Every finding on record at Rehab Center of Cheraw

Based on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible. Specifically, the facility failed to identify risks and hazards, failed to implement processes and failed to implement and monitor person-centered interventions for smokeless tobacco use for 3 of 3 Residents reviewed, (R)51, (R)71, and (R)77. Findings include:Review of R77s admission Record revealed the facility admitted R77 on 11/11/25. According to the admission Record, the resident had a medical history that included but was not limited to diagnoses of cognitive communication deficit, alcohol-induced persisting dementia, and acute cough.Review of R77's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/10/26, revealed R77 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated the resident had moderate cognitive impairment.Review of R77's Care Plan Report, included a problem area initiated on 01/05/26, that indicated the resident had a behavior of spitting on floor, uses chewing tobacco provided by family. Approaches directed staff to provide spit cup, created, 01/22/26.Review of R71 s admission Record revealed the facility admitted R71 on 04/15/19. According to the admission Record, the resident had a medical history that included but was not limited to diagnoses of vascular dementia, moderate with other behavioral disturbance, cognitive communication deficit, schizoaffective disorder, and anxiety disorder.Review of R71's Annual MDS with an ARD of 05/07/26, revealed R71 had a BIMS score of 08 out of 15, which indicated the resident had moderate cognitive impairment.Review of R71's Care Plan Report, included a problem area initiated on 04/23/19, that indicated the resident uses nicotine pouches.Review of R51s admission Record revealed the facility admitted R51 on 06/13/24. According to the admission Record, the resident had a medical history that included but was not limited to diagnoses of vascular dementia and chronic obstructive pulmonary disease.Review of R51's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/20/26, revealed R71 had a Brief Interview for Mental Status (BIMS) score of 06 out of 15, which indicated the resident had severe cognitive impairmentReview of R51's Care Plan Report, included a problem area initiated on 06/20/24, that resident uses nicotine pouches.During observation on 07/12/26 at 10:34 AM of R77's room, revealed his door was opened and a white Styrofoam cup without a lid was observed on R77's bedside table, with a white napkin and tobacco spit in it.During observation on 07/12/26 at 3:12 PM, R77 was sitting alone on the sunporch behind the South Day Room, a cup was on the floor beside the resident, no staff were present on the porch.During observation on 07/13/26 at 1:07 PM, R77 was in his wheelchair on the sunporch. He was spitting into a cup. Two other residents were also present on the porch at this time; no staff were present on the porch.During an observation on 07/14/26 at 10:41 AM with R77 revealed he was on the sun porch listening to music, sitting in his wheelchair, with the spit cup on the floor beside the wheelchair.During an interview on 07/12/26 at 10:34 AM, R77 stated that the cup on his bedside table was where he spits. He stated that he chews tobacco and that the facility is aware of his use. He further stated that he keeps the tobacco on his person, though he did not show it to the surveyor.During an interview on 07/12/26 at 3:12 PM, R77 again stated that he uses tobacco and that the facility is aware of it. When asked how long he had been using it, he stated it began shortly after he was admitted to the facility. When asked how he obtains the tobacco, he stated that someone brings it to him. When asked if the person gives the tobacco to the facility staff, he stated that the person gives it directly to him.During an interview on 07/13/26, Certified Nursing Assistant (CNA)3 stated that the facility is strictly non-smoking but noted that certain residents use chewing tobacco. CNA3 reported seeing chewing tobacco in the drawer of R77 about a week prior, guessing that the resident receives money from the Activities department to purchase it at the store. CNA3 further noted that a nurse holds the tobacco for R71, though they were unsure if a nurse also holds tobacco for R77. On multiple occasions over the course of a week, CNA3 witnessed R77 chewing tobacco out of his pocket and putting it into his mouth, inside the facility. CNA3 reported these incidents to the nurse on duty, who was an agency shift nurse. Upon checking the facility matrix to see if any residents had valid orders for chewing tobacco, CNA3 did not see R77's name listed. Additionally, CNA3 stated that R71 uses tobacco products and receives them directly from the nurse.During an interview on 07/13/26, time unspecified, CNA2 stated that the facility is a non-smoking property, which also prohibits the use of other tobacco products. CNA2 verified that R77 chews tobacco and became aware of this habit on the resident's admission date because spit would be found all over his room floor. CNA2 reported R77's tobacco use to Licensed Practical Nurse (LPN)2. Additionally, CNA2 stated that R51 chews snuff and keeps it in his pockets and dresser drawer.During an interview on 07/13/26 at 2:04 PM, Unit Nurse/LPN2 revealed this is a non-smoking facility. She stated that R51, R71 and R77 use tobacco products. To her knowledge R51 and R77 are care planned for using tobacco. R71 uses tobacco chews, which are kept and administered by the Activities Director. LPN2 also stated that tobacco is not considered smoking products. She stated that staff have been educated on the use of tobacco products. Surveyor requested the documentation on the education on 3 separate occasions, first during the interview, then on 07/14/26 at approximately 1:15 PM and approximately 2:30 PM, each time she stated, Oh yes, I do owe you that.During a follow-up interview on 07/14/26 at 10:41 AM with R77 revealed his family brings tobacco to him when they visit him. He stated he keeps the tobacco in his dresser drawer and on him when he has it. He has been chewing it since his was little and he goes crazy without it. He stated that his doctor has not discussed his tobacco use. He stated staff knows that he uses it, however he did not identify any staff. When asked when he chews the tobacco, he states when he has some. He refused to show the tobacco to the surveyor.During an interview with R71 on 07/14/26 at approximately 10:55 AM, R71 revealed that he uses tobacco, and he keeps it in his dresser drawer. During an observation with CNA2 on 07/14/26 at approximately 10:58 AM of R77's nightstand drawer, revealed there were fragments of tobacco.During an interview on 07/14/26 at 12:34 PM, the Activities Director stated she has held her position since November 2025 and is responsible for purchasing, storing, and administering tobacco products for R71. She noted that R71 uses ON! 2mg [milligram] Nicotine Pouches, three times daily following morning snack, lunch, and dinner. The Activities Director further stated that families bring tobacco products into the facility for R77 and R51. Specifically, R77 uses Stoker's Red Supreme Chewing Tobacco. This product is provided to R77 in a Ziplock bag, which he keeps on his person or in his top nightstand drawer, allowing him to use it unsupervised. Finally, the Activities Director stated she has never received education or training to monitor R51 and R71 during tobacco product use and confirmed that the facility does not maintain a product inventory log. At the time of the interview, an observation was conducted with the Activities Director. She revealed the key to the black locked box is kept in her office in a drawer that cannot lock; the black box is kept in a cabinet that was not locked, and all of the tobacco products for R71 and R77 were labeled and in the box, R51 did not have any tobacco products in the black locked box.During an interview on 07/14/26 at approximately 1:31 PM, CNA1 stated the facility maintained a smoke- and tobacco-free policy, meaning tobacco products were prohibited. However, she noted that some residents still possessed chewing tobacco. Specifically, she stated R71 and R77 both used chewing tobacco products. She noted that R71's tobacco was kept by the Activity Director and that R71 received two chewing tobacco pouches after every meal, which were provided in a small plastic cup like a medicine cup. CNA1 stressed that it was possible for other residents in the facility to access the spit cups, the containers where the resident spits fluid generated during the tobacco chewing process, presenting a significant safety and contamination risk. Finally, she stated that if she observed a resident with unauthorized tobacco products, she would report it to the nurse to ensure staff could safely remove the items from the resident.An interview was conducted on 07/14/26 at 2:16 PM with the Director of Nursing (DON) regarding facility assessment protocols and smoking safety policies. The DON stated that the nursing team assesses residents using the BIMS score, while the therapy department is responsible for assessing residents for swallowing issues. Regarding tobacco use, the DON stated that the facility has no designated areas or designated times for residents to use tobacco products. When asked about wandering residents entering rooms or areas where tobacco or spit cups are stored by tobacco-using residents, the DON stated this scenario would be no different than a resident grabbing food off another resident's plate, putting it in their mouth, and choking on it. When asked directly if this situation constitutes a safety issue, the DON stated, she guesses. DON stated regarding training/education on residents using tobacco products, that this takes place verbally. No proof of the education was provided to surveyor.During an interview on 07/14/26 at 2:49 PM, the Administrator and Mobile Administrator stated that although the facility is officially a non-smoking facility, they are aware of three residents who currently use chewing tobacco products. They noted that this tobacco use is managed directly through the Activities Director. When questioned about the risk of tobacco or spit cups falling into the hands of other residents, the administrators stated this scenario would be no different than residents grabbing food from another resident and potentially choking. Furthermore, both administrators acknowledged that the facility lacks any official facility policy regarding the use or oversight of tobacco products.During interviews on 07/14/26 at approximately 3:07 PM-3:10 PM, multiple CNAs confirmed never receiving training or education regarding resident tobacco use at the facility.

Based on review of the facility policy, observations and interviews, the facility failed to ensure expired/outdated medications and biologicals were not stored with, and removed from storage away from other medications and biologicals in use for residents in 1 of 2 treatments carts and 1 of 4 medication carts.Findings Include: Review of the facility policy titled, Pharmacy Services Policies and Procedures, Section 8-Medication Storage, General Guidelines for Storage of Medication and Biologicals. last revised 04/01/22 revealed, Policy: Medications and biologicals are stored safely, securely and properly following manufacturer's recommendations or those of the supplier. In accordance with State and Federal Laws, the facility will store all drugs and biologicals in locked compartments under proper temperatures and other appropriate environmental controls to preserve their integrity. Procedures: 5. Medications with manufacturer's expiration date expressed in month and year will expire on the last day of the month. 12. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction, and reordered from the Pharmacy, if replacements are needed. An observation on 07/13/26 at 1:35 PM, with Licensed Practical Nurse #1 (LPN1), of the North Treatment Cart revealed the following:One tube of Remedy Zinc Oxide Paste, 4 ounces, Manufactured by Medline, with Lot #24A1025, NDC-53329-156-44, was expired on February 2026.One tube of Remedy Antifungal Ointment, skin protectant 2.5 ounces, Manufactured by Medline, with Lot#2401133, was expired on April 2026.Eleven Catheter Stabilization Devices, Manufactured by Greystone Medical, with Lot #20230418 were expired on April 17, 2026.The outdated/expired medications and biologicals were confirmed by LPN1 and removed from storage with other medications and biologicals. An observation on 04/13/26 at 2:30 PM of the South B medication cart revealed:One bottle of UTI Stat, Cranberry, 30 fluid ounces, 887 milliliters partially used, with Lot #2501368-5566 was expired on 07/07/2026.The expired bottle of UTI Stat was confirmed by the Director of Nursing and removed from the South B medication cart.

Based on record review, Payroll-Based Journal (PBJ) staffing data, Resident Council interview responses, and a staff interview, the facility failed to ensure sufficient nursing staff to meet the needs of residents as evidenced by low weekend staffing and missing Registered Nurse (RN) hours, affecting residents' timely access to care on a facility-wide basis. Findings include:Record review of the Payroll-Based Journal (PBJ) staffing data for Fiscal Year (FY) 2025, Quarter Four (Q4) identified excessively low weekend staffing levels. The submitted PBJ data for Q4 is consistent with undocumented licensed Registered Nurse (RN) hours and required shifts for facilities with greater than 60 residents.Record review of Resident Council Meeting Minutes dated for 07/22/2025 identify an unresolved Nurse call out issue and reference late medication administration and unspecified disturbances.Record review of the Daily Licensed and Unlicensed Direct Care Staff hours between November 11, 2025 and December 30, 2025 reveal ten (10) instances of missing RN coverage and only document Licensed Practical Nursing (LPN) and Certified Nursing Assistant (CNA) hours. During a Resident Council meeting on 01/13/2026, at 10:30 AM with eleven (11) resident attendees, residents were asked: Do you get the help and care you need without waiting a long time, and does staff respond to your call light in a timely manner? All residents in attendance reported concerns regarding delays in assistance, indicating potential impacts related to insufficient staffing. During an interview on 01/14/2026, at approximately 2:40 PM, the Mobile Administrator was asked about the missing RN hours identified in the PBJ report. In response, she stated that the missing RN hours were covered by a Minimum Data Set (MDS) Nurse functioning as a Unit Charge Nurse, however, there was no documentation to prove the MDS Nurse was working in the capacity of the facility's RN during this time period.

Number of residents sampled: Number of residents cited: Based on review of the facility's policy entitled, Activity Policies and Procedures, record review, observations, and interviews, the facility failed to provide an ongoing program of activities to meet the needs and interest of each resident for one (1) of three (3) residents reviewed for activities (Resident (R)18).Findings include:Review of the facility's policy entitled, Activity Policies and Procedures, stated, POLICY: Based on a comprehensive assessment, individualized care plan and the preferences of each resident, the Activity/Recreation Director and staff will provide an ongoing Activity/Recreation program to support resident personal choice of activities, facility-sponsored group, one to one activities, and independent activities designed to meet the interests of and support the physical, intellectual, psychosocial, emotional and spiritual well-being of each resident, encouraging both independence and community interaction.Purpose: To implement an ongoing resident centered activities program that incorporates the resident's needs, interests, hobbies, and cultural preferences which is integral to maintaining and/or improving physical, Intellectual, psychosocial, emotional, spiritual wellbeing and independence. To create opportunities for each resident to have a meaningful life by supporting the domains of wellness (security, autonomy, growth, connectedness, identity, joy and meaning).R18 was admitted to the facility on [DATE] with diagnoses that included; displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, arthritis, right hip, muscle weakness, depression, anxiety disorder, and schizoaffective disorder.Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed R18 had a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment. The MDS further indicated rejection of care behaviors were not exhibited, and the resident required dependent assistance with bathing.During an observation on 01/11/26 at 2:20 PM, R18 was in her bed, in her room, with no staff present, no books or other reading materials observed.During an observation on 01/13/26 at 8:41 AM, R18 was observed in her bed.During an observation on 01/13/26 at approximately 10:15 AM, R18 was observed in her room alone, in her bed, no activities or reading materials were observed.During an interview on 01/11/26 at 2:20 PM, R18 stated she does not participate in one-on-one or group activities. R18 stated she would like to get out of bed and participate; however, staff do not come to assist her. She further stated the facility has not provided her with reading materials for independent activity or provide any other one on one activities.During an interview on 01/13/26 at 8:41 AM, R18 stated staff did not get her out of bed the previous day. The resident reported that although she would like to attend group activities, she did not attend in-room or group activities and stated no staff notified her of scheduled activities for that day.During an interview on 01/14/26 at 11:03 AM, the Assistant Director of Nursing (ADON) stated that it is her expectation that activities staff coordinate with nursing staff and certified nursing assistants (CNAs) to ensure residents that would like to attend group activities are able to attend scheduled activities.During an interview on 01/13/26 at 11:14 AM, Certified Nursing Assistant (CNA)1 stated she did not remember asking R18 if she wanted to get out of bed or participate in activities.During an interview on 01/14/26 at 12:55 PM, the Activities Assistant stated, while reviewing the activity log with the surveyor, that her previous statement indicating R18 had been invited to group activities was not supported by documentation in the activity log.

Based on observations, resident and staff interviews, record reviews and the facility's policy entitled, Nursing Policies and Procedures, the facility failed to provide Activities of Daily Living, (ADLs) for Resident (R)18 related to hair and dental care, and for R90 related to nail care, for two (2) of five (5) residents reviewed for activities. Findings include: Review of the facility policy titled, Staff Education /Orientation Polices and Procedures, revised 1/12/2024, states performance criteria as follows: 5. Fills basin with warm water 6. Soak nails 7. Clean under nails with orange stick. Review of R90's face sheet revealed R90 was admitted to the facility on [DATE] with diagnoses including but not limited to contracture of the left wrist, other pericardial effusion (non-inflammatory), other abnormal involuntary movements, other lack of coordination, muscle weakness (generalized), and flaccid hemiplegia affecting the left nondominant side. Review of the Physician Orders written on 08/11/25 revealed (Nursing) Nail Check Completed Special Instructions: Document results using KEY below: A. No intervention needed B. Toenails Trimmed C. Fingernails Trimmed D. Podiatry Consult requested Once A Day on Mon NAIL CHECK 07:00 - 19:00 08/28/2025 Review of R90's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 11/18/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition is intact. Review of R90's Care Plan, with a start date of 09/08/25, reveals a risk of deterioration in personal hygiene due to the resident's preference for long fingernails and refusal for staff to cut their nails. During an observation on 01/11/26 at approximately 11:48 AM, observed R90 lying in bed with contractures of bilateral hands, long fingernails with visible brownish-black debris under nails. During an observation on 01/12/26 at approximately 2:30 PM, R90 was observed in bed, supine position, both upper extremities resting on top of covers. R90 continues to have visible brownish-black debris under nails. During an observation on 01/13/26 at approximately 3:35 PM, R90 was observed lying in bed, upper extremities lying on top of the covers. There was visible brownish-black debris was under the nails of both contracted hands. During an observation on 01/14/26 at approximately 9:00 AM, R90's contracted hands were observed, nails cut and clean; however, jagged edges were noted. Licensed Practical Nurse (LPN)5 was notified and stated she would file R90's nails. During an interview on 01/13/26 with LPN4 at 2:31 PM, LPN4 revealed R90's nails should be checked and cleaned during ADLs, which included to check nails and cut nails as needed. During an interview on 01/13/26 with Certified Nursing Assistant (CNA)4 at 2:37 PM, revealed that during ADLs, she uses soap on washcloths and washes R90's hands, but does not do nail care. The facility has never told her she has to do nail care. CNA4 states she has never clipped nails. She uses a washcloth, antibacterial soap, and pulls it through the resident's hands. At this time, CNA4 observed R90's hands and acknowledges visible debris underneath R90's nails. During an interview on 01/13/26 with the Director of Nursing (DON) at 3:45 PM, she revealed her expectations regarding hand contractures and nail care/ADLs with residents with contractures is for it to be done daily. The DON revealed when R90 is bathed, hands should be cleaned, and underneath nails daily. Residents have the right to have long nails if they desire. The DON stated the activities staff has R90 on the list for painting and filing nails. During an interview on 01/13/26 at 3:15 PM, the Occupational Therapist Registered (OTR) reports that upon evaluation, R90 has deformities in the bilateral upper extremities, right flexion contracture of the right hand, and shoulder deformity of the right shoulder. The OTR reported R90 does not have active finger extension and confirmed R90's fingernails were dirty with debris under the fingernails. 2. R18 was admitted to the facility on [DATE] with diagnoses that include but were not limited to; displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, arthritis, right hip, Muscle weakness, depression, anxiety disorder, and schizoaffective disorder. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed R18 had a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment. The MDS further indicated rejection of care behaviors were not exhibited, and the resident required dependent assistance with bathing. During an observation on 01/11/26 at 2:20 PM, R18 was observed lying in bed. The resident's hair appeared disheveled and greasy. The resident's teeth were observed to have visible plaque buildup. During an observation on 01/13/26 at 8:41 AM, R18 was observed lying in bed wearing the same shirt observed on 01/11/2026. The resident's hair appeared greasy and unkempt. The residents' teeth were observed to have visible, yellow-colored plaque buildup. During an observation on 01/13/26 at approximately 10:15 AM, R18 was observed lying in bed in her room. The resident's hair appeared disheveled and greasy. The resident's teeth continued to have visible, yellow-colored plaque buildup. During an interview on 01/11/26 at 2:20 PM, R18 revealed she prefers bed baths and not showers. She does not remember the last time her hair was washed. She has requested on numerous occasions to have her hair shampooed and it is not done. The last time she recalled getting it done was months ago. She did not have a bed bath yesterday or today. She also does not get to brush her teeth daily and should like them to be brushed daily. During an interview on 01/13/26 at 8:41 AM, R18 stated she was in bed all day yesterday, she did not get a bed bath or have her hair shampooed or brushed her teeth. During an interview on 01/14/26 at 11:03 AM, the Assistant Director of Nursing (ADON) stated that it is her expectation that staff will offer residents twice daily the opportunity to brush their teeth. Hair washing should be included in bed baths. R18's shower days are Tuesdays, Thursdays and Saturdays. During interview on 01/13/26 at 11:14 AM with Certified Nursing Assistant (CNA)1 revealed that she is assigned to R18 today. She has provided ADL for her today; she gave her a bed bath. She did not ask R18 if she wanted her teeth brushed today, although that is a part of providing ADLs to residents.

Based on the facility policy, observation and interview, the facility failed to ensure a significant medication error did not occur for Resident (R)50, when Licensed Practical Nurse (LPN)1 failed to correctly prime an insulin pen before administering a dose of insulin for 1 of 1 residents observed, receiving insulin via a pen during med pass. Findings include: Review of the facility policy titled, Staff Education/Orientation Policies and Procedures, under the competency, Medication Administration - Insulin Pen, states under the Performance Criteria, Priming the Pen, 1. Remove the outer needle cap and dial 2 units. 2. Points the pen up and presses the plunger button to expel 2 units of insulin. 3. Repeats these steps as needed until a drop or stream of insulin appears at the needle tip. During a observation on 01/12/2026 at 11:25 AM, LPN1 placed a needle on a Degludec Insulin Pen, then held the pen in the downward position toward the trash can and pushed the dose button expelling the 2 units used to prime the pen in the trash can. LPN1 confirmed that he had held the insulin pen downward to prime the pen and not in the correct upward position. Review of R50's Physician Orders indicated, Degludec Insulin Pen- Inject 15 units subcutaneously, twice a day. LPN1 could not confirm that R50 had received the correct amount of insulin as ordered by the physician causing a significant medication error.

Based on record review, observation, and staff interviews, the facility failed to ensure medications were properly stored in one (1) of two (2) medication storage rooms at safe and appropriate temperatures in accordance with facility policy and manufacturer recommendations.Findings include:Review of procedure number 10.A.1 of the facility policy titled Pharmacy Services Policies and Procedures, last revised on 04/01/2022, revealed that facility staff are required to monitor and record refrigerator and freezer temperatures twice daily, with medication refrigerator temperatures maintained between 36-46 F (2-8 C). On 01/13/2026 at approximately 09:15 AM, review of medication storage areas was conducted. The facility was observed to have one medication storage room and two medication carts each located on the North and South wings. Review of the South Med Room refrigerator temperature logs revealed multiple documented dates with temperatures outside of the acceptable range.On 01/13/2026 at approximately 01:20 PM, the Mobile Director of Nursing (DON) was interviewed regarding the out-of-range temperature logs in the South Med Room refrigerator and the facility's process for managing medications and resolving temperature discrepancies. The Mobile DON was unable to provide an explanation regarding the management of medications stored in the refrigerator during periods of out-of-range temperatures and referred the surveyor to other staff members, who stated they would need to revisit the issue.On 01/13/2026 at approximately 02:00 PM, the Regional Environmental Services (EVS) staff member met with the surveyor regarding the South Med Room refrigerator thermometer. The staff member presented an infrared thermometer and stated that the infrared reading differed by approximately five (5) degrees from the refrigerator thermometer, noting the infrared thermometer measured 35 F while the refrigerator thermometer measured 30 F. The acceptable refrigerator temperature range of 36-46 F was discussed. The Regional EVS staff member stated that the old thermometer would be replaced; however, no further explanation was provided to address out-of-range temperature resolution to ensure medication safety.

Based on the facility policy, medical records, observations and interviews, the facility failed to ensure a medication administration error rate of less than 5 percent for 2 out of 25 opportunities for error. The med error rate was 8 percent. Findings include: Review of the facility policy titled, Medication Management Program, under Policy states,The facility implements a Medication Management Program to meet the pharmaceutical needs of patients and residents, according to established standards of practice and regulatory requirements.3. Licensed nurses will evaluate, assess, monitor, document and report the effectiveness of the medication regimen that includes all medications and supplements prescribed to treat illness, disease process, or enhance the patient's/resident's quality of life. Review of the facility policy titled, Staff Education/Orientation Policies and Procedures, under the competency, Medication Administration - Insulin Pen, states under the Performance Criteria, Priming the Pen, 1. Remove the outer needle cap and dial 2 units. 2. Points the pen up and presses the plunger button to expel 2 units of insulin. 3. Repeats these steps as needed until a drop or stream of insulin appears at the needle tip. An observation on 01/12/2026 at 10:06 AM of med pass by Licensed Practical Nurse (LPN)1 revealed LPN1 pulled the Miralax 17 grams from the medication cart, and placed the 17 grams in a plastic cup. LPN1 then filled the cup with water. The cup did not contain the 6 to 8 ounces as prescribed by the physician. LPN1 then administered the cup of Miralax with the small amount of water to Resident (R)41. Review of the medical record on 01/12/2026 at 10:30 AM for R41 revealed an order for Miralax 17 grams dissolved in 6 to 8 ounces of water or a liquid of the resident's choice, by mouth each day. During an interview on 01/12/2026 with LPN1, he confirmed the amount of water was not the ordered 6 to 8 ounces. During a observation on 01/12/2026 at 11:25 AM, LPN1 placed a needle on a Degludec Insulin Pen, then held the pen in the downward position toward the trash can and pushed the dose button expelling the 2 units used to prime the pen in the trash can. LPN1 confirmed that he had held the insulin pen downward to prime the pen and not in the correct upward position. LPN1 could not confirm that R50 had received the correct amount of insulin as ordered by the physician. Review of R50's Physician Orders indicated, Degludec Insulin Pen- Inject 15 units subcutaneously, twice a day.

Based on record review, interview, and observation, the facility failed to ensure Resident (R)32's wound dressing was changed daily in accordance with physician orders. The resident's bandage had not been changed for five (5) days and was observed to be visibly soiled with dried blood. Findings include:R32 was admitted to the facility on [DATE], with diagnoses including, but not limited to, cerebral palsy, functional quadriplegia, psychosis, mild intellectual disability, and left hand contracture.R32 was assessed as having a 0.5 cm x 0.5 cm wound on the right upper arm.Review of Physician Orders revealed orders including, but not limited to: Wound R[right] Arm Upper: Clean the wound with wound cleanser or normal saline, pat dry, apply honey, and cover with a bordered gauze dressing (BGD) to be changed daily and as needed (PRN).Review of R32's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/07/2025 revealed R32 had a Brief Interview of Mental Status (BIMS) score of 2 out of 15, indicating the resident was severely cognitively impaired.An observation of R32 on 01/11/2026 at 11:05 AM revealed the resident had an unclean bandage on the right upper arm, dated 01/06/2026, indicating the dressing had not been changed for five (5) days. The bandage was observed to be visibly soiled with excessive dried blood.During an interview with Licensed Practical Nurse (LPN)5 on 01/13/2026 at 1:40 PM, it was stated that R32 has a behavior of biting when upset and that this behavior caused the wound. LPN5 confirmed the wound dressing should have been changed daily and as needed per physician orders.During an interview with the Director of Nursing (DON) on 01/13/2026 at 2:30 PM, the DON stated the facility has a wound care nurse who works Monday through Friday. The DON further stated that when the wound care nurse is not present, it is the responsibility of the assigned nurse to provide wound care. The DON confirmed the wound dressing should have been changed daily and stated dressings are dated so staff can identify when the dressing was last changed.

Based on review of facility policy, record review, and interview, the facility failed to ensure that 1 of 3 residents reviewed for nutrition, Resident (R)248, received a therapeutic diet consistent with the resident's clinical condition and the recommendations of the Speech Language Pathologist (SLP). Specifically, the facility did not implement a recommended mechanical soft diet for R248, with dysphagia and documented swallowing difficulties. As a result, the resident continued to receive regular textured food resulting in the resident suffering from asphyxiation and expiring in the facility. On [DATE] at 3:26 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has cause or was likely to cause serious harm, serious impairment or death. On [DATE] at 4:19 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of [DATE]. The IJ was related to 42 CFR 483.25- Nutritional and Hydration Status. On [DATE] at 5:45 PM, the facility provided an acceptable IJ Removal Plan. On [DATE], the survey team validated the facility's corrective actions and confirmed the facility identified and corrected the noncompliance. The SA is considering this IJ at Past Non-Compliance as of [DATE]. An extended survey was conducted in conjunction with the Recertification/Complaint Survey for non-compliance at F692, constituting substandard quality of care. Findings Include: Review of facility policy titled Rehabilitation Services Policies and Procedures last revised [DATE], revealed, Screens will be conducted on all new admissions/readmission. Screens are also conducted on a quarterly and annual basis unless indicated. A Speech Language Pathologist will screen all patients/residents in facility at least every six months to assist in the determination of patient/resident need for ongoing use of feeding tube and/or to provide services to attempt to restore, if possible, normal eating skills and/or identify and manage related complications of feeding tube use. Under circumstances whereby a screening process is insufficient to determine above an SLP, and the order of physician, may conduct a formal evaluation to accomplish same. Review of the undated facility policy titled Mechanical Soft revealed, The mechanical soft diet is used to optimize nutritional intake for individuals who have difficulty chewing or swallowing. Clients who exhibit dental problems, missing teeth, no dentures, chewing or swallowing problems that may be diagnosed with oral pharyngeal dysphagia, and those with generalized weakness to help improve overall intake. Individuals with a wide variety of chewing and swallowing abilities as well as having a variance in alertness will benefit from this altered consistency diet. Foods to avoid: hot dogs; sausages (unless ground or finely chopped; chunky nut butter; fish with bones. Review of R248's Face Sheet revealed R248 was admitted to the facility on [DATE], with diagnoses including but not limited to: Dementia, dysphagia and aphasia. Review of R248's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating that the interview was unable to be completed. Further review revealed, R248 presented with the following signs and symptoms of a swallowing disorder: Holding food in mouth/cheeks or residual food in mouth after meals, coughing or choking during meals or when swallowing medications, and a nutritional approach of a Mechanically Altered Diet while a resident. R248 also required supervision or touching assistance when eating. Review of R248's Electronic Medical Records (EMR) revealed a diet order with a start date of [DATE], revealed, House, Nectar. Special Instructions: Fortified Mashed Potatoes lunch & dinner. Review of R248's SLP Evaluation and Plan of Treatment dated [DATE] and [DATE], revealed R248 was referred for services due to poor swallow safety and moderate confusion. R248 had recommendations for Mechanical Soft textures and Nectar thick liquids. Review of R248's Weekly SLP Evaluation and Plan of Treatments dated [DATE]/, [DATE] and [DATE] - [DATE], revealed R248 had recommendations for Mechanical Soft textures and Nectar thick liquids. Review of the Week-at-a-Glance menu for [DATE], revealed, Chili Dog with cheese, seasoned French fries, seasoned corn, sherbet and a beverage of choice. Review of R248's Care Plan did not revealed a Care Plan or interventions related to R248's theraputic diet. Review of R248's Progress Note dated [DATE], revealed, She has expressive aphasia and requires mech altered meals/liquids for aspiration precautions. Review of R248's Progress Note dated [DATE], revealed, This nurse was notified by [CNA1] and [CNA3] that resident looked pale and asked me to assess resident. Resident was noted to be very pale with no respirations and no pulse. Resident was immediately lowered to the floor by staff from her wheelchair and this nurse initiated CPR while [CNA3] called 911. RN (residents nurse) entered the day room and took over CPR as this nurse began to gather residents paperwork and notify [residents emergency contact]. notified residents other family including the residents father. EMS arrived and continued life saving interventions in facility and in the ambulance. Interventions were unsuccessful. notified administrator, notified on call MD. Review of a South Carolina Pre-Hospital Care Report dated [DATE], revealed the following: Incident Information: [Local] Emergency Medical Services (EMS) agency was dispatched to Rehab Center of Cheraw at 5:33 PM for Unconscious/Fainting/Near-Fainting, patient evaluated, and care provided. Impression: Primary and secondary symptoms/impressions noted as cardiac arrest. Patient Care Report Narrative: A- [EMS1] dispatched for a female patient unconscious CPR in progress. Upon arrival on scene patient was found laying supine on the floor workers doing compressions. Facility stated that she was eatting [sic] and they come to check on her and found her not breahting [sic] no pluse [sic] and began chest compression stated she might have choked on a hotdog that she was eatting [sic]. Patient treatment is as documented. IGEL (device for securing and maintaining a patient's airway) Put in place after removing hotdog pieces from airway. Cardiac Arrest: Yes, Prior to EMS Arrival, Etiology (Cause): Respiratory/Asphyxia (Oxygen deprivation) Review of R248's Emergency Department (ED) progress note dated [DATE] at 6:16 PM, revealed, Per, EMS, presenting from [Facility] for cardiac arrest. Staff members reportedly had served [R248] a dinner tray, and about 3 to 4 minutes when they return to her room, found her slumped over, unresponsive and pulseless. EMS had performed 30 minutes of cardiac resuscitation prehospital, 4 rounds of epinephrine and placed an I-gel. They noticed chunks of hotdog in her airway that was obstructing, and they removed some prior. Under the medical decision making section the following was also revealed: Patient was intubated by me as I suspected foreign body/aspiration. I was able to remove a chunk of a hot dog from her left cheek, otherwise I did not visualize any additional foreign body or food products within the airway/covering her cords. Review of surveillance video footage provided by the facility, recorded on [DATE] at 5:24 PM, R248 can been seen in an empty day room, wheeling herself up to a table where she begins to eat her lunch. At approximately 5:31 PM, R248 is noted to be slumped over the back of her wheelchair non- responsive. A facility staff member is then seen walking up to R248, stands a few feet from her looks over then exits the room. At 5:32 PM, two additional staff members enter the day room and seen checking on the resident and places her on the floor. One minute later at 5:33 PM, CPR is begun and the video ends. During an interview on [DATE] at 11:02 AM, the Registered Dietitian (RD) stated, he visits the facility weekly. He will ask the floor nurses if there have been any changes with residents, he needs to be aware of. The RD also reviews speech therapy notes and if they make any recommendations, they go with them and follow the recommendations. The RD also states when changes are made to diet orders the floor supervisor will place those in the resident's records. The RD was unable to recall what diet R248 was on, or any recommendations made as he did not have the information available to review. During an interview on [DATE] at 12:03 PM, Licensed Practical Nurse (LPN)1 and Certified Nursing Assistant (CNA)1 stated, they are familiar with R248 and her care. They stated on the day of the incident R248 was in the north day room eating when CNA1 noticed that she was looking pale and went to get the nurse. LPN1 and other staff members removed her from the chair down to the floor and started CPR. LPN1 did a clean sweep of her mouth and food was present such as bread and portions of a hot dog. LPN1 states that she was aware that she had diagnoses of dysphagia, but she wasn't aware of any changes with her diet, she just knows that she was working with ST. They stated, supervision or touch assistance with meals means the residents are in a group setting to be monitored more closely. LPN1 stated the ST makes the recommendations to the nursing department, unit manager then staff on the floor and it's also conveyed on the meal ticket and R248 was on a regular diet always. During an interview on [DATE] at 12:21 PM, the Director of Nursing (DON) stated she isn't aware of any foods they are restricted on certain diets. When a resident is on a house diet that's like a regular diet with no restrictions. When diet orders change, they follow diet communication slips. The nursing department and dietary manager can update diet orders. During an interview on [DATE] at 12:36 PM, CNA1 stated she is very familiar with R248's care. She also stated to her knowledge she isn't familiar with any residents who have difficulty swallowing, but normally sees residents who are packers, so their diet will change from regular to a mechanical or pureed diet. CNA1 states the ST communicates with the nurses and dietary staff when changes are needed via a communication slip and verbal order from ST. During an interview on [DATE] at 12:42 PM, the ST stated, R248 was admitted on a regular diet, but he was trying her out on a mechanical soft diet. R248 was not eating as much as she should with the regular diet. ST notes the texture for a resident with dysphagia depends on the resident, but the lowest level is pureed honey and highest is chopped easy chew. ST stated R248 had mild difficulty with chewing, and he was seeing her 5x a week for 8 weeks. ST noted dysphagia affected R248's eating and swallowing as she was chewing, spitting and spilling food out of her mouth. The ST further revealed when he completes a diet communication slip, he gives them both to dietary and the DON, and he also lets them know verbally. ST states if he turns in a diet communication slip for lunch, it is to be in effect at dinner. ST confirmed the discharge summary from his assessment on [DATE] had recommendations for soft mechanical textures and nectar thick liquids. On [DATE] at 5:45 PM the facility provided an acceptable IJ Removal Plan, identicating Past-Non- Compliance which included: Resident identified has diagnosis of dysphagia. Resident is no longer in the facility. Resident admitted on diet of regular textures and nectar thick liquids. Resident was picked up on speech caseload on [DATE] and [DATE] with a goal of consuming regular diet and th.in liquids. Resident was discharged from speech on [DATE] with recommendations for mechanically altered diet and thin liquids. New diet recommendation not communicated effectively by speech therapist to dietary or nursing departments. Investigation initiated and contracted therapy provider was notified. SLP will be suspended pending investigation. Regional therapist in house the week of [DATE] thru [DATE] for an additional audit of residents on current speech caseload. An audit of current resident's diet as well as most current speech recommendations will be completed by Interdisciplinary Team to identify any discrepancies on [DATE]. Discrepancies identified were corrected with recommended speech diets, provider notified, and care plans updated on [DATE]. Meal Tracker will also be audited on [DATE] to ensure ordered diets match the tray ticket. Discrepancies identified were corrected on [DATE]. Licensed nurses and therapy department were re-educated starting on [DATE]/2025, regarding the expectation that any changes to diet are communicated within the IDT team via diet communication slip. SLP to complete diet communication slip, keep a copy, and give a copy to DOR, CDM, and Nurse Manager. Dietary Communication Slips will be reviewed in clinical morning meeting Monday-Friday. Administrator/designee will review 3 residents per week, according to MDS assessment per calendar, to validate ordered diet matches most current speech recommendation. Facility Administrator/designee will be responsible for the overall implementation and validation of this plan. Results of these reviews will be presented to the Quality Assurance Performance Improvement committee for review and recommendations for 3 months. Any concerns will be addresses at time. An Ad Hoc QAPI will be held on [DATE]. Medical Director was notified of the incident and plan for improvement on [DATE]. Allegation of Compliance: [DATE]

Based on review of the facility's policy, record review, pharmacy delivery manifests, and interviews, the facility failed to ensure medications were available and administered as ordered, for 1 of 1 resident (Residents (R)6), reviewed for pharmacy services. Specifically, R6 missed six scheduled doses of a controlled pain medication (Oxycodone), over a three-day period. Finding Include: Review of the facility policy titled Medication Management Program last revised 01/15/25 revealed, The Facility implements a Medication Management program to meet the pharmaceutical needs of patients and residents, according to established standards of practice and regulatory requirements .Administering the Medication Pass . 15. If a medication is unavailable, contact the pharmacy and document accordingly. Notify physician for possible alternatives available in e-kits at time of discovery. Review of R6's Face Sheet revealed he was admitted to the facility on [DATE], with diagnoses including but not limited to: pain, spondylosis with radiculopathy, parkinsonism and hemiplegia and hemiparesis. Review of R6's significant change in status Minimum Data Set Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/10/25, revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment. Review of R6's Physician Order Report dated 04/25 showed an active order, originally started on 03/20/24, for Oxycodone 10 milligrams (mg), four times daily (QID) with special instructions to notify MD [as needed] PRN. Review of the Pharmacy Delivery Manifest revealed the following deliveries of Oxycodone 10 mg: 1. 03/12/25, 4:10 AM - Two packs of 30 tablets. 2. 03/28/25, 4:19 AM - 28 tablet. 3. 04/13/25, 11:19 PM - Three packs of 30 tablets and one pack of 28 tablets. Review of a Controlled Drug Receipt/Record/Disposition Form dated 03/28/25, revealed, a total of 58 tablets of Oxycodone 10 mg were received. However, no medication administration was recorded from 04/11/25 at 12:00 AM to 04/14/25 at 12:00 AM. Review of R6's Medication Administration Record (MAR) for the period 04/01/25 - 04/30/25, revealed six missed doses of Oxycodone 10 mg from 04/11/25 through 04/14/25, with the following documentation noted: 1. 04/12/25 at 12:00 AM - Not given: Medication unavailable (noted on 04/11/25 at 11:28 PM). 2. 04/12/25 at 6:00 AM - Not given: Medication unavailable (noted on 04/12/25 at 5:44 AM). 3. 04/13/25 at 12:00 AM - Not given: Medication unavailable (noted on 04/12/25 at 11:21 PM). 4. 04/13/25 at 6:00 AM - Not given: Medication unavailable (noted on 04/13/25 at 5:34 AM). 5. 04/13/25 at 12:00 PM - Not given: Medication unavailable (noted on 04/13/25 at 12:20 PM). 6. 04/13/25 at 6:00 PM - Not given: Awaiting delivery from pharmacy (noted on 04/13/25 at 5:46 PM). Review of R6's Electronic Medical Record did not reveal documentation to indicate the facility staff attempted to obtain the medication through an emergency supply system, or that the pharmacy was notified. During an interview on 05/04/25 at 11:43 AM, R6 stated, I am scheduled to receive oxycodone every 6 hours due to pains in my legs, but on several occasions, I've gone without my pain medication. During an interview on 05/06/25 at 9:18 AM, Licensed Practical Nurse (LPN)1 stated, All nurses are responsible for monitor medications and place orders for more if we notice that it is running low. When medication levels are low, we can initiate a refill directly in the MAR during medication passes. However, with narcotics, we typically remove the medication sticker and fax it to the pharmacy for a refill. During an interview on 05/06/25 at 9:31 AM, the Director of Nursing stated, When a narcotic medication runs out, a new prescription is required. The nurse currently passing medications should have contacted the pharmacy or physician if the medication was unavailable. All nurses have access to the Emergency (E-Kit), and they have been trained to use it in situations like this. Additionally, the nurses could have contacted the physician for an order for pain management or to replenish the medication from the E-Kit to control the resident's pain.

Based on observation, interview, and policy review, the facility failed to maintain infection prevention and control practices designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This was evidenced by medication administration observations of Resident (R)1 and R18. The findings include: Review of the facility policy titled, Hand Hygiene/Handwashing dated 5/15/23 documented, Procedures: 1. Hand hygiene/hand washing is done: Before: A. Before patient/resident contact .After: .B. After patient/resident contact. C. After contact with a contaminated object or source where there is a concentration of microorganisms, such as, mucous membranes, non-intact skin, body fluids, blood or wounds .J. Contact with environmental surfaces in the immediate vicinity of patients/residents. Review of the facility policy titled, Blood Glucose Monitoring dated 5/5/23 documented, .If the manufacturer doesn't specify how the device should be cleaned and disinfected, then it shouldn't be shared. Review of the facility policy titled, Infection Prevention and Control Policies and Procedures dated 5/15/23 documented, Subject: Transmission Based/Standard Precautions, and Enhanced Barrier Precautions, Standard Precautions vs. Transmission Based Precautions .B. Personal Protective Equipment: determined by the nature of staff interaction, extent of anticipated blood, body fluid or pathogen exposure. Appropriate use of PPE includes but is not limited to: Gloves .4) Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another patient/resident .E. Patient/Resident-Care Equipment .2) Verify that reusable equipment is cleaned, disinfected, and reprocessed appropriately. Review of R1's electronic medical records, revealed an admitted [DATE], and diagnosis list that consisted of Type Two (2) Diabetes Mellitus with Diabetic Neuropathy, Acute Osteomyelitis unspecified femur, Acquired Absence of Right Leg Above the Knee, Cardiomyopathy among other conditions not listed. Resident #1 Physician's Orders showed an order for Insulin Aspart U-100 solution; per sliding scale to be given subcutaneously four (4) times a day. In an observation on 10/7/24 at 11:31 a.m. made during medication administration of R1, Registered Nurse (RN)1 was seen placing the gauze, an open alcohol swab, the glucometer and gloves on the seat of a chair in the resident's room, with no barrier underneath, while donning Personal Protective Equipment (PPE) gown after performing hand hygiene. Then RN1 put on gloves and gathered the supplies. Next RN #1 placed the same supplies on the resident's bed, wiped the resident's finger with the opened alcohol swab and performed the finger stick to check R1's blood glucose. The first attempt was unsuccessful, so RN1 wiped the resident's finger with the same swab and made a second attempt to collect a blood sample. After collecting the sample and getting the resident's blood glucose reading, RN1 took off her gloves and set them on the resident's bed, doffed the PPE gown, returned to their assigned medication cart and placed the glucometer inside without cleaning or disinfecting it. Review of R18's electronic medical records, revealed a current admitted of 9/1/21, and also the latest return admitted [DATE] and diagnosis list that consisted of Type Two (2) Diabetes Mellitus without complications, Chronic Kidney Disease, Squamous Cell Carcinoma of Skin among other conditions not listed. R18's Physician's Orders showed an order for Humalog U- 100 solution Insulin: per sliding scale to be given subcutaneously three (3) times a day. An observation on 10/7/24 at 11:38 AM, made during medication administration of R18 revealed RN1 performed hand hygiene, walked into the resident's restroom to get a pair of gloves, and was seen placing the gauze, an open alcohol swab, the glucometer and gloves on the resident's bedside table with no barrier underneath. RN1 wiped the resident's finger with the opened alcohol swab and performed the finger stick to check R18's blood glucose. The first attempt was unsuccessful, so RN1 wiped the resident's finger with the same swab and made a second attempt to collect a blood sample. After collecting the sample and getting the resident's blood glucose reading, RN1 returned to their assigned medication cart and placed the glucometer inside without cleaning or disinfecting it. RN1 returned to R18's room to administer the resident's medication. RN1 performed hand hygiene, then touched the resident's restroom door, donned gloves, then with gloved hands touched the restroom door to close the door and administered insulin injection to R18. In an interview with RN1 on 10/7/24 at 11:45 AM, she stated that there was no reason why they placed the items down without a barrier underneath, only used one alcohol swab, or did not clean glucometer between residents. RN1 did state that they understood the reason for infection control, but felt that the facility layout made it difficult, saying, It's kind of hard here, I get it, but it is nit-picky. In an interview on 10/9/24 at 8:56 AM with Licensed Practical Nurse (LPN)1, the current unit nurse manager on they stated that the expectation was to improve on infection control, putting down barriers, hand sanitizer use, for the safety of residents and staff and to re-educate. In an interview on 10/9/24 at 9:17 AM with the Director of Nursing (DON) and the Administrator, the DON stated that the expectation was to do better, and that RN1 said that they knew better and should not have exhibited those behaviors. The Administrator stated that re-education with staff had already occurred.

Based on record review, interviews, and review of the facility policy, the facility failed to ensure 1 out of 3 residents was free from significant medication errors for 1 out of 30 days for the month April 2024. Resident (R)1 received Lyrica; 1 capsule by mouth, 1 time a day and Norco 325 milligrams (mg); 1 tablet, 2 times a day. R1's Controlled Drug Receipt/Record/Disposition Form revealed medication was pulled and reported not administered, which heightened the likelihood of a decline in medical conditions. Findings include: Review of facility's policy titled, Medication Management Program with a revision date of 05/05/23 documented under Administering Medication Pass (8) The authorized staff member or licensed nurse must identify the resident before administering any medication. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including but not limited to;anxiety, dementia, chronic obstruction pulmonary disease and heart failure. Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/15/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R1 is cognitively intact. Review of R1's Medication Administration History documented the following orders for April 22, 2024: Lyrica 25 mg; 1 time a day (10am) for muscle weakness; Hydrocodone-acetaminophen; twice a day (10:00AM and 9:00PM) for pain. Review of R1's Controlled Drug Receipt/Record/Disposition Form dated 04/08/24 for Pregabalin cap 25 mg, generic for Lyrica, documented on 04/22/24 signature signed off as administered by Registered Nurse (RN)1. Hydrocodone/APAP tab 325 mg generic for Norco, 1 tablet by mouth two times a day as needed for pain signature signed off on 04/22/24, as administered by RN1. Review of RN1's Suspension Pending Investigation dated 04/23/24 documented the suspension of RN1 for the allegation of medication administration errors. Review of RN1's Corrective Action Form dated 05/03/24 documented violation of facility policy action required: termination of RN1. In an interview on 06/03/24 at 11:24 AM in resident's room, R1 stated he remembered when he didn't get his medication. R1 stated the administration of medication on both halls are very strange because he is included on the South Hall, when he resides on the North Hall. In an interview on 06/03/24 at 1:37AM, RN1 stated she was running behind all day, she stated she was new to hall and the halls are split, it's confusing. RN1 stated when she got to R1, he was not in his room, and she thought he wanted dialysis. She stated she was working with a new orientee, and she had checked back several times. RN1stated when she was asked if R1 received his medications that day, she was honest and stated she hadn't given them to him. RN1 stated she told the truth. RN1 stated she had pulled the narcotic medications, but did not administer them. R1 stated she pulled and wasted the narcotic medications. RN1 stated to dispose, you must have two signatures. RN1 stated she had the new orientee to sign off the medication narcotic sheet witnessing she disposed of the medications. RN1 stated she could not remember the new orientee's name. In an interview on 06/03/24 at 2:28 PM, the Director of Nursing (DON) stated that RN1 stated she disposed of meds. DON stated the disposition of the meds should be listed on the narcotic sheet with two signatures, one as a witness; but this was not done on R1's narcotic sheet. DON stated RN1 admitted to her she did not administer the medications on that day to R1. In an interview on 06/03/24 at 3:16 PM, Administrator stated she expects Nursing staff not to pull medications until the resident is standing in front of them.

Based on review of facility policy, observations, and interviews, the facility failed to ensure foods stored in the refrigerator and the main kitchen preparatory area were labeled, dated, and free from expiration. This failure had the potential to affect all 102 residents in the facility, who consumed food from the kitchen. Findings include: A review of the facility's policy titled, Nutrition Orientation and Competency Policy and Procedures on Food Storage with a complete revision date of [DATE] stated If food is not stored properly, chances are that it will spoil quickly. Remember these pointers for storage. 1. -Follow the first in, first out (FIFO) rule. a. Always cover, label, and date leftovers that are to be stored. They should be date marked with the use-by date. 2. -Throw TCS leftovers out if not used within 3 days. On [DATE] at 10:27 AM, the following observations in the kitchen were made with and verified by the Dietary Manager (DM): Main refrigerator/Cooler-Two clear bags, both with 3 heads of lettuce with no open date or use-by date listed on the bag. All 6 heads of lettuce in the bags were brown with pink build-up surrounding the entire head of lettuce. Main refrigerator/Cooler-One black crate with 2 heads of lettuce with black/brown spots. No original packing, no open date or use-by date observed. Main refrigerator/Cooler-One-half of the head of lettuce, wrapped in saran wrap, with a brown/pink substance. No label was observed, and no open date or use-by date was observed. Main refrigerator/Cooler- One metal pan, approximately 6 inches deep, labeled Stewed [NAME] Use by date [DATE]. On [DATE] at 10:39 AM observation of the main kitchen preparatory area revealed a brown cardboard box/case containing whole Idaho potatoes. 8 out of approximately 20 were rotten, containing black, grey, and green spots on potatoes. The potatoes were soft to the touch. An interview with the DM on [DATE] at 11:10 AM revealed I have been in this position since [DATE], about five months. DM stated, Staff is expected to check the coolers, freezers, and all other food storage areas for expired foods daily. DM stated, It's everyone's responsibility. Normally, her kitchen staff is to use the first in first out method. I am going to ensure that it is done and do another in-service on expired food. During an interview with the Director of Nursing on [DATE] at 3:40 PM revealed that her expectation of kitchen staff is to monitor items and dispose of items before they go bad. She stated she will talk to the kitchen staff about the monitoring and the removal of expired foods. An interview with the Administrator on [DATE] at 03:47 PM revealed My expectation of the kitchen is for all items to be labeled with open and use-by dates. Staff should label food as they go in and discard items that have expired to not compromise other foods.

Based on review of the policy, Staff Education/Orientation for administering Insulin via an Insulin Pen, record reviews, observations and interviews, the facility failed to ensure Resident (R)90 received insulin via an insulin pen correctly. The facility further failed to ensure R60 received insulin as ordered, R5 received blood pressure medication as ordered and R20 received psychotropic and tremor medications as ordered and each resident was free from significant medication errors. Findings include: Review of the facility's policy titled, Staff Education/Orientation Policies and Procedures, the nursing, Competency: Medication Administration-Insulin Pen, states under Priming The Pen, 1. Remove the outer needle cap and dial 2 units. 2. Point the pen up and press the plunger button to expel 2 units of insulin. 3. Repeat these steps as needed until a drop or stream of insulin appears at the needle tip. NOTE: A new pen may have to be primed up to 6 times before it will expel insulin. 4. Shake the insulin off the needle top. An observation on 04/23/24 at 08:30 AM of medication administration revealed Licensed Practical Nurse (LPN)1 administering Lantus Insulin via an Insulin Pen. R90 was to receive 45 units. The insulin pen only had 42 units after the priming of the pen so the LPN opened a second Lantus Pen for the resident. The LPN took an alcohol wipe and cleaned the rubber stopper on the end of the pen, then applied the insulin needle. She dialed up the 2 units for priming the pen and did not remove the cover from the needle and held the pen horizontally and pushed the dose button to expel the 2 units used to prime the pen and then dialed up the 42 units for the dosage to be administered to the resident. The LPN then opened the new Lantus Insulin Pen and cleaned the rubber stopper on the end of the pen and applied the needle leaving the needle covered and holding the pen horizontally she pushed the dose button to expel the 2 units she had dialed up to prime the pen. Then she dialed up the 3 units needed to make up the 45 units as ordered. The LPN then went into the resident's room and administered the 45 units of insulin with the 2 pens. During an interview on 04/23/24 at 08:40 AM with LPN1, she confirmed that she had held the 2 pens with the needle covered horizontally and expelled the 2 units used to prime the pens. She could not confirm that she saw insulin come out of the needle. She stated that pharmacy had in-serviced the staff on the correct administration of insulin via a pen and they had demonstrated holding of the pen horizontally and not vertically. 48834 A review of the facility policy titled, Pharmacy Services Policies and Procedures- Medication Management, revised 04/01/2022, indicated the facility will ensure that each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial wellbeing. R20 was admitted to the facility with diagnoses including but not limited to, schizoaffective disorder, generalized anxiety disorder, urinary tract infection, and dementia. A review of R20's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/10/24, indicated R20 is ordered to take, but is not limited to, antipsychotic and antidepressant medications. A review of R20's care plan indicated a potential for discomfort & adverse effects related to the use of antipsychotic and antidepressant medications. A review of R20's care plan and progress notes did not reveal that R20 refused medications on 04/15/24 or 04/16/24. A review of R20's physician orders indicate benztropine tablet with a start date of 07/13/23, Depakote ER tablet extended release 24 hr with a start date of 11/22/23, methenamine hippurate tablet with a start date of 12/14/23, olanzapine tablet with a start date of 03/12/24, trazodone tablet with a start date of 07/19/23, UTI-Stat liquid with a start date of 03/26/24. - blanks on 4/16/24 night shift. A review of R20's Behavior Monitoring Administration History, from 04/01/24 until 04/23/24, indicated that R20 did not receive benztropine tablet; 0.5 mg, Depakote ER (divalproex) tablet extended release 24 hr; 500 milligrams (mg), methenamine hippurate tablet; 1 gram, olanzapine tablet; 5 mg, trazodone tablet; 50 mg, UTI-Stat (cran-vitc-mannose-[NAME]-bromeln) liquid; 3,875 mg/30 mL, on 04/16/24 during the night shift. During an interview on 04/23/24 at 03:00 PM, The Director of Nursing (DON) expressed they expect nurses to document the Medication Administration Record (MAR) and Treatment Administration Record (TAR) once completing a task ordered by the physician. The DON confirmed that there were several blanks on R20's TAR and MAR for April 24, but could not give a reason why there were several blanks. 49801 Review of the facility policy titled Nursing Policies and Procedures Subject: Medication Management Program revision date 05/05/23 revealed, Policy: The Facility implements a Medication Management program to meet the pharmaceutical needs of patients and residents, according to established standards of practice and regulatory requirements. Scope and Roles: 3. Licensed nurses will evaluate, assess, monitor, document and report the effectiveness of the medication regimen that includes all medications and supplements prescribed to treat illness, disease process, or enhance the patient's/resident's quality of life. Guidelines for Implementing an Efficient Medication Pass: 1B. The facility will ensure the schedules for administering medications: 1) Maximize the effectiveness of the medications. 2) Prevent potential for significant medication interactions .3D. Insulin daily orders, sliding scale orders, and blood glucose results are documented on the same page or screen. Preparing for the Medication Pass 8. Documentation of medications administered is completed according to State and Federal requirements. The initials and verifying signature are generally required. Administering the Medication Pass 11. Immediately after administering the medication to the resident, the authorized staff or licensed nurse will return to the medication cart and document medication administration with initials on the MAR. If a medication is not administered, the authorized staff or licensed nurse must explain why it was not given. Review of R60's Face Sheet revealed R60 was admitted to the facility on [DATE] with diagnoses including but not limited to: Acute respiratory failure, Chronic obstructive pulmonary disease, Diabetes mellitus due to underlying condition with diabetic neuropathy, Type 2 diabetes mellitus with diabetic neuropathy, Major depressive disorder, Myocardial infarction, Ventricular tachycardia, Ischemic cardiomyopathy, Unspecified systolic (congestive) heart failure, and Peripheral vascular disease. Review of R60's Admission MDS with an ARD of 02/19/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R60 was cognitively intact. Review of R60's Care Plan with a start date of 11/09/2022 and target date 05/24/24 documented, the problem: R60 .has a dx [diagnosis] of DM [diabetes mellitus] Type 2, potential for hypo [low]/hyper [high] Glycemia [glucose]. Documented goal: R60 will adhere to diet to aide in controlling glucose and HgbA1C; will not have any acute episodes of hypo/hyper glycemia episodes through. Documented approach revealed, Insulin to be administered per MD orders. Review of R60's MAR for 04/01/24 - 04/22/24 revealed an order for Lantus Solostar U-100 Insulin (insulin glargine) insulin pen; 100 unit/mL (3 mL); amt: 10 UNITS; subcutaneous Special Instructions: NOTIFY MD/NP PRN. At Bedtime 9:00 PM. The document revealed no documentation from 04/08/24 for administration at 9:00 PM, blood sugar value, route, site, or units. Review of R60's Physician Order with a start date of 02/13/24 documented, Lantus Solostar U-100 Insulin (insulin glargine) insulin pen; 100 unit/mL (3 mL); amt: 10 UNITS; subcutaneous Special Instructions: NOTIFY MD/NP PRN. At Bedtime 9:00 PM. During an interview on 04/23/24 at 11:42 AM, the DON stated that her expectations are that physician orders are followed for medication administration. She stated the process for medication administration would include reading the order, checking the order against the medication label when pulling it up or preparing the medication and then administering the medication to the resident. Documentation of the medication being administered would be expected after the resident has received the medication on the MAR. The DON revealed she expects that there would be documentation even if the medication was not given along with notification to the Medical Doctor (MD) and to the resident responsible party if medication is not given. She reported that the facility ensures accuracy of documentation on the MAR by pulling a compliance report daily and either the DON or Assistant Director of Nursing (ADON) addresses identified issues. Education is provided to staff. She stated that unfortunately, they use a lot of agency nurses, which makes it challenging. The DON verified the missing documentation on the MAR for the Lantus insulin on 04/08/24. During an interview on 04/23/24 at 1:15 PM, contact information for the nurse working on 04/08/24 was requested. The DON stated that she would get the number but the nurse was from an agency and was not reliable in returning calls. During an interview on 04/23/24 at 3:21 PM, an attempted call was made to LPN4 but no answer was received and the mailbox was not set up to leave a message. Review of R5's Face Sheet revealed R5 was admitted to the facility on [DATE] with diagnoses including but not limited to: Chronic kidney disease, dependence on renal dialysis, peripheral vascular disease, chronic obstructive pulmonary disease, heat failure, and type 2 diabetes mellitus with diabetic neuropathy. Review of R5's MDS with an AED of 03/22/24 revealed a BIMS score of 15 out of 15, indicating R5 was cognitively intact. Review of R5's Care Plan with a start date of 08/27/20 and target date 05/17/24 documented, the problem as R5 .is at risk for potential cardiac problem r/t dx of HTN [hypertension], HLD [hyperlipidemia], Hyperkalemia [elevated potassium], CHF-stable [congestive heart failure]. Documented goal R5 .will have no alteration in cardiac output through next review. Documented approaches revealed, Meds per [by] MD [medical doctor] order, Observe for c/o [complaints of] chest congestion, cyanosis, or SOB [shortness of breath], s/s [signs and symptoms] of stroke (H/A, one sided weakness, facial drooping, etc.) and notify MD prn, V/S [vital signs] per protocol. Review of R5's MAR for 04/01/24-04/23/24 revealed no documentation from 04/22/24 at 10:00 AM or 9:00 PM for metoprolol tartrate tablet 25 mg amount to administer: 1/2; oral. Review of R5's Physician Order with a start date of 03/22/24 documented, an order for Furosemide tablet; 40 mg; amt: 40 mg; oral twice a day, metoprolol tartrate tablet; 25 mg; amt: 1/2; oral twice a day, Procardia XL (nifedipine) tablet extended release 24 hr; 30 mg; amt: 1: oral once a day. Additionally dialysis every T-Thur-Sat @ 6 AM obtain vital signs after dialysis and completed dialysis sheet once a day on Tue, Thur, Sat 11:00, dialysis every T-Thur-Sat @ 6 AM obtain vital signs after dialysis and completed dialysis sheet once a day on Tue, Thur, Sat 0500, dialysis every t-thurs-sat @ 5:30 AM heartline to transport resident. Pick-up time 0530 AM once a day on Tue, Thu, Sat 05:15, Perma cath to right chest. Monitor for s/s bleeding every shift. Notify MD/NP PRN every shift days 0700-1900, Nights 1900-0700. During an interview on 04/23/24 at 10:00 AM, R5 approached surveyor to show vital signs on the dialysis flowsheet taken at the facility prior to leaving which was 182/121 and at dialysis center 158/91. The resident reported that their blood pressure was high this morning because they did not receive blood pressure medication last night at 9:00 PM. When asked if the nurse was notified, the surveyor was informed that this had not been reported because they was in the bed. The surveyor immediately went to inform the ADON, who was on the medication cart of the reported situation and was told that they would check on it as the resident was assigned on the other cart not this one where the two were standing. The surveyor then spoke with LPN1 who had come out of a room while the surveyor was walking off the unit. LPN1 was standing at the other medication cart and was asked to check the orders for the resident. Upon review of the MAR on the computer screen it was observed that the resident had a nighttime blood pressure medication scheduled: Metoprolol Tartrate 25 mg tablet was scheduled for twice a day. On Monday, April 22, 24 at 10:00 AM and 9:00 PM, there were blanks observed on the MAR. During an interview on 04/23/24 at 11:42 AM, the DON stated expectations are that physician orders are followed. The process for medication administration would include reading the order, checking order against medication when pulling up and then administering to the resident. Documentation of the medication being administered would be expected. She expects that there would be documentation if medication was not given, that the MD be made aware along with the resident or responsible party be made aware if medication is not given. During an interview on 04/23/24 at 3:43 PM with LPN5 revealed that she came on shift at 11:00 PM and was not on duty when the 9:00 PM medication was due. She reported that the resident verbalized to her between 12:00 AM and 1:00 AM that the resident did not receive the scheduled blood pressure medication. This nurse stated she verified the order and observed that the MAR was blank and had not been signed by the previous nurse. LPN5 informed the resident that it was outside of the timeframe for it to be administered. The resident voiced a concern that there needed to be 6 hours for the medication to clear the blood stream before dialysis. This nurse reported the concern to LPN6 and stated that she was not sure what the proper next steps should have been although everyone working were agency nurses on last night. An attempted interview on 4/23/24 at 4:05 PM was made via telephone to LPN6 with no success.

Based on Staff Education/Orientation for administering Insulin via an Insulin Pen, record reviews, observations and interviews, the facility failed to ensure a medication administration error rate of less than 5 percent. The medication error rate was 10.71 percent (%). Additionally, R5's medications were administered and charted late for 22 out of 31 days in March '24. Findings Include: Review of the facility's Staff Education/Orientation Policies and Procedures, the nursing,Competency: Medication Administration-Insulin Pen, states under Priming The Pen, 1. Remove the outer needle cap and dial 2 units. 2. Point the pen up and press the plunger button to expel 2 units of insulin. 3. Repeat these steps as needed until a drop or stream of insulin appears at the needle tip. NOTE: A new pen may have to be primed up to 6 times before it will expel insulin. 4. Shake the insulin off the needle top. During an observation on 04/22/24 at 08:22 AM of medication administration revealed Registered Nurse (RN)1 administering Miralax 17 grams (g) to R84. RN1 measured the 17 grams and emptied it into a 5 ounce (oz.) cup and then added water. The Miralax is to be mixed in 6 to 8 ounces of a liquid for administration. RN1 was not available for interview. An observation on 04/23/24 at 08:30 AM of medication administration revealed Licensed Practical Nurse (LPN)1 administering Lantus Insulin via an Insulin Pen to R90. The resident was to receive 45 units. The insulin pen only had 42 units after the priming of the pen so LPN1 opened a second Lantus Pen for the resident. LPN1 took an alcohol wipe and cleaned the rubber stopper on the end of the pen, then applied the insulin needle. She dialed up the 2 units for priming the pen and did not remove the cover from the needle and held the pen horizontally and pushed the dose button to expel the 2 units used to prime the pen and then dialed up the 42 units for the dosage to be administered to the resident. LPN1 then opened the new Lantus Insulin Pen and cleaned the rubber stopper on the end of the pen and applied the needle leaving the needle covered and holding the pen horizontally she pushed the dose button to expel the 2 units she had dialed up to prime the pen. Then she dialed up the 3 units needed to make up the 45 units as ordered. LPN1 then went into the resident's room and administered the 45 units of insulin with the 2 pens. During an interview on 04/23/24 at 08:40 AM with LPN1, she confirmed that she had held the 2 pens with the needle covered horizontally and expelled the 2 units used to prime the pens. She could not confirm that she saw insulin come out of the needle. She stated that pharmacy had in-serviced the staff on the correct administration of insulin via a pen and they had demonstrated holding of the pen horizontally and not vertically. 46991 Review of the facility's policy titled, Medication Management Program with a revision date of 05/05/23 documented under Preparing for Medication Pass, Section Q (4), Authorized staff must understand: (D) The 8 Rights for administering medication: (4). The Right Time (6). The Right Charting (7). Medications are administered no more than one hour before to one hour after the designated medication pass time. Review of R5's Face Sheet revealed R5 was admitted to the facility on [DATE] with diagnoses including but not limited to; chronic kidney disease, muscle weakness, peripheral vascular disease, lack of coordination, insomnia, diabetes, anxiety disorder, dementia, chronic obstruction pulmonary disease and heart failure. Review of R5's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD ) of 02/15/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R5 is cognitively intact. Review of R5's Medication Administration Record for March '24 revealed the following medication errors: Advair Diskus (fluticasone propion-salmeterol); two times daily (10am/9pm) for Chronic Obstructive Pulmonary disease was charted late 25% for the month. Daily multi-vitamin (multivitamin) tablet; once daily (9am) for Vitamin D deficiency was charted late 12% for the month. Eliquis 5 milligrams (mg); 2 times daily (10am/9pm) for heart failure, charted late; 29% for the month. Folic Acid 1 mg; 1 time daily (10am) for Vitamin D deficiency; charted late; 12% for the month. Furosemide 40 mg; 2 times daily (10am/9pm) for renal dialysis; charted late; 25% for the month. Lyrica 25 mg; 1 time a day (10am) for muscle weakness; charted late; 19% for the month. Melatonin 3 mg; 1 time a day (9pm) for insomnia; charted late; 12% for the month. Metoprolol tartrate 25 mg; 2 times a daily (10am/9pm) for peripheral vascular disease; charted late; 25% for the month. Pantoprazole 20 mg; 2 times daily (10am/10pm) for gastro-esophageal reflux disease; charted late; 12% for the month. Paroxetine HCl 30 mg; 1 time daily (9pm) for anxiety; charted late; 12% for the month. PreserVision AREDS-2 (vit c,e-zn-coppr-lutein-zeaxan) capsule; 250-90-40-1 mg; 1 time daily (10am); charted late; 12% for the month. Pro-Stat AWC (amino acids-protein hydrolys) liquid; 17-100 gram-kcal/30 mL; 2 times a day(10am/9pm); charted late 9% for the month. Procardia XL 30 mg; 1 time daily (10am) for hyperparathyroidism; charted late 16% for the month. Ropinirole .25 mg; 1 time daily (9pm) for cramps (hyperparathyroidism); charted late 12% for the month. Sevelamer carbonate 800 mg; 3 times daily (10am/2pm/9pm) for chronic kidney disease; charted late 29% for the month. Tradjenta 5 mg; 1 time daily (10am) for Diabetes; charted late 16% for the month. Trazodone 50 mg; 1 time daily (9pm) for anxiety; charted late 12% for the month. Tums 200 mg; 1 time daily (10am) for dependence on renal dialysis; charted late 16% for the month. Vitamin C 500 mg; 1 time daily (10am) for chronic kidney disease; charted late 16% for the month. In an interview on 04/23/24 at 3:53 PM, Director of Nursing stated her expectations is for staff to administer medications within the one-hour window before and after scheduled times and document immediately thereafter. In an interview on 04/23/23 at 4:25 PM, Administrator stated she expects medication to be given within the time frame of medication administration or one hour before or after.

Based on records reviews and interviews, the facility failed to implement the Comprehensive Plan of Care for Resident (R)24 related to a significant weight loss for 1 of 2 residents reviewed with a significant weight loss. The facility further failed to implement the Comprehensive Plan of Care related to the provision of activities of interest for R24 to attain or maintain the resident's highest practicable-physical, mental and psychosocial well being for 1 of 1 residents reviewed for activities. Findings include: The facility admitted R24 on 01/31/24 with diagnoses including, but not limited to, depression, anxiety, bipolar disorder and schizophrenia. Review on 04/22/24 at 01:55 PM of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated severe cognitive impairment. Review on 04/22/24 at 01:55 PM of the medical record for R24 revealed the following weights: On 02/01/24, R24 weighed 243.8 pounds. This was the weight on admission. On 02/05/24, R24 weighed 239.0 pounds. On 02/06/24, R24 weighed 237.6 pounds. On 02/13/24, R24 weighed 224.6 pounds. On 03/09/24, R24 weighed 215.8 pounds. On 03/11/24, R24 weighed 218.6 pounds. On 03/12/24, R24 weighed 215.6 pounds. On 03/19/24, R24 weighed 213.8 pounds. On 03/26/24, R24 weighed 213.8 pounds. On 04/02/24, R24 weighed 211.2 pounds. On 04/09/24, R25 weighed 215.0 pounds. Total weight loss from 01/31/24 until 04/09/24 is 28.8 pounds. Review on 04/22/24 at 02:10 PM of the Comprehensive Plan of Care revealed a nutritional status problem area and states: Resident is at risk for malnutrition. She is receiving a regular diet with thin liquids. The goal dated 02/01/24 reads: Resident will maintain nutritional status as evidenced by no significant weight change through next review. The interventions listed are: Encourage to dine in dining room as is appropriate, honor food preferences as feasible, monitor and encourage intakes of foods and fluids, offer alternates if intakes are less than adequate. Monitor weights, skin report, and labs per policy, offer snacks per policy, provide assistance with meals and snack if needed and provide diet as ordered by the physician. During an interview on 04/23/24 at 10:00 AM with the Registered Dietician (RD), he stated that he put in an order for a dietary supplement today. The RD was asked what interventions were put into place to prevent significant weight loss, and he stated, R24 was obese and sometimes weight loss is a good thing. The RD was asked how he found out about weight loss and he stated that he looks at the weights in the computer by just looking them up, but no one informs him of weight loss within the residents. During an interview on 04/23/24 at 12:05 PM with the Director of Nursing concerning the weight loss, she stated that her expectations were that staff would notify the physician and the RD. She stated that she will look at weights from time to time and staff do offer the resident snacks, eventhough there is no documentation to ensure the snacks are offered or consumed. Review on 04/22/24 at 3:18 PM of the activity attendance sheets for R24 revealed no one to one activities, and no activities documented for February 24 and only socialization for March 24. Review on 04/22/24 at 3:48 PM of the Comprehensive Plan of Care R24 revealed a problem area of activities and states: Resident is non-verbal and will be receiving one to one visits with documentation by activity staff in an effort to meet her physical, emotional, and intellectual needs. The goal states: Resident will actively participate in one on one visits with activity staff until next review. The interventions start date is 03/18/24 and include, staff will provide one to one pet therapy, staff will provide one to one religious visits, one on one music hour, and one to one reading. Staff will provide one on one socialization. Staff will observe and document her participation level during activities. Staff will provide one on one outdoor activities, staff will provide one to one beauty/barber as tolerated. Staff will provide manicures as tolerated and staff will provide monthly activity calendar. No documentation could be found in the medical record for R24 to ensure R24 was receiving the one to one activities. During an interview on 04/23/24 at 09:00 AM with the Activity Director, this surveyor had her to take a look at the activity attendance sheets she had provided to me for January, February and March 24. She stated this resident has been in and out of the hospital. I asked her about the Comprehensive Plan of Care which had a start date of 03/18/24 for one to ones, and she did provide a sheet from 04/01/24 through 04/22/24. She confirmed that no one to one activities as listed on the plan of care were provided to R24 and no activities were offered or documented in February '24.

Based on observation, interview, and record review, the facility failed to monitor behaviors and medication side effects for Resident (R)60 and 20 for 2 of 5 residents reviewed for unnecessary medications. Findings include: Review of the facility policy titled Nursing Policies and Procedures Subject: Medication Management Program revision date 05/05/23 revealed, Policy: The Facility implements a Medication Management program to meet the pharmaceutical needs of patients and residents, according to established standards of practice and regulatory requirements. Scope and Roles: 3. Licensed nurses will evaluate, assess, monitor, document and report the effectiveness of the medication regimen that includes all medications and supplements prescribed to treat illness, disease process, or enhance the patient's/resident's quality of life. Guidelines for Implementing an Efficient Medication Pass: 1B. The facility will ensure the schedules for administering medications: 1) Maximize the effectiveness of the medications. 2) Prevent potential for significant medication interactions .Preparing for the Medication Pass 8. Documentation of medications administered is completed according to State and Federal requirements. The initials and verifying signature are generally required. Administering the Medication Pass 11. Immediately after administering the medication to the resident, the authorized staff or licensed nurse will return to the medication cart and document medication administration with initials on the MAR. If a medication is not administered, the authorized staff or licensed nurse must explain why it was not given. Review of R60's Face Sheet revealed R60 was admitted to the facility on [DATE] with diagnoses including but not limited to: acute respiratory failure, chronic obstructive pulmonary disease, diabetes mellitus, major depressive disorder, and myocardial infarction. Review of R60's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/19/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R60 was cognitively intact. Review of R60's Care Plan with a start date of 11/05/2020 and target date 05/24/2024 documented, the problem: R60 .has potential for discomfort & adverse effects r/t [related to] use of antipsychotic & antidepressant medications. Documented goal: R60 .will be free of discomfort or adverse effects of antipsychotic & antidepressant use through next review. Documented approach revealed, Observe for muscle rigidity, increased temp, hypotension, dry mouth, sedation, tremors, tardive dyskinesia, increased confusion, change in LOC, sudden change in mood/behavior status. Additionally, the care plan documented, the problem: R60 .has potential for side effects r/t use of multiple rx [prescription]. Documented goal: R60 .will experience no drug related side effects. Documented approach revealed, Observe for inc confusions, insomnia, nervousness, tremors, changes in loc, dec appetite, wt loss. Additionally, the care plan documented, the problem: R60 .has hx [history] of verbally abusive behavioral symptoms. Documented goal: R60 .will have a decreased number of verbally abusive episodes through next review. Documented approach revealed, Assess whether the behavior endangers the resident and/or others. Intervene if necessary. The care plan had a start date of 03/15/21 and target date 05/24/24, documented the problem: R60 .has potential for difficulty falling asleep & [and] remaining asleep r/t [related to] dx [diagnosis] of Insomnia. Documented goal: R60 .will be comfortable as evidenced by verbalization of getting enough sleep most of the night through next review. Documented approach revealed, Meds as ordered per MD. Review of R60's Medication Administration Record (MAR) for 04/01/24 - 04/22/24 revealed an order for Behavior Monitoring twice daily: ANTIDEPRESSANT Drug ** DULOXETINE. CRYING/SADNESS. Special Instructions: INTERVENTIONS: A: Physical Needs Met B: Distraction C: Redirection D: Validation E: Activity Program F: Quiet Time/Rest G: Increased Observation H: Other I: No interventions needed OUTCOMES: 1. Improved, 2. Unchanged, W. Worsened Twice A Day 07:00 - 19:00, 19:00 - 07:00. The MAR also revealed an order for, Behavior Monitoring twice daily: ANTIPSYCHOTIC Drug Use **CRYING/SADNESS Special Instructions: INTERVENTIONS: A: Physical Needs Met B: Distraction C: Redirection D: Validation E: Activity Program F: Quiet Time/Rest G: Increased Observation H: Removal of Stressors J: Other K: No interventions needed OUTCOMES: 1. Improved, 2. Unchanged, Twice A Day 07:00 - 19:00, 19:00 - 07:00. The MAR also revealed an order for, Behavior Monitoring twice daily: HYPNOTIC Drug Use **MELATONIN. CHANGES IN SLEEP PATTERN. Special Instructions: INTERVENTIONS: A: Physical Needs Met B: Distraction C: Redirection D: Validation E: Activity Program F: Quiet Time/Rest G: Increased Observation H: Removal of Stressors J: Other K: No interventions needed OUTCOMES: 1. Improved, 2. Unchanged, Twice A Day 07:00 - 19:00, 19:00 - 07:00. The MAR also revealed an order for, Monitor for side effects twice daily: ANTIDEPRESSANTS Special Instructions: SIDE EFFECTS: 0. NONE 1. Dry Mouth 2. Blurred Vision 3. Constipation 4. Urinary Retention 5. Hypotension 6. Appetite Changes 7. Headache 8. Insomnia 9. Dyspepsia 10. Weight Changes 11. Suicidal ideations; Wishes of death; Attempts to harm self Twice A Day 07:00 - 19:00, 19:00 - 07:00. The MAR also revealed an order for, Monitor for side effects twice daily: ANTIPSYCHOTIC DRUG USE Special Instructions: SIDE EFFECT CODES: 0. NONE 1. Neck Stiffness 2. Confusion 3. Muscle Rigidity 4. Involuntary Movements 5. Drooling 6. Tremors 7. Restlessness 8. Sleep Disturbances 9. Dry Mouth 10. Blurred Vision 11. Constipation 12. Sedation Twice A Day 07:00 - 19:00, 19:00 - 07:00. The MAR also revealed an order for, Monitor for side effects twice daily: HYPNOTICS Special Instructions: SIDE EFFECT CODES: 0. NONE 1. Sedation 2. Dizziness 3. Confusion 4. Nightmares 5. Daytime Anxiety 6. Hallucinations 7. Fatigue 8. Headache 9. Sedation Twice A Day 07:00 - 19:00, 19:00 - 07:00. Review of R60's Physician Order with a start date of 02/13/24 documented, Behavior Monitoring twice daily: ANTIDEPRESSANT Drug ** DULOXETINE. CRYING/SADNESS. Special Instructions: INTERVENTIONS: A: Physical Needs Met B: Distraction C: Redirection D: Validation E: Activity Program F: Quiet Time/Rest G: Increased Observation H: Other I: No interventions needed OUTCOMES: 1. Improved, 2. Unchanged, W. Worsened Twice A Day 07:00 - 19:00, 19:00 - 07:00. The MAR also revealed an order for, Behavior Monitoring twice daily: ANTIPSYCHOTIC Drug Use **CRYING/SADNESS Special Instructions: INTERVENTIONS: A: Physical Needs Met B: Distraction C: Redirection D: Validation E: Activity Program F: Quiet Time/Rest G: Increased Observation H: Removal of Stressors J: Other K: No interventions needed OUTCOMES: 1. Improved, 2. Unchanged, Twice A Day 07:00 - 19:00, 19:00 - 07:00. The MAR also revealed an order for, Behavior Monitoring twice daily: HYPNOTIC Drug Use **MELATONIN. CHANGES IN SLEEP PATTERN. Special Instructions: INTERVENTIONS: A: Physical Needs Met B: Distraction C: Redirection D: Validation E: Activity Program F: Quiet Time/Rest G: Increased Observation H: Removal of Stressors J: Other K: No interventions needed OUTCOMES: 1. Improved, 2. Unchanged, Twice A Day 07:00 - 19:00, 19:00 - 07:00. The MAR also revealed an order for, Monitor for side effects twice daily: ANTIDEPRESSANTS Special Instructions: SIDE EFFECTS: 0. NONE 1. Dry Mouth 2. Blurred Vision 3. Constipation 4. Urinary Retention 5. Hypotension 6. Appetite Changes 7. Headache 8. Insomnia 9. Dyspepsia 10. Weight Changes 11. Suicidal ideations; Wishes of death; Attempts to harm self Twice A Day 07:00 - 19:00, 19:00 - 07:00. The MAR also revealed an order for, Monitor for side effects twice daily: ANTIPSYCHOTIC DRUG USE Special Instructions: SIDE EFFECT CODES: 0. NONE 1. Neck Stiffness 2. Confusion 3. Muscle Rigidity 4. Involuntary Movements 5. Drooling 6. Tremors 7. Restlessness 8. Sleep Disturbances 9. Dry Mouth 10. Blurred Vision 11. Constipation 12. Sedation Twice A Day 07:00 - 19:00, 19:00 - 07:00. The MAR also revealed an order for, Monitor for side effects twice daily: HYPNOTICS Special Instructions: SIDE EFFECT CODES: 0. NONE 1. Sedation 2. Dizziness 3. Confusion 4. Nightmares 5. Daytime Anxiety 6. Hallucinations 7. Fatigue 8. Headache 9. Sedation Twice A Day 07:00 - 19:00, 19:00 - 07:00. During an interview on 04/23/24 at 11:42 AM, the Director of Nursing (DON) stated that her expectations are that physician orders are followed for medication administration. She reported that the facility ensures accuracy of documentation on the MAR by pulling a compliance report daily and either the DON or Assistant Director of Nursing (ADON) addresses identified issues. Education is provided to staff. She stated that unfortunately they use a lot of agency nurses, which makes it challenging. During an interview on 04/23/24 at 4:34 PM, Licensed Practical Nurse (LPN)1 verified that there was no documentation for behavior monitoring related to antidepressant use on 04/19/24 at the 7A-7P timeframe on the MAR, no documentation for side effect monitoring related to antipsychotic use on 04/19/24 at the 7A-7P and 7P-7A timeframes on the MAR, and no documentation for side effect monitoring related to hypnotic use on 04/19/24 at the 7A-7P timeframe on the MAR. LPN1 stated that the expectation is to have this documentation completed by the end of the shift. 48834 A review of the facility policy titled, Pharmacy Services Policies and Procedures- Medication Management, revised 04/01/2022, indicated the facility will ensure that each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial wellbeing. R20 was admitted to the facility with diagnoses including but not limited to, schizoaffective disorder, generalized anxiety disorder, urinary tract infection, bipolar disorder, depressive episodes, and dementia. A review of R20's annual MDS with an ARD of 04/10/24, indicated R20 is ordered to take, but is not limited to, antipsychotic and antidepressant medications. A review of R20's care plan indicated a potential for discomfort & adverse effects related to the use of antipsychotic and antidepressant medications. A review of R20's care plan and progress notes did not reveal that R20 refused medications on 04/15/24 or 04/16/24. A review of R20's physician orders indicate Monitor for side effects every shift: Antipsychotic Drug Use with a start date of 07/13/2023, Monitor for side effects twice daily: Anticonvulsant with a start date of 07/26/2023, Monitor for side effects twice daily: Antidepressant with a start date of 07/13/2023. A review of R20's Behavior Monitoring Administration History, from 04/01/2024 until 04/23/2024, indicated that R20 did not receive Behavior Monitoring Every Shift: Antipsychotic Drug Use- Olanzapine, Behavior Monitoring twice daily: Anticonvulsant Drug- Depakote, Behavior Monitoring twice daily: Antidepressant- Trazadone/Paxil, Monitor for side effects every shift: Antipsychotic Drug Use, Monitor for side effects twice daily: Anticonvulsant, and Monitor for side effects twice daily: Antidepressants on 04/15/2024 during the day shift. During an interview on 04/23/24 at 03:00 PM, the DON expressed they expect nurses to document the MAR and TAR once completing a task ordered by the physician. The DON confirmed that there were several blanks on R20's TAR and MAR for April 2024, but was unsure why there were several blanks.

Based on review of the facility policy titled,Weighing the Resident, records reviews and interviews, the facility failed to ensure Resident (R)24 and R91 received care and services to prevent significant weight loss or to decrease the likelihood of further weight loss for 2 of 2 residents reviewed with significant weight loss. Findings include: Review of the facility policy titled, Weighing the Resident, states as the policy statement, Patient/Resident weights will be recorded and monitored at least monthly. Under the section on titled, Procedures states, 2. If the month-to-month weight shows more than a five-percent gain or loss, the patient/resident is reweighed in the presence of licensed personnel. 3. Record all weights per facility protocol. 4. If there is an actual 5% or more gain or loss in one month, notify the patient/resident/family, physician, and the Registered Dietician. Document this notification per facility protocol. 5. The facility Dietitian reviews the patient's/resident's nutritional status and makes recommendations for intervention if significant weight change is noted. 7. Update the plan of care with goals and approaches/interventions listed. 9. Unplanned and undesired weight variance will be evaluated for significance utilizing the following guidelines: 3% in one week; 5% in 30 days; 7.5% in 90 days; 10% in 180 days. The facility admitted R24 with diagnoses including, but not limited to, depression, anxiety, bipolar disorder and schizophrenia. Review on 04/22/24 at 01:55 PM of the admission minimum data set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated severe cognitive impairment. Review on 04/22/24 at 01:55 PM of the medical record for R24 revealed the following weights: On 02/01/24, R24 weighed 243.8 pounds. This was the weight on admission. On 02/05/24,R24 weighed 239.0 pounds. On 02/06/24, R24 weighed 237.6 pounds. On 02/13/24, R24 weighed 224.6 pounds. On 03/09/24, R24 weighed 215.8 pounds. On 03/11/24, R24 weighed 218.6 pounds. On 03/12/24, R24 weighed 215.6 pounds. On 03/19/24, R24 weighed 213.8 pounds. On 03/26/24, R24 weighed 213.8 pounds. On 04/02/24, R24 weighed 211.2 pounds. On 04/09/24, R25 weighed 215.0 pounds. Total weight loss from 01/31/24 until 04/09/24 is 28.8 pounds. During an interview on 04/23/24 at 10:00 AM with the Registered Dietician (RD), he stated that he put in an order for a dietary supplement today. He went on to say that the resident had been in the hospital. He stated R24 was obese and sometimes weight loss is a good thing. I informed him that unless the physician orders a weight loss program then interventions should be put into place to ensure the residents do not have significant weight loss. I asked how he found out about weight loss and he stated that he looks at the weights in the computer by just looking them up. No one notifies him of weight loss. I also stated that a dietitian note had recommended a supplement but was not ordered. During an interview on 04/23/24 at 12:05 PM with the Director of Nursing (DON) concerning the weight loss, she stated that her expectations were that staff would notify the physician and the RD. She stated that she will look at weights from time to time. She stated that staff do offer the resident snacks, eventhough there is no documentation to ensure the snacks are offered or consumed. 46991 Review of R91's Face Sheet revealed R91 was admitted to the facility on [DATE] with diagnoses including but not limited to; sepsis, mycosis, pain, dysphagia, muscle weakness, long term use of opiate analgesic, nausea, constipation, major depressive disorder, urinary tract infection, diabetes, anxiety disorder, unsteadiness, lack of coordination, and cognitive communication deficit. Review of R91's Quarterly MDS with an Assessment Reference Date (ARD ) of 03/18/24 revealed a BIMS score of 05 out of 15, indicating R91 has severe cognitive deficits. Review of R91's Nutrition note dated 04/09/24, revealed the Reason for Referral: Weight Review. Diet Order: Pureed with thin liquids. Supplements: Glucerna and Sugar free ice cream with lunch/dinner. Documented intake: Poor. Snacks provided appropriately, HS. Weight: 121.6 pounds (lbs)(4/7/24); 125 pounds (3/13/24); 142 pounds (1/23/24); 166 pounds (10/10/23). BMI: 19.04. Medications reviewed. Skin Integrity intact. Blood glucose values within target goal range X ~ 30 days. Nutrition Diagnosis: 1) Unintended weight loss related to intake as evidenced by significant decrease-CONTINUE. 2) Diet consistency difficulty related to chronic condition as evidenced by mechanically altered diet-CONTINUE. Summary: Poor intake continues, family providing Ensure - resident accepts well. Note GI referral due to persistent vomiting. Undesired weight loss continues. Recommendations/Plan: 1) Discontinue Glucerna 2) Add Ensure Plus or equivalent TID 3) RDN available PRN or when nutrition status changes; will follow as needed. 4) Weights as ordered. Goals: 1) Maintain a healthy weight status without further significant/severe change. 2) Maintain skin integrity. 3) Tolerate PO. Review R91's of Progress Note dated 03/19/24 documented, Nutrition Note. Reason for Referral: Quarterly Review and Weight Review. Diet Order: Pureed with thin liquids. Supplements: Glucerna with lunch/dinner. Documented intake: Poor. Snacks provided appropriately, HS. Weight: 125 pounds (3/13/24); 132 pounds (2/6/24); 150 pounds (12/5/23); 181.6 pounds (9/15/23). BMI: 19.58. Medications include Cyproheptadine, Omeprazole, Mirtazapine and Vitamin D. Skin Integrity intact. Blood glucose values within target goal range X ~ 30 days. Nutrition Diagnosis: 1) Unintended weight loss related to intake as evidenced by significant decrease-CONTINUE. 2) Diet consistency difficulty related to chronic condition as evidenced by mechanically altered diet. Summary: Diet downgraded 3/15/24, which may be contributing to continued poor intake-receiving 2 appetite stimulants (second added recently and to increase mg) and supplements to encourage intake. Undesired weight loss continues, although it has slowed recently. Skin intact. Blood glucose values within target goal range. Recommendations/Plan: 1) Continue plan of care. 2) RDN available PRN or when nutrition status changes; will follow as needed. 3) Weights as ordered. Goals: 1) Maintain a healthy weight status without further significant/severe decrease. 2) Maintain skin integrity. 3) Tolerate. No changes were made even after a steady weight loss and a noted -7.04 weight loss in March. Review of R91's weights on Electronic Medical System revealed for the past six months from November 2023 to April 24, he lost -23.62 lbs. R91's weights were recorded as follows: 04/07/24 - 121.6 lbs 03/13/24 -125 lbs. 02/06/24-132 lbs. 01/23/24-142 lbs. 12/05/23-150.0 lbs. 11/04/23-159.2 lbs. Review of R91's Intake report from 11/01/2023 to 04/23/24 documented minimum intake of meals and fluids. During an interview on 04/23/24 at 9:59 AM, the RD acknowledged R91's weight loss. He stated they added ensure and sugar free ice cream, but in March '24, the RD noted weight loss, but they did not make any additional revisions to address weight loss. During an interview on 04/23/24 at 12:11 PM, the DON stated, she expects staff to notify the Doctor and RD if there is a weight loss. She stated if she is aware of a noted weight loss, she will intervene. She stated she would let the doctor know and notify the RD. She stated she pulls weights often. She stated R91 has an upcoming appointment for digestive problems.

Based on review of the facility policy, staffing documentation and interview, the facility failed to ensure that each Certified Nursing Assistant (CNA) employed by the facility received the required no less than 12 hours of in-service education based on their individual performance reviews and is calculated by their employment date with the facility during review of Sufficient and Competent Nurse Staffing. Findings include: Review of the facility policy titled Staff Education/Orientation Policies and Procedures, without a date or revision date listed. The policy states, The facility will provide orientation and training to fulfilling the organization's mission thus creating a culture that foster staff self development and continued learning. (1). Day 1: All new employees receive the general facility orientation program on day one of employment and it is completed with the designated member of the facility staff. (2). Day 2: Each new employee will receive their specific department orientation starting on day 2 and continue through to completion of the department specific orientation. Role and department specific orientation includes any state or local level requirements that are in addition to or more inclusive than federal requirements. (3). Individualized: The facility leadership has the discretion to increase the new employee's orientation if deemed necessary. (4). Annually: The employee completes the competency/performance evaluation(s) and educational requirements according to state specific regulation. Review on 04/23/24 at approximately 11:45 AM of the facility's CNA annual 12-hour in-service training based on performance reviews revealed less than the required 12 hours of training from the date of hire for CNAs. There was no documentation in the CNA's personnel files that verified the required training. There were 3 out of 5 CNAs who did not receive training in resident's rights, abuse, neglect, exploitation, and dementia training; CNA2 hire date 05/23/19, CNA3 hire date 02/01/23, and CNA5 hire date 03/10/23 revealed no training of the required areas. During an interview on 04/23/24 at approximately at 3:42 PM with the Director of Nursing (DON) revealed, to ensure the staff are competent and have the knowledge and skills to care for the residents, they attend an annual training and a skills check. If there are any concerns, we will provide additional training. DON stated staff are evaluated by the staff development coordinator to ensure competency levels. The DON confirmed the staff had not met their required hours.

Based on review of facility policy, record reviews and interviews, the facility failed to properly supervise 1 of 1 resident to prevent an elopement. Specifically, Resident (R)1 had a successful elopement from the facility on 09/22/23. On 10/03/23 at 4:55 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 10/03/23 at 4:59 PM, the Administrator was notified that the failure to properly supervise a resident, resulting in the resident successfully eloping from the facility constituted Immediate Jeopardy (IJ) at F689. On 10/03/23 at 4:59 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 09/22/23. The IJ was related to 42 CFR 483.25 - Quality of Care. On 10/04/23 at 11:59 AM, the facility provided an acceptable IJ Removal Plan. On 10/04/23, the survey team validated the facility's corrective actions and removed the IJ as of 10/04/23. The facility remained out of compliance at F689 at a lower scope and severity of D. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care. Findings include: Review of the facility policy titled, Elopement, with a revision date of 11/01/17 states, To safely and timely redirect patients/residents to a safe environment. A prompt investigation and search will be conducted if a patient/resident is considered missing. Document Requirements: Incident Report, Investigative Report, Nursing Notes should reflect an accurate and detailed account of situation and outcome. Social Services notes need to address emotional assessment and interventions. Missing Patient/Resident Profile and Notification Record. Review of R1's Electronic Medical Record (EMR) revealed, R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to: vascular dementia, history of hallucinations, pain, mild anxiety and history of falling. Review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/15/23 revealed a Brief Interview of Mental Status (BIMS) score of 10 out of 15, indicating R1 was moderately cognitively impaired. Review of R1's Elopement assessment dated [DATE], indicated R1 was low risk for elopement. Review of R1's progress note dated 09/22/23 at 6:00 PM, states, Visitor noted resident exiting the front door. Resident assisted per staff back into the building without difficulty. Resident previously noted up in a wheel chair in the day room talking with other residents. Body audit completed, 15 minute checks in place. Resident redirected without difficulty, MD, RP and DON made aware. Review of the facility investigation (reportable) revealed , Resident noted exiting the front door and staff notified immediately. Two nurses and a Certified Nursing Assistant (CNA) went to assist resident back into the building. Resident noted to be walking towards parking area when staff arrived to him. Resident assisted into wheelchair and back into building without difficulty. Body audit completed with no skin deficits noted. Resident is alert and oriented as per usual. Fifteen minute checks initiated. Wanderguard ordered and to be placed on ankle to alert staff of any other attempts to exit the building. The resident's personal representative and the physician are made aware. During an interview on 10/03/23 at 1:05 PM, the Director of Nursing (DON) stated, The nurse called and reported that a family member was leaving the facility and reported the resident in the parking lot just outside the front door. I think he walked out behind a visitor because you cannot open the front door without a code or you have to hold your hand on door and try to push it open for 30 seconds and then it will open. The DON stated that R1 did not have a wanderguard prior to his elopement due to the fact that an elopement assessment was completed prior to the elopement and he was found to be low risk for elopement. The DON was not present at the time of the elopement but stated that the alarm did not sound. The DON further stated that a family member that visits her family frequently saw him in the parking lot and notified us. A request was made to see the video surveillance of the parking lot for 09/22/23, but it was not provided. During an interview on 10/03/23 at 1:30 PM, the Administrator stated that she found out today that there was additional information that she was not aware of. During an interview on 10/03/23 at 2:50 PM, R8 stated that she was sitting in her room and happened to look out the window and saw a resident in the road. I thought to myself, he is going to get run over by a car. So I went up to a nurse that was talking to a family member and told them of a the resident in the road. During an interview on 10/03/23 at 3:02 PM, with the family member (FM) that found the resident in the street. The FM stated she was talking to the hospice nurse about her family members. And R8 came up to her and stated there was a resident outside in the road. The FM looked out the window and saw the resident across the street near the house at the end of the road. The FM stated she ran out there and the resident was unstable and she rested him against her knee to prevent him from falling, then a staff member yelled out to her to bring the resident back. The FM stated she yelled, No, someone bring a wheel chair. The FM further stated, there were several cars stopping to ask if assistance was needed and law enforcement came up. The FM did not know if there was a police report or not. The FM concluded that she pushed the resident back into the facility after he was in the wheel chair. During an interview on 10/03/23 at 3:58 PM, the Activity Director (AD), that is also a CNA, revealed on the day of the alleged incident she was notified by a resident that another resident was outside across the street. The AD went to the front and saw the resident, she then went and got a wheel chair and the AD along with the hospice nurse, went and got the resident and brought him back into the building. Another nurse was also at the scene. The AD stated once back in the building the resident stated that his chest hurt. The AD made sure the resident was put to bed and reported the incident to the nurses on duty. The AD further stated, that no one has spoken to her about the incident until today and no one has asked for a witness statement from her. On 10/03/23 and 10/04/23 multiple attempts were made to contact the nurses on duty and were unsuccessful. On 10/04/23 at 11:59 AM, the facility presented a Removal Plan which included the following: Resident #1 without injury and elopement risk evaluation repeated on 10/03/2023 with interventions in place per care plan. Residents in the facility had Elopement Risk Assessments repeated on 10/03/2023 with no concerns identified. Maintenance Director performed an audit on 10/03/2023 to validate facility exit alarms are functioning. No concerns identified at this time. The codes to the front entrance were changed on 10/04/2023. The double doors prior to entering the unit will be closed after 5:00 PM daily. Residents at risk of elopement have the potential to be affected. Elopement risk evaluations done in the past 90 days on current residents in the facility reviewed by nursing managers for accuracy on 10/04/2023. Residents identified a risk to be reviewed for appropriate interventions by 10/04/2023. Educate all facility staff on the expectation that if a door is noticed to be non-functioning to report to management immediately and post an employee at the door until otherwise indicated and redirected by a member of management and ensuring double doors entering the unit are to remain closed after PM. All facility staff will be reeducated on the Elopement process by 10/04/2023. All Licensed nurses will be re-educated on the elopement risk assessment process/accuracy and putting interventions in place based on the risks identified by the Director of Nursing by 10/04/2023. Any member of target audience not receiving this education by 10/4/2023 will receive prior to next scheduled shift. Facility Activity Report and 24 hour report will be reviewed Monday - Friday in clinical morning meeting to validate elopement assessments completed are accurate and interventions have been implemented accordingly. The Director of Nursing will randomly audit a minimum of 3 elopement assessments weekly for 4 weeks then monthly for 2 additional months to validate accuracy. The Maintenance Director will inspect facility doors 3 times weekly for 4 weeks then weekly for 2 additional months. The Facility Administrator will make rounds weekly for 4 weeks then monthly for 2 additional months with maintenance director to validate that doors are functioning properly. Ad hoc QAPI held on 10/03/2023. Medical Director was notified of the incident and plan for improvement on 10/03/2023. This process will be reviewed in QAPI for a minimum of 3 months. Allegation of Compliance date 10/04/2023.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident was assessed and monitored after an unwitnessed fall for one (Resident (R) 71) of four residents reviewed for accidents out of a total sample of 34 residents. Findings include: Review of the facility's policy titled, Fall Management, revised 05/05/23, indicated, Qualified staff evaluates patient/resident for injury from a fall, identify and treat for pain related to fall, and determine contributing causes, including ascertaining what the resident was trying to do before he or she fell , addresses the risk factors for the fall such as the resident's medical conditions(s), facility environment issues, or staffing issue; and determines interventions to prevent future falls and completes a Fall lnvestigation Worksheet. The facility's policy further indicated, Neurological evaluations will be performed for a resident who sustains an unwitnessed fall, regardless of the resident's cognitive status at the time of the incident. The policy further indicated, The physician and family are promptly notified, and an incident report is completed. Review of R71's Resident Face Sheet, located under the Resident tab of the electronic medical record (EMR), revealed R71 was admitted on [DATE] with diagnoses of dementia, unsteadiness on feet, and other abnormalities of gait and mobility. Review of R71's quarterly Minimum Data Set (MDS), located in the EMR under the RAI [Resident Assessment Instrument] tab with an Assessment Reference Date (ARD) of 08/14/23, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating R71 was moderately cognitively impaired. During an observation on 08/30/23 at 7:40 AM, during initial screen, R71 was observed on the floor of his bedroom. R71 was observed to be completely unclothed, lying in a supine position, with his head on the floor at the foot of the bed. R71 was observed to be gripping his bed linen and has covered his genitals with the bed linen. R71 heard stating, Help and his bedroom smelled of urine at the time of observation. During this time of observation, the survey team immediately alerted the Director of Nursing (DON), who was coming to introduce herself to the survey team. The DON immediately alerted two Certified Nursing Assistants (CNA) and Registered Nurse (RN) 1 to assist R71. During an observation on 08/30/23 at 9:14 AM, R71's bedroom door was closed. R71 stated, My legs are hurting. R71 was unable to state if staff had checked on him after his fall. During continuous observation of R71's bedroom from 08/30/23 at 9:14 AM until 08/30/23 at 11:30 AM, no staff entered R71's bedroom and his bedroom door remained closed. Review of R71's Morse Fall Scale, dated 08/16/23, located in the EMR under the Resident tab revealed a fall score of 35, indicating a low fall risk. Review of R71's Care Plan, dated 08/08/23, located in the EMR under the RAI tab revealed the following fall care plan with focus and interventions: has potential for falls/injuries r/t [related to] limited mobility, dx [diagnosis] of Anxiety, hx [history] of falls, adequate vision, dry eyes @ [at] times-res [resident] likes to sit on side of bed; Investigate all falls/ injuries/ circumstances; Follow facility fall/head injury protocol if actual fall/head injury occurs. The facility did not provide the fall/head injury protocol to the survey team at time of survey. During an interview on 08/31/23 at 11:21 AM Unit Manger (UM) 2 stated, When a resident has an unwitnessed fall, the facility should notify the physician, the resident's responsible, document a progress note, get vitals, complete an incident report form which goes to DON. UM2 further stated, If a resident is found on the floor - assess for injuries, implement neurochecks and still do all of the above. During this time of interview, UM2 reviewed R71's medical record and confirmed there was no documentation of R71's fall that occurred on 08/31/23. During an interview 08/31/23 at 11:38 AM, RN1 stated, A progress note should have been done after the fall. I did a note this morning. I should have done it yesterday. He belongs to the other side. When asked if she was the first nurse on the scene, RN1 stated, Yes. When asked if she assessed R71 for injuries and vitals, RN1 stated, Of course, I did. When asked about the completion of an incident report for R71's fall, RN1 stated, A incident report wasn't written to my knowledge. When asked about neurological checks for R71's fall, RN1 stated, I don't know if neurochecks were started because he belongs to the other side. When asked if the incident was reported to the nurse on the other unit and who should have reported the incident, RN1 stated, I don't know. Review of R71's complete medical record on 08/31/23 revealed no documented evidence of R71's unwitnessed fall, assessment of R71, neurological checks, or incident report. During an interview on 08/31/23 at 11:44 AM, the DON stated that after an unwitnessed fall, the nurse should assess the resident, if no injuries and able to move, assist back to safe position whether that is bed or wheelchair, responsible party and doctor aware, follow up with acute charting where each shift is monitoring and documenting in the progress notes. Neurochecks because it was an unwitnessed fall. The DON further stated, When we found him, I called those two CNAs and [RN1]. Since [RN1] was the first nurse, [RN1]was responsible for documenting a progress note, starting neurochecks, and incident report. The DON confirmed these procedures had not been completed. During an interview on 08/31/23 at 5:46 PM, UM1 stated, I assessed the resident [R71] when he came back from dialysis today about 1:30 PM. I started neurochecks. UM1 stated he did not see any evidence in the medical record of the resident being assessed. During an interview on 09/01/23 at 12:13 PM, the Clinical Services Director (CSD) stated, At minimum, if it is an unwitnessed fall, I would expect an incident report, vitals, assessment, family and doctor notified and neurochecks.

Based on interview, record review, and facility policy review, the facility failed to identify potential neglect and/or abuse for two (Resident (R) 203 and R75) of two sampled residents reviewed for abuse and neglect. This failure placed all residents at increased risk for mistreatment or neglect. The facility failed to recognize the neglect/abuse and continued to operate without corrective action or additional training. On 08/31/23 at 7:22 PM, the Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) at F-600 Freedom from Abuse, Neglect, and Exploitation. The Immediate Jeopardy began on 08/31/23 when the survey team identified that R203 was in the hallway with no clothing nor brief soiled with urine and feces and a certified nursing aide (CNA 1) refused to assist the resident. CNA1 also left R75 in urine and feces which had dried upon her skin. The facility provided an acceptable removal plan on 09/01/23 at 3:09 PM. The removal plan included education to staff on the abuse policy and procedure, review of grievances, 24-hour report and the facility activity report to identify possible allegations of neglect/abuse, and terminations of the identified CNA, pending completion of investigation. On 09/01/23 at 5:40 PM the plan of removal was validated. Findings Include: Review of the facility's policy titled, Abuse, Neglect, Exploitation or Mistreatment, revised 10/11/22 (date handwritten on the policy) revealed, The facility's Leadership prohibits neglect, mental, physical and/or verbal abuse, use of a physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment, and misappropriation of a patient's/resident's property and/or funds and ensures that alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately. 1. Review of R203's Face Sheet, located under the Profile tab of the electronic medical record (EMR) revealed R203 was admitted to the facility on [DATE] with diagnoses that included cellulitis of the right lower limb, cellulitis of the left lower limb, and muscle wasting and atrophy. Review of R203's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/24/23 and located in the EMR under the MDS tab, revealed R203 scored a 12 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated R203 was moderately cognitively impaired. The MDS recorded R203 required limited assistance with bed mobility and transfers. Review of R203's Progress Notes, located in the EMR under the Progress Notes tab, dated 08/28/23, and written by Licensed Practical Nurse (LPN) 2, revealed, On 08/28/2023 at approx. [approximately] 1:00am, CNA yelled that resident was standing in the hallway undressed. Resident noted to be in hallway outside of room door holding onto the rail without clothing or brief. I attempted to redirect resident into room with no success. Resident was unable to bear weight any longer & began lowering himself down, I safely assisted resident to the floor. Resident did not sustain any injury during this time. Resident was noted to be heavily soiled with urine and feces. Resident bedding noted to be heavily soiled with urine & feces. Resident was unable to assist staff in helping himself from the floor. Resident was very upset and distraught from situation, attempted to console resident but he was at that time inconsolable. Took several attempts and several staff members to assist resident back to bed . During an interview on 08/31/23 at 10:11 AM, R203 revealed that on 08/28/23, he had a bowel movement and an urinary incontinent episode and had been waiting for two hours for someone to come and help him. R203 stated, I decided to get up and get someone to come and help me. I was able to get to the door and into the hallway. I was so weak, I had to hold onto the rail. Then I was punched and kicked by a staff member and went to the floor. R203 indicated he was then dragged and thrown into his bed. During an interview with Unit Manager (UM2) on 08/31/23 at 10:51 AM, UM2 was asked about the incident with R203. UM2 stated, I have heard some bits and pieces about something happening over the weekend and know that it was reported to the Director of Nursing [DON] and Administrator. During an interview on 08/31/23 at 11:03 AM, the DON, Administrator, and Clinical Service Director (CSD) were asked about the incident with R203 on 08/28/23. The DON stated she had received a call from the night unit nurse that R203 had gotten in the hallway, and the staff member had to lower him to the ground until she could get assistance to put him back in bed. The DON reported that CNA1 was the aide assigned to R203 on that night. The DON reported that CNA1 was currently suspended due to concerns related to resident care. The DON reported that R203 had stated he had walked into the hallway because he had used the bathroom on himself and had reported that staff was rough and had slung him into the bed. The DON reported a complete body audit was performed, and no injuries had been noted. The DON stated she did not see the incident as abuse or neglect. The DON stated, If I had known this earlier (before the CNA's shift was over), I would have sent her out of the building. The DON reported CNA1 was a part of the CNA program the facility provided and had been at the facility only a few months. The DON stated CNA1 first worked on the day shift and then was switched to the third shift. The DON was asked to provide the facility's investigation of the incident. Continuing with the interview, the DON provided a document titled, 'Patient/Resident Incident/Accident Investigation Worksheet, written by LPN2 and dated 08/28/23. Review of the document revealed, At approximately 1:00 AM [CNA1] yelled down the hall that R203 was standing in the hallway undressed because he was heavily soiled in urine and feces. [CNA1] did not stop to help resident, instead continued to yell, your man is in the hallway. I proceeded to the resident room and noted the resident in hallway outside of room holding onto the railing. Resident noted to be undressed and without brief. [CNA1] refused to help residents to room and to clean properly. The resident was unable to bear weight any longer and began lowering himself to the floor. I safely assisted the resident to the floor. No injury noted, resident bedding noted to be heavily soiled which contributed to incident. Resident unable to assist staff in helping himself from floor. The unit manager and a CNA from another hall had to come and assist in getting the resident off the floor and back into the bed. After several attempts and staff X3 resident was put back in bed. During an interview on 08/31/23 at 6:14 PM, LPN2 stated, I was standing at my cart and [CNA1] yelled to me that R203 was in the hallway. He was undressed and did not have a brief on. He was soiled and tried to clean himself up, that's how he ended up in the hallway. [R203] had a bowel movement it was everywhere and on his sheets. I went and lowered him to the floor and then his CNA that was assigned to him refused to assist and had to get the other unit manager and CNA to help with him. His CNA cleaned him up and put a brief on him while he was on the floor and changed his sheets. [CNA1] said she could not help getting [R203] off the floor. [CNA1] was making up the bed, I told [CNA1] we had to get him off the floor and [CNA 1] told me to call 911 to get him up. Before lowered to the ground, [CNA1] was leaving him standing up, and he could not keep standing up so lowered to the ground. LPN2 stated, As far as insubordinate yes, there was a problem. LPN2 reported that R203 was saying he rang his call light to be changed and CNA1 took too long. LPN2 stated R203 was saying he had been laying there, and CNA1 did not change him. LPN2 stated, I don't know if [R203] had been asking [CNA1] to change him. LPN2 stated the DON was contacted at 1:34 AM and called her back between 6:30 AM and 6:40 AM. During an interview on 08/31/23 at 9:37 PM, CNA1 stated, I was doing my rounds and the resident was in the hallway and I called [LPN2] and said [R203] had bowel movement on his backside. I was cleaning him up and he started to go to the ground and the nurse assisted him to the ground. I was not able to help get up because of my back and people falling all weekend. A CNA from another unit had to assist in getting the resident up off the floor. I stayed present the whole time and just was not able to help lift him off the floor. There was no hitting or kicking that happened that I am aware of. All his sheets and things were changed as well. [R203] had taken off his brief in the bed and that is why he had it all over his hand. Not sure what he was doing prior to that. [R203] had not pushed his call bell. I had been walking the hall all night and checking on the residents, especially him because he was new. [R203] just suddenly was out the room and hollered and told [LPN2] that he was walking and out in the hall. Seen [R203] bowel movement on his backside and grabbed the wipes and started trying to clean him up and get him together. The other unit nurse was there as well. There were two nurses, and a CNA was there as well. CNA1 stated there was nothing that captured her attention about the night as being wrong. CNA1 stated she had been suspended and was unsure of when she was supposed to return to work. CNA1 stated because of this incident and other stuff, the facility would be calling her and letting her know when she could return to work. CNA 1 did admit to not helping with R203 because her back was hurting. 2. Review of R75's Face Sheet, located in EMR under the Profile tab, revealed an admitted [DATE] with diagnoses including metabolic encephalopathy; altered mental status; unspecified and unspecified dementia, mild, without behavioral disturbance; psychotic disturbance; mood disturbance; and anxiety. Review of R75's quarterly MDS, located in the EMR under the MDS tab, with an ARD of 07/28/23, revealed R75 had a BIMS score of eight out of 15, which indicated R75 was moderately cognitively impaired. Review of CNA1's personnel files revealed a Performance Feedback, dated 8/26/27/23 (date recorded on the performance feedback form), which documented an opportunity for improvement. The performance feedback indicated, . [R75] was left wet and soiled with change of shift. Gown, bed and person smelled and visible urine partially dried on resident at 7:15 AM. Also, a sheet with stool on it left in the floor in R75's room. CNA1 continued to work with residents after this performance feedback was completed. CNA1's usual shift was 11PM to 7AM. During an interview on 08/31/23 at 5:18 PM, the DON revealed Registered Nurse (RN)1, who had worked the weekend day shift with CNA1, had written the performance feedback. The DON stated the performance review had been placed under her door over the weekend and on 08/28/23 when she returned to work, she found the document. The DON stated she called CNA1 at that time and suspended her due to allegations of performance deficiencies that jeopardized operations. During an interview on 08/31/23 at 5:25 PM, RN1 revealed when she started her shift on the morning of 08/27/23, the morning nurse technician took her in R75's room to show the sheet on R75's bed that was soaked with body fluids that had started drying and the clean sheet that was on top of the dirty one. RN1 stated there was also a dirty sheet soiled with feces on the floor. RN1 stated R75 had been assigned to CNA1 on the previous shift. RN1 stated, This resident belonged to [CNA1]. I did not get a chance to talk with her about it. I referred it to the DON to talk with her about. Usually if I do something like that, I write it up and give it to the DON. In response to the IJ survey citation for Tag F-600-J in which Rehab Center of Cheraw failed to ensure residents were free from abuse and neglect Rehab Center of Cheraw agrees to complete the following corrective actions to ensure compliance with this standard is met: Rehab Center of Cheraw will present education on the facility's abuse and neglect policy at new hires and agency staff orientation. This education will include: Identification of abuse or neglect, by observable and objective evidence, witness reports of unusual occurrence or patterns or trends of potential abuse or neglect. Abuse is the willful infliction of injury unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual of goods or services that are necessary to maintain physical, mental, and psychosocial wellbeing. lt includes verbal abuse, sexual abuse, physical abuse, and mental abuse. Neglect is the failure to provide goods and services or treatment and care necessary to avoid physical harm, mental anguish or mental illness. Immediate identification and removal of the alleged perpetrator. Identification and assessment of the alleged victim. Reporting immediately to Facility Abuse Coordinator, Director of Nursing, and Social Worker regardless of time of day. Administrator contacted Regional Ombudsman and scheduled additional abuse and neglect training with facility staff. This training will be completed on 09/08/23. Administrator will review incident reports and grievance reports daily for identification of possible allegations of abuse. Members of nursing Management will interview three random residents daily for one week, then weekly for three months validating residents feel safe and have no care concerns. The IJ removal was confirmed through staff interviews regarding identification of abuse and neglect, defining abuse and neglect, identification and removal of the alleged perpetrator, identification and assessment of the victim, and how to report abuse and neglect. Staff interviews confirmed requirements in the removal plan that the staff were reeducated by the facility prior to the start of their shifts and/or during their shift on 09/01/23 regarding how to identify abuse and neglect, protect residents from abuse and neglect and to immediately report abuse and neglect. The survey team validated the immediacy was removed on 09/01/23 at 5:40 PM. The noncompliance at F600 remained out of compliance at a lower scope and severity of D (Isolated of no actual harm with the potential for more than minimal harm that was not immediate jeopardy).

Based on interview, record review, and facility policy review, the facility failed to properly prevent and contain Coronavirus (COVID)-19 for three (3) of eight (8) sampled residents (Resident #6, #7, and #8). The facility failed to implement quarantine measures for 14 days for Resident #6 and Resident #7 who were admitted from the hospital which created an immediate jeopardy situation starting on [DATE]. Residents #6 and #7 did not remain in their rooms and socialized with resident #8 from another unit, which was around the corner. All three residents were diagnosed with [REDACTED]. The facility implemented corrective actions and removed the immediacy of non-compliance by [DATE]. Findings included: 1. Review of the facility's policy titled, Accepting and Transferring Patients/Residents, ([DATE]) was conducted. The policy noted: Patients/Residents with No Clinical Concerns for COVID-19 -All hospitalized patients/residents should be assessed for COVID-19 prior to transfer to a long-term care facility. If a test is not indicated per Centers for Disease Control and Prevention (CDC) testing criteria, and the patient/resident has no clinical concerns for COVID-19. The following must be implemented: 1. The patient/resident should be placed on a 14-day quarantine on admission from the hospital 2. Based on the facilities (sic) status (respiratory illness present) The resident screening tool should be completed daily for non-respiratory illness facilities, and twice a day for facilities with respiratory illness-on all patients/residents Things to Remember: 1. Patients/Residents on therapy must have therapy completed in their room if they are on isolation and/or quarantine. 2. All Patients/Residents must cover their nose and mouth with tissue, cloth, or mask when care is being provided in their rooms. All Patients/Residents must wear a mask when outside of their room. 3. Patients/Residents should not be in hallways, dining rooms, activity rooms etc. 4. ADL (Activities of Daily Living) care should be completed by as few staff members as possible. Coordinate care to provide multiple jobs during one room entry. The least number of interactions prevents spread of the disease. 2. Per the facility Infection Control Line Listing starting on [DATE] to present, the facility had no residents with COVID-19 on [DATE]. Then on [DATE] the facility had two (2) residents positive for COVID-19. On [DATE] the facility had four (4) residents positive with COVID-19. Upon entry into the facility on [DATE] for the COVID-19 Focused Survey, the facility had 26 residents positive for COVID-19 and seven (7) residents who had expired from COVID-19. 3. During the entrance conference on [DATE] starting around 10:45 AM with the Administrator and Director of Nurses (DON), the Administrator stated the facility's first diagnosed case of COVID-19 was on [DATE]. The Administrator and DON stated at the beginning of [DATE] the facility had three (3) residents (Residents #6, #7, and #8) that liked to socialize together, and staff had to redirect them to social isolate. Per the DON during the entrance conference, residents coming back from the hospital were put on the Observation Unit for 14 days of monitoring. The facility also moved recovered COVID-19 residents to the Observation Unit for 14 days of monitoring before going back to a long-term care room. During an interview on [DATE] at 9:15 AM, the Administrator stated the facility had investigated how the outbreak of COVID-19 began in the building and believed that Resident #6 was the resident who started the outbreak. The Administrator stated she/he and her/his staff found Resident #6, #7, and #8 talking together and they had to redirect them and remind the residents to social distance. During an interview with the Administrator and DON on [DATE] at 12:06 PM, when a resident was admitted from the hospital, they were put on the Observation Unit. The Observation Unit had private rooms so the residents could be separated. The residents received increased monitoring and assessment screening for 14 days following admission. During the timeframe from [DATE] through [DATE], a nurse covered the Observation Unit and part of the North long hall. That practice changed after [DATE]; the nurse and aides only worked on the Observation Unit. The Administrator stated that staff working with Resident #6 had come to her/his concerned about the resident not following the social distancing rules. The Administrator told the staff to redirect the resident and chart about the behavior. During an interview on [DATE] at 2:52 PM, the Administrator stated the facility had no policy defining quarantine. The Administrator stated quarantine meant no visitation from anyone including family or other residents. A resident on the observation unit would be on quarantine and should be in isolation from other residents. 4. Resident #6 was admitted to the facility on [DATE], then transferred back to the hospital on [DATE]. The resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the resident's Admission Minimum Data Set (MDS) assessment dated [DATE], Resident #6 was cognitively intact, having scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. The resident had no [MEDICAL CONDITION] or acute onset of mental changes noted. Resident #6 had verbal behavioral symptoms directed toward others and other behavioral symptoms not directed toward other one (1) to three (3) days during the assessment period. The resident rejected care and was noted to wander one (1) to three (3) days during the assessment period. The resident required extensive assistance from one (1) person with bed mobility, transferring, locomotion on and off the unit, dressing, toileting, and personal hygiene. According to Resident #6's Discharge Assessment-Return Anticipated MDS dated [DATE], Resident #6 was cognitively intact, having scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #6 rejected care and was noted to wander one (1) to three (3) days during the assessment period. The resident required extensive assistance with one (1) person assistance for bed mobility, transferring, locomotion on the unit, and personal hygiene. The resident required limited assistance with one (1) person for dressing. The resident was totally dependent on one (1) person for locomotion off the unit and toileting. The resident used a wheelchair for locomotion. Review of Resident #6's care plan contained the following problem, dated [DATE]: Resident #6 is a new admission to the facility following a hospital stay for [MEDICATION NAME] (type of bacteria). She/He was alert and oriented but had confusion and disorganized thinking. She/He understood/understands. She/He is having no moods at this time. She/He has hallucinations, delusions, wanders, rejects care, and has verbal behaviors. She/He is receiving skilled therapy services at this time and plans to return home. Family is supportive. Resident #6 likes to socialize with other residents. The facility documented the following approach on [DATE]: Encourage compliance with social distancing and use of mask as resident will allow. Per Psychoactive Medication Monthly Flow Record for [DATE], the staff was monitoring Resident #6 for paranoia behaviors from [DATE] through [DATE]. The resident had no paranoia behaviors noted during this time. On [DATE], the day shift Nurse's Note contained: Resident up in wheelchair at the desk. No respiratory distress oxygen at three (3) liters per minute via nasal canula. Oxygen saturation was 98%. Alert and oriented times one (1), verbally responsive. On [DATE] at 2:55 PM, the Unit Manager's Note contained: Resident noncompliant with staying in her room and wearing mask. Resident redirected several times to wear mask and stay in her room. On [DATE] at 9:00 PM, the Nurse's Note contained: At Nurses' Station in wheelchair. Alert and verbally responsive, refused all 9:00 PM medications. Keeps attempting to get out of wheelchair. No sign/symptoms of acute distress. On [DATE] at 6:00 AM, the Nurse's Note contained: Resident attempting to climb out of bed, alert, refused finger stick blood sugar check. The resident was combative. On [DATE] the day shift Nurse's Note contained: Resident up in wheelchair at desk. Alert and oriented times one (1), verbally responsive to staff. No respiratory distress. Oxygen as ordered via nasal cannula. Incontinent of bowel and bladder, bowel sounds times four (4) quadrants, abdomen soft and nondistended. Therapy as ordered. On [DATE] at 3:00 PM the Unit Manager's Note contained: Resident noncompliant with wearing mask and staying in her room. On [DATE] at 10:00 PM the Nurse's Note contained: Resident in bed, alert, skin warm/dry. No signs/symptoms of diabetic distress. Resident refuses finger stick blood sugar or 9:00 PM medications. On [DATE] at 9:00 PM the Nurse's Note contained: Refused evening medications and finger stick blood sugar checks. Combative when approached. Alert and verbally responsive. Skin warm/dry. No signs/symptoms of acute distress. Review of the SBAR (Situation-Background-Assessment-Recommendation) Communication Form dated [DATE] at 3:29 PM revealed the resident had an increased heart rate of 144 beats per minute and shortness of breath with respirations at 26 breaths per minute. The resident's temperature was 98.9 degrees Fahrenheit. The Physician ordered the resident to be sent to the emergency room to be evaluated. At this time, the nursing staff also filled out Suspected COVID-19 Infection SBAR form due to the resident having a change of condition, a respiratory rate greater than 25 breaths/minute, and an age of 65 or older. The resident was discharged to the hospital on [DATE] with increased and irregular heart rate of 144 beats a minute, shortness of breath and increased respirations 26 breaths a minute. The facility was notified on [DATE] of the resident's COVID-19 positive test. At the time of survey, the resident was still at the hospital. In an interview on [DATE] at 3:04 PM the North Unit Manager stated Resident #6 was on the Observation Unit after being admitted back to the facility on [DATE]. The resident was on 14 days of quarantine, meaning the resident was supposed to stay in the room and have no contact with other residents. Resident #6 was combative, refused medications, staying in her/his room, and wearing a mask if out of the room. The Unit Manager and the unit staff redirected Resident #6 back to the resident's room and tried to have the resident apply a mask. The Unit Manager stated she/he brought her/his concerns to her/his supervisor about Resident #6 not following social distancing and quarantine. The double doors to the Observation Unit were not closed when Resident #6 was residing on the unit, which allowed the resident to go to other units and residents from other non-restricted units to come onto the Observation Unit. In an interview on [DATE] at 3:04 PM, CNA #1 stated Resident #6 was very combative, anything he/she tried to do with the resident, the resident refused. CNA #1 stated he/she had to get the nurse to help intervene with the resident; sometimes the nurse could get the resident to do what the CNA needed her/him to do. Anytime the resident was in the wheelchair, she/he rolled out into the hallway or into other residents' rooms on the unit. The resident refused to wear a mask if out of the room. The CNA stated they tried to redirect Resident #6 back to her/his room or to put a mask on him/her while out in hallway or unit. CNA #1 stated she/he notified her/his nurse of her/his concerns. 5. Resident #7 was admitted from the hospital to the facility on [DATE]. The resident was quarantined on the Observation Unit for 14 days. The resident had [DIAGNOSES REDACTED]. According to the Resident's Admission MDS assessment dated [DATE], Resident #7 was severely cognitively impaired, having scored three (3) out of 15 on the BIMS assessment. The resident had no wandering noted during the assessment period. The resident required limited assistance with one (1) person assistance with bed mobility, transfers, locomotion on and off of the unit, dressing, toileting, personal hygiene and bathing. The resident used a wheelchair for locomotion. The Resident's care plan was reviewed; nothing was documented about the resident wandering out of the room or on to the unit. Review of the SBAR Communication Form dated [DATE] at 11:45 PM revealed, the resident had an increased heart rate of 126 beats per minute and a temperature of 100.4 degrees Fahrenheit. The Physician ordered the resident to be sent to the emergency room to be evaluated. At this time the nursing staff also filled out Suspected COVID-19 Infection SBAR form due to the resident having fever higher that 99.6 degrees Fahrenheit and pulse greater than 100 beats a minute. During an interview on [DATE] at 3:04 PM, CNA #1 stated Resident #7 was confused and wandered out of her/his room. The CNA stated the resident wandered the hallway looking for her/his room. The staff redirected the resident back to her/his room, but the resident said that wasn't her/his room. The resident went to other residents' rooms to look for her/his room. The resident opened the door if someone was in the room the resident would go in to ask where her/his room was located. The resident was confused so the staff had problems with her/him keeping a mask on him/her or even putting a mask on when he/she was out of the room. In an interview on [DATE] at 3:04 PM, the North Unit Manager stated Resident #7 was on the Observation Unit after being admitted to the facility on [DATE] from the hospital. The resident was on 14 days of quarantine, meaning the resident was supposed to stay in the room with no contact with other residents. The resident came out of her/his room at times. The staff redirected the resident back to her/his room and tried to get the resident to wear a mask when out of the room. 6. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the resident's Admission MDS assessment dated [DATE], Resident #8 was severely cognitively impaired, having scored five (5) out of 15 on the BIMS assessment. The resident was coded as having inattention behavior and disorganized thinking that was present but fluctuated throughout the day. The resident required extensive assistance with one (1) person for bed mobility and transfers. The resident was dependent with one (1) person assistance for locomotion on and off the unit, dressing, toileting, personal hygiene, and bathing. The resident used a wheelchair for locomotion. The resident was discharged to the hospital on [DATE] with yellow drainage at nephrostomy site, bilateral lower extremity discoloration with coldness to touch, heart rate 114 beats a minute, and labored breathing. The facility was notified the resident tested positive for COVID-19. Resident #8 was readmitted to the facility on [DATE], onto the COVID-19 positive unit. In an interview on [DATE] at 3:04 PM the North Unit Manager stated Resident #8 was off of the Observation Unit and currently resided on the North Long Hall Unit. The resident had completed 14 days of quarantine before [DATE] and was allowed to be out of his/her room. The resident sat in the wheelchair near the nurses' station during the day separated from other residents. The resident wheeled her/himself in the wheelchair short distances. 7. Per review of the facility's resident Infection Control Line Listing starting on [DATE] to present and record review, Residents #6 and #7 resided on the Observation unit on the North hall and Resident #8 resided on the North long hall, which was not part of the Observation Unit. Per the Infection Control Line Listing, Resident #6 was sent to the hospital on [DATE] with an increased heart rate of 144 beats per minute and shortness of breath with respirations at 26 breaths per minute. The resident's temperature was 98.9 degrees Fahrenheit. The facility was notified of the positive COVID-19 test on [DATE]. Per the information from the Infection Control Line Listing, Resident #8 was sent to the hospital on [DATE] with a temperature of 100.3 degrees Fahrenheit and heart rate of 124 beats a minute. The facility was notified of the positive COVID-19 test on this date. Per the information from the Infection Control Line Listing, Resident #7 was sent to the hospital on [DATE] with yellow drainage at nephrostomy site, bilateral lower extremity discoloration with coldness to touch, heart rate 114 beats a minute, and labored breathing. The facility was notified of the positive COVID-19 test. 8. On [DATE] at 4:45 PM the Administrator stated Resident #6 had the right to move about. The Administrator stated the facility, cannot keep her/him locked up. The Administrator stated Residents #6, #7 and #8 were observed talking at the double doors on the Observation Unit. During that time the double doors to the Observation Unit were not closed. The Administrator stated these were three (3) alert and oriented residents and stated she/he could not tell then what to do. The Administrator stated they had the right to go about the building. 9. Per record review noted above, Resident #7 had a BIMS score of three (3) and Resident #8 had a BIMS score of five (5). Both residents had severely impaired cognition.

On the days of the survey, based on observations, record review, interviews, and review of the facility's investigative materials related to a fall with serious injury, the facility failed to ensure residents received adequate supervision and devices for 1 of 7 residents reviewed for falls (Resident # 13). The facility failed to develop a plan to ensure that Resident # 13, with a known history of repeated falls was provided with adequate supervision to prevent falls. The resident sustained [REDACTED]. Additionally, Resident #8, designated to self-administer 4 medications, was found with unsecured medications in her room. The findings included: The facility admitted Resident #13 on 5/05/10 with [DIAGNOSES REDACTED]. Review of the medical record on 4/18/11 revealed the Admission Minimum (MDS) data set [DATE] assessed Resident #13 as having a short-term and long-term memory problem with moderately impaired cognitive skills for daily decision-making. The resident ambulated using a wheelchair. Observations of Resident #13 on the days of the survey revealed a self release, Velcro seatbelt in place. Review of the medical record revealed the resident fell on [DATE] at 6:00 PM. He was found lying face down on the bathroom floor. Documentation stated, "...Resident stated he tried to get up and hit his face on the face basen (sic) in room..." The resident was assessed and found to have blood coming from his mouth and a swollen left eye with coming from the side of the eye. The physician was notified and the resident was transferred to the emergency room . Review of the hospital CT scan dated 11/23/2010 stated, "...Impression: Very proptrotic left eye with associated soft tissue swelling... The superior nasal spine is fractured..." The care plan dated 11/18/2010 showed a problem of "Potential for falls/injuries r/t (related to) hx (history) of falls, will attempt to transfer without assist @ x's (times)..." The facility's planned approaches to assist the resident with this problem were: Investigate all falls/injuries/circumstances, place gold star on door and chart to identify as a fall risk, follow facility fall/head injury protocol if actual fall/head injury occurs, keep call light within easy reach, keep frequently used items within easy reach, may use w/c (wheelchair), keep room well lit and free of clutter, fall/contracture assessment quarterly and prn (as needed), bed alarm, chair alarm, observe seizure precautions assure adequate airway and safety or res (resident) if seizure noted, observe of s/s (signs/symptoms) of seizure activity, reg (regular) ophthalmic visits, lift/transfer res (resident) per assessment, meds (medications) per MD order, labs per MD order, monitor labs as ordered per MD, Floor mats beside bed @ all x's, top s/r (siderail) up x 2 to aid in t & r (transfer/repositioning), OOB (out of bed) with lap belt in place - check & release per MD order, may use r/w (rolling walker) with restorative &/or skilled therapies, floor mat to (L) (left) side of bed @ all x's (times), position res's (R) (right) side of bed against wall, restorative nrsg (nursing) to tx(treat) per restorative plan when not working with skilled therapies, floor alarm WIB (when in bed), Toilet res (resident) per plan and prn as res will allow, supervise resident at all times while in bathroom, staff may wait outside bathroom with door slightly cracked open." A review of Resident #13's Plan of Care Sheet (purpose: Ensure proper communication among staff members about what this particular resident needs. Listed below is specific plan of care that staff needs to be paying close attention to. Note the date the plan was put in place and write d/c (discharge) beside it if it was discontinued or changed) indicated: "Fall Risk Bed and Chair Alarm 11/28/10 - Left SR (side rail) x's 1 Resident wants to raise bed up high 1 Person assist Check mats on floor every shift R/T(related to) res.(resident) urinating on them Wander Band... 11/23/10 - Self Release Velcro Alarm Belt 11/30/10 - Resident will be supervised at all times while in the bathroom. Resident prefers to have bathroom door slightly cracked open; assigned staff may wait outside of the bathroom door..." The facility's investigation dated 12/01/2010 stated, "On 11/24/2010, I spoke with --- who is his regular CNA (Certified Nursing Assistant) on 3/11 shift in an effort to determine Mr.--- (Resident #13) ability to alert staff or his needs as well as his ability to comprehend and or follow instructions given..." The facility's investigation and interviews with the Certified Nursing Assistant (CNA) who routinely provide Resident #13's care, revealed no consistent plan regarding how Resident #13 was to be supervised during toileting despite his known history of multiple falls. On 11/30/2010, after the fall on 11/23/2010, the statement, "Resident will be supervised at all times while in the bathroom. Resident prefers to have bathroom door slightly cracked open; assigned staff may wait outside of the bathroom door..." was added to the Plan of Care Sheet. Additional information and Plan of Care Sheets requested during the survey from the Director of Nursing, were not provided prior to exiting the facility on 04/21/2011. The facility admitted Resident #8 on 10/25/06 with the following [DIAGNOSES REDACTED]. Her most recent Brief Interview for Mental Status (BIMS)score on the Minimum Data Sets((MDS) dated [DATE] was 13 and she was listed on the facility's current Interviewable List. The resident was care planned to self administer Biotene Toothpaste, Thera Tears, Sinus Rinse Kit, and Aquaphor Ointment. The Self Administration assessment dated [DATE] documented that the Aquaphor Ointment was to be kept on the medication cart, the toothpaste and sinus rinse were to be kept in the bathroom, and there was no documentation of where the Thera Tears were to be kept. During an observation of the resident's room on 4/21/11 at 10:00 AM it was observed that the Aquaphor Ointment was on the bedside table. There was a warning label on the ointment which read, "Keep out of reach of children, if swallowed get medical help or contact Poison Control Center right away." The resident stated she always kept it there and when questioned stated she was out of her Thera Tears, but they were usually kept in her room in the bedside table drawer. She stated that the Biotine Toothpaste was kept in her bathroom and she showed the surveyor that the Sinus Rinse was kept in her dresser drawer. In an interview with Licensed Practical Nurse(LPN) #1 (who administered medications on the resident's hall ) on 4/21/11 at 10:15 AM, she was unaware of the hazard presented by the medications being kept in the resident's room unsecured. She did not recall the assessment specifically stating that Aquaphor was to be kept on the Medication Cart.