Every finding on record at Morrell Nursing Center

Based on review of facility policy, observation and interview, the facility failed to ensure Resident (R)66 was free from a significant medication error. Specifically, R66 was administered insulin via an insulin pen by Registered Nurse (RN)1 who failed to correctly prime the pen before administering the needed 12 units of insulin, for 1 of 1 residents observed receiving insulin during med pass. Findings include: Review of the facility policy titled Insulin Pens states as the policy, It is the policy of this facility to use insulin pens in order to improve the accuracy of insulin dosing and provide increased resident comfort. The Policy Explanation and Compliance Guidelines states under #6, Insulin pens will be primed prior to each use to avoid a collection of air in the insulin reservoir. Number 11, Prime the insulin pen: i. Dial 2 units by turning the dose selector clockwise. ii. With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears. Review of R66's Face Sheet revealed the facility admitted R66 with diagnosis including but not limited to Diabetes Mellitus Type 2. During an observation on 02/18/2026 at 9:47 AM, during med pass, revealed RN1 preparing a Novolog Insulin pen to administer 12 units of insulin to R66. RN1 wiped the hub with an alcohol prep and then placed the needle. She then removed the needle cover, dialed the 2 units in order to prime the pen, held the insulin pen downward to expel the 2 units to ensure air was removed and to ensure the correct dosage, and then dialed up the ordered dosage of 12 units. RN1 then proceeded to administer the 12 units of Novolog Insulin to R66. During an interview on 02/18/2026 at 9:50 AM, RN1 confirmed that she had primed the pen holding it downward. After administering the insulin, RN1 could not ensure that R66 had received the full 12 units due to the incorrect priming.

Based on review of facility policy, observation and interviews, the facility failed to ensure expired medications were removed, and not stored with medications in date and in use for residents, from Medication Cart #1 on Rehab Hall 400, for 1 of 4 medication carts reviewed.Findings include: Review of the facility policy titled Storage Of Drugs states as the policy, All drugs shall be stored appropriately . Under Procedure, . 4. Drugs shall not be kept on hand after the expiration date on the label. 5. Discontinued drugs shall be returned to the provider pharmacy for destruction. During an observation on 02/18/2026 at 8:35 AM, of the Medication Cart #1 located on Rehab Hall 400, with Licensed Practical Nurse (LPN)1 revealed, 3 boxes of Systane Lubricant Eye Drops with Lot #23463A, 30 vials with each vial containing 0.7 milliliters, was expired on 10/2025 and were stored in the medication cart with meds in use for residents. Further observation of Medication Cart #1 revealed, Refresh Classic Eye Drops, 7 vials with Lot #483633 were expired in 10/2025. During an interview on 02/18/2026 at 8:35 AM LPN1 confirmed the expired medications and removed them from the medication cart.

Based on observations, record reviews, and interviews the facility failed to ensure that Resident (R)66 was appropriately assessed and dosed for 1 of 5 residents reviewed for unnecessary medications. Findings included: The facility policy titled, Psychotropic Medication dated 1/18 stated: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Review of the electronic medical record (EMR) revealed R66 was admitted to the facility on [DATE] with diagnoses including but not limited to major depressive disorder, persistent mood [affective] disorder and dementia with behavioral disturbance. On 12/04/24 at approximately 11:30 AM, a review of the EMR for R66 revealed that all doses had been administered according to the following physician orders: 1. quetiapine (Seroquel) fumarate Tab (tablet) 25 mg (milligram)-Give 1 tablet orally at bedtime related to Major depressive disorder with Start Date 07/01/2024 2000 (8:00 PM) and D/C (discontinued) Date 11/11/24 1232 (12:32 PM). 2. quetiapine fumarate Tab 25 mg (milligram)-Give 2 tablet by mouth at bedtime related to INSOMNIA with Start Date 11/11/2024 2000 and D/C Date 11/20/24 1025 (10:25 AM). 3. quetiapine fumarate Tab 50 mg (milligram)-Give 1 tablet by mouth at bedtime related to INSOMNIA with Start Date 11/20/2024 2000 (8:00 PM). Further review of the EMR MAR (medication administration record) revealed the following physician order: Resident receives psychotropic medication. Monitor for the following behaviors: hitting, biting, yelling, kicking, resisting care, moaning, wringing hands, pacing, etc. every shift Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and progress note findings. Active O7/1/2024 0700 (7:00 AM) . On 12/04/24 at approximately 11:42 AM, review of the EMR MAR/TARs (medication administration record/treatment administration record) revealed: -7/2024 behaviors charted Yes on 16th, 26nd, 29th day shift and 9th, 24th, 29th evening shift with no description of the behaviors -8/2024 behaviors charted Yes on 10th, 12th day shift with no description of the behavior -9/2024 behaviors charted Yes on 10th day shift and 12th evening shift with no description of the behaviors -10/2024 behaviors charted Yes on 5th, 8th and and 2nd evening shift with no description of the behaviors -11/2024 no behaviors charted -12/2024 through 12/4/2024 no behaviors charted On 12/04/24 at approximately 11:55 AM, review of the EMR revealed AIMS (Abnormal Voluntary Movement) scores on 11/11/2024 and 9/3/2024 = 0.0 (0-29), which indicate no behaviors. On 12/04/24 at approximately 12:10 PM, review of R66's hard paper chart located at the nursing station revealed the following notes by NP (Nurse Practitioner )1: -11/6/2024 CHIEF COMPLAINT: Requested to review his medications per his daughter who is on HIPPA list to evaluate for what she thinks are some symptoms that are worsening with paranoia. HISTORY OF PRESENT ILLNESS: The patient does have dementia and does not have any significant behavioral disturbances here. He had obstructive sleep apnea and BIPAP has been added at bedtime within the last year. He does fairly well with that bust does not wear it the entire night. He also denies any significant issues. Appetite is good. He reports his breathing has been fine. He denies any shortness of breath. No significant activities are reported per nursing staff. MEDICATIONS: Reviewed on MAR. For depression and rest he is on Seroquel 25 mg at bedtime and also as an adjunct for pain he is on duloxetine 20 mg daily. He has Gabapentin t.i.d. (three times daily) for chronic pain and uses some hydrocodone. We have not seen any oversedation. No significant falls have been reported. ASSESSMENT/PLAN: 1. Dementia with some concerns for paranoia. 2. Hypothyroidism. 3. Chronic obstructive pulmonary disease with obstructive sleep apnea. 4. Gastroesophageal reflux disease. 5. Depression. 6. Dementia. PLAN FOR THERAPY: We will request his recent labs to be reviewed. We will also try to discuss the concerns with his family members as well. Hate to adjust medications that would inhibit him more at night wearing his CPAP (continuous positive airway pressure). We will continue for chronic obstruction disease, his DuoNebs and budesonide b.i.d. (two times daily) Continue chronic pain medication. Certainly consider adjusting if paranoia is truly observed. We will also evaluate TSH (thyroid stimulating hormone). -11/11/2024 CHIEF COMPLAINT: Follow-up from last week's visit when I was requested to look at the medication list from the family. HISTORY OF PRESENT ILLNESS: The family called me back after a left a message on the 6th. They called me back today on the 11th to give me more clarity as to their concerns. The daughter reports that R66 heard his roommate talking loudly on the telephone to someone and it frightened him and made him feel that he was going hurt someone or hurt other ladies here although this is certainly what R66 is understanding. He does have difficulty hearing and is in room with a roommate and unsure if this certainly happened or not. The daughter is requesting that his medications be adjusted to see if he would be less worried and concerned about this. ASSESSMENT/PLAN: Dementia with some concerns for agitation. PLAN FOR THERAPY: We will increase his Seroquel to 50 mg at bedtime to try to improve the worries over the feeling that someone is going to hurt someone. We will follow up with this and continue to monitor very closely. Further review of the paper medical record revealed the following statement: 11/11/24; increase Serouquelto 50mgs po by (mouth) daily and HS (bedtime) signed by NP1. During an interview on 12/04/24 at 01:43 PM, NP1 stated that she had been working at this facility since 2023. When asked, she stated that she was unaware of the FDA Food and Drug Administration) and CMS (Centers for Medicare and Medicare Services) guidelines for prescribing Seroquel (quetiapine), but was aware of the black box warning. She stated that the daughter of R66 had expressed concern about R66 having been frightened by his roommate and had requested an increase in his Seroquel dose. NP1 stated that with some reluctance due to a recent room change and different roommate who talks loud, she had increased the dose from 25 mg to 50 mg. NP1 acknowledged that there had been no behaviors reported by staff or indication of behaviors on his AIMS assessments and proceeded to write an order decreasing the quetiapine dose for R66 back to 25 mg. During an interview on 12/04/24 at approximately 2:17 PM, Medical Director (MD)1 stated that he had been coming to this facility for quite a few years and also saw residents at another facility. When asked, he stated that in the case of R66 you have to look at his medical history and there may have been reason to increase the Seroquel dose, but he was unable to describe any specific behaviors beyond the one incident reported to the NP by the daughter, that could have warranted the Seroquel increase from 25 mg to 50 mg on 11/11/24. During an interview on 12/04/24 at approximately 3:42 PM, the Administrator and DON (Director of Nursing) stated that NP1 is employed by MD1, not the [NAME] Group, that issues related to psychotherapeutic medication are brought to QAPI (Quality Assurance and Performance Improvement) and when informed that no details related to the type of behavior could be found, stated that the American Health Tech (AHT, their previous EMR system) included those details. They were unsure if specifics related to observed behaviors was charted in Point Click Care which was implemented at the facility on 7/1/2024 and that they would further investigate and advise. During an interview on 12/05/24 at approximately 8:31 AM, the DON stated that behavior specifics were not presently included in PCC (Point Click Care) and that this issue was being worked on. The DON provided an attending MD note regarding R66 dated 11/15/24, stating it had been provided to her on the previous evening (12/4/24). The note stated: CHIEF COMPLAINT: Follow-up on chronic obstructive pulmonary disease and chronic pain. HISTORY OF PRESENT ILLNESS: Patient has had some worsening behavioral issues with worsening paranoia. Seroquel was increased. This seems to have improved. He is tolerating this without any other problems. Breathing seems to be stable. He starts with a CPAP at night but usually takes it off at some point. Chronic pain seems to be at baseline with what limited history we can get from him. ASSESSMENT/PLAN: 1. Severe obstructive sleep apnea. Continue BIPAP (bilevel positive airway pressure). 2. Chronic obstructive disease. Continue DuoNebs. 3. Chronic pain: Continue Lorcet 5/325 every 4 hours p.r.n. (as needed) as well as Gabapentin and duloxtine, 4. Dementia. Continue Aricept 10 mg daily. He does have some paranoia and psychosis involved. Increase Seroquel to 50 mg. 5. Depression. Again, continue Seroquel. On 12/05/24 at approximately 8:43 AM, review of November 2024 MAR paper copies provided by the DON revealed that Quetiapine 25 mg had been administered at bedtime from 7/1/24 through 11/10/14, was changed to 25 mg x 2 tablets (50 mg) at bedtime on 11/11/24, then changed to 50 mg (1 tablet) at bedtime on 11/20/24. On 12/05/24 09:04 AM during an interview, the Administrator and DON confirmed that the first Seroquel 50 mg bedtime dose was administered pursuant to physician orders on 11/11/24 and that the note from MD1 which had been received the previous evening (12/4/24) was dated 11/15/24.

Based on record reviews, interviews and review of the facility policy titled, Abuse, Neglect and Exploitation, the facility failed to ensure Resident (R)71 and R11 were free from abuse, specifically sexual abuse, by Certified Nursing Assistant (CNA)1, for 2 of 4 residents reviewed for abuse. On 11/29/22 at 6:00 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 11/29/22 at 6:00 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 11/15/22. The IJ was related to 42 CFR 483.12 - Freedom from Abuse, Neglect, and Exploitation. On 11/29/22 at 6:00 PM, the Administrator and the Director of Nursing (DON) were notified the failure to protect R71 and R11 form sexual abuse by Certified Nursing Aide (CNA)1 constituted IJ at F600. The facility presented an acceptable plan of removal of the IJ on 11/30/22 at 1:07 PM. The survey team validated that the IJ was removed on 11/30/22 at 1:07 PM following the facility's implementation of the plan of removal of the IJ. The facility remained out of compliance at F600 at a lower scope and severity of D (pattern with potential for minimal harm) following removal of the IJ. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F600, constituting substandard quality of care. Findings include: Review on 11/30/22 at 5:30 PM of the facility policy titled, Abuse, Neglect and Exploitation, states, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Under definitions, Willful: The individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Sexual Abuse, non-consensual sexual contact of any type with a resident. The facility admitted R71 with diagnoses including, but not limited to, anxiety disorder, depressive episodes, Cerebrovascular Accident, Hemiplegia and Seizures. Review of R71's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/03/22 revealed a Brief Interview of Mental Status (BIMS) score of 13 out of 15, indicating R71 was cognitively intact. The facility admitted R11 with diagnoses including, but not limited to, dysphagia, cerebral ischemia, anxiety disorder, Parkinson's disease, and cognitive communication deficit. Review of R11's Annual MDS with an ARD of 11/04/22 revealed a BIMS score of 15 out of 15, indicating R11 was cognitively intact. Review on 11/29/22 at 12:45 PM of the reportable submitted by the facility revealed CNA1 had sexually abused R71 and R11 and outside counseling services had been offered and declined by R71 and R11. During an interview with R71 on 11/29/22 at 3:20 PM, he stated, CNA1 came into his room and told him he was there to change his brief. He unfastened the brief and took my penis in hand and closed his hand around the shaft and started moving his hand up and down in an attempt to make me ejaculate. I said, Hey man what are you doing? Then he asked me, Does it feel good? I asked him to stop, and he did. During an interview with R11 on 11/29/22 at 3:30 PM, he stated, CNA1 came into his room and told him he was there to change him. I told him I did not need changing and he stated he had to check me. CNA1 unfastened his brief and wrapped his hand around his penis and started moving it up and down in an effort to make me ejaculate. I told him he was wasting his time; my penis has not worked like that for [AGE] years. Review of R71's and R11's Comprehensive Plan of Care on 11/29/22 at 1:00 PM revealed R71 and R11 are at risk for emotional/mood disturbance. They both had the potential for behavior/mood symptoms related to history of trauma related event. The goal indicated, resident will remain free of signs and symptoms of distress through next review to decrease potential for any behavioral /mood related events related to past trauma. The interventions included, actively listen to resident, allow resident to express fears, goals and frustrations. Attempt to redirect behavior to something positive when resident is feeling down or depressed. Monitor behaviors and notify physician as needed. Review of R71's and R11's progress notes on 11/29/22 at 1:30 PM revealed social visits weekly from the social worker to monitor R71 and R11 for behaviors, change in mood, depression and to just ensure if they wanted to talk about the abuse then they could, and to offer any support that they may need. Daily monitoring and visits were also provided by staff each shift. During an interview on 11/29/22 at 3:30 PM, R71 was pleasant but he would not look at this surveyor when we talked. R71 would focus his eyes on something in his room and change his focus to different things as we talked about the abuse incident. It was documented in the reportable that he was embarrassed about the abuse by CNA1. R71 does recount the sexual assault with detail. He went on to state CNA1 was a likable person and he never wanted to get anyone in trouble. During an interview on 11/29/22 at 3:40 PM, R11 was pleasant and spoke of the sexual abuse encounter freely. R11 stated, CNA1 was a likable person. R11 also spoke of the incident being embarrassing. During an interview on 11/29/22 at 4:00 PM with R71's and R11's attending physician revealed, R71 is usually quiet, but up front and blunt. He did comment on how R71 will look away and he used to make eye contact when conversing with him. The attending physician described R71's behavior as more reserved than usual. The attending physician further stated he told R71 that he could talk to him anytime about anything and R71 stated to the physician he knew that, and he would if he needed to. R71had no signs of distress, but he did say that R71's appetite had been a little off. The attending physician also mentioned that R11's appetite was affected by the incident. The physician concluded that counseling had been offered to both residents. CNA1 was unavailable for interview via telephone. During an interview on 11/29/22 at 5:00 PM, CNA2 confirmed during her shift on 11/15/22, R71 reported the incident to her in explicit detail and CNA2 reported the incident to the Administrator. During an interview on 11/30/22 at 3:50 PM the Social Worker (SW) confirmed that she continues to support R71 and R11. The SW periodically visits R71 and R11 to follow up on how they are feeling. The SW stated R71 does provide eye contact when talking to her. She also has a good rapport with R11 and he will talk with her freely about the incident. The SW further stated she interviewed all the male residents no matter the BIMS score in order to find out if any other male residents had been sexually abused by CNA1. The SW identified R11 was also sexually abused by CNA1. A credible Allegation of Compliance was accepted on 11/30/22 at 1:07 PM and reads as follows: #1. Identified employee arrested on 11/16/22 and terminated from employment. Resident number 71 and 11 were provided with ongoing nursing and social services support. Resident number 71 and 11 were assessed by MD with no distress noted. Residents 71 and 11 were monitored daily per nursing x 1 week. Care plans were updated for resident number 71 and 11 on 11/16/22 per MDS Coordinator. On 11/16/22, SC DHEC certification, Licensure, local Ombudsman, and Law Enforcement notified per Executive Director. #2. All residents that were care for by the accused CNA had the potential to be affected. All residents that were cared for by CNA interviewed and assessed by Social Services Director on 11/16/22 with no other confirmed cases of abuse noted. Residents that had the potential to be affected by CNA will be monitored for signs and symptoms of psychosocial wellbeing/distress per nursing utilizing psychosocial nursing intervention in American Healthtech daily x 1-week, weekly x 1 month, then monthly until substantial compliance has been met. #3. Director of Nursing and Staff Development Coordinator will provide one on one education, including but not limited to abuse education, signs and symptoms of abuse, and abuse recognition and reporting, including chain of command. Education initiated on 11/16/22 and is ongoing. Staff will not be allowed to report to work until one-on-one education is provided. Education will be provided to new hire employees in orientation, annually and as needed. Residents Rights including the right to be free of abuse will be reviewed with residents in Resident Council monthly per Social Services Director and/or designee. Residents will be informed at Resident Council monthly that is they witness or are a victim of abuse to report it immediately. #4. Director of Nursing and/or Designee will monitor psychosocial intervention daily x 1-week, weekly x 1 month, then monthly until substantial compliance has been met. Findings from monitoring will be discussed by the QAPI team in the quarterly QAPI Meeting until such time consistent substantial compliance has been met.

Based on record reviews, interviews and review of the facility policy titled, Abuse, Neglect, and Exploitation, the facility failed to report alleged sexual abuse to the state agency, as required, no later than 2 hours after the allegation is made for Resident (R)71) for 1 of 4 residents reviewed for Abuse. On 11/29/22 at 6 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 11/15/22. The IJ was related to 42 CFR 483.12 - Reporting of Alleged Violations. On 11/29/2022 at 6 PM, the Administrator and the Director of Nursing were notified the failure to promptly report the sexual abuse of F71 by Certified Nursing Assistant (CNA)1 constituted immediate jeopardy at F609. The facility presented an acceptable plan of removal of the immediate jeopardy on 11/30/22 at 1:07 PM. The survey team validated that the immediate jeopardy was removed on 11/30/22 at 1:07 PM following the facility's implementation of the plan of removal of the immediate jeopardy. The facility remained out of compliance at F609 at a lower scope and severity of D (pattern with potential for minimal harm) following removal of the IJ. Findings include: Review on 11/30/22 at 5:30 PM of the facility policy titled, Abuse, Neglect, and Exploitation, states under, Procedure for Response and Reporting Allegations of Abuse/ Neglect/Exploitation: Number 2. States, The Administrator, Director of Nursing and/or designee will: a. Report alleged violations to the state agency and to all other required agencies (Ombudsman, Law Enforcement if applicable) within specified time frames: i. Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. ii. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. The facility admitted R71 with diagnoses including, but not limited to, anxiety disorder, depressive episodes, Cerebrovascular Accident, Hemiplegia and Seizures. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/03/22 revealed a Brief Interview of Mental Status (BIMS) score of 13 out of 15, indicating R71 was cognitively intact. The facility admitted R11 with diagnoses including, but not limited to, dysphagia, cerebral ischemia, anxiety disorder, parkinson's disease, and Cognitive Communication Deficit. Review of the Annual MDS with an ARD of 11/04/22 revealed a BIMS score of 15 out of 15, indicating R11 was cognitively intact. Review on 11/29/22 at 1:40 PM of the sexual abuse allegation reportable indicated that the state agency was notified on 11/16/22 at 9:22 AM. During an interview on 11/29/22 at 5:00 PM with CNA2, she stated that on 11/15/22 at around 11:30 PM, she stated she was sure it was before 12 midnight, she went into R71's room to provide incontinent care and he explained in detail the entire account of the sexual abuse by CNA1. She stated that she felt like the resident was safe so she went to the nurse on the unit and asked for a witness statement form. She stated when she asked the nurse for the form she did not tell her why she wanted it and never told the nurse what it was about and filled it out. The next morning when the Administrator came in she told her about the incident that R71 had explained to her and gave her the statement. During an interview on 11/30/22 at 9:45 AM, the Administrator verified that she had reported the alleged sexual abuse for R71 to the state agency on 11/16/22 and not within the 2 hour window as required by the state agency. A credible Allegation of Compliance was accepted on 11/30/22 at 1:07 PM and states: #1. CNA #1 suspended on 11/16/22 and terminated from the facility effective 11/17/22. CNA #2 educated on abuse education, signs symptoms of abuse, and abuse recognition and reporting not limited to reporting chain of command. On 11/16/22, SC DHEC certification, Licensure, local Ombudsman, and Law Enforcement notified per Executive Director. #2. All residents that were cared for by the accused CNA had the potential to be affected. All residents that were cared for by CNA #1 were interviewed and assessed by Social Services Director on 11/16/22 with no other confirmed cases of abuse noted. Residents that had the potential to be affected by CNA regardless of cognition, will be monitored for signs and symptoms of psychosocial well being/distress per nursing utilizing psychosocial nursing intervention in American Healthtech daily x 1 week, weekly x 1 month, then monthly until substantial compliance has been met. #3. Director of Nursing and Staff Development Coordinator will provide one on one education, including but not limited to abuse education, signs and symptoms of abuse, and abuse recognition and reporting not limited to reporting chain of command. Education initiated on 11/16/22 and is ongoing. Staff will not be allowed to report to work until one-on-one education is provided. Education will be provided to new hire employees in orientation, annually and as needed. #4. Director of Nursing and/or Designee will interview 5 employees x 4 weeks to verify understanding of current policies for reporting allegations of abuse not limited to chain of command for reporting. Re-education will be provided at that time of the interview, if needed. Findings from the interviews will be discussed by the QAPI team in the quarterly QAPI meeting until such time consistent substantial compliance has been met.

Based on observations, facility policy review, record review, and interviews, the facility failed to anchor an indwelling urinary catheter for 1 of 1 Resident (R)19 reviewed for catheters. This failure had the potential to cause harm by failing to prevent tugging/pulling, dislodging of the catheter, infection or inflammation pain, as well as severe trauma to the urethra. Findings Include: Review of the policy titled, Catheter Care (Female), dated 04/2008 revealed, the facility staff will Anchor catheter tube, hold securely and cleanse down the center of catheter tube approximately 4 inches with wipe/washcloth. Review of the medical record revealed the facility admitted R19 on 09/22/22, with diagnoses including, but not limited to, Chron's inflammatory bowel disease, urinary tract infection, anxiety disorder, bipolar disorder, muscle weakness, cognitive communication deficit, and neuromuscular dysfunction of bladder. Review of R19's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 09/29/22 revealed R19 had a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. The resident displayed no behaviors and required extensive assistance for self-performing dressing, eating, toilet use, and personal hygiene. The MDS revealed R19 was admitted with an indwelling catheter and coded as always incontinent of bladder and bowel function. Review of physician's orders dated 09/22/22 indicated, foley catheter care, once daily. Review of R19's care plan dated 10/12/22 indicates she requires extensive to total assistance with activities of daily living (ADLs) related to cognitive loss, impaired mobility, paraplegia, muscle weakness, abnormalities of gait, and need for assistance with personal care, potential for variation in level of assistance required to complete ADLs r/t [related to] above dx [diagnoses] problem statements. The approach for care suggests Check for incontinent episodes approx Q2 hrs and provide care as needed; resident has use of briefs for dignity; provide perineal care as needed; apply moisture barrier with care to promote skin integrity, wash and dry well after each incontinent episode; encourage good intake of fluids; observe for s/s of uti; obtain u/a nd c&s as ordered for s/s of uti; change foley cath 16 fr with 10ml bulb as ordered; foley cath care as ordered; change foley cath as ordered; document foley output as ordered; administer meds as ordered. Review of an interdisciplinary note dated 10/20/22 at 2:57 AM revealed, 1:45 AM res pulled out cath. Noted in bag urine reddish orange amount 450cc in bag. Attempting to replace foley, res being aggressive with staff and stating that she was going to pull out again because she didn't need it. Attempted to explain to res the reason for foley while res calling me all sorts of things. Res stated it hurts inside her. Explained to res she pulled out the foley bulb fully inflated. Replaced foley with 16fr foley with 10 cc bulb. Review of an interdisciplinary note dated 10/31/22 at 1:49 AM revealed, Res in bed with her eyes closed . Res states that foley feels uncomfortable and would like it out. Explained to res the need for the foley and the place on her butt. Res stated she understood and agreed. Incontinent of bowel and incontinent care given as needed on rounds. Observation of R19 on 12/01/22 at 9:50 AM revealed the surveyor was not able to visually verify an anchor on either of R19's legs. Observation of R19 on 12/01/22 at 10:52 AM revealed Licensed Practical Nurse (LPN)2 and Certified Nursing Assistant (CNA)4 moved R19 from her wheelchair to her bed to observe if an anchor was on her leg. R19 did not want her pants to be taken down, so LPN2 pulled her left pant leg up and was not able to feel or see an anchor for her foley catheter. During an interview on 12/01/22 at 10:30 AM, Registered Nurse (RN)2 revealed the reason R19 has a catheter was due to a sacral wound that she was admitted to the facility with. RN2 was unable to provide information related to R19 having an anchor for her catheter. When asked by the surveyor to provide an anchor that the facility would use for catheter residents, RN2 had to retrieve one from a mass supply closet, that was not on the unit. RN2 provided a cath-secure multipurpose tube holder plus. Concurrently, the Staff Development Coordinator was standing in proximity to the surveyor and RN2, as she listened to the conversation, she proceeded to offer to provide another form of catheter anchor that is available for use for residents as well. During an interview with the Director of Nursing (DON) on 12/01/22 at 11:59 AM, s/he revealed staff has been trained on catheter care and is aware of the facility's policy. The in-service provided to all staff is a hands-on return demonstration for each competency. The DON stated her expectations are for all nurses to go by the facility's policies and to establish proper care of no tears or draining and verifying nothing is coming out of the indwelling catheter and the resident is comfortable. All information for catheter care is documented in the MAR and in the nurse's notes. Additionally, the DON stated she is aware of the risks that could potentially happen if the anchor would have an adverse response due to it not being properly cleaned and anchored.

Based on review of the facility policy titled, Gastrostomy/PEG Tube Feeding, record review, observation, and interview, the facility failed to ensure Resident (R)47 received tube feeding timely as ordered by the Physician for 1 of 1 resident reviewed with tube feeding. Findings include: Review of the facility policy titled, Gastrostomy/PEG Tube Feeding, states under Policy, Feeding to be performed upon order of physician to provide hydration/tube patency. Number 12, states, Hang formula as ordered by the physician. The facility admitted R47 with diagnoses including, but not limited to, nutritional deficiency, cerebrovascular accident, aphasia, dysphasia, anemia and moderate protein calorie malnutrition. Review of the medical record for R47 revealed Physician's orders dated 11/2022. The orders revealed an order dated 11/18/22 for Jevity 1.5 to infuse at 55 milliliters per hour with a 30 milliliter flush per hour of water to infuse from 10:00 AM to 6:00 AM via a feeding pump and to take off at 6:00 AM. The Jevity 1.5 was to infuse for 20 hours. An observation on 11/30/22 at 11:52 AM revealed the tube feeding was not infusing as ordered. During an interview on 11/30/22 at 12:10 PM, Licensed Practical Nurse (LPN)1 confirmed that the tube feeding was not infusing as ordered at 10:00 AM and stated, I was making my way down the hall, and got tied up with other residents.

Based on interview, record review and review of facility policy and procedure, the facility failed to ensure that 1 of 3 closed records for hospitalization received bed hold notice upon transfer. The findings include: On [DATE] at 09:56 am record review of R #97 revealed the resident was admitted with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 09:45 am record review revealed R #97 was transferred to the hospital on [DATE]. Further review of the chart revealed no signed bed hold notice provided to the resident's representative post the resident's transfer to the hospital on [DATE]. On [DATE] at 11:23 am interview with Social Worker (SW) #1 revealed that the bed hold information and transfer form are normally sent to the hospital with the resident but the forms were not sent to the representative because the patient expired the next morning. Review of the medical record revealed documentation of the the facility contacting the hospital on [DATE] at 10:16 AM, A review for notification of insurance benefits and bed hold document revealed no documentation of the resident expiring prior to this time. Facility policy, Bed Hold Policy/Reserve Payment Policy/ Notification of Bed Hold, revealed 2. Bed-Hold Notice upon Transfer: If a resident requires transfer to an acute hospital, the facility will offer the resident the opportunity of electing to have the bed held for 10 days. Upon admission, the facility will notify the resident or the resident's representative of the bed-hold option. The resident or the resident's representative is liable to pay reasonable charges, not to exceed thee resident's daily room rate, for the bed-hold period. Insurance may not cover such costs. Medicaid provides payment for a bed-hold up to 10 days .

Based on record reviews and interviews the facility failed to ensure a Significant Change assessment was completed in a timely manner for Resident #79 for 1 of 5 residents reviewed for Nutrition. The findings included: The facility admitted R #79, on 3/16/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 5/13/2021 at approximately 9:55 AM of the medical record for Resident #79 revealed an admission weight of 223.2 pounds. Further review of the medical record for R #79 revealed a weight on 3/31/2021 of 208.2 pounds. On 4/6/2021 R #79 weighed 197.5 pounds. R #79 continued to loose weight and by 4/29/2021 his/her weight was 184.2 lbs. A weight loss since admission of 39 pounds. Further review of the Minimum Data Set (MDS) revealed that a significant change assessment had not been completed for the weight loss. Additional review of the medical record for Resident #79 revealed that the Foley catheter had been removed and the decubitus ulcers were healed and a significant change had not been completed for R #79's MDS. An interview on 5/13/2021 at approximately 10:00 AM of the Nutrition Note by the Registered Dietician dated 5/3/2021 stated, Resident had an 11.5 percent significant weight loss x 30 days. The Registered Dietician recommended, Discontinue the Prostat AWC 2 times daily because the wounds have resolved. Add No Sugar Added Medpass 2 times daily related to weight loss. The Resident will benefit from additional kcal's to prevent additional weight loss. During an interview on 5/13/2021 at approximately 10:10 AM with the MDS/Care Plan Coordinator revealed that he/she was not agreeable that a Significant Change Assessment should have been completed for R #79. During an interview on 5/13/2021 at approximately 10:30 AM with the Registered Dietician, he/she stated that he/she likes to wait 2 weeks before reassessing the resident again even though R #79 had already lost 39 pounds since admission on 3/16/2021.

Based on record reviews, interviews, and review of the Hospice Services Agreement, the facility failed to ensure coordination of care for Resident #90 related to assessments by the Registered Nurse (RN), Certification, and visits by the Social Worker (SW) and the Chaplain for 1 of 1 residents reviewed for Hospice Care and Services. The findings included: The facility admitted R #90 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Admission to Hospice Care and Services was prior to admission. Review on [DATE] at approximately 1:55 PM of the Hospice notebook for coordination of care between the Hospice entity and the Nursing Home revealed an expired Recertification dated [DATE] as end of service. The last visit from the RN, which was ordered to visit one time weekly, had a full assessment dated [DATE]. No documentation could be found in the notebook, nor the facility to ensure that the Chaplain and the SW had visited but was ordered by the physician as monthly. An interview on [DATE] at approximately 2:15 PM with the Administrator and the DON confirmed that the Recertification, the full assessments by the RN and the visits from the Chaplain and the SW were not in the facility. The Administrator went on to say that he/she had to remind the Hospice entity to complete the visits assessments and to get them to the facility in a timely manner. The Certificate for continued Hospice Care and Services was faxed to the facility, dated [DATE] through [DATE], on [DATE] at 2:25 PM. Review on [DATE] at approximately 3:00 PM of the facility, Hospice Services Agreement, under, Responsibilities & Acknowledgements of Hospice: states, c. Hospice will coordinate care with the attending physician and the Hospital Medical Director. Hospice will give in writing, to the facility signed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Hospice will supplement Facility services by providing certain routine hospice Services in accordance with the Hospice Care Plan and will document its activities in Facility's Patient records as directed by the facility. Routine hospice care and services will include services required by the Hospice Care Plan will be accomplished through visits made by nurses, social workers, Chaplains and hospice health aides,

Based on record reviews and interviews the facility failed to ensure interventions were put into place to ensure a decrease in weight loss and or no further weight loss for Resident #79 for 1 of 5 residents reviewed for Nutrition. The findings included: The facility admitted R #79, on 3/16/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 5/13/2021 at approximately 9:55 AM of the medical record for R #79 revealed an admission weight of 223.2 pounds. Further review of the medical record for R #79 revealed a weight on 3/31/2021 of 208.2 pounds. On 4/6/2021 R #79 weighed 197.5 pounds. R #79 continued to loose weight and by 4/29/2021 his/her weight was 184.2 lbs. A weight loss since admission of 39 pounds. An interview on 5/13/2021 at approximately 10:00 AM of the Nutrition Note by the RD dated 5/3/2021 stated, Resident had an 11.5 percent significant weight loss x 30 days. The RD recommended, Discontinue the Prostat AWC 2 times daily because the wounds have resolved. Add No Sugar Added Medpass 2 times daily related to weight loss. The Resident will benefit from additional kcal's to prevent additional weight loss. R #79 was receiving fortified mashed potatoes for lunch and dinner. No other interventions or supplements were documented as attempted. During an interview on 5/13/2021 at approximately 10:30 AM with the RD, he/she stated that he/she likes to wait 2 weeks before reassessing the resident again even though R #79 had already lost 39 pounds since admission on 3/16/2021.

Based on observation, interview, and review of manufacturer recommendations, the facility failed to ensure that blood glucose strips and blood glucose controls were properly labeled post opening and that a nutritional shake was used within the manufacturer's time frame for 2 of 4 medication carts. The findings are: On 05/12/2021 at 11:23 am observation of (2) Medication Carts revealed (2) Assure Platinum test strip bottles with no date when opened denoted on the bottles and (1) bottle of Assure Platinum controls with no date when opened for usage. On 05/12/2021 at 11:44 am interview with Licensed Practical Nurse (LPN) # 3 revealed I am unsure of how long the test strips and the glucose controls are good for once opened or how long they have been in use but I will look it up. Review of the manufacturer's guidelines for Assure Platinum Test Strips revealed, Storage and Handling: When you first open the vial, write the date on the vial label. Use the test strips within 3 months of first opening the vial . Review of the manufacturer's guidelines for Assure Dose Control Solution, revealed Storage and Handling: Use the control solution within 90 days (3 months) of first opening. It is recommended that you write the date of opening on the control solution bottle label (Date Opened) as a reminder to dispose of the opened solution after 90 days . On 05/12/2021 at 10:37 am observation of LPN #2 during medication administration revealed Med Pass 2.0 Nutritional Shake dated 05/11/2021 with no time when opened. On 05/12/2021 at 11:20 am interview with LPN #2 revealed Med Pass is pulled by the 3rd shift nurse and put on the medication cart. I use it until I leave at the end of my 8 (eight) hour shift. On 05/12/2021 at 1:43 pm observation of the medication cart for the 200 and 500 Halls revealed Med Pass Fortified Nutritional Shake noted opened at 8 am and dated as 05/12. On 05/12/2021 at 1:45 pm interview with LPN #1 revealed that I use it for 4 days until its completed. I get my own shake for my med cart and I opened it at 8 am this morning. Review of the manufacturer's guidelines revealed Storage and Handling, Store in a cool, dry area. Do not expose to moisture or heat. Do not freeze. After open, consume product within 4 days if properly refrigerated. After open, consume product within 4 hours if not refrigerated.

Based on interview, record review, and review of the facility policy titled, Clinical Records the facility failed to update Immunizations and Medical Records for R #72 R #72 was admitted to the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R #72 has a BIMS (Brief Interview for Mental Status) of 13. An interview with R #72 on 5/12/2021 at 12:41 revealed that R #72 goes out to [CONDITION(S)] on Tuesday ' s, Thursday ' s, and Saturday ' s and could not remember if they received the Second Dosage of the COVID-19 Vaccine (2/11/2021) but could recall going to [CONDITION(S)] on that date. A record review of the progress notes on 5/12/2021 at approximately 1:30 PM revealed that R #72 on 2/11/2021 at 11:17 AM Resident out of the facility with Med-One transport for [CONDITION(S)] appointment, no distress noted upon departure. A progress note on 2/12/2021 at 11:28 revealed that Late Entry: Resident returned to the facility via Med-One transport from [CONDITION(S)]. Chest Catheter dressing dry and intact, resident denies pain/discomfort, call light within reach. A record review of R #72 Health Record revealed a COVID-19 Vaccination Card dated on 1/14/2021 (First Dosage) and 2/11/2021 (Second Dosage), and a COVID-19 Vaccination Intake Consent Form signed and dated on 1/8/2021 by R #72. An interview with the Administrator and DON (Director of Nursing) on 5/12/2021 at 2:20 PM revealed that C.V.S. Pharmacy made special accommodations and came earlier than scheduled on that date so that R #72 could receive the Second Dosage of the COVID-19 Vaccine and attend [CONDITION(S)]. The Administrator stated that the facility used the COVID-19 Vaccination Card as their documentation and proof of Vaccine administration but did not update the R #72 Medical Record. Review on 5/13/2021 at approximately 12:00 PM policy tilted Clinical Record revealed that Nurse's notes containing observations made by the nursing personnel will document the resident's course of treatment.

Based on observation and interview, the facility failed to maintain the kitchen reach-in cooler, dry food storage, and nourishment refrigerator free from expired food items. The findings included: A kitchen tour conducted on [DATE] at 11:03 AM revealed three 36 ounce chocolate milk containers in the reach-in cooler and four 32 ounce bags of pure cane sugar in the dry food storage that were expired. In the nourishment room of the 100 unit, there were two 8 ounce of expired and four 8 ounce dented therapeutic nutrition supplements. At the time of discovery, the Certified Dietary Manager confirmed the expired food in the kitchen, and Registered Nurse #1 confirmed the expired supplements in the nourishment refrigerator.

Based on observation and interview, the facility failed to treat each resident with respect and dignity, and care for each resident in a manner that promoted enhancement of quality of life. During dining observations, staff was observed to knock and enter resident rooms without permission. The findings included: On 5/2/19 at approximately 1:10 PM, observation of the meal tray delivery revealed three staff members knocking and entering rooms before residents gave their permission to enter. During an interview immediately after the meal tray delivery on 5/2/19, the Director of Nursing (DON) stated the staff knew the residents well and knew when to enter the resident's rooms. During the interview, the DON confirmed since this was the resident's home, staff should knock, introduce self, and ask permission prior to entering the resident's room. During an observation 4/29/2019 at approximately 1:11 PM during the lunch meal service on the 300 Unit staff was observed knocking on resident room doors to deliver the lunch meal tray and not waiting for a reply, just walking in without permission to do so. An additional observation during the lunch meal service on the 300 hall on 4/2/2019 at approximately 1:11 PM revealed a staff member knocking on the door of room [ROOM NUMBER] and shouted, Hey Sweetie. and walked in room and did not wait for permission to enter. In room [ROOM NUMBER], the staff member cleansed his/her hands and entered the room without permission. The Certified Nursing Assistant rearranged the over the bed table and placed a bed pillow behind the resident in bed.

Based on record reviews, interviews and review of the facility policy titled, Notice Before Transfers, the facility failed to ensure Resident #113, #85, #83, #55, #94, #113 and Resident #109 and their Personal Representatives received in writing and in a language they could understand of the reason for the transfer/discharge to the hospital for 6 of 6 residents reviewed for hospitalization . The findings included: The facility admitted Resident #55 with [DIAGNOSES REDACTED]. Review on 4/19/2018 at approximately 2:04 PM of the medical record for Resident #55 indicated that Resident #55 was admitted to the hospital on [DATE] and discharged back to the facility on [DATE]. No documentation could be found in the medical record for Resident #55 to ensure that he/she and the Personal Representative received in writing and in a language they could understand of the reason for the discharge/transfer to the hospital prior to the the transfer/discharge to the hospital. The facility admitted Resident #83 with [DIAGNOSES REDACTED]. Review on 4/18/2018 at approximately 8:34 AM of the medical record for Resident #83 revealed a hospital stay from 3/17/2018 until 3/22/2018 and then readmitted into the nursing facility. No documentation could be found in the medical record for Resident #83 to ensure he/she or the Personal Representative for Resident #83 receiving in writing in a language they could understand of the reason for the transfer/discharge to the hospital. The facility admitted Resident #94 with [DIAGNOSES REDACTED]. Review on 4/20/2018 at approximately 10:55 AM of the medical record for Resident #94 indicated a hospital stay from 1/25/2017 and returned to the facility on [DATE]. A hospital stay on 1/26/2018 and returned to the facility on [DATE] and a third hospital stay from 2/16/2018 and returned to the facility on [DATE]. No documentation could be found in the medical record to indicate that Resident #94 nor his/her Personal Representative received in writing and in a language they could understand of the reason for the transfer/discharge to the hospital. The facility admitted Resident #109 with [DIAGNOSES REDACTED]. Review on 4/20/2018 at approximately 4:34 PM of the medical record for Resident #109 revealed a hospital stay on 3/16/2018 and returned to the facility on [DATE] and out to the hospital in 3/31/2018 and returned to the hospital on [DATE]. No documentation could be found in the medical record for Resident #109 to ensure he/she or the Personal Representative for Resident #109 receiving in writing and in a language they could understand of the reason for the transfer/discharge to the hospital. During an interview on 4/18/2018 at approximately 10:00 AM with the DON (Director of Nursing) and he/she stated, we call the personal representative and let them know what is going on with the resident and we send a discharge summary with them. If the resident is a Medicare recipient then we send an ABN (Advance Beneficiary Notice), and if a Medicaid recipient then we notify the personal representative, If Medicare recipient then we send a bed hold. Review on 4/20/2018 at approximately 6:00 PM of the facility policy titled, Notice Before Transfers, states, Before a resident is transferred, the facility will notify the resident and/or resident representative of the transfer or discharge. The notice shall be in a language and manner they understand. This notice shall be in writing and shall include the reason for the transfer or discharge. The notice will be made either 30 days before the resident is transferred or discharged or as soon as practicable depending on the reason for the transfer or discharge. A copy of the notice will be sent to the Office of the State Long Term Care Ombudsman. The facility admitted Resident #113 with [DIAGNOSES REDACTED]. Record review on 4/18/18 revealed Resident #113 was discharged to the hospital on [DATE]. Further review of the nurse's notes and the social services noted revealed there was no documentation written information of the reason for the transfer was distributed to the resident and the resident's representative. In addition, there was no documented evidence the Ombudsman was sent information related to the discharge. The facility admitted Resident #85 with [DIAGNOSES REDACTED]. Resident #85 was admitted to Lexington Medical Center 01/31/18 and returned to the facility on [DATE] there was no evidence that the Transfer and Bedhold information was distributed to the Resident/Responsible Party and/or Ombudsman.

Based on observation and interview, the facility failed to provide privacy during toileting for 1 of 1 random observation. The findings included: Resident #429 was admitted to the facility with [DIAGNOSES REDACTED]. On 4/16/18 at approximately 12pm, Resident #429 was observed to be toileting inside of the room with a housekeeping attendant present. The curtain was not pulled and the door was not closed. At this point, the Surveyor asked for permission to enter the room, and once permission was granted, asked Resident #429 if the privacy curtain could be pulled. At this point, the housekeeping attendant stopped cleaning, stepped out of the room and continued down the hallway. On 4/18/18 at approximately 4pm, Resident #429 was interviewed and stated staff members were often present whenever toileting took place. Resident #429 also stated that it doesn't make her/him uncomfortable. An interview with the Housekeeping Supervisor (HS) on 4/20/18 at approximately 12pm revealed that it is the expectation of staff to knock on the resident's door and wait for permission before entering. HS then states that if a resident is observed to be using the restroom, the expectation of staff members is to excuses themselves until the resident is finished. HS states that education and training on resident dignity is given to staff, but was unable to provide any documentation.

Based on record reviews, interviews and review of the facility policy titled, Notification of Bed Hold, the facility failed to ensure Resident #113, #83, #94 and Resident #109 and or their personal representative received the Bed Hold Policy and the bed payment policy prior to a transfer/discharge to the hospital for 4 of 6 residents reviewed for hospitalization . The findings included: The facility admitted Resident #83 with [DIAGNOSES REDACTED]. Review on 4/18/2018 at approximately 8:34 AM of the medical record for Resident #83 revealed a hospital stay from 3/17/2018 until 3/22/2018 and then readmitted into the nursing facility. No documentation could be found in the medical record for Resident #83 and or the personal representative received the Bed Hold Policy with the reserve payment policy upon discharge/transfer to the hospital The facility admitted Resident #94 with [DIAGNOSES REDACTED]. Review on 4/20/2018 at approximately 10:55 AM of the medical record for Resident #94 indicated a hospital stay from 1/25/2017 and returned to the facility on [DATE]. A hospital stay on 1/26/2018 and returned to the facility on [DATE] and a third hospital stay from 2/16/2018 and returned to the facility on [DATE]. No documentation could be found in the medical record to indicate that Resident #94 and/or nor his/her Personal Representative received the Bed Hold Policy and the reserve payment policy upon transfer/discharge to the hospital. The facility admitted Resident #109 with [DIAGNOSES REDACTED]. Review on 4/20/2018 at approximately 4:34 PM of the medical record for Resident #109 revealed a hospital stay on 3/16/2018 and returned to the facility on [DATE] and out to the hospital in 3/31/2018 and returned to the hospital on [DATE]. No documentation could be found in the medical record for Resident #109 to ensure he/she or the Personal Representative for Resident #109 received the Bed Hold Policy upon discharge/transfer to the hospital. Review on 4/18/2018 at approximately 11:09 AM of the facility policy titled, Bed Hold Policy, states, Notification of Bed Hold, 1. Notice before Transfer: Before a resident is transferred to a hospital or goes on therapeutic leave the facility will provide written information to the resident and or resident representative specifying the duration of the bed-hold policy under the state plan, during which resident is permitted to return and resume residence in the facility. Number 2. states, Bed Hold Notice Upon Transfer, If a resident requires transfer to an acute hospital, the facility will offer the resident the opportunity of electing to have the bed held for 10 days. Upon admission, the facility will notify the resident or the representative of the bed hold option. The resident or the resident's representative is liable to pay reasonable charges, not to exceed the resident's daily room rate, for the bed hold period. Insurance may not cover such costs, Medicaid provides payment for a bed hold up to 10 days. The facility admitted Resident #113 with [DIAGNOSES REDACTED]. Record review on 4/18/18 revealed Resident #113 was discharged to the hospital on [DATE]. Further review of the medical record revealed a Bed Hold Status form with a date of 3/5/18 was signed 3/6/18. There was no documentation the bed hold policy was given to the resident upon discharge to the hospital.

Based on Record Review, Observation and Interview the facility failed to develop a comprehensive Care Plan related to the use of a Communication Assistance Device for 1 of 3 sampled Residents reviewed for Communication/Sensory. The findings included: The facility admitted Resident #92 with [DIAGNOSES REDACTED]. Observation and interview of Resident #92 on 04/18/18 at approximately 9:57 AM revealed a picture/word book that was made by his/her family to assist with communication between the resident and staff. When asked if the book was helpful the resident indicated it was. Further review of the book revealed pictures and words related to simple questions, items the resident may want or need including staff, food, medications, toiletries and activities. Record review on 04/18/18 at approximately 12:16 PM revealed the Care Plan for Resident #92 did not include the use of the communication device. In an interview on 04/18/18 at approximately 12:16 PM the Minimum Data Set (MDS) Coordinator stated s/he thought the book was included in the care plan.

Based on record review, interview, and review of the facility policy titled Care Plans, the facility failed to ensure all required disciplines were involved with the care plan process for 3 of 28 care plans reviewed.(Resident #55,#87 & #113) In addition, the facility failed to update the care plans for Resident #128 for weight loss and Resident #87 for code status.(2 of 28 care plans reviewed) The findings included: The facility admitted Resident #113 with [DIAGNOSES REDACTED]. Record review on 4/20/18 of the Care Plan Conference Signature Sheets dated 3/29/17 and 6/21/17 revealed a Certified Nursing Assistant(CNA) did not participate in the care plan process. In addition, on 12/13/17 the dietary department was not represented in the care plan process. The facility admitted Resident #87 with [DIAGNOSES REDACTED]. Record review on 4/20/18 of the Care Plan Conference Signature Sheets dated 4/19/17 and 7/5/17 revealed a CNA did not participate in the care plan process. Further review of the care plan revealed the code status for Resident #87 had not been updated to reflect a Do Not Resuscitate request by the resident representative which went into effect on 2/14/18. During an interview with the Director of Nursing on 4/20/18 at 10:43 AM, s/he confirmed Resident #87's care plan had not been updated to reflect the current code status. S/he continued by stating Social Services would ensure information related to code status is correct and at that time, the Care Plan Coordinator would update the care plan. Review of the facility policy titled Care Plans revealed the following under the Procedure section: 5. The Care Plan is reviewed and updated as necessary, but not less than quarterly or when there is a change in the resident's condition. 10) Other revisions/updates will be made by hand as indicated. The facility admitted Resident #55 with [DIAGNOSES REDACTED]. Review on 4/19/2018 at approximately 2:04 PM of the form titled, Care Plan Conference Signature Sheet, dated 1/30/2018 for Resident #55 indicated the CNA (Certified Nursing Assistant) most closely involved with the care for Resident #55 did not have input into the care planning process for this resident. The facility admitted Resident #128 with [DIAGNOSES REDACTED]. Review on 4/19/2018 at approximately 10:15 AM of the weights for Resident #128 revealed an admission weight on 3/7/2018 of 89.8 pounds and on 3/28/2018 a weight loss of 9.2 pounds in 21 days. Further review on 4/19/2018 at approximately 10:15 AM of the weights for Resident #128 revealed a continued weight loss from 3/28/2019 until 3/17/2018 of 12 pounds. No documentation could be found in the medical record for Resident #128 to ensure he/she was reweighed to ensure accuracy of the weights. Review on 4/19/2019 at approximately 10:19 AM of the Plan of Care for Resident #128 revealed no review and no revision to ensure the weight stabilized or any interventions to prevent further weight loss for Resident #128. During an interview on 4/19/2018 at approximately 12:30 PM with the RD (Registered Dietician ) he/she stated. the resident would certainly need to be seen today. The RD agreed and verified that Resident #128 did have a huge weight loss but did not verbalize that interventions were added to stabilize Resident #128's weight or to prevent further weight loss. Review on 4/19/2018 at approximately 2:20 PM of the facility policy titled, Weight Protocol, states under, Policy:, Resident experiencing undesirable weight loss or gain will receive appropriate interventions. Number 8. states, The CDM (Certified Dietary Manager) and/or Registered Dietician will review the plan of care and document nutritional assessment and recommendations/interventions as indicated for the individual resident.' Number 9 states, Nursing will communicate dietary recommendations to the MD (Medical Doctor) and obtain MD orders as indicated and approved by the MD. Number 12. states, If all interventions are unsuccessful and weight loss continues, a tube feeding may be recommended per the MD. If the resident or RP (Responsible Party) decide against a tube feeding, the resident should continue to be evaluated per CDM or RD and interventions recommended and implemented as indicated.