Every finding on record at Pocotaligo River Health And Rehab

Based on interview, record review, and facility document review, the facility failed to ensure a safe transfer for 1 (Resident (R)2) of 4 residents reviewed for accidents. Specifically, R2 was transferred without the use of a sit to stand lift by a Certified Nursing Assistant (CNA) resulting in fractures to the resident's left ankle. Findings included: An admission Record revealed the facility admitted R2 on 06/19/2023. According to the admission Record, the resident had a medical history that included diagnoses of rheumatoid arthritis, anemia, diabetes, right hip osteoarthritis, muscle weakness, anxiety, depression, hypertension, neoplasm of the colon, repeated falls, low back pain, unsteadiness of feet, muscle weakness, radiculopathy, and dementia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/11/2025, revealed R2 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated R2 was dependent on staff assistance for transfers and moving from sitting to standing. The MDS indicated R2 had one fall with no injuries since admission/entry or re-entry or their prior assessment. R2's Care Plan Report included a focus area, initiated 11/27/2024, that indicated the resident needed assistance with their activities of daily living self-performance and functional mobility needs due to impaired balance. Interventions directed staff that R2 was to complete functional transfers utilizing a sit to stand lift (initiated 01/27/2025). A quarterly Fall Risk Evaluation, dated 08/11/2025, indicated R2 was a high risk for falls. A nursing Health Status Progress Note[s], dated 08/15/2025 at 9:31 AM, revealed R2 had pain and swelling in their left foot and ankle. The Progress Note indicated that a nurse practitioner (NP) was notified, and orders were obtained for an x-ray of the resident's left foot and ankle. R2's Radiology Report, dated 08/15/2025 at 6:09 PM, indicated an x-ray was completed to left ankle which revealed oblique fractures (bone break in a diagonal angle across the bone's shaft) involving the distal tibia (lower end of the shin bone that forms the top of the ankle joint) and fibula (slender outer bone of the lower leg that provides muscle attachment points and stabilizes the ankle) with minimal callus (stabilization allowing primary bone healing) and modest displacement (bone fracture where the bone pieces shifted from alignment). A handwritten, untitled facility document, dated 08/15/2025, revealed a witness statement by CNA3. The witness statement indicated that the night prior to CNA3 had assisted transferring R2 to bed, around 10:30 PM, using a stand to pivot technique from the resident's wheelchair to their bed. A handwritten Employee Statement, dated 08/15/2025, by Licensed Practical Nurse (LPN)2 indicated that when LPN2 was completing medication administration around 7:03 AM, R2 asked LPN2 for a pain pill. The Employee Statement indicated R2 stated My leg is hurting so bad and I think I broke my leg, while rubbing their left leg. The Employee Statement indicated LPN2 asked R2 how their leg was broken if the resident did not walk. The Employee Statement indicated R2 stated that, when a girl put them to bed the prior night, the resident hit their foot, and the resident gestured toward the area beside the resident's bed indicating where they hit their foot. The Employee Statement revealed R2 had a history of leg pain and was administered an as needed dose of oxycodone (an opioid medication used for pain management) as requested by the resident. The Employee Statement indicated LPN2 reported R2's complaint to the unit manager. A handwritten Employee Statement, dated 08/15/2025, by Unit Manager (UM)1 indicated they were notified of R2's complaints of foot pain by LPN2. The Employee Statement indicated R2 had swelling to their left ankle. The Employee Statement revealed R2 heard a pop when they were transferred on the night shift. The Employee Statement indicated that the NP was notified, and orders were obtained to complete an x-ray. A hospital admission H&P [History and Physical], dated 08/16/2025 at 5:07 PM, indicated R2 was admitted to the hospital on [DATE] at 7:45 AM with a closed fracture of the left tibia and fibula. The record revealed orthopedic services evaluated R2 and recommended nonsurgical management with splinting, a non-weight bearing status to the left lower extremity, and a recommendation to follow-up with orthopedic clinic for casting and continued management of the fracture. A Five-Day Follow-up Report, dated 08/20/2025, revealed a Reportable Incident that occurred on 08/15/2025 at 5:30 PM. The Five-Day Follow-up Report indicated on 08/15/2025 at 7:03 AM, R2 requested a pain pill from a nurse for foot pain. The Five-Day Follow-up Report indicated R2 revealed that while being placed in bed the previous night, 08/14/2025, the resident hit their foot on the side of the bed. The Five-Day Follow-up Report indicated R2 had swelling and a UM notified the provider, who ordered x-rays. The Five-Day Follow-up Report indicated a night shift CNA reported that Resident #2 stated they heard a pop when they were placed on the bed. The Five-Day Follow-up Report indicated the CNA reported she thought the noise was the Velcro strap on the resident's shoes because R2 did not complain of pain. The Five-Day Follow-up Report indicated R2's left foot and ankle were swollen and tender to touch. The Five-Day Follow-up Report indicated an x-ray revealed a left tibia/fibula fracture. The Five-Day Follow-up Report indicated R2 was admitted to the hospital, underwent surgery to the left leg, and remained in the hospital. The Five-Day Follow-up Report indicated that interventions in place prior to the incident included, resident is a lift stand transfer. R2's hospital Discharge Summary, dated 08/22/2025 at 11:09 AM, indicated a discharge diagnosis of closed fracture of the left tibia and fibula. The Discharge Summary revealed that on 08/18/2025 R2 had undergone a left tibia intramedullary rod insertion (a metal rod placed inside the hollow bone marrow cavity to stabilize and align fractured bone fragments). During an interview on 01/11/2026 at 1:16 PM Resident #2 stated they recalled hurting their foot a few months prior when a female staff member put them to bed one night. R2 stated the staff member lifted the resident under the resident's arms and around the resident's chest to place the resident in the bed. R2 stated that during the transfer, there was a loud noise like a gunshot, but the resident stated they did not have any pain at the time. R2 stated the next morning they notified the nurse that their leg was hurting badly. R2 stated they went to the hospital and had surgery. During a telephone interview on 01/10/2026 at 6:55 PM, LPN2 stated she recalled working from 7:00 PM on 08/14/2025 until 7:00 AM on 08/15/2025 and was assigned to care for R2. LPN2 stated she recalled entering R2's room to administer morning medications and check the resident's glucose levels when the resident informed her they were experiencing pain in their foot and thought their foot may be broken. LPN2 stated R2 accused the CNA of breaking the resident's foot while placing the resident in the bed. LPN2 stated CNAs should know a resident's transfer status from the Kardex (a quick reference patient care document), or they could ask her, and she would look it up on the computer. During a telephone interview on 01/10/2026 at 7:07 PM, UM1 stated she was notified by LPN2 of a complaint of foot pain made by R2. UM1 stated she assessed R2's foot and identified one foot to be more swollen than the other. UM1 stated she was notified by LPN2 of a complaint of foot pain made by R2. UM1 stated she assessed R2's foot and identified one foot to be more swollen than the other. UM1 stated when she performed a range of motion check and palpated the foot R2 informed her the area was sore. UM1 stated when a CNA had helped R2 into bed the night before, a noise was heard, and the resident and the CNA thought the noise was from the resident's sandal straps. UM1 stated she informed R2's provider and obtained an order for x-rays to be completed. UM1 indicated that when the mobile x-ray technician was completing the x-rays, the technician notified her they were able to see an area of concern and showed UM1 the images obtained. UM1 stated she again contacted the provider and was given orders to complete x-rays with additional views. UM1 stated the provider also provided orders to send R2 to the hospital while waiting for the radiologist confirmation of the suspected fracture. UM1 stated that the facility contacted emergency medical services, and R2 was transported to the local hospital.

Based on observation, interview, and review of facility policy, the facility failed to ensure staff performed adequate hand hygiene while washing dishes in 4 of 5 kitchens and failed to ensure kitchen staff thoroughly air-dried pans prior to storage in the main kitchen. Failure to perform adequate hand hygiene before touching clean dishes and not thoroughly drying pans can have the potential to lead to contamination and the increased risk of foodborne illness. This had the potential to affect 74 of 77 residents in the facility who received dietary services.Findings include:Review of the facility's undated policy titled, Dishwashing Manual and Dishwashing: Machine Operation revealed, Policy: . 6. The pots and pans will be drained and air-dried on the drain counter or designated drying rack . f. Use clean, washed hands to pull out clean racks, and allow to air dry before putting dishes away for storage. Place glasses, cups, pots, and pans upside down on the drying rack .1. During an observation on 08/19/25 at 1:35 PM in the Palmetto Dining Room, Dietary Aide (DA)4 along with a new dietary aide, DA6, were using the dishwasher in the kitchen area. DA4 was handwashing dirty dishes in the sink, then moved to the dishwasher and pulled clean dishes out without performing hand hygiene.During an observation on 08/20/25 at 9:47 AM in the main kitchen revealed DA1 handwashing dishes. DA1 moved from the dirty dish sink to the dishwasher, removing clean dishes and placing them on the clean racks. DA1 handled the clean dishes without performing hand hygiene.During an interview on 08/20/25 at 10:05 AM, DA1 confirmed she was touching clean dishes with dirty hands for a while and did not realize she was doing that.During an observation on 08/20/25 at 12:45 PM in the Dogwood Dining Room revealed DA2 was washing dishes by hand and then removed clean dishes out of the dishwasher without performing hand hygiene.During an observation on 08/20/25 at 1:25 PM in the Cypress Dining Room revealed DA5 was washing dirty dishes and then walked over to the dishwasher and, without performing hand hygiene, removed clean dishes from the dishwasher and placed them to dry.During an interview on 08/20/25 at 12:50 PM, the visiting Dietary Manager (DM) revealed her expectation was that staff should wash hands before handling clean dishes coming out of the dishwasher. The Dietary Manager Assistant (DMA) confirmed that the facility's policy Dishwashing: Machine Operation, required hand hygiene before handling clean dishes.2. During an observation in the main kitchen on 08/19/25 at 8:43 AM revealed five metal pans that had been washed and placed on storage racks had water standing on them.During an interview and observation on 08/20/25 at 9:45 AM in the main kitchen revealed there were five metal pans 6 inches by 12 inches by 2 inches and four plastic lids 6 3/4 inches by 4 1/4 inches that had water on them and were stored ready for use. The pans were found to have been stacked wet and not allowed to air dry. The DM and DMA stated all dishes were to be dry before stored on the shelf. The DM stated there should be a separate place to place pans and items that need longer to air dry before placing them on storage shelves.

Based on record review, interview, and facility policy review, the facility failed to ensure 1 resident or resident representative (RP) of 1 resident (Resident (R)6) reviewed for hospitalization, received written notice that specified the duration of the bed hold policy. Specifically, the facility failed to include the current rate for the reserve bed payment in the event the resident did not return within ten (10) days, leaving the resident without all the necessary decision-making information.Findings include:Review of the facility's undated policy titled, ''Bed Hold Notice'' indicated that ''It is the policy of this facility to provide written information to the resident and/or the resident representative bed hold practices both well in advance, and at the time of, a transfer for hospitalization or therapeutic leave . 'Reserve Bed Payment' refers to payments made by a State to the facility to hold a bed during a resident's temporary absence from a nursing facility . The facility will provide this written information to all facility residents, regardless of their payment source .''Review of R6's ''admission Record'' located in the electronic medical record (EMR) under the ''Resident'' tab indicated she was originally admitted to the facility on [DATE].Review of R6's entry tracking ''Minimum Data Set (MDS)'' with an Assessment Reference Date (ARD) of 07/06/25 indicated the resident was re-admitted from a short-term general hospital.Review of R6's ''Notice of Resident Transfer or Discharge'' dated 07/02/25 confirmed that R6 was transferred to the hospital due to '' . needs cannot be met in this facility .''Review of R6's ''Bed Hold Notice'' dated 07/02/25 confirmed R6 was transferred to the hospital on [DATE] and did not include the ''basic per diem rate.'' Additionally, the notice indicated that ''The State bed-hold period is 10 days consecutive for hospital stay .''During an interview on 08/21/25 at 12:32 PM, the Administrator and Social Services Director (SSD) stated that the SSD filled out all ''Bed Hold Notice'' forms and confirmed that the ''basic per diem'' rate was not included in the ''Bed Hold Notice'' dated 07/02/25. The SSD stated that when residents were admitted , the bed hold rates were reviewed with the resident/RP. The SSD provided R6's admission documents indicating the bed hold rate as of 02/28/22 was $240.00 per day and as of 11/01/24 the rate increased to $297.00 per day. The SSD stated that the rate increase was mailed to all RP's on 10/01/24 but was not included on the ''Bed Hold Notice'' and that she was not aware that it was required.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure 2 of 11 residents (Resident (R) 6 and R17) observed received care performed with the proper use of personal protective equipment (PPE). Specifically, R6 was on enhanced barrier precautions (EBP) for indwelling catheter/wound status, and a staff member did not wear a gown during a bed bath, and R17 was on contact and droplet precautions for Covid-positive status, and a staff member did not wear gloves or eye protection during medical administration. This failure increased the risk for spread of COVID-19 and other infections to residents and staff.Findings include:Review of the facility's policy titled ''Enhanced Barrier Precautions'' revised on 06/02/24 indicated that '' . It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms [MRDO] . EBP refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities . An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds . ii . MDRO . high-contact resident care activities include: . bathing . providing hygiene . changing linens . device care or use: . catheters . ''Review of the facility's policy titled ''Isolation - Categories of Transmission-Based Precautions'' revised on 10/20/28 indicated that '' . Transmission-based precautions are additional measures that protect staff, visitors and other residents from becoming infected . Contact Precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items . staff and visitors will wear gloves . wear a disposable gown . Droplet precautions may be implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets . masks will be worn when entering the room . gloves, gown, and goggles should be worn ''Review of the facility's policy titled, ''COVID-19 Prevention, Response and Reporting revised on 12/31/24 indicated that '' . HCP [healthcare personnel] who enter the room of a resident with suspected or confirmed SARS-CoV-2 [COVID-19] infection should adhere to standard precautions and use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection .''1. Review of R6's ''admission Record'' located in the electronic medical record (EMR) under the ''Resident'' tab indicated she was admitted to the facility on [DATE] with diagnoses including but not limited to pressure-induced deep tissue damage of left heel, proteus mirabilis, disorder of the kidney and ureter, obstructive and reflux uropathy, and extended spectrum beta lactamase (ESBL, antibiotic) resistance.Review of R6's five-day ''Minimum Data Set (MDS)'' with an Assessment Reference Date (ARD) of 07/12/25 included indwelling catheter and wound status.Review of R6's ''Care Plan'' provided by the facility and initiated on 01/12/25 included the use of enhanced barrier precautions related to urinary catheter and ESBL.Review of R6's ''Order Summary Report'' located in the EMR under the ''Orders'' tab included an order for enhanced barrier precautions initiated on 07/23/25 related to urinary tract infection and ESBL resistance.During an observation and interview on 08/19/25 at 10:40 AM, Certified Nursing Assistant (CNA)1 was providing a bed bath to R6. CNA1 was wearing gloves and a surgical mask. CNA1 confirmed that R6 was on EBP and that she had not put on a gown but should have. At the time of the observation, R6 was lying in bed, the linens were draped over the foot of the bed, and a trash bag of soiled linens was on the floor next to the wall. CNA6 then exited the room and went to retrieve a gown. R6 had Center for Disease Control and Prevention (CDC) signage outside of the room indicating the need for EBP, stating, ''Providers and staff must also: wear gloves and a gown for the following high-contact resident care activities, dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use: . urinary catheter .''During an interview on 08/21/25 at 12:49 PM, the Director of Nursing (DON) was made aware of the observation of R6 and CNA1 on 08/19/25 and confirmed that R6 was on EBP for urinary catheter and wound status. The DON confirmed that CNA1 should have been wearing a gown during the procedure.2. Review of R17's ''admission Record'' located in the EMR under the ''Resident'' tab indicated that she was admitted to the facility on [DATE] with a primary diagnosis of hyperlipidemia. The admission Record did not include COVID-19 status.Review of R17's ''Care Plan'' provided by the facility and revised 08/18/25 included COVID-19 positive status with the need for droplet and contact precautions.Review of R17's ''Order Summary Report'' located in the EMR under the ''Orders'' tab, included an order dated 08/19/25 for droplet and contact precautions for ten days due to testing positive for COVID. Precautions were to be in place through 08/28/25.Review of R17's ''Progress Note'' located in the EMR under the ''Progress Notes'' tab and dated 08/18/25, indicated that R17 tested positive for COVID-19.During an observation and interview on 08/20/25 at 4:45 PM, Licensed Practical Nurse (LPN)1 was administering metoprolol tartrate 50 milligrams oral tablet (blood pressure medication) mixed in pudding and brimonidine 0.2-0.5% eye drops (glaucoma treatment) to R17. Prior to entering R17's room, it was observed that there was signage for contact and droplet precautions with the requirement to wear a gown, mask, gloves, and eye protection. LPN1 donned a gown and N95 mask. LPN1 assisted R17 to reposition in the bed, donned and doffed gloves, performed hand hygiene and then proceeded to administer oral medications without donning gloves. After LPN1 completed oral medication administration, she performed hand hygiene again, donned gloves, and administered eye drops. Eye protection was not worn at any time during the administration of medications. At the end of the administration, LPN1 confirmed the requirements for residents on contact and droplet precautions were to wear gowns, masks, gloves, and eye protection. LPN1 stated she was nervous and forgot to don gloves prior to oral administration of medications and forgot to don eye protection prior to entering the room but should have.During an interview on 08/21/25 at 12:49 PM, the DON confirmed that R17 was diagnosed with COVID-19 on 08/18/25 and was immediately placed on contact and droplet precautions which require the use of gowns, gloves, N95 masks and face shields. The DON was informed of LPN1 not wearing gloves during oral medication administration and the failure to wear eye protection during medication administration. The DON confirmed that LPN1 should have worn gloves and eye protection during medication administration.

Based on review of facility policy, record reviews, and interviews, the facility failed to ensure Resident (R)1 was free from verbal abuse for 1 of 2 residents reviewed for abuse. Specifically, R1 was verbally abused during care by a Certified Nursing Assistant (CNA). Findings include: Review of the undated facility policy titled, Abuse Policy, states, The facility recognizes that each resident has the right to be free from all types of abuse including verbal . The facility also recognizes that the residents must not be subjected to abuse by anyone, including, but not limited to staff . Willful, as used in the definition of Abuse, means the individual must have acted deliberately, not that the individual intended to inflict injury of harm . Mental Abuse, is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. Verbal Abuse, may be considered a type of mental abuse. It is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability . Examples of verbal and mental abuse includes, but are not limited to: harassing a resident; mocking, insulting, ridiculing; yelling or hovering over a resident with the intent to intimidate. Review of R1's Face Sheet revealed the facility admitted R1 on 12/05/23 and readmitted R1 on 06/26/24, with diagnoses including, but not limited to: dementia, anxiety disorder, restlessness and agitation, major depressive disorder, insomnia, violent behavior, obstructive sleep apnea, and mild intellectual disabilities. Review of R1's Admission Minimum Data Set (MDS) with an Assessment Reference Date of 07/02/24, revealed a Brief Interview for Mental Status (BIMS) score of 8 out of 15 indicating R1 was moderately cognitively impaired. Further review of the MDS revealed R1 is understood and understands verbal content and reacts and answers appropriately, speech is clear and hearing is adequate. Review of CNA1's Notice of Disciplinary Action dated 07/29/24, revealed, CNA was terminated from employment for Resident Abuse and Violation of Company Policy/Procedure/Rules. Further review of the Notice of Disciplinary Action revealed remarks which documented, CNA used profanity and was yelling at a resident. This was witnessed by the nurse. CNA stated Sit your a** back in the chair, if you fall your a** on the floor you gonna stay on the d*** floor. Move your d*** hand. Review of the Employee Remarks documented, I didn't said any of that. During an interview on 09/12/24 at 10:25 AM, CNA1 stated, [R1] was up in her wheel chair all night, the CNA on the evening shift should have put her to bed. I know that is their choice if they do not want to go to bed. [Licensed Practical Nurse (LPN)1] was on the phone. She had called me to help get the resident in bed, and then she was on the phone. I was charting when the nurse called me, then I could not find her to help me. She said, I cursed the resident, but I did not, I did say that if she fell on the floor I was not going to pick her up. I knew I could not get her back to bed by myself. During an interview on 09/12/2024 at 10:40 AM, LPN1 stated, The resident was yelling for help, so I went to see what she needed. I called for the CNA to help me put her to bed but she did not come right away. I was on the phone with the nurse on the other unit. The next thing I knew, the CNA was yelling for me to come and help her get [R1] back to bed. I carried the phone in the resident's room and the nurse could hear what was being said. The resident was sitting on the edge of the wheelchair seat and yelling. [CNA1] has always been loud and rough. The CNA told me she did not know why the resident was yelling so I tried to talk to the resident and calm her down. She calmed down and the CNA started yelling and cursing at her. LPN1 stated that she asked the CNA to go and get the sit-to-stand lift so they could get the resident in bed. CNA1 went and got the lift and came back into the room and started yelling at the resident and cursing her again. LPN1 further stated, [R1] was upset at that point, so all I was focused on was getting the resident in bed, cleaned up and comfortable. After getting the resident back in bed, I called the Director of Nursing [DON], I believe it was between 4:00 AM and 5:00 AM, and reported the incident. The DON told me to tell the CNA to clock out and go home. She called the administrator because she came in early to talk to the resident and make sure she was alright. During an interview on 09/12/24 at 12:48 PM, LPN2, the nurse that was on the phone, stated she overheard CNA1 telling the resident to Get your d*** a** in the bed. LPN2 stated that she heard that CNA1 talks rough to the residents. During an interview on 09/12/24 at 1:42 PM, the DON stated that CNA1 came in the next day to tell her side of the story. The DON stated that CNA1 said she was ruff with the resident, but she did not curse. The CNA came in only for an exit interview, and to sign the termination form and then I escorted her out of the facility and reported her to the state registry. During an interview and observation on 09/12/24 at 3:12 PM, R1 stated CNA1 curses at her all the time. R1 stated, Look at my arms they are bruised all over, that is from them grabbing me to turn me over, I guess I do not move quickly enough for them. This surveyor observed R1's arms and did not see the bruising she was referring to, but did report the allegation to the Administrator. R1 began talking about places she has lived in the past, and how she loved to cook. R1 continued telling me about her family, while laughing, and was happy. R1 did not have any concerns. During interviews on 09/12/24 at 3:30 PM, with random interviewable residents on the same hall, revealed they did not have any concerns with staff or any abuse concerns. Residents stated they were happy with the staff caring for them and the nurses were good to them.

Based on review of facility policy, observation, interview, and record review, the facility failed to ensure accurate labeling and dating of foods. Furthermore, the facility failed to ensure cold foods are held at safe temperatures. Findings include: Review of the facility policy titled Labeling, Dating Foods (Date Marking) dated 2020, revealed, Procedure: 2. Date marking for refrigerated storage food items. Once a case is opened, the individual, refrigerated food items are dated with the date the item was received into the facility and place in/on proper storage location utilizing the first in-first out method of rotation. Once opened, all ready to eat, potentially hazardous food will be re-dated with a use by date according to the current safe food storage guidelines or by the manufacture's expiration date. Review of the facility policy titled Monitoring Food Temperatures for Meal Services dated 2020, revealed, Guideline: Food temperatures will be monitored to prevent foodborne illness and ensure foods are served at palatable temperatures. Procedure: 1. Prior to serving a meal, food temperatures will be taken and documented for all hot and cold foods to ensure proper serving temperatures, any food item not found at the correct holding/serving temperature will not be served but will undergo the appropriate corrective action listed below. 2. The temperature for each food item will be recorded on the Food Temperature Log Foods that required corrective action (such as reheating) will have the new temperature recorded with a notation of the corrective action intervention. During an observation on 07/22/24 at 10:14 AM, of the kitchen with the Registered Dietician (RD) revealed the following in the Walk in Cooler: one box of opened romaine lettuce labeled with an open date of 07/19/24, but no discard date. One opened box of lettuce with an open date of 07/19/24, but no discard date. One box of cucumbers with an open date of 07/16/24, but no discard date. During an interview on 07/22/24 at approximately 10:17 AM, the Registered Dietician (RD) revealed that all staff are trained on how to properly receive, label, rotate and discard items. During an observation on 07/23/24 at approximately 12:09 PM, of temperature checks in the kitchen, the following readings were captured for cold items being served during lunch: beets at 48 degrees Fahrenheit, chicken salad at 42 degrees Fahrenheit, chicken salad on croissant at 54 degrees Fahrenheit, pureed chicken salad at 45 degrees Fahrenheit, chicken salad on white bread at 53 degrees Fahrenheit, salad at 58 degrees Fahrenheit, and salad without tomatoes at 61 degrees Fahrenheit. Review on 07/23/24 of food temperature for Cypress Wing, Dogwood Wing, Magnolia Wing, and Palmetto Wings, revealed no food temperatures were recorded prior to service. During an interview on 07/23/24 at 12:20 PM, the Dietary Aide revealed, when the food temperature is not in range it is the procedure to notify the manager and the manager gives directions as to what to do. During an interview on 07/23/24 at 12:20 PM, the Homemaker revealed, When the regulatory food temperature is not in reach it is the procedure to notify the [RD] for further instructions. She is to document the temperature on the temperature logs while temping the food item. During a follow up interview on 07/23/24 at 1:57 PM, the Homemaker stated, They do not temp foods once the food leaves the kitchen and are bought to the satellite kitchens. During an interview on 07/23/24 at 2:05 PM, the Registered Dietician (RD) states that they do not temp foods before they serve in the satellite kitchens. If the meals were delayed, then they would but the carts have hot plates that hold the temps. The RD states she does not know if they are always properly working or if the temp stays the same because they have never checked to see.

Based on observations, interviews, record review, review of facility policy, and manufacturer recommendations, the facility failed to ensure the proper cleaning and disinfection of a glucometer for 1 of 4 medication pass observations of finger stick blood sugars. Furthermore, the facility failed to ensure staff used appropriate PPE (personal protective equipment) when handling soiled laundry for 2 of 2 staff observed processing laundry. Findings include: Review of the facility policy titled Glucometer Disinfection dated 2024, states, The purpose of this procedure is to provide guidelines for the disinfection of capillary-blood glucose sampling devices to prevent transmission of blood borne diseases to resident and employees . Glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions. Review of the Quality Control Reference Manual for the Assure Platinum Blood Glucose Monitoring System dated 2024, states, Cleaning can be accomplished by wiping down with soap and water or isopropyl alcohol, but will not disinfect a meter. Disinfecting the meter can be accomplished with an EPA (Environmental Protection Agency) registered disinfectant or germicide that is approved for healthcare settings or a solution of 1:10 concentration of sodium hypochlorite (bleach) . In accordance with CDC (Center for Disease Control) guidelines, we recommend that the Assure Platinum meter be cleaned and disinfected after each use for individual resident care. During an observation and interview on 07/22/24 at approximately 4:03 PM, Registered Nurse (RN)1 removed an Assure Platinum glucometer from the medication cart, placed it on a plastic tray and proceeded to use the glucometer to test the blood sugar of Resident (R)133. On 7/22/24 at approximately 4:07 PM, RN1 returned to the medication cart, wiped the plastic tray used to carry the glucometer with a Sani-wipe but did not wipe the glucometer. The glucometer was then placed back in its medication cart compartment, not cleaned or disinfected. When asked about cleaning and disinfecting the glucometer, RN1 stated the glucometer had not been wiped and was not typically wiped since everyone has their own. Review of the facility policy titled Infection Prevention and Control Program dated 05/15/23 revealed, Policy Explanation and Compliance Guidelines: 12. Linens: a: Laundry and direct care staff shall handle, store, process and transport linens to prevent the spread of infection. Review of a Third Party Laundry Services policy and procedure titled Handling Soiled Linen dated 03/17/14, revealed, Handling Soiled Linen on Units Laundry personnel must use proper protective equipment when pulling the soiled linens from the floor (gloves, apron, goggles, etc.) Handling Soiled Linen in Laundry Proper personal protective equipment should always be worn when sorting soiled linens. Handling clean linen on the Units Personnel handling clean linen must wear proper protective equipment especially if the same person handles both the soiled and clean linens. During an observation on 07/23/24 at 8:24 AM, Laundry Aide (LA)1 was observed in the laundry room, on the dirty laundry side, standing in front of a washing machine, with gloves on but no apron. LA1 was reaching in a large yellow bin, pulling out soiled linen and putting them into the washing machine. During an observation on 07/23/24 at 8:40 AM, LA1 was observed entering the soiled linen room on the 100 Hall. LA1 put on gloves, pulled bags of soiled linen and resident clothes from one bin and placed it into another. LA1 pulled Hoyer slings from a bin with trash in it and placed it in a bin with bagged soiled linen and clothing (slings were not bagged). LA1 removed their gloves as they exited the soiled linen room and proceeded to push bins back to the laundry room. Once they entered the laundry room LA1 put on gloves, without washing their hands, and began removing bagged items from the large yellow bin and separating them into a larger black bin. The large black bin has a cover marked 1&2. LA1 opened bags one at a time slightly shaking them and placed white linen to the front side of the bin and residents' dark clothes to the back side of the bin. During an observation on 07/23/24 at 8:52 AM, Laundry Supervisor entered the laundry room and began assisting LA1 in separating clothes. The Laundry Supervisor was observed removing bags of soiled linen and clothing from a large yellow bin and placing them in a separate large black bin with a cover marked 3&4 on top. The Laundry Supervisor wore gloves but no other PPE as she removed the soiled items from the bags and placed them into the large bin. The Laundry Supervisor was also observed handling heavily soiled linens and pads, with large wet brown stains and placed it in the bin. Both the Laundry Supervisor and LA1 sprayed and wiped down the bins once they were empty. During an observation on 07/23/24 at 11:26 AM, LA1 pulled a load of clean linen out of one dryer and the Laundry Supervisor began folding the linen. While folding the linen the Laundry Supervisor pressed the linen against her body. During an interview on 07/23/24 at 8:50 AM, the Laundry Supervisor revealed the linen with heavily soiled brown stain will sit at the bottom of the bin and be washed last. The Laundry Supervisor further explains, we try to reclaim them two times but if they are too bad, we just get rid of them. During an interview on 07/23/24 at 11:08 AM, the Laundry Supervisor revealed the procedure for processing the laundry is as follows: bins are pulled in from the floor, separate the whites from the color, we usually load whites which includes the towels and linens first because that's what they need the most of first thing in the morning. After the bins are emptied, we wipe the bins down and the floor techs take them back to the floor. The Laundry Supervisor explains, each hall has a separate washer, we wash halls 1 and 2 together and we wash halls 3 and 4 together. After loading the machine we wash hands, check the chemicals to make sure they are not low and wash our hands again, then we take clean linen out on clean side. The Laundry Supervisor further explains, an apron is worn if there is an infection control outbreak along with goggles, each staff have their own goggles. The Laundry Supervisor revealed that at the scheduled times of 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM and 4:00 PM, the machines (both washers and dryers) are wiped down and the lint filters are checked. The Laundry Supervisor revealed that staff do not wear aprons when they fold clothes, only when there is an infection, but staff should not allow clean clothes to touch their clothes when they are folding. During an interview on 07/23/24 at 4:25 PM, with the Infection Preventionist (IP) and the Director of Nursing (DON). The DON revealed, when handing soiled linen contaminated with blood or bodily fluids, in the laundry room, staff should have on gloves, gowns/aprons, and mask to prevent inhalation of aerosol or splatter of blood and body fluids. The IP further explains staff should keep soiled and clean separated at all times wash hands before contact with clean leaning and after contact with soiled linen. The IP revealed their expectation is that staff wear PPE at all times because there may be body fluid on soiled linen or clothing. 49818

Based on the facility policy, record reviews and interviews, the facility failed to develop a Comprehensive Plan of Care for Resident (R)79 related to dialysis, for 1 of 1 resident reviewed for Dialysis. Findings include: Review on 07/23/2024 at 01:07 PM of the facility policy titled, Comprehensive Care Plans, states, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives ad timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The Policy and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally-competent and trauma-informed. 3. the comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 6. The comprehensive care plan will include measurable objectives and timeframe's to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented as needed. Review of R79's Face Sheet revealed R79 was admitted to the facility on [DATE], with diagnoses including, but not limited to: end stage renal disease, diabetes insipidus and diabetes mellitus, diabetic chronic kidney disease, acute kidney failure, and dependent on renal dialysis. Review of R79's Comprehensive Care Plan on 07/23/24 at 1:07 PM, did not reveal a plan of care addressing R79's Dialysis treatment and care. During an interview on 07/24/24 at 2:10 PM, the Care Plan Coordinator stated the care plans were put into a PDF (portable document format) file, but now they could not locate the file. The Care Plan Coordinator further stated the care plans were being rewritten manually and it was taking a lot of time. The facility changed computer systems on 07/01/24. The Care Plan Coordinator confirmed the care plan for R79 was not developed to include dialysis. During an interview on 07/24/24 at 3:25 PM, the Administrator stated that all the care plans were printed out so that the facility would have a copy before the system change on 07/01/24. The Administrator further stated that the care plans were to be updated when they came due again. 50788

Based on review of facility policy, record reviews, and interviews, the facility failed to ensure interventions were in place to ensure Resident (R)79 maintained acceptable parameters of nutritional status and decreased the likelihood for further weight loss for 1 of 3 residents reviewed for nutrition. Findings include: Review of the undated facility policy titled, Weight Monitoring states as the Policy, Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameter of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. Compliance Guidelines: Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem. 1. The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes. a. Identifying and assessing each resident's nutritional status risk factors. b. Evaluating/analyzing the assessment information, c. Developing and consistently implementing pertinent approaches. d. Monitoring the effectiveness of interventions and revising them as necessary. 4. Interventions will be identified, implemented, monitored and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status. 7. Documentation: a. The physician should be informed of a significant change in weight and may order nutritional interventions. c. Meal consumption information should be recorded and may be referenced by the interdisciplinary team as needed. e. The Registered Dietitian, Dietary Manager should be consulted to assist with interventions: actions are recorded in the nutrition progress notes. g. The interdisciplinary plan of care communicates care instructions to staff. Review of R79's Weights located in the medical record revealed the following weights: On admission (06/14/2024), R79 weighed 156 pounds. On 06/16/2024, R79 weighed 153 pounds. On 06/23/2024, R79 weighed 152 pounds. On 07/03/2024, R79 weighed 153 pounds. On 07/07/2024, R79 weighed 145 pounds. On 07/14/2024, R79 weighed 145 pounds. On 07/22/2024, R79 weighed 142 pounds. No interventions were in place to decrease the likelihood of further weight loss. Review of R79's Medication Administration Record (MAR) revealed a supplement Nepro with Carb Steady after meals give 1 carton 3 times daily. The Nepro Carb Steady was ordered on 07/02/24 and was to be discontinued on 07/19/24. The MAR documented R79 receiving 3 times per day from 07/02/24 until 07/18/24. R79 did not receive the supplement after 07/18/24. Further review of the MAR revealed that on 07/24/24 the supplement was reordered due to the weight loss. No other supplements were ordered or had been ordered prior to 07/24/24. Review of the meal intake from 07/01/24 through 07/21/24 revealed no documentation for percentage of meals (breakfast, lunch, and dinner) eaten on 07/02/24, 07/07/24, 07/08/24, 07/11/24, 07/12/24, 07/15/24, 07/16/24 or 07/18/24. During an interview on 07/24/24 at 8:40 AM, the Registered Dietitian (RD) brought in a RD note dated 06/17/24, as there were no other RD notes in the medical record for R79. The RD stated she would be making recommendations today. On 07/24/24 the Nepro Carb Steady dietary supplement was reordered. During an interview on 07/24/24 at 10:40 AM, the Director of Nursing (DON) stated that was due to the new software and the changing from one computer system to the current one as of 07/01/24. All the medications are documented but not the supplement. The DON stated that if the surveyor asked the resident, he could tell me that he received it 3 times daily even though it is not documented. The documented meal intake was reviewed with the DON and she stated that they had had multiple issues changing from the old computer system to the new computer system.

Based on record review, interviews, and review of facility policy, the facility failed to provide a completed performance review for 4 of 5 staff members reviewed for employee performance. Findings include: Review of the facility policy titled Competency Evaluation with a revision date of February 2023, revealed, It is the policy of this facility to evaluate each employee to assure appropriate competencies and skills for performing his or her job and to meet the needs of facility residents. Employee competency forms are maintained in the Staff Development Coordinator's office for current training year. Then forwarded to the Human Resource Director for placing into the employee's personnel file. Review of 5 Pocatiligo Health and Nursing Employee Personnel files revealed, current performance reviews were not included in personnel files for 4 of 5 staff members. Review of Nurse Aide Competency Performance Reviews revealed, competencies were assessed for 5 of 5 staff members, 4 of 5 Nurse Aide Competency Performance Reviews were without competency type and signature of staff member. During an interview on 07/24/24 at 4:14 PM, the Director of Nursing (DON) revealed, staff will be bringing performance reviews shortly. Competencies are based on patient acuity and determines the level of competency a staff member will need. Competencies are assessed by the unit managers, Assistant Director of Nursing (ADON), and DON. During a follow up interview on 07/24/24 at 4:40 PM, the DON revealed, she doesn't know why evaluations were not signed, had a lot that day just probably forgot to get them to sign.

Based on review of facility policy, interview, and record review, the facility failed to ensure that residents were free of unnecessary psychotropic medication, for 1 out of 5 residents reviewed for unnecessary medications, Resident (R)22. Findings include Review of the undated facility policy titled, Use of Psychotropic Medication revealed, Policy: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Policy Explanation and compliance guidelines: 12. Use of psychotropic medications in specific circumstances: c. New admissions: i. The facility shall identify the indication for use, as possible, using pre-admission screening and other pre-admission data. ii. The physician in collaboration with the consultant pharmacist shall re-evaluate the use of the medication and consider whether or not the medication can be reduced or discontinued up admission or soon after admission. Review of R22s Admission Record revealed R22 was initially admitted on [DATE] and readmitted to the facility on [DATE] with a diagnoses including but not limited to encounter for other orthopedic aftercare, Parkinsonism, and chronic obstructive pulmonary disease. Review of R22s Quarterly Minimum Date Set (MDS) with an Assessment Reference Date (ARD) date of 06/26/24 a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating R22 has severe cognitive impairment. Review of R22's Physician Order revealed the following orders: Seroquel Oral Tablet 25 MG Give 25 mg by mouth at bedtime for sleep for 7 days order date of 07/11/24, start date 07/25/24, end date 08/01/24. Seroquel Oral Tablet 50 MG Give 50 mg by mouth at bedtime for sleep for 7 days order date of 07/11/24, start date 07/18/24, end date 07/25/24. Review of R22s Care Plan with a start date of 06/26/24 revealed no diagnoses that required that use of antipsychotic medications nor a plan related to adverse effects of the medication. During an interview on 07/24/24 at 12:02 PM, the Medical Director (MD) revealed that inability to consent determination for resident stated that resident is unable to consent due to dementia and encephalopathy. The MD states, resident does not have a true diagnosis of dementia and that's why I added the encephalopathy. The MD states that R22 does have encephalopathy. When advised that neither diagnosis was listed on R22's diagnosis list the MD revealed that because, signing the inability to consent form is not something we charge for, I would not go back and add an ICD on the diagnosis, it's done off of clinical judgement. During a follow-up interview on 07/24/24 at 12:43 PM, related to R22 receiving Seroquel for sleep, the MD revealed that, [R22] came to the facility from the hospital, back in June with Parkinsons, had some falls, which goes back to encephalopathy. The MD states, I saw him on the 25th and the nurse practitioner saw him on the 27th. He came to us on it, we wouldn't have done a psychotic GDR (gradual dose reduction) yet, medication reviews are done quarterly. The MD continues to explain, everyone I work with knows I like I like to see a correct diagnosis. If there is not one on there that is on us. The MD further explains, I don't think pharmacy has mentioned that to me, I don't have a good explanation. When asked is there something you all do when residents come in regarding medications, the MD revealed, with new admits it's a team discussion and if they don't have a past history, staff knows I don't like keeping them on it. I like to stop it. This has been an oversight. The MD states I will see the resident today. The encephalopathy would be a correct diagnosis. During an interview on 07/24/24 at 3:05 PM, Registered Nurse (RN)2 revealed they are familiar with R22 and their diagnoses and care and explains that R22 has a diagnosis of dementia, congestive heart failure, blind, and needs to be fed. RN2 continues to explain that R22 is taking Seroquel for behaviors. RN2 reviewed R22's chart during the interview and revealed that R22 had no listed diagnosis of dementia then stated, dementia is a loose term when residents are confused. RN2 further explains that, the MD and admin team make the call for the medication based on input from nurses, bottom line is the doctor, he relies on the admin team's input to warrant medication. During an interview on 07/24/24 at 3:47 PM, the Administrator revealed that residents come in with discharge summary, every medication should have a diagnosis. The Administrator states, I think pharmacy reaches out to us or the MD for clarification of the order if there are two orders for the same medication. The Administrator states that a medication review is done when a resident comes in but is unable to specify the exact time frame. The Administrator further explains, pharmacy is in here every month doing drug reviews. The Administrator revealed their expectation is that, residents would have a proper diagnosis, but I leave it to the MD to make the determination.

Based on facility policy review, record review, observations, and interviews, the facility failed to ensure optimal placement was maintained related to an indwelling urinary catheter for 1 (Resident (R) 164) of 1 resident reviewed for catheter use, in a total sample of 23 residents. This failure resulted in the potential for decreased urinary flow and urinary tract infections to occur. Findings include: Review of the facility's policy titled, Catheter Care dated 11/2017, indicated staff were to, ensure drainage bag is located below the level of the bladder to discourage backflow of urine. Review of R164's undated Admission Record, located in the Electronic Medical Record (EMR) under the Resident Profile tab, revealed R164 was admitted to the facility on [DATE] on Hospice services. R164's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 08/03/22 at 11:00 AM, R164 was lying in bed in his room with the bed noted to be in the low position and a pillow under his left arm. The urinary catheter bag was positioned on the left side of the bed, above the level of the resident's bladder, and the bottom of the urinary catheter bag/drainage spout was resting on the floor. Based on the position of the resident's arm on the pillow, the resident's urinary catheter bag was out of reach. During an observation on 08/03/22 at 3:00 PM, R164 was lying in his bed. The bed was noted to be in the low position and the resident had a pillow under his left arm. The urinary catheter bag was positioned on the left side of the bed, above the level of the resident's bladder, and the bottom of the urinary catheter bag/drainage spout was resting on the floor. Based on the position of the resident's arm on the pillow, the resident's urinary catheter bag was out of reach. During an observation on 08/04/22 at 8:00 AM, R164 was lying in bed in his room, with a pillow under his left arm. R164's urinary catheter bag hung from the bedframe, on the left side of the bed, above the level of his bladder, with the bottom of the urinary catheter bag/drainage spout directly touching the floor. Based on the position of the resident's arm on the pillow, the resident's urinary catheter bag was out of reach. During an observation on 08/04/22 at 3:00 PM, R164 was lying in bed in his room, with a pillow under his left arm. R164's urinary catheter bag hung from the bedframe, on the left side of the bed, above the level of his bladder, with the bottom of the urinary catheter bag/drainage spout directly touching the floor. Based on the position of the resident's arm on the pillow, the resident's urinary catheter bag was out of reach. During an observation on 08/05/22 at 8:30 AM, R164 was lying in bed in his room, with a pillow under his left arm. R164's urinary catheter bag hung from the bedframe, on the left side of the bed, above the level of his bladder, with the bottom of the urinary catheter bag/drainage spout directly touching the floor. Based on the position of the resident's arm on the pillow, the resident's urinary catheter bag was out of reach. During an interview on 08/05/22 at 10:00 AM, the Director of Nursing (DON) stated she expected staff to ensure the catheter bag was positioned below the level of the resident's bladder and that it did not come into contact with the floor. During the same interview, the Clinical Services Support (CSS) Registered Nurse (RN), who was also present, stated she was aware the survey team had been observing the resident's urinary catheter bag each day of the survey. After the interview at 10:00 AM on 08/05/22 with the DON and CSS, an additional observation was made of R164's urinary catheter bag on 08/05/22 at 10:15 AM, in the presence of the DON and CSS. R164's urinary catheter bag continued to hang from the bedframe, on the left side of the bed, above the level of his bladder. During the observation, the CSS moved the urinary catheter bag to the end of R164's bed, which resulted in an immediate observation of cloudy yellow urine flowing in the tubing.

Based on observations, record reviews, and interviews, the facility failed to ensure: 1) Expired foods were discarded, 2) The Dietary Cook was appropriately handling raw chicken and utilizing appropriate hand washing after touching raw chicken with bare hands and before touching clean serving utensils and clean knife, 3) Tube Feedings were not stored in the employee restroom (toilet in room) in 1 of 1 reviewed kitchen and 1 of 2 employee restrooms in the facility. The findings included: An observation made during the initial tour on [DATE] at 9:55 AM, while in the walk-in cooler of a container of gravy and hamburger patties, the label stated Exp ,[DATE] (Expires ,[DATE]). The Dietary Manager verified and discarded. A second observation made while in the walk-in cooler of a container of Cranberry Sauce, the label stated [DATE], when the Dietary Manager was asked when the Cranberry Sauce expired, he/she stated he/she could not find an expiration date and discarded. A third observation made while in the Walk-In Cooler, a case of raw chicken no label to show open date or expiration date, the Dietary Manager located a label from the Vendor that stated, [DATE], when the Dietary Manager was asked when the raw chicken expired, he/she said, Food is discarded after 3 days, which would have been [DATE]. On [DATE] at 8:00 AM during an interview with the CDM regarding labeling and dating. CDM said: We discard after three days of opening and or go by the manufacturer's expiration date for discard of food products. A review of the facility form titled, Dietary Services-Departmental Operations, Dietary Services: Refrigerators and Freezers, states, Policy Statement, The facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, wan will observe food expiration guidelines. Policy Interpretation and Implementation, .7. All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. All opened refrigerator items will be labeled with open date and discarded within 7 days of open date., 8. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. Supervisors should contact vendors or manufactures when expiration dates are in question. On [DATE] at 08:30 AM during an observation of Dietary Cook #1, he/she was handling raw chicken with his/her bare hands. He/she was using the 3 compartment pot sink which was emptied of water and pots. There was a flat, open, rack of clean serving utensils stored on draining shelf of the sink. Observed cold running water, spilling over the raw pieces of chicken sitting directly on the bottom surface of the sink. Dietary Cook #1 is handling the raw chicken with bare hands. He/she then reaches over to the flat, open rack of clean, drying serving utensils stored on the draining shelf of the sink, he/she then touches the clean serving utensils with his/her soiled and bare hands, selects a a knife out of the rack and returns with bare hands and began cutting and trimming the raw chicken with the knife. During an interview with Dietary Cook #1, he/she said I should have washed my hands in the hand skink after touching the chicken, and I should have had gloves on my hands when handling the chicken. A review of the facility form titled: Dietary Services: Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, states, Policy Statement, Food Services employees shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. The Policy Interpretation and Implementation states: .6. Employee must wash their hands: .e. After handling raw meat, poultry, or fish and when switching between working with raw food and working with ready-to-eat food; .g. During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; .8. Contact between food and bare (ungloved) hands is prohibited. During an observation on [DATE] at 09:57 AM, of tube feeding stored in the employee restroom in closed and locked cabinet. The observation was verified by the Administrator. He/she said, we have been storing it there for [AGE] years and never had a problem, and we do not have anywhere to store it. The facility immediately relocated the tube feeding products to another location in the building. The Food Code, U.S. Public Health Service, FDA (Food Drug Administration), 2013. Pages, ,[DATE] states: ,[DATE].11 Food Storage. (A) Except as specified in ¶¶ (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) FOOD in packages and working containers may be stored less than 15 cm (6 inches) above the floor on case lot handling EQUIPMENT as specified under § ,[DATE].122. (C) Pressurized BEVERAGE containers, cased FOOD in waterproof containers such as bottles or cans, and milk containers in plastic crates may be stored on a floor that is clean and not exposed to floor moisture. ,[DATE].12 Food Storage, Prohibited Areas. FOOD may not be stored: (A) In locker rooms; (B) In toilet rooms; (C) In dressing rooms; (D) In garbage rooms; (E) In mechanical rooms; (F) Under sewer lines that are not shielded to intercept potential drips; (G) Under leaking water lines, including leaking automatic fire sprinkler heads, or under lines on which water has condensed; (H) Under open stairwells; or (I) Under other sources of contamination.

Based on limited record review and interview the facility failed to ensure services were provided in accordance with the written comprehensive plan of care for 1 of 5 residents reviewed for unnecessary medications. Resident # 50's care plan states to chart any behaviors as indicated. The findings included: The facility admitted Resident# 50 on 4/23/15 with [DIAGNOSES REDACTED]. During review of the April's (YEAR) physician's orders [REDACTED]. During record review on 4/5/18 at 11:15AM revealed the Care Plan with problem onset: 3/20/18 Potential for undesirable side effects related psychoactive drug therapy receives [MEDICATION NAME] related to Depression. Approaches observe/assess and report signs and symptoms of drug induced postural [MEDICAL CONDITION]. Chart any behaviors as indicated. Further record review on 4/5/18 at 12:07 PM revealed no documentation on the Medication Administration and the Nurses' Notes of the resident's behaviors. During an interview on 4/6/18 with Registered Nurse# 1 stated the facility did not have to document the resident being on [MEDICATION NAME]. Surveyor stated according to the care plan Resident#50 should be.

Medication labeling and storage Based on observations, interviews, and review of the facility ' s policy, the facility failed to label insulin pens accurately and ensure an accurate count of [MEDICATION NAME] in 2 of 2 medication carts and 1 of 1 refrigerator. The findings included: During inventory of the Carolina Hall medication cart on [DATE] at approximately 11:33 AM with RN #2, a Narcotic Inventory Record was found with [MEDICATION NAME] 2 milligrams (mg)/milliliter (ml) beginning quantity 2 on [DATE], however, the amount remaining was changed to 1 with no explanation listed. RN #2 stated, There is one [MEDICATION NAME] vial for each hall. I just count one. During an observation of the Virginia Hall narcotic count on [DATE] at approximately 07:17 PM, LPN #2 and LPN #3 checked for 1 vial of [MEDICATION NAME] 2 mg/ml in the refrigerator. They stated, We check for 1 vial and the other hall (Carolina) checks for 1 vial. However, both vials in the refrigerator were labeled for Carolina Hall. In addition, the Virginia Hall narcotic sheet labeled for (MONTH) (YEAR) was mislabeled as [MEDICATION NAME] 0.5 mg tablet in the refrigerator instead of [MEDICATION NAME] 2 mg/ml. There was no narcotic sheet to sign for [MEDICATION NAME] 2 mg/ml. The total amount of [MEDICATION NAME] vials in the refrigerator was not documented. During inventory of the medication cart on Carolina Hall on [DATE] at approximately 11:05 AM with RN #2, multiple vials of the same insulin was found for Resident #35. Two vials of [MEDICATION NAME] 100 unit(u)/ml vial were found. The first vial had a label showing the date opened [DATE] and expiring [DATE], totaling 32 days. RN #2 verified the insulin should expire in 28 days on [DATE] but was mislabeled. The second vial was labeled as opened on [DATE] and expiring on [DATE], totaling 43 days. RN #2 verified the insulin should be labeled to expire on [DATE], totaling 28 days. The second vial was in a box labeled with a date opened on [DATE], RN #2 stated, I would use the date on the vial. In addition, Resident #8 had a 10 ml [MEDICATION NAME]vial 100units/ml, labeled as opened on [DATE] and expiring on [DATE]. RN #2 stated, It should have been removed because today is [DATE]. This vial is expired. RN #2 verified Resident #8 received 7 doses of the expired insulin from (MONTH) 2 -4, (YEAR). During inventory of the Virginia Hall medication cart on [DATE] at approximately 7:30 PM with LPN #2, a Tresiba insulin pen was found dated incorrectly for Resident #16. Tresiba insulin pen was labeled as opened on [DATE] expiring on [DATE], totaling 29 days. LPN #2 verified Tresiba is good for 56 days after being opened. A [MEDICATION NAME]pen was also found for Resident #16 opened and without an expiration date. In an interview on [DATE] at 9:35 AM, Other Staff #2 stated, Insulin should be dated when opened and when the expiration is. The facility policy entitled, Medication Expiration Dates & Storage reveals under INSULIN - 28 days from the date of puncture (refrigerate until open, then room temp), with the following exceptions: [MEDICATION NAME] MIX ,[DATE] pen: 14 days [MEDICATION NAME] vial and pen and Toujeo: 42 days Humalog MIX ,[DATE] pen and Humalog MIX ,[DATE] pen: 10 days Tresiba: 56 days

Based on record review, interview and review of the facility policy titled, Water Management Program to Reduce Legionella, the facility failed ensure the water in high risk areas was tested for Legionella in a timely manner and to act on a positive test on 1 of 2 Halls. The findings included: Review on 4/6/2018 at approximately 2:45 PM of the results from a water test for Legionella, revealed the water was tested on [DATE] and a positive result was reported on 4/3/2018 in the shower head/hose on the Virginia Unit. The results was 12.6. Review on 4/6/2018 at approximately 3:00 PM of the facility policy titled, Water Management Program to Reduce Legionella, states under, Policy Statement, Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella. Policy Interpretation and Implementation, number 2 states, The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread and to reduce the risk of Legionella's Disease. During an interview on 4/6/2018 at approximately 3:10 PM with the Administrator, she was aware of the results but called the testing company to get guidance on making sure the residents were safe. No documentation was found in the facility to ensure the water management team was taking action on the positive results and no further testing was planned.

Based on observations, interview, and review of the facility ' s policy titled, Maintaining Dignity, and Assistance with Meals, the facility failed to provide an environment to promote dignity of residents during the dining experience for 2 of 2 dining observations on the VA Unit. Staff was observed entering rooms without knocking and placing clothing protectors on residents without first asking if they would like to have one applied. The findings included: An observation on 4/3/2018 at approximately 11:47 AM during the lunch meal service on the VA Unit revealed CNA's (Certified Nursing Assistants) yelling knock, knock, and then entering rooms, not waiting for a response to enter, and applying clothing protectors without first asking if they would like to have one applied. An observation on 4/6/2018 at approximately 11:55 AM during the lunch meal service on the VA Unit revealed CNA's passing out lunch trays. The CNA's were yelling knock, knock, and then entering rooms, not waiting for a response to enter, and applying clothing protectors without first asking if they would like to have one applied. An interview on 4/6/18 at 12:10 PM with CNA #1 confirmed the findings, and she stated, We are working on that. Review on 4/6/2018 at approximately 1:20 PM of the facility policy titled, Maintaining Dignity, policy statement reads, To ensure the residents are cared for in a manner and in an environment that maintains or enhances their dignity and respect. Under, Policy Interpretations and Implementation, number 6. states, Resident's private space and property will be respected, TV/Radio station will not be changed without resident's permission, resident room doors will be knocked on and permission to enter granted prior to entering resident rooms, resident room doors will be open or closed per resident choice, resident's personal items will not be moved or inspected without residents permission. Review on 4/6/2018 at approximately 1:30 PM of the facility policy titled Assistance with Meals, states under, Policy Interpretation and Implementation, #3b.(4) states, Avoid the use of clothing protectors without asking resident before use.

Based on limited record reviews, and interviews, the facility failed to ensure that a representative of the Office of the State Long-Term Care Ombudsman was notified of the transfers and discharges of residents for 1 of 1 reviewed for discharge. Resident#52 was discharged from the facility without notification provided as required to the State Long-Term Care Ombudsman. The findings included: The facility admitted Resident# 52 on 6/29/17 with [DIAGNOSES REDACTED]. During limited record review on 4/5/18 at 1:29 PM revealed Discharge from Windsor Manor listed Resident#52 was discharged home on[DATE]. The memory transmission report have the Ombudsman's fax number with the end date 4/5/18. In addition discharges from (MONTH) (YEAR) through (MONTH) (YEAR) were sent on 4/5/18. During an interview on 4/5/18 at 1:29 PM with the Administrator stated talked to Social Services Director about sending information to the Ombudsman and was not aware. Administrator called the Ombudsman and ask how they prefer to receive the information.

Based on record review and interview the facility failed to ensure the CNA (Certified Nursing Assistant) had input into the care planning process for Resident #20 for 1 of 15 residents reviewed for Participation in Care Planning. The findings included: The facility admitted Resident #20 with [DIAGNOSES REDACTED]. Review on 4/6/2018 at approximately 2:30 PM of a form titled, Resident Care Plan Conference Attendance Record, dated 11/29/2016 and 2/14/2017 indicated that the CNA involved in the care for Resident #20 did not have input into the care planning process for Resident #20. During an interview on 4/6/2018 at approximately 2:50 PM the Social Service Director confirmed that the CNA most involved with the care for Resident #20 did not have input into the care planning process.

Based on record review and interview, the facility failed to ensure to provide quality care for Resident #29, the physician was not notified of laboratory findings for 1 of 2 residents reviewed for Urinary Tract Infection [MEDICAL CONDITION]. There was no evidence that the facility notified the Physician of abnormal laboratory findings for Resident #29 resulting in a 5-day delay in treatment. The findings included: Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Lab results reviewed on 4/5/18 at 11:04 AM, revealed a UA was obtained on 3/21/18 as ordered and received by the lab on 3/22/18. The lab results were reported to the facility on [DATE] at 09:34 AM. There was no evidence that the facility notified the Physician of the UA results. The Physician signed and dated the lab results 3/29/18 and noted orders written on the lab sheet. Physician order [REDACTED]. In an interview with the Director of Nursing (DON) on 4/5/18 at approximately 11:40 AM, the DON stated, Either the Unit Manager or Floor Nurse write any pertinent information on the lab results and fax it to the Physician and they call back or fax over orders. The DON verified there was no evidence of staff notifying the Physician of the abnormal UA after receiving the results 3/24/18. During a phone interview on 4/5/18 at approximately 3:00 PM, Other Staff #3 stated, I expect the nurses to call me with any abnormal lab results, even on a weekend. When asked if an antibiotic would have been indicated on 3/24/18 based on the UA results, Other Staff #3 stated, Probably so.

On the days of the survey, based on record review and interview, the facility failed to provide fall prevention measures as ordered and care planned for Resident # 57 including a self releasing seatbelt and a chair/bed alarm. The facility also failed to follow the plan of care for Resident # 51 related to leaving the resident unattended in the bathroom, the resident was observed in his/her room without a call light in reach, without a chair/bed alarm in place and with a bed mat alarm that was turned to silence mode. Resident 6 was observed without physician ordered safety devices in place. (3 of 4 sampled residents reviewed for careplans related to falls) The findings included: . Record review revealed Resident 51's careplan stated the resident was to wear bed/chair alarm when out of bed to the wheelchair at all times (page 8 of 16) . The plan of care also stated to encourage resident to remain in supervised areas when out of room. (page 6 of 16). Additionally, incident accident reports included additional steps to be taken to prevent reoccurrence of falls and these included: "Resident to be in staff presence when up in chair". (3/16/13) On 6/5/13 Resident # 51 was observed seated in a wheelchair in the dining area with no bed/chair alarm attached. On 6/6/13 at 10 AM, the resident was observed in his/her room, the call bell was in the resident wheelchair that was out of the residents reach. The bed/chair alarm was still attached to the wheelchair. Resident # 51 was awake, reaching for the wheelchair but unable to reach it. A bed mat alarm was observed under the resident. A CNA working in the room was notified that the resident was awake and reaching for the wheelchair. S/he was unable to visualize the resident because the bedside curtains were pulled around the resident. CNA # 1 verified the call bell was out of reach for the resident and that the bed/chair alarm was attached to the wheelchair. The CNA was unsure if the resident needed the bed/chair alarm because there was a mat alarm under the resident. The transfer of the resident was observed and when the resident was stood from the bed, no alarm sounded from the bed mat alarm. Subsequently, the maintenance Director stated that inside the battery box there was a switch to silence the alarm and it had been placed in the silence mode. Further review of the incident reports provided by the facility revealed on 5/20/13 the resident fell in the bathroom. Following the fall, the resident was transferred to the emergency room related to hip pain. "Resident trying to get back in his/her wheelchair after using toilet." The intervention was to not leave the resident unattended in the bathroom. However, that intervention had already been put in place in March. The facility admitted Resident #29 with [DIAGNOSES REDACTED]. Review of the resident's care plan dated 4/30/13 revealed the resident was care planned for a right hand palmer splint at all times except during ADL(Activities of Daily Living) care. Observation of the resident on 6/3/13 at 10:37 AM, 3:35 PM ; 6/5/13 at 8:37 AM; and 6/6/13 at 3:20 PM revealed the the palmer splint had not been placed on the resident. This was confirmed by the Unit Manager on 6/6/13 at 3:20 PM. Record review on 6-5-13 at 11:42 AM revealed that Resident #6 had been admitted to the facility with [DIAGNOSES REDACTED]. Review of the 4-23-13 Annual Minimum Data Set (MDS) Assessment on 6-5-13 at 9 PM revealed that Resident #6 had a Brief Interview for Mental Status (BIMS) score of "2", indicating severe cognitive impairment. S/he had unclear speech, was sometimes understood and sometimes had the ability to understand. The only behavior noted was inattention. S/he required moderate assistance with dressing and extensive assistance with transfers and toileting. Eating and locomotion required only supervision. No impairments in ROM were noted. Supervision was required in locomotion. S/he was incontinent of bowel and bladder. Resident #6 had an unsteady balance and was noted as having 2 or more falls since the prior assessment. Section N of the MDS noted that the resident had received antianxiety and antidepressant medication daily during the 7 day lookback period. No restraints were coded as in use. Review of the 11-13-12 and 2-5-13 Quarterly MDS assessments revealed that the resident had declined in cognition (developed "inattention"), ability to transfer, toileting, and ambulation. No falls were listed for the 11-13-12 MDS, one for the 2-5-13 MDS (minor injury), and 2 or more (no injuries) for the 4-23-13 MDS. No decline in range of motion was noted. Continued record review revealed that Physician's Orders were received on 6-15-11 and continued on the current cumulative monthly Physician's Orders for "bed chair alarm at all times. Orders were noted on 3-4-12 and continued on the current cumulative monthly Physician's Orders for "Res(ident) may be up OOB (out of bed) daily to WC (wheelchair) with alarming self-releasing safety belt applied." an order for [REDACTED]. Record review at 12:20 PM on 6-5-13 revealed Nurse's Notes indicating that Resident #6 was able to open the seatbelt and remove the tab/clip alarm on 3-6-13, 3-7-13, and 4-3-13. Review of Incident/Accident Reports provided by the facility on 6-5-13 and Nurse's Notes revealed the following information: (1) On 11-14-12 at 8 PM, the resident stated s/he hit her/his knee on the bedrail, sustaining a reddened area. The nurse noted that "res gets in & out of bed". "...Steps taken to prevent recurrence" included addition of siderail pads. According to Physician's Orders, this order had been in place since 10-30-12. There was no evidence that the resident was evaluated for use of less than full rails at this time, even though the resident sustained [REDACTED]. (2) On 1-20-13, Resident #6 "Went to restroom in res room by her(him)self. States her (his) leg gave out and she (he) slid down the wall to the floor. Found by...CNA (Certified Nursing Assistant)." No injuries were sustained. "...Steps taken to prevent recurrence" included: "Bed/chair alarm AAT (at all times). Enc(ourage) res to ask for assistance & use call light if needed." (Resident #6 was noted as severely cognitively impaired.) (3) On 1-24-13 at 9:20 AM, "Called to room by CNA. Res sitting on floor with back against the bed..." No injuries were sustained. "...Steps taken to prevent recurrence" included: " Enc res to use call light for assistance. Bed/chair alarm AAT. Order written for alarming self releasing seatbelt to w/c." There was no mention of an alarm being in place as ordered at the time of the fall. (4) On 3-17-13 at 9 PM, "Res chair alarm went off, went to res room & res sitting on buttocks on floor." No injuries were sustained. "...Steps taken to prevent recurrence" included: "Cont(inue) with bed/chair alarm. Cont with alarming seatbelt when up in w/c. Enc res to ask for assistance to get OOB (out of bed)." There was no mention of a second alarm being in place as ordered. (5) On 4-2-13 at 6:30 PM, "Res found on floor in room beside bed, sitting up position, self release safety belt unfastened in w/c..." "...Steps taken to prevent recurrence" included: "Cont with self releasing alarming belt to w/c. Enc res to ask for assistance to get OOB. Keep call light in reach WIB (when in bed)." No injuries were sustained. There was no evidence that the resident was evaluated for use of less than full rails at this time. There was no mention of a second alarm being in place as ordered. (6) On 4-3-13 at 8:20 PM, "Res w/c alarm sounded + res FOF (found on floor) @ front door..." "...Steps taken to prevent recurrence" included: "Cont with alarming self releasing safety belt. Enc res to ask for assistance to get OOB. Keep call light in reach WIB." No injuries were sustained. There was no mention of a second alarm being in place as ordered. Observations throughout the first day of the survey (6-4-13) revealed Resident #6 self propelling in a wheelchair with a buckle-type seatbelt in place. No chair alarm was in evidence. On 6-5-13 at 11:25 AM, the resident was observed in the dining/activity room playing BINGO. The seatbelt was in place, but no tab alarm was observed. After lunch on 6-5-13, at approximately 1:45 PM, the resident was observed in the hall between the nursing station and the front door with a tab/clip-type alarm in place on the wheelchair, but the seatbelt alarm was not attached. At least three staff members stopped to talk with Resident #6 but failed to address the seatbelt which was supposed to be in place. The CNA assigned to the resident's care was one of the three. The CNA locked the resident's wheelchair in place and left to assist smokers. After approximately ten minutes, the CNA returned and buckled the seatbelt. When asked if the buckled belt was the alarming type, s/he said, "It's broken. That's why a tab alarm is on." The CNA was unaware of how long the belt had been broken. During an interview on 6-5-13 at 1:54 PM, Registered Nurse (RN) #1, responsible for the care of Resident #6 that day, was unaware that the seatbelt alarm was broken. The nurse stated s/he had replaced the battery on Sunday 5-26-13 and, "The following Wednesday, l know it was working." The RN and surveyor went to the dining/activity area and found the resident with the belt not in place. At this time, CNA #3 stated the resident "tore up the box last week." When questioned, CNA #3 stated that the resident was "supposed to have both the tab alarm and seatbelt alarm in place." During an interview on 6-5-13 at 2 PM, the Unit Manager stated s/he had just been advised by CNA #3 at 11:30AM that morning that the seatbelt alarm was broken. When notified that the tab/clip-type alarm had not been on the wheelchair on Tuesday, s/he stated," It should have been." On 6-6-13 at 8:20 AM, the resident was in her/his room, seated on the side of the bed, with feet on the floor. Full padded siderails were noted on the bed. No bed alarm was in evidence. CNA #3 was assisting the resident with dressing and stated s/he was just getting her/him up for the day. When asked to check for the bed alarm, s/he confirmed it was not on the bed. The CNA located the alarm still attached to the wheelchair in the hall where s/he said it had been stored the previous night. Review of the 6-13 Treatment Sheet revealed that, although the alarms were both listed on the form and initialed as being in place, they were found not to be in place and/or not functional. The facility failed to provide evidence of how staff ensured the safety of the residents when the alarm was noted to be non-functional. On 6-5-13 at 2 PM, the Unit Manager stated that staff did not routinely check the function of the alarms. A siderail assessment dated [DATE], most recently updated on 4-30-13 noted the resident as requiring limited assistance with bed mobility and extensive assistance with transfers. During a staff interview during Stage 1 of the survey on 6-4-13 at 9:12 AM, the Director of Nursing stated that full siderails were used for Resident #6, that the resident was physically capable of getting out of bed, and that the siderails did not prevent the resident from getting out of bed. S/he stated that the resident went to the foot of the bed and went around the rails. Quarterly Falls Risk Assessments were completed on 2-5-13 and 4-30-13. The 2-5-13 assessment noted no falls during the quarter, though the facility provided Incident/Accident Reports for falls for review dated 1-20-13 and 1-24-13. The fall risk score for this resident was "17", indicating the resident was at high risk for falls. Interventions listed on this and the Care Plan reflected the Physician's Orders and included: "Bed/chair alarm at all times", "Alarming self release safety belt to w/c at all times", and "SR's (siderails) X 2 for TAP." The 4-30-13 Quarterly Falls Risk Assessment noted the resident as having had "three + falls in a mo(nth)/qtr (quarter)." The risk score at this time was "23". There was no evidence in the medical record that alternate methods of maintaining the resident's safety had been attempted. During an interview on 6-5-13 at 11:30 AM, Licensed Practical Nurse #1 stated s/he had expressed concern to facility staff and suggested alternative fall prevention measures for Resident #6, but there had been no changes made. During an interview on 6-6-13 at 8:45AM, when asked if alternative fall prevention measures had been attempted, such as a pressure activated alarm or low bed and fall mats in lieu of the siderails which the resident could climb around, the Unit Manager only responded that the rails were used for turning and positioning. This was in direct opposition to the Quarterly Falls Risk Assessments which noted the siderails as an intervention for the resident at high risk for falls. Since the documentation noted that the resident was capable and did remove both the seatbelt and the tab/clip alarm, the surveyor asked if alternate methods had been attempted. The Unit Manager stated that a lap buddy had been used, but there was no record in the active chart or in incident reports provided. When asked how staff knew residents had orders for alarm, belts, or restraints, the Unit Manager stated, "The nurse has it on the TARs (Treatment Administration Records) and is supposed to check. The Nurse and CNAs are supposed to check to be sure they are working." When asked what staff should do if a seatbelt or alarm was not on as ordered, s/he replied, "Notify the nurse to get the alarm and put it on immediately." Resident #57 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the 5-16-13 30 day MDS on 6-5-13 at 7:39 PM revealed that Resident #57 had a BIMS score of "6", indicating severe cognitive impairment. Speech was clear and s/he had the ability to understand. The only behavior noted was intermittent disorganized thinking. Balance was noted as unsteady. No falls were noted since admission. Section N of the MDS noted that the resident had received antianxiety medication three times during the 7 day lookback period. Review of the 4-22-13 Admission MDS revealed that the resident had a history of [REDACTED]. Record Review on 6-5-13 at 3:04 PM revealed admission Physician's Orders for "Res to have bed/chair alarm at all times." On 5-9-13, a Physician's Order was obtained that "Res may be up OOB daily to W/C with self releasing safety belt." Review of the Care Plan revealed that initial orders for a gerichair with lap tray (restraint) had been updated to a lap buddy on 4-25-13. The current Care Plan reflected the Physician's Order for the self releasing belt, but did not include the order for the alarms. The bed/chair alarm was not observed in use on 6-5-13. The self releasing seatbelt was not observed in use at all on 6-5-13 or 6-6-13. On 6-5-13 at 11:03 AM, the resident was observed standing in the bathroom adjacent to his/her room. The CNA was making up the bed located second from the bathroom. At 2 PM on 6-5-13, the resident was in therapy, ambulating with contact guard assistance. The therapist stated the resident was impulsive. When told of the earlier observation, the therapist stated that s/he had concerns with nursing follow-through on the resident's plan of treatment. At 3PM on 6-5-13, the resident was observed in the hall in a wheelchair with no belt or alarm in place. On 6-6-13 at 10:30AM, Resident #57 was observed participating in an activity in the dining area, seated on sofa. The tab alarm was on the seat next to him. The wheelchair with the belt attached was parked next to him. A blanket was over his/her head. The Administrator verified this observation and stated, "Therapy said he (she) did not need the belt." Record review at this time revealed no physician's order had been obtained to discontinue fall prevention measures. Review of the 5-7-13 psychiatric consult revealed that the resident had a "dream d/o (disorder)" and that his/her judgment was impaired. On 4-16-13, an order was received for the resident to be treated for [REDACTED]. On 5-16-13, a Physician's Order was written to continue "ST 5x/w(ee)k x 4wk (for) cognitive training." During an interview on 6-5-13 at 3:50PM, the MDS/Care Plan Coordinator reviewed the Care Plan and Physician's Orders, verified them and said, "I must have missed that."

On the days of the complaint and Recertification surveys, based on observations, record reviews, and interviews, the facility failed to provide fall prevention measures as ordered for three of four sampled residents reviewed for accidents/falls. Resident # 51 was observed without alarms in place and without a call light in reach. Resident #51 was observed to have a bed alarm in place that had been turned to the silence mode. In addition, the resident's restraint was observed inappropriately applied for all three days of the survey. Resident #6 was observed without the physician-ordered alarmed seatbelt and bed/chair alarm in place. The facility failed to evaluate Resident #6 following falls to implement changes in the plan of care to prevent recurrence. Resident #57 did not have the seatbelt and/or chair alarm applied as ordered. The findings included: Record review on 6-5-13 at 11:42 AM revealed that Resident #6 had been admitted to the facility with [DIAGNOSES REDACTED]. Review of the 4-23-13 Annual Minimum Data Set (MDS) Assessment on 6-5-13 at 9 PM revealed that Resident #6 had a Brief Interview for Mental Status (BIMS) score of "2", indicating severe cognitive impairment. S/he had unclear speech, was sometimes understood and sometimes had the ability to understand. The only behavior noted was inattention. S/he required moderate assistance with dressing and extensive assistance with transfers and toileting. Eating and locomotion required only supervision. No impairments in ROM were noted. Supervision was required in locomotion. S/he was incontinent of bowel and bladder. Resident #6 had an unsteady balance and was noted as having 2 or more falls since the prior assessment. Section N of the MDS noted that the resident had received antianxiety and antidepressant medication daily during the 7 day lookback period. No restraints were coded as in use. Review of the 11-13-12 and 2-5-13 Quarterly MDS assessments revealed that the resident had declined in cognition (developed "inattention"), ability to transfer, toileting, and ambulation. No falls were listed for the 11-13-12 MDS, one for the 2-5-13 MDS (minor injury), and 2 or more (no injuries) for the 4-23-13 MDS. No decline in range of motion was noted. Continued record review revealed that Physician's Orders were received on 6-15-11 and continued on the current cumulative monthly Physician's Orders for "bed chair alarm at all times. Orders were noted on 3-4-12 and continued on the current cumulative monthly Physician's Orders for "Res(ident) may be up OOB (out of bed) daily to WC (wheelchair) with alarming self-releasing safety belt applied." an order for [REDACTED]. Record review at 12:20 PM on 6-5-13 revealed Nurse's Notes indicating that Resident #6 was able to open the seatbelt and remove the tab/clip alarm on 3-6-13, 3-7-13, and 4-3-13. Review of Incident/Accident Reports provided by the facility on 6-5-13 and Nurse's Notes revealed the following information: (1) On 11-14-12 at 8 PM, the resident stated s/he hit her/his knee on the bedrail, sustaining a reddened area. The nurse noted that "res gets in & out of bed". "...Steps taken to prevent recurrence" included addition of siderail pads. According to Physician's Orders, this order had been in place since 10-30-12. There was no evidence that the resident was evaluated for use of less than full rails at this time, even though the resident sustained [REDACTED]. (2) On 1-20-13, Resident #6 "Went to restroom in res room by her(him)self. States her (his) leg gave out and she (he) slid down the wall to the floor. Found by...CNA." No injuries were sustained. "...Steps taken to prevent recurrence" included: "Bed/chair alarm AAT (at all times). Enc(ourage) res to ask for assistance & use call light if needed." (Resident #6 was noted as severely cognitively impaired.) (3) On 1-24-13 at 9:20 AM, "Called to room by CNA. Res sitting on floor with back against the bed..." No injuries were sustained. "...Steps taken to prevent recurrence" included: " Enc(ourage) res to use call light for assistance. Bed/chair alarm AAT. Order written for alarming self releasing seatbelt to w/c." There was no mention of an alarm being in place as ordered at the time of the fall. (4) On 3-17-13 at 9 PM, "Res chair alarm went off, went to res room & res sitting on buttocks on floor." No injuries were sustained. "...Steps taken to prevent recurrence" included: "Cont(inue) with bed/chair alarm. Cont with alarming seatbelt when up in w/c. Enc(ourage) res to ask for assistance to get OOB (out of bed)." There was no mention of a second alarm being in place as ordered. (5) On 4-2-13 at 6:30 PM, "Res found on floor in room beside bed, sitting up position, self release safety belt unfastened in w/c..." "...Steps taken to prevent recurrence" included: "Cont(inue) with self releasing alarming belt to w/c. Enc(ourage) res to ask for assistance to get OOB. Keep call light in reach WIB (when in bed)." No injuries were sustained. There was no evidence that the resident was evaluated for use of less than full rails at this time. There was no mention of a second alarm being in place as ordered. (6) On 4-3-13 at 8:20 PM, "Res w/c alarm sounded + res FOF (found on floor) @ front door..." "...Steps taken to prevent recurrence" included: "Cont with alarming self releasing safety belt. Enc res to ask for assistance to get OOB. Keep call light in reach WIB." No injuries were sustained. There was no mention of a second alarm being in place as ordered. Observations throughout the first day of the survey (6-4-13) revealed Resident #6 self propelling in a wheelchair with a buckle-type seatbelt in place. No chair alarm was in evidence. On 6-5-13 at 11:25 AM, the resident was observed in the dining/activity room playing BINGO. The seatbelt was in place, but no tab alarm was observed. After lunch on 6-5-13, at approximately 1:45 PM, the resident was observed in the hall between the nursing station and the front door with a tab/clip-type alarm in place on the wheelchair, but the seatbelt alarm was not attached. At least three staff members stopped to talk with Resident #6 but failed to address the seatbelt which was supposed to be in place. The Certified Nursing Assistant (CNA) assigned to the resident's care was one of the three. The CNA locked the resident's wheelchair in place and left to assist smokers. After approximately ten minutes, the CNA returned and buckled the seatbelt. When asked if the buckled belt was the alarming type, s/he said, "It's broken. That's why a tab alarm is on." The CNA was unaware of how long the belt had been broken. During an interview on 6-5-13 at 1:54 PM, Registered Nurse (RN) #1, responsible for the care of Resident #6 that day, was unaware that the seatbelt alarm was broken. The nurse stated s/he had replaced the battery on Sunday 5-26-13 and, "The following Wednesday, l know it was working." The RN and surveyor went to the dining/activity area and found the resident with the belt not in place. At this time, CNA #3 stated the resident "tore up the box last week." When questioned, CNA #3 stated that the resident was "supposed to have both the tab alarm and seatbelt alarm in place." During an interview on 6-5-13 at 2 PM, the Unit Manager stated s/he had just been advised by CNA #3 at 11:30AM that morning that the seatbelt alarm was broken. When notified that the tab/clip-type alarm had not been on the wheelchair on Tuesday, s/he stated," It should have been." On 6-6-13 at 8:20 AM, the resident was in her/his room, seated on the side of the bed, with feet on the floor. Full padded siderails were noted on the bed. No bed alarm was in evidence. Certified Nursing Assistant (CNA) #3 was assisting the resident with dressing and stated s/he was just getting her/him up for the day. When asked to check for the bed alarm, s/he confirmed it was not on the bed. The CNA located the alarm still attached to the wheelchair in the hall where s/he said it had been stored the previous night. Review of the 6-13 Treatment Sheet revealed that, although the alarms were both listed on the form and initialed as being in place, they were found not to be in place and/or not functional. The facility failed to provide evidence of how staff ensured the safety of the residents when the alarm was noted to be non-functional. On 6-5-13 at 2 PM, the Unit Manager stated that staff did not routinely check the function of the alarms. A siderail assessment dated [DATE], most recently updated on 4-30-13 noted the resident as requiring limited assistance with bed mobility and extensive assistance with transfers. During a staff interview during Stage 1 of the survey on 6-4-13 at 9:12 AM, the Director of Nursing stated that full siderails were used for Resident #6, that the resident was physically capable of getting out of bed, and that the siderails did not prevent the resident from getting out of bed. S/he stated that the resident went to the foot of the bed and went around the rails. Quarterly Falls Risk Assessments were completed on 2-5-13 and 4-30-13. The 2-5-13 assessment noted no falls during the quarter, though the facility provided Incident/Accident Reports for falls for review dated 1-20-13 and 1-24-13. The fall risk score for this resident was "17", indicating the resident was at high risk for falls. Interventions listed on this and the Care Plan reflected the Physician's Orders and included: "Bed/chair alarm at all times", "Alarming self release safety belt to w/c at all times", and "SR's (siderails) X 2 for TAP." The 4-30-13 Quarterly Falls Risk Assessment noted the resident as having had "three + falls in a mo(nth)/qtr (quarter)." The risk score at this time was "23". There was no evidence in the medical record that alternate methods of maintaining the resident's safety had been attempted. During an interview on 6-5-13 at 11:30 AM, Licensed Practical Nurse #1 stated s/he had expressed concern to facility staff and suggested alternative fall prevention measures for Resident #6, but there had been no changes made. During an interview on 6-6-13 at 8:45AM, when asked if alternative fall prevention measures had been attempted, such as a pressure activated alarm or low bed and fall mats in lieu of the siderails which the resident could climb around, the Unit Manager only responded that the rails were used for turning and positioning. This was in direct opposition to the Quarterly Falls Risk Assessments which noted the siderails as an intervention for the resident at high risk for falls. Since the documentation noted that the resident was capable and did remove both the seatbelt and the tab/clip alarm, the surveyor asked if alternate methods had been attempted. The Unit Manager stated that a lap buddy had been used, but there was no record in the active chart or in incident reports provided. When asked how staff knew residents had orders for alarm, belts, or restraints, the Unit Manager stated, "The nurse has it on the TARs (Treatment Administration Records) and is supposed to check. The Nurse and CNAs are supposed to check to be sure they are working." When asked what staff should do if a seatbelt or alarm was not on as ordered, s/he replied, "Notify the nurse to get the alarm and put it on immediately." Based on observations,record review, and interviews, the facility failed to provide fall prevention interventions as ordered for Resident #57. Resident #57 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the 5-16-13 30 day MDS on 6-5-13 at 7:39 PM revealed that Resident #57 had a BIMS score of "6", indicating severe cognitive impairment. Speech was clear and s/he had the ability to understand. The only behavior noted was intermittent disorganized thinking. Balance was noted as unsteady. No falls were noted since admission. Section N of the MDS noted that the resident had received antianxiety medication three times during the 7 day lookback period. Review of the 4-22-13 Admission MDS revealed that the resident had a history of [REDACTED]. Record Review on 6-5-13 at 3:04 PM revealed admission Physician's Orders for "Res to have bed/chair alarm at all times." On 5-9-13, a Physician's Order was obtained that "Res may be up OOB daily to W/C with self releasing safety belt." Review of the Care Plan revealed that initial orders for a gerichair with lap tray (restraint) had been updated to a lap buddy on 4-25-13. The current Care Plan reflected the Physician's Order for the self releasing belt, but did not include the order for the alarms. The bed/chair alarm was not observed in use on 6-5-13. The self releasing seatbelt was not observed in use at all on 6-5-13 or 6-6-13. On 6-5-13 at 11:03 AM, the resident was observed standing in the bathroom adjacent to his/her room. The CNA was making up the bed located second from the bathroom. At 2 PM on 6-5-13, the resident was in therapy, ambulating with contact guard assistance. The therapist stated the resident was impulsive. When told of the earlier observation, the therapist stated that s/he had concerns with nursing follow-through on the resident's plan of treatment. At 3PM on 6-5-13, the resident was observed in the hall in a wheelchair with no belt or alarm in place. On 6-6-13 at 10:30AM, Resident #57 was observed participating in an activity in the dining area, seated on sofa. The tab alarm was on the seat next to him. The wheelchair with the belt attached was parked next to him. A blanket was over his/her head. The Administrator verified this observation and stated, "Therapy said he (she) did not need the belt." Record review at this time revealed no physician's order had been obtained to discontinue fall prevention measures. Review of the 5-7-13 psychiatric consult revealed that the resident had a "dream d/o (disorder)" and that his/her judgment was impaired. On 4-16-13, an order was received for the resident to be treated for [REDACTED]. On 5-16-13, a Physician's Order was written to continue "ST 5x/w(ee)k x 4wk (for) cognitive training." During an interview on 6-5-13 at 3:50PM, the MDS/Care Plan Coordinator reviewed the Care Plan and Physician's Orders, verified them and said, "I must have missed that." Resident #57 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the 5-16-13 30 day MDS on 6-5-13 at 7:39 PM revealed that Resident #57 had a BIMS score of "6", indicating severe cognitive impairment. The only behavior noted was intermittent disorganized thinking. Section N of the MDS noted that the resident had received antianxiety medication three times during the 7 day lookback period. Review of Physician's Orders and Nurse's Notes at 3:04 PM on 6-5-13 revealed that within less than 12 hours of admission to the facility, at 2 AM on 4-17-13, Nurse's Notes stated, "Res... with increased confusion & severe agitation. Order for 1 mg Ativan now. Res repeatedly yelling staff 'put fire out'." Further review revealed that a Physician's Telephone Order was received on 5-5-13 for "Ativan 0.5 mg (milligrams)-1 mg IM or PO (by mouth) for agitation X l." Review of the 5-13 MAR revealed "agitation" as the reason for administration. Review of the Nurse's Notes revealed no entries citing behaviors exhibited by the resident or any specific interventions attempted prior to administration of the Ativan. No entries were made for the time the medication was administered (3:15 AM). Record review revealed no Care Plan for behaviors or use of psychoactive medication. During an interview on 6-5-13 at 3:50 PM, the MDS coordinator reviewed the medical record and verified there was no documentation in the Nurse's Notes of non-pharmacological interventions prior to administration of Ativan. S/he also confirmed that there were no entries in the 5-5-13 notes related to resident behaviors requiring Ativan. When asked about Care Plan inclusion of psychoactive medications and side effects, the MDS coordinator reviewed the Care Plan and stated, "I must have missed that." Record review revealed Resident 51's careplan stated the resident was to wear a bed/chair alarm when out of bed to the wheelchair at all times (page 8 of 16) . The plan of care also stated to encourage resident to remain in supervised areas when out of room. (page 6 of 16). Additionally, incident accident reports included additional steps to be taken to prevent reoccurrence of falls included: Resident to be in staff presence when up in chair, (3/16/13) . On 6/5/13 Resident # 51 was observed seated in a wheelchair in the dining area with no bed/chair alarm attached. A soft clip belt was observed to be applied in manner conflicting with manufacturer's instructions. The strings of the belt were woven around one rear anti-tip bar and knotted. The restraint remained tied in the same fashion during repeated observations on all days of the survey. On 6/6/13 at 10 AM, the resident was observed in his/her room, the call bell was in the resident wheelchair and was out of the residents reach. The bed/chair alarm was still attached to the wheelchair. Resident # 51 was awake, reaching for the wheelchair but unable to reach it. A bed mat alarm was observed under the resident. A CNA (Certified Nursing Assistant) working in the room was notified that the resident was awake and reaching for the wheelchair. S/he was unable to visualize the resident because the bedside curtains were pulled around the resident. CNA # 1 verified the call bell was out of reach for the resident and that the bed/chair alarm was attached to the wheelchair. The CNA was unsure if the resident needed the bed/chair alarm because there was a mat alarm under the resident. The transfer of the resident was observed and when the resident was stood from the bed, no alarm sounded from the bed mat alarm. Subsequently, the Maintenance Director stated that inside the battery box there was a switch to silence the alarm and it had been placed in the silence mode. On 6/6/13, at approximately 12:45pm, the resident was observed in his/her room alone, seated in the wheelchair next to the bed. The Unit Manager was summoned and verified s/he should not have been left in the room alone. The medication nurse was standing in the hallway but not in view of the resident. S/he stated s/he had left the resident "just for a moment." Further review of the incident reports provided by the facility revealed on 5/20/13 the resident fell in the bathroom. "Resident trying to get back in his/her wheelchair after using toilet." The intervention was to not leave the resident unattended in the bathroom. However, the same intervention was previously noted to have been in use on 3/16/13. Following the fall in the bathroom, the resident complained of hip pain. The resident was sent to the emergency room . From 12/19/12 to 5/29/13, s/he sustained approximately 24 incidents where s/he fell , or was found on the floor or mat. Of those incidents, 7 resulted in emergency room treatments for X-rays, sutures or abrasions treated within the facility. Resident # 51 was admitted to the facility on [DATE] in the late afternoon with a known history of falls. On admission, the resident had order to apply full, bilateral siderails to assist with turning and positioning. On 12/19/12 at 1 PM, a nurses note stated: "Res.(resident) cont.(continues) to make several attempts to get oob. (out of bed) Res. attempting to climb over side rails, res. placed in recliner chair , placed at nurses station..... Res. attempted to get out of recliner chair. Res. climbed over the side of the recliner chair and fell to floor on buttocks"....order received for low bed. Resident placed in bed with siderails up x 2...continues to make several attempts to get oob. Resident turned horizontally in bed with legs over siderails. Resident placed back in recliner. 12/20 /12 8:30 AM, :...in bed, siderails up x 2, attempting to climb oob with legs hanging over siderails." There was no documentation of the use of a low bed as ordered on [DATE] until 12/20/12 at 7:15 PM. A siderail assessment was documented as completed on 12/18/12. The assessment documented the resident had behaviors of anxiety, was at great risk for falls required assistance for bed mobility, transfers and was unable to sit. The resident was documented as needing assistance to turn and move and was unable to use the call system. However, the assessment documented the bilateral padded siderails would be used when in bed for turning and positioning. On 1/28/13 a nurses note stated "leg restraints removed as ordered." No order was found for the use of leg restraints. When interviewed, the facility staff stated the Broda chair used for the resident "came" with leg restraints and the resident had an order for [REDACTED]. Additional chart review concerns related to falls and fall prevention for Resident # 51 included the following: 12/21/12 PM - ....Attempted to redirect resident without much improvement. Removed from activity area and allowed resident to have privacy and quiet time in own room. No improvement seen in behaviors when "secluded." 12/22/12 Moving about in gerichair. Attempting to crawl out of chair. 01/11/13 Resident climbed out of Broda chair and fell on floor on his knees...placed back in to Broda chair with leg straps applied 01/26/13 Resident had taken bed/chair alarm off and had gotten out of Broda chair. Small cut to right side of head and complained of rib pain. 01/28/12 New orders to discontinue Broda chair leg restraints 03/15/13 Found resident on floor. Another resident stated the resident removed his alarm, and slipped waist belt over his/her head and climber out of chair. 03/22/13 Will pull restraint up and attempt to slide underneath. 03/30/13 Resident weaker and can no longer stand up by himself 04/11/13 Continues to take bed/chair alarm plus taking restraint up over head. 04/12/13 Resident attempting to slide beneath waist restraint 04/16/13 Tries to slip out of waist restraint if not observed closely 04/22/13 Continues to try to get out of waist restraint 04/24/12 Found on floor, waist restraint very loose 05/17/13 Continues to attempt to get out of wheelchair by sliding under waist restraint. There was no evidence that facility staff identified the unsafe behaviors associated with the various restrictive devices that were place and initiated prompt action to prevent potential injury. No assessment for the various restraints were completed (excluding siderails) to assure they were the least restrictive or safe for the resident to use. The siderail assessment was noted to be inaccurate, deemed the resident safe to use siderails when s/he was not. Additionally, record review revealed the resident traumatically removed the gastric tube on 12/22/12 and on 12/23/12 an abdominal binder was put in place. An order to discontinue the binder was written on 12/24/12 without further explanation. On 6/5/13 during medication pass observation an abdominal binder was observed in place. There was no order noted and no other documentation related to its use noted and when observed on 6/6/13 the abdominal binder was not in place. On 6/5/13, in an interview with Licensed Practical Nurse #1, s/he stated when the resident returned to the facility on [DATE], an abdominal binder was in place. S/he stated s./he left the binder in place and relayed the information to the Unit Manager as s/he was uncertain if it should be continued or not. Review of the resident's careplan initiated on 1/1/13 revealed not all restraints used for the resident were noted on the plan of care. The careplan noted the use of the Broda chair, Broda chair with waistbelt and wheelchair with waist belt. The Care plan did not address the documented use of a Geri chair with/without table, abdominal binder or the use of the leg restraints. The careplan also included the approaches to encourage resident to remain in supervised areas when out of room; Keep call light within easy reach while in room; and instruct resident how to use call bell and call for assistance as needed. During an interview with the MDS Coordinator,s/he verified not all the devices were listed and that some approached were not suitable for a resident with significant cognitive impairment. A copy of the facility provided policy for restraints stated restraints would be used only after alternatives had been tried unsuccessfully. A restraint should be the least restrictive device. Restraints are of the type that can be easily removed . Restraints should be reevaluated at least quarterly. The residents careplan must indicate the continued use of the restraint has been reevaluated. The Manufacturers instructions for the use of a quick release cushion belt stated: (under contraindication for use) : Do not use this device for a patient who: slides down in the wheelchair, has a history of easily removing belt-style,vest style and poncho style restraints, is in a bed, gerichair or lounge chair. This device is intended for wheelchair use only. Never place a patient wearing a restrictive device in a place where s/he is not easily monitored. On 6/6/13 the collected information was reviewed with the facility Corporate consultant who did not dispute the surveyors concerns related to the use of restraints for Resident # 51.