated 01/30/25, indicated Certified Nurse Aide (CNA) 4 was in room doing care to R109, when the resident coughed through her trach and slid off the right side of the bed. The resident had a small amount of redness to her cheek and was sent to the emergency room for evaluation and treatment. Review of a document provided by the facility and titled Fall, dated 01/31/25, indicated R109 was reviewed by the IDT and a root cause analysis was completed. The documented indicated Licensed Practical Nurse (LPN) 1 and CNA 4 were at the resident's bed side and providing care when the resident had a strong cough and slid off the bed. During an observation on 03/11/25 at 8:51 AM, R109 was in bed and had a fall mat on each side of her bed. The resident did not move while in bed. During an interview on 03/11/25 at 1:21 PM, LPN1 stated she was in the room along with CNA4 when the fall occurred. LPN1 stated she turned the resident towards CNA4, and CNA4 was present but did not grab the resident, the resident then coughed and then fell from the bed. LPN1 checked on the resident, placed her back into bed, and then informed her manager of the incident. During an interview on 03/11/15 at 2:40 PM, the Therapy Program Manager (TPM) stated the resident did not have the capacity to initiate movement in her bed or to remain on her side. Three calls and messages were left for CNA4, and there were no returned calls received. During an interview on 03/12/25 at 8:35 AM, the Director of Nursing (DON) stated she was not the staff member who completed the root cause analysis. The Assistant Director of Nursing (ADON) stated this was the first time LPN1 had experienced a resident fall while she worked with them. During an interview on 03/12/25 at 2:16 PM, LPN2, who was the unit manager for the [NAME] and Camillia Units, stated his understanding of R109's fall was LPN1 reported she had turned the resident towards CNA4, and CNA4 did not have her hands on the resident. LPN2 stated the ADON provided education to CNA4 regarding bed mobility. LPN2 stated CNA4 told him she was distracted and when the resident began to fall, it was too late to grab her. During an interview on 03/12/25 at 2:47 PM, the DON stated the staff were taught to use the draw sheet to pull the resident towards them and not to push the resident away from the staff member. The DON stated R109 was totally dependent on staff for all cares.

Based on review of the facility policy, record review, and interviews, the facility failed to develop a comprehensive care plan to include concerns about allegations of family member interfering with care and whom to notify in change of condition for 1 of 3 residents (R)105, reviewed for comprehensive care plan. Findings include: Review of the facility's policy titled, Comprehensive Person-Centered Care Planning, with a revision date of 02/2024 states, The Interdisciplinary Team shall develop a person centered care plan to meet a residents medical, nursing and mental and psychosocial needs .to properly care for a resident. Record review of R105's electronic health record (EHR) revealed diagnoses including, but not limited to; anoxic brain damage and persistent vegetative state. R105's EHR revealed, under Special Instructions: Guardian makes decisions for resident. He is to be notified before mother, indicating he is called first, and she will be notified after. Review of R105's care plan revealed there was not a plan of care indicating R105's mother was interfering with his care. Futhermore, there was not a plan of care to instruct staff to contact mother after the guardian was notified of any changes. During an interview with the Social Services Director on 3/28/24 at 2:25 PM the Social Services Director stated, I don't care plan for having a guardian and for concerns from familiy member who interfere with care. An interview with the Mimimum Data Set (MDS) Nurse on 3/28/24 at 2:52 PM revealed, If there is a concern with a family, including behaviors and affecting care of the resident, and them being banned from the facility, we normally would not care plan something like that. We have several people with Guardians, and we do not care plan that. An interview with the Director of Nursing (DON) on 3/29/24 at 10:45 AM revealed, His mother has a language barrier and uses her hands when speaking and tries to use gestures. This is how she tries to communicate with us. So I called the Guardian and asked if we can use the language line, he said, yes. So I called as I was told mom was touching his catheter. She kept saying pee pee too small. They said she was trying to take it off. But, actually she was trying to say the condom catheter was too big for him. We got a different size and she was happy. This should have been care planned to include who to contact and when. His mother isn't listed on the paper work to be notified. We don't even have her phone number.

Based on review of the facility policy, observation, interview, and record review, the facility failed to ensure a medication error rate of less than five (5) percent for 1 of 7 residents observed for medication administration. The medication error rate was 42.31 percent. Findings Include: Review of the facility's undated policy titled, Administering Medication through an Enteral Tube, revealed Preparation: #23 Administer medication by gravity flow. Review of the facility policy titled, Medication Administration, Medication Administration Standards and Principles dated 7/2014, revealed, Medication will be administered based on the Eight Rights. 1. Right time- medications are administered within prescribed timeframe. Review of Resident (R)75's medical record revealed he was admitted to the facility on [DATE] with diagnoses including but not limited to; chronic respiratory failure, anoxic brain damage, persistent vegetative state, dependence on respirator and use of gastrostomy. Review of R75's Physician orders revealed the following medications and supplements to be administered via g tube at 9 AM: Midodrine 10 milligram (mg), Baclofen 10 mg, Thiamine 100 mg, Liquid Protein, Multiple Vitamins, Reglan 5 mg, Zinc 220 mg, Sodium Chloride 1 gram, Norco 5-325 mg, and Ascorbic Acid 500 mg. During an observation and interview on 1/25/24 at 9:36 AM of medication administration for R75, Licensed Practical Nurse (LPN)4, who was drawing up the medication stated, I dont have 3 of the medications to give right now, they are not available. The medications, Zinc 220 oral capsule, Sodium Chloride 1 Gram; two tablets, and Reglan 5 milligrams (mg) tablet, were not drawn up to administer. LPN4 then plunged 9 medications individually into the gastrostomy tube. During an interview on 1/25/24 at 10:05 AM, LPN4 stated, We're taught to allow the meds to free flow. During an observation and interview on 1/25/24 at 2:50 PM of LPN4 pulling medication from the Pyxis revealed Reglan 5 mg was available, but the Zinc 220 and the Sodium Chloride were not in the Pyxis machine. LPN4 stated, Well, I missed the morning dose. Record review of the Medication Administration Record (MAR) for R75 dated January 2024 revealed Zinc 220 oral was signed as given at 1000, Sodium Chloride Oral Tablet 1 Gram; give 2 tablets was signed as given at 900 and 1300, and Reglan 5 milligram (mg) was signed as given at 0900 and 1300. During a second interview on 1/25/24 at 2:45 PM, LPN4 stated, I need to go to the Pyxis to see if these medications are available. During an interview on 1/26/24 at 8:10 AM, the interim Director of Nursing (DON) stated, Nurses should administer all medication as ordered. We always administer gastrostomy medication by gravity.

Based on review of facility policy, observations, interviews, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 2 residents reviewed for respiratory care, Resident (R)69. Findings include: Review of the facility's policy titled, Policy & Procedures Department: Respiratory Subject: Infection Control dated 01/2022 revealed, Policy: Disposable equipment is for single patient use only and will be changed per facility policy based off of manufacture guidelines under the criteria listed below . Procedure: 4. All disposable equipment will be replaced as follows: a. SVN (small volume nebulizer): will be changed every 7 days and PRN (as needed), to be stored in a setup bag loosely and not sealed. Review of R69's Face Sheet revealed R69 was admitted to the facility on [DATE] with diagnoses including but not limited to, hypertension, dementia, bipolar disorder, and obstructive sleep apnea. Review of R69's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 01/05/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R69 was cognitively intact. Review of R69's Care Plan with a start date of 11/30/21 and target date of 03/21/24 documented, focus Has altered respiratory status r/t Chronic Respiratory failure and OSA, COPD and emphysema cough resident with respiratory allergies, allergic rhinitis. Documented goal Will have no complications related to SOB though the review date. Documented intervention revealed, nebulizer as ordered. Further review of the Care Plan with start date of 11/15/21 and target date 03/21/24 documented focus Has Oxygen Therapy r/t Respiratory illness with documented goal Will have no s/sx (signs and symptoms) of poor oxygen absorption through the review date. Review of R69's Medication Administration Record (MAR) for 01/01/24 - 01/31/24 revealed an order for change nebulizer tubing/mask/mouthpiece weekly and PRN (as needed) every night shift every Wed, Sun -Order Date 01/14/2024. The document revealed documentation on the following days as noted with nurse initials: 1/14/24, 1/17/24, 1/21/24, and 1/24/24. Review of R69's Physician Order with a start date of 01/14/24 documented, change nebulizer tubing/mask/mouthpiece weekly and PRN (as needed). Review of R69's MAR for 01/01/24 - 01/31/24 revealed an order for O2 AT 3 L (liters)/min continuous per nasal Cannula every shift for resp. failure -Order Date 01/14/2024. During an observation on 01/23/24 at 10:37 AM, R69 was observed in room, sitting in wheelchair at bedside, with oxygen at 4L/min via nasal canula. The nebulizer mask was dated 11/20/23 and uncovered. R69's Trelegy mask was also uncovered. During an interview at this same time, R69 stated that the nebulizer mask had not been changed in a month and needs to be changed. She reported that both masks were in a bag, but it was thrown away. She reported that a Certified Nursing Assistant (CNA) told her it didn't need to be in a bag. During an observation 01/25/24 at 8:33 AM, R69 was observed in her room sitting in her wheelchair at bedside, finishing breakfast. Oxygen noted at 3L/min via nasal canula. During an interview on 01/26/24 at 8:15 AM, CNA1 confirmed the nebulizer mask should be stored in a bag, and confirmed it was not in one. She then verified the date on the mask as 11/20/23. She stated that she did not know who was responsible for changing the masks, but it was not a CNA responsibility. CNA1 also verified R69's O2 was set a 3 1/2 L/min. During an interview on 01/26/24 at 8:25 AM, Licensed Practical Nurse (LPN)5 verified the date on the mask as 11/20/23 and that it should be in a bag. LPN5 placed the mask into the bag at this time and stated she did not know how often the mask was supposed to be changed. LPN5 verified at the computer oxygen rate of 3 L/minute. During an interview 01/26/24 at 8:25 AM, LPN5 verified R69's Oxygen was set on 3 1/2 L/min and that the order stated 3L/min but did not change the setting at this time. At the computer, LPN5 pulled up orders to verify oxygen rate of 3L/min. During an interview on 01/26/24 at 8:48 AM, the Interim Director of Nursing (DON) stated that oxygen was set on 3.75 L/minute and did not know what the order stated but would look. Observation at this time with the DON revealed the nebulizer mask was not in the bag, as it was previously put by LPN5 at 8:25 AM. During an interview on 01/26/24 at 9:49 AM, the Interim DON confirmed that she reviewed the documentation and noted that it was being signed on the medication administration record (MAR) for changing the mask and that R69 refuses at times. She stated that if the resident refused the nurses should not be signing off, but instead indicating a refusal within the system for documentation. She confirmed that the mask needs to be changed every Sunday per orders. She also stated that her expectation for ensuring oxygen is at correct rate, is that nurses should be checking during the time they are taking vital signs to ensure the accuracy of the flow rate. 49801 49918

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure that two residents (Resident (R) 69 and 49) of two residents reviewed were clinically appropriate to self-administer medications. Findings include: Review of the facility policy titled, Policy/Procedure-Nursing Administration- Section: Care and Treatment, Subject: Self Administration of Medications revised 05/2022 revealed Policy: It is the policy of this facility to respect the wishes of alert, competent residents to self-administer prescribed as allowable under state regulations. Procedures: 2. If a resident desires to participate in self-administration, the interdisciplinary team will assess and periodically re-evaluate the resident based on change in the resident's status. 3. The residents cognitive, communication, visual, and physical ability to carry out this responsibility will be evaluated. If the interdisciplinary team determines that this resident is unable to carry out this responsibility (this would be dangerous to resident or others), the interdisciplinary team may withdrawal this right. 4. If the resident is a candidate for self-administration of medications, this will be indicated in the record. 5. Resident will be instructed regarding proper administration of medication by the nurse and this will be care planned. 7. Storage and location of drug administration (e.g., resident's room, nurses' station, or activities room) will comply with state and federal requirements for medication storage. 9. Appropriate notation of these determinations will be placed in the residents care plan. Review of the facility policy titled, Policy & Procedures-Department: Respiratory, Subject: Medication Access/Storage. Policy: It is the policy of this facility to store all drugs and biological in locked compartments under proper temperature controls. The medication supply is accessible only to licensed respiratory personnel, nursing personnel, or staff members lawfully authorized to administer medications. 2. Only licensed respiratory therapists, nurses, the consultant pharmacist and those lawfully authorized to administer medications are allowed access to medications. Medication rooms, carts, and medication supplies are locked . Review of R69's Face Sheet revealed R69 was admitted to the facility on [DATE] with diagnoses including but not limited to: hypertension, type 2 diabetes mellitus with hyperglycemia, anemia, hyperlipidemia, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and bipolar disorder. Review of R69's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/05/24 revealed R69 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, which indicates R69 was cognitively intact. Review of R69's Care Plan initiated 04/18/22 with target date of 03/21/24 revealed, At risk for impaired cognitive function r/t (related to) Dementia. Will maintain current level of cognitive function through the review date. Administer medications as ordered. Review of R69's Physician Orders for 01/01/24 - 01/25/24 revealed an order for Saline Nasal Solution 0.65% (Saline) two sprays in each nostril, two times a day for dry nostrils. Further review of R69's Physician Order for 01/01/24 - 01/25/24 revealed no Physician Order for R69 to have Saline Nasal Solution 0.65% (Saline) at her bedside. During an observation and interview on 01/25/24 at 8:33 AM, surveyor observed Major/Deep Sea Spray Premium Saline 1.5 oz. (ounces) spray on the overbed table beside R69's breakfast tray with opened date of 12/17/23. When R69 was asked about this medication, she stated that the nurse had left it and said she would come back to get it. R69 reported that this medication is usually left for her to self-administer because the nurses want to administer it and leave, but the resident is not always ready for the medication, related to the need to frequently go to the bathroom. During an interview on 01/25/24 at 8:33 AM in the resident's room, Licensed Practical Nurse (LPN)5 confirmed that the nasal spray was on the overbed table and stated that the patient administers by herself, so she leaves it for her and comes back. When asked if medications are left at bedside for the resident, LPN5 verbalized that only the nose spray is left. When asked what the facility policy stated for leaving medications unattended, she confirmed that this was not the policy to leave medications at bedside. During an interview on 01/26/24 at 9:49 AM, the interim Director of Nursing (DON) confirmed that she knew about the medication being left at the bedside and had educated the nurse, as she is a new nurse. Her expectation was that the nurse would stay at the bedside during medication administration. Review of R49's facesheet revealed R49 was admitted to the facility on [DATE] with diagnoses including but not limited to: personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, overactive bladder, hypertension, obstructive sleep apnea, and morbid obesity. Review of R49's Quarterly MDS with an ARD of 11/02/23 revealed R49 had a BIMS score of 15 out of 15, which indicates R49 was cognitively intact. Review of R49's Medication Administration Record (MAR) dated 01/01/24 - 01/31/24 revealed an order for Nystatin External Cream 100,000 unit/gram (Nystatin Topical); Apply to right ankle topically one time a day for yeast to right ankle for 14 days that was ordered 12/26/23 and discontinued on 01/09/24. Review of R49's Physician Orders for 01/01/24 - 01/31/24 revealed no Physician Order for R49 to have Antifungal powder or Zinc ointment at bedside. During an interview on 01/25/24 at 12:17 PM with R49 revealed the nurse will leave meds, sometimes. When asked if she had an order to self-administer medications, R49 stated that she did not know. During an interview on 01/25/24 at 2:13 PM with LPN1 and LPN2 revealed they were not aware of medications in R49's room. LPN1 stated that anyone could get in the cart, but clarified that nurses had a key for access to the wound carts. LPN2 stated that she did not think the resident had an order for antifungal powder and thinks it was discontinued. LPN2 voiced that medications should not be left at the bedside and confirmed that there had been an antifungal order for cream that was discontinued, but not for powder. LPN2 confirmed that zinc ointment was also discontinued. It was confirmed that the resident does not have an order for self-administration. During an interview on 01/25/24 at 2:21 PM, LPN6 stated that she saw the antifungal powder and zinc ointment and removed them from the room, as it was the right thing to do.

Based on observation, interview, and facility policy the facility failed to provide dignity for 1 of 1 Resident (R)27 related to his urinal. Finding include: Review of the facility policy titled, Resident Rights Dignity and Privacy last revised 11/30/21, revealed It is the policy of the facility that all residents be treated with kindness, dignity, and respect. Residents shall be examined and treated in a manner that maintains the privacy of their bodies. Privacy of a resident's body shall be maintained during toileting, bathing, and other activities of personal hygiene, except when staff assistance is needed for the resident's safety. Resident (R)27 was admitted to the facility on [DATE] with diagnoses including but not limited to; type 2 diabetes, spastic hemiplegia affecting the right dominant side, and encounter for attention to tracheostomy. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed R27 has a Brief Interview of Mental Status (BIMS) score of 13 out of 15, which indicates that he is cognitively intact. Further review of the Quarterly MDS revealed that R27 is dependent on staff with Activities of Daily Living and has impairment to both his upper and lower extremities. An observation and interview on 01/25/24 at 12:16 PM revealed R27 in bed awake. There was a urinal with urine beside the resident, hanging on the side rail. R27 stated that several staff members have been in his room to provide care to his roommate and himself and have not offered to empty his urinal. R27 further stated that staff will also walk by his room with his door open and not offer him assistance to use his urinal, as well. A second observation on 01/26/24 at 08:44 AM revealed R27's urinal with urine hanging on the side rail of the resident's bed, R27 at the time was asleep. A third observation on 01/26/24 at 10:24 AM revealed R27's urinal with urine hanging on the side rail of the resident's bed. During the observation, a staff member, Respiratory Therapist (RT)1, was in the room speaking with the resident and exited the room, without offering to assist R27 in emptying his urinal. An interview on 01/26/24 at 10:24 AM with RT1 revealed that Certified Nursing Assistants (CNAs) and all staff members can assist residents with urinal care to provide dignity for residents. RT1 further stated that they did not notice the resident's urinal with urine, on the side rail of his bed. An observation and interview on 01/26/24 at 10:26 AM with CNA5 revealed that they were R27's assigned CNA for the day and they were unaware that R27 needed assistance with his urinal, because he did not use his call light for assistance. CNA5 further stated that she completes rounds on residents every 2 hours and last checked on the resident around 8:30 AM. A follow-up interview with R27 on 01/26/24 at 10:33 AM revealed that his urinal has been sitting at his bedside for several hours and he has had several staff members in his room this morning and no one offered to empty his urinal.

Based on review of the facility policy, observation, and interviews, the facility failed to ensure proper infection control protocols were followed for 1 of 1 Resident (R)82. Findings include: Review of the facility's policy titled, Subacute Resident Respiratory Equipment Cleaning dated 10/2022, revealed it does not include procedures for cleaning the oximeter. An observation on 1/25/24 at 7:56 AM with Respiratory Therapist (RT)1 performing respiratory treatment on R82 revealed when she checked his oxygen saturation with a pulse oximeter, she removed it from her pocket multiple times after placing it on R82's finger during treatment, and returning it to her pocket. At the end of the treatment, she again placed it in her pocket, and exited the room. During an interview on 1/25/24 at 8:25 AM with RT1, she stated, I should have cleaned the pulse ox before I placed it in my pocket. We're taught cleaning of the equipment. I used sanitizer in my pocket, my pocket is silk lined. During an interview on 1/25/24 at 8:55 AM with the Manager of Respiratory Services, she stated, All of the equipment we bring into the room to use should be sanitized before the therapists put it in their pocket.

Based on review of facility files and interview, the facility failed to ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, to the administrator of the facility and to other officials (including the State Survey Agency). Resident #7 was noted with an allegation of verbal abuse against CNA (Certified Nurse Aide) #2 on 8/17/18. LPN (Licensed Practical Nurse) #2 overheard the CNA arguing with the resident but did not report the incident to administration. One of two residents reviewed for allegations of abuse. The findings included: The facility reported an allegation of abuse to the State Agency for Resident #7 and CNA #2. Review of the facility's Five-Day Follow-Up Report dated 8/21/18 indicated following resident and staff interviews the allegation of verbal abuse was substantiated for Resident #7 and CNA #2 In an interview with the surveyor on 8/29/18 at approximately 11:05 AM, the Social Services Director stated Resident #7 reported the incident to LPN #2 when it happened. The incident happened on night shift of 8/16/18, but was in the morning of 8/17/18. LPN #2 told the Social Services Director and admission nurse that s/he had some customer service issues on the morning of 8/17/18. LPN #2 said CNA #2 was very abrupt and was being rude to Resident #7. The Social Services Director went in to talk with Resident #7 who stated the CNA was very short with him/her, rude and argumentative. In an interview with the surveyor on 8/29/18 at approximately 12:05 PM, the administrator stated the incident started as a grievance. Resident #7 said CNA #2 was rude and s/he didn't want the CNA working with him/her. The grievance was made on the morning of 8/16/18. They suspended CNA #2 based on customer service on 8/16/18. They interviewed LPN #2 and s/he heard CNA #2 and the resident arguing, but did not know what they were arguing about. The administrator interviewed CNA #3 on 8/17/18 at approximately 8:00 AM. CNA #3 said CNA #2 and Resident #7 were arguing and s/he intervened and sent the CNA out. The administrator stated they did not report the incident to the State Agency until the 17th when s/he talked with CNA #3 and received more information about what happened. LPN #2's facility-obtained statement indicated s/he was outside of the room passing medications. LPN #2 heard the CNA and resident arguing, but s/he didn't exactly hear what they were arguing about. CNA #2 came out of the room very upset, so s/he changed the assignment. CNA #3's facility-obtained statement dated 8/15/18 indicated CNA #2 was complaining about one of his/her residents, Resident #7. CNA #2 kept referring to Resident #7 as a [***] . S/he said, The [***] is nasty and s/he does things on purpose because s/he doesn't like me. The [***] keeps passing gas and stool while I'm cleaning him/her up. I'm tired of that [***] . CNA #3 went to Resident #7's room with CNA #2. CNA #3 asked Resident #7 if there was something wrong. S/he said yes, then went into great detail about his/her complaints or problems with CNA #2. Resident #7 said s/he didn't want CNA #2 in his/her room anymore. S/he didn't like how CNA #2 would throw things around at him/her. S/he didn't like CNA #2's attitude towards him/her. Each time Resident #7 would explain or describe his/her experiences with CNA #2, CNA #2 kept cutting the resident off and denying everything. CNA #3 took care of Resident #7 the rest of the night and gave CNA #2 another resident to take care of. Resident #7 was in tears. CNA #3 kept apologizing for his/her bad experience. The nurse, LPN #2, was outside the room in the hall giving medicine. CNA #2 had already talked to LPN #2 about Resident #7. In a facility telephone interview with CNA #3 on 8/17/18 conducted by the facility administrator, CNA #3 stated Resident #7 started explaining to him/her how displeased s/he was with the conduct and nasty attitude. While the resident was explaining his/her concerns CNA #2 continued to interrupt and argue with the resident. Resident #7 did not want the tech to return to his/her room or provide care. CNA #3 offered to take the resident for the remainder of the shift and asked CNA #2 to leave. CNA #2 told the resident s/he could spell his/her name out for him/her if s/he wanted. After CNA #2 left s/he continued to vent and yell in the hallway related to Resident #7. LPN #2 remained in the hallway during the incident and did not intervene with the incident. Review of the Counseling/Disciplinary Notice dated 8/23/18 revealed LPN #2 was terminated. When questioned, LPN #2 stated s/he had gone in the room to check on the resident's call light. After leaving the room LPN #2 continued to hear loud voices from the CNA and resident, but did not go back in as s/he wasn't sure what was being said. Once the CNA left LPN #2 did acknowledge that s/he changed the CNA's assignment, but did not report the incident to administration. At the conclusion of the investigation the alleged abuse was substantiated. The corrective action indicated due to the serious nature of this occurrence of which LPN #2, a charge nurse with supervisory responsibilities, did not address a situation that jeopardized a resident's well-being, nor did s/he report it to administration, it is in the best interest of the facility to separate his/her employment effective immediately.

Based on review of facility files and interview, the facility failed to implement written policies and procedures that prohibit and prevent abuse. Resident #5 was observed by CNA (Certified Nurse Aide) inappropriately touching Resident #6. Resident #7 was noted to have a substantiated allegation of verbal abuse by CNA #2. Two of two residents reviewed for allegations of abuse. The findings included: The facility reported an allegation of abuse to the State Agency on 8/1/18 related to Resident #5 and Resident #6. Review of the summary included with the Five-Day Follow-Up Report date 8/6/18 revealed based on resident and staff interviews the allegation is substantiated that Resident #5 went into the room attempting to touch Resident #6 inappropriately before CNA intervened. While going to check on the resident the CNA did observe Resident #5's hand under Resident #6's blanket with the left side of his/her brief unfastened. The residents were both interviewed that night and the following day and are inconsistent. The CNA made rounds between 9:30 PM and 10:00 PM when s/he found Resident #5 in the room at Resident #6's bedside in his/her wheelchair on the left side of Resident #6's bed. The CNA immediately pulled the covers and identified Resident #5's hand was under the covers but not in the brief. The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review of the 7/12/18 Quarterly Minimum Date Set (MDS) assessment revealed that the resident had a Brief Interview for Mental Status (BI[CONDITION]) score of 15, no behaviors. The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Review of the 5/25/18 Significant change Minimum Date Set (MDS) assessment revealed that the resident had a Brief Interview for Mental Status (BI[CONDITION]) score of 13, no behaviors. CNA #1's facility-obtained statement dated 8/1/18 indicated upon entering Resident #6's room Resident #5 was at the resident's bedside on the left side in his/her wheelchair. CNA #1 immediately told Resident #5 to get out and never come back in the room again. CNA #1 pulled the covers back and noticed the left side of Resident #6's brief was unfastened and the resident was holding on to his/her brief. CNA #1 waited until Resident #5 was completely out of the room before getting the nurse. LPN #1's facility-obtained statement dated 8/1/18 indicated the CNA came into the hallway and asked him/her to come inside the room. LPN #1 observed Resident #5 sitting on the left side of Resident #6's bed in his/her wheelchair. The cover was pulled back and the right side of Resident #6's brief was undone. CNA informed me when s/he entered room Resident #5 had his/her hand inside Resident #6's brief in his/her peri area. Resident #5's facility-obtained statement dated 8/2/18 indicated s/he heard Resident #6 crying. Resident went to Resident #6's room, rolled up to the bed and began talking to Resident #6. Resident #5 stated they talked and Resident #6 finally stopped crying. Resident #5 stated before leaving s/he kissed Resident #6 on the forehead and s/he kissed him/her on the cheek. Resident #5 stated CNA came in the room, pulled Resident #6's blanket back and left running out the room. Resident stated the CNA said nothing to him/her or Resident #6. Resident #5 stated s/he rolled him/herself back to room and watched television. In an interview with the surveyor on 8/28/18 at approximately 3:20 PM, the Social Services Director stated s/he talked with Resident #6 on 8/3/18 and asked the resident if anyone had abused him/her. Resident #6 denied anything happened. The Social Services Director also talked with Resident #5 and s/he denied any incident. Resident #6 stated s/he was in the resident's room consoling him/her, s/he had his/her hand on top of the covers and was talking with the resident. The Social Services Director stated s/he was not aware of the information related to Resident #6's brief being unfastened and the Resident #5's hand being under the covers that was in the facility's summary statement on the incident included in the investigation. The Social Services Director stated s/he did not document in Resident #5's medical record related to the incident. In an interview with the surveyor on 8/29/18 at approximately 12:05 PM, the administrator stated s/he was told Resident #5 was found in the room with his/her hand under Resident #6's covers. The administrator stated s/he interviewed CNA #1 about what happened, who stated s/he told Resident #5 to go back to his/her room. The administrator stated s/he did not talk with the LPN #1 to verify his/her statement. The facility reported an allegation of abuse to the State Agency for Resident #7 and CNA #2. Review of the facility's Five-Day Follow-Up Report dated 8/21/18 indicated following resident and staff interviews the allegation of verbal abuse was substantiated for Resident #7 and CNA #2 In an interview with the surveyor on 8/29/18 at approximately 11:05 AM, the Social Services Director stated Resident #7 reported the incident to LPN #2 when it happened. The incident happened on night shift of 8/16/18, but was in the morning of 8/17/18. LPN #2 told the Social Services Director and admission nurse that s/he had some customer service issues on the morning of 8/17/18. LPN #2 said CNA #2 was very abrupt and was being rude to Resident #7. The Social Services Director went in to talk with Resident #7 who stated the CNA was very short with him/her, rude and argumentative. In an interview with the surveyor on 8/29/18 at approximately 12:05 PM, the administrator stated the incident started as a grievance. Resident #7 said CNA #2 was rude and s/he didn't want the CNA working with him/her. The grievance was made on the morning of 8/16/18. They suspended CNA #2 based on customer service on 8/16/18. They interviewed LPN #2 and s/he heard CNA #2 and the resident arguing, but did not know what they were arguing about. The administrator interviewed CNA #3 on 8/17/18 at approximately 8:00 AM. CNA #3 said CNA #2 and Resident #7 were arguing and s/he intervened and sent the CNA out. The administrator stated they did not report the incident until the 17th when s/he talked with CNA #3 and received more information about what happened. LPN #2's facility-obtained statement indicated s/he was outside of the room passing medications. Resident #7 was shouting out why s/he hadn't been changed. Then LPN #2 went into the room to check it out. The CNA was present in the room. LPN #2 went to check and see if the call light was working properly. The CNA had turned the call light off when LPN #2 went to see if it was working. LPN #2 went back into the room and asked the CNA not to turn the call light back off so that s/he could see if it was working correctly. S/he checked the call light and it was working properly. LPN #2 showed Resident #7 how too properly work the call light and s/he demonstrated it back. LPN #2 continued down the hall passing medications. LPN #2 heard the CNA and resident arguing, but s/he didn't exactly hear what they were arguing about. CNA #2 came out of the room very upset, so s/he changed the assignment. CNA #3's facility-obtained statement dated 8/15/18 indicated CNA #2 was complaining about one of his/her residents, Resident #7. CNA #2 kept referring to Resident #7 as a [***] . S/he said, The [***] is nasty and s/he does things on purpose because s/he doesn't like me. The [***] keeps passing gas and stool while I'm cleaning him/her up. I'm tired of that [***] . CNA #3 went to Resident #7's room with CNA #2. CNA #3 asked Resident #7 if there was something wrong. S/he said yes, then went into great detail about his/her complaints or problems with CNA #2. Resident #7 said s/he didn't want CNA #2 in his/her room anymore. S/he didn't like how CNA #2 would throw things around at him/her. S/he didn't like CNA #2's attitude towards him/her. Each time Resident #7 would explain or describe his/her experiences with CNA #2, CNA #2 kept cutting the resident off and denying everything. CNA #3 took care of Resident #7 the rest of the night and gave CNA #2 another resident to take care of. Resident #7 was in tears. CNA #3 kept apologizing for his/her bad experience. The nurse, LPN #2, was outside the room in the hall giving medicine. CNA #2 had already talked to LPN #2 about Resident #7. In a facility telephone interview with CNA #3 on 8/17/18 conducted by the facility administrator, CNA #3 stated Resident #7 started explaining to him/her how displeased s/he was with the conduct and nasty attitude. While the resident was explaining his/her concerns CNA #2 continued to interrupt and argue with the resident. Resident #7 did not want the tech to return to his/her room or provide care. CNA #3 offered to take the resident for the remainder of the shift and asked CNA #2 to leave. CNA #2 told the resident s/he could spell his/her name out for him/her if s/he wanted. After CNA #2 left s/he continued to vent and yell in the hallway related to Resident #7. LPN #2 remained in the hallway during the incident and did not intervene with the incident. Review of the Counseling/Disciplinary Notice dated 8/23/18 revealed LPN #2 was terminated. When questioned, LPN #2 stated s/he had gone in the room to check on the resident's call light. After leaving the room LPN #2 continued to hear loud voices from the CNA and resident, but did not go back in as s/he wasn't sure what was being said. Once the CNA left LPN #2 did acknowledge that s/he changed the CNA's assignment, but did not report the incident to administration. At the conclusion of the investigation the alleged abuse was substantiated. The corrective action indicated due to the serious nature of this occurrence of which LPN #2, a charge nurse with supervisory responsibilities, did not address a situation that jeopardized a resident's well-being, nor did s/he report it to administration, it is in the best interest of the facility to separate his/her employment effective immediately. Review of the facility's Abuse Prevention policy revealed it is the policy of the facility that each resident has the right to be free from abuse. All alleged violations of abuse are reported immediately to the administrator of the facility and to the officials in accordance with State law through established procedures. Prevention included that the employees of the facility will take action to protect and prevent abuse and neglect from occurring within the facility by supervision of staff to identify inappropriate behaviors (i.e., derogatory language, rough handling, ignoring residents while giving care, etc.). Protection includes if a resident incident is reported, discovered or suspected, where the health, welfare or safety of the residents is involved, the facility will take the following steps to prevent further potential abuse while the investigation is in progress: if suspected perpetrator is another resident: separate the residents so they do not interact with each other until circumstances of the reported incident can be determined. Verbal abuse is defined as any use of oral, written, gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend or disability. Review of the facility's Abuse Reporting policy revealed any person witnessing or having knowledge of potential or actual abuse must report the incident to the administrator immediately. The person reporting the potential or actual abuse must complete a report or provide information. The report is to be submitted to the administrator within 2 hours for further investigation.

Based on review of facility files and interview, the facility failed to ensure each resident remained free from abuse. Resident #5 was observed by CNA (Certified Nurse Aide) inappropriately touching Resident #6. Resident #7 was noted to have a substantiated allegation of verbal abuse by CNA #2. Two of two residents reviewed for allegations of abuse. The findings included: The facility reported an allegation of abuse to the State Agency on 8/1/18 related to Resident #5 and Resident #6. Review of the summary included with the Five-Day Follow-Up Report date 8/6/18 revealed based on resident and staff interviews the allegation is substantiated that Resident #5 went into the room attempting to touch Resident #6 inappropriately before CNA intervened. While going to check on the resident the CNA did observe Resident #5's hand under Resident #6's blanket with the left side of his/her brief unfastened. The residents were both interviewed that night and the following day and are inconsistent. The CNA made rounds between 9:30 PM and 10:00 PM when s/he found Resident #5 in the room at Resident #6's bedside in his/her wheelchair on the left side of Resident #6's bed. The CNA immediately pulled the covers and identified Resident #5's hand was under the covers but not in the brief. The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review of the 7/12/18 Quarterly Minimum Date Set (MDS) assessment revealed that the resident had a Brief Interview for Mental Status (BI[CONDITION]) score of 15, no behaviors. The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Review of the 5/25/18 Significant change Minimum Date Set (MDS) assessment revealed that the resident had a Brief Interview for Mental Status (BI[CONDITION]) score of 13, no behaviors. CNA #1's facility-obtained statement dated 8/1/18 indicated upon entering Resident #6's room Resident #5 was at the resident's bedside on the left side in his/her wheelchair. CNA #1 immediately told Resident #5 to get out and never come back in the room again. CNA #1 pulled the covers back and noticed the left side of Resident #6's brief was unfastened and the resident was holding on to his/her brief. CNA #1 waited until Resident #5 was completely out of the room before getting the nurse. LPN #1's facility-obtained statement dated 8/1/18 indicated the CNA came into the hallway and asked him/her to come inside the room. LPN #1 observed Resident #5 sitting on the left side of Resident #6's bed in his/her wheelchair. The cover was pulled back and the right side of Resident #6's brief was undone. CNA informed me when s/he entered room Resident #5 had his/her hand inside Resident #6's brief in his/her peri area. Resident #5's facility-obtained statement dated 8/2/18 indicated s/he heard Resident #6 crying. Resident went to Resident #6's room, rolled up to the bed and began talking to Resident #6. Resident #5 stated they talked and Resident #6 finally stopped crying. Resident #5 stated before leaving s/he kissed Resident #6 on the forehead and s/he kissed him/her on the cheek. Resident #5 stated CNA came in the room , pulled Resident #6's blanket back and left running out the room. Resident stated the CNA said nothing to him/her or Resident #6. Resident #5 stated s/he rolled him/herself back to room and watched television. In an interview with the surveyor on 8/28/18 at approximately 3:20 PM, the Social Services Director stated s/he talked with Resident #6 on 8/3/18 and asked the resident if anyone had abused him/her. Resident #6 denied anything happened. The Social Services Director also talked with Resident #5 and s/he denied any incident. Resident #6 stated s/he was in the resident's room consoling him/her, s/he had his/her hand on top of the covers and was talking with the resident. The Social Services Director stated s/he was not aware of the information related to Resident #6's brief being unfastened and the Resident #5's hand being under the covers that was in the facility's summary statement on the incident included in the investigation. The Social Services Director stated s/he did not document in Resident #5's medical record related to the incident. In an interview with the surveyor on 8/29/18 at approximately 12:05 PM, the administrator stated s/he was told Resident #5 was found in the room with his/her hand under Resident #6's covers. The administrator stated s/he interviewed CNA #1 about what happened, who stated s/he told Resident #5 to go back to his/her room. The administrator stated s/he did not talk with the LPN #1 to verify his/her statement. The facility reported an allegation of abuse to the State Agency for Resident #7 and CNA #2. Review of the facility's Five-Day Follow-Up Report dated 8/21/18 indicated following resident and staff interviews the allegation of verbal abuse was substantiated for Resident #7 and CNA #2 In an interview with the surveyor on 8/29/18 at approximately 11:05 AM, the Social Services Director stated Resident #7 reported the incident to LPN #2 when it happened. The incident happened on night shift of 8/16/18, but was in the morning of 8/17/18. LPN #2 told the Social Services Director and admission nurse that s/he had some customer service issues on the morning of 8/17/18. LPN #2 said CNA #2 was very abrupt and was being rude to Resident #7. The Social Services Director went in to talk with Resident #7 who stated the CNA was very short with him/her, rude and argumentative. In an interview with the surveyor on 8/29/18 at approximately 12:05 PM, the administrator stated the incident started as a grievance. Resident #7 said CNA #2 was rude and s/he didn't want the CNA working with him/her. The grievance was made on the morning of 8/16/18. They suspended CNA #2 based on customer service on 8/16/18. They interviewed LPN #2 and s/he heard CNA #2 and the resident arguing, but did not know what they were arguing about. The administrator interviewed CNA #3 on 8/17/18 at approximately 8:00 AM. CNA #3 said CNA #2 and Resident #7 were arguing and s/he intervened and sent the CNA out. The administrator stated they did not report the incident until the 17th when s/he talked with CNA #3 and received more information about what happened. LPN #2's facility-obtained statement indicated s/he was outside of the room passing medications. Resident #7 was shouting out why s/he hadn't been changed. Then LPN #2 went into the room to check it out. The CNA was present in the room. LPN #2 went to check and see if the call light was working properly. The CNA had turned the call light off when LPN #2 went to see if it was working. LPN #2 went back into the room and asked the CNA not to turn the call light back off so that s/he could see if it was working correctly. S/he checked the call light and it was working properly. LPN #2 showed Resident #7 how too properly work the call light and s/he demonstrated it back. LPN #2 continued down the hall passing medications. LPN #2 heard the CNA and resident arguing, but s/he didn't exactly hear what they were arguing about. CNA #2 came out of the room very upset, so s/he changed the assignment. CNA #3's facility-obtained statement dated 8/15/18 indicated CNA #2 was complaining about one of his/her residents, Resident #7. CNA #2 kept referring to Resident #7 as a [***] . S/he said, The [***] is nasty and s/he does things on purpose because s/he doesn't like me. The [***] keeps passing gas and stool while I'm cleaning him/her up. I'm tired of that [***] . CNA #3 went to Resident #7's room with CNA #2. CNA #3 asked Resident #7 if there was something wrong. S/he said yes, then went into great detail about his/her complaints or problems with CNA #2. Resident #7 said s/he didn't want CNA #2 in his/her room anymore. S/he didn't like how CNA #2 would throw things around at him/her. S/he didn't like CNA #2's attitude towards him/her. Each time Resident #7 would explain or describe his/her experiences with CNA #2, CNA #2 kept cutting the resident off and denying everything. CNA #3 took care of Resident #7 the rest of the night and gave CNA #2 another resident to take care of. Resident #7 was in tears. CNA #3 kept apologizing for his/her bad experience. The nurse, LPN #2, was outside the room in the hall giving medicine. CNA #2 had already talked to LPN #2 about Resident #7. In a facility telephone interview with CNA #3 on 8/17/18 conducted by the facility administrator, CNA #3 stated Resident #7 started explaining to him/her how displeased s/he was with the conduct and nasty attitude. While the resident was explaining his/her concerns CNA #2 continued to interrupt and argue with the resident. Resident #7 did not want the tech to return to his/her room or provide care. CNA #3 offered to take the resident for the remainder of the shift and asked CNA #2 to leave. CNA #2 told the resident s/he could spell his/her name out for him/her if s/he wanted. After CNA #2 left s/he continued to vent and yell in the hallway related to Resident #7. LPN #2 remained in the hallway during the incident and did not intervene with the incident. Review of the Counseling/Disciplinary Notice dated 8/23/18 revealed LPN #2 was terminated. When questioned, LPN #2 stated s/he had gone in the room to check on the resident's call light. After leaving the room LPN #2 continued to hear loud voices from the CNA and resident, but did not go back in as s/he wasn't sure what was being said. Once the CNA left LPN #2 did acknowledge that s/he changed the CNA's assignment, but did not report the incident to administration. At the conclusion of the investigation the alleged abuse was substantiated. The corrective action indicated due to the serious nature of this occurrence of which LPN #2, a charge nurse with supervisory responsibilities, did not address a situation that jeopardized a resident's well-being, nor did s/he report it to administration, it is in the best interest of the facility to separate his/her employment effective immediately.

Based on review of facility files and interview, the facility failed to ensure each resident remained free from misappropriation of resident property. The facility receptionist confessed to using Resident #2's debit card to steal more than $30,000 from her/his checking account . One of three resident's reviewed for funds. The findings included: The facility reported an allegation of misappropriation of property to the State Agency regarding Resident #2. Review of the facility's Five-Day Follow-Up Report dated 1/6/17 indicated the receptionist confessed to the theft of the debit card and having made the fraudulent transactions. Law enforcement was involved and the facility terminated the employee. The resident's responsible party was also notified. Review of the medical record revealed Resident #2's [DIAGNOSES REDACTED].#2 as having a BI[CONDITION] (Brief Interview for Mental Status) score of 5. The Quarterly MDS dated [DATE] coded Resident #2 as short-term and long-term memory ok with modified independence for cognitive skills for daily-decision making. The Quarterly MDS dated [DATE] coded Resident #2 as having a BI[CONDITION] score of 3. Review of the care plan revealed cognitive loss as evidenced by confusion related to [MEDICAL CONDITION]/dementia was identified as a problem area on 2/12/15. Interventions and approaches to this problem area were documented on the care plan and included to approach/speak in a calm, positive manner. Review of Resident #2's physician progress notes [REDACTED]. Review of the physician progress notes [REDACTED]. Review of the physician progress notes [REDACTED]. The plan was to start [MEDICATION NAME] 50 mg daily. Review of the Physician Telephone Orders dated 1/24/17 revealed [MEDICATION NAME] 50 milligrams daily was ordered for Resident #2 related to depression. Review of the Social Services note dated 1/25/17 revealed the social worker was advised of the new order for [MEDICATION NAME] daily to assist resident in coping with recent stressful life events previously documented. The social worker spoke with the resident who acknowledged that it had been difficult at times to adjust and stay positive in coping with certain matters and states that s/he is okay with trying the medication if staff thinks it will help. Review of Resident #2's bank statements revealed the following: September 10- October 09, 2016 revealed the resident had a closing balance of $28,762.95; October 10 - November 09, 2016 a closing balance of $24,1[AGE].00; November 10 - December 09, 2016 a closing balance of $12,[AGE]4.25. In a facility obtained statement dated 1/3/17 the social worker stated that s/he accompanied Resident #2 to the bank on 1/3/17 to file a formal dispute against the charges identified on his/her bank statement as fraudulent. On 1/3/17 the resident had a negative balance and moneys from his/her overdraft were being used. Per the social work statement the Staff at the bank advised the resident that s/he could utilize his/her overdraft protection on the account to withdraw the remaining $351.00 balance of the $500.00 overdraft limit so the s/he would have some funds should there be any needs. Review of Resident #2's facility-obtained statement dated 1/1/17 indicated s/he and the facility receptionist went to the bank and that is when the receptionist found out there was around $30,000 in the resident's bank account. Resident #2 got money for clothes and s/he gave the receptionist money for clothes. Resident #2 ordered 2 debit cards that day. Resident #2 never received the cards and s/he put the facility address as the address to mail the cards. Resident #2 set the PIN number standing at the counter together with the receptionist. Review of an email sent to the Administrator in Training from the receptionist revealed s/he stated s/he was extremely sorry for stealing money from the resident. The activities assistant's facility-obtained statement dated 1/2/17 indicated s/he was assisting Resident #2 with his/her mail. The activities assistant opened and held the mail so that the resident could review. Resident #2 stated that his/her bank statement was not correct. Resident #2 requested assistance calling the bank to cancel his/her debit card that s/he never received. The bank associate informed the resident that the debit card was activated 10/25/16. The business office manager's facility-obtained statement dated 1/3/17 indicated over a month ago s/he accidentally opened Resident #2's bank statement from his/her bank account. S/he saw that the resident had over $28,000 in the account at that time. The business office manager took the bank statement to the administrator and the president of the east coast subsidiary of the corporation and told them of his/her concerns. At that time, the business office manager noticed that there were charges on the statement from places such as Victoria's Secret. The business office manager expressed his/her concerns to both the administrator and the president from the corporation about the account. At that time, the business office manager was told to do nothing because s/he had opened Resident #2's mail without his/her permission and that they may have a Resident's Rights violation because s/he had opened the resident's mail. The administrator in training's facility-obtained statement dated 1/4/17 indicated s/he talked with the receptionist on 1/3/17. The receptionist told him/her s/he stole about $20,000 from Resident #2. In an interview with the surveyor on 4/12/17 at approximately 11:30 AM, the DON (Director of Nursing) stated they put Resident #2 on psychosocial documentation after the incident. Resident #2 was started on an antidepressant. The resident was concerned that someone would take his/her money. Resident #2 said the receptionist helped him/her the most at the bank. According to the receptionist, Resident #2 asked him/her to set up transportation and s/he assisted the resident to the bank. Resident #2 said the receptionist assisted him/her to the bank and s/he requested a new debit card. The DON stated the receptionist should not have accompanied the resident to the bank. In an interview with the surveyor on 4/12/17 at approximately 12:15 PM, the administrator in training stated the receptionist sent him/her a text. The receptionist texted s/he needed to talk to the administrator in training as soon as possible. The administrator in training called him/her and the receptionist confessed. The receptionist said s/he stole money, the administrator in training asked from where. The receptionist said from a patient, the administrator in training asked who and the receptionist said Resident #2. The receptionist said s/he took the resident to the bank to get another card. The receptionist did not give the card to the resident when it arrived at the facility, s/he kept the card. In an interview with the surveyor on 4/13/17 at approximately 11:45 AM, the administrator stated social services would normally take a resident to the bank. The administrator stated staff would normally sign the resident out and document where they went. The DON stated Resident #2 said s/he didn't make the charges, the resident said s/he thought the receptionist had made the charges. Resident #2 stated s/he was with him/her at the bank when s/he requested the bank card and set the PIN. The corporate president of east coast subsidiary stated s/he was in the building when the business office manager brought the statement to their attention. There was a concern about opening the resident's mail. The corporate president asked if the resident was alert and oriented and the business office manager said yes. The corporate president said to make sure the resident saw his/her bank statement and if everything was in order, then there should not be a problem. The corporate president is not sure if the business office manager showed the resident the statement and everything was okay. The corporate president noted a resident with a bank account with $28,000 and a Brief Interview for Mental Status score of 3 should have been followed up on. The corporate president stated if s/he knew the resident had a BI[CONDITION] of 3, they would have pushed harder about the strange transactions. Review of the facility's Abuse Prevention Policy revealed it is the policy of the facility that each resident has the right to be free from abuse. Review of the definitions of abuse revealed misappropriation of resident property is defined as, the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent.

Based on record review and interview, the facility failed to provide the necessary care and services for each resident to maintain the highest practicable physical well-being in accordance with the comprehensive assessment and plan of care. Resident #2 [MEDICAL CONDITION] his/her skin from hot coffee while at the facility. The facility failed to properly assess and treat the resident's burns. One of one resident reviewed for burns. The findings included: Review of Resident #2's Nurse's Progress Notes dated 6/13/14 as a late entry for 6/12/14 indicated the resident stated s/he reached over to get something and knocked coffee in his/her lap. The nurse noted redness and blisters in various sizes to the inner thighs bilaterally with one large open blister noted to the right inner thigh. The Nurse's Progress Note indicated the resident's physician was notified and s/he ordered [MEDICATION NAME] cream to be applied twice a day. Review of Resident #2's medical record revealed an order dated 6/12/14 for [MEDICATION NAME] Cream twice a day for 5 days. Review of the Incident Report dated 6/12/14 at 9:00 AM revealed Resident #2 knocked a cup of hot coffee off his/her bedside table into his/her lap. Review of the resident's June TAR (treatment record) revealed the resident received [MEDICATION NAME] cream to his/her inner thighs and legs from 6/12/14 through 6/18/14. There was no treatment documented as administered from 6/19/14 until 6/23/14. Review of the June 2014 TAR revealed [MEDICATION NAME] cream with foam dressing to inner thighs and legs every day for [MEDICAL CONDITION] started on 6/23/14. Review of the physician's orders [REDACTED]. Review of Resident #2's medical record revealed an order dated 6/30/14 for [MEDICATION NAME] cream with foam dressing every day to inner thighs and legs for coffee burns. Review of the Nurses' Progress Notes dated 6/18/14-6/30/14 revealed no documentation related to why the [MEDICATION NAME] cream was stopped and restarted. On 6/20/14 the Nurses' Progress Note indicated Resident #2 had blood tinged mostly clear drainage to the right inner thigh and no drainage noted to the left inner thigh burn. The resident's inner thighs were wrapped with a pillowcase to prevent skin tearing during transfer at burn sites. On 6/24/14 the Nurses' Progress Note indicated Resident #2 stated that his/her pain score on a 0 to 10 scale was a 10. Resident #2 stated that the burned areas on his/her inner thighs were the source of his/her primary pain. Review of Resident #2's Nurses' Progress Notes dated 6/22/14 indicated the resident and family expressed concern over his/her coffee burn. They requested an appointment be scheduled to see a specialist. There was no documentation the doctor was notified of the request for a consult. Review of Resident #2's medical record revealed an order dated 6/26/14 for a consult with the wound center [MEDICAL CONDITION] his/her bilateral thighs. Review of the facility Consult Form dated 7/1/14 revealed recommendations from the wound center for Resident #2. The wound center recommended to paint the abdominal wound with [MEDICATION NAME] daily, cover with nonstick gauze and secure with paper tape. Cover left thigh wound with [MEDICATION NAME] border and change every 2-3 days. Apply [MEDICATION NAME] to the right thigh wound and cover with [MEDICATION NAME], change daily. Review of Resident #2's medical record revealed an order dated 7/4/14 to discharge [MEDICATION NAME] cream to inner thighs. Cleanse right inner thigh with IHC, pat dry and apply [MEDICATION NAME] with foam dressing every day for burns. Cleanse left inner thigh with IHC, pat dry and cover with foam dressing every three days for burns. There were no orders related to Resident #2'[MEDICAL CONDITION] 7/1/14 and 7/4/14. Review of Resident #2's Nurses' Progress Notes revealed no documentation related to the resident's recommendations from the wound center. There was no documentation the physician was notified of the recommendations from the wound center. Review of the resident's July 2014 TAR revealed there was no treatment documented as administered to the resident's abdominal wound from 7/1/14 through 7/10/14. Review of the resident's June 2014 TAR revealed no treatment ordered for the abdominal wound. Review of Resident #2's medical record revealed an order dated 7/9/14 to discharge left inner thigh dressing change every three days and discharge right inner thigh dressing change daily. Cleanse abdominal wound with IHC, pat dry and apply Dakins 0.125% daily with wet to dry dressing for burns. Cleanse bilateral inner thighs with IHC, pat dry and apply [MEDICATION NAME] cover with foam dressing daily. These orders were based on recommendations on Resident #2's visit to the wound center on 7/9/14. Review of the Skin Alteration Record for Resident #2 revealed an entry for a burn dated 6/12/14. The documentation indicated an area that was 3 centimeters (cm) x 4 cm on the right thigh that was pink and dark red and a 2 cm x 1 cm raised blister on the left thigh. There was no additional documentation until 6/26/14 which indicated a 3 cm x 3 cm pink area with scant serous drainage (the location of the area was not identified). The next entry was dated 7/4/14 and indicated a 3 cm x 3 cm pink area with scant serous drainage (the location of the area was not identified). There was no additional monitoring documentation available from the facility. Resident #2 continued to receive treatment to the left and right thigh and abdomen until s/he was discharged from the facility on 7/16/14. In an interview with the surveyor on 1/8/15 at approximately 2:35 PM, the facility wound care nurse stated that s/he did not assess Resident #2's burn while the resident was at the facility. The wound care nurse stated that s/he did not see the resident'[MEDICAL CONDITION] s/he completed his/her assessments of the resident's pressure ulcer. The wound care nurse stated that s/he does not remember Physician Assistant #1 talking with him/her about a dressing change or a wound clinic consult for Resident #2. Review of Resident #2's medical record revealed there was no documentation related to the resident's burn from either the physician or the physician's assistant. In a telephone interview with the surveyor on 1/8/15 at approximately 2:25 PM, Physician Assistant #1 stated Resident #2 had [MEDICAL CONDITION] his/her thighs. Physician Assistant #1 saw the resident the day of the incident and ordered [MEDICATION NAME] cream. Physician Assistant #1 stated s/he talked with the wound care nurse about dressing changes and a consult for the wound clinic on the day of the incident. The Physician Assistant stated s/he was not sure if the Physician saw Resident #2's burns. In an interview with the surveyor on 1/8/15 at approximately 11:25 AM, the Director of Nursing (DON) stated that Skin Alteration forms should be updated at least weekly and also as needed. The DON stated that floor nurses are responsible for completing Skin Alteration forms. The facility's Wound Nurse would look at a burn if asked but usually only monitors residents with pressure ulcers and difficult wounds that require [DEVICE]. The DON stated a wound center consult would not necessarily mean the wound nurse would be notified. The DON reviewed the Nurse's Progress Notes and physician's orders [REDACTED]. When asked about the lapse in treatment the DON stated s/he would expect the nurse to document why a treatment was restarted after being stopped. The DON stated that the physician should be notified of a resident or family's request to see a specialist when the request is made. The order should then be written for a consult on that date. On 1/8/15 at approximately 12:08 PM, the DON stated s/he did not see a note from the physician or physician's assistant related to Resident #2's burns. In an interview with the surveyor on 1/8/15 at approximately 2:30 PM, the DON (Director of Nursing) stated that consult forms come back to the facility with the resident. The DON confirmed the recommendation for the abdominal treatment on 7/1/14 was not started. The DON reviewed Resident #2's Progress Notes and confirmed there was no documentation related to the order for the abdominal treatment. The DON stated that when recommendations come from the wound center the nurse calls the physician. If the physician agrees with the recommendations then the order is written, if not the nurse should document in the Nurses' Progress Notes, that the physician does not agree with the recommendation. In a telephone interview with the surveyor on 1/8/15 at approximately 1:35 PM, Resident #2 stated s/he was brought a cup of coffee that was very hot. When s/he tried to pick the cup up s/he knocked it over. Resident #2 stated the coffee burned both his/her legs and stomach. Resident #2 stated the wound to his/her stomach just healed on 12/31/14. The CNA told him/her the coffee came out of the coffee dispenser. Resident #2 stated they called the physician and received an order to put [MEDICATION NAME] cream on the burns. The physician never came and looked at the burns.

On the days of the survey, based on record review and interview the facility failed to provide adequate monitoring of prescribed medication for a newly admitted resident. Resident #22 was admitted to the facility with a [DIAGNOSES REDACTED]. On 10/23/2010, at 2 AM, when noted with a change in mental status and a blood sugar of 82, Resident # 22 was sent to the emergency room . The findings included: The facility admitted Resident #22 on 10/22/2010, with [DIAGNOSES REDACTED]. Review of the closed medical record revealed the Resident was admitted to the facility on [DATE] at 4:30 PM. Review of the Nurse's Notes dated 10/22/2010 at 6:00 PM indicated the resident fed himself supper and a poor appetite was documented. The family was observed at the bedside. Nursing documentation on 10/23/2010 at 0200 AM stated, "Resident only responsive to painful stimulation. Pt. (patient) sticks out tongue consistently. Eyes with a stare. Was yelling but yelling stopped. V/S (vital signs) T (temperature) 96 P (pulse) 79 R (respirations) 20 BP (blood pressure) 143/63, Sats (oxygen saturations) 96% 3 LNC (liters nasal cannula). BS (blood sugar) 82. MD (medical doctor) notified N. O. (new orders) obtained. Left message for (wife) about transfer to (hospital) for evaluation..." 10/23/2010 at 0645 AM stated, "Resident returned to facility via stretcher via ambulance. ...RN (registered nurse) at hospital states BS (blood sugar) was 34 on arrival to ER (emergency room ). MD wants BS checks before meals, and make sure resident eats..." Review of the Physician's admission orders [REDACTED]. Review of the Medication Administration indicated the 4:30 PM blood sugar and the 8:30 PM blood sugar on 10/22/10 were not obtained. There was no explanation as to why the order was not followed. In an interview with the surveyor on 03/22/2011 at approximately 2:30 PM the Director of Nursing confirmed there was no documentation that the blood sugars were obtained on 10/22/2010. Cross Refer to F281 as it relates to the failure of the facility staff to assess and monitor the resident's blood sugar and possible need for intervention.

On the days of the survey, based on record reviews, interviews, and review of the South Carolina Board of Nursing Advisory Option #9 the facility failed to provide care and services that met professional standards of practice for; one of one newly admitted resident reviewed, Resident #22, with a [DIAGNOSES REDACTED]. sugars. On 10/23/2010, at 2 AM, when noted with a change in mental status and a blood sugar of 82, Resident # 22 was sent to the emergency room . The resident on transfer was found to have a blood sugar of 34; one of three residents reviewed with a Peripheral Inserted Central Catheter (PICC) Line. Resident #14 was administered PICC Line flushes that were not per physician order, Licensed Practical Nurses (LPN) administered PICC Line medications with no documentation of advanced training and there were numerous occasions when a Registered Nurse (RN) was not on site when the LPN's administered the medications via the PICC Line; the facility failed to obtain a physician order before placing Resident # 21 on oxygen for one of three resident's reviewed for oxygen use. The findings included: The facility admitted Resident #22 on 10/22/2010, with [DIAGNOSES REDACTED]. Review of the closed medical record revealed the Resident was admitted to the facility on [DATE] at 4:30 PM. Review of the Nurse's Notes dated 10/22/2010 at 6:00 PM indicated the resident fed himself supper and a poor appetite was documented. The family was observed at the bedside. Nursing documentation on 10/23/2010 at 0200 AM stated, "Resident only responsive to painful stimulation. Pt. (patient) sticks out tongue consistently. Eyes with a stare. Was yelling but yelling stopped. V/S (vital signs) T (temperature) 96 P (pulse) 79 R (respirations) 20 BP (blood pressure) 143/63, Sats (oxygen saturations) 96% 3 LNC (liters nasal cannula). BS (blood sugar) 82. MD (medical doctor) notified N. O. (new orders) obtained. Left message for (wife) about transfer to (hospital) for evaluation... 0313 Regional Ambulance employees at bedside for pickup. Report given. Pt transported via stretcher..." 10/23/2010 at 0645 AM stated, "Resident returned to facility via stretcher via ambulance. ...RN (registered nurse) at hospital states BS (blood sugar) was 34 on arrival to ER (emergency room ). MD wants BS checks before meals, and make sure resident eats..." The Nurse's Notes failed to show that Resident #22's vital signs or blood sugars were monitored after the 10/23/2010 entry at 0200. Review of the hospital Transfer Summary dated 10/20/2010 included transfer diagnosis #8 as "Type 2 diabetes mellitus, insulin dependent with fluctuations..." The summary stated under the Hospital Course: ...In regards to his diabetes, he has had fluctuant levels requiring changing of his insulin regimen. He did require IV (intravenous) insulin drip while in ICU (intensive care unit)..." Review of the Physician's admission orders [REDACTED]. Review of the Physician's Admission History and Physical, assessment date 10/25/2010 stated under the heading "... Overall Medical Assessment... Is there any other worthy things about this individual, from a physician's perspective? He went to ...(hospital) ER (emergency room ) 10/23/10 due to mental status changes BS 34..." Review of the Medication Administration indicated the 4:30 PM blood sugar and the 8:30 PM blood sugar on 10/22/10 were not obtained. There was no explanation as to why the order was not followed. In an interview with the surveyor on 03/22/2011 at approximately 2:30 PM the Director of Nursing confirmed there was no documentation that the blood sugars were obtained on 10/22/2010. The facility admitted Resident #14 on 10/20/10, with a re-admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the January 2011 Medication Administration Records (MARS) showed the resident received [MEDICATION NAME] via a PICC line at 4 AM and 4 PM on 1/1/11 through 4 AM on 1/12/11. The [MEDICATION NAME] was not given at 4 PM on 1/12/11 per order, as the facility was waiting for the medication to arrive from the pharmacy. It was re-started on 1/12/11 at 4 AM and continued through the end of the month. The resident was also noted to be receiving [MEDICATION NAME] (an additional antibiotic) intravenously every day at 9 AM. Documentation related to flushing the resident's PICC with 5 cc's (cubic centimeters) of normal saline before/after the antibiotic was signed as administered at 9 AM and 9 PM from 1/1/11 through 1/5/11. It was then documented on the medication administration record that the PICC line to right upper arm was flushed with 5 cc's of NS (normal saline) before and after IV abt. (antibiotic)- followed by 5 ML (milliliters) of a [MEDICATION NAME] flush solution. This was signed as being done on the 11 PM -7 AM shift and the 7 AM - 3 PM shift from 1/7- 1/31/11. The January 2011 medication administration record also listed documentation that the PICC line was flushed with an additional 5 cc's of NS (normal saline) every shift and it was signed off as being done for the entire month. Review of the facility staffing sheets and time clock punches for the month of January 2011 showed that there were nine shifts when a Registered Nurse (RN) was not in the building as required while the medication and flushes were being done via a PICC line per documentation on the medication administration record. Further record review showed that Resident #14 received [MEDICATION NAME] via PICC line every day at 9 AM from 2/1/11 through 2/22/11 and [MEDICATION NAME] at 4 AM and 4 PM from 2/1/11 through 4 AM on 2/23/11. The medication administration record for February 2011 (2/1/11 - 2/23/11) documented- Flush PICC line to right upper arm with 5 cc of NS before and after IV antibiotic followed by 5 ml [MEDICATION NAME] flush solution and it was signed as done on the 11 PM - 7 AM shift, 3 PM - 11 PM shift and the 7 AM - 3 PM shift. Also on the MARS was a notation to 'Flush PICC line with 5 cc's of NS every shift'. This was also signed as being done on all three shifts. The physician orders for the resident's re-admission on 2/25/11 through 2/28/11 stated the resident was to receive [MEDICATION NAME] at 5 AM and 5 PM via IV. The medication was later changed to be given at 9 PM via IV. The order to flush the PICC line was not obtained until 2/26/11 and it read as follows: 1) Flush PICC line with 5 cc's of NS before and after IV abt. 2) Flush PICC line with 5 cc's of NS q shift. There were three nursing shifts for the month of February where there were no RN's in the building as required during the IV medication administration or the PICC line flushes. The March 2011 physician orders stated [MEDICATION NAME] was to be given at 9 PM via PICC line and the [MEDICATION NAME] was to be given at 5 AM and 5 PM via PICC line. The orders also contained the following directions for the flushes: 'Normal Saline flush 0.9% disp (dispense) syringe. Flush PICC line as directed.' It was documented to be done on the 7 AM - 3 PM shift, the 3 PM - 11 PM shift and the 11 PM - 7 AM shift. The March MARS showed that the [MEDICATION NAME] was given at 5 AM on 3/1 and 3/2 and at 5 PM on 3/1. The MARS later showed a time change to give the [MEDICATION NAME] at 4 AM and 4 PM and it then was signed off as being given at those times. [MEDICATION NAME] was given via the PICC line at 9 PM on 3/1, 3/2 and 3/3. The administration time for the [MEDICATION NAME] was then changed to 9 AM and was signed off as being given at that time. The March MARS also showed that the PICC line flush was signed off as being done every shift from 3/1/11 through 3/21/11 for the 7 AM - 3 PM shift. A new order obtained on 3/21/11 was written as follows: ' 1) D/C (discontinue) flush PICC line flush with 5 cc NS q shift 2) flush with 5 cc NS pre and post IV ABT (for [MEDICATION NAME] and [MEDICATION NAME] ABT IV).' This was changed on the March MARS on 3/21/11 with the flushes to be done at 4 AM, 4 PM and 9 AM. The first NS flush was at 4 PM on 3/21/11. There was one shift found to be without RN coverage during 3/1/11 - 3/21/11. Review of the March 2011 MARS revealed that the PICC line medication and the PICC line flushes were administered by six Licensed Practical Nurses (LPN) who had no proof of having been trained to work with PICC lines per state regulations as confirmed by the Director of Nurses and the Administrator on 3/23/11 at approximately 12:15 PM. Per the South Carolina Department of Labor, Licensing and Regulation, (Advisory Opinion # 9B) states: "The selected LPN shall document completion of special education and training to include: cardiopulmonary resuscitation and intravenous therapy course relative to the administration of fluids via peripheral and central cenous access devices/lines that includes didactic and supervised clinical competency training with return demonstration.... The LPN may not give medications directly into the vein (intravenous push) or insert medication via an external catheter sire (port A cath). The Agency must have specific standing orders to deal with potential complications or emergency situations and provision for supervision by the RN." Section 40-33-20 defines supervision as meaning " the process of critically observing, directing, and evaluating another's performance." The facility admitted Resident #21 on 11/15/2010, with [DIAGNOSES REDACTED]. Review of the closed medical record revealed a Physician's Progress Note dated 11/17/2010 that stated, "11/17/2010 Medicine Late entry Nurse informed me yesterday evening when in facility that pt (patient) had been on O2 it was removed not ordered. When signing rehab orders of 11/16/10 it was also noted that pt was to be cont (continued) on O2 - this was crossed out since pt was not on O2. When passing room last nt (night) - pt was not on O2. He appeared comfortable. Wife left facility shortly after that time. No expressed concerns to me." Review of the Physician Orders Occupational Therapy dated 11/16/10 showed under Precautions: " Falls, cont. O2 2 L(continue oxygen at 2 liters per minute) - cannula (not ordered)..." The order for " O2 2 L - cannula" was marked out. Review of the Physical Therapy Evaluation dated 11/16/2010 indicated under Other Related Medical, Rehab, Social Hx (history) ..."Says he wears O2 when needed and [MEDICAL CONDITION] (breathing machine) at night." ...Additional Tests: Pt (patient) on 2L O2 via NC (nasal cannula) during eval(uation)..." In an interview with the surveyor on 03/22/2011 at 11:40 AM Physical Therapist #1 stated that Resident #21 was seated in a wheelchair, at the nurse's station around 2:00 PM on 11/16/2010, wearing oxygen when she went to do his initial evaluation. She stated that she assisted the resident from the wheelchair to his bed and hooked the oxygen to the concentrator, which was already set at 2 liters for his [MEDICAL CONDITION]. Review of the November 2010 Physician's Orders indicated "O2 @ 2 LPM (liters per minute) hs (hours of sleep) with [MEDICAL CONDITION]." Review of the Nurse's Notes from 11/15/2010 through 11/17/2010 revealed no documentation related to the resident receiving oxygen on 11/16/2010. Review of the Statement of Witness (Occupational Therapist #1) dated 11/16/10 stated, "Went into patient room @ 11:00 AM and helped patient get dressed. Patient was found with O2 concentrator on and [MEDICAL CONDITION] mask next to his head... Patient said he wanted a cannula for O2. OT went to nurse and asked for cannula. The nurse asked who it was for and OT told nurse the patient name. Nurse gave him a cannula..." In an interview with the surveyor on 03/22/2011 at approximately 3:20 PM LPN #1 confirmed she gave OT #1 a cannula for a resident but she was not sure who the resident was who needed the cannula. Review of the facility policy for Oxygen Administration stated, "Purpose: To describe method for delivering oxygen in order to improve tissue oxygenation, reduce risk for [MEDICAL CONDITION], decrease work of breathing and reduce shortness of breath with activity. During a respiratory emergency it is appropriate for nursing to administer oxygen immediately and obtain physician's order after patient is stabilized or transferred... Procedure: 1. Verify Physician's order..." There was no documentation noted that Resident #21 was short of breath or had an emergency arise which necessitated the use of oxygen at 2 liters.