Every finding on record at Richard M Campbell Veterans Nursing Home

Based on facility policy, observation, record review and interview, the facility failed to ensure standards of practice for Resident (R)62's suprapubic catheter care, were followed for 1 of 2 residents reviewed for catheter care. Findings include: Review of the facility policy dated June 2024, titled, Suprapubic Catheter Care stated under the policy, Remove old dressing around suprapubic catheter if applicable, remove gloves and wash or sanitize your hands. Review of R62's Face Sheet revealed he was admitted to the facility on [DATE], with diagnoses including but not limited to: Parkinson's, chronic kidney disease, dysphagia, Diabetes Type 2, unspecified dementia, and chronic obstructive pulmonary disease. Review of R62's Physician Orders revealed an order dated 04/24/24, Suprapubic Catheter Care Daily and as needed (PRN) one time a day and every 24 hours as needed. During an observation of catheter care on 09/19/24 at 11:02 AM, with Certified Nursing Assistant (CNA)1 and CNA2. Both CNA's washed their hands and applied a gown and gloves. CNA1 repositioned R62, elevated his bed up, removed gloves and donned another set of gloves. CNA2 setup the table with prep pad and placed the disposable wipes and a towel on the table. CNA2 donned another set of gloves without washing her hands. CNA2 assisted R62 up in the bed. Both CNAs removed gloves, sanitized hands, and donned another pair of gloves. Both CNAs uncovered R62 and placed a towel over the groin area. CNA1 unfastened the brief. A dressing, split sponge dated 09/19/24 was removed by CNA1. Using the same gloves, CNA1 cleaned around the suprapubic catheter, then used 3 wipes, cleaned from the tip of the catheter from abdomen outward three times. During an interview on 09/19/24 at 11:15 AM, CNA1 stated, We should have changed our gloves after removing the dressing and sanitized after removing the gloves. During an interview on 09/19/24 at 12:38 PM, LPN6 stated, We change [R62's] dressing every day. I change it in the morning. After I remove a soiled dressing, I remove my gloves, and I sanitize and apply new gloves. The CNAs should removed their gloves after they removed his dressing. During an interview of 09/19/24 at 3:00 PM, the Director of Nursing (DON) stated, They need to change gloves after you touch something soiled, then sanitize and apply new gloves. Going in, sanitize, apply gloves, setup supplies. Position resident, remove gloves, hand sanitize, don [put on] new gloves, perform task, remove gloves and sanitize. If removing the dressing, remove gloves, sanitize, apply new gloves.

Based on observation, interview, and facility policy review, the facility failed to prevent complications with Resident (R)95's feeding tube, by not flushing the tube prior to the administration of medications. Findings include: Review of the facility's policy titled, Gastrostomy Tube Flush (G-Tube) revised date June 2024, revealed, Gastrostomy tube flush to be administered per physician's order. To provide hydration to resident and maintain G-Tube patency . 16. Fill 60cc syringe with ordered amount of flush. Review of R95's Face Sheet revealed R95 was admitted to the facility on [DATE], with diagnoses including but not limited to: COVID-19, dysphagia, vascular dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and adult failure to thrive. Review of R95's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/30/24, revealed a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating R95 had severe cognitive impairment. Review of R95's Physician Orders with a start date of 05/02/24 documented, TF: Flush Peg with approximately 30ml water before and after medication administration every shift. During an observation on 09/19/24 at 8:20 AM, Registered Nurse (RN)2 did not flush the feeding tube after checking placement and prior to administering medication. During an interview on 09/19/24 at 8:25 AM, RN2 stated, I should have flushed prior to giving the medication. It is always good to have extra flush. During an interview on 09/19/24 at 9:00 AM, the Director of Nursing (DON) stated, [RN2] gets very nervous during observations and skill check off. She is a very good nurse. She came and discussed the observation afterwards with me. We will continue to do education to make sure tube feedings are flushed before and after administration of medications.

Based on review of the facility policy, observation and interviews, the facility failed to ensure medications and biological's, that were expired, were removed from 1 of 3 medication storage rooms. The findings include: Review of the facility policy, effective date [DATE], titled, Storage of Medications states, medications and biologicals are stored safely, securely, and properly, following manufacturer's provider pharmacy recommendations, or those of the supplier to maintain their integrity. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications . Q. 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 disposal (See Section 5 Disposal of Mediations, Syringes and Needles), and reordered from the pharmacy if a current order exists. During an observation on [DATE] at 4:00 PM, the Medication Storage Room on 200 Hall revealed Fibracol Plus collagen wound dressing with alginate 10.2 cm x 11.1 cm (4 in x 4 ,d+[DATE] in) x 3; Reference # 2982, Lot ## 2237V[DATE]/1 Expired [DATE]. Further observation of the Medication Storage Room on 200 Hall revealed GelRite instant hand sanitizer with Vitamin E Manufacturer DermaRite 118 ml (4 fl oz) Lot# 00793A Expires ,d+[DATE]. During an interview on [DATE] at 6:36 PM, Licensed Practical Nurse (LPN)3 stated, At some point we do the checking for expired items and the unit clerk goes through the storage rooms too. During an interview on [DATE] at 4:16 PM, Registered Nurse (RN)2 stated, They have assigned duties for each nurse. I am sure it is listed somewhere of who checks the medication storage room. During an interview on [DATE] at 5:00 PM, the Director of Nursing (DON) stated, It is every nurse responsibility to check for expired items in the medication storage room. I did speak with the pharmacist concerning the labeling system and how it shows a discrepancy versus the filled date for the expiration dates.

Based on review of facility policy, interview, observation, and record review, the facility failed to protect Resident (R)2 from accidents/accident hazards related to elopement. Specifically, on 07/02/23 at approximately 2:15 PM, R2 was found outside the facility in the back parking lot. R2 was last seen by staff at approximately 1:55 PM in the courtyard of the facility. Due to R2 being outside the facility, without staff knowledge or supervision, R2 was placed at increased risk of serious harm or death. On 07/06/23 at approximately 12:00 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 07/06/23 at approximately 12:00 PM the Administrator was notified that the failure to prevent a successful elopement of a resident constituted Immediate Jeopardy (IJ) at F689. On 07/06/23 at 3:52 PM the facility presented an acceptable plan of removal of the IJ. The survey team validated that the immediacy of the IJ was removed on 07/06/2023 at 5:00 PM following the facility's implementation of the plan of removal of the immediate jeopardy. The facility remained out of compliance at F689 at a lower scope and severity of D (isolated with potential for more than minimal harm) following removal of the IJ. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care. After a Quality Assurance Review on 07/17/23, the SA determined the IJ at F689 is at Past-Noncompliance. Review of the facility's removal plan and supporting documentation revealed good faith efforts were put into place prior to the beginning of the survey and the immediacy of the IJ was removed as of 07/02/23. Findings include: Review of facility policy titled Elopement with a last revised date of October 2012 revealed, .the facility will provide a secure environment to residents at risk for elopement. Review of R2's Face Sheet revealed R2 was admitted to the facility on [DATE] with diagnoses including, but not limited to; alcohol dependence, Alzheimer's disease, type 2 diabetes mellitus, anemia, and depression. Review of R2's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/05/23, revealed R2 scored a Brief Interview for Mental Status (BIMS) of 3 out of 15, indicating R2 was severely cognitively impaired. Review of R2's Elopement Risk Screen dated 05/08/23, revealed R2 was screened as an elopement risk and given a secure bracelet. Review of R2's Adverse Incident Report dated 07/03/23, revealed R2 was found on 07/02/23 at 2:15 PM in the back parking lot. His secure bracelet was in place and functioning. Review of Registered Nurse (RN)1's witness statement, to the facility, written on 07/02/23, revealed RN1 saw R2 in the courtyard between units 2 and 3 at approximately 1:55 PM. When alerted that he was in the back parking lot, she assisted him inside and performed a body audit - revealing no injury. He was offered a snack and water and given a sitter. During an interview and observation with RN1 on 07/06/23 at approximately 11:45 AM, confirmed her statement to the facility. RN1 stated R2 was sitting in the courtyard at 1:55 PM. RN1 was then alerted at around 2:15 PM that R2 was in the back parking lot. RN1 further stated the weather was warm and sunny. R2 was found approximately 100 feet away from the facility. R2 was approximately three parking spaces away from the facility. R2 would have had to cross the parking throughway around the facility, Review of Certified Nursing Assistant (CNA)2's witness statement, to the facility, written on 07/04/23, revealed CNA2 was providing care to another resident, when CNA2 saw R2 in the back parking lot. CNA2 then alerted the nurses. During an interview with CNA2 on 07/06/23 at approximately 11:50 AM, confirmed her statement to the facility. CNA2 was providing care to another resident when she saw R2 in the back parking lot through the window. CNA2 was assigned to R2 that day and did not know that he was outside the facility. CNA2 stated she alerted the staff but could not assist R2 since she was in the middle of care with another resident. Review of Licensed Practicing Nurse (LPN)1's statement, to the facility, on 07/02/23, revealed LPN1 was made aware by a CNA that R2 was outside in the back parking lot. While redirected the resident back inside, LPN1 noted the lock on the courtyard's gate was broken. During an interview with LPN1 on 07/06/23 at approximately 11:55 AM, confirmed her statement to the facility. LPN1 stated she was with another resident when a CNA shouted R2 was in the back parking lot. LPN1 went with a CNA and the nurse supervisor to take in the resident. R2 was a few cars back into the lot - past the throughway around the facility. LPN1 did not know he had exited the facility prior to being made aware by the CNA. When they brought the resident in, they noted the lock on the courtyard's gate was broken. Review of CNA1's statement, to the facility, written on 07/02/23, revealed she was notified by the nurse that R2 was in the parking lot and brought him back to the facility. During an interview with CNA1 on 07/06/23 at approximately 12:00 PM, confirmed her statement to the facility. CNA1 was notified that R2 was in the parking lot and went to retrieve him, accompanied by the nurse and nurse supervisor. CNA1 stated she did not know the resident was outside the facility prior to being made aware by CNA2, who saw the resident outside the window. CNA1 further stated the weather was sunny and hot that day. CNA1 concluded, they later discovered R2 had eloped through the courtyard gate, which was broken. Review of R2's Care Plan dated 09/02/20, revealed R2 was care planned for wandering with an intervention for a secure device. Review of R2's Orders dated 05/03/23 revealed, a secure device was ordered. Review of R2's July Treatment Administration Record (TAR) revealed the secure care bracelet function was checked at 6:00 AM the day of the elopement. Review of timeanddate.com revealed the weather in [NAME], South Carolina at approximately 1:56 PM was 88 degrees Fahrenheit and sunny. During an interview with the Maintenance Director (MD) on 07/06/23 at 1:30 PM, revealed the MD was not aware the gate was broken prior to the elopement, and that maintenance checks gates weekly per policy. During a follow up interview with the MD on 07/06/23 at approximately 4:00 PM, revealed the reason the courtyard gate's magnetic lock failed was because it lost power which disabled the lock. The facility's removal plan included the following: R2 was assessed by RN1 on 07/02/2023, with no injuries noted. R2's secure care bracelet was in place and functioning at time of incident. The physician and resident representative were notified on 07/02/2023. Social services assessed R2 on 07/03/2023. The resident was placed on 1:1 staff supervision on 07/02/2023. R2's Care Plan was reviewed and updated on 07/03/2023. R2 was assessed by the nurse practitioner on 07/03/2023. Unit managers completed a 100% head count of all residents on 07/02/2023. Nursing administration obtained statements from staff working on the unit on 07/02/2023. Nursing administration completed an audit of secure bracelets for placement, function, and expiration date on 07/02/2023. Maintenance audited all gates and doors for functioning on 07/02/2023. Facility staff were re-educated on facility Elopement policy beginning on 07/03/2023 and completed by 07/06/2023. This will include licensed, non-licensed, and contract staff. Staff will receive education prior to their next shift. Newly hired staff will receive this education during orientation by the Staff Development Coordinator. Maintenance staff will conduct facility rounds to inspect door and gate security weekly x 4 weeks and monthly x 2 months. The results of the audit will be reviewed at the facility QAPI meetings for 3 months.

Based on observations, record review, facility policy review, and staff interviews, the facility failed to ensure 1 out of 7 Residents, (R)59, reviewed for abuse out of a total sample of 39 residents, was free from abuse. A resident-to-resident altercation resulted in harm to R59 when he sustained a fractured finger. Findings include: Review of the facility's revised November 2019 policy titled, Abuse, indicated, Each resident has the right to be free from abuse .Residents must not be subjected by anyone, including, but not limited to facility staff, other residents .Abuse is defined as the willful infliction of injury .with resulting in physical harm, pain, or mental anguish. Willful: The individual must have acted deliberately, not that the individual must have intended to inflict injury of harm .Physical abuse includes but is not limited to hitting, slapping, pinching, and kicking . Review of the facility's revised January 2017 Abuse policy titled, Prevention, indicated, It is the policy of the facility to provide residents an environment free from abuse through prevention .The facility will identify residents whose personal histories, aggressive behaviors, and/or communication needs render them at risk for abuse and/or abusing other residents .The facility will monitor residents for changes that could trigger abusive behavior . Review of the facility's revised January 2017 Abuse policy titled, Protection, indicated, It is the policy of the facility to provide residents an environment free from abuse through protection .With resident-to-resident abuse, the residents will immediately be separated. The behaviors and physical condition of the residents will be evaluated with appropriated interventions identified to address the behaviors . Review of the facility's revised September 2017 Abuse policy titled, Investigation, indicated, It is the policy of the facility to thoroughly investigate .any allegations of abuse that include Physical Abuse .Allegation of Abuse: 1. The resident(s) will be evaluated for any physical, emotional, and/or cognitive changes. 2. Identify: if possible, the date of the alleged abuse and immediately begin an investigation. 3. Interview the resident. 4. Interview and obtain written statements from the person(s) reporting the allegation .7. Obtain written statements from individuals identified as possibly having any knowledge of the allegation. At the conclusion of the investigation, the Administrator and Director of Nursing (DON) and designated staff will review all evidence and reach a conclusion if abuse has been substantiated, and any corrective actions to be taken . Review of the facility's revised October 2012 policy titled, Administration Policy and Procedure Directives-Memory Care Unit, indicated, It is the policy of this facility to provide each resident who is diagnosed with dementia, a safe and structured environment in the State Veterans Home that meets their physical, emotional, social .needs throughout the disease's progression. Review of an undated Face Sheet provided by the facility revealed R59 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R59's Minimum Data Set (MDS) provided by the facility with an Assessment Reference Date (ARD) of 06/03/22 indicated a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicated R59 had severe cognitive impairment. Review of an undated Face Sheet located in R92's electronic medical record (EMR) under the Profile tab revealed R92 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R92's quarterly MDS provided by the facility with an ARD of 04/29/22 indicated a BIMS score of 4 out of 15, which indicated R92 had severe cognitive impairment. Review of an Accident/Incident Reporting Form Bureau of Health Facilities Licensing, 24-report provided by the facility and dated 06/01/22, indicated a resident-to-resident altercation took place between R59 and R92 on 06/01/22. It indicated no witnesses present. The 24-report indicated, On 06/01/22 at approximately 9:00 am, resident [R59] (BIMS-8) approached the nurse and reported he broke my finger. Upon assessment, the left 4th finger appears displaced and bent toward the left 3rd finger with slight redness and blue discoloration beginning to form at the base of the finger. When asked what happened, resident [R59] stated, he [referring to R92] came in my bathroom and attacked me. He hit me in my jaw and bent my finger. A 1cm (centimeter) red area was noted on his right cheek. [Name of R59] then pointed to resident [R92] (BIMS-4) and identified him as the person who hurt him. When [name of R92] was asked what happened, he reported words were exchanged and that he whooped him. Resident [R92] had a 1 cm pink area observed on the bridge of his nose. Both residents were separated, assessed, neuro checks completed and were within normal limits for both residents. An order was given to send R59 to the emergency room for evaluation of his finger. R92 was sent to the hospital for psychiatric evaluation. Review of the 06/01/22 hospital X-ray results provided by the facility for R59, indicated, Findings-There is marked [CONDITION(S)] changes of the first carpometacarpal joint. There is a comminuted slightly displaced fracture at the base of the proximal phalanx of the fourth digit. The X-ray results indicated, Impression: Comminuted slightly displaced fracture at the base of the proximal phalanx of the left fourth digit. [CONDITION(S)] changes of the left hand. Review of a Psychosocial Visit dated 06/01/22 provided by the facility, indicated, Met with [name of R59] for psychosocial visit .was asked to start at the beginning. He said, It was one of those things. Asked him what happened. He said, I don't know really. He went on to say, He was in the bathroom. My finger got in the way. Asked [name of R59] if he hit the man [referring to R92]. He said, No. Asked him if he was upset. He said, No. I asked if the man hit him. He said, No. Review of a Departmental Note dated 06/01/22 provided by the facility, indicated, Resident [R59] approached this nurse [Licensed Nurse (LN)2] stated, He broke my finger. Resident [59] wearing boxers and a collared shirt and socks. Noted left 4th finger displaced, bend [sic] toward left 3rd finger with slight redness at first (after body audit noted blue discoloration beginning to form at base of finger) .body audit completed. Noted another resident [referring to R92] walking in the same hallway. This resident [R59] pointed at the other resident [R92] and stated, that's him. Other resident [R92] stated, He shouldn't have been running his mouth that way. This nurse [(LN)2] asked the other resident [R92] what happened. The other resident [R92] stated, I was getting comfortable in the bathroom, and he [R59] came in and ask [sic] if I thought I could whoop him. I told him yes and I did. Review of a Nurse Practitioner Note dated 06/02/22 provided by the facility, indicated, [R59] assessed in r/t [related to] altercation with another resident resulting in a fx [fracture] of 4th finger. [R59] was sent to the ER for evaluation of hand .splint was placed and was re-x-rayed in ER which showed: Mild improved alignment of the fourth proximal phalanx fracture. When asked what happened, resident [R59] stated, He got me in the bathroom. I probably hit him and didn't even know it after he hit me in the eye. [R59] denies any c/o [complaints of] pain. Able to move thumb, index, and middle finger of L [left] hand with complaints. Able to move all extremities. No discoloration to face/cheek/eye. Review of a second Accident/Incident Reporting Form Bureau of Health Facilities Licensing document 5-day report, dated 06/06/22 and provided by the facility, indicated a summary of events as was indicated in the 24-hour report and, [name of R59] sent to the emergency room where a finger reduction took place and the Xray revealed mild improvement alignment and a fracture of the fourth proximal phalanx. A finger splint has been put in place. Will be assessed by an Orthopedist on 06/06/22. Review of a Hospital Occupational Therapy Visit-OT Evaluation dated 06/06/22, indicated, This is an .male patient who was in an altercation with another demented resident at the nursing home where he resides resulting in the injury to the ring finger .Type of Splint- prefabricated, custom. Purpose of Splint- Provide protection and safe healing position. Treatment- Tolerated well. Patient was educated in proper wear and care. Further review of the document indicated, The patient is experiencing no tenderness .Comments: Gross swelling about 4th and 5th digit with ecchymosis (bruising) present. Assessment: He was referred to occupational therapy for a custom splint. Review of a hospital Orthopedic Surgery Office Visit dated 06/06/22, indicated, New patient-left ring finger. Pt. [patient] got into an altercation with another resident at the VA [Veterans] last week. Pt [patient] has a splint on today .He went to the ED [emergency department] and had a fractured proximal phalanx of the 4th digit which was displaced and reduced in the ED. He has a splint, but his daughter stated he has been taking it off. He denies pain . Review of a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Res [resident] non-compliant with brace. During an observation and interview on 08/17/22 at 11:04 AM, R59 was observed in his room lying down. During interview regarding the resident-to-resident altercation that took place on 06/01/22 between R59 and R92, R59 stated, All I really recall is a guy was winding up his fist. It's been about 9-10 weeks ago. When asked what happened, R59 stated, I wasn't paying no attention and I put my hand on the shoulder of a guy in front of me. I put my finger on the shoulder of a guy. He said, I'm winding up and it happened a pretty good while ago. I don't remember a lot of stuff. It wasn't that bad of a fight. I went to the hospital, but they didn't do anything. It was a stupid fight. All I did was to karate chop him with my hand and that was the end of that. I think I hit him, but I don't remember where. I can't recall it. At this time R59 could not recall any specifics of the resident-to-resident altercation. During an observation of R92 on 08/17/22 at 2:00 PM, R92 was observed in his room. During this time, R92 was not interviewable and when asked about any incidents could not recall. During an interview on 08/17/22 at 4:00 PM, the Social Services Director (SSD) stated, With [name of R59], he has a history of being territorial. He has a pattern of cursing at other residents if they come in his room. He startles easily. He has [CONDITION(S)] [[CONDITION(S)]] related to his time in war. Regarding the resident-to-resident altercation that occurred between R59 and R92, the SSD stated, The private room adjacent from [R59] was vacant. There is a bathroom that connects both rooms. From what we could determine, [R92] came in that vacant room and went to the bathroom. [R59] was sitting on the toilet and from we could determine, [R92] said [R59] yelled at him, and [R92] must have grabbed [R59's] hand. [R59] told us that He hit me in the face and broke my finger. During an interview with the Assistant Director of Nursing (ADON) on 08/18/22 at 2:03 PM, the ADON stated she did the 5-day follow up investigation. The ADON stated, They were not roommates at the time of this incident. From what [R59] reported, he approached [LN2] and reported, he broke my finger. [LN2] noticed some deformity to the left finger. [R59] pointed to [R92] who was walking down hallway and said he was the one. It occurred around 9:00 AM, so staff were finishing breakfast, cleaning up trays, starting to give showers, etc. Both families were notified. Prior to this there were no altercations between these two residents. None of their demeanors had changed and neither recalled the details of the incident. Since then, these two residents have had no altercations with one another. They pretty much keep to themselves and have no history of seeking out one another. During an interview on 08/19/22 at 10:18 AM, regarding the resident-to-resident altercation between R59 and R92, the SSD stated, We are going off what R59 reported to staff, we think R92 may have stood up from the toilet and attempted to hit R59 in the face because R59 was pointing his finger at R92 when sitting on the toilet. In an effort to try to block R92 from being hit in the face, grabbed R59's his hand/finger and that is how R59's finger got broken. The SSD stated, Staff heard the commotion and went in the room and [R59] reported to staff. The SSD stated, R59 reported to the nurse, he came into my bathroom, hit me in the jaw and broke my finger. During an interview on 08/19/22 at 6:19 PM with the Administrator and Director of Nursing (DON), the Administrator stated, With [name of R59] he may not have struck out. He was in a private room and is very territorial and thinks that is his bathroom. Per the DON, [name of R59] came up to the nurse and told the nurse what happened, but we couldn't say for sure that [name of 92] broke R59's finger. [name of R59] could have hit his finger on the door, sink, wall. We can't say for sure that [name of R92] intentionally intended to break a person's finger or [name of R59] finger. We can't say that it was willful, sought out abuse by R92. We just can't. We only have to report what was being reported to us by [name of R59] which we did. With it being unwitnessed, we cannot say [name of R92] broke his finger. We are not substantiating abuse in any way. We are simply saying there was some sort of resident-to-resident altercation that occurred, but not abuse.

Based on observation, record review, staff interviews, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for 1 of 2 residents (Resident (R) 59) receiving hospice services out of a total sample of 39 residents. Specifically, the facility failed to accurately code the MDS for hospice services for R59 in which the MDS indicated the resident no longer had a terminal prognosis of less than six months but was also coded as receiving hospice services. By not ensuring the accuracy of the MDS, these failures placed the resident at risk for unmet care needs and/or provision of care needs of residents. Findings include: Review of the MDS-3.0 R-A-I Manual-v1.17.1 under Section J1400 Prognosis: indicated, Definition: Condition or chronic disease that may result in a life expectancy of less than 6 months; In the physician's judgement, the resident has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This judgement should be substantiated by a physician note. Steps for Assessment: 1. Review the medical record for documentation by the physician that the resident's condition or chronic disease may results in a life expectancy of less than 6 months, or that they have a terminal illness. 2. If the physician states that the resident's life expectancy may be less than 6 months, request that he or she document this in the medical record .3. Review the medical record to determine whether the resident is receiving hospice services. Coding Instructions: Code 0, no: if the medical record does not contain physician documentation that the resident is terminally ill and the resident is not receiving hospice services. Code 1, yes: if the medical record includes physician documentation: 1) that the patient is terminally ill; or 2) the resident is receiving hospice services .Terminally ill means that the individual has a medical prognosis that his or her life expectancy is 6 months or less if the illness runs its normal course. Section O0100: Special Treatments, Procedure, and Programs: O0100K, Hospice care: Code residents identified as being in a hospice program for terminally ill persons .is provided . During an observation on 08/17/22 at 11:04 AM, R59 was observed alone in his room lying in bed. At this time when asked about hospice services, R59 was not able to communicate if he was receiving hospice services or not. Review of R59's undated Face Sheet, provided by the facility, indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Medicare Hospice Election Statement, dated 01/21/21 and provided by the Hospice company as part of R59's medical record indicated, R59 chose to elect the Medicare Hospice benefits and receive Hospice services to begin on 01/21/21. Review of a Nursing Facility Notification of Hospice Admission or Discharge document, dated 01/21/21 and provided by the Hospice company as part of R59's medical record, indicated R59 was admitted to [name of Hospice company] on 1/21/21 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Hospice Physician Orders/Plan of Care, dated 07/21/21 to 09/17/21 and provided by the Hospice company as part of R59's medical record, indicated admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The patient is being re-certified in our program. The document signed by the hospice medical director on 07/21/21 indicated, I certify that this patient has a medical prognosis that limits life expectancy to 6 months or less (if the disease follows as normal course) and this is considered terminally ill and eligible for hospice services. Review of the Notice of Medicare Non-Coverage document provided by the Hospice company as part of R59's medical record, indicated, The effective date coverage of your current Hospice services will end: 09/16/21. Review of a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a significant change MDS revealed an Assessment Reference Date (ARD) of 09/24/21, and completed by the MDS Coordinator (MDSC) on 09/24/21. The MDS was coded as R59 had no terminal prognosis of less than 6 months, but, was also coded as still receiving hospice services. Hospice services were discontinued as of 09/21/21. Review of a quarterly MDS revealed an ARD date of 12/17/21. It was completed by the MDSC on 12/17/21. The MDS was coded as R59 had no terminal prognosis of less than 6 months, but was also coded as still receiving hospice services. Hospice services had been discontinued as of 09/21/21. Review of an additional quarterly MDS revealed an ARD date of 03/11/22, and completed by the MDSC on 03/16/22. The MDS indicated R59 with no terminal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Hospice services had been discontinued as of 09/21/21. Review of an additional significant change MDS revealed an ARD date of 06/03/22, and completed by the MDSC on 06/07/22. The MDS indicated R59 with no terminal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Hospice services had been discontinued as of 09/21/21. Review of a Care Plan, dated 01/22/21, indicated, Resident is approaching end of life. Resident's preferences regarding care at end of life will be honored. This care plan was resolved on 09/30/21, as R59 was no longer receiving hospice services. During an interview on 08/17/22 at 9:30 AM, when Licensed Nurse (LN) 2 was asked if R59 was receiving hospice services, LN2 stated, No, he is not receiving hospice services. After reviewing the medical record of R59 and identifying a discrepancy with the MDS regarding R59 no longer receiving hospice services, during a second interview on 08/18/22 at 3:00 PM, (LN)2 was again asked if R59 was receiving hospice services. LN2 stated, No, he is not receiving any type of hospice services. No. I think he was on it at some point, then was taken off hospice services. During an interview on 08/18/22 at 3:14 PM, regarding the MDS for R59, the MDSC stated, Our process is, when they are started on hospice services, we have 14 days to do a significant change MDS, and I would be the one to be doing that. We get all the consents signed, family is aware, then I will code it on the MDS under the prognosis section they have less than 6 months of life and they are now on hospice. When the MDSC was asked when did R59 come off hospice services, the MDSC stated, He is not on hospice services anymore. He went on Hospice January 21, 2021, and stayed on it, then came off of hospice on 09/16/21. The MDSC verified that she completed the Sig. change MDS dated [DATE]. The MDSC stated, I took off a terminal prognosis on the life expectancy of less than 6 months section because he came off hospice services on 09/16/21. However, when the MDS was verified the MDS was still showing as R59 receiving hospice services and was coded incorrectly. The MDSC verified she completed the next quarterly MDS dated [DATE]. She indicated, He did not have a terminal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . However, when the 12/17/21 quarterly MDS was reviewed with the MDSC as being coded as still receiving hospice services, she stated, I see that it is still there as he is receiving hospice services. It was checked inadvertently. I will need to do a correction on that. The MDSC verified she completed the next quarterly MDS dated [DATE]. She indicated, There is no terminal prognosis of less than 6 months, but it still says he is on hospice. I'm seeing hospice is checked. There was no reason for that one as well. The MDSC verified she completed the next significant change MDS dated [DATE]. She indicated, He does not have a terminal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . I'm the one that did it. There was no reason for it, and it should not be checked. The MDSC stated, her process is, Once we get the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . I review their hospice notebooks, all hospice documentation and IDT (interdisciplinary notes). I have access to all of that. I follow the RAI manual. All I can do is get it corrected and I'm thinking it may have just been pulled over from one MDS to the next. During an interview on 08/18/22 at 3:47 PM, the Administrator stated, He [referring to R59] was d/c [discontinued] from hospice services on 09/16/21 and was no longer considered terminal and no longer needing hospice services. During an interview on 08/18/22 at 4:07 PM, Hospice Licensed Nurse (HLN)1 stated, He [referring to R59] is currently not on hospice services. This resident came onto hospice services on 01/21/21 and was discharge from hospice on 09/16/21 and has not been receiving any further hospice services since 09/16/21.

Based on interview and record review, the facility failed to thoroughly investigate an abuse allegation for 1 of 10 residents reviewed for abuse. Resident (R) 2 was discovered sitting on the bed with skin tears (STs) to his cheek and face. Examination revealed a misaligned nose. R3 was discovered standing over the resident. R2 would later describe that he was attacked, but the facility did not investigate if R3 was his attacker or why R3, who required 1:1 supervision, was in R2's room. Because the potential resident-resident abuse was not investigated thoroughly, R2 was potentially put at risk for recurrence of abuse. Findings include: R2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility investigation of the incident on 03/22/22 at 11:20 AM revealed that on 11/27/21 at approximately 12:10 PM, staff heard R2 cry for help. The resident was discovered sitting on bed with skin tears to his left cheek, left arm, and right arm. The nurse was notified and the resident was discovered with a nose misalignment on exam. The resident required steri strips for his skin tears and an ENT referral for the nasal fracture. R2 said I got hit in the face. Review of witness statements on 03/22/22 at approximately 11:40 AM, revealed Certified Nursing Aide (CNA)1 was the first staff member on the scene. She heard R2 yell for help. Upon entering the resident's room, she discovered R3 standing over the resident, using profanity. R2 was on the bed, bleeding. CNA1 escorted R3 from the room and alerted the nurse. Review of 11/27/21 incident report for R2 on 03/22/22 at approximately 11:50 AM revealed R2's nose was turned slightly out of alignment to the right. Exam also revealed a wedge-shaped ST to his upper right triceps measuring 2.5 cm x 1 cm, a ST to the left side of his nose measuring 1 cm x 0.5 cm, a ST under his left cheek measuring 0.5 cm x 0.5 cm, a ST to the left forearm measuring 5 cm x 4 cm, and a ST to the right forearm measuring 5 cm x 7 cm. Review of progress notes for R2 on 03/22/22 at approximately 12 PM revealed an 11/29/21 progress note written by social services. Staff asked R2 what happened to his eye and he replied, I got beat up. When asked who beat him up, he replied, I don't know his name but he's the one who likes to fight. Interview with the Administrator and Director of Nursing (DON) on 03/22/22 at approximately 12:10 PM revealed R3 was not investigated as a potential source of R2's injuries because there were no direct witnesses. Interview revealed that R3 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the DON and review of R3's chart on 03/22/22 at approximately 12:45 PM revealed that R3 was meant to be on 1:1 supervision during R2's incident. Review of his 1:1 sign-off sheets from the date and time of the incident revealed CNA2 was supervising him at that time. Interview with DON confirmed the facility never investigated whether R3 physically abused R2. The facility did not investigate why CNA1 discovered R3 in R2's room while CNA2 was supposed to be watching R3 on 1:1 supervision. Interview with CNA2 on 03/22/22 at approximately 2:10 PM revealed she did not witness the incident and did not recall any times when R3 was unsupervised. She stated, Since sitters often ask other staff members to watch residents when they require breaks, it's difficult to be certain who was meant to be watching R3 when he was discovered in R2's room. Review of facility abuse policy on 03/22/22 at approximately 5:50 PM revealed the following; In instances of allegations of abuse, the facility is meant to obtain a written statement from the alleged person and individuals that might have any knowledge of the investigation.

Based on record review and interview, the facility failed to follow the care plan for a pressure pad bed alarm for Resident #137 and Resident #3, 2 of 9 residents reviewed for accidents, and for cleaning oxygen filters for Residents #192 and Resident #84, 2 of 2 residents reviewed with oxygen. The findings included: The facility admitted Resident #137 on 12/17/17 with [DIAGNOSES REDACTED]. On 05/21/19 at 11:37 AM, review of Resident #137's Nursing Notes revealed documentation that the resident was found sitting on the floor on 1/1/19 and on 3/20/19 was observed on the floor in the doorway to the room. On 05/22/19 at 11:37 AM, review of Resident #137's Care plan dated 12/7/17 revealed Risk for injury/falls was identified as a problem with an intervention for a pressure pad bed alarm. On 05/22/19 at 04:41 PM, review of the Incident Investigations related to Resident #137's falls revealed the following documentation: 01/09/19 Bed alarm present and in use but documented as not working 01/12/19 Bed alarm present and in use but not working 01/17/19 Bed alarm present and in use but documented as not working 03/20/19 Bed alarm present and in use but not working. During an interview on 05/22/19, the Director of Nursing (DON) and the QA (Quality Assurance)/ Risk Manager confirmed the findings that the bed alarm was not working at the time of falls on 01/09/19, 01/12/19, 01/17/19, and 03/20/19. They reported that the alarm was positional noting that Resident #137 moves around in the bed and moves off of the pressure pad alarm. The DON further stated that because the resident weighs 110 pounds that the pressure pad alarm is not activated when the resident was placed in the bed, so it doesn't alarm when the resident moves off of the pad alarm. The DON stated they have tried other measures and updated the care plan with other measures. The DON nor the QA/ Risk Manager would confirm or deny the effectiveness of a pressure pad alarm. Resident #84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Care Plan review for Resident #84 on 5/22/19 at 10:31 AM documented interventions to provide Oxygen as ordered, change filter per facility protocol, and administer oxygen as prescribed by physician. The care plan was noted with a problem onset date of 1/22/2018 with updated interventions for the oxygen orders and cleaning of the oxygen filters on 3/26/2019. Review of physician's orders [REDACTED]. Resident #84 requires oxygen continuous via nasal cannula at 3 liters per minute. Observations of the dirty/dusty filters for Resident #84's oxygen concentrator filters were performed on 05/20/19 at 12:26 PM, 5/20/19 at 03:14 PM, 5/21/19 at 02:45 PM and on 5/22/19 at 10:21 AM at the bedside of Resident #84. On 05/22/19 at 10:56 AM the dirty/dusty filters were observed and confirmed with Licensed Practical Nurse (LPN) #3, the nurse immediately removed the dirty filter for cleaning. LPN #3 also confirmed the physician's orders [REDACTED]. Resident #192 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. and Chronic pain. Care Plan review for Resident #192 documented interventions to provide Oxygen as ordered and to maintain equipment per orders. The care plan was noted with a problem onset date of 5/23/2017 with updated interventions for the oxygen equipment orders on 1/22/2019. Review of Physicians orders for Resident #192 revealed a Physician order [REDACTED]. Observations of the dirty/dusty filters was conducted on 05/21/19 at 02:50 PM in Resident #192's room, and on 5/22/19 at 09:55 AM in the resident's room. Observations of a moderate amount of dust were easily observed from the resident's doorway and closer observations at the bedside to confirm the buildup of dust/dirty oxygen concentrator filters. During an interview with LPN #4 on 5/22/19 at 11:01 AM s/he confirmed with observation the dirty oxygen filter. The nurse immediately went to clean the dirty filter. LPN #4 confirmed the care plan interventions and physicians' orders to clean daily and prn. The facility admitted Resident #3 on 12/20/17 with [DIAGNOSES REDACTED]. During an observation on 5/20/19 at approximately 1:45 PM noticed Resident #3 sitting in his/her wheelchair at the nurse station wearing a heel protecting boot. S/he had a skin tear with a slight bruise on the bridge of his/her nose and a bruise on his/her forehead right between the eyebrows. The surveyor did not see a chair alarm on Resident #3's wheelchair. Review of Resident #3's care plan dated 12/20/17 on 5/22/19 at 12:57 revealed that Resident #3 is at risk for injury/fall due to impaired mobility, visual deficit, history of fall, and medication regiment. Interventions dated 12/31/18 included Pressure pad chair alarm. Check function and placement q (every) shift. An incident report for Resident #3 was reviewed on 5/22/19 at approximately 3:25 PM revealed that on 5/18/19 Resident #3 was found on the floor in his/her room, lying in front of his/her wheelchair. Review of Resident #3's nurse's note date 5/18/19 revealed Resident was attempting to get into (his/her) bed from (his/her) wheelchair. (S/he) fell and sustained a small skin tear to the bridge of (his/her) nose, and a moderate sized know between (his/her) eyes . Review of Resident #3's Fall investigation dated 5/18/19 revealed the boxes for Tab alarm bed and Tab alarm chair were checked as not present and not working. During an interview with the director of nursing (DON) on 5/24/19 at approximately 2:00 PM, s/he acknowledged that the facility did not provide proper supervision to Resident #3, who is high-risk for fall, has impaired mobility, and visual deficit. The facility did not ensure that the resident had the devices (bed and chair alarms) in placed or functioning properly to alert the staff when (s/he) tried to transfer without assistance.

Based on observation, record review, and staff interview, the facility failed to provide adequate supervision, assistance, and devices to prevent falls for Residents #3 and #137, two of nine sampled residents reviewed for accidents. The facility failed to utilize bed and/or chair alarms as ordered resulting in an injury to Resident #3. The findings included: The facility admitted Resident #3 on 12/20/17 with [DIAGNOSES REDACTED]. During an observation on 5/20/19 at approximately 1:45 PM noticed Resident #3 sitting in his/her wheelchair at the nurse station wearing a heel protecting boot. S/he had a skin tear with a slight bruise on the bridge of his/her nose and a bruise on his/her forehead right between the eyebrows. The surveyor did not see a chair alarm on Resident #3's wheelchair. Review of Resident #3's care plan dated 12/20/17 on 5/22/19 at 12:57 revealed that Resident #3 is at risk for injury/fall due to impaired mobility, visual deficit, history of fall, and medication regiment. Interventions dated 12/31/18 included Pressure pad chair alarm. Check function and placement q (every) shift. Review of Resident #3's Fall-risk screening on 5/22/19 at 12:18 PM, revealed Resident #3 is at high-risk for falls. Resident #3 scored a 14 (high-risk) on the fall-risk screening done on 12/31/18, a 16 (high-risk) on 2/13/19, a 14 (high-risk) on 5/7/19 and a 16 (high-risk) on 5/18/19. An incident report for Resident #3 was reviewed on 5/22/19 at approximately 3:25 PM revealed that on 5/18/19 Resident #3 was found on the floor in his/her room, lying in front of his/her wheelchair. Review of Resident #3's nurse's note date 5/18/19 revealed Resident was attempting to get into (his/her) bed from (his/her) wheelchair. (S/he) fell and sustained a small skin tear to the bridge of (his/her) nose, and a moderate sized know between (his/her) eyes . Review of Resident #3's Fall investigation dated 5/18/19 revealed the boxes for Tab alarm bed and Tab alarm chair were checked as not present and not working. During an interview with the director of nursing (DON) on 5/24/19 at approximately 2:00 PM, s/he acknowledged that the facility did not provide proper supervision to Resident #3, who is high-risk for fall, has impaired mobility, and visual deficit. The facility did not ensure that the resident had the devices (bed and chair alarms) in placed or functioning properly to alert the staff when (s/he) tried to transfer without assistance. The facility admitted Resident #137 on 12/17/17 with [DIAGNOSES REDACTED]. On 05/22/19 at 11:37 AM, review of Resident #137's Care plan revealed Risk for injury/falls was identified as a problem on 12/07/17 with an intervention for a pressure pad bed alarm added to the care plan on 01/31/18. On 05/22/19 at 11:37 AM, review of Resident #137's Care plan dated 12/7/17 revealed Risk for injury/falls was identified as a problem with an intervention for a pressure pad bed alarm. On 05/22/19 at 04:41 PM, review of the Incident Investigations related to Resident #137's falls revealed the following documentation: 01/09/19 Bed alarm present and in use but documented as not working 01/12/19 Bed alarm present and in use but not working 01/17/19 Bed alarm present and in use but documented as not working 03/20/19 Bed alarm present and in use but not working. During an interview on 05/22/19, the Director of Nursing (DON) and the QA (Quality Assurance)/ Risk Manager confirmed the findings that the bed alarm was not working at the time of falls on 01/09/19, 01/12/19, 01/17/19, and 03/20/19. They reported that the alarm was positional noting that Resident #137 moves around in the bed and moves off of the pressure pad alarm. The DON further stated that because the resident weighs 110 pounds that the pressure pad alarm is not activated when the resident was placed in the bed, so it doesn't alarm when the resident moves off of the pad alarm. The DON stated they have tried other measures and updated the care plan with other measures. The DON nor the QA/ Risk Manager would confirm or deny the effectiveness of a pressure pad alarm. Observations of Resident #137 on 05/22/19 at approximately 04:00 PM revealed the call light to be hanging behind the bed and not within reach of the resident. Observations of Resident #137 on 05/23/19 at approximately 08:00 AM when the resident stated s/he didn't have a call light. CNA (Certified Nursing Assistant) #3 confirmed the call light was hanging behind the bed and that the resident was not able to reach it on 05/23/19.

Based on record review, observations, and interview the facility failed to ensure cleaning of oxygen filters daily and as needed for Resident #84 and Resident #192. 2 of 3 residents reviewed for oxygen. The findings included: Resident #192 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. and Chronic pain. Care Plan review for Resident #192 documented interventions to provide Oxygen as ordered and to maintain equipment per orders. The care plan was noted with a problem onset date of 5/23/2017 with updated interventions for the oxygen equipment orders on 1/22/2019. Review of Physicians orders for Resident #192 revealed a Physician order [REDACTED]. Observations of the dirty/dusty filters was conducted on 05/21/19 at 02:50 PM in Resident #192's room, and on 5/22/19 at 09:55 AM in the resident's room. Observations of a moderate amount of dust were easily observed from the resident's doorway and closer observations at the bedside to confirm the buildup of dust/dirty oxygen concentrator filters. During an interview with LPN #4 on 5/22/19 at 11:01 AM s/he confirmed with observation the dirty oxygen filter. The nurse immediately went to clean the dirty filter. LPN #4 confirmed the care plan interventions and physicians orders to clean daily and prn. Resident #84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Care Plan review for Resident #84 on 5/22/19 at 10:31 AM documented interventions to provide Oxygen as ordered, change filter per facility protocol, and administer oxygen as prescribed by physician. The care plan was noted with a problem onset of 1/22/2018 with updated interventions for the oxygen orders and cleaning of the oxygen filters on 3/26/2019. Review of physician's orders [REDACTED]. Resident #84 requires oxygen continuous via nasal cannula at 3 liters per minute. Observations of the dirty/dusty filters for resident #84's oxygen concentrator filters were performed on 05/20/19 at 12:26 PM, 5/20/19 at 03:14 PM, 5/21/19 at 02:45 PM and on 5/22/19 at 10:21 AM at the bedside of Resident #84. On 05/22/19 at 10:56 AM the dirty/dusty filters were observed and confirmed with LPN #3, the nurse immediately removed the dirty filter for cleaning. LPN #3 also confirmed the physician's orders [REDACTED].

Based on observations, interview, and review of the facility policy, the facility failed to follow a procedure to ensure that expired medications were removed from 2 of 5 medication storage rooms reviewed for medication storage. Expired insulin was in the unit 2 and unit 4 medication storage room refrigerators. The findings included: On 5/20/19 at 11:45 AM, an observation of the unit 4 medication storage room refrigerator with Licensed Practical Nurse (LPN) #1 revealed (1) vial of [MEDICATION NAME] R insulin with a hand written puncture date of 11/10 on the vial. There was a pharmacy delivery date of 6/28/18 which was stamped on the vial. On 5/20/19 at 11:50 AM, and interview with LPN #1, s/he verified the [MEDICATION NAME] R insulin was expired. On 5/20/19 at 12:05 PM, an observation of the unit 2 medication storage room refrigerator with LPN #2 revealed (1) vial of [MEDICATION NAME] R insulin with a hand written puncture date of 5/4/18, The vial expiration date stamped on the vial was 10/20/18. The pharmacy delivery date which was stamped on the vial carton revealed the vial was delivered on 10/17/17. On 5/20/19 at 12:10 AM, during an interview with LPN #2, s/he verified the [MEDICATION NAME] R insulin was expired. Review of the facility policy, 4.1 Storage of Medications, revealed under (O.) Insulin products should be stored in the refrigerator until opened. Note the date on the label for insulin vials and pens when first used/punctured. The opened vial of insulin may be stored in the refrigerator or at room temperature . Also, (P.) states, Outdated, contaminated, frozen or deteriorated medications and those in containers that are cracked, soiled, or without secured closures are removed from stock, disposed of according to procedures for medication destruction, and reordered from the pharmacy, if a current order exists.

Based on interview and record review the facility failed to ensure staff followed protocol for caring for difficult and combative residents. Certified Nursing Aide (CNA) #1 did not call for assistance or pause care when Resident #19 became combative, resulting in accidental or inadvertent physical contact for 1 of 1 resident reviewed for abuse. The findings included: Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Facility Investigation on 4/17/18 at approximately 10:21 AM revealed the Resident #19 was combative while CNA #1 was obtaining vitals. The CNA inappropriately touched the resident's face. The resident was assessed with [REDACTED]. At the completion of the investigation it was determined that CNA #1 inappropriately touched the resident and was dismissed. Review of Facility Interviews on 4/17/18 at approximately 11:47 AM revealed CNA #2 entered the room of Resident #19 to assist CNA #1. S/he observed the CNA to grab the nose of the resident when s/he became combative and then slap the resident as s/he continued to be obstreperous. Facility Interview of CNA #1 confirmed s/he slapped the resident accidentally. Interview with CNA #2 4/17/18 at approximately 4 PM confirmed that she entered the room of Resident #19 to assist CNA #1. S/he witnessed the CNA grab the resident's nose when s/he became combative. When the resident continued to fight the CNA, s/he slapped the resident. CNA #2 confirmed the resident appeared unharmed. She confirmed she had never had prior care concerns from CNA #1. Abuse prohibition interviews were conducted throughout 4/19/18 with nursing staff. There were no concerns. All CNAs stated that if handling an obstreperous resident they would ensure safety, withdraw, ask for assistance, and reapproach. Interview with Director of Nursing (DON) on 4/19/18 at approximately 4:20 PM revealed CNAs were expected to walk away and/or ask for assistance when providing care to obstreperous residents. Review of policy for Catastrophic Reactions on 4/19/18 at approximately 7 PM revealed staff is to Prevent escalation by backing off. If the resident does not present a danger to themselves or to others, observe them from a distance and allow them to settle down without intrusion before proceeding further.

Based on record review and interview, the facility failed to complete a Significant Change in Status Assessment (SCSA) in a timely manner for 1 of 1 resident reviewed for bowel and bladder incontinence. The facility did not complete the SCSA within 14 days following identification of decline in two areas for Resident #82. The findings included: The facility admitted Resident #82 with [DIAGNOSES REDACTED]. Further review of the medical record on 4/19/18 at 12:14 PM revealed that on the comprehensive Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 8/11/17. Section G on the MDS with ARD of 8/11/17 was coded to reflect resident was independent with no assistance needed for transfers. Further review revealed Section H of the MDS with ARD of 8/11/17 was coded to reflect the resident was occasionally continent of both bowel and bladder. Review of the quarterly MDS with ARD of 11/10/17 revealed that there was a decline in function coded in sections G&H. The resident was coded to reflect that s/he was totally dependent upon staff for transfers and needed assistance from two or more staff members for the task. Additionally, s/he was coded as being totally incontinent of bowel and bladder. Review of the MDS assessments indicated that a SCSA was not initiated within 14 days of the identification of the declines in sections G and H at the time the quarterly MDS was completed as required. During an interview on 4/19/18 at 12:56 PM, MDS nurses #1 & #2 reviewed the MDS assessments with ARD's of 8/11/17 and 11/10/17 and confirmed that Resident #82 had a decline in two areas of their assessment and a SCSA was not completed at the time of the review for the quarterly MDS and that it was an oversight.

Based on record review and interview, the facility failed to complete/ encode Minimum Data Set (MDS) 3.0 information within required 7 day timeframe as required by CMS (Centers for Medicare and Medicaid Services) and the State for 3 of 3 residents identified as not having assessments completed within 120 days. The findings included: Resident #5 expired in the facility on [DATE]. A death in facility tracking form with ARD (Assessment Reference Date) of [DATE] was signed as being complete by MDS Nurse #1 on [DATE], which was not within the 7 day time frame mandated by regulatory guidelines. During interview on [DATE] at 11:22 AM, MDS Nurse #1 verified that the assessment completed was completed late. Resident #1 expired in the facility on [DATE]. A death in facility tracking form with ARD (Assessment Reference Date) of [DATE] was signed as being complete by MDS Nurse #1 on [DATE], which was not within the 7 day time frame mandated by regulatory guidelines. During interview on [DATE] at 11:22 AM, MDS Nurse #1 verified that the assessment completed was completed late. Resident #2 expired in the facility on [DATE]. A death in facility tracking form with ARD (Assessment Reference Date) of [DATE] was signed as being complete by MDS Nurse #1 on [DATE], which was not within the 7 day time frame mandated by regulatory guidelines. During interview on [DATE] at 11:22 AM, MDS Nurse #1 verified that the assessment completed was completed late.

Based on observation and interview, the facility failed to remove expired food items from storage and serve food under sanitary conditions for 1 of 1 kitchen. Opened, unlabeled, and expired food items were found in dry storage. Soiled equipment and general cleanliness in main kitchen. The findings included: Observation in the kitchen on 01/23/2017 at 11:30 AM with the Kitchen Manager revealed trash on the floor of the main kitchen and dry storage, grease on the floor surrounding the deep fryers (not in use) in the main kitchen, built up substance in floor corners in the main kitchen, dried spilled substance on stove and ovens in the main kitchen, ripped bag of grits on shelf that had spilled onto other shelves in dry storage, an expired bag of pasta in dry storage that was verified by Kitchen Manager, and a bag of pasta in dry storage that was not labeled and had been opened was verified by the Kitchen Manager. Observation on 01/25/2017 at 11:30 AM revealed trash on the floor, grease on the floor surrounding the fryers not in use, built up substance in floor corners, dried spilled substance on stove and ovens, spilled substance on floor, and dried spills on appliances. Observation on 01/26/2017 at 09:40 AM revealed dried spilled substance in the microwave on Ward 601. Observation on 01/26/2017 at 09:45 AM revealed dried spilled substance in the microwave on Ward 602 which was verified by Ward Clerk #1.

Based on interview and record review the facility failed to notify the responsible party of changes in treatment for 1 of 1 sampled resident reviewed for notification of change. The responsible party for Resident #32 was not notified of a change in treatment. The findings included: The facility admitted Resident #32 with [DIAGNOSES REDACTED]. During on 1/24/2017 at 3:44 PM the responsible party stated that she/he had not been notified by staff that the Resident's [MEDICAL CONDITION] had been discontinued. A record review on 1/24/2017 revealed a physician's orders [REDACTED]. During an interview on 01/25/2017 at 2:35 PM, the Assistant Director of Nursing (ADON) verified that no family notification was documented for the discontinued [MEDICAL CONDITION]. During an interview on 01/25/2017 at 2:59 PM, the Director of Nursing (DON) reviewed Resident #32's chart and stated that she/he could not find documentation of family notification. During an interview on 01/25/2017 at 3:03 PM, the DON stated that it was policy that the facility notify the responsible party when there was a change in treatment and medication in a timely manner.

Based on observation and interview expired medications were found in Medication Room on Unit 605. ( 1 of 3 units checked) The findings included: Medication Room on Unit 605 was checked with LPN # 1 (Licensed Practical Nurse) for Stock medications on 1/26/17 at 10:40 AM. 100 tablets of Zinc Sulfate 220mg (milligrams) were found in stock medication storage room labled as expired 7/6/16. Stock meds are checked monthly for expiration dates. These expired meds had been in the stock med cabinet since 7/6/16 until discovered on 1/16/17. Licensed Practical Nurse # 2 also confirmed that the medications had not been removed as they should have been.

Based on review of facility files and interview, the facility failed to thoroughly investigate an injury of unknown origin. The facility failed to obtain statements from all staff who worked with Resident #1 prior to discolorations on the resident being reported. The facility's Abuse Policy included procedures to interview and obtain statements from staff assigned to the resident 24 to 48 hours prior to the incident. One of one residents reviewed for reportable incidents. The findings included: The facility reported an injury of unknown source for Resident #1 to the State Agency on 7/12/16. Resident #1 was noted to have discoloration to the right upper back. Review of Resident #1's Nurses' Notes dated 7/11/16 indicated the Certified Nursing Assistant (CNA) notified the nurse to come to the shower room. Upon assessment of the resident, the nurse noted 2 discolorations. One to the right upper back 9 cm x 6 cm oval shaped purple in color with yellow border. The second area was a discoloration to the right elbow 5 cm x 4.5 cm circular/purple in color with a scab in the center. During the complaint investigation the surveyor requested a copy of the facility's complete investigation into the incident for Resident #1 on 7/11/16. Review of the investigation revealed there was no statement from CNA #1, who was assigned to the resident on 1st shift on 7/9/16 and 7/10/16. Further review of the investigation revealed there was no statement from CNA #2, who was assigned to the resident on 3rd shift on 7/10/16 or CNA's #3 and #4 who were assigned to the resident on 3rd shift on 7/9/16. Review of the facility's Abuse Policy revealed a section for investigation that indicated it was the policy of the facility to thoroughly investigate all alleged mistreatment, neglect and abuse, and have evidence that all allegations were thoroughly investigated. Procedures for investigation included to identify, if possible, the date of the alleged abuse. Procedures also included to interview and obtain written statements from staff assigned to the resident at the time of the alleged incident, and staff caring for the resident prior to the alleged incident (24 to 48 hours prior to the alleged incident). In an interview with the surveyor on 10/3/16 at approximately 2:55 PM, the Director of Nursing (DON) stated s/he reviewed the statements and did not see statements from the 3rd shift CNA or the 1st shift CNA who worked on 7/10/16. The process was to interview all staff that worked on that unit 48-72 hours prior to the incident. The DON stated s/he was not sure what would have happened to their statements. Normally they would document if they talked with the staff on the phone and did not have written statements.

Based on personnel record reviews and interview, the facility failed to ensure that 3 of 6 staff nurses ' licenses/qualifications were verified prior to hire. The findings included: The personnel records of 3 Licensed Practical Nurses (LPNs) hired since 11-1-14 were reviewed on 2-11-16. Two of the 3 LPNs had no evidence of license verifications prior to hire. The personnel records of 3 Registered Nurses (RNs) hired since 11-1-14 were reviewed on 2-11-16. One of the 3 RNs had no evidence of license verification prior to hire. During an interview at 5:20 PM on 2-11-16, the Human Resource Director stated s/he was unable to locate the missing license verifications.

Based on observations, interviews and review of the facility's policy entitled Pharmacy Services, the facility failed to ensure that medications were stored properly to prevent contamination on Ward 605 and Ward 603. Two of 10 medication carts observed for medications, contained medications with open packages or placed in an open medication cup. The facility also failed to maintain sterility of treatment medications and/or dressing supplies on 4 of 5 treatment carts on Ward 601, 602 , 603 and 604. The findings included: On Ward 605 on [DATE] at 5:13 PM, 7 small yellow tablets with a heart on the center of the tablet was observed in the top drawer of a medication cart, in a small clear medication cup uncovered. In an interview at that time with Licensed Practical Nurse (LPN) #2, the LPN identified the tablets as Enteric Coated 81 milligram (mg) Aspirin tablets. The nurse stated that they ran out of the medication on Sunday and borrowed them from the other cart. The LPN verified that they had been in the cup open to air and unlabeled since Sunday. The LPN stated that they had forgotten to reorder the Aspirin. The nurse did not remove the EC ASA from the cart prior to the surveyor leaving the area. On [DATE] at 8:45 AM, the 604 Ward Treatment Cart was noted to have 1- 4 X 4 Hydrophilic Sterile Foam Dressing with the package open and the dressing partially used; ,[DATE] X 9 Sterile Xeroform Occlusive Gauze Strip, package opened and the dressing partially used. LPN #3 verified that the items were sterile items and had been opened, partially used and placed back in the cart. On the 603 Ward at approximately 9:30 AM on [DATE] the Treatment Cart contained, ,[DATE] gram container of Nystatin Powder; 1000,000 units/gram- opened with no lid, 1- 60 gram tube Desonide Ointment 0.005% with no lid on the tube, 1- 4 X 5 Aquacel Extra AG- opened and partially used, ,[DATE] X 2 Algidex- opened and partially used, ,[DATE] X 4 ,[DATE] Fibracol Plus- opened and partially used; ,[DATE] X 4 Hydrophilic Dressing, opened, partially used; 2 Foam type dressings, opened and partially used; and 1 Flexicol 4 X 4 dressing, opened, partially used. The medication Cart 2 on the 603 Ward contained 10 Vitamin B-1,000 unit tablets with the package torn and leaving the medications open to air. The items in the treatment cart were verified as sterile items which should not be partially used and placed back in the cart by Registered Nurse (RN) #1. The RN also verified the medications in the medication cart had been left open to air in torn packages at the time of the observation. On [DATE] at 12:01 PM on Ward 601, the treatment cart contained ,[DATE] ounce bottle- 70% rubbing alcohol with an expiration date of ,[DATE], 1-Triamcininalone Acetonide 0.1% cream with no lid on the tube,1-Vasolex ointment- 60 grams- no top on the tube and with an expiration date of "Expiration ,[DATE]". The Assistant Director Of Nursing was present when the items were noted and removed them at that time. On Ward 602 on [DATE] at approximately 9:00 AM, the medication room had ,[DATE] ounce strawberry glucerna shakes with an expiration date of [DATE]. The treatment cart contained ,[DATE] ounce tube Biofreeze which expired ,[DATE]. LPN #4 verified the items expiration date and stated that the family had brought the items to the facility and that they would have to check dates when they were brought in. Review of the facility's policy entitled Pharmacy Services provided by the Director Of Nursing (DON) on [DATE] at approximately 8:35 AM indicated "...Storage Of Medications On Wards. A. All medications on ward are to be kept and stored in the original containers as received from the Pharmacy. Any alterations of the labels or transferring of medications between containers is specifically prohibited. The DON when interviewed stated that the facility had no policy or procedure related to the maintenance of medications or dressing supplies in the treatment carts.