Every finding on record at PruittHealth- Blythewood

Based on observation, interview, and facility policy review, the facility failed to ensure commercially prepared hard-cooked eggs were not stored for use beyond their use-by-date. This deficient practice had the potential to affect all residents receiving meals from the dietary department. Findings included: Review of a facility policy titled, Label, Dating, and Storage, revised 11/11/2022, specified, 4. Food and beverage items will be discarded according to guidance from a government agency such as the United States Department of Agriculture (USDA) and Food and Drug Administration (FDA). During an initial tour of the facility's kitchen on 09/15/2025 at 9:17 AM, with the Dietary Manager present, the walk-in cooler was observed to contain a white, plastic food-grade bucket of commercially prepared, hard-cooked eggs. The front of the bucket included a 'Use By' date of 09/09/2025. During an interview on 09/15/2025 at 11:09 AM, the Dietary Manager stated that the kitchen staff were supposed to discard all food on their expiration or use-by-dates. During an interview on 09/19/2025 at 9:49 AM, the Director of Health Services (DHS) stated she expected food items to be removed and discarded after their use-by-dates.

Based on observation, interview, record review, and facility document and policy review, the facility failed to ensure wound care orders were transcribed into the electronic medical record at the time of admission for 1 (Resident (R)134) of 3 residents reviewed for wound care. This resulted in one missed wound care treatment on 09/15/2025. Findings include: Review of the facility policy titled, admission Orders, dated 09/2002, specified 5. Once all admission orders have been verified and documented appropriately, they are to be transcribed by the admitting nurse on the appropriate documents in the record (i.e. [id est, that is] MAR [Medication Administration Record], TAR [Treatment Administration Record], etc. [et cetera, other similar things]). Review of an undated facility document titled Dressing a Wound specified Check the individual's medical record for the healthcare provider's order, including the: order for the dressing change, type of dressing, frequency of dressing change, location of wound, cleansing solution, and peri wound protectant. Review of a Resident Face Sheet indicated the facility admitted R134 on 09/11/2025 with a medical history that included diagnoses of sepsis due to methicillin-resistant staphylococcus aureus (MRSA), cellulitis of the right lower limb, and type two diabetes mellitus with a foot ulcer. R134's Care Plan included a problem statement, initiated 09/11/2025, that indicated R134 had a foot infection, a right foot diabetic wound, right lower extremity cellulitis, and MRSA bacteremia. R134's facility History and Physical, dated 09/11/2025, revealed R134 had a right foot wound and required wound care twice daily, was minimal weight bearing on the right foot, and required a follow-up with orthopedic surgery and infectious disease as an outpatient. R134's Order History revealed wound care orders were not transcribed into the resident's medical record until 09/17/2025, six days after their admission. Per the Order History, an order was started on 09/17/2025 to cleanse the residents right foot with wound cleanser/normal saline, pat dry, apply topical A and D ointment to the wound bed, cover with an absorbent abdominal pad, and wrap with stretch-conforming gauze on Mondays, Wednesdays, and Fridays and as needed if the dressing became soiled or fell off. An observation on 09/16/2025 (Tuesday) at 3:52 PM revealed R134 was seated in their wheelchair with a white dressing on their right foot that was dated 09/13/2025 (the previous Friday). No outward signs of drainage were visible to the exterior of the dressing, and the dressing appeared intact. An observation on 09/17/2025 at 9:08 AM revealed a white dressing to R134's right foot dated 09/17/2025 with an outer dressing that contained no visible signs of drainage from the wound. During an interview on 09/18/2025 at 12:16 PM and a follow-up interview on 09/18/2025 at 12:37 PM, Licensed Practical Nurse (LPN)2 reported she assessed R134's foot wound on 09/12/2025 and obtained orders for wound care. LPN2 stated she documented the wound assessment and the new orders on a paper form but failed to transcribe the orders into the electronic medical record until 09/17/2025. LPN2 stated since the orders were not transcribed and accessible to facility nursing staff following their initiation on 09/12/2025, the dressing change was not completed on 09/15/2025 as ordered. During an interview on 09/18/2025 at 4:09 PM, Registered Nurse (RN)1 stated staff were to enter new orders in the electronic medical record at the time of admission, and she was not aware orders had not been transcribed for R134's wound care until 09/17/2025. During an interview on 09/19/2025 at 10:23 AM, the Director of Health Services (DHS) stated she expected R134's wound care orders to be transcribed into the electronic medical record on the date the order was obtained. During an interview on 09/19/2025 at 11:44 AM, the Administrator stated he would have expected the wound care orders to have been transcribed when they were first obtained.

Based on review of facility policy, observations, and interviews, the facility failed to ensure foods stored in the main cooler, dry storage, and the preparatory area were labeled, dated, and not expired. This failure could potentially affect all 116 residents in the facility, who consumed food from the kitchen. Findings include: Review of the facility policy titled, Labeling, Dating, and Storage with a complete revision date of [DATE], states, 4. Food and beverage items will be discarded according to guidance from a government agency such as the USD and FDA. During an observation on [DATE] at 10:35 AM, the following food items were observed in the main cooler and verified by the Certified Dietary Manager (CDM): 5 bags, unopened - NET WT 5 LBS (pounds) per bag of [NAME] Farms Shredded Carrots with Use by date [DATE]. 1 open bag of [NAME] Farms Shredded Carrots, wrapped in plastic wrap with no date or label. 1 bag Iceberg salad mix with an expiration date of [DATE]. During an observation on [DATE] at 11:00 AM, the following food items were observed in the dry storage and verified by the CDM: 1 10 lb. bag of [NAME] Macaroni Noodles wrapped in plastic wrap with no label or date. 1 box containing six (6) 66.5 OZ Empress Chunk Light Tuna with an In date of [DATE] and Out date of [DATE]. During an observation on [DATE] at 11:06 AM, the following food items were observed in the preparatory area and verified by the CDM: An observation of a 9-tier Bakery Bread Tray/Bread Rack located by the main preparatory area contained the following: On the second rack - 8 loaves of [NAME] Bread with a use-by date of [DATE]th, 2024. On the third rack - 8 loaves of [NAME] Bread with a use-by date of [DATE]th, 2024. On the fourth rack - 10 loaves of [NAME] Bread with a use-by date of [DATE]th, 2024. On the fifth rack - 10 loaves of [NAME] Bread with a use-by date of [DATE]th, 2024. On the sixth rack - 8 loaves of [NAME] Bread with a use-by date of [DATE]th, 2024. On the seventh rack - 10 loaves of [NAME] Bread with a use-by date of [DATE]th, 2024. On the eighth rack - 8 loaves of [NAME] Bread with a use-by date of [DATE]th,2024. During an interview on [DATE] at 11:18 AM, the CDM stated, As far as the cooler, dry storage, and the bread, it's everyone's job to make sure everything is done as far as checking them daily and removing the expired products, I've told them about this. During an interview on [DATE] at 1:26 PM, the Administrator states that he has been identifying concerns with the kitchen since August of 2024 while prepping for the facility's annual survey. The Administrator stated concerns were related to expired foods once he conducted an audit. The Administrator concluded that his expectation is for staff to be monitoring for expired foods and labeling open products appropriately.

Based on review of facility policy, record review and interview, the facility failed to provide Resident (R)106 ongoing activities designed to meet the resident's interests, hobbies, and cultural preferences to promote physical, mental, and psychosocial well-being for 1 of 2 residents reviewed for activities. Findings include: Review of the undated facility policy titled, Activities Program, states, The Health Care center provides an ongoing program of Activities designed to meet the physical, mental, and psychosocial well-being of each resident while offering a rich array of activities to the residents of the center. The center shall offer a variety of recreational programs to suit the interest and physical/cognitive of the residents that choose to participate. The center shall provide recreational activities that provide stimulation, promote or enhance physical, mental, and or party as well as information obtained by an initial assessment. Review of R106's Face Sheet revealed R106 was admitted to the facility on [DATE], with diagnoses including, but not limited to: depression, difficulty in walking, other encephalopathy, and vascular dementia without behavioral disturbance. Review of R106's Physician Order revealed, May have activities/social rehab as tolerated. Review of R106's Care Plan revealed, [R106] is a risk for social isolation and low activity participation related to: New Residents/Short-term residents. Resident has dementia and identifies with activities of prior lifestyle - prefers independent activities, and spending time with visitors, and loved ones. Category Activities Start Date 08/02/2024. Further review of the Care Plan revealed the following approaches, Introduce [R106] to other residents with similar interests and [R106] is to choose activities that match his interests and abilities. Review of R106's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/05/24, revealed R106 has a Brief Interview for Mental Status (BIMS) score of of 99, indicating the resident is severely cognitively impaired. Further review of the MDS revealed R106's activity pursuit and preferences; attempt to interview all residents able to communicate daily and activity preferences. Preferences on admission included but were not limited to: somewhat important to have books, newspapers, and magazines to read, somewhat important to listen to music you like, somewhat important to keep up with the news, somewhat important to do things with groups of people, somewhat important to go outside to get fresh air when the weather is good. The primary respondent noted was family or significant other. Review of R106's Activity Log with a start date of 08/02/24 revealed no activities were provided for 17 out of 31 days. September 2024 - No activities for the entire month. October 2024 - No activities were charted for 1st and 3rd. During an observation and interview on 10/01/24 at 12:48 PM, revealed R106 sitting in his non-motorized wheelchair, looking out of the window, and exhibiting tearfulness from watching residents participate in live music. R106's wife revealed she visits daily and alternates visits with the sister-in-law. She is here during the day and her sister-in-law follows up during dinner time and weekends. R106's wife states she's never seen residents participate in activities since he's been here. She states she has witnessed it daily where Certified Nurse Aides (CNAs) just skip rooms and don't ask if he would like to participate. R106's wife further states, R106 is not very vocal, neither she or her sister-in-law has seen anyone come into his room to encourage the resident to participate in anything since he was admitted in August 2024. R106's wife stated, Today there was live music, and no one came and even asked him. He gets fidgety and starts crying when staying in his room too long. Weekends are horrible, no one is here, and I don't even think activities are provided on weekends. The facility does not provide any books to read or color. R106's wife concluded, I already told the facility staff his likes and dislikes. We must bring magazines, and different things from home to keep him entertained or he will get tearful. Review of R106's medical record revealed no evidence of activity attendance sheets for one-to-one activities or any group activities. During an interview on 10/02/24 at approximately 12:00 PM, R106's wife stated her husband went out to therapy and is waiting on his return. R106's wife states since yesterday (10/01/24), he has not participated in anything other than therapy. During an observation and interview on 10/03/24 at approximately 11:00 AM, R106's sister states, His wife and I take turns with him to make sure he is not alone because it will cause him to get more depressed. I'm surprised, this is the first day since he has been here that they came into his room and asked him to go to bingo here in the courtyard. I was shocked because we had never seen them come in and ask. The only time we have seen him leave his room is for therapy. He looks so happy, and I hope they keep this up when you all leave. During an interview on 10/03/24 at 12:30 PM, the Activities Director (AD) states that typically when a resident gets admitted , her role is to follow up with them to ask for likes and dislikes, and it gets documented in the MDS. The AD states the activity for the day gets announced through morning announcements to make residents aware. The AD further states she is only one person and is dependent on the CNAs on each unit to bring the residents to activities, and is unsure of what they do, throughout all units. The AD stated, I can confirm that residents don't get pushed out like they are supposed to daily. The AD confirmed that R106 had not participated in activities for September 2024. During an interview on 10/04/24 at 1:26 PM, the Administrator revealed activities are provided for residents daily and the Activity Director along with CNAs are to visit the patient's room daily. They are to ask if they want to attend and if a resident declines, then provide alternatives. The Administrator states he was not aware of residents not being asked if they would like to participate or being brought to activities. However, the Administrator states he would follow up on the concern.

Based on observation, interview, and review of facility policy, the facility failed to offer Resident (R)59, R106, R2, and R79, [NAME] or ice in-between meals and failed to provide a minimum of 16 ounces of fluids on resident's lunch trays. Findings include: Review of the facility policy titled Hydration: Dietary Services with a revision date of 10/18/17, states, All patient/resident will be provided a minimum of 16 OZ of fluids on each meal tray unless contraindicated. Water pitchers are filled with ice/water at least, but not limited to, twice per day. Review of R59's Face Sheet revealed R59 was admitted to the facility with diagnoses including but not limited to: urinary tract infection, quadriplegia, neuromuscular dysfunction of the bladder, and bacteremia. During an observation and interview on 10/02/24 at 11:01 AM, R59 was observed asking Certified Nursing Assistant (CNA)2 for water to drink. CNA2 did not address the resident and walked out of the room. R59 then presses his call light and states that CNA2 came back to his room and says to him, You pressed your light so how can I help you? R59 is observed telling CNA2, I just need some water; I'm not feeling well. CNA2 left the room and later returned with water in a clear plastic cup. R59 states that staff does this all the time and he will often drink fluids when trays come out. R59 states, it's a constant battle with staff to bring basic needs. During an interview on 10/02/24 at approximately 11:15 AM, CNA2 states staff are doing rounds every shift once they arrive for their scheduled shift, not every two hours. CNA2 states, If a resident is on fluid restriction, then it gets monitored, other than that, we don't monitor fluids. Review of R106's Face Sheet revealed R106 was admitted to the facility with diagnoses including but not limited to: muscle weakness, other symbolic dysfunctions, difficulty in walking, and vascular dementia. During an observation and interview on 10/01/24 at 1:12 PM, revealed that R106's spouse went into her bag, took out a 16-ounce (approximately) water bottle, opened it, and poured it into the resident's stainless-steel cup. R106's spouse stated, Staff does not provide water or enough beverages throughout the day. Only on meal trays. R106's spouse further states, The resident does not need assistance to drink the fluids. I have to come in daily and I have to beg staff multiple times. I get tired of asking for basic needs and went and purchased him a stainless-steel travel cup and I come in every day to fill it up myself with water and ice. During an observation and interview on 10/02/24 at 12:30 PM, the Certified Dietary Manager (CDM) and Registered Dietician (RD) revealed dietary staff was observed putting one (1) 8-ounce fluid drink (iced tea) on all trays during the plating of meals. No water was observed on the trays. Both the CDM and RD, confirmed the residents receive 1 cup of iced tea with their lunch and dinner meals. Water is available upon request from the resident to have it added to their meal. Review of R2's Face Sheet revealed R2 was admitted to the facility with diagnoses including but not limited to: Type 2 diabetes mellitus without complications, dementia, muscle weakness, and chronic kidney disease, stage 3. During an observation on 10/04/24 at approximately 8:49 AM, CNA1 was observed pushing a hydration cart, that contained 1 red cooler of ice, and a scoop in a plastic bag. CNA1 stops in front of R2's room and walks into R2's room providing R2 with ice only. CNA1 did not offer water. Further observation revealed that R2 had no fluids at the bedside or in her room. Review of R2's Medical Record, under Vitals, from 09/01/24 through 10/03/24, revealed R2 had 0 mL of fluid consumption on 09/12/24, 09/27/24, and 10/03/24. Review of R79's Face Sheet was admitted to the facility with diagnoses including but not limited to: urinary tract infection, bacteremia, muscle weakness, and constipation. During an observation and interview on 10/01/24 at 3:44 PM, R79 had an empty water pitcher with no straw sitting on the bedside table. R79 stated he gets drinks on the trays, but it's just one drink and I don't receive fluids any other time. It's like they forget about me, trying to get their attention is horrible. I get tired of trying. During an observation and interview on 10/03/24 at 3:30 PM, revealed an empty water pitcher with no straw sitting on R79's bedside table. R79 stated his pitcher remained empty since the first observation and he had no water at all today, other than the tea for lunch. During an interview on 10/03/24 at 3:37 PM, Registered Nurse (RN) states typically resident rounding is during the beginning of the shift to her knowledge. The RN states the CNAs will pass ice that's in a cooler but has not seen the CNAs offer or pass water as far as every 2 hours or in between the meals. During an interview on 10/04/24 at 1:26 PM, the Administrator revealed that he is new to his role, and he had not been aware of the hydration concerns of the residents. The Administrator stated his expectations are to ensure residents have enough fluids throughout the day.

Based on review of facility policy, manufacturers instruction for use, observation and interview, the facility failed to ensure a medication error rate less than 5 percent. Specifically, the Humalog Kwikpen and Lantus Solostar Pen for Resident (R)44 was not properly primed prior to administration. The medication error rate was 7.14 percent for 2 of 28 opportunities for error. Findings include: Review of the facility policy titled, Medication Administration: General Guidelines revised on 04/10/19 states, Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Review of the [NAME] Lilly and Company Humalog Kwikpen, revised on 07/2023, instructions for use states,Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin . Step 6: To prime your Pen, turn the Dose Knob to select 2 units. Step 7: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 8: Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. If you do not see insulin, repeat priming steps 6 to 8, no more than 4 times. If you still do not see insulin, change the Needle and repeat priming steps 6 to 8. Review of Sanofi 2022 [NAME]-Aventis U.S LLC Lantus Solostar Pen 08/2022 instructions for use states, Step 3 Perform a safety test. Dial a test dose of 2 Units. Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero . If no insulin comes out, repeat the test 2 more times. If there is still no insulin coming out, use a new needle and do the safety test again. Always perform the safety test before each injection. Never use the pen if no insulin comes out Review of R44's Physician Orders revealed the following: Humalog [NAME] KwikPen U-100 (insulin lispro) insulin pen, half-unit; 100 unit/mL; amt: 2 units; subcutaneous with special Instructions: Give 2 units under the skin 4 times daily before meals and at bedtime Four Times A Day, and Lantus Solostar U-100 Insulin (insulin glargine) insulin pen; 100 unit/mL (3 mL); amount: 10 units; subcutaneous special Instructions: Give 10 units under the skin every morning once A Day. During an observation on 10/02/24 at 9:29 AM, revealed Licensed Practical Nurse (LPN)1 preparing to administer insulin to R44. LPN1 failed to properly prime the insulin pens before administering the units 2 units of Humalog insulin and Lantus 10 units to R44. LPN1 attempted to prime both pens with needle facing downward above trash bin next to the medication cart. During an interview on 10/02/24 at an unspecified time, LPN1 verbally repeated the steps of insulin administration. LPN1 stated check the order, review for units, check expiration date, clean the hub off, apply the needle cap and prime with two units of insulin. LPN1 revealed the expectation is to set dosage to two units, press the pen with the pen facing downward until it empties. LPN1 stated then set the dose to the order set. During an interview on 10/03/24 at 4:13 PM, the Director of Health Services (DHS) revealed staff are to review the orders, they knock and give privacy, clean site, and administer insulin per physician orders. Prior to administration the nurse should prime the needle to ensure there is no air. During an interview on 10/04/24 at 9:48 AM, the Administrator revealed prior to administration, the flex pen should be primed and primed upwards. The same as insulin in the bottle/vial it is the same to prime upwards.

Based on review of facility policy, observation, and interviews, the facility failed to ensure medications were secured and properly stored for 3 out of 21 residents, Resident (R)20, R23, R43. Findings include: Review of the facility policy titled, Medication Storage in the Healthcare Centers dated 04/09/24 states, Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those the supplier. The medication supply is accessible only to licensed nursing personnel and pharmacy personnel . 2. Only licensed nurses and the pharmacy personnel are allowed to access to medications . Medication room, carts, and medication supplies are locked or attended by persons with authorized access. Review of the facility policy titled, Medication Administration: General Guidelines revised on 04/10/19 states, 1. Medications are prepared, administered, and recorded only by licensed nursing, medical, or pharmacy personnel. 2. Medications are administered in accordance with written orders of the attending physician . 3. Patients/residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. 6. Topical medications unused in treatments are listed on the Treatment Administration Record or within the e-TAR system for facilities using electronic charting of treatments. During an observation on 10/01/24 at 1:09 PM, revealed the following on the nightstand and dresser in R20's room: 16 oz of Beta[DATE]% Lot number 2310491 with expiration date 03/2026, Biotene Dry Mouth 16oz Lot number 3H14OC expiration 07/08/2026, and Mupirocin Ointment 2% expiration 06/2025 Lot number 744123 on resident's dresser and nightstand. During an observation on 10/01/2024 at 11:12 AM, revealed the following medications on the bedside table and dresser in R23's room: two 1 oz tubes of Equate Anti-Itch Cream extra strength Lot 4ET0435 expiration date of 2026/APR, Equate Nasal Spray Oxymetazoline HCL 0.05% Nasal Decongestant 1 Fl oz Lot 4CK0912 [DATE], Azelastine HCL 0.1% nasal solution expiration date of 11/2016 Lot MD0524 30mL NDC 60505-0833-5, Visine Dry Eye Relief 15 mL Lot MFB 1X01 expiration date of 11/2024, Iodent Oral Analgesic gel Benzacaine 20% oral pain Reliever expiration date of 03/2025 LOT: ZDP2240. During an observation on 10/01/24 at 3:12 PM, revealed the following medications on the counter in R43's bathroom: one 4 oz tube of Calmoseptine Ointment lot number 2790 and a 3 oz bottle of Antifungal Powder lot number E240217. During an interview on 10/03/24 at 3:43 PM, Licensed Practical Nurse (LPN)1 revealed the only time any resident has medications at bedside is with teaching, a completed assessment form, and with a physician's order. There are to be no over the counter or prescribed medications at bedside. If the patient refuses medications, the medication should be taken out the room with the nurse. It is the same for the treatment medications cream or powder, anything from the pharmacy or with any active medications. They should be locked up and applied only by a nurse. During an interview on 10/03/24 at 4:30 PM, the Director of Health Services (DHS) revealed medications should not be at bedside or drawer. Medications should be locked and only accessible to nursing or pharmacy staff. There should only be medications in storage that are ordered and active for the patient. The DHS further stated the expectation is for nurses to scan rooms for items family could bring in to protect the patient, staff and facility with patient permission. This will help with patient safety. These items should not have been at bedside, and they were removed once notified. During an interview on 10/04/24 at 9:51 AM, the Administrator revealed medications should not be at bedside unless there is an order. The patient should be checked off if they are cognitive aware and has passed in service to administer medication. There would be an order and a care plan to review if this patient is allowed to have medication at bedside or self-administration. There is no patient at this facility that can self-administer or have OTC (over the counter) medications at bedside.

Based on observation, interviews, record review, and facility document and policy review, the facility failed to ensure an allegation of abuse was reported to the administrator of the facility and to the state survey agency within two hours for 1 (Resident (R)2) of 3 sampled residents reviewed for abuse. Specifically, on 02/14/2024, R2 reported to Licensed Practical Nurse (LPN)5 that Certified Nursing Assistant (CNA)7 was rough when providing care. LPN5 failed to notify the Administrator immediately; subsequently, the allegation was not reported to the State Agency until 02/15/2024 at 7:08 PM, the day after the incident occurred. Findings included: A review of the facility policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, revised on 07/29/2019, revealed, 1. Any allegation, suspicion, or identified occurrence is identified involving patient abuse, neglect, exploitation, mistreatment, and misappropriation of property, including injuries of an unknown source, should be immediately reported to the Administrator of the provider entity. The policy revealed, The state survey agency and the state agency for adult protective services should be notified in accordance with state law through established procedures of any allegation 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 results 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. A review of R2's Resident Face Sheet revealed the facility readmitted the resident on 06/20/2023. The Resident Face Sheet revealed the resident had diagnoses that included cognitive communication deficit, anemia, muscle weakness, difficulty walking, bone marrow transplant status, chronic pain syndrome, myelodysplastic syndrome (a group of disorders caused by blood cells that are poorly formed or do not work properly. Symptoms may include easy or unusual bruising and pinpoint-sized red spots just beneath the skin that are caused by bleeding), immunodeficiency, a disorder of iron metabolism, excoriation (skin-picking) disorder, and anxiety disorder. A review of R2's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/12/2023 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS revealed R2 had no behavioral symptoms during the assessment period. The MDS revealed R2 had no impairment in upper body range of motion but had impairment in the lower extremity on one side. The MDS revealed the resident required partial/moderate assistance with rolling left and right and was incontinent of bowel and bladder. A review of R2's Care Plan revealed a Problem area dated 06/21/2023 that indicated the resident was at risk for skin discoloration related to excoriation (skin-picking) disorder and an iron metabolism disorder. The facility developed interventions that directed staff to anticipate the resident's needs, meet activities of daily living (ADL) needs, and turn and reposition frequently during rounds and as needed. The Care Plan revealed a Problem area dated 07/03/2023 that indicated the resident had a history of osteoporosis and was at risk for injury. The Care Plan revealed a Problem area dated 07/03/2023 that indicated the resident had a risk of a decline in activities of daily living (ADL). The facility developed interventions that directed staff to provide safe positioning and transfers. During an observation on 04/15/2024 at 9:00 AM, R2 was in bed. The resident's hands and arms were observed to be largely discolored with purplish/brownish spots. The resident's skin appeared thin. During an interview on 04/15/2024 at 9:00 AM, R2 stated the CNA they had in February 2024 seemed to be rougher when turning them causing their arm to be discolored. R2 stated they had no areas of redness and their arms stayed discolored. A review of the facility's Initial Report dated 02/15/2024 revealed R2 stated during ADL care on 02/14/2024 at dinner time, CNA7 attempted to roll them over and caused discoloration to the upper left arm. The report revealed the allegation was reported to the state agency on 02/15/2024 at 6:35 PM, the day after the allegation occurred. A review of a typed statement dated 02/15/2024, signed by CNA7 revealed CNA7 provided care for R2 on 02/14/2024 and indicated she did not hurt or harm R2. The statement revealed she assisted the resident with ADL care on 02/14/2024 and changed R2 when the resident was soiled. The statement revealed the resident did not have any complaints during care but reported to the nurse that CNA7 was rough with the resident. During a phone interview on 04/15/2024 at 12:52 PM, CNA7 stated she was passing out dinner trays when R2 called her name. She stated she answered R2's call light and the resident stated they did not know why she did not know how to clean them correctly. CNA7 stated R2 told her to get out of their room. CNA7 stated she reported the incident to the nurse (LPN5), who checked on the resident. CNA7 stated R2 told the nurse that she was rough with them before dinner and asked the nurse to check their arm because she hurt their arm. CNA7 stated she had not provided care for R2 when the incident occurred because the resident had told her to leave the room. CNA7 stated the resident's skin normally appeared bruised. She stated the nurse asked the resident if they wanted her to continue to care for them, and the resident said yes. CNA7 stated that after the incident, she provided incontinence care for R2 during the night, and the resident had no concerns when she provided care. A review of electronic mail (email) sent from LPN5 to the Director of Nursing (DON) on 02/15/2024 at 7:08 PM revealed that on 02/14/2024, LPN5 was called to R2's room to look at the resident's arm for bruising. The email revealed R2 stated they felt the CNA was rough. The email revealed LPN5 informed the resident they did not see anything on their arm and was going to find another CNA to work with the resident. During a phone interview on 04/15/2024 at 2:39 PM, LPN5 stated R2 had her look for a bruise; however, she did not see anything. LPN5 stated she never saw hand marks or finger marks on R2. She stated she told R2 she could have another CNA care for them, and the resident said no. LPN5 stated she considered the incident as a bedside manner issue and possibly that the CNA had not explained care prior to rolling the resident or that the CNA possibly held the resident's arm too hard. LPN5 stated she did not report to anyone but told CNA7 to make sure she was gentle with the resident. LPN5 stated she did not think this was an abuse allegation, especially since R2 wanted to keep the CNA that night. LPN5 stated R2 had thin skin, and their skin appeared bruised at all times. During an interview on 04/15/2024 at 1:58 PM, the DON stated they learned of the incident when R2 asked her and the previous Administrator to come to their room. The DON stated R2 told her what happened and that they wanted to make a report. The DON stated the resident's concern was that the CNA handled them roughly. The DON stated the resident said the first time CNA7 came into their room, they kicked the CNA out. The DON stated then later, the resident wanted CNA7 to take care of them. The DON stated the resident's skin stayed discolored due to their diagnosis of myelodysplastic syndrome and the medications they received. The DON stated the resident had generalized discoloring; however, they had no bruises from fingerprints. The DON stated LPN5 should have reported the allegation immediately. During a follow-up interview on 04/16/2024 at 11:48 AM, the DON stated she would expect any abuse allegation or concern to be reported immediately to the abuse coordinator. During an interview on 04/16/2024 at 11:50 AM, the Administrator stated if there was suspected abuse or abuse it should be reported to the Administrator. The Administrator stated residents had a right to be protected from any type of abuse.

Based on policy review, observation, and interview, the facility failed to provide food storage in a safe and consistent manner. This had the potential to affect 107 of 114 residents who consumed food from the kitchen. Findings include: Review the of facility's policy titled, Food Ordering, Receiving, and Storage dated 08/03/17, indicated, Date all stock items with delivery date. During an observation and initial kitchen walk through with the Dietary Manager (DM) on 09/19/22 beginning at 9:00 AM, the following was observed: 1. In the dry storage area, there was a clear, opened container of peanut butter with no label indicating open date or use by date. DM stated that this item should have been labeled and dated. 2. In the dry storage area, there was a large, clear storage bin containing a bag of breadcrumbs and a bag of meal. Both had been opened and securely closed, but there were no labels on either bag indicating an open or use by date. DM stated that these items should have been labeled. 3. In the dry storage area, there were four large containers of thousand island dressing labeled 01/24/22. DM stated that the date written on the lids was the received date. DM said the kitchen is allowed to keep them for five months and then the items should be discarded. DM stated that these containers should have been discarded. 4. In the dry storage area as well as in the actual kitchen area, several containers of spices were being used and were unlabeled with no opened date. DM stated that these containers should have been labeled as well. A follow up interview with the DM on 09/19/22 at 9:30 AM confirmed the above findings.

Based on review of the facility policy, interviews, and record reviews, the facility failed to thoroughly investigate potential abuse for 2 of 2 residents (Resident (R) 65 and R110) sampled for abuse in a total sample of 30 residents. A lack of investigation has the potential to place other dependent residents at risk for neglect/abuse. Findings include: Review of the facility policy titled, Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, revised October 2020 revealed, Interviews should be conducted of all individuals who have relevant information, utilizing open-ended questions. Written signed statements from any involved parties should be obtained (and notarized, if necessary). Statements should be gathered from the following individuals: the suspect; the person(s) making accusation(s); the patient(s) involved; reliable patients who may have witnessed the incident; and any other persons who may have information. During a screening interview on 09/19/22 at 10:53 AM, when asked if anyone had abused her or if she had seen anyone be abused, R13 stated Staff hit my roommate. The staff still cares for me, but not her. Review of the quarterly Minimum Data Set (MDS) located in the electronic medical record (EMR) under the RAI tab with an Assessment Reference Date (ARD) of 06/20/22 revealed, R13 had a Brief Interview of Mental Status (BIMS) score of 8 out of 15, indicating R13 was moderately, cognitively impaired. During an interview on 09/19/22 at 10:59 AM, R65 informed the survey team that Certified Nursing Assistant (CNA) 1 hit her in the face and that she was afraid of CNA1. R65 stated CNA1 made her wash up and she did not want to wash up. R65 stated the police came to the facility and she told the police that she was afraid of CNA1. R65 stated CNA1 still worked at the facility and came into her room to help her roommate. R65 appeared despondent during this interview and stated she felt as if the facility was letting me go down because they don't believe me. Review of the Resident Face Sheet located in the electronic medical record (EMR) under the Resident tab revealed R65 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS located in the EMR under the RAI tab with an ARD of 08/09/22 revealed R65 had a BIMS score of 13 out of 15, indicating R65 was cognitively intact. During a follow-up interview on 09/20/22 at 4:00 PM, R65 stated .wished I wasn't here [at the facility] and staff doesn't believe me. R65 started crying during this interview. A review of the Initial 2/24-Hour Report, provided by the facility dated 08/02/22 was completed. This report documented, Resident [65] states that CNA [1] hit her in the face with her fist and that she hit her back. A review of the Five-Day Follow-Up Report, provided by the facility dated 08/02/22 was completed. This report documented the following: Suspended CNA, did reportable, investigation, police report. The summary of the report documented, We feel the allegation is false due to dx [diagnosis] and interviews. Review of the facility's complete investigation included the following interviews: CNA1; Licensed Practical Nurse (LPN)1; R95, BIMS score of 9, indicative of moderate cognitive impairment; R75, BIMS score of 3, indicative of sever cognitive impairment. The investigation did not include interviews with R65 or R65's roommate, R13. During an interview on 09/20/22 at 8:48 AM, when asked about the incident that occurred on 08/02/22, CNA1 stated, Went to get ready for breakfast. She [R65] asked me to change her so was going to go ahead and wash her up, but she didn't want me to wash her up. I changed her brief and decided to wash her up anyway. Then she started to fight me. She grabbed the bed sheet and my fingers at the same time. I moved my hand from her hand got the nurse. During an interview on 09/20/22 at 9:45 AM, LPN1 stated she was not in the room when the incident occurred but entered the room after the incident and encouraged R65 to get into her wheelchair to start her day. LPN1 stated when she went into the room, R65 had already been bathed by CNA1 and was R65 was stating, You see how she is treating me? LPN1 stated the roommate, R13, was in the room at the time of the incident. During a follow up interview on 09/20/22 at 10:36 AM, CNA1 stated R13 was in the room at the time of the incident. During an interview on 09/20/22 at 10:38 AM, the Social Services Director (SSD) stated the Administrator informed her of the incident. The SSD stated she assessed to see if R65 had distress or bruising. The SSD stated R65 did not have any bruising or distress. During an interview on 09/20/22 at 10:42 AM, the Activities Director (AD) stated when she went to visit R65 on the morning of 08/02/22, R65 reported that CNA1 slapped her. The AD stated she immediately reported the incident to the SSD. During an interview on 09/20/22 at 10:54 AM, Registered Nurse (RN)1 stated she was informed of the incident by the team and R65's Responsible Party (RP). RN1 stated the Administrator was already aware of the incident by the time that she was informed. RN1 stated the normal procedure when there was an allegation of abuse notify abuse coordinator, assess the patient, get a statement from resident, get staff statement, and ask staff to work in a different area while the investigation is going on. During an interview on 09/20/22 at 11:05 AM, R65's RP (RP65) stated R65 told her that CNA1 tried to give her a bath and she did not want one so R65 yanked the covers and CNA1 hit her in the face. During an interview on 09/21/22 at 1:30 PM, the Administrator stated he had provided the survey team with R65's complete investigation. The Administrator stated the roommate, R13, had not been interviewed because he was told that she was not in the room. The Administrator stated he did not interview R65 because she had given a statement to the AD. The Administrator stated the investigation could have been better and he would do better in future investigations. 2. Review of the facility investigation for R110 revealed, on 08/01/22, R110's family member alleged that R110 was possibly neglected and/or abused by facility staff. The investigation revealed the allegation was advised to the State Agency on 08/01/22 at 2:21 PM (an attempt at 1:02 PM failed due to a busy signal, according to the fax sheet) and that the allegation was made at 12:30 PM. Review of R110's MDS history showed an entry MDS with an ARD of 07/29/22 and a discharge MDS with an ARD of 08/03/22 showed R110 had a BIMS score of 15 out of 15, indicative of being cognitively intact. Review of the facility census for R110's hall on 08/01/22 showed 18 residents, the 08/02/22 census showed 20 residents. Review of the facility five-day investigation report sent to the State Agency on 08/05/22 at 11:55 AM according to the confirmation email, showed one Licensed Practical Nurse was interviewed on 08/01/22, three middle management staff members were interviewed on 08/05/22, along with two residents on 08/05/22. R110 was not interviewed. One of the two resident interviews completed for the investigation was the roommate of R110. According to the electronic medical records Census subtab, R110 discharged at 4:45 PM on 08/03/22 and the interviewed roommate admitted at 12:09 PM on 08/03/22; two days after the allegations were made. During an interview on 09/20/22 at 1:45 PM, the Administrator responded to the query regarding why R110 was not interviewed stating, The resident discharged before I had a chance to talk with her. I have called but the family or resident has not returned my call. When asked if allegation was made on 08/01/22 and R110 discharged on [DATE] if he could have spoken with R110, the Administrator stated, By the time I was ready to talk to the resident she had discharged . Review of the FRI investigation did not reveal any documented attempts to contact R110 or RP110 after the discharge. During a follow-up interview on 09/21/22 at 2:55 PM, the Administrator stated RP110 was not specific, more generalized in that she thought maybe R110 was being neglected or abused; I reviewed the [EMR] Progress Notes and talked to staff and the resident didn't verbalize any complaints. I opened a reportable and when I went to close the reportable, she had been discharged . So, I finished [the investigation] by interviewing staff and patients in the general area. When asked why those two residents were interviewed, the Administrator stated I usually do two or three resident interviews. When the query was clarified, were those two residents cared for by the same staff as R110, the Administrator stated, Oh, I see. but was not definitive.

Based on review of facility policy, record review, and interviews, the facility failed to provide care and services to maintain nutritional status and prevent weight loss for 1 resident (R)413, of 30 sampled residents. Specifically, the facility failed to follow their policy to obtain an admission weight for R413. R413 had significant weight loss and new nutritional interventions were not implemented to prevent additional weight loss. Findings include: Review of the facility's policy Weight Monitoring Program dated 06/13/18 revealed It is the policy . for each patient/resident to be weighed once a month unless ordered by the physician or contraindicated by patient/resident's medical condition. The Weight Team will review patient/resident weights on a monthly basis to determine risk of weight loss or weight gain. In a phone interview with the Resident's Representative (RR) (Family Member (F) 413) on 09/21/22 at 4:15 PM, F413 stated that R413 went from 118 lbs from entry date of 07/11/22 to 98 lbs on discharge date of [DATE]. F413 stated that R413 was unable to feed herself and staff were aware of this because F413 noted needs assistance with eating written on R413's daily meal ticket placed on her serving tray to remind staff to assist her. F413 said sometimes staff assisted the resident and sometimes they told her they will come back and help after meals got delivered and that sometimes took up to an hour and a half. F413 said she came to visit R413 one day and R413 was crying, and food was all over the resident and the floor because no staff assisted R413 to eat and she was hungry. F413 said the week before discharge, R413 called her crying at 4:00 PM because she was hungry and had not received lunch yet. R413's 07/14/22 admission Minimum Data Set (MDS) assessment indicated that R413 was admitted on [DATE] with active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed R413 had a Brief Interview for Mental Status score of 14 out of 15 indicating intact cognition and R413's weight upon entry was 117 pounds (lbs). R413 discharged from the facility on 09/16/22. R413's Initial Nutrition Assessment found in the resident's electronic medical record (EMR) completed on 07/14/22 indicated the following: R413 receives a no fried food diet r/t [related to] dx [diagnosis] HLD [[CONDITION(S)]]. She was admitted with [CONDITION(S)] [urinary tract infection] and weakness. She is consuming 50% or less of meals and refuses Ensure. Agrees to Ensure Clear 1 x [time] day. Receives [MEDICATION(S)]. At risk for malnutrition r/t [related to] inadequate energy intake, dx [diagnosis] AFTT [adult failure to thrive] and dementia requiring a therapeutic diet. At risk for dehydration r/t [related to] diuretic use. There were no other nutrition assessments or dietitian notes found in R413's EMR. R413's Care Plan, located in the resident's EMR under the RAI tab (Resident Assessment Instrument) dated 07/14/22, documented R413 is malnourished r/t [related to] inadequate energy intake, dx [diagnosis] AFTT [adult failure to thrive] and dementia requiring a therapeutic diet. The Care Plan also documented that resident requires assistance for eating meals (must be fed per staff). Review of R413's EMR under the Vital Signs Weight section included the following weights: 08/08/22: 102.2 lbs (a severe weight loss of 12.6% from R413's admission weight), 08/15/22: 103 lbs, 08/26/22: 98 lbs (a significant weight loss of 4.9% in one week), 09/15/22: 99 lbs. In the electronic medical record (EMR) under Physicians Orders, a nutritional milkshake was ordered on 07/26/22. There were no other nutritional interventions in the orders. In the EMR under Progress Notes on 08/10/22, the IDT team first noted poor dietary intake. Supplements offered after R413's weight was taken for the first time on 08/08/22 and was documented in Vital Signs Weight to be 102.2 lbs. There were no new nutrition interventions implemented at that time. In the EMR under Progress Notes dated 08/24/22 at 2:58 PM indicated IDT meeting: continues weight loss. Resident has poor intake. Refuses most meals. Staff assists with meals. Daughter provides premier shakes. Resident often refuses. There were no new interventions implemented at that time. In a telephone interview with the Registered Dietitian (RD) on 09/21/22 at 5:01 PM regarding the weight loss concern, RD stated that the weight of 117 lbs noted on the hospital's discharge summary was used as the admission weight for the initial dietary assessment even though I expect staff to weigh the new admissions and get their weight within the first 72 hours and then at least monthly. RD stated staff did not weigh R413, even though that was the expectation. Per RD's review of R413's EMR, RD confirmed that the resident's first weight taken by the facility was documented to be on 08/08/22 and R413 weighed 102 lbs at that time. RD stated that R413 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . RD stated that the only supplement that the resident would drink was the shake offered by the resident's daughter. RD stated that R413 refused all supplements that the facility offered. RD also stated that the facility only offered Ensure Clear to the resident because the other supplements they have were milk based and the resident refused them. RD stated they did offer R413 a nutritional milkshake at lunch time per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked how RD could know for sure without having an accurate admission weight taken by staff, RD stated, we can't know the resident didn't lose weight in the facility. RD stated that a Significant Change assessment was completed for the resident on 08/22/22 and the facility was offering supplements, honoring resident's food preference, and offering alternates. RD stated that they did not try any other changes to R413's diet at that time due to resident's refusals and the fact that she would only drink the shakes that the daughter brought in. During an interview on 09/21/22 at 5:20 PM, the Director of Nursing (DON) and the facility's Nurse Consultant (NC), DON stated the expectation was that weights are to be taken within one hour of admissions by the Admissions Nurse (AN) or a Certified Nursing Assistant (CNA) on duty. When asked to show documentation of R413's weight being noted upon admission by the facility, DON and NC were unable to find this information in the resident's EMR. Both agreed that the only weight documented was from the hospital discharge summary. While reviewing the policy Weight Monitoring Program, DON and NC said, per policy, it does not specify where the admission weight has to come from even though DON previously stated it is expected to be taken by facility staff within one hour of admission. DON provided a printed meal intake report for R413 from 07/11/22 admitted through 09/16/22 discharge date . The copy showed that no documentation of meal intakes were completed for R413 until 08/22/22, which indicated almost an entire month had lapsed with no staff documenting the resident's intake. When asked if DON thought expectations and policies were followed for this resident, DON stated they should have taken another weight in July. DON was then asked to provide the policy was on meal intake. DON stated there was no specific policy but it would be nice if staff would document meal intake daily, but it's not required unless ordered by a physician.

Based on observation, interview, record review, and facility policy review, the facility failed to follow the menu by failing to provide a substitution of equally nutritive value for 1 of 1 resident (R)38 reviewed for following menus in a total sample of 30 residents. Findings include: During an observation on 09/20/22 at 12:54 PM, R38 was observed being assisted to eat his lunch meal. During this observation, R38's lunch meal tray included cabbage, stewed tomatoes, rice, cornbread, and sweet tea. Review of R38's lunch meal ticket dated 09/20/22 included the following items: veggie burger, scalloped potatoes, sauteed cabbage, cornbread, sweet tea, canned fruit, fortified juice, and cranberry juice. During an observation on 09/20/22 at 6:06 PM, R38 was observed eating dinner. During this observation, R38's dinner meal tray included noodles, corn, sweet peas, banana pudding, and sweet tea. Review of R38's dinner meal ticket dated 09/20/22 included the following items: veggie burger, buttered parslied noodles, whole kernel corn, dinner roll, diet banana pudding, iced sweet tea, canned fruit, canned fruit, orange juice, and fortified juice Review of the Resident Face Sheet located in the electronic medical record (EMR) under the Resident tab revealed R38 was admitted to the facility on [DATE] with diagnoses that included but were not limited to anorexia, acute kidney failure, and diabetes. Review of the annual Minimum Data Set (MDS) located in the EMR under the RAI tab with an Assessment Reference Date (ARD) of 07/11/22 revealed, R38's Brief Interview of Mental Status (BIMS) score could not be assessed due to resident rarely understood. The survey team attempted to interview R38, but unable to complete due the language barrier. A review of R38's Orders located in the EMR under the Resident tab revealed the following order, dated 11/30/21, indicated, CCHO [consistent carbohydrate]/Liberalized Diabetic Special Instructions: VEGAN Fortified juice all meals. A review of R38's Care Plan dated 07/28/22 located in the EMR under the RAI tab, revealed the following: .is Malnourished r/t [related to] poor meal intake with increased nutrient needs, receiving a therapeutic diet and limited ability to communicate food preferences r/t language barrier: Hindu faith. BMI [body mass index] in underweight range. During an interview on 09/21/22 at 11:35 AM, the Certified Dietary Manager (CDM) stated, We did not have veggie burgers on yesterday, so we just gave him veggies. The CDM stated she did not contact the Registered Dietitian (RD) to approve the substitution. The CDM stated, I just mark out the item and write on the log what I substituted. When asked for a copy of the CDM's marked up log, the CDM stated she had not written the menu substitutions in the log. Additionally, the CDM stated that R38 was the only vegan in the facility and was unable to state the length of time that the facility had not had vegetarian burgers in stock. During an interview on 09/21/22 at 1:02 PM, the RD stated she was not informed that the facility did not have vegetarian burgers in stock. The RD stated she expected to be informed when a menu item was not in stock. Additionally, the RD stated the CDM can make substitution for vegetable to vegetable and fruit to fruit without approval. The RD stated the CDM should have received her approval for the vegetarian burger substitution. The RD stated a vegetable was not an appropriate substitute for the vegetarian burger. The RD stated a substitution of similar nutritive value would have been dried beans or legumes. During an interview on 9/21/22 at 6:05 PM, the Administrator There is no substitution policy. For substitutions they use the log and make sure they have approval by the RD and me and then let the resident know about the change. When asked if he was aware that the CDM was substituting menu items without approval, he stated Usually the CDM and RD communicate but if that's what they told you, I trust that.

Based on facility policy review, observations, record review, and interview, the facility failed to accommodate a resident's dietary preferences for 1 of 1 resident (R)38, reviewed for food preferences in a total sample of 30 residents. The facility served R38 foods that were not part of his religious dietary preference. This deficient practice could result in reduced consumption for R38. Findings include: Review of the facility policy titled, Nutritional Screening and Assessment/Food Preferences, reviewed January 2021 revealed, Patient/resident food preferences and choices will be honored within reason according to the patient/resident's diet order and menu selections available. During an observation on 09/20/22 at 9:08 AM, R38's breakfast meal tray was observed to have the following items: scrambled eggs, a slice of toast, a sausage link, grits, skim milk, apple juice, coffee, and Nepro (a commercial nutritional shake). Review of R38's breakfast meal ticket dated 09/20/22 included but not limited to the following items: apple juice, fortified juice, buttered grits, toast, skim milk, coffee, and canned fruit. The sausage link and the scrambled eggs was not listed on the meal ticket. During three additional meal observations on 09/20/22 at 12:54 PM, 09/20/22 at 6:06 PM, 09/21/22 at 9:07 AM, R38 did not receive his ordered fortified juice. The fortified juice was listed on the meal tickets. Review of the Resident Face Sheet located in the electronic medical record (EMR) under the Resident tab revealed R38 was admitted to the facility on [DATE] with diagnoses that included but were not limited to anorexia (loss of appetite), acute kidney failure, and diabetes. Review of the annual Minimum Data Set (MDS) located in the EMR under the RAI tab with an Assessment Reference Date (ARD) of 07/11/22 revealed, R38's Brief Interview of Mental Status (BIMS) score could not be assessed due to resident rarely understood. The survey team attempted to interview R38, but unable to complete due the language barrier. A review of R38's Orders located in the EMR under the Resident tab revealed the following order, dated 11/30/21, indicated, CCHO [consistent carbohydrate]/Liberalized Diabetic Special Instructions: VEGAN Fortified juice all meals. A review of R38's Care Plan dated 07/28/22 located in the EMR under the RAI tab, revealed the following: .is Malnourished r/t [related to] poor meal intake with increased nutrient needs, receiving a therapeutic diet and limited ability to communicate food preferences r/t language barrier: Hindu faith. BMI in underweight range. Further review of the Care Plan revealed the following interventions: Provided Vegan diet per Resident perferences [sic], (No fish, Meat, Eggs,). During an interview on 09/21/22 at 9:16 AM, Certified Nursing Assistant (CNA)5 stated she had been R38's CNA for the past three weeks. CNA5 stated, If he likes his meal, he will eat 100%. He loves oatmeal and so he always eats 100% of that. He also likes anything sweet so he will eat 100% of that also. I attempted to feed him breakfast yesterday, but he wouldn't eat. He tried a small spoonful of grits but didn't like. There was sausage on his plate, and he is a vegetarian. Whenever there is meat on his plate, I don't give it to him. CNA5 stated R38 had eggs on his plate but did not eat them. During an interview on 09/21/22 at 11:35 AM, the Certified Dietary Manager (CDM) stated, there is one dietary staff that reads the meal ticket and the other dietary staff that plates the food items. When informing the CDM R38 had scrambled eggs and sausage on his breakfast tray but those items are were not on the meal ticket, the CDM was unable to state how those items were added to R38's tray. The CDM stated that R38 was Vegan and did not eat meat or eggs and stated those items were not to be served to the resident. The CDM was also unable to state why R38 did not receive the ordered fortified juice. During an interview on 09/21/22 at 1:02 PM, the RD stated R38 does not eat meat or eggs due to being a Vegan. The RD stated she expected the staff to follow R38's meal ticket as written. The RD stated fortified juice is juice based but added but has added protein. The RD stated the fortified juice was added to help with R38's needed nutrition.

Based on observation, interview, record review, policy review, and review of Centers for Disease Control and Prevention (CDC) recommendations, the facility failed to ensure appropriate personal protective equipment (PPE) was worn into quarantine/isolation resident rooms by two facility contracted staff. This failure had the potential to spread infectious organisms throughout the facility to the 114 current residents and any staff working. Findings include: Review of the CDC's webpage Infection Control Recommendations, updated 02/02/22 revealed HCP [health care professionals] who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html. Review of the facility policy titled COVID-19 Isolation and Cohorting [sic] Process, revised 07/27/22, revealed: .II. Level I and Level II area/Room: 1. Healthcare centers that admit residents who are confirmed COVID-19 positive, have residents confirmed positive or exposed, and/or admit residents not Up to Date with COVID vaccination and require quarantine will be cohort [sic] residents based on Positive or PUI [person under investigation] status. 2. Entering or exiting Level I or II area room: .3) When ENTERING the Level I or II area/room, you must make sure you have the proper PPE on. The proper PPE are N95 Mask and Eye Protection. 4) Multiple isolation carts will be placed throughout the unit either outside the door of the resident's room or adjacent to the room to accommodate easy access to proper PPE. a) N95 masks will be used throughout the levels I and II (extended use) . b) Eye protection will be removed after leaving the resident's room and cleaned with disinfectant wipes or discarded. c) Gown and gloves are donned outside the doorway of the resident room where care will be provided. d) Gown will be changed between rooms. e) Gloves will be changed between residents. Review of the Centers for Disease Control and Prevention (CDC) COVID Data Tracker website, https://covid.cdc.gov/covid-data-tracker/#datatracker-home, revealed the Community Transmission Level for the county was High on 09/19/22. During the entrance conference on 09/19/22 at 9:11 AM, the Director of Nursing (DON) stated there was one COVID positive resident on the 100 hall and the 100 hall was a combination of all levels. The levels were clarified as Level 1 was a COVID positive patient on isolation, Level 2 was a person under investigation for COVID or on quarantine, and Level 3 had no precautions. During observation of the 100 hall on 09/19/22 at 11:52 AM, a sign showing Level 2 with an arrow on both sides of the hall pointed to rooms [ROOM NUMBERS], no PPE was located outside of the rooms. During an interview at that time, the Admissions Coordinator (Admissions 1) stated the rooms were on quarantine and was not sure why nothing [no PPE] was by the door. During a follow-up observation and interview on 09/19/22 at 3:00 PM, rooms [ROOM NUMBERS] now had PPE by the doors and Licensed Practical Nurse (LPN)2 confirmed those rooms and all rooms to the double doors were on quarantine or isolation status. During observation on the quarantine/isolation section of the 100 hall on 09/20/22 at 9:37 AM, the Nurse Practitioner (NP) was observed with a rolling business case exiting R112's room (a level two room), asked hall staff a question and was directed to/went to the 200 hall with the rolling case. At 9:40 AM Physical Therapy Assistant (PTA) was observed entering R113's room with facemask and face shield, but without a gown. At 9:41 AM, a Housekeeper (HSK) was in the hall and also observed the Physical Therapy Assistant (PTA). Signs on the doors of R112's and R113's rooms (all isolation/quarantine rooms) stated: Special Contact/Droplet Precautions All Healthcare Personnel must: Clean hands before entering and when leaving room. Wear a gown when entering room and remove before leaving. Wear N95 or higher level respirator before entering the room and remove after exiting. Protective eyewear (face shield or goggles) Wear gloves when entering the room and remove before leaving. On 09/20/22 at 9:43 AM, NP was observed entering R263's room without PPE of gown and gloves, and with the rolling bag. The NP was wearing a facemask and face shield. A Level 2 sign was hanging in plain sight outside of R263's room. A sign on top of night stand/bedside table stocked with PPE outside Level 2 rooms had sign sitting on the top of the table that stated: Warning: Isolation/Quarantine Area High Risk of COVID-19 Transmission with icons showing an KN95 mask, Gloves, Gown, and Face Shield, Appropriate PPE Required Review of R112's Continuing Care Document [CCD], from the electronic medical record (EMR) Resident tab, showed a facility admitted [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R113's CCD, from the EMR Resident tab, showed a facility admitted [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R263's CCD, from the EMR Resident tab, showed a facility admitted [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on the Level 2 hall on 09/20/22 at 9:52 AM, the Infection Preventionist (IP) confirmed all rooms were for new admits (PUI) rooms and required full PPE (gloves, gown, facemask, face shield). At 9:57 AM, the NP was observed exiting R263's room with the rolling case and was asked if she was aware of the PPE requirement, the NP responded, I'm aware of the face shield and facemask, but I wasn't aware of the gown and glove requirement. In a follow-up interview at 10:01 AM, the NP explained going down to the 200 hall (a level 3 area) and clarified she did not enter any rooms. On 09/20/22 at 10:09 AM, the PTA and was asked about the PPE requirement. The PTA stated, Yes ma'am, I was just in doing an interview. Unless I physically touch them and move them around, no gown is required. I wash my hands in the room and put on gloves. The PTA confirmed a gown was not required in a Level 2 room for interviews of residents on quarantine. In an interview on 09/21/22 at 3:10 PM, the Administrator expressed an expectation that the NP, PTA, any contract staff would follow transmission-based precautions/PPE requirements. During an interview on 09/21/22 at 3:42 PM regarding equipment between quarantine/isolation rooms, the IP stated The policy we follow, not sure it's in writing, the equipment is to be cleaned with wipes [retrieved a canister of Force Disinfectant Wipes] before it goes into another room. The NP should not have taken her bag into other rooms. The IP confirmed the NP and PTA should have been in full PPE and that they were contract staff not employees.

Based on review of the facility policy, record review, and staff interviews, the facility failed to ensure residents medical records were complete and accurate for 1 of 5 sample residents reviewed. Resident (R) 2 had several blanks on her Medication Administration Records (MARs). This failure had the potential to affect the resident's quality of care/treatment by not receiving physician ordered medications. Findings include: Review of the facility policy titled, Medication Administration: General Guidelines revealed Procedure: 9 At the end of each medication pass, the person administering the medications reviews the paper MAR or the electronic version of e-Mar to ascertain that all necessary doses were administered, and all administered doses were documented. 11 . After medication administration for facilities utilizing electronic MAR, the patient/resident's e-MAR is electronically signed off. The facility admitted R2 from the hospital on 03/30/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 04/01/22 revealed R2 had a Brief Interview of Mental Status (BIMS) score of 10 out of 15, indicating R2 had moderate cognitive impairment. On 04/11/22 at 1:37 PM, review of R2's physician orders revealed physician orders for the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 1000 mcg oral capsule for Vitamin B12 deficiency order dated 03/31/22. [MEDICATION(S)] 40 mg oral tablet for fluid retention order dated 03/31/22. [MEDICATION(S)] 5 mg oral tablet for [CONDITION(S)] (hypertension) order dated 03/31/22. [MEDICATION(S)] 150mg/ml for DVT dated 04/01/22. On 04/11/22 at 3:15 PM, review of R2's Medication Administration Record revealed the following: [MEDICATION(S)] tablet was not documented as administered on 04/01/22 and 04/02/22 for the 9:00 AM administration. [MEDICATION(S)] oral tablet was not documented as administered on 04/01/22 and 04/02/22 for the 9:00 AM administration. [MEDICATION(S)] ([MEDICATION(S)]) was not documented as administered on 04/02/22 for the 9:00 AM administration. [MEDICATION(S)] ([MEDICATION(S)]) was not documented on 04/01/22 and 04/02/22 for the 9:00 AM administration. Further review of the MAR revealed no documentation indicating whether the medications were refused by R2. On 04/11/22 at 3:45 PM, review of R2's progress notes revealed no documentation indicating R2 refused medications during her stay. Further review of the progress notes revealed R2 was discharged to the hospital on 04/04/22. A telephone interview on 04/11/22 at 11:45 AM with R2's representative (RP) revealed she had concerns with the resident's stay at the facility. The RP stated the resident had been discharged from the facility on 04/04/22 after she was admitted to the hospital. RP stated she had concerns with the medications not being administered, showers not being given, and with wound care. The RP further stated that call lights were not being answered timely while she was present in the building. An interview on 04/12/22 at 1:39 PM with Licensed Practical Nurse (LPN)1 revealed medications must be administered per physician orders 1 hour before and 1 hour after administration time. LPN1 stated that if a resident refuses medication, it is documented in Matrix care and progress notes. LPN1 stated refusals will be indicated on the MAR and the reasons/comments section will include why the medication was refused. LPN1 further stated that if residents refuse medications, they are to notify the physician and resident representative. An interview on 04/12/22 at 1:51 PM with LPN2 revealed there should not be any blanks on resident's MAR. LPN2 stated that nurses are to review MAR at the end of their shift for holes. LPN2 stated that if residents refuse medication, it would documented as not given and nurses will have an option in Matrix care to select the reasoning for refusals. LPN2 stated everything is documented on the MAR whether a medication has been given/refused. LPN2 stated that if a resident is not in the facility, it would be documented on the MAR. During the complaint survey, the Director of Nursing (DON) was unavailable for interview. An interview on 04/12/22 at 3:30 PM with the Administrator revealed there should not be any blanks on the MAR. The Administrator stated that it is his expectation the nurses will check each resident's MAR at the end of each shift to ensure there are no blanks with medication administration.

Review of Resident #10's medication administration history 05/01/21 to 05/31/21 on 07/08/21 at 2:15 pm revealed incomplete documentation of the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 37's medication administration history 04/01/21 to 04/30/21 on 07/08/21 at 2:45 pm revealed incomplete documentation of the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . Subsequent review of Resident 37's medication history 05/01/21 to 05/31/21 on 07/08/21 at 3:15 pm revealed incomplete documentation of the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . On 07/08/21 at 4:10 pm interview with registered nurse #3 revealed unable to explain why the medications were not documented.

Based on observations and interviews, the facility failed to provide a privacy bag for 1 out of 1 resident reviewed for catheters. Findings Include: Resident #392 was admitted to the facility on [DATE] with the diagnoses including but not limited to: Pyelonephritis, [CONDITION(S)] and Anxiety Disorder. Observations of Resident #392 revealed on 07/06/21 at 03:38 PM, s/he was observed in the hallway with his/her catheter bag exposed, full of urine with no privacy bag in place. Additional observations on 07/07/21 at 11:45 a.m. revealed Resident #392 in the hall sitting in his/her wheelchair with catheter bag fully visible and filled with urine. This surveyor then asked the Resident was his/her bag ever covered, in which Resident #392 stated no. During an interview on 07/07/2021 at 11:52 am with the Unit Manager, s/he stated catheter bags should be covered with a privacy bag. S/he then went on to confirm that Resident #392's was exposed. During an observation of Resident #392 on 07/08/21 at 9:51 am, s/he was once again observed with his/her catheter bag exposed without a privacy bag. Resident #392 then stated s/he does not like having everyone see his/her urine in their bag. During this observation, Certified Nursing Assistant (CNA) #1 was also present in the room. CNA #1 was asked about the usage of a privacy bag for the catheter and replied, I did not know s/he was supposed to have a privacy bag, but the nurse did tell me to put a privacy bag on the catheter.

Based on interview, record review, and review of facility policy and procedure, the facility failed to prepare an interdisciplinary comprehensive assessment and complete a quarterly comprehensive assessment for one (Resident #20) of two resident charts reviewed. The findings include: The facility admitted Resident #20 with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 07/06/21 at 11:07 am interview with Resident #20 revealed they have not been including his/her or his/her family member in the care plan meetings. Review of the care plan dated 03/03/21 revealed the comprehensive care plan was signed by the Registered Nurse, Resident Activity Director, and the Kitchen Manager only. Further review of the chart revealed no documentation of the 06/01/21 care plan. On 07/07/2021 at 1:26 pm, an interview with Registered Nurse #6 revealed the care plan for 06/01/21 was not completed, this was an oversight. We are running behind. The facility's policy dated 12/31/1996 addressing Care Plans Definitions: Interdiciplinary Team (IDT): The Interdisciplinary Team members includes a Registered Nurse, LPN (licensed practical nurse) Charge Nurse, CNA (certified nursing assistant), Social Worker, Activity Director, Dietary Manager, Registered Dietician, Skilled Therapist, Hospice partner, and other appropriate partner as determined by the patient/resident's needs 6. If the patient and representative participated in the Post Admission Care Conference, follow the below bullet points A designated member of the IDT will follow up with patient and representative to review those changes. The form should be printed and signed by the IDT member and the patient/representative. A copy of the signed (Multidisciplinary Care Conference Form) should be provided to patient and or representative and original filed in medical record 1. Comprehensive care plans should be reviewed not less than quarterly according to the OBRA (Omnibus Budget Reconciliation Act) MDS (Minimum Data Set) schedule, following the completion of the assessment .

Based on observation, interview, and review of resident care plan, the facility failed to ensure that one (Resident #20) of four residents received an ongoing program of activities to meet the individual needs and interests, which had the potential to negatively affect the well-being of the resident. The findings included: On 07/06/21 at 10:57 am, an observation of Resident #20 revealed the resident laying in bed on his/her back watching television. At 2:51 pm on 7/6/2021, the resident was awake and laying on his/her back watching television. In an interview with him/her on 7/6/2021 at 2:53 pm, Resident #20 stated no activities were being offered this afternoon. At 4:16 pm on 7/6/21, the resident was again observed laying in bed on his/her back with no activities, still watching television. Interview with Resident #20 revealed the resident stated when I first came here but not anymore. I don't know why it stopped. The last activity calendar I got was in May. Subsequent observations of Resident #20 at 11:35 am on 07/07/21 revealed s/he was laying in bed watching television. Resident stated no activities have been offered today. At 1:33 pm, resident was once again observed laying in bed watching television. Resident stated that no activities have been offered. S/he then stated they don't come around and see if you want to do anything. At 2:25 pm, the resident was observed laying in bed with no activities observed. On 07/07/21 at 11:45 am, an interview with Resident Activities Director revealed that I have only been here since the end of June. The activity calendar for July is awaiting for it to come from the print shop. On 07/08/21 at 12:05 pm, an interview with Licensed Practical Nurse #2 revealed the resident watches TV and will get activities when out of the bed. I don't have anything for him/her for activities. Review of Resident #20's 03/03/21 care plan denoted At risk for activities decline r/t (related to) his/her hx (history) of stroke with right side [CONDITION(S)], Goal: Will express satisfaction with quality and quantity of activities with modifications as needed Approach: Adjust the intensity of activities to accommodate energy level and tolerance and right side [CONDITION(S)] .

Based on record review, interview and review of facility policy, the facility failed to follow up on lab work in a timely manner for Resident #391, 1 of 1 sampled residents reviewed for Labs. The facility did not follow up on a urinalysis until 8 days after the results were available. The findings included: The facility admitted resident #391 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Lab Reports, on 7/7/21 at 11:40 AM, revealed urinalysis results, dated 5/18/21, indicating Resident #391 had a urinary tract infection (UTI). A handwritten note on the report indicated treatment did not begin until 5/26/21. Record review of nurse's notes, on 7/7/21 at 12:17 PM, revealed a note from 5/26/21 at 7:28 PM, indicating the resident's family reported the resident had chills and the resident stated s/he was cold. The nurse checked the resident's temperature, which was normal at 98.6. The note also indicated the lab report from 5/18/21 was reviewed by nursing for the first time. The nurse noted the lab report indicated the resident had a UTI and contacted the provider. The provider ordered antibiotics, which were started on 5/26/21. Review of a nurse's note from 5/27/21 revealed the resident was very confused and disoriented, complained of not feeling well at all, and complained of headache and neck pain. The resident was sent to the hospital for further evaluation. Review of hospital progress notes from 5/27/21 and 5/29/21, on 7/7/21 at 1:59 PM, revealed lab work and blood cultures completed in the hospital indicated the resident did not have a UTI and did not have [CONDITION(S)]. Antibiotics for the suspected UTI were discontinued. CT scan results revealed abnormal findings to the spine that may have been indicative of an uncommon condition known as Discitis, an [CONDITION(S)] condition of the spine. During an interview with the Nursing Home Administrator (NHA) and Registered Nurse (RN) #1 on 7/7/21 at 12:45 PM, the NHA confirmed the resident's lab results were not acted upon until 5/26/21. The NHA stated the facility implemented a plan of correction for lab follow up on 5/27/21. The plan of correction included daily audits of all labs and monthly meetings of the Quality Assessment and Assurance Committee until the issue was corrected. During a telephone interview with the Director of Nursing (DON), on 7/8/21 at 1:09 PM (with the NHA and RN #1 present), the DON explained what happened related to the lab results from 5/18/21. The DON stated nurses have to go online and look up labs. S/he stated the lab typically calls or sends an email to notify the facility labs are available online. The DON stated the lab did not do that on this occasion. The DON was asked what the facility's responsibility is for follow up on lab results. The DON stated it is policy and nursing's responsibility to follow up on all the labs within 48 hours and report abnormal findings to the provider. The DON confirmed this was not done. Review of the facility's Diagnostic and Laboratory Services: Procedure for Processing policy revealed nursing was responsible for obtaining lab results and communicating the results with the provider upon receipt. However, the policy did not indicate a timeframe for following up on the availability of lab results.

Based on record review and interview, the facility failed to promote prevention of pressure ulcer development as evidenced by 1 of 2 sampled residents reviewed for pressure ulcers. Resident #13 developed a preventable pressure ulcer after application of an Immobilizer. The findings included: Resident #13 was admitted to the facility on [DATE] and re-admitted [DATE] with [DIAGNOSES REDACTED]. Review of the medical record for Resident #13 on 10/2/2018 at approximately 3:30 PM revealed he/she sustained a knee fracture from a fall on 6/11/2018. Further review revealed an immobilizer was applied because of this injury. Further review revealed the immobilizer was left in place for several weeks causing a pressure ulcer to Resident #13's left Achilles. Review of Nurses Note dated 6/14/2018 revealed remove left leg immobilizer Q (every) shift to check skin integrity. Review of CNA Bath Report revealed documentation for 10/5/2018 only. Review of Physician Renewals signed 9/27/2018 revealed place soft boot material to left Achilles post dressing change to prevent friction, rubbing, and promote comfort and place underneath leg immobility brace. Review of the medical record revealed no documentation to suggest the immobilizer had been removed and Resident #13's skin had been checked each shift as ordered. Interview with MDS Coordinator #1 on 10/2/2018 at approximately 3:30 PM verified staff failed to remove the immobilizer daily for general care and this caused a pressure ulcer to develop.

Based on record reviews, interviews, review of the facility policy titled Do Not Resuscitate Policy: South Carolina, and review of the South Carolina Code of Laws, TITLE 44. HEALTH, CHAPTER 66. Adult Health Care Consent Act, the facility failed to initiate cardiopulmonary resuscitation (CPR) as required for 2 of 3 sampled residents reviewed for death in the facility. Residents #205 and #210 had advance directives signed by family/responsible party without two physicians' determinations of inability to make health care decisions completed. The facility failed to establish and implement policies and procedures consistent with State law regarding health care decisions/formulation of advance directives. The facility transferred decision-making responsibility to the legal representatives of Residents #205 and #210 without two physicians' determinations of the residents' inability to make health care decisions. It was determined on [DATE] at 11:45 AM that Immediate Jeopardy existed as of [DATE] for Resident #205 and on [DATE] for Resident #210 for F-155 which was identified at a scope and severity level of (J). The findings included: Cross Refer to CFR 483.25 F-309 Provision of Care and Services was identified at a scope and severity level of (J). The Immediate Jeopardy existed on [DATE] for Resident #205 and on [DATE] for Resident #210 when licensed nursing staff failed to provide the necessary care and services when the residents exhibited absence of vital signs and did not receive cardiopulmonary resuscitation (CPR). Cross Refer CFR 483.75 F-490 Administration was identified at a scope and severity level of (J). The facility administration failed to ensure appropriate polices and procedures were developed and implemented to identify if Advanced Directives were formulated and proper care and services were provided related to cardiopulmonary resuscitation. The failure of the facility to ensure policies and procedures were established and implemented according to State law regarding Advanced Directives placed all residents at risk for serious harm/death. Cross Refer CFR 483.75(o)(1) F-520 Quality Assurance was identified at a scope and severity level of (J). The facility failed to ensure the Quality Assurance process was utilized to identify, and implement a plan of action regarding adherence to legally executed Advanced Directives. The facility admitted Resident #205 with past medical history of [REDACTED]. S/he was treated at the hospital for a Subcapital Right Femoral Neck Fracture resulting from a fall at the Assisted Living Facility (ALF) where s/he resided. According to Social Services Progress Notes, the discharge plan was to return to the ALF. Review of the [DATE] Admission and [DATE] 14 Day Minimum Data Set assessments revealed that the resident scored a 0 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Review of Nurse's Notes at 10:07 AM on [DATE] revealed that Resident #205 was participating in therapy daily. On [DATE] at 8:20 AM, a staff member called the nurse to the resident's room. S/he stated when s/he assisted the patient out of bed to the chair, s/he did not respond to his/her name. At this time, the resident had no blood pressure (BP) and oxygen (O2)saturation (sat) was 82%. Oxygen was administered at 2 liters/minute. The physician was notified and gave orders to hold medication and notify the family. When notified of the resident's decline in condition, the daughter-in-law stated they did not want the resident hospitalized and to just keep him/her comfortable. According to the notes, the family arrived at 9:45 AM and left at 10:00 AM. At 10 AM, O2 sat 87(%). Pulse 37 (beats per minute). Extremities cool to touch. Patient with some upper extremity movement . At 10:50 AM, the Registered Nurse (RN) Weekend Supervisor noted, Called to room by (Licensed Practical Nurse (LPN) #8) stating resident not breathing. Resident found unresponsive, in bed, no respirations, no pulse, no heart or breath sounds auscultated. No code called per advance directives and signed DNR order in chart . Record review at 8:31 AM on [DATE] revealed a red DNR (Do Not Resuscitate) sticker on the face sheet in the front of the medical record. There was also a [DATE] Physician's Interim Order for DNR. Review of the Authorization of Do Not Resuscitate Order Without Decision-Making Capacity revealed it was signed, but not dated, by the physician. There was no second physician signature to indicate that the resident had been assessed for ability to make health care decisions. The form was signed by a family member to indicate consent to the order and witnessed by Social Services. In addition, there was a DNR order on a Florida Department of Health form indicating that Resident #205 had a durable power of attorney. Multiple requests (on [DATE] at 9 AM, 12:45 PM, and 2 PM) were made to the Administrator to review the power of attorney and on [DATE] at 5:30 PM, s/he stated they were unable to locate the document. During an interview at 9:20 AM on [DATE],Social Services #2 stated that advance directives were discussed on admission. If the resident had an advance directive or durable power of attorney for health care, a copy was requested at that time and placed in the medical record. When asked to describe the process for obtaining an advance directive such as a DNR, s/he stated that Social Work would discuss it with the resident and responsible party, get the forms signed and put them in the doctor's box for his/her signature upon next visit. If the resident was able to make his/her own decisions, the resident would sign the Authorization of Do Not Resuscitate Order With Decision Making Capacity form. If the resident was unable to make health care decisions, the family/responsible party would sign the Authorization of Do Not Resuscitate Order Without Decision-Making Capacity form. The forms were then put into the doctor's box. Social Services #2 reviewed Resident #205's Authorization of Do Not Resuscitate Order Without Decision-Making Capacity form and verified that there was only 1 physician's signature determining the resident's inability to make health care decisions. The surveyor asked, In this case, if the resident had been found without vital signs, should s/he have been resuscitated? Social Services #2 stated,Yes. During an interview at 9:45 AM on [DATE], the attending physician/Medical Director confirmed that a second physician needed to assess a cognitively impaired resident and sign that s/he was unable to make health care decisions before the resident could be considered a DNR and the next of kin could make the advance directive decision for him/her. The physician verified his/her signature on the form and confirmed there was no second physician's signature. S/he stated,They (the facility) used to fax or take the form to (physician) to review and sign as the second physician. I don't know what has happened to that. During an interview on [DATE] at 11:08 AM, the Director of Nurses (DON) reviewed the medical record. When asked how the nurse knew what to do in the event the resident was found without vital signs, the DON stated,They have the DNR sticker. Nurses don't go by the sticker. They go by the doctor's order. After reviewing the record, s/he further stated, They needed the second doctor's signature before the order was written and put on the chart. S/he confirmed that, in these circumstances, CPR should have been initiated. During an interview at 11:38 AM on [DATE], LPN #8 stated s/he could not recall all the details of the incident. S/he reviewed and confirmed the entries in the record. At 1:15 PM, when asked how s/he determined when to initiate CPR, LPN #8 stated s/he would look for the physician's order in the chart. Review of the Care Plan at 1:28 PM on [DATE] revealed no reference to advance directives being in place or resident/family participation in the plan of care. During an interview at approximately 2 PM, with the Administrator present, a corporate representative stated s/he thought advance directives were portable from state to state. The facility admitted Resident #210 with [DIAGNOSES REDACTED]. Closed record review at 9:22 AM on [DATE] revealed that the resident was initially admitted on [DATE], was hospitalized for [REDACTED]. Review of Skilled Daily Nurse's Notes at 11:17 AM revealed that at 11:20 AM on [DATE], Resident #210 was alert (with) confusion .denied pain/discomfort .has been OOB (out of bed) -> (to) chair . The next note at 5 AM on [DATE] stated, Resident in bed resting with eyes closed. No complaints of pain or discomfort. No signs of distress noted . At 6:50 AM, the Certified Nursing Assistant (CNA) requested the nurse to come to the resident's room. The LPN noted, There was no movement at this time. There was no pulse, respiration. The RN on duty noted no vital signs and no response to tactile stimuli. Resident is DNR, Resident expired at present time. Closed record review at approximately 9:30 AM revealed a red DNR (Do Not Resuscitate) sticker on a [DATE] Physician's Interim Do Not Resuscitate Order in the front of the medical record. Review of the Authorization of Do Not Resuscitate Order Without Decision-Making Capacity revealed it was signed by one physician on [DATE]. There was no second physician signature to indicate that the resident had been assessed for ability to make health care decisions. The form was signed by a family member to indicate consent to the order. The [DATE] Multidisciplinary Care Conference Meeting form noted: DNR signed during meeting. Review of the ,[DATE] cumulative monthly Physician's Orders at 11:06 AM revealed that they also included a DNR order. Review of the Care Plan at 10:50 AM on [DATE] revealed no reference to advance directives being in place or resident/family participation in the plan of care. During an interview at 10:30 AM on [DATE], the Administrator reviewed the medical record. S/he verified that, although the family had signed for a DNR order, and a physician's order had been written, there was only one physician's signature determining the resident's inability to make health care decisions. The South Carolina Code of Laws, TITLE 44. HEALTH, CHAPTER 66. Adult Health Care Consent Act notes persons who may make health care decisions for a patient who is unable to consent in order of priority. SECTION [DATE]. Definitions states: (8) Unable to consent means unable to appreciate the nature and implications of the patient's condition and proposed health care, to make a reasoned decision concerning the proposed health care, or to communicate that decision in an unambiguous manner . A patient's inability to consent must be certified by two licensed physicians, each of whom has examined the patient . Review of the facility policy titled Do Not Resuscitate Policy: South Carolina and the South Carolina Code of Laws, TITLE 44. HEALTH, CHAPTER 66. Adult Health Care Consent Act revealed the policy was not in conformance with State law. The [DATE] policy stated: Definitions: 4. Decision Making Capacity .Every adult is presumed to have decision making capacity unless determined otherwise by a physician in writing .Procedure: I. Receiving a DNR Order from Another Healthcare Provider: A. Any written order issued by any attending physician using the term 'do not resuscitate', 'DNR', .or substantially similar language, and that is contained in the patient's medical record shall constitute a sufficient order .C. If an adult patient/resident does not have decision-making capacity and is a candidate for non-resuscitation a physician may issue a DNR with the consent of the patient/resident's representative. Based on full and/or limited record reviews, interviews, and review of the facility policies, it was determined on [DATE] at 11:45 AM that Immediate Jeopardy and/or Substandard Quality of Care existed in the following areas: CFR 483.10(b)(4) F-155 Right to Formulate an Advance Directive was identified at a scope and severity level of (J). The facility transferred decision-making responsibility to the representatives of Residents #205 and #210 without two physicians' determinations of the residents' inability to make health care decisions. This failure resulted in staff not initiating cardiopulmonary resuscitation (CPR) as required. The facility Administrator was informed of the Immediate Jeopardy on [DATE] at 12:40 PM. The facility provided an Allegation of Compliance (A(NAME)) that was acceptable and implemented on [DATE]. The Immediate Jeopardy at F-155, F-309, F-490, and F-520 was removed on [DATE] but the citations remained at a lower scope and severity of D. The A(NAME) included the following: (1) The residents with the alleged deficient practice are no longer residing in the facility. (2) The Director of Health Services will complete a review of all residents in the facility to ensure that do not resuscitate orders have been obtained per policy and state regulations. The Social Worker will also ensure where appropriate two physician signatures have been obtained. (3) All new residents' code status will be included on the 24 hour chart check daily and then reviewed during the daily morning meeting for compliance. (4) The DNR policy is as follows: · Prior to, or upon Admission, the patient/resident and/or their responsible party will be asked about the existence of any advance directives. The Advance Directives Checklist, which is in the South Carolina Admission Packet, will be completed. · Should the patient/resident indicate on the Advance Directive Checklist that he/she has issued advanced directives about his/her treatment, the healthcare center will require that copies of such advance directives be given to the healthcare center for inclusion in the patient/resident's medical record. A copy of the advance directive shall become a permanent part of the patient/resident medical record. The Director of Health Services will notify the attending physician of advance directives and document such notification in the medical record. · Should the patient/resident indicate on the Advance Directive Checklist that he/she does not currently have an advance directive, but would like further information on advance directives; the patient/resident shall be provided with legal forms located on the South Carolina's Office on Aging website. · If upon admission, or any time thereafter a patient/resident or his Representative requests a DNR order, the Social Worker/Case Mix Director or Director of Health Services shall be responsible for completing the process. · If an adult patient/resident HAS decision making capacity, he/she may consent to an order not to resuscitate. · If an adult patient/resident does not have decision making capacity and is a candidate for non- resuscitation and the attending physician may decide to withhold life-prolonging measures or discontinue life prolonging measures by initiating a without decision making capacity form and having a concurring physician signature along with the authorized person signature. · All resident will be a full code until this procedure is complete (5) The facility Admission Director will review advance directive checklist with resident and or responsible party. If there resident is confused and BIMS (Brief Interview for Mental Status) score is 9 or below, a decision making capacity form will be completed with two physician signatures. The BIMS score will be completed on the day of admission for all new residents. (6) Social service was educated on the process for obtaining Advance Directive upon admission and change of condition per policy and by regulation, by the Regional Nurse Consultant. All future hires for the department will be trained during the orientation and all of the Social Workers in the facility will be reeducated annually with their evaluation. (7) The Regional Nurse Consultant has educated both physicians at the facility on the DNR and requirements for the second signature. (8) The Clinical Competency Coordinator will educate all of the licensed nursing personnel on the DNR orders and requirements for DNR orders to be valid before the start of their next work shift.

Based on record reviews, interviews, review of the facility policy titled Do Not Resuscitate Policy: South Carolina, and review of the South Carolina Code of Laws, TITLE 44. HEALTH, CHAPTER 66. Adult Health Care Consent Act, the facility failed to initiate cardiopulmonary resuscitation (CPR) as required for 2 of 3 sampled residents reviewed for death in the facility. CPR was not initiated for Residents #205 and #210 when they were noted without vital signs. Advance directives were signed by the family/responsible party without two physicians' determinations of inability to make health care decisions completed. The facility failed to establish and implement policies and procedures consistent with State law regarding health care decisions/formulation of advance directives. The facility transferred decision-making responsibility to the legal representatives of Residents #205 and #210 without two physicians' determinations of the residents' inability to make health care decisions. In addition, based on observation, record review and interviews the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 5 of 5 residents reviewed for care and services. The facility failed to monitor Resident #257 for adverse effects and/or complications related to the administration of antibiotic therapy with failure to maintain contact isolation precautions on a consistent basis as ordered. The facility failed to monitor for mood fluctuations related to potential grief or adjustment issues related to unexpected roommate expiration and subsequent room change. The facility failed to ensure that Resident # 95's temperature was consistently monitored with antibiotic administration for active infection, with further failure to ensure that urology consultation was arranged as ordered by physician. The facility failed to ensure that Resident #156 received the skin treatment as ordered by the physician. The facility failed to ensure that Resident # 178 received appropriate hospice services as evidenced by no physician order in place, no evidence of hospice nurse, chaplain or social work visits as required. The findings included: Cross Refer to CFR 483.10(b)(4) F-155 Right to Formulate an Advance Directive was identified at a scope and severity level of (J). The facility transferred decision-making responsibility to the representatives of Residents #205 and #210 without two physicians' determinations of the residents' inability to make health care decisions. This failure resulted in staff not initiating cardiopulmonary resuscitation (CPR) as required. Cross Refer CFR 483.75 F-490 Administration was identified at a scope and severity level of (J). The facility administration failed to ensure appropriate polices and procedures were developed and implemented to identify if Advanced Directives were formulated and proper care and services were provided related to cardiopulmonary resuscitation. The failure of the facility to ensure policies and procedures were established and implemented according to State law regarding Advanced Directives placed all residents at risk for serious harm/death. Cross Refer CFR 483.75(o)(1) F-520 Quality Assurance was identified at a scope and severity level of (J). The facility failed to ensure the Quality Assurance process was utilized to identify, and implement a plan of action regarding adherence to legally executed Advanced Directives. The facility admitted Resident #205 with past medical history of [REDACTED]. S/he was treated at the hospital for a Subcapital Right Femoral Neck Fracture resulting from a fall at the Assisted Living Facility (ALF) where s/he resided. According to Social Services Progress Notes, the discharge plan was to return to the ALF. Review of the [DATE] Admission and [DATE] 14 Day Minimum Data Set assessments revealed that the resident scored a 0 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Review of Nurse's Notes at 10:07 AM on [DATE] revealed that Resident #205 was participating in therapy daily. On [DATE] at 8:20 AM, a staff member called the nurse to the resident's room. S/he stated when s/he assisted the patient out of bed to the chair, s/he did not respond to his/her name. At this time, the resident had no blood pressure (BP) and oxygen (O2)saturation (sat) was 82%. Oxygen was administered at 2 liters/minute. The physician was notified and gave orders to hold medication and notify the family. When notified of the resident's decline in condition, the daughter-in-law stated they did not want the resident hospitalized and to just keep him/her comfortable. According to the notes, the family arrived at 9:45 AM and left at 10:00 AM. At 10 AM, O2 sat 87(%). Pulse 37 (beats per minute). Extremities cool to touch. Patient with some upper extremity movement . At 10:50 AM, the Registered Nurse (RN) Weekend Supervisor noted, Called to room by (Licensed Practical Nurse (LPN) #8) stating resident not breathing. Resident found unresponsive, in bed, no respirations, no pulse, no heart or breath sounds auscultated. No code called per advance directives and signed DNR order in chart . Record review at 8:31 AM on [DATE] revealed a red DNR (Do Not Resuscitate) sticker on the face sheet in the front of the medical record. There was also a [DATE] Physician's Interim Order for DNR. Review of the Authorization of Do Not Resuscitate Order Without Decision-Making Capacity revealed it was signed, but not dated, by the physician. There was no second physician signature to indicate that the resident had been assessed for ability to make health care decisions. The form was signed by a family member to indicate consent to the order and witnessed by Social Services. In addition, there was a DNR order on a Florida Department of Health form indicating that Resident #205 had a durable power of attorney. Multiple requests (on [DATE] at 9 AM, 12:45 PM, and 2 PM) were made to the Administrator to review the power of attorney and on [DATE] at 5:30 PM, s/he stated they were unable to locate the document. During an interview at 9:20 AM on [DATE],Social Services #2 stated that advance directives were discussed on admission. If the resident had an advance directive or durable power of attorney for health care, a copy was requested at that time and placed in the medical record. When asked to describe the process for obtaining an advance directive such as a DNR, s/he stated that Social Work would discuss it with the resident and responsible party, get the forms signed and put them in the doctor's box for his/her signature upon next visit. If the resident was able to make his/her own decisions, the resident would sign the Authorization of Do Not Resuscitate Order With Decision Making Capacity form. If the resident was unable to make health care decisions, the family/responsible party would sign the Authorization of Do Not Resuscitate Order Without Decision-Making Capacity form. The forms were then put into the doctor's box. Social Services #2 reviewed Resident #205's Authorization of Do Not Resuscitate Order Without Decision-Making Capacity form and verified that there was only 1 physician's signature determining the resident's inability to make health care decisions. The surveyor asked, In this case, if the resident had been found without vital signs, should s/he have been resuscitated? Social Services #2 stated,Yes. During an interview at 9:45 AM on [DATE], the attending physician/Medical Director confirmed that a second physician needed to assess a cognitively impaired resident and sign that s/he was unable to make health care decisions before the resident could be considered a DNR and the next of kin could make the advance directive decision for him/her. The physician verified his/her signature on the form and confirmed there was no second physician's signature. S/he stated,They (the facility) used to fax or take the form to (physician) to review and sign as the second physician. I don't know what has happened to that. During an interview on [DATE] at 11:08 AM, the Director of Nurses (DON) reviewed the medical record. When asked how the nurse knew what to do in the event the resident was found without vital signs, the DON stated,They have the DNR sticker. Nurses don't go by the sticker. They go by the doctor's order. After reviewing the record, s/he further stated, They needed the second doctor's signature before the order was written and put on the chart. S/he confirmed that, in these circumstances, CPR should have been initiated. During an interview at 11:38 AM on [DATE], LPN #8 stated s/he could not recall all the details of the incident. S/he reviewed and confirmed the entries in the record. At 1:15 PM, when asked how s/he determined when to initiate CPR, LPN #8 stated s/he would look for the physician's order in the chart. Review of the Care Plan at 1:28 PM on [DATE] revealed no reference to advance directives being in place or resident/family participation in the plan of care. During an interview at approximately 2 PM, with the Administrator present, a corporate representative stated s/he thought advance directives were portable from state to state. The facility admitted Resident #210 with [DIAGNOSES REDACTED]. Closed record review at 9:22 AM on [DATE] revealed that the resident was initially admitted on [DATE], was hospitalized for [REDACTED]. Review of Skilled Daily Nurse's Notes at 11:17 AM revealed that at 11:20 AM on [DATE], Resident #210 was alert (with) confusion .denied pain/discomfort .has been OOB (out of bed) -> (to) chair . The next note at 5 AM on [DATE] stated, Resident in bed resting with eyes closed. No complaints of pain or discomfort. No signs of distress noted . At 6:50 AM, the CNA requested the nurse to come to the resident's room. The LPN noted, There was no movement at this time. There was no pulse, respiration. The RN on duty noted no vital signs and no response to tactile stimuli. Resident is DNR, Resident expired at present time. Closed record review at approximately 9:30 AM revealed a red DNR (Do Not Resuscitate) sticker on a [DATE] Physician's Interim Do Not Resuscitate Order in the front of the medical record. Review of the Authorization of Do Not Resuscitate Order Without Decision-Making Capacity revealed it was signed by one physician on [DATE]. There was no second physician signature to indicate that the resident had been assessed for ability to make health care decisions. The form was signed by a family member to indicate consent to the order. The [DATE] Multidisciplinary Care Conference Meeting form noted: DNR signed during meeting. Review of the ,[DATE] cumulative monthly Physician's Orders at 11:06 AM revealed that they also included a DNR order. Review of the Care Plan at 10:50 AM on [DATE] revealed no reference to advance directives being in place or resident/family participation in the plan of care. During an interview at 10:30 AM on [DATE], the Administrator reviewed the medical record. S/he verified that, although the family had signed for a DNR order, and a physician's order had been written, there was only one physician's signature determining the resident's inability to make health care decisions. The South Carolina Code of Laws, TITLE 44. HEALTH, CHAPTER 66. Adult Health Care Consent Act notes persons who may make health care decisions for a patient who is unable to consent in order of priority. SECTION [DATE]. Definitions states: (8) Unable to consent means unable to appreciate the nature and implications of the patient's condition and proposed health care, to make a reasoned decision concerning the proposed health care, or to communicate that decision in an unambiguous manner . A patient's inability to consent must be certified by two licensed physicians, each of whom has examined the patient . Review of the facility policy titled Do Not Resuscitate Policy: South Carolina and the South Carolina Code of Laws, TITLE 44. HEALTH, CHAPTER 66. Adult Health Care Consent Act revealed the policy was not in conformance with State law. The [DATE] policy stated: Definitions: 4. Decision Making Capacity .Every adult is presumed to have decision making capacity unless determined otherwise by a physician in writing .Procedure: I. Receiving a DNR Order from Another Healthcare Provider: A. Any written order issued by any attending physician using the term 'do not resuscitate', 'DNR', .or substantially similar language, and that is contained in the patient's medical record shall constitute a sufficient order .C. If an adult patient/resident does not have decision-making capacity and is a candidate for non-resuscitation a physician may issue a DNR with the consent of the patient/resident's representative. Based on full and/or limited record reviews, interviews, and review of the facility policies, it was determined on [DATE] at 11:45 AM that Immediate Jeopardy and/or Substandard Quality of Care existed in the following area: CFR 483.25 F-309 Provision of Care and Services was identified at a scope and severity level of (J). The Immediate Jeopardy existed on [DATE] for Resident #205 and on [DATE] for Resident #210 when licensed nursing staff failed to provide the necessary care and services when the residents exhibited absence of vital signs and did not receive cardiopulmonary resuscitation (CPR). The facility Administrator was informed of the Immediate Jeopardy on [DATE] at 12:40 PM. The facility provided an Allegation of Compliance (A(NAME)) that was acceptable and implemented on [DATE]. The Immediate Jeopardy at F-155, F-309, F-490, and F-520 was removed on [DATE] but the citations remained at a lower scope and severity of D. The A(NAME) included the following: (1) The residents with the alleged deficient practice are no longer residing in the facility. (2) The Director of Health Services will complete a review of all residents in the facility to ensure that do not resuscitate orders have been obtained per policy and state regulations. The Social Worker will also ensure where appropriate two physician signatures have been obtained. (3) All new residents ' code status will be included on the 24 hour chart check daily and then reviewed during the daily morning meeting for compliance. (4) The DNR policy is as follows: · Prior to, or upon Admission, the patient/resident and/or their responsible party will be asked about the existence of any advance directives. The Advance Directives Checklist, which is in the South Carolina Admission Packet, will be completed. · Should the patient/resident indicate on the Advance Directive Checklist that he/she has issued advanced directives about his/her treatment, the healthcare center will require that copies of such advance directives be given to the healthcare center for inclusion in the patient/resident ' s medical record. A copy of the advance directive shall become a permanent part of the patient/resident medical record. The Director of Health Services will notify the attending physician of advance directives and document such notification in the medical record. · Should the patient/resident indicate on the Advance Directive Checklist that he/she does not currently have an advance directive, but would like further information on advance directives; the patient/resident shall be provided with legal forms located on the South Carolina ' s Office on Aging website. · If upon admission, or any time thereafter a patient/resident or his Representative requests a DNR order, the Social Worker/Case Mix Director or Director of Health Services shall be responsible for completing the process. · If an adult patient/resident HAS decision making capacity, he/she may consent to an order not to resuscitate. · If an adult patient/resident does not have decision making capacity and is a candidate for non- resuscitation and the attending physician may decide to withhold life-prolonging measures or discontinue life prolonging measures by initiating a without decision making capacity form and having a concurring physician signature along with the authorized person signature. · All resident will be a full code until this procedure is complete (5) The facility Admission Director will review advance directive checklist with resident and or responsible party. If there resident is confused and BIM score is 9 or below, a decision making capacity form will be completed with two physician signatures. The BIM score will be completed on the day of admission for all new residents. (6) Social service was educated on the process for obtaining Advance Directive upon admission and change of condition per policy and by regulation, by the Regional Nurse Consultant. All future hires for the department will be trained during the orientation and all of the Social Workers in the facility will be reeducated annually with their evaluation. (7) The Regional Nurse Consultant has educated both physicians at the facility on the DNR and requirements for the second signature. (8) The Clinical Competency Coordinator will educate all of the licensed nursing personnel on the DNR orders and requirements for DNR orders to be valid before the start of their next work shift. The facility admitted Resident #257 with [DIAGNOSES REDACTED]. During initial tour on [DATE] from which was conducted between 10:30 AM and 11:15 AM, it was observed that there was no contact isolation cart, nor any posted signage which indicated that visitors must report to nurse prior to entering room located outside the door at room [ROOM NUMBER], which was assigned to Resident #257. Additional observation at 11:30 AM on [DATE] revealed that a contact isolation cart was located directly outside of room [ROOM NUMBER] and sign was posted on door that directed visitors to report to nurse before entering room. Record review [DATE] at 8:00 AM revealed nursing progress note dated [DATE] that reflected .called labs and result relayed to MD with order for contact isolation and to start antibiotic for Urinary Tract Infection .Report given to in-coming nurse. Further review of record revealed that there were no further nursing notes until [DATE]; additionally, there is no indication of nurses monitoring for adverse effects/ complications related to the use of antibiotic therapy with concurrent contact isolation initiated on [DATE] secondary to urine culture results with >/= 100,000 cfu (colony-forming units)/ milliliter (ml) of [MEDICATION NAME] Resistant [MEDICATION NAME]. Additional review of Medication Administration Record [REDACTED]. Review of Facility Policy titled Contact Precautions with revision date of [DATE], revealed that the required documentation for contact isolation included that nurses must record the need for contact precautions on the nursing care plan and as otherwise indicted by your facility. Document initiation and maintenance of the precautions, the patient's tolerance of the procedure, any patient and family teaching provided and their understating of that teaching. Also record the date you discontinued contact precautions. Ongoing Review of Comprehensive Care Plan problem with onset date of [DATE] identified that Resident requires contact isolation due to an infection / VRE urine with the intervention educate resident's visitors about the isolation requirements. Further review of medical record revealed an interdisciplinary teaching record included no entries after [DATE] that outlined any education provided to Resident #257 and/or their Responsible Party regarding isolation requirements initiated on [DATE]. When asked during interview on [DATE] at 9:15 AM why the contact isolation cart was not in use during initial tour for Resident #257 in room [ROOM NUMBER] on [DATE] from approximately 10:30 AM until 11:15 AM, Registered Nurse (RN) #1 replied that s/he was told during her/his inquiry that the central supply clerk had moved the cart to restock it that morning and that s/he would further investigate and return with findings; however, she further stated that when s/he observed that there was not an isolation cart in place, s/he reviewed the physician orders and determined that the order for contact isolation was still an active order, at which time a new cart was placed at the door of room [ROOM NUMBER]. RN #1 returned on [DATE] at 9:53 AM and stated that s/he received confirmation from supply clerk that the isolation cart was removed from room [ROOM NUMBER] at approximately 9:30 AM on [DATE] to restock it and by the time s/he returned the cart, there was another isolation cart already in place. During interview on [DATE] at 10:10 AM, RN #1 verified that there was no evidence of Resident and/or family education provided regarding isolation requirements as outlined on comprehensive care plan page 12 of 12 with onset date of [DATE], and therefore care plan was not followed as required per facility policy. When asked what the procedure was for monitoring for signs/ symptoms or complications secondary to use of antibiotic, s/he replied .when residents are receiving antibiotics, the nurses should be monitoring for adverse effects related to that antibiotic therapy and documenting this in the medical record. When asked at what intervals this process should be repeated and recorded, s/he replied .at least daily, if not every shift. The facility admitted Resident # 107 with [DIAGNOSES REDACTED]. Resident #107 reported during interview on [DATE] at 12:21 PM that when her/his roommate passed away suddenly, the facility staff moved her/him and her/his belongings into another room without prior notification. Resident #107's roommate expired on [DATE]. Review of medical record on [DATE] revealed that on both the Initial Activity Assessment and the [DATE] Group Attendance Record Form it identifies that the Resident #107 reports that s/he will get sad/ cry easily. Further review revealed that social services progress note dated [DATE] that indicates S/he is taking [MEDICATION NAME]. SS (social services) to observe mood, behavior, psychosocial areas of concern and provide support as needed. Additional social services progress note dated [DATE] identifies that (Resident #107) denies feelings of anxiety and depression at this time. SS will continue to observe mood, behavior, psychosocial areas and provide support as needed. Additional medical record review on [DATE] of comprehensive care plan with Interdisciplinary Team meeting date of [DATE] revealed that there were no care plan problems or interventions in place to address risk for fluctuation in mood with current use of antidepressant medication and self-reported propensity to get sad and cry easily. Further review reveals no updates made to care plan to address additional stressors with potential impact on mood/ psychosocial status related to unexpected roommate expiration and subsequent room change on [DATE]. During interview with Social Service #1 on [DATE] at 1:29 PM, when asked where the comprehensive care plan addressed the risk for mood status changes and interventions in place to maintain optimal psychosocial status while observing psychosocial areas of concern, as outlined in social service progress notes was located, s/he replied there is not a care plan that addresses mood specifically. When asked if, in her/his professional opinion, a resident who experiences a roommate's unexpected expiration would be at risk for fluctuation in mood or behavior as well as other symptoms associated with grieving related to experiencing the dying process of someone in close proximity, s/he replied: yes. When asked if Resident #107's care plan should have been updated to address such a potential risk, s/he replied yes. When asked if s/he could identify where it was addressed in Resident #107's care plan that her/his roommate unexpectedly expired with subsequent room change on [DATE], s/he replied that it does not. Finally, when SS#1 was asked if the social service documentation reflects that Resident #107 was specifically monitored for potential for grief or adjustment issues related to unexpected expiration of roommate and subsequent room change, s/he reported that it did not. Review of the social services progress notes revealed notes dated [DATE] and [DATE], neither of which addressed identification of risk for grief and adjustment issues and active monitoring by social services related to unexpected expiration of roommate and subsequent room change. The facility admitted Resident # 178 for hospice care and services with [DIAGNOSES REDACTED]. Record review on [DATE] at 4:28 PM revealed no written physician's orders for hospice services and no evidence of hospice-nurse visits during the period of [DATE] through [DATE]. Review of hospice documentation, kept in a separate binder from facility documentation, revealed there was an Initial Plan of Care dated [DATE] which included scheduled visits by Nursing Social Services, and Chaplin. Continue record review on [DATE] at approximately 4:35 revealed Nursing visits scheduled for 2 times per week were not done for the period of [DATE]rd through [DATE]th, Chaplin visits scheduled for 2 times per month were not done between the period of [DATE]th through [DATE]th, and Social Services scheduled for 1 time per month was not done for the month of July and August. Review of the facility's Care Plan on [DATE] 10:55:21 AM revealed that Hospice Care was listed as a problem, but the plan was not integrated to include frequency of visits by hospice disciplines or services Social Services and Chaplin. The care plan also revealed no evidence of hospice agency and/or resident's family member participation in the care plan review meeting. During an interview on [DATE] at 6:40 PM, the Director of Nursing stated, I have looked through the chart and everywhere and I cannot find the order for Hospice. I do not know what happened to it. Based on interview on [DATE] at 10:20 Am, the registered nurse for Hospice was unable to provide evidence of nursing visits during the period of August mentioned above. She reported that there were technical issues with the computer system and resident #178 have to be discharge and readmitted , however she could not explain the missing data. During an interview on [DATE] at approximately 2:40 PM, the Minimum Data Set (MDS) Assessment/Care Plan (CP) Coordinator confirmed that the facility's interdisciplinary care plan did not include frequency of visits or services provided by hospice personnel. The facility admitted Resident #156 with [DIAGNOSES REDACTED]. During an observation on [DATE] at 8:51am, multiple dark areas were noted on the resident's arm. Record review on [DATE] at 11am revealed a Physician's Telephone Order dated [DATE] that stated, Consult to (dermatologist). There was no evidence of the consult in the medical record. On [DATE] at 1pm, a request was submitted to Registered Nurse (RN) #1 for a copy of the consult. The copy of the completed consult was provided on [DATE] at 12:09pm. Further record review on [DATE] at 1115am revealed a Physician's Order on [DATE] that stated, Discontinue [MEDICATION NAME] cream and start [MEDICATION NAME] cream 0.5% ointment. Apply to affected areas on bilateral legs, feet, and arms daily and PRN (as needed). Further review revealed a Physician's Order on [DATE] that reflected the Columbia Skin Clinic recommendations and stated, [MEDICATION NAME] 0.1% ointment apply to affected areas BID (twice a day) for 21 days. Sponge bath QD (daily) and only use soap under arms, groin and feet. Do not use washcloths or luffas, and apply mineral cream to affected areas every day. During an interview on [DATE] at 12:09pm, RN #1 verified that a copy of the consult was not in the chart and s/he had to request a copy from the dermatologist's office. Record review on [DATE] at 12:10pm of the dermatologist's recommendations dated [DATE] stated, The resident is diagnosed with [REDACTED]. Treatment should include sponge baths or bathing with soap only under the arms, groin and feet. Shower twice weekly but only rinse the skin with water. After bathing, apply [MEDICATION NAME] 0.1% ointment twice a day for ,[DATE] weeks to the affected areas, and a cream based moisturizer such as [MEDICATION NAME] or [MEDICATION NAME] to the damp skin, and follow up if not improving in ,[DATE] weeks. No evidence was in the record of a follow up visit. Review of the [DATE] Medication Administration Record [REDACTED]. Review of the [DATE] TAR revealed a handwritten entry for [MEDICATION NAME] ointment, apply to affected areas BID (twice daily) for 21 days. The entry had no dose percentage of the medication of the ointment to be applied. There was no entry for the mineral cream ordered on [DATE] on the May TAR. Further review of the June, August, and [DATE] TAR records revealed no evidence of the Physician's Order nor treatment administration for the PRN order for [MEDICATION NAME] 0.5%. The [DATE] Physician Orders and MAR indicated [REDACTED] During an interview on [DATE] at 11:30am, Registered Nurse (RN) #1 verified the order for [MEDICATION NAME] 0.5% cream on the [DATE] MAR indicated [REDACTED]. There was no evidence that the resident was receiving the treatment. During another interview on [DATE] at 5:13pm, RN #1 verified the lack of dosing percentage of the entry for the [MEDICATION NAME] cream transcribed on the [DATE] TAR. S/he was unable to determine if the resident was receiving 0.5% or 0.1%. RN #1 verified that the mineral cream ordered on [DATE] was not on the April or [DATE] TAR. S/he confirmed there was no evidence that the resident was receiving the treatment. RN #1 reviewed and verified the skin care treatment recommendations ordered on [DATE], which were specific for bathing the resident, should have been added to the CNA Care Record. RN #1 reviewed the CNA Care Record and confirmed there were no instructions on the CNA Care Record regarding no soap use except under arms, groin, and feet, and not to use washcloths when bathing the resident. During an interview on [DATE] at 12:10pm, CNA #9 stated s/he was familiar w (TRUNCATED)

Based on full and/or limited record reviews, interviews and review of the facility policies, the facility administration failed to ensure appropriate polices and procedures were developed and implemented to identify if Advanced Directives were formulated and proper care and services were provided related to cardiopulmonary resuscitation for 2 of 3 sampled residents reviewed for death in the facility. The failure of the facility to ensure policies and procedures were established and implemented according to State law regarding Advanced Directives placed all residents at risk for serious harm/death. CFR 483.75 F-490 Administration was identified at a scope and severity level of (J). It was determined that Immediate Jeopardy existed on [DATE] for Resident #205 and on [DATE] for Resident #210 when licensed nursing staff failed to provide cardiopulmonary resuscitation (CPR). The facility failed to establish and implement policies and procedures consistent with State law regarding health care decisions/formulation of advance directives. The facility transferred decision-making responsibility to the legal representatives of Residents #205 and #210 without two physicians' determinations of the residents' inability to make health care decisions. The findings included: Cross Refer to CFR 483.10(b)(4) F-155 Right to Formulate an Advance Directive was identified at a scope and severity level of (J). The facility transferred decision-making responsibility to the representatives of Residents #205 and #210 without two physicians' determinations of the residents' inability to make health care decisions. This failure resulted in staff not initiating cardiopulmonary resuscitation (CPR) as required. Cross Refer to CFR 483.25 F-309 Provision of Care and Services was identified at a scope and severity level of (J). The Immediate Jeopardy existed on [DATE] for Resident #205 and on [DATE] for Resident #210 when licensed nursing staff failed to provide the necessary care and services when the residents exhibited absence of vital signs and did not receive cardiopulmonary resuscitation (CPR). Cross Refer CFR 483.75(o)(1) F-520 Quality Assurance was identified at a scope and severity level of (J). The facility failed to ensure the Quality Assurance process was utilized to identify, and implement a plan of action regarding adherence to legally executed Advanced Directives. The facility Administration failed to ensure appropriate policies and procedures were developed in accordance with State Law and implemented to identify and clarify Advance Directives, to ensure residents were provided appropriate services related to Advance Directives and provision of care consistent with those directives, and to ensure the Quality Assurance process was utilized to identify, clarify, and implement a plan of action related to such. The South Carolina Code of Laws, TITLE 44. HEALTH, CHAPTER 66. Adult Health Care Consent Act notes persons who may make health care decisions for a patient who is unable to consent in order of priority. SECTION [DATE]. Definitions states: (8) Unable to consent means unable to appreciate the nature and implications of the patient's condition and proposed health care, to make a reasoned decision concerning the proposed health care, or to communicate that decision in an unambiguous manner . A patient's inability to consent must be certified by two licensed physicians, each of whom has examined the patient . Review of the facility policy titled Do Not Resuscitate Policy: South Carolina and the South Carolina Code of Laws, TITLE 44. HEALTH, CHAPTER 66. Adult Health Care Consent Act revealed the policy was not in conformance with State law. The [DATE] policy stated: Definitions: 4. Decision Making Capacity .Every adult is presumed to have decision making capacity unless determined otherwise by a physician in writing .Procedure: I. Receiving a DNR Order from Another Healthcare Provider: A. Any written order issued by any attending physician using the term 'do not resuscitate', 'DNR', .or substantially similar language, and that is contained in the patient's medical record shall constitute a sufficient order .C. If an adult patient/resident does not have decision-making capacity and is a candidate for non-resuscitation a physician may issue a DNR with the consent of the patient/resident's representative. The facility Administrator was informed of the Immediate Jeopardy on [DATE] at 12:40 PM. The facility provided an Allegation of Compliance (A(NAME)) that was acceptable and noted to be implemented on [DATE]. The Immediate Jeopardy at F-155, F-309, F-490, and F-520 was removed on [DATE] but the citations remained at a lowered scope and severity of D. The A(NAME) included the following: (1) The residents with the alleged deficient practice are no longer residing in the facility. (2) The Director of Health Services will complete a review of all residents in the facility to ensure that do not resuscitate orders have been obtained per policy and state regulations. The Social Worker will also ensure where appropriate two physician signatures have been obtained. (3) All new residents ' code status will be included on the 24 hour chart check daily and then reviewed during the daily morning meeting for compliance. (4) The DNR policy is as follows: · Prior to, or upon Admission, the patient/resident and/or their responsible party will be asked about the existence of any advance directives. The Advance Directives Checklist, which is in the South Carolina Admission Packet, will be completed. · Should the patient/resident indicate on the Advance Directive Checklist that he/she has issued advanced directives about his/her treatment, the healthcare center will require that copies of such advance directives be given to the healthcare center for inclusion in the patient/resident's medical record. A copy of the advance directive shall become a permanent part of the patient/resident medical record. The Director of Health Services will notify the attending physician of advance directives and document such notification in the medical record. · Should the patient/resident indicate on the Advance Directive Checklist that he/she does not currently have an advance directive, but would like further information on advance directives; the patient/resident shall be provided with legal forms located on the South Carolina's Office on Aging website. · If upon admission, or any time thereafter a patient/resident or his Representative requests a DNR order, the Social Worker/Case Mix Director or Director of Health Services shall be responsible for completing the process. · If an adult patient/resident HAS decision making capacity, he/she may consent to an order not to resuscitate. · If an adult patient/resident does not have decision making capacity and is a candidate for non- resuscitation and the attending physician may decide to withhold life-prolonging measures or discontinue life prolonging measures by initiating a without decision making capacity form and having a concurring physician signature along with the authorized person signature. · All resident will be a full code until this procedure is complete (5) The facility Admission Director will review advance directive checklist with resident and or responsible party. If there resident is confused and BIMS (Brief Interview for Mental Status) score is 9 or below, a decision making capacity form will be completed with two physician signatures. The BIMS score will be completed on the day of admission for all new residents. (6) Social service was educated on the process for obtaining Advance Directive upon admission and change of condition per policy and by regulation, by the Regional Nurse Consultant. All future hires for the department will be trained during the orientation and all of the Social Workers in the facility will be reeducated annually with their evaluation. (7) The Regional Nurse Consultant has educated both physicians at the facility on the DNR and requirements for the second signature. (8) The Clinical Competency Coordinator will educate all of the licensed nursing personnel on the DNR orders and requirements for DNR orders to be valid before the start of their next work shift.

Based on full and/or limited record reviews, interviews and review of the facility policies, it was determined on [DATE] at approximately 11:45 AM that Immediate Jeopardy existed at CFR483.75 F-520 at a scope and severity level of (J) beginning on [DATE]. The facility failed to identify quality deficiencies related to 2 of 3 sampled residents reviewed for death in the facility for whom cardiopulmonary resuscitation (CPR) was not provided as required. The facility failed to implement a plan of action related to Advance Directives for and initiation of CPR. Failure of the Quality Assurance (QA) Committee to identify and implement action plans to ensure residents who exhibited absence of pulse and respirations received CPR when indicated and according to State Law resulted in Immediate Jeopardy for Residents #205 and #210. It was determined that Immediate Jeopardy existed on [DATE] for Resident #205 and on [DATE] for Resident #210 when licensed nursing staff failed to provide the necessary care and services when the residents exhibited absence of vital signs and did not receive cardiopulmonary resuscitation (CPR). The findings included: Cross Refer to CFR 483.10(b)(4) F-155 Right to Formulate an Advance Directive was identified at a scope and severity level of (J). The facility transferred decision-making responsibility to the representatives of Residents #205 and #210 without two physicians' determinations of the residents' inability to make health care decisions. This failure resulted in staff not initiating cardiopulmonary resuscitation (CPR) as required. Cross Refer to CFR 483.25 F-309 Provision of Care and Services was identified at a scope and severity level of (J). The Immediate Jeopardy existed on [DATE] for Resident #205 and on [DATE] for Resident #210 when licensed nursing staff failed to provide the necessary care and services when the residents exhibited absence of vital signs and did not receive cardiopulmonary resuscitation (CPR). Cross Refer CFR 483.75 F-490 Administration was identified at a scope and severity level of (J). The facility administration failed to ensure appropriate polices and procedures were developed and implemented to identify if Advanced Directives were formulated and proper care and services were provided related to cardiopulmonary resuscitation. The failure of the facility to ensure policies and procedures were established and implemented according to State law regarding Advanced Directives placed all residents at risk for serious harm/death. Based on observations made throughout the course of the standard and extended survey process and interviews, the facility failed to identify and implement appropriate plans of action to address issues that resulted in failure to comply with multiple regulatory guidelines that resulted in citations in multiple areas with negative impact on the quality of life or quality of care provided to those residents present in the facility for two of two nursing units. When asked on [DATE] at 8:00 PM if there were any current Quality Assurance action plans in place that addressed any of the numerous concerns identified by the survey team and shared during the survey process that the facility would like to have taken into consideration during the decision making meeting, the Administrator reported that there were areas that they had been addressing; however there were no specific Performance Improvement Plans in place and that what information was available was in the form of notes that s/he would endeavor to locate as soon as possible. There was no further information related to any current Performance Improvement Plans provided to the survey team to review and discuss through the end of both the standard and extended survey process which was concluded on [DATE]. The facility Administrator was informed of the Immediate Jeopardy on [DATE] at 12:40 PM. The facility provided an Allegation of Compliance (A(NAME)) that was acceptable and noted to be implemented on [DATE]. The Immediate Jeopardy at F-155, F-309, F-490, and F-520 was removed on [DATE] but the citations remained at a lowered scope and severity of D. The A(NAME) included the following: (1) The residents with the alleged deficient practice are no longer residing in the facility. (2) The Director of Health Services will complete a review of all residents in the facility to ensure that do not resuscitate orders have been obtained per policy and state regulations. The Social Worker will also ensure where appropriate two physician signatures have been obtained. (3) All new residents ' code status will be included on the 24 hour chart check daily and then reviewed during the daily morning meeting for compliance. (4) The DNR policy is as follows: · Prior to, or upon Admission, the patient/resident and/or their responsible party will be asked about the existence of any advance directives. The Advance Directives Checklist, which is in the South Carolina Admission Packet, will be completed. · Should the patient/resident indicate on the Advance Directive Checklist that he/she has issued advanced directives about his/her treatment, the healthcare center will require that copies of such advance directives be given to the healthcare center for inclusion in the patient/resident's medical record. A copy of the advance directive shall become a permanent part of the patient/resident medical record. The Director of Health Services will notify the attending physician of advance directives and document such notification in the medical record. · Should the patient/resident indicate on the Advance Directive Checklist that he/she does not currently have an advance directive, but would like further information on advance directives; the patient/resident shall be provided with legal forms located on the South Carolina's Office on Aging website. · If upon admission, or any time thereafter a patient/resident or his Representative requests a DNR order, the Social Worker/Case Mix Director or Director of Health Services shall be responsible for completing the process. · If an adult patient/resident HAS decision making capacity, he/she may consent to an order not to resuscitate. · If an adult patient/resident does not have decision making capacity and is a candidate for non- resuscitation and the attending physician may decide to withhold life-prolonging measures or discontinue life prolonging measures by initiating a without decision making capacity form and having a concurring physician signature along with the authorized person signature. · All resident will be a full code until this procedure is complete (5) The facility Admission Director will review advance directive checklist with resident and or responsible party. If there resident is confused and BIMS (Brief Interview for Mental Status) score is 9 or below, a decision making capacity form will be completed with two physician signatures. The BIMS score will be completed on the day of admission for all new residents. (6) Social service was educated on the process for obtaining Advance Directive upon admission and change of condition per policy and by regulation, by the Regional Nurse Consultant. All future hires for the department will be trained during the orientation and all of the Social Workers in the facility will be reeducated annually with their evaluation. (7) The Regional Nurse Consultant has educated both physicians at the facility on the DNR and requirements for the second signature. (8) The Clinical Competency Coordinator will educate all of the licensed nursing personnel on the DNR orders and requirements for DNR orders to be valid before the start of their next work shift.

Based on record review, interview, and review of Lippincott Procedures-Fall Management policy, the facility failed to notify the responsible party (RP) and/or the physician of changes in residents' conditions requiring potential physician intervention for 3 of 3 sampled residents reviewed for notification. Resident #156 had no evidence of physician or responsible party notification of a fall. Resident #42 had no evidence of the responsible party and/or the physician being notified of the following: a fall, a complaint of harm by a Certified Nursing Assistant (CNA), and the results of a urinalysis and the physician's decision not to treat the infection. The findings included: The facility admitted Resident #42 with [DIAGNOSES REDACTED]. Record review of the Care Plan on 9/7/17 at 3pm revealed the resident fell on [DATE], 5/10/17, and 5/16/17. Review of the Nurse's Note on 9/7/17 at 3:10pm, revealed an entry on 5/6/17 that stated, S/p (status [REDACTED]. Further review of the Care Plan regarding falls revealed it had been updated with a handwritten entry that noted, 5/4/17 fall: no injuries. There was no evidence in the medical record that the responsible party or physician was notified of the fall. Further review revealed a Nurse's Note dated 5/18/17 that stated, Resident s/p fall on 5/15/17 with injury to forehead. Her (his) left eye is swollen but no pain. Neuro checks completed. There was no evidence in the record that the physician or responsible party was notified of the newly identified swollen eye and the injury to forehead. During an interview on 9/7/17 at 3pm, the DON verified there was no documentation in the record regarding notification of the responsible party or the physician of the fall on 5/4/17, or the injuries noted from the 5/15/17 fall. Review of the Lippincott Procedures- Fall Management policy provided by the facility on 9/9/17 at 3pm revealed that the procedures for a resident fall included: A post fall assessment, monitoring the status for 48 hours, institute fall precautions, complete a detailed incident report, and document information about the fall in the record including notification of the practitioner and the patient's health care power of attorney. Further review of the record revealed a lab report with a positive urinalysis reported on 7/29/17 with [DIAGNOSES REDACTED] pneumoniae growth. The Nurse's Notes on 7/17/17 stated, Resident with periods of confusion, and s/he displays this type of behavior when s/he has a UTI (urinary tract infection). Order for urinalysis and culture obtained. An undated SBAR (Situation, Background, Assessment and Recommendation) Communication Form in the Nurse's Notes stated the symptoms started on 7/26/17 and include an odor to the urine, increased confusion with non-verbal signs of pain, and that the physician was notified of the results of the urine culture. The Nurse's Note on 8/7/17 stated, Resident complains of burning pain when she (he) urinates. There is no evidence of physician assessment or documentation regarding the resident's change in status and rationale regarding the decision not to treat the urinary tract infection. There was no documentation in the record that the responsible party was notified of the positive urine cultures and the physician's decision not to treat the infection with antibiotics. A Physician's Telephone Order dated 8/9/17 stated, Send to emergency room to evaluate and treat for UTI. The resident was admitted to the hospital from 8/9/17 through 8/23/17 for treatment of [REDACTED]. During an interview on 9/9/17 at 5pm, Registered Nurse #1 verified there was no evidence in the record that the responsible party was notified of the urinalysis and the decision not to treat the infection. Additional record review on 9/7/17 at 3pm revealed a Nurse's Note dated 5/21/17 that stated, Resident reports that the CNA hurt her (his) wrist and made a verbal request for the CNA not to come back. There was no evidence in the record that the responsible party was notified of the allegation of abuse, nor that the physician was made aware of the hurt wrist. Review of the facility policy on Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property on 9/9/17 stated the following: 1. The Administrator or his or her designee should notify the state agency, the patient's attending physician, and the patient's designated representative of any allegation, suspicion, or identified occurrence involving patient abuse, neglect, or mistreatment. During an interview on 9/7/17 at 7:45pm, the DON stated s/he was unaware of the incident and verified there was no evidence that the responsible party or the physician was notified of the allegation of abuse. The facility admitted Resident #156 with [DIAGNOSES REDACTED]. Record review on 9/7/17 at 2pm revealed the resident fell on [DATE] and 8/3/17. There was no evidence in the record that the physician and/or responsible party were notified. During an interview on 9/7/17 at 3:30pm, the Director of Nursing (DON) reviewed the medical record and verified there was no documentation in the record that the physician and responsible party were notified of the 8/3/17 fall. On 9/9/17 at 4pm, the DON verified there was no documentation in the record regarding notification of the physician or responsible party of the fall on 2/16/17.

Based on record review, interview, and review of the facility policy titled Abuse Identification and Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property the facility failed to ensure the residents rights to be free from abuse for 1 of 3 sampled residents reviewed for abuse. The facility failed to provide an environment free from abuse. The staff failed to identify the incident as possible abuse. They failed to report the incident to administration and investigate the incident. Resident #42 stated the Certified Nursing Assistant (CNA) hurt her/his wrist during care and had requested the CNA not come back. The findings included: The facility admitted Resident #42 with [DIAGNOSES REDACTED]. Record review on 9/7/17 at 3pm revealed a Nurse's Note dated 5/21/17 that stated Resident reports that CNA hurt her (his) wrist and made a verbal request for the CNA not to come back. There was no evidence of the staff identifying and reporting the allegation of abuse to administration. There was evidence that the CNA's assignment was changed. There was no evidence that the CNA was immediately suspended to protect all residents until the investigation of alleged abuse was completed. There was no evidence in the record that the responsible party was notified of the allegation of abuse, nor that the physician was made aware of the hurt wrist. Review of the facility [MEDICATION NAME] and Incident Log on 9/9/17 at 3pm revealed no evidence of the occurrence being investigated or reported. The facility policy for Abuse Identification on 9/9/17 at 4pm stated the following: 1. In attempting to identify a type of abuse or neglect, the following will be examined as to whether it is suspicious and may constitute abuse or neglect: Abuse Indicator includes complaints of pain with or without injury. 2. Any person hearing a complaint of any signs and symptoms of abuse or mistreatment should report it to the Administrator as soon as possible. The Administrator will inform and designate other staff members to assist in the investigation as indicated. The facility policy on Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property on 9/9/17 stated the following: 1. The Administrator or his or her designee should notify the state agency, the patient's attending physician, and the patient's designated representative of any allegation, suspicion, or identified occurrence involving patient abuse, neglect, or mistreatment. 2. The state agency should be notified within 2 hours after the allegation is made if the events upon which the allegation is based involves abuse. During an interview on 9/7/17 at 7:45pm, the Director of Nursing verified that there was no investigation or reporting of the incident because s/he was not aware of the allegation.

Based on record review, interview, and review of the facility policy titled Abuse Identification and Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to report and investigate an allegation of abuse to the State Agency for 1 of 3 sampled residents reviewed for abuse. The facility failed to investigate the report of alleged abuse and failed to report the initial allegation of abuse by Resident #42 within the two-hour timeframe to the state agency. Resident #42 stated the Certified Nursing Assistant (CNA) hurt her/his wrist during care and requested the CNA not come back. The findings included: The facility admitted Resident #42 with [DIAGNOSES REDACTED]. Record review on 9/7/17 at 3pm revealed a Nurse's Note dated 5/21/17 that stated Resident reports that CNA hurt her (his) wrist and made a verbal request for the CNA not to come back. There was no evidence of the staff identifying and reporting the allegation of abuse to administration. There was evidence that the CNA's assignment was changed. There was no evidence that the CNA was immediately suspended to protect all residents until the investigation of alleged abuse was completed. There was no evidence in the record that the responsible party was notified of the allegation of abuse, nor that the physician was made aware of the hurt wrist. Review of the facility [MEDICATION NAME] and Incident Log on 9/9/17 at 3pm revealed no evidence of the occurrence being investigated or reported. The facility policy for Abuse Identification on 9/9/17 at 4pm stated the following: 1. In attempting to identify a type of abuse or neglect, the following will be examined as to whether it is suspicious and may constitute abuse or neglect: Abuse Indicator includes complaints of pain with or without injury. 2. Any person hearing a complaint of any signs and symptoms of abuse or mistreatment should report it to the Administrator as soon as possible. The Administrator will inform and designate other staff members to assist in the investigation as indicated. The facility policy on Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property on 9/9/17 stated the following: 1. The Administrator or his or her designee should notify the state agency, the patient's attending physician, and the patient's designated representative of any allegation, suspicion, or identified occurrence involving patient abuse, neglect, or mistreatment. 2. The state agency should be notified within 2 hours after the allegation is made if the events upon which the allegation is based involves abuse. During an interview on 9/7/17 at 7:45pm, the Director of Nursing verified that there was no investigation or reporting of the incident because s/he was not aware of the allegation.

Based on record review, interview, and review of the facility policy entitled Occurrences the facility failed to implement its policy for reporting and investigating occurrences that result in an injury for one of seven residents reviewed for Abuse/Neglect. Resident #10 had an accident on 9/27/2016 that resulted in an injury and was not reported to the state Survey and Certification Agency. The findings included: Cross refer to F323 as it relates to an injury with Resident #10 that the facility did not report to the state Survey and Certification Agency. Review of the facility's Incident Log revealed an incident on 9/27/2016 that resulted in an injury to Resident #10. Review of Resident Incident Report dated 9/27/2016 revealed that Resident #10 was sitting in his/her wheelchair when Licensed Practical Nurse (LPN) #1 assisted the resident with propping up her/his feet, the wheelchair was not locked and the residents chair became unstable causing the resident to fall back and hit her/his head. Review of the facility Policy and Procedure on Occurrences revealed the section on Investigation and Follow-up stated, The Administrator or designee will complete the supervisor investigation on all occurrences, and report to the appropriate state agency and/or other external agencies according to law. This documentation is to be typed on the patient/resident care software occurrence report follow up section. The Administrator's findings will include, but not limited to: -Interview findings. -Was abuse ruled out, if abuse was noted list in detail type of abuse and who was involved, date of when report was completed, date external agencies were notified, etc. -When the physician and responsible party was notified. -List any education and/or corrective action related to the occurrence. During an interview with the surveyor on 03/16/2017 at 12:34 PM, the Interim Administrator stated that it is the facility's policy to collect statements from all staff that are involved in an incident. The Interim Administrator stated that only one witness statement was collected for the incident on 9/27/16 involving Resident #10.

Based on record review, observation and interview, the facility failed to assure the service provided by the facility meet professional standards of quality. Services were provided that resulted with an injury to Resident #10; one of one residents reviewed for accidents. Resident #3 had a significant weight loss and a pressure ulcer that was not monitored by the facility. During interview with the facility Interim Administrator and Interim Director of Nursing it was revealed that the facility was not having weekly IDT meetings to monitor resident's with significant weight loss, wounds, etc. Two of twelve residents reviewed for professional standards. The findings included: Review of the facility's Incident Log revealed an incident on 9/27/2016 that resulted in an injury to Resident #10. Review of Resident Incident Report dated 9/27/2016 revealed that Resident #10 was sitting in his/her wheelchair when Licensed Practical Nurse (LPN) #1 assisted the resident with propping up her/his feet, the wheelchair was not locked and the residents chair became unstable causing the resident to fall back and hit her/his head. Further review revealed no evidence of documentation of State Survey and Certification Agency notification. The Resident Incident Report contained only one witness statement from LPN #2 and no statement from the nurse that provided the service that resulted in an injury. During an interview with the surveyor on 03/16/2017 at 12:34 PM, the Interim Administrator stated that it is the facility's policy to collect statements from all staff that are involved in an incident. The Interim Administrator stated that only one witness statement was collected for the incident on 9/27/2016 involving Resident #10. Review of the facility Policy and Procedure on Occurrences revealed the section on Investigation and Follow-up stated, The Administrator or designee will complete the supervisor investigation on all occurrences, and report to the appropriate state agency and/or other external agencies according to law. This documentation is to be typed on the patient/resident care software occurrence report follow up section. The Administrator's findings will include, but not limited to: -Interview findings. -Was abuse ruled out, if abuse was noted list in detail type of abuse and who was involved, date of when report was completed, date external agencies were notified, etc. -When the physician and responsible party was notified. -List any education and/or corrective action related to the occurrence. Review of the facility investigation report revealed LPN #2's witness statement which stated that LPN #1 noticed that Resident #10 had [MEDICAL CONDITION] in his/her lower extremities and informed LPN #2 the s/he was going to elevate Resident #10's legs. LPN #1 attempted to raise the residents legs up by placing her/his legs on the sofa. LPN #2 heard a noise and noticed Resident #10 lying on his/her back on the floor. The wheelchair was tipped over. LPN #2 noticed that the resident had a raised area to the back of his/her head that was not discolored. The area was approximately the size of a quarter. The resident complained of pain and Tylenol was administered. The Physician and the resident's son were notified. Neurochecks were initiated and there was no change from his/her baseline. Ice was applied intermittently to the raised area on his/her head. After the resident was assessed we noted the wheelchair had not been locked. I discussed with LPN #1 the need to lock the wheel prior to attempting to raise the resident's legs. Review of Resident #10's Care Plan dated 5/31/2016 revealed a history of falls. The Care Plan stated, Potential for injury from falls related to cognitive loss, poor safety awareness, dementia, functional limitations, bladder incontinence, use of meds that can alter alertness. In an interview with the surveyor on 3/15/2017 at 10:15 AM, Certified Nursing Assistant (CNA) #1 stated that Resident #10 cannot propel her/himself in a wheelchair and s/he was assisted by staff to get from the residents room to the day room to watch television. Observation on 3/15/2017 at 2:44 PM, revealed Resident #10 sitting in a wheelchair in the day room watching television. The wheelchair wheels were not locked and there were no foot rests on the wheelchair. Observation on 3/16/2017 at 10:13 AM, revealed Resident #10 sitting in a wheelchair in the day room watching television. The wheelchair wheels were not locked and there were no foot rests on the wheelchair. Review of the Minimum Data Set ((MDS) dated [DATE] revealed that the resident required extensive assistance with bed mobility, transfer, and locomotion. The MDS also revealed that the resident's balance was not steady and s/he was only able to stabilize with staff assistance. In an interview with the surveyor on 03/29/2017 at 12:40 PM, LPN #1 stated that the resident looked uncomfortable in his/her wheelchair so s/he was going to transfer the resident from the wheelchair to the sofa in the day room. LPN #1 stated that s/he tilted the resident's wheelchair backwards to move it forward because the resident's feet were touching the floor and s/he did not want to injure the resident's feet. When s/he tilted the wheelchair backwards, s/he fell to the floor with the resident and the wheelchair falling on top of him/her. LPN #1 stated that the resident hit his/her head on the floor. The LPN #1 stated that s/he thought the resident could help with the transfer and that the resident was a one person assist. Resident #3 was admitted to the facility on [DATE] with a Stage 3 pressure ulcer to the sacrum, surgical wound to the right middle chest, malignant neoplasm of the lung, [MEDICAL CONDITION] and dysphagia. Resident #3 discharged from the facility on 7/26/16 to another facility. Review of Resident #3's Yearly Weight Record Form revealed an entry on 6/20/16 - 143 #, 7/5/16 - 138 # and 7/22/16 - 125.6 #. There were no additional weights recorded for Resident #3. Resident #3's weight loss between 6/20/16 and 7/22/16 was 12 % which indicated a significant weight loss. There was no documentation in the medical record that Resident #3's physician and responsible party were notified of the resident's significant weight loss. Review of Resident #3's Departmental Narrative Notes revealed no documentation related to the resident's weight loss or pressure ulcer measurements. Review of the Nutritional Progress Notes revealed one entry by the Registered Dietitian (RD) on 6/14/16. The note indicated Resident #3 had a Stage 3 pressure ulcer to the sacrum and a surgical wound to the right middle chest. There was no weight documented in the Nutritional Progress Note dated 6/14/16. Review of the Physician's Interim Orders dated 6/15/16 revealed an order for [REDACTED]. Review of Resident #3's June 2016 and July 2016 Medication Administration Record [REDACTED]. Review of the facility's Weight Monitoring Program revealed new admissions initial weight and height will be obtained and documented on the Yearly Weight Record Form within 24 hours of admission. New admissions will be weighed weekly times four weeks and/or until weight is stable. The policy indicated re-weights must be obtained on all weights that show a weight loss of 5% or more. Re-weights must be obtained and documented within 24 hours of prior weight. Review of the facility's Weight Monitoring Program revealed a significant weight change is defined as 5% loss in one month. For a significant weight loss: add to weekly weights, add to colored napkin program, weekly weight team documentation, update care plan, and update interventions as needed. Further review of the facility's Weight Monitoring Program revealed the facility will have a Master Weight Book that will be maintained by the Weight Program Coordinator. The Master Weight Book contents include: Yearly Weight Record for each patient/resident, copy of weight program policy, weekly weight lists with meeting signatures of the weight team and the Colored Napkin List. Review of Resident #3's care plan revealed potential for alteration in nutrition was identified as a problem area. Interventions and approaches were listed on the care plan and included to weigh resident per protocol. The resident's care plan was not updated to reflect the significant weight loss. Review of Resident #3's Admission Body Audit dated 6/8/16 revealed documentation of a Stage 3 pressure ulcer to the sacrum with slough present. There were no measurements of the wound noted. Review of Resident #3's medical record revealed there was no Wound Observation and Assessment Form completed for the stage 3 pressure ulcer on the resident's sacrum. Review of the facility's Wound Observation and Assessment Documentation policy revealed the wound observation and documentation form is completed with each dressing change. Wound assessment and documentation is completed weekly and when there is significant change using the Documentation of Wound Observation and Assessment Form. Wound measurements are completed when there is a significant change in wound status and weekly by the registered nurse. The nurse will complete the documentation as follows: enter resident's name, type of wound, document anatomical location, date and sign each wound observation and assessment on each line, wound measurements are completed when there is a significant change in wound status and weekly by the registered nurse. In an interview with the surveyor on 3/14/17 at approximately 8:55 AM, the Interim DON (director of nursing) stated they are supposed to weigh new admissions weekly x 4 weeks. If there is weight loss, wounds, etc. the resident should be addressed at the IDT (interdisciplinary team) meeting. The Interim DON stated there were no additional weights for Resident #3, other than the 3 listed on the Yearly Weight Record Form. The Interim DON also stated that all appointments, changes in condition and notification should be documented in the Narrative Notes. The Interim DON stated there is an IDT team, but they were not meeting at that time. Every new admission should be discussed weekly, and the MD (medical doctor) and RD should be notified of weight loss. The Interim DON stated the IDT would document in the Narrative Notes for the residents they discuss. The Interim DON confirmed there was no documentation of the wound measurements/ monitoring for Resident #3. They use the Wound Observation and Assessment Form to document wound monitoring. The Interim DON stated meal intake should be documented in the computer. Resident #3's meal intake was not documented in the computer. The Interim DON stated s/he was not sure why the resident's meal intake was not documented. S/he looked at 4 residents the surveyor requested meal intake for and none of the residents had meal intake documented. CNAs document meal intake for residents in the computer. They have a corporate registered dietitian who comes to this building approximately 4 times a month. The Interim DON stated the nurse should sign as administered or circle and note refusal on back of the MAR for the prostat. The Interim DON stated MDS can update the care plan, they are part of the morning rounds, or nursing can update the care plan. The Interim DON stated Resident #3's weight loss should have been documented on the care plan when it was identified. In an interview with the surveyor on 3/16/17 9:45 AM, the Interim Administrator and Interim DON stated they had a team meeting yesterday, it was a planning meeting. They will actually start next Wednesday with meeting and discussing residents. The Interim DON has been at the facility for 19 months and they haven't had IDT meetings to talk about the residents during that time. They started a nurses meeting last week. The CDM (certified dietary manager) sends the weights to the RD, if there is a weight loss or gain, the resident should be reweighed. The reweighs have not been done as they should be.

Based on record review, observation and interview the facility failed to ensure that the resident's environment remained as free from potential/actual hazards as was possible and provide supervision to prevent accidents. Resident #10 sustained an injury when her/his wheelchair turned over backwards during care. One of one resident injury reviewed during the survey. The findings included: Review of the facility's Incident Log revealed an incident on 9/27/2016 that resulted in an injury to Resident #10. Review of Resident Incident Report dated 9/27/2016 revealed that Resident #10 was sitting in his/her wheelchair when Licensed Practical Nurse (LPN) #1 assisted the resident with propping up her/his feet, the wheelchair was not locked and the residents chair became unstable causing the resident to fall back and hit her/his head. Further review revealed no evidence of documentation of State Survey and Certification Agency notification. The Resident Incident Report contained only one witness statement from LPN #2 and no statement from the nurse that provided the service that resulted in an injury. During an interview with the surveyor on 03/16/2017 at 12:34 PM, the Interim Administrator stated that it is the facility's policy to collect statements from all staff that are involved in an incident. The Interim Administrator stated that only one witness statement was collected for the incident on 9/27/2016 involving Resident #10. Review of the facility Policy and Procedure on Occurrences revealed the section on Investigation and Follow-up stated, The Administrator or designee will complete the supervisor investigation on all occurrences, and report to the appropriate state agency and/or other external agencies according to law. This documentation is to be typed on the patient/resident care software occurrence report follow up section. The Administrator's findings will include, but not limited to: -Interview findings. -Was abuse ruled out, if abuse was noted list in detail type of abuse and who was involved, date of when report was completed, date external agencies were notified, etc. -When the physician and responsible party was notified. -List any education and/or corrective action related to the occurrence. Review of the facility investigation report revealed LPN #2's witness statement, which stated that LPN #1 noticed that Resident #10 had edema in his/her lower extremities and informed LPN #2 the s/he was going to elevate Resident #10's legs. LPN #1 attempted to raise the residents legs up by placing her/his legs on the sofa. LPN #2 heard a noise and noticed Resident #10 lying on his/her back on the floor. The wheelchair was tipped over. LPN #2 noticed that the resident had a raised area to the back of his/her head that was not discolored. The area was approximately the size of a quarter. The resident complained of pain and Tylenol was administered. The Physician and the resident's son were notified. Neurochecks were initiated and there was no change from his/her baseline. Ice was applied intermittently to the raised area on his/her head. After the resident was assessed we noted the wheelchair had not been locked. I discussed with LPN #1 the need to lock the wheel prior to attempting to raise the resident's legs. Review of Resident #10's Care Plan dated 5/31/2016 revealed a history of falls. The Care Plan stated, Potential for injury from falls related to cognitive loss, poor safety awareness, dementia, functional limitations, bladder incontinence, use of meds that can alter alertness. In an interview with the surveyor on 3/15/2017 at 10:15 AM, Certified Nursing Assistant (CNA) #1 stated that Resident #10 was unable to propel her/himself in a wheelchair and was assisted by the staff to get from the residents room to the day room to watch television. Observation on 3/15/2017 at 2:44 PM, revealed Resident #10 sitting in a wheelchair in the day room watching television. The wheelchair wheels were not locked and there were no foot rests on the wheelchair. Observation on 3/16/2017 at 10:13 AM, revealed Resident #10 sitting in a wheelchair in the day room watching television. The wheelchair wheels were not locked and there were no foot rests on the wheelchair. Review of the Minimum Data Set ((MDS) dated [DATE] revealed that the resident required extensive assistance with bed mobility, transfer, and locomotion. The MDS also revealed that the resident's balance was not steady and s/he was only able to stabilize with staff assistance. In an interview with the surveyor on 03/29/2017 at 12:40 PM regarding the incident, LPN #1 stated that the resident looked uncomfortable in his/her wheelchair so s/he was going to transfer the resident from the wheelchair to the sofa in the day room. LPN #1 stated that s/he tilted the resident's wheelchair backwards to move it forward because the resident's feet were touching the floor and s/he did not want to injure the resident's feet. When s/he tilted the wheelchair backwards, s/he fell to the floor with the resident and the wheelchair falling on top of him/her. LPN #1 stated that the resident hit his/her head on the floor. The LPN #1 stated that s/he thought the resident could help with the transfer and that the resident was a one person assist.

Based on review of facility files and interviews, the facility failed to ensure that residents are free from verbal, physical and mental abuse. Resident #4 had a substantiated allegation of abuse by a Certified Nurse Aide (CNA). CNA #1 allegedly verbally and physically abused Resident #4. One of one resident reviewed for abuse. The findings included: The facility submitted an allegation of physical abuse on 10/1/14 for Resident #4 and Certified Nurse Aide (CNA) #1 that indicated the resident reported to staff that CNA #1 came into the room rambling about the bible with a bible in the resident's face. Resident #4 stated CNA #1 covered his/her mouth causing a discolored area to the left lower lip. Review of the facility's Five-Day Follow-Up Report dated 10/6/14 indicated Resident #4 reported CNA #1 came into his/her room and shoved him/her against the wall in the wheelchair. Resident #4 was able to turn on the call light but CNA #1 canceled it. Resident #4 started to yell and CNA #1 placed his/her hand over the resident's mouth and told him/her to shut up. CNA #2 entered the room and observed the incident at which time CNA #1 ran out. Resident #4 stated that CNA #2 allegedly said, you better stop this and get out of here or you'll go back to jail. Resident #4 was noted to be emotionally upset and anxious. The facility's investigation concluded that the allegation of abuse was substantiated. Review of the Incident Witness Statement for Resident #4 on 10/1/14 at approximately 6:30 AM revealed the resident's statement indicated s/he was sitting in the doorway of their room looking down the hallway. CNA #1 came down the hall and forcefully grabbed Resident #4's wheelchair and pushed the resident back into the room. CNA #1 went into the bathroom. Resident #4 rolled his/her wheelchair to the bedside and turned on the call light. CNA #1 told the resident s/he was not going anywhere because the CNA was there to save them. CNA #1 came out of the bathroom and noticed the call light on and went over and turned it off. CNA #1 grabbed the chair and shoved the resident up against the room door. While doing this the CNA was ranting about the bible, mumbling and chanting while shoving the bible in the resident's face and hitting the resident with the bible. CNA #1 then got down on his/her knees in front of the resident and put a plastic bag on the resident's lap and laid his/her head down again ranting about hate and the bible. CNA #1 then got up shoving the bible and a glass at the resident telling the resident to shut up. Resident #4 yelled for help at that time CNA #1 covered the resident's mouth with his/her hand and kept saying shut up. CNA #1 then got up off the floor and put his/her head against the resident's face touching his/her head and nose to the resident's head and nose. During this time the resident was in the wheelchair shoved against the door. CNA #2 came to the door trying to get in and wrestled with the door and entered the room. CNA #1 seemed to calm down some when CNA #2 entered the room. CNA #2 said "You better stop this and get out of here or you'll go back to jail." CNA #3's facility-obtained statement dated 10/1/14 indicated s/he heard a loud noise around 7:17 AM. CNA #3 went to clock in and then assisted another resident. CNA #3 went to Resident #4's room and could not get in the door. Someone said something from behind the door. As CNA #3 was walking down the hall s/he saw CNA #1 going out the back door. CNA #3 went to the resident door and the resident was in front of the door with a bloody mouth. Resident #4 stated someone had him/her pinned down and had fingers in his/her mouth. In an interview with the surveyor on 11/12/14 at approximately 10:10 AM, CNA #3 confirmed the accuracy of his/her statement. CNA #3 stated that CNA #2 said something like "I have it" from behind the door. As CNA #3 was going to report to the nurse s/he saw CNA #1 come out of the room and go out a side door. CNA #2 also came out of the room. CNA #3 went to the resident's room and saw Resident #4 had blood around his/her mouth. CNA #3 stated Resident #4 indicated CNA #1 pushed the resident into his/her room. CNA #1 pushed the chair against the door and had the resident cornered with a bible in his/her face. Resident #4 tried to yell out and CNA #1 covered his/her mouth and that is when their mouth got hurt. Licensed Practical Nurse (LPN) #2's facility-obtained statement dated 10/1/14 indicated that upon entering the room s/he noted Resident #4 in the bathroom cleaning blood from his/her lips. In an interview with the surveyor on 11/12/14 at approximately 10:20 AM, LPN #2 confirmed the accuracy of his/her statement. LPN #2 stated CNA #3 came to him/her and said to come to Resident #4's room because the resident was bleeding and the resident said CNA #1 had hit him/her. LPN #2 stated that Resident #4 was upset that whole day talking about CNA #1. Resident #4 was fearful that CNA #1 would come back. LPN #1's facility-obtained statement dated 10/1/14 indicated s/he was called to the room and witness Resident #4 stating that CNA #1 put his/her hand in the resident's mouth while speaking about religion and calling the resident Satan. Resident #4 appeared to have an injury to the left side of bottom lip and the resident was at the sink wiping blood off his/her lip. LPN #1 was in the resident's room at approximately 5:30 AM to administer medications and did not notice an injury to the resident's lip at that time. Review of the Behavior Management Log Form for Resident #4 revealed the form was started on 10/2/14 at 7 AM and completed through 10/3/14 at 6 AM. Review of Resident #4's Body Audit Form dated 10/2/14 revealed the resident was noted to have a discoloration to the left corner of their mouth. Review of Resident #4's Skilled Daily Nurses Note dated 10/1/14 revealed one entry at 4:15 PM "Resident alert and able to make needs known. No c/o (complaints of) pain or discomfort voiced @ this time." Review of the Skilled Daily Nurses Note dated 10/2/14 revealed on entry that indicated "Resident alert and able to make needs know. No c/o pain or discomfort voiced thus far this shift. No behaviors noted." Review of the Occupational Therapy Note dated 10/1/14 revealed Resident #4's therapy was held due to the resident feeling ill and not being able to participate with occupational therapy services that day. Review of the Physical Therapy Note dated 10/1/14 indicated the resident did not feel well and requested no further therapy.

On the days of the Recertification, Complaint and Extended Survey, based on full and/or limited record reviews and interviews, and review of the facility policy for Elopement Risk Assessments, the facility failed to ensure that 12 of 13 cognitively impaired, self mobile, sampled residents reviewed had accurate and/or timely elopement assessments. Residents # 17, 19, 22, 23, 26, 27, 28, 29, 30, 32, 33 and 34 had missing and/or inaccurate assessments, thus providing inaccurate baselines from which to develop viable plans of care to maintain the safety of the residents. The findings included: The facility admitted Resident #19 on [DATE] with the following Diagnoses: [REDACTED]. Review of the closed record on [DATE] revealed a form entitled "Elopement Risk Assessment Form" dated [DATE]. This form indicated that the resident scored an "8" and that the resident was not at risk for elopement. There were no other Elopement Risk Assessments done until [DATE]. There was no assessment noted or provided for January or April of 2012. Review of the Policy for the Elopement Risk Assessment revealed "Guideline: All patients/residents will be assessed on admission, re-admission, significant change in condition, and at least quarterly. Patients/resident who score (18) or more, interventions should be promptly be (sic) put in place. If patient/resident verbally express the desire to go home, prior history of elopement, history of leaving center without needed supervision or informing staff, these be (sic) on behavior management." The facility admitted Resident #32 on [DATE] with [DIAGNOSES REDACTED]. Record review on [DATE] revealed an Elopement Risk Assessment Form had been completed on [DATE] with a score of "6", indicating the resident was not at risk. The next Elopement Risk Assessment was dated [DATE] which also had a score of 6. There was no assessment for March, 2012. Review of the MDS (Minimal Data Set) revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 6, indicating severe cognitive impairment on assessments with ARDs (Assessment Reference Date) of [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. She was also coded as having wandering behaviors 1 to 3 days during the 7 day look-back period on the [DATE] assessment. No other assessments had wandering behaviors documented. The resident was inaccurately coded requiring extensive assistance with locomotion on the unit on ,[DATE], ,[DATE], ,[DATE] and [DATE]. She was also inaccurately coded requiring limited assistance with locomotion on the unit on the [DATE] and [DATE] assessments and extensive assistance for locomotion off the unit on all assessments. Review of the Nurses Notes revealed the following notations: [DATE] 21:00 PM..."confused, crying to go home, talking to deceased husband" [DATE] 11:00 PM..."propels self about, c/o (complains of) looking for her father and her husband" [DATE] 09:30 AM..."able to push self around...seemed confused asking to go downstairs to meet with her husband" [DATE] 08:30 AM..."very confused and restless this am. Many attempts to leave out of facility, resident move about well in wheelchair w/o (without) assistance" [DATE] 07:05 AM..."wandering around facility looking for family." [DATE] 3:10 PM ..."Cont(inue) to wander & (and) look for family members & request to go home." [DATE] 08:00 AM..."able to push self around...states that she needs to sit at the front entrance to wait on her ride." [DATE] 09:00 AM..."seems confused stating that she is going home today and needs to call son for pick up time." [DATE] 08:30 AM..."moving about well in wheelchair w/o assistance...rolling around in hallways, going in other people's rooms stating "I am trying (to) find the exit so that I can find my husband...constantly needing reorienting & redirecting." [DATE] (un-timed) ..."propels self about halls, occ(asionally) in attempt to seek exit from facility." [DATE] 10:30 PM..."able to wheel self around." [DATE] 12:10 AM..."awake (with) confusion, stated 'I want to go home, this is not my home.' " The resident was moved to another room in early March and there were no further documented incidents of exit seeking or attempts to leave. Interviews on [DATE] at approximately 3:45 PM with the Transitional Care Unit Manager and the Skilled Care Unit Manager indicated that the nurses were responsible for completing the "Elopement Risk Assessment" and that the assessments were to be completed at least quarterly. The facility admitted Resident #27 on [DATE] with [DIAGNOSES REDACTED]. Record review and interview revealed that this resident, identified by the facility as cognitively impaired and self mobile, had missing and/or inaccurate elopement assessments. Record review on [DATE] at approximately 10:20 a.m. revealed that an Elopement Risk Assessment Form was completed on [DATE]. There was no evidence that any elopement assessments were completed since [DATE]. Review of the assessment form revealed that the resident was coded with a score of "2" related to "Disoriented x 3/ Dementia". Review of the admission Nurses Notes revealed that the resident was "alert with periods of confusion noted" and should have been coded a "4" related to "Intermittent Confusion". Review of the assessment form also revealed that the "Pertinent Diagnosis" section was not coded to include dementia. During interview an [DATE] at 2:30 p.m., Registered Nurse #4 reviewed the medical record and confirmed that there were no quarterly assessments in the thinned record. At the same time, Licensed Practical Nurse #2 confirmed that there were no quarterly assessments in the resident's active medical record. The facility admitted Resident #23 on [DATE] and readmitted her on [DATE] with [DIAGNOSES REDACTED]. Record review and interview revealed that this resident, identified by the facility as cognitively impaired and self mobile, had missing and/or inaccurate elopement assessments. Record review on [DATE] at approximately 3:30 p.m. revealed that Elopement Risk Assessment Forms were completed on [DATE] and [DATE]. There was no evidence that elopement assessments were completed upon readmission on [DATE] or quarterly. During an interview on [DATE] at 11:35 a.m., the Director of Nursing reviewed the medical record and confirmed that there were no readmission or quarterly assessments. Review of the [DATE] assessment form revealed that the resident was coded a "0" for "Predisposing Condition" but should have been coded a "2" for "new admission". During an interview on [DATE] at 11:35 a.m., the Director of Nursing reviewed the Elopement Risk Assessment Form and confirmed that it was not coded accurately. In response to a concern identified during the survey process, an Elopement Risk Assessment Form was completed on [DATE]. Review of the [DATE] and [DATE] assessments revealed discrepancies in the coding for the areas of ambulation, sensory deficits, and medications. During an interview on [DATE] at 11:55 a.m., the Director of Nursing confirmed that the [DATE] Elopement Risk Assessment Form was not coded accurately. The facility admitted Resident #33 on [DATE] with [DIAGNOSES REDACTED]. Record review and interview revealed that this resident, identified by the facility as cognitively impaired and self mobile, had missing and/or inaccurate elopement assessments. Review of the Skilled Daily Nurses Notes on [DATE] at approximately 9:30 AM revealed that the resident was able to propel himself in the wheelchair. Staff consistently documented him as wandering in and out of other resident rooms and up and down the hallways. Cognitive status was noted as variable in the notes, ranging from alert and oriented X(times) 3 to being oriented to person only. Increased confusion was noted during the evening hours. The resident was not easily redirected, became agitated, restless, and/or combative. On [DATE], the resident stated, "I'm looking for my wife." Review of the [DATE] Interim Admission Care Plan revealed problems of Dementia and [MEDICAL CONDITION] medication ([MEDICATION NAME]) administration. A "Behavior Problem" related to "wandering" was added to the plan on [DATE]. The [DATE] initial interdisciplinary Care Plan noted that the resident had "difficulty with recall and orientation...Advanced dementia with behaviors...requires use of an antipsychotic (medication)...Confusion increases at night with wandering on hall, searching for room...decreased safety awareness." On [DATE], a problem was added: "Resident becomes combative at times when attempting to redirect..."(last reviewed and updated on [DATE]). Interventions included redirection and the offering of nonspecific activities of interest. Record review revealed that the facility Elopement Risk Assessment Forms (2006) were completed on [DATE] and [DATE]. No other Elopement Risk Assessments were noted in the record. There was no evidence that the quarterly elopement assessment had been completed for ,[DATE]. Review of the [DATE] and [DATE] assessment forms revealed that the resident was inaccurately coded with a score of "0" related to "Ambulation" for "Chair or Bed Bound". He should have been coded a "2" for "Ambulatory with assistive device". The [DATE] Fall Risk Assessment and Elopement Risk Assessment noted the resident with "Poor vision (with or without glasses)". The Case Mix Director's Assessment Tool (dated ,[DATE], ,[DATE], and [DATE]) noted that the resident wore a hearing aid. Hearing loss was not addressed on the [DATE] Elopement Risk Assessment. The [DATE] Elopement Risk Assessment did not address any "Sensory Deficits" (hearing/vision loss). The "Summary of interventions and explanation of actions:" was blank on both elopement assessments. The facility admitted Resident #17 on [DATE] with [DIAGNOSES REDACTED]. Record review on [DATE] at approximately 3:35 pm revealed "Elopement Risk Assessment" had been completed on [DATE] and [DATE]. Per facility policy, the assessment was to be completed on a quarterly basis. The facility admitted Resident #22 on [DATE] with [DIAGNOSES REDACTED]. Record review on [DATE] at approximately 2:15 pm revealed "Elopement Risk Assessment" had been completed on [DATE] and [DATE]. Per facility policy the assessment was to be completed on a quarterly basis. The facility admitted Resident #26 on [DATE] with [DIAGNOSES REDACTED]. Record review on [DATE] at approximately 12:15 pm revealed "Elopement Risk Assessment" had been completed on [DATE], [DATE], [DATE], [DATE], and [DATE]. Per facility policy the assessment was to be completed on a quarterly basis. The facility admitted Resident #28 on [DATE] with [DIAGNOSES REDACTED]. Record review on [DATE] at approximately 10:45 am revealed an Elopement Risk Assessment had been completed on [DATE]. Per facility policy the assessment was to be completed on a quarterly basis. The facility admitted Resident #34 on [DATE] with [DIAGNOSES REDACTED]. Record review on [DATE] at approximately 3:15 PM revealed a Quarterly Minimum Data Set Assessment with an Assessment Reference Date of [DATE] which documented a Brief Interview for Mental Status score of 10, indicating moderate cognitive impairment. According to the assessment, Resident #34 used a wheelchair/walker and did not wander. She required extensive assistance with one person assist for locomotion off the unit and limited assistance with one person assist for locomotion on the unit. Review of the Elopement Risk Assessments revealed the resident had an assessment done [DATE] . The next Elopement Risk Assessment in the record was dated [DATE]. The Elopement Risk Assessments were not conducted quarterly as per the facility policy. The facility admitted Resident #29 on [DATE] with [DIAGNOSES REDACTED]. Review of the Initial Minimum (MDS) data set [DATE] revealed he had a history of [REDACTED]. An initial Elopement Risk Assessment was dated [DATE]. There were no further Elopement Risk Assessments in the chart. The facility admitted Resident #30 on [DATE] with [DIAGNOSES REDACTED]. The initial Elopement Risk Assessment was dated [DATE] There were no further Elopement Risk Assessments in the chart. Cross Refer: CFR 483.20(d)(3) F-280 related to facility failure to update care plans for Residents #19 and #35 for wandering and/or exit seeking behavior. Cross Refer: CFR 483.25(h) F-323 related to facility failure to provide adequate supervision to prevent accidents/incidents for 2 of 2 sampled residents reviewed for elopement. The facility was not aware that Residents #19 and #35 had exited the building multiple times until they were found outside of the building without supervision. Failure by the facility to supervise these residents adequately placed these residents, as well as other cognitively impaired self mobile residents at risk for elopement and serious harm. Risk assessments were missing and/or inaccurate, care plans were not developed and interventions implemented to address potential elopement risk. Furthermore there were no environmental systems in place to maintain the safety of the residents. Cross Refer: CFR 483.75 F-490 related to facility administration failure to ensure that policies and procedures were developed and/or implemented to maintain the safety of cognitively impaired self-mobile residents at risk for elopement. Administration failed to identify residents at risk for elopement, failed to develop viable interventions, and failed to ensure adequate supervision was provided to prevent elopement. Management failed to ensure timely intervention when two residents (Residents #19 and #35) repeatedly exhibited wandering/exit-seeking behavior and exited the building multiple times without direct supervision. Cross Refer: CFR 483.75(i) F-501 related to facility failure to keep the Medical Director informed of policies/procedures and incidents relating to elopement so as to enable him to provide clinical guidance, oversight, and have input in review/revision of policies as needed. The Medical Director did not routinely review incident reports and was unaware of repeated instances of elopement by Residents #19 and #35. CFR 483.75(o)(1) F-520 related to facility failure to identify the potential for harm in a timely manner and implement a viable plan of action via the Quality Assurance process to address cognitively impaired, self-mobile residents with wandering/exit-seeking behaviors. The Administrator was notified on [DATE] at 2:45 PM that Substandard Quality of Care and/or Immediate Jeopardy had been identified after consulting with the State Agency. The facility submitted an Allegation of Compliance (AOC), which was reviewed and approved by the survey team in conjunction with the State Agency on [DATE] at 11:30 AM. The immediacy was removed prior to exit from the facility on [DATE] after (1) review of the ongoing training content and participation and staff interviews related to that training were conducted, (2) evidence was presented that the medical record audits (with findings) were completed, (3) evidence was presented that Elopement Risk Assessments were completed on all active residents, (4) wander books were located with pictures/descriptions of Residents identified as high risk placed at the reception desk and at each nursing station, and (5) all doors were checked and found to be secure or manned. CFR 483.20(b)(1) Resident Assessment F-272 was lowered to a scope and severity of "E". The facility will be in compliance when an acceptable Plan of Correction is submitted and a follow up visit is conducted to determine that the facility has implemented their Plan of Correction.

On the days of the Recertification, Complaint and Extended Survey, based on record reviews and interviews, the facility failed to update care plans for 2 of 4 sampled residents with documented wandering and/or exit seeking behaviors. Care Plans for sampled Residents #19 and #35 were not updated related to wandering and/or exit seeking behavior. The findings included: The facility admitted Resident #19 on 10/12/11 with the following Diagnoses: [REDACTED]. Review of the closed record on 6/13/12 revealed a care plan dated 10/23/11 which had no wandering/exit seeking problems noted. The care plan addressed the resident's cognitive status due [MEDICAL CONDITION]( [MEDICAL CONDITION]) with [DIAGNOSES REDACTED]." On 12/4/11, the Nurses Notes stated "Resident in depressed mood state 'I want to go home'. Resident out of wheel chair refusing to sit back down, attempting to hit nurse in face." On 12/5/11, the Nurses Note at 10 AM stated, "resident alert and oriented to person and place, resident refusing to stay in chair will walk around room and pack belongings as if she is leaving to go home." On 12/8/11, "resident ambulating out of room with walker and no assistance. Yells at staff to get out of her room". On 12/15/11, "resident out of wheel chair refusing to sit down. Ambulating in hall with walker and without assistance". On 12/22/11, "resident alert and oriented to person and place, getting out of wheel chair to ambulate down the hall without assistance. Further review of Nurse's Notes showed multiple entries of resident behavior escalating to yelling, striking out at staff and attempting to leave the facility. The care plan was updated on 1/25/12 and stated: "will refuse care, therapy, medications, will curse at times especially at family." The Care Plan was not updated related to wandering or exit seeking. Nurse's Notes dated 3/7/12, stated: "Resident seen ambulating hall with walker shortly thereafter nurse was notified that resident is outside, resident was encouraged to return to the unit". The care plan was not updated to include wandering and exit seeking behaviors until the resident was found outside in the parking lot on 4/18/12. The Care Plan, updated on 4/18/12, stated: "resident is on behavior management program for potential aggressive behavior secondary to significant cognitive deficits related to [MEDICAL CONDITION]. Has tendency to wander in hallways". The interventions included: "1. place patient in area where constant observation is possible 2. alert staff to patients wandering behavior. 3. Provide diversional activities for patient like watching TV or movies. 4. Approach patient in calm accepting manner. 5. If resident is wandering away from unit, instruct staff to stay with resident, converse and gently persuade resident to walk back to designated area with them. 6. Assign staff to account for patient whereabouts at all times. 7. Note which exits patient favors for potential elopement from center, alert staff working near those areas. 8. Remind patient and visitors of need to inform staff if they are leaving the designated area with the patient. 9. Social Service to evaluate patient for change in behavior 10. Activity staff to visit and provide diversional activities 11. Monitor and document patient behavior. Report increase in negative findings to the physician. 12. Review patient drug regime, evaluate for dosage reduction and document findings. 13. Redirection 14. TV (television) works appropriately." The resident was found outside the building again on 5/24/12 and 6/7/12. The Care Plan intervention dated 5/24/12 was: "15 minute checks on resident times 72 hours". However, no documentation was found related to every fifteen minute checks for 5/24/12. The Care Plan intervention added 6/7/12 was: "one on one, medications per MD orders". The Nurses Note dated 6/8/12 stated: "one on one continues with every 15 minute checks/observation. Resident in room at this time." On 6/8/12 at 5 PM, Nurses Note stated: "Resident transferred out of facility." The facility admitted Resident # 35 on 6-24-11with [DIAGNOSES REDACTED]. Resident # 35 was discharged from the facility on 4-23-12. Review of the Medical Record on 6-13-12 revealed a computer generated care plan dated 7-6-11 which did not have a problem related to wandering or exit seeking behaviors. Additionally, there was a separate undated Care Plan form which did not address Resident #35's individual behaviors until updated on 3-15-12. The problem stated: "Will wander through out the building and will exit seek at times." approaches listed were: "Observe for restlessness/exit seeking behaviors. If exit seeking, stay with patient. Do not argue with patient. Provide diversional activities if possible. Redirect as needed." A hand written/undated entry listed under Approach included: "Q (every) 15 min (minutes) (checks) as indicated. Place 1-1 as indicated. Redirect as needed." A problem dated 3/15/12 read: "Continues to ask to go to Sumter. Wanders up and down hall with occasional exit seeking behavior noted." The approach added was: "Family meeting and aware of exit seeking behavior. Strongly encourage resident transfer to locked unit, family desires Resident to remain at facility." There were no entries on this part of the care plan that addressed the exit seeking behaviors exhibited/documented on 10-27-11, 1-5-12, 1-18-12, 1-27-12, 1-31-12, 2-3-12, 2-7-12, 2-11-12, or 4-11-12. An Against Medical Advice Acknowledgment Form was in Resident #35's chart, which stated: "Uni (health) and the physician have informed me that the benefits that I might be expected to receive from the services offered include: Skilled nursing services excluding wander/elopements protection and the risks of the offered services are: Mr (Resident) has the potential to exit this facility. Uni-Health has offered the medical advice to transfer to our facility with wander guard locks. My reason(s) for refusing is: He has adjusted where he is and family has decided not to move him again. We understand the risk." This was signed and dated on 1-20-12 by the Responsible Party. Cross Refer: CFR 483.20(b)(1) F-272 related to facility failure to ensure that 12 of 13 cognitively impaired sampled residents reviewed had accurate and/or timely elopement assessments. Residents # 17, 19, 22, 23, 26, 27, 28, 29, 30, 32, 33 and 34 had missing and/or inaccurate assessments, thus providing inaccurate baselines from which to develop viable plans of care to maintain the safety of the residents. Cross Refer: CFR 483.25(h) F-323 related to facility failure to provide adequate supervision to prevent accidents/incidents for 2 of 2 sampled residents reviewed for elopement. The facility was not aware that Residents #19 and #35 had exited the building multiple times until they were found outside of the building without supervision. Failure by the facility to supervise these residents adequately placed these residents, as well as other cognitively impaired self mobile residents at risk for elopement and serious harm. Risk assessments were missing and/or inaccurate, care plans were not developed and interventions implemented to address potential elopement risk. Furthermore there were no environmental systems in place to maintain the safety of the residents. Cross Refer: CFR 483.75 F-490 related to facility administration failure to ensure that policies and procedures were developed and/or implemented to maintain the safety of cognitively impaired self-mobile residents at risk for elopement. Administration failed to identify residents at risk for elopement, failed to develop viable interventions, and failed to ensure adequate supervision was provided to prevent elopement. Management failed to ensure timely intervention when two residents (Residents #19 and #35) repeatedly exhibited wandering/exit-seeking behavior and exited the building multiple times without direct supervision. Cross Refer: CFR 483.75(i) F-501 related to facility failure to keep the Medical Director informed of policies/procedures and incidents relating to elopement so as to enable him to provide clinical guidance, oversight, and have input in review/revision of policies as needed. The Medical Director did not routinely review incident reports and was unaware of repeated instances of elopement by Residents #19 and #35. CFR 483.75(o)(1) F-520 related to facility failure to identify the potential for harm in a timely manner and implement a viable plan of action via the Quality Assurance process to address cognitively impaired, self-mobile residents with wandering/exit-seeking behaviors. The Administrator was notified on 06/13/12 at 2:45 PM that Substandard Quality of Care and/or Immediate Jeopardy had been identified after consulting with the State Agency. The facility submitted an Allegation of Compliance (AOC), which was reviewed and approved by the survey team in conjunction with the State Agency on 6/14/12 at 11:30 AM. The immediacy was removed prior to exit from the facility on 6/14/12 after (1) review of the ongoing training content and participation and staff interviews related to that training were conducted, (2) evidence was presented that the medical record audits (with findings) were completed, (3) evidence was presented that Elopement Risk Assessments were completed on all active residents, (4) wander books were located with pictures/descriptions of Residents identified as high risk placed at the reception desk and at each nursing station, and (5) all doors were checked and found to be secure or manned. The immediacy was removed prior to exit from the facility on 6/14/12 and CFR 483.20(d)(3) Resident Assessment/Care Plan F-280 was lowered to a scope and severity of "E". The facility will be in compliance when an acceptable Plan of Correction is submitted and a follow up visit is conducted to determine that the facility has implemented their Plan of Correction.

On the days of the Recertification, Complaint and Extended Survey, based on observations, record reviews and interviews, the facility failed to provide adequate supervision to prevent accidents/incidents for 2 of 2 sampled residents reviewed for elopement. The facility was not aware that Residents #19 and #35 had exited the building multiple times until they were found outside of the building without supervision. Failure by the facility to supervise these residents adequately placed these residents, as well as other cognitively impaired self mobile residents at risk for elopement and serious harm. Risk assessments were missing and/or inaccurate, care plans were not developed and interventions implemented to address potential elopement risk. Furthermore, there were no environmental systems in place to maintain the safety of the residents. In addition the facility failed to limit resident access to hazardous substances randomly observed in residents' rooms. The findings included: The facility admitted Resident #19 on 10/12/11 with the following Diagnoses: [REDACTED]. Review of the closed record on 6/13/12 revealed the following nurse's notes: 11/30/11 "Resident is exhibiting exit seeking behaviors." 12/3/11 "shouting at nurses station 'I am going home'." 12/4/11 "Resident in depressed mood state ' I want to go home'." 12/5/11 10 AM "resident alert and oriented to person and place, resident refusing to stay in chair will walk around room and pack belongings as if she is leaving to go home." There were multiple entries of the resident refusing medication, attempting to ambulate without assistance and resisting care throughout the Nurse Notes from 12/1/11 through discharge on 6/8/12. 3/7/12 "Resident seen ambulating hall with walker shortly thereafter nurse was notified that resident is outside, resident was encouraged to return to the unit. Resident became aggressive and stated that 'she is going home and has to wait outside for her son'." 4/18/12 "Resident observed outside in parking lot ambulating without assistive device. Staff trying to encourage resident to come inside. Resident refuses, staff continues to encourage and walk with resident until resident agrees to come inside." 5/24/12 "Patient found outside of facility in front at curb. Patient was trying to leave. Staff gathered around patient who was very unsteady and had left building without walker. Her gait unsteady and she refused to return to the building with much coaxing. Able to place patient in wheelchair and return to building." 6/2/12 "Resident was observed by staff exit seeking, resident had all her bed covers trying to walk out doors in sitting area near nurse station." 6/7/12 "Resident walked out of facility and was observed by an associate walking out near Longtown Road. Resident was brought back to facility without injury." Further review of the closed medical record revealed a care plan dated 10/21/11 with updates on 1/25/12 and 2/14/12 which did not include problem/intervention for wandering and or exit seeking behaviors. The Care Plan for wandering and exit seeking was initiated on 4/19/12 with the following interventions: "1. place patient in area where constant observation is possible 2. alert staff to patients wandering behavior. 3. Provide diversional activities for patient like watching TV or movies. 4. Approach patient in calm accepting manner. 5. If resident is wandering away from unit, instruct staff to stay with resident, converse and gently persuade resident to walk back to designated area with them. 6. Assign staff to account for patient whereabouts at all times. 7. Note which exits patient favors for potential elopement from center, alert staff working near those areas. 8. Remind patient visitors of need to inform staff if they are leaving the designated area with the patient. 9. Social Service to evaluate patient for change in behavior 10. Activity staff to visit and provide diversional activities 11. Monitor and document patient behavior. Report increase in negative findings to the physician. 12. Review patient drug regime, evaluate for dosage reduction and document findings. 13. Redirection 14. TV works appropriately." An added Care Plan intervention dated 5/24/12 was "15 minute checks on resident times 72 hours." No documentation was found related to the every fifteen minute checks for 5/24/12. A Care Plan intervention was added 6/7/12 "one on one, medications per MD orders" A nurse's note dated 6/8/12 stated: "one on one continues with every 15 minute checks/observation. Resident in room at this time." On 6/8/12 at 5 PM, a nurse's note stated: "Resident transferred out of facility." On 6/7/12 an Elopement Risk Assessment Form was completed and the resident scored 8 indicating low or no risk. The Policy/Guideline for the Elopement Risk Assessment provided by the facility on 6/13/12 stated: "All patients/residents will be assessed on admission, re-admission, significant change in condition, and at least quarterly. Patients/ resident who score (18) or more, interventions should be promptly be (sic) put in place. If patient/resident verbally express the desire to go home, prior history of elopement, history of leaving center without supervision or informing staff, these need to be on behavior management." The Behavior Management Program Documentation Form was initiated on 4/19/12 (greater than 4 months after the resident began exhibiting exit seeking behavior) by the Social Service Director (SSD). The form indicated by a check mark that "Communications Sheet in ADL (Activities of Daily Living) Book" on 4/19/12. Registered Nurse (RN) # 2 and Licensed Practical Nurse (LPN) #3 stated "There should have been a behavioral check sheet in front of her MAR's (Medication Administration Record) that tells us what kind of behavior to monitor for." During the interview with the SSD on 6/13/12 at 10:00 AM, she stated, "The behavior management program is just redirecting and watching the resident. We meet and talk about the resident and the things we will do. This information is kept in the SSD office and a behavior monitoring sheet is placed at the unit". The Nurse Consultant confirmed on 6/14/12 that a Behavioral Monitoring Sheet was not in the resident's medical record. During an interview with the Director of Health Services (DHS) on 6/13/12 at 10:20 AM, she stated, "If they (residents) score high on the elopement risk assessment or exhibit behaviors of exit-seeking that can't be redirected, then we try to transfer them to a sister facility." When asked how long before a transfer is initiated, she stated, "Every one is different." When asked about Resident #19, she had no answer as to how or why it took so long for the transfer (greater than 6 months, while exhibiting behaviors from 11/11 through 6/12). The DHS provided copies of incident reports for the previous 6 months which included the elopements on 4/18/12, 5/24/12 and 6/7/12. On 6/14/12 at 9:40 AM, the DHS stated, when asked about the elopement on 3/7/12, "I could not find one." When asked about the person who should review the reports, she stated, "The Unit Manager should review incident reports within 24 hours. Then it comes to me. But we review incident reports in the morning meeting, Monday through Friday, and discuss interventions." Observation at 10:30 AM on 6-11-12 revealed that the exit near the therapy department had no alarm system to alert staff to residents exiting the building. A staff member seated at the reception desk stated that the doors automatically locked at 7 PM and remained so until 7 AM. She also stated that this area was not routinely manned, she was just there "for a few minutes to do some work". During an interview on 6-13-12 at 1:20 PM, the Receptionist stated that the front desk (main entrance) was manned from 8:30 AM to 6 PM, at which time the doors were locked by Housekeeping. After this time, visitors could enter the building from the unlocked side doors on both sides of the building, directly adjacent to the community areas near the nurses stations. Random observations on 6/11/12 and 6/12/12 revealed residents, staff and/or visitors entering and exiting the building without hindrance. Observation of all exit doors on 6/13/12 revealed all doors were locked except the front extrance, manned by the receptionist. The Administrator was interviewed on 6/13/12 at 2:00 PM regarding the doors and how they were secured. He stated, "The doors are locked by a timer from a different location. Yesterday, they were working on the timer so the doors were unlocked. The doors are unlocked during the day except the two doors in the back of the building. The lobby door is locked at 6:00 PM when the receptionist leaves. During the day the doors are unlocked and people can go in or out." He also stated, "This facility was not designed for people that wander and exit seekers." The facility admitted Resident #35 on 6-24-11 with [DIAGNOSES REDACTED]. Resident #35 was discharged from the facility on 4-23-12. Review of the medical record revealed the following nurse's note dated 10-27-11: "Dietary employee brought to this nurse attention that this resident was on the ground; outside of the building (The rear parking lot). Upon assessment; the resident was in a sitting position; wheelchair on it's side, mobility monitor intact." The next attempts to elope were not documented in the Nurses' Notes, but only in the Social Service Progress Notes dated 1-5-12: "Made aware by staff of resident attempt to exit building. Easily redirected, intervention in place." 1-18-12: "Pt (patient) observed seeking exit, Sister facility #1 and #2 awaiting bed offer." The following Nurses' Notes indicated additional exit seeking behavior: 1-27-12 "Cont's (continues) to ask for a ride to Sumter." 1-31-12 "Resident trying to elope through the storm doors located near the dinning room. Resident was able to open the first set of doors and redirection unsuccessful. The resident opened the 2nd set of storm doors and went down the ramp." 2-3-12 "Continues to ask staff/visitors for a ride to Sumter." 2-7-12 "Resident noted by staff to be wandering and exit seeking. It has become increasingly harder to prevent him from going out the exit door and once he's out, harder to coach back inside." 2-11-12 "Resident attempted several times to exit the facility at the front door by theatre. Nurse observed resident rolling through double doors at the end of the 600 hall. Resident angry and combative." 4-11-12 "Resident noted to be rolling in w/c (wheelchair) out the door and a family member was leaving out at the same time with door open. Resident was stopped outside side door of SCU (Skilled Care Unit). Resident was immediately put on 15 min(ute) monitoring checks." The Behavior Management Communication Sheet form supplied for Resident #35 was dated 3-29-12 (6 months after documented elopement and continued exit seeking behavior) and offered only 4 interventions when wandering behavior occurred: 1. Redirect, 2. Conversation -Allow resident to vent, 3. Invite to Activities, and 4. Offer distraction. The facility reviewed this resident in the Behavior Management meetings on 4-5-12, 4-12-12, and 4-19-12, but no additional interventions were put in place. The Behavioral Symptoms monitoring tools completed by the staff identified Resident #35 as a wandering resident only for the months of January and April. January 31st was not documented and April 11 was completed with "0" for wandering behaviors, although the Nurses Notes and the Social Service Notes describe exit seeking behavior on those days. An Against Medical Advice Acknowledgment Form was in Resident #35's chart, which stated: "Uni (health) and the physician have informed me that the benefits that I might be expected to receive from the services offered include: Skilled Nursing services excluding wander/elopements protection, and the risks of the offered services are: Mr (Resident) has the potential to exit this facility. UniHealth has offered the medical advise to transfer to our facility with wander guard locks. My reason for refusing is: He has adjusted where he is and family has decided not to move him again. We understand the risk." This was signed and dated on 1-20-12 by the Responsible Party. During a tour of resident rooms on 06-11-12 at approximately 10:00 am, medications were observed on the bureau in room 301. These medications included a partially used tube of Muscle Rub Cream 1.25 ounce, an open bottle labeled Aleve 24 tablets, an open bottle labeled Aspirin 81 milligrams 16 tabs and a partially used tube of Athlete's Foot Anti-fungal Cream 1.25 ounce. In room 303, a partially used tube of Xenaderm Ointment was observed in the bathroom by the sink. Additional observations of room 301 on 06-11-12 at 12:20 PM and 6:08 PM, showed that the bottle labeled Aleve had been removed, but the other medications remained. In room 303 at 12:15 PM and at 2:40 PM, the medication was observed to be in the bathroom by the sink. Additional observations were made on the second day of the survey (06-12-12) and the medications in rooms 301 and 303 had been removed. Staff were unable to report where the medications had gone. It is unknown how long the medications had been in the rooms. A copy of the facility's policy/procedure entitled Medication Administration: Oral Medications was obtained. It stated: "Never leave a medication in a patient/resident's room without orders to do so." On 6-12-12 at approximately 5:45 PM, the Facility Administrator stated that Compliance Rounds were conducted at the facility daily by management staff. The policy/procedure regarding compliance rounds was requested on 06-12-12 and provided on 06-13-12 at 10:35 AM. The policy/procedure stated "Compliance rounds have been instituted to provide quality resident/patient care at all times; therefore maintaining compliance with state and federal rules and regulations." The policy/procedure specifically stated to "check for over-the-counter drugs (oral and topical)." Copies of the Compliance Rounds forms for the month of June were obtained on 06-13-12 at 2:51 PM. Several dates (June 2, 9, 10, 2012) had no reports. Rooms 301 and 303 were recorded only on June 01, 04, 05, 06, 07, 2012 indicating that no room checks were done for 4 days prior to the survey entry date. There were no notations of medications being in either room. The Compliance Rounds policy/procedure (Issued: May, 2001) stated "Compliance rounds will be made at least once per shift by Charge Nurse Supervisor/Staff Nurse utilizing the Compliance Rounds Guide and Form." It also stated "A Compliance Rounds Sheet will be kept at the nurses station on a clipboard." The policy/procedure listed 11 areas and items to be checked. The policy/procedure contained a COMPLIANCE ROUNDS form which contained a column labeled 'PROBLEM', a column labeled 'CORRECTED BY', and a 'Maintenance/Housekeeping Issues-Work Orders Written' section. There were spaces for Date, Time, Unit and Signature of Person Making Compliance Rounds at the top of the form under the title COMPLIANCE ROUNDS. The copies of Compliance Round forms from the Compliance Rounds book currently in use, were different from the form in the policy/procedure. Interview with the Director of Nursing, and the Senior Care Partner on 06-13-12 at 2:20 PM revealed that the form in the Compliance Rounds book had been used for sometime. The form had a specific item: "26. No meds / ointments at bedside." There are no dates to indicate when this form was created or put into use. The Director of Nursing and Senior Care Partner reported the form was completed daily by a member of the management team who was assigned to a group of rooms. The policy and procedure stated Compliance Rounds would be done once per shift by a Charge Nurse Supervisor/Staff Nurse. Registered Nurse #5, who was present during the interview, stated she had not seen a Compliance Form at the nurses station. On 06-13-12 at 6:30 PM, Registered Nurse #5 identified 3 residents present in the facility who were cognitively impaired and self mobile, with potential access to the hazardous substances. Cross Refer: CFR 483.20(b)(1) F-272 related to the facility failure to ensure that 12 of 13 cognitively impaired sampled residents reviewed had accurate and/or timely elopement assessments. Residents # 17, 19, 22, 23, 26, 27, 28, 29, 30, 32, 33 and 34 had missing and/or inaccurate assessments, thus providing inaccurate baselines from which to develop viable plans of care to maintain the safety of the residents. Cross Refer: CFR 483.20(d)(3) F-280 related to facility failure to update care plans for Residents #19 and #35 for wandering and/or exit seeking behavior. Cross Refer: CFR 483.75 F-490 related to facility administration failure to ensure that policies and procedures were developed and/or implemented to maintain the safety of cognitively impaired self-mobile residents at risk for elopement. Administration failed to identify residents at risk for elopement, failed to develop viable interventions, and failed to ensure adequate supervision was provided to prevent elopement. Management failed to ensure timely intervention when two residents (Residents #19 and #35) repeatedly exhibited wandering/exit-seeking behavior and exited the building multiple times without direct supervision. Cross Refer: CFR 483.75(i) F-501 related to facility failure to keep the Medical Director informed of policies/procedures and incidents relating to elopement so as to enable him to provide clinical guidance, oversight, and have input in review/revision of policies as needed. The Medical Director did not routinely review incident reports and was unaware of repeated instances of elopement by Residents #19 and #35. CFR 483.75(o)(1) F-520 related to facility failure to identify the potential for harm in a timely manner and implement a viable plan of action via the Quality Assurance process to address cognitively impaired, self-mobile residents with wandering/exit-seeking behaviors. The Administrator was notified on 06/13/12 at 2:45 PM that Substandard Quality of Care and/or Immediate Jeopardy had been identified after consulting with the State Agency. The facility submitted an Allegation of Compliance (AOC), which was reviewed and approved by the survey team in conjunction with the State Agency on 6/14/12 at 11:30 AM. The immediacy was removed prior to exit from the facility on 6/14/12 after (1) review of the ongoing training content and participation and staff interviews related to that training were conducted, (2) evidence was presented that the medical record audits (with findings) were completed, (3) evidence was presented that Elopement Risk Assessments were completed on all active residents, (4) wander books were located with pictures/descriptions of Residents identified as high risk placed at the reception desk and at each nursing station, and (5) all doors were checked and found to be secure or manned. The immediacy was removed prior to exit from the facility on 6/14/12 and CFR 483.25(h) Quality of Care/Free of Accident Hazards/Supervision F-323 was lowered to a scope and severity of "E". The facility will be in compliance when an acceptable Plan of Correction is submitted and a follow up visit is conducted to determine that the facility has implemented their Plan of Correction.

On the days of the Recertification, Extended, and Complaint Survey, based on full and/or limited record reviews and interviews, facility administration failed to ensure that policies and procedures were developed and/or implemented to maintain the safety of cognitively impaired self-mobile residents at risk for elopement. Administration failed to identify residents at risk for elopement, failed to develop viable interventions, and failed to ensure adequate supervision was provided to prevent elopement. Management failed to ensure timely intervention when two residents (Residents #19 and #35) repeatedly exhibited wandering/exit-seeking behavior and exited the building multiple times without direct supervision. The findings included: On 6/13/12, review of the facility policy entitled Elopement Prevention (Revised 2/99) revealed that all residents/patients would be assessed for elopement history or potential and would be placed on the Behavior Management Program. The Policy stated: "The primary goal of the healthcare center related to the resident at risk for elopement is to provide resident/patient safety utilizing the least restritive means available. Therefore, door alarms activated 24 hours a day and/or 15 minute location checks by specifically assigned staff will be used to monitor resident/patient activity." Record review and interviews revealed that Resident #19 initially exhibited exit-seeking behavior (as documented in the Nurses Notes) on 11-30-11. Staff documented multiple instances of the resident expressing the desire to go home or definitively stating she was going home, as well as packing her belongings. She actually exited the building unaccompanied/unsupervised on 3-7-12, 4-18-12, 5-24-12, and 6-7-12. No Care Plan or Behavior Management Plan was developed until 4-19-12 related to wandering/exit-seeking behavior. Although a new intervention of 15 minute checks was added to the Care Plan following the third incident of elopement (5-24-12), there was no evidence to indicate this was done. Even after the fourth actual incident of elopement on 6-7-12, the resident was still not assessed "at risk" for elopement per the facility documentation (Elopement Risk Assessment). Record review and interviews revealed that Resident #35 exited the building unaccompanied/unsupervised on 10-27-11. Staff documented at least seven instances of exit-seeking behavior in January and February of 2012. No Care Plan was developed until 3-15-12 related to wandering/exit-seeking behavior. The Behavior Management Plan was not initiated until 3-29-12. After exiting the building on 4-11-12, 15 minute checks were initiated (and continued an undetermined period of time) per Nurses Notes, but there was no evidence that any other interventions were put in place to ensure the safety of the resident until his discharge on 4-23-12 (twelve days later). Environmental systems were not in place to maintain the safety of cognitively impaired self-mobile residents who exhibited wandering/exit-seeking behavior. Random observations on 6/11/12 and 6/12/12 revealed residents,staff and/or visitors entering and exiting the building without hindrance. The Administrator was interviewed on 6/13/12 at 2:00 PM regarding the doors and how they were secured. He stated, "The doors are locked by a timer from a different location. Yesterday, they were working on the timer so the doors were unlocked. The doors are unlocked during the day, except the two doors in the back of the building. The lobby door is locked at 6:00 PM when the receptionist leaves. During the day the doors are unlocked and people can go in or out." He also stated, "This facility was not designed for people that wander and/or exit seekers". The Administrator confirmed that he was aware that two residents had gotten outside on several occasions. He stated, "I had one family member sign an Against Medical Advice (AMA) form because the family did not want to move (Resident #35) to our sister facility, which has secure doors and a locked unit." The management staff knowingly disregarded the safety of the resident when they had the family sign an AMA form alleviating the facility from responsibility should the resident continue the exhibited behavior. Management staff failed to identify their inability to meet the resident's needs at that time and failed to put additional interventions in place to do so until he was discharged . During an interview with the Director of Health Services (DHS) on 6/13/12 at 10:20 AM she stated, "If they (residents) score high on the elopement risk assessment or exhibit behaviors of exit-seeking that can't be redirected, then we try to transfer them to a sister facility." When asked how long before a transfer is initiated, she stated, "Every one is different." When asked about Resident #19, the DHS had no answer as to how or why it took so long to transfer the resident. The DHS provided incident reports on Resident #19 for the elopements on 4/18/12, 5/24/12 and 6/7/12. On 6/14/12 at 9:40 AM, when asked about the elopement on 3/7/12, the DHS stated, "I could not find one." Additionally, no incident report was provided for 4-11-12 when Resident #35 exited the building. When asked about the person who should review the reports, the DHS stated, "The Unit Manager should review incident reports within 24 hours. Then it comes to me. But we review incident reports in the morning meeting Monday through Friday and discuss interventions." There was no evidence provided to indicate that nursing management or administration were reviewing the reports and ensuring that appropriate interventions were implemented. Cross Refer: CFR 483.20(b)(1) F-272 related to facility failure to ensure that 12 of 35 sampled residents reviewed had accurate and/or timely elopement assessments. Residents # 17, 19, 22, 23, 26, 27, 28, 29, 30, 32, 33 and 34 had missing and/or inaccurate assessments, thus providing inaccurate baselines from which to develop viable plans of care to maintain the safety of the residents. SHOULD THE UNIVERSE BE 12 OF 13 COG IMP RES??? Cross Refer: CFR 483.20(d)(3) F-280 related to facility failure to update care plans for Residents #19 and #35 for wandering and/or exit seeking behavior. Cross Refer: CFR 483.25(h) F-323 related to facility failure to provide adequate supervision to prevent accidents/incidents for 2 of 2 sampled residents reviewed for elopement. The facility was not aware that Residents #19 and #35 had exited the building multiple times until they were found outside of the building without supervision. Failure by the facility to supervise these residents adequately placed these residents, as well as other cognitively impaired self mobile residents at risk for elopement and serious harm. Risk assessments were missing and/or inaccurate, care plans were not developed and interventions implemented to address potential elopement risk. Furthermore there were no environmental systems in place to maintain the safety of the residents. Cross Refer: CFR 483.75(i) F-501 related to facility failure to keep the Medical Director informed of policies/procedures and incidents relating to elopement so as to enable him to provide clinical guidance, oversight, and have input in review/revision of policies as needed. The Medical Director did not routinely review incident reports and was unaware of repeated instances of elopement by Residents #19 and #35. CFR 483.75(o)(1) F-520 related to facility failure to identify the potential for harm in a timely manner and implement a viable plan of action via the Quality Assurance process to address cognitively impaired, self-mobile residents with wandering/exit-seeking behaviors. The Administrator was notified on 06/13/12 at 2:45 PM that Substandard Quality of Care and/or Immediate Jeopardy had been identified after consulting with the State Agency. The facility submitted an Allegation of Compliance (AOC), which was reviewed and approved by the survey team in conjunction with the State Agency on 6/14/12 at 11:30 AM. The immediacy was removed prior to exit from the facility on 6/14/12 after (1) review of the ongoing training content and participation and staff interviews related to that training were conducted, (2) evidence was presented that the medical record audits (with findings) were completed, (3) evidence was presented that Elopement Risk Assessments were completed on all active residents, (4) wander books were located with pictures/descriptions of Residents identified as high risk placed at the reception desk and at each nursing station, and (5) all doors were checked and found to be secure or manned. The immediacy was removed prior to exit from the facility on 6/14/12 and CFR 483.75 Administration F490 was lowered to a scope and severity of "E".

On the days of the Recertification, Complaint and Extended Survey, the facility failed to keep the Medical Director informed of policies/procedures and incidents relating to elopement so as to enable him to provide clinical guidance, oversight, and have input in review/revision of policies as needed. The Medical Director did not routinely review incident reports and was unaware of repeated instances of elopement by Residents #19 and #35. The findings included: During an interview on 6-13-12 at 5:15 PM, the Medical Director was asked if he was aware that the facility's exit doors were unlocked from 7 AM to 7 PM and that there were no methods in place to alert the staff should a resident exit the building. The Medical Director stated that he was not aware, but that he "thought the facility was pretty secure." He stated that he had been notified of Resident #19 exiting the building the previous week, but he had been unaware of any prior incidents. The Medical Director stated that the reason Resident #19 was discharged was because of the elopement. He stated he had spoken with the Director of Nurses, at length, about the incident to determine how it had happened and what they could do to prevent it from happening again. They determined that the best thing was to transfer the resident to a sister facility because they were better equipped to care for this type of resident. He acknowledged that another resident had been transferred there in the past because the environment was more appropriate for wandering/exit-seeking residents. When asked if he was aware of any other cognitively impaired, residents exiting the building unattended, he stated he was not. When asked what the facility had in place to keep cognitively impaired, self-mobile residents from leaving the building, he stated he was not aware of specific policies. When asked how these residents were kept safe, the Medical Director stated that the staff screened residents prior to admission, discussed identified at-risk residents in the morning meeting, had mandatory meetings and inservices about elopement, and discussed interventions. When asked about the Quality Assessment and Assurance (QAA) meetings, the Medical Director stated that he participated on a monthly basis. He did not recall discussing any concerns related to elopement. When asked if he participated in policy and procedure development, the Medical Director stated, "Corporate does that." He stated that he and the facility staff did discuss policies/procedures in the monthly QAA to "try to do better and initiate changes. All changes have to go through corporate." He stated that the usual procedure was: "Here's a new policy. I don't get much of a vote on it." He stated he had no knowledge of the elopement policy. Review of the Nursing Services Policy and Procedure Manuals on 6-14-12 revealed that the Letter of Adoption, indicating review and approval of the policies "as being adequate in meeting the needs of this healthcare center," were not signed by the Medical Director. Review of Resident Incident Reports for the previous six months, on 6-13-12, revealed that they were only signed by the nurse completing them. Three incidents were noted for Resident #19 involving elopement (4-18-12, 5-24-12 and 6-7-12). There was no evidence that any of the reports were reviewed by the Medical Director. During the interview, the Medical Director stated that he did not recall signing incident reports. He stated he was in the facility weekly on Thursdays for periods of 7-8 hours and that "We go over everything related to the facility." Again it was clarified that he had not been made aware of any elopement issues except for the previous week related to Resident #19 and he did not routinely review/sign incident reports. Related to residents who do get out of the building, the Medical Director stated he would expect the proper authorities to be notified as needed, "make sure it doesn't happen again, and make sure the residents are safe." If staff were unable to keep a cognitively impaired resident from exiting the building, he stated he would expect one-to-one care to be provided "at the resident's side at all times." He did not know if this actually happened with Resident #19. Review of the Medical Director Agreement revealed that his services included "3.3 Implementing resident care policies; 3.4 Coordinating medical care in Facility..." ADDENDUM A noted "Performance Requirements: ...1.1. Participate in developing resident care policies,...1.2. Participate in meetings...to discuss clinical and administrative issues, specific patient care problems,...2.2. Implement resident care policies regarding accidents and incidents...5.6 Help the facility administrator and professional staff ensure a safe...environment for residents...by reviewing incident reports, identifying hazards to health and safety, providing corrective strategies, and advise about improving the environment." Cross Refer: CFR 483.20(b)(1) F-272 related to facility failure to ensure that 12 of 13 cognitively impaired sampled residents reviewed had accurate and/or timely elopement assessments. Residents # 17, 19, 22, 23, 26, 27, 28, 29, 30, 32, 33 and 34 had missing and/or inaccurate assessments, thus providing inaccurate baselines from which to develop viable plans of care to maintain the safety of the residents. Cross Refer: CFR 483.20(d)(3) F-280 related to facility failure to update care plans for Residents #19 and #35 for wandering and/or exit seeking behavior. Cross Refer: CFR 483.25(h) F-323 related to facility failure to provide adequate supervision to prevent accidents/incidents for 2 of 2 sampled residents reviewed for elopement. The facility was not aware that Residents #19 and #35 had exited the building multiple times until they were found outside of the building without supervision. Failure by the facility to supervise these residents adequately placed these residents, as well as other cognitively impaired self mobile residents at risk for elopement and serious harm. Risk assessments were missing and/or inaccurate, care plans were not developed and interventions implemented to address potential elopement risk. Furthermore there were no environmental systems in place to maintain the safety of the residents. Cross Refer: CFR 483.75 F-490 related to facility administration failure to ensure that policies and procedures were developed and/or implemented to maintain the safety of cognitively impaired self-mobile residents at risk for elopement. Administration failed to identify residents at risk for elopement, failed to develop viable interventions, and failed to ensure adequate supervision was provided to prevent elopement. Management failed to ensure timely intervention when two residents (Residents #19 and #35) repeatedly exhibited wandering/exit-seeking behavior and exited the building multiple times without direct supervision. CFR 483.75(o)(1) F-520 related to facility failure to identify the potential for harm in a timely manner and implement a viable plan of action via the Quality Assurance process to address cognitively impaired, self-mobile residents with wandering/exit-seeking behaviors. The Administrator was notified on 06/13/12 at 2:45 PM that Substandard Quality of Care and/or Immediate Jeopardy had been identified after consulting with the State Agency. The facility submitted an Allegation of Compliance (AOC), which was reviewed and approved by the survey team in conjunction with the State Agency on 6/14/12 at 11:30 AM. The immediacy was removed prior to exit from the facility on 6/14/12 after (1) review of the ongoing training content and participation and staff interviews related to that training were conducted, (2) evidence was presented that the medical record audits (with findings) were completed, (3) evidence was presented that Elopement Risk Assessments were completed on all active residents, (4) wander books were located with pictures/descriptions of Residents identified as high risk placed at the reception desk and at each nursing station, and (5) all doors were checked and found to be secure or manned. The immediacy was removed prior to exit from the facility on 6/14/12 and CFR 483.75(i) Medical Director F501 was lowered to a scope and severity of "E". The facility will be in compliance when an acceptable Plan of Correction is submitted and a follow up visit is conducted to determine that the facility has implemented their Plan of Correction.

On the days of the Recertification, Extended, and Complaint Survey, based on full and/or limited record reviews, and interviews, the facility failed to identify the potential for harm in a timely manner and implement a viable plan of action to address cognitively impaired, self-mobile residents with wandering/exit-seeking behaviors. The facility failed to accurately evaluate the effectiveness of interventions implemented for Resident #21 relative to his pressure ulcers and lack of treatment. The findings included: Record review and interviews revealed that facility staff were aware of cognitively impaired, self-mobile residents with wandering/exit-seeking behaviors in the facility for over six months, a concern that became increasingly evident when Residents #19 and #35 repeatedly exhibited these behaviors and actually exited the facility. There was no evidence that a plan of action was developed in a timely manner to accurately identify residents at risk for elopement and implement systems/interventions to ensure their safety. There was no evidence that a process was implemented/followed to ensure that residents were being accurately assessed for elopement risk in a timely manner, that Care Plans and Behavior Management Programs were developed and reviewed/updated with additional interventions in a timely manner, and that behavior monitoring tools were accurate. During an interview on 6-13-12-at 5:15 PM, when asked about the Quality Assessment and Assurance (QAA) meetings, the Medical Director stated that he participated on a monthly basis. He did not recall discussing any concerns related to elopement. During an interview on 6/14/12 at 1:45 PM regarding the Quality Assurance (QA) process, the Administrator stated, "We started a wandering and exit-seeking PI (Performance Improvement) last week, but we haven't had time to work on it yet." Review of the facility's Process Improvement Policy revealed, under "PI Committee", that they "meet monthly to evaluate issues and determine opportunities for improvement." The facility admitted Resident #21 on 2/1/12 with [DIAGNOSES REDACTED]. Review of the Performance Improvement Plan provided via fax by the facility on 6/18/12 revealed information that the facility was aware of problems related to "Proper documentation of wounds, skin audits, and verification of proper treatment for [REDACTED]. According to the plan, the goal was to do a "100% audit of inhouse wounds, body audits, careplans to ensure proper documentation per policy and procedure". The implementation date was 3/5/12. The date the plan was to be re-evaluated was 4/5/12 with a resolve date listed as 4/26/12. The facility QA process failed to identify concerns and/or to timely identify concerns with Resident #21's documentation and treatment of [REDACTED]. Record review and staff interviews during the survey failed to show that the facility was aware of any concerns with wound treatment for [REDACTED]. There was no evidence that the Performance Improvement Plan had identified this resident and implemented measures to address concerns with wound care for his sacrum and heels. Cross Refer: CFR 483.25(c) F314 related to facility failure to identify and initiate treatment for [REDACTED]. Cross Refer: CFR 483.20(b)(1) F-272 related to facility failure to ensure that 12 of 13 cognitively impaired sampled residents reviewed had accurate and/or timely elopement assessments. Residents # 17, 19, 22, 23, 26, 27, 28, 29, 30, 32, 33 and 34 had missing and/or inaccurate assessments, thus providing inaccurate baselines from which to develop viable plans of care to maintain the safety of the residents. Cross Refer: CFR 483.20(d)(3) F-280 related to facility failure to update care plans for Residents #19 and #35 for wandering and/or exit seeking behavior. Cross Refer: CFR 483.25(h) F-323 related to facility failure to provide adequate supervision to prevent accidents/incidents for 2 of 2 sampled residents reviewed for elopement. The facility was not aware that Residents #19 and #35 had exited the building multiple times until they were found outside of the building without supervision. Failure by the facility to supervise these residents adequately placed these residents, as well as other cognitively impaired self mobile residents at risk for elopement and serious harm. Risk assessments were missing and/or inaccurate, care plans were not developed and interventions implemented to address potential elopement risk. Furthermore there were no environmental systems in place to maintain the safety of the residents. Cross Refer: CFR 483.75 F-490 related to facility administration failure to ensure that policies and procedures were developed and/or implemented to maintain the safety of cognitively impaired self-mobile residents at risk for elopement. Administration failed to identify residents at risk for elopement, failed to develop viable interventions, and failed to ensure adequate supervision was provided to prevent elopement. Management failed to ensure timely intervention when two residents (Residents #19 and #35) repeatedly exhibited wandering/exit-seeking behavior and exited the building multiple times without direct supervision. Cross Refer: CFR 483.75(i) F-501 related to facility failure to keep the Medical Director informed of policies/procedures and incidents relating to elopement so as to enable him to provide clinical guidance, oversight, and have input in review/revision of policies as needed. The Medical Director did not routinely review incident reports and was unaware of repeated instances of elopement by Residents #19 and #35. The Administrator was notified on 06/13/12 at 2:45 PM that Substandard Quality of Care and/or Immediate Jeopardy had been identified after consulting with the State Agency. The facility submitted an Allegation of Compliance (AOC), which was reviewed and approved by the survey team in conjunction with the State Agency on 6/14/12 at 11:30 AM. The immediacy was removed prior to exit from the facility on 6/14/12 after (1) review of the ongoing training content and participation and staff interviews related to that training were conducted, (2) evidence was presented that the medical record audits (with findings) were completed, (3) evidence was presented that Elopement Risk Assessments were completed on all active residents, (4) wander books were located with pictures/descriptions of Residents identified as high risk placed at the reception desk and at each nursing station, and (5) all doors were checked and found to be secure or manned. The immediacy was removed prior to exit from the facility on 6/14/12 and CFR 483.75(o)(1) Quality Assessment and Assurance (QAA) F-520 was lowered to a scope and severity of "E". The facility will be in compliance when an acceptable Plan of Correction is submitted and a follow up visit is conducted to determine that the facility has implemented their Plan of Correction.

On the days of the Recertification, Complaint and Extended Survey, based on record reviews and interviews, the facility failed to provide necessary treatment and services to promote healing for 1 of 6 sampled residents reviewed with pressure ulcers. The facility failed to identify and initiate treatment for [REDACTED]. The findings included: The facility admitted Resident #21 on 2/1/12 with [DIAGNOSES REDACTED]. The resident was transferred to the hospital on [DATE] and did not return to the facility. Record review on 6/12/12 at 11:38 AM revealed Nurses Notes dated 2/1/12 at 11:30 AM which stated Resident #21 was admitted to the facility from the hospital with a pressure ulcer noted to his sacrum. Review of the Admission/Nursing Evaluation Form revealed the resident had an open area to the sacrum measuring 3.5cm (centimeter) X (by) 4cm X .1cm. An order to treat this area was initiated on 2/1/12 and the treatment was discontinued on 2/15/12 when the area resolved. Review of the Braden Scale-For Predicting Pressure Sore Risk revealed that on 2/8/12, 2/15/12, 2/22/12, and 2/29/12, the resident scored a 16 which indicated a mild risk. Continued record review on 6/12/12 at 1:30 PM revealed weekly Body Audit Forms dated 2/6/12 and 2/13/12 which documented a "normal" sacrum. However,the Documentation of Wound Observation and Assessment Form dated 2/6/12 stated the resident's sacral wound measured 3cm X 4.1cm X .1 cm and did not document the wound healing until 2/15/12 when an order was received to discontinue the treatment. Further review of weekly Body Audit Forms dated 2/20/12 through 3/26/12 revealed documentation of a dressing "dry and intact " to sacrum (2/20/12) and documentation of an open area to the sacrum (2/27, 3/5, 3/12, 3/19, and 3/26) with no corresponding treatment in progress or order for treatment for [REDACTED]. Review of Daily Skilled Nurse's Notes on 6/12/12 at 12:50 PM revealed a note dated 3/28/12 at 7:30 PM that documented the resident as having been sent to the hospital for altered mental status. The Nurses Notes documented the resident's return on 3/29/12 at 1:10 AM and stated: "...Open area on sacrum- area cleanse (with) NS (Normal Saline) pat dry, apply [MEDICATION NAME] absorbent, change q (every) 4 days + PRN (As Needed)..." Review of the Body Audit Form dated 3/29/12 revealed notations of a new open area to the sacrum with a new treatment in progress. It included information relative to a new treatment order for the area and that the resident's RP (Responsible Party) had been notified on 3/29/12 at 7:00 AM. Review of documentation revealed no wound measurements were documented until 4/1/12. According to the Documentation of Wound Observation and Assessment Form, the sacral wound measured 1.4 cm X 0.5cm X 0.1cm on 4/1/12. Record review on 6/12/12 at approximately 2:15 PM revealed "Patient Visit Information" from the hospital dated 3/29/12 at 12:20 AM. The information stated to "...Please pay close attention to the early skin changes on his bilateral feet as they are close to becoming pressure ulcers. Please have patient evaluated by wound care. Turn frequently. Take direct pressure off his feet". Further review revealed Physician's Telephone Orders dated 3/29/12 that stated to "...Clean left heel with normal saline, pat dry. Apply [MEDICATION NAME] foam adhesive. Change q 4 days + PRN" and "Clean right heel with normal saline, Pat dry. Apply [MEDICATION NAME] foam adhesive. Change q 4 days + PRN". Review of the April 2012, cumulative orders revealed the orders for treatments to the resident's heels had been carried over to the April orders. There was no documentation found that showed the treatments to the heels had been done as ordered for the month of April (Every 4 days and PRN from 4/1/12 through 4/13/12). During an interview on 6/12/12 at 2:55 PM, Licensed Practical Nurse (LPN) #1 reviewed the Body Audit Forms and Wound Documentation/Treatment sheets. She verified that there were discrepancies in the documentation between the body audit sheets and the wound documentation. She stated the treatments to the sacrum were done from 2/1/12 through 2/15/12 and were not restarted until 3/29/12. The LPN stated she had not been informed that the sacral wound had re-opened after it had resolved and the order for treatment had been discontinued on 2/15/12. She verified the Physician's Telephone Order dated 3/29/12 for treatment to both heels. She also stated she would look in Medical Records to find documentation of the treatment to the heels for the month of April, but was unable to locate any documentation. During an interview on 6/12/12 at 3:07 PM, Registered Nurse (RN) #1 stated she did Body Audits on assigned residents once a week on the 3-11 shift. After reviewing the Admission Nursing Assessment and Wound/Treatment documentation, comparing it to the Body Audit documentation, she verified there were discrepancies. She stated she usually only did body audits on two residents a day and would document at the end of the shift. She was unable to explain why the Body Audit Form dated 2/20/12 documented a dressing to the sacrum when there were no ordered treatments to the sacrum in progress. She verified the weekly body audit documentation indicated the resident had an open area to the sacrum from 2/27/12 through 3/26/12. During an interview on 6/13/12 at 8:37 AM, LPN #1 (wound care nures) stated that upon Resident #21's return from the hospital on [DATE], she had evaluated the resident's heels and had written the order for the treatment to his heels. She stated the heels had not opened up, but were just boggy. When asked about the sacral wound, she stated she remembered the wound closing, but couldn't recall the wound reopening until the end of the month when the resident returned from the hospital.

On the days of the survey based on record review, observation, interviews and review of the professional resource of Perry and Potter Clinical Nursing Skills and Techniques 7th Edition, the facility failed to provide services that met professional standards of quality. The clinical record for Resident # 1 lacked documentation that physician ordered treatments had been completed as ordered. Resident # 5's medication was administered without following physician ordered parameters and in the presence of potential significant side effects. Resident # 9's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. (3 of 16 sampled resident's reviewed for professional standards related to documentation of following physician orders) The findings included: The facility admitted Resident # 5 on 5-12-11 with [DIAGNOSES REDACTED]. Review of Resident # 5's medical record revealed that three medications ([MEDICATION NAME] 5 mg (milligrams), [MEDICATION NAME] ER (extended release) 300 mg, and [MEDICATION NAME] 320 mg) used for the treatment of [REDACTED].< (less than) 110." The instructions for administration were clearly identified on the MAR (Medication Administration Record). Further review of the medical record revealed that Resident # 5 was having his BP (blood pressure) and other vital signs checked each shift using the following code: D (Day) E (Evening) N (Night) on a Vital Sign Record sheet. The readings from the Vital Sign Record sheets were brought forward onto the NN (Daily Skilled Nurses Notes), however, review revealed 5 of 6 NN were not fully completed. Additionally, it was unclear if the blood pressure was obtained immediately prior to the administration of the medications as the time was not documented. Comparison of the NN and the MAR indicated [REDACTED] 5-16-11 [MEDICATION NAME] 5 mg, [MEDICATION NAME] 320 mg were administered. The B/P was listed on MAR indicated [REDACTED].) 5-17-11 [MEDICATION NAME] 5 mg, [MEDICATION NAME] ER 300 mg, [MEDICATION NAME] 320 mg were administered. The BP's in the nurses notes were D 73/52, E 99/62, N 94/58 5-19-11 [MEDICATION NAME] 5 mg, [MEDICATION NAME] ER 300 mg, [MEDICATION NAME] 320 mg were administered. The BP's in the nurses notes were D blank, E 76/53, N 82/51 5-22-11 [MEDICATION NAME] 5 mg, [MEDICATION NAME] ER 300 mg, [MEDICATION NAME] 320 mg were administered. The BP's in the nurses notes were D 96/56, E 93/58, N blank 5-23-11 [MEDICATION NAME] 5 mg, [MEDICATION NAME] ER 300 mg, [MEDICATION NAME] 320 mg were administered. The BP's in the nurses notes were D 75/48, E 72/46, N blank. It appeared that five different nurses had documented the medications were administered without following the physician ordered parameters for administration. The facility admitted Resident #9 on 12/25/10 with [DIAGNOSES REDACTED]. Review of the medical record on 5/25/11 revealed a current physician's orders [REDACTED]. Further review of the medical record indicated a telephone order dated 3/03/11 for Prostat 101 30 ml daily. Record review noted that Resident #9 had pressure ulcers to the sacrum and heel and continued to receive treatment for [REDACTED]. Review of the May 2011 Medication Record (MAR) revealed blanks on the MAR for 5/23/11 and 5/24/11 indicating Resident #9 did not receive Prostat on those dates. The scheduled time for Prostat administration was 9 AM, and all other 9 AM medications on 5/23/11 and 5/24/11 were documented by staff as administered per orders. Review of the back of the MAR indicated [REDACTED]. The above findings were shared with the Staff Development Coordinator on 5/25/11 at approximately 10:30 AM. The facility afterward provided a handwritten statement from staff indicating Resident #9 "did receive Prostat on May 23 & 24. Medication administration was not documented on MAR." Review of the professional resource of Perry and Potter Clinical Nursing Skills and Techniques 7th Edition, page 515 states: "Standards are those actions that ensure safe nursing practice. To ensure safe medication administration, nurses follow the nursing standard called the six rights of medication administration consistently every time they administer medications. All medication errors are linked, in some way, to an inconsistency in adhering to the six rights." The rights include:...."right documentation." After administering the medication, documentation of the administration of the medication should occur as soon as possible. When preparing medications from bottles or containers, "compare the label of the medication with the MAR indicated [REDACTED] Cross Refer to F 329 as it relates to failure of the facility to adequately monitor medications for Resident # 5. Medications were administered without following physician defined parameters and in the presence of potential side effects. Resident # 1 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. Discontinue use and notify Occupational Therapy if redness / irritation persist greater than 30 minutes after taking off- remove for personal care" ; Left knee orthotic to be worn 3-6 hours 7-3 shift every day- discontinue use and notify Physical Therapy if redness persists greater than 30 minutes after removing"; "Cleanse peg tube site with normal saline pat dry and apply dry dressing change every day". Review of the May Treatment Record showed a lack of documentation that the treatment(s) were completed to the elbow on 05/07/11, 05/08/11, and 05/17/11; the treatment to the Peg tube site for 05/14/11 and 05/15/11; the treatment to the left upper extremity for 05/08/11 and 05/17/11; and the treatment for [REDACTED].

On the days of the survey, based on record review and interview, the facility administered medications to Resident # 5 without following the physicians parameters for administration and in the presence of potentially significant adverse side effects of the medication. Resident #15 received [MEDICATION NAME] without an order for [REDACTED]. The findings included: The facility admitted Resident # 5 on 5-12-11 with [DIAGNOSES REDACTED]. The resident was ordered by the physician to recieve three medications ([MEDICATION NAME] 5 mg (milligrams), [MEDICATION NAME] ER (extended release) 300 mg, and [MEDICATION NAME] 320 mg) for the treatment of [REDACTED]. The instructions for administration were clearly identified on the MAR (Medication Administration Record). Resident # 5 was having his BP (blood pressure) and other vital signs checked each shift using the following code: D (Day) E (Evening) N (Night) on a Vital Sign Record sheet. The findings from the Vital Sign Record sheets were then carried forward onto the NN (Daily Skilled Nurses Notes). However, 5 of 6 nurses notes were not fully completed. Review of the NN and the MAR indicated [REDACTED] 5-16-11 [MEDICATION NAME] 5 mg, [MEDICATION NAME] 320 mg were administered. The B/P was listed on MAR indicated [REDACTED].) 5-17-11 [MEDICATION NAME] 5 mg, [MEDICATION NAME] ER 300 mg, [MEDICATION NAME] 320 mg were administered. The BP's in the nurses notes were D 73/52, E 99/62, N 94/58 5-19-11 [MEDICATION NAME] 5 mg, [MEDICATION NAME] ER 300 mg, [MEDICATION NAME] 320 mg were administered. The BP's in the nurses notes were D blank, E 76/53, N 82/51 5-22-11 [MEDICATION NAME] 5 mg, [MEDICATION NAME] ER 300 mg, [MEDICATION NAME] 320 mg were administered. The BP's in the nurses notes were D 96/56, E 93/58, N blank No pulse recorded for night shift. 5-23-11 [MEDICATION NAME] 5 mg, [MEDICATION NAME] ER 300 mg, [MEDICATION NAME] 320 mg were administered. The BP's in the nurses notes were D 75/48, E 72/46, N blank. Evening shift pulse was 50. 5-24-11 No pulse recorded for evening shift. It appeared that five different nurses had documented the medications were administered without following the physician ordered parameters for administration. Additionally, the time the vital signs were obtained were not documented. It was unable to be determined if the vital signs were obtained immediately prior to the administration of the medications. Further review of the medical record revealed a Pharmacy Consult had been completed on 5-18-11. During a phone conversation on 5-25-11 at approximately 10:00 AM with the Consultant Pharmacist, he reported that he had notified the facility on 5-20-11 via fax the following recommendation: "---- (Resident # 5 ) has multiple order to hold meds (medications) per parameters. Please make sure these are being checked and documented prior to each dose of medication being given." During a subsequent interview with the Director of Health Services, she stated that she had received the recommendation on 5-20-11, however, there was no evidence of interventions put in place to ensure the recommendations were followed. There was no indication that the pharmacist had taken immediate action upon the discovery that the physician's orders [REDACTED]. Observations of Resident # 5 over the course of the survey, revealed he was in bed sleeping during the initial tour at approximately 10:50 AM on 5-23-11. At 1:10 PM Resident # 5 was observed in bed with his meal on the over the bed table untouched. Resident # 5 replied slowly to questions asked and appeared lethargic. At 5:40 PM Resident # 5 was still in bed with eyes closed, but he responded to conversation talked slowly and appeared confused when asked simple questions. He stated that he had not eaten lunch and was not hungry. When asked if he needed help to eat, he stated "yes", then after a few minutes he said "no, I don't want to eat now." On 5-24-11 at approximately 11:00 AM, wound care was attempted, however Resident # 5 stated he was in pain, so mediation was given and wound care was delayed. Resident # 5 again seemed lethargic and was slow to respond to questions by the nursing staff. On 5-24-11 at approximately 3:00 PM during a telephone interview with the Primary Physician, who was also the Medical Director of the facility, this surveyor conveyed concerns related to Resident # 5 displaying lethargic behavior and medications given to the resident when the Systolic Blood Pressure was below 110. The Medical Director stated that he was unaware that the blood pressure medications were being given when the Systolic Blood Pressures were below the parameters which he had ordered. On 5-25-11 at approximately 7:30 AM, the Medical Director assessed Resident # 5. The nurses note documented: "Upon revaluation, noticed resident to be lethargic (with) pinpoint pupils. VS (vital signs) taken (with) machine B/P 57/29 T(temperature) 98.2 HR (heart rate) 67 RR (respiratory rate) 20. B/P rechecked manual 60/40 HR 64. Resident stated that 'I feel awful.' Last pain medication [MEDICATION NAME] 7.5/325mg given at 2:30AM on 5/25/11.... Order recieved from Dr.... to have resident transported to ... for evaluation." This surveyor asked the facility Director of Health Services for information related to Resident # 5's condition at the hospital but none was supplied before the survey ended. Review of the Drug facts and Comparison which is updated monthly revealed the following statement about the [MEDICATION NAME] and [MEDICATION NAME] on page 438b: "Carefully monitor blood pressure during initial administration. Closely observe patients already taking antihypertensives." The facility admitted Resident #15 with [DIAGNOSES REDACTED]. Review of the Daily Skilled Nurses Notes dated 4/12/11 at 9:15 PM stated, "Resident was given liquid [MEDICATION NAME] and liquid [MEDICATION NAME] as ordered. MD was notified that previous [MEDICATION NAME] order was given and not Roxinol (sic). Roxinol was held per physician... D/C previous [MEDICATION NAME] order per MD..." The nursing documentation for 4/14/11 (not timed) stated, "N.O. (new order) [MEDICATION NAME] 20 mg (milligrams)/ml (milliliter) 0.5 ml Q (every) 4 hours, order noted and faxed. At 9:00 PM on 4/14/11 the Daily Skilled Nurses Notes stated, "9 PM meds (liquid MSO4, [MEDICATION NAME]) given as ordered..." Review of the Physician's Interim Orders revealed the following: "4/11/11 (untimed) Schedule Roxinol drops 2 cc po q 4 4/12/11 (untimed) Hold 9 PM, D/C [MEDICATION NAME] 4/14/11 (untimed) D/C [MEDICATION NAME] tabs, D/C [MEDICATION NAME] 2:30 Order Clarification: [MEDICATION NAME] SO4 20 mg/ml 0.5 mls po Q 4 hr" Review of the United Pharmacy Services, Controlled Drug Report for Resident #15's [MEDICATION NAME] 100 milligrams/5 milliliters take 1 ml to 2 ml po q 3 hrs (hours) prn (as needed) pain showed the resident continued receiving [MEDICATION NAME] 2 milliliters on 4/13/11 at 1:00 AM, 5:00 AM, 9:00 AM, 1:00 PM, 5:00 PM, 9:00 PM; on 4/14/11 at 1:00 AM and 5:00 AM. Review of the United Pharmacy Services, Controlled Drug Report for Resident #15 dated 4/14/2011 for [MEDICATION NAME] Solution 20 mg/ml 0.5 ml (10 mg) by mouth every 4 hours documented the resident received [MEDICATION NAME] 0.5 ml on 4/14/11 at 9:00 PM. Review of the Medication Record (MAR) for April 2011 documented "Roxinol gtts (drops) 20 mg/ml 2 cc po q 4 hours" given on 4/12/11 at 5:00 PM and held at 9:00 PM; on 4/13/11 [MEDICATION NAME] was given at 9:00 AM, 1:00 PM, 5:00 PM and 9:00 PM; on 4/14/11 [MEDICATION NAME] was given at 9:00 AM only. No order was written to discontinue the [MEDICATION NAME]. No order was written to clarify the dose or indication for the "Schedule Roxinol drops 2 cc po q 4 hours" order written 4/11/11. On 4/14/11 an order was written to clarify how Resident #15 was to receive pain medication. The order stated, "[MEDICATION NAME] 20 mg/ml give 0.5 ml po Q 4 hours". The [MEDICATION NAME] was given as ordered on [DATE] at 1:00 PM, 5:00 PM, and 9:00 PM. [MEDICATION NAME] 0.5 mg IM (intramuscular) or liquid Q 4 hours r/t (related to agitation) was given on 4/11, 4/12, 4/13/11 at 9:00 AM, 1:00 PM, 5:00 PM and 9:00 PM. [MEDICATION NAME] 0.5 mg was given on 4/14/11 at 9:00 AM and 1:00 PM. There was no written physician's orders [REDACTED]. There was no documentation in the MAR indicated [REDACTED].

On the days of the inspection, based on record review and interview, the facility failed to provide nursing services which met professional standards of quality related to [MEDICATION NAME] administration for 2 of 5 of residents prescribed [MEDICATION NAME] (Residents #7 and #17); 1 of 1 residents who received 2 different medications for [MEDICAL CONDITION] for a period of 3 days (Resident # 2); 5 of 14 residents reviewed for admissions (Residents #1, #4, #7, #15 and #19); 2 of 9 residents reviewed for pain (Residents #10 and #11). The findings included: The facility admitted Resident #7 on 1/27/11 with [DIAGNOSES REDACTED]. Review of the hospital "Discharge Summary" dated 1/27/11 revealed Resident #7 was admitted on [DATE] with a right femoral neck fracture and a right hip hemiarthroplasty. Continued review revealed, "Postoperatively, she was placed on [MEDICATION NAME] and foot pumps for [MEDICAL CONDITION]". Under "Transfer Instructions:" was listed ...4. She is to continue [MEDICATION NAME] for a total of 3 weeks, maintaining a target INR (International Normalization Ratio) of 1.8-2.2, which will likely be low dose of 2 milligrams daily or every other day. INR on postoperative day #3 was 3.4, and [MEDICATION NAME] is being held at this time". The "Discharge Medication Reconciliation List" included a typed entry for "[MEDICATION NAME] Sliding Scale, Dose Daily, Oral As Directed". Under "Should Patient Continue Taking This Medication At Home" was typed "Yes" and "No" with "Yes" being circled. During an interview on 2/8/11, RN #1 verified she had completed the admission for Resident #7 on 1/27/11 and stated she had not notified the attending Physician when the resident was admitted , nor did she verify the resident's medications with the Physician. Review of the facilities "Admission H&P" signed by the Physician and dated 1/28/11 revealed the resident had been admitted after right hip arthroplasty. Under "Assessment/Plan:" at the bottom of the second page, the following entries contained a check mark: "Admit for: Rehab(ilitation), PT/OT, ST, Continue current Meds, Routine Standing orders, Skilled Nursing Care, Rehab Potential: Good". Review of "Physician's Orders" for 1/27/11 through 1/31/11 revealed that the Physician signed and dated the orders 2/1/11. The medications listed on the 1/27/11 Physician's Orders were the following: 2nd step PPD (Purified Protein Derivative), [MEDICATION NAME], and [MEDICATION NAME] 2 mg (milligrams) (1) PO (By Mouth) Daily X 3 weeks- to keep INR 1.8-2.2 (Stop 2/17/11)". Under "Lab Orders:" was listed "PT ([MEDICATION NAME])/INR within 14 days of admission, within 7-14 days after change in dose or at least monthly, if no dose change". Review of the lab section of the chart revealed a PT/INR drawn and resulted on 2/4/11 PT "41.3 (CH) (Critical High)" and the INR was "4.1 (H) (High)". On the lab was a handwritten note to "Hold [MEDICATION NAME] X 2 days, Re(check) PT/INR 2/7/11". Further review revealed a physician's order dated 2/4/11 that stated, "Hold [MEDICATION NAME] X 2 days then start [MEDICATION NAME] 1.5 mg q HS (Bedtime), Re (check) PT/INR 2/7 and 2/14". Further review of labs revealed a PT/INR drawn and resulted on 2/7/11. The PT was 62.0 (CH) and the INR was 5.79 (CH). On the lab was a handwritten note to "Hold [MEDICATION NAME] until Friday 2-11-2011, 10 mg Vitamin K 1 X dose, Repeat PT/INR on Thursday 2-10-11, Call results to Dr. -- for further orders 2/10/11". An order dated 2/7/11 stated "Hold [MEDICATION NAME] 1.5 mg daily until 2-11-2011. Admin (ister) 10 mg Vitamin K IM 1 X dose. Repeat PT/INR on 2-10-11". Review of the "Medication Record" for January and February 2011 revealed Resident #7 received [MEDICATION NAME] 2 mg from 1/27/11 through 2/4/11 at 9:00 PM. [MEDICATION NAME] 2 mg was held on 2/5/11 and 2/6/11; and next to the entry was a handwritten note "Orders changed 2/4/11". Included on the record was a listing for "Vit(amin) K 10 mg IM 1 time" documented as having been given on 2/7/11 at 5:00 PM. [MEDICATION NAME] 1.5 mg had also been held as ordered starting on 2/7/11. During an interview on 2/10/11 at 5:40 PM, Licensed Practical Nurse (LPN) #1 reviewed the resident's February MAR and verified her initials for the 2/4/11 dosage of [MEDICATION NAME] at 9:00 PM and stated she had given this. She stated she came in at 3:00 PM that day and was working 3 PM - 11 PM and was not told the [MEDICATION NAME] was on hold. She stated the order may have been taken off after the medpass, but after reviewing the Interim Order, was unable to tell what time it was taken off or written. She verified the Physician's Progress Note dated 2/4/11 at 4:00 PM stated the Physician had discussed the plan with the nursing staff regarding the resident's elevated INR and that it said to "...see orders". The facility admitted Resident #17 on 12/30/10 with [DIAGNOSES REDACTED]. An order dated 1/24/11 for an increase in [MEDICATION NAME] dosage was not carried out until 2/1/11. A PT/INR lab was not drawn as ordered on [DATE]. Review of labs revealed a PT of 17.0 (H) and an INR of 1.59 dated 1/24/11; a Physician's Interim Order dated 1/24/11 stated, "1. (Increase) [MEDICATION NAME] 1 mg QD (Daily) (from 4 mg to 5 mg). Re-check PT-INR in one week". Review of the Medication Record dated 1/14/11 through 1/31/11 revealed an entry for "[MEDICATION NAME] 4 mg PO (By Mouth) q (Every) PM, NO (New Order) 1-17-11". The entry had been initialed from 1/17/11 through 1/31/11 at 9:00 PM. The [MEDICATION NAME] dosage was not changed as ordered on [DATE] from 4 mg to 5 mg. Review of the Medication Record dated 2/1/11 through 2/28/11 revealed [MEDICATION NAME] 5 mg started on 2/1/11. Continued review of labs dated 1/27/11 revealed a PT of 27.3 (H) and an INR of 2.55, initialed by the Physician. The next PT/INR result dated 2/3/11 documented the PT of 64.8 and an INR of 6.06 (CH). Review of Physician's Interim Orders dated 2/3/11 revealed an order to "Hold [MEDICATION NAME], Administer 1 time dose Vitamin K 10 mg Sub Q (Subcutaneously), Re-check PT/INR on 2-4-11". Review of the Medication Record revealed Vitamin K 10 mg had been given at 3:00 PM on 2/3/11. During an interview on 2/10/11 at 6:00 PM, Licensed Practical Nurse (LPN) #1 stated she had received the order for the change in [MEDICATION NAME] dosage on 1/24/11 increasing the [MEDICATION NAME] from 4 mg to 5 mg daily. After reviewing the Medication Record for January 2011, she verified the [MEDICATION NAME] dosage had not been changed on the MAR to reflect the new order change and that [MEDICATION NAME] 4 mg had been given from 1/24/11 through 1/31/11. The facility admitted Resident # 2 on 11-1-10 with [DIAGNOSES REDACTED]. Review of the medical record revealed a pharmacy recommendation dated 12-1-11 which recommended the following: "Discontinue the [MEDICATION NAME] when the current supply is exhausted and then start [MEDICATION NAME] 40 mg (milligram) orally every evening." The Physician on 12-1-10 signed this recommendation. The pharmacy records revealed that [MEDICATION NAME] 20 mg was sent to the facility on [DATE], and that the new order for [MEDICATION NAME] 40 mg was sent to the facility on [DATE]. Review of the MAR (Medical Administration Record) for December revealed that the order for [MEDICATION NAME] was altered with the following statement: "D/C (discontinue) when supply exhausted then start [MEDICATION NAME] 40 mg (Stop 1/3/10)"and that the [MEDICATION NAME] order had been hand written in with the following notation: "*start when [MEDICATION NAME] completed 12/2/10." Both medications were signed off as given on 12-2, 12-3, and 12-5. This was confirmed with the Pharmacist Consultant on 2-8-11 at approximately 10:55 AM. The facility admitted Resident # 1 on 1-27-11 with [DIAGNOSES REDACTED]. Review of the Medical Record revealed that the Admission/Nursing Evaluation Form for Resident # 1 was completed on 1-27-11 at 12:30 PM, but that there was no documented notification of the Medical Director, and the Physician's Orders were not signed by a Physician until 2-1-11. Medications (including [MEDICATION NAME], [MEDICATION NAME] Insulin, and Oxygen Therapy) were received from the pharmacy, and given to the Resident beginning on 1-28-11. The facility admitted Resident #4 on 12/2/10 with [DIAGNOSES REDACTED]. Review of the Medical Record on 2/7/10 between 3:30 PM and 5:00 PM revealed that the Admission/Nursing Evaluation Form was completed on 12/2/10. Review of "Daily Skilled Nurses Notes" dated 12/2/10 through 12/6/10 revealed no mention of contacting the Physician to acknowledge the resident's admission or to verify orders for the resident. Review of "Physician's Orders" for 12/2/10 through 12/31/10 revealed an entry that stated "Meds Reviewed By: (Registered Nurse #1)" with a date of 12/2/10. There was an entry that stated "Physician's Signature" in which the Physician had signed and dated the orders 12/6/10. The medications listed on the 12/2/10 Physician's Orders were the following: 2nd step PPD (Purified Protein Derivative), [MEDICATION NAME], Mag Ox, [MEDICATION NAME], and [MEDICATION NAME]. The resident's diet was listed as "NPO (Nothing by Mouth)- [MEDICATION NAME] 1.2 @ 60 cc (cubic centimeters)/hr (hour) (Per Dietician), Flush - Water 100 ml Q (Every) 4 hrs (hours)". During an interview on 2/9/11, RN #1 verified Resident #4 had been admitted [DATE] and stated she had completed the admission. She verified the blanks on the Admission/Nursing Evaluation Form and stated she had not called the Physician to acknowledge the resident's admission or to verify orders. She verified the Physician signed the resident ' s Physician ' s Orders and History and Physical on 12/6/10. The facility admitted Resident #7 on 1/27/11 with [DIAGNOSES REDACTED]. Review of the "Admission/Nursing Evaluation Form" and the resident's "Face Sheet" revealed Resident #7 had been admitted on [DATE]. Review of "Physician's Orders" for 1/27/11 through 1/31/11 revealed that the Physician signed and dated the orders 2/1/11. The medications listed on the 1/27/11 Physician's Orders were the following: 2nd step PPD (Purified Protein Derivative), [MEDICATION NAME], and [MEDICATION NAME] 2 mg (milligrams) (1) PO (By Mouth) Daily X 3 weeks- to keep INR 1.8-2.2 (Stop 2/17/11)". Under "Lab Orders:" was listed "PT ([MEDICATION NAME])/INR within 14 days of admission, within 7-14 days after change in dose or at least monthly, if no dose change". During an interview on 2/8/11, RN #1 verified she had completed the admission for Resident #7 on 1/27/11 and stated she had not notified the attending Physician when the resident was admitted , nor did she verify the resident's medications with the Physician. The facility admitted Resident # 15 on 12-30-11 with [DIAGNOSES REDACTED]. Review of the Medical Record on 2-10-11 revealed that the resident's Physician / Medical Director did not review the admission assessment, medications and did not complete a History & Physical until 1-3-11. Resident # 15's admitting medications included the following: [MEDICATION NAME] 10/325, Calcitonin 200 units, Vitamin B 3 2000 units, [MEDICATION NAME] 30 mg, [MEDICATION NAME] 20 mg, [MEDICATION NAME] 40 mg, [MEDICATION NAME] 1000 mg, [MEDICATION NAME] 75 mcg, [MEDICATION NAME] 15 mg, [MEDICATION NAME] 150 mg, [MEDICATION NAME] 15 mg, [MEDICATION NAME] 4.5 mg S,T,T, S and 5 mg on M,W,F, [MEDICATION NAME] 17 g, Tylenol ES 500 mg, Qvar 40 mcg, [MEDICATION NAME] 8.6 mg. During an interview on 2-10-11 at approximately 12:45 PM with the Admissions Nurse, RN # 1, she stated that she did had not notified the Physician except by notating the admission in the Physician's Log book. The facility admitted Resident # 19 on 1-13-11 with [DIAGNOSES REDACTED]. Review of the Medical Record revealed that the resident's Physician/Medical Director did not review the admission assessment, medications or complete a History & Physical until 1-17-11. During an interview with RN# 1, who did the Initial Nursing Assessment Form on 1-13-11, she confirmed that she had not notified the Physician except by notating the admission in the Physician's Logbook. During an interview with the Admission Coordinator on 2-8-11 at approximately 10:45 AM, she stated that she routinely assesses residents for admission, at hospitals and from their homes. She further stated that when she has a candidate for admission, she contacts the Admission Nurse for help, but that she does not notify the Medical Director that a patient will be coming. The facility admitted Resident # 11 on 11-17-10 with [DIAGNOSES REDACTED]. Review of the Medical Record on 2-7-11 revealed that upon admission, Resident # 11's medications were as follows: [MEDICATION NAME], Nephro-vite, [MEDICATION NAME], Folic Acid, [MEDICATION NAME]. Also included in the medications were the following to control pain: [MEDICATION NAME] 10 mg every twelve hours, [MEDICATION NAME] Patch 100 mcg every 72 hours, and [MEDICATION NAME] 5/325 mg PRN (as needed) every 6 hours. Review of the MAR (Medical Administration Record) revealed for the month of November, [MEDICATION NAME] 5/325 mg was given to the resident a total of 22 times. Review of the month of December revealed that [MEDICATION NAME] 5/325 was given to the resident a total of 64 times. During the month of January, Resident # 11 was out of the facility in the hospital from 1-2 until 1-5, but she still received the PRN [MEDICATION NAME] 5/325 a total of 42 times. On 1-24-11 at 9:00 PM, the resident received [MEDICATION NAME] 5/325, but on 1-25-11 at 5:00 AM, Resident # 11 received [MEDICATION NAME] 7.5/500 mg for pain. During an interview with the resident on 2-9-11, she stated "Recently, they ran out of the [MEDICATION NAME], and gave me [MEDICATION NAME] instead." The facility admitted Resident # 10 on 11-8-10 with [DIAGNOSES REDACTED]. Review of the Medical Record revealed the following medications [MEDICATION NAME], [MEDICATION NAME] HCT, and for pain Tylenol 650 mg PRN, [MEDICATION NAME] 5/325 mg PRN, and [MEDICATION NAME] 10/500. Review of the MAR for January revealed that [MEDICATION NAME] was given for pain relief beginning on 1-25-11. During an interview with the DON (Director of Nursing) on 2-8-11 at approximately 4:15 PM, she stated that on the early morning of 1-25-11, she had to get [MEDICATION NAME] from the back up pharmacy to supply pain medication for several residents. The DON identified 2 of those residents as Resident # 10 and Resident # 11. She further stated that she was unable to get [MEDICATION NAME] because it was a class II medication and required a written prescription from the back up pharmacy. When asked why the medication was not available in the facility, the DON said it was just an oversight by the nursing staff. On 2/7/11 at 5:17 PM, during observation of medication pass for Resident A, Registered Nurse (RN) #2 was observed to administer one [MEDICATION NAME] Extended Release 500 milligram (mg) tablet, one [MEDICATION NAME] 5 mg tablet, one [MEDICATION NAME] 30 mg tablet, and one [MEDICATION NAME] 25 mg/200 mg extended release capsule to the resident. During reconciliation of medication pass, review of current "PHYSICIAN'S ORDERS" (02/01/11 through 02/28/11) for Resident A, revealed that all 4 of the listed medications were ordered to be administered at 9 AM and 9 PM. Review of the current Medication Administration Record (MAR) (02/01/11 through 02/28/11) for Resident A, revealed that the 9 PM administration time for the medications had been marked out and changed to 5 PM. No physician's order to change the PM administration time could be found. During an interview on 2/7/11 at 5:48 PM, RN #2 verified that the physician's order for the medications was for 9 AM and 9 PM and that there was no order to change the PM administration time. During an interview on 2/8/11 at 12:26 PM, the facility's Medical Director revealed that every 12 hours (9 AM and 9 PM) would be preferred administration times for twice a day medications because that would give better medication coverage for the resident. He was not sure that 9 AM and 9 PM were on the "PHYSICIAN'S ORDERS" when he signed then but that would be the preferred times. During an interview on 2/8/11 at 11:33 PM, the Pharmacy Manager stated that when Physician Orders and MARs are sent to the facility they are preprinted with times of administration. If the pharmacy gets a notice of a change in times of administration, the pharmacy would print new times of administration and new MARs for the next month. During an interview on 2/8/11 at 3:35 PM, RN #1 stated that she had made the error and coded the evening dose for 5 PM instead of 9 PM on the MAR. Because of the color coding coding used on the MAR the evening dose was not legible and she coded it wrong. It was strictly human error. On 2/8/11 at 3:53 PM, review of the MARs on both medication carts, with the Director of Nursing (DON) revealed that some twice a day medications were listed as 9 AM and 9 PM and some were listed as 9 AM and 5 PM. There was no consistency in relation to twice a day times of administration.

On the days of the inspection, based on interview and record review, the facility failed to provide necessary care and services to maintain the highest practicable physical, mental and psychosocial well-being for residents related to [MEDICATION NAME] not given as ordered for 2 of 5 of residents (Residents #7 and #17); 1 of 1 residents who received 2 different medications for [MEDICAL CONDITION] for a period of 3 days (Resident # 2); 5 of 14 residents reviewed for admissions (Residents #1, #4, #7, #15 and #19); 2 of 9 residents reviewed for pain management (Residents #10 and #11). The findings included: The facility admitted Resident #7 on 1/27/11 with [DIAGNOSES REDACTED]. Review of the hospital "Discharge Summary" dated 1/27/11 revealed Resident #7 had been admitted on [DATE] with a right femoral neck fracture and had undergone a right hip hemiarthroplasty the same day. Continued review revealed, "Postoperatively, she was placed on [MEDICATION NAME] and foot pumps for [MEDICAL CONDITION]". Under "Transfer Instructions:" was listed ...4. She is to continue [MEDICATION NAME] for a total of 3 weeks, maintaining a target INR (International Normalization Ratio) of 1.8- 2.2, which will likely be low dose of 2 milligrams daily or every other day. INR on postoperative day #3 was 3.4, and [MEDICATION NAME] is being held at this time". The "Discharge Medication Reconciliation List" included a typed entry for "[MEDICATION NAME] Sliding Scale, Dose Daily, Oral As Directed". Under "Should Patient Continue Taking This Medication At Home" was typed "Yes" and "No" with "Yes" being circled. During an interview on 2/8/11, RN #1 verified she had completed the admission for Resident #7 on 1/27/11 and stated she had not notified the attending physician when the resident was admitted , nor did she verify the resident's medications with the Physician. Review of the facilities "Admission H&P" signed by the Physician and dated 1/28/11 revealed the resident had been admitted after right hip arthroplasty. Under "Assessment/Plan:" at the bottom of the second page, the following entries contained a check mark: "Admit for: Rehab(ilitation), PT/OT, ST, Continue current Meds, Routine Standing orders, Skilled Nursing Care, Rehab Potential: Good". Review of "physician's orders [REDACTED]. The medications listed on the 1/27/11 physician's orders [REDACTED]. Under "Lab Orders:" was listed "PT ([MEDICATION NAME])/INR within 14 days of admission, within 7-14 days after change in dose or at least monthly, if no dose change". Review of the lab section of the chart revealed a PT/INR drawn and resulted on 2/4/11 PT "41.3 (CH) (Critical High)" and the INR was "4.1 (H) (High)". On the lab was a handwritten note to "Hold [MEDICATION NAME] X 2 days, Re(check) PT/INR 2/7/11". Further review revealed a physician's orders [REDACTED]. Further review of labs revealed a PT/INR drawn and resulted on 2/7/11. The PT was 62.0 (CH) and the INR was 5.79 (CH). On the lab was a handwritten note to "Hold [MEDICATION NAME] until Friday 2-11-2011, 10 mg Vitamin K 1 X dose, Repeat PT/INR on Thursday 2-10-11, Call results to Dr. -- for further orders 2/10/11". An order dated 2/7/11 stated "Hold [MEDICATION NAME] 1.5 mg daily until 2-11-2011. Admin (ister) 10 mg Vitamin K IM 1 X dose. Repeat PT/INR on 2-10-11". Review of the "Medication Record" for January and February 2011 revealed Resident #7 received [MEDICATION NAME] 2 mg from 1/27/11 through 2/4/11 at 9:00 PM. [MEDICATION NAME] 2 mg was held on 2/5/11 and 2/6/11; and next to the entry was a handwritten note "Orders changed 2/4/11". Included on the record was a listing for "Vit(amin) K 10 mg IM 1 time" documented as having been given on 2/7/11 at 5:00 PM. [MEDICATION NAME] 1.5 mg had also been held as ordered starting on 2/7/11. During an interview on 2/10/11 at 5:40 PM, Licensed Practical Nurse (LPN) #1 reviewed the resident's February MAR and verified her initials for the 2/4/11 dosage of [MEDICATION NAME] at 9:00 PM and stated she had given this. She stated she came in at 3:00 PM that day and was working 3 PM - 11 PM and was not told the [MEDICATION NAME] was on hold. She stated the order may have been taken off after the medpass, but after reviewing the Interim Order, was unable to tell what time it was taken off or written. She verified the Physician's Progress Note dated 2/4/11 at 4:00 PM stated the Physician had discussed the plan with the nursing staff regarding the resident's elevated INR and that it said to "...see orders". The facility admitted Resident #17 on 12/30/10 with [DIAGNOSES REDACTED]. An order dated 1/24/11 for an increase in [MEDICATION NAME] dosage was not carried out until 2/1/11. A PT/INR lab was not drawn as ordered on [DATE]. Review of labs revealed a PT of 17.0 (H) and an INR of 1.59 dated 1/24/11; a Physician's Interim Order dated 1/24/11 stated, "1. (Increase) [MEDICATION NAME] 1 mg QD (Daily) (from 4 mg to 5 mg). Re-check PT-INR in one week". Review of the Medication Record dated 1/14/11 through 1/31/11 revealed an entry for "[MEDICATION NAME] 4 mg PO (By Mouth) q (Every) PM, NO (New Order) 1-17-11". The entry had been initialed from 1/17/11 through 1/31/11 at 9:00 PM. The [MEDICATION NAME] dosage was not changed as ordered on [DATE] from 4 mg to 5 mg. Review of the Medication Record dated 2/1/11 through 2/28/11 revealed [MEDICATION NAME] 5 mg started on 2/1/11. Continued review of labs dated 1/27/11 revealed a PT of 27.3 (H) and an INR of 2.55, initialed by the Physician. The next PT/INR result dated 2/3/11 documented the PT of 64.8 and an INR of 6.06 (CH). Review of Physician's Interim Orders dated 2/3/11 revealed an order to "Hold [MEDICATION NAME], Administer 1 time dose Vitamin K 10 mg Sub Q (Subcutaneously), Re-check PT/INR on 2-4-11". Review of the Medication Record revealed Vitamin K 10 mg had been given at 3:00 PM on 2/3/11. During an interview on 2/10/11 at 6:00 PM, Licensed Practical Nurse (LPN) #1 stated she had received the order for the change in [MEDICATION NAME] dosage on 1/24/11 increasing the [MEDICATION NAME] from 4 mg to 5 mg daily. After reviewing the Medication Record for January 2011, she verified the [MEDICATION NAME] dosage had not been changed on the MAR to reflect the new order change and that [MEDICATION NAME] 4 mg had been given from 1/24/11 through 1/31/11. The facility admitted Resident # 2 on 11-1-10 with [DIAGNOSES REDACTED]. Review of the medical record revealed a pharmacy recommendation dated 12-1-11 which recommended the following: "Discontinue the [MEDICATION NAME] when the current supply is exhausted and then start [MEDICATION NAME] 40 mg (milligram) orally every evening." The Physician on 12-1-10 signed this recommendation. The pharmacy records revealed that [MEDICATION NAME] 20 mg was sent to the facility on [DATE], and that the new order for [MEDICATION NAME] 40 mg was sent to the facility on [DATE]. Review of the MAR (Medical Administration Record) for December revealed that the order for [MEDICATION NAME] was altered with the following statement: "D/C (discontinue) when supply exhausted then start [MEDICATION NAME] 40 mg (Stop 1/3/10)"and that the [MEDICATION NAME] order had been hand written in with the following notation: "*start when [MEDICATION NAME] completed 12/2/10." Both medications were signed off as given on 12-2, 12-3, and 12-5. This was confirmed with the Pharmacist Consultant on 2-8-11 at approximately 10:55 AM. The facility admitted Resident # 1 on 1-27-11 with [DIAGNOSES REDACTED]. Review of the Medical Record revealed that the Admission/Nursing Evaluation Form for Resident # 1 was completed on 1-27-11 at 12:30 PM, but that there was no documented notification of the Medical Director, and the physician's orders [REDACTED]. Medications (including [MEDICATION NAME], [MEDICATION NAME] Insulin, and Oxygen Therapy) were received from the pharmacy, and given to the Resident beginning on 1-28-11. The facility admitted Resident #4 on 12/2/10 with [DIAGNOSES REDACTED]. Review of the Medical Record on 2/7/10 between 3:30 PM and 5:00 PM revealed that the Admission/Nursing Evaluation Form was completed on 12/2/10. Review of "Daily Skilled Nurses Notes" dated 12/2/10 through 12/6/10 revealed no mention of contacting the Physician to acknowledge the resident's admission or to verify orders for the resident. Review of "physician's orders [REDACTED].#1)" with a date of 12/2/10. There was an entry that stated "Physician's Signature" in which the Physician had signed and dated the orders 12/6/10. The medications listed on the 12/2/10 physician's orders [REDACTED]. The resident's diet was listed as "NPO (Nothing by Mouth)- [MEDICATION NAME] 1.2 @ 60 cc (cubic centimeters)/hr (hour) (Per Dietician), Flush - Water 100 ml Q (Every) 4 hrs (hours)". During an interview on 2/9/11, RN #1 verified Resident #4 had been admitted [DATE] and stated she had completed the admission. She verified the blanks on the Admission/Nursing Evaluation Form and stated she had not called the Physician to acknowledge the resident's admission or to verify orders. She verified the Physician signed the resident ' s physician's order [REDACTED]. The facility admitted Resident #7 on 1/27/11 with [DIAGNOSES REDACTED]. Review of the "Admission/Nursing Evaluation Form" and the resident's "Face Sheet" revealed Resident #7 had been admitted on [DATE]. Review of "physician's orders [REDACTED]. The medications listed on the 1/27/11 physician's orders [REDACTED]. Under "Lab Orders:" was listed "PT ([MEDICATION NAME])/INR within 14 days of admission, within 7-14 days after change in dose or at least monthly, if no dose change". During an interview on 2/8/11, RN #1 verified she had completed the admission for Resident #7 on 1/27/11 and stated she had not notified the attending Physician when the resident was admitted , nor did she verify the resident's medications with the Physician. The facility admitted Resident # 15 on 12-30-11 with [DIAGNOSES REDACTED]. Review of the Medical Record on 2-10-11 revealed that the resident's Physician / Medical Director did not review the admission assessment, medications and did not complete a History & Physical until 1-3-11. Resident # 15's admitting medications included the following: [MEDICATION NAME] 10/325, Calcitonin 200 units, Vitamin B 3 2000 units, [MEDICATION NAME] 30 mg, [MEDICATION NAME] 20 mg, [MEDICATION NAME] 40 mg, [MEDICATION NAME] 1000 mg, [MEDICATION NAME] 75 mcg, [MEDICATION NAME] 15 mg, [MEDICATION NAME] 150 mg, [MEDICATION NAME] 15 mg, [MEDICATION NAME] 4.5 mg S,T,T, S and 5 mg on M,W,F, [MEDICATION NAME] 17 g, Tylenol ES 500 mg, Qvar 40 mcg, [MEDICATION NAME] 8.6 mg. During an interview on 2-10-11 at approximately 12:45 PM with the Admissions Nurse, RN # 1, she stated that she did had not notified the Physician except by notating the admission in the Physician's Log book. The facility admitted Resident # 19 on 1-13-11 with [DIAGNOSES REDACTED]. Review of the Medical Record revealed that the resident's Physician/Medical Director did not review the admission assessment, medications or complete a History & Physical until 1-17-11. During an interview with RN# 1, who did the Initial Nursing Assessment Form on 1-13-11, she confirmed that she had not notified the Physician except by notating the admission in the Physician's Logbook. During an interview with the Admission Coordinator on 2-8-11 at approximately 10:45 AM, she stated that she routinely assesses residents for admission, at hospitals and from their homes. She further stated that when she has a candidate for admission, she contacts the Admission Nurse for help, but that she does not notify the Medical Director that a patient will be coming. The facility admitted Resident # 11 on 11-17-10 with [DIAGNOSES REDACTED]. Review of the Medical Record on 2-7-11 revealed that upon admission, Resident # 11's medications were as follows: [MEDICATION NAME], Nephro-vite, [MEDICATION NAME], Folic Acid, [MEDICATION NAME]. Also included in the medications were the following to control pain: [MEDICATION NAME] 10 mg every twelve hours, [MEDICATION NAME] Patch 100 mcg every 72 hours, and [MEDICATION NAME] 5/325 mg PRN (as needed) every 6 hours. Review of the MAR (Medical Administration Record) revealed for the month of November, [MEDICATION NAME] 5/325 mg was given to the resident a total of 22 times. Review of the month of December revealed that [MEDICATION NAME] 5/325 was given to the resident a total of 64 times. During the month of January, Resident # 11 was out of the facility in the hospital from 1-2 until 1-5, but she still received the PRN [MEDICATION NAME] 5/325 a total of 42 times. On 1-24-11 at 9:00 PM, the resident received [MEDICATION NAME] 5/325, but on 1-25-11 at 5:00 AM, Resident # 11 received [MEDICATION NAME] 7.5/500 mg for pain. During an interview with the resident on 2-9-11, she stated "Recently, they ran out of the [MEDICATION NAME], and gave me [MEDICATION NAME] instead." The facility admitted Resident # 10 on 11-8-10 with [DIAGNOSES REDACTED]. Review of the Medical Record revealed the following medications [MEDICATION NAME], [MEDICATION NAME] HCT, and for pain Tylenol 650 mg PRN, [MEDICATION NAME] 5/325 mg PRN, and [MEDICATION NAME] 10/500. Review of the MAR for January revealed that [MEDICATION NAME] was given for pain relief beginning on 1-25-11. During an interview with the DON (Director of Nursing) on 2-8-11 at approximately 4:15 PM, she stated that on the early morning of 1-25-11, she had to get [MEDICATION NAME] from the back up pharmacy to supply pain medication for several residents. The DON identified 2 of those residents as Resident # 10 and Resident # 11. She further stated that she was unable to get [MEDICATION NAME] because it was a class II medication and required a written prescription from the back up pharmacy. When asked why the medication was not available in the facility, the DON said it was just an oversight by the nursing staff.