Every finding on record at Presbyterian Communities Of South Carolina-Summerv

Based on review of the facility policy, observations, and interviews, the facility failed to ensure foods were stored, prepared and served under sanitary conditions in 1 of 1 Main Kitchen and 1of 1 Satellite Kitchen. Additionally, 3 out of 5 dietary staff were observed without the use of proper hair restraints, while in the kitchen. Findings include: Review of the facility's policy, titled Food Storage (Dry, Refrigerated, and Frozen) copyright 2020, revealed the following: Guideline: Food shall be stored on shelves in a clean, dry area free from contaminants. Food shall be stored at appropriate temperatures and using appropriate temperatures and using appropriate methods to ensure the highest level and food safety. Under Procedure it states, 1. General storage guidelines to be followed: a. All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discard. See date marking guidelines in this section for exceptions to dating individual dry storage food items. c. Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration. f. Leftover contents of cans and prepared food will be stored in covered, labeled and dated containers in refrigerators and/or freezers. h. Follow and adhere to the guidelines regarding proper storage temperatures and maximum length of storage found in storage guidelines in the Sanitation section of the manual. Review of the facility's policy titled, Dietary Employee Hair Restraint with a revision date of 04/09/2025, revealed, It is the policy of this facility to utilize the following as guidelines for employee hair restraint to prevent contamination of food by foodservice employees. Hair Restraints: a. Except as provided in (c) of this section, food employees must wear hair restraints (e.g., hairnet, hat and/or beard restraint, clothing) to prevent hair from contacting food, equipment and utensils. b. Head covering must be clean. c. This section does not apply to food employees such as counter staff who only serve beverages and wrapped or package food, hostesses, and wait staff, if they present a minimal risk of contaminating exposed food, clean equipment, utensils, linens, and unwrapped single-service or single -use articles. An initial observation of the main kitchen on 08/24/2025 at 10:12 AM, revealed the following: Observation of the first refrigerator in the main kitchen revealed: -opened, unlabeled 16 ounces (oz.) bag of green beans -opened, unlabeled 24 oz. bag of shredded cabbage -opened, unlabeled 12 oz. bag of almonds -opened, unlabeled 12 oz. bag of cranberries -crate of celery with brown spots -crate of eggplants with white fuzz growing out of it and brown spots noted on them -crate of cucumbers with white fuzz growing out of it and brown spots on them. Observation of the second refrigerator in the main kitchen revealed: -no whipped topping with an expiration date of 8/20/25 -crabmeat patties mix with an expiration date of 8/23/25 -Roast Beef with an expiration date of 8/23/25 - 1 serving container with raw stew beef, unlabeled -(4) 5-pound (lb.) boxes of opened and unlabeled, bacon. Additionally, there were 3, opened loaves of bread without a label and a 5 oz. opened pack of tortilla wraps with an expiration date of 7/16/25. During an observation and interview with the Executive Chef (EC) on 08/24/2025 at 10:16 AM revealed, upon entry into the main kitchen, when the surveyor asked about the wearing of beard covers, the EC stated, I thought that it depends on the length of the beard and if its low-cut, a cover is not needed. When asked about the unlabeled and expired food in both walk-in refrigerators and dry storage, the EC did not comment and proceeded to discard those select items. During a second observation of the main kitchen on 08/25/2025 at 12:23 PM, the EC, Director of Culinary Services (DCS) and 3 male staff members were observed without beard covers. During an interview with the DCS on 08/25/2025 at 12:35 PM revealed, while standing in the main kitchen, the DCS was asked by the surveyor, Why are staff not wearing beard covers? The DCS responded, Well, I am not in production, so it's not required. The DCS did not respond when questioned about staff in production wearing beard covers. After no response from the DCS concerning staff in production wearing beard covers, the EC walked away from prepping food, grabbed a beard cover, placed it over his beard and returned to preparing food. An observation of the satellite kitchen on 08/25/25 at 10:27 AM revealed there was dirty dish water in the 3-compartment sink. The dish water was a taut color, without visible soap, with food particles floating around in it. The Kitchen [NAME] (KC) was observed reaching into the dirty dish water and grabbing a dish towel to clean kitchen surfaces. The KC was then observed using plain water to clean the kitchen surfaces. When the solution in the red sanitizer bucket was tested, it indicated there was no sanitizer present. Continued observation of the satellite kitchen revealed the stove hood was covered with brown matter. Additionally, there were two, uncovered trash cans the kitchen, with gnats present. Observation of the satellite kitchen revealed the following: -multiple cake slices on a serving tray, partially covered with parchment paper stored on top of 1 of the 5 refrigerators -opened, unlabeled, 16 oz. bag of shredded cheese -opened, unlabeled, package of Sausage links -unlabeled, raw, thawed chicken breast in the original packaging -opened, unlabeled, 5 lb. box of bacon -opened, unlabeled, roll of ground beef -24 oz. container of Vegetable beef soup, with an expiration date of 7/15/25 -opened, 4 lb. ham with an expiration date of 8/20/25 -16 oz. jar of pimento cheese with an expiration date of 8/15/25 -24 oz. bag of spinach with an expiration date of 8/24/25 -24 oz. bag of cauliflower with an expiration date of 8/23/25 -16 oz. jar of spicy mustard with an expiration date of 8/21/25 -large blue bag of frozen egg rolls with an expiration date of 8/23/25 -1 bell pepper with brown spots and white fuzz growing out of it -1 zucchini with brown spots and white fuzz growing out of it, mixed with the fresh produce. During an interview and observation with the Assistant Director of Dietary Culinary Services (ADDCS) on 08/25/2025 at 10:32 AM, the plain water in the red sanitizer bucket was confirmed. ADDCS stated, Although it was only water in the red bucket, our best practices are to have sanitizer in the red bucket.

Based on review of the facility policy, observations and interviews, the facility failed to ensure proper infection control practices were followed. Specifically, Enhanced-Barrier Precautions (EBP) were not followed for Resident (R)2, who was observed receiving care while on EBP. The facility further failed to ensure oral medications were not touched using bare hands during a random observation while on the unit for 1 of 1 residents receiving oral medications during the random observation. Findings include: Review of the facility's policy titled, Enhanced Barrier Precautions, reviewed and revised on 04/01/2024, states, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. The definition of, Enhanced Barrier Precautions, EPH refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. 2. Initiation of Enhanced Barrier Precautions: b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., such as pressure ulcer, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO. ii. Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply. 3. Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside of the resident's room. b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. 4. High-contact resident care activities include: a. Dressing b. Bathing c. Transferring d. Providing hygiene e. Changing linens f. Changing briefs or assisting with toileting g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes h. Wound care: any skin opening requiring a dressing. 5. 'Enhanced barrier precautions should be followed outside the resident's room when performing transfers and assisting during bathing in a shared/common shower room and when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility. The facility admitted R2 with diagnoses including, but not limited to, stroke, a feeding tube and a catheter. During an observation on 08/24/2025 at 02:30 PM, Certified Nursing Assistant (CNA)1 was observed assisting R2 from the wheelchair to the bed. She pushed the wheelchair close to the bed, and then without gloves and a gown, proceeded to assist the resident to a standing position from the wheelchair, and with bare hands lowered him onto the bed and helped him to lay down. Then she took both legs into her ungloved hands and placed then onto the foot of the bed. CNA1 then, with bare hands, put the sheet and bedspread over the resident. There was no personal protective equipment on the outside of the door and no signage to ensure staff and visitors were aware of the enhanced barrier precautions. There was also no signage in the resident's room. During an interview on 08/24/2025 at 02:38 PM with CNA1, she confirmed that she had not worn the required PPE. When asked about the signage and the PPE, CNA1 and the surveyor went into R2's room and there was a plastic bag of disposable gowns on the back of the door, but no gloves. She informed the surveyor that the black star alerted staff and visitors of the enhanced barrier precautions. During an interview on 08/26/2025 at 10:40 AM with the Infection Control Preventionist (ICP), she stated that the facility does not use the signage on the door nor in the resident rooms. They have the black star on the outside of the door by the resident's name. She stated that staff are trained annually and on hire using the onboarding computer learning module. She stated that the gowns are on back of the door in a plastic bag, and the gloves are in the bathroom. I asked how would visitors know that the resident is on enhanced barrier precautions. She went on to say that the families are informed of the enhanced barrier precautions at the care plan conferences. We both agreed that all visitors are not family. She reviewed the policy and stated that staff are expected to wear the appropriate PPE when transferring a resident and during high contact with residents. Review of the facility policy titled, Medication Administration, with a revised date of 04/09/25 revealed, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Specifically, 14. Remove medication from source, taking care not to touch medication with bare hand. During a random observation on 08/26/25 at 09:42 AM, Licensed Practical Nurse (LPN)1 was observed dispensing medications at Medication Cart #3 for R22. She was observed multiple times pushing tablets out of the punch cards into the palm of her bare hand and then transferring the tablets from the palm of her bare hand, into a medication cup. Review of R22's face sheet revealed she was admitted to the facility on [DATE]. R22 had diagnoses that include, but are not limited to, urinary tract infection, hypertension (high blood pressure), muscle weakness, heart failure, dementia, and mood disorder. During an interview on 08/26/25 at 09:45 AM, LPN1 stated, I should be punching the medications into the medication cup directly. I know. When asked if she knew the reason for this, she stated, I guess because some medications could get into my system and because it is more sanitary. During an interview on 08/26/25 at 10:05 AM, LPN1 stated, I thought of a third reason I should be punching the medicine directly into the medication cup: To reduce medication errors. When asked if she had changed her practice based on our earlier interaction, she stated, Absolutely. During an interview on 08/26/25 at 11:45 AM, the Director of Nursing (DON) revealed, When a nurse starts here, they are paired up with another nurse for training. When a nurse gives medications, they go into PointClickCare (the facility's electronic health record.) The medications that are due are yellow. They take the medication punch card out of the drawer and check it against what is in the computer. They are expected to punch the medication directly into the medication cup. Once they put the medication into the cup, they click the medication in the computer. However, they do not sign the medications off until they have administered the medications to the Resident. During an interview on 08/26/25 at 12:50 PM, the Executive Director (ED) stated, I would expect a nurse not to touch any medication with their bare hands. They should be popping the medication directly into the cup.

Based on review of the facility policy, record review,and staff interviews, the facility failed to ensure one Resident (R)1 out of 3 residents reviewed for wandering/elopement was provided adequate supervision. Specifically, R1 was able to exit out of a window in his room without staff knowledge. Review of the facility's undated policy titled Wander/Elopement Risk Precautions revealed- 2. The following actions will be implemented for residents with a Wander Risk Assessment: a. 0-6 Reassessment as per policy b. 7-10 Initiate Wander Monitoring Log to further assess risk c. 11 or > Initiate Wander Monitoring Log to assess wandering patterns and initiate care conference to consider further measures 3. A Wandering Monitoring Log may be completed for any resident when staff becomes aware of a change in behavior that may increase risk of elopement. Review of the face sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including but not limited to, wedge compression fracture of lumbar vertebra, alcohol dependence, nicotine dependence, psychoactive substance abuse, and history of falling. Review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/20/22 revealed R1 had a Brief Interview of Mental Status (BIMS) score of 9 out of 15, indicating R1 had moderate cognition. Review of R1's admission Nursing Elopement Risk Screening, dated 05/18/22, revealed a score of 6, indicating the resident was not at risk for elopement. Further review of the document revealed potential interventions: secured unit, frequent monitoring, review of medications, tapes with reassuring messages from family, recreational activities, music, exercise, personalization of room with familiar objects and photographs, decorate doors and doorknob to look like something else, use of visual barriers, stop sign, ribbons, tape, photograph updated, and staff aware of resident's elopement risk. Review of R1's care plan dated 05/19/22 and revised on 05/25/22 revealed R1 is at risk for mood and behavior disturbances. Dx (Diagnoses): h/o (history of) alcohol abuse, h/o polysubstance abuse, and nicotine dependence. He roams in hallways, but he is easily redirected and returns back to his room. He wheels around asking staff to buy him cigarettes and liquor. Redirection provided PRN (as needed). Resident will have no or improved moods or behaviors noted. Administer meds (medications) per MD's (medical doctor) orders. Allow resident time to vent any needs, frustrations, or concerns. Encourage family involvement and visits. Explain all procedures before beginning. If resident were to display any moods or behaviors, provide diversional activities, such as but not limited to toileting, incontinence care, snacks, drinks, 1:1 visits, rest period, etc. Monitor for any changes with moods or behaviors and record. Redirect, distract, and/or encourage activities. Review of R1's Progress Notes dated 05/20/22 at 3:13 PM by Licensed Practical Nurse (LPN) 1 revealed Resident found to have eloped through one side door out on to sidewalk, res assisted back in w/ order obtained for a Wander Guard, secured to (R) ankle. Ambulates with walker, gait and stride uneven. Later found walking down hallway w/o walker w/ reminder given to use walker. Ate 100% of breakfast & lunch & ate lunch in dining room socializing with other residents. Receives daily multi-vitamin, B12, [MEDICATION(S)] & [MEDICATION(S)] supplements as-well. Last BM was this morning with no constipation or abdominal discomfort. Continues scheduled nicotine patch w/ no cravings voiced. Reports some mild pain to lower back with scheduled Tylenol tid providing some relief; feels that the daily [MEDICATION(S)] patch to lower back doesn't do much. Continues scheduled [MEDICATION(S)] bid with no dyskinesia observed. Mood is pleasant & friendly. Likes to wander hallways, staff to monitor. Sitting in common area watching tv at this time. Review of R1's Nursing Elopement Risk Screening dated 05/20/22 revealed a score of 26, indicating the resident is at risk for elopement. Further review of the document revealed the potential interventions were the same from the admission elopement risk screening form and no additional interventions were added. Review of R1's Progress Notes dated 05/24/22 at 5:53 PM by LPN 1 revealed Admit'g dx AMS, seizures: Two attempts at elopement noted today w/ res trying to exit door near room 29/30 setting off alarm each time. Res redirected away from this area. Wander guard also secured in place to (R) ankle. Res also noted later on to wander hallway without use of walker, reminder given that he needs to use walker to avoid possible fall. Ate 100% of breakfast & lunch & ate lunch in dining room socializing with other residents. Receives daily multi-vitamin, B12, [MEDICATION(S)] & [MEDICATION(S)] supplements as-well. Continues on scheduled nicotine patch w/ no cravings voiced. Continues on scheduled [MEDICATION(S)] bid with no dyskinsia observed. Denies experiencing any SOB at rest sitting upright or laying flat, denies with activity as-well. Tolerating physical therapy well with no concerns voiced. Mood is pleasant & friendly. Currently sitting in common area watching tv. Review of the facility's Staff Statements for Incident Report dated 05/28/22 by LPN 1 revealed he was informed by the nurse supervisor that R1 was seen outside walking with his cane. LPN 1 further revealed the supervisor immediately went to where he was (R1) and brought him back to the unit. An interview on 06/02/22 at 10:40 AM with LPN 1 revealed he was the admitting nurse when R1 was admitted to the facility. LPN 1 stated R1 was not at risk for elopement during his admission assessment, however R1 became at risk after several attempts to exit the facility. LPN 1 was asked to describe R1's exit seeking behavior and he revealed the resident would walk up to the fire exit doors and try to leave. LPN 1 stated R1 got out of the building on 05/20/22 and staff decided to conduct a second elopement assessment to address the wandering/exit seeking behaviors. LPN 1 stated that on 05/28/22 around 3:45 PM, the nurse supervisor reported to him that R1 was seen outside walking. LPN 1 stated once R1 was returned to his room, R1 confirmed he had exited through his window to find someone outside with a cigarette. LPN 1 stated he observed R1's window and noticed that R1 had broken the safety locks and was able to push the window up to exit. LPN 1 stated R1 was assessed by the nurse supervisor with no injuries noted and staff were advised to monitor resident using the facility's Wandering Monitoring Log. A telephone interview on 06/02/22 at 10:53 AM with RN 1 revealed R1 attempted to leave the facility on serval occasions prior to his elopement on 05/28/22. RN 1 confirmed R1 was assessed for elopement/ exit seeking on admission and was not at risk for elopement. RN 1 stated after R1's successful attempt to exit the building on 05/20/22, he was assessed and given an order for a wanderguard. RN 1 revealed R1 was okay with the wander guard and did not attempt to take it off. On 05/28/22, RN 1 stated she was in the facility, and received a call from the receptionist at the front desk. RN 1 stated the receptionist informed her R1 was observed outside walking in the parking lot. RN 1 stated she immediately left the unit and went out front to get R1. RN 1 stated R1 was alert and oriented, even laughing about how he got out of the building. RN 1 stated she asked R1 how he got out of the building and R1 was able to vividly describe in grave detail how and why he left the building. RN 1 revealed R1 was trying to get outside to find someone who would give him a cigarette. RN 1 stated R1 revealed to her that he was okay and took his cane with him so he wouldn't fall or hurt himself. RN 1 stated after the incident, R1 was placed on 15 minute observations and his window was repaired and closed by staff. RN 1 stated she began in-servicing her staff on resident elopement policy and procedures. RN 1 stated they have different codes that are used during an emergency and all staff were in-serviced on the multiple emergency codes. A telephone interview on 06/02/22 at 11:03 AM with Certified Nursing Assistant (CNA) 1 revealed on 05/28/22, she was informed by RN 1 that R1 had eloped from his room. CNA 1 stated she was R1's primary nursing aide that day and had saw him about 20-30 minutes before he exited through his window. CNA 1 stated R1 would frequently ask staff for cigarettes and alcohol. CNA 1 stated the facility is non-smoking, so R1 did not have access to cigarettes while at the facility. CNA 1 revealed after the incident, R1 was placed on a 1 to 1 observation. CNA 1 was asked was R1 placed on 1 to 1 observation after previous attempts to leave the facility and she stated she was not sure. An interview on 06/02/22 at 12:05 PM with the Maintenance Assistant (MA) revealed he repaired the window of R1's room after the incident. The MA stated the windows in the resident's room have open control devices that keep the windows from opening no more than 2-3 inches. The MA stated he observed R1's window and concluded the open control devices were broken and R1 was able to lift his window pass the 2-3-inch mark. In the presence of the surveyor, the MA was asked to demonstrated how the open control devices prevent the window from opening no more than 2-3 inches. The MA revealed the open control safety devices are designed to be broken in case of a fire. The MA revealed after the incident he did a complete check of all of the resident windows and did not observe any issues. The MA stated he conducted a check of R1's wander guard and revealed it was working appropriately. The MA revealed that since R1 exited out of the window, and there are no alarms on the resident's windows, staff would not have been alerted of R1's exit. An interview with the Administrator at 1:42 PM revealed she was aware of R1's elopement on 05/28/22. The Administrator stated R1 was not at risk for elopement upon admission. The Administrator did confirm that R1 exhibited exit seeking behaviors and a physician order for a wanderguard was placed after he successfully exited the building on 05/20/22. The Administrator stated that in her opinion R1 did not elope because he was not away from the facility for more than 24 hours. The Administrator confirmed staff were unaware R1 exited through the window until he was brought back inside. During the exit conference, the Administrator stated R1 was placed on 1 to 1 observation after the incident on 05/28/22. The Administrator did not provide any additional documentation indicating R1 was placed on 1 to 1 observation on 05/20/22 and 05/24/22.

Based on record review and interview, the facility failed to provide adequate supervision and assistance to prevent accidents. Resident #183 had an unwitnessed fall with minor injuries to the resident's knee, elbow, wrist, and abdomen (1 of 5 residents reviewed for accidents). Immediate Jeopardy Past Noncompliance and Substandard Quality of Care were cited at a scope and severity level of [NAME] The facility Administrator was notified of the Immediate Jeopardy on 8/15/19 at 3:00 PM. The Immediate Jeopardy existed on 11/18/18 and was removed on 11/26/18. The findings included: The facility admitted Resident #183 on 11/01/18 with [DIAGNOSES REDACTED]. Resident #183's Minimum Data Set (MDS) assessment dated [DATE] indicated the in the Brief Interview for Mental Status Resident #183 scored a 12 (moderately impaired cognition). The MDS for functional status indicated the resident needed limited help in bed mobility, transfer, and dressing. S/he required extensive assistance with toilet use and only supervision with eating. A progress note dated 11/18/18 and reviewed on 7/25/19 at 9:48 AM stated that at 5:15 PM Resident #183 approached the Licensed Practical Nurse (LPN) of the unit and said s/he was leaving the facility. The notes indicated that the resident stood up from his/her wheelchair, oxygen still attached, and stated that his/her spouse was going to pick her/him up. The resident then got upset with the LPN when s/he tried to stop the resident from leaving the facility unassisted. The LPN stated, in the progress notes, that s/he was unable to reach the resident's spouse but was able to contact the resident's friend. The resident calmed down after talking with his/her friend. The LPN was than able to assist the resident back to his/her room and informed the staff of the event. Further review of the resident's progress notes revealed that on 11/19/18 at approximately 1:12 AM the Certified Nursing Assistant (CNA) informed the LPN that Resident #183 was not in his/her room. The facility staff initiated an in/out of the building search for the resident. The LPN drove around the facility and found the resident knocking at the door of another resident's apartment at approximately 1:23 AM. The resident had signs consistent with a fall, including abrasion to the right knee and elbow, and discoloration to the right lower abdomen. Review of a CNA statement dated 11/19/18 indicated that s/he last saw the resident wandering on the unit at approximately midnight. Around 1:00 AM, while passing by the resident's room s/he noticed that Resident #183 was not in his/her bed. The CNA notified the LPN and started looking for the resident immediately. The facility's investigation report dated 11/19/18 stated that the resident left the facility unassisted and without his/her oxygen or wheelchair, in an attempt to return to his/her assisted living apartment. The resident exited the facility through the front door without anyone noticing it. In a phone interview with LPN #1, s/he said that after the CNA informed the nursing staff that the resident was not in his/her room. The staff started looking for the resident all over the place. The facility staff called assisted living and alerted them to look for the resident. The staff also called security and management. LPN #1 voiced that the resident was found by his/her LPN knocking on a resident's apartment front door. The resident was found confused, wet (it had rained that night) wearing one sock and no shoes, sweat pants, and a T-shirt. The resident fell and scraped his/her right knee and elbow and complained of pain to the right wrist. The staff brought oxygen and a wheelchair to assist the resident. The resident was cleaned and dried and assessed for further injury, and all parties notified. LPN #1 stated that 20 to 25 minutes had elapsed from the time the CNA noticed the resident was missing to the time the resident was found. In an interview with the Director of Nursing (DON) and Registered Nurse (RN) Consultant on 7/25/19 at approximately 4:00 PM, they both acknowledged that Resident #183 left the faciity on foot and without his/her oxygen. They also acknowledged that the facility did not provide adequate supervision and assistance to prevent the resident from exiting the facility without anyone noticing it. The DON added the resident had lived at the assisted living and was not exit seeking on admission. Removal Plan: 1. Resident #183 was cited on the alleged deficient practice. A head to toe assessment was completed and documented by the LPN assigned to the resident after she was assisted back to healthcare. A nursing staff member (RN, LPN, or a CNA) was assigned to resident for one on one monitoring at all times from the time resident was back at healthcare on 11/19/2018 at 1:23 AM until a wander guard was secured. Wander guard was placed on 11/20/2018. No further elopement attempts since 11/19/2018. A sitter was assigned to resident from 11/21/2018 until discharge on [DATE]. A wander guard intervention was discussed by the nurse on duty with the son prior to the incident but the son refused as he does not want his mother to have one for concerns of limiting her movement in the community. After the (MONTH) 19, (YEAR) incident the son agreed to use wander guard. 2. Elopement risk assessment is completed on all new admissions and post elopement incident. There is no current resident who has a wander guard that is at risk for elopement. 3. Staff Development Coordinator or designee did the training on elopement at various times beginning 11/19/18. Nursing staff (RNs, LPNs, and CNAs) on duty beginning 11/19/2018 until 11/26/2018 were educated and other Nursing staff were educated on their earliest scheduled work day. All new hires (RN, LPN, MOS, CNAs, Housekeeping, Laundry, Maintenance, Therapy, Dining Services, Security, Sitters, Social Services, receptionist, and Activities) will be educated by the staff development coordinator or designee on elopement protocol and exit door locking system during orientation. Facility does not use agency staff. 4. Exit door check for function started 11/19/2018 the day of the incident. A security guard is on duty to patrol community wide from 5 PM to 7 AM. For residents with wander guard, the charge nurse will continue the current process to check function of the wander guard every shift. All exit doors to health center were tested for locking function and alarm response to wander guard. Exit door check is completed by the maintenance staff or designee. Any concern on exit door function are discussed during stand up meeting. No concerns on exit door function was presented by maintenance since 11/19/2018 to present. Facility alleged compliance date 11/26/2018

Based on observation and interview, the facility failed to: 1. ensure kitchen personnel wore hairnet/bear guards; 2. label/date all food items in refrigerators; 3. discard expired food items; 4. keep the walk-in cooler/freezer floor free from condensation/trash; 5. keep the ice machine drainage pipe and the floor drain free from buildup; 6. store dishware in a sanitary condition; and 7. maintain the sanitation concentration, used to sanitized food prep surfaces, within standards levels (1 of 1 central kitchen reviewed). The findings included: During the initial observation of the central kitchen on [DATE] at 10:41 AM, two males with a large amount of facial hair were in the kitchen preparing food without beard guard coverage. Another male, going in and out of food prep, was partially wearing a beard guard. Eight to ten minutes later, a third bearded male came into the kitchen without protection. The dietary manager confirmed that the males were not wearing beard guards and instructed them to do so immediately. On [DATE] at approximately 10:54 AM, observation revealed 38 8 ounce cartons of expired 2% milk, two large containers with what appeared to be a sauce with no label of the date and trash on the floor of the walk-in cooler. There was also trash and substantial condensation on the floor of the walk-in freezer. The dietary manager was present during these observations. On [DATE] at 11: 05 AM, observation in the dry food storage area revealed a clear large bag containing pasta with no label or date on it. Also, there was a sugar scoop on top of a 10 x 18 pan covered with ceramic wrap. The pan had flour and sugar mixed together with no date or label on it. The dietary manager was present during these observations. On [DATE] at 11:15 AM, observation of the back of the ice machine revealed a drainage pipe was dripping condensation from the ice maker into a floor drain. Both the pipe and floor drain had a dark build up around them. The dietary manager was present during this observation. According to the chef/supervisor, the facility used disposable wipes to sanitize food prep surfaces. S/he stated that the staff added the sanitation solution to the wipes before using them. The sanitation concentration in the disposable wipes being used at the time was approximately 100 parts per million (standards 150 to 200 parts per million). The chef took the bucket containing the wipes and added more sanitation solution and measured the concentration again. At that time, the sanitation concentration was within standards (200 parts per million). During a revisit to the kitchen on [DATE] at noon, the administrator and food and nutrition services director also observed male staff in the kitchen preparing food without wearing or properly wearing beard guards. They also confirmed that the sanitation concentration in the red buckets was not within standards.

Based on record reviews and interviews the facility failed to assure that pain medications were given according to physicians order for 2 of 5 residents reviewed for unnecessary medications (Residents #14 and #132). The findings included: Resident #14 had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/24/19 at approximately 11:20 AM, a review of the (MONTH) and July, 2019 physicians orders revealed an order dated 6/28/19 for [MEDICATION NAME]-[MEDICATION NAME] Tablet 10-325 mg (milligram) Give 1 tablet by mouth every 6 hours as needed for pain - severe. Further review of the MARs (medication administration records) for (MONTH) and July, 2019 revealed that a total of 56 doses of [MEDICATION NAME]-Acetamoinophen 10-325 mg had been administered. Of the 56 doses, 54 had been administered when a pain level of less than 8 had been recorded. Resident #132 had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/24/19 at approximately 12:10 PM, a review of the July, 2019 physicians orders revealed an order dated 7/16/19 for [MEDICATION NAME] HCl ([MEDICATION NAME]) tablet 50 mg Give 1 tablet by mouth every 6 hours as needed for pain - Moderate 4-6 related to Pain. Further review of the (MONTH) MAR indicated [REDACTED]. Of the 2 doses, one had been administered at a pain level of 3. On 7/24/19 at approximately 12:45 PM, a review of the facility's policy and procedure related to Administrating Pain Medications revealed the following guidelines for assessing the resident's level of pain prior to administrating [MEDICATION NAME] pain medication. Pain Severity: Mild 0-3, Moderate 4-7 and Severe 8-10. Further review under General Guidelines 3. revealed: Residents are not at risk for addiction to narcotic [MEDICATION NAME] if used as prescribed for moderate and severe pain. On 7/24/19 at approximately 1:54 PM, the findings that pain medications were not being administered to these two residents according to physician's orders [REDACTED].# 1.

Based on observation, interview, and review of the facility policy titled, Linen Transport Procedure, the facility failed to ensure soiled linen was bagged at point of use and not put into bins in the hallway for pickup by laundry for 1 of 1 observations of the soiled linen transported to the laundry room. The findings included: An observation on 7/25/2019 at approximately 9:20 AM of the soiled linen pick up on the halls by the laundry department revealed soiled linen in bins in the hallway not bagged prior to placing it in bins for transport by the laundry workers. The laundry worker would not comment on whether or not the linen should be bagged prior to placing it in the soiled linen bins in the hallways. During an interview on 7/25/2019 at approximately 9:30 AM with the Housekeeping Supervisor, he/she stated the soiled linen should be bagged prior to placing it in the soiled linen bins in the hallway. Review on 7/25/2019 at approximately 10:40 AM of the facility policy titled, Linen Transport Procedure, states, These steps are to be used for all situations. 2. Gather linen and put directly into a leak resistant bag in soiled linen cart. 4. No soiled linen/laundry will be transported in the hallways. 6. Soiled linen saturated with blood and bodily fluids will follow linen handling process. Place in a clear leak resistant bag.

Based on record review and interview, the facility failed to ensure the progress notes for Resident #34 were complete and accurate for 1 of 1 residents reviewed for death. The findings included: The facility admitted Resident #34 on [DATE] with [DIAGNOSES REDACTED]. Review on [DATE] at approximately 9:15 AM of the progress notes for Resident #34 from [DATE] until expired on [DATE] revealed no documentation of events prior to death and after death. Review on [DATE] at approximately 9:30 AM of the progress notes for Resident #34 revealed a nursing progress note dated [DATE] at 2:09 PM and reads, Resident admitted for Acute [MEDICAL CONDITION]. Alert, able to make needs known. Assist x 1 with ADLs (Activities of Daily Living) and transfers. Ambulates with W/C (wheelchair). Incontinent. Denies pain and discomfort. Wound care provided. Dressing reapplied to left axillary, C/D/I (clean, dry and intact). Continues PT/OT (physical therapy/occupational therapy) as ordered. Call light and hydration in reach. Safety maintained. Further review on [DATE] at approximately 9:30 AM of the progress notes for Resident #34 revealed a nursing progress note dated [DATE] at 3:33 PM and reads, Resident has productive cough. Clear sputum. Standing order for [MEDICATION NAME] 100 milligrams by mouth as needed x 3 days for symptomatic cough per MD (Medical Doctor) order activated. Additional review on [DATE] at approximately 8:30 AM of the progress notes for Resident #34 revealed a nursing progress note dated [DATE] at 5:47 PM and reads, Was called to patient room at 5:25 PM. Patient had no pulse and no breath sounds. No blood pressure. Notified the physician, Coroner, and family. Notified the Director of Nursing, Chaplain. Patient received post mortem care. No documentation could be found in the medical record for Resident #34 of events leading up the the death on [DATE] at 5:25 PM, nor was any documentation found in the the medical record for Resident #34 of any events after the death, (ie, disposition of body, family wishes, physician visit, etc.) During an interview on [DATE] at approximately 10:30 AM with the Administrator, he/she confirmed the findings and stated he/she would look further for additional information.

Based on observations and interviews, the facility failed to ensure that hazardous chemicals were secured in a resident's room (a random observation during the Initial Pool Process), in one of four soiled utility rooms, and in one of two janitor closets. These areas were particularly hazardous to any cognitively impaired self-mobile residents in the facility. The findings included: During the Initial Pool Process, a 30 ounce bottle of hand snitizer was noted unsecured in Resident #285's bathroom multiple times (on 5/29/18 at 10:40 AM, 12 PM, 2:21 PM and 4:32 PM; on 5-30-18 at 8 AM, 9:34 AM, and 12:05 PM). Following observation of the tube feeding on 5/30/18 at 2:10 PM, Licensed Practical Nurse (LPN) #3 stated s/he had not noticed the hand sanitizer on the sink in the resident's bathroom. When asked if residents were allowed to keep hand sanitizer of that size in their rooms, LPN #3 stated s/he would check with the Assistant Director of Nursing (ADON). At 2:30 PM, the ADON said, That was not supposed to be in the resident's room. Following observation of a pressure ulcer treatment on 5/30/18 at 10:38 AM, Registered Nurse (RN) #1 bagged the trash and proceeded to the soiled utility room to dispose of it. As RN #1 opened the unlocked door, a biohazard sign was noted on it. After disposal of the trash from the treatment, the nurse exited the room without locking it. At that time, the RN verified the biohazard storage and that the area had been left unlocked. On 5/29/18 between approximately 10:02 AM to 10:45 AM observations of the janitor's closet located adjacent to the nursing station on Pod 1-11 revealed that the door was unlocked and contained the following chemicals: - Antibacterial Cleaner ([MEDICATION NAME] chloride) 0.5% (percent) 1,250 ml (milliliters) x 1 - Coffee & Tea Destainer 1.75 lb (pound) x 2 - Ultra Dry 1 gallon x 1 This finding was verified by the Assistant Director of Nursing on 5/28/18 at approximately 10:46 AM.

Based on observation, interview and record review the facility failed to ensure that the character and amount of urinary output was monitored and the leg band was used to secure urinary catheter for Resident #23 with history of hematuria for 1 of 1 resident reviewed with a urinary catheter. The findings included: Resident #23 was admitted with [DIAGNOSES REDACTED]. Review of the Care Plan for Resident #23 which states: Focus, Resident at risk from complications r/t (related to) f/c (foley catheter), Dx: [MEDICAL CONDITION] and [MEDICAL CONDITION] Goal Catheter will remain intact and patent. Interventions: Cath care q shift., Change catheter per MD'sOrders, Change drainage bag every shift ., Focus: Resident was readmitted from the hospital with a UTI noted and antibiotic noted. Goal, Resident will have no signs/symptoms of UTI without intervention through next review, Interventions: .Monitor for signs symptoms of urinary tract infections such as dark foul smelling urine, . Review of the Progress notes for resident #23 from 5/7/18 to 5/30/18 shows 2 Nursing progress notes which state the amount of Urine emptied from the urinary collection bag, on 5/7/18 and on 5/14/18. During an interview with CNA #3 on 06/01/18 at 11:00 AM , he/she said that he/she measures the urine that comes out of the bag and records in the Computer System. He/She stated that he/she empties the urinary catheter bag three times on her 8 hour shift. He/She said that he/she would report to nurse if too little urine, blood in bag or tubing. CNA#3 stated that he/she had not recorded in the system today. On 06/01/18 at 11:10 AM RN #1, is on a cart today. He/She verified that there is no order to record urinary output. He/She said that to record output, he/she thinks that unless there is an order he/she would not look at the amount of urinary output. During an interview with Resident #23 said on 06/01/18 at 11:22 AM, They measure the urine that comes out of the bag. On 06/01/18 at 11:26 AM this surveyor requested from the DON the outputs recorded for Resident #23, none were provided. Prior to observation of catheter care at 1:35 PM on 5-30-18, while Certified Nursing Assistant (CNA) #1 was preparing Resident #23 for the procedure, the resident was noted not to have a leg band in place to secure the catheter. After the perineal area and catheter were cleansed, as CNA #1 assisted the resident to turn back and forth to redress, the catheter drainage tubing was pulled taut. After the procedure was complete and the resident made comfortable, when asked about placement of the leg band, CNA #1 stated, I don't know why he (she) doesn't have a strap on. I didn't dress him/her this morning. As the CNA had not applied a leg band following the procedure either, the surveyor asked if s/he was going to apply one. The CNA stated, I can see if we have one in the supply room. The resident's spouse, who was present for the procedure, expressed concern because he (she) has had bloody urine. Review of the care plan on 5-31-18 at 1:30 PM revealed a Focus of Resident at risk for complications r/t (related to) f/c (Foley catheter). Interventions included to Provide leg strap or securement device PRN (as needed). The facility policy titled Catheter Care, Urinary states: .Maintain an accurate record of the resident's daily output . Empty the collection bag at least every eight (8) hours . Secure catheter utilizing a leg band .

Based on review of inservice records and interviews, the facility failed to ensure that 5 of 17 Certified Nursing Assistants (CNAs) received 12 hours of continuing education on an annual basis as required. This has the potential to affect patient care rendered to all residents to whom they are assigned. The findings included: Review of the facility's inservice records on 6-1-18 revealed that 5 of the 17 CNAs employed greater than one year had not completed their 12 hours of continuing education as required to maintain their certification. During an interview on 6-1-18 at 5:54 PM, the Staff Development Coordinator reviewed and verified the records.

Based on observation, record review and interview the facility failed to provide adequate Care and Services for 3 of 5 sampled residents reviewed for Unnecessary Medicines as evidenced by failure to complete Neurological Checks for Resident #235, delay in starting of medications for Resident #239 and not administering [MEDICATION NAME] for 5 days. Also for 2 of 5 sampled residents reviewed for Care and Services as evidenced by Calcitonin administered with rotation of nares for Resident #3 and failure to change drain pouch every 7 days and not documenting drainage amount and character as ordered for Resident #285. The findings included: The facility admitted Resident #235 with [DIAGNOSES REDACTED]. Record review on 05/30/18 at approximately 9:40 AM revealed an incident report dated 05/21/18 detailing a fall by Resident #235 where the resident was found laying on the right side near wheelchair and sustained a skin tear to the right shin and elbow. The incident report stated neurological (neuro) checks were initiated. Further review of the record revealed an incomplete form entitled Neuro Checks dated 05/21/18. Record review also revealed an incident report for Resident #235 dated 05/22/18 which detailed a fall by Resident #235 where the resident was found by a Certified Nursing Assistant (CNA) investigating a yell. Resident #235 sustained a skin tear to the left lower leg. The incident report stated neuro checks were initiated. Further review of the record revealed an incomplete form entitled neuro checks dated 05/22/18. In an interview on 05/31/18 the Director of Nursing (DON) reported s/he could not provide a reason why the neuro checks were not completed. On 06/01/18 at approximately 2:29 PM the DON provided a copy of facility policy entitled Neurological Assessment Policy which states neurological assessments are indicated following an unwitnessed fall and that these should be documented in the resident's medical record. The policy states checks are to be done every 15 minutes x4, every 30 minutes x2, every 4 hrs x2 and every 8 hours x8. The facility admitted Resident #239 with [DIAGNOSES REDACTED]. Record review on 05/30/18 at approximately 8:52 AM revealed Resident #239 was admitted to the facility on [DATE]. Review of the Medication Administration Records for 05/23/18 revealed the medications Aspirin, [MEDICATION NAME], Tolterodine [MEDICATION NAME] and Sodium Chloride contained in the initial Physician order [REDACTED]. In an interview on 05/31/18 at approximately 11:06 AM the DON stated the expectation for the nurse administering medications to Resident #239 was to utilize the Omnicell dispensary to access the needed medications. The DON could not state a reason why this was not done. The DON provided a copy of facility policy entitled Automated Medication Dispensing System (AMDS) which states facilities may use the AMDS to access first dose, medically necessary medications and interim orders. Resident #23 was admitted with [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. The Medication Administration Record [REDACTED]. During an interview with the DON on 05/31/18 09:42 AM, he she verified that no doses of Atorvastatin Calcium were given from 5/3/ to 5/8. He/She said that it was his/her expectation that when a Physician order [REDACTED]. The facility failed to ensure the physicians order for Atorvastatin calciumf/c 20 mg was given to Resident #23 as ordered. The medication was ordered on [DATE] and the first dose was administered on 5/9/18. The facility admitted Resident #3 on 2/21/18 with [DIAGNOSES REDACTED]. Record review on 5/31/18 at 9:03 AM revealed physician's orders [REDACTED]. 1 spray in nostril one time a day .Alternate nostrils daily-document which nostril under site. Review of the 5/18 Medication Administration Records (MAR) on 5/31/18 at 9:26 AM revealed that 11 of the 30 days did not have the site recorded as required. During an interview on 5/31/18 at 12:21 PM, the Director of Nurses verified that the documentation on the MAR indicated [REDACTED] The facility admitted Resident #285 on 5-22-18 with [DIAGNOSES REDACTED]. Record review on 5/30/18 at 3:40 PM revealed physician's orders [REDACTED]. Review of the MAR indicated [REDACTED]. During an interview on 5/31/18 at 4:27 PM, the Assistant Director of Nursing (ADON) verified the documentation on the MAR. On 6/01/18 at 9:00 AM, the ADON and Registered Nurse Consultant stated they had reviewed the record and could find no other documentation.

Based on record review and interview, the facility failed to ensure that insulin was administered according to physician's orders for one of five sampled residents reviewed for unnecessary medication. Staff failed to administer insulin as ordered 24 times over a 10 day period. The findings included: The facility admitted Resident #285 on 5-22-18 with [DIAGNOSES REDACTED]. Record review on 5/30/18 at 3:40 PM revealed admission Physician's Orders for Humalog Insulin to be administered according to a sliding scale based on finger stick blood sugar (FSBS) four times daily: 0-200=0 units; 201-250=4 units; 251-300=6 units; 301-350=8 units; 351-400=10 units; 401-450=15 units; >450, notify MD. Review of the Medication Administration Records on 5/31/18 at 1:58 PM and Progress Notes on 5/31/18 at 3:03 PM revealed that insulin was not administered according to Physician's Orders on the following dates/times: 5-23-18 at 7:30 AM, BS=215. No insulin given. 5-23-18 at 11 AM, BS=349. No insulin given. 5-23-18 at 4 PM, BS=207. No insulin given. 5-24-18 at 4 PM, no BS documented. 5-25-18 at 7:30 AM, BS=252. No insulin given. 5-25-18 at 11 AM, BS=321. No insulin given. 5-25-18 at 4 PM, no BS documented. 5-25-18 at 9 PM, BS=250. No insulin given. 5-26-18 at 7:30 AM, BS=279. No insulin given. 5-26-18 at 11 AM, BS=233. No insulin given. 5-26-18 at 4 PM, no BS documented. 5-27-18 at 7:30 AM, BS=225. No insulin given. 5-28-18 at 7:30 AM, BS=247. No insulin given. 5-28-18 at 11 AM, BS=289. No insulin given. 5-28-18 at 9 PM, BS=237. No insulin given. 5-29-18 at 7:30 AM, BS=288. No insulin given. 5-29-18 at 11 AM, BS=273. No insulin given. 5-29-18 at 4 PM, BS=261. No insulin given. 5-30-18 at 7:30 AM, BS=269. No insulin given. 5-30-18 at 11 AM, BS=262. No insulin given. 5-30-18 at 4 PM, BS=313. No insulin given. 5-30-18 at 9 PM, BS=214. No insulin given. 5-31-18 at 7:30 AM, BS=291. No insulin given. 5-31-18 at 11 AM, BS=240. No insulin given. In addition, on 5-27-18, a BS of 225 was recorded on the MAR. The nurse documented in the Progress Notes that only 2 units of insulin were administered for the BS of 225 when 4 units should have been given. During an interview on 5/31/18 at 4:27 PM, the Assistant Director of Nurses (ADON) verified that no entries were documented on the MAR related to the amount of insulin given based on FSBS results. The ADON stated s/he would check the nurses notes for further information. Only 9 entries were provided on 6-1-18 at 8:30 AM related to the amount of insulin given for FSBS results.

Based on observation, interview and review of the facility policy and procedure the facility failed to ensure: 1) Cold food temperatures were 41 or below prior to food transportation from the main kitchen to the satellite kitchen. 2) Cold food temperatures at point of service in the satellite kitchen were 41 or below at point of service. 3) Food which had been cooked and chilled and then reheated was reheated to 165 degrees prior to service. 4) Food was covered or placed under sneeze guard during meal distribution and protected from service staff during meal service. The findings included: During an observation on 5/29/18 at 11:45 AM while at the main building where the food is cooked. The Director of Dietary was loading the food carts in the main kitchen. The initial cold food temperatures were greater than 41 degrees: Flank steak was 44 degrees and had to be chilled in the Blast Chiller, the temperature was then recorded at 40 degrees. The foods were then transported to the satellite kitchen where the Flank Steak was reheated to 159 degrees, then reheated again to 162 egress. The Director of Dietary stated the temperature for reheated food should be 165 degrees. The cold salad on the serving line was 44 degrees and had to be pulled and put in the freezer to achieve the temperature of 41 degrees. A small bowl of tartar sauce was placed on serving line the plastic wrap was removed and the bowl remained open to air where the Certified Nurse Assistants were standing in front of the container while it was open to air. The Director of Dietary removed the tartar sauce and discarded. The Director of Dietary provided a copy of the form titled, Proper Maintenance of Food Temperatures and Transportation Policy modified 5/30/2018, which states, .3. When hot foods are transported temperatures will be checked and documented by the food transporter when the food leaves the main kitchen to ensure that the food is at or above 135., 4. The cold foods will be prepared in the cold production area located in the main kitchen and held in refrigeration until ready to transport.the food temperature will be taken logged to ensure it is at 40 F or less. If the food is above 40 degrees Fahrenheit (f), it will be returned to the bast chiller and cooled to the appropriate temperature before transport .6. When delivery reaches the satellite kitchens the chilled food will be immediately placed in refrigeration unit until service During an observation on 5/29/18 at approximately 12:15 PM a male employee with facial hair walked through the food preparation area without a protective covering over the facial hair. The Director of Dietary provided a copy of the form titled, Use of Hair Restraints, which states: Procedure: 1. Hair nets, and/or beard restraints must be worn when any employee is in the food production and kitchen area.

Based on observation, record review and interview the facility failed to follow protocol for implementation of Contact Precautions for [MEDICAL CONDITION] for Resident #238, 1 of 2 sampled resident reviewed for Transmission Based Precautions. The findings included: The facility admitted Resident #238 with [DIAGNOSES REDACTED]. Record review on 05/30/18 at approximately 1: 57 PM revealed a the Care Plan focus area entitled Resident presently is being tested for [MEDICAL CONDITIONS]. Interventions for the goal, Infection will not spread included: Maintain infection control practices per facility protocol. Date initiated: 05/29/18 and Universal and contact precautions Date initiated: 05/29/18. During the 1st 2 days of the survey, Resident #238 was observed eating in the main dining room during the lunch meal service on (MONTH) 29 and 30. (YEAR) at approximately 12:00. In an interview on 05/30/18 at approximately 2:06 PM the Director of Nursing confirmed that being on contact precautions would include isolation and not eating in the main dining room with the other residents.

Based on observation, interview, and review of the policy titled Advance Directives, the facility failed to ensure that one of 10 sampled residents reviewed for advance directives was afforded the right to formulate his/her own advance directive. Advance directives were signed by Resident #7's spouse without certifications of inability to make health care decisions by two physicians. The findings included: The facility admitted Resident #7 on 4/9/18 with [DIAGNOSES REDACTED]. Record review at 6:42 PM on 5/29/18 revealed a 4/9/18 physician's orders [REDACTED]. Review of advance directives on 05/29/18 at 1:32 PM revealed a Physician order [REDACTED]. There were no physician certifications of the resident's inability to make healthcare decisions on file. During an interview on 5/30/18 at 2:42 PM, Social Services stated that s/he only got physicians' signatures this week-1 today, determining the resident's inability to make health care decisions. The facility policy titled Advance Directives states: The resident will always sign his or her DNR sheet unless they have been determined unable to make health care decisions by two physicians.

Based on observation, interview and record review the facility failed to notify the Physician in a timely manner of 1) Resident #3's signs and symptoms of thrush resulting in a delay in treatment Dr not notified in a timely manner of s/s of thrush resulting in delay in treatment, and 2) Resident #16's significant weight gain for 2 of 2 residents reviewed for notification. The findings included: Resident #16 was admitted with [DIAGNOSES REDACTED]. The form titled, Physician order [REDACTED]., Date: 4/2/2018 Review of the form titled, : Resident Medication Administration Records for Resident #16 for Month: April; Year: (YEAR) shows multiple entries for weights:4/3-4/26 in sequence starting on 167.8,165.2,166.6, 4/6: no entry, 160.2,156.4,159.2,159.8. 162,147,148,148,154.4,154.3,152.8,155.8,150.6,154.6, 2.2,152.2,151.6,151.4,154.6. Resident was discharged on ,[DATE]. Resident was readmitted to the facility on ,[DATE]//18 thru 5/15/18, weights recorded were: 5/15: 156.2, 5/25: 145.4, 5/26: 148.6, and 5/30/18: 156. There was no admission weight recorded for admitted on 5/2/18, in fact the first weight recorded was on 5/15/18 which is the day the resident was discharged . The weight record shows that Resident #16 had multiple weight changes including a weight loss of 19.2 pounds/11.4# from 4/3 to 5/26 which is significant for 8 weeks, a weight loss of 11.4 pounds from 4/3: 1678. to 4/8: 156.4, on 4/11 weight of 162 and weight gain of 5.6 pounds from 4/3, on 4/13: 148 pounds and weight loss of 14 pounds from 4/3, and on 4/15: 154.3 and weight gain of 6.3 pounds from 4/3. During the month of (MONTH) weight gains and weight losses which were significant. During an interview on 06/01/18 at 02:20 PM with the DON, ADON and the Nurse Consultant they verified weight entries and verified that there was no admission weight obtained for the admission from 5/2/18 to 5/15/18. The DON, ADON and the Nurse Consultant also verified the weight losses and gains and said they cannot find evidence in the progress notes that the physician was notified of the significant weight changes. During an interview on 06/01/18 02:33 PM the DON, ADON stated that the physician and the family are notified by nursing when there is a significant weight change, or if a supplement is started and or an intervention for nutrition is begun. The form titled, Weight Management Protocol, states, Policy: The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss or gain for our residents . There will be a systematic and interdisciplinary approach to monitoring resident weights Procedures: All new admits will be weighed on the admission day, weekly for the first 4 weeks, and monthly afterwards unless physician order [REDACTED]. The facility admitted Resident #3 on 2/21/18 with [DIAGNOSES REDACTED]. Review of Progress Notes on 5/31/18 at 11:09 AM revealed that on 5/9/18 at 1:24 AM, the resident refused her/his evening nebulizer treatment, stating that her/his mouth was sore and 'I feel like I'm getting thrush.' Inside mouth noted to be red with a thin white coating covering roof of mouth. Physician to be notified of patient status. Further review revealed no evidence that the physician was notified until 5/10/18 when s/he was seen with concerns for thrush and painful swallowing. She (he) reports previous similar episodes when using her (his) novelize machine more frequently . Reports dry month and general pain and is concerned about having oral sores . Clinical history and exam consistent with oral candidiasis 2/2 (secondary to) inhaler/ nebulizer use. [MEDICATION NAME] Swish and Swallow was ordered every 6 hours at that time. During an interview on 5/31/18 at 12:28 PM, the Director of Nursing (DON) verified that symptoms began on 5/8/18 with the nebulizer refusal and were not addressed until 5/10/18. The DON stated s/he was unsure why there was no follow up until 5/10/18 as the physician had been on site on 5-9-18.

Based on record review and interview, the facility failed to provide evidence of a written notice of hospital transfer to the resident representative for one of one sampled resident reviewed for hospitalization (Resident #35). The findings included: The facility admitted Resident #35 on 4/19/18 with [DIAGNOSES REDACTED]. Review of Progress Notes on 6/01/18 at 10:58 AM revealed that Resident #35 was admitted to the hospital for port placement and [MEDICAL CONDITION] on 4/30/18. Further review revealed no evidence that the resident and resident representative had been notified in writing of the transfer. An unsigned copy of the Notice of Resident Transfer or Discharge was reviewed with Social Services on 6/01/18 at 12:20 PM at which time s/he stated a copy had been mailed. Social Services confirmed it was not signed by the resident and there was no documentation to support that the notice had been mailed to the resident's representative.

Based on observation, record review and interview the facility failed to follow the Care Plan as related to Contact Precautions for Resident #238, 1 of 2 sampled residents reviewed for Transmission Based Precautions; as related to Continuous Oxygen for Resident #3, 1 of 1 sampled residents reviewed for Respiratory and as related to Application of Legband to Secure Catheter for Resident #23, 1 of 1 sampled residents reviewed for Catheters. The findings included: The facility admitted Resident #238 with [DIAGNOSES REDACTED]. Record review on 05/30/18 at approximately 1: 57 PM revealed the Care Plan focus area entitled Resident presently is being tested for [MEDICAL CONDITIONS]. Interventions for the goal, Infection will not spread included: Maintain infection control practices per facility protocol. Date initiated: 05/29/18 and Universal and contact precautions Date initiated: 05/29/18. During the 1st 2 days of the survey, Resident #238 was observed eating in the main dining room during the lunch meal service on (MONTH) 29 and 30. (YEAR) at approximately 12:00. In an interview on 05/30/18 at approximately 2:06 PM the Director of Nursing (DON) confirmed that Resident #238 was on Contact Precautions pending results of testing for [MEDICAL CONDITION]. The DON stated a resident should be isolated and not eating in the main dining room if on contact precautions. The facility admitted Resident #3 on 2/21/18 with [DIAGNOSES REDACTED]. Record review on 5/31/18 at 9:03 AM revealed physician's orders [REDACTED]. Review of the Care Plan on 5/31/18 at 10:06 AM revealed a Focus of Resident is at risk for respiratory distress related to [MEDICAL CONDITIONS] fibrosis . Interventions included to administer 02 per MD's orders. Multiple times throughout the survey, the care plan was not followed as the resident was observed in activities, ambulating in the hall, and eating her/his meals in the dining room without the oxygen in place. Further review of the care plan revealed no reference to resident removal or refusal of oxygen. During an interview on 5/29/18 at 3:07 PM, Licensed Practical Nurse (LPN) #1 verified the resident had gone to the dining room at lunch without oxygen. At 4:22 PM, LPN #1 stated, She (He) goes out without her (his) O2 frequently. During an interview on 5/31/18 at 12:14 PM, the Director of Nursing verified the above information. The facility admitted Resident #23 on 5-3-18 with [DIAGNOSES REDACTED]. Review of the care plan on 5-31-18 at 1:30 PM revealed a Focus of Resident at risk for complications r/t (related to) f/c (Foley catheter). Interventions included to Provide leg strap or securement device PRN (as needed). Prior to observation of catheter care at 1:35 PM on 5-30-18, while Certified Nursing Assistant (CNA) #1 was preparing Resident #23 for the procedure, the resident was noted not to have a leg band in place to secure the catheter. After the perineal area and catheter were cleansed, as CNA #1 assisted the resident to turn back and forth to redress, the catheter drainage tubing was pulled taut. After the procedure was complete and the resident made comfortable, when asked about placement of the leg band, CNA #1 stated, I don't know why he (she) doesn't have a strap on. I didn't dress him/her this morning. As the CNA had not applied a leg band following the procedure either, the surveyor asked if s/he was going to apply one. The CNA stated, I can see if we have one in the supply room. The resident's spouse, who was present for the procedure, expressed concern because he (she) has had bloody urine. The facility policy titled Catheter Care, Urinary states: .Secure catheter utilizing a leg band .

Based on record review and interview, the facility failed to provide a copy of the bed hold policy upon hospital transfer for one of one sampled resident reviewed for hospitalization (Resident #35). The resident/resident representative was not issued a copy of the bed hold policy when transferred to the hospital for acute care. Additionally, the facility's policy provided on admission did not include all required information. The findings included: The facility admitted Resident #35 on 4/19/18 with [DIAGNOSES REDACTED]. Review of Progress Notes on 6/01/18 at 10:58 AM revealed that Resident #35 was admitted to the hospital for port placement and [MEDICAL CONDITION] on 4/30/18. Further review revealed no evidence that the resident/resident representative was notified of the bed hold policy in writing at the time of transfer. During an interview on 6/01/18 at 12:20 PM, Social Services provided a Bed Hold Agreement/Release of Bed Space signed at the time of admission which stated the resident had been informed of the facility's bed holding policy. Social Services stated,I do not give them anything (about bed hold) when they are sent to the hospital. A copy of the policy was requested as it was not in the admission packet provided as requested in the Entrance Conference. Review of the bed hold policy issued on admission on 6-1-18 at 1:05 PM revealed that it stated: The Resident and/or legal representative will be contacted by the Community designee about a bed hold when the Member/Resident is transferred to a hospital for admission or plans a leave of absence (LOA). The notice did not specify written notification of the policy at the time of transfer/LOA, the reserve bed payment/cost policy, or the resident's right and conditions under which the resident may return to the next available bed.