Every finding on record at Oakbrook Health and Rehabilitation Center

Based on interviews, record review, and facility policy, the facility failed to ensure adequate Registered Nurse (RN) coverage for 4 of 31 days in October 2025; 7 of 30 days in November 2025; and 3 of 31 days in December 2025, totaling 14 days during these 3 months/quarters. This failure has the potential to affect all resident quality of care outcomes that residents experience. Findings include: Record review of facility policy titled Leadership Policies and Procedures, Staffing last revised 11/01/17 revealed The facility's leadership will provide sufficient staff to successfully implement patient/resident focused functions. To provide a sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practical physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnosis of the facility's resident population. Procedures include, provides qualified personnel based on the organization's mission, scope of services provided, the population served, and federal and state certification and licensure requirements. The adequacy and competency of staff is determined by a facility assessment of the resident population. Nursing, based on the facility's assessment, determines care needs that consistent with patient/resident needs, provides sufficient numbers of licensed nurses and other nursing staff (Registered Nurse RN, Licensed Practical Nurse LPN, Certified Nursing Assistants CNA) on a 24- hour basis. Designates a RN to serve as a full-time Director of Nursing (DON), who may serve as charge nurse only when the facility has an average daily occupancy of 60 or fewer patients/residents. Except when waived, uses the services of a RN for at least eight (8) consecutive hours a day, seven (7) days a week. Record review of the facility's daily staffing Per Patient Day (PPD) for October 2025 revealed the facility did not have adequate RN coverage and had a census above 60 residents on 10/04/25, 10/08/25, 10/12/25, 10/13/25, 10/14/25, 10/17/25,10/18/25, 10/19/25, 10/22/25, 10/26/25, 10/27/25, 10/28/25, 10/30/25, and 10/31/25. Record review of the facility's daily staffing PPD for November 2025 revealed the facility did not have adequate RN coverage and had a census above 60 residents on 11/01/25, 11/08/25, 11/09/25, 11/12/25, 11/16/25, 11/19/25, 11/23/25, 11/26/25, 11/29/25, and 11/30/25.Record review of the facility's daily staffing PPD for December 2025 revealed the facility did not have adequate RN coverage and had a census above 60 residents on 12/02/25, 12/03/25, 12/06/25, 12/10/25, 12/14/25, 12/21/25, 12/24/25, and 12/28/25.An interview on 05/05/26 at 3:57 PM with the facility's staffing scheduler revealed the facility had a difficult time staffing RN coverage during October - December 2025, and further stated that some days the Director of Nursing (DON) and Minimum Data Set (MDS) Coordinator had to be utilized for RN coverage.An interview on 05/05/26 at 4:20 PM with the Assistant Director of Nursing (ADON) revealed that they were aware of the failure to have adequate RN coverage during October - December 2025. The facility did attempt to use agency staffing during this time period, but still had difficulty ensuring RN coverage due to the holidays. An interview with the DON and Administrator on 05/05/26 at 4:38 PM revealed both were aware of the failure to have RN coverage during October - December 2025. During this time, the facility attempted to utilize agency staffing companies to have coverage but still had several days where RN's would not show up for work.

Based on review of the facility policy, observations, and interviews, the facility failed to remove expired medications, and label open medications in 3 of 4 medication carts and 1 of 2 medication rooms. Review of the facility policy, Pharmacy Services Policies and Procedures: Section 8 - Medication Storage with a revision date of 04/17/24, revealed, 7. Once any multi-dose packaged medication or biological is opened, nursing will mark multi-dose products (e.g. inhalers, insulin, ophthalmics, otics, and the like) with the date opened and follow the manufacturer/supplier guidelines with respect to expiration dates, and 12. Outdated, contaminated, or deteriorated medications. are immediately removed from stock, disposed of according to procedures for medication destruction.During an observation on 05/05/26 at approximately 1:50 PM of the Dogwood 1 medication cart, the following was found:1. Buspirone 15mg tablets card - Expired 01/29/26.During an observation on 05/05/26 at 2:02 PM of the [NAME] Front medication cart, the following items were found:1. Fluticasone propionate/ Salmeterol Inhalation - Inhaler was in a Ziploc bag. No prescription label found on the inhaler or Ziploc bag.2. Anero Ellipta 625/25 mcg - Open. No label with the open date found.3. Artificial Tears exp. 11/27 - Open. No label with the open date found.4. Artificial Tears exp. 11/27 - Open. No label with the open date found. 5. Albuterol HFA Inhaler 100 puffs left - No label with the open date found.6. Even Care Glucose Control Solutions Low Control - Expired 11/06/25.7. Even Care Glucose Control Solutions High Control - Expired 11/07/25. Surveyor gave the expired glucose control solutions to the Unit Manager (UM) of the [NAME] Unit.During an observation on 05/05/26 at 2:10 PM of the [NAME] Unit medication room, the following item was found:1. Even Care Blood Glucose Test Strips - Expired 03/18/26.During an observation on 05/05/26 at 2:15 PM of the [NAME] Back medication cart, the following item was found:1. Albuterol Sulfate inhaler - Meter read 0 puffs. During an interview on 05/05/26 at 2:20 PM with the UM of the [NAME] Unit, she revealed she audits the medication carts weekly. She stated the pharmacist also audits the medication carts monthly. He rotates units, so each cart gets audited by him every other month. She revealed she expects the nurses to do spot checks of the carts when they are passing medications. During an interview on 05/05/26 at 3:45 PM with the UM of the Dogwood Unit, she revealed she audits the carts weekly. She revealed the Pharmacist audited the carts yesterday. During an interview on 05/05/26 at 4:30 PM with the Director of Nursing (DON), she revealed the pharmacist and pharmacy nurse audit the medication carts and medication rooms once a month. She stated each medication cart is also audited once a week by a nurse manager.

Based on observations and interviews, the facility failed to ensure the master menu and the posted daily menu matched the meal served during two lunches for 4 of 4 residents reviewed, (Resident (R)45, 26, 82 and 73).During an observation on 05/03/26 the posted menu for lunch was: Chili with beef, Tossed salad, Cornbread, Chilled fruit cup and a Beverage. During an observation on 05/03/26 at 11:50 AM in the main dining room, R45's lunch ticket read:House Mechanical Soft/ Regular bread, Chopped meats1/2 cup soft seasoned green beans6 oz Chili con carne1 2x3 Cornbread1 ea Margarine1 sl Mech soft pie of choice8 oz Beverage of choiceInner lip plateR45 was served: Bowl of ChiliPlain baked potatoContainer of cheese sauceSlice of cakeR45 did not receive the cornbread, margarine, or pie listed on her lunch ticket. She did not receive the tossed salad or chilled fruit cup listed on the posted menu. Instead, she received a baked potato, cheese sauce, and cake. During an observation on 05/03/26 at approximately 11:55 AM, R26's meal ticket read: Consistent carb/ Large protein portion, No fish1/2 cup Tossed salad/ Dressing1 pkt Dressing of choice8 oz Chili con carne1 2x3 Cornbread1 ea Margerine1 sl Pie of choice8 oz Beverage of choiceR26 was served: ChiliPlain baked potatoContainer of cheese sauceSlice of cakeR26 did not receive the tossed salad, salad dressing, cornbread, margarine, or pie listed on her ticket. She did not receive the tossed salad or chilled fruit cup listed on the posted menu. Instead, she received a baked potato, cheese sauce, and cake. During an observation on 05/03/26 at 11:55 AM of the master menu plan, the following was listed for lunch:Chili Baked potatoCornbreadMarble cakeOn 05/04/26, the posted menu for lunch was: Chicken and dumplingsSteamed green beans BiscuitChilled fruit cupBeverage of choiceDuring an observation on 05/04/26 at 12:07 PM, R26's meal ticket read:Chicken and dumplingsSteamed green beansBiscuitMandarin oranges with whipped toppingBeverageR26 was served: Chicken and dumplingsMixed vegetablesBiscuitIce creamR26 did not receive the green beans and mandarin oranges with whipped topping listed on her ticket. She did not receive the green beans and chilled fruit cup listed on the posted menu. She received mixed vegetables and ice cream instead. During an observation on 05/04/26 at approximately 12:10 PM, R82's meal ticket read: Chicken and dumplingsSeasoned green beansBiscuitJellyMargarineMandarin oranges with whipped toppingBeverage of choiceR82 was served:Chicken and dumplingsMixed vegetablesBiscuitMargarineIce creamR82 did not receive the green beans, jelly, or mandarin oranges with whipped topping as listed on her ticket. She did not receive the green beans or chilled fruit cup as listed on the posted menu. She received mixed vegetables and ice cream instead. During an observation on 05/04/26 at approximately 12:12 PM, R73's meal ticket read:Spinach SaladItalian dressingHamburger bunChilled fruit cupMandarin Oranges with whipped toppingPimento cheese cottage cheese sandwichCranberry juiceDiet colaR73 was served:Chicken and dumplingsMixed vegetables BiscuitMargarineIce creamR73 did not receive the spinach salad, dressing, hamburger bun, chilled fruit cup, mandarin oranges with whipped topping, and pimento cheese cottage cheese sandwich as listed on her ticket. She did not receive the green beans and chilled fruit cup listed on the posted menu. She received chicken and dumplings, mixed vegetables, biscuit with margarine, and ice cream instead. During an interview on 05/03/26 at 11:55 AM with the Certified Dietary Manager (CDM), he revealed the lunch menu on 05/03/26 was changed by him to chili, tossed salad (or soft vegetable for those on soft diet) because Residents voiced they did not want a baked potato with chili. He stated the concerns were voiced by Residents in the Resident council meetings. He revealed he does not change the Master menu when changes are made. He stated the menu posted today matches what is on the meal tickets. However, the relief cook working did not look at the tickets or the posted menu and prepared what was on the Master menu. He revealed the morning and evening cooks look at the tickets to see what needs to be made for the meals. He stated the evening meal was also being changed from the Master menu. Because the Residents had breaded fish on Friday for dinner, the dinner meal was being changed from baked fish to stuffed cabbage rolls. He stated this was based on feedback from the Resident council meeting. CDM revealed he consults with the Dietician any time he changes the menu, and he keeps a record of doing that. During an interview on 05/05/26 at 12:10 PM with the Dietician, she revealed the CDM is supposed to notify her immediately if the menu is changing for a meal. She stated she was not aware of the menu change for Sunday's lunch. She revealed she was aware of the green beans being substituted for mixed vegetables for Monday's lunch and stated the CDM told her a pan of green beans was dropped, which necessitated the change. She revealed the CDM has told her the Residents do not like baked potatoes. During an interview on 05/05/26 at 5:20 PM with the Administrator, he revealed the facility has no specific policy on posted menus matching what is served. He stated his expectation is that what is posted as the menu for meal is what is served.

Based on observation, interview, and review of the facility policy titled Indications for Glove Use, the facility failed to ensure adequate infection control practices were followed related to glove use for one of one observation. Findings included: Findings include: Review of the facility policy titled Indications for Glove Use states under the Key Points, the following: 1A- Gloves are discarded after each use with a patient or resident. 1B-Gloves are changed when contaminated with blood or body fluids, before touching other parts of the same person. 2. Hand hygiene is performed immediately after gloves are removed, before contact with another person or items in the environment. During an observation on 05/05/26 at 1:45 PM, Registered Nurse (RN)2 was observed exiting a resident's room carrying a closed plastic bag with gloved hands. RN2 then entered the code to the soiled utility room while wearing the soiled gloves. During an interview on 05/05/26 at 1:59 PM, RN2 confirmed wearing the gloves in the hallway and entering the soiled utility room. RN2 stated the contents of the bag was a soiled brief.

Based on interview, record review, and review of facility policy, the facility failed to provide appropriate supervision for Resident (R)1, resulting in R1 successfully eloping from the facility on 06/22/25.On 07/15/25 at 1:51 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations had caused or was likely to cause serious injury, serious harm, serious impairment, or death.On 07/15/25 at 1:55 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility that IJ existed as of 6/22/25. The IJ was related to 42 CFR 483.25 - Free of Accident Hazards/Supervision/Devices.On 07/15/25 at 4:17 PM, the facility provided an acceptable IJ Removal Plan. On 07/15/25 at 4:17 PM, the survey team validated the facility's corrective actions and determined the facility put forth due diligence in identifying and addressing the non-compliance. The SA is considering this as Past Non-Compliance as of 06/23/25.An Extended Survey was conducted in addition to the Complaint Survey for F689, constituting substandard quality of care.Findings Include:Review of the facility policy titled Elopement with a complete revision date of 11/01/17, states, To safely and timely redirect patients/residents to a safe environment.Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including but not limited to: other speech and language deficits following cerebral infarction, symptoms and signs involving cognitive functions following cerebral infarction, orthostatic hypotension, cognitive communication deficit, unsteadiness on feet, and abnormalities of gait and mobility. Review of R1's Quarterly Minimal Data Set (MDS) with an Assessment Reference Date of 06/10/25, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated R1 had severe cognitive impairment. Further review of the MDS revealed that R1 had wandering behaviors during the assessment period.Review of Quarterly Nursing - Elopement Risk Observation dated 6/11/25, revealed R1 requires frequent redirection.Review of R1's Care Plan with revealed the following active problems, [R1] is at risk for falls R/T wondering the halls DX: decreased cognion, CVA, Seizures with a start date of 06/16/25, [R1] has displayed signs or symptoms of delirium: New or ACUTELY worsening confusion, disorderly expressions of thought, change in level of consciousness or hallucinations with a start date of 06/16/25, [R1] wanders throughout the facility and recently displayed exit seeking behavior, as evidenced by exiting facility, is a risk for 1. Elopement 2. Entering into others private space 3. Increased fall risk. Related to diagnosis of CVA. with a start date of 06/12/25.Review of R1's Progress Notes dated 06/22/25 revealed, 9:43 PM- At approximately 8:10 PM Staff left resident outside to sit on the porch; resident sat in rocking chair. After a few minutes staff seen resident get up and walk across the lawn to stand on the sidewalk. CNA reported to this nurse that resident was outside on the sidewalk walking, this nurse and other staff immediately went outside to assist resident back into the building. Resident was easily redirected and was brought back in the facility. NP did a skin assessment NAD. Upon speaking with resident NP had concerns regarding resident mental status, flat facial affect NP noted resident began staring blankly at her, hands trembling, body shaking. NP sent resident out for a psych evaluation. Resident left facility via stretcher at 9:35 PM DON aware. Resident's brother made aware of resident's transfer to TRMC for psych eval.Review of R1's Progress Notes dated 06/22/25 at 3:00 PM, revealed, Progress note to clarify events of 6/22/25 after interviews and further investigation. Event: an employee exited the facility front doors after entering the code. A visitor entered the facility before the doors automatically lock down. After the visitor entered, the resident got up from his wheelchair and exited the building sitting in a rocking chair on the front porch. The witness was an alert and oriented resident. The alert resident stated R1 wheeled up to the front lobby and stated to the alert resident he was 'going home'. The alert res stated he told [R1] he shouldn't leave. The alert resident stated [R1] exited before he could stop him. The alert resident alerted staff who in turn alerted nursing staff who immediately went out of the facility to retrieve [R1]. The alert resident stated [R1] sat on the porch then got up and started walking to the front (driveway). The resident did walk down the side of the road for a short distance before staff could stop him. A nursing staff member picked up the resident in her car due to unsteady gate and risk for fall. [R1] was returned to the facility without incident. A skin assessment was completed. NP was in facility and examined the resident. Order received to transfer to ER due to resident's behavior: blank stare, flat affect, and body shaking. Returned from ER with no new orders and with 1:1 supervision.During a phone interview with Certified Nursing Assistant (CNA)1 on 07/15/25 at 11:23 AM, CNA1 revealed that she was the CNA assigned to R1 on the day of the incident. She stated that she was changing another resident when one of the nurses asked her if she had seen R1 and then told her that they were looking for him. CNA1 stated that the last time she saw R1 was in the dining room. CNA1 proceeded to drive down to Arby's and Circle K in attempts to locate R1 but didn't see him. By the time she got back to the facility, R1 had been found. She was informed that R1 was sitting at the front door with another resident prior to walking out. CNA1 further stated he did not have any injuries upon return but kept wandering around the facility, so he was sent out to the ER for a psychiatric evaluation. CNA1 concluded that she isn't sure if any alarms went off, and she is unsure if he had on a wander guard. CNA1 revealed that R1 was out of the line of sight of facility staff during the elopement.During a phone interview with Licensed Practical Nurse (LPN)1 on 07/15/25 at 11:56 AM, LPN1 revealed that between 8 and 8:30 PM, a CNA came to the desk and told her that R1 walked outside. LPN1 then had all the CNAs go room to room to look for him. LPN1 and the Nurse Practitioner (NP) went out to the front door and a witnessing resident stated that R1 walked outside to the front porch after the door was opened for a visiting family member, he sat down for a few minutes and then got up and walked across the lawn. The NP, LPN1, multiple CNAs, and another nurse walked outside to look around the building. An agency nurse and another CNA drove in their vehicles to look for him. When R1 was located by a CNA, he told the CNA that he was trying to go to Arby's. Upon return to the facility, LPN1 completed a body audit, the NP spoke with him for 20 minutes, and he was sent out for a psych eval. The entire incident happened in less than an hour. LPN1 confirmed that R1 did get out of the line of sight of staff during the elopement. During an interview with the Administrator, in the presence of the Director of Nursing (DON) on 07/15/25 at 11:43 AM, it was revealed that she learned about the elopement when the DON called and notified her. The Administrator confirmed that R1 did elope out of the line of sight of staff members. A witnessing resident saw him sitting in the front before he left. R1 had no injuries upon return. He was located around the Arby's area, which is on the same side of the facility, so it is unlikely that R1 crossed any dangerous roads. Prior to the elopement, R1 was known to be a wanderer but at the time he wasn't exit-seeking. He always walked around the building but had never tried to leave up until this point. Elopement observations are completed for all residents upon admission. Elopement drills are done monthly for different shifts, and elopement precautions are spoken about during new hire orientation. There have been no more elopements since this incident.On 07/15/25 at 4:17 PM, the facility provided an acceptable IJ Removal Plan, which included the following:Resident #1 discharged home.Director of Nursing and Administrator were reeducated on the Elopement Policy and Process on 6/23/25 by the Clinical Consultant including: Completing the elopement risk evaluation thoroughly and implementing interventions based on risk identified. Documentation of exit seeking behavior and completing elopement risk evaluation for increased exit seeking behaviors.Elopement risk Assessments were reviewed for completion and accuracy on 6/23/25 by the Director of Nursing/Designee on current residents in facility to identify residents at risk for elopement. Those residents identified at risk had interventions validated and care plan updated on 6/23/25.Licensed Nurses were reeducated on the Elopement Policy and Process and Abuse & Neglect Policy on 6/23/25 by the Director of Nursing/Designee including: Completing the elopement risk evaluation thoroughly and implementing interventions based on risk identified. Documentation of exit seeking behavior and completing elopement risk evaluation for increased exit seeking behaviorsCertified Nursing Assistants were reeducated on Elopement Policy and Process and Abuse/Neglect on 6/23/25 by the Director of Nursing/Designee on 6/23/25.Target staff not receiving this education by 6/23/25 will receive prior to their next scheduled shift.An elopement Drill was completed on 6/23/25 with facility staff.Facility Activity Report and 24hour report will be reviewed Monday - Friday in clinical morning meeting to validate elopement assessments completed. The Director of Nursing/Designee will review completed elopement assessments Monday - Friday in clinical morning meeting to validate accuracy and interventions have been implemented if necessaryAd hoc QAPI held on 6/23/25.Medical Director was notified of the Immediate Jeopardy and the contents of this plan on 6/23/25.Date of alleged compliance: AOC 6/23/2025.

Based on review of the facility policy, record review, observations, and interviews, the facility failed to ensure Resident (R)281 received prescribed tube feeding for 1 of 1 resident receiving tube feeding. This failure caused R281's blood sugar levels to drop, warranting additional orders needing to be obtained to increase his blood sugar to an acceptable level. Findings include: Review of the facility policy titled, Enteral and Parenteral Feedings, with a complete revision of May 5, 2023 revealed Nutritional complete enteral (tube) feedings may be indicated for residents who are unable to obtain adequate nutritional intake orally or whose clinical condition demonstrates that enteral feedings are unavoidable. Obtain a physicians order for all enteral feedings. Communicate orders with nutrition services. Monitor and report problems and complications to the Physician and nutrition services. Record review of R281's medical record revealed he was admitted to the facility on [DATE] with diagnosis that include, but are not limited to malignant neoplasm of base of tongue, hypertension, and type 2 diabetes mellitus. Record review of R281's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score as 15, indicating R281 was cognitively intact. Record review of R281's Physician orders revealed enteral feeding Osmolite1.5 at 70 cubic centimeters (cc) an hour x 22 hours with 175 cc's every 4 hours water flush, every shift. Start feeding at 6:00 AM and stop feeding at 4:00 AM to give a total of 22 hours, dated 02/05/2025. Record review of R281's Physician orders revealed, Lantus U-100 Insulin give 14 units; subcutaneous, Special Instructions: If BS is <70 or >400 notify provider, at 09:00 AM. Record review of R281's Physician orders revealed Glutose-15 (dextrose) gel, 1 tube; oral once, one time. Start time, 5:30 PM. Record review of R281's progress note dated 02/10/2025 at 12:23 PM revealed, 9am (fasting blood sugar)FSBS 76 Insulin given as ordered. Order states to hold insulin if less 70. 11:40 AM FSBS 53 and 54. Glucagon 1 (milligram) mg given (subcutaneous) sc. 11:55am FSBS 63, 12N FSBS 64, 2nd Glucagon SC given 12:15PM FSBS 79 MD aware. Record review of R 281's progress note dated 02/10/2025 at 01:57 PM recorded, 1:55 FSBS 70. Record review of R281's progress note dated 02/10/2025 at 01:40 PM recorded, 12:30 FSBS 83. 1:30pm FSBS 67 MD notifed, received order for Glucose el 15 via g tube. Record review of a progress note dated 02/10/2025 at 05:26 PM recorded, FSBS 52-54 R281, alert and oriented x 4. Stated he had no discomfort. Nurse Practitioner (NP) notify received order for Glucose 15 gel via g tube. An observation and interview with R281 on 02/10/25 at 12:44 PM revealed, I feel better. My sugar was low. They gave me Glucatrol. I was laying in bed, they checked my sugar, it was low, they gave me insulin this morning. He said, I need to get food in me. He confirmed he cannot eat anything by mouth, but can have ice chips. Observed Osmolite 1.5, no rate on Osmolite bottle. A water bag marked 75cc/hour. Water was infusing at 174 milliliter (ml) every 4 hours per the rate on the pump. The pump was on, infusing water. An interview on 02/10/2025 at 12:55 PM with Registered Nurse (RN)1 revealed, His blood sugar (BS) was 76 at 11:40 AM. Then earlier it was 53. I got another machine, rechecked it, it was 54. Then I gave him Glucagon. He got a second shot of Glucagon. He is on tube feeding 22 hours, then off for 2 hours. R281 is aware of what's going on. He had insulin around 9 am, Lantus 14 units. His BS was 76, so I gave it. The last check it was 83. I told the nurse during an observation he was getting water, not feeding. She said, It will alternate for the flush. He is getting his feeding. On 02/10/2025 at 4:12 PM, an observation of R281's pump revealed water flush was still running. R281 said, It has been running clear, since you left earlier. This surveyor then went out to get the nurse. RN1 stated, His blood sugar is 72, it dropped from 80. I can't understand why his blood sugar is still dropping. This surveyor told RN1 the water flush has been running each time I entered the room. RN1 then stated, It should be alternating. This surveyor requested RN1 come to R281's room. R281 stated to RN1, It's been running clear since you were in here earlier. He confirmed that the feeding has not been running and he's been checking. He stated, I'm burning up. RN1said, I will turn off the pump and restart it, it may be the machine. On 02/11/2025 at 8:26 AM, during an interview with RN1, she stated, I turned the whole thing off and reset it. I didn't look at the machine when you came in. With your help I was able to figure it out. It was an education. It seemed to be a freak malfunction of the pump. I should have looked to see what was going in, I didn't even realize. She said, At 11:40 AM was the first Glucagon injection. The next was at 12:15 PM. I gave the glucose gel in the gastrotomy tube (G/T) at 5:32 PM. On 02/11/2025 at 9:05 AM, an interview with the Director of Nurses (DON) revealed, she was aware of R281's low blood sugar. She stated, My nurses use the pumps everyday. There is a way to go back and look in the history. If the resident has a G/T and the blood sugar was low, I'd look at the feeding to ensure that it has been running correctly and for the proper amount of time. It sounds like it was backwards. I can look at the pump history and try to figure out was was going on. A second interview with the DON on 02/11/2025 at 10:52 AM revealed, she went back 2 days, a total of 48 hours. She stated, R281 received TF, 1439 ml. He received 1394 ml of water for 48 hours. He received 609 ml of TF in 24 hours, it should have been 1540 ml of feeding. The water was 872 ml and he should have received 522 ml in the 48 hours. She said, My nurse said she didn't reset the settings. The MD went into the room and didn't notice it either. I appreciate you found it and talked to RN1 about it. We are continuing to monitor him for 72 hours. The Registered (RD) will be here today and will assess him. An interview was conducted on 02/11/2025 at 11:20 AM with the NP. She stated, The MD saw R281 yesterday and consulted with me about his blood sugar and insulin. She said she was going to drop his insulin according to his blood sugars dropping yesterday. Close to 8 pm I got a phone call that his blood sugar was dropping again. I asked, did anyone make sure his pump is running properly. The nurse said, yes I checked the pump. They had me on speaker. I asked multiple times, was it the tube feeding? MD's don't know how to check the pump. I ordered gel, his bs was in the 50s, I think 53. RN1 told me she checked the pump, looked to ensure it was running, and she said she didn't actually check to see if the TF was running versus the water. On 02/11/2025 at 11:42 AM, the DON returned and stated she was going to change out the pump on R281.

Based on review of the facility policy, record review, observation, and interview, the facility failed to ensure Resident (R)58 was free from significant pain for 1 of 2 residents reviewed for pain. Findings include: Review of the facility policy with a complete revision date of May 5, 2023 titled, Pain Management revealed that Pain can be defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. Pain is whatever the experiencing person says it is, existing whenever the experiencing person it does. Negative verbalizations and vocalizations, groaning, crying, whimpering or screaming. Facial expressions, grimacing, frowning, fright or clenching the jaw. Based on the evaluation, the IDT, resident physician, and the resident and or representative will develop, implement, monitor, and revise as necessary interventions to prevent or manage the residents pain. Record review of R58 revealed she was admitted to the facility on [DATE] with diagnosis that include, but not limited to pain right knee, paraplegia, end stage renal disease and type 2 diabetes mellitus. Record review of R58's Annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 01/04/2025 revealed a Brief Interview of Mental Status (BIMS) score of 13, revealing she was cognitively intact. Record review of R58's Physician's orders revealed she does not have anything ordered for pain. Record review of R58's Medication Administration Record (MAR) dated February 2025 revealed there was no pain monitoring recorded. Record review of a Pain Assessment in Advanced Dementia Scale dated 01/20/2025 for R58, recorded a score of zero, indicating no pain. Record Review of Physician progress notes for R58, by Nurse Practitioner (NP) dated 02/02/2025 recorded, Able to demonstrate flexing both knees, left more than right. Admits to keeping right leg extended most of the time to avoid pain. Diagnosis: Right knee pain, unspecified chronicity. Past Medical History included lower extremity paralysis, chronic lower extremity paresis and deconditioning. New order, Tylenol 500 milligram, 2 tablets by mouth 3 times a day. During an interview on 02/09/25 at 1:44 PM, R58 stated, My right thigh, it hurts me. I take pain medication. A follow-up interview with R58 at 12:35 PM on 02/10/2025, when asked if she was well, as she was grimacing, she stated, I was sleeping and it woke me up. I can't hardly move it, it really hurts, it's so stiff, referring to her right knee as she was holding it and rubbing it. I've not had anything yet for pain. R58 said her pain was a 10 out of 10. R58 was observed wincing in pain, stating Lord, have mercy making facial grimaces. At 12:37 PM, this surveyor requested she put her call light on for assistance. At 12:38 PM, a Speech Therapist (ST) answered the call light. Overheard ST say to resident, Let me go get the nurse. At 12:42 PM, a nurse was observed entering the room. On 02/11/2025 at 8:59 AM, an interview with the ST revealed, Poor thing, she was in pain yesterday, her right leg. She had a lot of pain in the right and she couldn't move it too much. I grabbed Licensed Practical Nurse (LPN)3, she was behind me. We went into the room and then I left and let the nurse take care of her. She had facial grimacing and tears coming down. On 02/11/2025 at 9:44 AM, an interview with LPN3 revealed, She was complaining of her right knee hurting. I went to look, pulled the cover back. She cried when I put my hand on it, and she said, Ouch. I told her I will let the NP know. She was at the end of the hall seeing a patient. I told the NP, R58 was hurting, I asked her to please go into the room and look at her. I looked for pain medication and didn't see anything ordered. I gave the NP a note. A lot of times she [NP] will put a note in the computer after she goes home and write notes/orders. Later, I was doing a follow up and asked R58 did the NP come in and see her. I didn't ask her if she was in pain. She couldn't remember if the NP came into the room when I asked her. It was after dinner. On 02/11/2025 at 10:02 AM, an interview with the NP revealed, Yesterday they said they put in the book a note to see R58 for pain and I said I'd see her tomorrow. The knee pain is known, since I met her over a year ago. Now consistently, the last 2 visits, it's been knee pain. The NP reviewed her notes and stated, Oh yes, I ordered Tylenol. I put in an order electronically to the pharmacy. The system or internet will glitch, it will stay in queue. It appears to look like the order went through on my end, and then it didn't. I didn't realize her order didn't go through. I usually follow up a week later on her and had planned to see her. On 02/11/2025, an interview at 12:23 PM with the Director of Nurses (DON) revealed, I was helping the NP yesterday morning with her computer, orders weren't going through. She said she ordered Tylenol for R58. She should have pain monitoring on her MAR. That is a problem. The nurse should have followed up to be sure the order had gone through. R58's never complained of pain that I know of and she should have been followed up more closely. On 02/11/2025 at 12:30 PM, during an interview with R58, she stated, I've been in and out of the hospital so long, you just find a way to handle it and the pain. I just manage through it, crying and laying here. The last month or so, the right knee just gives me problems and it hurts. It's not as bad as it was right now. I can't remember if anyone ever gave me anything for it, I know I was crying.

Based on review of the facility policy, observations, and interviews, the facility failed to ensure foods stored in the main walk in refrigerator and dry storage were labeled, dated and not expired. This failure could potentially affect all 85 residents in this facility, who consumed food from the kitchen. Findings include: Review of the facility policy titled, Food Safety in Receiving and Storage with a complete revision date of [DATE] states, Check expiration dates and use by dates to assure the dates are within acceptable parameters. Store foods at least 6 inches off the floor .Refrigerated, ready to eat Time/Temperature Control for Safety Foods are properly covered, labeled, dated with a use by date . During an observation on [DATE] at 10:41 AM, the following food items were observed in the walk in refrigerator and freezer and verified by the Cook; 1 can of beef base open and dated [DATE]. 1 plastic bag of chicken nuggets that was open, not sealed or dated. 1 plastic bag of french fries, open and not dated. During an observation of the dry storage on [DATE] at 10:55 AM, the following food items were observed and verified by the Cook; Approximately 18 cases of food not put away, on the floor, several were open and cans were on the floor directly without pallet. An open bottle of vanilla open, not dated, with the lid missing. Italian crushed seasoning, cinnamon rosemary and nutmeg all open, not dated. A large salt bin open, with the lid inside the salt. An interview with the [NAME] on [DATE] at approximately 11:10 AM revealed, :The lid on the containers are not supposed to be in the salt. She confirmed all open foods are to be labeled and dated with open date and expiration date. She also said, There was a delivery on Friday, the food should have been put away. An interview on [DATE] at 8:30 AM with the Certified Dietary Manager (CDM) confirmed, When we get a delivery, they need to put up the groceries, get them off the floor. Place end dates on cans, spices are tagged with a yellow sticker, and we rotate stock. Once pulled, they zip lock with a sticker, name of product, date open. Once open we have 3 days to use, then discard. Those would be refrigerated items. You have to have the date open. An interview on [DATE] at 2:10 PM with the Administrator revealed, When the food is delivered, it should be put away by the next shift. To be stored, they need to be 6 inches off the floor. Food items that are in the refrigerator and the freezer need to be dated upon opening them. Also, all food should be labeled when it is delivered. The lids for the storage should not be in the food product.

Based on review of the facility policy, observations, record reviews and interviews, the facility failed to ensure that medications were properly stored and labeled in 2 of 2 medication rooms and 2 of 3 medication carts. Findings include: A review of the facility policy entitled Medication Storage revised 4/17/24 states: Medications and biologicals are stored safely, securely and properly following manufacturer's recommendations or those of the supplier. In accordance with State and Federal laws, the facility will store all drugs and biologicals in locked compartments under proper temperatures and other appropriate environmental controls to preserve their integrity. Once any medication or biological package is opened, the facility should follow manufacturer/supplier guidelines with respect to expiration dates of opened medications. Once any multi-dose packaged medication or biological is opened nursing will mark multi-dose products (e.g. (for example) .insulin ) with the date opened and follow manufacturer/supplier guidelines with respect to expiration dates. All Scheduled medications and other drugs subject to abuse are stored in a separate, permanently affixed area and are under double lock. On 2/10/25 at approximately 10:59 AM inspection of the Dogwood Medication Room revealed: - the refrigerator container one vial of Tubersol (tuberculin purified protein derivative) 5 tuberculin units/0.1 ml (milliliter) 10 tests/package by Sanofi, opened and approximately 1/2 full and not dated as to opened date. The Tubersol was stored in the manufacturer's box which bore a pharmacy label which stated Date of First use______Discard 30 days after first use. The Sanofi package insert, dated October, 2021 stated: A vial of TUBERSOL which has been entered and in use for 30 days should be discarded - the open metal shelving unit contained a locked, but not permanently affixed Control E-Kit 16. This E-kit contained these controlled substances: alprazolam 0.25 mg (milligram) x 3, Clonazepam 0.5 mg x 3, Hydrocodone/Acetaminophen 5 mg/325 mg x 3, Hydrocodone/Acetaminophen 10 mg/325 mg x 3, Lorazepam 0.5 mg x 3, Morphine Sulfate 20 mg/ml 15 ml x 1, Oxycodone 5 mg x 3. Oxycodone 10 mg x 3 and Tramadol 50 mg x 3. -one opened bottle of Urinalysis Reagent Strips by Medline, Lot 98122100008 with expiration date of 12/28/24. On 2/10/25 at approximately 11:09 AM during an interview, Registered Nurse (RN)1 confirmed that the vial of Tubersol was opened and in-use, that the Control E- Kit 16 was not fastened to the shelf where it was stored and that the Urinalysis Reagent Strips had expired. On 2/10/25 at approximately 11:22 AM, inspection of the Dogwood Medication Cart #1 revealed multiple insulin syringes (Toujeo, Lispro Kwik, Lantus Solostar, Novolog Flex) which were in-use and had been opened and not dated as to opened date or were unopened and stored in the medication cart. These insulin syringes bore pharmacy label which stated Discard 28 days after opening and store unopened pen in the refrigerator. On 2/10/25 at approximately 11:39 AM during an interview, Licensed Practical Nurse (LPN)1 inspected and confirmed that multiple insulin syringes had been opened and/or unopened with the opened insulin syringes not been having dated when opened and that the unopened insulin syringes should have, according to pharmacy labelling, been stored in the refrigerator. On 2/10/25 at approximately 11:36 AM inspection of the [NAME] Medication Cart #1 revealed multiple insulin syringes (Basalgar Kwikpen, Lispro Kwik, Lantus Solostar, Novolog Flex) which were opened, in-use and not dated as to opened date or were unopened and stored in the medication cart. These insulin syringes bore \a pharmacy label which stated Discard 28 days after opening and store unopened pen in the refrigerator. On 02/10/25 at 11:48 AM, during an interview, LPN2 inspected and confirmed that multiple insulin syringes had been opened and/or unopened with the opened insulin syringes not been having dated when opened and that the unopened insulin syringes should have, according to pharmacy labelling, been stored in the refrigerator. On 2/10/25 at approximately 11:53 AM, inspection of the [NAME] medication room revealed: -an empty, unsecured to refrigerator shelf and locked controlled substance tackle box inside the locked refrigerator. -one opened bottle of Urinalysis Reagent Strips by Medline, Lot 98122100008 with expiration date of 12/28/24. On 2/10/25 at approximately 12:04 PM, LPN1 confirmed that the controlled substance tackle box was empty and was not affixed to refrigerator shelf and that the Urinalysis Reagent Strip had expired. On 2/10/25 at approximately 12:36 PM, the Director of Nursing (DON) inquired and was informed of the findings. She confirmed that insulin should have been dated and/or stored correctly, that expired medications should be discarded and stated controlled substance e-kit was not attached to the shelf, but was unaware of a regulation requiring it to be attached.

Based on review of the facility policy, record review, observations, and interviews, the facility failed to ensure that the environment was free from accidents for Resident (R) 231. Findings include: Review of the facility's policy titled, Pharmacy Services Policies and Procedures. Subject: 4.4 Self-Administration of Medications dated 04/17/2024 stated, Procedures: 2. Interdisciplinary Care Team (IDT) assessment will be performed upon admission, readmission and quarterly with the MDS assessment for a resident choosing to self-administer . 3. Residents are not permitted to self-administer or store controlled substances at the bedside. Review of R231's Face Sheet revealed R231 was admitted to the facility on [DATE] with diagnoses including but not limited to: presence of prosthetic heart valve, atherosclerotic heart disease of native coronary artery without angina pectoris, and allergic rhinitis. Review of R231's Physician Orders revealed no order for medication to be kept at the bedside, and no order for self-administration for R231. During an observation and interview on 02/09/25 at 11:03 AM, Fluticasone spray was observed in the windowsill with a prescription label. R231 stated that the spray was left in room for her to administer. During an observation and interview on 02/09/25 at 11:07 AM, Licensed Practical Nurse (LPN)4 verified order for medication in computer and stated that R231 did not have an order to self-administer or to have medication left at bedside. LPN4 reported that the medication is over the counter and sometimes they leave it at bedside. During an interview on 02/11/25 at 11:58 AM, the Director of Nursing (DON) reported that her expectations are that the nursing staff should not leave medications at bedside. They should observe the resident taking the medication and then the medication if not a pill would need to go back in the medication cart. She reported that they do have wandering residents. In addition, she reported that education was provide to the resident this morning to R231 because they found stool softener that the resident had family to bring in. She looked in the medical record and stated, I do not see an order for self-administration.

Based on review of the facility policy, record review, observations, and interviews, the facility failed to ensure that Resident (R)34 was free of significant medication error for 1 of 1 reviewed for insulin administration. Findings include: Review of the facility policy: Staff education/orientation policies and procedures. Competency: Medication Administration-Insulin Pen dated 01/12/2024 stated, Performance Criteria: Priming the Pen: 1. Removes the outer needle cap and dials 2 units. 2. Points the pen up and presses the plunger button to expel 2 units of insulin. Review of R34's Face Sheet revealed R34 was admitted to the facility on [DATE] with diagnoses of but not limited to: Hypoglycemia and Type 2 diabetes mellitus with diabetic neuropathy. Review of R34's Physician Orders revealed order for Insulin Lispro: Insulin pen give 3 units subcutaneous with meals at 8:00 AM, 11:30 AM, and 5:00 PM. Additionally Physician Orders revealed order for Insulin Lispro Insulin pen per sliding scale before meals and at bedtime at 6:00 AM, 11:30 AM, 4:30 PM, and 8:00 PM. If blood sugar is 201-250 give 4 units, 251-300 give 6 units, 301-350 give 8 units, 351-400 give 10 units, 401-450 give 12 units, 451-500 give 16 units. If greater than 500 call NP/PA. During an observation and interview on 02/09/25 at 4:00 PM, observed Licensed Practical Nurse (LPN)5 complete a Finger Stick Blood Sugar (FSBS) on R34. Blood sugar value observed to be 413. LPN5 administered a total of 15 units of insulin per orders, without priming the insulin pen. During an interview on 02/09/25 at 4:16 PM, LPN5 agreed that she should have primed the needle before dialing up the dose to be administered. During an interview on 02/09/25 at approximately 4:45 PM, the Director of Nursing (DON) confirmed that on the check off titled, Staff Education/Orientation Competency: Medication Administration-Insulin Pen, priming the pen is part of the procedures in completing the task of administering insulin.

Based on review of the facility policy, record review, and interviews, the facility failed to complete an annual Minimum Data Set (MDS) for 1 of 3 residents (R)1, reviewed. Findings include: Review of the facility policy titled, MDS Primary Assessment, revised 2023, revealed, Complete at a minimum, three querterly reviews and one comprehensive assessment every 12 months (366 day) period. Review of R1's medical record revealed he was admitted on [DATE] with diagnosis including Parkinsons Disease, Hypertension and a new diagnosis of Fracture Left Femur Neck. His Brief Interview of Mental Status (BIMS) of 2, indicating severe cognitive loss. Review of the last MDS dated [DATE] revealed it was a quarterly assessment. Additional review of the MDS' revealed there were 2 previous MDS quarterly (Q) assessments dated 09/11/23, 06/12/23 and an annual assessment with a date of 03/12/23. On 04/09/2024 at 12:13 PM, an interview with the Director of Nurses (DON) revealed, I believe we complete them quarterly and an annual. We do 3 quarterlys and then an annual. I have a calendar in my office. She reviewed her MDS calendar and stated R1 was due 03/12/24. If it is not in the computer, it did not get done. She confirmed the 4 PPS assessments did not include a quarterly MDS combined into any of the assessments. On 04/09/24 at 12:20 PM, an interview with the MDS Nurse revealed, We complete assessments quarterly, followed by an annual assessment. It looks like I missed R1's annual MDS in March 2024. He had 3 quarterly assessments and his last annual MDS dated [DATE]. She reviewed his MDS' and Perspective Payment Plan (PPS) assessments and stated, I didn't combine the quarterly into any of those assessments.

Based on review of the facility policy, record review, and interviews, the facility failed to develop/implement a Comprehensive care plan for 2 of 3 resident (R)2 and R3, reviewed. Findings include: Review of the facility policy revised 2023, and titled Care Plan Process, Person Centered Care revealed, thru on-going assessment, the facility will initiate person centered care plans when the residents clinical status or change of condition indicates the need . Review of R2's medical record revealed he was admitted to the facility on [DATE] with diagnoses including but not limited to; acute respiratory failure with hypoxia, hypertension and left elbow and pelvis fracture. Review of an unspecified Minimum Data Set (MDS) revealed R2 has a Brief Interview of Mental Status (BIMS) score of 12, indicating intact cognition. Review of R2's medical record revealed he had a fall in the hallway on 02/22/24 and the hospital confirmed two new fractures, left elbow and pelvis. Review of R2's care plan revealed there was not a care plan to indicate R2 suffered two new fractures or pain associated with having new fractures. He was placed on bedrest until 03/07/24, when his orthopedic physician discontinued bedrest. An interview with R2 on 04/09/24 at 9:30 AM revealed, I had a fall and went down sideways. I hurt my leg and my arm. Observation of R2 on 04/09/24 at 9:30 AM revealed R2 was wearing a splint to his left elbow area. An interview on 04/09/24 at 12:20 PM with the Director of Nurses (DON) revealed, The fractures and pain should have been care planned. Review of R3's medical record revealed she was admitted to the facility on [DATE] with diagnoses including but not limited to diabetes, anxiety, and heart failure. Review of an unspecified MDS revealed R3 has a BIMS score of 3, indicating severe cognitive impairment. Review of R3's care plan dated 02/07/24 revealed her Advanced Care Planning code status as a Full Code. Review of the South Carolina Emergency Medical Services Do Not Resuscitate (DNR) dated 02/15/24 revealed it was signed by her physician and Responsible Party. Review of her Physician's orders dated 03/11/24 for code status, DNR. An interview on 04/09/24 at 11:28 AM with the Social Services Director revealed, I educate and confirm a DNR/Full Code. I will schedule a meet and greet. I explain in detail what occurs in both situations to ensure the resident and responsible party understand. I will then get the appropriate paper work. The DNR form is initiated by myself or the nurses. Our nurse practitioner can sign or the physician. I also add the DNR to the care plan, for all advance directive. She confirmed she did not update the care plan.

Based on record review, policy review and staff interview, the facility failed to provide documentation of a written agreement or contract with the company providing hemodialysis services for one (1) resident (Resident #12) reviewed for [CONDITION(S)]. Findings include: Review of the facility policy, Vendor Agreements Policy, revised 2/2015, documented, In order to ensure consistency in the services that your residents receive, and to protect the interests of your healthcare facility, the following procedures for entering into vendor agreements are recommended. Please be advised that the FAS Legal Department is available to review all agreements before signature. The following individuals are your points of contact for assistance with vendor agreements: Review of the clinical record revealed Resident #12 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's most recent Quarterly Minimum Data Set (MDS) dated , 7/2/21, revealed a Brief Interview for Mental Status (BIMS) was completed and coded the resident as 12, indicating mildly impaired cognition with activities of daily living. The MDS also coded the resident to be receiving [CONDITION(S)]. Review of the care plan dated 4/2/21 with a long-term goal of 1/2/22, documented, Resident has [CONDITION(S)] every T, TH, Saturday at [NAME] Hall [CONDITION(S)] located at 2060 [NAME] Hall Blouvard .Pick up time is 9:45 a.m., for an 11:00 a.m., chair time. Review of the Physician's Orders, dated 9/8/21 through 10/8/21, revealed a recurring order for [CONDITION(S)] on Tuesdays-Thursdays-Saturdays (T/TH/Sat) with a 9:45 a.m. pickup. Interview on 10/8/21 at 09:18 a.m. with the Administrator revealed the facility did not have a contract with Fresenius, which manages [NAME] Hall [CONDITION(S)]. S/he stated Resident #12 was admitted from a sister facility and they faxed over their contract with Fresenius Kidney Care- [NAME] Hall. The Administrator stated they are currently working on a contract, but at this time, they don't have one. It is in their legal department at this time.

Based on observation, interview, record review, review of facility policy, the facility Pandemic Prevention and Response Plan, and Center for Disease Control (CDC) information, the facility failed to test all residents for coronavirus (COVID)-19 in response to seven (7) nursing staff members testing positive for COVID-19. The facility experienced the first positive resident COVID-19 case on [DATE]. In response, the facility then tested 14 staff who worked with Resident #1 (the resident who initially tested positive) of which seven (7) tested positive for COVID-19. Between [DATE] through [DATE], 54 residents (Residents #s ,[DATE]) and 17 staff tested positive for COVID-19 which involved residents residing in 37 of 45 rooms. Six (6) the 54 residents testing positive for COVID-19 expired and eight (8) were discharged from the facility and admitted to Hospice care. The facility failed to update their Coronavirus policy to perform immediate testing of residents when an outbreak occurred after the facility experienced the outbreak of COVID-19 and in accordance with CDC recommendations. The facility's failure to update their policy had the potential to affect all residents of the facility. The findings include: Review of facility policy, Coronavirus Disease 2019 (COVID-19) dated [DATE], revealed in the event of a suspected or actual case of COVID-19, the facility initiates current recommended strategies for prevention of the spread of the disease and treatment methods. Review of the facility Coronavirus Disease 2019 (COVID-19) Pandemic Prevention and Response Plan dated [DATE], revealed the Infection Preventionist monitors CDC recommendations for pandemic prevention and response and coordinates post plan review after the first pandemic wave and implements changes to the response plan to improve outcomes for future waves. Review of CDC Website https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-testing.html dated [DATE], Diagnostic Testing revealed: Testing asymptomatic residents with known or suspected exposure to an individual infected with COVID-19, including close or expanded contacts (e.g., there is an outbreak in a facility). The facility should perform expanded [MEDICAL CONDITION] testing of all residents, in the nursing home if there is an outbreak in the facility. A single case of COVID-19 infection in a nursing home should be considered an outbreak. When there is one case detected in a nursing home, there are often other residents and health care personnel who are infected and can continue to spread the infection. Performing testing of all residents as soon as there is a confirmed case in the facility will identify infected residents quickly, in order to assist in their clinical management and allow rapid implementation of necessary interventions, (e.g., isolation, cohorting, use of personal protective equipment) to prevent COVID-19 transmission. Review of Oakbrook COVID Testing Board, provided by the facility documented the facility had received results that residents tested positive for COVID-19 on the following dates: Resident #1 -[DATE] Resident #2 -[DATE] Resident #3- [DATE] Resident #4- [DATE] Resident #5- [DATE] Resident #6- [DATE] Resident #7- [DATE] Resident #8- [DATE] Resident #9- [DATE] Resident #10-[DATE] Resident #11-[DATE] Resident #12 [DATE] Resident #13-[DATE] Resident #14-[DATE] Resident #15-[DATE] Resident #16-[DATE] Resident #17-[DATE] Resident #18-[DATE] Resident #19-[DATE] Resident #20-[DATE] Resident #21-[DATE] Resident #22-[DATE] Resident #23-[DATE] Resident #24-[DATE] Resident #25-[DATE] Resident #26-[DATE] Resident #27-[DATE] Resident #28-[DATE] Resident #29-[DATE] Resident #,[DATE]/!,[DATE] Resident #31-[DATE] Resident #32-[DATE] Resident #33-[DATE] Resident #34-[DATE] Resident #35-[DATE] Resident #36-[DATE] Resident #37-[DATE] Resident #38-[DATE] Resident #39-[DATE] Resident #40-[DATE] Resident #41-[DATE] Resident #42-[DATE] Resident #43-[DATE] Resident #44-[DATE] Resident #45-[DATE] Resident #46-[DATE] Resident #47-[DATE] Resident #48-[DATE] Resident #49-[DATE] Resident #50 [DATE] Resident #51-[DATE] Resident #52-[DATE] Resident #53-[DATE] Resident #54-[DATE] Resident #8 and Resident #25 expired at the facility. Resident #9, Resident #14, Resident #15, and Resident #23 expired at the hospital. Resident #3, Resident #7, Resident #10, Resident #11, Resident #12, Resident #22, Resident #26 and Resident #53 were discharged from facility to Hospice care. Further review of Oakbrook COVID Testing Board documented the facility received positive COVID-19 results for staff as follows: CNA #1(Certified Nursing Assistant) -[DATE] CNA #2-[DATE] CNA #3-[DATE] CNA #4-[DATE] Nurse #1-[DATE] Nurse #2-[DATE] Maintenance-[DATE] Housekeeping #1-[DATE] CNA #6-[DATE] CNA #7-,[DATE]//2020 ADON (Assistant Director of Nursing)-[DATE] Housekeeping #2-[DATE] Nurse #3-[DATE] Housekeeping #3-[DATE] CNA #8-[DATE] Nurse #4-[DATE] A tour of the facility on [DATE] a 10:30 a.m. revealed a thick plastic barrier toward the end of the 100 Hall, which contained rooms 109 through 114. The Director of Nursing (DON) stated behind the plastic barrier were four (4) isolation rooms for the current four (4) active COVID-19 cases in the facility (Residents #33, Resident #50, Resident #51 and Resident #52). The DON further stated during the height of the outbreak, the facility had 25 beds for isolation for COVID-19 positive residents. The DON further revealed through interview on [DATE] at 1:10 p.m. Resident #1 was sent out for a medical appointment on [DATE] to be evaluated for a feeding tube due to not eating well. He/she said the resident was transported via medical transportation service. The DON stated the resident was scheduled to have a feeding tube placed and a COVID-19 test was requested prior to the medical procedure being performed. He/she said the COVID-19 test was performed on [DATE] and was positive and the resident was transferred to a sister facility that had an isolation unit. The DON stated 14 staff that had recently provided care to Resident #1 were tested and seven (7) of the 14 staff tested positive for COVID-19. He/she said the facility did not immediately test the residents that the seven (7) positive COVID-19 staff had recently provided care to, that facility staff monitored the residents and as residents exhibited signs and symptoms of COVID-19, they were then tested . An interview with the facility's Infection Preventionist (IP) on [DATE] at 11:20 a.m. revealed he/she had been unable to work during the peak of the Coronavirus outbreak from [DATE] until [DATE]. He/she said during the COVID-19 outbreak staff monitored residents for signs and symptoms of COVID-19 and would then get orders for testing as indicated. The IP stated he/she was aware of the CDC recommendations dated [DATE]. He/she stated after getting approved polices from corporate office the Infection Control manual would be updated with new policies and procedures, and he/she would provide in-service education for implementation of the new procedures. The IP said he/she did not have the autonomy to update facility policies. A telephone interview with the Nurse Practitioner (NP) on [DATE] at 1:50 p.m. revealed Resident #1 was scheduled to have a feeding tube placed and the Physician had requested a COVID-19 test prior to the procedure. He/she said the resident was tested on [DATE] and was this was the first positive COVID-19 case at the facility. The NP stated Resident #1 could have been exposed to COVID-19 when he/she had been transported by medical transportation service to a medical appointment a week or so before testing positive. He/she said the facility made the decision to not test all residents after Resident #1 and seven (7) staff tested positive for COVID-19. The NP stated the facility monitored residents for signs and symptoms of COVID-19 and he/she wrote orders for tests as signs and symptoms were exhibited by residents. A telephone interview with the Medical Director (MD) on [DATE] at 9:30 a.m. he/she stated the NP kept him/her informed on a daily basis of residents having signs and symptoms and those testing positive for COVID-19. The MD said he/she had conducted telehealth visits with all the residents that had remained in the facility with COVID-19. He/she stated after the facility had the first positive case of COVID-19, residents were monitored and when showing signs and symptoms were tested for COVID-19. The MD said looking at it now, it would have probably been easier to manage the outbreak if all residents had been tested after the initial positive resident case and the seven (7) staff tested positive. He/she said there had been a learning curve for and there was no mandate that all residents were required to be tested after receiving the positive COVID-19 tests (of Resident #1 and the seven (7) staff). An interview with Administrator on [DATE] at 9:10 a.m. revealed after Resident #1 was diagnosed with [REDACTED]. office. He/she stated the facility had a contact person with DHEC and when the facility received a positive COVID-19 test he/she completed a profile and e-mailed it to the contact person at DHEC. The Administrator said the DHEC contact person told him/her on [DATE] to only test residents when they were exhibiting signs and symptoms of COVID-19 and that the state laboratory was back logged. He/she said on [DATE] he/she decided to test the remainder of the residents in the facility that had not been tested . The Administrator stated the facility kept constant communication with their corporate office reporting the number of COVID-19 cases the facility had, and the corporate office would update the facility with new CDC guidelines. The Administrator said the facility had not updated any polices since the COVID-19 outbreak began at the facility. He/she stated all new polices must come from corporate office and must first be reviewed by a legal team and that took time.

Based on observation, interview, and recipe review, the facility failed to adhere to corporate puree recipes in making puree foods for nine (9) of nine (9) residents that received pureed diet. Findings include: Observations made in the kitchen during a follow up on 10/17/19 at approximately 10:14 AM revealed the Cook #1 had just finished making pureed pork to be served for lunch. When asked how she made the puree pork she reported she took the steamed pork and put it in the [NAME]ot Coupe food processor and then added hot water, barbeque sauce, and three (3) cups of powdered thickener. When asked how much pork she used in doing this she was not able to answer. When the cook was asked if she received any training at this facility regarding puree diets and recipes she replied No. Observation of the same Cook on 10/17/19 at 11:27 AM revealed she took seven (7) servings using a #8 (four (4) ounces) scoop of okra and tomatoes including its own liquid out of deep pan and placed it in a six (6) inch () deep stainless-steel steam table pan. She then placed the okra and tomatoes with its own liquid with three (3) cups of powdered thickener into the [NAME]ot Coupe food processor. Once done she placed the mixture in a six (6) deep stainless-steel steam table pan and into the steamer at 11:31 AM. Review of the facility's corporate recipe for Puree Pulled BBQ (Barbeque) Pork Plate revealed the following instructions: Measure desired number of servings of BBQ pork into food processor. Blend until smooth. Add gravy if product need thinning. Add commercial thickener if product need thickening. Review of the facility's Resident Consistency Report provided by the facility on 10/17/19 at 1:23 PM revealed the facility had a total of nine (9) residents receiving diets in puree consistency. Kitchen observations made on 10/18/19 at 11:11 AM revealed the Assistant Dietary Manager (ADM) put about two (2) tablespoons of powdered chicken broth into a four (4) deep stainless-steel steam table pan. She then added hot water into the pan and mixed together. She then proceeded to use a #10 scoop (three (3) ounces) to obtain nine (9) servings of boiled diced chicken into a pan. At 11:14 AM the ADM placed the diced boiled chicken into the [NAME]ot Coupe food processor. She then added the previously mixed chicken broth, and one 6-ounce spoon of powdered thickener and turned the food processor on. She then said it needed to be mashed potato consistency and stopped the food processor. Using a plastic spatula, the ADM scooped out some of the chicken in the processor. She said it was not quite mashed potato consistency and then added another three quarters of 6-ounce spoon full of powdered thickener to the chicken in the processor. At 11:28 AM the ADM placed the pureed chicken in the steamer. When the ADM asked why diced boiled chicken was used instead of fried chicken, she indicated they always used diced boiled chicken for the puree, and because it had no flavor she used the broth. Interview with the Dietary Manager on 10/18/19 at approximately 11:30 AM revealed the food service staff had been trained on diets including pureed textures in (MONTH) 2019, and as needed training was provided on the spot when needed. She reported when on the spot training was done no record was kept. She reported the recipes used at the facility were provided by corporate. Observations in the kitchen on 10/18/19 at approximately 11:33 AM revealed the ADM used an eight (8)-quart square food container and filled it with three (3) liters of cooked collard greens and liquid. She then placed the liquid and collard greens into the food processor with two (2) 6-ounce spoon full of powdered thickener. At 11:53 AM the ADM dished out nine (9) servings using a #8 scoop (4 ounces) of cooked macaroni and cheese from a lunch pan on the steam table into a four (4) deep stainless-steel steam table pan. She then placed the macaroni and cheese into the food processor and used the same pan to fill with hot water without measuring amount used. The ADM then placed the hot water into the food processor and then added two (2) 6-ounce spoons full of powdered thickener. At 11:58 AM she stopped the food processor and used a plastic spatula to scoop out some of the mixture. She reported it was still a little runny and added one third (1/3) of 6-ounce spoon full of powdered thickener into the food processor. At 12 noon she stopped the food processor and transferred what appeared to be a smooth pasty pureed macaroni and cheese into a 1/3 Size 4 Deep Anti-Jam Stainless Steel Steam Table Pan and placed it on the lunch steam table already in progress. Review of the week I day 6 Diet Guide Sheet for Friday 10/18/19 revealed residents were to receive fried chicken, seasoned greens, macaroni and cheese. Review of the puree recipes revealed the following instructions: Fried Chicken: Measure desired # of servings into food processor. Blend until smooth. Add broth or gravy if product needs thinning. Add commercial thickener if product needs thickener. Seasoned Greens: (portion size = #8 dipper/scoop) measure 1/2 cup cooked vegetable, 1 tablespoon water for each serving needed into food processor. Blend until smooth. Macaroni and Cheese: (portion size = #8 dipper/scoop) measure #8 dipper and 1 tablespoon water for each serving needed. Using food processor, blend until smooth.

Based on record review, observation, interview and review of the facility policy titled Dressing, Simple: Application Of, the facility failed to provide the necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing for 3 of 4 residents reviewed for pressure ulcer. Resident #76's specialty mattress was not inflated on two observations. Resident #15 and #30 concerns with the treatment related to the cleaning of the wounds. In addition, Resident #15 with an incomplete order for pressure ulcer treatment. The findings included: The facility admitted Resident #76 with [DIAGNOSES REDACTED]. Record review on 8/4/18 revealed the resident was admitted with an inherited Stage II pressure ulcer which was documented as resolved. Further record review revealed an intervention to prevent pressure ulcers was to have an air mattress on the bed and to check the settings every shift. Observation of the Resident #76 on 8/1/18 at 12:40 PM and 4:51 PM revealed the mattress had deflated. At the time of the second observation, Unit Manager#1 confirmed the mattress was not inflated. The facility admitted Resident #15 with [DIAGNOSES REDACTED]. Record review on 8/3/18 at 1:13 PM revealed a current physician's order to cleanse open area on right ischium, pack with 25% Dakin's soaked gauze tape, and cover with absorbent dressing daily and as needed. During observation of wound care on 8/4/18 at 11:38 AM, Registered Nurse(RN) #1 was observed to cleanse the wound with 25% Dakins soaked gauze. During the cleaning of the wound, RN#1 was observed to cleanse the wound several times without obtaining more gauze or changing the portion of the gauze. In addition, the resident was noted to roll back over after the cleaning of the wound while RN#1 washed his/her hands. During an interview with RN#1 on 8/4/18 at 4:40 PM, s/he confirmed the order was incomplete as to what medium should be used to clean the resident's wound. S/he also confirmed the resident had rolled back over while s/he was washing his/her hands and confirmed new gauze or changing the portion of the gauze was not done during the cleaning process of the wound. The facility admitted Resident #30 with [DIAGNOSES REDACTED]. Record review on 8/4/18 at 8:48 AM revealed a current physician's order to cleanse the second left toe with normal saline and paint area with [MEDICATION NAME] every day. Observation of wound care on 8/3/18 at 4:07 PM revealed RN#1, during the cleaning of the wound bed, did not change the position of the gauze. S/he was observed to dab and wipe all over the wound bed. During an interview with RN#1 on 8/3/18 at 4:40 PM, s/he stated was taught to clean a wound inside to outside. After informing him/her of the observation, s/he confirmed s/he had not cleaned the wound as s/he was taught. Review of the facility policy titled Dressing, Simple: Application Of did not address preventing residents from rolling over onto the clean wound and cleansing of the wound.

Based on record review and interview, the facility failed to ensure each Certified Nursing Assistant(CNA) received twelve hours of inservice training. The findings included: Record review on 8/3/18 of CNA inservice records revealed multiple CNA's had not received twelve hours of inservice in a twelve month time frame from their date of hire. On 8/4/18 at 7:46 PM, the Minimum Data Set Coordinator confirmed all CNA's had not had the twelve hours of inservice as required.

Based on observation, interview and review of facility policy titled Laundry, the facility failed to follow infection control protocols during the handling of soiled linen for one of one observation of the laundry. Laundry Staff was observed to collect soiled laundry with no clothing protection; all soiled laundry was not bagged; staff did not wash hands after collecting soiled laundry; clean linen were stored on soiled side; and contamination of clean linen was observed. The findings included: During observation of the laundry on 8/3/18 at 9:30 AM, Laundry Staff #1 was observed during the collection of the soiled linen without a gown or apron on to protect his/her clothing. Multiple soiled items were observed loose and not contained in a bag. After the collection of the soiled items, Laundry Staff #1 removed his/her gloves and did not wash his/her hands. Upon entering the soiled side of the laundry multiple clean items were observed covered. Entering into the washer room, after Laundry Staff #1 donned personal protective equipment(PPE), s/he removed clean clothes out of the washer and placed them in a basket; removed the lid off the soiled barrel and placed the lid onto the basket of clean clothes. After loading the washer, Laundry Staff #1 removed his/her gloves, closed the washer door and started the machine. S/he removed the PPE and began to push the cart with the contaminated clean clothes into the dryer room. The surveyor stopped the laundry worker and explained due to the placement of the soiled lid onto the clean clothes, the clothes/linens were now contaminated. During an interview with Laundry Staff #1 after the observation, s/he did not disagree with the concerns with infection control practice. Review of the facility policy titled Laundry revealed the following under the procedure section: 5. Personnel in the laundry services are properly garbed at all times. When handling soiled linens, gown and gloves, at a minimum will be donned. Under the Handwashing section: 2. Hands are washed after handling soiled linens even if gloves have been worn.

Based on record review, observation, interview, and review of activity policy, the facility failed to offer Resident #76 varying activities.(1 of 4 residents reviewed for activities) The findings included: The facility admitted Resident #76 with [DIAGNOSES REDACTED]. Record review on 8/4/18 at 8:51 AM revealed the activity assessment dated [DATE] listed sports, education, watching television, watching movies and cooking as activities the resident enjoyed. Review of the Minimum Data Set((MDS) dated [DATE] listed Resident #76's preferences as books, music, pets, and favorite activities. Review of the resident's care plan revealed Resident #76 had complex medical conditions that hindered him/her leisure ability with approaches of 1) appears to accept and at time enjoy passively participating in sensory stimulation activities; offer hand massages and musical interventions and 2) offer 1:1 visits for leisure stimulation and monitoring. Review of the one to one visit sheet revealed Resident #76 was to receive visits 2-3 times weekly. Review of the one to one log for (MONTH) (YEAR) revealed music was played for the resident six times and the resident was read to three times. Review of the individual resident daily participation record for (MONTH) (YEAR) revealed the resident was in bed during activities and the only active activity was television. There was no variation of activities. Review of the activity note dated 2/12/18 revealed one to one visits were in place and interventions included music, reading spiritual passages, hand massages and pet therapy would be offered. Only reading, music and television were offered during the month of (MONTH) (YEAR). During an interview on 8/4/18 at 6:06 PM with the Activity Director, s/he stated resident received visits and activities were conducted with resident. He/she continued by stating from the information gathered, the facility was offering activities the resident enjoyed. The Activity Director was asked would you not want to offer something new to see if the resident enjoyed something different and s/he stated that could certainly be done. During observations throughout the survey process, Resident #76 was observed in bed with no stimulant activity in progress. Review of the facility policy titled Activity/Recreation Program Variations/Categories list the following: 11. The Activity/Recreation Director and/or staff provide small group or individual programming specifically for residents with dementia, e.g. folding sorting, sensory stimulation, reminiscing, personal care of the environment, etc.