Every finding on record at Oak Hollow Of Sumter Rehabilitation Center

Based on review of facility policy, record review, and interview, the facility neglected to provide services and care to Resident (R)15. Specifically, the facility failed to monitor and prevent inappropriate touching of R15 by R14, for 1 of 27 residents reviewed for abuse.Findings include:Review of the facility's policy titled Abuse Prevention Program with a revised date of December 2016, revealed, Our residents have the right to be free from abuse, neglect, . This includes but is not limited to . sexual or physical abuse . As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to: . other residents .Review of R15's Face Sheet revealed R15 was admitted to the facility on [DATE], with diagnoses including, but not limited to, Dementia, essential hypertension, depression and Pure Hyperglyceridemia.Review of R15's Medication Administration Record (MAR) revealed an order for Donepezil 10mg give 1 tablet by mouth at 2100, Drisdol 1.25mg tablet give 1 tablet by mouth every day at 09:00.Review of R15's Quarterly Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 2 out of 15, which indicated severe cognitive impairment.Review of R15's Care Plan with a start date of 06/24/26 documented, Resident has an actual or potential psychosocial well-being problem related to dependent behavior, distractibility/inability to concentrate, inability to problem solve, and social isolation secondary to cognitive impairment/dementia, as evidenced by impaired memory, decreased ability to make appropriate decisions, reliance on others for assistance with daily needs, limited social interactions, and difficulty maintaining attention and participating in meaningful activities. On 06/24/26, staff reported an alleged inappropriate interaction with a male resident. Due to the resident's cognitive impairment, she was unable to consistently describe the incident or express how it affected her emotionally. No physical or emotional distress was observed or reported. Facility staff Implemented interventions to ensure the resident's safety.Review of R14's Face Sheet revealed R14 was admitted to the facility on [DATE], with diagnoses including, but not limited to, hypertension, left above the knee amputation, anxiety disorder, neurogenic bladder and Chronic Obstructive Pulmonary Disease.Review of R14's Medication Administration Record (MAR) revealed an order for Hydralazine 75mg give 1 tablet by mouth at 09:00, Carvedilol 12.5mg tablet give 1 tablet by mouth every day at 17:00, Amlodipine Besylate 10mg tablet give 1 tablet by mouth at 09:00.Review of R14's admission MDS revealed a BIMS score of 11 out of 15, which indicated moderate cognitive impairment.Review of R14's Care Plan with a start date of 06/24/26 documented, Resident exhibits impaired cognition: Resident will experience a and/or altered perception resulting in supportive environment where inconsistent reporting of events, inaccurate concerns are addressed statements, and difficulty distinguishing respectfully, and staff will between actual and perceived respond to reports in a manner occurrences, which may affect that promotes dignity, reduces relationships, care planning, and problem distress, and maintains the resolution. I display inappropriate social resident's psychosocial well-behavior (unwanted hand holding, attempts being through the next review at kissing, touching) period. 06/24/26 Allegation of inappropriate touching involving another resident. Resident denied the allegation and was educated on personal boundaries, consent, and reporting concerns to staff. Facility interventions remain in place to ensure resident safety and provide ongoing psychosocial support. During a phone interview on 07/02/26 at 4:08 PM, R15's Resident Representative (RR) revealed they visited R15 after they were notified on 06/25/26; during this visit, the RR stated R15 appeared withdrawn and not her normal happy self, which is typically her baseline. The RR further stated that when she spoke with the facility staff on 06/25/26, they weren't very forthcoming with the details on this situation and refused to provide her with a copy of the police report and would not say who the staff member/nurse was that witnessed this incident and did not adequately report this situation. RR finally stated that she would like the resident to transfer to another facility because she does not believe that facility has enough staff to adequately supervise residents. During a phone interview on 07/02/26 at 5:13 PM, Licensed Practical Nurse (LPN)1 revealed, I was doing med rounds, the RN (registered nurse) from the other end came over and told me that [R14] touched [R15] inappropriately in the dining room. I took [R15] back to her room first. I then assisted [R14] back to his room. I discussed personal boundaries with him and how his actions were inappropriate. [R14] said that he thought [R15] was a visitor and not a resident and he apologized.During an interview on 07/02/26 at 3:30 PM, the Social Services Director revealed, It was reported to me on 06/24/26 that on 06/22/26 a nurse said that she saw [R14] touch [R15] on the outside of her clothes in between her legs. I immediately got statements. When [R15] was asked about the incident, [R15] revealed, Yes, that man who lives over there. The resident was pointing at another resident. [R15] then indicated areas of her body where she reported being touched. [R15] pointed to her upper chest to her knees as being touched.During an interview on 07/02/26 at 5:45 PM, the Director of Nursing (DON) revealed, I have worked here since May of 2025. On Wednesday of last week, 06/24/26, I was made aware by the nurse that witnessed the events of an incident that took place a couple of nights prior. A male resident and a female resident were in the dining room. The male resident was facing the female resident and he was leaning forward. The female resident carries a baby doll around with her. The nurse thought the resident was looking at or talking to the doll. The nurse moved closer to get a better look at what was going on and observed the male resident rubbing the female resident's vaginal area on the outside of her clothing. The nurse immediately separated the residents. [R14] was taken to his room on 200 hall. [R15] was taken to her room on 100 hall. The nurse reported to the nurse assigned to the residents what occurred. On Wednesday when I found out, I made the Administrator and my consultant aware. A psychosocial assessment was performed on both residents. A head-to-toe assessment was completed on [R15] to check for injuries. [R14] was moved to the 400 hall far away from [R15]. We initiated one on one with [R14]. [R14] continues on one on one. Staff are aware that the Administrator is the abuse coordinator. They know that they are to report abuse immediately. If we are not here, they should notify myself and the on-call nurse and we will notify the administrator. [R14] also had a tele-visit with psyche this week.During an interview on 07/02/26 at 5:50 PM, the Administrator revealed, we suspended one nurse and terminated the other. The nurse that was suspended separated the residents when the incident occurred and reported it to the nurse assigned to the residents. She was correct up to that point. The nurse assigned to the residents did not report the incident. I was disappointed that this was not reported to me immediately. Staff have been educated to report witnessed or suspected abuse immediately.

Based on review of the facility policy, record review, and interview, the facility failed to report an allegation of abuse within the regulated timeframe, for 2 of 27 residents reviewed for abuse.Findings include:Review of the facility's policy, with a copyrighted date of 2001, titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, revealed, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation: Reporting Allegations to the Administrator and Authorities 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury: or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.Review of R15's Face Sheet revealed R15 was admitted to the facility on [DATE] with diagnoses including, but not limited to: Dementia, essential hypertension, depression and Pure Hyperglyceridemia.Review of R14's Face Sheet revealed R14 was admitted to the facility on [DATE] with diagnoses including, but not limited to: hypertension, left above the knee amputation, anxiety disorder, neurogenic bladder and Chronic Obstructive Pulmonary Disease.During an interview on 07/02/26 at 3:30 PM, the Social Services Director revealed, It (incident involving R14 and R15) was reported to me on 06/24/26, that on 06/22/26, a nurse said that she saw R14 touch R15 on the outside of her clothes in between her legs. The Social Services Director stated, I immediately got statements. When R15 was asked about the incident, R15 stated, Yes, that man who lives over there. The resident was pointing at another resident. R15 then indicated areas of her body where she reported being touched. R15 pointed to her upper chest to her knees as being touched.During a phone interview on 07/02/26 at 4:08 PM, R15's Resident Representative (RR) revealed that they were not notified about this incident with R15 and R14 until last Wednesday (06/24/26); however, this incident occurred on 06/22/26. The RR further stated that when she spoke with the facility staff on 06/25/26, they weren't very forthcoming with the details on this situation and refused to provide her with a copy of the police report and would not say who the staff member/nurse was that witnessed this incident and did not adequately report this situation. RR finally stated that she would like the resident to transfer to another facility because she does not believe that facility has enough staff to adequately supervise residents. During a phone interview on 07/02/26 at 5:13 PM, Licensed Practical Nurse (LPN)1 revealed, I was doing med rounds, the RN (registered nurse) from the other end came over and told me that [R14] touched [R15] inappropriately in the dining room. I took [R15] back to her room first. I then assisted [R14] back to his room. I discussed personal boundaries with him and how his actions were inappropriate. [R14] said that he thought [R15] was a visitor and not a resident and he apologized. I did not report it. I thought the RN was going to report it to the Director of Nursing since she saw it.During an interview on 07/02/26 at 5:45 PM, the Director of Nursing (DON) revealed, On Wednesday of last week 06/24/26, I was made aware by the nurse that witnessed the events of an incident that took place a couple of nights prior . The nurse observed the male resident rubbing the female resident's vaginal area on the outside of her clothing. The nurse immediately separated the residents. The nurse reported to the nurse assigned to the residents what occurred. On Wednesday when I found out, . Staff are aware that the Administrator is the abuse coordinator. They know that they are to report abuse immediately. If we are not here, they should notify myself and the on-call nurse and we will notify the administrator.During an interview on 07/02/26 at 5:50 PM, the Administrator revealed, we suspended one nurse and terminated the other. The nurse that was suspended separated the residents when the incident occurred and reported it to the nurse assigned to the residents. She was correct up to that point. The nurse assigned to the residents did not report the incident. I was disappointed that this was not reported to me immediately.

Based on interview, record review, and facility document and policy review, the facility failed to ensure an assessment was completed for 1 (Resident (R)67) of 1 sampled resident reviewed for an injury of unknown origin when the resident experienced a change in condition. Specifically, on Friday, 03/27/26, Certified Nurse Assistant (CNA)15 discovered R67 had a red, swollen left arm and informed the Unit Manager (UM) of the resident's change in condition. There was no evidence that the facility assessed R67's arm until Monday, 03/30/26, when an x-ray revealed R67 had a displaced fracture of the left humerus (the long bone in the upper arm). Records revealed that prior to the discovery of the fracture, pain assessments completed every shift indicated R67 had a pain level of 0 (on a scale of 0-10, with 0 being no pain and 10 being the worst possible pain), except for two incidences of moderate pain, once on 03/29/26 and once on 03/30/26, which was relieved with acetaminophen (an analgesic/pain reliever). Findings included: A facility policy titled, Acute Condition Changes - Clinical Protocol, dated 03/2018, specified, in the section Assessment and Recognition that, 2. In addition, the nurse shall assess and document/report the following baseline information: a. Vital signs; b. Neurological status; c. Current level of pain, and any recent changes in pain level; d. Level of consciousness; e. Cognitive and emotional status; f. Resident's age and sex; g. Onset, duration, severity; h. Recent labs; i. History of psychiatric disturbances, mental illness, depression, etc. [et cetera, and other similar things]; j. All active diagnosis; and k. All current medications. The policy also specified, 7. Before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician; for example, the history of present illness and previous and recent test results for comparison. a. Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident/patient's current symptoms and status. An admission Record revealed the facility admitted R67 on 06/14/23. According to the admission Record, the resident had a medical history that included diagnoses of unspecified protein-calorie malnutrition, severe intellectual disabilities, vascular dementia, contracture of unspecified muscle and joint, muscle weakness, hypomagnesemia (low magnesium levels in the blood), hypokalemia (low potassium levels in the blood), and hypothyroidism. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/26/26, revealed R67 had severe impairment in cognitive skills for daily decision-making and had a short-term and long-term memory problem per a staff assessment of mental status (SAMS). The MDS indicated R67 was dependent on staff assistance for oral hygiene, toileting hygiene, showering and bathing, upper and lower body dressing, putting on and taking off footwear, and personal hygiene. The MDS indicated R67 was also dependent on staff assistance to roll left and right, to move from sitting to lying, for chair-to-bed and bed-to-chair transfers, and for tub and shower transfers. The MDS indicated that R67 had a feeding tube. R67's undated Care Plan Report included a focus area that indicated the resident had limited physical mobility related to contractures of the left arm and bilateral lower extremities, intellectual disabilities, and vascular dementia. Interventions (undated) directed staff: - to turn and reposition the resident as needed; - to utilize a mechanical lift, the assistance of two staff members, and an extra-large sling for transfers; - that the resident was maximally dependent on one staff for locomotion; and - to monitor, document, and report as needed any signs or symptoms of immobility, contractures forming or worsening, thrombus formation, skin breakdown, and fall related injuries. R67's undated Care Plan Report also included a focus area that indicated the resident was nonverbal but could point, smile when happy, and cry to alert staff of a perceived issue or need. Interventions (undated) directed staff to observe nonverbal cues. R67's Order Recap Report, dated for the timeframe starting 04/01/25 through 04/30/26, revealed: - Document Pain Level every shift for pain monitoring, started 07/17/23, and - Acetaminophen Tablet 326 MG [milligrams] Give 2 tablet[s] via PEG [percutaneous endoscopic gastrostomy tube, a tube from the abdomen to the stomach] Tube every 6 hours as needed for pain, started 07/25/24. R67's Medication Administration Record [MAR], dated 03/26, revealed: - On 03/27/26, 03/28/26, and 03/29/26 during the Day and Nigh[t] shifts and on 03/30/26 during the day shift the resident's pain level was assessed as 0 on a scale of 0 - 10; - On 03/29/26 at 6:08 AM, the resident's pain was 5, on a scale of 0 - 10, staff administered 650 mg of acetaminophen, and the medication was effective; and - On 03/30/26 at 3:11 PM the resident's pain was 4, on a scale of 0 - 10, staff administered 650 mg of acetaminophen, and the medication was effective. R67's Skin Monitoring: Comprehensive CNA Shower Review, dated 03/27/26, revealed that CNA15 informed the floor nurse that she noticed the resident's arm was red and swollen. A late entry UM's Progress Note[s], dated 03/27/26, at 3:46 PM, indicated a CNA reported that R67's arm appeared swollen. The Progress Note indicated that the observation was reported to the Nurse Practitioner (NP) while the NP was present at the facility. The Progress Note indicated that the NP was contacted by telephone to follow up regarding the reported swelling. The Progress Note indicated the NP acknowledged the report and stated they would evaluate the resident upon return to the facility on the following Tuesday. The Progress Note indicated that no new orders were given at that time. There was no documented evidence that the facility assessed R67's arm on 03/27/26. An order administration Progress Note[s], by Licensed Practical Nurse (LPN)14, dated 03/29/26 at 6:08 AM, indicated R67 received two tablets of 325 mg acetaminophen, via a PEG tube for signs and symptoms of pain. There was no documentation that the location of the pain was assessed. A review of UM's Progress Note[s], dated 03/29/26 at 8:47 AM, indicated the administration of the acetaminophen was effective, and R67's pain was 0 on a scale of 0 -10. A nurse's Progress Note[s], by LPN13, dated 03/30/26 at 3:11 PM, indicated R67 was in bed grabbing their left arm. The note revealed the resident's arm was swollen from the elbow to the shoulder, the arm was slightly warm to touch, and the resident had facial grimacing with range of motion of the left arm. The Progress Note indicated LPN13 notified the NP and received a new order for a venous doppler (non-invasive ultrasound) of R67's left arm and an x-ray of the resident's left shoulder, humerus, and elbow. The Progress Note indicated Tylenol (Brand name for generic acetaminophen) was given to R67 for pain. A nurse's Progress Note[s], by LPN13, dated 03/30/26 at 5:33 PM, indicated the administration of the acetaminophen was effective, and R67's pain was 0. An SBAR (Situation Background Assessment Recommendation) Summary for Providers Progress Note[s], dated 03/30/26 at 7:00 PM, indicated R67 experienced a change in condition, and nursing observations included facial grimacing. The SBAR Progress Note revealed a primary care provider recommendation to send R67 to an emergency room. A nurse's Progress Note[s], by LPN13, dated 03/30/26 at 7:00 PM, indicated R67 had a fracture of the right humerus, and the radiology technician stated a formal report would be sent to the facility. A nurse's Progress Note[s], by LPN13, dated 03/30/26 at 10:54 PM, indicated a correction was made to indicate R67's fracture was to the left humerus. A nurse's Progress Note[s], dated 03/31/26 at 9:30 PM, indicated R67 was hospitalized . R67's hospital admission H & P [History and Physical], in the section Objective revealed: - a CT [Computed Tomography] Humerus Left wo [without] Contrast, dated 03/31/26, indicated the resident had an acute comminuted [a broken bone with multiple pieces] and displaced fracture of the distal [away from the center of the body] humerus; - an XR [x-ray] Shoulder 2+ Vw [two views] Left, dated 03/30/26, indicated the resident had a displaced fracture of the distal left humerus; and - an XR Humerus Left, dated 03/30/26, indicated the resident had an acute mildly displaced fracture of the distal left humerus. A Witness Statement Form, completed by CNA18, dated 03/30/26, revealed they went into R67's room to provide care and noticed the resident was holding their arm and crying. The Witness Statement Form revealed CNA18 called the nurse into the room to check the resident before providing care. A Witness Statement Form, completed by LPN13, dated 03/30/26, indicated that at approximately 10:00 AM a CNA called LPN13 to R67's room to look at the resident's left arm. LPN13's Witness Statement Form revealed R67's left arm was swollen, painful, and slightly warm to the touch; the resident usually had flaccid range of motion and at baseline was contracted; and this was a new finding. LPN13's Witness Statement Form revealed LPN13 reported the findings to the NP, and new orders were received for a radiology exam and venous ultrasound. LPN13's Witness Statement Form revealed at 6:50 PM a radiology technician did an x-ray and verbally reported a fracture of the left humerus. LPN13's Witness Statement Form revealed LPN13 reported the results to the NP, and a new order was given to transfer the resident to an emergency department. CNA17's emailed witness statement, dated 03/30/26 at 8:53 PM, indicated that on Monday, 03/30/26 at around 6:19 AM, they were doing their last round (systematic, scheduled nursing staff visits to check on residents) for R67 and noticed the resident's left arm looked bigger than normal. CNA17 stated they noticed that R67 cried when the resident was rolled toward the wall. CNA17 stated they asked LPN2 and LPN9 to look at R67's arm to see if it was swollen, and the LPNs both agreed it was. CNA17 stated LPN2 contacted the UM and was told they had been putting something on the resident's arm since Friday, 03/27/26; however, CNA17 stated they worked the weekend and that information was not communicated to them. CNA15's emailed witness statement, dated 03/30/26 at 8:58 PM, indicated they were assigned to R67 on Friday, 03/27/26, and Saturday, 03/28/26, morning. CNA15 stated on Friday, 03/27/26, they noticed swelling to R67's arm, and they notified LPN9, who instructed the CNA to let the UM know. CNA15 stated they told the UM about the swelling but accidentally informed the UM of the wrong resident. CNA15 stated that the UM immediately notified the doctor, who was in the facility at the time. Per the statement, CNA15 followed up two hours later to see if R67 had been seen and discovered that she had mistakenly given the UM R67's roommate's name when she initially notified the UM of the concern. CNA15 revealed the UM stated they would contact the doctor to inform them of the error. CNA15 stated R67's arm was still swollen when CNA15 came into work the following day, and they informed LPN9 immediately. The UM's emailed Witness Statement, dated 03/30/26 at 9:19 PM, revealed that on 03/27/26 during the morning hours, CNA15 reported to them that a resident's arm appeared swollen and identified the resident as R67's roommate. The UM's Witness Statement revealed the UM promptly communicated to the NP, who was in the facility at the time, and the NP assessed R67's roommate. The UM's Witness Statement revealed CNA15 later notified the UM that the resident name initially provided was incorrect, and CNA15 clarified that R67 was the resident observed to have a swollen arm. The UM's Witness Statement revealed on 03/27/26 at 3:36 PM the UM called the NP and informed them of the correct resident; the NP acknowledged receipt of the updated information; and the NP indicated they would evaluate R67 upon their return to the facility on [DATE]. LPN9's emailed Witness Statement, dated 03/31/26 at 8:21 AM, revealed that on the morning of 03/27/26, CNA15 asked them to look at R67's arm. LPN9's Witness Statement revealed they asked CNA15 to notify the UM since they were working on the medication cart. LPN9's Witness Statement revealed they overheard CNA15 asking the UM to look at R67. LPN9's Witness Statement revealed later LPN9 briefly listened to a conversation between CNA15 and UM long enough to hear the UM say that the NP went in to look at a patient in R67's room. LPN9's Witness Statement revealed they were never made aware of any concern or follow-up needed with R67. During an interview on 04/29/26 at 3:11 PM, LPN2 stated they had never heard R67 complain of pain and had never seen the resident grimace. LPN2 stated she was not aware that there was an issue with R67 until the morning of Monday, 03/30/26, when the CNA asked her to look at the resident's arm. LPN2 stated that when she saw R67's arm, it looked swollen, but the resident did not display any facial expressions of pain. LPN2 stated she did not do any type of assessment on the resident. LPN2 stated that when the situation was discussed with the UM, she learned it was known since Friday, 03/27/26 that R67's arm was swollen. During an interview on 04/29/26 at 3:20 PM, the UM stated that on 03/27/26 CNA15 reported a concern with a resident (not R67), and the NP saw the resident and did not see any concerns. The UM stated that when CNA15 later asked if they had looked at R67's arm, she pointed out to CNA15 that they had given a different resident's name earlier. She said that CNA15 apologized and confirmed that they needed to look at R67's arm. The UM stated that when the NP was notified of the correct resident, the NP gave orders to monitor the resident and stated they would assess R67 when they came back to the building the next Tuesday (03/31/26). The UM stated they were not sure whether the assigned nurse did an assessment of R67. The UM stated that monitoring meant observing the resident and assessing pain. The UM stated that they did not perform any type of assessment themselves as the assigned nurse was responsible for doing the assessment. The UM stated no one reported anything else regarding R67 that day. The UM stated they came in for about three hours over the weekend to assist with medication administration, and during that time no one made them aware the resident was having any pain or swelling. During an interview on 04/29/26 at 3:43 PM, CNA15 stated they were very particular with positioning residents, so when they came in around 6:30 AM (on 03/27/26) to make rounds, they noticed R67 was positioned awkwardly and picking at their arm. CNA15 stated that after showering and dressing R67, the resident kept picking at their arm. CNA15 stated R67's arm looked different, so they let LPN9 know. CNA15 stated LPN9 instructed them to tell the UM because they (the UM) would be the one to notify the doctor. CNA15 stated a few hours later it was determined the wrong resident was observed. CNA15 stated they used a pillow to prop up R67's arm. During an interview on 04/30/26 at 9:54 AM, LPN9 stated that on 03/27/26 there were three nurses completing medication pass, she was assigned to Medication Cart 3, and she was not assigned to R67. LPN9 stated a CNA approached her and requested that she assess R67, and she informed the CNA that the UM was assigned to R67's cart. LPN9 stated that later the CNA returned to the UM to inquire what actions had been taken regarding R67. LPN9 stated she cared for R67 during the afternoon of 03/27/26 and throughout the remainder of the weekend. LPN9 stated she did not become aware which arm was swollen until Monday, 03/30/26. LPN9 stated the swelling involved the resident's left arm, which was positioned closest to the wall. LPN9 stated the resident did not appear to be grimacing or exhibiting signs of pain, and the resident was quiet and watched television. LPN9 stated that while providing care, she approached the resident from the right side due to the resident's PEG tube placement. LPN9 stated she had no reason to assess the resident's left arm because the UM had not communicated any concerns regarding the arm during report. LPN9 stated that several days later, she asked the UM whether the resident's arm had ever been assessed, and the UM responded that the arm did not appear swollen. During an interview on 04/30/26 at 10:27 AM, LPN13 stated she was caring for R67 (on 03/30/26) when, at approximately 10:00 AM, a CNA informed her that the R67's left upper limb appeared swollen. LPN13 stated she observed visible swelling of R67's left upper limb, and the resident was uncomfortable. LPN13 stated she contacted the NP and reported that R67's left upper extremity appeared swollen and that the resident seemed uncomfortable. LPN13 stated that the NP instructed her to order tests, and the radiology department completed testing that revealed R67 had sustained a fracture. LPN13 stated she was instructed to send the resident to the hospital immediately. LPN13 stated she had cared for R67 on Thursday, 03/26/26, and at that time the resident was at their baseline without swelling or pain. During an interview on 04/30/26 at 11:26 AM, the UM stated she was not responsible for completing the assessment on R67, as the assigned nurse was responsible for performing the assessment. During a follow-up interview on 05/01/26 at 11:01 AM, the UM stated she assisted with medication administration on Friday, 03/27/26 and Saturday, 03/28/26. The UM stated that if an issue arose with a resident, either she or the assigned nurse could have completed the assessment. The UM further stated that if there was a change in condition, she or another member of management would follow up to ensure an assessment was completed. The UM stated she was unsure why an assessment was not completed for R67. The UM stated LPN9 was the floor nurse, and her expectation was that LPN9 would have completed the assessment for R67 on 03/27/26. The UM stated that the incorrect resident information had initially been provided to the NP. The UM stated that when she contacted the NP again with the correct resident information, the NP instructed staff to monitor R67 and stated she would follow up on Tuesday, 03/31/26. The UM stated monitoring included observing R67's arm for any irritation and following up regarding complaints of pain. During an interview on 04/30/26 at 1:02 PM, the NP stated that when a resident had a change in condition, she expected staff to report it to her. The NP stated she was initially informed of a resident that had experienced arm swelling; however, the resident she assessed did not have any swelling. The NP stated she was notified on Monday, 03/30/26, regarding the correct resident, R67, and she did not recall being notified otherwise. The NP stated when she received a text message from the floor nurse reporting that R67 had arm swelling and was holding their arm crying, she ordered a stat (statim, immediately, at once) x-ray because she wanted the results as soon as possible. The NP stated later that evening she was notified that R67 had a fracture, and she ordered the resident to be sent out for further evaluation. The NP stated she believed R67's fracture may have been pathological due to the resident's comorbidities. During a follow-up interview on 05/01/26 at 12:15 PM, the NP stated that when R67's swelling was reported to her on Monday, 03/30/26, she ordered a doppler and x-ray, and, if she had received that call on Friday she likely would have provided the same order. The NP stated that when she was contacted on Monday, she believed the nurse informed her that R67 was holding their arm and crying in pain. During an interview on 05/01/26 at 4:27 PM, the DON stated that if a resident had a change in condition an instant assessment should be completed and the findings reported to the NP. The DON stated staff now also had to notify the medical doctor. The DON stated he would also expect to be notified, even if he was off work, so that he was aware of what was going on. The DON stated that after they were notified on Monday (03/30/26) of R67's change in condition an ad hoc (for this purpose only) Quality Assurance and Performance Improvement (QAPI) meeting was held, and a skilled assessment was completed on every resident in the facility. The DON stated an immediate assessment was done on R67, the resident was sent to the hospital, and notifications were made. The DON stated that all staff were educated on the transfer process for dependent adults. The DON stated they did a daily audit of all residents who had experienced a change in condition during the last seven days to ensure they were handled appropriately. The DON stated the facility completed weekly audits for resident changes in condition for four weeks to ensure they were handled appropriately, and they were just starting monthly audits for the next two months. During a concurrent interview on 04/30/26 at 12:23 PM with the Director of Nursing (DON) and the Registered Nurse Consultant (RNC), the DON stated he was not in the facility during the time period of R67's change in condition and was made aware of the situation on Monday, 03/30/26. The DON stated that when the UM was told the correct resident's name, the NP had already left the facility. The DON stated the expectation was that once the UM was notified, an assessment should have been completed on R67, and the assessment findings should have been communicated to the NP. The RNC stated their investigation revealed that clinical staff initially identified the wrong resident, and the facility implemented a Plan of Correction (POC), including staff education and audits. During an interview on 05/01/26 at 4:53 PM, the Administrator (ADM) stated that when a resident experienced a change in condition, they expected the nurse to assess the resident for whatever issue was being reported, to ensure the concern was addressed. The ADM stated that the nurse should then notify the provider and nurses of any findings and follow the orders given. The facility's actions to correct the failed practice related to not assessing a resident after a change in condition revealed: 1. [Initials of R67] was assessed with a change of condition on 3/30/26 [03/20/26] with notification and new orders received and carried out by LN [licensed nurse] on shift. 2. A physical assessment of residents residing in the facility will be completed on 3/30/26 [03/30/26] to identify other residents that may have a change of condition. Those identified (change of condition) will be addressed immediately by the licensed nurse. 3. Licensed nurses will be re-educated regarding the requirements of managing resident change of condition beginning 4/1/26 [04/01/26] and continuing until all LN's receive this education. 4. An audit of clinical change of condition (24 hour report, change of condition notification) will be completed daily for 7 days, weekly for 3 weeks and monthly for 2 months to validate staff continue to identify and manage resident change of condition as required. Results of these audits will be brought to the monthly QAPI [Quality Assurance Performance Improvement] for review and recommendations for 3 months and as needed. The DON is responsible for ongoing compliance. 5. Date of Compliance: 4/1/26 [04/01/26]. Verification of the facility's corrective actions revealed the following: - R67's Skilled Evaluation, dated 03/30/26, revealed a new issue involving the left forearm and non-verbal/facial expressions of pain was identified, notifications were made, and new orders were received and carried out; - A Midnight Census Report, dated 03/31/26, and a UDA [unscheduled assessment] List, dated 04/01/26, revealed physical assessments of all residents residing in the facility were completed, and no other residents were identified with a change in condition; - An In-Service Training Record, dated 04/01/26, titled Change in Condition/Event Reporting revealed the training was attended by 11 nurses and covered the requirements of a resident change in condition, the correct chain of command, correct documentation, correct follow-up, medical doctor notification, and DON notification. Interviews with staff revealed their knowledge on how to manage a resident's change in condition included assessing the resident, reporting to the physicians, following physician orders, and notification of the DON; - In-Service Training Record, dated 04/02/26 and 04/05/26, titled Repositioning - transferring Resident from bed to chair was completed by 34 nursing staff; - On 04/02/26 an audit of clinical changes was completed daily for seven days and completed weekly for three weeks. Audit reports for Changes of Condition were dated for the timeframe starting 04/02/26 through 04/08/26, 04/15/26, 04/22/26, and 04/29/26. A facility document titled QAPI Meeting Minutes for March 26, revealed an Ad [NAME] QAPI - Injury of Unknown Origin discussion; and - A Disciplinary Action Record, signed 04/03/26, revealed the UM received verbal disciplinary action regarding Failure to follow up with staff and NP regarding a change in condition of patient, failure to have staff reassess through weekend, no documentation provided, failure to obtain further orders; result in harm/reportable event. Based on verification of the facility's corrective actions, harm past noncompliance was cited.

Based on observation, interview, and facility document review, the facility failed to provide a safe, clean, and comfortable environment for residents in 2 (rooms [ROOM NUMBER]) of 7 rooms observed. Specifically, room [ROOM NUMBER] had a ceramic soap dish that was broken in half, resulting in jagged, sharp edges, and room [ROOM NUMBER] had a clogged sink. Findings include: During an interview on 04/30/26 at 9:25 AM, the Administrator (ADM) stated the facility did not have any policies regarding a homelike environment, building repair, or repair reporting. 1. An observation on 04/28/26 at 2:38 PM in room [ROOM NUMBER] revealed the soap dish inside the resident's bathroom was observed to be broken and missing half of its structure. The broken part exposed sharp and jagged edges of what remained of the soap dish. During an observation on 04/30/26 at 8:50 AM in room [ROOM NUMBER], the soap dish in the bathroom was still broken. During a concurrent observation and interview on 04/30/2026 at 10:14 AM with Licensed Practical Nurse (LPN)5 in room [ROOM NUMBER], LPN5 stated that the broken soap dish had the potential to pose a hazard to any resident who used it. LPN5 stated she did not know whether there was a work order for the broken soap dish. 2. An observation on 04/28/26 at 2:24 PM in room [ROOM NUMBER] revealed the bathroom sink was clogged and water was not draining. During an observation on 04/30/26 at 8:57 AM in room [ROOM NUMBER], the bathroom sink was clogged. During an interview on 04/30/26 at 9:01 AM, Housekeeper (HK)4 stated that he told the Maintenance Director about the sink two to three weeks prior, and the Maintenance Director poured de-clogging solution in the sink; however, he stated it did not resolve the problem. HK #4 stated he did not know what other attempts had been made to repair the issue. A facility Maintenance Punch List revealed no documented concerns or repairs for room [ROOM NUMBER]'s broken soap dish or room [ROOM NUMBER]'s clogged sink. Facility Work Order documents for the timeframe from 11/05/25 through 04/30/26 indicated no documented evidence that a Work Order had been completed for room [ROOM NUMBER]'s broken soap dish or room [ROOM NUMBER]'s clogged sink. During an interview on 04/30/26 at 1:57 PM, the Maintenance Director stated he was responsible for facility repairs. The Maintenance Director stated that staff notified him of maintenance requests verbally and in writing via a work order log binder located at each of the nursing stations. Per the Maintenance Director, staff were supposed to log work orders in the binder, even if they had verbally notified him of an issue. However, he stated that staff did not always follow up with logging work orders after verbal notification. The Maintenance Director stated that he was notified approximately three weeks prior that the sink in room [ROOM NUMBER] was clogged, and he poured acid in the pipe to resolve the problem. He stated he was not aware that the sink was clogged again. According to the Maintenance Director, he was not aware of room [ROOM NUMBER]'s broken soap dish. During an interview on 05/01/26 at 2:37 PM, the Director of Nursing (DON) stated that he expected residents to have a clean, safe, and functional environment. During an interview on 05/01/26 at 2:50 PM, the ADM stated that she expected repairs to be addressed.

Based on observation, interview, record review, Devilbiss 515 Series Instruction Manual review, and facility document review, the facility failed to maintain oxygen concentrators consistent with professional standards of practice for 2 (Resident (R)11 and R18) of 6 residents who utilized oxygen. Specifically, the facility failed to clean R11's oxygen concentrator filter weekly and failed to ensure preventative maintenance/servicing was completed for R11 and R18's oxygen concentrators. Findings included: During an interview on 04/30/26 at 10:33 AM, the Director of Nursing (DON) stated that the facility did not have a policy related to preventative maintenance or cleaning for oxygen concentrators. 1. An undated Devilbiss 515 Series Instruction Manual revealed, The air filter and connector should be cleaned at least once a week. To clean, follow these steps: 1. Remove the air filter, located on the back of the unit. Remove the oxygen outlet connector (if used). 2. Wash in a solution of warm water and dishwashing detergent Figure 10. 3. Rinse thoroughly with warm tap water and towel dry. The filter should be completely dry before reinstalling. An admission Record revealed the facility admitted R11 on 12/09/25. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease (COPD), vascular dementia with anxiety, sleep apnea. and hypertension (high blood pressure). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/18/2025, revealed that R11 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS revealed that the resident experienced shortness of breath or trouble breathing when lying flat and was receiving continuous oxygen therapy. R11's Care Plan Report dated 12/09/2025, included a focus area, that indicated the resident was at risk for respiratory complications related to a diagnosis of COPD, sleep apnea, and hypercapnia. Interventions (undated) directed staff to start supplemental oxygen as ordered and monitor for effectiveness. An Order Recap Summary for the timeframe from 12/27/2025 through 04/30/26 revealed that R11 had an order dated 01/12/26 for 3 liters (L) of supplemental oxygen via nasal cannula for an oxygen saturation level of less than 90%. The Order Recap Summary also contained an order dated 01/12/26 for staff to change and date the oxygen tubing and water humidification every Sunday night shift. An undated facility document revealed R11 utilized a Devilbiss Healthcare oxygen concentrator. R11's April 26 Medication Administration Record [MAR] revealed staff signed the MAR indicating they had changed and dated the resident's oxygen tubing and water humidifier bottle every Sunday on the night shift on the following dates: 04/05/26, 04/12/26, 04/19/26, and 04/26/26. There was no documented evidence that staff had cleaned the oxygen concentrator's air filter/connector. During an observation on 04/28/26 at 11:30 AM, R11 was observed lying in bed wearing an oxygen cannula, and an oxygen concentrator was on the floor next to the bed. The observation revealed that the oxygen concentrator filter was dislodged and was covered with visible dirt and lint. During an observation of R11 on 04/29/26 at 5:10 PM, the resident was observed lying in bed wearing an oxygen cannula and the oxygen concentrator was on the floor next to the bed. Resident 11's oxygen concentrator was observed to have thick, grayish white lint and dirt that covered the filter. The lint was so thick on the filter that it could not be pulled off with the fingers. During an observation and concurrent interview on 04/30/26 at 10:11 AM, Resident 11's oxygen concentrator was observed with visible thick, grayish white lint and dirt that covered the filter. Licensed Practical Nurse (LPN) #7 stated the filter was dirty and that it needed to be cleaned or changed. She further stated that the night shift nurses were responsible for ensuring the oxygen tubing was changed, filters were cleaned or replaced, and the entire concentrator was wiped down with alcohol wipes at least once a week, and if they appeared dirty. During an interview on 04/30/26 at 10:17 AM, the Unit Manager (UM) stated that the nurses and management team were responsible for ensuring concentrators were cleaned and filters were changed weekly on Sunday. The UM stated that the night shift nurses were responsible for cleaning the concentrators and changing the tubing. The UM stated she had not looked at R11's oxygen concentrator. During an interview on 04/30/26 at 10:59 PM, LPN8 stated that she worked the night shift and that night shift staff were responsible for cleaning oxygen concentrator filters. She stated that she had taken care of R11, and at times staff could not enter the resident's room at night due to the resident's behavior, which resulted in things being missed. During an interview on 4/30/26 at 11:21 AM, the DON stated that he expected oxygen concentrators to be cleaned weekly on Sunday night and as needed. He stated that any staff member could clean them. The DON stated that he had not seen R11's concentrator and had not been notified that it was dirty. During an interview on 04/30/26 at 1:41 PM, the Administrator stated that the expectation was for the facility to follow protocol. During an interview on 05/01/26 at 9:52 AM, the Regional Nurse Consultant (RNC) stated nursing staff should monitor the cleanliness of oxygen concentrators when changing out the tubing, but there was no documentation that they were monitoring the cleaning of the oxygen concentrators. 2. An undated manufacturer's Devilbiss 515 Series Instruction Manual revealed, The following troubleshooting chart will help you analyze and correct minor oxygen concentrator malfunctions. If the suggested procedures do not help, switch to your reserve oxygen system and call your [medical supply homecare provider]. Do not attempt any other maintenance. The manual did not address preventative maintenance/servicing. A list provided by the facility of residents who utilized oxygen concentrators revealed two residents, R11 and R18, utilized the DeVilbiss brand concentrator. During an interview on 04/30/26 at 1:57 PM, the Maintenance Director stated that the oxygen concentrator company was responsible for their machines and performed maintenance and servicing. He was unable to provide any records indicating the oxygen concentrators had received preventative maintenance or servicing. He stated it was the responsibility of the DON or the Unit Manger (UM) to contact the 800 number on the machines to have them serviced and checked regularly. During an interview on 04/30/26 at 11:21 AM, the DON stated that he did not have any knowledge of when the last time the facility oxygen concentrators had been serviced. He stated he did not know who to call about servicing the concentrators. He was unable to provide any documentation indicating when the oxygen concentrators had received preventative maintenance or servicing. During a follow-un interview on 04/30/26 at 3:22 PM, the DON stated their oxygen provider company maintained the concentrators that they (the oxygen provider company) provided. During a telephone interview on 05/01/26 at 9:35 AM, a Customer Service Representative (CSR) from the oxygen provider company revealed that they did not provide DeVilbiss Healthcare concentrators to the facility. During an interview on 04/30/26 at 1:41 PM, the Administrator stated that the expectation was for the facility to follow protocol. She stated that she was not aware of any timeframe or schedule for cleaning or maintenance of the oxygen concentrators.

Based on facility policy review, facility document review, record review, and interview, the facility failed to ensure that dialysis services were consistent with professional standards of practice including monitoring and documenting of ongoing assessment and oversight of a resident before and after dialysis treatments, and documentation of ongoing communication and collaboration with the dialysis center for 1 (Resident (R)28) of 1 resident reviewed for dialysis. Findings included: A facility policy titled, End-Stage Renal Disease, Care of Resident with, revised September 2010, revealed, Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. A facility policy titled, Charting and Documentation, revised July 2017, revealed, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. An admission Record revealed the facility admitted R28 on 04/10/26. According to the admission Record, the resident had a medical history that included diagnoses of ESRD, dependence on renal dialysis, type 2 diabetes without complications, hypocalcemia, essential hypertension, hyperkalemia, and hypomagnesemia. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/15/26, revealed R28 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed the resident received insulin, and special treatments included hemodialysis. R28's Care Plan Report included an undated focus area that indicated the resident was at risk for complications related to the diagnosis of diabetes mellitus and indicated that the resident received insulin injections. Undated interventions directed staff to administer medications, including insulin, as ordered, and report abnormal fingerstick blood sugar levels to the physician per the ordered ranges. The Care Plan Report included an undated focus area that indicated the resident needed hemodialysis related to ESRD. Undated interventions directed staff to check and remove the dressing at the right subclavian access site daily as ordered; document any bleeding or leakage from the site and apply pressure as needed; monitor/document/report as needed any signs and symptoms of infection to the access site such as redness, swelling, warmth or drainage; monitor/document/report any signs or symptoms of renal insufficiency such as changes in level of consciousness, changes in skin turgor, oral mucosa, and changes in heart and lung sounds as needed; and monitor/document/report any signs or symptoms of bleeding, hemorrhage, bacteremia, or septic shock, as needed. The Care Plan Report included an undated focus area that indicated the resident had a potential for fluid alterations related to ESRD and indicated the resident was on hemodialysis and used diuretic medications. Undated interventions directed staff to administer medications as ordered, monitor/document for side effects and effectiveness, and monitor vital signs as ordered/per the protocol and record. R28's Order Summary Report, with active orders as of 04/29/26 included an order, dated 04/13/26, for dialysis chair time scheduled for 12:30 PM. The order specified that transportation pickup was arranged for 12:00 PM and the resident was to be ready by 11:00 AM. The order indicated that a progress note was to be completed prior to the visit. The order specified that dialysis was to be completed every day shift every Monday, Wednesday, and Friday. A facility agreement between the facility and the dialysis provider used for Resident #29 titled, Long-Term Care Facility Outpatient Dialysis Services Agreement, effective 11/01/2013, revealed, Preparation of ESRD Residents included The Nursing Facility shall ensure that ESRD Residents are prepared to spend an extended length of time at the ESRD Dialysis Unit and have received proper nourishment and any medications prescribed, as appropriate, before coming to the ESRD Dialysis Unit. The agreement also revealed, Collaboration of Care included Both parties shall ensure that there is documented evidence of collaboration of care and communication between the Nursing Facility and ESRD Dialysis Unit. R28's dialysis binder included a page that revealed, When documenting a resident returning from dialysis, the goal is to clearly show their condition, any changes, and continuity of care. Keep it concise but clinically complete. Here is a guide you can follow. The document revealed, Start with arrival details, which specified Time of return from dialysis; Mode of transport; and Who accompanied (if applicable). The document also revealed, Assess and document the condition immediately, which specified, Level of consciousness (alert, drowsy, confused); General appearance (stable, fatigued, pale, etc. [et cetera; and so forth]), Vital signs (BP [blood pressure], pulse, respirations, temperature, 02[oxygen] if needed). The document revealed, Note dialysis-related observations, which specified Presence of common post-dialysis symptoms including Fatigue, Dizziness, Hypotension, and Nausea/vomiting; and any complications reported by dialysis staff. The document revealed, Check the access site, which specified AV fistula/graft or catheter; Bruit/thrill present (if applicable); and Bleeding, swelling, redness, or dressing condition. The document revealed, Review weight and fluid status, which specified, Pre-and post-dialysis weight if available; and Signs of fluid overload or dehydration. The document revealed, Pain assessment, which specified Location, rating (0-10), and intervention if needed. The document continued, Medications and treatments, which specified Meds [medications] given post-dialysis (if ordered); and Any new orders received. The document continued, Safety measures, which specified Fall precautions (especially if weak/dizzy); and Assistance with ambulation. The document continued, Resident response, which specified How they tolerated dialysis overall; and Any complaints or statements from the resident. The document continued, End with status and plan, which specified Current condition (stable, resting, etc.), and What staff will continue to monitor. The binder contents included the phone number to the dialysis center. R28's dialysis binder included a Dialysis Communication Record form, which included a section to be completed by the facility and a section to be completed by the dialysis center. The form revealed the section completed by the facility included general information, including the resident's name; physician's name; facility contact information; and dialysis frequency, time, and center. The form revealed the section also completed by the facility included pre-dialysis information, which included Vital Signs, Medications Administered, Medications Held, Meal Provision, and the resident's Condition Alert. The form revealed the section to be completed by the dialysis center included Pre-dialysis Weight, Post Dialysis Weight, if there were any incidents related to the dialysis, Antibiotics Given, Lab Work Completed, Post Dialysis Vital Signs, and Recommendations/Follow Up. R28's April 26 Medication Administration Record [MAR] indicated that the resident was transferred to dialysis on 04/15/26, 04/17/26, 04/20/26, 04/24/26, and 04/29/26 according to the order. The MAR revealed no coding for 04/22/26. Per the MAR, the resident refused dialysis on 04/27/26. R28's dialysis binder revealed the following: -An undated Dialysis Communication Record with the information completed by Licensed Practical Nurse (LPN)3 and by the dialysis center. - A Dialysis Communication Record, dated 04/24/26, completed by LPN5 and by the dialysis center. - An undated Dialysis Communication Record completed by LPN7 and not completed by the dialysis center. - A Dialysis Communication Record revealed the section to be completed by the facility was completed by LPN7 but was undated, and the section to be completed by the dialysis center was completed and dated 04/22/26. - An undated Dialysis Communication Record completed by the Unit Manager (UM) and by the dialysis center. Also included were additional vital signs documented at the bottom of the form with a time of 6:00 PM written. - An undated Dialysis Communication Record completed by the UM and by the dialysis center. - An undated Dialysis Communication Record completed by the dialysis center but not the facility. R28's Progress Notes revealed no pre-dialysis notes on 04/15/26, 04/20/26, 04/22/26, 04/24/26, or 04/29/26. R28's record revealed no evidence that the facility's staff completed a post-dialysis assessment of the resident on 04/15/26, 04/17/26, 04/22/26, 04/24/26, or 04/29/26. During an interview on 05/01/26 at 11:45 AM, LPN9 stated that there was a form that staff filled out that went with R28 to dialysis. She stated that staff checked the resident's vital signs and administered the medications prior to the resident going to dialysis. She stated that the nurses put the information on the form, not in the electronic medical record. She stated that when the resident returned from dialysis, they got the dialysis binder back, and the form included information, such as post dialysis weight and vital signs. She stated that staff checked the resident's vital signs again, and they also went on the form. She stated that staff had to call the dialysis center if they did not document on the form, but she never had to call them. LPN9 reviewed the communication form for 04/15/26 and stated that the UM helped her that day and filled out the communication form for her. She stated she checked the resident's blood pressure because she had to with the medication the resident took. She stated that the UM helped with the other vital signs. She stated that they got the communication form back when the resident returned, and it went into the dialysis binder. She stated staff were supposed to enter a progress note into the electronic medical record when the resident went to dialysis and when the resident came back from dialysis. She stated they documented how the resident left, such as on a stretcher. She stated staff did not have to document the weight or vital signs because that information was on the communication form. During an interview on 4/30/26 at 11:41 AM, LPN2 stated that there was a dialysis binder for R28 with communication forms. She stated that there was not a communication form for 04/17/26 and if the vital signs were not in the dialysis binder, she documented them in the electronic medical record. She stated that when she checked the resident's blood sugar level, she documented that under the vitals section in the electronic medical record and then she put it on the communication form. She stated she knew she had filled out the form on 04/17/26. She stated that there was a lot going on that day. She reviewed the progress notes and stated she did not do a progress note for that day after dialysis. LPN2 stated that there was only one dialysis binder for the resident. She stated the post dialysis vital signs would not be in the electronic medical record because they were from the dialysis center. She stated that if there was a concern from the dialysis center, staff followed up on it and brought it to the doctor's or nurse practitioner's attention and made a progress note. During an interview on 04/30/26 at 12:06 PM, LPN7 stated nurses were to check vital signs and follow any parameters for medications and filled out the communication form prior to dialysis. She stated that R28 did not have parameters for holding medications prior to dialysis. She stated the pre-dialysis information on the communication form dated 04/22/26 by the dialysis center was the pre-dialysis information for 04/20/26 that she had completed. She stated the form was placed in the wrong order in the dialysis binder, and the dialysis center staff dated the form as 04/22/26. She stated that when a resident went to dialysis, staff filled out the communication form, and she thought there might be a parameter in the electronic medical record to make a progress note. She stated that if there were no parameters, it would be best practice to make a progress note. LPN7 stated that they completed a post-dialysis assessment of the resident with vital signs and checked the catheter for excessive bleeding, bruit, and thrill. She stated staff should document that in the progress notes. During an interview on 04/30/26 at 11:05 AM, LPN5 stated that prior to R28's dialysis appointment, she administered the resident's insulin and medication and checked the resident's blood sugar level. She stated she completed the information on the communication form in the dialysis binder and added the blood sugar level, so the dialysis center knew what the levels were. She reviewed the communication forms in R28's dialysis binder and confirmed that there were multiple undated forms. She stated that of the ones she filled out, one for Wednesday (04/29/26) had no date on it, and she was not sure why she did not date it. She stated that the communication form dated 04/24/26 was signed by her. She stated the dialysis center filled out their part on the form, and if there were any order changes, the dialysis center staff put that on the form. She stated that she checked the dialysis binder when R28 returned. She stated that she checked the resident's port for thrill and bruit and if there was any bleeding, and that it was on the treatment administration record (TAR) to check off. She stated that if the dialysis center did not fill out the communication form, she let the UM know. She stated she just filled out the communication form, and she did not document a pre-dialysis or post-dialysis progress note. She stated she left the communication forms in the binder so the nurses could all see them. During a phone interview on 04/30/26 at 8:03 AM, LPN8 stated the process she followed prior to a dialysis appointment was to obtain the resident's vital signs and document them in the dialysis binder on the communication form. She stated that she put a progress note in the electronic medical record when the resident returned from dialysis. She stated she usually just put a note that indicated when the resident came back from dialysis, and if something changed, they wrote that information on the communication forms in the dialysis binder. During an interview on 04/30/26 at 5:10 PM, the UM stated that for a dialysis resident, staff were to make sure medications were taken, and an assessment was completed prior to going to a dialysis appointment. She stated that the nurse was to get the dialysis binder together and enter everything needed for the pre-dialysis documentation and make sure the communication form was filled out. She stated the nurse was to make sure to document the resident's vital signs, if medications were held, and stated that the assessment was documented in the progress notes in the electronic medical record. She stated that when the resident came back from dialysis, the nurse was to do a full assessment and check vital signs and make sure the communication form was filled out. She stated that if the communication form was not filled out, the nurse was to call the dialysis center. She stated the nurse was to document all of that (communication, assessments, vital signs, abnormalities, pain) in a progress note. She stated that the management team monitored to ensure progress notes and communication forms were completed, which included her, the Assistant Director of Nursing (ADON), the MDS Coordinator, and the Director of Nursing (DON). She stated the management team should be reviewing the progress notes and communication forms for R28, but they did not have the time. During an interview on 05/01/26 at 4:54 PM, the DON stated that the staff needed to make sure there was a progress note. He stated that when the patient arrived back from dialysis, staff completed their assessment of the patient and completed a progress note. He stated that prior to leaving and when a patient returned, there should be an assessment of the patient. He stated that the communication form should be uploaded in the electronic chart at a minimum. He stated that the nurse was responsible for ensuring the progress notes were completed and that the communication forms were completed. He stated the UM should review the progress notes and communication forms daily, and he would assist if needed. He stated that he expected the UM to bring concerns to his attention if anything was needed. During an interview on 05/01/26 at 4:36 PM, the Nursing Home Administrator stated that her expectation was for the nurses to follow the procedures that were in the dialysis binder, and to follow up on care that would have taken place at the dialysis center, when necessary, if there were any questions or concerns. She stated that documentation in the progress notes of the resident's record and the communication forms was important to show updated information from the resident's appointment/visit at the dialysis center. She stated that should the information from the dialysis center be unclear or not on the form, the nurse should call them and ask what was done.

Based on facility policy review, facility document review, observation, and interview, the facility failed to ensure expired medications were not available for resident use in 1 (Medication Cart #3) of 3 medication carts. Specifically, observations revealed a bottle of naproxen (medication used for pain) and a bottle of Orajel 2X Medicated Toothache Rinse had past the manufacturer's expiration date and were available for resident administration. Findings included: A facility policy titled, Storage of Medications, revised 11/01/2015, indicated, XII. Expired, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without closures are promptly destroyed according to facility procedures, and a replacement is ordered from the pharmacy. XIV. Medication storage conditions are monitored routinely and corrective action taken if problems are identified. A facility policy titled, Medication Labeling and Storage, revised 02/2023, indicated, Medication Storage 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. The policy further indicated, Medication Labeling 5. Multi-dose vials that have been opened or accessed (e.g., [exempli gratia or for example] needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. A facility Weekly Medication Cart Audit for Hall 400 dated 04/03/26, 04/10/26, 04/17/26, 04/24/26, and 04/27/26, revealed staff documented that there were no expired medications in the medication cart. During an observation of Medication Cart #3 (utilized for Hall 300 and 400) with Licensed Practical Nurse (LPN)6 on 04/29/26 at 2:51 PM the following medications were in the cart available for resident use beyond their expiration date: - a bottle of naproxen 220 milligrams (mg) with an opened dated of 04/29/26 (date of the observation) and a manufacturer's expiration date of 03/26 - a half empty bottle of Orajel 2X Medicated Toothache Rinse with an expiration date of 10/2024. LPN6 stated that the naproxen and Orajel were house stock medications and confirmed that both medications were expired. LPN6 stated it was important not to give expired medications to residents as they were not effective. During an interview on 04/29/26 at 3:08 PM, LPN5 stated that the Unit Manager (UM) and the Assistant Director of Nursing (ADON) audited medication carts for expired medications at least once per week. LPN5 stated that if nurses found expired or undated medications, they reported to the UM or Director of Nursing (DON) to have the medications destroyed. LPN5 stated expired medications were not effective. During an interview on 04/29/26 at 3:26 PM, LPN2 stated that expired medications were not effective. LPN2 stated that the UM audited medication carts weekly to check for expired medications and completed an audit form. During an interview on 04/29/26 4:03 PM, the UM stated she was responsible for completing weekly medication cart audits and completing an audit form, which was then submitted to the DON. The UM stated expired medications were destroyed. The UM stated she bought the bottle of naproxen that day and had brought it into the facility, but she did not check the expiration date on the bottle. During an interview on 04/30/26 at 4:17 PM, the Administrator (ADM) stated that the UM should have checked the naproxen before placing it into the medication cart. During an interview on 05/01/26 at 2:37 PM, the DON stated that he expected medication carts to be free of expired medications. He stated that expired medications would not be effective. During an interview on 05/01/26 at 2:50 PM, the ADM stated expired medications had to be disposed of and should not have been inside any medication cart.

Based on observation, interview, record review and facility policy and procedure review, the facility failed to maintain an effective infection control program across three (3) of three (3) units (Units 100, 300, and 400) and in the facility's kitchen and main dining room, which potentially increased the risk of disease and infection transmission for all residents who resided in the faciity. Findings include: The facility's Handwashing/Hand Hygiene policy (Version 2.0, H5MAPL0300) undated, identified hand hygiene as the primary method of infection prevention. This policy required all personnel to receive regular training on proper hand hygiene techniques to prevent healthcare-associated infections. Staff must use either alcohol-based hand rub or soap and water before and after direct resident contact, including when touching residents' intact skin and assisting with meals. A review of the policy and procedures document titled, Infection Control Manual Standard Precautions And Enhance Barrier Precautions last revised 4/24, noted: Purpose: Standard Precautions, first-tier, will be utilized on all residents. Enhanced Barrier Precautions will be utilized to reduce transmission of multidrug-resistant organisms (MDRO) that is not currently targeted by the CDC [Center for Disease Control]. The Transmission-Based Precautions (Contact, Droplet, Airborne), second-tier, will be utilized as applicable. The nurse will have the authority to initiate precautions without a physician's order in an emergency. The facility will utilize the Two-Tier Transmission Based Precautions as recommended by The Centers for Disease Control and Prevention (CDC). Observation during the initial tour from 9:05 a.m. through 10:30 a.m. of the 100 Unit on 4/15/25 revealed multiple bathrooms with signage displayed out of order. Further observation of the 300 Unit during the initial tour revealed the isolation cart was outside of a resident's room but the room lacked signage to indicate the resident was required infection control precautions (Resident (R)1. Observation on 4/15/25 at 11:30 a.m. revealed Certified Nursing Assistant (CNA)8 entered room [ROOM NUMBER] (same room without signage) to utilize 304-B's phone charger for another resident. The aide left the phone on top of the resident's chest of drawers. No hand sanitization was performed by CNA8 before or after entering the room. Observation of the lunch meal service in the main dining room on 4/15/25 from 11:45 a.m. through 12:00 p.m. revealed residents in the dining area were not provided with hand sanitization before meal service. Interview with CNA5 during meal service on 4/15/25 at 12:10 p.m. revealed sanitizer wipes were available for resident use but at times residents may get missed due to moving in and out of dining room. Observation during room meal service on 4/15/25 at 12:15 p.m. to room [ROOM NUMBER]-A revealed meal set-up was provided, but the resident was not offered hand hygiene prior to service. Observation in the dining room on 4/15/25 at 1:30 p.m. revealed the wall mounted hand sanitizer located between the dining room and room [ROOM NUMBER] was empty. Continued observation throughout the survey revealed the hand sanitizer at this location remained empty until 4/18/25 at 10:45 a.m. In an interview on 4/16/25 at 9:45 a.m., the Director of Nursing (DON) informed the surveyor that anyone on enhanced barrier precautions needed to wear a gown and gloves before entering a resident's room for any reason. In a follow-up interview on 4/18/25 at 11:55 a.m., the DON indicated the Infection Control Nurse provided him/her education on when to utilize enhance barrier precautions. The DON stated PPE was required when direct care was provided. Observation on 4/16/25 at 2:40 p.m. revealed that the wall mounted hand sanitizer located between the beauty shop and room [ROOM NUMBER] was empty. Additional observations on 4/18/25 at 11:00 a.m. revealed the same hand sanitizer remained empty. Observation of R1 on 4/17/25 at 9:15 a.m. revealed agency CNA2 was providing personal hygiene care to the resident without wearing proper Personal Protective Equipment (PPE). Observation outside of the resident's room revealed no Enhance Barrier Precautions signage was posted. R1's clinical record review revealed a diagnosis of Urinary Retention that required the use of a suprapubic catheter. Interview on 4/17/25 at 1:35 p.m. with agency CNA2 revealed that on the first day working in the facility, the Unit Manager (UM) instructed him/her on the R1's care needs, but the aide was not instructed on Enhance Barrier Precautions. In a phone interview conducted on 4/17/25 at 11:00 p.m. Licensed Practical Nurse (LPN)1 revealed that he/she was employed with the facility for over a year. She/he stated that plumbing had been an issue since her employment. Therefore, residents and staff had to share bathrooms. Observation on 4/18/25 at 9:15 a.m. revealed CNA4 entered the kitchen to retrieve a carton of milk. CNA4 entered the kitchen without a hair covering and without performing hand sanitation. Following the observation, an interview was conducted with CNA4 who indicated no one should enter a dietary area without hair covering and hand hygiene. The CNA stated due to being busy at times, he/she forgot to utilize hand hygiene. Interview with LPN2, who was also the Infection Control Nurse, on 4/18/25 at 10:00 a.m. revealed there were no infection control systems in place when she/he assumed the role three (3) months ago. The LPN verbalized that it was important for staff to adhere to Enhanced Barrier Precautions to protect the residents and staff from possible infections. LPN2 verbalized when a resident was on enhance barrier precaution, PPE should only be worn when direct care was provided. She/he acknowledged that surveillance was performed often, and was unsure how some rooms were missing Enhance Barrier signage. LPN2 acknowledged hand sanitation should also be provided to residents who choose to eat meals in their rooms. Also, it was everyone's responsibility to notify housekeeping when hall hand sanitizers were empty. The purpose of hall hand sanitizers was to provide easy access for hand hygiene.

Based on observations and interviews, the facility failed to ensure that facility staff followed the proper protocols of sanitation to decrease the risk of spread of infection and maintain kitchen equipment in a clean and sanitary manner to prevent the outbreak of foodborne illness. This was evidenced by the facility staff not using the correct test strip to check the sanitation concentrations for the dish machine and the three compartment sink to monitor the sanitation level. This deficient practice had the potential to affect all the residents. Findings include: During the initial tour of the kitchen on 4/15/25 at 11:05 a.m., observation revealed a trash bin in front of the three doors of the refrigerator without a lid/cover. Further observation revealed dust, and debris were on top of the dishwashing machine. On 4/15/25 at 2:44 p.m. Observation of Dietary Staff 1 completed the test strip sanitation for the three-compartment sink for the wash and the rinse; the concentration read zero (0). The test strip stayed with the original color, orange. Dietary Staff 1 was observed performing the test strip for the dishwashing machine. The test trip also read zero (0). On 4/15/25 at 2:46 p.m. observed a dish machine log on the wall. The log was up to date for the month of April 2025. Observed the log to reveal daily testing was conducted three (3) times a day with chlorine concentration equal to 100 parts per million (ppm) for breakfast, lunch, and dinner from April 1, 2025, through April 15, 2025. On 4/15/25 at 3:35 p.m., the Certified Dietary Manager (CDM) stated that the staff used the wrong test trip, and that was the reason the chlorine concentration read zero (0). The CDM then stated that he/she had just given education to the staff about using the test trips, specifically the difference between the test trip for the washing machine and the three-compartment sink. On 4/15/25 at 3:35 p.m., the CDM stated that he/she agreed that the kitchen needed some cleaning. When pointed on top of the dishwashing machine, the CDM stated, Yes. That needs to be cleaned. We'll clean it. The CDM also observed a trash bin in the kitchen with no lid. On 4/15/25 at 3:35 p.m., the CDM was observed while he/she performed the chlorine concentration test trip for both the three-compartment sinks and the dishwasher machine, and they read 100 ppm.

Based on observation, interview, and record review, the facility failed to maintain a safe, functional, sanitary and comfortable homelike environment for residents and staff. Findings include: The environment observed during the survey period from 4/15/25-4/18/25 revealed the following environmental concerns but not limited to: room [ROOM NUMBER] exhibited cracked drywall. In room [ROOM NUMBER], a chest of drawers displayed extensive paint chipping, and the bathroom contained thick black substances in all corners. room [ROOM NUMBER] showed multiple layers of chipped paint. room [ROOM NUMBER] had exposed drywall, while room [ROOM NUMBER]-1 demonstrated paint chipping behind the resident's bed. Resident (R)4's manual wheelchair was observed with torn and damaged black foam on the left armrest. room [ROOM NUMBER] revealed multiple layers of exposed paint through chipping. room [ROOM NUMBER] contained unpainted patched holes throughout, and Bed-A showed a longitudinal crack extending the entire length of the footboard. room [ROOM NUMBER] exhibited paint peeling above the baseboard trim. room [ROOM NUMBER] displayed peeling paint in multiple colors (pink, tan, and dark tan), with black residue visible on the ceiling near two (2) fan vents. room [ROOM NUMBER] showed extensive peeling paint without touch-up work, including multiple scratches measuring approximately1.5 x 1.5 feet at the head of the bed. The room also contained a deteriorated blue chair with worn fabric, and both the main room and bathroom ceilings showed black residue from air vents. room [ROOM NUMBER]'s bathroom walls were peeling, and door jams were cracked. During an interview on 4/15/25 at 10:45 a.m., Certified Nursing Assistant (CNA)1, an agency staff member, reported that due to plumbing issues, staff and residents were required to share bathroom facilities. In a telephone interview conducted on 4/17/25 at 11:00 a.m., Licensed Practical Nurse (LPN)1 confirmed ongoing plumbing concerns since the beginning of their employment and verified the shared bathroom situation between staff and residents. On 4/18/25 at 12:30 p.m., an unsampled resident was interviewed regarding the facility's wall conditions. The resident stated, It's been like this a long time, I can't remember how long. The resident's room contained three (3) walls of different colors, with one wall displaying two distinct colors where painting had been initiated, but not completed. During an interview with the Corporate Executive on 4/18/25 at 11:45 a.m., it was revealed that the facility's owner had left the property, leaving numerous concerns including poor plumbing (reference F 867). 44785

Based on observation, interview and review of the facility policy, the facility failed to maintain patient care electrical equipment in safe operating condition for Resident (R)1. Findings include: The facility did not have a policy regarding maintaining patient care electrical equipment. On 4/15/25 at 10:46 a.m., observation revealed R1 was lying in bed with an alternating pressure mattress. The resident reported having to sit in the front lobby area on 4/14/25 due to his mattress malfunctioning. He stated on that prior day his mattress felt like he/she was lying on rocks. A request was made to review the maintenance personal care electrical inspection record for the mattress; however, there was no documentation available. In an interview on 4/18/25 at 11:45 a.m., the Corporate Executive revealed the Maintenance Director was not aware of the electrical testing requirement of the mattress; therefore, a record had not been maintained.

Based on observations, interviews and record review, the facility failed to develop and implement an action plan for repairing and improving the facility environment. This affected all residents' safety and quality of life. Findings include: Review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Plan, dated 4/1/25 documented., 1. Purpose and Mission - The purpose of this QAPI Plan is to support and sustain a culture of continuous quality improvement at Oak Hollow of [NAME], ensuring residents receive the highest quality of care in a safe, effective, and person-centered environment. Our mission is to provide compassionate, individualized care that respects the dignity and needs of every resident, guided by data-driven strategies and interdisciplinary collaboration . 4. Design and Scope of Activities - QAPI activities will be comprehensive and focused on both clinical care and facility operations. Priority areas include: -Resident safety (falls, infections, medication errors) - Quality of life (pain management, social engagement, satisfaction) Care planning and delivery - Staff training and competency - Compliance with CMS [Centers for Medicare and Medicaid Services] Quality Measures and Five-Star domains An observation on 4/15/25 at 1:48 p.m. in room [ROOM NUMBER], revealed fall mat edges were sticking up. An observation on 4/15/25 at 1:50 p.m. in room [ROOM NUMBER], revealed nail holes in the wall next to window. An observation on 4/15/25 at 1:55 p.m. in room [ROOM NUMBER], revealed a floor mat that had a rip at least seven (7) inches long and two (2) inches wide. The floor mat also curled up on the ends. In an interview on 4/16/25 at 12:30 p.m. with Resident (R)38, he/she stated they had to use the bathroom down the hall. R38 stated this had been this way for a few months. An interview on 4/17/25 at 3:55 p.m. with the Administrator revealed the Quality Assurance and Assessment Committee were aware the toilets were not working and they had not developed a Performance Improvement Plan (PIP). In an interview on 4/18/25 at 10:45 a.m., the Corporate Executive stated that they had worked on fixing the many issues. The Corporate Executive stated they have not discussed any of the repairs with the Quality Assurance and Performance Improvement (QAPI) Committee.

Based on observation, record review, and interviews, the facility failed to have a full time certified dietary manager (CDM) or a certified food service manager (CFSM) to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population. This deficient practice had the potential to affect all the residents. The findings include: During the initial tour of the kitchen on 4/15/25 at 11:05 a.m., observation revealed two staff members (Cook 1 and [NAME] 2) were in the kitchen. On 4/15/25 at 11:05 a.m., [NAME] 1 stated, We do not have a Dietary Manager in this place, not even a supervisor; everyone is on their own. We just need to get the job done. On 4/15/25 at 11:05 a.m., [NAME] 2 stated that her shift started at 5:00 a.m. and ended at 2:00 p.m. [NAME] 2 also stated that the kitchen did not have a Dietary Manager. On 4/15/25 at 3:38 p.m., the CDM stated, I was not here last week; no, the entire week. I was over two other buildings helping out. I started working here like two weeks ago. I am the regional manager managing a total of three buildings. I haven't had time to come here to sit down with the administration and train the staff. On 4/18/2025 at 9:06 AM, Registered Nurse (RN) Consultant stated, Don't quote me on this, but right now he (CDM) is a vendor. He is in between two buildings. We have a full-time CDM coming next week. But I will find out. During an interview with the Administrator on 4/18/2025 at 9:47 a.m. regarding the CDM job description and responsibility, the Administrator stated that the CDM started coming either last week or two weeks ago. The Administrator stated that the CDM was a full-time Dietary Manager. The Administrator then stated that the Dietary Manager was at the facility all day last week, He was here last week and worked 40 hours. He/she is a full-time Manager here. When he/she started, I was on medical leave. He/she came last week. The Administrator was informed that the Dietary Manager reported he was not in the building for 40 hours last week, the Administrator stated, I left the building at 1:00 p.m. last week. I don't know if he left after I left. But he was here last week. I saw him in the morning, for at least 3 days last week. The Administrator was informed that the Dietary Manager said he was not in the building last week because he was in two other buildings. The Administrator then stated, I'm not sure. I would go with what he said. If he said he wasn't here last week, maybe he wasn't, because I was only here half of the day and only for 3 days. The Administrator further stated, They (the dietary staff) know because I was not here when HSG (Healthcare Services Group) came. They made their transition and did a whole inservice with the staff. I assumed that they told them that they had a new manager because I was not here when they came. The [CDM] would have to tell you how the company made the switchover. One of my staff members told me they were in the conference room with HSG. I would have to get the date when the transition happened and when the Dietary Manager started. On 4/18/2025 at 10:04 a.m., the CDM stated that he started April 1, 2025, two weeks ago. He then stated, I was not here last week. My first week, I was getting everybody on board. The next week, I was supposed to be here, but they pulled me to go to another building. I was planning to start working by training them, but I had got pulled to go to another building for a week. This week I'm here. I actually was in another building this week, then I got pulled from it, so I can be here this week because I got three (3) buildings to manage. All three buildings started at around the same time. So, I'm trying to get training for all of the employees. He went on to state, Honestly, I haven't had time to really sit down and work with the ones that are here. I hired a couple managers for the other buildings. I was providing them with training. They're training the other buildings right now because I've been getting pulled with these three new startups. I have hired a new Manager for this building but will not start until the second week of May. I'm just trying to think. I can't remember what day, but I know it's after May 6, the week after May 6. I guess that's what he/she said, the week after May 6 she can start. So, I have a manager for this building, and I have managers for the other two buildings. I've been pulling out to go help out. I just had them to start on their own because they couldn't do their part, so I've done the 2 other buildings. Those two managers are training those employees right now, so I'm here training trying to help train these people when I get time. Honestly, I'm supposed to be a full-time manager, but because of the schedule I become an interim manager. Review of the Dietary Manager's Job description, titled Dining Services Director/Account Manager, noted that it was a full-time position. The position summary also noted, Manages the dining services program in a single site according to Healthcare Services Group (HCSG) policies and procedures, and federal/state requirements. Must hold state and/or federal required credential within no more than three months of placement in Dining Services Director/Account Manager position. Provides leadership, support and guidance to ensure that food quality standards, inventory levels, food safety guidelines and customer service expectations are met. Consistently embodies the characteristics necessary to drive the Company's Purpose, Vision, Values, and DNA. Maintains records of income and expenditures, food, supplies, personnel and equipment and provides reports to HCSG District Manager on such. Make sure the facility has sufficient supplies. Takes periodic inventories of supplies and materials, trains new employees, and recommends dismissals. Acts as liaison between building occupants, client managers or administrators and HCSG and staff. The Manager must be able to communicate effectively all directives from client managers, building occupants and administrators and HSCG staff. Must be able to perform the essential job functions of dietary aide, cook, and dishwasher positions for purposes of training and assisting when there are call-outs. Training, quality control and in-servicing staff to HSCG standards is an essential part of the Manager's responsibility and includes touring the kitchen several times per day to assess work quality using QCIs for documentation purposes. The Manager is a department head in the facility and must conduct themselves and their department in a professional manner. The Dietary Manager's job description also listed: Job Function: People Management & Management. Interviews, hires and orients of dietary staff for the dietary department. Maintains proper staffing levels, scheduling all dietary staff. Maintains personnel files in a locked cabinet. Supervises, coordinates and evaluates the work of all dining services employees in preparing and serving food, and cleaning facilities and utensils in a production kitchen. Drives employee engagement through championing PVV and Company recognition program/s. All other duties as assigned.[sic]

Based on observation, interviews, and record review, the facility failed to ensure Physician's Orders were followed as evidenced by observation on 4/15/25 at 11:42 a.m. in dining room, a resident (Resident (R)38) was observed to have red, swollen legs and did not have TED hose when the Physician's order required them. Failure to wear TED hose could increase the risk of blood clots, pain and ineffective treatment. The facility also failed to provide timely incontinent care to R2. The resident required staff assistance but did not receive it promptly, resulting in extended periods in a soiled brief. Findings include: During an observation 4/15/25 at 11:42 a.m., R38 was in the dining room and both of his/her legs appeared red and swollen. In an interview on 4/16/25 at 12:30 p.m. with R38, he/she stated he/she had not worn TED hose in two (2) weeks. R38 stated their legs hurt because of this. R38 stated that his/her TED hose was destroyed after being washed in the washing machine. In an interview on 4/16/25 at 12:31 p.m., Certified Nurse Aide (CNA)1 stated they were agency staff. CNA1 stated they were not aware of R38's order to wear TED hose. CNA1 stated they were informed of care by another staff member from a previous shift. CNA1 stated they should not rely on word or mouth and should've reviewed the residents' Kardex (quick reference of patient care plan) to identify care needs. In an interview on 4/16/25 at 12:33 p.m., Licensed Practical Nurse (LPN)4 stated they have worked at facility for over a year and provide care for R38. LPN4 stated that not wearing TED hose can cause swelling of the legs and TED hose are to be worn when out of bed. Review of Physician Orders for R38 documented apply compression stockings to legs covering hematoma every day and night shift for hematoma while out of bed. Stockings may be removed when showering and bathing. In an interview on 4/18/25 at 12:16 p.m., the Director of Nursing (DON) stated they were not aware R38 did not have on TED hose on 4/15/25. The DON stated it was important to wear them due to vascular insufficiency and to increase blood flow. The DON stated that nurses were responsible for applying TED hose to residents. The DON stated there was no policy regarding following Physician's Orders. On 4/15/25 at 11:30 a.m. observation during the initial tour revealed the resident was self-propelling in a wheelchair (w/c) and wearing weather-appropriate clothing with non-skid shoes. During the observation, an interview was conducted and the resident verbalized that staff treated him/her like crap and stated that he/she was unable to get needed assistance. Review of the clinical record for R2 revealed: admitted : 7/20/20 Readmitted : 5/28/24 Diagnoses: Anxiety Disorder, Depression, Schizophrenia, and Hemiparesis The resident's most recent quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 3/6/25 noted a Brief Interview Mental Status (BIMS) score of 8 which indicated moderately impaired cognition. The assessment showed no mood or behavior symptoms, and the resident was assessed as consistently incontinent of bowel and bladder. The Resident Concern/Grievance Response Form dated 3/28/24 documented that R2's Power of Attorney (POA) reported the resident needed changing, however, staff informed once he was placed in the bed and incontinent care was provide, staff would not allow the resident to get back out of bed. A subsequent grievance on 8/28/24 noted the resident requested incontinent care and, after waiting for one hour, requested assistance again, but was told to wait. R2 report that he/she waited an additional two (2) hours before staff came to provided incontinent care. Review of a Nursing Progress Note dated 4/13/25 documented that after R2 returned from church service, the resident and his/her family requested twice for Licensed Practical Nurse (LPN)3 to provide incontinent care for R2. The family member reported skin irritability, but the LPN indicated the resident's assigned Certified Nursing Assistant (CNA) was unavailable. R2's Behavior Care Plan, revised on 3/6/25, identified that R2 had attention-seeking behaviors. The care plan goal was to reduce attention-seeking episodes through anticipating and meeting the resident's needs. The interventions included: to anticipate and meet the resident ' s needs; to monitor behavior episodes and attempt to determine the underlying cause; when determining the underlining cause consider location, time of day, persons involved, and situations. The resident's Incontinent Care Plan, revised 3/6/25, identified bowel and bladder incontinence. Interventions included: Maintaining resident cleanliness, dryness, and comfort through the next review Frequent checks and provision of incontinent care An interview with the Director of Nursing (DON) on 4/16/25 at 12:15 p.m. revealed the facility maintained a No Pass Zone policy (policy requested but not provided), that indicated every employee should answer the call light, and then find the appropriate staff member to assist the resident. On 4/17/25 at 1:45 p.m., an interview was conducted with an agency CNA8 who explained that the previous shift gave verbal report about resident care needs. The CNA voiced that since most residents require a mechanical lift (to include R2), two staff members must work together, which often created delays in care. Staff members were expected to ask other CNAs for assistance rather than requesting assistance from nurses. In an interview with LPN3, on 4/17/25 at 1:55 p.m. she/he acknowledged that staff should assist residents when care was requested. The LPN recalled R2's 4/13/25 progress note. She/he stated R2, and a family member demanded for the resident to be changed. However, the resident's assigned CNA was busy providing care for another resident. The LPN acknowledge that she/he instructed the resident to wait for needed care before having another CNA assist the resident. The LPN stated she was busy which was why she/he was unable to assist.

Based on interview, record review, facility document review, and facility policy review, the facility failed to protect the resident's right to be free from physical abuse by another resident for 2 (Resident (R)5 and R6) of 5 residents reviewed for abuse. Specifically, R4, who had a history of physical aggression, physically abused and injured R5. Additionally, R4 physically abused R6. Findings included: An undated facility policy titled, Abuse Prevention Program indicated, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required treat the resident's symptoms. R4's Admission Record indicated the facility admitted the resident on 10/29/2024. According to the Admission Record, the resident had a medical history that included diagnoses of paranoid schizophrenia, vascular dementia with other behavioral disturbance, psychophysiologic insomnia, violent behavior, and generalized anxiety disorder. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/04/2024, revealed R4 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS indicated the resident exhibited delusions during the assessment timeframe. Per the MDS, the resident exhibited physical behavioral symptoms and verbal behavioral symptoms directed towards others one to three days during the assessment timeframe. The MDS indicated the resident's behavioral symptoms put the resident and others at risk for physical illness or injury. R4's care plan included a focus area initiated 11/01/2024, that indicated the resident had a potential to be physically aggressive related to a history of harm to others and poor impulse control. Interventions directed staff to administer medications as ordered (initiated 11/01/2024); and to analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document (initiated 11/01/2024). Interventions also indicated the resident's physical aggression was triggered by verbal abuse and indicated that the resident's behaviors were de-escalated by therapeutic communication (initiated 11/10/2024). Further review revealed that the interventions of Depakote and medication review were initiated on 11/19/2024. R4's [Previous Nursing Facility] Continuity of Care record, dated 10/16/2024, revealed the resident had diagnoses of paranoid schizophrenia (effective 08/14/2023) and violent behavior (effective 05/28/2024). R4's Level II South Carolina Mental Health Authority Determination, dated 08/15/2024, revealed R4 had a serious mental illness. The Level II evaluation revealed R4 would require close monitoring, some structured socialization, assistance with activities of daily living (ADLs), memory care, medication therapy, and monitoring of medication therapy. The [NAME] II evaluation also revealed R4 had a history of intermittent agitation, including hitting others, and would likely require hospitalization for medication adjustments and behavioral control. R4's Progress Notes revealed a Health Status Note, dated 10/29/2024 at 2:26 PM, that indicated the resident admitted to the facility from another nursing facility. 1. R5's Admission Record indicated the facility admitted the resident on 03/22/2024. According to the Admission Record, the resident had a medical history that included diagnoses of Alzheimer's disease, vascular dementia with behavioral disturbance, bipolar disorder, and depression. A quarterly MDS, with an ARD of 10/03/2024, revealed R5 had a BIMS score of 11, which indicated the resident had moderate cognitive impairment. Per the MDS, the resident did not exhibit any physical or verbal behavioral symptoms directed toward others during the assessment period. R5's care plan included a focus area initiated 04/01/2024, that indicated the resident had impaired cognitive skills as evidence by deficits in short-term and long-term memory with a BIMS score of 12. The care plan indicated that the resident was understood and could understand. Interventions directed staff to provide cues and prompting if the resident was unable to complete a task independently (initiated 04/01/2024) and anticipate and meet the resident's needs (initiated 04/01/2024). R4's Progress Notes revealed a Health Status Note, dated 10/30/2024 at 11:40 PM and created by Licensed Practical Nurse (LPN) #18, that revealed R4 struck their roommate in the face over their roommate's wheelchair and personal bag. The note indicated that the residents were separated an hour before the incident. Per the note, the residents were separated, and R4 was sitting on the bed eating a sandwich and snack and R5 was brought to the dining room area. R4's Progress Notes revealed a Health Status Note, dated 10/31/2024 at 12:46 AM, that revealed R4 was sent to the emergency room (ER) for an evaluation and treatment related to aggressive behavior. The note indicated that R4 struck their roommate in the face with their fist, over the roommate's wheelchair and personal bag. A handwritten witness statement dated 10/30/2024 signed by Certified Nursing Assistant (CNA)4 revealed that on the night of 10/30/2024, she was helping another resident when she heard CNA26 yell out no [ma'am/sir] you can not do that. The statement revealed CNA4 did not witness what happened but was told by CNA26 and by R5 that R4 had punched R5 in the face knocking the resident's glasses off their face and knocking them back in the bed. The statement revealed CNA4 stated that she noticed R5 looked fearful of R4. The statement revealed R4 was trying to take R5's wheelchair because they were under the impression it was theirs. The statement revealed CNA4 and CNA26 redirected R4 and informed them that the wheelchair was not theirs but was R5's. The statement revealed R4 stated rude remarks to R5 and R5 stated that they did not feel safe being in the room with R4 anymore. R5's Skin Only Evaluation, dated 10/30/2024, revealed R5 had pain to their right eye from being struck in the face by a fell ow resident. R5's Pain Interview, dated 10/30/2024, revealed the resident had a pain level of 5, on a scale from 0-10, to the right eye and was given acetaminophen with effective results. R5's Progress Notes revealed a Health Status Note, dated 10/31/2024 at 11:15 AM, that indicated the resident had purple discoloration under their right eye in the periorbital area below eye. The note indicated that the resident complained of tenderness upon palpation of the area, but did not report pain. During an interview on 12/19/2024 at 1:27 PM, R5 stated they were sitting on the side of their bed, doing a puzzle on the bedside table. R5 stated that their wheelchair was in front of the table, and R4 came up and said that it was their wheelchair. R5 stated they did not say anything, but the staff in the hall kept telling R4 that it was not their wheelchair. R5 stated that R4 unexpectedly hit them. R5 stated they had a black eye from the incident and had to go to the doctor. R5 stated staff made R4 come out of the room. R5 stated they were moved to a different room that day. R5 stated that was the first time they had encountered the resident and did not know the resident was new there. During an interview on 11/21/2024 at 1:28 PM, Former Administrator #20 stated she got a call from LPN18 on 10/30/2024 that R4 and R5 had an altercation because R4 thought a wheelchair was theirs. Former Administrator #20 stated a CNA was checking on residents, heard something, and then separated the residents. She stated that R4 was sent to the hospital because the resident would not calm down. She stated the Director of Nursing (DON) talked to R5's family, and R5 was moved to a different room that night based on the family's request. During an interview on 11/21/2024 at 3:18 PM, LPN18 stated she was the nurse at the time of the incident between R4 and R5. LPN18 stated that R4 and R5 were roommates at the time of R4's admission. She stated that when R4 was first admitted , R4 and R5 got along fine. LPN18 stated R4 was in bed and R5 came into the room, got out of their wheelchair, and into bed. LPN18 stated R4 got up and went to get the wheelchair and a bag that was on the back of the wheelchair. She stated that she tried to calm R4 and explain that it was not their wheelchair and put the resident back to bed, but the next thing she knew, R5 reported that R4 had hit them. LPN18 stated the residents were immediately separated, and a room change was completed for R5 following the incident. During an interview on 12/20/2024 at 8:22 AM, Physician #29 stated he recalled seeing R4 on 10/31/2024, and stated the resident had a history of schizophrenia, most likely chronic paranoid schizophrenia. Physician #29 stated R4 was on a high dose of antipsychotic medications, and he would sometimes prescribe benzodiazepine to help calm the resident down. Physician #29 stated he had gotten a lot of calls on the resident, and he felt the resident was not familiar with the facility because they came from another facility. Physician #29 stated the resident had their days and nights mixed up, so he had put the resident on some medication to help the resident sleep at night and to help with their behaviors. During an interview on 12/20/2024 at 1:16 PM, the DON stated for residents that came in with a known psychiatric history, he would monitor the resident upon entry. The DON stated they monitored all residents upon initial entry, completed assessments, and CNAs documented their behaviors every shift. The DON stated part of the plan of care documentation included whether any types of behaviors were noticed during the shift. The DON stated behaviors were reported to nurses, and they would follow up. The DON stated R4 was admitted two days after he started working at the facility, so he did not approve the resident's admission to the facility and did not know the resident's history. The DON stated he was made aware after the incident on 10/30/2024, and he reviewed their chart and realized the resident had a Level II evaluation. The DON stated, going forward, since he had started, they clinically reviewed residents more thoroughly and refused residents with known behavioral issues. The DON stated he had not clinically approved of anyone with a violent history or any known history that had caused them to become violently aggressive. 2. R6's Admission Record indicated the facility admitted the resident on 08/28/2018. According to the Admission Record, the resident had a medical history that included diagnoses of hemiplegia (paralysis) and hemiparesis (one-side muscle weakness) on the left side and vascular dementia. A Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/15/2024, revealed R6 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. Per the MDS, the resident did not exhibit any physical or verbal behavioral symptoms directed toward others during the assessment period. R6's care plan included a focus area initiated 03/30/2021, that indicated the resident was at risk for developing traumatic stress reactions related to exposure to a motor vehicle accident. Interventions directed staff to allow the resident to express concerns and feelings (initiated 03/30/2021). R4's Progress Notes revealed a Behavior Note, dated 11/10/2024 at 8:20 PM and created by Licensed Practical Nurse (LPN)18, that revealed R4 punched another resident in the face after being repeatedly called a derogatory name by the fell ow resident as they were attempting to pass them going to their room. The note indicated that the residents were separated. R4's Progress Notes revealed a Health Status Note, dated 11/10/2024 at 10:07 PM and created by LPN18, that revealed R4 was sent to the emergency room for an evaluation and treatment related to striking another resident in the face with their fist. R4's Psychiatry Follow Up Note, dated 11/15/2024, indicated that R4 was seen for a follow-up visit for ongoing management. The record indicated that the resident punched two residents in the previous month. R6's Skin Only Evaluation, dated 11/10/2024 at 9:36 PM, revealed the resident did not have any new skin issues. During an interview on 11/21/2024 at 3:18 PM, LPN18 stated she was on the 400 Hall administering medications when R4 came up the hall from the dining room. LPN18 stated R4 was trying to hurry and get to their room to go to the bathroom. LPN18 stated R6 was coming in front of the cart at the same time. LPN18 stated when R4 asked R6 to move out of their way, R6 called the resident a derogatory name. LPN18 stated before she had a chance to react, R4 made a fist and hit R6. LPN18 stated once the incident occurred, she separated them. LPN18 stated R6 was normally on the 300 Hall but had walked down to the 400 Hall.

Based on interview, record review, facility document review, and facility policy review, the facility failed to ensure a complete and thorough investigation was completed for 1 (Resident (R)1) of 4 residents reviewed for accidents. Specifically, R1 sustained a fall on 09/21/2024 from a mechanical lift when the sling strap broke while being transferred from the bed to a wheelchair by Certified Nursing Assistant (CNA)7 and Licensed Practical Nurse (LPN)8. R1 sustained another fall on 09/28/2024 from a mechanical lift when the shower harness strap broke while being transferred from a shower chair to the bed by CNA13 and CNA14. There was no evidence CNA13 had received re-education on mechanical lift safety after the 09/21/2024 incident. There was also no evidence of an investigation for the 09/28/2024 incident. Findings included: An undated facility policy titled, Investigating Injuries, indicated, The Administrator will ensure that all injuries are investigated. An undated facility policy titled, Hoyer Lift: Operation Instructions and Proper Use, indicated, Only trained personnel should operate the Hoyer [mechanical] lift. An undated facility policy titled, Safe Lifting and Movement of Residents, indicated, 4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. The policy also indicated, 6. Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents. 7. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques. R1's Admission Record indicated the facility admitted the resident on 07/20/2020. Review of the Admission Record, the resident had a medical history that included diagnoses of diffuse traumatic brain injury (TBI) with loss of consciousness of unspecified duration, hemiplegia (paralysis) affecting the right dominant side, and muscle weakness. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/03/2024, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had impairment on one side to both the lower and upper extremity, utilized a wheelchair, and was dependent on staff to transfer to and from a bed to a chair, and was dependent on staff to transfer in and out of a tub and shower. R1's care plan included a focus area initiated 04/20/2021, that indicated the resident was at risk for falling related to epilepsy, hemiplegia, history of repeated falls, incontinence, TBI, and impaired safety awareness. Interventions directed staff to transfer the resident with a mechanical lift with two-person assistance (initiated 09/15/2023). The care plan included a focus area initiated 04/20/2021, that indicated the resident was at risk for falling related to epilepsy, hemiplegia, a history of repeated falls prior to admission, incontinence, TBI, and impaired safety awareness. The focus area further revealed that on 09/21/2024 the resident had a fall with an intervention dated 09/21/2024 for a therapy screen as indicated. Further review revealed the resident sustained a fall on 09/28/2024 where the resident was lowered to the floor with a bruise and skintear [sic], with an intervention dated 09/28/2024 of the mechanical lift pad changed. A Health Status Note, dated 09/21/2024 at 12:02 PM, revealed R1 was being transferred from their bed to the wheelchair with a mechanical lift. The Health Status Note revealed when the resident was above the wheelchair, the blue strap broke, and the resident hit their head on the arm of the wheelchair. The Health Status Note further revealed, the resident was sent to the emergency room (ER). An ED [Emergency Department] Provider Note, for R1 dated 09/21/2024, revealed the residents visit diagnoses included a concussion and cervical strain. The note revealed the resident had a contusion in the lower back posterior head. Per the note, the resident's computed tomography (CT) scan revealed no acute injury, but the provider documented that they believed the resident had a mild concussion. An Accident/Incident Reporting Form, revealed that on 09/21/2024, CNA7 and LPN8 were assisting R1 with the mechanical lift, transferring the resident from their bed to their wheelchair. According to the Accident/Incident Reporting Form, while lowering the resident to the chair, the sling strap broke, causing the resident to fall into the wheelchair and hit the back left side of their head on the arm of the wheelchair. The Accident/Incident Reporting Form indicated staff had been re-educated on resident abuse, neglect and exploitation and on proper techniques on using a mechanical lift. A Staff Education Sign In Sheet, included with the facility's investigation documents revealed staff signatures dated 09/21/2024, 09/24/2024, and 09/30/2024 that indicated they had received education on Hoyer Lift & [and] Sling training. CNA7 and LPN8 had signed the document on 09/21/2024 to indicate they had received the education. The Staff Education Sign In Sheets revealed there was no documented evidence CNA13 had received the re-education prior to the 09/28/2024 incident. A document titled 354 Other, dated 09/28/2024 at 11:43 PM, revealed the shower harness strap broke while R1 was being transferred from the shower chair to the bed. The document revealed the CNA used their right leg to guide the resident to the floor. The document revealed the immediate actions taken included assessing that the resident was safe, obtaining the resident's vital signs, and the nurse and two CNAs assisted getting the resident off the floor and onto their bed safely. The document indicated the resident sustained an open area to the left ankle and a bruise to the upper back. During an interview on 11/21/2024 at 10:03 AM, LPN12 stated that on 09/28/2024, it was brought to his attention that the shower sling broke for R1. LPN12 stated he completed the incident report. LPN12 stated that was the first time he had heard of any slings breaking and he was not sure if an investigation was done. LPN12 stated the CNA involved in the incident was CNA13. During an interview on 11/21/2024 at 10:08 AM, CNA13 stated that on 09/28/2024, he made an incident report to LPN12. CNA13 stated it was on a Saturday, and they had gotten the resident (R1) up from the bed, transferred them to the shower chair, and gave the resident a shower. CNA13 stated that while transferring the resident back to bed from the shower chair, the straps around the leg started to pop. CNA13 stated he put his leg under the resident to brace the resident. CNA13 said they got the nurse, and the nurse did a body audit. CNA13 stated they got another sling, got it up under the resident, and lifted the resident up into the bed. CNA13 stated that when using slings, they would inspect them and make sure everything was working. CNA13 stated that during the incident, the loops broke, not the sling. CNA13 stated he was not aware of any other times that slings had broken. CNA13 stated he had been a CNA for [AGE] years and had received training on using mechanical lifts. CNA13 stated he had two trainings the current year. During an interview on 11/21/2024 at 3:05 PM, Former Admissions Director #23 stated for the incident that occurred on 09/28/2024, she was not present but did remember getting a phone call from CNA13 because he had gotten injured while at work. Former Admissions Director #23 stated she remembered calling Former Administrator #20 to inform her of what happened, but stated she was not involved in the investigation and was unaware if one was completed. During an interview on 11/21/2024 at 9:44 AM, the Director of Nursing (DON) stated every incident needed to be investigated. During a follow-up interview on 12/20/2024 at 1:16 PM, the DON stated they were not sure why all staff were not in-serviced after the 09/21/2024 incident. The DON said all nursing staff received mechanical lift training upon hire and annually. The DON stated there was no additional documentation available for the 09/28/2024 incident. During an interview on 11/21/2024 at 8:35 AM, the Interim Administrator stated they did not have an investigation report for the 09/28/2024 incident for R1. The Interim Administrator stated all she could find was the training provided from 09/21/2024 through 09/30/2024.

Based on record review, interviews, and review of facility policy, the facility failed to provide treatment and services to prevent and/or heal Resident (R)6's pressure ulcers for 1 of 1 resident. This failure resulted in R6 acquiring multiple pressure ulcers. On [DATE] at 4:30 PM, the Administrator was provided a copy of the CMS Immediate Jeopardy Template and informed that the failure to provide treatment and services to prevent or heal multiple pressure ulcers for R6 constitued IJ at F686 with an effective date of [DATE]. On [DATE] at 6:18 PM, the facility provided an acceptable IJ Removal Plan. On [DATE], the survey team validated the facility's corrective actions and removed the IJ as of [DATE]. The facility remained out of compliance at F686 at a lower scope and severity of D. An Extended Survey was conducted in conjunction with the Complaint Survey for non-compliance at F686, constituting substandard quality of care. Findings include: Review of the undated facility policy titled Skin and Wound Management revealed, Assessment and Recognition 1. The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s). Treatment/Management 1. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing abd debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. Monitoring 1. During resident visits, the physician will evaluate and document the progress of wound healthing . 2. The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. Review of the undated facility policy titled Repositioning revealed, The purpose of this procedure is to provide guidelines for the evaluation of resident repositioning needs . to prevent skin breakdown, promote circulation and provide pressure relief for residents. General Guidelines 1. Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief. 3. Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. 5. Positioning the resident on an existing pressure ulcer should be avoided since it puts additional pressure on tissue that is already compromised and may impede healing. Interventions 3. Residents who are in bed should be on at least an every two hour (q2 hour) repositioning schedule. 6. If ineffective, the turning and repositioning frequency will be increased. Review of R6's Face Sheet revealed R6 was admitted to facility on [DATE], with diagnoses of but not limited to: vascular Dementia, diverticulosis, Chronic Obstructive Pulmonary Disease and hyperlipidemia. Further review of R6's Face Sheet revealed R6 was receiving hospice care and expired on [DATE]. Review of R6's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 3 out of 15 indicating R6 had severe cognitive impairment. Review of R6's Care Plan revealed, Skin: Resident is at risk for skin breakdown & PU r/t frequent incontinence, hemiplegia post CVA, & cognitive impairment . Interventions for this Care Plan revealed, Assess and record changes in skin status. Report pertinent changes to physician, Administer/monitor effectiveness of/response to preventive treatments as ordered, encourage patient to turn and reposition in bed and limit time up in Geri-chair, Heel protectors BID when in bed, minimize pressure over bony prominence, monitor lab results as ordered and report abnormal results to physician, provide diet as ordered and monitor nutrition status and dietary needs. Further review of R6's Care Plan revealed the following Focus, [R6] requires extensive to total assistance with ADLs [activities of daily living] . [R6] is incontinent of B&B [bowel and bladder] . Review of R6's Physician Orders revealed, Monitor function and setting of air mattress. Used as prevention and protection d/t [due to] being bed bound and non ambulatory start date [DATE]. Apply heal boots to bilateral feet for protection of skin breakdown start date ,d+[DATE]. unstageable wound left elbow: cleanse with Dakin's 0.125% apply TAO [triple antibiotic ointment] and border gauze dressing daily start date [DATE]. Unstageable wound to back: cleanse with Dakin's 0.125% apply TAO, abd pad daily start date [DATE]. Unstageable sacral wound Cleanse with Dakin's 0.125%, apply Dakin's 0.125% damp gauze to wound bed, cover with abd pad daily start date [DATE]. Skin prep to right heel q [every shift] shift start date [DATE]. Review of R6's Skin assessment dated [DATE], revealed, Skin warm & dry, skin color within normal limits, mucous membranes moist, turgor normal. No current skin issues noted at this time. Review of R6's Skin assessment dated [DATE], revealed, Skin warm & dry, skin color within normal limits, mucous membranes moist, turgor normal. No current skin issues noted at this time. Review of R6's Skin assessment dated [DATE] revealed, Skin warm and dry, skin color within normal limits, mucous membranes moist, turgor normal. Resident has current skin issues. The skin issues were listed as follows: 1. Skin Issue: Deep tissue injury. Skin issue location: right lateral ankle including 1st toe Length: 11.8 Width: 1.7 Wound bed: Epithelial. Wound odor: No. Tunneling: No. Undermining: No. Tissue: Painful. Tissue: Firm. 2. Skin Issue: Deep tissue injury. Skin issue location: sacrum Length: 6 Width: 9 Depth: 0.1 Wound bed: Necrotic. Peri wound condition: Fragile. Wound odor: No. Tunneling: No. Undermining: No. Tissue: Firm. Tissue: Warm. 3. Skin Issue: Deep tissue injury. Skin issue location: right hip Length: 0.8 Width: 0.4 Depth: 0.1 Wound bed: Epithelial. Wound odor: No. Tunneling: No. Undermining: No. Skin Issue: Deep tissue injury. Skin issue location: right ischium Length: 5 Width: 6 4. Skin Issue: Deep tissue injury. Skin issue location: right upper back Length: 17 Width: 17 Dressing saturation: None. Wound odor: No. Tunneling: No. Undermining: No. Tissue: Painful. Tissue: Firm. Tissue: Warm. 5. Skin Issue: Deep tissue injury. Skin issue location: right ankle Length: 2 Width: 2 Wound bed: Granulation. Wound exudates: None. Wound odor: No. Tunneling: No. Undermining: No. Tissue: Mushy. Tissue: Warm. 6. Skin Issue: Deep tissue injury. Skin issue location: left first toe Length: 0.6 Width: 2.8 Wound odor: No. Tunneling: No. Undermining: No. Tissue: Painful. Tissue: Firm. Tissue: Warm. 7. Skin Issue: Deep tissue injury. Skin issue location: left buttock Length: 1.8 Width: 3.9 Depth: 0.1 Wound bed: Necrotic. Wound odor: No. Tunneling: No. Undermining: No No other documentation on skin assessments to review after [DATE]. Review of R6's Progress Note dated [DATE], revealed, Resident has new skin break down on back, sacrum, buttocks, ankles and feet . Review of R6's Medication Administration Record (MAR) dated [DATE] revealed, Triple Antibiotic External Ointment . Apply to left foot ulcer topically one time a day . was not completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of R6's Treatment Administration Record (TAR), indicated that no treatment to wounds were being done as ordered by the physician. During an interview on [DATE] at 3:35 PM, the Director of Nursing (DON) revealed that when a resident is receiving hospice services, the hospice nurse does the wound care. The DON stated that wound care was ordered by the physician, but the family no longer wanted wound care performed as of [DATE]. The DON stated that bed bound residents are turned every 2 hours and as needed. The DON further stated that staff do not document turning residents or ADLs, they just know to do it. During an interview on [DATE] at 2:30 PM, the Administrator stated that she has only been at the facility for 2 weeks and she could not attest to why care was not provided to R6. During an interview on [DATE] at 1:17 PM, the Ombudsman stated that the allegation was a referral from Department of Social Services and Agape Hospice. The Ombudsman further stated that R6 was being neglected. R6 had pressure wounds that were not being taken care of and R6 was bed bound and not being repositioned. During an interview on [DATE] at 11:48 AM, R6's Representative (RR) stated they never told the facility not to provide wound care. RR further stated, they wanted their mother to receive all comfort measures including wound care. During an interview on [DATE] at 12:00 PM, the Hospice Social Worker (HSW) stated that R6 has been receiving hospice services since 2023. HSW further stated R6 was not getting up as she use to and was always lying on her right side. A hospice Certified Nursing Assistant informed her that R6 was not being turned. The HSW stated she reported the incident to the police, Ombudsman, and Department of Social Services. And that is when the wounds were discovered. During an interview on [DATE] at 12:05 PM, the Hospice RN (HRN) stated hospice nurses did not change R6's dressing daily as ordered because they were not in the facility daily. On [DATE] at 6:18 PM, the facility provided an acceptable IJ Removal Plan, which included the following: Criteria One: Unable to correct for resident six (R6) due to her being on hospice and her expected death on [DATE]. Criteria Two: [DATE] The CEO/Nurse met with the Agape Nurse to ensure treatments for residents under their care were being documented in the hospice notes and the staff of the facility will complete on days they are not in the facility. All residents had a head-to-toe assessment completed by licensed nurses on [DATE]. All identified areas were provided treatment if warranted. The attending physician and resident's representative were notified by [DATE]. All residents will have a head-to-toe skin assessment upon admission and weekly skin assessment thereafter. All current residents will have a weekly skin assessment completed completed to ensure the skin remains intact by [DATE]. Criteria Three: All licenses and certified staff will be educated on ensuring residents preventative measures are in place for wound care to include. 1. Weekly Skin Assessment and prevention. 2. Shower Skin Audit (completed by C.N.A.). 3. New Admission Skin Assessment and prevention. 4. Turning and repositioning. 5. Abuse and Neglect. Licenses nurses were educated on the protocol for identifying risk and wounded residents on [DATE] and ongoing to include notifying the MD and RR. The Director of Nursing or designee will audit the treatments weekly to ensure the residents have been provided proper wound care treatment per the MD order. The Director of Nursing will review the audit with the administrator weekly for 4 weeks, monthly for 5 months to ensure the protocol is being followed. Criteria Four: The Administrator and DON will review the completed weekly skin audits with the monthly QAPI Committee for further follow-up and recommendations. Date of Correction of [DATE] Education Started [DATE]

Based on observations, record review, interviews, and facility policy review, the facility failed to provide adequate supervision to prevent the elopement of 1 of 3 residents reviewed for accidents related to elopement. Specifically, Resident (R)1 had a successful elopement from the facility on 03/30/24. On 4/09/24 at 4:30 PM, the Administrator was provided a copy of the CMS Immediate Jeopardy Template and informed that the failure to provide R(1) with adequate supervision to prevent elopement from the facility constituted Immediate Jeopardy (IJ) at F689 with a start date of 03/30/24. The IJ was related to 42 CFR 483.25 - Quality of Care. On 4/10/24 the facility presented an acceptable IJ Removal Plan. On 04/10/24, the survey team validated the facility's corrective actions and removed the IJ as of 04/09/24. The facility remained out of compliance at F689 at a lower scope and severity level of D. An Extended Survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care. Findings include: Review of the undated facility policy titled, Wandering, Unsafe Resident documented, Policy Statement The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for resident who are at risk for elopement. Policy Interpretation and Implementation 1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). 2. The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering. 3. the resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as a detailed monitoring plan will be included. Review of R1's Face Sheet, revealed R1 was admitted to the facility on [DATE] with diagnoses including but not limited to: major depressive disorder, fibromyalgia, bipolar disorder, vascular dementia, chromic pain, essential (primary) hypertension, muscle weakness, panic disorder, and altered mental status. Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/21/24, revealed a Brief Interview for Mental Status (BIMS) score of 6 out of 15, indicating R1 had severe cognitive impairment. Review of R1's Care Plan with an initiated date of 04/26/21 and a revision date of 04/10/24, revealed, Behavior: [R1] is at risk for elopement r/t cognitive impairment, ambulatory with walker. Resolved 2021 no further issues. 03/30/24 at approximately 2030, door exit alarms heard and resident was outside xx feet ambulating with rollator, returned to facility with no injuries. Continue care plan 03/30/24 Noted exit seeking behavior, redirected, Medication changes, continue care plan. The goal indicated, [R1] will ambulate safely within specified boundaries. Will not have any successful elopements through review Date initiated: 03/30/24 Target date: 05/22/24. Further review of the care plan revealed, R1 was at risk for falls and impaired vision. Review of R1's Elopement Evaluation dated 02/21/24, revealed, Late Entry: Evaluation: Elopement Score: 2.0 At Risk History of elopement while at home: No. History of attempting to leave the facility without informing staff: Yes. Verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door: Yes. Wanders: Yes. Wandering behavior, a pattern or goal-directed: No. Wanders aimlessly or non-goal-directed: No. Wandering behavior likely to affect the safety or well-being of self/others: No. Wandering behavior likely to affect the privacy of others: No. Recently admitted or readmitted (within the past 30 days) and has not accepted the situation: No. Review of R1's Progress Notes dated 03/31/24 at 7:53 AM, revealed, Note Text: At approximately 2030, door exit alarms heard. Panel displays Hallway 4 backdoor. 400 hall rooms checked to account for all residents. [R1] not in room. [R1] observed outside of facility; means of egress, hallway 4 emergency exit backdoor. [R1] was approximately 200 feet from the building, ambulating with assistive device, rollator walker. On contact, [R1] alert and oriented to situation. [R1] stated, I went out the wrong door. [R1] fully and appropriately dressed for weather and wearing tennis shoes. [R1] alert and no distress and injuries observed. [R1] was returned inside with only a brief moment of no exit seeking behavior. [R1] did not want to return to her room. [R1] ambulated to front and attempted to exit thru front door. The director of nursing [DON] was made aware. An unsuccessful attempt was made to contact person representative. [R1] continues exit seeking behavior. Unable to redirect. MD made aware. New order received for every 15 minute checks initiated to maintain safety and accountability. Exits checked at regular intervals. At change of shift, multiple exit seeking attempts made. (2) two of those attempts resulting in door alarms going off. During an interview on 04/09/24 at 11:36 AM, Registered Nurse (RN)1 stated, [R1] is alert with confusion. She self ambulates and frequently exit seeks. We have to constantly redirect her. During an interview on 04/09/24 at 11:39 AM, Certified Nursing Assistant (CNA)1 stated, I was not here the day she had the elopement but staff told me they heard the alarm sounding and went looking to see who was missing and found [R1] walking alone on the path outside the door. [R1] exit seeks and she needs constant reminders. It appears that her memory has declined a bit in the past 2 months. During an interview on 04/09/24 at 12:20 PM, the Director of Nursing (DON) stated, I was not here the day of the elopement. I was called by the nurse on duty and she told me that they heard an alarm and they all thought it was the front door alarm. A certified nursing assistant on the 400-hall called out to us that the 400 hall door alarm was alarming. Staff observed [R1] wearing white shoes, as it was very dark outside because the light at the back of the building was not working. We could just see her shoes and her walker in the dark. [R1] was escorted back into the facility and staff was placed with [R1] to conduct 15-minute checks for 3 days. On 04/10/24 at 10:52 AM, the facility provided a removal plan, which included: Criteria One: Resident 1 was leaving the facility and was escorted back in the facility and at no time was off the property on March 30, 2024. The IJ template identified the temperature outside was 50-degree Ferhenite [sic] and upon assessment the resident was without injury or hypothermic. The IJ template did not identify nor was it reported but by heresy witnesses of the resident dress. No interviews were conducted that witnessed the occurrence. The resident was returned to the facility, assessed without injury, placed on q15 minute checks, MD and RP notified. The elopement assessment was revised with a score of 4 indicating at risk for elopement and the care plan was updated with the new assessment information on 03/30/2024. The facility staff thought it was the smoke door on 400 but immediately identified it was the 400 door and retrieved the resident expeditiously per the elopement policy and procedure. All egress doors were checked by the Maintenance Director on 03/30/2024 AFTER the elopement and all doors were working properly. Criteria Two: The DON and Unit Coordinator are completing the wandering and elopement assessment on all residents (45) and will be complete by 04/09/2024. Any change in elopement status will be care planned, and the MD and RR notified. Criteria Three: The Director of Nursing and Administrator was educated on 04/09/2024 on the Elopement Resource manual and Elopement Policy and Procedure by the CEO who is a licensed nurse, Social Worker and LNHA. ALL departments will be educated on the Elopement Resource manual and Elopement Policy and Procedure by the Administrator and Director of Nursing to be completed by 04/09/2024. The Elopement Resource Manual and Elopement Policy and Procedure Education will be included in the new hire orientation on 04/09/2024. The maintenance or designee will audit the door daily and Manager on Duty on the weekend to ensure the egress doors are in good repair and enunciate correctly. The Administrator will review the completed audits for further follow-up if warranted. Criteria Four: The Plan of Correction for F689 was reviewed with the QAPI Committee to include the Medical Director [name] on 04/09/2024 without changes. The completed audits and identified listing of residents that are at risk of elopement will be reviewed monthly in the QAPI committee for further follow up and recommendations.

Based on interview and review of facility policy, the facility failed to ensure four (4) Certified Nursing Assistants (CNAs) had a minimum of 12 hours of annual training. Findings include: Review of the facility's undated policy titled, Nurse Aide Qualifications and Training Requirements revealed, Nurse aides must undergo a state-approved training program. In keeping with the Omnibus Budget Reconciliation Act of 1987 (OBRA) our facility will only employ those nurse aides who meet the requirements set forth in the federal and state statutes concerning the staffing of long-term care facilities. The employee must participate in a state-approved training and competency evaluation program. During an interview on 04/10/24 at 1:30 PM, a request was made to the Administrator for documentation related to CNAs annual training and she responded: I will look to see what I can find. During an interview on 04/10/24 at approximately 2:45 PM, the Administrator stated, I am new to the facility and I cannot find any supporting documents that the 4 CNAs have the required in-service and training for the minimum 12 hours of training required. I have called the agency to have them send in the supporting training for the CNAs.

Based on record reviews and interviews, the facility failed to ensure weekly body audits were completed on all residents and further failed to ensure the weekly treatment audits were completed as stated in the plan of correction. The facility further failed to review the completed weekly skin audits and the treatment audits with the monthly Quality Assurance and Performance Improvement (QAPI) committee for further follow-up and recommendations. The findings include: No documentation could be found to ensure the weekly skin and treatment audits were reviewed by the QAPI Committee. During an interview on 06/13/2024 at 02:05 PM with the Administrator and the Administrator in Training, it was confirmed that the weekly body audits for all residents was not being completed as stated in the plan of correction. During an interview on 06/13/2024 at 02:25 PM with the Director of Nursing, she stated she was completing the audits of wound care, but did not have documentation to ensure the treatments were audited and completed as stated in the plan of correction.

Based on record review, interview, and review of the Facility Abuse Policy, the facility failed to ensure policies and procedures were implement to protect Resident #184 from abuse through misappropriation of the resident's charge card by a staff member (1 of 3 residents reviewed for abuse). The findings included: The facility admitted Resident #184 with [DIAGNOSES REDACTED]. The facility was notified on 10/12/18 by the resident's family of fraudulent activity occurring on the residents credit card that occurred on 10/9 and 10/10/18. The facility Policy-Abuse Prevention Program documented Our Facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment and involuntary seclusion by anyone including but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians surrogates, sponsors, friends, visitors,or any individual. Resident #184 was not protected from misappropriation of his/her credit card and use of that card by an employee of the facility. Interview with the Director of Nursing and the Administrator on 1/17/19 confirmed the misappropriation did occur in the facility by an employee of that facility. The Sumter County Sheriff's Department did arrest and charge the employee, who is awaiting trial.

Based on record review and interview, the facility failed to protect Resident #184 from misappropriation/exploitation (1 of 1 residents reviewed for misappropriation of property). Resident #184's charge card was fraudulently used by a staff member. The findings included: The facility admitted Resident #184 with [DIAGNOSES REDACTED]. The facility was notified on 10/12/18 by the resident's family of fraudulent activity occurring on the resident's credit card which occurred on 10/9 and 10/10/18. The local law enforcement was notified. It was verified the resident had possessed the credit card and was now missing. The facility interviewed staff on duty and employees at the facility. Thirty four statements from staff were reviewed including statement form the perpetrator (who gave a false statement). Once turned over to the Sumter County Sheriff's Department a Detective took over the investigation. Fraud alert had contacted the resident of an alert that her card had been used on 10/9/18 in the amount of approximately $300.00, 10/10/18 at 8:16 PM in the amount of $213.00, and 10/9/18 in the amount of $80.00. The Director of Nursing remained in continuous contact with the investigator as to progress on the case. On 10/16/18, the Sheriff's Office completed all paperwork for release of all property sent to a retail store for photo's. On 10/18/18 at 2:30 PM, the Investigator arrived at the facility with the photo from the retail store. Certified Nursing Assistant #1 was identified. The employee was removed from the facility and the Investigator placed the employee in custody. During interview at the Sheriff's office, the employee was charged with code 2657-Exploitation of a vulnerable adult, code 0348- Financial Transaction Card Theft, and code 0731- Financial Transaction Card fraud value $500 or less in six month period. The facility inserviced all staff about misappropriation of residents property and consequences. The Resident Council was also enlisted to help inform all residents about not keeping money and valuables in the facility. Residents were reminded that the facility could place valuables in a safe in the facility. Families and residents were encouraged to send any valuables home. On admission, Families/Residents were encouraged to leave all valuables at home. The credit card company credited the resident's account for all monies. Interview with the Director of Nursing and the Administrator on 1/17/19 confirmed the misappropriation did occur in the facility by an employee of that facility. The Sumter County Sheriff's Department did arrest and charge the employee, who is awaiting trial.

Based on record review and interview, the facility failed to protect Resident #184 from abuse through misappropriation of the resident's charge card by a staff member (1 of 3 residents reviewed for abuse). The findings included: The facility admitted Resident #184 with [DIAGNOSES REDACTED]. The facility was notified on 10/12/18 by the resident's family of fraudulent activity occurring on the residents credit card that occurred on 10/9 and 10/10/18. The local law enforcement was notified. It was verified the resident had possessed the credit card. The facility interviewed staff on duty and employees at the facility. Thirty four statements from staff were reviewed including a statement from the perpetrator (who gave a false statement). Once turned over to the Sumter County Sheriff's Department a Detective took over the investigation. Fraud alert had contacted the resident of an alert that her card had been used on 10/9/18 in the amount of approximately $300.00, 10/10/18 at 8:16 PM in the amount of $213.00, and 10/9/18 in the amount of $80.00. The Director of Nursing remained in continuous contact with the investigator as to the progress on the case. On 10/16/18, the Sheriff's office completed all paperwork for release of all property sent to a retail store for photo's. On 10/18/18 at 2:30 PM the Investigator arrived at the facility with a photo from the retail store. Certified Nursing Assistant #1 was identified. The employee was removed from the facility and the Investigator placed the employee in custody. During interview at the Sheriff's office, the employee was charged with code 2657-Exploitation of a vulnerable adult, code 0348- Financial Transaction Card Theft, and code 0731- Financial Transaction Card fraud value $500 or less in six month period. The facility inserviced all staff about misappropriation of residents property and consequences. The Resident Council was also enlisted to help inform all residents about not keeping money and valuables in the facility. Residents were reminded that the facility could place valuables in a safe in the facility. Families and residents were encouraged to send any valuables home. On admission Families/Residents were encouraged to leave all valuables at home. The credit card company credited the resident's account for all monies. Interview with the Director of Nursing and the Administrator on 1/17/19 confirmed the misappropriation did occur in the facility by an employee of that facility. The Sumter County Sheriff's Department did arrest and charge the employee, who is awaiting trial.

Based on observations, interview and record review the facility failed to notify the physician of presence of multiple daily episodes of behaviors (specifically chewing on clothing and/or linen to the point of destruction). There is no evidence that the physician was aware of multiple daily episodes of behaviors exhibited by Resident #67 from the date he assumed care on 2/1/17 through 12/13/17 for 1 of 1 resident reviewed for behaviors. CFR 483.10 (g) (14) F-580. Notification of Changes was identified at a scope and severity of level (K). The facility failed to ensure that the physician was aware of Resident #67's recurrent behavior of chewing on clothing and/or bed linen to the point of shredding resulting in the release of threads which could be aspirated and/or swallowed resulting in [MEDICAL CONDITION] or gastrointestinal complications from the time the physician assumed the care for Resident #67 on February 1, 2017 until December 13, 2017. The findings included: Record review on 12/12/17 at 4:20 PM revealed that Resident #67 was admitted to the facility with the [DIAGNOSES REDACTED].P.), [MEDICAL CONDITION], unspecified intellectual disabilities, other specified eating disorder-pica-fabric, and specific developmental disorder of motor function. Observation on 12/11/17 at 2:47 PM revealed resident lying in bed chewing on damaged hospital gown with strings observed scattered around neck and protruding from oral cavity, behavior observation immediately verified by Registered Nurse (RN) #5 during interview. Ongoing observation on 12/12/17 at 9:25 AM revealed resident #67 was lying in bed chewing on damaged hospital gown with strings observed scattered around neck and protruding from oral cavity, behavior observation immediately verified by Licensed Practical Nurse (LPN) #3 on interview. Further observation on 12/12/17 at 4:00 PM revealed Resident #67 lying in bed chewing on damaged hospital gown, with strings protruding from oral cavity and scattered around neck area, behavior observation immediately verified during interview with (RN) #5. Finally, Certified Nursing Assistants (C.N.A.'s) #1, #5, & #6 revealed during interviews on 12/12/17 from 4:56-5:00 PM that Resident #67 must have hospital gown changed at least once a shift related to chewing behavior. Review of medical record on 12/12/17 at 4:30 PM revealed that there was no mention of Resident #67's ongoing behavior of chewing on hospital gowns/ bed linen in any of the physician progress notes [REDACTED]. Additional review of social worker progress notes on 12/12/17 revealed the quarterly progress notes with documentation to reflect presence on-going behaviors including chewing on clothing and linen. The social worker progress note dated 3/23/17 included the statement .Resident continues to exhibit behaviors of chewing on clothing and linen. The social worker progress note dated 8/25/17, included the statement .exhibits on-going behavior of chewing garments and linen . And finally, social worker progress note dated 11/29/17 included the statement .Continues to exhibit behaviors of chewing on clothing and linen . During interview on 12/13/17 at 9:15 AM the Physician was asked if s/he was aware that Resident #67 has behavior referred to as pica by staff, which was evidenced by three observations between 12/11/17 and 12/12/17 at 5:00 PM of Resident #67 chewing on hospital gowns and tearing fabric to shreds/ strings at the neckline requiring staff to change her gown frequently. The physician stated that s/he was not aware of Resident #67's pica or any other behavior. S/he further stated that Resident #67 had a [DIAGNOSES REDACTED]. Physician verified that Resident #67 received scheduled and as needed medications for constipation and [MEDICATION NAME] for [DIAGNOSES REDACTED]. Physician stated s/he must be doing that because she is hungry, I will look at him/her and maybe order double portions. When asked if s/he considered this chewing of her gowns/ linen as a behavioral issue, s/he stated when someone tries to put something in their mouth that it usually means that they are hungry. When asked if s/he could recall when Resident #67 was last seen by a psychiatric specialist, Physician stated that s/he did not recall Resident #67 being seen by anyone else and that resident had been here a long time. At conclusion of interview, Resident #67 was observed sitting in a Geri-chair in direct view of Physician and actively displayed behavior of chewing on blanket which was immediately verified by the physician. The physician did not identify the behavior as pica, but agreed that the resident was chewing on his/her blanket. After which, physician stated s/he had not seen this behavior before and then repeated the statement that Resident #67 must be hungry and that s/he will double Resident #67's meal portions. Record review on 12/13/17 at 10:00 AM revealed that a new order had been initiated for Resident #67 to double portions with lunch and supper which was initiated on 12/13/17 at 9:22 AM. The facility Administrator was informed of the Immediate Jeopardy on 12/13/2017 at 3:17 PM. The facility provided a final Allegation of Compliance (A(NAME)) that was acceptable and implemented on 12/15/17. The Immediate Jeopardy at F-550, F-580, F-636, F-656, F-679, F-740, and F-742 was removed on 12/15/17 at 11:15 AM, but the citations remained at a lowered scope and severity of E. The A(NAME) included the following: Immediately upon notification by the state surveyor Resident #67 was placed on one on one supervision due to behaviors related to PICA (chewing on fabric, gown). The facility will continue to seek a psychiatric evaluation until available (related to PICA) and develop a behavioral management program. The facility will seek local resources such as C.P. organization, if available, for specialized training related to the C.P. ([MEDICAL CONDITION]) MD notified of Immediate Jeopardy; one on one to continue until psychiatric evaluation and training completed. Facility social work contacting appropriate facilities/ professionals for referral for evaluation related to resident's behavior (PICA, chewing on fabric, gown). All staff providing care for the resident will monitor every bowel movement for presence of strings. All staff on duty was in-serviced for new plan of care. All oncoming staff will be in-service prior to clock in at facility. Assigned one on one member will provide diversional tactics such as: 1. Provide snacks (twizzlers, fruit roll ups) 2. Dexterity exercises (Range of Motion) with active behaviors 3. Redirect hands from clothing as needed 4. Increased engagement in activities Please see attached sheet for list of psychiatric services the facility has contacted at this point to obtain in house services. Possible transfer to (sister facility) with in-house psychiatric services. Blue Ridge of Sumter Schedule for One on One observation Days: 7-10 am Assist with AM care and meal completion 10am-12pm: Resident will be provided opportunity for activities 12-1 pm: Lunch 1-3 pm 1:1 activities (ROM, provide snacks) Afternoons: 3-5pm Time in scheduled activities 5-6 pm Dinner 6-9 pm 1:1 Read, offer music, hand massage with lotion 9-11 pm Assist with PM care, provide snacks if needed Nights 11pm-7 am Sleep-if awake offer snacks and diversional activities.

Based on observation, record review and interview, the facility failed to comprehensively assess Resident #67's physical, mental and psychosocial needs related to individual preferences and activity program for 1 of 1 resident reviewed for activities. CFR 483.20 F-636. Resident Assessment was identified at a scope and severity of level (K). The facility failed to ensure that Resident #67 received a periodic accurate assessment of his/her physical, mental and psychosocial needs related to individual preferences and activity program. The findings included: Record review on 12/12/17 at 4:20 PM revealed that Resident #67 was admitted to the facility with the [DIAGNOSES REDACTED].P.), [MEDICAL CONDITION], unspecified intellectual disabilities, other specified eating disorder-pica-fabric, and specific developmental disorder of motor function. Additional record review on 12/12/17 at 7:00 revealed that there was no evidence of comprehensive assessment for resident preferences for customary routine and activities in coordination with the scheduled Annual Comprehensive Minimum Data Set (MDS) assessment with Assessment Reference Date of 11/22/17. Review of activities progress note dated 11/22/17 revealed that Resident #67 was identified as .nonverbal .unable to participate independently with individual or group activities r/t (related to) cognitive deficits and physical deficits .enjoys being up watching people, laughs frequently. Review of the Comprehensive MDS assessment with ARD of 11/22/17 under item F0800 Staff assessment of Daily and Activity Preferences, only item E- receiving bed bath was checked. Further review of the Care Area Assessment #10 related to annual comprehensive MDS with ARD of 11/22/17 for the section Activities reveals the only statement entered is identical to the activity progress note dated 11/22/17 .nonverbal .unable to participate independently with individual or group activities r/t cognitive deficits and physical deficits .enjoys being up watching people, laughs frequently. During interview with Activity Director on 12/13/17 at 9:01 AM, s/he verified that s/he completed section F and that only item F0800E was checked in that section on the annual comprehensive MDS with ARD of 11/22/17. When asked why only item F0800E was checked in section F0800, s/he replied I don't know. The facility Administrator was informed of the Immediate Jeopardy on 12/13/2017 at 3:17 PM. The facility provided a final Allegation of Compliance (A(NAME)) that was acceptable and implemented on 12/15/17. The Immediate Jeopardy at F-550, F-580, F-636, F-656, F-679, F-740, and F-742 was removed on 12/15/17 at 11:15 AM, but the citations remained at a lowered scope and severity of E. The A(NAME) included the following: Immediately upon notification by the state surveyor Resident #67 was placed on one on one supervision due to behaviors related to PICA (chewing on fabric, gown). The facility will continue to seek a psychiatric evaluation until available (related to PICA) and develop a behavioral management program. The facility will seek local resources such as C.P. organization, if available, for specialized training related to the C.P. ([MEDICAL CONDITION]) MD notified of Immediate Jeopardy; one on one to continue until psychiatric evaluation and training completed. Facility social work contacting appropriate facilities/ professionals for referral for evaluation related to resident's behavior (PICA, chewing on fabric, gown). All staff providing care for the resident will monitor every bowel movement for presence of strings. All staff on duty was in-serviced for new plan of care. All oncoming staff will be in-service prior to clock in at facility. Assigned one on one member will provide diversional tactics such as: 1. Provide snacks (twizzlers, fruit roll ups) 2. Dexterity exercises (Range of Motion) with active behaviors 3. Redirect hands from clothing as needed 4. Increased engagement in activities Please see attached sheet for list of psychiatric services the facility has contacted at this point to obtain in house services. Possible transfer to (sister facility) with in-house psychiatric services. Blue Ridge of Sumter Schedule for One on One observation Days: 7-10 am Assist with AM care and meal completion 10am-12pm: Resident will be provided opportunity for activities 12-1 pm: Lunch 1-3 pm 1:1 activities (ROM, provide snacks) Afternoons: 3-5pm Time in scheduled activities 5-6 pm Dinner 6-9 pm 1:1 Read, offer music, hand massage with lotion 9-11 pm Assist with PM care, provide snacks if needed Nights 11pm-7 am Sleep-if awake offer snacks and diversional activities.

Based on observation, interview and record review, the facility failed to provide an ongoing and consistent activity program to support Resident #67's physical, mental and psychosocial well-being for 1 of 1 resident reviewed for activities. CFR 483.24(c) (1) F-679 Activities was identified at a scope and severity of level (K). The facility failed to provide an ongoing and consistent activity program to support Resident #67's physical, mental and psychosocial well-being. The findings included: Record review on 12/12/17 at 4:20 PM revealed that Resident #67 was admitted to the facility with the [DIAGNOSES REDACTED].P.), [MEDICAL CONDITION], unspecified intellectual disabilities, other specified eating disorder-pica-fabric, and specific developmental disorder of motor function. Review of documentation provided by facility on 12/13/17 at 9:55 AM revealed the frequency of 1:1 activity visits from August 2017 through December 2017. Resident #67 participated in 1:1 activity programs during the month of August 2017 on 8/1/17, 8/3/17, 8/15/17, 8/17/17, 8/29/17 and 8/31/17. There were no visits during the weeks of 8/7/17-8/11/17 or 8/21/17-8/25/17. Resident #67 participated in 1:1 activity programs during the month of September 2017 on 9/5/17, 9/7/17, 9/19/17, and 9/21/17. There were no visits during the week of 9/11/17-9/15/17 or 9/25/17-9/29/17. Resident #67 participated in 1:1 activity programs during the month of October 2017 on 10/3/17, 10/12/17, 10/17/17, and 10/26/17 (once weekly during month of October). Resident #67 participated in 1:1 activity programs during the month of November 2017 on 11/6/17 and 11/15/17. There were no visits during the week of 11/20/17-11/24/17 or 11/27/17-12/1/17. Resident #67 participated in 1:1 activity programs during the month of December 2017 (12/1-12/12/17) on 12/5/17 and 12/7/17. Review of Resident #67's care plan on 12/12/17 at 9:45 revealed that activity care plan problem with start date identified of 12/12/16 does not identify how often Resident #67 will be engaged in 1 on 1 or group activities. Further review of the interventions reveals that there is no specific time frame or frequency identified for when sensory stimulation will be provided. During interview with activity director on 12/13/17 at 9:01 AM, s/he verified that there was no evidence of consistent activity program in place for Resident #67. S/he further stated that due to changes in department staff over the past quarter, the 1:1 visits for the facility as a whole were not done on a regular basis; however, this issue was currently being addressed and new schedules were being implemented. S/he further verified that the activity care plan goal did not identify how often Resident #67 would be engaged in 1 on 1 or group activities and that there is no specific time frame or frequency identified in intervention for when sensory stimulation will be provided. The facility Administrator was informed of the Immediate Jeopardy on 12/13/2017 at 3:17 PM. The facility provided a final Allegation of Compliance (A(NAME)) that was acceptable and implemented on 12/15/17. The Immediate Jeopardy at F-550, F-580, F-636, F-656, F-679, F-740, and F-742 was removed on 12/15/17 at 11:15 AM, but the citations remained at a lowered scope and severity of E. The A(NAME) included the following: Immediately upon notification by the state surveyor Resident #67 was placed on one on one supervision due to behaviors related to PICA (chewing on fabric, gown). The facility will continue to seek a psychiatric evaluation until available (related to PICA) and develop a behavioral management program. The facility will seek local resources such as C.P. organization, if available, for specialized training related to the C.P. ([MEDICAL CONDITION]) MD notified of Immediate Jeopardy; one on one to continue until psychiatric evaluation and training completed. Facility social work contacting appropriate facilities/ professionals for referral for evaluation related to resident's behavior (PICA, chewing on fabric, gown). All staff providing care for the resident will monitor every bowel movement for presence of strings. All staff on duty was in-serviced for new plan of care. All oncoming staff will be in-service prior to clock in at facility. Assigned one on one member will provide diversional tactics such as: 1. Provide snacks (twizzlers, fruit roll ups) 2. Dexterity exercises (Range of Motion) with active behaviors 3. Redirect hands from clothing as needed 4. Increased engagement in activities Please see attached sheet for list of psychiatric services the facility has contacted at this point to obtain in house services. Possible transfer to (sister facility) with in-house psychiatric services. Blue Ridge of Sumter Schedule for One on One observation Days: 7-10 am Assist with AM care and meal completion 10am-12pm: Resident will be provided opportunity for activities 12-1 pm: Lunch 1-3 pm 1:1 activities (ROM, provide snacks) Afternoons: 3-5pm Time in scheduled activities 5-6 pm Dinner 6-9 pm 1:1 Read, offer music, hand massage with lotion 9-11 pm Assist with PM care, provide snacks if needed Nights 11pm-7 am Sleep-if awake offer snacks and diversional activities.

Based on observations, interview and record review, the facility failed to provide the necessary behavioral health care and services for Resident #67 to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 of 1 resident reviewed for behaviors. CFR 483.40 F-740. Behavioral health services was identified at a scope and severity of level (K). The facility failed to provide the necessary behavioral health care and services for Resident #67 to attain or maintain the highest practicable physical, mental, and psychosocial well-being related to underlying [DIAGNOSES REDACTED]. The findings included: Record review on 12/12/17 at 4:20 PM revealed that Resident #67 was admitted to the facility with the [DIAGNOSES REDACTED].P.), [MEDICAL CONDITION], unspecified intellectual disabilities, other specified eating disorder-pica-fabric, and specific developmental disorder of motor function. Observation on 12/11/17 at 2:47 PM revealed Resident #67 lying in bed chewing on damaged hospital gown with strings observed scattered around neck and protruding from oral cavity. This behavior observation was immediately verified by Registered Nurse (RN) #5 during interview at which time the damaged gown was removed in addition to completion of oral cavity check as tolerated by resident with removal of strings from mouth and area surrounding neck, followed by application of new hospital gown. Ongoing observation on 12/12/17 at 9:25 AM revealed resident #67 was lying in bed chewing on damaged hospital gown with strings observed scattered around neck and protruding from oral cavity. This behavior observation immediately verified by Licensed Practical Nurse (LPN) #3 on interview which was followed by oral cavity check as resident would tolerate, removal of strings from mouth and area surrounding by neck with removal of damaged gown and replacement with clean, undamaged hospital gown. When asked what staff would do as a diversional activity to keep her from chewing on gowns and/or linen, s/he replied well, we just watch her and try to stop her but there really isn't anything we can do to stop her, it isn't just her clothing, it is anything s/he can get his/her hands on. Sometimes the linen or sheets. S/he further reported during interview 12/12/17 at 4:55 PM that we try to keep him/her eating at night to keep him/her occupied. Further observation on 12/12/17 at 4:00 PM revealed Resident #67 lying in bed chewing on damaged hospital gown, with strings protruding from oral cavity and scattered around neck area, behavior observation immediately verified during interview with (RN) #5 which was followed by oral cavity check as tolerated by resident with removal of strings from mouth and area surrounding neck, followed by removal of damaged hospital gown and application of clean, undamaged hospital gown. RN#5 further reported s/he does this all the time, we don't know what else to do. During interview with RN #6 on 12/12/17 at 4:53 PM, when asked what diversional activities are used for Resident #67 when s/he is observed to be chewing on her hospital gown and/or linens, s/he replied talk to him/her, turn on the TV maybe? Finally, Certified Nursing Assistants (C.N.A.'s) #1, #5, & #6 revealed during interviews on 12/12/17 from 4:56-5:00 PM that Resident #67 must have hospital gown changed at least once a shift related to chewing behavior. C.N.A. #1 reported during interview that s/he works both 1st and 2nd shifts and will frequently peek in and talk to or offer a drink or snack to Resident #67 when s/he is observed to be chewing on gowns. When asked if Resident #67 has been observed out of bed/ out of room, C.N.A. #1 replied that s/he has seen Resident #67 out of bed in Geri Chair in common area occasionally, but it is not a regular occurrence. Record review on 12/12/17 at 9:45 revealed that the comprehensive plan of care did not include individualized interventions to address multiple areas including, but not limited to, management of behaviors, communication deficits, cognitive and physical deficits with measurable and realistic goals that was reflective of current status. Interventions included provide resident with diversional activities when behavioral symptoms arise but did not identify what specific diversional activities were to be provided. Additional interventions included administration of routine and as needed pain management medications as ordered; however, there are no pain management medications whatsoever ordered for Resident #67 at the time of review on 12/12/17. Further review revealed additional interventions which included provide alternate form of communication: (Pen and paper, communication board, book, etc.) despite resident being identified as rarely/never understood and rarely/never understands on Minimum Data Set (MDS) comprehensive assessment with assessment reference date of 11/22/2017. During interview on 12/13/17 at 9:15 AM the Physician was asked if s/he was aware that Resident #67 has behavior referred to as pica by staff, which was evidenced by three observations between 12/11/17 and 12/12/17 at 5:00 PM of Resident #67 chewing on hospital gowns and tearing fabric to shreds/ strings at the neckline requiring staff to change her gown frequently. The physician stated that s/he was not aware of Resident #67's pica or any other behavior. S/he further stated that Resident #67 had a [DIAGNOSES REDACTED]. Physician verified that Resident #67 received scheduled and as needed medications for constipation and [MEDICATION NAME] for [DIAGNOSES REDACTED]. Physician stated s/he must be doing that because she is hungry, I will look at him/her and maybe order double portions. When asked if s/he considered this chewing of her gowns/ linen as a behavioral issue, s/he stated when someone tries to put something in their mouth that it usually means that they are hungry. When asked if s/he could recall when Resident #67 was last seen by a psychiatric specialist, Physician stated that s/he did not recall Resident #67 being seen by anyone else and that resident had been here a long time. At conclusion of interview, Resident #67 was observed sitting in a Geri-chair in direct view of Physician and actively displayed behavior of chewing on blanket which was immediately verified by the physician. The physician did not identify the behavior as pica, but agreed that the resident was chewing on his/her blanket. After which, physician stated s/he had not seen this behavior before and then repeated the statement that Resident #67 must be hungry and that s/he will double Resident #67's meal portions. MDS nurse verified during interview on 12/13/17 at 9:30 AM that the comprehensive care plan related to areas including, but not limited to behaviors, pain management, communication, bladder incontinence, activities, and activities of daily living did not contain individualized interventions, realistic and/or measurable goals and/or did not reflect the current status of Resident #67. The facility Administrator was informed of the Immediate Jeopardy on 12/13/2017 at 3:17 PM. The facility provided a final Allegation of Compliance (A(NAME)) that was acceptable and implemented on 12/15/17. The Immediate Jeopardy at F-550, F-580, F-636, F-656, F-679, F-740, and F-742 was removed on 12/15/17 at 11:15 AM, but the citations remained at a lowered scope and severity of E. The A(NAME) included the following: Immediately upon notification by the state surveyor Resident #67 was placed on one on one supervision due to behaviors related to PICA (chewing on fabric, gown). The facility will continue to seek a psychiatric evaluation until available (related to PICA) and develop a behavioral management program. The facility will seek local resources such as C.P. organization, if available, for specialized training related to the C.P. ([MEDICAL CONDITION]) MD notified of Immediate Jeopardy; one on one to continue until psychiatric evaluation and training completed. Facility social work contacting appropriate facilities/ professionals for referral for evaluation related to resident's behavior (PICA, chewing on fabric, gown). All staff providing care for the resident will monitor every bowel movement for presence of strings. All staff on duty was in-serviced for new plan of care. All oncoming staff will be in-service prior to clock in at facility. Assigned one on one member will provide diversional tactics such as: 1. Provide snacks (twizzlers, fruit roll ups) 2. Dexterity exercises (Range of Motion) with active behaviors 3. Redirect hands from clothing as needed 4. Increased engagement in activities Please see attached sheet for list of psychiatric services the facility has contacted at this point to obtain in house services. Possible transfer to (sister facility) with in-house psychiatric services. Blue Ridge of Sumter Schedule for One on One observation Days: 7-10 am Assist with AM care and meal completion 10am-12pm: Resident will be provided opportunity for activities 12-1 pm: Lunch 1-3 pm 1:1 activities (ROM, provide snacks) Afternoons: 3-5pm Time in scheduled activities 5-6 pm Dinner 6-9 pm 1:1 Read, offer music, hand massage with lotion 9-11 pm Assist with PM care, provide snacks if needed Nights 11pm-7 am Sleep-if awake offer snacks and diversional activities.

Based on observations, interview and record review, the facility failed ensure that staff who provide direct services to Resident #67 had the appropriate skill sets to provide services to assure their safety and that s/he attain the highest practicable physical, mental and psychosocial well-being related to [DIAGNOSES REDACTED]. There is no evidence that direct care staff have received training regarding how to care for adult population with cognitive disorders such as [MEDICAL CONDITION] and intellectual disabilities with behaviors for 1 of 1 residents reviewed for behaviors. CFR 483.40(a) F-741. Competent staff- behavioral health needs was identified at a scope and severity of level (K). The facility failed to ensure that direct care staff have received training regarding how to care for Resident #67 and similar adult population with cognitive disorders such has [MEDICAL CONDITION] and intellectual disabilities with behaviors. The findings included: Record review on 12/12/17 at 4:20 PM revealed that Resident #67 was admitted to the facility with the [DIAGNOSES REDACTED].P.), [MEDICAL CONDITION], unspecified intellectual disabilities, other specified eating disorder-pica-fabric, and specific developmental disorder of motor function. Observation on 12/11/17 at 2:47 PM revealed Resident #67 lying in bed chewing on damaged hospital gown with strings observed scattered around neck and protruding from oral cavity. This behavior observation was immediately verified by Registered Nurse (RN) #5 during interview at which time the damaged gown was removed in addition to completion of oral cavity check as tolerated by resident with removal of strings from mouth and area surrounding neck, followed by application of new hospital gown. Ongoing observation on 12/12/17 at 9:25 AM revealed resident #67 was lying in bed chewing on damaged hospital gown with strings observed scattered around neck and protruding from oral cavity. This behavior observation immediately verified by Licensed Practical Nurse (LPN) #3 on interview which was followed by oral cavity check as resident would tolerate, removal of strings from mouth and area surrounding by neck with removal of damaged gown and replacement with clean, undamaged hospital gown. When asked what staff would do as a diversional activity to keep her from chewing on gowns and/or linen, s/he replied well, we just watch her and try to stop her but there really isn't anything we can do to stop her, it isn't just her clothing, it is anything s/he can get his/her hands on. Sometimes the linen or sheets. S/he further reported during interview 12/12/17 at 4:55 PM that we try to keep him/her eating at night to keep him/her occupied. Further observation on 12/12/17 at 4:00 PM revealed Resident #67 lying in bed chewing on damaged hospital gown, with strings protruding from oral cavity and scattered around neck area, behavior observation immediately verified during interview with (RN) #5 which was followed by oral cavity check as tolerated by resident with removal of strings from mouth and area surrounding neck, followed by removal of damaged hospital gown and application of clean, undamaged hospital gown. RN#5 further reported s/he does this all the time, we don't know what else to do. During interview with RN #6 on 12/12/17 at 4:53 PM, when asked what diversional activities are used for Resident #67 when s/he is observed to be chewing on her hospital gown and/or linens, s/he replied talk to him/her, turn on the TV maybe? Finally, Certified Nursing Assistants (C.N.A.'s) #1, #5, & #6 revealed during interviews on 12/12/17 from 4:56-5:00 PM that Resident #67 must have hospital gown changed at least once a shift related to chewing behavior. C.N.A. #1 reported during interview that s/he works both 1st and 2nd shifts and will frequently peek in and talk to or offer a drink or snack to Resident #67 when s/he is observed to be chewing on gowns. When asked if Resident #67 has been observed out of bed/ out of room, C.N.A. #1 replied that s/he has seen Resident #67 out of bed in Geri Chair in common area occasionally, but it is not a regular occurrence. The facility was not able to provide evidence of specialzed training provided to direct care staff related to [DIAGNOSES REDACTED]. The facility Administrator was informed of the Immediate Jeopardy on 12/13/2017 at 3:17 PM. The facility provided a final Allegation of Compliance (A(NAME)) that was acceptable and implemented on 12/15/17. The Immediate Jeopardy at F-550, F-580, F-636, F-656, F-679, F-740, and F-742 was removed on 12/15/17 at 11:15 AM, but the citations remained at a lowered scope and severity of E. The A(NAME) included the following: Immediately upon notification by the state surveyor Resident #67 was placed on one on one supervision due to behaviors related to PICA (chewing on fabric, gown). The facility will continue to seek a psychiatric evaluation until available (related to PICA) and develop a behavioral management program. The facility will seek local resources such as C.P. organization, if available, for specialized training related to the C.P. ([MEDICAL CONDITION]) MD notified of Immediate Jeopardy; one on one to continue until psychiatric evaluation and training completed. Facility social work contacting appropriate facilities/ professionals for referral for evaluation related to resident's behavior (PICA, chewing on fabric, gown). All staff providing care for the resident will monitor every bowel movement for presence of strings. All staff on duty was in-serviced for new plan of care. All oncoming staff will be in-service prior to clock in at facility. Assigned one on one member will provide diversional tactics such as: 1. Provide snacks (twizzlers, fruit roll ups) 2. Dexterity exercises (Range of Motion) with active behaviors 3. Redirect hands from clothing as needed 4. Increased engagement in activities Please see attached sheet for list of psychiatric services the facility has contacted at this point to obtain in house services. Possible transfer to (sister facility) with in-house psychiatric services. Blue Ridge of Sumter Schedule for One on One observation Days: 7-10 am Assist with AM care and meal completion 10am-12pm: Resident will be provided opportunity for activities 12-1 pm: Lunch 1-3 pm 1:1 activities (ROM, provide snacks) Afternoons: 3-5pm Time in scheduled activities 5-6 pm Dinner 6-9 pm 1:1 Read, offer music, hand massage with lotion 9-11 pm Assist with PM care, provide snacks if needed Nights 11pm-7 am Sleep-if awake offer snacks and diversional activities.

Based on observations, interview and record review, the facility failed to ensure that Resident #67 received appropriate treatment and services to correct behaviors to attain the highest practicable mental and psychosocial well-being for 1 of 1 residents reviewed for behaviors. CFR 483.40(b) F-742. Treatment/ service for Mental/ Psychosocial concerns was identified at a scope and severity of level (K). The facility failed to ensure that Resident #67 received appropriate treatment and services to correct behaviors to attain the highest practicable mental and psychosocial well-being. The findings included: Record review on 12/12/17 at 4:20 PM revealed that Resident #67 was admitted to the facility with the [DIAGNOSES REDACTED].P.), [MEDICAL CONDITION], unspecified intellectual disabilities, other specified eating disorder-pica-fabric, and specific developmental disorder of motor function. Observation on 12/11/17 at 2:47 PM revealed Resident #67 lying in bed chewing on damaged hospital gown with strings observed scattered around neck and protruding from oral cavity. This behavior observation was immediately verified by Registered Nurse (RN) #5 during interview at which time the damaged gown was removed in addition to completion of oral cavity check as tolerated by resident with removal of strings from mouth and area surrounding neck, followed by application of new hospital gown. Ongoing observation on 12/12/17 at 9:25 AM revealed resident #67 was lying in bed chewing on damaged hospital gown with strings observed scattered around neck and protruding from oral cavity. This behavior observation immediately verified by Licensed Practical Nurse (LPN) #3 on interview which was followed by oral cavity check as resident would tolerate, removal of strings from mouth and area surrounding by neck with removal of damaged gown and replacement with clean, undamaged hospital gown. When asked what staff would do as a diversional activity to keep her from chewing on gowns and/or linen, s/he replied well, we just watch her and try to stop her but there really isn't anything we can do to stop her, it isn't just her clothing, it is anything s/he can get his/her hands on. Sometimes the linen or sheets. S/he further reported during interview 12/12/17 at 4:55 PM that we try to keep him/her eating at night to keep him/her occupied. Further observation on 12/12/17 at 4:00 PM revealed Resident #67 lying in bed chewing on damaged hospital gown, with strings protruding from oral cavity and scattered around neck area, behavior observation immediately verified during interview with (RN) #5 which was followed by oral cavity check as tolerated by resident with removal of strings from mouth and area surrounding neck, followed by removal of damaged hospital gown and application of clean, undamaged hospital gown. RN#5 further reported s/he does this all the time, we don't know what else to do. During interview with RN #6 on 12/12/17 at 4:53 PM, when asked what diversional activities are used for Resident #67 when s/he is observed to be chewing on her hospital gown and/or linens, s/he replied talk to him/her, turn on the TV maybe? Finally, Certified Nursing Assistants (C.N.A.'s) #1, #5, & #6 revealed during interviews on 12/12/17 from 4:56-5:00 PM that Resident #67 must have hospital gown changed at least once a shift related to chewing behavior. C.N.A. #1 reported during interview that s/he works both 1st and 2nd shifts and will frequently peek in and talk to or offer a drink or snack to Resident #67 when s/he is observed to be chewing on gowns. When asked if Resident #67 has been observed out of bed/ out of room, C.N.A. #1 replied that s/he has seen Resident #67 out of bed in Geri Chair in common area occasionally, but it is not a regular occurrence. Record review on 12/12/17 at 9:45 revealed that the comprehensive plan of care did not include individualized interventions to address multiple areas including, but not limited to, management of behaviors, communication deficits, cognitive and physical deficits with measurable and realistic goals that was reflective of current status. Interventions included provide resident with diversional activities when behavioral symptoms arise but did not identify what specific diversional activities were to be provided. Additional interventions included administration of routine and as needed pain management medications as ordered; however, there are no pain management medications whatsoever ordered for Resident #67 at the time of review on 12/12/17. Further review revealed additional interventions which included provide alternate form of communication: (Pen and paper, communication board, book, etc.) despite resident being identified as rarely/never understood and rarely/never understands on Minimum Data Set (MDS) comprehensive assessment with assessment reference date of 11/22/2017. During interview on 12/13/17 at 9:15 AM the Physician was asked if s/he was aware that Resident #67 has behavior referred to as pica by staff, which was evidenced by three observations between 12/11/17 and 12/12/17 at 5:00 PM of Resident #67 chewing on hospital gowns and tearing fabric to shreds/ strings at the neckline requiring staff to change her gown frequently. The physician stated that s/he was not aware of Resident #67's pica or any other behavior. S/he further stated that Resident #67 had a [DIAGNOSES REDACTED]. Physician verified that Resident #67 received scheduled and as needed medications for constipation and [MEDICATION NAME] for [DIAGNOSES REDACTED]. Physician stated s/he must be doing that because she is hungry, I will look at him/her and maybe order double portions. When asked if s/he considered this chewing of her gowns/ linen as a behavioral issue, s/he stated when someone tries to put something in their mouth that it usually means that they are hungry. When asked if s/he could recall when Resident #67 was last seen by a psychiatric specialist, Physician stated that s/he did not recall Resident #67 being seen by anyone else and that resident had been here a long time. At conclusion of interview, Resident #67 was observed sitting in a Geri-chair in direct view of Physician and actively displayed behavior of chewing on blanket which was immediately verified by the physician. The physician did not identify the behavior as pica, but agreed that the resident was chewing on his/her blanket. After which, physician stated s/he had not seen this behavior before and then repeated the statement that Resident #67 must be hungry and that s/he will double Resident #67's meal portions. MDS nurse verified during interview on 12/13/17 at 9:30 AM that the comprehensive care plan related to areas including, but not limited to behaviors, pain management, communication, bladder incontinence, activities, and activities of daily living did not contain individualized interventions, realistic and/or measurable goals and/or did not reflect the current status of Resident #67. The facility Administrator was informed of the Immediate Jeopardy on 12/13/2017 at 3:17 PM. The facility provided a final Allegation of Compliance (A(NAME)) that was acceptable and implemented on 12/15/17. The Immediate Jeopardy at F-550, F-580, F-636, F-656, F-679, F-740, and F-742 was removed on 12/15/17 at 11:15 AM, but the citations remained at a lowered scope and severity of E. The A(NAME) included the following: Immediately upon notification by the state surveyor Resident #67 was placed on one on one supervision due to behaviors related to PICA (chewing on fabric, gown). The facility will continue to seek a psychiatric evaluation until available (related to PICA) and develop a behavioral management program. The facility will seek local resources such as C.P. organization, if available, for specialized training related to the C.P. ([MEDICAL CONDITION]) MD notified of Immediate Jeopardy; one on one to continue until psychiatric evaluation and training completed. Facility social work contacting appropriate facilities/ professionals for referral for evaluation related to resident's behavior (PICA, chewing on fabric, gown). All staff providing care for the resident will monitor every bowel movement for presence of strings. All staff on duty was in-serviced for new plan of care. All oncoming staff will be in-service prior to clock in at facility. Assigned one on one member will provide diversional tactics such as: 1. Provide snacks (twizzlers, fruit roll ups) 2. Dexterity exercises (Range of Motion) with active behaviors 3. Redirect hands from clothing as needed 4. Increased engagement in activities Please see attached sheet for list of psychiatric services the facility has contacted at this point to obtain in house services. Possible transfer to (sister facility) with in-house psychiatric services. Blue Ridge of Sumter Schedule for One on One observation Days: 7-10 am Assist with AM care and meal completion 10am-12pm: Resident will be provided opportunity for activities 12-1 pm: Lunch 1-3 pm 1:1 activities (ROM, provide snacks) Afternoons: 3-5pm Time in scheduled activities 5-6 pm Dinner 6-9 pm 1:1 Read, offer music, hand massage with lotion 9-11 pm Assist with PM care, provide snacks if needed Nights 11pm-7 am Sleep-if awake offer snacks and diversional activities.

Based on medical record review, observation, and interviews, the facility failed to provide respect and dignity to promote, maintain, and enhance Resident #67' s quality of life as evidenced by daily use of hospital gown in lieu of personal clothing during first three days of survey for 1 of 1 resident reviewed for behaviors and activities. CFR 483.10(a) F-550 Resident Rights was identified at a scope and severity level of (K). The facility failed to ensure that the manner of care and the environment in which it was provided to Resident #67 neither maintained nor enhanced his/her quality of life by recognizing his/her individuality as evidenced by repeated daily use of a hospital gown in lieu of personal clothing. The findings included: Record review on 12/12/17 at 4:20 PM revealed that Resident #67 was admitted to the facility with the [DIAGNOSES REDACTED].P.), [MEDICAL CONDITION], unspecified intellectual disabilities, other specified eating disorder-PICA-fabric, and specific developmental disorder of motor function. Observation on 12/11/17 at 2:47 PM revealed resident lying in bed with hospital gown, verified by Registered Nurse (RN) #5 during interview. Ongoing observation on 12/12/17 at 9:25 AM revealed resident #67 was lying in bed wearing hospital gown, verified by Licensed Practical Nurse (LPN) #3 on interview. Further observation on 12/12/17 at 4:00 PM revealed Resident #67 lying in bed wearing hospital gown, verified during interview with (RN) #5. Certified Nursing Assistants (C.N.A.'s) #1, #5, & #6 revealed during interviews on 12/12/17 from 4:56-5:00 PM that Resident #67 wears a hospital gown daily and must have his/her hospital gown changed at least once a shift related to chewing behavior. When asked during interview with RN #5 on 12/13/17 at 9:25 AM why Resident #67 was wearing hospital gown instead of personal clothing, s/he reported that the Resident #67 does have pants and is wearing them, but no shirts. Further stating that Resident #67 has destroyed all of his/her tops and the family has not brought in any new clothing therefore the hospital gowns are used. S/he further reported that the family is very hard to contact and rarely visits. The facility Administrator was informed of the Immediate Jeopardy on 12/13/2017 at 3:17 PM. The facility provided a final Allegation of Compliance (A(NAME)) that was acceptable and implemented on 12/15/17. The Immediate Jeopardy at F-550, F-580, F-636, F-656, F-679, F-740, and F-742 was removed on 12/15/17 at 11:15 AM, but the citations remained at a lowered scope and severity of E. The A(NAME) included the following: Immediately upon notification by the state surveyor Resident #67 was placed on one on one supervision due to behaviors related to PICA (chewing on fabric, gown). The facility will continue to seek a psychiatric evaluation until available (related to PICA) and develop a behavioral management program. The facility will seek local resources such as C.P. organization, if available, for specialized training related to the C.P. ([MEDICAL CONDITION]) MD notified of Immediate Jeopardy; one on one to continue until psychiatric evaluation and training completed. Facility social work contacting appropriate facilities/ professionals for referral for evaluation related to resident's behavior (PICA, chewing on fabric, gown). All staff providing care for the resident will monitor every bowel movement for presence of strings. All staff on duty was in-serviced for new plan of care. All oncoming staff will be in-service prior to clock in at facility. Assigned one on one member will provide diversional tactics such as: 1. Provide snacks (twizzlers, fruit roll ups) 2. Dexterity exercises (Range of Motion) with active behaviors 3. Redirect hands from clothing as needed 4. Increased engagement in activities Please see attached sheet for list of psychiatric services the facility has contacted at this point to obtain in house services. Possible transfer to (sister facility) with in-house psychiatric services. Blue Ridge of Sumter Schedule for One on One observation Days: 7-10 am Assist with AM care and meal completion 10am-12pm: Resident will be provided opportunity for activities 12-1 pm: Lunch 1-3 pm 1:1 activities (ROM, provide snacks) Afternoons: 3-5pm Time in scheduled activities 5-6 pm Dinner 6-9 pm 1:1 Read, offer music, hand massage with lotion 9-11 pm Assist with PM care, provide snacks if needed Nights 11pm-7 am Sleep-if awake offer snacks and diversional activities.

On the day of the complaint inspection, based on record reviews and interviews the facility failed to assure that each resident was adequately and accurately assessed for pressure ulcers for one of seven resident records reviewed for pressure ulcers. Resident #2 had either no assessments or inaccurate assessments for pressure ulcers. The findings included: The facility admitted Resident #2 on 03/16/2011 with [DIAGNOSES REDACTED]. Review of Resident #2's medical record on 6/01/2011 revealed Weekly Skin Audit (assessments) sheets from 04/04/2011 through 05/25/2011 did not correspond to the Weekly Body Audits (assessments) documented in the Nurse's Notes for the same time period. On 05/13/2011 documentation on the Weekly Skin Audits sheets showed the resident's pressure ulcer worsened and the treatment was not changed until 05/20/2011. Cross Refers to F-314 related to the facility failed to initiate interventions to prevent pressure ulcers from developing and failed to timely assess and treat a pressure ulcer for 1 of 7 residents reviewed for pressure ulcers.

On the day of the complaint inspection, based on record review, interviews, observation, and review of the facility's policy for wounds entitled Pressure Ulcer Treatment, the facility failed to initiate interventions to prevent pressure ulcers from developing, and failed to timely assess and treat a pressure ulcer for 1 of 7 residents reviewed for pressure ulcers. (Resident #2) The findings included: The facility admitted Resident #2 on 03/16/2011 with [DIAGNOSES REDACTED]. Review of the hospital discharge summary indicated that Resident #2 had a fall at home 4 to 5 days before coming to the hospital. On arrival at the hospital she was diagnosed with [REDACTED]. Following the surgery her appetite was poor but she did start to eat more and was discharged to the nursing home on 03/16/2011 for a 2 to 3 month course of rehabilitation therapy before returning home. The Nursing Admission assessment dated [DATE] indicated Resident #2 weighed 113.5 pounds and was 5 feet 5 inches tall; her nutrition included a mechanical soft diet with Med Pass three times a day. Her skin assessment included a Stage II pressure ulcer on the right buttocks that measured 1 centimeter (cm) x .5 centimeters... Review of the medical record documented in the Nurse's Notes and the Social Work Notes that the resident's appetite was poor, she spit out her food and meds and she was not eating adequately. The notes stated that on 4/11/2011 a conference with the family was held to discuss the resident's poor intake and increased skin breakdown. The option of a feeding tube was discussed with the family and they declined at the time. The family was encouraged to speak with the physician regarding the feeding tube. The resident continued to decline and a feeding tube was placed on 05/09/2011. Review of the Dietary Notes documented that on 03/28/2011 Resident #2's weight was 104 pounds after she was weighed on new scales purchased by the facility. Dietary recommendations included, Decubivite twice a day, Prosource twice a day times 30 days, increase the Med Pass to twice a day and House shakes twice a day. On 05/12/2011, three days after the feeding tube was placed Resident #2 weighed 91.4 pounds. Dietary Notes stated that the resident's estimated dietary needs was provided by the tube feeding of Fibersource HN 50 cc with 100 cc of water. At the family's request Resident #2 continued to receive a mechanical diet. Dietary update dated 05/25/2011 recorded the resident's weight at 98.8 pounds, an increase of 7.4 pounds. Review of the resident Care Plan dated 03/25/2011 identified alterations in skin integrity as a concern. Interventions included Pressure reduction mattress and cushion to W/C, Reposition frequently, Keep clean and dry, and Weekly body audits. In reviewing the Weekly Skin Audits the 05/13/2011 audit included an addendum that stated, "Air mattress placed 05/15/2011". The intervention, "pressure reduction mattress" was not placed on Resident #2's bed until 05/15/2011. Review of the medical record on 6/01/2011 revealed weekly skin audit sheets that showed the following pressure ulcer measurements and treatments: 04/04/2011 Base of the spine (coccyx) L 1 cm (centimeter) x W 1 cm; [MEDICATION NAME] Cream 04/07/2011 Base of the spine (coccyx) L 1 cm x W l cm; [MEDICATION NAME] Cream 05/05/2011 Coccyx L 1cm x W 2 cm; [MEDICATION NAME] Cream 05/13/2011 Coccyx L 5 cm x W 3 cm Area on coccyx has 40% of necrosis noted with skin black. Surrounding and erthemotous centrally coccyx appears to be worsening. Skin easily sloughed; [MEDICATION NAME] Cream: Addendum Air Mat (mattress) placed 5/15/2011. 05/23/2011 Sacrum/Buttocks (previously identified as coccyx) L 6 cm x W 2.5 cm with tunneling 0.5 superior edge and 0.3 medially; [MEDICATION NAME] 05/27/2011 Sacrum L 5 cm x W 2.2 cm with tunneling 0.3 superior edge and 0.2 cm medially; Wound bed improved, regranulation noted; [MEDICATION NAME]. Review of the Nurse's Notes dated 04/04/2011 documented that at the weekly body audit an area measuring 2 cm x 1 cm stage I noted on Lt (left inner buttocks) Blistered area noted on Rt. (right) buttocks. Blistered area noted on Lt buttocks measuring 2 cm x 1 cm small stage I area noted above the coccyx. 04/10/2011 at body audit area to (L), (R) buttocks have increased in size since last weekend. (L) inner buttocks measures with 3.25 cm x 1.75 cm Stage I decubitus. (R) inner buttocks measures with 5 cm x 1.75 cm stage I decubitus. Area at base of spine is closed measures 2.25 cm x 1.25 cm. 04/25/2011 at the time of the weekly body audit documented ...Open areas on buttocks are beginning to show signs of healing - areas are pink and dry. 05/02/2011 stated that the areas on the buttocks show slight improvement. 05/08/2011 Body Audit done. Areas at (L) and (R) inner buttocks are healing. Areas are dry and light scabs noted. Area at coccyx remains open with no drainage noted... 05/22/2011 Open area to coccyx is larger in size and measures 4 cm x 8 cm. Area has yellow tissue covering the area with healing noted around the edges. [MEDICATION NAME] applied as ordered... 05/29/2011 Body audit done. ...Wound at sacral area noted with yellowish/white tissue in various places with small strand measuring approximately .2 cm x .25 cm that is white/yellow in color, hanging from edge of wound... Dr. was informed of the sacral wound measuring 1.75 cm in depth... New orders recd (received) to d/c present tx to wound at coccyx area and to initiate new tx of wet to dry drsg (dressing). Review of the physician's orders [REDACTED]. D/C (discontinue) Calazyme tx to coccyx 2. Cleanse Coccyx with wound cleanser, pat dry and apply [MEDICATION NAME] q (every) 3 days; 05/29/2011 stated, "T.O. (telephone order) clean wound at sacral area with wound cleanser, pat dry, pack with wet to dry dressing, cover with ABD dressing bid until healed." Review of the Weekly Skin Audits, the Nurse's Notes and the physician's orders [REDACTED]. Review of the facility Pressure Ulcer Treatment policy stated in the General Guidelines, "...The pressure ulcer treatment program should focus on the following strategies: a. Assessing the resident and the pressure ulcer(s) b. Managing tissue load..." In an interview with the Director of Nurses and the Administrator on 06/01/2011 they confirmed the findings related to Resident #2. They stated they had a QA (Quality Assurance) for pressure ulcers and their projected day of completion for the QA was 06/15/2011. The Director of Nurses stated that on 05/01/2011 it was determined that the QA was not working as they had planned and that an audit of all resident's with pressure ulcers was conducted, new work sheets were implemented and inservices for all licensed staff conducted. The facility staff stated that new mattresses, wheelchair cushions and wheelchairs were order as a result of the QA. The decline in Resident #2 wound occurred after the 05/01/2011 audit, this was confirmed by the facility.