Every finding on record at Presbyterian Home Of SC - Foothills

Based on document review and interviews, the facility failed to ensure that the arbitration agreement signed by all facility residents, with a current census of 19 residents, provided for the selection of a venue that was convenient to both parties. Additional information documented in the admission Agreement revealed a stipulation related to the South Carolina Code of Laws that was not further clarified in this signed contract. Specifically, the facility failed to ensure that a neutral venue available to both parties was documented within the arbitration agreement and that potential Arbitration Agreement exempts existed within this form. The exclusion of providing a mutually agreed upon neutral venue location, and providing additional information about a South Carolina Arbitration Agreement exemption placed facility residents and families at an unknown disadvantage to potential future disputes. Findings include:Review of the facility provided admission Agreement, dated August 2024, revealed a Header that included, NOTICE REQUIRED BY SECTION 15- 48-10 OF THE SOUTH CAROLINA CODE OF LAWS, 1976, IS HEREBY GIVEN THAT THE FOLLOWING AGREEMENT IS SUBJECT TO ARBITRATION. Review of the facility provided admission Agreement, dated August 2024, again revealed, 11. Dispute Resolution.11.2 Federal Arbitration Act: .Therefore, the Arbitration Agreement, if signed, is subject to enforcement under the Federal Arbitration Act. If a court of competent jurisdiction determines that the Federal Arbitration Act does not apply, the Arbitration Agreement, if signed, is enforceable under the South Carolina Uniform Arbitration Act.Review of the facility provided admission Agreement and Arbitration Agreement failed to include additional clarification of the South Carolina Code of Laws, 1976, for the signee to review.Review of the admission Agreement, dated August 2024, revealed under, 11. Dispute Resolution.11.5 Location of Arbitration: The arbitration proceeding will be conducted in the county where the Community is located.Review of the admission Agreement, dated August 2024, and located under Exhibit C revealed that . any legal disputes, controversies, demands or claims . shall be resolved exclusively by binding arbitration to be conducted in [NAME] South Carolina .During an interview on 03/05/26 at 4:46 PM, Case Manager (CM) stated any arbitration disputes would be conducted in [NAME], South Carolina at the company office. During an interview on 03/05/26 at 5:39 PM, the Executive Director stated that the admission Agreement had been updated at the end of 2024. The Executive Director confirmed that arbitration could occur anywhere and stated they would review the current documentation.During an additional interview on 03/05/26 at 6:00 PM, Executive Director confirmed that the admission Agreement showed that arbitration would take place in [NAME], South Carolina, and the same document also showed that it would take place in the specific county. The Executive Director stated they would have to revise the form.

Based on observation, interview, facility policy review, review of the Food and Drug Administration (FDA) guidelines and review of Manufacturer's Instructions for Use (MIFU), the facility failed to ensure bed frames, electrical components, and bed rails if present, were inspected and maintained by MIFU for the 19 current residents in the facility. This deficient practice has the potential for bed malfunction, contributing to possible resident injury.Findings include:Review of the facility provided Med [NAME] User Manual, page 13 Maintenance provided by the facility revealed: Maintenance and Service, Notice: Recommended to perform preventative maintenance every 12 months for best performance. 1. Inspect the frame for weld cracks or tears. 2. Check that all bolts, pins and fasteners are still in working order. 3. Perform functional test on the frame. 4. Inspect the casters for wear and tear. In a column titled Preventative Maintenance Inspection was a list of items: Inspect bed frame for cracks, tears, or bending, particularly at welds and joints. Inspect electrical enclosures for cracks or other damage. Check that screws, bolts, pins and other fasteners are in place, secured and properly tightened. Inspect actuators for excessive wear and misalignment. Inspect power cord for damage including the plug and strain relief. Verify that cables and wires are properly retained and clear of moving parts. Verify the plug connectors for the controls, drive motors, and motor control box are fully engaged. Verify the side rails/assist bars latch securely in the raised position. Verify all casters securely lock when activated. Verify that all bed control switches operate correctly.Review of the undated facility policy titled Proper Use of Side Rails revealed, The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids . General Guidelines . 12. When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment (the amount of safe space may vary, depending on the type of bed and mattress being used).Review of the Joerns User-Service Manual, UltraCare XT page 14 Preventative Maintenance provided by the facility revealed, Preventative Maintenance To ensure maximum life of your product, follow all warnings and cautions in the User Manual and maintain your bed with care, as outlined below. The maintenance required will be dictated by your bed's usage and care - a thorough inspection should be conducted monthly. To Maximize Service Life. 1. Joerns UltraCare(R) XT bed frames have self-leveling electronics and do not require a regular reset procedure to remain level. 2. Keep the bed clean. 3. Observe bed operation. 4. After initial week of use, check all threaded fasteners for looseness, and make sure all pins are in their normal location and fastened securely. Check monthly for loose bolts, nuts, pins and other retaining hardware. Tighten any loose hardware. 5. Make sure each inspection includes the underside of the bed frame and mattress support platform. 6. Visually inspect the bed frame and accessories for any cracking, bending, or hole enlargement. 7. Check wiring for proper connections and damage (fraying, kinking, or deterioration). 8. Check actuators for correct mounting at attachment points and ensure all related pins are mounted securely and properly to the bed frame. Actuators are not serviceable but are replaceable if required. 9. Lubricate pivot point, pins and bolts as required. 10. Properly stow pendant. Place pendant in pendant holder right side up or use hook to avoid excessive bending of cable. Avoid dropping or stretching pendant during use to maximize service life. If any discrepancies are noted during inspection, they must be corrected before continuing bed frame use.Review of the FDA guidance (https://www.fda.gov/regulatory-information/search-fda-guidance-documents/hospital-bed-system-dimensional-and-assessment-guidance-reduce-entrapment) recommendations for rail entrapment revealed, . Potential Zones of Entrapment, This guidance describes seven zones in the hospital bed system where there is a potential for patient entrapment. Entrapment may occur in flat or articulated bed positions, with the rails fully raised or in intermediate positions. The seven areas in the bed system where there is a potential for entrapment are: Zone 1: Within the Rail, Zone 2: Under the Rail, Between the Rail Supports or Next to a Single Rail Support, Zone 3: Between the Rail and the Mattress, Zone 4: Under the Rail, at the Ends of the Rail, Zone 5: Between Split Bed Rails, Zone 6: Between the End of the Rail and the Side Edge of the Head or Foot Board, Zone 7: Between the Head or Foot Board and the Mattress End. Dimensional Limits for Identified Entrapment Zones 1-4, FDA is recommending dimensional limits for zones 1 through 4 at this time because we believe the majority of the entrapments reported to FDA have occurred in these zones. We based these recommended limits upon the body parts entrapped in these individual zones identified through adverse event reports and entrapment scenarios described in the reports.During observation of R22's bed on 03/03/26 at 3:35 PM, revealed bilateral upper bed rails, in the up position; observation of R24's bed on 03/03/26 at 2:56 PM revealed bilateral upper bed rails, in the up position; observation of R40's bed on 03/03/26 at 11:58 AM revealed bilateral upper bed rails, in the up position, with an approximate eight inch gap from the mattress to the head board and approximate two inch gap from the foot of the mattress to the foot board; and observation of 41's bed on 03/03/26 at 12:20 PM revealed bilateral upper bed rails, in the up position.During an observation on 03/04/26 at 4:11 PM, the Executive Director (ED) revealed the gap at R40's head of the bed was measured by the ED to be nine inches. It was observed the gap at the foot of the bed was now approximately an inch.During an interview on 03/04/26 at 5:15 PM, the Facilities Services Director (FSD) stated, There are no inspections on the beds in the past 12 months. The FSD also noted a foam insert was placed in the bed gap for R40. During an interview on 03/05/26 at 2:39 PM, the Director of Nursing (DON) stated the facility did not have a policy on bed inspections.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure alternatives were attempted prior to the use of bed rails for 4 of 4 residents (Resident (R)22, R24, R40, and R41) reviewed for bed rails out of a total sample of 13. This failure had the potential to increase accidental entrapment or injury when an alternate assistive device may have been effective.Findings include:Review of the undated facility policy titled Proper Use of Side Rails revealed, .The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. General Guidelines . 2. Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents. 3. An assessment will be made to determine the resident's symptoms or reason for using side rails. 6. Less restrictive interventions that will be incorporated in care planning. 7. Documentation will indicate if less restrictive approaches are not successful prior to considering the use of side rails. 8. The risks and benefits of side rails will be considered for each resident. 9. Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks .1.Review of R22's admission Record from the electronic medical record (EMR) Profile tab revealed an admission date of 02/08/26, with diagnoses including but not limited to, artificial hip joint, muscle weakness, and periprosthetic fracture of the left hip.Review of R22's admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 02/10/26, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicative of being cognitively intact.During an observation and interview on 03/03/26 at 3:35 PM, R22 had bilateral assist bars on the bed. When queried if the facility advised her of the risks that can be associated with the use of bed rails, explaining about the possibility of entrapment, R22 stated, they [the facility] are good about everyone telling me how to use them, but did not remember anyone telling her about entrapment. Review of R22's Side Rail Evaluation, from the EMR Assessments tab revealed an assessment dated [DATE] that showed, Side Rail Conclusions: Side rails are not indicated at this time. The Side Rail Assessment did not document any attempted alternatives to the use of bed rails. Further review of R22's EMR Assessments, Progress Notes, and Miscellaneous tabs did not reveal any risk/benefit advisements regarding side rail use.2. Review of R24's admission Record from the EMR Profile tab revealed an admission date of 02/04/26, with diagnoses including but not limited to, osteoarthritis, muscle weakness, osteoporosis with current pathological fracture, and a humeral fracture.Review of R24's admission MDS with an ARD of 02/10/26, revealed a BIMS score of 13 out of 15, indicative of being cognitively intact.During an observation and interview on 03/03/26 at 2:56 PM, R24's bed was noted to have bilateral assist bars. When queried if the facility advised her of the risks that can be associated with the use of bed rails, explaining about the possibility of entrapment, R24 stated she does use the bed rails, but the facility had not advised her of the risks/benefits of the rails. Review of R24's EMR Assessments tab revealed a Side Rail assessment dated [DATE] revealed, Side Rail Conclusions: Side rails are indicated and serve as an enabler to promote independence in bed mobility. The Side Rail Assessment did not document any attempted alternatives. Further review of R22's EMR Assessments, Progress Notes, and Miscellaneous tabs did not reveal any risk/benefit advisements regarding side rail use. 3. Review of R40's admission Record from the EMR Profile tab revealed an admission date of 02/20/26, with diagnoses including but not limited to, osteoarthritis, orthostatic hypertension, and muscle weakness.During an observation and interview on 03/03/26 at 11:58 AM, R40's bed was noted to have bilateral upper side rails. R40 stated she does use the bed rails. When asked if the facility had advised of any risks/benefits of the bed rails, R40 responded No ma'am, nobody said anything. R40 answered questions during the interview and appeared to be cognitively aware.Review of R40's EMR Assessments tab revealed a Side Rail assessment dated [DATE], which revealed, Side Rail Conclusions: Side rails are indicated and serve as an enabler to promote independence in bed mobility. The Side Rail Assessment did not document any attempted alternatives. Further review of R40's EMR Assessments, Progress Notes, and Miscellaneous tabs did not reveal any risk/benefit advisements regarding side rail use. 4. Review of R41's admission Record from the EMR Profile tab revealed an admission date of 02/27/26, with diagnoses including but not limited to, polyosteoarthritis, right shoulder pain, muscle weakness, and a history of falling.During an observation and interview on 03/03/26 at 12:20 PM, R41's bed had bilateral upper assist bars that R41 stated he does use. When queried if the facility advised him of the risks that can be associated with the use of bed rails, explaining about the possibility of entrapment, R41 did not remember anyone reviewing the risks/benefits of the side rails. R41 answered questions during the interview and appeared to be cognitively aware.Review of R41's Side Rail Assessment, dated 02/27/26, revealed, Side Rail Conclusions: Side rails are indicated and serve as an enabler to promote independence in bed mobility. The Side Rail Assessment did not document any attempted alternatives to the use of bed rails. Further review of R41's EMR Assessments, Progress Notes, and Miscellaneous tabs did not reveal any risk/benefit advisements regarding side rail use.During an interview on 03/04/26 at 4:05 PM regarding documented attempted alternatives to bed rails, the Director of Nursing (DON) stated, No, we have always just had the side rails upon admission, using the Side Rail assessment. We have not attempted alternatives. [There is] No documented risk/benefit or consent.

Based on record review, interview, and facility policy review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for 1 resident (Resident (R) 32) of 13 residents in the sample reviewed for MDS accuracy. Specifically, R32's MDS failed to identify the correct discharge location at the end of the resident's stay. This failure created a potential for lack of identification of current problems and resident needs, leading to an incomplete or ineffective plan of care. Findings include:Review of the facility's policy titled, MDS 3.0 Completion dated 10/01/24 revealed, Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan . Discharge Assessment-completed using the discharge date as the ARD. Must be completed within 14 days of the discharge date /ARD. Review of R32's admission Record located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE], with diagnoses including but not limited to, fracture of the lower end of left radius and multiple fractures of pelvis without disruption of pelvic ring.Review of R32's EMR under the Progress Notes tab dated 12/26/25, revealed the resident was admitted for short-term rehab following a hospital stay for pubic fracture.Review of R32's EMR under the Progress Notes tab dated 01/29/26, revealed the resident with, complaints of dizziness, dr [doctor] notified.pt [patient] in afib [atrial fibrillation] . pt transfered [sic] to . hospital. Review of R32's Discharge Return Not Anticipated MDS with an Assessment Reference Date (ARD) of 01/29/26 and located under the MDS tab of the EMR revealed the Discharge Status was recorded to have discharged to Home/Community. R32 did not return to the facility. During an interview on 03/05/26 at 10:01 AM, the MDS Coordinator (MDSC) stated, R32 went to the hospital and did not return to the facility. Upon review of R32's Discharge MDS, the MDSC confirmed that they had mistakenly documented that the resident had gone home when they had not.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure 1 of 3 residents (Resident (R)35) reviewed for respiratory services, received oxygen as ordered by the physician. This failure placed the resident at risk of receiving insufficient oxygen to meet the assessed respiratory need.Findings include:Review of the facility's undated policy titled, Oxygen Administration stated, . Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration . Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered .Review of R35's Face Sheet located under the Profile tab of the electronic medical record (EMR) revealed R35 was initially admitted on [DATE], and readmitted on [DATE], with diagnoses including but not limited to, acute respiratory failure with hypoxia.Review of R35's EMR under the Orders tab revealed a physician order dated 02/27/26 for Oxygen 3 Liters via Nasal Cannula every day and night shift for hypoxia. This physician order was discontinued on 03/02/26 and a new physician order dated 03/02/26 indicated, Oxygen 2 Liters via Nasal Cannula every day and night shift for hypoxia. During an observation on 03/03/26 at 12:16 PM, R35 was observed in bed while using the oxygen from the room concentrator. The oxygen concentrator was revealed to be set at 4.5 LPM (Liters Per Minute).During an observation on 03/04/26 at 1:55 PM, R35 was observed in bed with the room oxygen concentrator on and set at 4.5 LPM.During an observation on 03/04/26 at 4:10 PM, R35 was observed in bed with the oxygen room concentrator on and set at 4.5 LPM. Review of R35's Care Plan dated 02/26/26 and located in the EMR under the Care Plan tab revealed the resident had altered respiratory status and difficulty breathing related to acute respiratory failure and congestive heart failure. Interventions included administering medication/puffers as ordered, and oxygen settings via nasal prongs at 3 LPM as ordered. The care plan was not revised to ensure the physician order was accurate.During an interview on 03/04/26 at 4:15 PM, Certified Nursing Assistant (CNA)1 said that CNAs could replace oxygen tanks, could take resident vitals, and could inform a nurse if there was a resident concern. CNA1 said that only nurses adjusted the LPM on an oxygen concentrator.During an interview on 03/04/26 at 4:20 PM, Registered Nurse (RN)1 said residents would receive oxygen as ordered by the physician. Upon review of R35's physician orders, RN1 confirmed that the resident was ordered to be on oxygen at 2 LPM continuously. RN1 observed the resident in their room and confirmed the resident was receiving oxygen at 4.5 LPM. RN1 lowered the oxygen room concentrator down to 2 LPM. RN1 stated that R35 received medication administration from Licensed Practical Nurse (LPN)1.During an interview on 03/04/26 at 4:34 PM, LPN1 stated that R35 had a physician order for 2 LPM, but that they could turn it up to 4 LPM as needed. Upon review of R35's physician orders, LPN1 stated that she thought there was a physician order for oxygen that could be titrated to 4 LPM. LPN1 reviewed R35's physician orders since the initial admission and confirmed there had not been a titrated order for oxygen administration.During an interview on 03/05/26 at 2:19 PM, the Director of Nursing (DON) said that none of the residents at the facility were provided with physician orders to titrate oxygen. The DON stated that the physician orders were to be followed, and none of them would be titrated. If residents were supposed to be on 2 LPM, then that was what they should be on.

Based on record review and interview, the facility failed to ensure that 1 of 3 residents (Resident (R)24) reviewed, that signed an arbitration agreement, were provided with an explanation of the binding agreement in a form and manner that they or their representative understood. The failures to ensure residents or their representatives were properly and clearly informed of the signed binding arbitration agreement could affect the ability for residents and families to be properly informed of the potential implication of the binding agreement on decisions and choices about important aspects of residents' health, safety, and welfare. Findings include:Review of R24's Arbitration Agreement located in the electronic medical record (EMR) under the Miscellaneous tab indicated the resident and family member (FM)1 had signed and initialed the facility Arbitration Agreement on 02/04/26. Review of R24's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/10/26, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated no cognitive impairment.During an interview on 03/05/26 at 5:01 PM, R24 stated that FM1 had signed the Arbitration Agreement upon admission. During an interview on 03/05/26 at 4:46 PM, Case Manager (CM) stated that they gave the resident and/or resident representative the paperwork to fill out upon admission and would answer any questions they might have. Regarding the Arbitration Agreement, CM said they told the resident and/or resident representative to read the document carefully, and if they had any questions, CM would read the Arbitration Agreement to them. If there were additional questions regarding the information, CM would refer the individual to the Executive Director who could explain it to them. CM said that did not happen often, and that reading the Arbitration Agreement together made it easier for them to understand. CM confirmed they only read the agreement as written but did not clarify the document.During an interview on 03/05/26 at 5:14 PM, FM1 stated that they had received paperwork, but there had not been an explanation of anything regarding what they signed. FM1 said that they had received the paperwork, and when the CM came back, they just picked it up from them. FM1 said they were not aware they did not have to sign the Arbitration Agreement. FM1 confirmed it was confusing, and they were requested to sign it. FM1 said they were not aware that they were giving up their right to sue. FM1 confirmed they read the information multiple times but did not understand what they signed. During an interview on 03/05/26 at 5:39 PM, Executive Director stated that if a resident and or resident representative did not understand the admission Agreement/Arbitration Agreement they could reach out to them. The Executive Director confirmed that CM went over the information with the new admissions and would inform them they did not have to sign it and would ensure they understood it.

Based on review of the facility policy, record review, and interviews, the facility failed to timely report an allegation of abuse for 1 of 1 residents (R)76, reviewed for abuse. Not reporting timely had the potential to cause further potential abuse. Findings include: Review of the facility's undated policy titled, Reporting Abuse to State Agencies and Other Entities/Individuals recorded under the policy, All suspected violations .of abuse will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law. When an incident of resident abuse is suspected or confirmed, the incident must be immediately reported to facility management regardless of the time lapse since the incident occurred. R76 was admitted to the facility on [DATE] with diagnoses that include, but not limited to multiple fractured ribs left side, atrial fibrillation, pleural effusion, congestive heart failure and hypertension. Record review of R76's Minimum Data Set (MDS) assessment dated [DATE] revealed that R76's cognitive status from a Brief Interview Mental Status (BIMS) was scored as 14 of 15, indicating she had no cognitive impairment. Review of the Against Medical Advice (AMA) form with R76 name was completed and signed on 09/03/2024. Review of the Facility Reported Incident (FRI) report date of 09/04/2024 of a 2 hour report revealed the Administrator and Director of Nurses (DON) during a care plan meeting the previous day, a resident's daughter used the word manhandled by a staff member and was afraid to stay another night. A fax confirmation of the 24 report was dated 09/04/2024 at 12:34 PM. An interview with the Administrator on 01/16/2025 at 12:15 PM revealed when discussing the allegation of abuse reporting, she stated, I learned of this on September 4th. The DON and I are the Abuse Coordinators. The reporting time is 2 hours. Staff are to report immediately to us if there is the suspicion or allegation. This was a late reportable with notification. If it was reported to me on the 3rd, I would have reported it on the 3rd. An interview with the DON on 01/16/2025 at 1:04 PM revealed, I was not here that day, September 3rd, 2024. The Administrator and I were out on training. I was made aware on the 4th. The Administrator was not made aware until I came to her and reported it to her. After it was reported on the 3rd, it should have been reported. We knew it was late reporting when we reported it.

Based on review of the facility policy, report review and interview, the facility failed to complete and submit 2 of 3 resident Minimum Data Sheet (MDS) assessments timely. Findings include: Review of the undated facility policy titled, Resident Assessment Using the Minimum Data Set (MDS), revealed under the policy, Every resident will be assessed using the MDS according to guidelines set forth in the Resident Assessment Instrument (RAI) manual. The facility will conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity. Review of the MDS 3.0 Missing OBRA Assessment Report dated 01/09/2025 revealed the facility had 3 resident assessments that were not submitted to CMS. Review of the MDS 3.0 Nursing Home Validation Report dated 01/14/2025 at 11:12 AM revealed the same 3 residents that were missing were submitted after the Missing OBRA Assessment Report was given to the Administrator. An interview with the MDS Nurse on 01/14/2025 at 3:25 PM revealed that the 3 resident assessment were not submitted and that 1 was completed. She stated, I unlocked it and set it for submission. I transmitted it today. She confirmed and stated, 2 of the 3 assessments was not completed at all. I completed it this morning after I received the report. It is now submitted. I just missed it. We follow the RAI. We have 14 days to close the admission assessment. On 01/16/2025 at 1:04 PM, an interview with the Director of Nursing (DON) revealed, I'm not an MDS nurse. When the residents admitm an Assessment Reference Date (ARD) is set, determined on multiple things. We should not miss or skip an MDS.

Based on interviews, record reviews, and review of the facility's policy, the facility failed to ensure a resident's end of life wishes and physician's orders were correctly documented throughout the medical record resulting in the potential that one resident's wishes (Resident (R) 122) out of a total sample of 13 residents would not be honored in the event of a life-threatening emergency. Findings include: Review of the facility's undated Advance Directives policy, indicated .information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record, on the MAR, TAR (Treatment Administration Record), and care plan . The assigned Nurse will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. Nursing will mark the residents chart . Review of the facility's undated Do Not Resuscitate Order Policy Statement indicated Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect .Do not resuscitate orders must be signed by the resident's Attending Physician on the physician's order sheet maintained in the resident's medical record. Review of R122's Admission Record, located in the Profile tab of the electronic medical record (EMR), revealed R122 was admitted to the facility on [DATE]. R122's diagnoses included chronic obstructive pulmonary disease, diabetes mellitus, and chronic respiratory failure. Review of R122's Brief Interview for Mental Status (BIMS) located in the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], located in the Assessment tab of the EMR, revealed a score of 13 out of 15 which indicated R122 was cognitively intact. Review of R122's Physician's Orders, dated [DATE] under the Orders tab located in the EMR, revealed R122's code status as Full Code. Full code means all resuscitative measures would be attempted in the event R122 was found without a pulse and/or not breathing. Review of R122's Authorization of DNR, dated [DATE] under Misc tab located in the EMR, signed by R122 revealed R122 chose the code status of Do Not Resuscitate [DNR]. DNR means no resuscitative measures would be attempted in the event R122 was found without a pulse and/or not breathing. Review of the provider note titled, Physician History and Physical, dated [DATE] under the Progress Notes tab located in R122's EMR, revealed .I spent <30 min discussing advanced care planning with this patient, and they desire DNR (Do Not Resuscitate). Appropriate paperwork completed placed on file and order in facility record reflects DNR. During an interview on [DATE] at 11:37 AM, R122 stated, I signed the paperwork to be a DNR, that is my wish. During an interview on [DATE] at 3:13 PM, Certified Nursing Assistant (CNA)1 stated a resident's code status was located in different places. CNA1 said if a resident were unresponsive she would get assistance, a nurse would come and make the decision on how to proceed. CNA1 said if a resident's chart says he was FULL CODE, Cardiopulmonary Resuscitation (CPR) would be done. During an interview on [DATE] at 3:15 PM, Registered Nurse (RN)1 stated I would call a code and ask them to call 911, R122 is a full code. RN1 was shown in R122's EMR where the Medication Administration Record (MAR) stated DNR. RN1 said since the written order was a Full Code she would try to bring him back. During an interview on [DATE] at 3:17 PM, the Social Services Director (SSD) said we talk about code status on admission when we go through the admission packet with a resident and/or responsible party. The SSD stated the Nurse Practitioner (NP) also reviews the resident's desire regarding code status. The SSD stated, If I found a patient unresponsive I would call the nurse and look in the system to check the code status. Right here on the EMR, R122 is a Full Code, but his paperwork says he is a DNR. I'm not going to lie I would look at the EMR and start CPR. During an interview on [DATE] at 8:06 AM with the Director of Nursing (DON), the DON stated, We admit everyone with a full code [status] until they are seen by a provider. If someone would code we need to look at the whole picture, I would expect staff to look at both places [the order and the document]. I don't think looking in both places would delay care. If there is a signed DNR I would expect staff to use that directive. During an interview on [DATE] at 9:49 AM with Licensed Practical Nurse (LPN)1, LPN1 said a resident's Code Status was found in the tool bar in the EMR. LPN1 stated, I would use the EMR Code Status. If the Code Status in the EMR and the DNR [paperwork] conflicted I would start CPR.

Based on observation, record review, interviews and facility policy, the facility failed to store food in a closed manner, failed to label food containers when opened, failed to store dishes and utensils in a sanitary manner, failed to maintain an air gap on the ice machine, failed to maintain appropriate sanitization levels in the cleaning buckets and failed to serve food in a sanitary manner. The facility had one (1) main kitchen and a satellite kitchen that provided meals for the skilled unit. Findings include: Review of the policy titled, Handwashing, with no date, revealed, rewash hands after touching anything that may contaminate hands. Review of the policy titled, Storing: Food and Equipment, with no date, revealed, label all food items that were not kept in their original containers, including condiments. Each label must contain the following: product name, use-by-date, date the product was prepared or opened, and team member initials where applicable. The policy also documented staff should store the glasses and cups upside down on a clean shelf or rack and do not nest wet glasses or cups. Review of the policy titled, Dishwashing and Pot Washing Procedures, dated 3/2020 revealed allow dishes to air dry, do not wipe them with cloths. Review of the policy titled, Cleaning and Sanitizing, with no date, revealed, the cleaning schedule must identified the cleaning jobs in each area of the kitchen, assign cleaning responsibilities to each job position, and schedule the time the cleaning was to be done and/or completed. Staff should train all team members on the following: importance of cleanliness in the food service operation, cleaning schedule assignments, correct tools, and chemicals to utilize when cleaning equipment, and check the completion of tasks on the Cleaning Log. Ensure team members understand who they should direct their questions to regarding the cleaning procedures. Review of the policy titled, Surface: Cleaning and Sanitizing, with no date, revealed, keep sanitizing solution between 200 to 400 parts per million (ppm) quaternary ammonium. Change sanitizer as often as necessary to keep water clean and sanitizer effective. Review of the policy titled, Dish machine, with no date, revealed, team members must clean, rinse, and sanitize tableware, dishes, utensils, and other approved equipment after each use. Air dry all items and do not stack or nest wet items. Review of the policy titled, Physical Facilities, with no date, revealed the location Supervisor and District Manager must work with the client to choose, install and maintain utilities, materials and equipment, to promote food safety and proper sanitation. Plumbing should be maintained to prevent backflow preventions or any cross-connection (link through which contaminants from drains, sewers or other wastewater sources could enter a drinkable water supply). 1. Observation of the main kitchen, during the initial tour on 5/25/2021 from at 10:30 a.m. to 11:42 a.m. revealed: Three (3) racks of steam table pans, baking sheets, muffin tins and mixing bowls by the three (3) compartment-sink. Further observation on all three (3) racks revealed, multiple number of the steam table pans, baking sheets, muffin tins and mixing bowls were stacked together with water between them, some were stored upright and some had dried food debris. · The dry storage room revealed the following opened to the air: Five (5) pound bag of Fish and Vegetable Batter Mix; container of cornmeal; opened bag of raisins inside an opened box; box of lentils; 11 kilogram box of rice; and ten (10) pound box of Quinoa. Further observation revealed an opened container of Pork Gelatin not dated when staff opened it. · The walk-in refrigerator revealed one (1) gallon container of Asian Sesame Dressing opened and not labelled with the opened date. · The prep area shelving revealed 19 opened containers of seasonings, vinegar or soy sauce unlabeled with the date staff opened them and a gallon size bottle of vinegar, on the bottom self with no lid an no label. Further observation revealed a plastic container of cream of tartar with a label to use within six (6) months with no documented date of when opened. · Check of the chemical level of the sanitization bucket in the prep area revealed it did not register on the test strip. Additional check of another sanitization bucket revealed brownish colored water and particles floating in the bucket. · Large floor mixer covered with a plastic bag and food noted on the underside where the beaters would go and along the shield of the mixer. · Five (5) tablecloths on hangers in a storage room with staffs' coats on same rack. · Linen room with plastic bags filled with towels on the floor and one (1) bag on the floor opened with towels exposed. · No air gap on the ice machine drain and dust particles on the side vents. · Two (2) Robot coupe (industrial food processor) bowls covered with a lid and blades inside the bowl, one (1) with standing water and the other with dried food on the blades. · Large flour bin with a label to use the flour by 5/15/21 still in use. · Stainless steel rack with stacked clear plastic containers with water between some of the containers, positioned on the shelf above dishes stored upright and not covered. · Mixer with food debris present. · One (1) gallon of red wine vinegar by the stove, opened and not labeled with the opened date. · Drawer containing knives with old food stains in the drawer, and food debris on some of the knives. · Steam table pan of buffalo sauce and steam table pan of butter (that had separated) dated 5/24 sitting on the shelf above over the stove. 2. Observation on 5/25/21 from 11:56 a.m. to 12:58 a.m. of the satellite kitchen revealed glasses and plate covers stacked and water between them. Cartons of Health Shakes in the cooler not dated when placed in the cooler to thaw. Review of the cartons of the Health Shake revealed documentation that stated the Health Shakes should be used within 14 days after thawing. Dishes in the cabinet with old food noted on the side of the plates, observable when the cabinet door was opened. 3. Further observation revealed the Wait Staff took the temperature on the steam table. The chopped chicken was 136.4 degrees Fahrenheit (F), egg rolls were 130.8 degrees F, pureed peas were 116.4 degrees F and the pureed chicken was 131.4 degrees F. Interview with the Executive Chef at that time revealed the temperature of the food should be 145 degrees F or higher. Dietary staff took the egg rolls, pureed peas and pureed chicken back to the main kitchen to reheat. Dietary staff brought the egg rolls, pureed peas and pureed chicken back and placed on the steam table. The surveyor prompted the staff the temperature of the ground chicken was 131.4 degrees when taken and the dietary staff then removed the ground chicken and took it back to the main kitchen to reheat. 4. Additional observation revealed the Health Care Dining Supervisor came into the satellite kitchen with gloves on, threw paper towels into the trash can by touching the sides of the lid and then lifted the tray covering the duck sauce. The surveyor at that time prompted the supervisor to change his/her gloves. 5. Observation at 12:52 p.m. revealed a nurse aide entered the satellite kitchen without a hair net on and obtained an item from the cooler while the food was still on the steam table and then left the kitchen. 6. Observation of the main kitchen on 5/27/21 at 10:12 a.m. revealed large plastic containers stacked in the dry storage room with water between them and some with dried debris. Further observation revealed ten (10) containers of spices from five (5) to 30 ounces in weight unlabeled as to when opened. Observation at 10:15 a.m. revealed the floor mixer with a small amount of dried food underneath where the beaters went and on the shield of the mixer. Further observation revealed the knife drawer with food debris on some of the knives. The stainless-steel rack had stacked plastic containers with water between them. On the same rack, stainless steel cup looking containers, several had water between them and two (2) with moist looking food between them. Further observation revealed two (2) staff drying dishes and trays with towels. The surveyor prompted the Regional Director to stop the towel drying of the dishes. Review of the training the kitchen staff received on employment and annually, did not include any training pertaining to dietary or kitchen. Review of the 5/2021 Back of the House Cleaning Log revealed, Daily Clean and Sanitize, Weekly, and Monthly sections. Further review of the cleaning log revealed checkmarks placed but inconsistent upon completion of the areas. The log did not assign a cleaning task by job title Interview with the Executive Chef on 5/25/21 at 11:00 a.m. revealed the staff should change the chemical solution in the sanitization buckets every two to four hours. Further interview with the Executive Chef regarding the kitchen cleaning schedule revealed the staff all worked together and started at the dishwashing area and worked towards the back door. A cleaning schedule with assigned jobs was not utilized. The Executive Chef stated he/she did not know the Health Shakes had to be used within 14 days of being thawed. Interview with Director of the Kitchen on 5/25/21 at 11:30 a.m. revealed the staff should change out the sanitization buckets when there were food particles in the water. Further interview with the Executive Chef on 5/27/21 at 9:45 a.m. revealed he/she was in charge of the ordering of the food and the kitchen staff. The Director of the Kitchen was his/her supervisor. The Executive Chef also stated the staff should keep food items from being opened to the air. The labels for the food containers should include the date opened, the used by date, day of the week, name of the product and the staff's initials. Staff should air dry the dishes after they were washed and anybody working can put the dishes/utensils away when they were dry. The Executive Director stated the ice machine air gap was not fixed yet but he/she had placed a maintenance order to have it fixed. Interview with the Cook on 5/27/21 at 10:16 a.m. revealed he/she started here four (4) years ago and when he/she started was trained on the normal things but could not remember what. The cook also stated the staff should label any item in the kitchen when opened. Interview with the Dishwasher on 5/27/21 at 10:30 a.m. revealed he/she started working in the kitchen about one (1) year ago and the training he/she received was following someone else around. The dishwasher stated he/she found out he/she had been doing everything wrong but did not have any towels to dry the dishes with previously.

Based on observation, record review, and interviews, the facility failed to follow the scoop size when plating the resident's diet. Review of the facility provided Resident and Diet List revealed five residents received a mechanical soft ground diet. Findings include: Observation on 5/25/21 beginning at 12:00 p.m., of the plating of the noon meal in the Satellite kitchen, revealed staff served bowtie pasta and used a four (4) ounce ladle to serve a sauce over the pasta. Further observation revealed the fullness of the ladle varied. Review of the Diet Spreadsheet for 5/25/21 lacked the sauce and the corresponding amount to serve. Interview with the Executive Chef and Wait Staff on 5/25/21 at 12:55 p.m., who plated the food, was unable to identify the size of the yellow scoop used to serve the chopped chicken and stated the scoops used to serve the pureed chicken and pureed peas were a size 16, but unable to state how many ounces that was. Wait Staff also stated the stir fry was served with a four (4) ounce ladle. Review of the Diet Spreadsheet for 5/25/21 revealed the staff should serve the residents six (6) ounces of the stir fry and four, (4) ounces of the pureed peas. Further review of the Diet Spreadsheet lacked evidence the staff should serve a sauce over the pasta and the pureed chicken and chopped chicken. Review of the Standard Scoop Measurements with no date. Revealed the yellow scoop consists of 1- 3/4 ounce instead of the usual six (6) ounce serving of meat. The Size 16 scoop consisted of 2 to 2 - ½ ounces instead of the documented four (4) ounce serving of peas and the usual six (6) ounce serving of meat. Review of the training the kitchen staff received on employment and annually, did not include any training pertaining to dietary or kitchen.

Based on record review, interview, review of facility files and policies the facility failed to ensure Resident #1 was free of significant medications errors, 1 of 1 sampled residents reviewed for medication errors. Resident #1 was given a sleeping pill that was not prescribed to him/her. The findings included: The facility admitted Resident #1 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a facility investigation, on 4/12/21 at 11:30 AM, revealed Resident #1 was given a 30 milligram tablet of [MEDICATION(S)] for [CONDITION(S)] on 3/31/21 at 3:00 AM. The investigation noted this was a medication error and the resident did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #2, who had the same last name as Resident #1, but was on a different unit then Resident #1. Licensed Practical Nurse (LPN) #1 received the [MEDICATION(S)] from the pharmacy and placed it in the medication cart in the area assigned to Resident #1, without verifying the first and last name on the medication label. Resident #2's medications were stored in a separate cart on Resident #2's unit. In addition, prior to administering the [MEDICATION(S)], LPN #1 noticed the resident did not have an active order for the [MEDICATION(S)]. LPN #1 sent a text message to the day shift nurse practitioner (NP) notifying her/him the [MEDICATION(S)] had been received and an order would be entered for the NP to sign. LPN #1 then administered the [MEDICATION(S)] to Resident #1. At 8:00 AM, the day shift nurse noticed the resident was lethargic. The resident was sent to the hospital at 8:30 AM. At 9:00 AM the NP checked her/his messages and realized the resident had received the [MEDICATION(S)] in error. The NP notified the Director of Nursing (DON) and called the hospital to inform them of the medication error. The DON checked Resident #1's medication cart and found Resident #2's [MEDICATION(S)] with 1 tablet missing. Resident #1 returned to the facility on [DATE]. Review of an email/statement by LPN #1 revealed Resident #1 had been having trouble sleeping all night. LPN #1 checked the orders and explained to the resident nothing was ordered to help her/him sleep. Around 3:00 AM, LPN #1 was in the narcotic box getting a medication for another resident when s/he noticed a medication card of [MEDICATION(S)] with the resident's last name on the label. The medication had been received earlier in the shift and placed in the narcotic box by LPN #1. LPN #1 assumed it was a mistake that the order was not in the computer. I put the order in the computer & administered the medication. I never checked the first name. Record review of nurse's notes, on 4/12/21 at 11:45 AM, revealed a note from 3/31/21 at 1:46 AM: Resident has been sitting on side of bed for the last few hours. Resident complains of [CONDITION(S)]. Will report to NP & continue to monitor. A Transfer to Hospital Summary note from 3/31/21 revealed: This nurse entered patient's room and noted that (s/he) was not responsive to (her/his) name, though (s/he) would open (her/his) eyes when asked to. This nurse reported patient's condition to NP, who then examined pt and suspected that pt had potentially aspirated. It was determined that pt required immediate emergency care. EMS were called and pt was transported to the hospital. An additional Transfer note indicated the resident was sent to the hospital at 8:30 AM. During an interview with the NP, on 4/12/21 at 11:57 AM, the NP stated shortly after arriving to work on 3/31/21 s/he was notified by nursing the resident was lethargic. The NP stated initially s/he thought they were talking about Resident #2, a hospice resident, because s/he had seen Resident #1 the day before and Resident #1 was doing fine. After realizing it was Resident #1 nursing was reporting about, the NP stated I then jumped and ran to her/him. The NP stated the resident was arousable and was responding to her/his name. The NP completed an exam and sent the resident to the hospital due to the resident's significant respiratory and cardiac history and the acute change in condition. The NP stated it wasn't until after this that s/he was able to check messages from the night before. The NP stated s/he had two texts from LPN #1. The first text was about the resident's [CONDITION(S)]. The second text was about the [MEDICATION(S)]. The NP stated s/he knew Resident #1 had no orders for [MEDICATION(S)] and notified the DON and the hospital. Review of the hospital discharge summary, on 4/12/21 at 1:00 PM, revealed initial work up in the Emergency Department was negative except for note of hypercapnia with mild acidosis. The resident had noted improvement 3 hours later without medical intervention and was very alert and conversive. There were no signs or symptoms of aspiration. Review of the facility's Resident Identifiers policy revealed: For the safety of our residents, we must positively identify the resident and match the resident to the service or treatment to be provided. To reduce the risk of wrong resident events, all healthcare employees will use two (2) resident identifiers when providing care, treatment or services to a resident. This includes but is not limited to the following situations: 1. Administering any medication or contrast media by any route 2. Phlebotomy 3. Administering blood or blood products 4. Obtaining specimen(s) for clinical testing 5. Providing any exam (ex. radiological exam) 6. Performing any procedure (ex. central line insertion) A. To facilitate accurate identification: 1. All resident must have an identification on the MAR/TAR/Room door 2. The resident ' s name must be one of the two resident identifiers used. 3. The second identifier can be: A. Medical Record number B. Date of Birth C. A picture in PCC B. The two (2) resident specific identifiers must be directly associated with the individual resident and the same two (2) identifiers must be directly associated with the care, treatment, or service that is being provided (such as on an attached label or document). The two (2) identifiers from the resident and the two (2) identifiers from the care, treatment, or service must match. C. Whenever possible, staff should also actively engage the resident in the process of ensuring proper identification by asking the resident to state, without any prompting, their full name and or date of birth (or other acceptable 2nd identifier) and compare or match the verbal confirmation to the written information on PCC.

Based on observation, record review, interview, and review of the facility's policy, Liberalized Medication Administration, the facility failed to ensure that its medication error rate was less than 5%. The facility had an error rate of 10% resulting from 3 errors out of 30 opportunities. The findings included: On 01/24/19 at 08:17 AM, Licensed Practical Nurse (LPN) #1 was observed during the medication pass for Resident #69. The LPN administered carvedilol, [MEDICATION NAME] duloxetine, folic acid, [MEDICATION NAME], and [MEDICATION NAME] acid. During medication pass reconciliation at approximately 3:30 PM, it was noted that Apixaban and Ranolazine were ordered at 09:00 AM and were not administered during the medication pass at 08:17 AM. During an interview at 3:55 PM. the LPN confirmed s/he did not administer the medications during the medication pass but stated s/he realized later that s/he had omitted the 2 medications and administered them late. Resident #69 was discharged on [DATE] and medications were sent home with the resident and therefore not available to count the remaining medications. There was no documentation in the Medication Administration Record [REDACTED]. LPN #1 was also observed during the medication pass for Resident #67 at 08:32 AM. LPN #1 placed [MEDICATION NAME], aspirin EC 81 mg (milligrams), [MEDICATION NAME], ranitadine, and [MEDICATION NAME] into a medication cup. The LPN stated s/he was going to place the aspirin EC in a separate cup because the computer prompted her/him to ask the resident about pain before administration. The LPN then placed a second aspirin EC 81 mg in the first medication cup with all the other medications. The LPN was stopped at the resident's door and asked how many Aspirin EC 81 mg were in the medication cup. LPN #1 confirmed there were 2 aspirin EC 81 mg in the medication cup and that there should be 1 tablet. Review of the facility's policy entitled Liberalized Medication Administration revealed .the time listed on the MAR (Medication Administration Record) is a generalized guideline based on a person's stated preferences. In addition, the policy stated, Medications ordered or standardized to be given at specific times (i.e. 7 AM and 7PM (sic)) will allow for 1 hour before or 1 hour after the designated time as timely administration. Further review revealed that The administration of medications will be time stamped to allow for safe administration and spacing for safe and therapeutic outcomes. Review of the Activity Initial Review and the Activity Interview for Daily and Activity Preferences revealed no documentation of the resident's preferences related to medication administration.

Based on record review and interviews the facility failed to follow their Abuse Prevention Program Policy related to reporting and investigating allegations of abuse for 2 of 2 residents reviewed for abuse. (Resident #114 and Resident #115) The findings included: The facility admitted Resident #114 with [DIAGNOSES REDACTED]. The facility self-reported an alleged abuse allegation to the State Agency on 9/20/2018. Record review revealed no 5-Day investigative report was sent to follow up the 24-Hour report. Review of the Facility policy Abuse Prevention Program documents the facility should make an initial report immediately or within 24 hours to the State Agency. A follow up investigation will be submitted to the State Agency within 5 working days. During an interview with the Company Consultant and the Administrator on 1/24/19 they confirmed that no 5 day follow up report was sent to the State Agency but was sent to another agency by mistake. Facility policy also states that reports of abuse are to be promptly and thoroughly investigated. The facility admitted Resident #115 with [DIAGNOSES REDACTED]. The facility self-reported a 24-hour alleged abuse report to the State Agency on 8/23/18. Record review revealed no 5 day follow up investigative report was submitted to the State Agency per the facility policy and state requirements. During an interview with the Corporate Consultant and the Administrator on 1/24/19 they confirmed that the 5-day report was not sent to the State Agency but was sent to another State Agency by mistake. Review of the facility Abuse Policy revealed under E. Investigation It is the policy of this community that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. Review of the facility Abuse Policy revealed under G. Reporting and Response It is the policy of this community that abuse allegations (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are reported per Federal and State Law.

Based on record review and interviews the facility failed to send the required 5-day follow-up reports for Residents #114 and Resident #115, 2 of 2 residents reviewed for abuse. The findings included: The facility admitted Resident #114 with [DIAGNOSES REDACTED]. The facility self-reported an alleged abuse allegation to the State Agency on 9/20/2018. Record review revealed no 5-Day investigative report was sent to follow up the 24-Hour report. Review of the Facility policy Abuse Prevention Program documents the facility should make an initial report immediately or within 24 hours to the State Agency. A follow up investigation will be submitted to the State Agency within 5 working days. During an interview with the Company Consultant and the Administrator on 1/24/19 they confirmed that no 5 day follow up report was sent to the State Agency but was sent to another agency by mistake. Facility policy also states that reports of abuse are to be promptly and thoroughly investigated. The facility admitted Resident #115 with [DIAGNOSES REDACTED]. The facility self-reported a 24-hour alleged abuse report to the State Agency on 8/23/18. Record review revealed no 5 day follow up investigative report was submitted to the State Agency per the facility policy and state requirements. During an interview with the Corporate Consultant and the Administrator on 1/24/19 they confirmed that the 5-day report was not sent to the State Agency but was sent to another State Agency by mistake. Review of the facility Abuse Policy revealed under G. Reporting and Response It is the policy of this community that abuse allegations (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are reported per Federal and State Law.

Based on record review and interviews the facility did not thoroughly investigate an allegation of abuse for Resident #114, 1 of 2 residents reviewed for abuse. The findings included: The facility admitted Resident #114 with [DIAGNOSES REDACTED]. Review of facility records revealed that on 9/20/18 the facility received an alleged allegation of abuse for Resident #114 which allegedly occurred on 9/16/18. An investigation was launched immediately. Because the name of the perpetrator given was a 3rd shift worker and a witness statement, who spent the night with the resident stated no incidents occurred during the 3rd shift, only 3rd shift employees were interviewed. All of the current residents on the unit were interviewed with no issues of any type of abuse noted. However, the witness did state the resident was in the floor when he/she arrived. Two Certified Nursing Assistants ( CNA's) got the resident up but there was no abuse by them. The resident fell but received no injuries. The facility Department Managers failed to interview any staff from the 2nd shift in order to obtain a more complete picture or possibly have uncovered any further details since the resident had been observed on the floor around 10:00 PM. During an interview on 1/24/19 with the Administrator and the Corporate consultant they confirmed the records only showed that the witness, the alleged perpetrator Certified Nursing Assistant #1 (CNA) and the residents on the unit were interviewed. Review of the facility Abuse Policy revealed under E. Investigation It is the policy of this community that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated.

Based on observation, interview, and review of the facility's policy, Insulin Administration, the facility failed to follow infection control practices during the administration of insulin to Resident #117, 1 of 1 resident reviewed for subcutaneous medication administration. The findings included: On 01/24/19 at 12:11 PM, Licensed Practical Nurse (LPN) #1 was observed administering Humalog Insulin to Resident #117. The LPN primed the insulin pen and proceeded with the administration. The insulin was administered subcutaneously in the left upper arm without first cleaning the site with alcohol. During an interview at 12:16 PM, the LPN confirmed the policy was to clean the injection site before administering medication. The LPN confirmed that s/he did not clean the site before administering the insulin. Review of the facility's policy entitled Insulin Administration in a section Steps in the Procedure (Insulin Injections via Syringe) revealed 19. Clean the injection site with an alcohol wipe and allow to air dry.

Based on observation and interview, the facility failed to date/label foods in the walk in cooler and freezer and dry storage, had expired foods in the cooler and had open meat and other food items in the freezer in 1 of 1 kitchen. The findings included: During the initial tour of the kitchen on [DATE] at 1105am with the (Certified Dietary Manager) CDM, it was discovered that several foods in the chiller, refrigerator, freezer and dry storage had missing labels or were expired. Tour of the chiller, the opened and unlabeled container of yogurt expired on [DATE] and a box that contained an additional eight containers of yogurt expired on [DATE]. A container of opened horse radish expired on ,[DATE], but was still in use. The container of banana peppers, mayo and Italian food dressing did not have labels that acknowledged when they were open or expired. Tour of the refrigerator revealed peaches that had an expiration of [DATE] and 3 bags of lettuce, one opened, that had an expiration date of [DATE]. Tour of the freezer revealed a bag of opened carrots and several boxes of opened chicken breasts and crab cakes. These items were opened and there was evidence of ice on all. Tour of the dry storage area concluded several items with no labels and also several expired items. The corn cereal crumbs were observed to have expired on [DATE]. Grits expired on [DATE]. The canola oil, Worcestershire sauce, seasoning and seasoning sauce all were opened but had no label. Upon recognition of all issues, CDM removed and discarded all items that were out-of-date or unlabeled.

Based on record review and interview, the facility failed to protect Resident #1 from misappropriation of property, 1 of 1 resident reviewed for misappropriation. Certified Nursing Assistant (CNA) #1 used the resident's phone charger without permission on 2 occasions. The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In an interview with resident on 1/9/18 at 1234pm, it was revealed that staff had misappropriated the property of Resident #1 on 12/29/17 and on another unknown occasion. Resident states that he/she was awoken one night to a staff member rummaging through his drawer, attempting to borrow his/her cell phone charger. Resident states I asked her/him what she/he was doing and she/he said that she/he was just borrowing a wire and then left. The charger was missing all night but was returned the next morning. Resident states that he/she did not give staff member permission and that this was done on two separate occasions. At the time of the interview, Resident had not yet reported the incident to management because he/she wanted to wait until his/her care plan meeting that would be happening later during the day of 1/9/18. In an interview on 1/10/18 at 945, the (Director of Nursing) DON was asked about her expectations as far as staff using resident's property, DON responded I would expect them to ask for permission. I would not want any of my staff using anything that belongs to the resident because that's their room and personal space. DON was then asked about the procedure that is followed when learning of a staff member misappropriating resident belonging and she stated Staff would be suspended pending investigation. Depending on the findings, the staff member may be terminated or brought back to work with education. In any case, there would be an in-service training for everyone. On 1/10/18 at 422pm, DON stated that a suspect had been identified and suspended. DON also stated that the incident had been reported to DHEC. At 530pm, DON returned and stated that CNA #1 had been terminated. On 11/11/18 at 1145am, a phone interview was held with CNA #1, the alleged suspect. CNA #1 stated that she/he had taken a trip to Jamaica and had pictures on her phone that she/he wanted to share with other staff members. CNA #1s phone was dead so it was suggested to her/him by another staff member to borrow the charger of Resident #1. CNA #1 states that permission was asked of Resident #1 to use the charger and she/he charged her/his phone to one bar, inside of Resident #1s room. On 1/11/18 at approximately 200pm, DON provided a full copy of the misappropriation investigation. The incident was reported to Ombudsman on 1/10/18 at 344pm and the state agency on 1/10/18 at 356pm.

Based on observation, interview, and review of the facility's policy, the facility failed to timely identify and remove an expired medication from the current medication supply in 1 of 1 Pyxis MedStation reviewed. The findings included: On 02/14/2017 at 2:43 PM, review of the Pyxis MedStation revealed a 1 ml (milliliter) vial of Promethazine HCL(hydrocholoride) Injection 25 mg (milligrams) / ml with an expiration date of 10/2016. During an interview at that time, the Consultant Pharmacist confirmed the vial of medication expired in October, 2016. The Pharmacist stated that there was no documentation of the last time the Pyxis MedStation was reviewed but confirmed the Pharmacy reviewed the Pyxis machine monthly stating I probably looked at it upside down and thought the 6 (in 2016) was an 8. Review of the facility's policy at 9:30 AM on 2/15/17 revealed that the Pharmacy representative should not place any medications with expiration dates of less than 90 days in the AMDS (Automated Medication Delivery System), or per applicable state regulation. In addition, the policy stated The AMDS will be routinely inspected by the pharmacy. During an interview when the facility policy was provided, the Nursing Home Administrator confirmed that the Pyxis should be inspected at least every 90 days and stated clearly it wasn't done.

On the days of the survey, based on observation, record review and interview the facility failed to provide necessary care and services for 1 of 5 residents reviewed for pain and 2 of 13 residents reviewed for allergies. The facility failed to ensure Residents #3 and #5 did not receive medications documented on the resident's known allergy list resulting in an adverse reaction for Resident #5 and failed to consistently monitor pain levels for Resident #4 to determine if the resident would benefit from a routinely administered pain medication. The findings included: The facility admitted Resident #5 on 5/15/12 with [DIAGNOSES REDACTED]. Review of the medical record on 8/14/12 revealed allergies noted in the record as Latex, [MEDICATION NAME], and [MEDICATION NAME]. Review of Resident #5's H&P documented Latex, [MEDICATION NAME] and [MEDICATION NAME] as allergies indicating the facility should have been aware of the residents allergies once admitted . Resident #5 had a Physicians order on 5/31/12 for Keflex 500 mg which is [MEDICATION NAME]. Following the administration of the Keflex Resident #5 had an adverse reaction to the medication. Review of the Nurses Notes on 8/14/12 dated 6/1/12 at 4:15 PM "Resident......an episode of diarrhea and vomiting." at 9:30 "Resident sitting up in w/c with complaint of (c/o) nausea and vomiting (n/v) times (x) episodes. States "I think that antibiotic made me sick." There was a order on 6/1/12 to discontinue Keflex 500 mg due to adverse reactions. During an interview with the Pharmacist on 8/16/12 he stated he was not aware of the event, and "being that there was only 1 dose given and a negative urinalysis and culture it is a possibility she may have been allergic to the [MEDICATION NAME]." The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Review of the medical record on 8/14/12 revealed allergies noted in the record as [MEDICATION NAME], Sulfa, [MEDICATION NAME], and Latex. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Medical History and Physical documented allergies as [MEDICATION NAME], Bactrim, [MEDICATION NAME], Sulfer, and Latex. A Review of the History and Physical (H&P) from Network Geriatrics documented "Allergies: Multiple and include [MEDICATION NAME], [MEDICATION NAME], and Sulfa drugs. [MEDICATION NAME] is listed as an allergy, although she is on it and [MEDICATION NAME]." Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 8/14/12 at 4:35 PM the Medical Director and also one of the [MEDICATION NAME] Physicians was interviewed. The Director stated he was not aware of this allergy. There were several ways to address conflicting allergies. Nursing could catch while reviewing the record and could notify the family to clarify which were true allergies. The Pharmacist could check allergies and notify Nursing or the Physician if an order came in that reflected allergy or medication would react with allergy medication. The Director stated he would contact the family immediately to verify and clarify which medications were true allergies. An order was written on 8/14/12 for allergy clarification: Remove [MEDICATION NAME], and [MEDICATION NAME] per conversation with daughter. ONLY true allergies are 1. Sulfa Drugs cause Sk--Johnson Symptoms, 2. [MEDICATION NAME] causes nausea, vomiting, and fever/malaise. On 8-16-12 at approximately 10:20 AM during an interview with the Pharmacy Consultant, he stated that he was not too concerned when a medication is ordered that is on a Resident's allergy list. He further stated that most of the allergies listed are not true allergies, but only side effects of the medication. He further stated that on a true allergy, the resident would be sent to the hospital almost immediately after taking the medication because it would shut down the air way with swelling. He stated that he had been in the business many years and he had not had any one die from taking a medication that was listed as an allergy. The facility admitted Resident # 4 with a [DIAGNOSES REDACTED]. Review of the Medical Record revealed that Resident # 4 did not have a routinely scheduled pain medication. She was receiving [MEDICATION NAME], 10 mg (milligram) Q (every) 4 hours PRN (as needed). Further review revealed that of the 31 times that pain medication was given to Resident # 4 from 8-5-12 through 8-14-12 only 13 times was the pain rated by a number. On 8-8-12 at 12:20 it was rated at a 10. On 8 occasions it was rated at a 9: on 8-14 at 9:50 and at 14:15, on 8-11 at 5:30 and at 17:10, on 8-8 at 12:20 & 17:55 on 8-6 at 19:40 and on 8-5 at 15:50. And on 5 times it was rated at a 7: on 8-14 at 14:15,on 8-11 at 22:40, on 8-10 at 17:45, on 8-9 at 8:30 and on 8-8 at 22:30. Interview with Physical Therapist # 1 on 8-15-12 at approximately 12:30 PM, she stated that Resident # 4 seldom verbalized that she was in pain. During an interview with the ADON (Assistant Director of Nursing) on 8-15-12 at approximately 2:00 PM, she reviewed Resident # 4's Doctors referral book. She stated that their were no notations related to pain or for toe nail care being needed. The ADON further stated that Resident # 4 has a flat affect and does not ask for pain medication, but will respond to a question about pain and indicate how much pain she is in and that it most always at a high level. The ADON further confirmed that Resident # 4 does not have routine pain medications to be given before therapy or before pressure sore treatment. During a conversation between Resident # 4 and this surveyor on 8-16-12 at 1:00 PM, she stated that she is always in pain.

On the days of the survey, based on record review and interview, the pharmacy failed to report an irregularity in the drug regimen of 2 of 13 residents reviewed for allergies [REDACTED].#3 receiving Valium which was documented as an Allergy for the resident, but also recommended a change to Xanax, which was also listed as an allergy for Resident # 3. An allergy to Penicillin documented for Resident #5 was not noted when a physician's orders [REDACTED]. The findings included: The facility admitted Resident #5 on 5/15/12 with [DIAGNOSES REDACTED]. Review of the medical record on 8/14/12 revealed allergies [REDACTED]. Review of Resident #5's H&P documented Latex, Benadryl, Penicillin and Codeine as allergies [REDACTED]. The pharmacy was notified by the facility per protocol of the medication order and the order was filled as written. Following the administration of the Keflex Resident #5 had an adverse reaction to the medication. Review of the Nurses Notes on 8/14/12 dated 6/1/12 at 4:15 PM "Resident......an episode of diarrhea and vomiting." at 9:30 "Resident sitting up in w/c with complaint of (c/o) nausea and vomiting (n/v) times (x) episodes. States "I think that antibiotic made me sick." There was a order on 6/1/12 to discontinue Keflex 500 mg due to adverse reactions. Review of the medical record did not have any documentation validating if Resident #5 was truly allergic to penicillin. During an interview with the Pharmacy Consultant on 8/16/12 he stated he was not aware of the event, and "being that there was only 1 dose given and a negative urinalysis and culture it is a possibility she may have been allergic to the penicillin." The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Review of the medical record on 8/14/12 revealed allergies [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Medical History and Physical documented allergies [REDACTED]. A Review of the History and Physical (H&P) from Network Geriatrics documented "allergies [REDACTED]. Valium is listed as an allergy, although she is on it and Xanax." Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Xanax was also listed as an allergy on the Physicians Order Sheet. A Pharmacy review was done on this resident on 6/22/12. There was no documentation in the record that the Pharmacist identified the drug "Valium" as an allergy. Instead the Pharmacist did recommend to the Physician that the Valium be changed to Lorazepam which would be longer acting. The Pharmacist did not note this drug was also listed as" Allergy To. " An interview with a Pharmacy Consultant on 8/16/12 at 9 AM revealed the following: He stated he wouldn't consider allergies [REDACTED]. He stated he would not note that to the Doctor or the DON (Director of Nursing.). He would assume this not to be a true allergy but maybe just some side effect that occurred at some point.