Every finding on record at PruittHealth- Bamberg

Based on observation, interview, and facility policy review, the facility failed to store food properly in one of two designated resident refrigerators on the hallways and failed to serve milk at a temperature of 41 degrees Fahrenheit (F) or below from the kitchen's lunch tray line. These failures had the potential to create an environment for food-borne illnesses which could affect the 42 residents who resided on the 100 hallway and/or who were served milk during the lunch meal. Findings include: Review of the facility's policy titled, . Patients/Residents' Personal Food, with a revised date of 05/12/23, indicated, Policy Statement: It is the policy of PruittHealth to allow the patient/resident's family to provide food items for patient/resident consumption. The patient/resident's personal food will be maintained in a clean environment to ensure sanitary storage, appropriate food handling and safe consumption of foods brought into the facility by residents' family, and visitors . Procedure . 4. Food item(s) will be labeled with the resident's name, contents, the date it was prepared (if known) and a discard/use by date . 6. Foods requiring refrigeration must be stored in the nursing unit's nourishment refrigerators or in existing individual in-room refrigerators. These items stored in the nursing units' nourishment refrigerators must be kept to a minimum due to limiter space. The main facility kitchen food storage refrigerators will not be used. All food items requiring refrigeration must be labeled and dated. Any opened (non-condiment) foods will be discarded after 48 hours. Condiments will be discarded per the manufacturer's expiration date . Review of the facility's policy titled, Food Temperatures, with a revised date of 10/21/25, indicated, . Policy Statement: It is the policy of PruittHealth that the Dietary Manager or designee be responsible for ensuring that all food has reached and continues to maintain proper temperature prior to tray assembly . Procedure . 2. All potentially hazardous cold foods must be held at 41 degrees or less . 12. Potentially hazardous cold food should be held on the line in an ice bath at 41 degrees or below . Temperature Monitoring Tips: . 3. Cold foods should not be set up on meal trays longer than 15 minutes prior to meal service, and must be kept on ice or chilled during the tray line/meal service . During an observation on 05/27/26 at 9:30 AM, the resident refrigerator on the facility's 100 hall, with the Dietary Manager (DM) present, revealed a sign was posted on the front of the refrigerator which read, Every Monday and Thursday, this refrigerator will be cleaned out (All items must be labeled with a name/date). An observation of the inside of this refrigerator revealed the following: - one previously opened eight-ounce package of shredded [NAME] jack cheese, which was hard to the touch and had an expired manufacturer's use by date of 12/13/25. - one previously opened 15-ounce container of a margarine spread had an expired manufacturer's use by date of 01/08/26. - one container dated 02/26/26 with a resident's name written on it contained rice, carrots, meat, and potatoes which had visible mold growth on the food. - one previously opened 32-ounce container of coffee creamer had an expired manufacturer's use by date of 04/12/26. - one Styrofoam container dated 05/11/26 with a resident's name written on it contained macaroni and cheese, lima beans, chicken, and ribs. - one undated plastic container with a resident's name written on it contained lima beans, okra, and rice. - one small undated Styrofoam container which contained rutabagas which had mold growth on the food. - one large undated Styrofoam container with a resident's name written on it contained an unidentifiable food which had mold growth on it. During an interview on 05/27/26 at 9:45 AM, the DM confirmed each of the above outdated, undated, and/or spoiled food that was observed stored in the 100-hall resident refrigerator. The DM stated it was the housekeeping staff's responsibility to check the food stored in this refrigerator. During an interview on 05/27/26 at 9:48 AM, the Administrator observed and confirmed the outdated, undated, and/or spoiled food that was observed stored in the 100-hall resident refrigerator. The Administrator stated that it was the housekeeping department's responsibility to check the food stored in this refrigerator twice a week on Monday and Thursday and to discard any food with an expired expiration date, signs of spoilage, and/or that was not labeled or dated. During an interview on 05/28/26 at 8:30 AM, the facility's Environmental Service Manager (EVSM) stated she was not aware her staff were to check the food stored inside the 100-hall resident refrigerator. The EVSM stated she thought the housekeeping staff only needed to check the internal temperatures of the residents' refrigerators on the hallways, not the food stored inside. During an observation on 05/28/26 at 12:10 PM, [NAME] (C)1 was using a calibrated thermometer to monitor the internal temperature of food that was going to be served to residents from the kitchen tray line during the lunch meal. No milk was observed on the lunch tray line for staff to monitor its internal temperature. During an interview on 05/28/26 at 12:15 PM, C1 stated during the lunch meal only a few residents requested milk to be served, so staff had placed a carton of milk on their meal trays which were already placed in the meal delivery carts. During an observation on 05/28/26 at 12:15 PM, resident meal trays which contained silverware, napkins, condiments, tray slip, and beverages (including milk) were placed in meal delivery carts. At this time, (Resident (R)4's) meal tray, which had a carton of milk on it, was observed in a meal delivery cart. During an observation on 05/28/26 at 12:45 PM, the kitchen staff prepared R4's hot meal from the tray line and placed the covered meal on the resident's tray which was still on the meal delivery cart. At this time, the DM was requested to use the kitchen's calibrated thermometer to monitor the internal temperature of R4's carton of milk that was to be served with her lunch meal. The DM was observed to use a calibrated thermometer to monitor the milk's temperature, and it registered at 56.1 degrees Fahrenheit (F). During an interview on 05/28/26 at 12:50 PM, the DM stated milk should be served from the kitchen at a temperature of 41 degrees F or below. During an interview on 05/29/26 at 1:25 PM, the DM stated two residents who resided on the 100 hall (including R4) and one resident who resided on the 200 hall, were the only three residents who requested milk to be served during the lunch meal. The DM explained that many residents requested milk to be served during breakfast and evening meals, so the kitchen staff who served these meals from the tray line placed cartons of milk in ice prior to serving them on resident trays to keep it cold at these meals.

Based on observation, review of the monthly resident council meeting minutes, and interviews, the facility failed to ensure reports with respect to the most recent Federal or State survey inspection results, certifications, complaint investigations, and any plans of correction during the three preceding years were readily accessible to residents and/or family members. The facility failed to ensure this information was posted in areas of the facility that are prominent and accessible to the public. This failure had the potential to affect all 80 residents residing in the facility. This had the potential to cause residents and visitors to be uninformed of survey, certification, and complaint investigation findings. Findings include: Review of the past six months of the Resident Council Meeting Minutes, dated 12/03/25, 01/21/26, 02/25/26, 03/25/26, 04/25/26, and 05/20/26, revealed no documentation that the State survey inspection results, certifications, complaint investigations, or plans of correction were discussed with residents as to where the information was posted for residents to review. During an observation on 05/27/26 at 11:30 AM, of the front entrance of the facility, including the front entrance sitting area, front reception area, nursing station on the 100-and 200-unit, activity room, and all dining rooms revealed there was no evidence of the State survey results posted. During this time, an observation was made of a brown box cabinet labeled Annual Survey Results Inside which was located mounted on the wall by the left side of 100 nurses' station. Once the cabinet door was opened, it was empty. During an observation on 05/28/26 at 7:52 AM, the same brown box cabinet located mounted on the wall by the left side of the 100 nurses' station and labeled Annual Survey Results Inside was observed. When the cabinet door was opened, it was empty. During an interview with the Resident Council president (Resident (R)71) on 05/28/26 at 10:03 AM, when asked if the resident(s) knew where the State survey inspection results, certifications, complaint investigations, or any plans of correction were posted, R71 stated, No. I don't know where that information is posted or any other whereabouts where that information is posted. When R71 was asked if this information was reviewed with residents during the monthly resident council meeting, she stated, No. During a third observation on 05/28/26 at 11:45 AM, the brown box cabinet located mounted on the wall by the left side of the 100 nurses' station and labeled Annual Survey Results Inside was again observed to be empty. During an interview on 05/28/26 at 11:50 AM, the Activity Director (AD) stated she oversaw the Resident Council meetings each month. When asked if she knew where the Federal or State survey inspection results, certifications, complaint investigations, or any plans of correction results were posted, the AD stated, I'm not sure where those are. I'm assuming at the front entrance, but I'm not sure. I have never seen those. When the AD was asked if she has ever reviewed this information with residents during the resident council meetings, or with any residents, she stated, No. I don't cover that in resident council. I was never told that is something I should be doing. During an observation and interview on 05/28/26 at 11:58 AM, the Director of Nursing (DON) stated, There is survey book box on the wall next to the 100 nurses' station. That has the survey information in it. During an observation with the DON, the brown box cabinet located mounted on the wall by the left side of the 100 nurses' station and labeled Annual Survey Results Inside was observed to be empty. At this time, the DON stated, This is where the survey binder should be. I can see it's not here. I will have to ask the Administrator. That would be the only place I know where the survey results would be posted. During an interview on 05/28/26 at 12:20 PM, the Administrator stated, There is a brown box on the wall near the nurses' station where that information should be. She then stated, I have the book in my office, and I will need to put it out there. However, at this time, the Administrator then asked the corporate nurse to assist her in locating the binder with the Federal and State inspection results which could not be located in the Administrator's office. During this interview, the Administrator stated her expectation was that the information was reviewed with residents and posted and available for anyone to review.

Based on observation, interview, record review, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure two resident's Minimum Data Set (MDS) assessments were accurately coded regarding having a feeding tube and receiving intake by an artificial route for one resident (Resident (R)67), and having a pressure ulcer over a boney prominence for R77 out of 23 sampled residents. This failure had the potential to affect the care planning and provision of needed services.Review of the Long-Term Care Facility Resident Assessment Instrument [RAI] Instrument 3.0 User's Manual, dated October 2025 and located at https://www.cms.gov/files/document/final-mds-3-0-rai-manual-v1-20-1-october-2025.pdf indicated, . In addition, an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian, and/or other legally authorized representative, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [Interdisciplinary Team] completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment . 1. Review of R67's Face Sheet, located under the Resident tab of the electronic medical record (EMR), indicated R67 was admitted to the facility on [DATE]. Review of R67's undated Continuity of Care Document (CCD), provided by the facility, indicated active diagnoses which included parkinsonism, dysphagia, and altered mental status. Review of R67's quarterly MDS, with an assessment reference date (ARD) of 04/10/26 and located under the RAI tab of the EMR, revealed the assessment specified the resident did not have a feeding tube, and had not received any intake by an artificial route. Review of R67's Medication Administration Report (MAR), from 04/04/26 to 04/10/26, provided by the facility, indicated the resident received an enteral feeding at 50 milliliters (ml) per hour continuously via a gastrostomy tube on each of these days. Review of R67's current Physician orders, located under the Resident tab of the EMR, revealed an order to receive an enteral feeding at a rate of 50 ml per hour via a gastrostomy tube with a start date of 08/17/25. During an observation on 05/27/26 at 3:50 PM, R67 was in bed with an enteral feeding being administered via a feeding pump and gastrostomy tube at a rate of 50 ml per hour. During an interview and record review on 05/29/26 at 9:30 AM, the Minimum Data Set Coordinator (MDSC) reviewed R67's quarterly MDS with an ARD of 04/10/26 and confirmed the MDS was inaccurate because it did not reflect that the resident had a feeding tube and did not reflect the resident received intake by an artificial route. The MDSC stated she would submit a correction for the coding error. 2. Review of R77's undated Face Sheet, located under the Resident tab of the EMR, indicated R77 was admitted to the facility on [DATE] with diagnoses including but not limited to, chronic kidney disease and anxiety disorder. Review of R77's Wound Management, report, provided by the facility, indicated the resident had a pressure ulcer on her sacrum when she was admitted on [DATE]. The report also specified this sacrum pressure ulcer was still present on 05/27/26. Review of R77's admission MDS, assessment with an ARD of 05/13/26 and located under the RAI tab of the EMR, indicated the resident did not have a pressure ulcer on a boney prominence. During an interview and record review on 05/29/26 at 9:21 AM, the MDSC reviewed R77's admission MDS with an ARD of 05/13/26 and confirmed the MDS was inaccurate because it did not reflect the presence of a pressure ulcer over a boney prominence. The MDSC stated the resident had a pressure ulcer on her sacrum when admitted on [DATE] and when the assessment was completed, but the assessment did not reflect the presence of a pressure ulcer over a boney prominence. The MDSC stated she would submit a correction for this coding error. The MDSC also stated the facility did not have a policy for the accurate completion of MDS assessments but utilized the RAI manual for any MDS issues.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure ongoing communication was taking place and documentation was provided regarding updates, referrals made to other skilled nursing facilities regarding the potential discharge, placement, and transition of care for one resident (Resident (R)71) in attaining and maintaining the resident's highest practicable well-being out of 23 sampled residents. This failure had the potential to affect the resident in a negative way by not receiving information from the Social Services Director (SSD) regarding her requests. Findings include: Review of the facility's policy titled, Discharge Planning, revised 02/24/25, indicated, . Discharge planning will begin with each patient/resident and patient/resident's representative upon admission. The process is coordinated by Social Services.Definitions: Community resources are services and agencies that have the potential to improve the quality of life in the community and to assist in the transition of care, including but not limited to: Rehabilitation Centers, Social Services Agencies. The policy then indicated, . For patients/residents for whom discharge to the community has been determined to not be feasible, the medical record must contain information about who made that decision and the rational for that decision. Review of the facility's Social Services Director Position Description, modified 12/2016 indicated, . Job Purpose: Responsible for coordinating, and directing Social Services in accordance with federal, state, and local regulations. It further indicated, Key Responsibilities.coordinates discharge plans with residents and families. Review of R71's Face Sheet, located under the Resident tab of the electronic medical record (EMR) indicated R71 was admitted to the facility on [DATE], with diagnoses including but not limited to, quadriplegia, C1-C4 complete, anxiety disorder, major depressive disorder, and epilepsy. It further indicated an extensive history of contractures of the right ankle, left ankle, left knee, right knee, and muscle wasting and atrophy. Review of R71's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 03/05/26 and located under the RAI tab of the EMR, revealed R71 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated no cognitive impairment. The MDS indicated R71 required total assistance for all Activities of Daily Living (ADLs) and was completely dependent on staff. Further review of the quarterly MDS indicated R71 participated in the MDS and goal setting. It indicated there was no active discharge planning already occurring for the resident to return to the community. Review of the Social Services Progress Notes, dated 03/14/24 and located under the Progress Notes tab of the EMR, indicated, Spoke with resident again on today regarding desire to transfer to [name of another skilled nursing facility]. SSD made aware by [name of skilled nursing facility] that admission would soon resume at which time the resident was placed on list of needed transfers with top priority. Further review of the Social Services progress notes revealed no ongoing documentation of communication; referrals made on behalf of R71 or the SSD communicating with R71 regarding her wishes to be transferred to another skilled nursing facility since 03/14/24. Review of R71's Care Conference Report, dated 12/31/25 and located under the Documents tab the EMR, indicated, IDT [Interdisciplinary Team] met with resident for care plan meeting.Would like some referrals sent to areas close to [name of another county] so she can see her children more. Review of R71's Care Conference Report, dated 03/19/26 and located under the Documents tab in the EMR, indicated, Care plan meeting held in room with resident.she [referring to R71] also asked SSD to try some of the facilities in the low country for bed availability since she would like to be closer to her family. Review of R71's EMR indicated no documentation since 03/14/24 of any referrals made by the SSD or any communication by the SSD to R71 regarding discharge planning of her wishes to transfer to another facility to be closer to her family. There were two documented care plan conferences held on 12/31/25 and 03/19/26 in which R71 expressed her wishes to move to other nursing facilities to be closer to her family. The EMR did not contain documentation of any referrals made by the SSD, or communication given to R71. During an observation and interview on 05/27/26 at 10:30 AM, R71 was observed lying in bed unable to move on her own. R71 was observed with both hands and legs contracted with splints and braces in place. During interview R71 stated, I'm very frustrated because I've been here for three years and I'm trying to get to [name of another skilled nursing facility]. I've talked to Social Services many times. She will tell me she will send off a referral, and I don't ever hear anything back from her. That is where my family is, and I've been waiting and wanting to be in another nursing facility. R71 then stated, When I talked to [name of the Social Services Director-SSD] she gives me no updates whatsoever. I'm paralyzed and need help doing everything. I would like to get closer to an area near my home. I have young kids and would like to see them. It's been very frustrating. During an interview on 05/28/26 at 8:04 AM, the SSD stated, We haven't been able to find placement for her due to her history. She is from [name of county] and that is where she wants to go. That is where her family is. The SSD stated, Over the past several years, I have reached out to [name of other nursing facilities] and asked about transfers. She stated, I've sent referrals to other facilities since then with no luck. When the SSD was specifically asked if she could show any documentation of communications she has had with R71 since her last documented social services progress note dated 03/14/24, the SSD stated, It's been a while since we've talked about the transfer thing. I can go in today and talk with her again. The SSD stated, I would say it's been a couple of months at least since I've communicated with any facilities and that has been through emails. When the SSD was asked if she could provide any documentation of corresponding emails, she submitted to other facilities regarding R71, the SSD stated, They have not been saved. The SSD stated, Most of my communication with her [regarding R71] has just been verbal. I don't have any recent progress notes or documentation. The SSD confirmed R71 made the requests during the last care plan conference on 03/19/26 to be closer to her family and wanted to know any updates or referrals made to other nursing facilities and stated, We just talk about it during her care conferences. Honestly, I have not done anything with that. There is no reason why I have not. During an interview on 05/28/26 at 9:53 AM, the Administrator stated, Any documentation regarding discharge or transfer would be what social services has. I would expect there to be more documentation and ongoing communication with [name of R71] regarding this and from now on, I will also ask to be included in any communications.

Based on observation, record review, interview, and review of the Academy of Nutrition and Dietetics Diet Manual, the facility failed to provide food in a form to meet the needs for one resident (Resident (R)23) out of two reviewed for nutritional status out of 23 sampled residents. This failure had the potential to cause nutritional needs to go unmet for residents who had a physician's diet order to be served finger food prepared from the facility's kitchen.Findings include: Review of the Academy of Nutrition and Dietetics Diet Manual, provided by the facility, indicated, . Finger Foods Some patients may be able to feed themselves, eat adequately, and be more independent if they are able to use their fingers to pick up foods. Utensils may become harder to use for some patients depending on their condition and/or age. Allowing patients to be as independent as possible during mealtime may improve their nutritional intake. Most foods can be eaten without utensils, but this requires creativity and planning. Review of R23's Face Sheet, located under the Resident tab of the electronic medical record (EMR), revealed an original admission date of 11/27/24 and diagnoses which included but was not limited to, type 2 diabetes mellitus, lack of coordination, and vascular dementia. Review of R23's quarterly Minimum Data Set (MDS),with an assessment reference date (ARD) of 03/26/26 and located under the RAI [Resident Assessment Instrument] tab of the EMR, indicated the resident received a mechanically altered and therapeutic diet. The assessment also specified R23 had a Brief Interview for Mental Status (BIMS) score of five out of 15, which indicated the resident was severely cognitively impaired. Review of R23's current undated Physician Orders, located in the EMR under the Resident tab, revealed an order for a controlled carbohydrate (CCHO), no added salt (NAS), and a mechanical soft diet with Special Instructions: please send finger foods. This order had a start date of 12/11/24. Review of R23's current Care Plan, provided by the facility, contained a Problem, which indicated, Nutritional Status [R23's name] requires a therapeutic diet and mechanically altered as order [sic] . A care plan Approach indicated, Diet as ordered. 12/11/24 CCHO/NAS/Mech[anical] Soft Diet, please send finger foods. This nutritional status care plan was noted as being most recently reviewed/revised by staff on 03/30/26. During an observation on 05/27/26 at 1:06 PM, R23 was in her room eating her lunch meal without staff present. Review of the tray slip served with R23's meal revealed she was to receive a CCHO, NAS, mechanical soft diet with finger foods. The resident was observed to have no problems eating a biscuit with her fingers. An observation of R23's plate revealed she also received a serving of ground chicken which she did not attempt to eat. During an observation on 05/28/26 at 1:35 PM, R23 was in her room eating her lunch meal without staff present. Review of the tray slip served with R23's meal revealed she was to receive a CCHO, NAS, mechanical soft diet with finger foods. The resident was observed to have no problems eating a dinner roll with her fingers. R23 was also observed to utilize a spoon in her right hand to eat her dessert, which was a cherry pie with whipped topping, and on two occasions spilled some of the dessert onto her left hand as she brought a spoonful of the dessert from the bowl to her mouth. R23 was also served ground pork on her meal tray which she did not attempt to eat. During an observation and interview on 05/28/26 at 1:45 PM, the Dietary Manager (DM) came to R23's room at the request of this surveyor. The DM observed R23's meal tray and confirmed she received ground pork which she did not eat and received cherry pie with whipped topping for dessert. The DM stated R23 enjoyed eating sandwiches and should have been served sliced bread with this meal and with her lunch meal of 05/27/26, so staff could place the ground meat served at these two meals on the bread, so R23 could use her fingers to eat the ground meat as part of a sandwich. During an interview on 05/29/26 at 11:50 AM, the DM stated R23 was the only resident who currently had a physician's order to be served finger foods at meals. The DM explained during the lunch meal on 05/28/26, R23 should have received a donut in place of the cherry pie with whipped topping, so she could have picked up the donut with her fingers to eat it. The DM also stated the facility did not have a policy for serving finger foods or therapeutic diets. During a phone interview on 05/29/26 at 1:45 PM, the facility's Registered Dietitian (RD) stated the facility did not have a policy for finger foods, but the Diet Manual utilized by the facility addressed the issue.

Based on review of facility policy, record reviews, and interviews, the facility failed to properly account for and reconcile controlled medications to prevent potential loss, diversion, or accidental exposure. This deficiency is evidenced by the missing controlled drug record sheet for Resident (R)4, 1 of 3 residents reviewed. Review of a facility policy titled, Controlled Substances for Healthcare Centers, last reviewed 04/01/25 revealed, It is the policy of PruittHealth Pharmacy that medications listed as controlled substances (Schedules I-V) under federal or state regulations will be properly stored with maintained accountability. Reconciliation of controlled substances will be performed at the end of each shift by licensed professional nurses. This policy applies to all nursing staff in a healthcare center serviced by PruittHealth Pharmacy. Records . 5. Current Controlled Drug Record forms are maintained in the narcotic book. When completed, the sheets are submitted to the Director of Health Services and kept on file for two (2) years at the healthcare center. Accounting: A physical inventory of all controlled substances is conducted at each shift change by the oncoming and outgoing licensed professional nurses. The inventory is documented on the Controlled Drug Shift Audit Sheet.Review of R4's Face Sheet revealed R4 was admitted to the facility on [DATE] with diagnoses including, but not limited to, paraplegia, pressure ulcer of sacral region, stage 4, neuromuscular dysfunction of bladder and psoriasis.Review of R4's admission Minimum Data Set (MDS) with an Assessment Reference Date of 07/25/25 revealed R4 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R4 is cognitively intact.Review of R4's Physician Orders dated July 28- August 22, 2025, revealed Oxycodone - Schedule II tablet, 15 milligram (mg) tablet, take 1 tablet orally every 4 hours per home regimen.R4's Controlled Substance (Narcotic) Sheet for 08/13/25 - 08/15/25 could not be found.During an interview on 08/25/25 at 10:26 AM, R4 stated, They are managing my pain. She didn't have any concerns.During an interview on 08/25/25, at 10:29 AM, the Director of Health Service (DHS) stated, Our policy states we contact the pharmacy to notify if anything is going on with the medications and or if there are any missing doses. We have a sheet where you count the cards and match them to the narcotic sheet. We count the narcotic sheets individually and make sure they match. The Medical Director (MD) was not notified because we did not have any doses missing for R4, just the narcotic sheets. The pharmacy knew that the narcotic sheets were missing, but the MD did not. I found out on Sunday morning when Licensed Practical Nurse (LPN)2 called me.During an interview on 08/25/25 at 10:37 AM, LPN1 stated, I am new. I only worked there for about a month. That day, we had 4 nurses working. One nurse took all her cards off my cart, and she had the medication cart keys. I told her to let me know when she was finished so I could make sure my narcotic count was right. After we counted the next day, I found out the narcotic cards were missing. Another nurse was working on the other hall. We both had a set of the narcotic keys. She had to get the narcotics medications off my cart. She took her resident's cards off my cart and took them to her cart. She placed all the medications and narcotics back in the medication cart at the end of the shift. I don't know the normal practice of removing medications from the medication cart. That was my first day back from being sick. We counted the narcotic sheets. We record the residents' medications by marking them off when we give any narcotics. If we take a narcotic card off or a sheet we highlight the whole sheet for completion. The next day, when I came in to work. I was asked what happened. I was told to write a statement and then I was suspended until further investigation. I am still on suspension.During an interview on 08/25/25 at 10:58 AM, LPN2 stated, I was on the medication cart afterwards. The count was accurate. All the narcotic sheets were accounted for. The narcotic card procedure is we count and make sure the narcotic count validates the count on the narcotic sheet card. Cards are counted every shift. Everything must match on the cards. The day shift forgot to add the new narcotic medications to the narcotic card. We add the cards as they come in at night. The unit manager checks behind us as they are added to the inventory sheet. One nurse counts, and the other nurse counts behind us. The unit manager zeros the other sheet out.During an interview on 08/25/25 at 11:51 AM, LPN3 stated, I don't know much. I was called to write a statement. I heard my signature was used, but I didn't work that day, and I didn't sign for anything because I wasn't there. They implemented the log to count the narcotic cards. We sign a narcotic log sheet where we have to enter the count at each shift.During an interview on 08/25/25 at 02:38 PM, the Administrator stated, The staff have to make sure they are signing narcotics on the paper and the MAR. The nurses check the inventory sheets every shift. The DHS checks the paperwork as well as the unit manager. The DHS is responsible for checking off the narcotic sheets. She has unit managers check the sheets.During an interview on 08/25/25 at 02:56, DHS stated that the unit managers check the narcotic sheets weekly, and I check the narcotic sheets monthly.During an interview on 08/25/25 at 03:13 PM, LPN4 stated, We have 3 nurses working typically. That day we had 4 nurses working. Two of the nurses have to take narcotics off each cart. Me and the other nurse had to get medications off the cart that we needed. About 6 o'clock, the nurse ask me if I was good with the medications, I told her no because I wasn't finished. LPN1 stated she was finished with her work for the day. She started cleaning my cart off. At that time, I pulled the narcotics out of my drawer to review my sheets at the nursing desk. I asked LPN1 if she wanted to come over and verify, but she didn't respond. When I started to check the medication cart LPN1's phone started ringing. She set her keys on the medication cart and told me she had to take that phone call. I kind of hesitated to take her medication cart keys. I wouldn't leave my keys with another nurse. I replaced the medications in her cart. As far as I know, her count and my count were correct. Then, I received a call at 02:00 AM stating narcotic sheets were missing.

Based on observation, interview, and review of facility policy, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety, in 1 of 1 kitchen. Findings include: Review of the facility policy titled Dietary Partner Hygiene and Dress Code last revised on 06/14/16, revealed, It is policy of the facility for partners working in the Dietary Department to dress in a manner appropriate for preparing, handling, and serving food that prevents contamination and spread of bacteria. This applies to all dietary partners, and any person(s) who handles and served food employed by the facility. Hygiene: hair is covered with hair net and or/cap. Facial hair is completely covered with a hair net or beard guard. Review of the facility policy titled Labeling, Dating, and Storage last revised on 11/11/22, revealed, It is policy of the facility for all partners who assist in handling, preparing, and serving food and beverage items to follow the proper procedures for labeling, dating, and storage to ensure proper food safety. Food and beverage items will have an identifying label as well as a received date and opened date, as applicable, for items prepared onsite, a 'use by' date will also be indicated. Foods will be stored in their original or approved container and, if opened shall be wrapped tightly with film, foil, etc. Review of the facility policy titled Dish Room Sanitation last revised 03/22/16, revealed, It is policy of the facility that the dish room must be maintained in a clean and sanitary condition. Dishwashing and sanitizing procedures will be available in the Dietary Department. Procedures include both full and empty dish racks are to be stored on a dish dolly, cart, or under a shelf in the dish room at all times. Keep dish room work surfaces in a clean and sanitary condition. Wash the soiled dish table, exterior of machine and other work surfaces with detergent, rinse thoroughly, and then sanitize. Review of the facility policy titled Cleaning Schedule Policy last revised on 09/29/22, revealed, It is policy of the facility that the Dietary Manager prepares a list of all cleaning tasks and posts them in the Dietary Department. It is the Dietary Manager's responsibility to develop and enforce the cleaning schedules and to monitor the completion of assigned cleaning tasks to promote a sanitary environment. The cleaning schedule: daily, weekly, and monthly lists all cleaning tasks. Review of the facility policy titled Food Temperatures last revised on 02/24/23, revealed, It is policy of the facility that the Dietary Manger or designee be responsible for ensuring that all food has reach and continues to maintain proper temperature prior to tray assembly. Procures include how to take temperatures: remove thermometer from sleeve and place it into the side clip, thermometer should be held by the sleeve, calibrate thermometer before using. Clean the thermometer shaft with an alcohol pad prior to use. The thermometer shaft must be cleaned with an alcohol pad prior to temping each food item. During an observation and interview on 07/03/25 at 10:18 AM, revealed the facility's Kitchen Manager (KM) without a hair net and standing near food being prepped for meal service. The KM stated it is expected that dietary staff put on a hair net when entering the kitchen. During an observation on 07/03/25 at 10:20 AM, of a drying rack near food preparation, revealed a plastic tray underneath with a sticky substance on 3 of 4 shelves. During an observation and interview on 07/03/25 at 10:21 AM, of a drying rack near the 3 compartment sink, revealed plastic totes/bins stacked on top of each other and visibly wet. The KM stated that wet items should not be stack on top each other so it can dry freely. During an observation and interview on 07/03/25 at 10:24 AM, of the cooler revealed an opened gallon of milk with an expiration date of 07/14/25. The gallon of milk was in a grocery store bag and was not dated. The KM stated that staff had brought that milk from the store earlier this morning. During an observation on 07/03/25 at 10:27 AM, of the freezer revealed an opened bag of ready to bake cookies not labeled/dated when opened. During an observation and interview on 07/03/25 at 12:06 PM, of food items being temped on the steam table revealed the [NAME] was reusing the same sanitizer wipe for sanitizing the thermometer. The [NAME] stated that she should have gotten more wipes to sanitize the thermometer, and those wipes are to be discarded after single use. During an observation on 07/03/25 at 12:10 PM, revealed personal items (car keys) on two separate food preparation tables/ areas. A follow up interview on 07/03/25 at 1:06 PM, with the KM and Cook, revealed the [NAME] admitted to using the same sanitizer wipe by folding it in smaller portions to tempt the last 3 food items on the steam table. The KM agreed that after temping each food item the thermometer should be cleaned with a new sanitizer wipe. During a phone interview on 07/03/25 at 2:05 PM, the Registered Dietitian (RD) revealed that their expectation is that all staff should have on hair nets/beard guards when entering the kitchen. Wet bins/trays and other kitchen equipment should not be stacked on top of each other while wet, to allow items to dry without the potential of bacterial build-up. The RD further stated all food items should labeled/dated after opening or removed from their original packaging. The RD concluded that when testing the temperature of the food on the tray line, the thermometer should be cleaned with a new sanitizer wipe after each food item is temped.

Based on observations, record review, and interviews, the facility failed to ensure food was at appropriate temperature and palatable for four of five residents (Resident (R) 22, R26, R81, and R35) reviewed for the food palatability of 25 sample residents. This failure had the potential for residents who disliked a meal to experience nutritional problems or dissatisfaction with their meals. Findings include: 1. Review of R22's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/20/25 and located under the MDS 3.0 tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS) score of eight out of 15 which indicated moderately impaired cognition. During an interview on 05/06/25 at 1:40 PM, R22 stated the food sucks, adding that it was too salty and was always cold. 2. Review of R26's quarterly MDS assessment with an ARD of 04/23/25 and located under the MDS 3.0 tab of the EMR, revealed she was admitted to the facility on [DATE] and had a BIMS score of 15 out of 15 which indicated intact cognition. During an interview on 05/06/25 at 2:23 PM, R26 stated she did not like the food, and felt the food was unrecognizable at times. She stated, It's stuff you wouldn't even feed your dog. 3. Review of R81's admission MDS assessment with an ARD of 02/24/25 and located under the MDS 3.0 tab of the EMR, revealed he was admitted to the facility on [DATE] and had a BIMS score of 13 out of 15 which indicated intact cognition. During an interview on 05/06/25 at 3:16 PM, R81 stated the food was not great and stated most of the food was too dry and didn't contain sufficient gravy to keep them moist. 4. Review of R35's quarterly MDS assessment with an ARD of 03/10/25 and located under the MDS 3.0 tab of the EMR, revealed he was admitted to the facility on [DATE] and had a BIMS score of 15 out of 15 which indicated intact cognition. During an interview on 05/06/25 at 1:22 PM, R35 stated the food was not good and was not served hot. 5. Review of the undated lunch menu Daily Spreadsheet, provided by the facility for 05/08/25 documented the following for a regular diet: Turkey Ala King, rice, and sweet peas. During observation of the steam table on 05/08/25 at 12:26 PM, the turkey was 190 degrees F. (Fahrenheit), the rice was 196 degrees F., and the peas were 200 degrees F. During observation on 05/08/25 at 1:10 PM, the Dietary Manager (DM) took the temperature of the food on a test tray of the turkey, rice, and sweet peas and confirmed the temperatures were 110 degrees F. During the evaluation of the test try, the regular turkey: Dry and bland, cool to palate; the regular rice: Flavorful but cool to the palate; the peas: Flavorful but cool to the palate; the puree turkey: Unseasoned, cool; the puree vegetable: Very garlicky, did not taste like peas, cold; the puree rice: Unseasoned cream of rice, no flavor and gluey, cool. During an interview on 05/09/25 at 1:13 PM, the [NAME] Dietary Aide (CDA)1 stated the food temperatures on the resident's plate before serving should be at least 165 degrees. During an interview on 05/09/25 at 1:14 PM, CDA2 stated the food temperatures on the resident's plate before serving should be at least 165 degrees. During an interview on 05/09/25 at 1:17 PM, the DM stated the food temperatures on the resident's plate before serving should be at least 165 degrees. The DM also stated the kitchen staff tasted each meal after it had been cooked every day.

Based on observation, interview, record review, and policy review, the facility failed to ensure medications in the resident's room were deemed safe for self-administration for one of 22 Initial Pool residents (Resident (R) 22) observed for medications in the room. This failure placed R22 at risk for medication errors, accidental overdose, or misappropriation of her medications. Findings include: Review of the facility's policy titled, Self-Administration of Medications by Patients/Residents, dated 01/06/25, revealed All nurses and aides are required to report to the Charge Nurse on duty any medications found at the bedside not authorized for bedside storage and to give unauthorized medications to the Charge Nurse for return to the family or responsible party. Families or responsible parties are reminded of this procedure and related policy when necessary .When the interdisciplinary team determines that bedside or in-room storage of medications would be a safety risk to other patients/residents, the medications of patients/ residents .are stored in the central medication cart or medication room. The patient/resident requests each dose from the medication nurse, who provides the medication to the patient/resident. Review of R22's Face Sheet tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including schizophrenia, dementia, anxiety, depression, delusions, hallucinations, bipolar disorder, and chronic pain. Review of R22's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/20/25 and located under the MDS 3.0 tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of eight out of 15 which indicated moderately impaired cognition. She exhibited verbal behavioral symptoms directed toward others and rejection of care daily. Review of R22's Care Plan located under the Care Plan tab of the EMR and dated 01/03/23, revealed, Resident has impaired decision making R/T [related to] dx. [diagnosis] of schizophrenia. Resident has pattern of delusional thought processes which impair ability to make safe decisions. Review of R22's Self-Administration of Medication assessment, located under the Observations tab of the EMR and dated 12/11/24, revealed she did not wish to self-administer medications, staff would administer all medications, and her medications would be kept in the nurses' cart. During an observation on 05/06/25 at 1:40 PM in R22's room, R22 was lying in bed. There was a round, red pill that looked as if it had been moistened that was stuck to the front of her gown on her chest. During a concurrent interview, R22 stated she did not know whether the object was a pill or not and did not know where it came from. During an interview on 05/06/25 at 1:56 PM, Licensed Practical Nurse (LPN) 1 stated she always ensured R22 took her pills, and the pill on her gown may be pill from another shift. During a concurrent observation in R22's room, LPN1 stated it was a pill that was stuck to R22's gown and looked like it may be ibuprofen. R22 confirmed she only received ibuprofen at bedtime the night before and LPN1 stated she had not administered ibuprofen on 05/06/25. LPN1 compared the pill to the ibuprofen stored in the nurses' cart and verified the pill on R22's chest was an ibuprofen tablet. She stated the night nurse (LPN3) had administered the medication last night. LPN1 stated the pill looked as if it had been moistened, and it probably fell out of the resident's mouth during administration. Review of R22's May 2025 Medication Administration Record (MAR), located under the Reports tab of the EMR, revealed an order for two tablets of ibuprofen, 200 milligrams (mg) three times a day as needed for pain. The MAR indicated the most recent administration of ibuprofen was on 05/04/25 at 11:52 PM. During an interview on 05/08/25 at 4:15 PM, the Director of Nursing (DON) stated the nurses should watch the residents while taking their pills to ensure all pills were swallowed.

Based on interview, record review, and review of facility policy, the facility failed to ensure that an allegation of injury of unknown source was reported to the State Survey Agency (SSA) within two hours of discovery for one of four residents (Resident (R) 2) reviewed for abuse of 25 sample residents. The failure to timely report the incident created a risk for potential further abuse or injury. Findings include: Review of the facility's policy titled, Reporting Patient Abuse, Neglect Exploitation, Mistreatment, and Misappropriation of Property, dated 11/15/24, revealed In accordance with applicable laws and regulations, the Administrator or his or her designee should notify the appropriate state agency (or agencies) .of any allegation or incident .The state survey agency .should be notified in accordance with state law through established procedures of any allegations of abuse, neglect, exploitation or mistreatment, including injuries of an unknown source and misappropriation of patient property, within 2 hours after the allegation is made if the events upon which the allegation is based involve abuse or result in serious bodily injury, and not later than 24 hours if the events upon which the allegation is based do not involve abuse and do not result in serious bodily injury. Review of R2's Face Sheet tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including vascular dementia, unsteadiness on feet, muscle weakness, and hemiplegia on the right side. Review of R2's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/14/25 and located under the MDS 3.0 tab of the EMR, revealed she was unable to complete the Brief Interview for Mental Status (BIMS) and was assessed with long- and short-term memory problems and severely impaired cognition. She did not exhibit any behavioral symptoms. Review of the facility's 24-Hour Initial Report to the SSA, provided on paper in the incident report packet by the Administrator, revealed an injury of unknown source was discovered on 04/22/25 at 3:35 PM. The report indicated R2 had complained of pain in her right knee, an x-ray was done which showed a supracondylar fracture across the femur, and R2 was sent to the emergency department for treatment. The report documented it was sent to the SSA on 04/23/25 at 3:19 PM, almost 24 hours after the fracture was first discovered. Review of R2's x-ray Patient Report, included on paper in the incident report packet, revealed the report was received on 04/22/25 at 3:17 PM and indicated a supracondylar facture across the distal femur with mildly displaced bony edges. Review of R2's Care Plan, located in the Care Plan tab of the EMR and dated 04/24/25, revealed, Resident is s/p [status post] ORIF [open reduction internal fixation] for fracture to right fibula. Review of the facility's Five-Day Follow-Up Report, included in the incident report packet on paper and dated 04/28/25, revealed there was no fall or incident that was witnessed. The injury was substantiated; however, the resident had risk factors for sustaining injury, wheeled herself most of the day over long distances, and had cognitive deficiencies. During an interview on 05/08/25 at 5:23 PM, the Administrator stated she submitted the report to the SSA in 24 hours by mistake, thinking the incident was a fall rather than an injury of unknown source. The Administrator confirmed there was no fall, and it should have been submitted within two hours due to the situation of an injury of an unknown source that resulted in serious bodily harm.

Based on interview, record review, and policy review, the facility failed to ensure the Minimum Data Set (MDS) accurately reflected the status of two of 25 sample residents (Resident (R) 32 and R48) whose MDS indicators were reviewed in Initial Pool. These failures created a potential for lack of identification of current problems and resident needs, leading to an incomplete or ineffective plan of care. Findings include: Review of the facility's policy titled, MDS Assessment Accuracy, dated 01/11/24, revealed It is the policy of this healthcare center that each Minimum Data Set (MDS) reflects the acuity and the medical status of each patient/resident in accordance with acceptable professional standards and practices. 1. Review of R32's Face Sheet tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including bipolar disorder, traumatic brain injury, mood disorder, depression, and anxiety, Review of R32's quarterly MDS with an Assessment Reference Date (ARD) of 03/31/25 and located under the MDS 3.0 tab of the EMR, indicated she did not use antipsychotic medications. Review of R32's Orders tab of the EMR revealed a physician's order, dated 07/13/23, for aripiprazole (an antipsychotic medication), 10 milligrams (mg) every night. Review of the March 2025 Medication Administration Record (MAR), located under the Reports tab of the EMR, revealed R32 received aripiprazole as ordered daily during the MDS lookback period. During an interview on 05/08/25 at 2:47 PM, the Case Mix Director (CMD) stated she originally had marked usage of antipsychotic, but had made corrections to all MDS assessments over the past year to show no antipsychotic use because she thought it was inaccurate. The CMD stated she did not see aripiprazole in the resident's medication list. She stated she would need to correct the assessments again to indicate antipsychotics were received. 2. Review of R48's Face Sheet tab of the EMR revealed he was admitted to the facility on [DATE] with diagnoses including chronic kidney disease. Review of R48's quarterly MDS with an ARD of 02/28/25 and located under the MDS 3.0 tab of the EMR, revealed he was receiving dialysis. Review of R48's Orders tab of the EMR revealed there was no order for dialysis treatment. Review of R48's EMR revealed there was no evidence he received dialysis treatment. During an interview on 05/08/25 at 2:42 PM, the Case Mix Coordinator (CMC) stated R48 had never been on dialysis, and she must have hit that button in error. During an interview on 05/08/25 at 4:15 PM, the Director of Nursing (DON) stated each MDS was reviewed for accuracy by the CMD prior to submission and should reflect an accurate assessment of each resident.

Based on observation, interview, record review, and policy review, the facility failed to ensure staff, and a visitor used the proper personal protective equipment (PPE) when in contact with one of one resident (Resident (R) 82) who was on transmission-based precautions (TBP) out of a census of 79 residents. This failure had the potential to spread infection among the visitors, staff, and other residents. Findings include: Review of the facility's policy titled, Transmission-Based Isolation Precautions, dated 12/11/23, revealed Personal protective equipment (PPE) is provided for everyone who needs to care for or visit a resident on isolation precautions .Contact Precautions .Personal Protective Equipment (PPE): 1) Gloves: Perform hand hygiene prior to donning gloves. -Wear gloves (clean, non-sterile gloves are adequate) upon entry into the room. -Wear gloves when touching the resident's intact skin, surfaces and items near the resident. 2) Gowns -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 .Visitation with residents on Transmission-based Requirements: While not recommended, residents who are on transmission-based precautions (TBP) or COVID-19 quarantine can still receive visitors . Before visiting residents, who are on TBP or quarantine, visitors should be made aware of the potential risk of exposure by visiting and precautions necessary to visit the resident. Review of R82's Face Sheet tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] with diagnoses including an unstageable pressure ulcer to the right buttock. Review of R82's Nursing note, dated 04/22/25, revealed, Wound culture results received from [lab]. New order for contact precautions. ABT [antibiotic] therapy already in place. RP [responsible party] in room and notified. Review of R82's Orders tab of the EMR revealed an order, dated 04/22/25, for contact precautions due to a wound infection. During an observation on 05/06/25 at 2:12 PM, R82's room had a sign on the door indicating Contact Precautions, which directed to sanitize hands and don (put on) a gown and gloves before entering. R82 was lying in bed, and his Family Member (F) 1 was in the room. F1 was not wearing a gown or gloves. During an observation on 05/07/25 at 12:21 PM, R82 was lying in bed, and F1 was in the room. F1 was not wearing a gown or gloves. The sign indicating Contact Precautions was posted on the door of the room. A PPE cabinet was located across the hall from R82's room; however, it did not contain gowns. There were no other PPE cabinets in the vicinity. During an interview on 05/07/25 at 12:23 PM, Licensed Practical Nurse (LPN) 2 stated R82 was on contact precautions due to a wound infection. During an interview on 05/08/25 at 9:11 AM, F1 stated she did not know R82 was on contact precautions. She stated, I saw the sign on the door and was wondering about it, but nobody has talked to me about it. F1 stated she had never been told to wear a gown or gloves while in contact with objects in the room or with R82. F1 also stated the nursing staff typically did not don a gown while working with R82; however, the therapy staff typically did wear gowns. During an observation on 05/08/25 at 9:49 AM, R82's room door was observed with the sign announcing, Contact Precautions. The PPE cabinet located across the hall from R82's room did not contain gowns and there were no other PPE cabinets in the vicinity. The Unit Manager (UM) entered R82's room. She did not perform hand hygiene or don a gown or gloves before entering. The UM joined Certified Nurse Assistant (CNA) 2 who was also in R82's room. CNA2 was not wearing a gown in the room. The staff closed R82's door and provided care. At 10:03 AM, the room door was opened, and the UM and CNA2 were again observed in the room without wearing gowns. During an interview on 05/08/25 at 10:03 AM, the UM stated she gave R82 a bed bath while in the room and confirmed she did not don a gown while providing care. The UM stated R82 was on contact precautions because of a wound infection, and she should have donned a gown and gloves prior to entering the room. The UM added there was no reason why she did not don the appropriate PPE; it was just an oversight. During an interview on 05/08/25 at 10:03 AM, CNA2 stated she had given R82 a bed bath while in his room. She stated she did not wear a gown while providing care. CNA2 stated she should have donned a gown and gloves prior to entering the room because the resident was on contact precautions and stated there was no reason why she did not don the appropriate PPE; it was just an oversight. During an observation on 05/08/25 at 10:06 AM, CNA2 again entered R82's room without first performing hand hygiene or donning a gown and gloves. During an interview on 05/08/25 at 1:23 PM, the Infection Preventionist (IP) stated R82 was on contact precautions due to a wound infection. She stated the staff should wash their hands, don a gown and gloves before entering the room, and dispose of PPE and wash hands when leaving the room. The IP stated F1 was always in R82's room and could decide whether to wear PPE or not after being educated on what's going on and the recommendations. The IP stated she had not talked to F1 about contact precautions even though she interacted with F1 frequently. The IP stated it was her responsibility to ensure PPE was available in the carts on the halls; however, she typically only checked them once a week. The IP stated she had not done any recent training with the staff on transmission-based precautions and did not know how often the education was provided.

Based on observation and interview, the facility failed to have adequate equipment to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area. Specifically, the call light system did not function in residents' rooms 102, 103, 108, 109, 111, 113, 117, 128, 210, 215 and the facility did not provide residents in these rooms an alternate means to communicate with nursing staff, such as a manual bell to ring when the resident's required assistance from nursing staff. The facility also failed to have a policy and procedure to direct staff when call lights malfunction, and to ensure that another method to call for assistance was implemented. Findings include: During an interview on 01/24/24 at 11:01 AM, the Maintenance Director revealed that he was aware on 12/11/23 that rooms 103, 108, 111, and 202 call light systems were not functioning. The Maintenance Director stated that not all ordered parts have been received to fix the nonfunctioning call lights. Observation of these rooms on 01/24/24 starting at 10:30 AM until 12:00 PM revealed that only room [ROOM NUMBER] had an alternate means of obtaining staff assistance. room [ROOM NUMBER] was provided with a manual bell to ring for assistance. A call light audit of the entire facility was conducted on 01/24/24 at 11:45 AM and revealed rooms 102, 103, 108, 109, 111, 113, 117, 128, 202, 210, and 215 each had at least one resident in the room and the call lights were nonfunctioning. Of these 11 rooms, only three rooms [ROOM NUMBER] were given an alternate means to summon nursing staff in that the residents in these rooms were provided with a manual bell. Interview on 01/24/24 at 10:45 AM, the resident in room [ROOM NUMBER] stated that the call light had been nonfunctioning for one week The resident stated that in order to receive assistance from staff, she would have to yell out for help and that the facility did not provide another means of calling for assistance. Interview on 01/24/24 at 3:21 PM, the Director of Health Services (DHS) revealed, It is everyone's responsibility to notify maintenance of nonfunctioning call lights and to provide another means of calling for assistance. This is to be communicated during daily walking rounds. I only knew of two rooms, 109 and 202, where the call light system were not functioning properly. Interview on 01/24/24 at 12:05 PM, Certified Nursing Assistant (CNA) 6 revealed, I do not know of any call lights not working in the building. Interview on 01/24/24 at 12:11 PM, Licensed Practical Nurse (LPN) 3 revealed, I only know of room [ROOM NUMBER] where the call light stays on continuously. The two residents in that room do not have a bell to ring. Interview on 1/24/24 at 12:12 PM, CNA7 revealed, room [ROOM NUMBER]'s call light stays on continuously. That is the only room that I know where the call light was not working properly. Interview on 01/24/24 at 12:14 PM, LPN5 revealed, I work both the 100 and 200 halls and I only know of room [ROOM NUMBER] where the call light was not working, and that room has a hand bell. Interview on 01/24/24 at 12:36 PM, CNA8 revealed, room [ROOM NUMBER]'s call light does not work, and room [ROOM NUMBER]'s call light stays on continuously. I am not sure why they do not have a hand bell to use. Interview on 01/26/24 at 10:03 AM, the Administrator revealed, We need to have a system to check call lights and then a way to alert staff about the issue. Now, staff enter a work order to maintenance when there is an issue, but no one else knows about the issue. We need a temporary solution for residents to get assistance until the issue is resolved.

Based on observation, record review, interview, and policy review, the facility failed to ensure care plan interventions were implemented for one of three sampled residents (Resident (R) 22) reviewed for pressure ulcers. Specifically, the facility failed to implement the interventions of off-loading to a pressure ulcer on the left heel as indicated in the care plan. This failure had the potential for the resident to not receive the necessary care needed to promote healing of a pressure ulcer. Findings include: Review of the facility's undated policy titled, Pressure Injury Assessment and Documentation revealed, . Manage tissue loads: Positioning techniques and use of support surfaces . The goal of load management is to create an environment that enhances soft tissue viability and promotes healing of the pressure ulcer(s) . Avoid positioning residents on a pressure ulcer; avoid donut-type devices .Use devices such as pillows or foam to elevate the heels off the bed, and keep knees and ankles from touching or rubbing together . Review of R22's Face Sheet, located in the electronic medical record (EMR) under the Resident tab, revealed R22 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease and unstageable pressure ulcer of the left heel. Review of R22's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/02/24 and located under the RAI (Resident Assessment Instrument) tab of the EMR revealed R22 was severely cognitively impaired, dependent for bed mobility, and had a stage IV pressure ulcer. Review of R22's Care Plan, dated 01/03/24, located in the EMR under the RAI tab, revealed R22 had a left heel pressure ulcer with interventions that included turning and reposition resident as tolerated, float heels or use heel protectors as tolerated. Review of R22's Wound Management documentation dated 01/24/24, located in the EMR under the Wound Documentation tab revealed a stage IV pressure ulcer on the left heel that measured 1.0 centimeter (cm) by 1.5 cm by 0.2 cm. There was moderate serous exudate, 70% granulation tissue, 5% eschar tissue and the wound were improving. Observation on 01/24/24 at 10:00 AM, 12:00 PM, and 4:00 PM revealed R22 was in bed with the left heel resting on the mattress and was without the benefit of off-loading. A heel boot was observed on the nightstand and a wedge cushion was leaning against the wall. Observation on 01/25/24 at 10:30 AM, 12:00 PM, and 3:00 PM revealed R22 was in bed and did not have off-loading of the left heel. A heel boot was observed on the nightstand and a wedge cushion was leaning against the wall. Observation on 01/26/24 at 9:30 AM, with Certified Nursing Assistant (CNA)1, assigned to provide care to R22, revealed R22 was in the bed with the left heel resting on the mattress and was without the benefit of off-loading. CNA1 opened R22's closet and removed a heel boot from the top shelf. During an interview at the time, CNA1 stated she would put the heel boot on R22's left heel after she was finished providing care. CNA1 said when she came on duty that morning and checked the resident, the heel boot was not on, and R22's heels were resting on the mattress. During an interview on 01/26/24 at 9:40 AM, Licensed Practical Nurse (LPN)1, the charge nurse, stated the resident should have the left heel boot on at all times or some type of off-loading of the heel. LPN1 stated she did not know why R22 did not have the left heel boot on. During an interview on 01/26/24 at 10:00 AM, the Director of Health Services (DHS) stated R22 should have some type of off-loading provided to the left heel to promote healing when in bed. The DHS confirmed the resident did not have off-loading of the left heel.

Based on interview, record review, and review of facility policy, the facility failed to protect and prevent misappropriation of Resident (R)1's personal funds. Findings include: Review of facility policy titled Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property last revised 10/27/20, revealed It is the policy of the facility and its affiliated entities 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. Misappropriation of property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a patient's belongings or money without the patient's consent. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to: congestive heart failure, cognitive communication deficit, hypertension, and type 2 diabetes. Review of R1's annual Minimum Data Set (MDS) with an Assessment Reference date of 08/14/23, revealed R1 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, which indicates that R1 is cognitively intact. During an interview on 09/21/23 at 12:20 PM, R1 revealed that Certified Nursing Assistant (CNA)1 had stolen about $1,000 from his bank account. R1 stated that he would give CNA1 his bank card to get food but CNA1 was withdrawing money at a nearby automated teller machine (ATM). R1 further stated that he pressed charges against CNA1 and she has been arrested for fraud. Review of a Police Incident Report dated 09/02/23 revealed, Officers were dispatched to the facility for an individual stating one of the workers stole his money. [R1] informed the officer that his bank app alerted him about a withdrawal from a ATM for $200 plus the $2.75 ATM fee total, as well as a $1 ATM fee from [R1's] bank for using ATM other than their institution totaling $204.75. [R1] told the officer that this was not the first time this has happened but the third. The officer asked [R1] if he had his debit card and he stated yes she brought it back to me. [R1] and the Officer called [R1's] bank and they alerted the officer which ATM [CNA1] withdrew the money from [R1's] debit card. [R1] told the officer's that he wanted to press charges against [CNA1] for fraud. The Officer spoke with the nurse supervisor and informed them that [CNA1] violated facility policy and procedures by accepting the debit card from the resident. The officer was able to retain footage of [CNA1] at a local gas station withdrawing money from a ATM with [R1's] bank card. Review of a Witness Statement dated 09/02/23 written by CNA1 revealed, [R1] asked me to bring him something from a nearby fast-food restaurant. He gave me his bank card and every time I go out for him with his bank card or cash I bring back his receipt. Review of a Witness Statement written by the Director of Nursing (DON) revealed, On Saturday 09/02/23 I spoke with [CNA1] related to the situation with [R1] and taking money. She [(CNA1)] stated that her and [R1] had a conversation about her getting money from him. She stated he gave her his ATM pin and she got money out of the ATM on Saturday and withdrew $200. She also stated that when she goes to get him food on other occasions that he gave her permission to get gas with his bank card, and she has been getting gas on other occasions. She stated that she thought that their conversation was private and that nobody else would know. An attempted phone interview with CNA1 on 09/21/23 at 12:45 PM was unsuccessful due to the phone no longer being in service. During an interview with the DON on 09/21/23 at 1:38 PM, revealed that CNA1 was terminated from the facility for misappropriation of R1's bank account and law enforcement has charged CNA1 with fraud. The DON further stated that all staff have been re-educated on the misappropriation of resident property and that the resident has been re-educated on how to use food delivery apps instead of facility staff.

Based on review of facility policy, observation, interview, and record review, the facility failed to assess and administer Resident (R)4's medications in a clinically appropriate manner, for 1 of 1 resident reviewed for medication. Findings include: Review of facility policy titled, Medication Administration: General Guidelines, last revised 04/10/19, revealed, Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Patient/residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. Review of R4's Face Sheet revealed R4 was admitted to the facility on [DATE] with diagnoses including, but not limited to: dementia without behaviors, depression, seizures, and type 2 diabetes. Review of R4's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/20/23, revealed R4 had a Brief Interview of Mental Status (BIMS) score of 3 out of 15, which indicates R4 is severely cognitively impaired. Review of R4's Physician Orders for September 2023, revealed no order to allow R4 to self administer medications. Review of R4's Care Plan, last revised 09/14/23, revealed, Resident has impaired decision making related to diagnosis of dementia, refuses medications at times. Interventions include, reapproach the resident when he refuses care; encourage him to verbalize feelings, concerns, and fears to clarify misconceptions; respect the resident right to make decisions; and provide cues and supervision for daily decision-making. During an observation and interview on 09/21/23 at 10:40 AM, there were two medications in a cup on a bedside table in front of R4. R4 stated that his nurse at times will leave medications for him to take later, R4 then took the medications with water. During an interview on 09/21/23 at 1:52 PM, Licensed Practical Nurse (LPN)1 and the Administrator revealed that LPN1 had left medications with R4 to take later because he refused. LPN1 stated that they were unsure of the facility's policy for residents to self-administer medications. During an interview on 09/21/23 at 2:00 PM, the Director of Nursing (DON) revealed that R4 does not have the decision-making capacity to self-administer his medications. The DON stated that residents must have a physicians order and a high cognitive ability to self-administer their medications.

Based on record review, interviews, and review of the facility's policy, the facility failed to protect 1 of 6 residents, from physical abuse by a staff member. Specifically, Certified Nursing Assistant (CNA)1 admitted to local law enforcement that she pinned Resident (R)7's arms to her chest, put her hands over R7's mouth and hit her multiple times. On 08/29/23 at approximately 10:00 AM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 08/29/23 at approximately 10:30 AM the Administrator was notified that the failure to protect R7 from physical abuse by CNA1 constituted Immediate Jeopardy at F600. On 08/29/23 at 10:30 AM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 02/20/23. The IJ was related to 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation. On 08/29/23 at 2:11 PM, the facility provided an acceptable IJ Removal Plan. On 08/29/23 at 6:00 PM, the survey team validated the facility's corrective actions were completed as of 02/22/23 and determined the IJ was at Past Non-Compliance. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F600, constituting substandard quality of care. Findings include: Review of the facility's policy titled Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property last revised on 10/27/20 documented, It is the policy of PruittHealth and its affiliated entities (collectively, the Organization) to actively preserve each patient's right's to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, exploitation, mistreatment, and misappropriation of patient property, (refereed 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. Review of R7's Face Sheet revealed R7 was admitted to the facility on [DATE] with diagnoses including but not limited to, unspecified dementia with behavioral disturbances, cognitive communication dysfunctions, hemiplegia and hemiparesis, type 2 diabetes mellitus, urinary retention, and dysphasia. Review of R7's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 08/07/23 documented a Brief Interview for Mental Status (BIMS) score of 99 out of 15 indicating R7 was not cognitively intact. Review of a Local Police Department Incident Report with an incident date of 02/20/23, documented, Assault Battery 3rd . arrived on scene and spoke to the manager who stated that an employee [CNA2] came to her and stated that the subject station had told her that the victim was combative and calling her a [N******] and that she took care of her. The manager stated that the victim does have a black eye. [Officer] contacted the witness [CNA2] she stated that the subject came up to her and told her that the victim was combative and calling her a N***** and that she took care of her. [Officer] asked if she told her how she took care of her, she stated yes that she told her that she had hit her in the face . [Officer] asked [CNA1] about the situation and at first she denied putting her hands on the subject except for changing her. As [Officer] asked more questions she changed her statement to say that the victim was fighting her while trying to change the victim and that she pinned her arms to her chest. Further review of the incident report revealed under section Visible Injury indicated Yes and documented Apparent Minor Injur. Review of R7's Observation Detail List Report with an observation date of 02/20/23 at 8:15 PM documented in the comments section, resident has small darkened area to the bridge of nose. Review of R7's undated Care Plan revealed the following, Behaviors: [R7] has a hx. of removing her dirty brief, throws it on the floor/wall, only after she has put her hands in the brief and made a mess on herself, the covers, the walls, etc. Dx. include: Altered mental status, mood disorder, dementia, depression, anxiety, hx. of UTI. 2/21/22 [R7] has periods of swinging arms around, waving arms around, sticking arms through side rails, flailing/moving around in bed 12/24/22 yelling out fusing meds, hitting staff, knocking food out of staff hands, complaints from roommates' family. N.O. for medication received 2/19/23-res pulling off brief, fighting and swinging at staff, yelling and calling staff derogatory names, hitting at lab tech and refusing blood draw and u/a. This Care Plan included the following approach, u/a c/s for increased behaviors. Medication as ordered and monitor for adverse reactions every shift. pad siderails to aid in protecting res skin from bruising when she hits her arms and other body parts on side rails. to be up out of bed daily as tolerated, frequent check on [R7] to make sure she is not soiled and playing or digging in feces, take [R7] to activities daily as tolerated. Add to behavior management program, PRN. Attempt to keep [R7] covered, keep the privacy curtain pull, so as to protect her privacy. Explain to [R7], so that she may understand, her behavior is inappropriate. Keep [R7] clean and dry. Review of R7's progress note [Recorded as Late Entry on 02/19/23 7:00 PM] revealed, [R7] heard from nurse's station yelling at CNA and calling her N*****, get out my room. CNA stated that [R7] had BM everywhere with her brief off, when she attempted to change [R7], she became combative. During an attempted phone interview on 08/14/23 at 4:59 PM, CNA1's telephone was not in service. During an interview on 08/14/23 at 4:56 PM, CNA2 reported that CNA1 told her that R7 called her the N word and said CNA1 hit R7. During an interview on 08/14/23 at 12:30 PM, the Director of Nursing (DON) stated that R7 is not verbal and one staff told another staff member that someone had abused the resident. When that staff was asked by the police, she admitted to abusing the resident and the facility fired the CNA1. On 08/29/23 at 2:11 PM, the facility provided an acceptable IJ Removal Plan which included the following: 1. Immediate Corrective Action: On 2/20/2023 CNA#2 reported to administration that CNA#1 had stated to her R7 was being combative and calling her a n******, and she just had beat R7 a**, stated that she hit her in the face. Administration immediately began an investigation, notifying local law enforcement, medical director, resident representative, and reports submitted per state and federal regulation. The partner was also immediately placed on suspension pending investigation. The partner initially denied the allegation to administration and law enforcement, however when meeting with the responding officer CNA#2 [sic] did admit to putting her hands on the resident. CNA#2 [sic] was charged with assault battery under city ordinance and was terminated by the facility. CNA#2 [sic] was also reported to the board of certification by facility administration. R7 had a body audit conducted on 02/20/2023 and recorded in the resident record by a licensed nurse. R7 was also referred for a psych services visit, which was conducted on 02/28/2023. Social Services interviewed all resident to determine if any other residents were affected, with no negative responses. Body audits were conducted on all residents who could not be interviewed by a licensed nurse and recorded in the resident's records, with no negative findings. Education to all staff on abuse, neglect, and exploitation was initiated and completed on 02/22/2023. A meeting was held and conducted by the Administrator on 02/21/2023 regarding the event with all department managers as an Interdisciplinary team discussion. The facility's date of compliance was 02/22/2023. 2. Methods to identify any other residents who might be affected: All residing residents had the potential to be affected by the alleged deficient practice. 3. Systemic Changes: All staff received education by the Director of Health Services, Clinical Competency Coordinator and/or licensed nurse designee on resident Abuse, Neglect, and exploitation. Education was completed on 02/22/2023. The facility Administrator and/or Director of Health Services will continue to follow all state and federal guidelines regarding investigating, reporting and concluding reportable events. The facility Administrator will retain a log to record all reportable events. 4. Monitoring: The Administrator and/or Director of Health Services will present any new investigations and results of those investigations to the QAPI Committee monthly x 3 months and/or until substantial compliance achieved.

Based on interview and record review, the facility failed to provide bed hold policies to residents or representatives at time of discharge for 3 of 4 residents reviewed for hospitalization . Residents (R)27, R223, and R40 received no notification of bed hold policy at time of transfer to hospital, nor did their representatives. The findings include: R27 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident record on 10/26/21 at approximately 9:49 AM revealed R27 was transferred to the hospital on 09/23/21 related to altered mental status (AMS). Review of resident record on 10/26/21 at approximately 2:10 PM revealed there was no notification of bed hold policy to resident or representative at time of transfer to hospital. Interview with Registered Nurse (RN)1 on 10/26/21 at approximately 2:33 PM confirmed there was no notification to R27 or representative of bed hold policy at time of transfer to hospital. The facility did not routinely provide that policy at time of transfer to hospital. Review of the facility's policy titled Bed Hold Authorization Form: South Carolina dated 05/30/18, revealed any patient/resident who was transferred or discharged from the healthcare center was allowed to be readmitted , in accordance with applicable regulations, including determining that there were no medical care issues that the medical staff believed the healthcare center would not be unable to treat. Two notices related to the healthcare center's bed policy would be issued. The first notice of bed hold policy was given during admission, well in advance of any transfer. The second notice specified the duration of the bed hold policy would be issued at the time of any transfer. Review of R223's electronic medical record (EMR) Face Sheet revealed an admitted [DATE] and the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R223's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the R223 had a Brief Interview for Mental Status (BIMS) score of 00 out of 15 indicating R223 was severely cognitively impaired. Review of R223's electronic medical record (EMR) clinical record revealed R223 was transferred to the hospital on 10/15/21 and returned on 10/17/21. Further review of the R223's clinical record located in the Documents section of the EMR clinical record revealed there was no documentation that the facility provided the Ombudsman's Office with the notification of R223's discharge to the hospital. Interview with the Regional Consultant Nurse (RCN) on 10/26/21 at 02:45 PM revealed the process for when a resident goes out to hospital was that the bed hold policy was to be sent with the resident. The RCN stated the facility had not been doing that. The RCN stated that the nurses had not been sending the bed hold notification at time of discharge. The RCN continued stating the Social Worker (SW) had only sent the discharges and not the notification of the transfers to the Ombudsman's office. The facility admitted R40 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of nurse's notes, on 10/26/21 at 1:42 PM, revealed R40 was transferred to the hospital on 08/09/21, due to a suspected femur fracture. The resident was admitted to the hospital and returned to the facility on [DATE], per the nurse's notes. Further review of the notes and resident documents revealed no documentation to indicate the resident or resident representative had been provided a copy of the facility's bed hold policy at the time of the transfer. During an interview with RN1, on 10/26/21 at 2:45 PM, RN1 stated when a resident is transferred to the hospital, the bed hold policy is sent to the hospital with the resident. RN1 stated the nurses have not been doing this for all transfers and did not provide the bed hold notice to R40 or to R40's representative. Review of the facility's bed hold policy revealed a bed hold policy will be issued at the time of any transfer. The requirement is met if the resident's copy of the policy is sent with the resident to the hospital.

Based on observation, record review and interview, the facility failed to promote and maintain the dignity of Resident #11, 1 of 1 sampled residents reviewed for Dignity. Resident #11 was observed dressed in a hospital gown on multiple days of the survey. The findings included: The facility admitted Resident #11 on 7/22/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #11 was observed in bed, dressed in a hospital gown on 10/25/21 at 11:30 AM and 3:30 PM; 10/26/21 at 2:20 PM; 10/27/21 at 11:09 AM and 1:51 PM. Record review of the care plan, on 10/27/21 at 10:35 AM, revealed no documentation to indicate it was the resident's preference to spend the day dressed in a hospital gown. During an interview with Registered Nurse #1, on 10/27/21 at 3:33 PM, RN #1 confirmed the resident was dressed in a hospital gown and the care plan did not indicate this was the resident's preference. RN #1 stated the resident was a newer resident in the facility and had come from another facility. RN #1 stated the resident did not have any clothes of her/his own and that was the reason s/he had been dressed in hospital gowns. RN #1 stated the social worker is new here, but is getting the resident some clothes of her/his own today. During an interview with the Social Worker (SW), on 10/28/21 at 12:20 PM, the SW stated s/he was unaware the resident had admitted to the facility with no clothes. The SW stated s/he was not made aware of this until yesterday. Apparently, the SW stated, the resident was admitted to the facility with 1 or 2 night gowns and no other clothing. The SW stated if it is not a resident's preference to wear a gown all day, then this is a dignity concern.

Based on record review, interview and review of facility policy, the facility failed to provide transfer notices to the State Long-Term Care Ombudsman for Residents (R) 40 and R27, 2 of 4 sampled residents reviewed for hospitalization s. The residents had been transferred to the hospital and the Ombudsman was not notified. The findings included: The facility admitted R40 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of nurse's notes, on 10/26/21 at 1:42 PM, revealed R40 was transferred to the hospital on 08/09/21 due to a suspected femur fracture. The resident was admitted to the hospital and returned to the facility on [DATE], per the nurse's notes. Further review of nurse's notes and social worker notes revealed no documentation to indicate the facility sent a copy of the transfer notice to the State Long-Term Care Ombudsman. During an interview with Registered Nurse (RN)1, on 10/26/21 at 2:45 PM, RN1 stated it is facility policy to notify the Ombudsman when residents are transferred to the hospital. RN1 stated the Ombudsman was not notified of R40's transfer to the hospital. RN1 stated the facility's social worker was new to the job and was unaware the Ombudsman needed to be notified when residents were transferred to the hospital. During an interview with the Social Worker (SW) on 10/26/21 at 3:14 PM, the SW stated s/he had been sending notification to the Ombudsman only when residents were discharged from the facility. The SW stated s/he had not been sending notification to the Ombudsman when residents were transferred to the hospital. The SW stated going forward s/he would be sending a list of all transfers and discharges to the Ombudsman on a monthly basis, per facility policy. Review of the facility's Involuntary Transfers and Discharges policy revealed: Administrator/Social Worker maintain a list of patients/residents temporarily transferred on an emergency basis to an acute care facility using the Emergency Transfers Log. Fax log to the Office of the State Long-Term Care Ombudsman on a monthly basis. R27 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident record on 10/26/21 at approximately 9:49 AM revealed the resident was transferred to hospital on 09/23/21 related to altered mental status (AMS). Review of resident record on 10/26/21 at approximately 2:10 PM revealed there was no notification to the ombudsman of resident transfer to hospital. Interview with RN1 on 10/26/21 at approximately 2:33 PM confirmed there was no notification to the Ombudsman of resident transfer to hospital, nor was it facility practice to notify the ombudsman of every resident transfer to hospital.

On the days of the complaint inspection, based on record reviews, observations and the Guidelines for Determining the Need for a SCSA for Residents with Terminal Conditions CMA ' s RAI Version 3.0 Manual, chapter 2: Assessments for the RAI, page 2, the facility failed to identify a significant change in one of one resident with a significant change. Resident #2 declined in all areas of Activities of Daily Living, and had a significant weight loss but was not assessed for a significant change in his condition. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the resident's Admission and Quarterly Minimum Data Set (MDS) revealed, the Admission MDS dated [DATE] coded the resident as requiring limited assistance with walking, locomotion, dressing and hygiene. The resident was coded as requiring supervision with meals. He was coded as continent of bowel and occasional incontinence of bladder. His weight was recorded as 174 pounds. Review of Resident #2's referral admission history and physical dated 11/14/11 documented, "...73 y/o (year old) ... the general health status is good. Review of symptoms negative. VSS (vital sign), though orthostatic readings are in the 70's. Pt (patient) is alert to self only... Assessment: Pt is continuing with dementia as expected recent addition of [MEDICATION NAME]. He has become increasing difficult for family to manage at home. Pt has two respite stays during his hospice certifications. He is wandering throughout the neighborhood and is not sleeping throughout the night. It is expressed to me today that the family wishes to admit to the... for long term placement. This means they have no choice to revoke hospice as this team will not be allowed to continue care for patient in new setting..." The Quarterly MDS dated [DATE] indicated the resident declined in his activities of daily living (ADLs). He was documented as requiring extensive assistance with transfers and eating. He was coded as not ambulating, and requiring total assistance with locomotion, dressing and hygiene. His elimination was coded as incontinent of bowel and frequently incontinent of bladder. His weight was recorded as 150 pounds. Review of the Hospice Nursing Visit Record Form: 12/27/11 stated, "...frail weak, total care. Increased sleep 2nd decline..." 1/5/12 Pt with increased agitation which is relieved with transfer to geri chair and or/ repositioning. S/Sx (signs and symptoms) of decline due to decrease overall status. The resident had a significant change in his over all condition between his admission assessment and his quarterly assessment, and was not assessed for a significant change. Observation of the resident on 4/11/12 at 8 AM, revealed the resident lying in the bed in a fetal position. There was no response to his name or knocking on the door; two CNA's entered the room and were observed pulling the resident up in the bed, turning and positioning him. Review of the Guidelines for Determining the Need for a SCSA for Residents with Terminal Conditions states, "The key in determining if a SCSA is required for individuals with a terminal condition is whether or not the change in condition is an expected, well-defined part of the disease course and is consequently being addressed as part of the overall plan of care for the individual. If a terminally ill resident experiences a new onset of symptoms or a condition that is not part of the expected course of deterioration and the criteria are met for a SCSA, a SCSA assessment id required..."

On the days of the inspection survey, based on record reviews, observations, and interviews, the facility failed to revise care plans to show the actual condition for 2 of 3 residents reviewed for care plans. Residents #2 and #3's care plans did not reflect the condition of the resident. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the resident's Admission and Quarterly Minimum Data Set (MDS) revealed, the Admission MDS dated [DATE] coded the resident as requiring limited assistance with walking, locomotion, dressing and hygiene. The resident was coded as requiring supervision with meals. He was coded as continent of bowel and occasional incontinence of bladder. His weight was recorded as 174 pounds. The Quarterly MDS dated [DATE] indicated the resident had declined in his activities of daily living (ADLs). He was documented as requiring extensive assistance with transfers and eating. He was coded as not ambulating and as requiring total assistance with locomotion, dressing and hygiene. His elimination was coded as totally incontinent of bowel and frequently incontinent of bladder. His weight was recorded as 150 pounds. Review of the Physician's Telephone Orders revealed: 2/12/12 Contact Precautions/ Isolation Precautions... [MEDICATION NAME] DS two tabs by mouth twice a day times 10 days. 3/8/12 "D/C (discontinue) contact & isolation precautions. Change diet to Mech (Mechanical) Soft." Review of Nurse's Notes dated 1/10/12 at 3:00 PM stated, "NO (new order) - noted to D/C (discontinue Wandergard/Resident displays 0 (no) action r/t (related to) leaving facility. Review of the Hospice Visit of 4/5/12 and The Hospice Interdisciplinary Group Care Plan Review/Comprehensive Assessment Update dated 3/28/12, stated, "beginning to become contracted". Review of a Change of Condition Nurses Note dated 2/3/12, documented the resident had a [MEDICAL CONDITION] episode. Review of the "Plan of Care: Facility Addendum Form dated 11/18/11, from hospice, identified a problem of "Alterations in Nutritional Status Diet: Regular, Actual weight loss. The goal was to provide assistance with meals. The Goal checked was "Eat to satisfaction x (times) 5 days". Review of the care plan originally dated 11/28/11, and updated 2/20/12 revealed the facility failed to have a care plan for potential for or actual weight loss. The care plan identified as a problem Wandering with the potential for elopement. The Wandergard was discontinued on 1/10/12. On 12/23/11 a care plan for the potential for injury from falls related to the resident "falling on floor' was initiated. Review of the nurse's notes documented falls on 11/22/11, 11/27/11, 12/2/11, 12/23/11 and 1/11/12. The care plan addressed the 12/23/11 fall but failed to include the other falls or an intervention to prevent further falls. The care plan failed to address the resident's Syncopal event documented in the change of condition nurse's note dated 2/3/12. The care plan identified a problem with ADL Function that stated, "Need assistance with ADLs" failed to show the change in the resident's ability to perform ADLs. Review of the MDS dated [DATE] and 2/15/12 indicated the resident deteriorated from limited assistance to extensive/total assistance. Review of the ADL Care Plan Record, dated 11/16/11 documented the resident as continent of bowels and occasional incontinence of bladder. He was documented as receiving a Regular diet and requiring set up only with meals. Review of the Hospice Nursing Visit Record Form dated 3/8/12 stated, "Patient has been refusing to eat... Patient is having difficulty chewing on regular diet... order to be written to change diet to Mechanical Soft". Physician's Telephone Orders for 3/8/12 changed diet to Mechanical Soft. On 4/5/12 there was an order to change diet to Pureed. The ADL Care Plan dated 11/16/11 indicated Resident #2 was independent with bed mobility and independent with ambulation. Review of the MDS dated [DATE] and observations on 4/10/12 revealed the resident was not ambulatory and required total care with bed mobility. Resident #2 was observed on 4/10/12 at approximately 9:40 AM in bed with a bed alarm in place. He failed to response when he name was called. On 4/11/12 at approximately 8:00 AM the resident was observed in bed on his left side, in a fetal position with his eyes closed. There was no response to a knock on door or when his name was called. At 8:25 AM the resident was observed receiving his breakfast tray. Two Certified Nurse Aides (CNA) pulled the resident up in the bed and repositioned him; the CNAs fed the resident a pureed breakfast. In an interview with the surveyor on 4/10/12 at 3:00 PM the MDS nurses stated they were not sure why there was not a care plan for weight loss. They stated, "The nurses are responsible for making changes in the care plans". MDS nurse #1 stated, "We thought the care plan for ADLs would cover the changes." The facility admitted resident #3 with [DIAGNOSES REDACTED]. Review of the resident's care plan revealed an identified problem with Activities. One of the goals was for the resident to read lips and communicate with a communication board. One of the approaches was "give patient verbal reminders of Activity prior to start". A problem was identified for ADL Function. One of the approaches was, "Explain what you are going to do prior to start". A problem was identified that the resident was at risk for weakness and fatigue due to diagnoses. Approaches included to encourage the resident to eat all meals and encourage to take rest periods. A problem was identified as "at Risk for impaired communication related to Rarely or never understands, rarely or never able to make understood". The goal was listed, "Demonstrate ability to communicate by reading lips and using communication board". One of the approaches included; "Speak in a manner that can be understood." A problem identified as Impaired Vision, Blind, Deaf and Mute was included in the plan of care. The approaches included, "Use large- print material with patient. Inform patient of intended action/procedure". During an interview with the MDS nurses and the Director of Health Services (DHS) on 4/10/12, at 3:00 PM, they failed to know if the resident was legally blind or totally blind. They stated they thought at one time he had a communications board but did not think he could use it. The resident was observed on 4/11/12 at 8:35 AM in the dining room. The surveyor said good morning. The resident held up 10 fingers, facing the surveyor, and motioned with hands in a circular motion (gestures similar to pedaling a bicycle) and pointed at the surveyor. The resident appeared to attempt to communicate. A CNA was at the resident's side. She was unable to say what the gestures meant. On 4/11/12 at 8:35 AM, CNA #2 was interviewed regarding communicating with the resident. She stated, "I don't understand sign language. I just know he needs more food. He will start to move his chair towards the table." On 4/11/12 at 8:50 AM, CNA #1 was interviewed regarding communicating with the resident. She stated, "He uses sign language. If you stand directly in front of him it is like he can read your lips. You may have to repeat a few times... He doesn't make words, just gestures." The care plan stated that the resident was blind and deaf/mute, however, the approaches included speaking to the resident, explaining to the resident, providing large print books, a communication board and the resident reading lips. There was no mention the resident would use sign language or gestures to communicate. The staff did not know what his signs/gestures meant.

On the days of the complaint survey, based on record reviews, observations and interviews, the facility failed to provide services to ensure that a resident's abilities in activities of daily living do not diminish. Resident #2 declined following admission with no interventions to maintain or decrease the deterioration of the resident. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the resident's Admission and Quarterly Minimum Data Set (MDS) revealed the Admission MDS dated [DATE] coded the resident as requiring limited assistance with walking, locomotion, dressing and hygiene. The resident was coded as requiring supervision with meals. He was coded as continent of bowel and occasional incontinence of bladder. His weight was recorded as 174 pounds. Review of Resident #2's referral admission history and physical dated 11/14/11 documented, "...73 y/o (year old) ... the general health status is good. Review of symptoms negative. VSS (vital sign), though orthostatic readings are in the 70's. Pt (patient) is alert to self only... Assessment: Pt is continuing with dementia as expected recent addition of [MEDICATION NAME]. He has become increasing difficult for family to manage at home. Pt has two respite stays during his hospice certifications. He is wandering throughout the neighborhood and is not sleeping throughout the night. It is expressed to me today that the family wishes to admit to the... for long term placement. This means they have no choice to revoke hospice as this team will not be allowed to continue care for patient in new setting..." The Quarterly MDS dated [DATE] indicated the resident declined in his activities of daily living (ADLs). He was documented as requiring extensive assistance with transfers and eating. He was coded as not ambulating and requiring total assistance with locomotion, dressing and hygiene. His was totally incontinent of bowel and frequently incontinent of bladder. His weight was recorded as 150 pounds. Review of the Social Services Progress Notes dated 11/18/11 stated, "...admitted from home. He is alert, talkative, confused and enjoys walking." 11/22/12: "Resident does walk about the facility without purpose..." The resident was observed on 4/10 and 4/11/12 in the bed, lying in a fetal position. On 4/11/12 at 8:25 AM, he was observed repositioned in the bed totally by staff and spoonfed by the staff. At the time of the survey the resident was total care for all of his ADLs. Review of the Nurse's Notes revealed: 11/16/12 Admission nurses note stated, "Resident is alert and oriented to self and place at times. Ambulating independently. Able to relay needs but depends on staff for ADL's - bathing & assist c (with) dressings... wears pull ups for occ (occasional) incont..." 11/23/11 ...ambulating in hallway earlier in shift.... 11/27/11 "...res observed per environmental svc (service) staff laying on floor @ foot of bed... AROM (active range of motion) per resident with verbal cuing... Resident had urinated between the bed and wall but he was on the floor at foot of bed. Assisted up & to geri-chair per nse (nurse) and CNA..." 11/29/11 ...attempts to transfer without assistance. On 11/29/11 the resident was checked for incontinence of bowel and bladder. 12/2/11 Checked for incontinence of bowel and bladder 12/3/11 "Resident requires assistance with dressing & toileting. Once food tray is set up resident can feed himself... kept trying to climb out of chair." 12/4/11 "Resident requires assistance with toileting & grooming x 1. Can feed self once tray has been set up...attempted to go out of facility. Wanderguard in place. Able to make needs known..." Change of Condition Nurses Notes dated 2/3/12: "...resident slow to respond, VS (vital signs) checked within normal limits. Review of the Hospice Nurse visits, revealed: 12/22/11: Staff reports increased time in bed. Overall increase weakness. 12/27/12: Frail weak, total care patient. Increase sleep secondary to decline. 1/5/12: CNA (Certified Nursing Assistant @ SNF (skilled nursing facility) reports that pt. is sleeping more and has good (50%+) po (by mouth) intake of meals. Pt. with increased agitation, which is relieved with transfer to geri chair and/or repositioning. Signs/symptoms of decline due to decrease in overall status. 2/27/12: ...According to LTC (long term care) staff, family made aware of weight loss from November 2011 to February 2012. 3/8/12 Patient has been refusing to eat, ate about 50% and 25% of meals. Patient is having difficulty chewing on regular diet. HRN (Hospice Registered Nurse) spoke with Unit Manager order to be written to change diet to Mechanical Soft, if still having difficulty, then to pureed diet... 3/26/12 Under evidence of decline/disease progression: Continuous weight loss, ADL Dependence total... 4/5/12: Bilateral legs beginning to contract. Legs stretched out as far as possible and supported with pillows. In an interview with the surveyor on 4/11/12 at 1:45 PM the DHS (Director of Health Services) regarding the decline in Resident #2 she stated there was nothing obvious with the decline. "He didn't have a stroke or anything like that. If they (resident) are hospice we have to get hospice approval for a screen or evaluation. If hospice made a referral hospice nurse deals with the physician to change. The hospice nurse should have relayed to facility nurse. Then the facility nurse would have referred to restorative to look at him." The Restorative Nurse was interviewed on 4/11/12 at 12: 15 PM. She stated there was no referral for resident #2 regarding the decline of his ADL's or development of contractures. On 4/11/12 at 1:45 PM Resident #2's Physician was interviewed regarding the decline in the resident. The Physician stated the resident was ambulating on admission, "with assistance". He was in danger of falling. The resident was admitted on hospice. The Physician stated, "No one let me know about the contractures. There are some things that can be done." The Physician confirmed restorative could look at the resident. "The problem with therapy is everything is paid for by Hospice and they won't cover therapy. .