Every finding on record at PruittHealth- Aiken

Based on record review, interview, and policy review, the facility failed to ensure staff provided Cardio-Pulmonary Resuscitation (CPR) to one of one resident (Resident (R) 160) who did not have a valid Do Not Resuscitate (DNR) order in place. As a result, R160 expired.The facility's Administrator, Nurse Consultant, and [NAME] President were informed on [DATE] at 11:30 AM that Immediate Jeopardy (IJ) existed at F678 at a Scope and Severity (S/S) of J related to the staff's failure to initiate CPR on R160 without a valid DNR order in place. The Immediate Jeopardy began on [DATE], when staff failed to initiate CPR on R160 without a valid DNR order in place. On [DATE] at 6:16 PM, the facility provided a Removal Plan that was accepted at 6:30 PM. The survey team validated the implementation of the removal plan through observations, staff interviews, and record reviews on [DATE] at 7:10 PM, and the scope and severity was lowered to D.Findings include:Review of the Face Sheet, located in R160's electronic medical record (EMR), under the Facility Face Sheet tab, indicated that staff admitted resident R160 to the facility from an acute care hospital on [DATE] and re-admitted the resident from an acute care hospital on [DATE]. Her code status was documented as DNR, Palliative Care under the Header and Advance Directives areas. Pertinent diagnoses included urinary tract infection (UTI), type 2 diabetes mellitus, chronic kidney disease (stage 3), acute on chronic systolic congestive heart failure, and hemiplegia (paralysis on one side of the body) and hemiparesis (one sided muscle weakness) following cerebral infarction (stroke) affecting the left non-dominant side.Review of the Physician's Orders, dated [DATE] (admission) and [DATE] (readmission), located in R160's EMR under the Orders tab, revealed R160's code status was Full Code (initiate CPR in the event the resident's heart or respirations cease).Review of R160's admission Packet dated [DATE], located in the EMR, under the Resident's Documents tab, revealed a document titled, Social Services SC [South Carolina] Advance Directive for Health Care Form, signed by R160 on [DATE], which indicated, I [R160] have not executed an advance directive but would like to obtain additional information and resources to complete an advance directive. Instructions and forms for completing advance directives were provided to me. The section titled DNR noted, I [R160] do not have a DNR Order in place but would like to obtain additional information and resources on how to have one executed on my behalf. Information regarding South Carolina DNR Orders was provided to me.Review of R160's Care Plan, initiated on [DATE] and last reviewed/revised on [DATE], located in the EMR, under the Care Planning tab, revealed R160's code status was Full Code The goal of the care plan noted that, If the patient/resident's heart stops, or if the patient/resident stops breathing, CPR will be initiated in honor of the FULL CODE wishes through the next review period. Review of the Minimum Data Set (MDS) assessments, located in R160's EMR under the MDS tab, revealed the facility did not complete an admission MDS assessment. R160 was not in the facility for more than 14 consecutive days during her stays.Review of R160's EMR, under the Advanced Directives tab, revealed R160 did not have an advance directive in place at any time during her admissions to the facility. Further review revealed that the resident did not have a South Carolina (SC) Emergency Medical Services (EMS) Do Not Resuscitate (DNR) Order form or a Physician Orders for Life-Sustaining Treatment (POLST) portable medical order on file at any time during R160's stay. Review of R160's hospital Discharge summary, dated [DATE], located in R160's EMR, under the Resident Documents tab, indicated, the Patient states that she has signed DNR paperwork however when I clarified this would mean no chest compressions she states you can do them. I stated this would be a full code and she said fine put a full code. She then stated that she wanted me to call [son's name] and have him make the decision for her. She states what ever [sic] he puts full code versus DNR/DNI [do not intubate] she will be in agreement with. She identifies her son [son's name] as her surrogate decision-maker and I [physician] called [son's name] for collateral information. Patient's son states that she has been continuing to decline for the last few years. He [patient's son] states ever since her stroke she has been acting childlike with fluctuating emotions. He also states that the patient was living with his brother who plans to move to Florida within the next week. [Son's name] states that he has signed documents that his mother requested to be a DNR and would like her to be DNR at this time given that it is her previously expressed wish in the documentation that they have. Will plan to engage case management, they are open to considerations of hospice as he is very aware his mother's medical conditions are not reversible.Review of R160's Physician Progress Note, dated [DATE], one day after readmission, located in R160's EMR, under the Resident Progress Notes tab, revealed, [R160] was re-admitted to the hospital for altered mental status. She was diagnosed with a UTI and treated. Imaging also showed evolving effects from her stroke. She had some mild acute renal failure treated with IV [intravenous] fluids. Given her condition and chronic medical conditions, it was decided to make her a DNR. There is a plan to initiate palliative care with a transition to hospice when she is ready. See the discharge summary for further details.Review of R160's Nursing Progress Note, dated [DATE] at 4:10 AM and documented by Registered Nurse (RN) 5, revealed Writer's rounds on the floor. Resident is at her baseline-with intermittent hollering and calling out. Between 4:10 AM-5:05 AM: Writer and Certified Nurse Aid [CNA] can still hear resident hollering [sound can be heard in the nurse's station]. 5:05 AM: Writer started morning medication pass . 5:15 AM: CNA called writer to go to resident's room. Once in the room, found resident flat on bed, warm, soft to touch, no pallor. Eyes closed, not breathing. Checked pulse while calling out resident's name, no pulse, no response, tried sternal rub. Still no response, breathless, and pulseless. CNA also called another RN [name] to confirm. Double checked by both writer and colleague, resident has passed. Resident DNR on file, no resuscitation done, called time of death at 5:20 AM . A review of the Certificate of Death, dated [DATE] and provided by the facility, indicated that the certificate, obtained from the coroner's office on [DATE], listed R160's cause of death was related to a stroke.Review of the facility's Investigation, dated [DATE], provided by the facility, revealed that the facility conducted a self-initiated investigation regarding R160's code status. The investigation concluded that the responding RN acted appropriately and ethically in deciding not to initiate resuscitation, along with validation from a second RN at the time of the event. However, the facility identified a failure to transcribe current physician orders onto the active orders page; these orders were documented only in the progress notes. Additionally, a second physician documented in the hospital discharge summary that the resident's code status was DNR. The facility obtained a copy of the SC EMS DNR Transfer Form, dated [DATE], signed by the resident, which was reimplemented upon return from the hospital and aligned with the discharge summary. Corrective actions included educating all licensed nurses on the facility's policy regarding Advance Directives and conducting a 100% audit of all residents' Advance Directives to ensure the medical record clearly reflected the resident's wishes and corresponding physician orders on the active orders page. Review of the Validation Audits, dated 05/2025 through 12/2025, provided by the facility, revealed that staff conducted an initial audit of all facility residents' code status to ensure accuracy on [DATE] and continued audits periodically thereafter.Review of the Quality Assurance and Performance Improvement (QAPI) Meeting Minutes, dated 06/2025 through 11/2025, provided by the Administrator, revealed that the facility reviewed the occurrence related to R160's DNR (code status). The facility noted that staff found R160 unresponsive. According to the Banner in MxC [MatrixCare- the EMR], resident DNR. MD [medical doctor] note from the facility shows the resident to be a DNR and the Nurse utilized that for determination. Nurse's determination to respect the resident's wishes and honors. Clinical Leadership stated education to be on-going related to ADs [advance directives]. Will audit accordingly to ensure validation and up-to-date. The facility continued to review code status at each monthly meeting.Review of the facility's Inservice Education Program Summary Record Forms, dated [DATE] through [DATE], revealed that the facility provided training on DNR and Full Code procedures. The training included instruction on the location and use of the DNR binder and crash cart, the facility's admission policy for Full Code/DNR status, procedures for contacting appropriate personnel during a code, and documentation of code events in Matrix. The facility provided additional in-service education sessions addressing code status on [DATE], [DATE], and [DATE]. However, the facility's documentation did not include evidence that it followed up to verify staff comprehension of the information presented during these trainings.During an interview on [DATE] at 3:49 PM, Licensed Practical Nurse (LPN) 3 stated that on [DATE], while working as a floor nurse, RN5 informed her that R160 passed away but expressed uncertainty because the Banner in the EMR indicated R160 was a DNR while the physician orders reflected Full Code. LPN3 stated that she reviewed R160's EMR and confirmed that the physician's orders documented R160 code status as Full Code. LPN3 stated that when she asked RN5 what time R160 expired, RN5 stated approximately 45 minutes ago. LPN3 contacted the Director of Health Services (DOHS) to report the situation and reported the DOHS told her that if R160 was already gone, there is nothing we can do about it now. During an interview on [DATE] at 6:00 PM, RN2 stated that if she found a resident unresponsive, she would look in Matrix (the EMR) to verify the code status. RN2 stated if there were discrepancies in the resident's code status, she would follow the code status noted in the resident's medical record; that was where she looked first.During an interview on [DATE] at 6:01 PM, CNA7 stated that if she found a resident unresponsive, she would alert the nurse. Upon inquiry, CNA7 stated that she would find the resident's code status in the resident's care plan.During an interview on [DATE] at 6:04 PM, LPN4 stated that if she found a resident unresponsive, she would call for help and look for the resident's code status. If the resident's code status were full code, she would activate a code blue and start CPR. She stated that she would follow the code status listed on the computer, as the binder may not be updated. If the clinical record contained conflicting information, she would call the responsible party first; if they did not answer, she would call the DOHS. LPN4 added that if the computer said the resident was a DNR and the binder said the resident was a full code, she would look at the notes in the clinical record, continue to research, but keep doing CPR. She would rather take the chance of keeping the resident alive.During an interview on [DATE] at 6:10 PM, LPN5 stated that if she found a resident unresponsive, she would look on the computer or the DNR binder to determine code status. If there were conflicts with the resident's code status, she would look for the signed DNR form. If one was not available, she would continue to code blue (CPR).During an interview on [DATE] at 6:10 PM, LPN1 stated that if she found a resident unresponsive, she would check the physician's order to determine the resident's code status. LPN1 stated all residents' codes statuses were noted in the resident's medical record and in a blue binder located at the nurses' station and crash cart. LPN1 stated that she followed the physician's order and that a discussion must be done with the resident or representative and paperwork completed for the resident's code status.During an interview on [DATE] at 6:10 PM, LPN7 stated that if she found a resident not breathing, she would call for help, look for the resident's code status in the DNR binder on the crash cart, in the computer, and the Banner in the EMR.During an interview on [DATE] at 6:20 PM, RN4 stated that if she found a resident unresponsive, she would look up the resident's code status on the iPad and notify the unit manager and DOHS via text. RN4 stated that there was also a blue binder at the nurses' station that listed the code status for all facility residents. RN4 stated that if there were any confusion or discrepancies in the documentation of code status, the resident would be considered a full code.During an interview on [DATE] at 6:23 PM, LPN9 stated that if she found a resident unresponsive, she would check the resident and immediately start CPR, if the resident was a Full Code. The resident's code status was listed in the computer on the Banner, the face sheet, and the DNR binder. LPN9 stated that if there were discrepancies between the code status in the computer or binder, she would opt for saving the life of the resident and start CPR.During an interview on [DATE] at 6:25 PM, LPN8 stated that the facility only accepted DNR requests that included the SC Department of Health and Environmental Control (DHEC) logo. The SC EMS DNR Order was not accepted. LPN9 stated that two providers must sign the document. If the resident had a BIMS score greater than 11, the resident could sign the form, or the proxy may sign it if a properly executed medical power of attorney were on record with the facility. LPN9 stated that if verbal consent from the proxy was used, a provider must be physically present and hear the conversation with the proxy, and two nurses at the facility must witness the conversation.During an interview on [DATE] at 6:30 PM, the DOHS confirmed that the resident's physician's order listed the resident as full code. The DOHS confirmed that R160 did not have the SC DHEC form in the clinical record and stated that they were in the process of getting it. The DOHS provided copies of R160's physician progress note dated [DATE], which stated, Given her [R160's] condition and chronic medical conditions, it was decided to make her a DNR. [Name of Hospitalist] at [local hospital], Code Status: During Arrest: Do Not Resuscitate. The DOHS stated that she completed a 100% validation audit at the time of the occurrence. Each unit had its own DNR binder that included a list of residents' code status, which was updated weekly on Tuesdays.During an interview on [DATE] at 6:51 PM, RN5 stated that when R160 coded, he was in the middle of a medication pass. While he was in another room, the resident's CNA came and told him that the resident was unresponsive. He went to R160's room with his iPad. RN5 stated that during report, the nurse advised him that R160's code status was a DNR. When the resident coded, he checked the Banner in the EMR, which listed R160 as a DNR. RN5 stated that, in that situation, the first thing he checked to determine the resident's code status was the Banner in the clinical record. RN5 stated that he did not look at the physician's order to verify the resident's code status stating, I do not have time to do that in that situation. RN5 stated that he asked RN3, who was working on another unit, to confirm that R160 expired. RN5 stated that he notified Unit Manager (UM) 1 that R160 expired (unable to state the time). At that time, they identified a discrepancy between R160's physician's order (Full Code) and the physician's progress note (DNR, Palliative Care) dated [DATE].During an interview on [DATE] at 7:15 PM with the Administrator, when asked what the facility did upon finding a discrepancy between R160's physician's order (full code) and the clinical record, he stated that he felt they had done everything they needed to do to ensure it would not happen again. On [DATE], seven months after the resident expired, and after the survey team advised the facility of the serious concern identified on [DATE], the facility obtained and uploaded a copy of R160's SC EMS DNR Order form dated [DATE], which the facility obtained from the local hospital.During an interview on [DATE] at 7:53 AM, RN3 stated that on [DATE] around 5:20 AM, RN5 came down the hall with his iPad and stated that he thought R160 had passed away and wanted her to verify the resident expired. RN5 showed her the Banner in the clinical record, which showed the resident was a DNR. So, she went to the resident's room, could tell she was not alive, checked her vitals and respirations, and there were none. RN3 stated that if a resident was found unresponsive, the first person on scene stayed with the resident, called for help, checked the resident's code status in documents located in the clinical record or in the DNR binder kept at the nurses' station, and verified if they were a full code or DNR. If staff were unsure of code status, a resident was treated as a full code. RN3 stated that the resident's code status in the Banner was not linked to the physician's orders. Instead, the code status was linked to the resident's face sheet. RN3 stated that she does not rely on the Banner in the clinical record, and that the DNR binder was updated once a week or more frequently.During an interview conducted on [DATE] at 9:16 PM (post-survey exit), the resident's physician returned a phone call initiated during the survey and stated that he no longer worked for the facility. He reported that he remembered the resident but no longer had access to the clinical record and had no recollection of the event in question. The physician indicated he could not provide additional information because the incident occurred approximately seven months prior.Review of the facility's policy titled, Cardiopulmonary Resuscitation, last reviewed on [DATE], indicated, Cardiopulmonary resuscitation [CPR] must be initiated on any patient/resident that has experienced cardiac arrest and does not have a Do Not Resuscitation [DNR] order. The nurse will not initiate CPR, even in the absence of a DNR, if a patient/resident is obviously clinically and irretrievably dead and the death was not witnessed. Examples of signs that a patient/resident is clinically irretrievably dead include: No measurable vital signs, cool to the touch, and pupils that are fixed and dilated. If there was no DNR order, and there was any question about whether or not the patient/resident was clinically and irretrievably dead, the nurse shall always initiate CPR. If the death is witnessed and there is no DNR order, CPR will be initiated, even if the patient/resident is clinically and irretrievably dead. The policy did not include a process for obtaining physician orders for code status.According to South Carolina Title 44, Chapter 78, the Emergency Medical Services [EMS] DNR Order applies only to pre-hospital personnel and does not fulfill nursing facility obligations to maintain a valid advance directive or physician orders for life-sustaining treatment [POST] order. Furthermore, EMS policy indicates that living wills or advance directives are not honored without a physician-signed POST order.

Based on observations and interviews, the facility failed to provide a safe, clean, and homelike environment for residents who used Spa 100 (the shower room). This failure had the potential to adversely affect all 40 residents currently residing on Hall 100 by preventing effective cleaning of the Spa 100 shower area. Findings include:During the Resident Council Meeting on 12/17/25 at 2:00 PM, some of the residents, who requested to remain anonymous, complained that the shower room on 100 Hall was in disrepair and had mildew on the walls. Observations on 12/18/25 at 12:15 PM of the 100 Hall Spa, with the 100 Hall Nurse Manager, Licensed Practical Nurse (LPN) 6, revealed: A wall area of approximately two feet by two feet in shower one had numerous missing wall tiles. On the opposite wall, in shower one, several wall tiles were missing, and the handrail was loose, held in place by one screw. Plywood was exposed on both walls where the tiles should have been located. In shower two there were several cracked shower tiles on the walls, and there was a black substance on the grout area of the tiles located in the right back corner. In addition, the shower room was missing several ceramic tiles on the floor, where water collected and left the area difficult to clean. During an interview on 12/18/25 at 12:18 PM, LPN6 stated she did not know why repairs had not been completed and said to ask housekeeping about the black substance on the tiles and grout lines. During an interview on 12/18/25 at 12:30 PM, the Housekeeping Manager (HM) stated the shower room was on an every-other-day cleaning schedule. The HM stated she did not know if the buildup of the black substance on the wall looked like it had been there longer than two days. The HM stated there were so many resident showers being completed daily that the shower room remained in a damp condition. During an observation and interview on 12/18/25 at 1:00 PM, the Administrator and Maintenance Director (MD) confirmed Spa 100's missing tiles in shower one, missing tiles on the shower room floor, and the black substance on the wall and cracked tiles in shower two. The MD stated he tried to repair the missing tiles on the floor, but the repaired tiles would not stay down. The Administrator stated that shower one used to be blocked off so no one could use it but agreed it was currently accessible for use. The Administrator explained the building was older, and this was one of the shower rooms that had not been remodeled. The Administrator stated he did not have a housekeeping policy or written process regarding cleaning of the shower tiles.

Based on record review and interviews, the facility failed to refer residents diagnosed with a serious mental illness for a Preadmission Screening and Resident Review (PASARR) level two evaluation for two of two residents (Resident (R) 4 and R34) reviewed for PASARR out of a total sample of 35 residents. This created a potential failure to identify what specialized services the residents needed and whether placement in the facility was appropriate.Findings include:1. Review of R4's Face Sheet located under the Resident tab in the electronic medical record (EMR) indicated R4 was admitted to the facility on [DATE] with diagnoses including major depression, bipolar disorder, and mood disorder.Review of R4's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/20/25 located in R4's EMR under the RAI tab, revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicating R4 was moderately cognitively impaired. Review of R4's EMR under the Resident Documents tab revealed a Level I PASARR completed on 10/16/19, which indicated a mental illness diagnosis of bipolar disorder with the recommendation of no further evaluation. Further review of R4's EMR revealed no Level II PASARR. The facility was unable to provide a Level II PASARR for R4 completed prior to the survey.2. Review of R34's Face Sheet located under the Resident tab in the EMR indicated R34 was admitted to the facility on [DATE] with diagnoses including personality disorders, dementia, adjustment disorder with depressed mood, and depression.Review of R34's quarterly MDS with an ARD of 11/19/25 located in R34's EMR under the RAI tab, revealed a BIMS score of 14 out of 15 indicating R34 was cognitively intact.Review of R34's EMR under the Resident Documents tab revealed a Level I PASARR completed on 12/01/22 indicating a mental illness diagnosis of depression with the recommendation of no further evaluation.Review of R34's EMR under the Resident Documents tab indicated a psychotherapy note dated 10/07/25 where R34 was provided the diagnosis of bipolar II disorder.The facility was unable to provide evidence of a request for a Level II PASSAR evaluation done prior to the survey and following R34's diagnosis of bipolar disorder.During an interview on 12/18/25 at 10:30 AM, Social Worker (SW) 2, stated she was not aware, until recently, of R34's additional diagnosis of bipolar disorder. When asked if there was a process in place for her to be notified of a resident's significant mental health changes so a referral for a Level II PASARR could be completed, SW2 stated, No. During an interview on 12/18/25 at 10:35 AM, the three MDS Case Manager (MDSC) nurses, MDSC1, MDSC2, and MDSC3, stated the mental health provider should notify the facility when a new, significant mental health diagnosis was added. A psychiatrist's note did not immediately pull over into the EMR for review.During an interview on 12/18/25 at 2:45 AM, the Administrator acknowledged they completed R4's Level II PASARR during survey when unable to locate the original one that was completed several years ago. When asked if there was a policy or procedure in place to prevent this from happening in the future, the Administrator stated, No.

Based on observation, interview, and review of facility policy, the facility failed to provide Resident (R)9 and R10, their right to a dignified existence. Specifically, the facility staff failed to provide R9 with appropriate clothing since his admission to the facility on [DATE]. Additionally, facility staff failed to provide R10 with dignity, when staff was observed completing in-service training in the resident's room. For 2 of 2 residents reviewed for dignity. Findings include:Review of the facility policy titled Resident's [NAME] of Rights revealed, As a resident of this facility, you have and your legal guardian has the right to personal treatment including, be treated with respect and dignity, and the right to personal privacy.Review of R9's Face Sheet revealed R9 was admitted to the facility on [DATE], with diagnoses including but not limited to cerebral infraction, other speech and language deficits following cerebral infraction, adult failure to thrive, and anxiety disorder due to known physiological condition. Review of R9's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/15/26, revealed R9 had a Brief Interview for Mental Status (BIMS) of 5 out 15, which indicated that R9 had severe cognitive impairment. Further review of the Quarterly MDS revealed that R9 requires substantial/maximal assistance with upper body dressing and is dependent on staff for lower body dressing.Review of R9's Care Plan with a problem last revised on 01/20/26, revealed, [R9] has attention seeking behavioral symptoms: yells when no on is near resident and curses when staff approach, crawls/rolls on floor in room and yells. Resident frequently states that he is hungry after receiving meals, fixated on getting food items. Interventions directed staff to behavior management program as needed, assess whether behavior endangers resident, keep bed low and pathways clear in room to decrease risk of injury when resident crawls on the floor. During an observation on 02/05/26 at 4:27 PM, R9 was observed in a reclining position wheelchair ([NAME]) in a green hospital gown and undressing himself in an area near the nurse's station, around other residents and staff. During this observation no staff made attempts to redirect the resident or cover him with appropriate clothing/blankets. During observation of R9 undressing himself in a public area Registered Nurse (RN)1 was at the nurse's station and also made no attempts to redirect the resident until asked by the surveyor. RN1 then went to place a blanket over R9 to protect his dignity while around other residents/visitors. During an interview on 02/05/26 at 4:38 PM, the Director of Nursing (DON) revealed that R9 is care planned for behaviors, but he does not have a specific care plan intervention related to his behavior of undressing himself in public. The DON further stated that [R9] has no clothes at the facility, and his Certified Nursing Assistant (CNA) had just given him Activities of Daily Living (ADL) care prior to placing him near the nurses station. We can't keep him in his room because we can't seclude the resident and he is a fall risk.During an observation on 02/05/26 at 4:46 PM, of R9's room and closet revealed that R9 had no clothing or shoes in his possession. R9 at this time was in a unit dining room/day area with a staff member supervising him, R9 was observed in a hospital type gown sitting in his [NAME] chair. During an interview on 02/05/26 at 5:22 PM, the Administrator and DON stated, [R9] has little to no family involvement and that they have not provided him with any clothing or personal items since he admitted to the facility. When residents don't have appropriate clothing nursing staff are expected to reach out to the Laundry staff to see if there any left-over clothing items from residents that have passed away or discharged from the facility. The DON stated that she was unsure why no staff made attempts to provide R9 with appropriate clothing or shoes. Review of R10's Face Sheet revealed R10 was admitted to the facility on [DATE], with diagnoses including but not limited to Alzheimer's Disease, muscle weakness, unsteadiness on feet, and restlessness and agitation. Review of R10's Quarterly MDS with an ARD of 12/01/25, revealed that R10 had a BIMS score of 3 out of 15, which indicated she had severe cognitive impairment. During an observation and interview on 02/05/26 at 4:26 PM, of R10's room revealed Certified Nursing Assistant (CNA)1 sitting in a chair with the resident's bedside table in front of her completing an in-service for the facility on a facility provided tablet. CNA1 denied being on one-to-one supervision with the resident and stated that the resident was near the nurse's station outside of room. CNA1 further stated that she should have completed the in-service in a break area or at the nurse's station and should not be in a resident's room without their permission to respect the privacy of their room/home. During an interview on 02/06/26 at 5:25 PM, the Administrator and DON revealed that staff should show respect/dignity in resident's rooms. Both later admitted that the CNA's behavior did not meet their expectations related to dignity.

Based on observations, document review, and interviews, the facility failed to provide public access to the most recent survey results and any plan of correction. The failure had the potential to affect all residents, families, and visitors at the facility by reducing transparency. The facility reported a census of 149 residents.Findings include:Observation in the main hallway of the facility, on 12/17/25 at 2:57 PM, revealed a small, brown cabinet with a sign indicating Annual Survey Results Inside. In the cabinet was a blue binder labeled Survey Results. The binder contained survey results of complaint surveys dated 06/18/25, 03/24/25, 02/22/25, 01/23/25, 12/31/24, 11/21/24, 07/26/24, 05/02/24, 11/02/23 and 08/02/23. The facility's previous recertification survey was conducted on 09/12/24. An interview with the Administrator on 12/17/25 at 3:00 PM confirmed the facility binder titled Survey Results lacked the results of the previous recertification survey conducted on 09/12/24. An additional interview with the Administrator on 12/18/25 at 9:00 AM confirmed the facility lacked a policy addressing the survey results postings.

Based on facility policy review, record review, observations, and interviews, the facility failed to ensure that Resident (R)1's medications were not misappropriated for 1 of 1 resident reviewed for misappropriation. Findings include: Review of the facility policy titled, Medication Administration: General Guidelines, with a last review date of 7/22/2024, revealed -Medications are administered in accordance with written orders of the attending physician. -All current medications and dosage schedules, except topicals used for treatments, are listed on the patient/resident's medication administration record (MAR) or within the e-MAR system for facilities using electronic charting of medications. -Medications for one patient/resident are never administered to another patient/resident. Review of the facility policy titled, Controlled Substance Diversion, with a last revision date of 4/29/24 reveals: It is the policy of [NAME] Health Pharmacy Services that medications listed as controlled substances (Scheduled I-V) under federal or state regulations will be properly stored with maintained accountability. Drug diversion is a medical and legal concept involving the transfer of any legally prescribed controlled substance from the individual for whom it was prescribed to another person for any illicit use. Review of the facility policy titled, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, with a last review date of 11/15/24 reveals: It is the policy of PruittHealth and its affiliated entities (collectively, the Organization) to actively preserve each patient's right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, exploitation, mistreatment, and misappropriation of patient property, (referred to collectively in this policy as abuse, neglect, mistreatment, and exploitation). The Organization and its partners should assure that best efforts are made to prevent any occurrences of any form of abuse, neglect, and exploitation. Record review of R1's face sheet revealed R1 was diagnosed with Anxiety Disorder. Review of R1's Physician orders revealed an order for Diazepam, Schedule IV tablet; 2 milligrams (mg); amt: 1 tab; oral Twice A Day 09:00 AM, 09:00 PM dated 7/2/24. There were no PRN (as needed) orders for Diazepam. Record review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/5/24 revealed R1 has a Brief Interview for Mental Status (BIMS) score of 15 out of 15, suggesting resident cognition is intact. Review of the facility document titled, Controlled Drug Record for [NAME] Health [NAME]. Dated 12/3/24 reveals: Date Medication was received 12/2/24 Count of 30 Drug: Diazepam tablet 2mg Order: 1 Tab by mouth twice daily. 12/15/24 at 10 PM reveals count of 9 after 1 tablet given. Signed initials 12/16/24 at 2 AM reveals count of 8 after 1 tablet given. Signed initials 12/16/24 at 6 AM reveals count of 7 after 1 tablet given. Signed initials 12/16/24 at 9 AM reveals count of 6 after 1 tablet given. Signed initials Record review of R1's Medication Administration Record (MAR) reveals: 12/16/24 at 9 PM: Licensed Practical Nurse (LPN)1 administered Diazepam 2 mg to resident. 12/16/24 at 9AM: LPN2 administered Diazepam 2 mg to resident. No recorded electronic documentation seen on MAR to indicate Diazepam 2 mg was given to resident by LPN1 at 2 AM and 6 AM as indicated by the Controlled Drug Record. Review of [NAME] Public Safety Incident Investigation/Report on 12/16/24 at 1945 (7:45 PM) revealed: 2 pills of diazepam 2 mg were documented as stolen by Officer Case (ID Number 883). Review of the facility document titled, Discipline 4 - Termination, dated 12/20/24 reveals staff member was terminated from the facility. Note states, Due to the serious nature of this allegation, and Partners failure to respond to requests for her statement regarding the matter, Partner is terminated from employment at this time. Review of undated witnessed statement by LPN2, revealed, During my morning med pass I noticed a med error when signing out a narcotic for one of my resident's. First, I went back to the orders to make sure I wasn't making a medication error. The order said to give BID, 9a,9P. I saw where the medication was signed out as given 10p, 2a, 6a then I gave it at 9a. I immediately made the unit manager aware of the situation who then made the DHS aware. Observation of hall 400 med cart with LPN3 on 12/23/24 at 12 PM revealed no additional discrepancies in controlled medication outside of date under investigation. An interview with R1 on 12/23/24 at 11 AM revealed, she knows she takes her Diazepam pills twice a day for her anxiety. R1 revealed that on 12/15/24, LPN1 gave her her nighttime pills, which included her Diazepam. R1 knows her Diazepam was in the cup, as she states its a white circular pill. R1 revealed she always checks her medication cups before taking her medications to ensure she is getting only what she is supposed to be getting. R1 denied receiving any additional doses of Diazepam 2 mg the following morning at 2 AM and 6 AM. An interview with LPN1 on 12/23/24 at 12:12 PM revealed LPN1 does not remember pulling two additional doses of Diazepam for the resident. LPN2 revealed that if the Controlled Drug Record reflects LPN1 signing out 1 dose of Diazepam at 2am and 6pm, LPN1 reveals that she probably did sign out those medication. LPN1 is unsure why she pulled the additional doses, despite not having a PRN order for diazepam and only an active order for diazepam twice a day at 9 AM and 9 PM. LPN2 also does not recall whether she administered the medication to R1, but states that if she did pull those additional doses, then she most likely gave them to the R1. She is unable to determine if the resident was experiencing increased anxiety that would warrant extra doses of diazepam. When asked why she acted outside of the provider's orders, the nurse responded, I don't know. An interview with the Director of Nursing (DON) and Administrator (ADR) at 12/23/24 at 12:30 PM revealed that when it comes to proper medication administration, it is their expectation for staff to follow provider orders and not deviate from the order. Additionally, it is the expectation of the DON and ADR to complete controlled medication reconciliation and counts during shift change between the off going and ongoing nurse. DON revealed that when discrepancy was found by LPN2, LPN1 was suspended pending investigation. LPN1 ignored the facilities attempts to contact her during the investigation. Due to LPN1's lack of communication with facility during investigation and the nature of the allegation, DON reveals the facility decided to terminate LPN1's employment. DON and ADR revealed that LPN1 was in breach of facility policy. DON revealed that at the conclusion of the investigation, the 2 missing Diazepam pills were considered unaccounted for.

Based on review facility policy, interview and record review, the facility failed to report an allegation of sexual abuse, involving Resident (R)2 and R1, to the Ombudsman, for 1 of 1 residents reviewed for abuse. Findings include: Review of the facility policy, with a revised date of 07/29/19 titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property documented, It is the policy to comply with all applicable federal and state requirements regarding the reporting of patient abuse, neglect, exploitation, mistreatment and misappropriation of property. The Ombudsman should also be notified as required by state law. Review of R2's Face Sheet revealed R2 was admitted to the facility on [DATE], with diagnoses including but not limited to: Alzheimer's disease, hypertensive chronic kidney disease, and anemia. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE], with diagnoses including but not limited to: chronic obstructive pulmonary disease, Type 2 diabetes mellitus with diabetic chronic kidney disease, and end stage renal disease. Review of R1's Progress Note, written by the Social Worker (SW), dated 11/22/24, revealed the SW was made aware by the charge nurse that his roommate, last night, had his penis out of his pants and told him to suck his penis. R1 reports his roommate did not touch him at all. The SW did speak with R1 who expressed he was awakened by roommate saying you gonna suck my dick. R1 also stated that his roommate walked from his side of the room to his and continued to make this statement along with I'll get the nurse to suck it then. R1 reports he told him to get away from him numerous times. The SW did inform the Administrator as well as the Director of Nurses (DON). The SW called the Responsible party (RP). Awaiting return call. Report has been made and police has been called. During an interview with the Regional Ombudsman Office on 12/02/24 at 10:12 AM, the Ombudsman stated, I didn't get the self-report from them on this allegation (sexual abuse). The last time I got something from them has been well over 6 months, any allegation of abuse, neglect or exploitation are to be reported to me. During an interview with the Administrator on 12/02/24 at 5:32 PM, the Administrator stated, I have not been reporting any allegations to the Ombudsman.

Based on observations, interview, and review of facility policy, the facility failed to ensure foods were properly stored and labeled. Additionally, the facility failed to remove expired food items from storage, in 1 of 1 main kitchen. Findings include: Review of the facility policy titled Quick References Shelf Life list, Brief Summary Sheet with an effective date of [DATE], and last revised on [DATE], states, All opened refrigerator items must have a use by date . all items will be dated on date of arrival. Further review of the policy states, Meat, poultry, fish, pork, vegetables and soup . 3 days shelf life. Review of the facility policy titled Leftovers with an effective date of [DATE] and last revised on [DATE], states, 2. Leftovers will be covered, labeled, and dated: then stored appropriately (refrigerated or frozen if necessary) immediately after the end of the meal service . 4. Leftovers that have not been properly stored will be discarded. (When in doubt throw it out.) During a tour of the kitchen on [DATE] at 9:47 AM, the following was observed in the walk-in refrigerator: Six (6) sandwiches, wrapped, undated and unlabeled. One (1) container of unknown orange pureed item, stored undated and unlabeled. Five (5) hard boiled eggs, undated and unlabeled. One (1) container of labeled pork loin with a used by date of [DATE]. Nine (9) small 2% white milk cartons with an expiration date of ,d+[DATE]. During an interview on [DATE] at 10:00 AM, the [NAME] Aid revealed the produce is to be dated and labeled as soon as it comes into the refrigerator and if it is not labeled, the policy is to take the food out and trash it. During an interview on [DATE] at 10:15 AM, the Kitchen Manager (KM) revealed that a label and date should be on all open foods in the walk-in refrigerator. The label is for 3 days and after 3 days the food is discarded. During an interview on [DATE] at 9:30 AM, the KM revealed that the expired milk was thrown out right after we left on yesterday and that the label for the snack bags for the residents with dialysis should be dated and labeled after the bags are made. During an interview on [DATE] at 4:00 PM, the Administrator revealed that the items should be labeled and thrown out if not. They (kitchen staff) should be checking the dates daily.

Based on observation, interviews, record review, and review of the facility policy. The facility failed to prevent the misappropriation of controlled medication for one of one resident (Residents (R)99) reviewed. Findings include: Review of the facility policy titled Controlled Substance for Healthcare Centers dated 2014, revealed, It is the policy of Pruitthealth Pharmacy that medications listed as controlled substance (Schedules 1-V) under federal or state regulation will be properly stored with maintained accountability. Reconciliation of controlled substances will be performed at the end of each shift by licensed professional nurses. The healthcare center will obtain and keep on file any permits related to ordering and storing controlled substances required by state or federal agencies. Review of R99's Face Sheet revealed the resident was admitted to the facility on [DATE], with diagnoses including but not limited to: trigeminal neuralgia, chronic pain, third degree burns involving 50-59% of body surface, burn of male genital region, post-traumatic stress disorder, acquired absence of right and left leg, and left fingers. Review of R99's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/25/24, revealed R99 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R99 was cognitively intact. Further review revealed R99 was on a scheduled pain medication regimen and reported severe pain. Review of R99's Care Plan last revised 07/29/24 states, R99 has chronic pain related to a history of burns and wounds, with the following interventions, Administer pain medications per physicians' orders. Review of R99's Physician Orders dated 08/14/24, indicated R99 was to receive Oxycodone- Scheduled II tablet: 11-tab amt: 1 tab: oral, Four Times a day, starting 06:00 AM, 12:00 PM, 06:00 PM and 12:00 AM. Morphine-Schedule II tablet extended release: 30 mg: amt: 1 tab: oral Special instruction: Give Morphine 30 ER 1 tab po every 12 hours for pain twice a day at 09:00 AM and 09:00 PM. Review of a Packing Slip dated 07/29/24 revealed that 2 cards of 30 pills of Oxycodone 10 mg (milligram) each with a total of 60 tablets all signed by the Director of Health Services (DHS). Review of a Packing Slip dated 08/13/24 revealed that 2 cards of 30 pills of Oxycodone 10 mg each with a total of 60 tablets all signed by the DHS. Review of R99's Controlled Drug Record (CDR) and Medication Administration Record (MAR) for Oxycodone 10 mg four times a day revealed several discrepancies. On August 11 at 2:00 PM and 10:00 PM doses were marked as not given due to Drug/item unavailable. August 12 at 06:00 AM, 2:00 PM and 10:00 PM, doses were marked as not given due to Drug/item unavailable. August 13 at 6:00 AM dose was marked as not given due to Drug/item unavailable. Further review revealed there was 1 card of Oxycodone 10 mg containing 30 pills that was missing. Review of a Focused Observation dated 08/13/24 at 11:36 AM, revealed, R99 was experiencing penetrating, shooting, twisting and aching pain at a level of 8 out of 10, indicating severe pain. During an interview on 09/10/24 at 11:00 AM, R99 stated, I have to take my medication because I will be in pain. I'm a double amputee and I was in a house fire that burned over 90 percent of my body. During an interview on 09/16/24 at 4:56 PM, License Practical Nurse (LPN)1 verified her statement, On Friday August 09, I didn't have a 2pm Oxycodone 10mg to give to [R99]. The nurse had given the last one at 6am that day. The resident reminds me often not to let his medication run out. I remember putting the order in the doctor's book and faxing it after it got sign; just can't recall what day. I notified the pharmacy on Saturday August 10, about the script and I was told they received it. When I returned to work on Sunday August 11; I was told in the report that the Oxycodone 10mg for [R99] July 29 (60) pills. I reviewed the Controlled Drug Inventory Form and noted 2 cards was signed in but only one was completed at 6am on August 09, 2024, and the other one was not present. I notified the DON [Director of Nursing] regarding this matter. I can't recall ever seeing the card in the medication cart. During an interview 09/11/24 at 5:10 PM, Registered Nurse (RN)1 verified her statement, On Wednesday, 8/7/24, I worked station 4 South cart. There were several narcotic prescriptions that were signed that I faxed to our pharmacy, was nearly out of oxycodone and morphine, both of which are scheduled. I called the pharmacy to ensure they did get the fax since we have been having intermittent issues with the fax. The pharmacy informed me that the morphine prescription was for immediate release. I rewrote the prescription as was ordered and placed it in [Medical Director] book for signature. I relayed this information to the nurse that relieved me on night shift. I also told the nurse om [sic] report that the medications should be in since I had confirmed verbally with the pharmacy that hard scripts had been received. There was only enough oxycodone for a day and a half. I worked another station the next day. During an interview on 09/16/24 at 10:06 AM, R99 stated, I was in a lot of pain. I was in pain for 2 to 3 days. The nurse did give me my Morphine medication and it helped a little bit, but not like the Oxycodone will. Yes, the nurse did inform me that they were looking for my Oxycodone. I'm on Medicaid, so they paid them. The in-house doctor here was mad, because that could mess up his license. During an interview on 09/16/24 at 1:15 PM, the DHS stated, When I got word about the incident, I came into the facility and interviewed the nursing staff that worked the cart that day and we also conducted a drug test on each nurse. It took about two hours to complete. I spoke with the Administrator; Unit Nurse and we told the pharmacist about the missing medication. A whole card of 30 oxycodone was missing, a medication that I had signed for prior. We needed approval from the facility to get another prescription. We do in-services with our nursing staff. We monitored his level of pain. The Unit Nursing Manager asked him about his level of pain. I did contact the physician.

Based on observation, interviews, record review, and review of the facility policy. The facility failed to prevent the misappropriation of controlled medication for one of one resident (Residents (R)99) reviewed. Findings include: Review of the facility policy titled Controlled Substance for Healthcare Centers dated 2014, revealed, It is the policy of Pruitthealth Pharmacy that medications listed as controlled substance (Schedules 1-V) under federal or state regulation will be properly stored with maintained accountability. Reconciliation of controlled substances will be performed at the end of each shift by licensed professional nurses. The healthcare center will obtain and keep on file any permits related to ordering and storing controlled substances required by state or federal agencies. Review of R99's Face Sheet revealed the resident was admitted to the facility on [DATE], with diagnoses including but not limited to: trigeminal neuralgia, chronic pain, third degree burns involving 50-59% of body surface, burn of male genital region, post-traumatic stress disorder, acquired absence of right and left leg, and left fingers. Review of R99's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/25/24, revealed R99 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R99 was cognitively intact. Further review revealed R99 was on a scheduled pain medication regimen and reported severe pain. Review of R99's Care Plan last revised 07/29/24 states, R99 has chronic pain related to a history of burns and wounds, with the following interventions, Administer pain medications per physicians' orders. Review of R99's Physician Orders dated 08/14/24, indicated R99 was to receive Oxycodone- Scheduled II tablet: 11-tab amt: 1 tab: oral, Four Times a day, starting 06:00 AM, 12:00 PM, 06:00 PM and 12:00 AM. Morphine-Schedule II tablet extended release: 30 mg: amt: 1 tab: oral Special instruction: Give Morphine 30 ER 1 tab po every 12 hours for pain twice a day at 09:00 AM and 09:00 PM. Review of a Packing Slip dated 07/29/24 revealed that 2 cards of 30 pills of Oxycodone 10 mg (milligram) each with a total of 60 tablets all signed by the Director of Health Services (DHS). Review of a Packing Slip dated 08/13/24 revealed that 2 cards of 30 pills of Oxycodone 10 mg each with a total of 60 tablets all signed by the DHS. Review of R99's Controlled Drug Record (CDR) and Medication Administration Record (MAR) for Oxycodone 10 mg four times a day revealed several discrepancies. On August 11 at 2:00 PM and 10:00 PM doses were marked as not given due to Drug/item unavailable. August 12 at 06:00 AM, 2:00 PM and 10:00 PM, doses were marked as not given due to Drug/item unavailable. August 13 at 6:00 AM dose was marked as not given due to Drug/item unavailable. Further review revealed there was 1 card of Oxycodone 10 mg containing 30 pills that was missing. Review of a Focused Observation dated 08/13/24 at 11:36 AM, revealed, R99 was experiencing penetrating, shooting, twisting and aching pain at a level of 8 out of 10, indicating severe pain. During an interview on 09/10/24 at 11:00 AM, R99 stated, I have to take my medication because I will be in pain. I'm a double amputee and I was in a house fire that burned over 90 percent of my body. During an interview on 09/16/24 at 4:56 PM, License Practical Nurse (LPN)1 verified her statement, On Friday August 09, I didn't have a 2pm Oxycodone 10mg to give to [R99]. The nurse had given the last one at 6am that day. The resident reminds me often not to let his medication run out. I remember putting the order in the doctor's book and faxing it after it got sign; just can't recall what day. I notified the pharmacy on Saturday August 10, about the script and I was told they received it. When I returned to work on Sunday August 11; I was told in the report that the Oxycodone 10mg for [R99] July 29 (60) pills. I reviewed the Controlled Drug Inventory Form and noted 2 cards was signed in but only one was completed at 6am on August 09, 2024, and the other one was not present. I notified the DON [Director of Nursing] regarding this matter. I can't recall ever seeing the card in the medication cart. During an interview 09/11/24 at 5:10 PM, Registered Nurse (RN)1 verified her statement, On Wednesday, 8/7/24, I worked station 4 South cart. There were several narcotic prescriptions that were signed that I faxed to our pharmacy, was nearly out of oxycodone and morphine, both of which are scheduled. I called the pharmacy to ensure they did get the fax since we have been having intermittent issues with the fax. The pharmacy informed me that the morphine prescription was for immediate release. I rewrote the prescription as was ordered and placed it in [Medical Director] book for signature. I relayed this information to the nurse that relieved me on night shift. I also told the nurse om [sic] report that the medications should be in since I had confirmed verbally with the pharmacy that hard scripts had been received. There was only enough oxycodone for a day and a half. I worked another station the next day. During an interview on 09/16/24 at 10:06 AM, R99 stated, I was in a lot of pain. I was in pain for 2 to 3 days. The nurse did give me my Morphine medication and it helped a little bit, but not like the Oxycodone will. Yes, the nurse did inform me that they were looking for my Oxycodone. I'm on Medicaid, so they paid them. The in-house doctor here was mad, because that could mess up his license. During an interview on 09/16/24 at 1:15 PM, the DHS stated, When I got word about the incident, I came into the facility and interviewed the nursing staff that worked the cart that day and we also conducted a drug test on each nurse. It took about two hours to complete. I spoke with the Administrator; Unit Nurse and we told the pharmacist about the missing medication. A whole card of 30 oxycodone was missing, a medication that I had signed for prior. We needed approval from the facility to get another prescription. We do in-services with our nursing staff. We monitored his level of pain. The Unit Nursing Manager asked him about his level of pain. I did contact the physician.

Based on record review and interviews, the facility failed to conduct a Preadmission Screening and Resident Review (PASARR) Level 1 for Resident (R)77 prior to admission. Additionally, the facility failed to refer R77 for a PASARR Level II, after a new diagnosis of a severe mental illness, for 1 of 3 residents reviewed for PASARR. Findings include: On 09/12/24 at 9:00 AM, the PASARR policy was requested, the Director of Nursing (DON) and Clinical Competency Coordinator (CCC) stated they do not have a PASARR policy. Review of R77's Face Sheet revealed the resident was admitted to the facility on [DATE], with diagnoses including but not limited to: type 2 diabetes mellitus, tachycardia, and osteoarthritis. Further review of the R77's diagnoses, listed on the Face Sheet, revealed R77 was diagnosed with, Other psychotic disorder on 07/05/21. Review of R77's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/08/24, revealed a Brief Interview for Mental Status (BIMS) score of 8 out of 15 indicating R77 was moderately cognitively impairmed, and had Potential Indicators of Psychosis for Delusions. Review of R77's Progress Note dated 05/11/24, revealed resident is alert to self with confusion and on 07/20/24 - 07/21/24, revealed resident is alert and oriented to self with hallucinations at times and has confusion. Review of [NAME] Psychiatric and Psychotherapy physician notes dated on 05/08/24, revealed, he is seen in follow up today. [R77]is now back on Haldol and Seroquel. Staff does not think [R77] is any different on it. Still yells and talks to people not there. Review of R77's PASSAR Level 1 dated 11/16/23, does not include the resident's psychotic disorder or antipsychotic medication. Further review revealed that a PASARR Level II was not recommended. During an interview on 09/12/24 at 1:53 PM, the Social Worker (SW)1 revealed that the decision to refer a resident for a PASARR Level II is based on if the resident is diagnosed with a psychotic disorder after admission. SW1 revealed she missed the diagnosis for R77 but is taking the steps necessary to refer the resident by contacting their physician to start the review.

Based on observation, interview and record review, the facility failed to ensure Resident (R)25 received a meal based on her preferences, for 1 of 13 residents reviewed during dining. Findings include: Review of R25's Face Sheet revealed the resident was admitted to facility on 04/19/24. R25 was admitted with diagnoses including but not limited to: varicose veins of right lower extremity with chronic obstructive pulmonary disease, diabetes mellitus due to underlying condition with diabetic nephropathy, venous insufficiency (chronic) (peripheral), muscle weakness, diastolic (congestive) heart failure, cognitive communication deficit, cellulitis, nutritional deficiency, and morbid (severe) obesity due to excess calories. Review of R25's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/25/24, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating the resident is cognitively intact. Review of R25's Diet Orders revealed an order dated 06/28/24 for, CCHO (consistent carbohydrate diet)/Liberalized diabetic plan with special instructions, which documented, no oatmeal, only grits, no fish and milk with breakfast. During an observation and interview on 09/12/24 at 1:11 PM, revealed R25 was served fish with her lunch. R25 stated she has an order to not have fish. R25 further stated, I have never eaten fish, and it is on my lunch ticket, but this happens all the time. Review of R25's Menu Ticket (which arrived on the lunch tray) on 09/12/24 at 1:11 PM, documented on the bottom of the ticket, NO FISH. During an interview on 09/12/24 at 9:21 AM, the Kitchen Manager (KM)1 stated, I am constantly reminding them to pay attention to the cards. The person calling out the resident meal should check and the person who puts the tray on the serving rack should check. During an interview on 09/12/24 at 1:59 PM, the Director of Nursing (DON) revealed the resident's preference and special diets should be listed on their meal ticket. The kitchen staff should ensure the resident's plate is in accordance with the ticket and the Certified Nursing Assistants (CNAs) should also be looking at the meal ticket to see the dislikes, and diet preferences are correct.

Based on record review and interview, the facility failed to ensure that there was a process in place for the review of provider recommendations and continuity of care for 1 (Resident (R)1) of 1 resident reviewed for coordination of care. Findings included: A Resident Face Sheet revealed the facility admitted R1 on 10/12/2020. According to the Resident Face Sheet, the resident had a medical history that included bipolar disorder, post-traumatic stress disorder (PTSD), schizoaffective disorder bipolar type, dementia, unspecified disorder of adult personality and behavior, generalized anxiety disorder, suicidal ideations, and major depressive disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/21/2024, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident did not have any concerns related to feeling down, depressed, or hopeless. The MDS indicated the resident was independent for self-care and mobility. The MDS indicated the resident had the following diagnoses of psychiatric/mood disorder: anxiety disorder, depression, bipolar disorder, psychotic disorder, schizophrenia, major depressive disorder, and PTSD. The MDS revealed that the resident received antipsychotic, antianxiety, and antidepressant medications during the seven-day lookback period. R1's Care Plan, included a problem statement initiated on 12/19/2023, that indicated the resident verbalized feelings of depression, had received electroconvulsive therapy, had a history of hallucinations/altered mental status, a history of expressing self-harm, and the resident was followed by a psychiatrist. The goal statement revealed the resident would not cause harm to self and have decreased episodes of feeling depressed thru the next review. Interventions directed staff to administer medications as ordered, consult the doctor as needed, notify the medical doctor of changes, observe for suicidal ideations and report to the nurse/physician, and obtain a psychological consult/psychosocial therapy. R1's Consultant Pharmacist Communication to Physician report dated 04/16/2024, revealed the Center for Medicare & Medicaid Services (CMS) gradual dose reduction (GDR) review indicated that the resident was ordered diazepam 2 milligram (mg) at bedtime (QHS) for anxiety, trazadone 100 mg QHS for insomnia, duloxetine 60 mg daily for bipolar disorder, and quetiapine 100 mg QHS for schizoaffective bipolar type. The report revealed R1 was due for a dose reduction evaluation. The report revealed that the last psychiatry note scanned into the system for R1 was from 03/22/2024. The report revealed that at that time, it was suggested to consider reducing duloxetine to 40 mg daily as serotonin-norepinephrine reuptake inhibitors (SNRI) had the potential to destabilize mood in residents with bipolar disorder. The report revealed it was also suggested to reduce trazadone and increase quetiapine. The report revealed that the recommendation was No change. An attempted GDR is likely to result in impairment of function or increased distressed behavior. A Psychiatry Follow Up Note, dated 05/10/2024, revealed the Psychiatric Nurse Practitioner (NP) discussed the resident's case with the collaborating psychiatrist. The note revealed the medication Tegretol was recommend as mood stabilizers were considered first line treatment for bipolar diagnosis and anti-depressants could increase manic cycling. The note revealed the resident and staff were aware to monitor for a spreading rash and to discontinue Tegretol at the first sign which could indicate Stevens-Johnson Syndrome. The note revealed a medication trough was needed after 10 days as Tegretol was an auto-metabolizer and dosage adjustments may be necessary. The note revealed the Psychiatric NP's recommendations/plan indicated an electrocardiography (EKG), complete blood count (CBC), comprehensive metabolic panel (CMP), liver function test (LFT), thyroid panel and lipid profile was to be completed prior to starting the medication Tegretol. The recommendations/plan revealed a recommendation to add the medication Tegretol 200 mg two times a day for bipolar diagnosis, monitor white blood cell count (WBC), complete a LFT, and draw medication trough after 10 days. The recommendations/plan revealed no further changes to psychotropic medications at this time. R1's Medication Administration Record [MAR] for the timeframe from 05/01/2024 to 05/29/2024 revealed a transcription of the following orders: Seroquel (quetiapine) 100 mg one tablet QHS with a start date of 12/06/2023; duloxetine capsule, delayed release/enteric coated (DR/EC) 60 mg one capsule once a day with a start date of 12/26/2023 and discontinued on 05/20/2024; donepezil tablet 10 mg one tablet QHS with a start date of 06/12/2023; memantine 10 mg one tablet twice a day with a start date of 06/12/2023; and diazepam 2 mg one tablet QHS with a start date of 12/28/2023 and discontinued on 05/20/2024. Further review revealed no transcription of an order for Tegretol. During an interview on 06/12/2024 at 9:10 AM, the Administrator stated that R1 refused to see the facility doctor and went to an outside primary care physician (PCP). During an interview on 06/12/2024 at 9:30 AM, Medical Doctor (MD)11, who was the facility's primary care physician, stated that R1 had fired him three times over the last [AGE] years the resident had been at the facility. MD11 stated that he did not touch R1's psychiatric medications. During an interview on 06/12/2024 at 9:14 AM, the Director of Health Services (DHS) stated MD12 (R1's outside PCP) had discontinued R1's trazadone order in April 2024, and diazepam and duloxetine were discontinued on 05/20/2024. The DHS stated that she was aware when R1's medications were stopped on 05/20/2024 and the nurses were made aware of the medication changes. The DHS stated if anything came from the psychiatrist, it should be shared with R1's outside PCP. The DHS said she did not know why the new recommendations were not sent to R1's outside PCP. Per the DHS, the resident would not see MD11. The DHS further stated that it was the responsibility of the facility to notify the Psychiatric NP that R1 was seeing an outside PCP. The DHS stated that the outside PCP was not documented on R1's Resident Face Sheet. She stated that it was an oversight that the facility did not notify the Psychiatric NP that R1 was seeing an outside PCP. During an interview on 06/12/2024 at 3:41 PM, the DHS stated that the facility had 30 days to act on recommendations and it was not the facility's practice to wait the 30 days. The DHS stated that was the first time they had a recommendation from the Psychiatric NP to relay to the residents outside PCP. She stated that if R1 was seeing the facility doctor, they would have put the recommendations in the provider notification book and the doctor would have signed off on the orders. Per the DHS, R1 was the only resident who saw an outside PCP. During an interview on 06/12/2024 at 10:47 AM, the Consultant Pharmacist stated that R1's outside PCP made many changes, and she would have liked to speak to them about GDRs and stopping the medication all together. During an interview on 06/12/2024 at 10:15 AM, R1 stated that the resident expressed concerns with MD12 about being on too many medications and asked him to decrease them. During an interview on 06/12/2024 at 11:45 AM, Licensed Practical Nurse (LPN)10 stated that she called R1's outside PCP on 05/20/2024 to clarify that he wanted the duloxetine and diazepam stopped. LPN #10 stated that the doctor said he was trying to get the resident off some of their medications at R1's request. During an interview on 06/12/2024 at 12:50 PM, MD12 stated that he stopped R1's medications because they were not working. He stated that he had prescribed duloxetine 60 mg for back pain. MD12 stated that he did not coordinate R1's care with the Psychiatric NP and he did not touch the resident's psychiatric medications. During an interview on 06/12/2024 at 1:40 PM, the DHS stated that the facility did not have a policy for carrying out orders for residents with an outside PCP. The DHS stated that the recommendation for Tegretol was probably not sent to R1's outside PCP for an order. The DHS stated that the recommendations were missed. During an interview on 06/12/2024 at 2:39 PM, the Psychiatric NP stated that there was no medication proven that would halt suicidal thoughts. She further stated that she could not say for sure that not adding Tegretol would cause suicidal ideations. The Psychiatric NP stated that she was adding Tegretol as a mood stabilizer for bipolar and it was a first line medication. She further stated that Seroquel was an adjunct medication for bipolar. The Psychiatric NP stated that she did know that R1 was seeing an outside PCP. During an interview on 06/12/2024 at 4:50 PM, the Psychiatric NP confirmed that R1 was not on a mood stabilizer, and she thought R1 would benefit from being on Tegretol. The Psychiatric NP stated that in the past when the facility doctor declined her recommendation, she would see the note in the resident's chart. The Psychiatric NP confirmed that she was unaware of R1 having an outside provider and that she did not know if the recommendations were carried out. During an interview on 06/12/2024 at 4:45 PM, the DHS stated that the Interdisciplinary Team (IDT) team did not meet on the process of R1 having an outside PCP. The DHS stated that they reached out to the Ombudsman but did not know how to handle the situation with coordination of care. During an interview on 06/12/2024 at 5:25 PM, the DHS stated that it was her expectation going forward that recommendations would be communicated to the resident's PCP and facility staff would receive a response within the given 30-day timeframe. The DHS stated that the facility did not have a policy that addressed following through on physician recommendations and orders. During an interview on 06/12/2024 at 5:50 PM, the Administrator stated it was his expectation that staff follow the process to make sure recommendations were followed through in a timely manner.

Based on review of facility policy, record reviews, and interviews the facility failed to ensure Resident (R)1 was free from verbal abuse by Certified Nursing Assistant (CNA)1. Findings include: Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program last revised on 10/27/20, states, It is the policy of [NAME] Health and its affiliated entities (collectively , the Organization) to actively preserve each patient's right to be free from verbal, sexual, physical, and mental abuse, corporal punishment , involuntary seclusion, neglect, exploitation, mistreatment, and misappropriation of patient property, (referred to collectively in this policy as abuse, neglect, and mistreatment, and exploitation). The Organization and its partners should assure that best efforts are made to prevent any occurrences of any form of abuse, neglect, and exploitation. Review of the facility's Inservice Education Program Summary Record Form dated 01/05/24, revealed the following: When communicating with residents be observant of your tone and keep in mind that it could/may be perceived as abuse. Do not argue with residents. If you feel that an interaction with a resident is escalating, please excuse yourself and get your supervisor. If you witness an encounter that could potentially be abuse (visually or auditory) you are to notify your direct supervisor immediately. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including but not limited to: bipolar disorder and depression. Review of R1's Quarterly Minimum Data Set (MDS) revealed that R1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R1 was cognitively intact. Review of R1's Care Plan dated 09/21/23, revealed problems related to mood and behavior. Behavioral Indicators: [R1] is noted to swear at times and can be impatient . Mood Indicators: [R1] exhibits s/s [signs/symptoms] of grief. He is hyper-verbal at times . Further review of the Care Plan indicated an approach which stated, Encourage appropriate interaction with staff and peers. During an interview on 03/28/24 at approximately 1:35 PM, R1 revealed it was a misunderstanding. R1 stated he did not know what happened. I just come back from the doctor and I feel the issue was resolved. I don't know how it started. During an interview on 03/28/24 at approximately 1:40 PM, the Director of Nursing (DON) revealed there was a verbal altercation between R1 and CNA1. The DON stated CNA1 admitted to using a curse word and witnesses heard her curse. The DON further stated she told CNA1 it was inappropriate to use profanity, and CNA1 was terminated immediately. During an interview on 03/28/24 at 3:09 PM, CNA1 stated, R1 was asking why his roommate was not given a shower and R1 was very belligerent. CNA1 further stated R1 was cursing at her because she did not give his roommate a shower. CNA1 then stated that she told R1 she could not share information about his roommate because it was a HIPPA violation. CNA1 revealed when R1 cursed at her she cursed back at him. CNA1 concluded that she was terminated from the facility.

Based on interviews, record review, and facility policy review, the facility failed to promptly notify the resident representative, of a change in the resident's room. Findings Include: Review of facility policy titled Room or Roommate Changes revised 12/06/22 stated It is our policy to inform patients/residents in advance of any change in room or roommate and allow patients/residents the opportunity to have input in the decision. Furthermore Procedure: 7. A progress note will be written in both roommates' medical records by the Social Worker or designee regarding the room change. A review of Resident (R)1 face sheet revealed the resident was admitted on [DATE] to room [ROOM NUMBER]B with diagnoses that include but not limited to dementia, depression, palliative care encounter and generalized anxiety disorder. A review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/05/23 revealed a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. A review of R1's Census Detail revealed that on 11/23/22, R1 was moved from room [ROOM NUMBER]B to 421A. Additionally on 01/25/23, R1 was moved from 421A to 416A and on 02/03/23, R1 was moved from 416A to 321B. A review of R1's progress note dated 11/23/22 stated RP requested she be notified immediately of any changes 24/7. States that she is not happy with this facility. Further review of R1's progress notes did not reveal any documentation of notification made to the resident's representative (RR) regarding the subsequent room changes. During an interview on 07/21/23 at 1:36 PM, the Social Worker (SW) stated that if a resident room is changed the nurses, nurse navigator and/or social worker is responsible for notifying resident representatives and if they are unable to reach a resident representative then a notification of change letter will be sent out and scanned into the resident chart. SW then stated that even if a letter is sent out notification should be noted in residents progress notes. Social worker was unable to provide documentation of notification for R1 nor an explanation for why the documentation of room notification was not done. During an interview on 07/21/23 at 1:50 PM, the Director of Nursing (DON) stated that the social worker is ultimately responsible for ensuring the paperwork is completed and that the nurses are also responsible for notifying families and resident as well of any room changes. The DON could not provide an explanation as to why notification was not made to R1's RR.

Based on record review, interview, and review of facility policy, the facility failed to provide necessary treatment and services consistent with professional standards of practice to promote healing of pressure ulcers related to assessing and providing treatments for residents admitted and with pressure ulcers. Findings Include: Review of facility policy revised on 07/13/23 titled Documentation of Skin and Wound Care Admission Documentation : states Admission skin assessment reflects current skin condition, noting wounds, areas of skin compromise, ect. At the time of admission. Wound Manager is to be completed at admission on any noted skin conditions, Furthermore, obtain an orders as needed. Any delay or concern related to orders or products- contact physician or adjunct for clarification/interim order. Review of a Face Sheet revealed Resident (R)1 was admitted on [DATE] with diagnoses including but not limited to acute embolism and thrombosis of unspecified deep veins of lower extremity, bilateral, altered mental status, dysphagia, generalized muscle weakness, and dementia. A review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/05/23 revealed a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. Review of R1's Admission Documentation revealed a wound note dated 10/17/22 from R1's discharge facility documenting R1's wounds as Sacrum and bilateral inner buttock-previous evolving DTPI, Right lateral heel-previous evolving DTPI, and Right medial heel-previous evolving DTPI. Furthermore, the note revealed a treatment plan that stated Sacrum-continue plan of care using calazime cream bid and prn. Right heel- keep dry and intact - paint with betadine daily and keep elevated off bed with [NAME] boots. Review of R1's Progress Note dated 10/17/22 stated .Resident noted to have a sl red area on his sacrum and a rt. heel DTI. Resident is non-ambulatory. Review of R1's Wound Management Detail Report revealed that R1's sacral wound was not added to his wound management until 01/26/23 and was reported as not present on admission. Furthermore R1's medial and lateral right heel wounds were not added until 11/01/22. Review of R1's physician's orders revealed that R1 did not receive treatment or orders for wound treatment until 10/25/22 for R1's sacral wound. During an Interview on 07/21/23 at 1:50 PM the Director of Nursing (DON) stated that it is her expectation that nurses complete full and accurate documentation of residents wounds upon admission. DON stated that when residents are admitted with treatment orders they are expected to follow those orders or if appropriate have the order changed immediately. Furthermore if a resident is admitted without wound treatment orders it is her expectation that nurses put in a clean and cover wound order until the wound care nurse can see them or place wound care orders for the resident. During an interview on 07/21/23 at 1:04 PM, Licensed Practical Nurse (LPN)1 stated that upon admission residents wounds should be entered into the wound manager. LPN1 further stated that they don't always receive wound care orders upon admission and it would depend on the particular hospital system if wound orders were sent. Furthermore, LPN1 stated that if residents are admitted with wound care orders, they would follow those orders unless the Registered Nurse (RN) over wound care does not find the orders suitable. LPN1 also states that if any changes are needed to the wound orders, then the current wound care order will remain in place until new orders can obtained. LPN1 states only RN's can document on admission wounds and place orders due to scope of practice.

Based on review of the facility policy, interviews, and observation, the facility failed to have a designated Infection Control Preventionist. This failure had the potential to impact all residents at risk for infections. Findings include: Review of facility policy titled, Infection Prevention and Control Program Overview last revised on 1/31/16, reviewed on 8/10/22, revealed It is the policy of this facility to establish and maintain an Infection Control Program that includes detection, prevention, and control of the transmission of disease and infection among patients/residents and partners. Infection Preventionist (IP): the person designated to carry out the daily functions of the program. The IP responsible for collecting, analyzing and providing infection data and trends to staff. The IP is responsible for assuring education and training is provided and assuring infection control policies and practices are followed in the facility. An interview on 8/10/22 at 10:34 with the Administrator revealed the Infection Preventionist for the facility, Registered Nurse (RN)4 was on leave, but would return on 8/13/22 and that RN3 assists RN4 with infection control tasks at the facility. An observation and interview on 8/12/22 at 9:32 AM with RN4 on the 400 COVID Isolation Unit revealed At times, I help with infection control but, I am not the designated nurse for infection prevention and mostly work as a floor nurse. RN4 further stated she last completed Antibiotic Stewardship for the facility in March of 2022. She stated she was down on paper as being the facility's IP, however, she does not continuously maintain the role and have not in months. An interview with RN3 on 8/12/22 at 5:39 PM revealed she is in the process of completing the Infection Preventionist training and have been completing the facility's Antibiotic Stewardship documentation at times, with the help from a consultant nurse for the facility. During the exit conference on 8/12/22 at approximately 6 PM, the Administrator stated a company Consultant was also the facility's Infection Preventionist. However, he was unable to provide any information to verify.

Based on observations, interviews, and review of facility policy, the facility failed to ensure expired medications were removed from 2 of 7 medication carts and 2 of 4 medication rooms. Furthermore, the facility failed to ensure opened medications on top of the medication card were attended to, on the 300 Unit. Findings include: Review of the undated facility policy titled, Medication Storage in Healthcare Centers, states under the Policy Statement, Medications and biological's are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. Section 3 under Procedure states, Nurses are required to check all medications for deterioration and expiration before administration. Nurses are also required to inspect medication storage facilities, including medication carts, routinely. Section 12 states, Outdated, contaminated, or deteriorated medications and those in containers that are cracked soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction, and reordered from pharmacy, if a current order exists. An observation on 8/11/22 at 7:45 AM of the medication cart located on 300 South unit revealed, the medication [MEDICATION(S)] 50 milligrams, 2 tablets with Lot # 1146, expired on 5/27/2022. The expired medication was verified by Licensed Practical Nurse (LPN) 1 and removed from the medication cart. An observation on 8/11/22 at 8:00 AM of the medication storage room on the 300 Unit revealed, the medication GoodSense [MEDICATION(S)] Relief (Children's) 4 ounces, distributed by [NAME] with Lot #DEK0928, expired on 4/2022. The expired medication was confirmed by the Unit Manager (UM) and removed from the storage room. An observation on 8/11/22 at 8:20 AM of the medication cart on the 100 Unit revealed, the medication Geri Care [MEDICATION(S)] - Stimulant [MEDICATION(S)] EC 100 count tablets, floor stock, 36 tablets with Lot 441S03 expired on 3/22. The expired medication was confirmed by LPN2 and removed from the storage room. Further observation on 8/11/22 at 8:20 AM of the locked refrigerator in the 100 Unit medication storage room revealed, 2 one milliliter (ml) syringes with a clear liquid that was in the syringe and amounted to 0.25 mls in each syringe. The two syringes were not properly labeled with the medication they contained. LPN2 confirmed that the syringes were not labeled with the medication or the date the medication was put in the syringes. Additional findings include: An observation on 08/11/22 at 9:34 AM, during a walk through of the facility revealed, the medication cart on Unit 2 was observed with opened medications on top, unsecured with no staff present. LPN2 was observed walking up to the cart and stated, she is on the cart and is in the process of passing morning medications. An interview on 08/12/22 at 5:33 PM with the Unit Manger revealed, the nurse should have locked the medications in the cart prior to leaving the cart. An interview on 08/12/22 at 5:39 PM with the Director of Nursing (DON) revealed, if the nurse administering the medication is not in view of the cart then all medications on top of cart should be locked away before the nurse steps away from the cart.

Based on review of facility policy, record review, and interviews, the facility failed to report an allegation of resident to resident abuse for 1 of 2 residents reviewed for abuse. Findings Include: Review of facility policy titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, with a revised date of 07/29/2019 revealed, 1. Any allegation, suspicion, or identified occurrence is identified involving patient abuse, neglect, exploitation, mistreatment, and misappropriation of property, including injuries of an unknown source, should be immediately reported to the Administrator of the provider entity. 2. In accordance with applicable laws and regulations, the Administrator or his or her designee should notify the appropriate state agency (or agencies) . Review of the R10's Progress Notes dated 07/20/2022 at 2:42 PM (recorded as late entry), revealed Resident and another resident was sitting in common area both sitting in w/c. This writer heard the 2 residents arguing. Writer heard don't you back your wheel chair in to me, I aint going to run my wheelchair in to you. As soon as writer heard the commotion, writer got up from nurse's station. Upon approaching both residents, [resident] was observed swatting toward other resident. Residents were immediately separated. RP notified. An interview with the Director of Nursing (DON) on 08/12/2022 at 5:42 PM revealed, a nurse witnessed the altercation. The DON further stated the altercation wasn't reported because it wasn't physical, but the resident has had 2 reportables in the past. An interview with Licensed Practical Nurse (LPN)1 on 08/12/2022 at 5:53 PM revealed, LPN1 was at the desk and she heard the two residents arguing. They were right beside each other and bickering. LPN1 stated she probably shouldn't have used the word swatting in the nursing notes. It wasn't like they were hitting each other. Both residents were separated and LPN1 notified the DON, family, and physician. LPN1 stated she did not think it needed to be reported because it was not abuse. The residents did not make contact with each other and there were no verbal threats. An interview with the Administrator on 08/12/2022, at an unspecified time revealed, both residents have dementia and behaviors. The Administrator stated it wasn't reported because there was no physical contact and no cursing. The staff handled it appropriately and there were no threats of violence.

Based on review of the facility policy, observation, and interview, the facility failed to follow a procedure during wound care to prevent infection and to promote healing of a Stage IV wound of the sacral area for Resident (R)51 for 1 of 3 residents reviewed for wound care. Findings include: Review of the undated facility policy titled, Procedure: Guidelines for cleansing and Observing a Wound, Section 9 states, To cleanse an injury or pressure ulcer, work in half or full circles, beginning in the center of the wound and working outward. Cleanse the skin at least on inch beyond the edge of the dressing. Use a new sponge for each circle. Section 14 states, As soon as you have finished removing the soiled dressing and cleansing the wound, remove and discard your gloves. Otherwise, everything you touch, including the faucet and handles, will be contaminated by microorganisms on your gloves. Section 16 states, Wash your hands (or use an alcohol cleanser) after removing and discarding the existing dressing. The facility admitted R51 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation on 8/12/22 at 10:15 AM of wound care revealed the following: Registered Nurse (RN)1 and this surveyor knocked on R51's door and waited for permission to enter. RN1 explained the procedure to the resident and this surveyor asked for permission to observe RN1 performing wound care on her sacrum and she gave permission. The Licensed Practical Nurse (LPN)1 assisting with wound care then removed the resident's brief and turned her onto her right side. RN1 had already set up the supplies on the over bed table. RN1, LPN1, and this surveyor had donned personal protective equipment (PPE) before entering the room. RN1 washed his hands and went to dry them and realized there were no paper towels in the bathroom in which to dry his hands. RN1 then doffed the PPE and went out of the room to get paper towels. RN1 returned with paper towels and had donned PPE before entering the room then went back to the bathroom to wash his hands. After washing his hands he applied gloves and went to the bedside and removed the soiled dressing from the sacral wound of R51. Without removing his gloves and cleaning his hands, he then sprayed a stack of 4x4 gauze pads with wound cleanser and then cleaned the wound bed and then the surrounding tissue again, he then took more 4x4 gauze pads and dried the wound bed and the surrounding tissue with the same 4x4 gauze pads. He then removed his gloves and washed his hands and applied gloves and then opened the mensal and applied it inside the wound bed. RN1 then took a pen from his pocket and cleaned it with a alcohol prep and then wrote the date and his initials on the dressing and applied it over the mensal that he had applied inside the wound bed. He then bagged the trash and the soiled linen and then helped LPN1 to make the resident comfortable. RN1 removed his gown and his gloves and placed them in the receptacle inside the room and then washed his hands and left the room. An interview on 8/12/22 at 10:30 AM with RN1, confirmed he had not removed his gloves and washed or cleaned his hands after removing the soiled dressing or before spraying the 4x4 gauze with wound cleanser and cleaning the wound. RN1 also confirmed he had used the same 4x4 gauze pads sprayed with wound cleanser to wipe inside the wound bed and around the wound bed. He also confirmed that he had dried the wound bed and the surrounding tissue using the same 4x4 gauze pad.

Based on observations, interviews, record review, review of the facility's infection control policies, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure infection control practices were in place for the following areas: 1. one Coronavirus Disease 2019 (COVID-19) positive Resident (R) 96 was not placed on quarantine with transmission-based precautions even though he was exhibiting symptoms related to COVID-19; 2. LPN25 was observed coughing and removing her mask at the rehabilitation unit nurses' station; 3. R393 was placed on isolation precautions due to his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R98 was placed on isolation precautions due to his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . diff), but without the appropriate precautions signage on his door; and 5. no hand hygiene during assisting with meals. Failure to properly quarantine the COVID-19 positive resident had the potential to increase the likelihood of spread of infections among all residents and staff in the facility due to staff coming into contact and working throughout the facility. On 09/15/21 at 5:55 PM, the Administrator was notified immediate jeopardy at F880: Infection Control-L existed related to the failure to adequately quarantine one COVID positive resident with use of all required PPE. The immediate jeopardy at F880 was determined to first exist on 09/15/21, the date when the non-compliance was observed. The facility presented an acceptable removal plan for the immediate jeopardy at F880-L on 09/17/21 at 8:20 PM. Through observations, interviews, and record review, the survey team validated the immediate jeopardy was removed on 09/17/21 at 9:22 PM following the facility's implementation of the plan of removal of the Immediate Jeopardy. The deficient practice remained at a lower scope and severity of an F (widespread with potential for more than minimal harm) following the removal of the immediate jeopardy. Findings include: Review of CDC's, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated Sept.10, 2021, revealed the following guidance HCP who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face) . Establish a process to identify anyone entering the facility, regardless of their vaccination status, who has any of the following so that they can be properly managed: 1) a positive [CONDITION(S)] test for [CONDITION(S)]-CoV-2, 2) symptoms of COVID-19, or 3) who meets criteria for quarantine or exclusion from work. Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which individuals can self-report any of the above before entering the facility. Healthcare personnel (HCP), even if fully vaccinated, should report any of the 3 above criteria to occupational health or another point of contact designated by the facility . Review of the facility policy titled, COVID-19 Pandemic Isolation and Cohorting Process for Healthcare Centers, revised 09/09/21, revealed Policy Statement: .will provide designated Levels of units within the center for isolating and cohorting residents when making decisions to accept hospital and community admission, transfers and with management of COVID-19 positive and presumptive in-house residents during the COVID-19 pandemic .Definitions: .severely Ill: Individuals who have respiratory frequency >30 breaths per minute, SpO2 <94% on room aur at sea level .Procedure: Healthcare centers designated to admit COVID-19 positive residents will follow procedures for Level 1 .Procedures: .New admissions from a hospital stay for COVID-19 Infection .If hospitalized resident is still recovering (I.E., requiring oxygen .requiring breathing treatments, etc) hospital days do not count down the Level I required days and must be admitted to a Level 1 bed until meets criteria for 10 days minimum symptom based strategy .Quarantine period listed in chart above will be 14 days on Level II (From Chart: Admission and Readmission, Unvaccinated or Partially Vaccinated Residents, Quarantine) .VI. Severely Ill or Severely Immunocompromised Individuals .1. Symptomatic resident with suspected or confirmed COVID-19. Symptom-based strategy. Remain on Level I: At least 20 days have passed since symptoms first appeared, and at least 24 hours have passed since last fever without the use of [MEDICATION(S)] medications, and improvement in symptoms . Document review of the facility's policy titled, Coronavirus COVID-19 Infection Prevention and Control Practices Policy revised 03/06/20 stated, Policy statement: It is the policy of the .organization to initiate the appropriate measures to protect our patients/residents, partners and families from risks associated with the Coronavirus (COVID-19) through mitigation and educational tools, utilizing resources as provided by the Department of Public Health and the Centers for Disease Control .Procedure: II. Screening of Partners, Visitors and Vendors 1. All locations are required to setup screening stations at the main entrance to screen partners .for the following: fever, cough, shortness of breath, fatigue .4. Should any partner present with all the above risk factors, the partner conducting the screening will: .notify the partner's direct supervisor for further instructions .The partner will be considered a Patient Under Investigation (PUI) for COVID-19 if the following criteria is met: .a. Fever of lower respiratory symptoms (e.g., cough or shortness of breath) and any person, including healthcare workers, who has had close contact with a laboratory-confirmed COVID-19 patient within 14 days of symptom onset . 1. Review of R96's undated Face Sheet, found in the electronic medical record (EMR) under the Face Sheet tab, revealed R96 was initially admitted to the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the R96's EMR under the Progress Notes tab revealed a brief history of R96's illness through progress notes: dated 09/01/21 stated, Testing Nurse reported R96 has tested positive for COVID-19 .; dated 09/04/21 stated, .R96 admitted to hospital with COVID + with [CONDITION(S)].; dated 09/07/21 stated, Resident returned to the facility. Primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .he is currently on 4 liters of oxygen; dated 09/14/21 stated, R96 continues on Level 1 isolation for COVID-19 .O2 (oxygen) at 4L (liters) via NC (nasal cannula), no s/s (signs and symptoms) of resp. (respiratory) distress observed, resp. (respirations) noted even and non-labored, afebrile . Review of R96's orders found in the EMR under the Orders tab, revealed orders on 09/07/21 stated, Admit to SNF (skilled nursing facility) .Full Code .Oxygen at 4 LPM (liters per minute) via nasal cannula continuous . [MEDICATION(S)] (medication to open airways) every 4 hours PRN (as needed) . Review of R96's EMR under the Census tab showed R96's movement within the facility: on 09/01/21 R96 was moved to a room on the COVID positive unit, on 09/04/21 he was transferred to the hospital, on 09/07/21 he returned from the hospital and was placed in a room on the COVID positive unit, on 09/14/21 he was transferred to a regular room on the rehabilitation floor and on 09/16/21 R96 was discharged to a sister facility due to his positive COVID-19 status with a continuation of symptoms. Observation on 09/15/21 at 9:00 AM, revealed R96 was residing alone in a two-person room on the general rehabilitation unit (moved from the COVID-19 positive unit on 09/14/21) with no precautions being taken by staff when direct patient care was being performed. The observation revealed no transmission based precautions signage located on the door of R96's room stating what precautions were in place and what PPE needed to be utilized for R96, a resident who continued to exhibit symptoms of COVID-19. Also, there was no PPE (gowns, N95 masks, gloves, eye protection) placed by or near R96's room for staff or visitor use. The following are observations on 09/15/21 of staff entering R96's room without wearing appropriate PPE (gowns, gloves, eye protection): At 11:00 AM Certified Nursing Assistant (CNA)26 went to check on resident; At 11:08 AM CNA26 went back into his room to provide patient care; At 11:12 AM Rehab Tech (RT)1 went into R96's room to assist CNA26; At 11:46 AM Housekeeping (HK) 15 entered R96's room and cleaned it. lnterviews with nursing staff on 09/15/21 from 10:45 AM to 11:50 AM revealed staff on the unit was unaware of R96's current COVID-19 isolation status. During an interview in the conference room on 09/15/21 at 11:05 AM, the survey team was informed that nursing and housekeeping staff on the Rehabilitation Unit were assigned a current patient load of 26 total residents (five of whom had not been vaccinated for COVID-19 due to recent admission). 2. An observation on 09/15/21 at 11:00 AM, at the nurses' station of the rehab unit, it was observed Licensed Practical Nurse (LPN) 25 coughed several times and did remove her mask, at times, while at the nurses' station. During an interview on 09/15/21 at 11:15 AM with LPN25, she stated when coming in to work a shift there is a questionnaire, at the front desk, we have to fill out and they take our temperature. I did that this morning. Last week they sent me home because I had more [MEDICATION(S)] stuff and a cough. They tested me three times last week, including a PCR (polymerase chain reaction) and I tested negative. I cough continuously so I don't remember what I put today on my screening. Review of LPN 25's COVID-19 screening dated 09/15/21 indicated LPN 25 failed to indicate her current symptom of coughing on the screening form. A request was made for the previous two months of the facility's staff wide COVID-19 Screening Documentation, but the facility was unable to provide the requested documentation to the survey team. During an interview on 09/15/21 at 12:20 PM with the Director of Nursing (DON), she stated when an employee notes they have a cough, during the screening process, the Administrator or Infection Control Preventionist (ICP) should be notified by the receptionist followed by a nurse assessment of the employee in order to decide how to proceed. 3. Observation on 09/14/21 at 10:49 AM revealed that R393 had a Personal Protective Cart to the left of his doorway. On top of the cart was a sign that stated Isolation Precautions. Review of the Face Sheet, located in the electronic medical record (EMR) revealed R393 was admitted on [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Progress Notes, located in the EMR revealed that on 09/09/21, R393 was diagnosed with Enterocolitis due to [CONDITION(S)] (C-Diff) and was placed on contact precautions. Observation on 09/15/21 at 10:52 AM, revealed an ambulance service arrived at the facility to transport R393 to [CONDITION(S)]. Two transport aides were observed to enter R393's room with no PPE or hand hygiene. The two transport aides exited the room and then donned (put on) PPE. At 11:16 AM, the two transport aides were observed to exit the room wearing the same PPE and exited the facility with R393. The transport aides did not doff (take off) their PPE before leaving R393's room. R393 was observed wearing a face mask covering his chin exposing his nose and mouth. Interview on 09/15/21 at 11:25 AM with Licensed Practical Nurse (LPN)10 revealed that transport staff is advised of isolation precautions on the paperwork that goes with the resident. LPN10 stated she processed the paperwork for R393 but did not tell the transport staff what isolation precautions were in place for R393. The transport staff did not stop at the nurses' station prior to going into R393's room. On 09/15/21 at 1:11 PM, observation and interview with the Infection Preventionist (IP) revealed that there was no signage on R393's room door. When asked how transport would know that someone is on contact precautions, the IP stated that they would see the sign on the door and nursing is to tell transport when they ask for the paperwork. During interview and observation on 09/16/21 at 4:05 PM, the Corporate Nurse Consultant verified that there was no signage on R393's door. The policy was reviewed with the Corporate Nurse Consultant. She verified that the policy states that an isolation sign is to be placed on the door. Review of facility policy titled Transmission-Based Isolation Precautions, dated 03/06/19,revealed .It is the policy of all Pruitthealth Healthcare Centers to implement and adhere to transmission based precautions to prevent and protect from exposure and transmission of suspected or confirmed infectious agents within the healthcare setting .promptly initiate isolation precautions for residents whose infectious disease(s) are detected by laboratory results, (i.e., [CONDITION(S)]-resistant Staphylococcus aureus ([CONDITION(S)]), positive [CONDITION(S)] (C. diff) .personal protective equipment (PPE) is provided for everyone who needs to care for or visit a resident on isolation precautions .display the appropriate isolation signage on the resident's doorframe/door .if a resident is to be transported to another facility, notify the receiving facility, medi-van or emergency vehicle personnel in advance about the infectious agent and type of transmission-based precautions being used .perform hand hygiene prior to donning gown; don a gown upon entry into the room; remove gown before leaving the resident's environment and perform hand hygiene 4. Review of the Face Sheet located in the EMR revealed revealed that R98 was admitted to the facility on [DATE]. Observation on 09/14/21 at 11:20 AM revealed no signage on residents door for isolation precautions. There was also no PPE cart located outside of his room. Review of the Orders, located under the Orders tab in the EMR revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview and observation on 09/14/21 at 4:15 PM, the Director of Health Services (DHS) verified that there was no signage on the door for contact precautions and no PPE located outside of R98's room. During an interview on 09/17/21 at 12:41 PM, Licensed Practical Nurse (LPN) 4 revealed that R98's received the last dose of antibiotic and that the isolation precaution order was to be discontinued on 09/18/21. During an interview on 09/17/21 at 12:57 PM, the IP stated that the PPE cart had been outside of the resident's room and for some reason was moved. The IP verified that there was not an isolation sign on R98's door. 5. During an observation on 09/14/21 at 12:56 PM, revealed RN8, Registered Nurse - Case Mix Director providing feeding assistance to Resident (R)339. RN8 was using a spoon to assist R339 with eating mechanical barbeque chicken and greens. RN8 then stopped assisting R339 and walked over to R34's table, picked up R34's spoon and attempted to serve the resident black-eyed peas but R34 did not eat. RN8 did not sanitize or wash her hands between the assistance of R339 and R34. During an observation on 09/14/21 at 1:03 PM, revealed ST24, Speech Therapist, providing feeding assistance to Resident (R)339. ST24 was using a spoon to assist R339 with eating mechanical barbeque chicken and black-eyed peas. ST24 then stopped assisting R339 and walked over to the table to check on R34. At this time, ST24 rubbed R34 on her shoulder, uncovered then recovered R34's food tray, picked up R34's glass of chocolate milk and moved the glass closer to R34. ST24 then walked back over to R339's table, picked up his spoon, and began assisting R339 with eating mechanical barbeque chicken. ST24 did not sanitize or wash her hands between the assistance of R339 and R34. During an interview on 09/14/21 at 1:06 PM, RN8 confirmed she did not wash or sanitize her hands between assisting R339 and R34. During an interview on 09/14/21 at 1:08 PM, ST24 confirmed she did not wash or sanitize her hands between assisting R339 and R34. Review of the facility's policy titled, Infection Prevention - Hand Hygiene, revised on 03/08/2019, indicated, hands should be washed before and after assisting a resident to eat.

Based on observation, interview, record review, and review of Centers for Medicare and Medicaid Services (CMS) QSO memo 20-38-NH REVISED, the facility failed to ensure twice weekly testing for COVID-19 was completed for all staff and residents during an outbreak. The facility failed to ensure the unvaccinated staff were tested twice weekly per their high county Community Transmission Rate. This failure had the likelihood for any resident who had not had COVID-19 within the past 90 days to contract and spread the virus and experience symptoms such as decreased oxygen saturations, fever, cough, respiratory failure, and death. The facility census was 141. Review of the CMS QSO 20-38-NH REVISED memo, dated 09/10/21, revealed that all unvaccinated staff should be tested twice weekly when the Community Transition Rate is in the substantial or high category. The Community Transition Rate in [NAME] County, SC was 13.1% on 09/15/21 putting the county in the high transmission category. In addition, CMS QSO 20-38-NH indicates that all staff and residents, regardless of their vaccination status, should be tested twice weekly during a facility outbreak investigation and for two weeks after the resolution of a facility COVID-19 outbreak. Review of the facility matrix revealed three residents tested positive for COVID-19 on 09/01/21 making the facility in outbreak status. Review of COVID immunization records revealed 16 unvaccinated residents resided in the facility. Interviews with staff currently working in the facility indicated staff was aware of the twice weekly COVID testing requirement however staff was unsure of the facility's testing schedule and was provided no direction from administration related to ensuring testing is done per current requirements. Seven of 30 nursing/ CNA/ therapy/housekeeping/maintenance/ dietary/hospice staff members who were interviewed and working in the facility on 09/15/21, revealed that they had not been tested for COVID-19 twice weekly. On 09/15/21 at 5:55 PM, the Administrator, Director of Health Services (DHS), and the Corporate Nursing Consultant were notified that an immediate jeopardy was identified at F886-L:COVID-19 testing of residents and staff for failure to ensure all staff and residents, regardless of their vaccination status, were tested for COVID-19 as required by current outbreak status as well as the high county COVID-19 Community Transmission Rate of 13.1%. The IJ was identified to have began on 09/01/21. The facility provided an acceptable Removal Plan for the immediate jeopardy on 09/17/21 at 2:47 PM. The survey team validated the Removal Plan through interviews, observations, and record review. The immediate jeopardy was removed on 09/17/21 at 9:22 PM following the facility's implementation of the Removal Plan. The deficient practice remained at F886 at a lower scope and severity of F (widespread with the potential for more than minimal harm) following the removal of the immediate jeopardy. Findings include: Review of CMS QSO 20-38-NH REVISED, dated 09/10/21, revealed for a facility located in a county with a high (red) level of Community Transmission unvaccinated staff are to be tested twice a week. Further review of CMS QSO 20-38-NH REVISED, dated 09/10/21, revealed that all staff and residents, regardless of their vaccination status, are to be tested every three to seven days during an outbreak. The outbreak testing of all staff and residents is to continue for 14 days after the last positive (staff or resident) COVID-19 result. Review of the facility matrix revealed three residents tested positive for COVID-19 on 09/01/21 making the facility in outbreak status. During an interview on 09/15/21 at 11:01 AM, the DHS and the Infection Preventionist (IP) revealed that they were unable to provide July, August, or September 2021 documentation of staff testing to verify that testing was completed per CMS guidelines. The DHS indicated that the expectation is for staff to be tested twice weekly based on the current County Transmission rate of 13.1%, and for the results of staff COVID-19 tests to be reported to her and the IP for evaluation and monitoring. The DON verified that the facility had no system in place to ensure staff was being tested for COVID-19 per the current county transmission rate. Observation and interview on 09/15/21 at 10:00 AM revealed Licensed Practical Nurse (LPN) 25 sitting at the nurse's station with her surgical mask hanging off her right ear. LPN25 had a constant dry cough and was continuously clearing her throat. When asked when the last time was she was tested for COVID-19, LPN25 stated eight days ago (09/07/21) even though the facility was in a high County Transmission rate of 13.1%. Interview on 09/15/21 at 10:40 AM with LPN20 confirmed that LPN25 did not test this week. Interview on 09/15/21 at 02:45 PM with LPN12 revealed that she had been tested today and that she worked the weekend, and no testing occurs on the weekend. LPN12 verified that she had not been tested twice a week and her last test was on 09/07/21 despite the facility being in a high County Transmission rate of 13.1% requiring staff be tested twice a week. On 09/16/21 at 05:23 PM, a surveyor completing a record review, found a note in a resident's chart that a staff member tested positive for COVID-19 on 09/16/21. The DHS stated that the staff member had worked the weekend, 09/11/21 and 09/12/21. When asked if she thought the facility should be in outbreak mode and following CMS guidelines, the DHS had no response. The DHS, the Corporate Nurse, and the Administrator returned to the conference room and reviewed the CMS testing guidelines for outbreak testing with the survey team. The facility immediately started testing all staff and residents per outbreak guidelines.

Based on observations, interviews, and record reviews, the facility failed to keep Resident #1 free from neglect related to elopement for 1 of 3 residents reviewed for neglect. Resident #1 (R #1) had a successful elopement from the facility. The Resident was without supervision for an extended period of time and Emergency Medical Services (EMS) personnel found Resident #1 on 5/23/2021 at 10:15 PM outside of the facility, fallen out of his/her wheelchair with abrasions to his/her knees and nose. Facility staff were unaware Resident #1 had been out of the facility. On May 25, 2021 at 2:48 PM, the survey team informed the facility's Administrator that Immediate Jeopardy (IJ) existed at F600 and F689 effective 5/23/2021. The completed IJ template was also provided to the Administrator at this time. On May 26, 2021 at approximately 11:47 AM, the facility provided an accepted IJ Removal Plan with a completion date of May 26, 2021. At that time, the IJ was lowered to a scope and severity of D. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview of Mental Status (BIMS) score of 5 out of 15, indicating cognitive impairment. Review of Section E of the MDS related to Behaviors indicated Resident #1 had behaviors present for wandering and was coded for wandering to a place that places the resident at significant risk of getting to a potentially dangerous place. The facility submitted a reportable to DHEC on 5/24/2021 at 11:53 AM indicating that on 5/23/2021 around 10:15 pm, Resident #1 had eloped from the facility and was found outside by Emergency Medical Services (EMS) having fallen on the sidewalk, sustaining abrasions to his/her knees and nose. Review of the medical record on 5/25/2021 at approximately 11:45 AM indicated no documentation in the progress notes related to the incident. Review of the Elopement risk observation form dated 5/5/2021 indicated Resident #1 scored an 11, indicating high-risk for elopement. Per the form, a score of 11 or greater interventions include: 3-day monitoring, weekly behavioral management, wanderguard program, MSU (Memory Secure Unit). Review of Resident #1's care plan dated 5/13/2021 with a problem start date of 5/5/2021 indicated behavior symptoms related to wandering behaviors. The goal indicated Resident will not leave the MSU unescorted through the next review. Approaches are to note favored exits during times of wandering, wanderguard as ordered, redirect when exit seeking is observed, and psyc evaluations as needed. All of these approaches had a start date of 5/5/2021. During an interview with the Administrator on 5/25/2021 at 12:30 pm, s/he confirmed a wanderguard was not placed on the resident on 5/5/2021 as stated as a response to the Elopement risk observation form and care plan. During an interview with Resident #1 on 5/25/2021 at 11:01 AM, s/he stated s/he had fallen years ago but not recently. When asked by the surveyor if s/he had gone outside recently, replied no. During a telephone interview with Certified Nurisng Assistant #1 on 5/25/2021 at 1:14 pm, s/he stated she was assisting his/her assigned residents with dinner when s/he noticed Resident #1 at the end of the nurses ' station conversing with another resident. At that time, s/he heard another resident make a sound and noted him/her to need immediate assistance around 7:30 pm. At this time, call lights were going off and other residents were yelling out for assistance, but due to shortage of staffing, s/he could not respond to them all. With everything going on, s/he did not notice Resident #1 had exited the building until EMS came and alerted the staff. During an interview via telephone with Registered Nurse #1 on 5/25/2021 at 2:30 pm, s/he indicated Resident #1 had been wandering since 7 pm and had asked the Certified Nursing Assistants (CNA) to keep an eye on the resident. S/he noted Resident #1 to be continuously going in and out of rooms and day areas trying to exit the patio doors. During this, another resident began experiencing a medical emergency. EMS had to be called and when they arrived, they originally came to the Therapy exit door, but proceeded to enter through the door at Station 4. At this time, staff was notified by EMS personnel that Resident #1 was outside on the ground and had fallen out of his/her wheelchair onto the sidewalk. When asked if the therapy door was unlocked, RN#1 replied s/he did not use his/her badge to unlock the door for EMS, sometimes it jams and you can get out the door but cannot get back in. Resident #1 did not have on a wanderguard at the time; therefore the alarm did not sound. RN #1 stated an attempt was made to notify the Resident Representative following the elopement and the Physician was notified via text. However, s/he did not notify the Administrator or Director of Nursing, neither did s/he report the incident to the proper state agencies. When asked if the resident complained of pain, RN #1 stated s/he noticed the knee abrasions but the resident seemed fine. S/he attempted a neuro check but the resident became combative, so there was no additional neuro checks performed. During an interview with the DON on 5/25/2021 at 11:20 am, s/he stated both the Administrator and DON should have been notified as soon as the incident occurred so that it could be reported timely to the proper state agencies.

Based on observation, interview, and record review, the facility failed to keep Resident #1 free from accidents related to elopement for 1 of 3 residents reviewed for accidents. Resident #1 (R #1) had a successful elopement from the facility. The Resident was without supervision for an extended period of time and Emergency Medical Services (EMS) personnel found Resident #1 on 5/23/2021 at 10:15 PM outside of the facility, fallen out of his/her wheelchair with abrasions to his/her knees and nose. Facility staff were unaware Resident #1 had been out of the facility. On May 25, 2021 at 2:48 PM, the survey team informed the facility's Administrator that Immediate Jeopardy (IJ) existed at F600 and F689 effective 5/23/2021. The completed IJ template was also provided to the Administrator at this time. On May 26, 2021 at approximately 11:47 AM, the facility provided an accepted IJ Removal Plan with a completion date of May 26, 2021. At that time, the IJ was lowered to a scope and severity of D. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses including but not limited to Dementia with behavioral disturbance, Diabetes, [CONDITION(S)], [CONDITION(S)], Acquired absence of right leg below knee, Insulin, and tobacco use. Review of the Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview of Mental Status (BIMS) score of 5, indicating cognitive impairment. Review of Section E of the MDS related to Behaviors indicated Resident #1 had behaviors present for wandering and was coded for wandering to a place that places the resident at significant risk of getting to a potentially dangerous place. The facility submitted a reportable to DHEC on 5/24/2021 at 11:53 AM indicating that on 5/23/2021 around 10:15 pm, Resident #1 had eloped from the facility and was found outside by Emergency Medical Services (EMS) having fallen on the sidewalk, sustaining abrasions to his/her knees and nose. Review of the medical record on 5/25/2021 at 11:45 AM indicated no documentation in the progress notes related to the incident. Review of the Elopement risk observation form dated 5/5/2021 indicated Resident #1 scored an 11, indicating high-risk for elopement. Per the form, a score of 11 or greater interventions include: 3-day monitoring, weekly behavioral management, wanderguard program, MSU (Memory Secure Unit). Review of Resident #1's care plan dated 5/13/2021 with a problem start date of 5/5/2021 indicated behavior symptoms related to wandering behaviors. The goal indicated Resident will not leave the MSU unescorted through the next review. Approaches are to note favored exits during times of wandering, wanderguard as ordered, redirect when exit seeking is observed, and psyc evaluations as needed. All of these approaches had a start date of 5/5/2021. During an interview with the Administrator on 5/25/2021 at 12:30 PM, s/he confirmed a wanderguard was not placed on the resident on 5/5/2021 as stated as a response to the Elopement risk observation form and care plan. During an interview with Resident #1 on 5/25/2021 at 11:01 AM, s/he stated s/he had fallen years ago but not recently. When asked by the surveyor if s/he had gone outside recently, replied no. During a telephone interview with CNA #1 on 5/25/2021 at 1:14 PM, s/he stated was assisting his/her assigned residents with dinner when s/he noticed Resident #1 at the end of the nurses ' station conversing with another resident. At that time, s/he heard another resident make a sound and noted him/her to need immediate assistance around 7:30 pm. At this time, call lights were going off and other residents were yelling out for assistance, but due to shortage of staffing, s/he could not respond to them all. With everything going on, s/he did not notice Resident #1 had exited the building until EMS came and alerted the staff. During an interview via telephone with Registered Nurse #1 on 5/25/2021 at 2:30 pm, s/he indicated Resident #1 had been wandering since 7 PM and had asked the Certified Nursing Assistants (CNA) to keep an eye on the resident. S/he noted Resident #1 to be continuously going in and out of rooms and day areas trying to exit the patio doors. During this, another resident began experiencing a medical emergency. EMS had to be called and when they arrived, they originally came to the Therapy exit door, but proceeded to enter through the door at Station 4. At this time, staff was notified by EMS personnel that Resident #1 was outside on the ground and had fallen out of his/her wheelchair onto the sidewalk. When asked if the therapy door was unlocked, RN#1 replied s/he did not use his/her badge to unlock the door for EMS, sometimes it jams and you can get out the door but cannot get back in. Resident #1 did not have on a wanderguard at the time; therefore, the alarm did not sound. RN #1 stated an attempt was made to notify the Resident Representative following the elopement and the Physician was notified via text. However, s/he did not notify the Administrator or Director of Nursing (DON), neither did s/he report the incident to the proper state agencies. When asked if the resident complained of pain, RN #1 stated s/he noticed the knee abrasions, but the resident seemed fine. S/he attempted a neuro check, but the resident became combative, so there were no additional neuro checks performed. During an interview with the DON on 5/25/2021 at 11:20 AM, s/he stated both the Administrator and DON should have been notified as soon as the incident occurred so that it could be reported timely to the proper state agencies.

Based on record review, interview, and review of facility policy, the facility failed to revised a care plan for one 1 of 26 sampled residents, Resident #16. Resident #16's initial care plan dated 6/5/18, for wandering behavior listed interventions which included giving the resident finger foods. The resident's diet order was changed on 3/3/19 to pureed diet due to swallowing difficulty. Staff failed to revise the resident's care plan which placed the resident at risk for harm and on 10/4/19 the resident choked on a peanut butter sandwich and was transferred to the emergency room later in the day and diagnosed with [REDACTED]. The facility's failure to update Resident #16's Care plan placed the resident at risk for serious injury, harm, impairment or death. The facility Administrator was notified of the Immediate Jeopardy on 12/12/19 at 1:30 PM. The Immediate Jeopardy was removed at 8:30 PM. The scope and severity was lowered to a D. The findings included: Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility policy, Care Plans, with revision date 10/5/17 revealed it is the policy of the facility to have a comprehensive care plan with the focus of the resident at the center of control. The care plan must include at a minimum information necessary to address the resident's health and safety concerns to prevent decline or injury. Care plans will be updated by nurses, Case Mix Director (CMD), or any member of the interdisciplinary team so that the care will reflect the resident's needs at any given time. The resident's quarterly Minimum Data Set ((MDS) dated [DATE] noted the resident was assessed with [REDACTED]. According to the assessment, the resident required extensive one (1) person physical assistance for transfers, dressing, eating, toilet use, personal hygiene and was totally dependent on one (1) staff for bathing. The resident had no impairment for functional limitation in range of motion for upper and lower extremity. The resident received a mechanically altered diet and speech therapy services were provided on [DATE]. Review of the Care Plan with revision date 9/23/19: Problem [ENTITY]t Date 6/5/18: 1.Category: Nutritional Status: Resident receives a therapeutic mechanically altered diet and is edentulous. History of significant weight loss with poor appetite Long Term Goal: Maintain weight without significant weight loss (Target date [DATE]) Approach [ENTITY]t Date:1/31/19: Pudding added to all meals, Observe and record all po (by mouth) intake. Provide diet as ordered. Provide alternative meals when resident is uninterested in meal served. Provide supplements as ordered. Weekly weight. 2. Problem [ENTITY]t Date 6/5/18: Category: Behavioral Symptoms: Resident wanders daily. Refuses to rest. Leans to one (1) side when tired. Will go in other's rooms. Will eat off other resident's trays. Refuses care, can be verbally and physically aggressive. Long Term Goal: Will wander safely within specified boundaries. Will have decreased episodes of refusing care and aggression. (Target date [DATE]) Approach [ENTITY]t Date: 8/26/19: Maintain a calm environment. Offer finger foods (initiated 6/5/18). Provide diversional activities. Remove resident from unsafe situations-other resident rooms, Staff to intervene to protect the right and safety of others. Review of Order History Dietary Order with start date 3/6/19 end date 10/13/19: Regular, Pureed with Special Instructions: Food in bowls A Speech Therapy Plan of Care (Evaluation Only) dated [DATE]: The resident is total care for ADL's (Activities of Daily Living), wanders the halls constantly. The resident has a [DIAGNOSES REDACTED]. The resident was administered the MASA ([MEDICATION NAME] of Swallowing Ability) to assess swallow functions with resident scoring 143, placing the resident in the moderate range for dysphagia and aspiration. The resident is on the least restrictive diet for safe po intake. Review of the Resident Progress Notes between [DATE] through 10/3/19 revealed the resident had 13 incidents of the resident wandering the halls incessantly, in other's room and not wanting to take rest breaks. An entry on 9/15/19 at 6:59 PM Resident continues to wander on [CONDITION]U and the only activities he/she is truly interested in is meals and snacks and on 10/2/19 at 6:37 PM resident was seen by staff to pick up food with his/her hands and threw it at another resident in dining room. Resident was removed from the dining room and redirected. Further review of the Resident Progress Notes: 10/4/19 at 11:15 AM (Recorded as late entry on 10/6/19 at 1:32 PM) documented by Director of Health Services (DHS) Approached the unit to find the resident in respiratory distress. Nurse Practitioner (NP) and nursing staff were present and providing care. Staff suctioned the resident applied O2 and a nebulizer treatment (medication used to open airway passages) was administered. The resident was difficult to manage as was making constant attempts to get up from chair. When the resident oxygen saturation levels improved to 90-[AGE]% the resident was transferred to room with staff assistance. 10/4/19 7:22 PM Documentation entry by NP (Nurse Practitioner): Was asked to come and look at the resident who was coughing. The resident is in a chair appearing pale and coughing. There is food pocketed in cheeks that looks like bread. A CNA (Certified Nursing Assistant) got the food out of the resident's cheek. The resident had just eaten a peanut butter sandwich. O2 saturation checked and was [AGE]%. 02 was started. More food was extracted from the residents left cheek. O2, nebulizer treatments and antibiotics were administered to the resident. Resident ambulated to room with staff assistance and remained stable and rested well. 10/6/19 5:38 PM Documentation entry by RN (Registered Nurse) #1: (Recorded as a late entry): On 10/4/19 around 10:46 PM Resident #16 was sitting in a chair in common area of [CONDITION]U. Resident was pale and attempting to cough. The resident's skin was cool and clammy with 02 saturation of [AGE]%. Resident given scheduled [MEDICATION NAME] nebulizer treatment with 02 saturation increase to 78% but decreased to [AGE]-[AGE]% when resident began moving around. Bilateral rales in lungs. Resident took off 02 and began hitting nurse. NP on call notified and received orders to send to hospital for evaluation. E[CONDITION] arrived and resident left facility via stretcher. An interview with LPN #1 on 12/13/19 at 1:10 PM revealed all nurses are responsible for updating care plans when physician orders change or if there is a change in the resident's condition. LPN#1 said if an order is received to change the resident's diet the nurse should take the order off, send a copy to dietary and update the care plan immediately. Unit Manager (UM) #1 said during an interview on 12/13/19 at 1:20 PM care plans should be updated for every new physician order or whenever there is a change in resident condition. The UM stated all nurses are educated on updating care plans and should be ensuring care plans are updated prior to leaving their shift and she could not say why Resident #16's care plan had not been revised to remove finger foods from the care plan. An interview with the Director of Nursing (DON) was conducted on 12/13/19 at 1:30 PM The DON stated nurses should update care plans at the time of change of condition with new interventions as needed and when new orders are received. The facility's failure to update Resident #16's Care Plan placed the resident at risk for serious injury, harm, impairment or death. REMOVAL PLAN: Facility failed to remove finger food intervention for a resident on a puree-only diet. [AGE] year-old resident on the secured dementia unit who staff identified as constant wanderer, required feeding by staff, and had a behavior of taking food from other residents' trays. This occurred on or around 10/4/2019. Resident no longer resides in the facility. All residents on the [CONDITION]U with a mechanically altered diet have the potential to be affected by the alleged deficient practice. All [CONDITION]U resident diets were reviewed to identify those with mechanically altered diet by the Case Mix Directors. These care plans have been reviewed and updated to ensure that interventions are appropriate for all [CONDITION]U residents with mechanically altered diets. The team reviewed 15 residents with mechanically altered diets and did not need to make any revisions. The care plan policy was last reviewed on 12/12/19 by the interdisciplinary team and signatures were secured. No nursing staff shall work until they have completed in services on updating care plans starting 12/12/19. Newly hired staff will be in serviced on updating care plans during orientation and annually thereafter by the CCC. Staff will not be permitted to work until education has been completed. The Director of Health Services (DHS), and/or nursing unit managers will review [CONDITION]U residents care plans weekly to ensure that they have been updated with acute changes, for four weeks starting 12/12/19 and quarterly there after for three months. The Director of Health Services (DHS) and or Unit Manager will report any adverse findings to the Administrator immediately and to QAPI. The Director of Health Services (DHS) and/or Unit Manages will review the Facility Activity Report five times a week to monitor for any acute changes of condition including diet changes and updated care plan for four weeks. The Director of Health Services (DHS) and/or Unit Managers will review care plans to ensure care plan interventions are updated. Any adverse findings will be reported by the Director of Health Services (DHS), Assistant Director of Health. An Ad Hoc QAPI meeting was held with the Medical Director, the Administrator, Director of Health Services (DHS), Licensed Practical Nurse, Restorative Nurse and Certified Nursing Assistant on 1212/2019 to discuss the immediate jeopardy finding and the removal plan. All corrective actions were completed by 12/12/2019. The immediacy of the IJ was removed on 12/12/2019.

Based on record review, interview, and review of facility policy, it was determined the facility failed to investigate an incident of potential neglect for one (1) of twenty-six (26) sampled residents, Resident #16. Resident #16 was assessed to have severe cognitive impairment and resided on the secured Memory Support Unit ([CONDITION]U). The resident was evaluated by Speech Therapy and it was determined the resident was at moderate risk for aspiration and needed a pureed diet which had initially been ordered by the physician on 3/ 6 /19. The resident's behaviors included wandering and taking resident's food from other residents in the [CONDITION]U. On 10/4/19, the resident was observed to be pale and to have difficulty breathing. When the Nurse Practitioner assessed the resident, a peanut butter sandwich was pocketed in the resident's mouth. After the sandwich was removed, the resident was suctioned, and oxygen was applied. Staff worked approximately one (1) hour to stabilize the resident. Later that evening the resident experienced respiratory distress and was transferred to the emergency room and was admitted to the hospital with [REDACTED]. The resident returned to the facility on Hospice with a [DIAGNOSES REDACTED]. The facility failed to investigate an incident potential of neglect, failed to obtain witness statements in an attempt to identify how the resident got the sandwich, thus no corrective action was taken to protect other residents from potential neglect. The facility's failure to conduct a thorough investigation of the choking incident placed residents at risk for serious injury, harm, impairment or death. The facility Administrator was notified of the Immediate Jeopardy on 12/12/19 at 1:30 PM. The Immediate Jeopardy was removed on 12/12/19 at 8:30 PM. The scope and severity was lowered to a D. The findings included: Resident #16 was admitted to the facility on [DATE] to the Memory Support Unit ([CONDITION]U). The resident's [DIAGNOSES REDACTED]. According to a quarterly Minimum Data Set (MDS) review dated [DATE] the resident's cognitive status was severely impaired, and the resident required supervision of one (1) person, physical assistance walking in room/ corridor, and required extensive one (1) person physical assistance with eating a mechanically altered diet. Review of the Care Plan with revision date 9/23/19 revealed the resident received a mechanically altered diet and would wander and eat off other resident's trays. Review of Order History Dietary Order with start date 3/6/19 end date 10/13/19: Regular, Pureed with Special Instructions: Food in bowls A Speech Therapy Plan of Care (Evaluation Only) dated [DATE]: The resident has a [DIAGNOSES REDACTED]. The evaluation determined the resident was at the moderate range for dysphagia and aspiration. The resident is on the least restrictive diet for safe po intake. Review of the facility policy, Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property with revision date of 11/21/16 revealed it is facility policy to investigate allegations and occurrences of abuse, neglect, exploitation, mistreatment and misappropriation of patient property. The administrator is responsible for assuring an accurate and timely investigation is completed. If there is an occurrence of abuse, neglect, exploitation, mistreatment or misappropriation of property an investigation will be conducted. A review of the facility policy, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, with revision date of 11/21/16 documented it is the policy of the facility to actively preserve each patient's right to be free from abuse and neglect. Neglect is the failure of the facility to provide goods and services to a patient that are necessary to avoid physical harm, mental anguish or emotional distress. Facilities are to identify and correct and intervene it situations in which abuse, neglect, mistreatment or exploitation may occur. This should include an analysis of the following: Features of the physical environment that could make abuse, neglect, mistreatment, or exploitation more likely to occur, such as secluded areas of the facility. The deployment of staff on each shift in sufficient numbers number to meet the individual needs of patients. Monitoring of patients with needs and behaviors such entering other resident's rooms and self-injurious behaviors. Review of the Resident Progress Notes: 10/4/19 11:15 AM (Recorded as late entry on 10/6/19 at 1:32 PM) documented by Director of Health Services (DHS: Approached the unit to find the resident in respiratory distress. Nurse Practitioner (NP) and nursing staff present and providing care. The resident was suctioned, given O2 (oxygen), nebulizer treatments and antibiotics. The resident was difficult to manage, was constantly attempting to get up from chair. The resident was eventually more relaxed when standing and leaning onto staff and ambulated with staff to bed where resident was able to rest without attempts to get up. 10/4/19 7:22 PM Documentation entry by NP: Received request to come to assess the resident who was coughing. Upon arriving to the unit, the resident sitting in chair, pale and coughing. There was food pocketed in the resident's cheeks that looks like bread. A CNA (certified nursing assistant) got the food out of the resident's cheek. The resident had just eaten a peanut butter sandwich. O2 saturation checked and was [AGE]%. 02 was started at two (2) liters and was increased to four (4) liters via nasal cannula to bring 02 saturation to [AGE]%. More food was then extracted from the residents left cheek. Resident was restless taking off the 02 saturation monitor constantly wanting to sit up and stand up. [MEDICATION NAME] nebulizer was given via mask with 02 level increased to [AGE]%. Suction was started. Resident appeared to be breathing better but rales (abnormal lung sounds characterized by discontinuous clicking or rattling sounds) still heard in bilateral lungs, A stat chest x-ray was ordered and [MEDICATION NAME] (antibiotic) one (1) gram was given IM (intramuscular) by the nurse. Resident then ambulated to room with 02 saturation still low at 82%. 02 at two (2) liters with concentrator was increased to three (3) liters per minute with 02 saturation at [AGE]-94%. Resident remained stable and rested well. 10/6/19 5:38 PM Documentation entry by RN (Registered Nurse) #1: (Recorded as a late entry): On 10/4/19 around 10:46 PM Resident #16 was noted to be pale with cool clammy skin and was attempting to cough. The resident's 02 saturation of [AGE]% and was given scheduled [MEDICATION NAME] nebulizer treatment with 02 saturation increased to 78% but decreased to [AGE]-[AGE]% when resident began moving around. The NP on call notified and received orders to send to hospital. An interview was conducted with the Administrator on [DATE] at 3:25 PM. The Administrator stated nobody knows how Resident #16 got the peanut butter sandwich he/she choked on. The nurse on the unit said she didn't know how the resident got the sandwich. She further said no investigation was conducted on Resident #16's choking incident but concluded the Director of Health Services (DHS) or a nurse could have done the investigation. An interview with the DHS on [DATE] at 2:00 PM revealed Resident #16 would not sit down for staff and the resident would remove food from other resident's meal trays. He/she said staff on the Memory Support Unit ([CONDITION]U) are constantly watching the residents and there was not a whole lot more staff could do, all staff could do was intervene as needed. The DHS stated she did not know how the resident got the sandwich, I did not address it at the time. He/she said I just asked nurses and CNA's (certified nursing assistants) and they said they didn't give the sandwich to the residents. The DHS concluded he/she did not initiate an investigation into Resident #16's choking incident. A further interview with the Administrator on 12/12//19 at 1:15 PM revealed he/she would not do an investigation just because a resident got the wrong tray or ate a food item that was not part of the resident's diet. The facility's failure to conduct a timely through investigation to the choking incident of Resident #16 in an attempt to identify causative factors of the incidents placed residents of the facility at risk for serious injury, harm, impairment or death. REMOVAL PLAN: Facility failed to remove finger food intervention for a resident on a puree-only diet. [AGE] year-old resident on the secured dementia unit who staff identified as constant wanderer, required feeding by staff, and had a behavior of taking food from other residents' trays. This occurred on or around 10/4/2019. Resident no longer resides in the facility. All residents on the [CONDITION]U with a mechanically altered diet have the potential to be affected by the alleged deficient practice. All [CONDITION]U resident diets were reviewed to identify those with mechanically altered diet by the Case Mix Directors. These care plans have been reviewed and updated to ensure that interventions are appropriate for all [CONDITION]U residents with mechanically altered diets. The team reviewed 15 residents with mechanically altered diets and did not need to make any revisions. The care plan policy was last reviewed on 12/12/19 by the interdisciplinary team and signatures were secured. No nursing staff shall work until they have completed in services on updating care plans starting 12/12/19. Newly hired staff will be in serviced on updating care plans during orientation and annually thereafter by the CCC. Staff will not be permitted to work until education has been completed. The Director of Health Services (DHS), and/or nursing unit managers will review [CONDITION]U residents care plans weekly to ensure that they have been updated with acute changes, for four weeks starting 12/12/19 and quarterly there after for three months. The Director of Health Services (DHS) and or Unit Manager will report any adverse findings to the Administrator immediately and to QAPI. The Director of Health Services (DHS) and/or Unit Manages will review the Facility Activity Report five times a week to monitor for any acute changes of condition including diet changes and updated care plan for four weeks. The Director of Health Services (DHS) and/or Unit Managers will review care plans to ensure care plan interventions are updated. Any adverse findings will be reported by the Director of Health Services (DHS), Assistant Director of Health. An Ad Hoc QAPI meeting was held with the Medical Director, the Administrator, Director of Health Services (DHS), Licensed Practical Nurse, Restorative Nurse and Certified Nursing Assistant on 1212/2019 to discuss the immediate jeopardy finding and the removal plan. All corrective actions were completed by 12/12/2019. The immediacy of the IJ was removed on 12/12/2019.

The facility failed to provide adequate supervision to maintain a safe environment for the resident and on [DATE], the resident was on a physician ordered pureed diet when the resident choked on a peanut butter sandwich. The resident was sent to hospital later that day, returned to the facility on [DATE] on Hospice and expired at the facility on [DATE]. The facility's failure to implement policy and ensure care plan interventions were revised and implemented resulted in a failure to provide adequate supervision to Resident #16 to ensure safety. The resident had a physician ordered pureed diet and on [DATE] the resident was observed having difficulty breathing. When assessed by staff the resident was pale, with low oxygen saturation levels and a peanut butter sandwich was found in the resident's mouth. Staff worked with the resident for approximately one (1) hour attempting to get the resident's oxygen saturation level up. Staff sat with the resident for several hours. Later that evening the resident experienced respiratory distress and was sent to the emergency room . The resident returned to the facility on [DATE] on Hospice care for [MEDICAL CONDITION] related to pneumonia. The resident expired at the facility on [DATE]. The facility Administrator was notified of the Immediate Jeopardy on [DATE] at 1:30 PM. The Immediate Jeopardy was removed on [DATE] at 8:30 PM. The scope and severity was lowered to a D. The findings included: Review of Resident #16's clinical record revealed an admitted to the facility of [DATE]. The resident's [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) review dated [DATE] revealed the resident was assessed to have unclear speech, rarely understood, rarely understands others, vision highly impaired and cognitive status was severely impaired. The resident had difficulty falling asleep two to six days of assessment period and exhibited physical, verbal and other behaviors directed toward others one to three days of the assessment period. According to the assessment, the resident required supervision of one (1) person, physical assistance for bed mobility, walking in room and corridor, required extensive one (1) person physical assistance for transfers and eating. The resident received a mechanically altered diet and speech therapy services were provided on [DATE]. Review of the Care Plan with revision date [DATE]: Problem [ENTITY]t Date [DATE]: 1. Category: Nutritional Status: Resident receives a therapeutic mechanically altered diet and is edentulous. History of significant weight loss with poor appetite Long Term Goal: Maintain weight without significant weight loss (Target date [DATE]) Approach [ENTITY]t Date:[DATE]: Pudding added to all meals, Observe and record all po (by mouth) intake. Provide diet as ordered. Provide alternative meals when resident is uninterested in meal served. Provide supplements as ordered. Weekly weight. 2. Problem [ENTITY]t Date [DATE]: Category: Behavioral Symptoms: Resident wanders daily. Refuses to rest. Leans to one (1) side when tired. Will go in other's rooms. Will eat off other resident's trays. Long Term Goal: Will wander safely within specified boundaries. Will have decreased episodes of refusing care and aggression. (Target date [DATE]) Approach [ENTITY]t Date: [DATE]: Maintain a calm environment. Offer finger foods (initiated [DATE]). Remove resident from unsafe situations-other resident rooms, Staff to intervene to protect the right and safety of others. Review of Order History Dietary Order with start date [DATE] end date [DATE]: Regular, Pureed with Special Instructions: Food in bowls. Surveyor received conflicting information both in the record and interviews with staff and the facility's [DATE] investigation of when the resident's choking incident occurred. From statements of staff and record review the incident occurred sometime between 11:15 AM and 7:22 PM. A Speech Therapy Plan of Care (Evaluation Only) dated [DATE]: The resident is total care for ADL's (Activities of Daily Living), wanders the halls constantly. The resident has a [DIAGNOSES REDACTED]. The resident was administered the MASA ([MEDICATION NAME] of Swallowing Ability) to assess swallow functions with resident scoring 143, placing the resident in the moderate range for dysphagia and aspiration. The resident is on the least restrictive diet for safe po intake. Review of the Resident Progress Notes documented on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. [DATE], [DATE], [DATE], [DATE] and [DATE], staff documented the resident wandering the halls incessantly, in others room and not wanting to take rest breaks. An entry on [DATE] at 6:59 p.m. Resident continues to wander on [CONDITION]U and the only activities he/she is truly interested in is meals and snack. On [DATE] at 6:37 p.m., resident was seen by staff to pick up food with his/her hands and threw it at another resident in the dining room. Resident was removed from the dining room and redirected. Further review of the Resident Progress Notes: [DATE] at 11:15 AM (Recorded as late entry on [DATE] at 1:32 PM) documented by Director of Health Services (DHS): Approached the unit to find the resident in respiratory distress. Nurse Practitioner (NP) and nursing staff present and providing care. Oxygen (02) at 2 liters with no effects. Titrated 02 up to four (4) liters also without effect. Audible crackles (clicking, rattling noises) in upper airway. Moderate amount of mucus obtained with suctioning. NP ordered [MEDICATION NAME] nebulizer treatment (medication used to open airway passages) which brought O2 saturation to low 90s. (normal 02 saturation levels ,[DATE]%). When 02 reapplied 02 saturation dropped back down to ,[DATE]'s. Resident continued with difficulty breathing second [MEDICATION NAME] nebulizer treatment was given with a decrease in rhonchi (low pitch wheezes in lung fields). Resident was difficult to manage as was making constant attempts to get up from chair. The resident seemed more relaxed when standing and leaning onto staff. Ambulated with staff to bed where resident was able to rest without attempts to get up. O2 was decreased to three (3) liters per minute on concentrator with 02 levels improved to ,[DATE]%. Staff sat at the bedside while the resident slept. [DATE] at 7:22 PM Documentation entry by NP: Was asked to come and look at the resident who was coughing. The resident is in a chair appearing pale and coughing. There is food pocketed in cheeks that looks like bread. A CNA got the food out of the resident's cheek. The resident had just eaten a peanut butter sandwich. O2 saturation checked and was [AGE]%. 02 was started at 2 liters and was increased to 4 liters via nasal cannula to bring 02 saturation to [AGE]%. More food was extracted from the residents left cheek. Resident was restless taking off the 02 saturation monitor constantly wanting to sit up and stand up. The nasal cannula was changed to a mask with still low 02 saturation levels. The DHS arrived to help support the resident. [MEDICATION NAME] nebulizer was given via mask with 02 level increased to [AGE]%. When 02 reapplied, 02 saturation level down to 81% and resident coughing. Suction started with regular suction and [MEDICATION NAME] suction which extracted some mucus. Resident appeared more ruddy (healthy reddish color) and breathing better but rales (abnormal lung sounds characterized by discontinuous clicking or rattling sounds) still heard in bilateral lungs, Stat chest x-ray ordered and [MEDICATION NAME] (antibiotic) one (1) gram IM (intramuscular) via nurse. Resident walked to room, toileted and assisted to bed. 02 saturation still low at 82%. 02 at two (2) liters with concentrator and increased to three (3) liters per minute with 02 saturation at ,[DATE]%. Resident remained stable and rested well. [DATE] at 5:38 PM Documentation entry by RN (Registered Nurse) #1: (Recorded as a late entry): On [DATE] around 10:46 PM Resident #16 was sitting in a chair in common area of [CONDITION]U. Resident was pale and attempting to cough. The resident's skin was cool and clammy with 02 saturation of [AGE]%. Resident given scheduled [MEDICATION NAME] nebulizer treatment with 02 saturation increase to 78%, but decreased to ,[DATE]% when resident began moving around. Bilateral rales in lungs. Resident takes off 02 and began hitting nurse. NP on call notified and received orders to send to hospital for evaluation. E[CONDITION] (Emergency Medical Services) arrived and resident left facility via stretcher. [DATE] at 6:34 PM Resident arrived back to facility from hospital via ambulance per stretcher. The resident was a manual lift from stretcher to bed. Resident returned on Hospice care. [DATE] at 12:53 PM Pharmacy review: Resident is on no routine meds. Resident was hospitalized for [REDACTED]. [DATE] at 12:19 PM Resident noted without respirations and heart rate. The Hospice nurse notified and confirmed death assessment. Review of the Nursing Home to Hospital Transfer Form dated [DATE] at 11:15 PM revealed Resident #16 was transferred to the hospital at 10:45 p.m. with oxygen saturation [AGE]% and heart rate of 134. Review of a hospital ER (emergency room ) Physician Record dated [DATE] at 4:50 PM, the patient presented with difficulty breathing, has severe dementia, noted to be very short of breath with loud respirations just before arrival per E[CONDITION] and was hypoxic in route. The course/duration is constant. Degree of onset severe. Degree at present severe. The resident was admitted to hospital for eight (8) day stay. A hospital Speech Therapy form dated [DATE] documented resident was seen for swallow study. The resident was admitted to the hospital in respiratory distress with bilateral lower lobe pneumonia and multifocal pneumonia. Spoke with ST at the facility the resident resides, the resident is ambulatory at baseline and is very active, constantly walking around the nursing home. The resident is on a pureed diet and apparently got a hold of a sandwich from another resident's tray. The ST assessment determined the resident's level of alertness combined with dementia affects ability to safely swallow, oropharyngeal dysphagia with signs and symptoms of aspiration with minimal intake. Recommend nothing by mouth with no exception. Family input is needed to determine wishes for alternate nutrition. Review of the Hospital Discharge Summary dated [DATE] revealed Resident #16 presented to the emergency room in respiratory distress. A CTA (computed tomography [MEDICATION NAME]) of the chest shows bilateral multifocal pneumonia. The resident was admitted to the hospital for acute hypoxic [MEDICAL CONDITION] secondary to bilateral multifocal pneumonia and was started on broad-spectrum IV (intravenous) antibiotics for healthcare associated pneumonia. Initially needed two (2) to three (3) liters of oxygen therapy and resident has severe dementia and would not follow verbal commands. Consulted with speech therapy and a PEG (percutaneous endoscopic [MEDEQUIP]) tube placement was recommended. Discussed with family about PEG tube placement and medical illness and family refused PEG tube placement and wanted comfort care. The resident is discharging to nursing home on Hospice Care. Review of the National Center for Biotechnology Information data base (a part of the United States Library of Medicine a branch of the National Institutes of Health) from an article in the British Journal of Radiology dated [DATE] documentation review revealed: Aspiration pneumonia can give rise to multifocal pneumonia consolidation affecting primarily the dependent portions of the lungs, in particular the posterior segments of the upper lobes and apical segments of the lower lobes. An interview with the Nurse Practitioner (NP) on [DATE] at 8:45 AM revealed she was called to the Memory Support Unit ([CONDITION]U) on [DATE] at approximately 2:00 PM He/she said upon arriving on the unit Resident #16 was noted to have labored breathing, and he/she did not immediately know why until he/she noted the resident had pocketed food in her mouth. The NP said he/she removed what appeared to be a peanut butter sandwich from the resident's mouth. He/she stated the resident was suctioned and that staff had a difficult time keeping the oxygen on the resident, that the resident was very restless she would get up and take the oxygen off. The NP stated he/she spent approximately one (1) hour providing treatment to the resident until his/her oxygen saturation levels improved and the resident was able to rest in bed with staff at bedside to monitor the resident closely. The NP said he/she felt upon leaving unit the resident was stable and was resting in bed. Later that evening at 9:45 PM the nurse on duty call the NP on duty due to the resident being in respiratory distress and the resident was transferred to the emergency room for evaluation. An interview was conducted with LPN (Licensed Practical Nurse) #3 on [DATE] at 10:05 AM The LPN stated on [DATE] upon entering the [CONDITION]U there were a lot of people surrounding Resident #16 in the common area of unit. The NP and the DHS were working with the resident and that he/she assisted them by suctioning the resident, removing mucus and encouraging the resident to cough. He/he stated the resident had a hard time coughing and it was difficult to get the resident to calm down. The LPN said when the resident's O2 saturation levels had improved the resident was transferred to room to bed with 02. The LPN said he/she sat by the resident's bedside for a couple of hours. He/she stated during the time he/she sat with the resident, the resident did not attempt to get up or walk and did not have anything to eat or drink because he/she was not responsive enough. The LPN concluded staff on the [CONDITION]U were focused and know how to approach the residents, but staff were unable to watch everybody because they (the residents) wander. A telephone interview was conducted with RN #1 on [DATE] at 10:00 AM The RN stated she received in report when coming on duty on [DATE] at 7:00 PM that Resident #16 had aspirated on a sandwich earlier in the day, the resident had choked, and oxygen saturations levels dropped significantly. The RN was told that staff had to work on the resident for a couple of hours to get oxygen saturation levels up. The RN said he/she questioned the nurse going off duty why the resident had not been sent out to the hospital to be evaluated, because the nurse would not be able to closely monitor the resident that evening because the RN was responsible for approximately 40 residents when coming on duty. RN #1 stated the resident was up walking the halls at 7:00 PM and when it was time to administer the resident's scheduled breathing treatment at approximately 9:30 p.m., the resident could barely stand up and was very pale, the resident's breathing was very loud, it sounded like a death rattle. The RN said she took the resident's oxygen saturation levels and they were down in the 70's with heart rate around 130, and the RN could actually hear the resident's breathing from down the hallway. RN #1 contacted the Nurse Practitioner on call and resident was sent out to emergency room for an evaluation. The nurse concluded, I could not understand why the resident was not sent out earlier. During an interview with the Medical Director (MD) on [DATE] at 9:45 AM, the MD said after reviewing Resident #16's hospital records, the resident was not diagnosed with [REDACTED]. The MD stated everybody aspirates all the time and that aspiration cannot be prevented. The MD stated he/she had no idea how the resident could have gotten the sandwich, but if you leave food out residents on the [CONDITION]U will get it. The MD said staff on the [CONDITION]U do the best they can do, and they can't monitor everyone every minute, that would be unrealistic expectations. He/she stated staff cannot watch all the residents all the time and that a pureed diet can also be aspirated. During an interview with the Speech Therapist (ST) on [DATE] at 11:00 AM he/she said a speech evaluation was conducted on Resident #16 in [DATE]. The ST said it was determined the resident could not be upgraded from a pureed diet. The ST said the assessment determined the resident remained at moderate risk for aspiration. The ST stated the resident had previously been able eat sandwiches, but since it was documented on the [DATE] speech therapy evaluation the resident could not safely eat sandwiches. An interview with CNA (certified Nursing Assistant) #3 was conducted on [DATE] at 4:35 PM The CNA said Resident #16 was on a pureed diet and was not supposed to have sandwiches, but the resident would grab out and get other resident's food if staff didn't have their eye on him/ her. The aide stated he/she witnessed the resident grabbing other resident's food, and if the resident saw staff coming the resident would cram the food in his/her mouth. LPN #1 stated during an interview on [DATE] at 10:30 AM Resident #16 was a wanderer who wandered almost non-stop. He/she said staff would attempt to get the resident to sit down and the resident would get right back up. She said the resident would wander to the point of exhaustion and that she would just pick up food and eat it. An interview with LPN #4 on [DATE] at 10:40 AM revealed Resident #16 had started out on a Regular diet, but she was downgraded to a pureed diet after a speech therapy evaluation. The LPN said the resident wandered all time and took very short rest breaks and was not easy to redirect. He/she said snacks are offered to all residents on the [CONDITION]U, the snacks are brought to the unit from the dietary department to include peanut butter and jelly sandwiches, which the residents love. She stated Resident #16 was on a purred diet with thickened liquids and could not have peanut butter and jelly sandwiches, but at times the resident would grab food and cram it in his/her mouth before staff could intervene. The LPN said once the resident got the food staff was not usually successful in getting the food back from the resident. Observation on [DATE] at 10:45 AM revealed 11 peanut butter and jelly sandwiches were in the unit snack refrigerator with dated ,[DATE] which the LPN stated was the expiration of the sandwiches. Observation on [DATE] at 1:08 PM in the [CONDITION]U dining room revealed 28 residents were sitting in the chairs/wheelchairs at four (4) person tables awaiting the lunch meal. Six (6) staff began serving the meals trays at 1:12 PM one table at a time. Resident # 25 and Resident #26 were observed sitting at a table with two (2) other residents. On [DATE] at 1:20 PM Resident #26 moved Resident #25's plate toward himself/herself, and Resident #26 immediately began eating the food from Resident #25's plate. After approximately one (1) minute CNA #2 walked by the table and pushed Resident #25's plate from Resident #26's reach and placed the plate back in front of Resident #25 which the resident began to eat. Surveyor immediately informed CNA #2 that Resident #26 had been eating from Resident #25's plate. CNA #2 stated he/she had only noted the plate had been moved and had not seen Resident #26 eating from Resident #25's plate. CNA #2 immediately removed Resident#25's meal and contacted the dietary department for a meal replacement. Observation on [DATE] at 1:30 PM of the tray cards sitting on the table by the residents, Resident #25's diet was listed as NCS (no concentrated sweets diet), Resident #26's diet was listed as Mechanical Soft Diet. Review of physician orders [REDACTED].#26 confirmed the residents had received the correct diets during the meal on [DATE]. Resident #26 ate from Resident #25's plate that did not contain mechanical soft food items. An interview with the Dietary Manager on [DATE] at 11:30 AM revealed a resident on a NCS diet would have regular textured diet with no concentrated and a Mechanical Soft Diet would have ground meat. Staff had no knowledge Resident #26 had eaten an undetermined amount of food off the tray of Resident #25 until surveyor intervention, thus the resident was at risk for potential choking due to consuming an incorrect diet. A review of facility policy revised [DATE] and titled, Occurrences, noted the facility recognizes that due to the frailty of residents served, there is an increased risk of occurrences that may result in injury to the resident. In an effort to prevent occurrences, each resident will be observed and assessed for risks, and appropriate interventions will be implemented in accordance to their plan of care. Occurrence hazards are physical features in the healthcare environment which may pose a risk to the resident's safety to include any event, accident or incident, which results in an injury or has the potential for injury. Review of a facility policy issued 2012 and titled, Support Unit Safety and Security revealed Memory Support Unit ([CONDITION]U) residents shall not be allowed to have any item or materials that could cause harm if used inappropriately. Staff on every shift shall periodically monitor common and private areas of the [CONDITION]U for safety hazards. The facility failed to implement their policy, failed to provide adequate supervision, update the resident's plan of care to address R#16's behavior wandering and eating food the resident had been assessed as unsafe to consume. These failures resulted in immediate jeopardy when Resident #16 ate a peanut butter sandwich, choked, was sent out to the hospital hours later, returned from hospital on Hospice care and expired at the facility 10 days later. An observation on [DATE] of the lunch meal on [CONDITION]U determined staff failed to supervise meal service again, when a resident was able to eat from another resident's plate. REMOVAL PLAN: Facility failed to remove finger food intervention for a resident on a puree-only diet. [AGE] year-old resident on the secured dementia unit who staff identified as constant wanderer, required feeding by staff, and had a behavior of taking food from other residents' trays. This occurred on or around [DATE]. Resident no longer resides in the facility. All residents on the [CONDITION]U with a mechanically altered diet have the potential to be affected by the alleged deficient practice. All [CONDITION]U resident diets were reviewed to identify those with mechanically altered diet by the Case Mix Directors. These care plans have been reviewed and updated to ensure that interventions are appropriate for all [CONDITION]U residents with mechanically altered diets. The team reviewed 15 residents with mechanically altered diets and did not need to make any revisions. The care plan policy was last reviewed on [DATE] by the interdisciplinary team and signatures were secured. No nursing staff shall work until they have completed in services on updating care plans starting [DATE]. Newly hired staff will be in serviced on updating care plans during orientation and annually thereafter by the CCC. Staff will not be permitted to work until education has been completed. The Director of Health Services (DHS), and/or nursing unit managers will review [CONDITION]U residents care plans weekly to ensure that they have been updated with acute changes, for four weeks starting [DATE] and quarterly there after for three months. The Director of Health Services (DHS) and or Unit Manager will report any adverse findings to the Administrator immediately and to QAPI. The Director of Health Services (DHS) and/or Unit Manages will review the Facility Activity Report five times a week to monitor for any acute changes of condition including diet changes and updated care plan for four weeks. The Director of Health Services (DHS) and/or Unit Managers will review care plans to ensure care plan interventions are updated. Any adverse findings will be reported by the Director of Health Services (DHS), Assistant Director of Health. An Ad Hoc QAPI meeting was held with the Medical Director, the Administrator, Director of Health Services (DHS), Licensed Practical Nurse, Restorative Nurse and Certified Nursing Assistant on ,[DATE] to discuss the immediate jeopardy finding and the removal plan. All corrective actions were completed by [DATE]. The immediacy of the IJ was removed on [DATE].

Based on review of facility files and interview, the facility failed to ensure that a resident who displays a psychosocial adjustment difficulty received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. Resident #237 was noted to develop behaviors after being admitted to the facility. Resident #237 was seen once by a psychiatrist and the recommendation was not followed up on. The resident's facility physician did not document anything related to the resident's behaviors or improvement. One of two residents reviewed for behaviors. The findings included: Resident #237 was admitted to the facility on [DATE]. Review of Resident #237's SC Limited Power of Attorney Form revealed the resident signed the form 12/29/16 and the witness attestation indicated the resident was of sound mind. Review of the resident's Admission Interim Care Plan revealed the resident required admission to the MSU and was admitted [DATE] for [DIAGNOSES REDACTED]. Admit to MSU. Review of the hospital Discharge Summary dated 12/16-12/28/16 revealed the resident's past medical history was positive for chronic [MEDICAL CONDITION] and it appears that he has dementia associated with it. Review of Resident #237's Physician's Progress Notes revealed the resident was seen 1/17/17, 2/14/17 and 3/14/17. The Physician's Progress Notes did not indicate anything related to the resident's mental status or overall cognitive status. There was no documentation related to the resident residing on the MSU or evaluating the resident being appropriate for the unit. The resident was seen by the psychiatrist on 1/22/17 who indicated the resident was hospitalized with withdrawal and possible [MEDICAL CONDITION] activity. The resident had a history of [REDACTED]. In addition, if his [MEDICAL CONDITION] are just related to withdrawal it is possible that the [MEDICATION NAME] is playing a role in his behavioral problems and I would consider tapering and discontinuing it. I would ask neurology their opinion. There was no documentation in the resident's medical record that there was follow up on the [MEDICATION NAME] or consulting the neurologist. Review of the resident's Care Plan revealed resident exhibits behaviors of rejecting care, disruptive to environment, disrobes. Interventions included to review patient drug regime, evaluate for dosage reduction and document findings. Assess resident for comfort level when disrobing. Review of the Physician's Telephone Orders dated 3/23/17 revealed may send to hospital for evaluation, may have 1:1 until leaves for hospital. Review of the Admissions to the Memory Support Unit (MSU) policy indicated the memory support unit is designed to provide person-centered care that meets the unique needs of adults who have been diagnosed with [REDACTED]. Review of the Behavior Management Documentation Form revealed the program was initiated 1/3/17 and Resident #237 entered into the program. Resident #237 was removed from the program 2/27/17 related to improved behaviors. Review of the Nurses' Notes dated 1/6/17 revealed behavior reviewed. Admit to behavior management program for aggression with staff during redirection, attempt transfer with no assist, wanders with exit seeking and refusal of care. The Nurse's Note dated 2/2/17 indicated resident behaviors reviewed with no new behavior noted. The Nurse's Note dated 2/27/17 revealed behaviors reviewed, no new behaviors noted since last review. Remove from behavior management program. There were no additional Nurses' Notes until 3/23/17 at 4:02 AM, the note indicated the resident was attempting to touch and rub the chest of female residents when in the MSU common area. Staff present and redirected him with a snack. He accepted the snack and went into the dining room and sat and ate his snack. No further behaviors noted. On 3/24/17 at 2:15 AM the nursing note indicated the resident was transferred to the hospital for psych evaluation. The resident left the facility at 2:00 AM. Review of the Social Services Progress Notes Form revealed the resident care plan meeting was held 1/13/17. The next Social Services Progress Note was dated 3/24/17 and indicated the social worker received report of resident to resident incident on 3/23/17. Review of Resident #68's medical record revealed a SBAR Communication Form dated 3/23/17 that indicated the resident was noted sitting on a male peer's lap (Resident #237). The SBAR noted Resident #68 was fully clothed sitting on the male peer's lap while the male peer had his penis exposed. Review of the medical record revealed Resident #68's [DIAGNOSES REDACTED]. The resident's resided on the facility's memory support unit (MSU), Review of the Resident Incident Report for Resident #68 dated 3/23/17 at 4:50 PM revealed Resident #68 was unable to be interviewed. Resident confused and disoriented x 3 at baseline. The Resident Incident Report indicated the location of the incident was resident room, but did not indicate the room number where the incident occurred. The follow-up section indicated the resident's physician was notified, deferred to ER physician for examination. ER physician did not perform a rape kit, but did screen for a urinary tract infection via urinalysis. Review of the Nurse's Note dated 3/23/17 at 10:15 PM revealed Resident #68 was transferred to the hospital ER via ambulance to be evaluated. The Nurse's Note dated 3/24/17 at 2:30 AM indicated Resident #68 returned to the facility from the hospital. In an interview with the surveyor on 4/19/17 at approximately 3:30 PM, the social worker stated when Resident #237 first came to the facility he didn't want anyone to bother him, he would get aggressive with staff. After he went through withdrawals he was fine. Resident #237 was on the behavior management program. Resident #237 would stay in his room, he would want to be nude most of the time. After the withdrawals, he would come out his room and socialize more. The social worker stated s/he thinks he may have disrobed out in the hall toward the end of his withdrawal, staff would redirect him. Resident #237 came off the behavior management program. Resident #237 was very social. In an interview with the surveyor on 4/19/17 at approximately 3:45 PM, MSU Unit Manager stated s/he was at the facility the day of the incident. S/he was on another unit when LPN #4 notified him/her about the incident. Resident #68 was found sitting on Resident #237's lap. Resident #237 was removed from the room. They were in room [ROOM NUMBER], the room of another resident. That resident was in the room at the time and was in his/her bed. When the MSU unit manager got to the unit, LPN #3 and LPN #4 had completed the body audit on Resident #68 and s/he was wandering around the unit. Resident #237 was in his room and was on 1:1. Resident #237 was sent out to the hospital for a psych evaluation on 3/23/17 after the incident. He was sent out for inappropriate, abnormal behaviors, sexual. Resident #237 was admitted to the rehab unit of the facility, he was sent to MSU because he was exit seeking. Resident #237 had some combative behaviors and resisted care when he first came onto the MSU unit. The resident's behaviors improved, he was on the behavior management program. Resident #237 was very friendly and talkative. He liked to talk with other staff and residents. The other residents on the unit could not talk appropriately. Resident #237 was alert and oriented. The MSU unit manager stated they have a FAST score that measures the progression of a disease. If the residents are at certain level, they don't meet criteria. They do FAST scores on admission and readmission, and if there have been any changes. Resident #237 did not have another FAST score done. It was being discussed to have him reevaluated during the behavior management program. They would have to discuss with the Administrator, social worker, director of nursing and the resident's family. At that point, they had been evaluating the resident . In an interview with the surveyor on 4/19/17 at approximately 2:15 PM, the facility administrator stated there were no additional physician or psychiatric progress notes for Resident #68. In an interview with the surveyor on 4/19/17 at approximately 4:30 PM, the facility administrator stated s/he found out about the incident right after it happened. The MSU unit manager told him that one of the resident's on the unit told LPN #4 s/he needed to check on a room. LPN #4 went into the room to check and found Resident #237's exposed penis and Resident #68 sitting in his lap still fully clothed. The facility administrator stated there was no one else in the room with them. The facility administrator stated s/he does not recall what resident told LPN #4 s/he needed to look in the room where the 2 residents were. The administrator stated the physician said Resident #68 did not need to go out to the hospital. Resident #68's husband wanted the resident to go to the hospital to have the rape kit performed. They secured transport for Resident #237 to go out as well to get him out of the patient population. Resident #237 was sent out because he could not remain on the MSU unit with that type of behavior. They cannot provide continuous 1:1. They notified the police about the incident because of the nature of the situation, Resident #237's attempt and exposure. The facility administrator stated s/he did not talk with Resident #237. The facility administrator stated they did not report the incident to certification because it was resident to resident and did not involve a staff member. The facility administrator stated they don't have a policy that says you do a reassessment within any time frame for residents on the memory support unit. In an interview with the surveyor on 4/19/17 at approximately 5:30 PM, the MSU Unit Manager stated there is no policy related to monitoring or discharging residents from the memory support unit. If the resident has a change, they monitor them through the behavior management program. Once they come off the behavior management program, they have a nurses note to document normal charting. Once they are off the behavior management program, then they are off. The resident goes back to regular charting. Any documentation about discussion related to the resident improving would be in the medical record. The MSU unit manager stated the physicians are involved in the MSU program. They will discuss residents with the physicians and get feedback. Resident #237 was seen by the psychiatrist on 1/22/17. The MSU unit manager reviewed the resident's medical record and stated the physician saw the resident in January, February and March. The MSU unit manager stated that is all the documentation completed by the physician. There were no additional notes from the psychiatrist. The behavior management program is started for a resident if they are admitted to the MSU with an antipsychotic on admission or if the resident has shown behavioral issues. The MSU unit manager stated there is no documentation from him/her related to talking about moving Resident #237 off the unit related to his improvement. If the pharmacist gives them a recommendation, they give it to the physician , s/he reviews and agrees or disagrees. The MSU unit manager reviewed Resident #237's medical record and stated the recommendation was not addressed by the physician. The MSU unit manager provided no additional information related to a pharmacy recommendation. In an interview with the surveyor on 4/19/17 at approximately 6:45 PM, the facility administrator stated the facility investigation consisted of the police report and the hospital report. The facility administrator stated there was no need to investigate because it was not an allegation, it was witnessed by staff. When asked what was witnessed, s/he stated the male resident was exposed. The administrator stated that a resident told LPN #4 s/he should go look at what was happening in the room. The facility administrator could not provide the name of the resident when asked by the surveyor who the resident was. The facility administrator stated they did not interview CNAs on the unit because they didn't want to start anything and have it spread around. The facility administrator stated that no one interviewed Resident #237, he was sent out because he was the perpetrator. When asked how they knew he was the perpetrator, the facility administrator stated because he was exposed. The surveyor asked how they knew Resident #68 was not the instigator, and they stated they didn't know. There were no staff interviews conducted to see if other staff witnessed any behavior between the 2 residents involved in the incident. In a telephone interview with the surveyor on 4/26/17 at approximately 2:20 PM, the residents' physician stated s/he did not remember Resident #237, too many residents come and go for him/her to remember. The physician stated s/he did know about the incident and that Resident #68 was found sitting on Resident #237's lap.

Based on review of facility files and interview, the facility failed to ensure that all alleged violations involving abuse are reported to the State Survey Agency and failed to provide evidence that an allegation of sexual abuse was thoroughly investigated. Resident #68 was found sitting in Resident #237's lap in a resident room. Resident #237 was noted to have his penis exposed. One of one allegation reviewed for abuse. The findings included: Review of Resident #68's medical record revealed a SBAR Communication Form dated 3/23/17 that indicated the resident was noted sitting on a male peer's lap (Resident #237). The SBAR noted Resident #68 was fully clothed sitting on the male peer's lap while the male peer had his penis exposed. Review of the medical record revealed Resident #68's [DIAGNOSES REDACTED]. The residents resided on the facility's memory support unit (MSU). Review of the Resident Incident Report for Resident #68 dated 3/23/17 at 4:50 PM revealed Resident #68 was unable to be interviewed. Resident confused and disoriented x 3 at baseline. The Resident Incident Report indicated the location of the incident was resident room, but did not indicate the room number where the incident occurred. The follow-up section indicated the resident's physician was notified, deferred to ER physician for examination. ER physician did not perform a rape kit, but did screen for a urinary tract infection via urinalysis. Review of the Nurse's Note dated 3/23/17 at 10:15 PM revealed Resident #68 was transferred to the hospital ER via ambulance to be evaluated. The Nurse's Note dated 3/24/17 at 2:30 AM indicated Resident #68 returned to the facility from the hospital. Review of the Nursing Home to Hospital Transfer Form for Resident #68 dated 3/23/17 revealed the reason for transfer section was not completed by the facility. Review of the Physician Telephone Order dated 3/23/17 indicated to send Resident #68 to the hospital for evaluation and treatment as needed. Resident #237 was admitted to the facility on [DATE]. The resident was seen by the psychiatrist on 1/22/17 who indicated the resident was hospitalized with withdrawal and possible [MEDICAL CONDITION] activity prior to nursing home admission. The resident had a history of [REDACTED]. Review of Resident #237's Physician's Telephone Orders dated 3/23/17 revealed, may send to hospital for evaluation, may have 1:1 until leaves for hospital. The surveyor requested a complete copy of the facility's investigation into the incident involving Resident #68 and Resident #237 on 3/23/17. The facility provided the surveyor with a copy of the police report and a copy of the hospital discharge summary. There was also a handwritten statement from the Memory Support Unit Manager, RN #1, that indicated s/he had interviewed 3 residents on the unit that were noted to have dementia and confusion. There was no additional information provided related to investigating the incident. In an interview with the surveyor on 4/19/17 at approximately 3:05 PM, CNA #7 stated s/he works on MSU. S/he is usually assigned to Resident #68. Resident #68 wanders but has no other behaviors. Resident #68 does not interact with the other residents very much. CNA #7 stated s/he has never noticed Resident #68 trying to approach other residents or sit in their laps. CNA #68 stated s/he was at the facility on the day of the incident, but did not see the residents. CNA #7 stated the nurses did not tell them very much about the incident. In an interview with the surveyor on 4/19/17 at approximately 3:45 PM, MSU Unit Manager stated s/he was at the facility the day of the incident. S/he was on another unit when LPN #4 notified him/her about the incident. Resident #68 was found sitting on Resident #237's lap. Resident #237 was removed from the room. They were in room [ROOM NUMBER], the room of another resident. That resident was in the room at the time and was in his/her bed. When the MSU unit manager got to the unit, LPN #3 and LPN #4 had completed the body audit on Resident #68 and s/he was wandering around the unit. Resident #237 was in his room and was on 1:1. Resident #237 was sent out to the hospital for a psych evaluation on 3/23/17 after the incident. He was sent out for inappropriate, abnormal behaviors, sexual. In an interview with the surveyor on 4/19/17 at approximately 4:30 PM, the facility administrator stated s/he found out about the incident right after it happened. The MSU unit manager told him that one of the resident's on the unit told LPN #4 s/he needed to check on a room. LPN #4 went into the room to check and found Resident #237's exposed penis and Resident #68 sitting in his lap still fully clothed. The facility administrator stated there was no one else in the room with them. The facility administrator stated s/he does not recall what resident told LPN #4 s/he needed to look in the room where the 2 residents were. The administrator stated the physician said Resident #68 did not need to go out to the hospital. Resident #68's husband wanted the resident to go to the hospital to have the rape kit performed. They secured transport for Resident #237 to go out as well to get him out of the patient population. Resident #237 was sent out because he could not remain on the MSU unit with that type of behavior. They cannot provide continuous 1:1. They notified the police about the incident because of the nature of the situation, Resident #237's attempt and exposure. The facility administrator stated s/he did not talk with Resident #237. The facility administrator stated they did not report the incident to certification because it was resident to resident and did not involve a staff member. In an interview with the surveyor on 4/19/17 at approximately 6:45 PM, the facility administrator stated the facility investigation consisted of the police report and the hospital report. The facility administrator stated there was no need to investigate because it was not an allegation, it was witnessed by staff. When asked what was witnessed, s/he stated the male resident was exposed. The administrator stated that a resident told LPN #4 s/he should go look at what was happening in the room. The facility administrator could not provide the name of the resident when asked by the surveyor who the resident was. The facility administrator stated they did not interview CNAs on the unit because they didn't want to start anything and have it spread around. The facility administrator stated that no one interviewed Resident #237, he was sent out because he was the perpetrator. When asked how they knew he was the perpetrator, the facility administrator stated because he was exposed. The surveyor asked how they knew Resident #68 was not the instigator, and they stated they didn't know. There were no staff interviews conducted to see if other staff witnessed any behavior between the 2 residents involved in the incident. The administrator stated there was no one else in the room at the time of the incident, while the unit manager stated in an earlier interview that there was another resident in the room at the time of the incident. There was no statement that indicated if there was any other interaction between the residents other than sitting. In a telephone interview with the surveyor on 4/26/17 at approximately 2:20 PM, the residents' physician stated s/he did not remember Resident #237, too many residents come and go for him/her to remember. The physician stated s/he did know about the incident and that Resident #68 was found sitting on Resident #237's lap. The physician stated both residents were dressed and there was no harm, no foul. Review of the facility's Abuse Policy revealed it is the policy of PruittHealth to investigate allegations and occurrences of patient abuse. The Administrator is responsible for assuring that an accurate and timely investigation is completed. If there is an occurrence of or allegation involving patient abuse, the following investigation and reporting procedures will be followed: documentation of the investigation, information gathering, interviews, all investigative information should be kept on file in a secured location. Documentation of the investigation should include date and time of the alleged occurrence, names of accused and any witnesses, names of staff who investigated the allegation, any physical evidence and description of emotional state of resident, details of the alleged incident, and information gathered from the investigation. Information gathering included who did it, what happened (be specific about the event that occurred), and where did it happen. Further review of the facility's Abuse Policy revealed it is the policy to comply with all applicable federal and state requirements regarding the reporting of patient abuse. Any allegation, suspicion, or identified occurrence is identified involving patient abuse should be immediately reported to the Administrator. The Administrator should notify the appropriate state agency. The state survey agency should be notified through established procedures of any allegations of abuse within 2 hours after the allegation is made if the events upon which the allegation is based involve abuse. The Administrator should direct an investigation into the allegation or incident.

On the days of the survey based on record reviews, interviews and observations, the facility failed to successfully develop, implement and monitor an action plan for identified concerns related to the accurate assessment, identification, and treatment of [REDACTED]. The findings included: On 3/30/11 a Census and Condition documented the facility had 8 resident's in the facility with pressure ulcers, 3 of which were present on admission. On 3/31/11, the facility became aware of concerns related to the care of pressure ulcers. Record review revealed that on 4/29/10, the facility had begun a Performance Improvement Plan for "Skin Integrity" with an "ongoing" date for resolution. The plan included the completion 100% body audits, weekly assessments, monitoring treatments, careplans, completing Braden scales, weekly documentation, compliance rounds, inservice's on pressure ulcer dressing technique, and adaptive devices. The last date related to the information submitted with this plan was 7/22/10 although the plan stated it was "ongoing." On 3/31/11 a second Performance Improvement Plan was begun titled "Wound Care Assessments" with a resolution date of 4/30/11 and on-going. This plan included: Wound care assessments would be completed on all new admissions; nurses were to notify the Director of Health Services of new admissions with skin breakdown; body audits were to have been completed on all residents by 4/11/11; no holes (lack of documentation) were to be noted on the treatment records; skin assessment books were to be brought to clinical meetings daily; the physician was to assess residents with wounds and place notes on charts; and filing of wound care nurses notes are to be started on 3/31/11. Additionally, wound care nurses were to participate in wound care classes; wound care nurses will state all wounds, which was to be signed by an Registered Nurse; monthly wound care notes were to be completed; and Nurses and Aides were to participate in in-service related to turning residents. Despite on-going Performance Improvement Plan(s), continued concerns were identified with six of tens sampled residents reviewed with pressure ulcers related to assessment/tracking, proper staging, treatment and adequate nutritional assessment /intervention related to the care of the resident's with known pressure ulcers. Cross refer to F-272 as it related to the facility's failure to assure each resident was adequately and accurately assessed for pressure ulcers, and the appropriate assessments were completed for residents with existing wounds. Cross refer to F-280 as it related to the facility failure to develop. review, and revise care plans of residents at risk of skin impairment or with existing skin impairment. Cross refer to F-314 as it related to the facility's failure to adequately assess residents with skin impairments, appropriately treat residents with wounds, adequately monitor residents with wounds and failed to identify residents with pressure ulcers which placed residents at risk for serious harm and or injury. Cross refer to F-490 as it related to the failure of the facility's Administration to provide the necessary oversight to assure policies and procedures related to wound care were implemented. The Administration with known knowledge of quality deficiencies failed to appropriately act upon those areas which placed residents at risk for serious injury and or harm. Cross refer to F-501 as it related to the failure of the medical director to assure facility policies and procedures related to wound care were implemented. The Medical Director also failed to assure the Quality Assurance Committee promptly acted upon known deficient practices which placed residents at risk for serious injury and or harm. Immediate Jeopardy was identified at F-520 at a scope and severity of "K" as it related to the facility's failure to ensure each resident was adequately and accurately assessed for pressure ulcers, and the appropriate assessments were completed for residents with existing wounds. The systemic failure of the facility to identify, accurately assess, and monitor residents with skin impairments and or potential impairments placed those residents at risk for serious injury and/or harm. Based on observations of inservices, staff interviews, and documentation provided by the facility, the Survey Team on 4/20/11 accepted the Allegation of Compliance for the Immediate Jeopardy before exiting the facility. The Immediate Jeopardy was removed but the deficiency at F-520 remained at a scope and severity of "E".

On the days of the survey, based on observations, record reviews, and interviews, the facility's Medical Director failed to ensure resident care policies and procedures were implemented related to wound care management. The findings included: In a telephone interview with the survey team on 4/20/11 at 5:00 PM the Medical Director (MD) stated that he did see resident's wounds, "Not every time, once a month or so if/when they tell me to look at them." When told that there was nothing in his progress notes pertaining to the pressure sores, he stated, "Documentation may be an issue, but I see them as needed". The Medical Director stated that the nurses made the recommendations regarding the treatment of [REDACTED]. "I do not oversee to the inth degree with wounds. Review of the Physician's Progress Notes dated from 4/15/10 through 4/5/11, (one year) revealed there was no documentation of Pressure sores. There was no mention of progression or deterioration of the resident's pressure sores by the physician. Cross refers to F-272 as it related to the facility's failure to ensure each resident was adequately and accurately assessed for pressure ulcers, and the appropriate assessments were completed for residents with existing wounds Cross refers to F-314 as it related to the facility's failure to adequately assess residents with skin impairments, appropriately treat residents with wounds, adequately monitor residents with wounds and failed to identify residents with pressure ulcers which placed residents at risk for serious harm and/or injury. Cross refers to F-325 as it related to the facility's failure to provide timely nutritional assessments to monitor and implement recommendations to assist in the healing of pressure ulcers. Cross refer to F-520 as it related to the facility failure to successfully develop, implement and monitor an action plan for identified concerns related to the accurate assessment, identification, and treatment of [REDACTED]. Immediate Jeopardy was identified at F-501 at a scope and severity of "K" as it related to the failure of the Medical Director to ensure facility policies and procedures related to wound care were implemented. Based on observations of inservices, staff interviews, and documentation provided by the facility, the Survey Team on 4/20/11 accepted the Allegation of Compliance for the Immediate Jeopardy before exiting the facility. The Immediate Jeopardy was removed but the deficiency at F-501 remained at a scope and severity of "E".

On the days of the Recertification and Extended Survey, based on record reviews, interviews, and observations, it was determined that Immediate Jeopardy and Substandard Quality of Care existed related to professional standards of practice and pressure sores. The facility Administration failed to ensure the established policies and procedures were carried out to ensure pressure sores were identified, assessed, and treated to promote healing and prevent development of additional wounds. Additionally, the Administration failed to ensure a resident's desire for full code was handled properly by Licensed nursing staff. The findings included: During the Recertification and Extended Survey, 6 of 10 sampled residents with pressure sores were noted to have concerns that included; assessments missing or not completed, wounds not identified or documented incorrectly, treatments not completed as ordered. Review of a Performance Improvement Plan developed and implemented 4/29/10 revealed these same concerns. From this Plan tools were developed and re-evaluation dates were to be ongoing. The last date to re-evaluate listed 7/22/10 and there was no further evidence of monitoring to ensure the goals were met and maintained. Immediate Jeopardy was identified at F490 related to the failure of the facility's Administration to adequately provide the necessary oversight for residents at risk for and with actual skin impairments which placed those residents at risk for serious harm and injury. Cross refer to F2-72 as it related to the facility's failure to ensure each resident was adequately and accurately assessed for pressure ulcers, and the appropriate assessments were completed for residents with existing wounds Cross refer to F-314 as it related to the facility's failure to adequately assess residents with skin impairments, appropriately treat residents with wounds, adequately monitor residents with wounds and failed to identify residents with pressure ulcers which placed residents at risk for serious harm and/or injury. Cross refer to F-325 as it related to the facility's failure to provide timely nutritional assessments to monitor and implement recommendations to assist in the healing of pressure ulcers. Cross refer to F-520 as it related to the facility failure to successfully develop, implement and monitor an action plan for identified concerns related to the accurate assessment, identification, and treatment of [REDACTED]. Immediate Jeopardy and/or Substandard Quality of Care was identified at F-490 at a scope and severity of "K" related to the failure of the facility's Administration to adequately provide the necessary oversight for residents at risk for and with actual skin impairments which placed those residents at risk for serious harm and injury. Based on observations of inservices, staff interviews, and documentation provided by the facility, the Survey Team on 4/20/11 accepted the Allegation of Compliance for the Immediate Jeopardy before exiting the facility. The Immediate Jeopardy was removed but the deficiency at F-490 remained at a scope and severity of "E".

On the days of the survey, based on observations, record reviews and interviews, the facility failed to ensure that nutritional interventions and assessments were completed in a timely manner in regards to weight loss and pressure ulcers for three of 15 resident's records reviewed. Resident #7 did not have interventions for weight loss and pressure ulcers put in to place in a timely manner, Resident # 9 did not have any nutritional documentation or assessments done since December 2010 and Resident #12 was not assessed in a timely manner for weight loss. The findings included: The facility admitted resident #9 on 9/21/07, readmitted on [DATE]/ 6/10/10 and 9/15/10 with [DIAGNOSES REDACTED]. During an interview with the resident on 4/20/11, he stated that he had wounds for 4 years and had wounds when he was admitted to the facility. The medical record was reviewed for Nutritional Assessments/notes in regards to nutritional interventions to promote healing of the wounds. The last Nutritional Assessment that was completed was dated 11/4/10. The assessment documented recommendations of Prostat 64 (a protein supplement used to promote healing of wounds). The residents weight at that time was documented at 398 pounds (lbs.). The assessment included abnormal lab results of an [MEDICATION NAME] of 2.1, normal values 3.5-5(Measures protein levels in the body), low Hemoglobin, 9.9 (normal value 14-18) and Hematocrit, 30.2, normal values for men 42-52, (measures the Red Blood Cell volume of the blood). There was no further nutritional assessment available for the resident. The last nutritional progress note was dated 12/22/10. There were no nutritional progress notes for 2011 (4 months) in regard to the resident's pressure sore and nutritional requirements. During an interview with the Certified Dietary Manager and the Registered Dietician (RD) on 4/20/11 at 9:25 AM, when asked how often the RD did Nutritional Assessments and progress notes on residents with wounds, the RD stated that she did progress notes on wounds monthly. She stated, "I look monthly, what stage it is (wound)." She stated she estimated the needs if the weight fluctuates and reviewed the labs. When asked where the progress notes and Nutritional Assessments were since December, the RD stated, "I got confused and just documented his weights. I should have been documenting on his wounds and nutritional needs as well." The facility admitted Resident #7 on 12/10/10 with [DIAGNOSES REDACTED]. Record review showed the resident weighing 124 lbs. on admission to the facility. She was placed on a mechanical soft diet. Further review revealed that the resident was seen by speech therapy for pocketing food and dysphagia was added to her list of diagnoses. Her most recent Minimum Data Set (MDS) stated that she was an assist of one for feeding. The residents care plan, which was updated on 3/11/11, under problems, stated DX (diagnoses) dysphagia - hold food in mouth req (required) verbal cues to swallow. A 12/28/10 problem was noted as stating: "Wt. (weight) loss noted". Review of the dietary section of the record showed that the RD completed the Nutritional Screening and Assessment Form on 12/17/10. The first note written by the RD was on 2/27/11 and it stated that the residents weight was 115 lbs on 2/16/11 and her plan was to follow up and monitor weights, labs ... An additional note on 3/27/11 stated the weight for the resident was 116 lbs. Review of the labs showed that the only metabolic profile was done on 12/15/10 with the [MEDICATION NAME] being 2.2 (normal 3.2 - 5.3) and the pre-[MEDICATION NAME] was 94 (normal 160 - 400). Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. An interview was conducted with the Administrator, the RD and the CDM on 4/20/11 at 9:00 AM. During the interview the CDM stated that the resident gets snacks between meals and the snacks are things such as puddings. There is no documentation of snacks being given or the percentage that was consumed. The RD stated that if a resident has a wound she would add supplements such as snacks, shakes ice cream and milk. She further stated that someone with a wound would be followed on a monthly basis and they would look at the diet, medications and labs. The RD also stated that she should have ordered follow up labs for the [MEDICATION NAME] level for the resident. The RD could not offer an explanation as to why the supplement was not ordered before 4/7/11 and why the weight loss was not acted upon in a timelier manner. The facility admitted Resident #12 on 2/4/11, with a re-admission date of [DATE] with [DIAGNOSES REDACTED]. The first observation of the resident was on 4/18/11 at 1:15 PM. The resident was in the dining room and she had not eaten any of her noon meal. A CNA (certified nurses aide) stated, "Miss....you need to eat something. I don't want to see you lose any more weight." The resident then stated, "I just don't have any appetite." Record review on 4/18/11 revealed that the resident's weight on 2/4/11 was 168 pounds (lbs). Her weight on 3/11/11 was 164 lbs. When the resident returned from the hospital her weight on 4/7/11 was 154 lbs. The Diet History/Food Preference List and the Nutritional Screening and Assessment Form were completed on 2/9/11. There were no other dietary notes in the record. An interview with the resident revealed that the resident has not had an appetite since re-admission to the facility. During an interview on 4/19/11 at 2:30 PM with the Assistant Director of Health Services (ADHS), when asked of she thought the resident should have been re-weighed, she stated that the resident should have been weighed on 4/12/11 but the resident refused to be weighed. There was no documentation to confirm this. She also stated that she was not sure if a facility Weight Loss/Gain report was completed. The resident was re-weighed on 4/19/11 and the weight was 150 lbs. An interview was conducted with the Administrator, the Certified Dietary Manager (CDM) and the Registered Dietician (RD) on 4/20/11 at 9:00 AM. The RD stated that she was aware of the fact that the resident refused to be weighed and it was on a sheet of paper but she could not find the paper. When asked why the resident was seen only one time the CDM stated that she sees the resident at least once a week on rounds but does not chart on the resident. Both the RD and the CDM were unaware of the fact that the resident was not eating. The RD stated that weight reports were due on Mondays and that the resident would have been picked up on 4/18/11. The Administrator stated that the resident should have been seen within 72 hours of admission and that every day in the daily meetings they talk about who is being admitted or readmitted to the facility and that the CDM attends those meetings. Cross refer to F-325 as it related to the facility's failure to provide timely nutritional assessments to monitor and implement recommendations to assist in the healing of pressure ulcers. Immediate Jeopardy and Substandard Quality of Care was identified at F-325 at a scope and severity of "K" as it related to the facility's failure to ensure nutritional assessment and interventions were in place for residents with pressure ulcers. Based on observations of inservices, staff interviews, and documentation provided by the facility, the Survey Team on 4/20/11 accepted the Allegation of Compliance for the Immediate Jeopardy and Substandard Quality of Care before exiting the facility. The Immediate Jeopardy and Substandard Quality of Care was removed but the deficiency at F-325 remained at a scope and severity of "E".

On the day of the Recertification Survey and Extended Survey, based on record reviews, interviews, observations, and facility policy review, the facility failed to ensure that residents with pressure ulcers were assessed timely and adequately, and were re-evaluated for necessary change in treatment or provision of treatment as ordered per physician for 6 of 10 residents reviewed for pressure ulcers (Residents #1, #2, #3, # 4, #7, and # 9.) The findings included: Resident #1 with [DIAGNOSES REDACTED]. The resident was aphasic with left side mobility impairment. She required total care from the staff for her activities of daily living. The resident received all nutrition and hydration via gastrostomy feeding tube. Review of the medical record revealed the resident arrived at the facility with no pressure ulcers. On 9/10/10, the nurse's note documented small open areas observed on the resident's right (sic) ear and right (sic) buttock. "... family notified - they were aware of ear wound since beginning of week. ..." Review of the Treatment Record showed the facility began treating the left ear ulcer daily with triple antibiotic ointment on 9/10/10 and the left buttock ulcer with [MEDICATION NAME] every three days and as needed on 9/11/10. Review of the Skin Notes showed an entry on 9/14/10, at 9 AM, describing the left buttock ulcer as a Stage II pressure ulcer measuring 5.5 by 2 by 0 centimeters (cm) with no bleeding or drainage. This was the first descriptive note concerning the ulcer. Review of the medical record, including the Skin Notes, Daily Skilled Nurses' Notes, Treatment Records, and Alteration In Skin Integrity Addendum To TAR (Treatment Administration Record) showed the right ear ulcer was deemed healed on 9/24/10. The records failed to show any additional assessment of the left buttock ulcer for September 2010. Review of the October 2010 records showed two documented assessments of the ulcer. On 10/8/10, it was noted to be a Stage II measuring 1.9 by 1 by 0 cm with a small amount of bloody drainage. On 10/12/10, the documentation showed the ulcer as a Stage II measuring 2.5 by 1 by 0 cm with a small amount of bleeding. Although the Treatment Record showed continued treatment to the left buttock ulcer until the resident's discharge, no further assessment of the ulcer was noted in the records. Review of the Nutritional Progress Notes showed an entry on 10/15/10 noting the right ear ulcer and left buttock ulcer were healed. Review of the Daily Skilled Nurses Notes on 11/4/10 revealed an entry at 6:30 PM stating an indwelling catheter was inserted secondary to "stage IV decub (decubitus ulcer) on sacrum that open today per Tx (treatment) nurse ..." The November 2010 Treatment Record showed the sacral ulcer received treatment with calcium alginate covered with [MEDICATION NAME] every three days and as needed beginning on 11/4/10. The Treatment Record also showed the continued treatment to the left buttock ulcer, indicating the sacral ulcer was a new site. Review of the medical record showed only one description of the new sacral ulcer. The Skin Notes on 11/16/10 showed measurements of 3.5 by 2 by 1.5 cm with a small amount of bleeding and drainage. There was no Alteration In Skin Integrity Addendum to TAR form for November 2010. A nurse's note on 11/16/10 stated: "... Tx continues to buttocks and (R) (right) heel. ..." Review of the medical record showed no other documentation concerning a pressure ulcer on the right heel except for two entries on the Skin Assessment forms. On 10/2/10, a red area on the right heel was noted, and on 10/30/10 thick brown skin on the right heel was noted. No information concerning a pressure ulcer to the right heel was noted in the Skin Notes or on the Treatment Record for November 2010. The resident was discharged to the hospital on [DATE] and did not return to the facility. Resident #2 with [DIAGNOSES REDACTED]. The resident required total care from the staff for her activities of daily living. Review of the Nurse's Notes revealed staff identified an open area on the resident's coccyx on 8/11/10. Review of the Treatment Record showed treatment to the site began on 8/13/10 with acrylic [MEDICATION NAME] to be change every five days. The first descriptive note related to the ulcer was noted in the Skin Notes and the Alteration In Skin Integrity Addendum To TAR form dated 8/13/10 showing it measured 1 by 0.4 by 0 cm with no drainage and a pink wound bed. The medical record showed weekly assessments of the pressure ulcer for the rest of August 2010. On 8/31/10, the ulcer was deemed healed. On 8/31/10, the nurse's note at 1:35 PM stated the resident had breakdown to the upper right buttock. It stated the wound nurse was notified and treatment was in place. This was the first documented evidence of this new ulcer. Documentation in the Skin Notes and on the Alteration in Skin Integrity form showed a Stage III ulcer measuring 3.2 by 2.0 by 0.1 cm with light drainage and pink surrounding skin. Acrylic [MEDICATION NAME] treatment with changes every five days was started. Facility staff was asked to produce pressure ulcer tracking and assessment information on the Skin Notes and Alteration in Skin Integrity forms for February 2011. They were unable to produce the documents. Review of the Treatment Record for February 2011 showed the upper right buttock ulcer treatment was changed to "siversorb sheet" covered with [MEDICATION NAME] and a "medfix" dressing secured with [MEDICATION NAME] film every other day and as needed. Review of the February telephone/verbal orders and the March 2011 cumulative orders failed to show a physician's order for this treatment change. Resident #3 with [DIAGNOSES REDACTED]. The resident required total care from the staff for her activities of daily living. Review of the Treatment Record for December 2010 showed the resident was being treated for [REDACTED]. On 12/21/10, a new pressure ulcer was noted on the right buttock. Documentation on the Treatment Record and in the Skin Notes revealed the ulcer measured 1.0 by 3.0 by 1.3 cm with yellowish tissue in the wound bed and pink surrounding skin. Documentation in the medical record and interview with the treatment nurses failed to provide a rationale showing why the wound was not identified before reaching a depth of 1.3 cm and developing yellow slough. Review of the skin documentation in January 2011 showed measurements on 1/4 and 1/12/11. On 1/12/11, the coccyx ulcer, deemed a Stage II at that time, measured 4 by 1.5 by 0.1 cm with scant drainage and a pink wound bed. The right buttock ulcer, deemed a Stage III ulcer, measured 2.5 by 4.0 by 3.5 cm with some slough in a pink wound bed. Review of the January 2011 Treatment Record showed the current treatments to both sites was discontinued on 1/20/11. Continuing treatment records for January 2011 were not available on request and it could not be determined if treatment was provided to the ulcers for the remainder of the month. Review of the available documentation for February 2011 showed no Skin Notes or Alteration in Skin Integrity notes. The Treatment Record revealed that the right buttock ulcer was treated with packed gauze soaked in basic Dakin ' s solution covered with a dry dressing twice a day and as needed. There was no record of treatment to the coccyx. A nurse's note on 2/5/11 stated the resident's buttock ulcer was a Stage IV. There was no other documentation in February 2011 to support or contradict this entry. Review of the Pressure Ulcer Report of 3/24/11 showed the resident's right buttock ulcer was a Stage II measuring 1 by 1 by 0.2 cm. Resident #4 with [DIAGNOSES REDACTED]. Review of the admission nurse's note showed the resident had "an area" on his sacrum. Review of the Skin Assessment sheet of 2/22/11 revealed a diaper rash with a red spot. The spot was drawn onto the body figure at the approximate site of the coccyx. Review of the Skin Notes showed that on 2/22/11, the resident was assessed as having a red inflamed perineal area. Review of the Treatment Record revealed an order to cleanse the sacral area then apply [MEDICATION NAME], to be changed every three days and as needed. Review of the medical record showed no assessment or descriptive note concerning the resident's sacral "area." The 3/2/11 Skin Note stated: "Completed assessment to resident sacral area & [MEDICATION NAME] applied ..." Zinc cream was applied to the red areas. The remainder of the note described that the resident refused to dress and refused to allow the bed linens to be changed. None of the documentation in the medical record described an open pressure ulcer but review of the Pressure Ulcer Report of 3/24/11 showed the resident's pressure ulcer as a Stage II measuring 1.5 by 2 by 2 cm. The facility admitted Resident #7 on 12/10/10 with [DIAGNOSES REDACTED]. The resident was admitted to the 400 unit for rehab and transferred to the 200 unit on 3/11/11. Review of the medical record on 4/18/11 showed the facility Admission Nursing Evaluation Form was completed on 12/10/10. This form showed that the resident had both long and short term memory problems, had swallowing problems, was a total assist with toileting and was incontinent of both bowel and bladder. She also had a bruise to the right elbow and a dressing on the left hip, her sacrum was normal and her feet and heel were normal. The Braden Scale was 11, which showed that the resident was at risk for skin breakdown. There were no other Braden Scales in the record. Review of the treatment records showed that the resident was receiving treatment to both heels starting 12/24/10 which was "Clean right heel and apply skin prep and tegafoam adhesive q (every) day" and "Clean left heel and apply skin prep and [MEDICATION NAME] foam adhesive q day and prn (as needed)." There was no physician order for [REDACTED]. There were no treatment records found for the month of February. A skin note dated 1/7/11 stated "both heels remain blanchable at this time." There were no other notations for January concerning the heels except for dressing changes. The next notation regarding the heels was noted on 3/24/11 and stated, "During assessment today measurements are 3.4 x 2.5 x 0.2. Wound bed is black eschar with some blanching around wound bed noted. No drainage at this time. Surrounding skin is pink dry and intact. Treatment continues as ordered." During an interview with Licensed Practical Nurse (LPN) #5 on 4/19/11, she stated that she started the treatment to the heels on 12/24/10 as a preventative measure and to protect the heels. She further stated that she did not look at the heels on a weekly basis. Random observations of the resident on 4/19/11 at 8:45 AM, 10:50 AM and 11:05 AM showed the resident to be flat on her back; she was not repositioned every two hours per protocol. While observing wound care on 4/19/11 at 11:20 AM, it was noted that the resident had blue booties to both feet and an area of eschar was noted to the residents left heel by this surveyor. The area was pointed out to both LPN #5 and LPN #6. Both stated that they had not seen the area before this time and they were doing the dressings daily. Both nurses had the eschar areas staged at a IV. The package insert for the [MEDICATION NAME] foam adhesive stated, "[MEDICATION NAME] foam adhesive dressing is not intended for use in pressure reduction." A skin note dated 1/28/11 stated, "Resident has a red area to her left buttock/ blanchable after pressure is applied. Area cleansed with ns (normal saline)and [MEDICATION NAME] placed as a preventive measure." There were no treatment records found for the month of February 2011, it is unknown if the treatment continued. There were no other skin notes or facility Skin Integrity Documentation Forms in the chart until March 2011. Review of the nurse's notes revealed that the resident was found to have an open area to the left buttock on 2/21/11. The note stated, "Called to room by CNA (certified nurses aide) earlier this shift to see a wound to resident's left buttock. Writer observed a wound 3 cm (centimeters) by 2 cm and 1/2 cm deep with possible tunneling under initial wound and also with possible surrounding area at risk for breakdown." There was no further documentation on the wound until March 2011. For the months of March and April the same treatment continued with little to no improvement. The first measurement on the forms was for 3/3/11. The wound measured 3.0 x 2.5 x 0.2 with tunneling and undermining, the wound bed was yellow, and there was moderate drainage. The last note dated 4/13/11 and the wound measured 3.0 x 2.5 x .5, with undermining, the wound bed was pink and there was light drainage. Interventions included a special mattress and turn and reposition every two hours. During an interview with the Administrator, LPN #5 and LPN #6 on 4/20/11 at 8:45 AM, both LPN's could not explain why the unstageable areas to the heels were not noted in a timelier manner. They both stated that they use the facility wound protocol to stage the areas and they actually thought that eschar was a stage IV when actually it was unstageable. For treatments they both refer to the treatment protocol. When asked why they did not recommend a change in treatment for [REDACTED]. During an interview with the medical director on 4/20/11 at 4:55 PM, he stated that he sees the wounds usually once a month or "whenever they tell me to look at them". When asked why there were no notations in the physician progress notes [REDACTED]. When asked if he actually gives the orders for the treatments he stated that the nurses recommend what should be used and he approves the standing wound orders that the facility has. Review of the facility Wound Care Reports (Excluding Pressure Ulcers) dated 12/24/10, 12/31/10, 1/14/11, 1/21/11, 2/3/11, 2/10/11, 2/24/11, 3/3/11, 2/10/11, 3/17/11 and 3/24/11 showed that the wound care nurses were documenting that both the right and left heels were red and the treatment was skin prep/[MEDICATION NAME] foam adhesive dressing. On the facility Pressure Ulcer Report dated 3/31/11, it was noted that on 3/29/11 the right heel was a stage IV pressure ulcer measuring 2.5 x 2.8 x 0. There was no drainage, the treatment was skin prep daily and it was a new area. Review of the facility Pressure Ulcer Reports dated 2/24/11 stated that the resident had a new pressure ulcer to the left buttock with an acquired date of 2/21/11. It was noted to be a stage III pressure ulcer measuring 3.0 x 2.5 x 0.2, with moderate drainage and basic Dakins was the treatment. The facility admitted resident #9 on 9/21/07, readmitted on [DATE]/, 6/10/10, and 9/15/10 with [DIAGNOSES REDACTED]. During an interview with the resident on 4/20/11, he stated that he had wounds for 4 years and had wounds when he was admitted to the facility. On 4/19/11 at 9:55 AM the Pressure Sore care was observed. The wound on the right hip/sacral area appeared as a horizontal split wound over the upper quadrant of the right buttocks extending to the sacral area. The last measurements dated 4/8/11 were recorded as Stage III 1 (one) CM (Centimeter) in length by 3 CM in width by 3 CM in depth. There was scarring extending out to the right of the wound. review of the resident's medical record revealed [REDACTED]. The Plan of care dated 11/05/2010 included the problem of pressure ulcer. The approaches listed for the the Pressure ulcer included: Reassess at least weekly... The Alteration in Skin Integrity Addendum to the TAR (Treatment Administration Record) forms, which contained the weekly measurements of the Pressure Sores were reviewed. There was no documentation as to when the wound originated. The Alteration in Skin form contained measurements and staging of the Pressure Sore from January 12, 2011 through April 8, 2011. There were no Alteration in Skin Integrity Forms located before January 12, 2011. The measurements for the week of 4/15/11 were not documented. Review of the Physician's Progress Notes dated from 4/15/10 through 4/5/11, (one year) revealed no documentation of Pressure sores. There was no mention of progression or deterioration of the resident's pressure sores by the physician. The Medical Doctor (MD) was interviewed on 4/20/11 at 5:00 PM via telephone. The MD stated that he did see the resident's wounds, "Not everytime, once a month or so if/when they tell me to look at them." When told that there was nothing in his progress notes pertaining to the pressure sores, he stated, "Documentation may be an issue, but I see them as needed". The MD stated that the nurses made the recommendations regarding the treatment of [REDACTED]. "I do not oversee to the nth degree with wounds." The medical record was reviewed for Nutritional Assessments/notes in regards to nutritional interventions to promote healing of the wounds. The last Nutritional Assessment completed was dated 11/4/10. The assessment documented recommendations of Prostat 64 (a protein supplement used to promote healing of wounds). The resident's weight at that time was documented at 398 pounds (lbs.). The assessment included abnormal lab results of an [MEDICATION NAME] of 2.1, normal values 3.5-5 (Measures protein levels in the body), low Hemoglobin, 9.9 (normal value 14-18) and Hematocrit, 30.2 (normal values for men 42-52) (measures the Red Blood Cell volume of the blood). There was no further nutritional assessment available for the resident. The last nutritional progress note was dated 12/22/10. There were no nutritional progress notes for 2011 (4 months) in regard to the resident's pressure sore and nutritional requirements. During an interview with the Certified Dietary Manager and the Registered Dietician (RD) on 4/20/11 at 9:25 AM, when asked how often the RD did Nutritional Assessments and progress notes on residents with wounds, the RD stated that she did progress notes on wounds monthly. She stated, "I look monthly, what stage it is (wound)." She stated she estimated the needs if the weight fluctuates and reviewed the labs. When asked where the progress notes and Nutritional Assessments were since December, the RD stated, "I got confused and just documented his weights. I should have been documenting on his wounds and nutritional needs as well." On 4/20/11 at 8:40 AM, an interview was conducted with the Administrator, the two wound nurses, the Corporate Nurse, the DHS (Director of Health Services). LPN (Licensed Practical Nurse) #5, one of the Treatment Nurses, stated that the Braden Scale was done weekly for four weeks following an admission. The resident's medical record contained one Braden Scale that was not dated, with the admission assessments of 9/15/10. The score was 12, which placed the resident at moderate risk for pressure sores. LPN #5 stated that she and the other Treatment Nurse; assessed the residents for wounds, see the risk factors, preventive measures such as cushions, wedges, podus boots "perform an over all assessment". When asked if they measure and staged the pressure sores, LPN # 5 agreed that they did. The DHS stated that she, as a RN (Registered Nurse), would go and look at the wounds when they were admitted or discovered. She admitted that she did not follow-up on the wounds. LPN #5 stated that they had a Certified Ostomy nurse that gave them direction on treatment of [REDACTED]. LPN #5 stated that she had never met the Ostomy Nurse, but talked with her over the telephone. Resident #9 was admitted with pressure wounds. There was no documentation available on the medical record of when the current pressure sore had developed. There was no documentation of weekly measurements or staging of the pressure sore before January 12, 2011. There were no nutritional assessments or progress notes related to nutritional intervention for 4 months, since December. The physician had no documentation over the past year of having seen or assessed the resident's pressure sores. The resident's pressure sore had been staged at a Stage IV in January and February 2011. A Stage IV is the highest staging of a pressure sore which indicated the pressure sore was severe. No Registered Nurse, had followed or assessed the pressure sore on a routine basis. The Wound Manual was reviewed on 4/20/11. The manual contained a form, "Pressure Ulcer Report". The report included the following information: Date Acquired, Date admitted , Site Location, Initial Stage, Highest Stage, Stage Now, Amount of Drainage, Odor, Treatment, Response to Treatment, and Pressure Relief Devices. During an interview with the Administrator on 4/20/11, the surveyor asked if the facility used the Pressure Ulcer Report. The Administrator stated, "Yes, all residents with pressure sores are included in the report. The report is done weekly." When asked where the report was kept, the Administrator stated she had it in her computer. "The Skin Integrity Nurse completed the information." The reports were requested from August 2010 to present day. The reports were not provided to the surveyors until approximately 8:00 PM on 4/20/11. The facility was repeatedly asked for information regarding pressure sores during the days of the survey. The information was inconsistent on the resident's medical records. The information of the pressure sore reports was not provided until the end of the survey. Cross refer to F-272 as it related to the facility's failure to ensure each resident was adequately and accurately assessed for pressure ulcers, and the appropriate assessments were completed for residents with existing wounds Cross refer to F-325 as it related to the facility's failure to provide timely nutritional assessments to monitor and implement recommendations to assist in the healing of pressure ulcers. Immediate Jeopardy and Substandard Quality of Care was identified at F-314 at a scope and severity of "K" as it related to the facility's failure to adequately assess residents with skin impairments, appropriately treat residents with wounds, adequately monitor residents with wounds and failure to identify residents with pressure ulcers which placed residents at risk for serious harm and/or injury. Based on observations of inservices, staff interviews, and documentation provided by the facility, the Survey Team on 4/20/11 accepted the Allegation of Compliance for the Immediate Jeopardy before exiting the facility. The Immediate Jeopardy was removed but the deficiency at F-314 remained at a scope and severity of "E".

On the days of the survey, based on record reviews, interviews, and review of scope of practice for Licensed Practical Nurses as determined by the South Carolina State Board of Nursing, the facility failed to assure that each resident was adequately and accurately assessed for pressure ulcers and that the appropriate assessments were complete for residents with existing wounds for six of ten resident records reviewed for pressure ulcers. Resident #'s 1, 2, 3, 4, 7, and 9 had either no assessments or inaccurate assessments for pressure ulcers. The findings included Resident #1 with [DIAGNOSES REDACTED]. The resident was aphasic with left side mobility impairment. She required total care from the staff for her activities of daily living. The resident received all nutrition and hydration via gastrostomy feeding tube. Review of the medical record revealed the resident arrived at the facility with no pressure ulcers. On 9/10/10, the nurse's note documented "small open areas observed on the resident's right (sic) ear and right (sic) buttock. ... " Review of the Skin Notes showed an entry on 9/14/10, at 9 AM, describing the left buttock ulcer as a Stage II pressure ulcer measuring 5.5 by 2 by 0 centimeters (cm) with no bleeding or drainage. This was the first descriptive note concerning the ulcer. Review of the medical record, including the Skin Notes, Daily Skilled Nurses' Notes, Treatment Records, and Alteration In Skin Integrity Addendum To TAR (Treatment Administration Record) showed the right ear ulcer was deemed healed on 9/24/10. The records failed to show any additional assessment of the left buttock ulcer for September 2010. Review of the October 2010 records showed two documented assessments of the ulcer. An assessment on 10/8/10 and again on 10/12/10. Skilled Nurse's Notes identified the area as Stage IV on 11/4/10. Although the Treatment Record showed continued treatment to the left buttock ulcer until the resident's discharge 11/18/10, no further assessment of the ulcer was noted in the records. Resident #2 with [DIAGNOSES REDACTED]. The resident required total care from the staff for her activities of daily living. On 8/31/10, a nurse's note at 1:35 PM stated the resident had breakdown to the upper right buttock. It stated the wound nurse was notified and treatment was in place. This was the first documented evidence of this new ulcer. Documentation in the Skin Notes and on the Alteration in Skin Integrity form showed a Stage III ulcer measuring 3.2 by 2.0 by 0.1 cm with light drainage and pink surrounding skin. Facility staff was asked to produce pressure ulcer tracking and assessment information on the Skin Notes and Alteration in Skin Integrity forms for February 2011. They were unable to produce the documents. Resident #3 with [DIAGNOSES REDACTED]. The resident required total care from the staff for her activities of daily living. Review of the Treatment Record for December 2010 showed the resident was being treated for [REDACTED]. On 12/21/10, a new pressure ulcer was noted on the right buttock. Documentation in the medical record and interview with the treatment nurses failed to provide a rationale showing why the wound was not identified before reaching a depth of 1.3 cm and developing yellow slough. Review of the January 2011 Treatment Record showed the current treatments to both sites was discontinued on 1/20/11. Continuing treatment records for January 2011 were not available on request and it could not be determined if treatment was provided to the ulcers for the remainder of the month. Review of the available documentation for February 2011 showed no Skin Notes or Alteration in Skin Integrity notes. The Treatment Record revealed that the right buttock ulcer was treated with packed gauze soaked in basic Dakin's solution covered with a dry dressing twice a day and as needed. There was no record of treatment to the coccyx. A nurse's note on 2/5/11 stated the resident's buttock ulcer was a Stage IV. There was no other documentation in February 2011 to support or contradict this entry. Review of the Pressure Ulcer Report of 3/24/11 showed the resident's right buttock ulcer was a Stage II measuring 1 by 1 by 0.2 cm. Resident #4 with [DIAGNOSES REDACTED]. Review of the admission nurse's note showed the resident had "an area" on his sacrum. Review of the Skin Assessment sheet of 2/22/11 revealed a diaper rash with a red spot. The spot was drawn onto the body figure at the approximate site of the coccyx. Review of the Skin Notes showed that on 2/22/11, the resident was assessed as having a red inflamed perineal area. Review of the Treatment Record revealed an order to cleanse the sacral area then apply [MEDICATION NAME], to be changed every three days and as needed. Review of the medical record showed no assessment or descriptive note concerning the resident's sacral "area." None of the documentation in the medical record described an open pressure ulcer but review of the Pressure Ulcer Report of 3/24/11 showed the resident's pressure ulcer as a Stage II measuring 1.5 by 2 by 2 cm. The facility admitted Resident #7 on 12/10/10 with [DIAGNOSES REDACTED]. The resident was initially admitted to the 400 Unit for rehab and was transferred to the 200 unit on 3/11/11. Review of the medical record on 4/18/11 showed the facility Admission Nursing Evaluation Form which was completed on 12/10/10. This form showed that the resident had both long and short term memory problems, had swallowing problems, was a total assist with toileting and was incontinent of both bowel and bladder. She also had a bruise to the right elbow and a dressing on the left hip, her sacrum was normal and her feet and heels were normal. The Braden Scale was 11 which showed that the resident was at risk for skin breakdown. There were no other Braden Scales in the record. The following body audits were noted in the record: 2/19/11, 2/26/11, 3/5/11, 3/16/11, 3/29/11, 4/11/11, and one with no date. Review of the treatment records showed that the resident was receiving treatment to both heels starting 12/24/10. The skin notes for December 2010 did not mention treatment to the heels or what the condition of the heels were. A skin note dated 1/7/11 stated "both heels remain blanchable at this time." There were no other notations for January concerning the heels except for dressing changes. A skin note dated 1/28/11 stated, "Resident has a red area to her left buttock/ blanchable after pressure is applied. Area cleansed with ns (normal saline)and [MEDICATION NAME] placed as a preventive measure." There were no other skin notes or facility Skin Integrity Documentation Forms in the chart until March 2011. Review of the nurse's notes revealed that the resident was found to have an open area to the left buttock on 2/21/11. The note stated, "Called to room by CNA (certified nurses aide) earlier this shift to see a wound to resident's left buttock. Writer observed a wound 3 cm (centimeters) by 2 cm and 1/2 cm deep with possible tunneling under initial wound and also with possible surrounding area at risk for breakdown." There was no further documentation on the wound until March 2011. The Alteration in Skin Integrity Addendum To TAR was done with wound measurements and documentation of the site on 3/4, 3/10, 3/17, 3/24, 3/31, 4/5 and 4/13/11 for the area to the left buttock. The notations on the skin notes for the month of March started on 3/24/11 and stated, "During assessment today measurements are 3.4 x 2.5 x 0.2. Wound bed is black eschar with some blanching around wound bed noted. No drainage at this time. Surrounding skin is pink dry and intact. Treatment continues as ordered." An interview was conducted with the Administrator, Licensed Practical Nurse (LPN) # 5 and LPN #6 on 4/20/11 at 8:45 AM. When asked which wound LPN #6 was referring to in the 3/24/11 skin note, she stated it was the right heel. When asked why this area was not noted before this time, she could not answer. She further stated that she thought the wound was a stage IV until she was informed on 4/19/11 that it was unstagable. LPN #5 stated she did not look at the heels weekly. When asked about the Braden Scales being completed, the policy states once a week for four weeks and then quarterly, they did not know why there was only the initial one in the record. When asked about the body audits, which are to be done weekly by the floor staff, they could not answer why they were not done and why the dressings were not removed to check the wounds. It was further stated in the interview that both of the LPN's are supervised by the DHS (Director of Health Services). LPN #5 has some wound care training and LPN #6 had no training for wound care. Both LPN's stated that skin assessments included looking at the nails, age spots, scars, tenting, hair, scalp and behind the ears. They assess a wound bed for color, drainage, sloughing and odor. No one in the interview could explain why the documentation and assessments were not completed on this resident. The two wound nurses assigned to these duties were LPNs (Licensed Practical Nurses). The South Carolina Board of Nursing has determined "the analysis and synthesis of clinical information and the formulation of problem statements, nursing [DIAGNOSES REDACTED]." The facility admitted resident #9 on 9/21/07, readmitted on [DATE]/, 6/10/10, and 9/15/10 with [DIAGNOSES REDACTED]. During an interview with the resident on 4/20/11, he stated that he had wounds for 4 years and had wounds when he was admitted to the facility. On 4/19/2011 at 9:55 AM the Pressure Sore care was observed. The wound on the right hip/sacral area appeared as a horizontal split wound over the upper quadrant of the right buttocks extending to the sacral area. The last measurements dated 4/8/11 were recorded as Stage III 1 (one) CM (Centimeter) in length by 3 CM in width by 3 CM in depth. There was scarring extending out to the right of the wound. review of the resident's medical record revealed [REDACTED]. The Plan of care dated 11/05/2010 included the problem of pressure ulcer. The approaches listed for the the Pressure ulcer included: Reassess at least weekly... Resident #9 was admitted with pressure wounds. There was no documentation available on the medical record of when the current pressure sore developed. There was no documentation of weekly measurements or staging of the pressure sore before January 12, 2011. There were no nutritional assessments or progress notes related to nutritional intervention for 4 months, since December. The physician had no documentation over the past year of seeing or assessing the resident's pressure sores. The resident's pressure sore was staged as a Stage IV in January and February 2011. A Stage IV is the highest staging of a pressure sore which indicated the pressure sore was severe. No Registered Nurse, had followed or assessed the pressure sore on a routine basis. Cross Refer to F314 as it relates to the failure of the facility to adequately, accurately, and consistently assess residents at risk for skin breakdown with both developing and existing wounds. Immediate Jeopardy was identified at F-272 at a scope and severity of "K" as it related to the facility's failure to ensure each resident was adequately and accurately assessed for pressure ulcers, and the appropriate assessments were completed for residents with existing wounds. The systemic failure of the facility to identify, accurately assess, and monitor residents with skin impairments and or potential impairments placed those residents at risk for serious injury and/or harm. Based on observations of inservices, staff interviews, and documentation provided by the facility, the Survey Team on 4/20/11 accepted the Allegation of Compliance for the Immediate Jeopardy before exiting the facility. The Immediate Jeopardy was removed but the deficiency at F-272 remained at a scope and severity of "E".

On the days of the survey, based on closed record review, interviews and review of the facility policy titled Cardiopulmonary Resuscitation (CPR) the facility failed to initiate CPR in a timely manner for one of two residents designated as having full code status. The facility did not initiate CPR on Resident #27 until one hour after finding the resident without a pulse. The findings include: The facility admitted Resident #27 on [DATE] with a re-admission date of [DATE] with [DIAGNOSES REDACTED]. Closed record review on [DATE] revealed the resident sustained [REDACTED]. An x-ray of the right leg from hip to ankle was ordered on [DATE] and completed on [DATE]. The resident was sent out to the hospital for evaluation and treatment for [REDACTED]. She returned to the facility on [DATE] at 12:15 AM with an immobilizer to the right leg. Further review of the record showed that on [DATE] at 2:25 PM a nurse's note stated, "Resident vomited this morning and c/o (complaint of) nausea. Order for [MEDICATION NAME] 25 mg. (milligrams) po (by mouth) q (every) 6 hours for 24 hours prn (as needed)". A nurse's note on [DATE] at 3:15 PM stated, "Resident sleeping in bed." The next notation in the nurse's notes written on [DATE] by LPN #4 stated, "Approximately 4:30 a (AM) CNA (certified nurse's aide) came up to me and told me resident wasn't breathing, went to room to check pulse, found no pulse and resident was unresponsive. Got other nurse to come down to check resident. She checked heart and lungs sounds, no lung sounds noted, left room to check code status was full code, ... approximately 4:45 p (PM) DHS (Director of Health Services) notified, approximately 5 p administrator notified. RN (registered nurse) arrived at approximately 5:30 p to assess resident. CPR started and AED (automated external defibrillator) pads administered. CPR continued until EMS (emergency medical services) arrived at approximately 5:50 p. EMS transported resident to ... at approximately 6:20 p." On [DATE] LPN #11 wrote the following nurse's note at 4:45 P, "Called to residents room by residents nurse. Noted resident to be cold to the touch, unresponsive to her name - color pale yellow- blue - heart sounds checked. None noted, code status checked. Crash cart taken to room O2 (oxygen) started at 6 L (liters) per NK (nasal cannula). Examined by ADHS (Assistant Director of Health Services). CPR started and cont. (continued) until ambulance arrived. EMS took over CPR - resident transferred to ... ER (emergency room )." The last nursing note entry was done by the ADHS on [DATE] and stated, "At approx. 5:30 this writer arrived to evaluate res. (resident) no heart sounds, no pulse noted. CPR initiated. 911 called. Family notified. At approx. 5:50 EMS arrived and took over CPR. Family arrived also. Res. transported via stretcher to ... at approx 6:20 pm. Family followed." Also noted in the record review was a facility face sheet, which stated, under code status, that the resident was a full code. A facility Advance Directive/DNR Documentation dated [DATE] and signed by the resident on [DATE] stated, "Verbalizes understanding of the do not resuscitate authorization as explained that no cardiopulmonary resuscitation (CPR) will be administered in the event of cardiac or respiratory arrest. A check mark beside the resuscitate statement was noted. During an interview with the Administrator, DHS, ADHS and a corporate consultant on [DATE] at 12:20 PM, the Administrator stated that the resident was pronounced deceased at the hospital. The ADHS stated that LPN #11 found the resident at 4:30 PM, CPR was started at 5:30 PM and EMS arrived at 5:50 PM. She further stated that she arrived at the facility at 5:30 PM, came in and started CPR. She confirmed that the staff found the resident at 4:30 PM unresponsive and without a pulse. She also confirmed that the staff did not start CPR and that the senior nurse on the floor stated that there were no signs or symptoms of life. When asked why the LPN did not call 911, the ADHS could not respond. An interview with LPN #11 on [DATE] at 3:00 PM revealed that she was present on the day in question and was assigned to the North Hall. The resident was on the South Hall. She stated that the other nurse asked her to come and check the resident. Her statement was the same as what was charted in the nurse's notes. She stated that after the ADHS was called she went back to work until the ADHS arrived at the facility at 5:30 PM. She also stated that she started CPR after the ADHS arrived and told her to do it. When asked if she knew what the facility policy said about CPR, she stated that if the resident is not a DNR (do not resuscitate) you should start CPR. LPN #11 has a current American Heart Association CPR training certificate, which expires ,[DATE]. An interview with LPN #4 on [DATE] at 3:45 PM revealed that she was informed that the resident was not breathing around 4:30 PM. She further stated that she called the other nurse on the floor; she assessed and we called the RN, we should have started CPR then but we waited for the RN. I know we should have started it sooner but we started CPR until the ambulance came and took over. LPN #4 has a current American Heart Association CPR training certificate, which expires on ,[DATE]. During an interview with the facility medical director on [DATE] at 5:00 PM, when asked when CPR should be started on a resident who is a full code he stated, "immediately." Review of the facility policy on CPR, under the Procedure section, #3 stated, "Designated staff will immediately call emergency services. #4 All staff members certified in CPR or licensed staff should immediately go to the identified room." Immediate Jeopardy and Substandard Quality of Care was identified at F-309 at a scope and severity of "J" as it related to the facility's failure to follow a resident's desire for Full Code and the facility did not attempt resuscitation timely. Based on observations of inservices, staff interviews, and documentation provided by the facility, the Survey Team on [DATE] accepted the Allegation of Compliance for the Immediate Jeopardy and Substandard Quality of Care before exiting the facility. The Immediate Jeopardy and Substandard Quality of Care was removed but the deficiency at F-309 remained at a scope and severity of "D".

On the days of the survey, based on record reviews, interviews, review of the facility Cardiopulmonary Resuscitation (CPR) policy and review of the South Carolina State Board of Nursing Advisory Option #9, the facility failed to provide care and services that met professional standards for one of two closed records reviewed for full code status and one of one resident reviewed with a Peripheral Inserted Central Catheter (PICC) Line. CPR was not initiated in a timely manner for Resident #27 with an advanced directive for a full code and Licensed Practical Nurses (LPN) with no proof of advanced training, administered antibiotics and flushes via a PICC Line to Resident #12. The findings include: The facility admitted Resident #27 on [DATE] with a re-admission date of [DATE] with [DIAGNOSES REDACTED]. Closed record review on [DATE] revealed the resident sustained [REDACTED]. Also noted in the record review was a facility face sheet, which stated, under code status, that the resident was a full code. A facility Advance Directive/DNR Documentation dated [DATE] and signed by the resident on [DATE] stated, "Verbalizes understanding of the do not resuscitate authorization as explained that no cardiopulmonary resuscitation (CPR) will be administered in the event of cardiac or respiratory arrest. A check mark beside the resuscitate statement was noted. Further review of the record showed that on [DATE] at 2:25 PM a nurse's note documented by LPN #4 stated, "Approximately 4:30 a (AM) CNA (certified nurse's aide) came up to me and told me resident wasn't breathing, went to room to check pulse, found no pulse and resident was unresponsive. Got other nurse to come down to check resident. She checked heart and lungs sounds, no lung sounds noted, left room to check code status was full code, ... approximately 4:45 p (PM) DHS (Director of Health Services) notified, approximately 5 p administrator notified. RN (registered nurse) arrived at approximately 5:30 p to assess resident. CPR started and AED (automated external defibrillator) pads administered. CPR continued until EMS (emergency medical services) arrived at approximately 5:50 p. EMS transported resident to ... at approximately 6:20 p." On [DATE] LPN #11 wrote the following nurses note at 4:45 P, "Called to residents room by residents nurse. Noted resident to be cold to the touch, unresponsive to her name - color pale yellow- blue - heart sounds checked. None noted, code status checked. Crash cart taken to room O2 (oxygen) started at 6 L (liters) per NK (nasal cannula). Examined by ADHS (Assistant Director of Health Services). CPR started and cont. (continued) until ambulance arrived. EMS took over CPR - resident transferred to ... ER (emergency room )." The last nursing note entry was done by the ADHS on [DATE] and stated, "At approx. 5:30 this writer arrived to evaluate res. (resident) no heart sounds, no pulse noted. CPR initiated. 911 called. Family notified. At approx. 5:50 EMS arrived and took over CPR. ......" During an interview with the Administrator, DHS, ADHS and a corporate consultant on [DATE] at 12:20 PM, the Administrator stated that the resident was pronounced deceased at the hospital. The ADHS stated that LPN #11 found the resident at 4:30 PM, CPR was started at 5:30 PM and EMS arrived at 5:50 PM. The ADHS stated that she arrived at the facility at 5:30 PM, came in and started CPR. She confirmed that the staff found the resident at 4:30 PM unresponsive and without a pulse. She also confirmed that the staff did not start CPR and that the senior nurse on the floor stated that there were no signs or symptoms of life. When asked why the LPN did not call 911, the ADHS could not respond. An interview with LPN #11 on [DATE] at 3:00 PM revealed when asked if she knew what the facility policy said about CPR, she stated that if the resident is not a DNR (do not resuscitate) you should start CPR. LPN #4 and LPN #11 have a current American Heart Association CPR training certificate, which expires ,[DATE]. During an interview with the facility medical director on [DATE] at 5:00 PM, when asked when CPR should be started on a resident who is a full code he stated, "immediately." Review of the facility policy on CPR, under the Procedure section, #3 stated, "Designated staff will immediately call emergency services. #4 All staff members certified in CPR or licensed staff should immediately go to the identified room." Cross Refer to F309 as it relates to the facility's failure to provide care and services that met professional standards of practice when Resident #27, identified as a Full Code, was not given CPR timely. The facility admitted Resident #12 on [DATE], with a re-admission date of [DATE], with [DIAGNOSES REDACTED]. Record review on [DATE] revealed that the resident was sent out of the facility on [DATE] to have a PICC Line placed. A physician order written [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Upon re-admission to the facility on [DATE] the physician ordered "D5W/0.9% Sod Cl ([MEDICATION NAME] 5 % water/0.9% sodium chloride) 1000 ml with potassium chloride 20 meq (milliequivalents) rate 24 ml/hour run via PICC line; [MEDICATION NAME]/D5W 750 mg/150ml IV (intravenously) Q (every) 24 hours, rate 150 ml/hr continue until ,[DATE] then d/c (discontinue)." Review of the [DATE] Medication Administration Records (MARS) revealed an order to "flush each lumen of 18 ga (gauge) PICC with 5 ml of ns (normal saline) every shift 7a-7p and 7p-7a". Also noted on the MARS was a order for "Flush each lumen in PICC line with 5 ml ns before and after each IV infusion." The MAR indicated [REDACTED]. The [MEDICATION NAME] was administered via PICC line on [DATE] by LPN #9, on [DATE] by LPN #10 and on [DATE] by LPN #4. The PICC Line flushes for the 7 AM to 7 PM shift were signed as being completed by LPN #9 on ,[DATE], ,[DATE] and ,[DATE], by LPN #10 on ,[DATE] and by LPN #4 on ,[DATE] and ,[DATE]. The initials and names of the LPN's were verified by the ADHS (Assistant Director of Health Services) on [DATE] at 3:15 PM. On [DATE] at 4:00 PM the DHS stated that LPN #4 was at IV training today, LPN #9 had no advanced IV training and LPN #10 stated that she had the training but had no certificate of training. The South Carolina Department of Labor, Licensing and Regulation, (Advisory Opinion #9 B) states, "The selected LPN shall document completion of special education and training to include: cardiopulmonary resuscitation and intravenous therapy course relative to the administration of fluids via peripheral and central venous access devices/lines that includes didactic and supervised clinical competency training with return demonstration... The LPN may not give medications directly into the vein (intravenous push) or insert medication via an external catheter site (port A cath)". Immediate Jeopardy was identified at F-281 at a scope and severity of "J" as it related to the facility's failure to follow a resident's desire for Full Code and the facility did not attempt resuscitation timely. Based on observations of inservices, staff interviews, and documentation provided by the facility, the Survey Team on [DATE] accepted the Allegation of Compliance for the Immediate Jeopardy before exiting the facility. The Immediate Jeopardy was removed but the deficiency at F-281 remained at a scope and severity of "D".

On the days of the inspection, based on record review and interviews, the facility failed to provide access to all medical records for 1 of 4 residents sampled for the request of medical records (Resident #1). A written request made by the wife (personal representative) of Resident #1 made initially to the facility on [DATE] and then again on [DATE] was denied. The Regional Ombudsman, after numerous attempts to assist the resident's wife in obtaining the medical records of Resident #1, filed a complaint with the State Survey Agency on [DATE]. Nurses' Notes documented that the facility notified Resident #1's wife with any change in condition and acknowledged her as his personal representative. The facility failed to acknowledge the Health Care Consent Act (SC Code [DATE] et. esq.) and failed to recognize Resident #1's wife as his personal representative when she requested copies of his medical record. The findings included: On [DATE] the facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] and Quarterly MDS assessment dated [DATE] coded the resident as having short-term and long-term memory problems with severely impaired cognitive skills for daily decision-making. Resident #1 required extensive to total assistance for all activities of daily living on the Admission and Quarterly MDS. Review of the current medical record revealed a Do Not Resuscitate (DNR) Authorization for Patient/Resident Without Decision-Making Capacity for Resident #1 signed [DATE] by two physicians and by the resident's wife ([DATE]). During an onsite visit to the facility on [DATE], Resident #1 was sampled as a result of a complaint received by the State Agency on [DATE]/2010, which alleged that the resident's wife failed to receive requested medical records. The allegation stated that the Ombudsman had worked since [DATE] to resolve a complaint filed against the facility related to the denial of requested copies of the medical record. Review of the current medical record indicated that on [DATE] the resident's wife signed a facility provided Authorization for Use & Disclosure of Information form requesting records for her husband (Resident #1) from "[DATE] - Present for personal purposes". On [DATE] Resident #1's wife received a letter from a representative of the facility, which stated, "...regarding your request for the above mentioned patients' medical records. As you are aware, the Health Insurance Portability and Accountability Act and the privacy regulations promulgated there under (collectively, "HIPPAA") has imposed strict requirements on health care providers regarding the release of protected health information ("PHI"). Under HIPPAA, a provider may disclose an individual's PHI to a personal representative who under state law has authority to act on behalf of the individual. See 45 CFR 164.502(g)(1), 164.514(h)(1)(i). Further, HIPPAA requires that the provider verify the identity of the personal representative and that person's authority to access PHI as a personal representative. See 45 CFR... Such a personal representative may be a durable power of attorney for health care or guardian of the person if the individual is living, or the permanent administrator or executor of the state if the individual is deceased . The Advance Directive provided to the facility does not provide the proper authority. The center will not be able to release these records until it receives verification of the applicable representation..." Information provided by the Ombudsman revealed a letter to Resident #1's wife dated [DATE] in which she was advised of her rights under the Health Care Consent Act (SC Code [DATE] et. esq.). A letter to the facility dated [DATE] from the Ombudsman was also provided, which included the following statement, "...I will meet with Resident #1's wife in the morning to visually inspect the medical record and from there will assist as needed in identifying the records she wants copied for her personal use." On [DATE] Resident #1's wife signed another Authorization for Use & Disclosure of Information form requesting records "from date of admission to present: nurses notes, skin asst. (assessments)/body audits, Soc (social) Services notes, all physical therapy, speech therapy, care plans" for personal use. Review of the Health Care Consent Act (SC Code [DATE] et. esq.) Section [DATE] states, "Persons who may make health care decisions for patient who is unable to consent; order of priority; exceptions. (A) Where a patient is unable to consent, decisions concerning his health care may be made by the following persons in the following order of priority: (1) a guardian appointed by the court pursuant to Article 5, Part 3 of the South Carolina Probate Code, it the decision is within the scope of the guardianship; (2) an attorney-in-fact appointed by the patient in a durable power of attorney executed pursuant to Section [DATE], if the decision is within the scope of his authority; (3) a person given priority to make health care decisions for the patient by another statutory provision; (4) a spouse of the patient..." Resident #1's spouse is his personal representative and per the Health Care Consent Act is the person who makes health care decisions for him. In a telephone interview with the facility on [DATE] the facility stated that this was a HIPPA concern and they would not release information to Resident #1's wife for "personal use" and that the wife would have to complete the request to list specific information and the purpose of the use of the information. In an interview with the surveyor on [DATE] the Ombudsman stated that she met with Resident #1's wife at the facility on [DATE] in order to review Resident #1's medical record during a care plan meeting. A verbal review was conducted of the medical record with the Administrator, Social Worker, Director of Health Services, Senior Care Partner and Speech Therapist present along with Resident #1's wife and the Ombudsman. Following the verbal review Resident #1's wife and the Ombudsman looked at the record page by page to determine what she wanted copied. When asked if the resident's wife filled out the authorization form, the Ombudsman stated that the facility staff completed the Authorization for Use & Disclosure of Information form and the resident's wife initialed and signed where needed. At no time did the facility staff give any instructions to the resident's wife regarding how to fill out the form. At the time of the survey Resident #1's wife had not received the requested copies of her husband's medical record.