Every finding on record at PruittHealth- Ridgeway

Based on observation, interview, and facility policy review, the facility failed to keep the kitchen's slicer, walk-in refrigerator's floor and shelves, and two stove top spill pans clean. These failures had the potential to create an environment for food-borne illnesses which could affect 128 residents who consumed food prepared from the facility's kitchen.Findings include:Review of the facility's policy titled, Cleaning Procedures: Kitchen Area, with a review date of 10/23/25, indicated, It is the policy of [Name] to maintain a clean and sanitary environment to prepare patient/resident meals . All soiled, dirty, dusty, surfaces and/or areas within the kitchen should be cleaned and/or sanitized [as needed] immediately upon identification.1. Observation during the initial kitchen inspection on 01/19/26 from 9:50 AM to 10:25 AM, with the Dietary Manager (DM) present, revealed the following concerns with the cleanliness of food storage and food preparation areas:a. Observation of the kitchen's walk-in refrigerator revealed the floor was unclean with loose debris and dried spills. The floor's edges and corners, which were under shelving units, had a very heavy buildup of black colored substances which could be wiped away with a paper towel. Additionally, two metal shelves in the refrigerator had plastic covers on them which were unclean with a black moldlike substance. Boxes of food were observed stored directly on these plastic shelf covers.b. Observation of the kitchen's electric slicer revealed it was covered and ready for use. Observations of the slicer's blade revealed it was unclean with a dried food substance.c. Observation of the kitchen's stove top spill pans revealed two of the pans were unclean with a heavy accumulation of dried food and dried food spills.During an interview on 01/19/26 at 10:25 AM, the DM confirmed the kitchen's walk-in refrigerator's floor and shelves, slicer, and stove top spill pans were not clean. The DM stated the walk-in refrigerator's floor and shelves should be cleaned daily, the slicer should be cleaned after each use, and the stove top spill pans should be cleaned weekly or as needed.

Based on observation, record review, and staff interviews, the facility failed to ensure that the environment for one of six residents (Resident (R) 32) remained free from accident hazards to prevent falls and failed to provide adequate supervision to prevent resident to resident altercations for seven of ten residents (R) 66, 84, 136, 120, 93, 125, and 115) reviewed. These failures placed residents at risk for physical harm. Findings include: 1.Review of R32's Face Sheet, located in R32's electronic medical record (EMR), under the Face Sheet tab, revealed the facility admitted R32 from home on [DATE]. R32's pertinent diagnoses included right above-knee amputation (AKA), right hemiplegia and hemiparesis following cerebral infarction, cognitive communication deficit, difficulty walking, and right-hand contracture. Review of the facility's Incident Report dated 06/29/25, provided by the Administrator, revealed the R32 sustained an unwitnessed fall out of bed with head involvement. Staff initiated a low bed as an intervention to help prevent further falls. Review of the Nursing Progress Note dated 06/29/2025, located in R32's EMR under the Progress Notes tab, revealed that a Certified Nursing Assistant (CNA) observed R32 on the floor next to their bed. R32 sustained a hematoma to their right forehead and right eye. Staff initiated neurological checks with no abnormal findings and notified R32's physician, who requested R32 be sent to the emergency room for further evaluation. [R32 returned from the hospital on [DATE] with no injuries noted]. Review of the Morse Fall Scale assessment, dated 06/30/25, located in R32's EMR under the Observations tab, revealed R32 was at high risk for falls. Review of the facility's Initial Report dated 06/30/25, provided by the Administrator, revealed R32 sustained a fall from their bed. R32 complained of head pain, and staff sent R32 to the emergency room for further evaluation. R32 returned to the facility with no injuries noted. Review of the facility's Five-Day Follow-Up Report, dated 07/02/25, provided by the Administrator, revealed that on 06/29/25, staff observed R32 on the floor by their bed. R32 fell exiting the bed without assistance. The nurse assessed R32 and noted a raised area on R32's right forehead and right eye. Staff assisted the resident back to bed, initiated neurological checks, and notified the provider, who ordered that R32 be sent to the hospital for further evaluation. Interventions implemented to prevent further injury included placing R32's bed in the lowest position, physical therapy referral, and re-education. Review of R32's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/14/25, located in R32's EMR under the RAI [Resident Assessment Instrument] tab, revealed R32 was readmitted to the facility from an acute care hospital on [DATE]. R32 had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 indicated severe cognitive impairment. R32 was dependent on staff for bed mobility, transfers, toileting, and personal hygiene. Review of R32's care plan, last reviewed/revised on 01/19/26, located in R32's EMR, under the Care Plan tab, revealed R32 was at risk for falls related to right AKA and fall on 06/29/25. On 07/02/2025, the facility updated the care plan directing staff to keep R32's bed in the lowest position. During an observation on 01/20/26 at 2:00 PM, R32 lay in bed watching television. R32's bed was elevated and not in its lowest position. At 2:19 PM, CNA8 entered the resident's room to provide care and exited shortly afterward without placing the bed in the lowest position. Follow up observations at 4:31 PM and 9:00 PM revealed R32's bed remained elevated. During an observation on 01/21/26 at 9:15 AM with Registered Nurse (RN)1, R32 was observed lying in bed watching television. R32's bed remained elevated. During an interview on 01/21/26 at 9:15 AM, RN1 reviewed R32's care plan and stated that R32 was at risk for falls. RN1 acknowledged R32's bed was not in the lowest position at this time. RN1 stated the bed should be as low to the ground as the mechanical bed would allow. During an interview on 01/21/26 at 1:12 PM, CNA8 stated that she has worked at the facility since July 2025. CNA8 stated that she learned today (01/21/25) that R32 was a fall risk, stated that fall interventions were outlined in the resident's care plan, and that she should have placed R32's bed in the lowest position before exiting the resident's room on 01/20/26. During a telephone interview on 01/21/26 at 1:16 PM, Licensed Practical Nurse (LPN)1 stated that prior to the fall on 06/29/25, R32 was not a fall risk. LPN1 stated that on 06/29/25, R32 sustained an unwitnessed fall out of bed. LPN1 assessed R32, notified the physician, and sent the resident to the emergency room for further evaluation. After the fall, LPN1 implemented a low bed to help prevent further falls. During an interview on 01/21/26 at 1:45 PM, LPN2 reviewed the resident's care plan and stated that the resident is at risk for falls but does not move around much in bed. LPN2 stated that R32's bed should be in the lowest position and that staff do not document whether it is in the lowest position during each shift. 2. Review of an investigation summary titled, [R66] and [R84] Investigation, provided by the Administrator, revealed Incident involves two residents on the secured unit. At approximately 3:41pm on 7/13/25 a CNA [Certified Nurse Aide] walked into their room and witnessed [R66] scratching [R84's] arm on the left arm. The CNA immediately moved [R84] from the room. The Director of Nursing (DON) assessed both residents and identified a skin tear to R84's right arm. Due to cognition, neither resident was able to answer questions. Review of R66's undated Face Sheet, located in the resident's electronic medical record (EMR) under the Resident tab, revealed the resident was admitted to the facility on [DATE] with diagnoses which included unspecified dementia with other behavioral disturbances and mood disorder. Review of R66's nursing Progress Note, dated 07/13/25 at 5:41 PM and located under the Resident tab of the EMR, revealed Patient conflict with [R84] earlier in shift . patient removed from resident immediately by nurse and CNA, [R66] was placed in day room with 1 on 1 [staff member assigned to monitor] care. R66 was calm while 1 on 1 care was provided. Review of R66's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/21/25, located under the RAI (Resident Assessment Instrument) tab of the EMR, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident was moderately cognitively impaired. The MDS also revealed the facility assessed the resident to not have engaged in any behaviors during the assessment period. Review of 84's undated Face Sheet, located in the resident's EMR under the Resident tab, revealed the resident was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, muscle weakness, and chronic pain. Review of R84's quarterly MDS with an ARD of 10/21/25, located in the resident's EMR under the RAI tab, revealed the facility assessed the resident to have a BIMS Score of 0 out of 15, which indicated the resident was severely cognitively impaired. During observations from 01/19/26 to 01/21/26, R84 propelled herself in her wheelchair on the secured unit. She was cognitively unable to answer questions and had no observed injuries, indicative of abuse. Attempts were made to interview R66, but she was not oriented and refused to speak at all or be interviewed. Review of an investigation summary titled, [R66] and [R136] Investigation, provided by the Administrator, revealed Incident involves two residents on the secured unit. At approximately 4:30pm on 7/27/25 [Licensed Practical Nurse [LPN] 4] was at the nurses' station and witnessed [R66] and [R136] attempting to get through the doorway to the dining room in their wheelchairs at the same time. According to the report, R66 began flailing her arms and hit R136 with open hands. R136 then hit R66 with her fists in the face. LPN4 separated the residents. R66 and R136 were assessed and no injuries were noted. Review of R136's undated Face Sheet, located in the resident's EMR under the Resident tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included dementia with other behavioral disturbances, and mood disorder. She was discharged to another facility on 9/10/25. Review of R136's quarterly MDS with an ARD of 08/08/25 revealed the facility assessed the resident to have a BIMS score of 12 out of 15, which indicated the resident was moderately cognitively impaired. The MDS also revealed the facility assessed the resident to not have engaged in any behaviors during the assessment period. Review of R136's nursing Progress Note, dated 07/27/25 at 4:30 PM and located under the Resident tab of the EMR, revealed Patient conflict with [R66] earlier in shift . patient removed from resident immediately by nurse and [CNA2]. [R136] placed in day room with 1 on 1 care. [R136] was calm while 1 on 1 care was provided. Attempts were made to interview R66, but she was not oriented and refused to speak at all or be interviewed. Review of an investigation summary titled, [R66] and [R120] Investigation, provided by the Administrator, revealed Incident involves two residents on the secured unit. At approximately 8:05 pm on 10/19/25 [CNA10] walked into their room and witnessed [R66] and [R120] grabbing each other. [R66] had scratches on her face and blood on her mouth, [R120] had scratches on her chest. The CNA immediately moved [R120] from the room. The DON assessed both residents with no serious injuries found. Neither resident was able to be interviewed due to their cognitive status. Review of R120's undated Face Sheet, located in the resident's EMR under the Resident tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included dementia with other behavioral disturbances, and mood disorder. Review of R120's nursing Progress Note, dated 10/19/25 at 8:05 PM and located under the Resident tab of the EMR, revealed Patient conflict with R66 earlier in shift . patient removed from resident [sic] immediately by nurse and CNA2. R120 placed in day room with 1 on 1 care. R120 was calm while 1 on 1 care was provided. Review of R120's quarterly MDS with an ARD of 10/25/25 revealed the facility assessed the resident to have a BIMS score of 0 out of 15, which indicated the resident was severely cognitively impaired. The MDS also revealed the facility assessed the resident to not have engaged in any behaviors during the assessment period. Attempts were made to interview R66, but she was not oriented and refused to speak at all or be interviewed. During an interview with LPN4 on 01/21/26 at 10:00 AM, she said R66 was not combative unless someone was in her space. LPN4 said she had no issues with R66, but the resident was monitored closely due to her history of altercations. She said the staff on the unit knew the resident well and removed her from situations when other residents were in her personal space. During an interview with CNA2 on 01/21/26 at 11:00 AM, she said R66 had not had any issues with any residents since October 2025. CNA2 said R66 was not exhibiting any behavior and was doing well on the secured unit. During an interview on 01/21/26 at 5:25 AM, the Administrator stated it was his expectation that all residents would be free from abuse, including resident to resident abuse. Review of the facility's investigation of a 09/04/25 incident between R93 and R125, provided by the facility, revealed the investigation specified the facility unsubstantiated resident to resident abuse. Included in the facility's investigation were witness statements from staff who were working when the incident occurred. A witness statement written by CNA11 indicated, Resident was in the dining room getting ready for dinner. Resident became very frustrated at this time and hit another resident multi [multiple] times across the back. A witness statement written by LPN4 specified, Staff alerted me that an altercation was happening in the dining room. I went in and removed the patient to her room. Review of R93's admission Record, located in the Resident section of the EMR, revealed R93 was admitted to the facility on [DATE] with a diagnosis of bipolar disorder. Review of R93's quarterly MDS assessment with an ARD of 08/16/25, located in the RAI tab of the EMR, revealed R93 scored 99 on the BIMS, which indicated she was unable to compete the interview. The MDS indicated R93 exhibited no physical, verbal, or other behavioral symptoms directed toward others. Review of R93's Care Plan, located under the RAI tab of the EMR, contained the following Problem area, which was initiated on 09/04/25, Presence of behavioral symptoms physical aggression as evidenced by: physical altercation with another resident on 09/04/25. The care plan's goal specified, Patient will not harm themselves or others secondary to their behaviors through next review. Review of R93's notes, located in the Progress Notes section of the EMR, revealed the following entry: 09/04/25 at 6:56 PM: While in dining room; before dinner; pt [patient] approached another pt that was sitting down at a table. She then struck the pt that was sitting with a closed hand at least 6 times. Staff immediately separated the residents taking the pt to her room, providing a calm environment by dimming the lights and turning the tv on low. When asked why she struck the other patient, the pt stated because she did not want a shower. Pt educated that we do not hit others no matter what or just because they're having a bad day. Pt stated she understood and that she was sorry. We are currently awaiting an incident number from police regarding incident. There were no injuries to either patient. Observation on 01/19/26 at 2:45 PM revealed R93 was in her room. R93 was exhibiting no problem behaviors and was confused. R93 did not understand questions being asked to her. Review of R125's admission Record, located in the Resident section of the EMR, revealed R1125 was admitted to the facility on [DATE] with a diagnosis of senile degeneration of brain. Review of R125's quarterly MDS assessment with an ARD of 07/21/25, located in the MDS tab of the EMR, revealed R125 scored three of 15 on the BIMS, which indicated she was severely cognitively impaired and had not exhibited any physical, verbal, or other behavioral symptoms towards others. Review of R125's notes, located in the Progress Notes section of the EMR, revealed the following entry: 09/04/25 at 5:34 PM: Pt struck by another pt while sitting in the dining area before dinner. Pt was struck in the back approx.6-10's, with a closed hand. Immediately moved the aggressive pt to her room; alleviating the situation. Pt states she is ok. The pt is assessed for an injury and there is none noted at this time. Pt states she is fine because the pt that hit her hits like a flea. Observation on 01/19/26 at 2:10 PM revealed of R125 was seated on a couch in a common area with other residents near her. R125 was pleasantly confused and was exhibiting no problem behaviors toward others. During an interview on 01/21/26 at 9:30 AM, LPN4 stated she was working on 09/04/25 when the incident between R93 and R125 occurred. LPN4 stated a CNA informed her that R93 was hitting R125 on the back in the 400-hall dining room. LPN4 stated she immediately went to the dining room, and the staff had the residents separated. LPN4 explained that the residents were taken to their rooms and she examined both residents for injuries and found none. LPN4 stated following the incident R125 was calm and did not express any signs of pain or being afraid. During an interview on 01/21/26 at 3:05 PM, CNA11 stated she recalled the incident between R93 and R125 which occurred on 09/04/25. CNA11 explained on 09/04/25 at around 5:00 PM she and another CNA were in the 400-hall dining room when she heard a loud slap. CNA11 stated she turned and observed R93 forcefully hitting R125 on the back. CNA11 stated she and the other CNA immediately separated the two residents and informed the nurse of the incident. CNA11 stated when the residents were separated R125 was not visibly upset or expressing any signs of pain. CNA11stated she was not aware of R93 or R125 exhibiting any physical behaviors towards others prior to or since the 09/04/25 incident. During an interview on 01/21/26 at 5:40 PM, the Administrator stated the facility's investigation of the 09/04/25 incident when R93 was observed hitting R125 on the back should have been substantiated by the facility because the abuse happened. The Administrator stated the staff try hard to prevent resident abuse and the facility trained staff on identification of abuse and to always immediately report abuse. Review of a facility investigation dated 08/29/25, and provided by the facility, noted on 08/26/25, R115 had wandered into R136's room several times prompting R136 to yell get out. Each time, staff redirected R115 out of the room. The last time R115 wandered into the room, staff seated him/her in the dining room, R136 came from behind and slapped R115 in the face. At the time of the incident, both residents resided on the secured Memory Support Unit. Review of the Face Sheet located under the Resident Dashboard tab in the EMR identified R115 was admitted on [DATE] with diagnoses that included dementia with mood disturbance. Review of R115's Care Plan, located under the RAI tab in the EMR, initiated 06/28/25, revealed R115 resided on the secured Memory Support Unit due to dementia and wandering. Review of R115's Quarterly MDS, located under the RAI tab in the EMR, with an ARD of 11/30/25 revealed a BIMS score of three out of 15 which indicated R115 was severely cognitively impaired. Review of the Face Sheet, located under the Resident Dashboard tab in the EMR identified R136 was admitted on [DATE] with diagnoses that included dementia, severe, with mood disturbance, and anxiety disorder. She was discharged to another facility on 9/10/25. Review of the Quarterly MDS, located under the RAI tab in the EMR, with an ARD of 08/08/25, revealed a BIMS score of 12 out of 15 which indicated R136 was moderately cognitively impaired. Review of the care plan, initiated 06/11/25, revealed When resident begins to become socially inappropriate and aggressive behaviors, provide comfort measures for basic needs [for example [ex.] pain, hunger, toileting]. Observation of R115, on the secured Memory Support Unit (MSU), on 01/21/26 from 2:00 to 2:45 PM, revealed R115 was in common area seated with other residents. She was calm, seated directly next to another resident and placed her head on the other resident's shoulder with both residents resting. At 2:45PM, R115 was observed up and walking about independently on the hallway. R115 was observed to wander into the room at the end of the hallway, exit, and walk back down the hall. R115 was observed walking in and out of the dining room speaking calmly with other residents. In an interview on 01/21/26 at 8:09 AM, the Administrator stated They fight back there [MSU] a lot. We usually substantiate these allegations because it happened. They have dementia. Some don't like others in their space. During an interview on 01/21/26 at 2:45 PM, CNA5 stated R115 is usually calm but can get agitated during care.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure residents seated at the same table ate at the same time for two of two residents (Resident (R)124 and R103) reviewed for dignity in dining out of a total sample of 37 residents. This failure had the potential to cause R103 and R124 to feel less dignified.Findings include:Review of the facility's policy titled, Dining Program, with a review date of 10/21/25, indicated, It is the policy of [Name] to enhance the meal experience for all patient/residents who participate in the dining program.1. Review of R124's significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/05/25 and located in the electronic medical record (EMR) under the RAI [Resident Assessment Instrument] tab, revealed the resident had problems with short-term memory and long-term memory. Further review revealed the resident was coded as being dependent with eating.Observation on 01/19/26 at 12:52 PM revealed R124 and R27 were seated at a table in the 400 hall dining room. At this time, a Certified Nurse Aide (CNA)2 was observed feeding R27. R124 was seated in a reclined geri-chair next to the table with her uneaten lunch meal tray positioned on the table.Continuous observation on 01/19/26 from 12:52 PM to 1:15 PM revealed CNA2 continued to feed R27 her meal, while R124 was not assisted with her lunch meal. At 1:15 PM CNA2 finished feeding R27 her meal and assisted the resident from the dining room. At 1:17 PM, CNA2 was observed to begin serving R124 her meal. At 1:34 PM CNA2 was observed to finish feeding R124 her meal.During an interview on 01/19/26 at 1:34 PM, CNA2 confirmed R124 was served her meal after her tablemate (R27) had finished eating her meal and had been assisted from the dining room.2. Review of R103's quarterly MDS, with an ARD of 11/18/25 and located in the EMR under the RAI tab, revealed the resident had problems with short-term memory and long-term memory.Observation on 01/20/26 at 12:35 PM revealed R103 and R27 were seated at a table in the 400 hall dining room. At this time, an CNA was observed feeding R27. R103 was seated in a reclined Geri (geriatric) chair (wheeled recliner) next to the dining room table and had not been served a lunch meal.Continuous observation on 01/20/26 from 12:35 PM to 12:45 PM revealed staff continued to feed R27 while R124 had not been served a meal and watched staff feed R27. At 12:45 PM staff finished feeding R27 her meal. At 12:47 PM, staff were observed to assist R27 from the dining room. At 1:07 PM, staff was observed to serve R103 her lunch meal in the dining room.During an interview on 01/20/26 at 1:40 PM, Licensed Practical Nurse (LPN)2, who was the 400-hall unit manager, confirmed R103 was served her meal later than her tablemate (R27). LPN2 stated during the 01/20/26 lunch meal some residents were served their lunch later than scheduled because the hallway's second meal delivery cart arrived much later than the hallway's first meal cart. LPN2 stated staff on the 400 hall were not informed there would be a delay in the hallway's meal service.During an interview on 01/20/26 at 3:45 PM, the Dietary Manager (DM) confirmed during the lunch meal on 01/20/26 the 400 hallway's second meal cart was transported to the hallway later than scheduled due to a mix up in the kitchen, and this delay was not communicated to the staff on the hall. The DM stated residents who ate meals at the same dining room table should be served their meals at the same time because it was a dignity issue.During an interview on 01/21/26 at 5:20 PM, the Director of Nursing (DON) stated she expected residents who were eating meals at the same dining room table to be served their meals at the same time to promote dignity.

Based on record review, interview, and policy review, the facility failed to ensure completion of a required PASRR (Pre-admission Screening and Resident Review) when a resident's diagnosis changed. Specifically, for Residents R6 and R9, the facility did not initiate or complete a new or updated PASRR after a change in the resident's diagnosis, which had the potential to affect the residents' need for specialized services. This failure placed residents at risk of not receiving appropriate evaluations, services, and support in accordance with federal requirements.Findings include: Review of the Social Services director for the facility job description provided by the facility indicated under key responsibilities .Responds to resident behavioral and psychiatric issues by completing behavioral and psychosocial assessments, providing treatment recommendations and making referrals to appropriate mental and behavioral health providers.completes psychosocial assessments of residents. According to the South Carolina Department of Health and Human Services, Federal PASARR regulations require nursing facilities to complete a PASARR Resident Review whenever a resident shows a significant change in condition, including the development of a new mental health diagnosis such as major depression, schizophrenia, bipolar disorder, or other serious mental illnesses. When a new diagnosis or psychiatric symptoms emerge after admission, this may indicate a PASARR significant change, requiring the facility to submit an updated Level I PASARR within 14 days and, if indicated, to trigger a Level II evaluation to determine continued eligibility and service needs. Guidance further explains that new behavioral or psychiatric symptoms suggesting mental illness—especially when not previously identified—must be referred to the appropriate PASARR authority for review. 1. Review of R9s Face Sheet from the facility electronic medical record (EMR) under the Resident tab showed an admission date of 05/02/18 with the most recent date of 10/31/24 with the following medical diagnoses that included schizoaffective disorder, bipolar type, Muscle weakness (generalized), Unsteadiness on feet, and Type 2 diabetes mellitus. Review of R9's South Carolina Department of Health and Services PASARR Level 1 screening Form provided by the facility, dated 05/02/18, indicated R9 had no diagnosis of mental illness at the time of admission. Review of R9's Orders sheet located in the EMR under the Residents tab revealed an order for Seroquel (quetiapine) tablet; 25 milligrams (mg); amount (amt): 1 tablet; oral at bedtime for the diagnosis of schizoaffective disorder, bipolar type with a created date of 12/05/24. Review of R9's Care Plan retrieved from the facility EMR under the RAI tab revealed R9 is hallucinating and seeing animals/diagnosis of schizoaffective disorder, bipolar type with a start date of 06/21/21 During an interview on 01/20/26 at 2:42 PM with the facility Social Services Director (SSD), the SSD stated R9 did not have a PASARR. When asked to clarify if that was PASARR level I or level II, the SSD responded, There is no PASARR. The SSD confirmed R9 had a new diagnosis and another Level 1 PASARR was not initiated. In an interview on 01/20/26 at 2:57 PM, the Administrator also confirmed R9 did not have a PASARR she further shared her expectation is all residents need a [PASARR] screening before admission or if there is a change in diagnosis indicating a mental illness (MI) or Intellectual Disability (ID). 2. Review of R6's Face Sheet, located in R6's EMR under the Face Sheet tab, revealed the facility admitted R6 on 03/12/25 from an acute care hospital. Review of the PASARR Level 1, dated 11/06/24, that was completed by the hospital prior to R6's admission to the facility, located in R6's EMR under the Resident Documents tab, revealed R6 did not have a mental illness diagnosis and indicated no further evaluation was recommended. Resident 6's pertinent diagnosis included Non-Alzheimer's dementia. Review of R6's admission MDS with an ARD of 03/12/25 revealed R6 had moderate cognitive impairment as evidenced by a BIMS score of 11 out of 15. R6's neurological diagnosis included Non-Alzheimer's dementia. R6's did not have any psychiatric or mood disorder diagnoses (i.e., bipolar disorder). R6 received antipsychotic medication during the review period. Review of the Psychiatry Initial Visit report, dated 04/15/25, located in R6's EMR, under the Resident Documents tab, revealed, Patient was admitted to the facility on [DATE]. Since admission, TID [three times daily] PRN [as needed] trazodone (antidepressant) was reduced to lower dose. She remains on chronic Seroquel for mood stabilization and history of verbal aggression. Psychiatry has been consulted for residual symptoms of mixed mood, including irritable dysphoria, disinhibition with verbal [NAME] control, hurling profanities and racial slurs at others, aggressive behaviors causing discomfort to others. Findings: Symptoms consistent with chronic bipolar disorder. Current mixed episode. She is tolerated [sic] antipsychotics in the past and was admitted on Seroquel and trazodone. Major Neurocognitive Disorder, Alcohol abuse disorder, and current remission. Progressive impairments to the nervous system secondary to chronic alcohol contributing to dementia. Symptoms consistent with likely late onset [sic] Alzheimer's disease. Orders/Plan: Start Depakote ER [extended release] 250 mg PO [by mouth] for mood stabilization, hypomania with insomnia, and reduction of impulsive disinhibited behaviors which pose risk to the safety of herself and others. In five days, increase Depakote ER to 500 mg [milligrams] PO HS (hour of sleep). During an interview on 01/20/26 at 2:38 PM, the SSD stated that she recently started working at the facility. The SSD reviewed R6's clinical record and could only find the PASSAR Level 1 dated 11/06/24. The SSD was unable to state if the facility submitted a new PASSAR Level 1 Screening as a resident review referral due to R6's new bipolar diagnosis. During an interview on 01/20/26 at 2:43 PM, the Social Worker stated that she reviewed R6's clinical record and located R6's PASSAR Level 1, which the hospital provided upon admission. The Social Worker was unable to state if the facility completed a new PASSAR Level 1 to see if a PASSAR Level 2 was needed due to the new bipolar diagnosis. During an interview on 01/20/26 at 3:00 PM, the Administrator stated that the facility relied on diagnoses provided by the hospital and information included in the PASSAR sent with the resident upon admission to the facility. They identify residents with newly evident or possible mental disorders or related conditions after admission based on observed behaviors, consults, laboratory reviews, but not the resident's diagnosis, unless they are started on a psychotropic medication. The Administrator stated that the social workers were responsible for making the referral to the appropriate state-designated authority. The Administrator was unable to state if the facility submitted a new PASSAR Level 1 Screening as a resident review referral due to R6's new bipolar diagnosis. During an interview on 01/20/26 at 4:21 PM, the Director of Nursing (DON) stated that the facility did not have a policy and procedure regarding PASSARs. The DON stated that if the resident's diagnoses changed to include a major mental illness, they would verify the diagnosis and send the information to the PASARR entity to see if a PASSAR level 2. The DON was unable to state if the facility submitted a new PASSAR Level 1 Screening as a resident review referral due to R6's new bipolar diagnosis.

Based on observations, record review, interviews, testing and tasting of food served on a requested test tray and policy review, the facility failed to ensure food was palatable and served hot to four of eight residents (Resident (R) 3, R28, R68, and R75). The failure had the potential to negatively affect 124 residents who consumed food prepared from the facility's kitchen by experiencing dissatisfaction with the meals, not eating the meals, and/or experiencing nutritional concerns.Findings include: Review of the facility's policy titled, Food Temperatures, revised 10/21/25, indicated, Policy: Statement: It is the policy of (facility name) that the Dietary Manager or designee be responsible for ensuring that all food has reached and continues to maintain proper temperature prior to tray assembly . Food will be served at palatable temperatures . In a Resident Group Interview on 01/20/26 at 1:30 PM, with eight residents, the facility identified to be reliable historians and cognitively intact, four residents voiced complaints that the food was not served hot to their rooms. 1.Review of R3's Quarterly Minimum Data Set (MDS) located under the RAI [Resident Assessment Instrument] tab in the Electronic Medical Record (EMR), with an Assessment Reference Date (ARD) of 12/13/25, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R3 was cognitively intact. 2.Review of R28's Quarterly MDS, located under the RAI tab in the EMR, with an ARD of 11/25/25, revealed a BIMS score of 15 out of 15 which indicated R28 was cognitively intact. 3.Review of R68's Quarterly MDS, located under the RAI tab in the EMR, with an ARD of 11/28/25, revealed a BIMS score of 15 out of 15 which indicated R68 was cognitively intact. 4.Review of R75's admission MDS, located under the RAI tab in the EMR, with an ARD of 10/20/25, revealed a BIMS score of 15 out of 15 which indicated R75 was cognitively intact. During the interview, R28 said her food often was cold when it arrived to her room and staff tell me they can't heat it up. During the interview, R68 said they had to eat in their rooms recently because of a flu outbreak and that they food is not hot when it comes to my room. Observation on 01/21/26 at 7:49 AM revealed a requested test tray was placed in an enclosed unheated meal delivery cart for the 300 hallway. Food temperatures on the kitchen tray line were monitored and were at acceptable levels of 135 degrees Fahrenheit (F) and above for the hot foods. The food was placed on heated plates and covered with an insulated dome lid prior to being placed in the enclosed meal delivery cart. The meal delivery cart arrived at the 300 hallway at 7:51 AM and nursing staff began serving resident meals. As nursing staff were serving meals from the meal cart it was observed that many of the insulated dome lids were not completely covering resident meal plates which was confirmed by the Dietary Manager (DM). At 8:01 AM, the last resident meal was delivered on the 300 hallway. After the last resident meal was delivered, the test tray was removed from the enclosed delivery cart by the DM. When the DM removed the test tray from the cart the insulated dome lid was only partially covering the meal plate. The DM used a calibrated facility thermometer, obtained the temperatures of the food on the test tray, and tasted each of the food items with the surveyor. The scrambled eggs on the test tray registered at 88 degrees F. This surveyor tasted the scrambled eggs and they tasted cold. The DM also tasted the scrambled eggs and agreed they were cold. The grits on the test tray registered 98 degrees F. This surveyor tasted the grits, and they tasted warm and needed to be hotter. The DM tasted the grits and agreed they were warm and could be hotter. During an interview on 01/21/26 at 8:08 AM, the DM stated the insulated dome lids covering resident meal plates on the meal cart had probably slid off the plates during transport to the 300 hallway when the cart ran over a slightly elevated area of flooring located at the beginning of the 300 hallway. The DM showed the surveyor where this elevated area of flooring was located on the 300 hallway. The DM stated staff would need to transport meal delivery cart slower over this area to prevent the insulated lids from sliding off resident meal plates.

Based on the facility policy, observations, interviews, and The 2017 FDA Food Code, the facility failed to ensure food was served under sanitary conditions during the 200 Hall meal service on 01/26/2025 for 1 of 3 halls observed during meal service. Findings include: Review of the facility policy titled, Meal Delivery, states as the policy statement: It is the policy of this facility that all food be transported under safe and sanitary conditions to prevent foodborne illness. Review of, The 2017 FDA Food Code, states: The 2017 FDA Food Code discourages bare hand contact with RTE food (i.e., food that is eaten without further washing or cooking) and requires the use of suitable utensils such as scoops, spoons, forks, spatulas, tongs, deli tissue, single-use gloves, or dispensing equipment when handling these food items. Bare hand contact with a RTE (ready to eat) food, such as sandwiches and salads, can result in contamination of food and contribute to foodborne illness outbreaks. Therefore, food employees should always use suitable utensils when handling RTE foods. During an observation on 01/26/2025 at 01:00 PM during the lunch meal service on the 200 Hall revealed, Certified Nursing Assistant (CNA)2 setting up a meal tray for the resident in room [ROOM NUMBER]A. CNA2 cleaned her hands with hand sanitizer and then picked up the resident's meal tray and brought it into the room and sat it on the over bed table. She elevated the over bed table with her bare hands, then took the bed control in her hand and elevated the head of the bed. CNA2 then took the cover from the plate and proceeded to remove the silver ware that was wrapped in a napkin, opened the straw and placed in the resident's glass of tea, and then opened a small plastic bag containing a roll and reached into the plastic bag with her bare hands and removed the roll and placed it on the meal tray for the resident to eat. A second observation on 01/26/2025, after pushing the meal cart down the hall to room [ROOM NUMBER]A, CNA2 cleaned her hands with hand sanitizer, took the meal tray into room [ROOM NUMBER] for the resident in the A bed. His lunch consisted of a sandwich. CNA 1 placed the tray on the over bed table and pushed the table up closer to the resident and raised the head of the bed, then removed the plate cover. She removed the silverware from the napkin, placed the straw into his beverage, asked the resident if he wanted mayonnaise on his sandwich. CNA2 took the top piece of bread from the sandwich with her bare hands, layed it onto the palm of her left hand and proceeded to spread the mayonnaise onto the bread, and then picked the piece of bread up with there right hand and placed it onto the sandwich for the resident to eat. During an observation on 01/26/2025 at 01:05 PM, during the lunch meal service on the 200 Hall, CNA1 was observed removing a dirty tray from a resident and placing it on the clean food cart. CNA1 then proceeded to grab a clean food tray and serve it to the resident without sanitizing or cleaning their hands. Additionally, the food tray cart was left open during the service. During an interview on 01/26/2025 at 01:10 PM with CNA1 and Registered Nurse (RN)2, RN2 stated that facility policy specifies that dirty trays should not be placed on the food cart. She explained that there is a designated kitchen area for dirty trays, but this procedure is not consistently followed. RN2 acknowledged that staff occasionally struggle with adhering to the policy and, at times, allow it to happen. CNA1 also confirmed that, while the policy prohibits placing dirty trays on the food cart, staff sometimes face situations where the policy is not followed. She mentioned that while staff attempt to redirect this behavior, they sometimes face challenges in enforcing the policy effectively. During an interview on 01/26/2025 at 01:10 PM, CNA2 confirmed that she had touched food on resident's meal trays with her bare hands. She also stated that she was not aware that she should not touch the food, that she had not been told that she could not touch the food with her bare hands.

Based on the facility policy, record reviews and interviews, the facility failed to ensure accuracy of staffing posted daily to include the total staff as worked with the census and hours to ensure the resident care and visitors were aware of staffing for each shift as well as each 24 hour period for 10 days from 11/26/2024 through 01/26/2025. Findings include: Review of the facility policy titled, State Minimum Staffing for Healthcare Centers, states as the Policy Statement: The facility will maintain a minimum staffing hours in accordance with federal law and the respective state's rules and regulations. Staffing shall be sufficient to meet the healthcare needs of each patient/resident as identified in the patient/resident's plan of care. Daily nursing hours will be posted at each facility in accordance with federal regulations. 1. Each facility will complete the Daily Nursing Hours for Healthcare Centers Form. Information on the form will include: a. The facility name. b. The current date. c. Resident census. d. The total number of each category directly responsible for resident care per shift. (Registered Nurses, Licensed Practical Nurses, and Certified Nursing Assistants). e. The actual working hours for each partner in each category per shift. f. The total number hours worked for each category per shift. 2. The facility will post the nurse staffing data on a daily basis by the beginning of each shift. 3. The form must be clean and readable and be posted in a prominent place accessible to residents and visitors. Review on 01/27/2025 at 08:32 AM of the staffing as posted from 11/26/2024 through 01/26/2025 revealed: On 12/5/2024 the actual number of staff worked on the 3-11 shift is 45 with no total hours worked and on the 11-7 shift 45 CNAs was documented as the actual number of staff worked with no total hours. On 12/28/2024, a Saturday, no Registered Nurses (RNs) are documented as in the facility for 8 consecutive hours. On 01/08/2025, the number of actual RNs and LPNs working on the 7 to 3 shift is blank and the total hours worked is also blank. On 01/18/2025, there is no actual number of staff worked and no total hours for each discipline on the posting. On 01/19/2025, there are no CNAs listed on the posting and no actual staff worked and no total hours for each discipline. On 01/20/2025, 01/21/2025, 01/22/2025, and 01/23/2025 there is no actual number of staff worked and no total hours worked on the posting for each discipline. On 01/26/2025 there are no actual number of staff worked on the 11 to 7 shift and no total hours worked at all for the day based on the posting. During an interview on 01/27/2025 at 10:50 AM with the Receptionist, who is responsible for the posting stated, that she asked for the information multiple times and had not received it. During the interview the Receptionist was diligently working to add the information to the form.

Based on observation, record review, interview, and facility policy review, the facility failed to provide and maintain dignity, for 1 of 1 resident, (Resident (R)13), reviewed for resident rights. Specifically, R13, was dressed in a hospital gown daily from 01/26/2025 through 01/28/2025. Findings Include: Review an undated facility policy titled, Resident's [NAME] of Rights stated, As a resident of this facility, you have or your legal guardian has, the right to: Be treated with respect and dignity .And Personal Treatment. Record review of R13's admission facesheet, revealed, R13 was admitted to the facility on [DATE] with diagnoses including, but not limited to: dementia, depression, cerebrovascular accident with hemiplegia and hemiparesis and weakness. Review of R13's Plan of Care revealed, R13 required extensive to total assistance with ADLs related to hemiplegia. During an observation on 01/26/25 at 10:50 AM, R13 was noted to be in bed wearing a hospital gown, later at 1:40 PM, R13 was still observed in the hospital gown. During an observation on 01/27/25 at 04:40 PM, R13 was observed seated in a geri-chair in the day room with other residents, watching television and still wearing a hospital gown. During an observation on 01/28/25 at 09:00 AM, R13 was again observed in a hospital gown. During an interview on 01/18/25 at 8:55 AM, the Director of Nursing (DON), was asked if R13 had personal clothes. She stated that she did not know but would check and see if this resident had any clothes. The DON returned and stated that R13 did have personal clothes, but they were too small for the resident. She stated that she would have to contact R13's responsible party to see about getting him clothes that fit.

Based on the facility policy, and the insulin pen instructions from The Institute of Family Health, observations and interviews, the facility failed to ensure a medication administration error rate less than 5 percent. Specifically, the insulin flex pens for Resident (R)108 and R99 were not primed correctly prior to administration for 3 of 30 opportunities for error. The medication administration error rate was 10 percent. Findings include; Review of the facility policy titled, Medication Administration: Insulin Injections, reviewed and revised on 07/18/2024, states as the Policy Statement: : It is the policy of this facility that the procedures outline in this policy must be followed to aid oxidation and utilization of blood sugar by the tissues and to control the blood sugar levels in residents/patients with diabetes mellitus through the correct administration of insulin. For Insulin Pens, page 4. 1. Remove the cover from the pen and swab with an alcohol swab. Screw on a new needle and remove cap. 2. Prime the pen by dialing 2 units on the pen and pressing the button on the end of the pen. Repeat priming procedure until insulin secretes from the needle. Review of the Insulin Pen Instructions, from The Institute of Family Health. Part C 1. Remove the paper tab from pen needle. 2. Screw pen needle firmly onto pen. 3. Take big cap off of pen needle. 4. Take little cap off of pen needle. Throw out little cap. Part D 1. Dial up 2 units on pen (each click is 1 unit). 2. Point pen needle up towards ceiling and tap on it gently. 3. Press button on bottom all the way. 4. I necessary, repeat steps 1-3 until you see a drop of insulin come out. Part E 1. Dial pen to your insulin dose. During an observation on 01/27/2025 at 04:55 PM, RN1 was preparing to give R108 an insulin injection using a Novolin 70/30 Kwik Pen. The RN rolled the insulin pen to ensure it was mixed then wiped the hub with an alcohol wipe and screwed on a needle. Holding the insulin pen horizontal with the cap on the needle she dialed the dose indicator to 2 units to prime the pen. Still holding the insulin pen horizontal, and the cap still applied she pressed the dose plunger to prime the pen. Then the RN proceeded to dial up the ordered dose of insulin and went into R108's room to administer the insulin. During a second observation on 01/27/2025 at 05:25 PM, RN1 was preparing to give R99 two insulin injections. One injection was Lantus 15 units and the second injection was Humalog 4 units subcutaneous via a sliding scale for a blood sugar of 260. The RN then took the Lantus pen and wiped the hub with alcohol and screwed on a needle. With the still capped again she dialed up the 2 units to prime the pen and held the pen horizontal with the needle capped and primed the pen. This surveyor then asked, is that the way you were taught to prime the pen. The nurse stated you are now making me nervous. This surveyor stated, I'm just asking, is that the way you were instructed to prime the pen. Do you hold the pen horizontal with cap on the needle and prime it? The RN then removed the cap and held the pen with the needle pointed toward the floor. RN 1 then primed the Humalog pen in the same manner with the cap on the needle and holding the pen horizontal and proceeded to give the 2 insulin injections to R99. RN1 confirmed that she had primed the 3 insulin pens with the cap on the needle and holding them horizontally.

Based on the facility policy, record reviews and interviews, the facility failed to ensure the Comprehensive Plan of Care was reviewed and revised for Resident (R)29 and R100 with goals and interventions to ensure an ongoing program of activities for each individual resident based on likes/dislikes and preferences for 2 of 4 residents reviewed for activities. Findings include: Review of the facility policy titled, Activities Program, states as the policy statement, 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 procedure number 7 states: After reviewing the Activities Assessment and Preferences for Customary Routine & Activities in the EHR (Electronic Medical Record), the IDT (Interdisciplinary Team) designates specific activities for individual residents in the resident's care plan based on their likes/dislikes, preferences, and impairments. The facility admitted R29 on 07/23/2024, with diagnoses including, but not limited to, muscle weakness, bilateral lower limb amputations, hypertension and chronic pain. Review on 01/27/2025 of the Comprehensive Plan of Care dated 10/24/2024 for R29, revealed a problem area which states, Resident prefers activities that identify with prior lifestyle, but has problems with his mobility. The goal states, Resident will express satisfaction with daily routine and leisure activities by participating with one leisure activity weekly for 90 days to improve social leisure skills. The plan of care did not include any interventions, activity preferences, or likes and dislikes. During an interview on 01/26/2025 with R29, when asked about going to activities and the facility providing activities he stated, What is that? R29 went on to say that he had not been invited to any activities and had not received any one to one activities. The facility admitted R100 on 04/06/2024 with diagnoses including, but not limited to, acute pulmonary edema, asthma, schizophrenia and mood disorder. Review on 01/27/2025 of the Comprehensive Plan of Care dated 08/03/2024 for R100, revealed a problem area which states, Resident prefers 1:1 activities and requires encouragement and motivation to participate with activities. The goal states, Resident will not exhibit boredom/isolation as evidenced by participating with at least 1 leisure activity weekly. The one and only intervention reads, Staff will verbally encourage and involve resident with those who have shared interests. During an interview with R100 on 01/26/2025 at approximately 1:30 PM, she stated that she has not gone to any activities and she had had no 1:1 activities at all. According to the Activity Director and the Director of nursing, no documentation could be found to ensure R29 and R100 had received any type of activities since admission.

Based on review of facility policy, record review, and interview, the facility failed to accurately document Resident (R)211's advance directives, for 1 of 2 residents. Specifically, R 211 had orders and signed documentation requesting Do Not Resuscitate (DNR), however R 211's Care Plan and Face Sheet documented Full Code. Findings include: Review of facility policy titled, Advance Directives: South Carolina with a review date of 11/28/17 revealed This healthcare center recognizes the right of patients/residents to control decisions related to their medical care. Advance Directives relate to the provision of care when the patient/resident lacks the capacity to make healthcare decisions. Advance Directives executed in accordance with state law will be honored by the healthcare center .The healthcare center shall enter in the patient/resident's medical record any change in or termination of the advance directive for health care that becomes known to the healthcare center .3. 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 medical record .A copy of the advance directives shall become a permanent part of the patient/resident's medical record .The Director of Health Services (or designee) will notify the attending physician of advance directives and document such notification in the medical record. Review of R 211's Face Sheet revealed, R 211 was admitted to the facility admitted on [DATE] with diagnoses including but not limited to: dementia, cerebral infarction, cerebellar stroke syndrome, and systolic (congestive) heart failure. Review of R 211's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/14/25, revealed, R 211 had a Brief Interview of Mental Status (BIMS) score of 08 out of 15, indicating moderate cognitive impairment. Review of R 211s electronic medical record (EMR) revealed, a document dated 01/02/25 stating R211 wishes to be DNR and will provide the facility with a copy Review of R 211'sPhysician Orders dated 01/07/25, revealed R 211's code status was DNR. Review of R 211's Care Plan dated 01/08/25 under the advance directive category, revealed, R 211 was a Full Code, with interventions noted to advise R 211 and/or resident representative to provide copies to the facility of any updated Advance Directives and for all staff to be made aware of R211's wishes. Review of a progress notes dated 12/02/24 by Social Services revealed Quarterly assessment R 211 remain DNR. Review of R 211's EMR revealed her code status on the dashboard of the EMR was marked as a Full Code. During an interview on 01/28/25 at 10:31 AM, Certified Nursing Assistant (CNA) 3 stated, Today is my first day. I am unsure of what the Do Not Resuscitate (DNR). The nurse told me about all the patients. During an interview on 01/28/25 at 11:20 AM Licensed Practical Nurse (LPN) 1 stated, Resident is full code. During an interview on 01/28/25 at 11:29 AM Admission stated, The son did the admission paperwork. R211 is a full code. I would have to look back at the admission paperwork to confirm status. During an interview on 01/28/25 at 11:32 AM, Social Worker (SW) stated, She is a full code. During an interview on 01/28/25 at 11:41 AM, R211's Resident Representative (RP) stated, Let me call my sister to verify. I believe it her code status is a full code. During an interview on 01/28/25 at 12:30 PM, the Director of Nursing (DON) stated, Not right off. The SW will follow up DNR status. We will follow up.

Based on observations, interviews, record review, and review of facility policy, the facility failed to ensure a comfortable and homelike environment was provided for 1 Resident (R)36 of 2 residents reviewed. Specifically, they failed to properly clean R36's room and failed to provide R36 with a clean mattress and linen. Findings Include: Review of facility policy titled, Infection Control-Housekeeping Services last revised 10/16/23, revealed, It is the policy of this facility to ensure housekeeping services will be performed on a routine and consistent basis to ensure an orderly, sanitary, and comfortable environment. Further review revealed, A deep cleaning will be performed for each patient/resident room monthly and at discharge and in patient/resident care areas, cleaning of non-carpeted floors and other horizontal surfaces will be performed daily and more frequently if spillage or visible soiling occurs. Review of an undated facility policy titled, Housekeeping: Discharge and Monthly Deep Cleaning of the Resident Room, revealed, To detail the proper steps for the Discharge & Monthly Deep Cleaning of resident rooms in order to create a sanitary and comfortable environment for the resident This task should be completed for all residents' rooms at a minimum of once per month or as needed. Spray and wipe down horizontal and high touch surfaces (bed, bed frame, bed rails. Mattress). Review of R36's Face Sheet revealed R36 was admitted to the facility on [DATE] with diagnoses including but not limited to: persistent vegetative state, dysphagia, gastroparesis and gastro-esophageal reflux disease. Review of R36's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/30/24 revealed that a Brief Interview for Mental Status (BIMS) was not performed. A review of the deep cleaning schedule for the month of January 2025 revealed that R36's room was scheduled for a deep clean on Wednesday, January 8, 2025. This cleaning was noted as part of the routine schedule, but it is unclear whether the cleaning was completed as planned. During an observation on 01/26/25 at 11:42 AM, R36 was observed lying on her bed in her room. It was noted that the bed did not have any sheets, and the mattress appeared unkempt. The surface of the mattress was visibly soiled, with crumbs scattered across it and a brown, crusty substance observed in multiple areas. Additionally, a noticeable stain, suspected to be blood, was observed on the floor near the bed. During an observation and interview on 01/26/25 at 12:53 PM, Registered Nurse (RN)2 visually confirmed the presence of blood stains on the floor and the unkempt state of the mattress. When shown R36's mattress, RN2 remarked, Yeah, that is filthy. RN2 then added that residents' rooms and mattresses are cleaned by housekeeping. During an interview on 01/26/25 at 12:56 PM, the Housekeeping Supervisor (HS) explained that typically, Certified Nursing Assistants (CNA) are responsible for notifying housekeeping if there are any concerns regarding the condition of residents' rooms. HS further stated that mattresses are scheduled for cleaning once a month, with additional cleanings conducted as needed. HS clarified that housekeeping notifies the nursing staff the day before any scheduled cleaning so that everyone is informed. HS stated R36 may need a new mattress. During an interview on 01/27/25 at 12:13 PM, the Director of Nursing (DON) confirmed that housekeeping follows a deep cleaning schedule and provides prior notice to nursing staff the morning before any scheduled cleanings. DON emphasized that staff could utilize the Equipment Lifecycle System (TELS) to communicate cleaning issues, or they can page housekeeping directly using the walkie talkie. DON reiterated that staff are expected to adhere to policies and procedures when addressing housekeeping concerns. However, DON was unaware of the condition of R36's mattress and room.

Based on record review, interviews, and facility policy review, the facility failed to provide the complete Bed Hold policy for 1 of 6 Residents (R) 23 reviewed for hospitalizations. Specifically, (R) 23 and or his responsible party did not receive the bed hold policy with the daily rate within a reasonable time frame upon transfer to the hospital. Findings Include: Review of the facility's policy titled Bed Hold Policy states, Any patient/resident who is transferred or discharged from the healthcare center may be readmitted , in accordance with applicable regulations. Another notice that specifies the duration of the bed hold policy will be issued at the time of any transfer. In cases of emergency transfer, the family and/or undersigned parties, will be provided with written notification within 24 hours. Please inquire with the business office, if you have a question about payer source at the time of transfer, which payer source is applicable, or if you need help determining whether a secondary payer source is effective. Review of R23's Face Sheet, revealed, R23 was admitted to the facility on [DATE] with diagnoses including, but not limited to: pressure ulcers, left leg below the knee amputation, chronic pain syndrome, and bacteremia. Review on 01/27/2025 of the documents sent to the hospital with R23 included a bed hold policy in a packet that was sent to the hospital at the time of discharge on [DATE]. There is no documentation in R23's medical record to ensure the responsible party nor the resident a copy of the bed hold policy in a timely manner. Further, review of the facility's Bed Hold Policy, revealed no bed hold amount in which the responsible party or resident would be required to pay if the hospital stay went beyond the ten day period. During an interview with the Social Service Director (SSD), she confirmed that the facility Bed Hold Policy went with the resident to the hospital in a packet and contained no bed hold amount. SSD could not ensure that R23 nor the responsible party received a copy of the bed hold policy with the bed hold amount after leaving for the hospital.

Based on record review and interviews, the facility failed to ensure a resident had received a Preadmission Screening and Resident Review (PASRR) prior to admission to the facility for 1 of 1 resident reviewed, Resident (R)101. Findings include: Review of CMS regulation of PASRR guidelines, dated revised September 30, 2005, revealed, Federal statue and regulations require all applicants to a Medicaid-certified nursing facility (NF) to be screened for mental retardation or related conditions (MR), and serious mental illness (MI). Review of admission record revealed the facility admitted Resident (R)101 on 02/16/1959, with a diagnosis that included metabolic encephalopathy, vascular dementia, severe with agitation, dementia in other disease classified elsewhere, severe, with agitation, and other frontotemporal neurocognitive disorder. Review of R101's Medication Administration Record (MAR) dated January 28, 2024, revealed Zyprexa Zydis (olanzapine) 5 mg tablet, disintegrating three times a day for agitation; haloperidol lactate 5 mg/mL syringe stat - Immediately 1 ml, intramuscular, STAT - Immediately for severe agitation; Seroquel (quetiapine) 100 mg tablet twice a day. Review of R101's Care Plan initiated on July 29, 2024, revealed, R101 uses psychotropic medications. The interventions include provide structured activities as a diversional technique, approach in a calm manner, and psychological consultation. Review of Quarterly Minimum Data Set (MDS) dated [DATE], revealed R101 had a Brief Interview of Mental Status (BIMS) score of 00, which indicated that R101 has no or minimal ability to perform activities of daily living. Review of R101's PASARR Level I screening form dated July 29, 2024, revealed a completed form and signature from Social Worker from [NAME] Health [NAME]. During an interview on 01/28/25 at 01:25 PM, Social Worker stated, I usually run a ICD 10 report every month and if warranted they will get screened for a Level II. We go by the federal regulations. The hospital completes the Level I PASAAR prior to admission During an interview on 01/28/25 at 11:53 AM, DON stated, We have a lot of Dementia training throughout the year. Every couple of months or so. During an interview on 01/28/25 at 12:21 PM, DON stated, She is on hospice, so she has had an overall decline. During an interview on 01/28/25 at 01:27 PM, DON stated, 'We do not have a PASARR policy, we go by the federal regulation.

Based on observations, interviews, record review, and review of facility policy, the facility failed to ensure Resident (R)36, 1 of 3 residents reviewed for enteral tube feedings received the appropriate treatment and services to prevent complications. R36 had two contradicting orders for enteral tube feedings. Findings Include: Review of the facility policy titled, Enteral Nutrition (Tube Feeding) with a review date of 09/12/2024 revealed, The goal is to provide enteral nutrition to the patient/resident in order to achieve and maintain optimal nutritional status. Further review revealed, the physician will write orders prescribing the formula, rate route of administration and flush orders for the individual patient/resident. Review of the facility policy titled, Physician Orders last revised 03/01/24 revealed, Procedures: 3. Any dose or order that appears to be inappropriate due to patient/resident's age, condition, or diagnosis should be verified with the attending physician and Medical Director if necessary. Review of R36's Face Sheet revealed R36 was admitted to the facility on [DATE] with diagnoses including but not limited to: persistent vegetative state, dysphagia, gastroparesis and gastro-esophageal reflux disease. Review of R36's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/30/24 revealed that a Brief Interview for Mental Status (BIMS) was not performed. Further review revealed R36 received 51% or more of total calories through tube feeding. Review of R36's Physicians Orders revealed the following orders: Check residual daily before restarting tube feeding at 10:00 am and record results with a start date of 09/25/23. Jevity 1.5 at 65 Milliliters (ml)/hour(hr.) for 18 hours per day with a 50ml/hr. water flush for 18 hours with special instruction to turn off from midnight to 6:00 am with a start date of 01/16/2025. During an observation on 01/26/25 at 11:40 AM, R36's tube feed was observed labeled and dated with a start time noted for 10:00 AM. During an observation and interview on 01/27/25 at 10:53 AM, R36's tube feed was again observed. This time, the feed was labeled and dated with a start time of 6:30 AM. RN1 confirmed that R36's tube feed is scheduled to start at 10:00 AM. When asked about the multiple tube feed orders for R36, RN1 stated she was unaware of these variations, but after confirming them, she stated she would discontinue the outdated order. RN1 further noted that, as a Unit Manager (UM), efforts are made to reconcile orders on a weekly basis, but she would need to consult her supervisor for clarification on facility policies regarding order management. During an interview on 01/27/25 at 12:13 PM, the Director of Nursing (DON) explained that both she and the UM attempt to review orders on a daily or weekly basis. DON emphasized that nursing staff are expected to contact the provider to clarify any discrepancies or necessary adjustments to orders. DON was unaware of R36's multiple orders. During an interview on 01/27/25 at 1:02 PM, the Dietary Manager (DM) stated that either the dietitian or the provider typically initiates changes to a resident ' s tube feed order. During an interview on 01/28/25 at 2:18 PM, the Dietitian confirmed that R36's current tube feed order is Jevity 1.5 at 65 ml/hr for 18 hours, with feeds off at midnight and restarted at 6:00 AM. The dietitian further clarified that on January 16, 2025, she increased R36's feed rate from 55 ml/hr to 65 ml/hr while maintaining the same duration. She noted that the order to begin feeds at 10:00 AM had been placed in 2023, and the dietitian was uncertain when the feeding schedule had shifted from 10:00 AM to 6:00 AM.

Based on the facility policy, and the insulin pen instructions from The Institute of Family Health, observations and interviews, the facility failed to ensure Resident (R)108 and R99 were free of significant mediction errors. Specifically, the insulin pens were not primed correctly, therefore the administered dose could not be verified as correct. Findings include: Review of the facility policy titled, Medication Administration: Insulin Injections, reviewed and revised on 07/18/2024, states as the Policy Statement: : It is the policy of this facility that the procedures outline in this policy must be followed to aid oxidation and utilization of blood sugar by the tissues and to control the blood sugar levels in residents/patients with diabetes mellitus through the correct administration of insulin. For Insulin Pens, page 4. 1. Remove the cover from the pen and swab with an alcohol swab. Screw on a new needle and remove cap. 2. Prime the pen by dialing 2 units on the pen and pressing the button on the end of the pen. Repeat priming procedure until insulin secretes from the needle. Review of the Insulin Pen Instructions, from The Institute of Family Health. Part C 1. Remove the paper tab from pen needle. 2. Screw pen needle firmly onto pen. 3. Take big cap off of pen needle. 4. Take little cap off of pen needle. Throw out little cap. Part D 1. Dial up 2 units on pen (each click is 1 unit). 2. Point pen needle up towards ceiling and tap on it gently. 3. Press button on bottom all the way. 4. I necessary, repeat steps 1-3 until you see a drop of insulin come out. Part E 1. Dial pen to your insulin dose. During an observation on 01/27/2025 at 04:55 PM, RN1 was preparing to give R108 an insulin injection using a Novolin 70/30 Kwik Pen. The RN rolled the insulin pen to ensure it was mixed then wiped the hub with an alcohol wipe and screwed on a needle. Holding the insulin pen horizontal with the cap on the needle she dialed the dose indicator to 2 units to prime the pen. Still holding the insulin pen horizontal, and the cap still applied she pressed the dose plunger to prime the pen. Then the RN proceeded to dial up the ordered dose of insulin and went into R108's room to administer the insulin. During a second observation on 01/27/2025 at 05:25 PM, RN1 was preparing to give R99 two insulin injections. One injection was Lantus 15 units and the second injection was Humalog 4 units subcutaneous via a sliding scale for a blood sugar of 260. The RN then took the Lantus pen and wiped the hub with alcohol and screwed on a needle. With the still capped again she dialed up the 2 units to prime the pen and held the pen horizontal with the needle capped and primed the pen. This surveyor then asked, is that the way you were taught to prime the pen. The nurse stated you are now making me nervous. This surveyor stated, I ' m just asking, is that the way you were instructed to prime the pen. Do you hold the pen horizontal with cap on the needle and prime it? The RN then removed the cap and held the pen with the needle pointed toward the floor. RN 1 then primed the Humalog pen in the same manner with the cap on the needle and holding the pen horizontal and proceeded to give the 2 insulin injections to R99. RN1 could not confirm the correct dose was administered as ordered.

Based on observation, interview and record review the facility failed to carry out orders for a splint/palm guard for one (Resident (R)36) of one resident reviewed for range of motion (ROM). This failure had the potential cause further decrease of ROM and/or pain for the resident. Findings Include: The facility Director of Nursing (DON) stated they do not have a policy for splints/devices. Review of R36's Face Sheet revealed R36 was admitted to the facility on [DATE] with diagnoses including but not limited to: persistent vegetative state, stiffness of right shoulder, and contractures of the right elbow, right hand and left hand. Review of R36's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/30/24 revealed that a Brief Interview for Mental Status (BIMS) was not performed. Further review revealed R36 had impairments of both upper and lower extremities and was dependent of others for all aspects of care. Review of R36's Physicians Orders revealed, [Passive Range of Motion] PROM to R [right] and L [left] upper extremities and application of L [left] and R [right] palmar guards daily during the day shift for 8 hours, with a start date of 08/06/2024. Review of a progress note dated 01/09/25 at 3:04 PM, revealed, [Interdisciplinary Team] IDT met and discussed resident. Will continue on restorative program [related to] r/t [Passive Range of Motion] PROM to [Bilateral upper extremities] BUE and palm guard to bilateral palms. Review of R36's Care Plan last reviewed/revised on 12/05/24 revealed, R36 required total assistances with her [Activities of Daily Living] ADL's and restorative nursing as ordered. Interventions included: provide assistive device as ordered and [Passive Range of Motion] PROM to R [right] and L [left] upper extremities and application of L [left] and R [right] palmar guards daily during the day shift for 8 hours. Review of a Facility Assessment titled Quarterly Observation dated 11/30/24, under the Musculoskeletal System: Musculoskeletal History and Physical Observation: revealed, R36 presented with contractures in the following areas: upper right and left extremities, right and left hands and wrist, and extremity weakness in the bilateral upper and lower extremities. During an observation on 01/26/25 at 11:43 AM, R36 was observed with both hands tightly curled inward, and the left hand was positioned near the edge of the mattress. No splints or assistive devices, such as palm guards, were observed on either hand. During an interview on 01/26/25 at 12:53 PM, RN2 explained that R36 did not have any orders for palm guards; however, they usually place rolled towels in her hands for positioning. RN2 also stated that passive range of motion (PROM) exercises should be performed daily for R36. During an observation and interview on 01/27/25 at 10:46 AM, R36 was again observed without palm guards on either her left or right hand. RN1 confirmed that R36 had orders for palm guards and was enrolled in a restorative nursing program that included the use of palm guards for both hands. RN1 then searched for and placed palm guards on R36's hands. RN1 further clarified that, to her knowledge, it is the responsibility of the nursing staff to ensure the placement of palm guards. During an interview on 01/27/25 at 12:13 PM, the Director of Nursing (DON) stated that either Certified Nursing Assistants (CNA) or nurses can place the palm guards on residents. DON also noted that both CNAs and nurses have access to the residents' care plans and orders through the charting system, ensuring that all necessary interventions are documented and available for reference.

Based on the facility policy, record reviews and interviews, the facility failed to ensure an ongoing program of activities designed to meet the physical, mental, and psychosocial well-being based on their preferences and likes and dislikes for Resident (R)29 and R100, for 2 of 4 residents reviewed for activities. Review of the facility policy titled, Activities Program, states as the policy statement, 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 procedure states: 1. The center shall designate a staff member responsible for the development of the recreational program to include responsibility for obtaining and maintaining recreational supplies. At least one staff person shall be responsible for providing/coordinating recreational activities for the residents. 2. The center shall off a variety of recreational programs to suit the interests and physical/cognitive capabilities 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 in the initial assessment.: 3. There shall be at least one different structured recreational activity provided daily each week that shall accommodate resident's needs/interests/capabilities as indicated in the care plan. 4. The facility posts a monthly schedule of planned activities for easy review in the center. This schedule shall include the activities, dates, times, and locations. If the resident has dementia and is unable to choose for him/herself, staff members/volunteers shall encourage participation and assist when necessary. 5. The programming should reflect. . Interests of the resident . Activities scheduled at appropriate and convenient times. . Cultural and ethnic interests of the resident. . Appeals to both men and women residents. . Seasonal and special events. . Includes appropriate activities for those impaired or with physical/cognitive capabilities. . Provides stimulation. . Promote or enhance physical and or mental well-being. 8. The activity participation will be recorded by the Activities Director/Assistant or designee in the EHR (Electronic Health Record). Participation will be completed for each resident per each activity. The findings include: The facility admitted R29 on 07/23/2024, with diagnoses including, but not limited to, muscle weakness, bilateral lower limb amputations, hypertension and chronic pain. During an interview on 01/26/2025 with R29, when asked about going to activities and the facility providing activities he stated, What is that? R29 went on to say that he had not been invited to any activities and had not received any one to one activities. The facility admitted R100 on 04/06/2024 with diagnoses including, but not limited to, acute pulmonary edema, asthma, schizophrenia and mood disorder. During an interview with R100, she stated that she has not gone to any activities and she had had no 1:1 activities at all. During an interview with the Activity Director on 01/27/2025 at 09:48 AM, she stated that she is a new employee and will look for the documentation on activity attendance for R29 and R100. According to the Activity Director and the Director of Nursing no documentation could be found to ensure R29 and R100 had received any type of activities since admission.

Based on record review, observation, interview, and policy review the facility failed to ensure that one resident (Resident (R) 1) of two residents reviewed for resident abuse was free from abuse. This deficient practice had the potential to impact all residents residing in the facility. Findings include: Review of the facility's policy titled, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property revised 10/27/20 stated, Policy Statement: It is the policy of PruittHealth .to actively preserve each patient's right to be free from .physical .abuse .Definitions: Abuse means willful infliction of injury .Procedures: 1. Providers are to identify, correct, and intervene in situations in which abuse .may occur .Features of the physical environment that could make abuse .more likely to occur .The deployment of staff on each shift in sufficient numbers to meet needs of patients and to see the staff assigned have knowledge of the individual patient's care needs .4. Providers should also assure the patients are free from physical or chemical restraints imposed for purposes of discipline or convenience . Review of the facility's policy titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriations of Property revised 07/29/19 stated, .Procedures: 1. Any allegation, suspicion, or identified occurrence is identified involving patient abuse, neglect .should be immediately reported to the Administrator of the provider entity .2 .The state survey agency .should be notified .within 2 hours after the allegation is made if the events upon which the allegation is based involve abuse or result is serious bodily injury .5 .a written investigation report should be submitted to the state agency within 5 days of the incident . Review of R1's Face Sheet located under the Face Sheet tab of the electronic medical record (EMR) revealed R1 was admitted to the facility on [DATE] with the diagnoses of Alzheimer's disease, unspecified convulsions, epilepsy, moderate intellectual disabilities, vascular dementia with without behavioral disturbance, major depressive disorder, anxiety disorder, abnormalities of gait and mobility, and unsteadiness on feet. Review of R1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 04/14/23, located under the Resident Assessment Instrument (RAI) tab, in the EMR, indicated R1 as extensive assist of one staff member for bed mobility, dressing and toileting and limited assist of one staff member for transfers and walking. The MDS showed a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated R1 was severely cognitively impaired. Review of R1's EMR under the Notes tab indicated a Progress Note dated 01/12/23 stated, On 01/11/23 at 2:56 PM it was reported that R1 had a fall/incident no injuries were noted. RP (responsible party) and MD were made aware. Review of R1's EMR under the Notes tab indicated a Progress Note dated 01/13/23 stated, Resident continues on fall f/u (follow up) resident continues to ambulatory[sic]. No signs of acute distress. No injuries noted and no complaints of pain VS (vital signs) are WNL (within normal limits). Review of the facility's investigation indicated a Witness Statement Form completed by Certified Nursing Assistant (CNA) 1 dated 01/12/23 stated, .What happened? I was sitting at the desk and heard the CNA to tell the resident to get up . Review of the facility's investigation indicated a Witness Statement Form completed by CNA4 dated 01/12/23 stated, .What happened? I heard the CNA5 tell the resident R1 to get up off the floor. I looked and seen R1 sitting on the floor and then seen CNA5 help get R1 off of the floor. The nurse was not on the floor . Review of the facility's investigation indicated a Witness Statement Form completed by Licensed Practical Nurse (LPN) 4 dated 01/12/23 stated, .What happened? Fall/Incident. Did you see this happen? No, I was on lunch break . Review of the facility's investigation indicated a handwritten statement, dated 01/12/23 at 8:30 AM, completed by the Administrator stated, While checking the camera from the day before I noticed at 2:56 PM hall 400 nurse station had 3 CNA's and 1 housekeeper looking down the hall. I changed cameras to see what they were looking at. I saw a CNA5 coming out of R1's room and R1 was going to her room. It appeared the CNA5 stopped her then pushed her to the floor. An investigation was started. Review of the facility's investigation indicated form titled Incident Report Fairfield County Sheriff's Office case number 23-000211, dated 01/12/23 stated, .The Administrator stated R1 was assaulted by an employee .The Administrator then displayed camera footage of what appeared to be CNA5 pushing R1 onto the floor . Review of CNA5's personnel record indicated: CNA5 was hired on 07/19/22; verification of Certified Nurse Aide #15758, expiration 12/31/24; received the following education: Abuse, Neglect and Misappropriation on 07/20/23, Dementia Care: Challenging Behaviors and Direct Care Staff on 11/30/22, Recognizing, Reporting and Preventing Abuse on 10/06/22. An observation on 05/17/23 at 12:37 PM of the facility's video of the incident provided by the Administrator, showed CNA5 placing her hands on R1's shoulders and slinging her to the floor on the other side of the hallway. Followed by CNA5 pulling R1 up off the floor by the arm. During an interview on 05/17/23 at 10:55 AM with LPN4 she said at the time of the incident she had gone to lunch. LPN4 confirmed she received education regarding resident abuse after this incident. During an interview on 05/17/23 at 11:10 AM with CNA1 she said at the time of the incident she was charting at the nurses' station when she heard a thump and looked down the hall and saw R1 on the floor and went to assist. CNA1 stated CNA5 did not say she pushed R1. CNA1 confirmed she received education regarding resident abuse after this incident. During an interview on 05/18/23 at 6:40 AM with LPN5 she stated she was not aware of R1 having any ill effects from the fall/altercation. LPN5 confirmed she received education regarding resident abuse after this incident. During an interview on 05/18/23 at 6:50 AM with CNA3 she stated she was not aware of any additional incidents of a staff member abusing a Resident in any way. CNA3 confirmed she received education regarding resident abuse after the incident. During an interview on 05/18/23 at 8:40 AM with CNA5, she said she remembered the incident and stated, I have felt bad about it. CNA5 said the memory unit was always very hectic. Regarding the incident, CNA5 stated R1 came up to the door to go into her room and she told her to go sit down. CNA5 said she was removing R1's hand from the doorknob when R1 lost her balance and fell . CNA5 said once R1 fell she went down to the floor and helped R1 up to her feet. CNA5 stated, following the fall, she assessed R1 for any bruising/injury and took her vitals. CNA5 said R1 did not show any distress or have complaints of pain after the fall. CNA5 stated she did not report the incident to nursing and that was something she should have done. CNA5 stated the facility did provide education regarding resident abuse and reporting of incidents during her orientation. During an interview on 05/18/23 at 9:00 AM with the Human Resources Director (HRD) to review the CNA hiring process, HRD stated a CNA candidate will be scheduled for an interview with the Administrator or DON, if approved the candidate will receive a drug screen, then return to the HRD to complete various paperwork, then background checks are completed, verification of license, and completion of reference checks. During an interview on 05/18/23 at 10:40 AM with R6 (BIMS 14) stated he had not witnessed a staff member abusing a Resident. R6 said he was not fearful of any staff and is not aware of a Resident who is fearful of staff. R6 stated he had been residing at this facility for the past seven years and would know if there were any issues regarding Resident abuse. During an interview on 05/18/23 at 10:55 AM with R8 (BIMS 12), she stated she had not witnessed a staff member abusing a Resident. R8 said she was not fearful of any of the staff. During an interview on 05/18/23 at 11:05 AM with R7 (BIMS 6) stated she had never witnessed a staff member be mean to a Resident. R7 said she was not fearful of staff. (When Surveyor questioned what resident from the memory unit would be the most appropriate to interview from a cognitive standpoint, the Administrator suggested R7.) During an interview on 05/18/23 at 11:50 AM with the Director of Health Services (DHS), the DHS stated she was quite shocked by CNA5's action against R1. The DHS said she did not observe any behaviors exhibited by CNA5 that would have raised concerns about CNA5 providing care for residents. The DHS stated she has not had any issues with other staff members regarding abuse of residents. The DHS confirmed CNA5 was placed on suspension as soon as they were aware of the incident and was terminated soon thereafter. The DHS added R1 was very sweet and was not combative. During an interview on 05/18/23 at 11:30 AM with the Administrator, she stated following her viewing the video, CNA5 was suspended immediately and was not allowed back in the building. The Administrator said CNA5 was terminated the next day due to video proof. The Administrator stated she would not have expected that behavior from CNA5, stating she was a good CNA.

Based on review of the facility policy, record review, interviews, and observation, the facility failed to ensure 1 resident, (R)114 out of 1 reviewed for accidents related to falls did not sustain a major injury. Specifically, R114 had an unwitnessed fall in the shower room, was transferred, and admitted to a local hospital which resulted in laceration to the head and a fractured elbow. The lack of adequate supervision placed the resident at risk for physical and or psychosocial harm. Findings include: Review of the facility's undated policy titled, Identifying and Managing Dementia Resident Safety Risks, last revised on 10/19/21, revealed the Policy Statement: PruittHealth recognizes that we serve a significant number of residents with various stages of dementia, which may change or progress over time. Residents with dementia are at a greater risk for falls, bruising, skin tears, wandering, and elopement, accidental ingestion of harmful substances, burns, and infection. Each resident's risks must be assessed, and a care plan developed based on those risks .3. Preventing Falls: 1. Assess the resident's risk of falling using the approved Falls Risk Assessment Tool . Review of the facility's undated policy titled, Occurrences, last revised 05/04/2016, revealed, The healthcare center recognizes that due to frailty of the patients/residents served, there is an increased risk of occurrences that may result in injury to the patient/resident and/or others. In an effort to prevent occurrences, each patient/resident will be observed and assessed for risks. ARicppropriate [sic], realistic interventions will be implemented in accordance to their plan of care .Definitions: Occurrence hazards are physical features in the healthcare center environment which may pose a risk to patient/resident's safety, included but not limited, any event, accident or incident, on or off healthcare which results in an injury or has potential for injury. Medication discrepancy and adverse drug reaction, Unexplained injury to a patient/resident where no specific or actual incident was observed; yet the patient/resident exhibits evidence of an injury, such as bruise or skin tear. Review of R114's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses including but not limited to, dementia with behavioral disturbance, adult failure to thrive, muscle weakness, unsteadiness on feet, scoliosis, osteoarthritis and cognitive communication deficit. Review of R114's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/24/22 revealed a Brief Interview of Mental Status (BIMS) score of 00 out of 15, indicating she is cognitively impaired. Further review of the MDS assessment revealed R114 required supervision to limited assistance with activities of daily living (ADLs). She also was coded for exhibiting behaviors of wandering daily. Review of the Comprehensive Care Plan with a start date of 08/24/22 revealed R114 was at risk for falls related weakness and impaired cognition. Under the section titled, Goal revealed resident will not sustain injury related to falling through next review. The goal target date was noted as 11/10/22. The following interventions were recorded: 1. Keep environment safe-start date 08/24/22 2. Cue for safety awareness-start date 08/24/22 3. Assist for toileting and transfers PRN-start date 08/24/22 4. Transfer to MUSC Fairfield ER for eval r/t [related to] fall head injury-start date 08/26/22 5. Ensure resident is wearing appropriately sized clothing-start date 08/26/22 6. Refer to ortho for fracture-start date 08/31/22 7. Move room closer to the nurses station-start date 09/02/22 Review of progress notes dated 08/26/22 revealed, Patient is a poor historian due to cognitive/psychiatric impairment. The chief complaint/reason for visit noted as fall. The history of present illness (HPI) relating to this visit revealed that R114 was seen to be examined after a fall. The staff reported to provider that R114 did complain of elbow pain, but no swelling was noted. Staff also reported no changes in R114's neurological status and vital signs stable. Will send R114 out to emergency room for further evaluation. The assessment and plan noted: 1. Falls: acute unwitnessed fall last night; no changes in neurological status; vital signs stable; maintain fall precautions 2. Laceration-injury: acute; top of head, deep laceration; will send out to emergency room for staples and further evaluation. Review of the two-hour initial incident report submitted to the state agency on 08/31/22 at 4:40 PM revealed the type of injury of unknown source as a humeral fracture (upper arm fracture). The date and time of the reportable incident was noted as 08/31/22 at 4:20 PM. The description given for reporting the incident was c/o [complaint of] pain to arm. X-ray complete. Fracture to the humeral bone. Previous fall on 08/25/22. Investigating cause of fracture. Possible second fall overnight. Review of the five day follow up report submitted to the state agency on 09/05/22 at 12:46 PM by Director of Nursing (DON) revealed the type of injury of unknown source as fracture of undetermined ae of greater trochanter proximal left femur, impacted fracture of the left humeral neck (upper arm fracture). The diagnosis/medications with potential for placing resident at risk for injury was noted as: unspecified dementia with behavioral disturbance, muscle weakness (generalized), unsteadiness on feet, scoliosis unspecified, clonazepam (medication to control seizures), methadone (medication to treat Opioid disorder), and fentanyl (Opioid medication for pain). The resident condition prior to reportable incident was noted as complaining of left arm pain, guarding (behavior aimed at preventing pain). Details of Reportable Incident: Guarding and pain noted to left arm noted on 08/31/22, X-ray revealed fracture of undetermined age. Sent toER on [DATE] and X-ray of left hip revealed a fracture of undetermined age. Interventions in place prior to reportable incident: removed large clothing from room. Immediate corrective action/assessment following reportable incident: X-ray ordered obtained, ortho referral made, sling provided. Physician notified: yes. Date/time: 08/31/22 at 3:00 PM. Interventions by facility to prevent future injury/alleged abuse: relocated resident room closer to the nurse's station. The summary report of the facility investigation noted an error in previous report; fall on 08/26/22 not 08/25/22. On 08/26/22 MSU resident had an unwitnessed fall. Initially complained of right elbow pain and PRN Tylenol was given. No further complaints at this time. However, resd [sic] did not allow nurse to assess her. The following morning assessment complete and open area was noted to head. Sent to ER where they placed staples and sent resd back to facility. Resd likely tripped over her clothing which has since been addressed. On 08/30/22 resd made complaints of pain to left arm but would not allow nurse to assess, is witnessed walking through out the shift as well. On 08/31/22 orders received to DC Fetanyl Patches and decrease Clonazepam to .05 mg every HS and taper methadone. Received n/o from NP to X ray left arm. Results show a humeral fracture of undetermined age. Orders given to refer to ortho, Ibuprofen 800 mg TID every 8 hours for 3 days and apt was made for 9/1/22 at 2:30 pm. Transportation not available for this apt. Therefore, MD gave orders to send to ER. At the hospital she began to complain of left hip pain as well. X-ray was done and a fracture of undetermined age and Osteopenia was noted. ER gave resd a sling for left arm and wt bearing as tolerated. Not a surgical candidate and to follow up with ortho. Returned to facility. Resd is observed continuing to walk on hip and use left arm daily since the fall on 8/26/22 through currently. Has been non-compliant with sling. Follow up ortho apt made for [DATE]th. Resd moved to a room closer to the nurse's station as she doesn't remember to use the call light. This is a frail 74 lb dementia patient with a BIMS of 10. States she recalls falling over a chair, and that she has only had 1 fall since she has been here. Fall on 8/26/22 was unwitnessed but in the shower room. Resd is very mobile and waunders [sic] through the unit. It is possible the resident had another fall and got herself up, not reporting to the nurse. Resd is identified as a high fall risk and has a history of falls prior to admission. She has been on several pain medications routinely, including DC' ed her fentanyl and methadone trapper down on 8/31/22. It is also possible that the pain medications were masking the pain from the initial fall on 8/26/22. However, the resident does not indicate that injuries was caused by a staff member or resident. I do not suspect abuse or neglect. During an interview with the Administrator on 11/17/22 at 11:48 AM, she revealed that she did not remember much about R114 and she did not know if she was still here. When surveyor stated she passed away, the Administrator stated that the staff working during the incident were Certified Nursing Assistant (CNA)1 and CNA2. During an interview with CNA2, she stated she does not work night shift; however, she knew about the fall but did not know or see how it happened. During an interview on 11/17/22 at 12:11 PM, CNA1 was asked about R114. Initially, CNA1 did not remember who it was. When asked if she remembered a resident falling, she stated oh yes, I remember now. When asked what happened, CNA1 stated she was at the nurses station her and another nurse and heard a thump. They went down the hall and she found R114 on the floor of the shower. She stated the shower should be locked but she thinks whoever was giving showers forgot and that is how R114 got into the shower. On 11/17/22 at approximately 1:33 PM, observation made with CNA2 of the shower unit where the fall occurred. CNA2 entered a code to open the shower door. She revealed that the door is to be always locked. When asked about the door being unlocked during the incident with R114, she didn't see how that could occur, unless someone forgot to close the door. She stated if you close the door, it automatically locks. During an interview on 11/17/22 at approximately 1:36 PM with CNA3, she states the shower is to be locked and always closed. During an interview with LPN2 at approximately 1:40 PM, she revealed that she remembers R114 as a very small woman. When asked if resident was a wanderer, she stated no. R114 did not go in and out of resident rooms but did walk up and down the hall. When asked about R114's fall, LPN2 stated that she was not at work at the time. When asked about the protocol for the shower doors, LPN2 stated it is to be locked at all times. During an interview on 11/17/22 at approximately 1:48 PM, with the DON, a request was made for the facility's policy on dementia and locked units. She revealed that they do not have one. When asked if the showers should be locked on the dementia unit, she stated yes because there could be chemicals in there. During an interview on 11/17/22 with DON at approximately 2:11 PM, she confirmed that they do not have a policy regarding locked showers on the dementia unit. During an interview on 11/17/22 with Corporate Clinical (CC) at approximately 2:58 PM, she also confirmed that there is no policy regarding locked showers on the dementia unit. She also stated that there are no chemicals in the shower, and they do not have to be locked.

Based on record reviews, interviews, and review of the facility's policy titled, Good Faith Reporting of Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property, the facility failed to provide resident with adequate supervision and safe support for 1 of 3 resident's reviewed for neglect relating to wandering/ elopement. Resident (R)1 had a successful elopement from the facility on 02/13/22 and was found by local police at 3:18 AM, 4.2 miles away from facility on Longtime Road. R1 was taken to a nearby hospital emergency room and was returned to the facility on [DATE] with no injuries. Video surveillance review by the Administrator on 02/14/22 revealed R1 eloped from the 400 hall memory care unit on 02/13/22 at 5:36 PM . Certified Nursing Assistant (CNA)1 was seen on video surveillance disarming the alarm system to the rear door earlier that evening to go out to smoke. Several interviews with staff revealed they were unaware R1 was not in her room until she was returned to the facility the next morning. The temperature on 02/16/22 (the night R1 eloped) was recorded at 30 degrees Fahrenheit (F) and R1 was observed on camera wearing a green sweater, black pants, and bedroom slippers. On 02/15/22, at 3:40 PM, the survey team provided an Immediate Jeopardy (IJ) template to the Administrator, notifying that an IJ existed at F600 and F689 due to the facility's failure to adequately monitoring R1, who had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 02/15/22 at 6:18 PM, the facility provided an acceptable IJ Removal Plan. The immediacy of the IJ was removed as of 02/16/22 at 10:18 AM. The IJ at F600 and F689 was lowered to a scope and severity of D, no actual harm with the potential for more than minimal harm that is not IJ. The facility's removal plan for F600 included: Resident #1 was admitted on [DATE]. Resident #1 successfully exited the facility unsupervised from the MSU nurse station back door on 02/13/22. Facility staff statements note that staff were unaware resident was not in facility when officer arrived around 5:00 AM. Per nurse verbal statement she peeked in on resident around 10 PM and 12 AM the night of 02/13/22. States she thought she seen her in there. Facility utilizes a camera system for Infection Control purposes, in review of the camera system it was observed that CNA appeared to flipping the switch to the door lock mechanism then proceeding in and out the back door without attempting key pad code to unlock. Facility staff immediately conducted rounding when notified Resident #1 had eloped to verify all other residents in house were accounted for to ensure no other potential residents eloped. On the morning of 02/14/22 around 5:30 AM the switch to the MSU nurse station back door was placed back into on position, to secure the door lock mechanism. Maintenance verified all doors were operating and functioning properly. A break away box was put into place to prevent further recurrence of manual deactivation of door mechanism via switch, to the MSU nurse station back door. On 02/14/22 one nurse and two CNA's immediately suspended pending investigation. 02/14/22 Education/ln-servicing was initiated by Director of Health Services pertaining to; Door alarms/switched not to be turned off, walking rounds when getting assignment and then standard rounding throughout shift on all residents assigned. 02/14/22 by 5:00 AM facility staff verified all other residents in house were accounted for to ensure no other potential residents eloped. Doors are checked daily by maintenance and recorded in building engines to ensure all doors functioning properly and all door alarms/switches activated. Education/ln servicing initiated on 02/14/22 will continue until all partners have been educated. The education will include instruction on door alarms/switched not to be turned off, walking rounds when getting assignment and then standard rounding throughout shift on all residents assigned. Partners who are on FMLA or otherwise out will receive education prior to returning to work effective 02/14/22. Doors are checked daily and recorded in building engines to ensure all doors functioning properly and all door alarms/switches activated.Weekly the DHS and/or Administrator will verify door checks completed daily by maintenance On 02/16/22, implementation of the removal plan was verified through observation, staff interviews, and record reviews. Observation verified that door alarms were functioning properly. Documentation review revealed staff were re-educated on alarms not to be turned off, walking rounds when getting assignment and then standard rounding throughout shift on all residents assigned. The Director of Health Services immediately began re-education on Abuse/Neglect Policies and Procedures conducted on 02/14/22. Findings include: R1 was admitted into the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment revealed as evidenced by a Brief Interview for Mental Status (BIMS) score of 02 out of 15, indicating R1 had severe impairment. Review of R1's care plan dated 11/17/21 revealed resident requires admission to the Memory Support Unit (MSU), potential for behaviors related to dx (diagnosis) of dementia and hx (history) of wandering behaviors. Approaches included but not limited to complete elopement observation and follow up as appropriate and orient to memory care unit, room, dining area, etc, add to behavioral management program as indicated, monitor and document behaviors, psych consult as indicated. Review of R1's medical record revealed the facility did not complete a wandering/ elopement assessment upon admission. The facility submitted a 24-hour report via facsimile to the State Agency on 2/14/22 indicating that around 5:36 PM on 2/13/22, resident had a successful elopement from the facility's memory care unit by exiting a disarmed rear door. R1 was found by local police 4.2 miles away from facility. The facility received a call from local police on 02/14/22 at 03:18 AM reporting that a resident from the facility was found and they will be taking them to the emergency room for evaluation. Video surveillance review by the administrator revealed that R1 eloped from 400 hall memory care unit at 5:36 PM on 2/13/22. CNA #1 was seen on video surveillance disarming the alarm system to the rear door earlier that evening to go out to smoke. R1 left the facility and was found 4.2 miles away. The next morning, local police notified the facility that they had found R1 on Longtime Road. The staff of the facility were unaware of R1's whereabouts. The temperature that night was recorded at 30 degrees Fahrenheit and the resident had on a green sweater, black pants, and bedroom slippers. A interview on 02/15/22 at 9:10 AM with the Senior Nurse Consultant revealed she interviewed the resident when she came back to the facility and R1 was unable to provide any details about where she went and why she left the facility. SNC stated she notified R1's family of the elopement and updated the care plan so staff could provide additional interventions regarding wandering behaviors. A telephone interview on 02/15/22 at 12:48 PM with Licensed Practical Nurse (LPN) 1 revealed she was the night shift nurse when R1 eloped from the facility on 02/13/22. LPN 1 stated she looked in the door several times during the night and thought she saw the resident in bed. LPN 1 stated R1 was at risk for elopement, but was not sure of the interventions/approaches in place when the resident exhibited wandering behaviors. LPN 1 stated she was unaware R1 eloped from the facility until she received a call from a police officer stating R1 was being transported to the emergency room . LPN 1 further stated R1 was returned to the facility by emergency medical services (EMS) on 02/14/22 around 7:00 AM and appeared alert with no visible injuries. A telephone interview on 02/15/22 at 1:00 PM with CNA 2 revealed she was one of the night staff working the MSU unit on 02/13/22. CNA 2 stated it was usual for her not to open R1's room door and visibly check on her because R1 was easily aroused and would have woke up. CNA 2 stated she didn't know much about the elopement other than R1 was found by local police during the middle of the night. CNA 2 further stated she was unaware of R1's whereabouts until the resident was brought back to the facility. A telephone interview on 02/15/22 at 1:30 PM with CNA 1 revealed he was one of the night staff working the MSU unit on 02/13/22. CNA 1 stated he was on the unit working alone with 24 residents to care for. CNA 1 stated that at some point during his shift, he needed a break, so he disarmed the alarm to go outside and smoke. CNA 1 stated at some point he went back inside the facility and did not remember to hit the switch for the alarm. A interview on 02/15/22 at 1:50 PM with R1's daughter revealed she was notified at 4:30 AM by a 911 dispatcher that police had found her mother on Longtime Road and R1 was able to tell them her name and address. The daughter stated the police officer was able to verify her phone number through her address. The daughter stated she was connected to a dispatcher officer and was told her mom was found 4.2 miles away from the facility and police were in route with R1 to a nearby hospital. The daughter stated she called the facility at 5:00 AM and asked was her mom there,CNA 1 told her that her mom was in her room. The daughter stated she told CNA 1 she was on the phone with the police and they found her mom on Longtime Road. The daughter stated CNA responded What the F***. On 02/16/22 at 5:45 PM, a review of the facility policy titled, Good Faith Reporting of Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property stated Neglect is the failure of the facility, its employees or service providers to provide goods and services to a patient that are necessary to avoid physical harm, mental anguish, or emotional distress.

Based on observation, record reviews, interviews and review of the facility's policy titled, Safe Support for someone at Risk for Elopement, the facility failed to provide resident with adequate supervision and safe support for 1 of 3 resident's reviewed for accidents related to wandering/ elopement. Resident (R)1 had a successful elopement from the facility and was found by local police at 3:18 AM, 4.2 miles away from facility on Longtime Road. R1 was taken to a nearby hospital emergency room and was returned to the facility on [DATE] with no injuries. Video surveillance review by the Administrator on 02/14/22 revealed R1 eloped from the 400 hall memory support unit (MSU) on 02/13/22 at 5:36 PM . Certified Nursing Assistant (CNA) 1 was seen on video surveillance disarming the alarm system to the rear door earlier that evening to go out to smoke. Several interviews with staff revealed they were unaware R1 was not in her room until she was returned to the facility the next morning. The temperature on 02/13/22 (the night R1 eloped) was recorded at 30 degrees Fahrenheit (F) and R1 was observed on camera wearing a green sweater, black pants, and bedroom slippers. On 02/15/22, at 3:40 PM, the survey team provided an Immediate Jeopardy (IJ) template to the Administrator, notifying that an IJ existed at F600 and F689 due to the facility's failure to adequately monitoring R1, who had diagnosis of [CONDITION(S)] with behavior distrubance, with effective date 2/13/22. On 02/15/22 at 6:18 PM, the facility provided an acceptable IJ Removal Plan. The immediacy of the IJ was removed as of 02/16/22 at 10:18 AM. The IJ at F600 and F689 was lowered to a scope and severity of D, no actual harm with the potential for more than minimal harm that is not IJ. The facility's removal plan for F689 included: Resident #1 was admitted on [DATE]. Resident #1 successfully exited the facility unsupervised from the MSU nurse station back door on 02/13/22. Facility staff statements note that staff were unaware resident was not in facility when officer arrived around 5:00 AM. Per nurse verbal statement she peeked in on resident around 10 PM and 12 AM the night of 02/13/22. States she thought she seen her in there. Facility utilizes a camera system for Infection Control purposes, in review of the camera system it was observed that CNA appeared to flipping the switch to the door lock mechanism then proceeding in and out the back door without attempting key pad code to unlock. Facility staff immediately conducted rounding when notified Resident #1 had eloped to verify all other residents in house were accounted for to ensure no other potential residents eloped. On the morning of 02/14/22 around 5:30 AM the switch to the MSU nurse station back door was placed back into on position, to secure the door lock mechanism. Maintenance verified all doors were operating and functioning properly. A break away box was put into place to prevent further recurrence of manual deactivation of door mechanism via switch, to the MSU nurse station back door. On 02/14/22 one nurse and two CNA's immediately suspended pending investigation. 02/14/22 Education/ln-servicing was initiated by Director of Health Services pertaining to; Door alarms/switched not to be turned off, walking rounds when getting assignment and then standard rounding throughout shift on all residents assigned. 02/14/22 by 5:00 AM facility staff verified all other residents in house were accounted for to ensure no other potential residents eloped. Doors are checked daily by maintenance and recorded in building engines to ensure all doors functioning properly and all door alarms/switches activated. Education/ln servicing initiated on 02/14/22 will continue until all partners have been educated. The education will include instruction on door alarms/switched not to be turned off, walking rounds when getting assignment and then standard rounding throughout shift on all residents assigned. Partners who are on FMLA or otherwise out will receive education prior to returning to work effective 02/14/22. Doors are checked daily and recorded in building engines to ensure all doors functioning properly and all door alarms/switches activated.Weekly the DHS and/or Administrator will verify door checks completed daily by maintenance On 02/16/22, implementation of the removal plan was verified through observation, staff interviews, and record reviews. Observation verified that door alarms were functioning properly. Documentation review revealed staff were re-educated on alarms not to be turned off, walking rounds when getting assignment and then standard rounding throughout shift on all residents assigned. The Director of Health Services immediately began re-education on Elopement Policies and Procedures conducted on 02/14/22. Findings include: R1 was admitted into the facility on [DATE] with the diagnoses including but not limited to [CONDITION(S)] with Behavior Disturbance, Mixed [CONDITION(S)], Muscle Weakness and Unsteady on feet. Review of the admission Minimum Data Set (MDS) assessment revealed as evidenced by a Brief Interview for Mental Status (BIMS) score of 02 out of 15, indicating R1 had severe impairment. Review of R1's care plan dated 11/17/21 revealed resident requires admission to the Memory Support Unit (MSU), potential for behaviors related to dx (diagnosis) of dementia and hx (history) of wandering behaviors. Approaches included but not limited to complete elopement observation and follow up as appropriate and orient to memory care unit, room, dining area, etc, add to behavioral management program as indicated, monitor and document behaviors, psych consult as indicated. Review of R1's medical record revealed the facility did not complete a wandering/ elopement assessment upon admission. The facility submitted a 24-hour report via facsimile to the State Agency on 2/14/22 indicating that around 5:36 PM on 2/13/22, resident had a successful elopement from the facility's memory care unit by exiting a disarmed rear door. R1 was found by local police 4.2 miles away from facility. The facility received a call from local police on 02/14/22 at 03:18 AM reporting that a resident from the facility was found and they will be taking them to the emergency room for evaluation. Video surveillance review by the administrator revealed that R1 eloped from 400 hall memory care unit at 5:36 PM on 2/13/22. CNA #1 was seen on video surveillance disarming the alarm system to the rear door earlier that evening to go out to smoke. R1 left the facility and was found 4.2 miles away. The next morning, local police notified the facility that they had found R1 on Longtime Road. The staff of the facility were unaware of R1's whereabouts. The temperature that night was recorded at 30 degrees Fahrenheit and the resident had on a green sweater, black pants, and bedroom slippers. A interview on 02/15/22 at 9:10 AM with the Senior Nurse Consultant revealed she interviewed the resident when she came back to the facility and R1 was unable to provide any details about where she went and why she left the facility. SNC stated she notified R1's family of the elopement and updated the care plan so staff could provide additional interventions regarding wandering behaviors. A telephone interview on 02/15/22 at 12:48 PM with Licensed Practical Nurse (LPN) 1 revealed she was the night shift nurse when R1 eloped from the facility on 02/13/22. LPN 1 stated she looked in the door several times during the night and thought she saw the resident in bed. LPN 1 stated R1 was at risk for elopement, but was not sure of the interventions/approaches in place when the resident exhibited wandering behaviors. LPN 1 stated she was unaware R1 eloped from the facility until she received a call from a police officer stating R1 was being transported to the emergency room . LPN 1 further stated R1 was returned to the facility by emergency medical services (EMS) on 02/14/22 around 7:00 AM and appeared alert with no visible injuries. A telephone interview on 02/15/22 at 1:00 PM with CNA 2 revealed she was one of the night staff working the MSU unit on 02/13/22. CNA 2 stated it was usual for her not to open R1's room door and visibly check on her because R1 was easily aroused and would have woke up. CNA 2 stated she didn't know much about the elopement other than R1 was found by local police during the middle of the night. CNA 2 further stated she was unaware of R1's whereabouts until the resident was brought back to the facility. A telephone interview on 02/15/22 at 1:30 PM with CNA 1 revealed he was one of the night staff working the MSU unit on 02/13/22. CNA 1 stated he was on the unit working alone with 24 residents to care for. CNA 1 stated that at some point during his shift, he needed a break, so he disarmed the alarm to go outside and smoke. CNA 1 stated at some point he went back inside the facility and did not remember to hit the switch for the alarm. A interview on 02/15/22 at 1:50 PM with R1's daughter revealed she was notified at 4:30 AM by a 911 dispatcher that police had found her mother on Longtime Road and R1 was able to tell them her name and address. The daughter stated the police officer was able to verify her phone number through her address. The daughter stated she was connected to a dispatcher officer and was told her mom was found 4.2 miles away from the facility and police were in route with R1 to a nearby hospital. The daughter stated she called the facility at 5:00 AM and asked was her mom there,CNA 1 told her that her mom was in her room. The daughter stated she told CNA 1 she was on the phone with the police and they found her mom on Longtime Road. The daughter stated CNA responded What the F***. On 02/15/22 at 5:55 PM a review of the facility policy titled, Safe Support for someone at Risk for Elopement, stated when wandering occurs in an unsafe environment, the client has the potential for severe injury and even death. An elopement occurs when a person supported leaves the premises of a residential care setting without authorization or the necessary supervision to do so (Centers for Medicare & Medicaid Services, [CMS], 2015).

Based on record review and interview, the facility failed to ensure services provided meet professional standards of quality. Resident #2 was found outside in (MONTH) slumped over and received 2nd and 3rd [MEDICAL CONDITION] skin that was exposed to the sun. There was no documentation of the incident in the resident's medical record the day of the incident. The resident was noted on a body audit to have red areas to the head, arms, and hands on 7/3/17 with no treatment started until 7/4/17. There was no documentation that the wounds were monitored per facility policy for the month of (MONTH) (YEAR). One of three residents reviewed for incidents. The findings included: Review of Resident #2's medical record revealed [DIAGNOSES REDACTED]. The resident discharged from the facility to the hospital on [DATE]. Further review of the medical record revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] and the Quarterly MDS dated [DATE] coded Resident #2 as having a Brief Interview for Mental Status score of 3. The MDS coded the resident as requiring extensive assistance with 1 person assist for locomotion on and off the unit. Review of Resident #2's Nurses' Notes revealed an entry on 6/28/17 and the next entry was on 7/4/17. Review of the Nurses' Notes dated 7/4/17 at 4:00 AM indicated the nurse was called to the room by the Certified Nurse Assistant (CNA). Observed large fluid filled blisters intact that start at knuckles on both hands and go down the fingers on the left hand and on the right hand only the knuckles have the blisters. Also noted fluid on bedsheet and pillow. Noted 2 large blisters that had burst on top of head. Blisters on head cleaned with NSS and applied silver sulfadine to the scalp. The blisters on the hands were sprayed with skin prep. Made wound care nurse aware. The next entry was on 7/5/17 at 6:00 AM and indicated other blisters were beginning to develop on both the resident's arms. Review of the SBAR Communication Form dated 7/4/17 revealed the resident was noted to have intact blisters to hands and one noted to top of head. The physician recommended to apply [MEDICATION NAME] to the top of head and [MEDICATION NAME] gauze to the blisters on hands. The note indicated the resident was outside sitting with the other residents in the courtyard. Resident became too hot and confusion was noted. Resident was brought back inside and cooled down. During the night blisters formed on hands and head. The physician was notified on 7/4/17 with no time noted, the responsible party was notified on 7/4/17 at 8:00 AM. There was no documentation in the medical record that the physician or responsible party were notified on 7/3/17 when the incident occurred. The orders for treatment to the resident's hands and head were written on 7/4/17. Review of the Physician's Progress Note dated 7/6/17 revealed the resident was exposed to direct sun light on a hot day for an indeterminate period of time. The resident was noted by the staff to be lethargic and confused secondary to the heat experience. In a short period of time it was noted that all areas of direct skin exposure on his/her arms, hands and head have 2nd and 3rd degree blisters on his arms/hand and head. Review of the Incident Report for 7/3/17 at 4:00 PM indicated Resident #2 was noted to have blisters develop on his hands and top of head after being outside in the courtyard. Interventions put in place included to wear a hat and long sleeves outside, drink plenty of fluids, and avoid direct sunlight. Review of the Body Audit Form dated 7/3/17 completed by Licensed Practical Nurse (LPN) #1 (treatment nurse) revealed the top of the resident's head was red, the resident had red small areas noted to bilateral arms. The resident's hands and fingers were red. Temperature of skin was noted to be warm. The surveyor reviewed the resident's Documentation of Wound Observation and Assessment Forms for the top of head, right hand and left hand and noted that all documentation was for (MONTH) (YEAR). There was no documentation that the facility could provide for (MONTH) (YEAR). The forms contained information on location of wounds, wound bed tissue type, wound edges, surrounding skin, and signs of infection. Review of the Nursing Home to Hospital Transfer Form dated 8/18/17 revealed the skin evaluation included wart on scrotum, sunburn to left hand and head. Review of the ER Progress Note dated 8/18/17 revealed the resident was sent to the hospital for open [MEDICAL CONDITION] on top of head, left hand, and sacral area. Resident noted to have a very large open wound skin edges on the scalp, left hand has a skin breakdown type lesion. Registered Nurse (RN) #1's facility-obtained statement dated 9/12/17 indicated on 7/4/17 after the morning meeting LPN #1 asked him/her to look at some blisters that s/he noted on Resident #2 that morning. LPN #1 stated that the day before the resident was outside and s/he did not know how long the resident was outside but s/he did not see any blisters on him. The next day s/he noted blisters to the top of both of his hands. RN #1 went to the resident's room and s/he noticed several fluid filled blisters to the top of both of his hands. While s/he was in the room Resident #2 mumbled something about his head leaking. RN #1 pushed his pillow down to see what he was talking about and that is when s/he noticed that he had a blister to the top of his head that had burst and the skin was pulled back. After s/he left the room, s/he told LPN #1 to notify the director of nursing and the physician of the resident's condition. In an interview with the surveyor on 9/25/17 at approximately 4:00 PM, LPN #2 stated that Resident #2 was sent out to the hospital because he had areas on his scrotum that looked like warts that had been scratched off. Resident #2 was sent to the hospital because of his head also. LPN #2 was the resident's nurse the day he went out to the hospital. From what s/he was told, he was outside and he had sunburn on top of his head. The area on his head was dark and not healing. Resident #2 would scratch at his head. LPN #2 stated s/he worked with Resident #2 on a regular basis. The resident also had sunburn blisters on both hands. One hand healed and one didn't. LPN #1 was the nurse the day the resident received the sunburn. LPN #1 is the treatment nurse but was working on the floor the day Resident #2 was sunburned. LPN #2 stated Resident #2 was alert with confusion. LPN #2 stated s/he did not like for the resident to go outside by himself because he was a bilateral [MEDICAL CONDITION]. Resident #2 was not able to get inside by himself because someone would have to help push him over the doorway. LPN #1's facility-obtained statement dated 7/6/17 indicated Resident #2 was sitting outside with other residents in the courtyard. Staff member that was outside at the time called for him/her to come get the resident. LPN #1 assessed the resident. There was no hypo/[MEDICAL CONDITION] noted after checking the resident's blood glucose. Resident #2 was warm to the touch. They placed the resident in bed and gave him a cool sponge bath and water to drink. Skin was intact and normal in color. Resident #2 had visitors that day that were related to him. Around 3:30 PM the visitors left and took the resident outside in the courtyard where he wanted to go at that time. During the time he was outside other residents were outside as usual. Staff member was getting ready to do the smoke break and called LPN #1 to come get Resident #1. In an interview with the surveyor on 9/25/17 at approximately 4:05 PM, LPN #1 stated s/he is the treatment nurse. LPN #1 stated s/he was Resident #2's nurse the day he received the sunburn. The resident was visiting with family, when they left they told him/her they were leaving and Resident #2 was outside. It was around 3:30 PM when the family said they were leaving. At the smoke break, around 4:00 PM, another staff member brought the resident in because they thought his blood sugar had dropped. The resident was slumped over, sweating and looked like he was having a hypertensive episode. S/he checked his sugar and it was fine. They gave him something to drink, laid him down and assessed him. At that time, he did not have any signs of sunburn. Throughout the night is when he developed the blisters on his head and hands. From that point on, the blisters were stage 2 blisters. The blisters deteriorated because the resident would remove the dressing and pick at the one on his head and the left hand. The one on the right hand healed because he wasn't picking at that one. LPN #1 stated Resident #2 liked to sit outside in the sun. LPN #1 stated they think the resident's sunburn may be related to some of his medications. He is on medications because he had a renal transplant. LPN #1 stated the resident has been on those medications for a while. In an interview with the surveyor on 9/26/17 at approximately 10:00 AM, the administrator stated s/he would have expected LPN #1 to document the resident's change in condition on 7/3/17 at the time on an SBAR. That is their practice to document the change in condition and who was notified. In an interview with the surveyor on 9/26/17 at approximately 11:05 AM, the director of nursing stated they talked with staff from the VA last week. The staff stated Resident #2 was at the burn center and had a debridement done at the burn center. Housekeeper #1's facility-obtained statement dated 7/6/17 indicated s/he was outside doing the smoke break and Resident #2 started leaning over in his wheelchair and stopped talking normal. Housekeeper #1 called the nurse to come check on the resident. In a telephone interview with the surveyor on 10/5/17 at approximately 11:20 AM, housekeeper #1 stated s/he was walking by the courtyard around 4:00 PM and saw Resident #2 slumped over. The housekeeper wondered why the resident was outside because it was hot. Resident #2 was sitting in his wheelchair out in the sun. There were no staff or residents outside when the housekeeper saw the resident and the housekeeper didn't remember anyone in the common area overlooking the courtyard at the time. Housekeeper #1 went and got the resident and took him to the resident's nurse. Prior to exiting the facility on 9/26/17, the administrator confirmed they could not locate any documentation that the resident's wounds were monitored and assessed during the month of (MONTH) (YEAR). Review of the facility's Wound Observation and Assessment Documentation policy revealed the 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 significant change in wound status and weekly by the SIC RN.

Based on record review and interview, the facility failed to ensure the resident received adequate supervision to prevent accidents. Resident #2 was found outside in (MONTH) slumped over and received 2nd and 3rd degree burns to skin that was exposed to the sun. There was no documentation of the incident in the resident's medical record the day of the incident. One of three residents reviewed for incidents. The findings included: Review of Resident #2's medical record revealed [DIAGNOSES REDACTED]. The resident discharged from the facility to the hospital on [DATE]. Further review of the medical record revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] and the Quarterly MDS dated [DATE] coded Resident #2 as having a Brief Interview for Mental Status score of 3. The MDS coded the resident as requiring extensive assistance with 1 person assist for locomotion on and off the unit. Review of Resident #2's Nurses' Notes revealed an entry on 6/28/17 and the next entry was on 7/4/17. Review of the Nurses' Notes dated 7/4/17 at 4:00 AM indicated the nurse was called to the room by the Certified Nursing Assistant (CNA). Observed large fluid filled blisters intact that start at knuckles on both hands and go down the fingers on the left hand and on the right hand only the knuckles have the blisters. Also noted fluid on bedsheet and pillow. Noted 2 large blisters that had burst on top of head. Blisters on head cleaned with NSS and applied silver sulfadine to the scalp. The blisters on the hands were sprayed with skin prep. Made wound care nurse aware. The next entry was on 7/5/17 at 6:00 AM and indicated other blisters were beginning to develop on both the resident's arms. Review of the SBAR Communication Form dated 7/4/17 revealed the resident was noted to have intact blisters to hands and one noted to top of head. The physician recommended to apply silvadene to the top of head and xerofoam gauze to the blisters on hands. The note indicated the resident was outside sitting with the other residents in the courtyard. Resident became too hot and confusion was noted. Resident was brought back inside and cooled down. During the night blisters formed on hands and head. The physician was notified on 7/4/17 with no time noted, the responsible party was notified on 7/4/17 at 8:00 AM. There was no documentation in the medical record that the physician or responsible party were notified on 7/3/17 when the incident occurred. The orders for treatment to the resident's hands and head were written on 7/4/17. Review of the Physician's Progress Note dated 7/6/17 revealed the resident was exposed to direct sun light on a hot day for an indeterminate period of time. The resident was noted by the staff to be lethargic and confused secondary to the heat experience. In a short period of time it was noted that all areas of direct skin exposure on his/her arms, hands and head have 2nd and 3rd degree blisters on his arms/hand and head. Review of the Incident Report for 7/3/17 at 4:00 PM indicated Resident #2 was noted to have blisters develop on his hands and top of head after being outside in the courtyard. Interventions put in place included to wear a hat and long sleeves outside, drink plenty of fluids, and avoid direct sunlight. Review of the Body Audit Form dated 7/3/17 completed by Licensed Practical Nurse (LPN) #1 (treatment nurse) revealed the top of the resident's head was red, the resident had red small areas noted to bilateral arms. The resident's hands and fingers were red. Temperature of skin was noted to be warm. The surveyor reviewed the resident's Documentation of Wound Observation and Assessment Forms for the top of head, right hand and left hand and noted that all documentation was for (MONTH) (YEAR). There was no documentation that the facility could provide for (MONTH) (YEAR). The forms contained information on location of wounds, wound bed tissue type, wound edges, surrounding skin, and signs of infection. Review of the Nursing Home to Hospital Transfer Form dated 8/18/17 revealed the skin evaluation included wart on scrotum, sunburn to left hand and head. Review of the ER Progress Note dated 8/18/17 revealed the resident was sent to the hospital for open lesions on top of head, left hand, and sacral area. Resident noted to have a very large open wound skin edges on the scalp, left hand has a skin breakdown type lesion. Registered Nurse (RN) #1's facility-obtained statement dated 9/12/17 indicated on 7/4/17 after the morning meeting LPN #1 asked him/her to look at some blisters that s/he noted on Resident #2 that morning. LPN #1 stated that the day before the resident was outside and s/he did not know how long the resident was outside but s/he did not see any blisters on him. The next day s/he noted blisters to the top of both of his hands. RN #1 went to the resident's room and s/he noticed several fluid filled blisters to the top of both of his hands. While s/he was in the room Resident #2 mumbled something about his head leaking. RN #1 pushed his pillow down to see what he was talking about and that is when s/he noticed that he had a blister to the top of his head that had burst and the skin was pulled back. After s/he left the room, s/he told LPN #1 to notify the director of nursing and the physician of the resident's condition. In an interview with the surveyor on 9/25/17 at approximately 4:00 PM, LPN #2 stated that Resident #2 was sent out to the hospital because he had areas on his scrotum that looked like warts that had been scratched off. Resident #2 was sent to the hospital because of his head also. LPN #2 was the resident's nurse the day he went out to the hospital. From what s/he was told, he was outside and he had sunburn on top of his head. The area on his head was dark and not healing. Resident #2 would scratch at his head. LPN #2 stated s/he worked with Resident #2 on a regular basis. The resident also had sunburn blisters on both hands. One hand healed and one didn't. LPN #1 was the nurse the day the resident received the sunburn. LPN #1 is the treatment nurse but was working on the floor the day Resident #2 was sunburned. LPN #2 stated Resident #2 was alert with confusion. LPN #2 stated s/he did not like for the resident to go outside by himself because he was a bilateral amputee. Resident #2 was not able to get inside by himself because someone would have to help push him over the doorway. LPN #1's facility-obtained statement dated 7/6/17 indicated Resident #2 was sitting outside with other residents in the courtyard. Staff member that was outside at the time called for him/her to come get the resident. LPN #1 assessed the resident. There was no hypo/hyperglycemia noted after checking the resident's blood glucose. Resident #2 was warm to the touch. They placed the resident in bed and gave him a cool sponge bath and water to drink. Skin was intact and normal in color. Resident #2 had visitors that day that were related to him. Around 3:30 PM the visitors left and took the resident outside in the courtyard where he wanted to go at that time. During the time he was outside other residents were outside as usual. Staff member was getting ready to do the smoke break and called LPN #1 to come get Resident #1. In an interview with the surveyor on 9/25/17 at approximately 4:05 PM, LPN #1 stated s/he is the treatment nurse. LPN #1 stated s/he was Resident #2's nurse the day he received the sunburn. The resident was visiting with family, when they left they told him/her they were leaving and Resident #2 was outside. It was around 3:30 PM when the family said they were leaving. At the smoke break, around 4:00 PM, another staff member brought the resident in because they thought his blood sugar had dropped. The resident was slumped over, sweating and looked like he was having a hypertensive episode. S/he checked his sugar and it was fine. They gave him something to drink, laid him down and assessed him. At that time, he did not have any signs of sunburn. Throughout the night is when he developed the blisters on his head and hands. From that point on, the blisters were stage 2 blisters. The blisters deteriorated because the resident would remove the dressing and pick at the one on his head and the left hand. The one on the right hand healed because he wasn't picking at that one. LPN #1 stated Resident #2 liked to sit outside in the sun. LPN #1 stated they think the resident's sunburn may be related to some of his medications. He is on medications because he had a renal transplant. LPN #1 stated the resident has been on those medications for a while. In an interview with the surveyor on 9/26/17 at approximately 10:00 AM, the administrator stated s/he would have expected LPN #1 to document the resident's change in condition on 7/3/17 at the time on an SBAR. That is their practice to document the change in condition and who was notified. In an interview with the surveyor on 9/26/17 at approximately 11:05 AM, the director of nursing stated they talked with staff from the VA last week. The staff stated Resident #2 was at the burn center and had a debridement done at the burn center. Housekeeper #1's facility-obtained statement dated 7/6/17 indicated s/he was outside doing the smoke break and Resident #2 started leaning over in his wheelchair and stopped talking normal. Housekeeper #1 called the nurse to come check on the resident. In a telephone interview with the surveyor on 10/5/17 at approximately 11:20 AM, housekeeper #1 stated s/he was walking by the courtyard around 4:00 PM and saw Resident #2 slumped over. The housekeeper wondered why the resident was outside because it was hot. Resident #2 was sitting in his wheelchair out in the sun. There were no staff or residents outside when the housekeeper saw the resident and the housekeeper didn't remember anyone in the common area overlooking the courtyard at the time. Housekeeper #1 went and got the resident and took him to the resident's nurse.

Based on record review and interview, the facility failed to provide pharmaceutical services to meet the needs of each resident. The facility failed to provide pharmaceutical services to meet the needs of Resident #5 who was receiving Total Parenteral Nutrition (TPN) (1 of 1 resident reviewed receiving TPN). The pharmacy failed to monitor labs and medications orders. The findings included: Cross refer to F-328 as it relates to the failure of the facility to ensure that residents receive proper treatment and care for parenteral fluids. The facility failed to provide quality of care in the management of Resident #5 who was receiving Total Parenteral Nutrition (TPN). The facility staff was not monitoring labs as ordered, assessing the resident, administering the TPN per protocol or adequatly documenting the administration of TPN (1 of 1 resident reviewed receiving TPN). Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #5 had an Ileostomy and Mucus Fistula. In an interview with the surveyor on 6/10/15 at approximately 10:10 AM, the 100/200 Unit Manager stated that Resident #5 was on TPN because of a short gut, most of the resident's small intestines were gone. The Clinical Competency Coordinator provided a Parenteral Nutrition Orders form dated 6/1/15 to the surveyor on 6/9/15 at approximately 3:30 PM. The form was noted to have a fax stamp across the top that indicated 6/9/15 at 12:52 PM. There was no Parenteral Nutrition Orders form dated 6/1/15 located on Resident #5's medical record. Review of the form revealed the TPN Base Formula was the same as the 5/19/15 order but the amount of additives per bag was different. Further review of the Parenteral Nutrition Orders form dated 6/1/15 revealed an order for [REDACTED]. Review of Resident #5's medical record revealed no results for the 6/3/15 labs ordered. Review of Resident #5's labs revealed liver function labs were drawn on 5/22/15 and 6/1/15. There were no additional results on the resident's medical record. Review of Resident #5's medical record revealed a Parenteral Nutrition Orders form dated 5/19/15. The order indicated to draw a basic metabolic panel (BMP), Phosphorus and Magnesium level daily. The order also indicated to draw a triglyceride level weekly. The order also indicated to draw a prealbumin and albumin level 3 x/d(ay). Review of Resident #5's medical record revealed the following lab results: Potassium - 5/22/15 5.9 (high), 5/27/15 5.8 (high), 5/29/15 4.7, 6/1/15 3.6, 6/4/15 3.4 (low) and 6/8/15 2.5 (critical low) Sodium - 5/22/15 139, 5/27/15 132 (low), 5/29/15 131 (low), 6/1/15 129 (critical low), 6/4/15 135 (low), 6/8/15 131 (low) Chloride - 5/22/15 104, 5/27/15 87 (low), 5/29/15 87 (low), 6/1/15 80 (critical low), 6/4/15 84 (low), 6/8/15 82 (low) Magnesium - 5/22/15 2.1, 5/27/15 2.3, 5/29/15 2.1, 6/1/15 2.0, 6/8/15 1.8 (low) Review of the physician's orders [REDACTED]. Review of Resident #5's medical record revealed no lab results for 5/23/15. The order on 5/21/15 also indicated to check a complete blood count (CBC), CMP, magnesium, phosphorus and triglycerides weekly on Wednesdays. There was no CMP result on 5/27/15 and no lab results for 6/3/15. Review of Resident #5's lab results dated 6/8/15 revealed the resident's potassium level was 2.5 (critical low) and their magnesium level was 1.8 (low). Handwritten at the bottom of the lab results was an order for [REDACTED]. There was a corresponding physician's orders [REDACTED]. There was also a handwritten note at the bottom of the lab results that indicated to change potassium tablets to liquid due to capsule passing in stool. Review of Resident #5's physician's orders [REDACTED]. There were no lab results for 6/5/15. The 5/21/15 order also included a hemoglobin A1C, prealbumin and c reactive protein every two weeks. There were no lab results for 6/5/15. Further review of the physician's orders [REDACTED]. There was a physician's orders [REDACTED]. Review of Resident #5's physician's orders [REDACTED]. The order indicated to do blood cultures in the AM x 2. A physician's orders [REDACTED]. Further review of the resident's Physician orders [REDACTED]. In a telephone interview with the surveyor on 6/10/15 at approximately 11:25 AM, the pharmacist stated they only fax TPN orders if a change is made to the formula. The TPN order originally came from the physician based on the hospital order. The original order is the 5/19/15 order. They monitor and adjust as needed. The pharmacist was at the facility on 6/9/15 and talked with the physician yesterday and Monday about the resident 's potassium. They discussed adding liquid potassium. Resident #5 was on oral capsules and they were passing through still intact. The resident's last potassium lab was 6/8/15 and was 2.5. The pharmacist stated that the capsule was not being absorbed so liquid potassium was added and the capsule was stopped. The pharmacist stated it had been noted that the resident 's sodium, chloride and potassium were all low. The pharmacist stated that they could adjust the sodium, chloride and potassium in the TPN and that would be the next step after the liquid. The pharmacist stated that s/he did not see documentation related to the pharmacist checking the order for a potassium tablet versus liquid form. The pharmacist stated s/he would check and send the information if s/he found it. The pharmacist also stated s/he could not read the prealbumin/albumin lab orders on the initial TPN order form dated 5/19/15. The pharmacist confirmed the ordered appeared to read check a prealbumin/albumin lab 3 x/ day but s/he could not tell for sure. The pharmacist stated s/he would check and send that information as well. Information was faxed from the pharmacy to the surveyor but there was no documentation that the pharmacist talked with the physician about using a liquid form of potassium versus the tablet since the resident had absorption concerns. There was no information to clarify the prealbumin/ albumin order on the initial TPN order dated 5/19/15. The facility Administrator, Nurse Consultant and the Clincal Competency Coordinator were informed of the Immediate Jeopardy and/or Substandard Quality of Care on 6/10/2015 at 4:30 PM, which existed in the facility due to the failure of the facility to ensure the care related to the management of Resident #5 who was receiving Total Parenteral Nutrition. On 6/11/15 the facility developed an Allegation of Compliance (AOC) that included the following: What corrective action will be accomplished for the residents found to have been affected by the deficient practice: MD notified by facility of concerns related to care cited at an immediate jeopardy level for resident #5 related to TPN (Total Parenteral Nutrition) administration. MD notified and orders were received to send the resident out to the hospital at approximately 5:10 PM on 6/10/15. The care and transfer was coordinated by a Registered Nurse. How will the corrective action be monitored to assure that the deficient practice will not reoccur, i.e., what quality assurance program will be put in place for monitoring to assure continued compliance: The facility will not admit residents on TPN unless the following has been done: qualified nurse is assigned to monitor residents receiving TPN 24 hours Qualified nurse is defined in the following manner: a registered nurse or licensed practical nurse who has received education and has been competency on TPN Education will include the following: Healthcare Centers TPN Therapy and Administration Policy, RN will verify TPN order prior to administration and will hang medications/ TPN, a qualified RN or LPN may monitor the TPN per facility policy, the licensed nursing staff were education on 6/11/15 by the Clinical Competency Coordinator and/or Administrator on the allegation of compliance. Any staff without education will not be permitted to work until education is completed, licensed nursing staff were educated on 6/11/15 by the Clinical Competency Coordinator on the Infusion Flow Sheet use, The Director of Health Services and/or RN Unit Manager will monitor the Infusion Flow Sheet for accuracy and completeness daily by initialing the Infusion Flow Sheet with the administering nurse. Process to monitor labs and coordinate lab orders relating to TPN: upon admission of a resident receiving TPN the monitor labs will be ordered by the attending physician, labs will be placed in lab draw book on the designated date, resulting labs will be faxed to the pharmacy by the receiving nurse and adjustments will be made in coordination with the attending physician and pharmacist, pharmacy will communicate changes to the TPN orders and labs to the facility via fax and phone call to the attending nurse for the TPN resident, attending nurse will complete a telephone order addressing TPN order changes and lab orders, attending nurse will transcribe the new TPN order to the MAR and labs will be transcribed to the lab draw book, the Director of Health Services and/or the Unit Managers will monitor the labs and pharmacy communication weekly for the duration of the TPN order. Allegation of Compliance: 6/11/2015 Observations and interviews revealed the AOC submitted by the facility on 6/11/2015 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. The facility nursing staff was educated and was knowledgeable of the policy related to the administration, assessment, monitoring of labs and the infusion procedure of TPN The Administrator was informed of this on 6/11/2015 at approximately 5:00 PM. The Immediate Jeopardy at F-425 was removed, the citations remained at a lower scope and severity of D.

Based on record review and interview, the facility failed to be administered in a manner that enables it to use its resource effectively to maintain the highest practicable physical well-being of each resident. The facility failed to provide quality of care in the management of Resident #5 who was receiving Total [MEDICATION NAME] Nutrition (TPN). The facility staff was not monitoring labs as ordered, assessing the resident, administering the TPN per protocol or adequatly documenting the administration of TPN (1 of 1 resident reviewed receiving TPN). The findings included: Cross refer to F-328 as it relates to the failure of the facility to ensure that residents receive proper treatment and care for [MEDICATION NAME] fluids. The facility failed to provide quality of care in the management of Resident #5 who was receiving Total [MEDICATION NAME] Nutrition (TPN). The facility staff was not monitoring labs as ordered, assessing the resident, administering the TPN per protocol or adequatly documenting the administration of TPN (1 of 1 resident reviewed receiving TPN). Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5 had an [MEDICAL CONDITION] and Mucus Fistula. Review of Resident #5's medical record revealed a [MEDICATION NAME] Nutrition Orders (PN) form dated 5/19/15. In an interview with the surveyor on 6/10/15 at approximately 10:10 AM, the 100/200 Unit Manager stated that Resident #5 was on TPN because of a short gut, most of the resident's small intestines were gone. The 100/200 Unit Manager reviewed the label on Resident #5's bag of TPN that was currently infusing. The 100/200 Unit Manager confirmed the label on the bag did not match the 5/19/15 TPN order. Review of the label revealed the TPN Base Formula matched the 5/19/15 order but the amount of additives per bag did not. The Clinical Competency Coordinator provided a [MEDICATION NAME] Nutrition Orders form dated 6/1/15 to the surveyor on 6/9/15 at approximately 3:30 PM. The form was noted to have a fax stamp across the top that indicated 6/9/15 at 12:52 PM. There was no [MEDICATION NAME] Nutrition Orders form dated 6/1/15 located on Resident #5's medical record. Review of the form revealed the TPN Base Formula was the same as the 5/19/15 order but the amount of additives per bag was different. Further review of the [MEDICATION NAME] Nutrition Orders form dated 6/1/15 revealed an order for [REDACTED]. Review of Resident #5's medical record revealed no results for the 6/3/15 labs ordered. Review of Resident #5's medical record revealed a [MEDICATION NAME] Nutrition Orders form dated 5/19/15. The order indicated to draw a basic metabolic panel (BMP), Phosphorus and Magnesium level daily. The order also indicated to draw a triglyceride level weekly. The order also indicated to draw a [MEDICATION NAME] and [MEDICATION NAME] level 3 x/d(ay). Review of Resident #5's medical record revealed the following lab results: Potassium - 5/22/15 5.9 (high), 5/27/15 5.8 (high), 5/29/15 4.7, 6/1/15 3.6, 6/4/15 3.4 (low) and 6/8/15 2.5 (critical low) Sodium - 5/22/15 139, 5/27/15 132 (low), 5/29/15 131 (low), 6/1/15 129 (critical low), 6/4/15 135 (low), 6/8/15 131 (low) Chloride - 5/22/15 104, 5/27/15 87 (low), 5/29/15 87 (low), 6/1/15 80 (critical low), 6/4/15 84 (low), 6/8/15 82 (low) Magnesium - 5/22/15 2.1, 5/27/15 2.3, 5/29/15 2.1, 6/1/15 2.0, 6/8/15 1.8 (low) Review of the physician's orders [REDACTED]. Review of Resident #5's medical record revealed no lab results for 5/23/15. The order on 5/21/15 also indicated to check a complete blood count (CBC), CMP, magnesium, phosphorus and triglycerides weekly on Wednesdays. There was no CMP result on 5/27/15 and no lab results for 6/3/15. Review of Resident #5's lab results dated 6/8/15 revealed the resident's potassium level was 2.5 (critical low) and their magnesium level was 1.8 (low). Handwritten at the bottom of the lab results was an order for [REDACTED]. There was a corresponding physician's orders [REDACTED]. There was also a handwritten note at the bottom of the lab results that indicated to change potassium tablets to liquid due to capsule passing in stool. Review of Resident #5's physician's orders [REDACTED]. There were no lab results for 6/5/15. The 5/21/15 order also included a hemoglobin A1C, [MEDICATION NAME] and c reactive protein every two weeks. There were no lab results for 6/5/15. Further review of the physician's orders [REDACTED]. There was a physician's orders [REDACTED]. Review of Resident #5's physician's orders [REDACTED]. The order also indicated to do blood cultures in the AM x 2. A physician's orders [REDACTED]. Further review of the resident's Physician orders [REDACTED]. Review of Resident #5's Skilled Daily Nurses Note revealed there was no documentation by an infusion qualified nurse on each shift on 5/20/15, 5/22/15, 5/24/15, 5/26/15, 5/27/15, 5/30/15, 5/31/15, 6/2/15, 6/5/15 Review of the facility's Total [MEDICATION NAME] Nutrition (TPN) Therapy and Administration policy revealed .The infusion qualified nurse will make observations and provide documentation each shift reporting any signs and symptoms of. Further review of the policy revealed under the procedure section check the bag label with the physician's orders [REDACTED]. and nurse's signature. Review of Resident #5's Infusion Flow Sheet revealed there was no documentation of the infusion on 5/23/15, 5/26/15, or 5/31/15 and no Infusion Flow Sheet for the month of June. In an interview with the surveyor on 6/10/15 at approximately 10:10 AM, the 100/200 Unit Manager stated that nurses should sign the Infusion Flow Sheet when they hang the TPN. S/he was not sure why the sheet was not completed every day. The 100/200 Unit Manager stated that Resident #5 was on TPN because of a short gut, most of the resident's small intestines were gone. The 100/200 Unit Manager stated that staff noticed a blue potassium tablet coming through Resident #5's fistula on 6/9/15. The talked with the pharmacist and physician and Resident #5's potassium was changed from a tablet to liquid. In a telephone interview with the surveyor on 6/10/15 at approximately 11:25 AM, the pharmacist stated they only fax TPN orders if a change is made to the formula. The TPN order originally came from the physician based on the hospital order. The original order is the 5/19/15 order. They monitor and adjust as needed. The pharmacist was at the facility on 6/9/15 and talked with the physician yesterday and Monday about the resident's potassium. They discussed adding liquid potassium. Resident #5 was on oral capsules and they were passing through still intact. The resident's last potassium lab was 6/8/15 and was 2.5. The pharmacist stated that the capsule was not being absorbed so liquid potassium was added and the capsule was stopped. The pharmacist stated it had been noted that the resident ' s sodium, chloride and potassium were all low. The pharmacist stated that they could adjust the sodium, chloride and potassium in the TPN and that would be the next step after the liquid. The pharmacist stated that s/he did not see documentation related to check the order for a potassium tablet versus liquid form. In a telephone interview with the surveyor on 6/10/15 at approximately 4:30 PM, Resident #5's physician stated that the pharmacy handles the TPN formulation. The pharmacy contacts the hospital prior to the resident's discharge and they calculate the TPN. The pharmacy adjusts the TPN as needed. The facility Administrator, Nurse Consultant and the Clincal Competency Coordinator were informed of the Immediate Jeopardy and/or Substandard Quality of Care on 6/10/2015 at 4:30 PM, which existed in the facility due to the failure of the facility to ensure the care related to the management of Resident #5 who was receiving Total [MEDICATION NAME] Nutrition. On 6/11/15 the facility developed an Allegation of Compliance (AOC) that included the following: What corrective action will be accomplished for the residents found to have been affected by the deficient practice: MD notified by facility of concerns related to care cited at an immediate jeopardy level for resident #5 related to TPN (Total [MEDICATION NAME] Nutrition) administration. MD notified and orders were received to send the resident out to the hospital at approximately 5:10 PM on 6/10/15. The care and transfer was coordinated by a Registered Nurse. How will the corrective action be monitored to assure that the deficient practice will not reoccur, i.e., what quality assurance program will be put in place for monitoring to assure continued compliance: The facility will not admit residents on TPN unless the following has been done: qualified nurse is assigned to monitor residents receiving TPN 24 hours Qualified nurse is defined in the following manner: a registered nurse or licensed practical nurse who has received education and has been competency on TPN Education will include the following: Healthcare Centers TPN Therapy and Administration Policy, RN will verify TPN order prior to administration and will hang medications/ TPN, a qualified RN or LPN may monitor the TPN per facility policy, the licensed nursing staff were education on 6/11/15 by the Clinical Competency Coordinator and/or Administrator on the allegation of compliance. Any staff without education will not be permitted to work until education is completed, licensed nursing staff were educated on 6/11/15 by the Clinical Competency Coordinator on the Infusion Flow Sheet use, The Director of Health Services and/or RN Unit Manager will monitor the Infusion Flow Sheet for accuracy and completeness daily by initialing the Infusion Flow Sheet with the administering nurse. Process to monitor labs and coordinate lab orders relating to TPN: upon admission of a resident receiving TPN the monitor labs will be ordered by the attending physician, labs will be placed in lab draw book on the designated date, resulting labs will be faxed to the pharmacy by the receiving nurse and adjustments will be made in coordination with the attending physician and pharmacist, pharmacy will communicate changes to the TPN orders and labs to the facility via fax and phone call to the attending nurse for the TPN resident, attending nurse will complete a telephone order addressing TPN order changes and lab orders, attending nurse will transcribe the new TPN order to the MAR and labs will be transcribed to the lab draw book, the Director of Health Services and/or the Unit Managers will monitor the labs and pharmacy communication weekly for the duration of the TPN order. Allegation of Compliance: 6/11/2015 Observations and interviews revealed the AOC submitted by the facility on 6/11/2015 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. The facility nursing staff was educated and was knowledgeable of the policy related to the administration, assessment, monitoring of labs and the infusion procedure of TPN The Administrator was informed of this on 6/11/2015 at approximately 5:00 PM. The Immediate Jeopardy at F-490 was removed, the citations remained at a lower scope and severity of D.

Based on record review and interview the medical director failed to be responsible for the implementation of resident care policies. The medical director failed to be responsible for the implementation of resident care policies in the management of Resident #5 who was receiving Total [MEDICATION NAME] Nutrition (TPN). One of one residents reviewed receiving TPN. The findings included: Cross refer to F-328 as it relates to the failure of the facility to ensure that residents receive proper treatment and care for [MEDICATION NAME] fluids. The facility failed to provide quality of care in the management of Resident #5 who was receiving Total [MEDICATION NAME] Nutrition (TPN). The facility staff was not monitoring labs as ordered, assessing the resident, administering the TPN per protocol or adequatly documenting the administration of TPN (1 of 1 resident reviewed receiving TPN). Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #5 had an [MEDICAL CONDITION] and Mucus Fistula. Review of Resident #5's medical record revealed a [MEDICATION NAME] Nutrition Orders (TPN) form dated 5/19/15. The 5/19/15 [MEDICATION NAME] Nutrition Order form included information on the Total Nutrient Admixture Base Formula and also the amount of additives per bag. In an interview with the surveyor on 6/10/15 at approximately 10:10 AM, the 100/200 Unit Manager confirmed the 5/19/15 [MEDICATION NAME] Nutrition Order form was the only one on the resident's medical record. The 100/200 Unit Manager stated that the nurse should verify the TPN bag label matches the order dated 5/19/15. The 100/200 Unit Manager stated that [MEDICATION NAME] Nutrition Orders are not kept anywhere other than the resident's medical record. The 100/200 Unit Manager reviewed the label on Resident #5's bag of TPN that was currently infusing. The 100/200 Unit Manager confirmed the label on the bag did not match the 5/19/15 TPN order. Review of the label revealed the TPN Base Formula matched the 5/19/15 order but the amount of additives per bag did not. The Clinical Competency Coordinator provided a [MEDICATION NAME] Nutrition Orders form dated 6/1/15 to the surveyor on 6/9/15 at approximately 3:30 PM. The form was noted to have a fax stamp across the top that indicated 6/9/15 at 12:52 PM. There was no [MEDICATION NAME] Nutrition Orders form dated 6/1/15 located on Resident #5's medical record. Review of the form revealed the TPN Base Formula was the same as the 5/19/15 order but the amount of additives per bag was different. Further review of the [MEDICATION NAME] Nutrition Orders form dated 6/1/15 revealed an order for [REDACTED]. Review of Resident #5's medical record revealed no results for the 6/3/15 labs ordered. Review of the Physical Examination Sheet revealed Resident #5 was seen by the physician on 5/21/15. Further review of Resident #5's medical record revealed Physician's Progress Notes dated 6/8/15 and 6/9/15. There were no additional Physician's Progress Notes in Resident #5's medical record. Review of Resident #5's physician's orders [REDACTED]. Review of Resident #5's Infusion Flow Sheet revealed there was no documentation of the infusion on 5/23/15, 5/26/15, or 5/31/15 and no Infusion Flow Sheet for the month of June. Review of the facility's Total [MEDICATION NAME] Nutrition (TPN) Therapy and Administration policy revealed .The infusion qualified nurse will make observations and provide documentation each shift reporting any signs and symptoms of. Further review of the policy revealed under the procedure section check the bag label with the physician's orders [REDACTED]. and nurse's signature. In an interview with the surveyor on 6/10/15 at approximately 10:10 AM, the 100/200 Unit Manager stated that nurses should sign the Infusion Flow Sheet when they hang the TPN. S/he was not sure why the sheet was not completed every day. The 100/200 Unit Manager stated that Resident #5 was on TPN because of a short gut, most of the resident's small intestines were gone. The 100/200 Unit Manager stated that staff noticed a blue potassium tablet coming through Resident #5's fistula on 6/9/15. The talked with the pharmacist and physician and Resident #5's potassium was changed from a tablet to liquid. In a telephone interview with the surveyor on 6/10/15 at approximately 4:30 PM, Resident #5's physician stated that the pharmacy handles the TPN formulation. The pharmacy contacts the hospital prior to the resident's discharge and they calculate the TPN. The pharmacy adjusts the TPN as needed. The physician stated that Resident #5 was on TPN because s/he had a surgical wound and short gut. The physician stated that Resident #5's potassium level kept falling. S/he ordered an oral tablet for the resident (6/4/15) for the low potassium level but it was not absorbed. The physician changed to normal saline with potassium and liquid potassium (6/9/15). The surveyor asked the physician why fluid/electrolytes were not adjusted in the TPN formula. The physician responded that TPN is made up on a 24 hour cycle and would be adjusted as needed. The physician also stated that the resident 's white count had increased and cultures were pending. S/he suspected a deep line infection and if the culture came back positive s/he would send the resident out to the hospital. The physician stated that the pharmacy requested the c-reactive protein labs. S/he stated that s/he would suspect an infection if the results were high. When asked if there was any communication with pharmacy when the results came back high, the physician stated s/he was not sure. The physician stated that s/he monitored liver function labs weekly to monitor liver function related to the resident receiving TPN. The physician stated that s/he was concerned about the resident's white count, though s/he was looking better last night than s/he was on Monday night. The physician stated if the resident's c-reactive protein was still high s/he would send the resident out to the hospital. S/he then stated s/he did not order a repeat c-reactive protein because once it was high s/he didn't expect it to come back down because the resident was not on antibiotics. The facility Administrator, Nurse Consultant and the Clincal Competency Coordinator were informed of the Immediate Jeopardy and/or Substandard Quality of Care on 6/10/2015 at 4:30 PM, which existed in the facility due to the failure of the facility to ensure the care related to the management of Resident #5 who was receiving Total [MEDICATION NAME] Nutrition. On 6/11/15 the facility developed an Allegation of Compliance (AOC) that included the following: What corrective action will be accomplished for the residents found to have been affected by the deficient practice: MD notified by facility of concerns related to care cited at an immediate jeopardy level for resident #5 related to TPN (Total [MEDICATION NAME] Nutrition) administration. MD notified and orders were received to send the resident out to the hospital at approximately 5:10 PM on 6/10/15. The care and transfer was coordinated by a Registered Nurse. How will the corrective action be monitored to assure that the deficient practice will not reoccur, i.e., what quality assurance program will be put in place for monitoring to assure continued compliance: The facility will not admit residents on TPN unless the following has been done: qualified nurse is assigned to monitor residents receiving TPN 24 hours Qualified nurse is defined in the following manner: a registered nurse or licensed practical nurse who has received education and has been competency on TPN Education will include the following: Healthcare Centers TPN Therapy and Administration Policy, RN will verify TPN order prior to administration and will hang medications/ TPN, a qualified RN or LPN may monitor the TPN per facility policy, the licensed nursing staff were education on 6/11/15 by the Clinical Competency Coordinator and/or Administrator on the allegation of compliance. Any staff without education will not be permitted to work until education is completed, licensed nursing staff were educated on 6/11/15 by the Clinical Competency Coordinator on the Infusion Flow Sheet use, The Director of Health Services and/or RN Unit Manager will monitor the Infusion Flow Sheet for accuracy and completeness daily by initialing the Infusion Flow Sheet with the administering nurse. Process to monitor labs and coordinate lab orders relating to TPN: upon admission of a resident receiving TPN the monitor labs will be ordered by the attending physician, labs will be placed in lab draw book on the designated date, resulting labs will be faxed to the pharmacy by the receiving nurse and adjustments will be made in coordination with the attending physician and pharmacist, pharmacy will communicate changes to the TPN orders and labs to the facility via fax and phone call to the attending nurse for the TPN resident, attending nurse will complete a telephone order addressing TPN order changes and lab orders, attending nurse will transcribe the new TPN order to the MAR and labs will be transcribed to the lab draw book, the Director of Health Services and/or the Unit Managers will monitor the labs and pharmacy communication weekly for the duration of the TPN order. Allegation of Compliance: 6/11/2015 Observations and interviews revealed the AOC submitted by the facility on 6/11/2015 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. The facility nursing staff was educated and was knowledgeable of the policy related to the administration, assessment, monitoring of labs and the infusion procedure of TPN The Administrator was informed of this on 6/11/2015 at approximately 5:00 PM. The Immediate Jeopardy at F-501 was removed, the citations remained at a lower scope and severity of D.

Based on record review and interview the facility failed to obtain laboratory services to meet the needs of Resident #5 who was receiving Total [MEDICATION NAME] Nurtition (TPN) (1 of 1 resident reviewed receiving TPN). The findings included: Cross refer to F-328 as it relates to the failure of the facility to ensure that residents receive proper treatment and care for [MEDICATION NAME] fluids. The facility failed to provide quality of care in the management of Resident #5 who was receiving Total [MEDICATION NAME] Nutrition (TPN). The facility staff was not monitoring labs as ordered, assessing the resident, administering the TPN per protocol or adequatly documenting the administration of TPN (1 of 1 resident reviewed receiving TPN). Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5 had an [MEDICAL CONDITION] and Mucus Fistula. Review of Resident #5's medical record revealed a [MEDICATION NAME] Nutrition Orders (PN) form dated 5/19/15. The 5/19/15 [MEDICATION NAME] Nutrition Order form included information on the Total Nutrient Admixture Base Formula and also the amount of additives per bag. In an interview with the surveyor on 6/10/15 at approximately 10:10 AM, the 100/200 Unit Manager confirmed the 5/19/15 [MEDICATION NAME] Nutrition Order form was the only one on the resident's medical record. The 100/200 Unit Manager stated that the nurse should verify the TPN bag label matches the order dated 5/19/15. The 100/200 Unit Manager stated that [MEDICATION NAME] Nutrition Orders are not kept anywhere other than the resident's medical record. The 100/200 Unit Manager reviewed the label on Resident #5's bag of TPN that was currently infusing. The 100/200 Unit Manager confirmed the label on the bag did not match the 5/19/15 TPN order. Review of the label revealed the TPN Base Formula matched the 5/19/15 order but the amount of additives per bag did not. The Clinical Competency Coordinator provided a [MEDICATION NAME] Nutrition Orders form dated 6/1/15 to the surveyor on 6/9/15 at approximately 3:30 PM. The form was noted to have a fax stamp across the top that indicated 6/9/15 at 12:52 PM. There was no [MEDICATION NAME] Nutrition Orders form dated 6/1/15 located on Resident #5's medical record. Review of the form revealed the TPN Base Formula was the same as the 5/19/15 order but the amount of additives per bag was different. Further review of the [MEDICATION NAME] Nutrition Orders form dated 6/1/15 revealed an order for [REDACTED]. Review of Resident #5's medical record revealed no results for the 6/3/15 labs ordered. Review of Resident #5's labs revealed the resident had a C Reactive Protein lab drawn on 5/22/15 with a result of 5.2. The American Health Associates lab, which processed the lab work, noted the reference range as < 1.2. Further review of the resident's medical record revealed [REDACTED]. The reference range was noted as 0.0-0.9. The results of the lab drawn on 6/1/15 revealed no communication between the physician and the pharmacy regarding the implications of the lab results. Review of Resident #5's labs revealed liver function labs were drawn on 5/22/15 and 6/1/15. There were no additional lab results for liver funtion on the resident's medical record. Review of Resident #5's medical record revealed a [MEDICATION NAME] Nutrition Orders form dated 5/19/15. The order indicated to draw a basic metabolic panel (BMP), Phosphorus and Magnesium level daily. The order also indicated to draw a triglyceride level weekly. The order also indicated to draw a [MEDICATION NAME] and [MEDICATION NAME] level 3 x/d(ay). Review of the medical record revealed these labs were not drawn daily. Review of Resident #5's medical record revealed the following lab variations: Potassium - 5/22/15 5.9 (high), 5/27/15 5.8 (high), 5/29/15 4.7, 6/1/15 3.6, 6/4/15 3.4 (low) and 6/8/15 2.5 (critical low) Sodium - 5/22/15 139, 5/27/15 132 (low), 5/29/15 131 (low), 6/1/15 129 (critical low), 6/4/15 135 (low), 6/8/15 131 (low) Chloride - 5/22/15 104, 5/27/15 87 (low), 5/29/15 87 (low), 6/1/15 80 (critical low), 6/4/15 84 (low), 6/8/15 82 (low) Magnesium - 5/22/15 2.1, 5/27/15 2.3, 5/29/15 2.1, 6/1/15 2.0, 6/8/15 1.8 (low) Review of the physician's orders [REDACTED]. Review of Resident #5's medical record revealed no lab results for 5/23/15. The order on 5/21/15 also indicated to check a complete blood count (CBC), CMP, magnesium, phosphorus and triglycerides weekly on Wednesdays. There was no CMP result on 5/27/15 and no lab results for 6/3/15. In a telephone interview with the surveyor on 6/10/15 at approximately 11:25 AM, the pharmacist stated they only fax TPN orders to the facility if a change is made to the formula. The TPN order originally came from the physician based on the hospital order. The original order is the 5/19/15 order. They monitor and adjust the TPN as needed. The pharmacist was at the facility on 6/9/15 and talked with the physician yesterday and Monday about the resident's potassium level being low. They discussed adding liquid potassium. Resident #5 was on oral potassium capsules and they were passing through still intact. The resident 's last potassium lab on 6/8/15 was 2.5. The pharmacist stated it had been noted that the resident's sodium, chloride and potassium were all low. The pharmacist stated that they could adjust the sodium, chloride and potassium in the TPN and that would be the next step after the liquid. The facility Administrator, Nurse Consultant and the Clincal Competency Coordinator were informed of the Immediate Jeopardy and/or Substandard Quality of Care on 6/10/2015 at 4:30 PM, which existed in the facility due to the failure of the facility to ensure the care related to the management of Resident #5 who was receiving Total [MEDICATION NAME] Nutrition. On 6/11/15 the facility developed an Allegation of Compliance (AOC) that included the following: What corrective action will be accomplished for the residents found to have been affected by the deficient practice: MD notified by facility of concerns related to care cited at an immediate jeopardy level for resident #5 related to TPN (Total [MEDICATION NAME] Nutrition) administration. MD notified and orders were received to send the resident out to the hospital at approximately 5:10 PM on 6/10/15. The care and transfer was coordinated by a Registered Nurse. How will the corrective action be monitored to assure that the deficient practice will not reoccur, i.e., what quality assurance program will be put in place for monitoring to assure continued compliance: The facility will not admit residents on TPN unless the following has been done: qualified nurse is assigned to monitor residents receiving TPN 24 hours Qualified nurse is defined in the following manner: a registered nurse or licensed practical nurse who has received education and has been competency on TPN Education will include the following: Healthcare Centers TPN Therapy and Administration Policy, RN will verify TPN order prior to administration and will hang medications/ TPN, a qualified RN or LPN may monitor the TPN per facility policy, the licensed nursing staff were education on 6/11/15 by the Clinical Competency Coordinator and/or Administrator on the allegation of compliance. Any staff without education will not be permitted to work until education is completed, licensed nursing staff were educated on 6/11/15 by the Clinical Competency Coordinator on the Infusion Flow Sheet use, The Director of Health Services and/or RN Unit Manager will monitor the Infusion Flow Sheet for accuracy and completeness daily by initialing the Infusion Flow Sheet with the administering nurse. Process to monitor labs and coordinate lab orders relating to TPN: upon admission of a resident receiving TPN the monitor labs will be ordered by the attending physician, labs will be placed in lab draw book on the designated date, resulting labs will be faxed to the pharmacy by the receiving nurse and adjustments will be made in coordination with the attending physician and pharmacist, pharmacy will communicate changes to the TPN orders and labs to the facility via fax and phone call to the attending nurse for the TPN resident, attending nurse will complete a telephone order addressing TPN order changes and lab orders, attending nurse will transcribe the new TPN order to the MAR and labs will be transcribed to the lab draw book, the Director of Health Services and/or the Unit Managers will monitor the labs and pharmacy communication weekly for the duration of the TPN order. Allegation of Compliance: 6/11/2015 Observations and interviews revealed the AOC submitted by the facility on 6/11/2015 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. The facility nursing staff was educated and was knowledgeable of the policy related to the administration, assessment, monitoring of labs and the infusion procedure of TPN The Administrator was informed of this on 6/11/2015 at approximately 5:00 PM. The Immediate Jeopardy at F-502 was removed, the citations remained at a lower scope and severity of D.

Based on observation, record review and interview the facility failed to ensure that residents receive proper treatment and care for [MEDICATION NAME] fluids. The facility failed to provide quality of care in the management of Resident #5 who was receiving Total [MEDICATION NAME] Nutrition (TPN). The facility staff was not monitoring labs as ordered, assessing the resident, administering the TPN per protocol or adequatly documenting the administration of TPN (1 of 1 resident reviewed receiving TPN). The findings included: Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5 had an [MEDICAL CONDITION] and mucus fistula. Review of Resident #5's medical record revealed a [MEDICATION NAME] Nutrition Orders (PN) form dated 5/19/15. The 5/19/15 [MEDICATION NAME] Nutrition Order form included information on the Total Nutrient Admixture Base Formula and also the amount of additives per bag. In an interview with the surveyor on 6/10/15 at approximately 10:10 AM, the 100/200 Unit Manager confirmed the 5/19/15 [MEDICATION NAME] Nutrition Order form was the only one on the resident's medical record. The 100/200 Unit Manager stated that the nurse should verify the TPN bag label matches the order dated 5/19/15. The 100/200 Unit Manager stated that [MEDICATION NAME] Nutrition Orders are not kept anywhere other than the resident's medical record. The 100/200 Unit Manager reviewed the label on Resident #5's bag of TPN that was currently infusing. The 100/200 Unit Manager confirmed the label on the bag did not match the 5/19/15 TPN order. Review of the label revealed the TPN Base Formula matched the 5/19/15 order but the amount of additives per bag did not. The Clinical Competency Coordinator provided a [MEDICATION NAME] Nutrition Orders form dated 6/1/15 to the surveyor on 6/9/15 at approximately 3:30 PM. The form was noted to have a fax stamp across the top that indicated 6/9/15 at 12:52 PM. There was no [MEDICATION NAME] Nutrition Orders form dated 6/1/15 located on Resident #5's medical record. Review of the form revealed the TPN Base Formula was the same as the 5/19/15 order but the amount of additives per bag was different. Further review of the [MEDICATION NAME] Nutrition Orders form dated 6/1/15 revealed an order for [REDACTED]. Review of Resident #5's medical record revealed no results for the 6/3/15 labs ordered. Review of the Physical Examination Sheet revealed Resident #5 was seen by the physician on 5/21/15. Further review of Resident #5's medical record revealed Physician's Progress Notes dated 6/8/15 and 6/9/15. There were no additional Physician's Progress Notes in Resident #5's medical record. Review of Resident #5's labs revealed the resident had a C Reactive Protein lab drawn on 5/22/15 with a result of 5.2. The American Health Associates lab, which processed the lab work, noted the reference range as < 1.2. Further review of the resident's medical record revealed [REDACTED]. The reference range was noted as 0.0-0.9. The lab drawn on 6/1/15 revealed no communication between the physician and pharmacy regarding the implications for the care of Resident #5. Review of Resident #5's labs revealed liver function labs were drawn on 5/22/15 and 6/1/15. There were no additional results for liver funtion on the resident's medical record. Review of Resident #5's medical record revealed a [MEDICATION NAME] Nutrition Orders form dated 5/19/15. The order indicated to draw a basic metabolic panel (BMP), Phosphorus and Magnesium level daily. The order also indicated to draw a triglyceride level weekly. The order also indicated to draw a [MEDICATION NAME] and [MEDICATION NAME] level 3 x/d(ay). Review of the medical record revealed these labs were not drawn daily. Review of Resident #5's medical record revealed the following lab variations: Potassium - 5/22/15 5.9 (high), 5/27/15 5.8 (high), 5/29/15 4.7, 6/1/15 3.6, 6/4/15 3.4 (low) and 6/8/15 2.5 (critical low) Sodium - 5/22/15 139, 5/27/15 132 (low), 5/29/15 131 (low), 6/1/15 129 (critical low), 6/4/15 135 (low), 6/8/15 131 (low) Chloride - 5/22/15 104, 5/27/15 87 (low), 5/29/15 87 (low), 6/1/15 80 (critical low), 6/4/15 84 (low), 6/8/15 82 (low) Magnesium - 5/22/15 2.1, 5/27/15 2.3, 5/29/15 2.1, 6/1/15 2.0, 6/8/15 1.8 (low) Review of the physician's orders [REDACTED]. Review of Resident #5's medical record revealed no lab results for 5/23/15. The order on 5/21/15 also indicated to check a complete blood count (CBC), CMP, magnesium, phosphorus and triglycerides weekly on Wednesdays. There was no CMP result on 5/27/15 and no lab results for 6/3/15. Review of Resident #5's lab results dated 6/8/15 revealed the resident's potassium level was 2.5 (critical low) and their magnesium level was 1.8 (low). Handwritten at the bottom of the lab results was an order for [REDACTED]. There was a corresponding physician's orders [REDACTED]. There was also a handwritten note at the bottom of the lab results that indicated to change potassium tablets to liquid due to capsule passing in stool. Review of Resident #5's physician's orders [REDACTED]. There were no lab results for 6/5/15. The 5/21/15 order also included a hemoglobin A1C, [MEDICATION NAME] and c reactive protein every two weeks. There were no lab results for 6/5/15. Further review of the physician's orders [REDACTED]. There was a physician's orders [REDACTED]. Review of Resident #5's physician's orders [REDACTED]. The order also indicated to do blood cultures in the AM x 2. A physician's orders [REDACTED]. Further review of the resident's Physician orders [REDACTED]. These orders revealed no indication that consideration was given to the order for magnesium oxide tablets on 6/8/15 and the change from potassium chloride tablets ordered 6/4/15 to liquid potassium chloride on 6/9/15 due to the tablets coming through Resident #5's fistula on 6/9/15. Review of the SBAR Communication Form dated 6/10/15 revealed Resident #5 had a change in condition related to abnormal labs. Resident #5 was noted to have a positive blood culture with gram negative rods on 6/10/15. Review of Resident #5's Skilled Daily Nurses Note revealed there was no documentation by an infusion qualified nurse on each shift on 5/20/15, 5/22/15, 5/24/15, 5/26/15, 5/27/15, 5/30/15, 5/31/15, 6/2/15, 6/5/15. Review of Resident #5's Infusion Flow Sheet revealed there was no documentation of the infusion on 5/23/15, 5/26/15, or 5/31/15. Further review of Resident #5's record revealed there was no Infusion Flow Sheet for the month of June. The facility Infusion Flow Sheet include the date and time, solution infusing, rate, type of access, site, dressing, technique and nurse's signature. Review of the facility's Total [MEDICATION NAME] Nutrition (TPN) Therapy and Administration policy revealed .The infusion qualified nurse will make observations and provide documentation each shift reporting any signs and symptoms of. Further review of the policy revealed under the procedure section check the bag label with the physician's orders [REDACTED]. and nurse's signature. In an interview with the surveyor on 6/10/15 at approximately 10:10 AM, the 100/200 Unit Manager stated that nurses should sign the Infusion Flow Sheet when they hang the TPN. S/he was not sure why the sheet was not completed every day. The 100/200 Unit Manager stated that Resident #5 was on TPN because of a short gut, most of the resident's small intestines were gone. The 100/200 Unit Manager stated that staff noticed a blue potassium tablet coming through Resident #5's fistula on 6/9/15. They talked with the pharmacist and physician and Resident #5's potassium was changed from a tablet to liquid. In a telephone interview with the surveyor on 6/10/15 at approximately 11:25 AM, the pharmacist stated they only fax TPN orders to the facility if a change is made to the formula. The TPN order originally came from the physician based on the hospital order. The original order is the 5/19/15 order. They monitor and adjust the TPN as needed. The pharmacist was at the facility on 6/9/15 and talked with the physician yesterday and Monday about the resident's potassium level being low. They discussed adding liquid potassium. Resident #5 was on oral potassium capsules and they were passing through still intact. The resident 's last potassium lab on 6/8/15 was 2.5. The pharmacist stated that the capsule was not being absorbed so liquid potassium was added and the capsule was stopped. The pharmacist stated it had been noted that the resident's sodium, chloride and potassium were all low. The pharmacist stated that they could adjust the sodium, chloride and potassium in the TPN and that would be the next step after the liquid. The pharmacist stated that s/he did not see documentation related to the pharmacist checking the order for a potassium tablet versus liquid form. The pharmacist stated s/he would check and send the information if s/he found it. The pharmacist also state s/he could not read the [MEDICATION NAME]/[MEDICATION NAME] lab orders on the initial TPN order form dated 5/19/15. The pharmacist stated s/he would check and send that information as well. Information was faxed from the pharmacy to the surveyor but there was no documentation that the pharmacist talked with the physician about using a liquid form of potassium versus the tablet since the resident had absorption concerns. There was no information to clarify the [MEDICATION NAME]/ [MEDICATION NAME] order on the initial TPN order. In an interview with the surveyor on 6/10/15 at approximately 9:55 AM, the Clinical Competency Coordinator provided a copy of Resident 5's nurses' notes with the names of RNs and trained LPNs highlighted. At approximately 11:15 AM, the Clinical Competency Coordinator reviewed the nurse's notes and confirmed there were days where no RN or trained LPN documented on Resident #5. In a telephone interview with the surveyor on 6/10/15 at approximately 4:30 PM, Resident #5's physician stated that the pharmacy handles the TPN formulation. The pharmacy contacts the hospital prior to the resident's discharge and they calculate the TPN. The pharmacy adjusts the TPN as needed. The physician stated that Resident #5 was on TPN because s/he had a surgical wound and short gut. The physician stated that Resident #5's potassium level kept falling. S/he ordered an oral tablet for the resident (6/4/15) for the low potassium level but it was not absorbed. The physician changed to normal saline with potassium and liquid potassium (6/9/15). The surveyor asked the physician why fluid/electrolytes were not adjusted in the TPN formula. The physician responded that TPN is made up on a 24 hour cycle and would be adjusted as needed. The physician also stated that the resident 's white count had increased and cultures were pending. S/he suspected a deep line infection and if the culture came back positive s/he would send the resident out to the hospital. The physician stated that the pharmacy requested the c-reactive protein labs. S/he stated that s/he would suspect an infection if the results were high. When asked if there was any communication with pharmacy when the results came back high, the physician stated s/he was not sure. The physician stated that s/he monitored liver function labs weekly to monitor liver function related to the resident receiving TPN. The physician stated that s/he was concerned about the resident's white count, though s/he was looking better last night than s/he was on Monday night. The physician stated if the resident's c-reactive protein was still high s/he would send the resident out to the hospital. S/he then stated s/he did not order a repeat c-reactive protein because once it was high s/he didn't expect it to come back down because the resident was not on antibiotics. The facility Administrator, Nurse Consultant and the Clincal Competency Coordinator were informed of the Immediate Jeopardy and/or Substandard Quality of Care on 6/10/2015 at 4:30 PM, which existed in the facility due to the failure of the facility to ensure the care related to the management of Resident #5 who was receiving Total [MEDICATION NAME] Nutrition. On 6/11/15 the facility developed an Allegation of Compliance (AOC) that included the following: What corrective action will be accomplished for the residents found to have been affected by the deficient practice: MD notified by facility of concerns related to care cited at an immediate jeopardy level for resident #5 related to TPN (Total [MEDICATION NAME] Nutrition) administration. MD notified and orders were received to send the resident out to the hospital at approximately 5:10 PM on 6/10/15. The care and transfer was coordinated by a Registered Nurse. How will the corrective action be monitored to assure that the deficient practice will not reoccur, i.e., what quality assurance program will be put in place for monitoring to assure continued compliance: The facility will not admit residents on TPN unless the following has been done: qualified nurse is assigned to monitor residents receiving TPN 24 hours Qualified nurse is defined in the following manner: a registered nurse or licensed practical nurse who has received education and has been competency on TPN Education will include the following: Healthcare Centers TPN Therapy and Administration Policy, RN will verify TPN order prior to administration and will hang medications/ TPN, a qualified RN or LPN may monitor the TPN per facility policy, the licensed nursing staff were education on 6/11/15 by the Clinical Competency Coordinator and/or Administrator on the allegation of compliance. Any staff without education will not be permitted to work until education is completed, licensed nursing staff were educated on 6/11/15 by the Clinical Competency Coordinator on the Infusion Flow Sheet use, The Director of Health Services and/or RN Unit Manager will monitor the Infusion Flow Sheet for accuracy and completeness daily by initialing the Infusion Flow Sheet with the administering nurse. Process to monitor labs and coordinate lab orders relating to TPN: upon admission of a resident receiving TPN the monitor labs will be ordered by the attending physician, labs will be placed in lab draw book on the designated date, resulting labs will be faxed to the pharmacy by the receiving nurse and adjustments will be made in coordination with the attending physician and pharmacist, pharmacy will communicate changes to the TPN orders and labs to the facility via fax and phone call to the attending nurse for the TPN resident, attending nurse will complete a telephone order addressing TPN order changes and lab orders, attending nurse will transcribe the new TPN order to the MAR and labs will be transcribed to the lab draw book, the Director of Health Services and/or the Unit Managers will monitor the labs and pharmacy communication weekly for the duration of the TPN order. Allegation of Compliance: 6/11/2015 Observations and interviews revealed the AOC submitted by the facility on 6/11/2015 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. The facility nursing staff was educated and was knowledgeable of the policy related to the administration, assessment, monitoring of labs and the infusion procedure of TPN The Administrator was informed of this on 6/11/2015 at approximately 5:00 PM. The Immediate Jeopardy and Substandard Quality of Care at F-328 was removed, the citations remained at a lower scope and severity of D.

Based on record review and interview the facility failed to ensure a resident having a pressure sore received necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Resident #5 was admitted to the facility on [DATE] with two small open areas on his/her sacrum. There were no orders for treatment to the area until 6/2/15. One of three residents reviewed for pressure ulcers. The findings included: Resident #5 was admitted to the facility on [DATE]. Review of Resident #5's Admission/Nursing Observation Form dated 5/20/15 completed by LPN (Licensed Practical Nurse) #1 indicated there were two small open areas at the top of the buttocks. Review of Resident #5's Body Audit Form dated 5/21/15 completed by LPN #2 indicated there were two small areas at the top of the buttocks. Review of the resident's physician's orders [REDACTED]. Review of Resident #5's Documentation of Wound Observation and Assessment Form dated 6/2/15 revealed the resident had a Stage III pressure ulcer to his/her sacrum that measured 1 x 0.5 x 0.2. Review of the physician's orders [REDACTED]. Cover the area with a dry dressing and change every 12 hours and as needed. Review of the resident's care plan revealed potential for alteration in skin integrity was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included to report any signs/symptoms of skin alteration to the charge nurse or supervisor. In an interview with the surveyor on 6/9/15 at approximately 1:34 PM, Wound Nurse #1 stated a nurse and CNA (certified nurse aide) were changing Resident #5 and noted the area to his/her sacrum. They told Wound Nurse #1 about the area and that is when s/he ordered a treatment for [REDACTED].#1 stated that the area was noted on May 20th during admission. The nurses who completed the 5/20/14 and 5/21/14 body audits did not let him/her know about the area. Wound Nurse #1 stated that the admitting nurse should have initiated treatment for [REDACTED]. The admitting nurse also should have filled out a communication form for the wound nurse to address the area. Initial body audits are reviewed during the daily clinical meeting. Wound Nurse #1 previously did not attend daily clinical meetings but does attend now. Wound Nurse #1 stated that weekly body audits should be filed in a file. S/he confirmed there was no body audit completed on 5/28/15.

Based on record review and interview the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies. Review of documentation provided by the facility revealed pressure ulcers were identified as an area of concern and a Performance Improvement Plan was implemented on 2/17/15. An updated Performance Improvement Plan related to pressure ulcers was created on 5/22/15. Resident #5 was admitted to the facility on [DATE] with two small open areas to his/her sacrum. No treatment was ordered and Wound Nurse #1 was not notified of the area until 6/2/15. One of one quality assessments reviewed. The findings included: Resident #5 was admitted to the facility on [DATE]. Review of Resident #5's Admission/Nursing Observation Form dated 5/20/15 completed by LPN (Licensed Practical Nurse) #1 indicated there were two small open areas at the top of the buttocks. Review of Resident #5's Body Audit Form dated 5/21/15 completed by LPN #2 indicated there were two small areas at the top of the buttocks. Review of the resident's physician's orders [REDACTED]. Review of Resident #5's Documentation of Wound Observation and Assessment Form dated 6/2/15 revealed the resident had a Stage III pressure ulcer to his/her sacrum that measured 1 x 0.5 x 0.2. Review of the physician's orders [REDACTED]. Cover the area with a dry dressing and change every 12 hours and as needed. Review of the resident's care plan revealed potential for alteration in skin integrity was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included to report any signs/symptoms of skin alteration to the charge nurse or supervisor. In an interview with the surveyor on 6/9/15 at approximately 1:34 PM, Wound Nurse #1 stated a nurse and CNA (certified nurse aide) were changing Resident #5 and noted the area to his/her sacrum. They told Wound Nurse #1 about the area and that is when s/he ordered a treatment for [REDACTED].#1 stated that the area was noted on May 20th during admission. The nurses who completed the 5/20/14 and 5/21/14 body audits did not let him/her know about the area. Wound Nurse #1 stated that the admitting nurse should have initiated treatment for [REDACTED]. The admitting nurse also should have filled out a communication form for the wound nurse to address the area. Initial body audits are reviewed during the daily clinical meeting. Wound Nurse #1 previously did not attend daily clinical meetings but does attend now. Wound Nurse #1 stated that weekly body audits should be filed in a file. S/he confirmed there was no body audit completed on 5/28/15. Review of the facility's Performance Improvement Committee Minutes Form dated 5/14/15 revealed pressure ulcers was identified as an area of concern and a Performance Improvement Plan was implemented on 2/17/15. Review of the updated Wound Care Documentation Performance Improvement Plan revealed the plan was implemented on 5/22/15. Interventions included 100% body audits with a goal end date of 6/26/15. In an interview with the surveyor on 6/10/15 at approximately 11:50 AM, the Nurse Consultant stated that s/he found problems with wound care during a quarterly audit started on 5/12/15. The audit was completed on 5/20/15 and a new performance improvement plan was implemented on 5/22/15. The Nurse Consultant stated that the facility scored a 30% out of 100% on the quarterly audit. The Nurse Consultant stated that the facility had a performance improvement plan in place for acquired wounds but that did not touch the surface of what s/he found.

Based on review of facility files and interview, the facility failed to implement written policies and procedures that prohibit mistreatment and abuse of residents. A Certified Nurse Aide (CNA) held a pillow over Resident #2's face while the resident was being transferred from the bed. A Licensed Practical Nurse (LPN) witnessed the incident and did not stop the CNA or report the incident to his/her supervisor. One of 11 residents reviewed for abuse/ neglect. The findings included: The facility reported an allegation of abuse to the State Agency for Resident #2. Review of the facility's Five-Day Follow-Up Report dated 6/29/14 indicated per investigation and interviews that they substantiated abuse on the part of CNA #1. Review of the medical record revealed Resident #2's [DIAGNOSES REDACTED]. Further review of the medical record revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] coded Resident #2 as having a short-term and long-term memory problem with moderately-impaired skills for daily decision making. The Quarterly MDS coded Resident #2 as requiring extensive assistance for transfers bed mobility. Resident #2 was coded as rejecting care 4-6 days during the assessment period. Review of the Nurse's Notes dated 6/24/14 indicated Resident #2 had increased confusion and weakness with refusal of all aspects of care and was transferred by the emergency medical services (EMS) to the hospital for evaluation. Review of the facility's information revealed on 6/24/14 EMS reported to the hospital that a CNA placed a pillow over a resident's face, to prevent the resident from spitting, while they transferred him/her to a stretcher for transport. Licensed Practical Nurse (LPN) #1 was in the room at the time and assisted with the transfer, s/he failed to report the alleged incident. The hospital called the facility administrator to report the incident. The facility's timeline of the incident indicated the ambulance arrived at the facility at 11:58 AM and left the facility at 12:17 PM on 6/24/14. LPN #1's facility-obtained statement indicated that an EMT came to the nurse's station and asked if they could help them move the resident onto the stretcher. As s/he and CNA #1 entered the room the other EMT stated "(s/he's) going to let us do it". The EMT asked the resident to cross his/her arms over his/her chest and the resident complied. LPN #1 walked to the foot of the bed and got a grip on the sheet and the resident's ankles. CNA #1 walked behind the LPN to the side of the bed and stated, "OK I'm going to do something but you can't tell on me". LPN #1 stated, "Okay". CNA #1 walked to the head of the bed and stated, "we have to do this all of the time." CNA #1 picked up a pillow and stated, "OK when I do this y'all need to move (him/her) fast". CNA #1 then put the pillow on Resident #2's face, then put a hand at each end on top of the pillow holding it in place. They moved the resident very quickly. LPN #1 walked out of the room to find the unit supervisor. LPN #1 sat beside the unit manager. There were family members, EMTs and other employees all around the nurse's station. LPN #1 told the unit supervisor s/he would talk to him/her later. LPN #1 got busy and forgot to tell his/her supervisor about what happened. CNA #1's facility-obtained statement dated 6/24/14 indicated the ambulance employees were trying to put Resident #2 on the stretcher and were having problems. Resident #2 was trying to spit on them so s/he put the pillow in front of him/her, not on him/her, to keep him/her from spitting on them. They got him/her on the stretcher fine after that. .

Based on review of facility files and interview, the facility failed to prevent physical and mental abuse of residents. A Certified Nurse Aide (CNA) held a pillow over Resident #2's face while the resident was being transferred from the bed. A Licensed Practical Nurse (LPN) witnessed the incident and did not stop the CNA or report the incident to his/her supervisor. One of 11 residents reviewed for abuse/ neglect. The findings included: The facility reported an allegation of abuse to the State Agency for Resident #2. Review of the facility's Five-Day Follow-Up Report dated 6/29/14 indicated per investigation and interviews that they substantiated abuse on the part of Certified Nurse Aide (CNA) #1. Review of the medical record revealed Resident #2's [DIAGNOSES REDACTED]. Further review of the medical record revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] coded Resident #2 as having a short-term and long-term memory problem with moderately-impaired skills for daily decision making. The Quarterly MDS coded Resident #2 as requiring extensive assistance for transfers and bed mobility. Resident #2 was coded as rejecting care 4-6 days during the assessment period. Review of the care plan revealed a history of refusing treatment, using profanity, being agitated and resisting care all identified as problem areas. Interventions and approaches to these areas were documented on the care plan and included to talk with the resident in a calm voice when behavior is disruptive. Review of the Nurse's Notes dated 6/24/14 indicated Resident #2 had increased confusion and weakness with refusal of all aspects of care. New order were given by the physician to send Resident #2 to the hospital for evaluation of increased confusion, evaluation of the right leg and lab work. S/he was sent via emergency medical services (EMS) to the emergency room for evaluation. Review of the facility's investigation revealed that on 6/24/14 EMS reported to the hospital that a CNA placed a pillow over the resident's face, to prevent the resident from spitting, while they transferred him/her to a stretcher for transport. The hospital called the facility administrator to report the incident. The facility's timeline of the incident indicated the ambulance arrived at the facility at 11:58 AM and left the facility at 12:17 PM on 6/24/14. Review of the County Sheriff's Office Incident Report dated 6/24/14 indicated that the facility administrator stated that two ambulance employees went into Resident #2's room with a stretcher for him/her to be placed on. The resident became combative and one of the ambulance employees left the resident's room to request assistance from the staff. CNA #1 and Licensed Practical Nurse (LPN) #1 entered the room to assist the two ambulance employees with transferring the resident. LPN #1 went to the foot of the bed and CNA #1 went to the head of the bed. Resident #2 was still being combative and thrashing around in the bed as s/he was being transferred. One of the ambulance employees statements indicated that CNA #1 stated, "we've done this before but you guys can't say anything." At that time CNA #1 picked up a pillow from the resident's bed and placed it on his/her face and applied pressure to his/her head. While CNA #1 had the pillow over Resident #2's face s/he was transferred to the stretcher. "The case is still under investigation." In a facility-obtained statement dated 6/27/14 LPN #2's indicated the nurse (LPN #1) on duty on 6/24/14 stated to him/her that s/he had something to tell him/her but would tell him/her later. The nurse never told him/her whatever s/he wanted to tell him/her. LPN #2 found out about the incident after it was reported by EMS. In an interview with the surveyor on 7/29/14 at approximately 1:15 PM, LPN #2 stated that LPN #1 came to him/her on 6/24/14 and said s/he wanted to talk to him/her about something. LPN #1 did not act like it was urgent and said it could wait until later. LPN #1's facility-obtained statement indicated that an EMT came to the nurse's station and asked if they could help them move the resident onto the stretcher. As s/he and CNA #1 entered the room the other EMT stated, "(s/he's) going to let us do it". The EMT asked the resident to cross his/her arms over his/her chest and the resident complied. LPN #1 walked to the foot of the bed and got a grip on the sheet and the resident's ankles. CNA #1 walked behind the LPN to the side of the bed and stated, "OK I'm going to do something but you can't tell on me". LPN #1 stated okay. CNA #1 walked to the head of the bed and stated "we have to do this all of the time." CNA #1 picked up a pillow and stated "OK when I do this y'all need to move (him/her) fast". CNA #1 then put the pillow on Resident #2's face, then put a hand at each end on top of the pillow holding it in place. They moved the resident very quickly. LPN #1 walked out of the room to find the unit supervisor (LPN #2). LPN #1 sat beside the unit manager. There were family members, EMTs and other employees all around the nurse's station. LPN #1 told the unit supervisor s/he would talk to him/her later. LPN #1 stated s/he got busy and forgot to tell his/her supervisor about what happened. CNA #1's facility-obtained statement dated 6/24/14 indicated the ambulance employees were trying to put Resident #2 on the stretcher and were having problems. Resident #2 was trying to spit on them so s/he put the pillow in front of him/her, not on him/her, to keep him/her from spitting on them. They got him/her on the stretcher fine after that. Ambulance employee #1's statement indicated s/he and his/her partner were having trouble moving Resident #2 from the bed to the stretcher due to him/her being combative. Two women came and the CNA said we've done this before you guys can't say anything. S/he went to the head of the bed and grabbed a pillow, put it over the patient's face and pushed down, "suffocating the patient". My partner pulled and I pushed and we got him/her to the stretcher where we had patient care and we transported him/her to the hospital and immediately told the staff at the emergency department. Ambulance employee #2's statement indicated that due to the patient being combative s/he requested help from the staff to move him/her to the stretcher. Two women came in the room. While they moved him/her over the CNA at the head of the bed placed a pillow over the resident's face with enough force to prevent him/her from breathing. S/he had no idea s/he was going to do it until they had already started moving the resident. Resident #2 had labored breathing when the pillow was removed it normalized in a few minutes. They reported this to the emergency department staff.

On the days of the Complaint Inspection, based on record review and interview, the facility failed to provide necessary treatment for [REDACTED]. The findings included: The facility readmitted Resident #1 with [DIAGNOSES REDACTED]. On 1/14/13 at 2:20 PM, review of the Nurse's Notes revealed a note timed and dated 10/24/12 7:10 PM that stated the CNA (Certified Nursing Assistant) reported Resident #1 "had loose stool x (times) 1. Stool was dark, watery, with a foul odor. Will continue to monitor for future loose stool." On 10/25/12 at 6:00 AM, the nurse documented that the resident had one episode of loose stool during the shift. There was no documentation that the physician had been notified or that the resident received treatment for [REDACTED]. A note timed and dated 6:00 AM on 10/28/12 stated the resident had "several episodes of loose stool noted this shift with foul odor. [MEDICATION NAME] given (no) relief noted. Will place in MD (Doctor) (book) for eval(uation)." On 11/2/12 the physician visited and ordered a stool sample to check for [MEDICAL CONDITIONS]. Further review of the Nurse's Notes revealed a note dated 11/8/12 at 6:00 AM that the resident had "profuse sweating" with a blood pressure of 84/48 and had vomited, at that time the physician was notified and ordered a chest x-ray which, was negative. A urinalysis and culture, change in peg feeding and [MEDICATION NAME] was ordered on [DATE]. On 11/9/12 the physician ordered a repeat urinalysis and culture and "continue to hold antibiotic until the urinalysis and culture results come in". Continued review revealed the urine specimen was collected at 6:30 AM on 11/10/12 via cath urine at 6:18 PM the resident was sent to the emergency room ; there was no documentation to indicate the resident's condition or the reason the resident was sent to the hospital. Review of the discharge summary from the hospital dated 11/22/12 revealed, "the patient was suddenly noted by the staff (at the Nursing Home) to be unresponsive and hypotensive." The note further stated that the resident was hypotensive upon presentation to the hospital and received fluid resuscitation. Review of the monthly physician orders [REDACTED]. Review of the Bowel Movement Record revealed Resident #1 had 2 stools on 10/27, 3 on 10/28, 1 on 10/29, 3 on 10/30 and on 10/31/12. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. At 2:07 PM on 1/14/13, review of the Physician's Interim Orders revealed an order dated 11/1/12 at 12:30 AM to "obtain a stool sample to check for [DIAGNOSES REDACTED] ([MEDICAL CONDITION]) (secondary) to loose stools per Dr..." At 2:20 PM on 1/14/13, review of the Nurses Notes revealed no documentation that the stool specimen was collected. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. At 4:12 PM on 1/14/13, review of the laboratory reports in the record revealed no results for a [MEDICAL CONDITION]. Review of the laboratory log revealed the nurse indicated that Resident #1 did not have a stool on 11/1/12. Review of the resident's BM (Bowel Movement) Report indicated that Resident #1 had a bowel movement on 11/2/12 at 3:20 AM and 9:27 PM; 11/3/12 at 7:05 AM, 10:44 AM, 5:52 PM; 11/4/12 at 8:05 PM; 11/5/12 at 8:09 PM; 11/7/12 at 6:26 PM; 11/8/12 at 7:36 PM; 11/9/12 at 2:45 AM and 9:29 PM and on 11/10/12 at 2:14 PM, providing opportunities for the staff to collect the specimen as ordered. On 1/15/13 the Director of Nursing confirmed no stool specimen was obtained per the lab sheet. S/he further confirmed that there was no documentation that the physician had been notified or that any further actions had been taken. The Staff Development Coordinator confirmed that the resident had multiple bowel movements prior to his/her admission to the hospital and that the stool specimen could have been obtained.