Every finding on record at NHC Healthcare - Sumter

Based on observations, interviews, record review, and review of the facility policy, the facility failed to ensure a functioning call light system was in place for 1 of 5 residents reviewed, Resident (R)102. This failure had the potential to cause harm due to insufficient communication systems available in the case of an emergency. Findings include:Review of the facility policy titled, Call light, with no revision date, documented, 1. For bedside call lights, a light and a sound will appear over the door of the resident's room and on the computer at the nursing station. The alarm will sound periodically. 10. Check all call lights prn and report any defective call lights to the maintenance staff immediately.Review of R102's Face Sheet revealed she was admitted on [DATE], with diagnoses including, but not limited to: displaced fracture of greater trochanter of left femur, chronic obstructive pulmonary disease, bipolar disorder, anxiety disorder, depression, irritable bowel syndrome, and bilateral primary osteoarthritis of knee. Review of R102's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/12/26 revealed R102 had a Brief Interview of Mental Status (BIMS) score of 13 of 15, indicating that the resident is cognitively intact. Review of R102's Care Plan revealed approaches for the resident including, Educate on call light use: Pt able to return demonstrate; and, Ensure call light is kept within reach at all times for resident/staff use.Review of the facility's maintenance work order log for the previous 30 days showed no documented repairs related to call light systems in any resident rooms.During an observation on 04/20/26 at 12:02 PM, the initial tour of R102's room revealed, the resident pushed the call light button with no visual notification or audio alert to voice concerns from the resident to the staff at the nursing station.During an observation on 04/21/26 at 9:01 AM, revealed R102's room without a working call light. When pressing the button, no visual notification or audio alert is available for the resident to use inside of her room.During an observation on 04/22/26 at 10:25 AM, revealed R102's pressed the call light which triggered the light but still no audio alert.During an interview on 04/22/26 at 10:19 AM, with Registered Nurse (RN)1 revealed if the resident needs help, then she can use her call light. She stated that the light itself does work but staff are not able to hear if the resident said anything at the nurse's station from the call light system. Staff have to walk to her room to know if she needs help or has a concern.During an interview on 04/22/26 at 10:25 AM, with the Director of Nursing (DON), revealed that when R102 presses the call light, the light comes on and the expectation is for the staff to come see what the resident needs since they are unable to hear what she needs through the audio system in the room.

Based on review of the facility policy titled, Refrigerator and Freezer Storage, observations, and interviews, the facility failed to ensure foods in the walk in freezer and the reach in cooler were labeled and stored properly in 1 of 1 main kitchen. This deficient practice has the potential to effect all residents eating meals that are prepared in the main kitchen. Findings include: Based on the facility policy titled, Refrigerator and Freezer Storage, under Outcome: states, Refrigerated and frozen foods will be stored properly for optimal product safety. Number 4 states, Refrigerated/Frozen foods will be rotated using the FIFO (first in, first out) method. New products are placed behind old products so that the older products are used first. Number 9 a. states, Foods will be stored in their original container or a NSF approved container or wrapped tightly in a moisture-proof film, foil, etc. Clearly labeled with the contents and the use by date. Number 10 states, Leftovers will be placed in approved containers, covered, labeled, dated, and stored in refrigerator or freezer at correct temperature. Observations during the initial tour of the kitchen with the Certified Dietary Manager (CDM) on 06/12/2023 at 10:20 AM revealed the following: The walk in freezer contained three bags of chicken breasts open, unsealed, and with no open date. A bag of seasoned beef patties open, without an open date. A bag of pork cutlets open, with no open date. A bag of biscuits open, with no open date. An observation during the initial tour of the reach in cooler revealed: Nine cups of yogurt with an expiration date of 06/09/2023. One pitcher of pineapple juice, undated. One cup of thickened water and one cup of thickened tea, undated. An observation of the walk in cooler during the initial tour revealed: One bag of lettuce, partially used with no open date. One onion partially used and rewrapped with no date. During an interview on 06/12/2023 at 10:25 AM, the CDM confirmed the findings.

Based on observations, interview, review of the manufacturer package insert, and review of the facility policy and procedure, the facility failed to ensure that an expired test reagent was removed from active storage in 1 of 6 medications carts. Findings include: Review of the facility's policy titled, Storage of Medications, dated [DATE] showed that outdated medications follow manufacturer's recommendations, are removed from inventory and that medication storage conditions are monitored quarterly by the consultant pharmacist or pharmacy designee and corrective action taken if problems are identified. On [DATE] at approximately 9:35 AM inspection of the 200 Hall medication cart #1 revealed one bottle of Hemoccult Developer by [NAME] with an expiration date of September, 2022. This finding was confirmed by Licensed Practical Nurse (LPN)2 on [DATE] at approximately 9:40 AM who stated okay, that's nothing and discarded the bottle. The [NAME] manufacturer package insert, dated [DATE], states under Storage and Stability that Hemoccult Developer will remain stable until the expiration date.

Review of the facility policy titled, Indwelling Catheter Care Policy, observations, interviews and review of the medical record for Resident #45 (R45) the facility failed to follow a procedure for catheter care to prevent or decrease the spread of infection for 1 of 1 residents reviewed with a catheter. Findings include: Review of the facility policy titled Indwelling Catheter Care Policy, states under Purpose: It is standard of care to provide indwelling catheter care cleansing with shower or bath and as needed when visibly soiled using approved technique in order to decrease the risk of catheter-associated infection. The procedure is as follows: 1. Knock on door. 2. Identify yourself and explain procedure to the resident. 3. Cover bedside table with barrier. 4. Place supplies on the barrier. 5. Provide privacy-door closed, blinds closed, curtain pulled all the way around bed. 6. Position resident minimal exposure. 7. Wash hands with soap and water using approved technique. 8. Set up equipment on barrier. 9. Don clean gloves. 10. Cleanse the catheter tubing by by anchoring the tubing with one gloved hand at the base of the catheter (close to the point of insertion, cleanse outward from meatus or stoma approximately 6-8 inches and discard wipe. (ONE SWIPE, ONE WIPE) 11. Wash hands. 12. Dispose of plastic bag with trash. 13. Wash hands with approved technique at nearest sink. 14. Assisting personnel will secure catheter tubing with anchor and reposition patient; Wash hands before leaving room. The facility admitted R45 with diagnoses including, but not limited to, malignant neoplasm of the prostate, presence of urogenital implants and obstructive and reflux uropathy. An observation of supra pubic catheter care on 06/13/23 at 3:00 PM by Registered Nurse (RN)1 with Licensed Practical Nurse (LPN)1 went as follows: RN1 knocked on the door and entered the room of R45. LPN1 then explained the procedure. RN1 cleaned her hands with hand sanitizer, but did not wash them. RN1 then pulled back the covers, unfastened the resident's brief and with her bare/ungloved hands, touched the tubing in multiple areas, ensuring it was draining properly. LPN1 cleaned his hands with hand sanitizer and applied gloves. He then proceeded to remove the soiled dressing from the insertion site of the supra pubic catheter tubing. RN1 used her scissors to cut the soiled dressing to aide in the removal of the dressing, RN1 did not clean the scissors before or after cutting the soiled dressing. LPN1 finished removing the soiled dressing and then changed his gloves. RN1 did not clean her hands, but applied gloves and took out 2 of the wipes from the package. RN1 then took one wipe and wiped around the insertion site and using the same wipe, she wiped down the tubing from the insertion site. RN1 took another wipe and wiped around the insertion site and then down the tubing a second time. RN1 then removed her gloves and touched the cath secure with her bare hands and stated that this particular cath secure was different from the ones she had seen in the past. LPN1 then prompted RN1 to apply gloves and then aided LPN1 in removal of the cath secure and applying a new one. RN1 then removed her gloves and wrapped the soiled dressing, the soiled wipes along with the soiled gloves and the dressing wrapper and folded it all together and then placed it in the trash can. LPN1 reapplied the resident's brief and pulled up the covers to make the resident comfortable. LPN1 removed his gloves and cleaned his hands with hand sanitizer and RN1 walked to the door of the room and cleaned her hands with sanitizer that was in the room. Neither RN1 nor LPN1 were observed washing their hands. An interview on 06/13/2023 at 3:15 PM with RN1 and LPN1 confirmed that neither had washed their hands prior to catheter care or after catheter care. RN1 also confirmed that she had touched the catheter tubing and the catheter secure using her bare hands along with the covers and the resident's brief.

Based on observation, interview, record review, and policy review, the facility failed to ensure equipment, food storage containers, walls, baseboards and floors throughout the kitchen were kept clean. This deficient practice had the potential to affect 117 of 117 residents who receive meals prepared in the facility's only kitchen. Findings include: During the kitchen tours with the Certified Dietary Manager (CDM) on 11/10/21 at 9:00 AM and 11/11/21 at 1:35 PM the following observations were made: Kitchen proper: The seven white food bins, containing sugar, thickener, breadcrumbs, pureed bread, oatmeal, and flour, were observed with dried spills, splatters and loose food debris on and around the lids and on the rims. The stove gas burners contained a build-up of grease and chard food debris. The side exteriors of the deep fryers had an accumulation of grease residue and sticky dried splatters. The floor under and around the deep fryers were soiled with an excess of grease residue. On 11/10/21 at 9:00 AM and 11/11/21 at 1:40 PM, the hand sink at the entrance to the kitchen was heavily stained with brownish tea-like discoloration. The tea/coffee station was adjacent to the sink. On 11/11/21 at 1:40 PM, the CDM denied staff used the hand sink to discard tea or coffee. She stated at this time she had requested a new sink due to these stains. The baseboards and floor throughout the parameters of the kitchen were in need of deep cleaning. An accumulation of a dark gummy substance was noted along the baseboards and dark stains were noted on the floor, especially behind equipment and other kitchen furniture. A narrow section of the floor between the reach-in refrigerator and wall, approximately three to four inches, were begrimed with a dark build-up of residue and dried spillage. On 11/10/21 at 9:00 AM and 11/11/21 at 1:50 PM, the three-compartment sink was noted to have a build-up of rust and food particles on the lower shelf. The small corridor where the three-compartment sink was stationed had a build-up of dirt-like substance and debris along baseboards and the floor. Two holes, approximately one to two inches in diameter, were observed in the lower wall under the three-compartment sink. On 11/11/21 at 1:50 PM, the CDM stated she had never noticed the holes. The wall and the two window seals in the three-compartment sink corridor were soiled with dirt-like substance and dried splatters. The wall and large office window seal at the back production table contained a collection of dried food splatters and a build-up of a dust-like substance. The wall behind the tea/coffee station was very sticky and contained a heavy collection of dried splatters. Food storage room: A large, dried spill was noted under the metal wire food storage shelving. The spill extended to the back of the wall. A build-up of dark thick debris was noted on the baseboards, lower walls and floor behind the food storage shelving and along the parameters of the room. During an interview on11/11/21 at 1:45PM, the CDM was asked about a cleaning schedule. She stated the soiled surfaces noted during the inspection were listed on the cleaning schedule. Staff initialed the cleaning items on the schedule indicating the cleaning was completed. Further interview on 11/12/21 at 6:45 PM, the CDM stated the holes under the three-compartment sink were immediately patched and a company was contacted to professionally clean the kitchen floors, baseboards and walls. Review of the kitchen's cleaning schedule, dated 10/25/21 through 11/20/21, reflected what items were to be cleaned by designated staff (partner's name). These items include equipment, food storage, walls and floors throughout the kitchen and storage room. Items noted during the inspection that were initialed included white bins, all storage rooms, aides area wall, prep [preparation] table, office window wall, three compartment sink area and windows, walls/floors in storage room, coffee station. The stove and storage rooms floors were not initialed. Review to the facility kitchen's policy for cleaning equipment, dated 11/2017, reflected OUTCOME: Equipment must be cleaned and/or sanitized after every use .9. The physical facilities shall be cleaned as often as necessary to keep them clean .

Based on observation and interview, the facility failed to ensure one of two residents (Resident (R) 55) who receive enteral feedings had clean equipment (i.e. feeding pump and intravenous pole). Failure to provide clean equipment could provide an environment conducive to bacterial growth leading to infections. Findings include: Observation on 11/10/21 at 11:00AM revealed R55 was observed in bed with a feeding pump and intravenous (IV) pole near the bed. The feeding and IV pole had a dried beige color crusty splatter. No tube feeding infusing at the time of observation. Observation on 11/10/21 at 1:30PM revealed the resident in bed with head of bed (HOB) elevated 45 degrees. [MEDICATION(S)] 1.5 feeding was infusing at 45 cubic centimeters (cc) an hour; the label read the bottle was hung at 10am with a 1000cc water bolus bag hanging. The feeding pump and pole had dried beige color crusty material. Observation on 11/11/21 at 11:15AM revealed R55 was awake in bed with HOB elevated 45 degrees. [MEDICATION(S)] 1.5 feeding infusing thru gastrostomy tube at 45cc an hour. IV pole and feeding pump continues have a dried beige color crusty material. Observation on 11/12/21 at 10:25 AM revealed the resident in bed with the HOB elevated 45 degrees. Tube feeding not infusing at this time; however, the feeding pump and IV pole continues to have a dried beige colored crusty splatter. During an interview with Unit Manager (UM)3 on 11/12/21 at 11:35AM, UM3 observed the resident's feeding pump and IV pole and confirmed the dried beige color crusty material appeared to be dried feeding formula. UM3 also stated the nursing is responsible for cleaning the equipment when formula spills on the pump and IV pole.

Based on observations, interviews and record review, the facility failed to ensure that one of 27 sampled residents (Resident (R) 55) identified with hand contractures received a positioning device. Failure to use the hand roll has the potential for the resident to develop skin breakdown in the palms of his hands. Findings include: Observation on 11/10/21 at 11:00 AM revealed R55 in low bed with head of bed (HOB) 35 degrees; two blue hand carrot rolls on the night stand next to the resident's bed. The resident's hands are covered at this time. Observation on 11/10/21 at 1:30 PM revealed two blue hand carrot rolls on the night stand next to the resident's bed. Observation of the resident's exposed right hand revealed the hand was contracted. The resident's tube feeding was infusing at this time. Observation on 11/10/21 at 4:45 PM revealed two blue hand carrot rolls on the resident's nightstand. Observation on 11/11/21 at 11:15 AM revealed the Certified Nursing Assistant (CNA) providing care showed the resident's hands, which were contracted with long fingernails. There was no skin breakdown nor any odor in the palms of the resident's hands. The two blue hand carrot rolls remain on the nightstand next to the resident's bed. Observation on 11/12/21 at 10:25 AM revealed the resident in bed while the hand rolls remained on the nightstand. Tube feeding was not infusing at this time. Record review of R55's annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) 09/13/21 located in the resident's electronic medical records (EMR) section called MDS assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 99 indicating R55 is severely impaired cognition and the resident has functional limitation in range of motion bilaterally in upper and lower extremities. Review of an Occupational Therapy (OT) Screen, dated with start date of 10/19/21 and completed on 11/02/21, found in the resident's EMR section called assessment documented, the resident is total assist with self-care and mobility. His hands are contracted, and orthopedic carrots were placed in his hands this date. The carrot fits well in the right hand but due to the extend of his left thumb palmar adduction, the carrot would not stay in his left hand. The OT recommendation was to continued current interventions as recommended above. Review of the resident's care plan with a revision date of 10/19/21 located in the resident's EMR in section care plans indicates the resident is to wear waffle boots and hand rolls as tolerated for protection and preventative measures; can be removed for activities of daily living care. A review of the nursing notes from 10/6/21 through 11/110/21 located in R55's EMR located in the section called documentation failed to reveal any documentation of the nursing attempting to place the resident's hand carrot rolls. During an interview on 11/11/21 at 11:15 AM, CNA4 stated that when the hand rolls are placed on the resident he will attempt remove the rolls. When the resident attempts to remove the hand rolls, he becomes entangled in the tube feeding tubing. Therefore, hand rolls are applied when the tube feeding is turned off. Interview on 11/12/21 at 10:24 AM Licensed Practical Nurse (LPN)2 states the resident will take hand rolls off during tube feedings and staff will put them aside. LPN2 stated they did not know if the resident has a care plan but will notify the MDS nurse. LPN2 also states occupational therapy evaluated the resident a couple of weeks ago and she is not sure if they placed the hand rolls in the resident's room. Interview with the Director of Nursing (DON) on 11/12/21 at 4:52 PM revealed the recommendation made by OT is considered a nursing order judgement and does not require an order from the physician. The DON also states even the care plan has the intervention for the hand rolls, the care plan does not reflect the exact recommendations made by the OT. The DON further stated she was unable to find any documentation of the resident refusing or resisting the hand rolls.

Based on observation, interviews, record review, and review of the facility's policy, the facility failed to ensure the proper administration of an inhalant medication for one of four residents (Resident (R) 54) observed for medication administration. Failure to administer the medication correctly could result in the resident developing uncontrolled symptoms, such as difficulty breathing. Findings include: During medication pass observation on 11/12/21 at 8:12 AM, Registered Nurse (RN)2 was observed preparing medications for R54. The medications included [MEDICATION(S)] ([MEDICATION(S)]- inhalant medication used to treat bronchospasms). RN2 handed the medications to the resident and explained her what medications she was receiving. R54 decided to take the [MEDICATION(S)] inhaler medication first. The resident shook the inhaler container first and then inhaled two puffs. The time between each puff was less than 10 seconds. The resident was not observed to inhale the medication deeply and hold her breath. The nurse did not intervene after the first puff to redirect the resident on the correct way to administer the medication. Review of the resident's quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 09/13/21, located in the electronic medical record section labeled MDS assessment, indicated the resident's cognition status is intact. Review of the resident's October physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with RN2 was conducted on 11/12/21 at 8:25 AM revealed the resident should have waited one minute between each puff of the inhalant. RN2 stated she could not think of any other directions that she should have given the resident regarding the administration of the inhalant. During an interview with the Director of Nursing (DON) on 11/12/21 at 4:00 PM the medication observation was discussed. The DON agreed the [MEDICATION(S)] inhalant was administered incorrectly. Review of the facility's policy titled, Oral Inhalation Administration with a revision date 01/01/19 indicated, .to ask the resident to breathe out as deeply as possible and place the inhaler mouthpiece under the top teeth and above the tongue with mouth lips closed around the mouthpiece. Press down on the inhaler once to release medication as the resident starts to breathe in slowly through the mouth over three to five seconds. Do not spray more one puff at a time. The resident should hold breath for 10 seconds or as long as possible to allow the medication to reach deeply into the lungs. Slowly exhale through the nose. If another puff of the same medication is required, wait at least one minute between then repeat the procedure .

Based on interview, record review, review of the Facility's Reported Investigation (FRI), and review of facility policy, the facility failed to ensure a resident was free from verbal and physical abuse from another resident. This affected one of three residents (Resident (R) 13) reviewed for abuse in a total sample of 27 residents. Findings include: 1.Review of the Resident Face Sheet, located in the Electronic Medical Record (EMR) under the Face Sheet tab, revealed R153 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 09/13/21, located in the EMR under the MDS tab, revealed R153 had a Brief Interview of Mental Status (BIMS) of three out of fifteen , which indicated severe cognitive impairment, had physical and verbal behaviors toward others, and was independent with ambulation. Review of R153's Care Plans, dated 09/18/21 located in the EMR under the Care Plan tab, revealed R153 had dementia, combative behaviors, and verbal and physical aggressive behaviors towards residents and staff and interventions included: call family, allow to calm, on to one conversation, show her pictures/videos of her great children, and chart behaviors. Review of R153's Nursing Progress Notes, dated 08/04/21 to 10/28/21, located in the EMR under the Progress Notes tab, revealed R153 had several episodes of yelling at R13 and two episodes of trying to hit R13 (10/02/21 and 10/13/21) with no evidence of injury. Review of R153's Nursing Progress Note, dated 10/02/21 revealed R153 was agitated and argumentative all evening. R153 attempted to hit R13. Review of R153's Nursing Progress Note, dated 10/13/21 at 6:19 PM, revealed R13 insulted R153 with expletives three times this shift. The note revealed R153 followed R13 to her room and attempted to strike her with her fist. The note revealed the incident was witnessed by staff, the residents were separated, and there were no injuries. During an interview with LPN 4 on 11/13/21 at 12:50 PM he stated on 10/29/21 R13 was cursing at R153 and R153 became upset. R153 yelled at R13 and was raising her fist as she followed R13 down the corridor. Staff heard the yelling, immediately responded, and directed R13 away from R153. LPN4 stated R153 was never near enough to have struck R13. LPN 4 stated the plan was for staff to increase their supervision of both residents after dinner and directed R13 away from R153 at the first sign of behaviors between the residents, which allowed R153 to calm. On 11/13/21 at 12:50 PM, he stated R153 easily became upset in the evening and sometimes yelled at R13 and staff. LPN4 stated when R153 yelled at R13, the staff directed R13 away from R153 to allow R153 to calm. LPN4 stated prior to 10/29/21, he never observed R153 touch or hit R13. Review of R153's Care Plans revealed revisions were made on 09/21/21, 09/28/21, and 10/21/21 included redirection of other resident away from area, monitor for signs of a urinary tract infection ([CONDITION(S)]), initiation of [MEDICATION(S)], and other medication changes. Between the resident altercation on 10/21/21 and 10/29/21 the facility increased the resident [MEDICATION(S)]. A review of R153's Nursing Progress Note, dated 10/29/21 at 6:15 PM, revealed the nurse was standing at the nurse's station, stepped away for a minute, returned and witnessed R153 and R13 holding each other's shirts and arguing with each other. As the nurse was attempting to separate the residents, R153 hit R13 on the top of her hand. R13 had no complaints of pain and no apparent injury. The residents were separated, and the Physician and Responsible Person were notified. 2. Review of the Face Sheet revealed R13 was admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R13's Care Plans, dated 05/17/21, revealed R13 easily became agitated, and interventions included: distract resident, reorient, offer music, provide 1:1[one to one] conversation, and chart behaviors. Review of the quarterly MDS assessment with an ARD of 08/02/21, revealed R13 had a BIMS of four out of 15, which indicated severe cognitive impairment, had no physical and verbal behaviors toward others, and was independent with ambulation. Review of R13's Nursing Progress Notes, dated from 07/21 to 10/13/21, revealed R13 and R153 had two episodes of yelling at each other, one episode (10/12/21) of R13 cursing at R153 and R153 attempting to strike R13. During an interview with the Administrator on 11/12/21 at 9:18 AM, she stated R153 and R13 both had dementia, were confused, and had increased behaviors in the evening. The Administrator stated both residents enjoyed each other's company and spent a lot of time together attending activities on the unit, sitting next to each other at the nurse's station, passing each other in the hallway while ambulating, and eating lunch together. The Administrator stated during the early evening, sometimes both residents argued with each other, and upset each other. The Administrator stated in August 2021, after a few verbal outbursts by R153 directed toward R13, R153 was moved to another unit. The Administrator stated at that time R153 was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated R153 had increased behaviors on the other unit as she continually stated she did not like her room and wanted to come back to the other unit. The Administrator stated on a few occasions, R153 walked to the other unit to visit with R13. The Administrator stated R13 and R153 were happy to see each other and there were no issues. The Administrator stated she spoke to both residents' family members, who stated they wanted the residents on the same unit if it was safe. The Administrator stated R153's behaviors improved and after a week, R153 was transferred back to the unit where R13 resided. Further interview with the Administrator on 11/12/21 at 9:18 AM, she stated although the staff tried to separate R153 and R13 during the early evening, they often continued to seek each other out. The Administrator stated although both residents enjoyed each other's company, they continued to argue and R153 sometimes yelled at R13. The Administrator stated both residents liked sitting in the one rocking chair that was on the unit. The Administrator stated a second rocking chair was brought to the unit, the rocking chairs were placed near the nurse's station, but not close together. The Administrator stated although on two occasions, R153 raised her fist toward R13, the staff immediately responded whenever R153 began yelling, and R153 was never close enough to come in direct contact with R13. The Administrator stated prior to 10/29/21, R153 never hit R13. During an interview with Registered Nurse (RN)1 on 11/12/21 at 2:16 PM she stated on 10/02/21 she was in front of the nurse's station, when she observed R153 yelling and walking toward R13 with a raised hand, and R153 stated she was going to hit R13. RN1 stated R153 was not close enough to hit R13 and the staff directed R153 away from R13. RN1 stated R153 was placed on increased supervision and calmed within a short time. A review of the Facility Reported Incident FRI report, dated 10/29/21, completed by the Administrator revealed that on 10/29/21 at 6:15 PM, R13 and R153 were standing up, holding each other's shirts, and arguing. As the nurse was attempting to separate them, R153 hit R13 on the hand. R13 had no injury. A review of the written statement by LPN4, dated 10/29/21, revealed that he heard R153 and R13 yelling at each other. LPN4 observed both residents holding each other by their shirts. As LPN4 tried to separate them, R153 hit R13 on the top of her hand. R13 did not complaint of pain and no injuries were observed. During further interview with LPN4 on 11/13/21 at 12:50 pm stated on 10/29/21, he was near nurse's station and heard R153 and R13 yelling. LPN4 stated he immediately stood between R153 and R13. LPN4 stated R153 was yelling and upset because she wanted to sit in the rocking chair occupied by R13. LPN4 stated R153 hit R13's hand and began stomping her walker. LPN4 stated a staff member assisted R13 away from the area. LPN4 stated within a few minutes, the situation deescalated. LPN4 stated he placed R153 and R13 on increased supervision and there were no further issues. LPN4 stated he assessed R13, and she had no injuries. LPN4 stated the Administrator, and the Director of Nurses (DON) came to the facility. Review of the facility's policy titled, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property, and Exploitation, dated 09/14/12, revealed that the patients of the facility have the right to be free from abuse, neglect, misappropriation of patient property, and exploitation. It is the policy of the facility to assure that patient safety, including freedom from risk of abuse or neglect holds the highest priority. The policy provides the following definitions: Abuse - The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical Abuse: includes hitting, slapping, pinching, and kicking. Verbal Abuse: the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to resident or their families, or within their hearing distances, regardless of their age, ability to comprehend, or disability.

Based on record review, observation and interview, the facility failed to maintain water temperatures in resident care areas at a safe level on 2 of 3 resident units. Multiple resident care areas were observed with water temperature greater than 120 degrees. The findings included: During the tour of resident rooms on 10/18/16 beginning at approximately 4:00 PM, surveyors noted the water temperatures in resident rooms on the 200 unit felt too warm. After obtaining a digital thermometer, water temperatures were taken in the shower rooms and in multiple resident rooms with the following results: Room 102- 128 Room 103/105 130.1 Room 108- 127.1 Room 110- 126.8 Room 115- 126 Room 121- 123.4 Room 200- 124.5 Room 206- 123 Room 213- 123.2 Room 219- 125.2 Room 220- 122 After the water temperatures were recorded, room rounds were made by the Maintenance Supervisor on 10/18/16 at approximately 6:00 PM with the following results: Room 102- 118.6 Room 103- 104.5 Room 108- 100 Room 110- 118 Room 115- 118 Room 121- 118 Room 200- 118 Room 206- 113.7 Room 213- 114.2 Room 219- 113.7 Room 220- 113.7 On 10/19/16 temperatures were rechecked by surveyors in resident rooms and showers with the following results: Shower Room 100 Unit- 120.2 Room 200- 121.6 Room 213- 125.2 Room 219- 126.7 On 10/18/16, all water temperatures were taken in resident rooms by maintenance. The temperature control valve was adjusted by maintenance. On 10/19/16 at 7:00 AM per documentation by Maintenance the water temperatures were down but still high. The temperature control valve was adjusted again and per documentation by Maintenance temperatures were at a constant 118 degrees at 7:30 AM on 10/19/16. On 10/19/16 the facility was notified a few rooms were still above 120 degrees. On 10/19/16 a plumber was contacted and installed bud thermometers on the two halls. At 5:00 PM a recheck of the room temperatures were taken by the facility and per a statement written by the facility no temperatures were higher than 117. On 10/18/16, a list of cognitively impaired mobile residents was requested. Of the rooms with concerns, Room 108 had a shared bathroom with Room 106 and Room 219 had a mobile cognitively impaired resident. During an interview on 10/18/16 at approximately 5:45 PM with the Maintenance Director, he/she stated it was facility practice to randomly choose rooms on each unit each week and check the water temperatures. He/she continued by stating a digital thermometer was used to check the water temperatures and the water temperatures should not exceed 120 degrees. During the interview, he/she explained how to calibrate the digital thermometer. On 10/18/16 the hot water heaters for each wing were observed and temperatures were 116-120 degrees. The water temperature logs for resident rooms and shower rooms were reviewed for six months with no irregularities. The accident/incident log was requested on 10/19/16. The Administrator stated the facility did not keep a log of accidents/incidents. He/she assured the surveyor no incidents of scalds/burns had occurred. Multiple staff were interviewed related to how do you check to make sure the water is not too hot for the resident and if water is hot what would you do. All staff answered appropriately. No work order requests had been filed related to elevated water temperatures during the last six months. Per the Administrator on 10/19/16, the facility had no policy related to water temperatures.

Based on record review, observation, interview, review of the facility policy titled Dressing-nonsterile and review of the facility Pressure Ulcer Treatment Check Off, the facility failed to provide appropriate pressure ulcer treatment to Resident #133. One of 3 residents reviewed for pressure ulcer treatment. The findings included: The facility admitted Resident #133 with [DIAGNOSES REDACTED]. Record review on 10/19/16 revealed Resident #133 had a Stage III to the sacral area with the last measurement documented as 1 x .8 x .5. Physician's order revealed a treatment which stated to cleanse the sacral area with wound cleanser, apply [MEDICATION NAME] Ag, cover with gauze and apply [MEDICATION NAME] dressing. During observation of gathering supplies for the pressure ulcer care on 10/20/16 at approximately 11:40 AM, Licensed Practical Nurse(LPN)#1 was observed to place an opened package of [MEDICATION NAME] Ag into the bag with the other supplies. At that time, the surveyor asked was the package open and LPN #1 stated yes. LPN #1 was asked if the package of [MEDICATION NAME] Ag was a multi-use package and he/she said yes. Upon further observation, LPN #1 obtained another package of [MEDICATION NAME] Ag and stated since the package was a sterile package he/she would have to throw the opened package away and use another unopened sterile package. During observation of the pressure ulcer treatment on 10/20/16 at approximately 11:43 AM, after cleansing the wound, washing hands and donning gloves, LPN #1 asked the Assistant Director of Nursing(ADON) to obtain a marker for him/her. After the ADON obtained the marker, LPN #1 took the marker dated and initialed the dressing, placed the [MEDICATION NAME] Ag and gauze and then placed the [MEDICATION NAME] dressing all with the same gloves. On 10/20/16 at 4:52 PM, during an interview with LPN #1, he/she confirmed she did not change gloves after dating/initialing the dressing. He/she also confirmed the opened package of [MEDICATION NAME] Ag would have probably been used had the surveyor not questioned him/her about it. Review of the facility policy Dressing, Non-Sterile on 10/21/16 at 9:52 AM revealed the policy did not address dating/initialing a dressing. Review of the facility pressure ulcer check off on 10/21/16 at 9:54 AM revealed to apply ointments/medications and clean dressing per the Doctor's orders. The next step listed was to date and initial. Review of the packet insert for [MEDICATION NAME] Ag [MEDICATION NAME] Dressing on 10/21/16 at 9:55 AM states sterility is guaranteed unless pouch is damaged or open prior to use-single use only.

Based on record review and interview, the facility failed to assure that 1 of 1 sampled resident reviewed for urinary incontinence received accurate assessments. Resident # 75 had 2 of 2 Minimum Data Set (MDS) assessments completed between the dates of 8/10/16 and 10/1/16 with inaccurate data ranging from nutritional approaches, skin injuries, active diagnoses, to medications. The findings included: The facility admitted Resident #75 with [DIAGNOSES REDACTED]. Record review of August 2016 Physician Orders, physician progress notes [REDACTED].#75 had active [DIAGNOSES REDACTED]. Further review of urine culture results with result date of 9/9/16 revealed >100,000 cfu/ml of E. coli bacteria and corresponding symptoms and treatment of [REDACTED]. Review of the MDS Admission assessment with Assessment Reference Date (ARD) of 8/10/16 revealed that Section I-Active [DIAGNOSES REDACTED]. Section I-Active [DIAGNOSES REDACTED]. Review of the MDS Significant Change in Status Assessment with ARD of 10/1/16 revealed that Section I-Active [DIAGNOSES REDACTED]. Section I-Active [DIAGNOSES REDACTED]. During an interview on 10/21/16 at approximately 2:35 pm, MDS Coordinator verified that Resident #75 had active [DIAGNOSES REDACTED]. MDS Coordinator also verified that on the MDS Admission Assessment with ARD of 8/10/16, the following items in Section I-Active [DIAGNOSES REDACTED]. MDS Coordinator also verified that on the MDS Significant Change in Status Assessment with ARD of 10/1/16, the following items in Section I-Active [DIAGNOSES REDACTED]. Record review on 10/21/16 at 10:15 AM revealed that Resident #75 was ordered to receive a No Added Salt diet upon admission to facility on 8/3/2016. Further review of Physician order [REDACTED].#75 received a No Added Salt Diet. During an interview on 10/21/16 at approximately 2:35 PM, MDS Coordinator verified that Resident #75 received No Added Salt Diet between 8/4/16 and 8/10/16. MDS Coordinator also verified that Section K-Swallowing/Nutritional Status-item K0510 D2 (Nutritional Approach-Therapeutic diet While a Resident) was not checked on MDS assessment with ARD of 8/10/16. Record review on 10/21/16 at 10:30 AM of History and Physical completed on 8/9/16 revealed that Resident #75 .sustained a R (right) arm laceration with the fall that was repaired with sutures in the hospital. The wound is healing well and she is to have her stitches out today. During an interview on 10/21/16 at approximately 2:35 PM, MDS Coordinator verified that Resident #75 was admitted to facility on 8/3/2016 with a laceration/ skin tear to right arm. MDS Coordinator also verified that Section M-Skin Conditions-item (M1040 G) Skin tear(s), was not checked on MDS assessment with ARD of 8/10/16. Record review of Physician order [REDACTED].#75 did not receive an anti-coagulant medication during the month of August 2016. Further review of MDS assessment with Assessment Reference Date (ARD) of 8/10/16 revealed that Section N-Medications-item N0410 E (Medications Received-Number of Days the resident received Anticoagulant during the last 7 days) was coded as 7. Review of Physician order [REDACTED].#75 did not receive an antidepressant medication during the dates of September 25th through October 1st, 2016. Further review revealed that Resident #75 did receive an antipsychotic medication for all 7 days between September 25th and October 1st, 2016. Further review of MDS Significant Change in Status Assessment with (ARD) of 10/1/16 revealed that Section N-Medications-item N0410A (Medications Received-Number of Days the resident received Antipsychotic during the last 7 days) was coded as 0, and N0410C (Medications Received-Number of Days the resident received Antidepressant during the last 7 days) was coded as 7. During an interview on 10/21/16 at approximately 2:40 PM, MDS Coordinator verified that Resident #75 did not receive an anticoagulant medication during the month of August 2016. MDS Coordinator also verified that Resident #75 had not received an antidepressant medication since admission to facility, and that s/he received an antipsychotic medication on each of the 7 days between 9/25/16-10/1/16.

Based on observations, record reviews, interviews and manufacturer package insert the facility failed to assure that medications were properly stored in 1 of 3 medication rooms, that medications were properly labeled as to expiration date in 1 of 6 medication carts and expired medication were not removed from active use in 1 of 6 medication carts. The findings include: -Inspection of the Hall 300 (Camellia) Medication Room refrigerator on [DATE] at approximately 10:36 AM revealed one white plastic tray containing multiple suppositories located on the right side of the 2nd shelf with standing water inside the tray. This finding was verified by LPN (Licensed Practical Nurse) # 1 on [DATE] at approximately 10:38 AM. -Inspection of the Hall 300 (Camellia) Medication Cart 1 on [DATE] at approximately 10:41 AM revealed one opened, in use and not dated as to date opened Advair Diskus ,[DATE] belonging to Resident # 95. The medication bore a pharmacy applied label for indicating opened date and expiration date, but was not filled out. On [DATE] at approximately 10:43 AM LPN # 1 verified that the medication was in use and had not been dated as to date opened or expiration date. -Inspection of the Hall 300 (Camellia) Medication Cart 2 on [DATE] at approximately 10:51 AM revealed one Advair Diskus ,[DATE] labeled by the facility as opened on [DATE] with an expiration date of [DATE]. This medication belonged to Resident # 50. On [DATE] at approximately 10:54 AM LPN # 2 verified that the medication was in use and was five days past the facility labeled expiration date. The manufacturer (GlaxoSmithKline) of Advair Diskus ,[DATE] package insert states: Discard 1 month after opening the foil pouch or when the counter reads 0 (after all blisters have been used), whichever comes first.

On the days of the survey, based on record reviews and interviews, the facility failed to maintain clinical records which were accurate and complete. There was conflicting documentation related to the notification of Resident 14's family following a fall. There was no documentation in the medical record that Resident # 14 was receiving range of motion per the resident's plan of care and there was conflicting information received from staff whether the resident received ROM. For three months, Resident 14's monthly summary did not indicate under skin conditions that the resident had a decubitus ulcer. One of 3 medical records reviewed for accuracy/completeness related to falls, pressure ulcers, range of motion. The findings included: The facility admitted Resident #14 with [DIAGNOSES REDACTED]. Review of Resident # 14's medical record on 4/9/2014 at approximately 9:20 AM revealed a Nurses Note dated 3/20/2014 which stated, "Resident resting in bed. See post fall assessment." Further review of Resident #14's medical record revealed a document entitled, "Post Falls Nursing Assessment." Under the section entitled, "Interventions," the question is asked, "Family Notified ?", answer is "No". Additional review of nurses notes dated 3/21/2014 stated, " Alert with confusion from incident. X-ray of right hand complete. Left message for responsible party, (RP) #1 to contact the facility." No other nurses notes were found to confirm the family and/or RP had been notified of the fall, or had returned the call . During an interview on 4/10/2014 at approximately 9:40 AM with Registered Nurse (RN) #1, he/she verified there was no evidence that the family had been notified of Resident #14's fall on 3/20/2014. On 4/11/2014 at approximately 9:23 AM, the Administrator provided a document entitled,"Patient Falls Incident Report," and he/she confirmed that this document was not in the resident's medical record. The report was dated 4/11/2014 at 9:01 AM, which included a date of 3/21/2014 and a time of 12:45 PM that the family/responsible party was notified which conflicted with the Nurses Notes dated 3/21/2014. Review of the document entitled, "Policies and Procedures Regarding Change in Patient Status," under Section C stated, "If unable to contact the family, efforts to reach the family will be continued and documented." Section D of the above mentioned document stated, "When a significant change in medical condition has occurred the patient's family or legal representative will be notified immediately." Review of Resident #14's Comprehensive Plan of Care revealed an intervention which stated, " Nursing to provide Range of Motion to all extremities daily as tolerated." During an interview with Licensed Practical Nurse (LPN) #2 on 4/7/2014 at approximately 3:47 PM he/she stated, "Resident #14 has contractures of his/her bilateral lower extremities, is not receiving Range of Motion (ROM) nor does he/she have use of any splints. A second interview on 4/9/2014 at approximately 10:38 AM with the Registered Nurse (RN) #1 stated Resident #14 was only receiving ROM during AM care but that was not documented anywhere in his/her medical record. Record review on 4/10/2014 at approximately 4:50 PM of a document entitled, "Wound Assessment Record," for Resident #14 revealed a Stage IV sacral decubitus ulcer, that has been measured and documented since 10/30/2013. Wound care of the sacral decubitus as performed by LPN #2 was observed on 4/9/2014 at 10:53 AM. Review of the medical record on 4/9/2014 at approximately 1:10 PM revealed reports entitled, "Nursing Summary Report," dated 1/29/2014, 2/22/2014, and 3/30/2014. Under the section entitled, "Skin Condition," the reports documented, "No problems, Dry."