Every finding on record at Rock Hill Post Acute Care Center

Based on interview, record review, and facility document and policy review, the facility failed to protect a resident's property from misappropriation for one of three residents (Resident (R) 96) reviewed for resident rights out of a total sample of 23. This failure had the possibility of negatively impacting all residents residing at the facility due to residents' property not being safeguarded against theft. Findings include: Review of the facility's Inservice Attendance Record, dated 04/04/25, indicated, Course Title: Resident Reported Theft/Loss . Subject: Theft/Loss by Residents: Theft of patient property is a form of abuse and should be reported to facility administration immediately. If the theft/loss is greater than $50.00 a police report must be filed. Employees could be subject to termination and/or legal consequences if found guilty of theft of resident property regardless of declared value .Review of the facility's policy titled, Abuse Prevention and Prohibition, dated 09/2023, indicated, . It is the policy of this facility that each resident has the right to be free from abuse, neglect, and misappropriation of resident property, and exploitation . Investigation: All identified events are reported to the Administrator/Designee immediately and will [be] thoroughly investigated . The facility will analyze occurrences and determine what changes are needed, if any, to the policies and procedures to prevent further occurrences . Review of R96's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R96 was originally admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of type II diabetes, traumatic subdural hemorrhage, cognitive communication deficit, heart failure, fatty liver, dementia, major depressive disorder, Alzheimer's disease, and osteoporosis. R96 was discharged from the facility on 09/05/25. During R96's stay at the facility she resided on Hall 100. Review of R96's undated Inventory of Personal Effects indicated an inventory was taken of R96's personal effects that included: five blouses, five brassieres, two dresses, one pair of eyeglasses, three pajamas, five shirts, two shoes, and five socks. A staff member did not sign the inventory. There was no jewelry listed on this inventory sheet. Review of R96's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) date of 09/03/25 and located under the RAI (Resident Assessment Instrument) tab, indicated R96 required set up assistance for eating and oral hygiene; partial/moderate assistancefor upper body dressing and personal hygiene; and substantial/moderate assistance for bed mobility, toileting hygiene, lower body dressing, and bathing. The MDS indicated R96 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated R96 was cognitively intact. Review of R96's Progress Note, dated 06/30/25 and located in EMR under the Progress Notes tab and written by Licensed Practical Nurse (LPN) 4, indicated, . Rt [resident] stated that on Friday night a young black lady told her that her fingers were swollen and that she needed to remove her rings and she would put them up. Called husband to verify that she returned to the facility with her rings on as well as verified with [Licensed Practical Nurse (LPN)3]. [LPN3] and I did do a thorough search of the room and did not find the rings. Also verified if rt recognized us as we were her nurses that night. Statement was made and filled out by CNA [Certified Nursing Assistant] who the rings were reported missing to as well as myself and [LPN3].Review of R96's Progress Note, dated 07/01/25 and located in EMR under the Progress Notes tab, indicated, SS [Social Services] called and made a police report about residents missing rings. Talked with officer . Case Id# is 2507010020 .Review of the facility's investigation regarding R96's missing rings indicated a written statement by LPN3, dated 07/01/25, which indicated, I . did the admission assessment on [R96] when she returned from the hospital on [DATE]. During her skin assessment, she was noted with two rings on her left ring finger, both gold in color . The rings were included in her inventory upon admission. I was also the nurse working the floor from 7:00 PM until 11:00 PM. Unfortunately, I did not pay attention to whether or not the rings were still on during that time. On Monday, June 30th at 1745 [5:45 PM], I was informed by the floor nurse . that [R96] stated her wedding ring was missing. I immediately informed my supervisor . searched [R96]'s room with [LPN4]. Still unable to locate rings . Review of the facility's investigation regarding R96's missing rings indicated an undated written statement by LPN4 which indicated, I . worked with R96 the night of June 27th from 11-7a but I did not notice if the resident was or was not wearing any rings .Review of the facility's investigation form titled, Five-Day Follow-Up Report, dated 07/07/25, indicated, . Immediate corrective action/assessment following Reportable Incident: Resident room searched, husband notified on details of police investigation. Showed resident pictures in an attempt to identify who asked her to remove her rings due to her fingers swelling, but she was unable to positively identify anyone . Interventions by Facility to prevent future Injury/Alleged Abuse: Facility has posted signage around the building and in resident rooms encouraging residents to send valuables home. Facility also acquired a safe and created a process for nursing to log and secure any valuables that resident is unbale to send home but wants stored at the facility. Summary Report of Facility Investigation: The facility does feel that this was a case of theft, but unable to prove who or exactly when the theft occurred .During an interview on 09/11/25 at 9:25 AM, the Administrator stated they now discourage Residents from bringing jewelry into the facility. The Administrator stated they posted signs around the facility about not keeping jewelry on site. The Administrator stated they hadpurchased a safe to enable them to store resident's jewelry securely. The Administrator said it was difficult to prove a case of theft.During an interview on 09/11/25 at 9:36 AM, Resident Representative (RP) 96 stated R96 had to go to the hospital for eight or nine days, and when R96 returned to the facility [R96] said some lady told her she needed to take the rings off due to her hands swelling. RP96 stated the following day a friend of R96 came to visit R96, and R96 asked her to locate the rings but she was unable to find them. RP96 stated the facility did make a police report and did show R96 pictures of staff that was working during that night. RP96 stated the facility staff had not offered any form of compensation for the missing rings. RP96 explained he had purchased replacement rings for R96. During an interview on 09/11/25 at 12:30 PM, the Director of Nursing (DON) confirmed he was involved with the investigation of R96's missing rings. The DON explained initially R96's room was searched, and after the rings were not located in R96's room or at her home, a report was made to the police department, staff was interviewed, and additional residents were interviewed. The DON stated as a result of the missing property, they put into place that the admission coordinator will discourage new residents from bringing jewelry with them into the facility. The DON also stated that during the admission process, when the Resident Inventory is being completed, there was now going to be a focus on jewelry items, and the documentation will be more detailed. The DON stated he watched hours of camera footage of people going in and out of R96's room but did not see anything out of the ordinary. During an interview on 09/11/25 at 1:45 PM, Occupational Therapy Assistant (OTA) confirmed he was familiar with R96 but did not remember if R96 had any rings on during her stay at the facility. During an interview on 09/11/25 at 1:55 PM, Speech Therapist (ST) 1 stated she was familiar with R96 but did not recall if R96 was wearing any rings.During an interview on 09/11/25 at 2:00 PM, Case Manager (CM) stated she did not remember seeing rings on R96's hand. CM stated R96 was admitted to the hospital and wondered if the rings were misplaced at the hospital.During an interview on 09/11/25 at 2:05 PM, CNA1 stated she was close to R96 and confirmed that R96 was wearing rings during her stay at the facility.During an interview on 09/11/25 at 2:15 PM, R96 stated on the night of the incident, someone told her to remove her rings due to her hands swelling. R96 stated she could not remember who the person was. R96 confirmed the facility staff did not offer any type of compensation for the missing rings.

Based on observations, interview, and facility policy review, the facility failed to administer medications in a manner to prevent cross-contamination for five out of six residents (Resident (R)14, R65, R87, R97, and R98) observed during medication administration. This had the potential to cause the spread of infection in the facility.Findings: Review of facility's undated policy titled, Infection Control Prevention and Control Program - Hand Hygiene revealed, . This facility considers hand hygiene the primary means to prevent the spread of infections . 3. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations:a. When hands are visibly soiled; and . 4. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations:a. Before and after coming on duty;b. Before and after direct contact with residents;c. Before preparing or handling medications .l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident;m. After removing gloves .5. Hand hygiene is the final step after removing and disposing of personal protective equipment6. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections . Review of undated policy titled, Medication Administration, revealed, . Hand hygieneLicensed nurse will foam in and out between residents unless resident is under enteric contact precautions or hands are visibly soiled then licensed nurse will wash hands with soap and water . 1. On 09/11/25 at 8:30 AM, Registered Nurse (RN) 1 was holding a cup of R97's medications. One pill accidentally dropped on the floor, and RN1 immediately picked it up with a bare hand, discarded the pill in the trash receptable of the medication cart, and failed to perform hand hygiene after. RN1 walked into R97's room holding the medication cup and gave the medications to R97. RN1 walked away to retrieve a replacement for the pill that was dropped. 2. On 09/11/25 at 9:06 AM, RN1 was dispensing a pill into a medication cup. RN1 dropped the pill on the medication cart. RN1 picked up the pill with a bare hand and placed it back in the medication cup. RN went ahead to give the pill to R98. During an interview on 09/11/25 at 9:09 AM, RN1 stated he had sanitized the medication cart at the beginning of medication pass and did not need to discard the medication. 3. On 09/11/25 at 9:10 AM, RN performed hand hygiene and donned a pair of gloves to administer eye drops to R65. On 09/11/25 at 9:12 AM, RN1 exited R65's room, wearing the same gloves. RN1 discarded the gloves in the medication cart's trash receptacle. RN1 did not perform hand hygiene. RN1 touched his computer mouse, keyboard, reached into his pocket for cart keys, opened the medication cart, and continued to dispense medications for the next resident (R87). 4. On 09/11/25 at 9:13 AM, without performing hand hygiene, RN1 entered R87's room with a cup of medications. R87 requested that his big pills be broken into two. On 09/11/25 at 9:18 AM, RN1 donned a pair of gloves while in R87's room without first performing hand hygiene, returned to the medication cart, broke some pills in the medication cup in two, and returned to R87's room to give the medications to R87. At 9:22 AM, wearing the same gloves, RN1 exited R87's room, doffed his gloves, and did not perform hand hygiene. 5. On 09/11/25 at 9:23 AM, RN1 touched the medication cart, the computer keyboard, mouse, and some paperwork on the cart. RN1 reached into his pocket for cart keys, opened the cart, and retrieved medications from the medication cart. RN1 accidentally dropped three pills on the medication cart. RN1 retrieved the pills with a bare hand and returned the pills into a medication cup. At 9:26 AM, RN1 entered R14's room and gave R14 the medications that had been picked off the medication cart. RN did not perform hand hygiene before entering R14's room. On 09/11/25 at 9:26 AM, RN1 performed hand hygiene upon exiting R14's room.During an interview on 09/11/25 at 9:28 AM, RN1 stated he had been performing hand hygiene. When told that he had entered several resident's rooms without performing hand hygiene, had donned and doffed gloves without performing hand hygiene, had not performed hand hygiene in between residents' rooms, and had picked up dropped pills with bare, unwashed hands, RN1 acknowledged these observations. During an interview on 09/11/2025 at 3:31 PM, the Infection Preventionist (IP) stated it was her expectation forRN1 to perform hand hygiene before donning and after doffing gloves. The IP stated RN1 should not have picked up dropped medications with bare hands and should have discarded dropped medications and not put them back in the medication cup for administration.

Based on review of observations, interviews, record review and facility policy, the facility failed to administer oxygen consistent with professional standards of practice for 1 of 1 residents reviewed for respiratory care, Resident (R)21. Findings include: Review of the facility's policy titled, Infection Control Policy/Procedure, Subject: Oxygen, Use of with revision date 05/2021 revealed, Policy: It is the policy of this facility to promote resident safety in administrating oxygen. Procedures: The following guidelines will be observed in oxygen administration. 1. The O2 cannula or mask will be changed at least every 7 days, as well as the disposable humidifier. Tubing, masks, humidifiers and other disposables used for oxygen administration will be changed weekly or as needed. Review of R21's Electronic Medical Record (EMR) revealed R21 was admitted to the facility on [DATE] with diagnoses including but not limited to: chronic diastolic (congestive) heart failure, atrial fibrillation, and dependence on supplemental oxygen. Review of R21's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 08/12/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R21 has cognition intact. Review of R21's Care Plan documented, Focus: Date Initiated 08/13/24 . has potential for significant wt changes and altered nutritional status r/t dx of cutaneous abscess of abdominal wall, sepsis, ascites, chronic CHF, PCM, muscle weakness, O2 dependent, bacteremia, hx of TIA, Vit D deficiency, MDD, A-fib, HTN, CKD 3, wound, and variable intake. Goal Target Date: 10/31/24 Will maintain adequate nutritional status as evidenced by maintaining weight with no s/sx of malnutrition through review date. Interventions Date Initiated: 08/13/24 Administer medications as ordered. Monitor/Document for side effects and effectiveness. Review of R21's Physician Order documented, CHANGE O2 TUBING, H2O BOTTLE EVERY WEEK ON WEDNESDAY every night shift every Wed. During an observation of R21's room on 08/13/24 at 1:06 PM oxygen was observed via nasal canula at 2L/min. with tubing not labeled. During an interview on 08/13/24 at 1:13 PM, Licensed Practical Nurse (LPN)1 was asked to view the electronic medication administration record (eMAR) to confirm the oxygen rate of 2L/min and to confirm the order for changing tubing. Order for tubing change revealed it was to be weekly on Wed. nightshift. On 08/07/24 the eMAR was observed as signed by a nurse as completed. During an observation and interview on 08/13/24 at 1:15 PM, LPN1 confirmed in the room that the oxygen tubing was not dated. LPN1 agreed that it looked like it was signed as being completed per the order but evidence at the bedside did not support as tubing was observed without a date. LPN1 stated she would change the tubing and label. During an interview on 08/15/24 at 3:36 PM the Director of Nursing (DON) stated the expectation for ensuring that orders for changing oxygen tubing would be to follow the order. Evidence of following the order would include documentation in Point Click Care (PCC), and for some items it would be to date the tubing.

Based on observations, facility policy, and interviews, the facility failed to remove expired biologicals in 1 of 2 medication storage rooms. Findings include: Review of the facility policy titled, Storing and Controlling Medications dated ,d+[DATE] revealed, Policy: It is the policy of this facility to: 1. Store medications safely, securely, and properly following manufacturer's recommendations or those of the supplier, and in accordance with federal and state laws and regulations .Procedure: 9. Medications that are discontinued, expired .are immediately removed from the locked medication storage area and disposed of in accordance with the facility policies and procedures. During an observation on [DATE] at 8:40 AM on Unit one (1) medication storage room revealed the condition of the following biological: 1. One (1) Red top BD Vacutainer with lot number 3025477 and expiration date of [DATE]. During an observation and interview on [DATE] at 8:40 AM the Director of Nursing (DON) verified the medication supply was expired.

Based on review of the facility policy, observation, interview, and record review, the facility failed to ensure that 1 of 5 residents (Resident (R) 70) reviewed for potential accidents related to bed rail use was care planned for bed mobility and positioning with bed rails. The failure to address the use of bed rails in the comprehensive care plan could increase the risk for falls, entrapments, and injuries related to the facility's use of bed rails for vulnerable residents. Findings include: Review of the facility policy titled Subject: Developing Baseline and Comprehensive Care plans, revised 02/2018, showed: Policy: It is the policy of this facility to develop and implement both a baseline care plan and a comprehensive care plan for each resident prepared by the interdisciplinary team Procedure: a. The facility will develop and implement a baseline care plan within 48 hours of admission including but not limited to: i. Initial goals based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] ii. Physician orders iii. Dietary orders iv. Therapy services v. Social Services vi If applicable, PASARR recommendations b. The facility will develop the comprehensive care plan within 7 days after completion of the comprehensive assessment. Review of the Resident Assessment Instrument [RAI] Manual, October 2017 edition, page G-2 showed: Planning for Care Individualized care plans should address strengths and weakness, possible reversible causes such as deconditioning, . These may contribute to needless loss of self-sufficiency. -For some residents, cognitive deficits can limit ability or willingness to initiate or participate in self-care or restrict understanding of the tasks required to complete ADLs . Individualized care plans should be based on an accurate assessment of the resident's self-performance and the amount and type of support being provided to the resident. -Many residents might require lower levels of assistance if they are provided with appropriate devices and aids, . This type of supervision requires skill, time, and patience. Page G-3 Activities of Daily Living Definitions A. Bed mobility: how resident moves to and from lying position, turns side or side, and positions body while in bed or alternate sleep furniture. Page 4-9 and 4-10 The care plan is driven not only by identified resident issues and/or conditions but also by a resident's unique characteristics, strengths, and needs. A care plan that is based on a thorough assessment, effective clinical decision making, and is compatible with current standards of clinical practice can provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents. A well developed and executed assessment and care plan: -Looks at each resident as a whole human being with unique characteristics and strengths; -Views the resident in distinct functional areas for the purpose of gaining knowledge about the resident's functional status (MDS); . Observation of R70 on 08/07/22 at 4:53 PM showed him dressed and sleeping on top of his bedding with bilateral upper quarter bed rails. During an observation and interview on 08/08/22 at 8:51 AM, R70 was dressed and seated at the bedside, bilateral upper rails in place. At 8:57 AM, R70 was asked if he used his side rails and responded that he did use them when in bed. Review of R70's Admission Record from the electronic medical record (EMR) Profile tab showed an original admitted [DATE], and readmitted s of 06/10/20 and 06/23/21, with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R70's EMR Orders tab showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R70's EMR Assessments tab showed LN [Licensed Nurse] - Restraint / Enabling Device / Safety Device Evaluation. showed the assessment for bed/side rails was completed on 06/24/22 with a recommendation for bilateral quarter side rails for bed mobility and positioning. Previous evaluations were completed on 03/24/22, 12/24/21, 09/24/21, 06/24/21, 06/12/20, and 02/11/20. A review of R70's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/11/22, showed a Brief Interview for Mental Status (BIMS) score of 15, indicative of cognitively intact; with a Bed mobility assessment of extensive physical assistance of one person. R70's annual MDS with an ARD of 06/01/22, showed a BIMS score of 14, indicative of being cognitively intact; with a Bed mobility assessment of limited assistance of one person. R70's 5-day readmission MDS with an ARD of 08/01/22, showed a BIMS score of 12, indicative of mild cognitive impairment; with a Bed mobility assessment of independent with set up help only. Review of R70's care plan from the EMR Care Plan tab showed: Focus: [Res Name] has ADL [Activities of Daily Living] Self Care Performance Deficit r/t [related to] Limited Mobility r/t [CONDITION(S)] [cerebral vascular accident] with right [CONDITION(S)]. He has a hx [history] of cerebral aneurysm. Date Initiated: 06/24/2021 Revision on: 05/26/2022 Goal: Will have ADL needs met with staff assist AEB [as evidenced by] neat clean appearance through the review date. Date Initiated: 06/24/2021 Revision on: 06/13/2022 Target Date: 09/01/2022 Interventions: -Converse with resident while providing care. -Explain all procedures/tasks before starting. -Offer masks QD [daily] and as needed -Pt to wear R arm sling when OOB, for RUE support and positioning, as tolerated by Patient -Right arm sling as indicated and tolerated -Therapy evaluation and treatment as per MD orders. -Encourage to participate to the fullest extent possible with each interaction. -Assist with transfers, dressing, grooming, toileting, and bathing QD and as needed. Further review did not show any care plan regarding bed mobility. During an interview on 08/08/22 at 3:15 PM regarding the care planning of bed mobility and side rails, MDS Coordinator (MDSC) 1 stated, Side rails should be care planned on the ADLs. MDSC1 reviewed R70's care plan in the EMR, and stated, It's not on his ADL care plan. I don't see where it [clarified, side rails] is on his care plan. In an interview on 08/09/22 at 2:53 PM, the Director of Nursing (DON) stated an expectation that bed rails would be care planned.

Based on review of the facility policy, observation, interview, and record review, the facility failed to ensure that 1 of 5 residents (Resident (R) 123) and/or Resident Representative (RR) reviewed for bed rail used were informed of the risks and benefits, and consent, for the use of bed rails. This failure had the potential for residents with bed rails to be uninformed of the risk of severe injury and/or death associated with bed rail use. Findings include: Review of the facility policy titled Subject: Bedrail Assessment, revised 08/2017, showed residents required assessment for bed rail use, but did not address the advisement of risks and benefits or obtaining an informed consent for bed rail use. Review of R123's Admission Record from the electronic medical record (EMR) Profile tab showed an admitted [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R123 was observed in bed on 08/07/22 at 4:07 PM with bilateral upper (quarter) bed rails and on 08/08/22 at 8:45 AM, R123 was observed in bed with bilateral upper bed rails. Review of the IDT [Interdisciplinary Team] - BIMS [Brief Interview for Mental Status], dated 08/05/22, from the EMR Assessments tab, showed R123 had a score of zero of a possible 15, indicative of severe cognitive impairment. During an interview on 08/07/22 at 5:14 PM, regarding if the facility had informed of the risks and benefits of bilateral upper bed rails, R123's RR stated, Nobody said anything. When queried if R123's RR had signed a consent, the RR responded that he had signed a lot, so he was unsure. In an interview on 08/08/22 at 11:50 AM, the Administrator stated the bed rail risks and benefits are gone over by the person completing the restraints assessment located in the EMR Assessments tab. Review of R123's EMR Assessment tab LN [Licensed Nurse] - Restraint / Enabling Device / Safety Device Evaluation ., completed by Licensed Practical Nurse (LPN)1 and dated 08/07/22 showed the risks and benefits, and in the box titled Consent received from was typed R123's name. During a follow-up interview on 08/08/22 at 1:35 PM with R123's RR, at R123's room door (R123 was in bed with the head of the bed elevated and bilateral upper bed rails) regarding the licensed nurse having gone over risks and benefits and obtained consent from R123, the RR responded Well they might have but she wouldn't have understood them and had no idea what she was consenting to. In an interview on 08/08/22 at 3:20 PM, regarding the risk and benefits and consent with R123 who was severely cognitively impaired, LPN1 stated, I didn't personally go over it with them [R123 or R123's RR] but if the resident wasn't cognitive and not able to consent, I would give the responsible party the information, but I thought it was gone over in the admission process. I was just assessing. LPN1 accompanied the surveyor to the Director of Admissions (DAdmit) office at 3:24 PM and was present when the query was made if bed rail risks and benefits were reviewed during the admission process; DAdmit responded I don't go over side rails, no not at all. During an interview on 08/09/22 at 2:53 PM, the Director of Nursing stated an expectation that bed rail risks and benefits would be reviewed with the patient and family.

Based on review of the facility policy, observation, interview, and record review, the facility failed to ensure, for 1 of 4 residents (Resident (R) 10) observed during medication administration observations, the medication was accurately labeled during 1 of 1 nasal spray medication observations. This failure to identify a mislabeled medication increases the potential of medication errors. Findings include: Review of the facility policy titled Labeling and Packaging Guidelines, 09/2020 version, showed: A. Medication Labeling: All prescription medications and all non-prescription medications not in the original manufacturer's package shall be dispensed in an approved container. Each container shall have at least the following information contained on the label: 1. The brand and generic name of the medication if the medication is a brand name drug. 2. Directions for use. During a medication administration observation on 08/09/22 at 9:10 AM, Registered Nurse (RN)1 retrieved a prescription bottle for R10 from the medication cart that contained a [MEDICATION(S)] 50 microgram (mcg) allergy spray labeled for two sprays in each nare daily; opened 05/14/22. Review of R10's electronic medical record (EMR) Orders tab showed a prescription for Allergy Relief 50 MCG/ACT [activation] Suspension 1 spray in both nostrils one time a day for allergies shake gently ordered 05/12/22. After reviewing the order versus the label on 08/09/22 at 9:10 AM, RN1 stated she would contact the pharmacy about the discrepancy. During a telephone interview on 08/09/22 at 2:39 PM, Registered Pharmacist (RPh), from the facility pharmacy, reviewed the pharmacy documentation and the order and stated, The label does say two and order is one. We corrected it today. The RPh confirmed the label issued in May on the allergy spray was incorrect. During an interview on 08/09/22 at 2:59 PM, the Director of Nursing (DON) stated, Medication labels should match the order.

Based on interviews and record review, the facility did not have sufficient nursing staff to assure highest practicable physical, mental, and psychosocial well-being of each resident. Interviews with residents, resident council, staff, and family indicated there were not enough staff to provide care for residents. This was confirmed by review of certified nursing (CNA) hours over the past three months. The findings included: Interview with Resident #2 on 4/19/2021 at approximately 11:52 PM revealed there was not enough staff. The resident stated wait times after pushing a call light could be 45 minutes - 1 hour. This might happen when they were wet, when they needed food / water, or when they wanted something that wasn't within reach. The resident continued that they didn't believe staff were lazy and knew they were trying their best, there just didn't seem to be enough of them. Interview with Resident #267 on 4/19/2021 at approximately 1:33 PM revealed that, when asked about staffing sufficiency, the resident stated food trays are often late and call lights are not promptly responded to. Interview with Resident #45 on 11 AM revealed that staff took too long to respond for help when the resident needed to go to the restroom - resulting in accidents. They stated, Sometimes you have to beat on the wall and floor threatening to go on the floor before they show up. When asked how long it usually takes to answer the call light, the resident said it could take up to an hour. Interview with family member of Resident #45 on 4/20/2021 at approximately 11:20 AM revealed that the resident did not receive appropriate cleaning from the staff after a bowel movement. The family member would wipe the resident with their own towelettes and find residual fecal matter - after the staff had completed cleaning her. Interview with random family member / visitor on 4/20/2021 at approximately 3:39 PM revealed one occasion where there were not enough staff. The family member said their relative had diarrhea, and there was only one CNA working both halls on the back side. According to the family, the staff member was working their hardest, but they were being stretched too thin. This happened on a Monday evening (approximately 5 - 6 PM). Review of staff postings for the prior three months (March 2021, February 2021, and January 2021) on 4/21/2021 at approximately 8:51 AM revealed multiple days where the total CNA hours and census ratio (CNA hours / census) was below 1.63 - against state regulations. This was confirmed by the administrator on interview. Interview with CNA #1 on 4/21/2021 at approximately 11:10 AM revealed there were not enough staff. The CNA continued that this was likely related to the pandemic, and emphasized that all nursing staff did their best to provide good care to the residents. 04/20/21 12:05 PM Resident Council meeting held on 4/20/2021. During the meeting, 3 Residents out of 5 of the Resident Council stated there is not enough staff to provide care in the facility. 2 Council members stated CNA's and nurses take up to thirty minutes to answer call lights. 2 Counsel members stated if s/he asked for assistance while a staff member was in her/his room, the staff member would say they would return in a few minutes to help resident. This might be a few minutes or a few hours depending on the staff member or time of day. Another Council member stated the number of Residents assigned to CNA's and nurses to each shift was 28, and this was just too many for anyone to provide necessary timely care. All residents indicated the end of shift (approximately 6:30 PM) staff are standing around at the nurses station not providing care. The additional residents present at the meeting all nodded their heads in agreement that there is not enough staff in the facility and they agreed wait times for call lights can sometimes take up to 30 minutes or longer. 3 of the Council members stated these wait times for care and staff shortages are on-going, but have continued to worsen in the last six to eight months.

Findings include: Resident #45 (R #45) was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 04/20/21 11:20 AM Telephone interview with R #45's family member who said R #45 doesn't receive appropriate cleaning after a Bowel Movement from facility staff. She said R #45 complained of discomfort after several incontinent care episodes from staff. The family member stated R #45 would wipe her/his buttock with towelettes and found residual fecal matter after staff completed incontinent care of R #45. 04/20/21 11:00 AM Interview with R #45's family member stated staff take too long to respond for assistance with elimination needs (Bowel Movements) resulting in incontinent episodes. 04/20/21 11:30 AM During an interview with R # 45 revealed sometimes you have to beat on the wall and floor threatening to go on the floor before they show up. When asked how long it usually takes them to answer the call light R #45 said sometimes up to an hour. When this surveyor asked R #45 how s/he developed a pressure ulcer, the Resident stated from not being cleaned adequately from staff after urinating or bowel movements. 04/20/21 02:01 PM This Surveyor observed R #45's sacral dressing change by wound care nurse assisted by R #45's assigned LPN. Workspace and supplies setup with clean/aseptic practice. Pre, during, and post hand hygiene completed per infection control practices. The sacral pressure ulcer was a stage III 1 inch in length with granulated tissue around opening and no discharge or drainage to dressing. Clean W/D dressing firmly attached to sacral area, dated, and initialed by Wound Nurse. 04/20/21 02:20 PM Record review of R #45's Progress notes from 4/15/2021 from the Skin Assessment Committee stated stage III to coccyx improving. Air mattress, foam wedge, roho cushion, supplements and daily treatments. Followed by wound care MD. RP aware. 04/20/21 02:22 PM A Record review of the 4/13/2021 Dietary Progress Notes read RD Note: Resident noted with Stage 3 wound noted to coccyx. Resident's weight is stable, but meal intake remains variable. Mighty Shake supplements offered with meals for nutritional support. Labs: 3/26/21- Na 141 K+ 4.1 Glu 97 BUN 10 creat .66 Calcium 9.0 GFR > 60 prealb was at lower end of normal limits at 17. Liquid protein supplement added. Will add Multi Vitamin with minerals and addition of Vit C supplement Q day (one per day). Will f/u with NP concerning recommendation for wound healing support. BMP lab to be drawn on tomorrow r/t dx of [CONDITION(S)]. Will f/u prn. 04/20/21 02:28 PM 4/14/2021 Weekly Skin assessment noted in chart. 04/20/21 02:31 PM 4/1/2021 doctor order reads Maintain air mattress to resident's bed on proper settings based on resident's current weight as tolerated. 04/20/21 02:33 PM 3/31/2021 Order reads Cleanse wound to coccyx with NS (Normal Saline/Sterile water), apply calcium alginate (wound cream) and cover with a dry dressing. 04/20/21 02:41 PM Wound Physicians Consult notes for 3/31/2021 state; initial assessment and care plan and Wound follow-up consult from 4/13/2021 provided. 04/20/21 02:59 PM Resident Matrix provided by facility Administrator on 4/19/2021 lists R #45 having a Facility Acquired Stage III Pressure Ulcer. 4/21/21 at 10:45 AM the Director of Nursing during an interview said R #45 did acquire the pressure ulcer while at the facility and that they have an aggressive wound care program and have had a lot of success with prevention since the program's implementation.

Based on interview and record review, the facility did not provide posted nursing staff information for 2 of 3 months reviewed. Review of the prior three months (March 2021, February 2021, and January 2021) revealed missing postings and blank postings. This was confirmed by the administrator. The findings included: Review of facility postings on 4/21/2021 at approximately 8:51 AM revealed missing staff postings in the month of February (2/1/2021, 2/9/2021, 2/13/2021, 2/14/2021, 2/27/2021, and 2/28/2021) as well as the month of January (1/30/2021). This was confirmed by the administrator on interview on 4/21/2021 at approximately 10:38 AM.

Based on review of facility files, facility policy, and interview, the facility failed to implement its Abuse policy related to a resident to resident altercation between Resident #27 and #276, 2 of 6 sampled residents reviewed for Abuse. The resident to resident altercation was not reported to the State agency or facility Administrator per policy. The findings included: The facility admitted Resident #27 with [DIAGNOSES REDACTED]. The facility admitted Resident #276 with [DIAGNOSES REDACTED]. Review of a facility reported incident and investigation on 11/20/19 at 8:53 AM revealed on 10/22/18 at 6:50 PM Resident #276 slapped Resident #27 in the face. The incident was not reported to the facility Administrator until 8:00 AM on 10/23/18, per the facility investigation. The incident was reported to the State agency on 10/23/18 at 9:51 AM. Review of the facility's Abuse policy revealed all allegations of abuse should be reported immediately to the facility Administrator. In addition, per the policy, allegations of abuse will be reported to appropriate States agencies in the applicable time frames, as per this policy and applicable regulations. During an interview with the facility Administrator on 11/21/19 at 9:00 AM the Administrator confirmed policy was not followed related to the resident to resident altercation on 10/22/18.

Based on review of facility files and interview, the facility failed to ensure an alleged violation involving resident to resident abuse between Resident #27 and #276 (2 of 6 sampled residents reviewed for Abuse) was reported immediately, but not later than 2 hours after the allegation to the facility Administrator or State agency. The findings included: The facility admitted Resident #27 with [DIAGNOSES REDACTED]. The facility admitted Resident #276 with [DIAGNOSES REDACTED]. Review of a facility reported incident and investigation, on 11/20/19 at 8:53 AM revealed on 10/22/18 at 6:50 PM Resident #276 slapped Resident #27 in the face. Per the facility's investigation, 3 staff members were aware of the incident after it occurred. The incident was not reported to the facility Administrator until 8:00 AM on 10/23/18 per the facility investigation. The incident was reported to the State agency on 10/23/18 at 9:51 AM. During an interview with the facility Administrator on 11/21/19 at 9:00 AM, the Administrator confirmed the alleged violation on 10/22/18 was not reported timely. The Administrator stated nursing should have notified the Administrator immediately after the incident so a report could have been made to the State agency. The Administrator stated staff have since been re-educated on reporting per facility policy and regulations.

Based on interview and record review, the facility failed to monitor for antibiotic use, antibiotic resistance patterns, and / or antibiotic outcomes per its Antibiotic Stewardship Program (ASP) policy. The findings included: Review of ASP policy on 11/20/19 at approximately 3:25 PM revealed the facility establishes a ASP team that monitors and summarizes antibiotic use from pharmacy data such as the rate of new starts, types of antibiotics used, or days of antibiotic treatment per 1,000 resident days. The ASP team, per policy, should also summarize antibiotic resistance patterns (e.g., antibiogram) as well as track measures of outcome surveillance related to antibiotic use (e.g., Clostridioides Difficile (C. diff), [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) or Carbapenem-resistant [MEDICATION NAME] (CRE)). Further, the ASP team should report on number of antibiotics prescribed and the number of residents treated each month. Interview with Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 11/20/19 at approximately 3:45 PM revealed there was no monitoring of antibiotic use. Both pointed only to infection surveillance, which was primarily used to track transmissible infections both [MEDICAL CONDITION] and bacterial. Further, the DON and ADON were unable to produce documentation of monitoring for resistance patterns based on lab data, per their policy, or monitoring for potential outcome surveillance to antibiotic use. When asked about how the facility monitors / tracks residents who, for example, may contract [DIAGNOSES REDACTED] after a course of antibiotics, the DON and ADON were unable to answer.

Based on observation and interview, the facility failed to maintain infection control practices during 1 of 1 laundry observations. The findings included: On 08/23/18 at 10:31 AM laundry services were reviewed with Laundry Worker #1 & #2 and Clinical Resource Consultant. Laundry Worker #2 was observed completing laundry services appropriately until s/he neglected to sanitize the door of the washing machine after closing it with the same gloved hands used to load the drum with soiled items. At the time of the observation there were multiple residents on contact precautions for various infections.

Based on observation, interview and record review the facility failed to ensure that the consistency of the Puree food was prepared the correct consistency for 12 residents of 83 who had physician orders for Puree Diets. The findings included: During an observation on 08/22/18 at 11:25 AM, the Puree Pork which was on the serving line, the texture was not a smooth consistency. The Puree Pork was lumpy and was not of a smooth cohesive consistency. This observation was verified by the RD (Registered Dietitian), who said his her expectation for puree food is smooth consistency similar to baby food or mashed potatoes, he/she removed the food from the serving line and placed the pork back in the food processor for further processing. The RD said that the Robot Coupe Food Processor that is usually used to prepare the puree food is being repaired at this time and they are using a small food processor to process the puree food. The RD shows the original work order in (MONTH) where the Robo coupe was repaired by Whaley Electric. The RD stated that a month later the Robot Coupe broke again and has not yet been repaired because the repair company stated the Robot Coupe needed to be replaced. The RD said they are still using the small processor. The RD stated that the facility plans to buy a Robot Cope Food Processor immediately. During an observation at lunch on 8/23/18 at approximately 12:15 PM, observed the puree broccoli served on the resident's plates at lunch had small pieces of the broccoli floret in the puree mixture, again the consistency of puree food had small pieces and the consistency of the puree mixture was not a smooth consistency. During an interview with the Administrator on 8/25/2018 at approximately 10:00 AM, he/she said the facility plans to purchase a new Robot Coupe Food Processor immediately. The form titled Service Report for Robot Coupe USA, Inc, Service Company Whaley Foodservice, Date: 4/5/2018: Action Taken: Found Bad Seal that let safety switch burn out 4-5/18. Install new switch and tested AMP are 5.5 and all controls are functioning. The unit is back in service. A review of the facility Policy and Procedure titled: Dietary, Subject: Diet Consistency Modification states: Policy: It is the policy of this facility to adequately meet nutritional needs of the resident. Purpose: To provide food in a consistency that the resident can tolerate. Procedures: 1 .C. The pureed diet is given to residents with chewing, swallowing or choking problems.

Based on observation and interview the facility failed to ensure the grease receptacles stored outside were clean and free from grease buildup and the ground or area surrounding the grease receptacles was clean and free from grease spills. The findings included: During an observation on 08/22/18 at 11:50 AM there there are 2 grease receptacles both are covered in old grease/dirty and spilling over on to the ground. This observation was verified by the RD (Registered Dietitian), he/she stated that they just changed grease companies and the company has not picked up the older container. Both containers are soiled. During an observation on 8/23/18 at approximately 2:30 PM, the same two soiled grease receptacles with grease spills on the ground remain in place. During an interview with the RD, he/she stated that the facility has tried to get the badly soiled unit removed, and the company which placed the unit there refuses to remove the unit from the facility property as this company no longer provides this service to the facility. He/She said does not know what to do to get the soiled unit removed from the property.

Based on limited record review, interview, and review of facility policy: Change of Condition Reporting, the facility failed to show sufficient evidence of notifying the Resident Representative of Resident #235 pertaining to changes in medical condition, furthermore the facility failed to provide evidence of notification to the Resident Representative, Physician and Coroner of death of Resident #71 and notification of lab results to Resident Representative of Resident #71. The findings included: Resident #235 was admitted to the facility with [DIAGNOSES REDACTED]. Record review on 08/24/18 at 2:52pm revealed, a progress note dated 04/12/18, Late entry: Note Text: MD (medical doctor) Communication submitted for review. NP (nurse practitioner) in to see patient regarding right foot. NP explained importance of seeing a specialist regarding wound care. Patient refuses at this time to go see a wound care specialist. Risks explained in detail to patient The weekly skin assessments revealed the resident had an Unstageable wound to Right heel on 04/09/18, and on 04/20/18 indicated the resident had a Suspected Deep Tissue Injury. Review of the most recently completed Minimum Data Set assessment dated [DATE] revealed the resident's cognitive assessment score to be 7 out of a possible 15 points. This score is indicative of Severe Cognitive Impairment. Resident #71 was admitted to the facility with [DIAGNOSES REDACTED]. Record review on 08/22/18 at 11:18 am revealed, physician telephone orders describing the resident's code status to be Do Not Resuscitate. Furthermore, the record revealed an 'Authorization for Allow Natural Death' signed by the resident's Power of Attorney, 2 physicians and a witness. Nurses notes were reviewed and noted on 05/20/18, Notified by daughter that resident was not breathing correctly .Daughter request to call physician and have abdomen scan performed .Review of the facility's electronic records revealed an X-ray was completed on 05/21/18 with no significant findings, but the facility was unable to provide evidence of notification to the Resident's Representative. According to the resident's medical record, there is no evidence of notification days later of the resident's expiration to the medical director, coroner or resident representative. During an interview with the Director of Nursing on 08/23/18 at 10:56 am, the documentation to indicate notification of change of condition, death or x-ray could not be found. Review of the facility's provided policy, entitled, Change of Condition Reporting, Reviewed 7/2017, revealed the following: Life Threatening Change .2. Licensed nurse will inform the primary physician (alternate physician or Medical Director) of resident status as soon as possible once resident needs have been met and immediately of nursing care completed. 3. Licensed nurse will inform family/responsible party of change of condition and document notification. 4. All nursing actions, physician contacts and resident assessment information will be documented in the nursing progress notes. Furthermore, the policy reads: Acute Medical Change .1. Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for physician visit promptly and/or acute care evaluation. The licensed nurse in charge will notify the physician .3. The responsible party will be notified that here has been a change in the resident's condition and what steps are being taken.

Based on limited record review and interview, the facility failed to ensure MDS assessment was coded accurately related to falls, for 1 of 4 reviewed for accidents. The findings included: Resident #14 was admitted to the facility with [DIAGNOSES REDACTED]. The Director of Nursing provided a list of falls the resident sustained [REDACTED]. Review of the resident's care plan reflected the resident's risk for falls, poor balance and safety awareness. Furthermore the care plan detailed the dates of the falls that occurred. Review of the Minimum Data Set quarterly assessment dated [DATE], indicated no falls since the admission or reentry. On 08/24/18 at 1:08pm the DON reviewed and confirmed the assessments to be inaccurately coded related to the number of falls sustained.

Based on limited record review, interview and review of facility policy, the facility failed to provide evidence of care plan meeting and/or Interdisciplinary Team collaboration for the care plan of Resident #235, for 1 of 3 residents reviewed for hospitalization . The findings include: Resident #235 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Admission MDS dated [DATE] indicated a BIMS score of 7. Review of admission paperwork included no clinical information or physician certification regarding inability to consent. March 12th note states the MDS nurse spoke with the resident regarding his plan of care and he had no concerns and did not want a copy of it.

Based on observation, interview and record review the facility failed to ensure that Resident #57's urinary output was monitored. The findings include: Resident #57 was admitted with [DIAGNOSES REDACTED]. During an observation on the Initial Tour on 08/20/18 at 04:13 PM Resident #57 is lying in the bed and there is a urinary catheter bag with blue privacy cover hanging below the bed. The Care Plan Focus for Resident #57 states: Potential for catheter related UTI (urinary Tract Infection), Date Initiated on 7/31/18, Goal: Interventions will be in place to prevent catheter related UTI through Date, Target Date: 10/31/18. The Interventions state: Monitor intake and output. Review of the (MONTH) (YEAR) MAR (Medical Administration Record)/ TAR (Treatment Administration Record), states, Monitor Indwelling Catheter Care every shift for Catheter Care every shift for Urine Retention, Order Date 11/28/17. During an Interview with the DON 08/24/18 at 10:00 AM, he/she verified that the amount of input/output of urinary catheter bag was not monitored by the facility. He/She said that the facility is not recording the amounts. During an Interview with the DON 08/24/18 at 11:05 AM, he/she verified that the care plan states that urinary output will be monitored. During an interview with LPN (Licensed Practical Nurse) #2 on 08/24/18 at 11:22 AM, he/she stated that he/she does not record the amount of urine in catheter bag, he/she said he/she has no order. LPN #2 said I do check the bag every two hours to make sure there is urine in the bag, but do not have order. He/She verified that there is no order or anywhere to record the amount of urine on the MAR/TAR. During an interview with CNA #1(Certified Nurse Assistant ) on 08/24/18 at 11:19 AM, he/she said stated that she empties the catheter bag for Resident #57 every 2 hours and the bag usually has about 250 milliners in it. CNA #1 reports that the residents urine is usually dark colored . said that he/she does not record the amount of urine in bag unless the nurse asks him/her to do so. The form titled, Policy/Procedure-Nursing Clinical, Section: Documentation, Subject: Intake and Output Documentation states: Policy: It is the policy of this facility that fluid intake and output shall be recorded for each resident with an indwelling Foley catheter as prescribed by the physician. This shall be recorded and monitored by a licensed nurse. Procedures: 2. The intake and output ( I & O) information is to be recorded at the end of each shift by a licensed nurse. The 24 hour total is to be entered.

Based on record review and interview the facility failed to notify timely the physician per facility policy with a change or decline in a resident's condition. Resident #173, 1 of 1 resident reviewed for quality of care and assessment, experienced a decline in respiratory condition resulting in hospitalization . The findings include: Review of the facility policy and procedure titled, Policy/Procedure- Nursing Administration, Section: Care and Treatment, Subject: Change of Condition Reporting Policy Number: NACT 05 (5/2007) states, Policy: It is the policy of this facility that all changes in resident condition will be communicated to the physician. Purpose: To clearly define guidelines for timely notification of a change in a resident condition. Procedure: Life Threatening Change 1. Licensed nurse will initiate appropriate first aid measures until emergency response personnel arrive on the scene. 2. Licensed nurse will inform the primary physician (alternate physician or Medical Director) of resident status as soon as possible before, during or after the change of condition. 3. Licensed nurse will inform family of change of condition and document notification. 4. All nursing actions, physician contacts and resident assessment information will be document in the nursing progress notes. 5. The nursing supervisor should be notified immediately of life threatening changes of condition. The nursing supervisor (or licensed nurse) will inform the Director of Nursing Services or Executive Director,as appropriate. Record review of Resident #173 closed medical chart revealed the resident was admitted to Agape Rehabilitation of Rock Hill on 10/20/15 at 11:14 AM with the [DIAGNOSES REDACTED]. Review of the document titled, Minimum Data Set (MDS) Version 3.0 For Nursing Home Resident Assessment and Care Screening - Admission Assessment, signed and dated by the facility on 11/2/15, scores Resident #173 to be cognitively intact and without behaviors. The resident is assessed by the facility to need limited assistance of one (1) staff person with walking, dressing and toilet use. He/She is scored to utilize supplemental oxygen (O2). Review of the document titled, Physicians Orders charting for 11/1/15 through 11/30/15 revealed Resident #173 to be on the following medications; [MEDICATION NAME] 150 mg by mouth twice a day (treatment for [REDACTED]. one tablet by mouth once a day, [MEDICATION NAME] 50 mg (anti-depressant) one tablet once a day for anxiety, Prostat 30 milliliters (ml) (nutritional supplement) by mouth twice a day, [MEDICATION NAME] one vial via nebulizer four times a day for shortness of breath, [MEDICATION NAME] 18 micrograms (mcg) (used to treat [MEDICATION NAME]) one puff daily, [MEDICATION NAME] 1 mg tablet (a sedative use to treat anxiety and panic disorder)three times a day as needed, Proair HFA AER (treatment for [REDACTED].>Review of Resident #173's Individualized Plan of Care states, Problem Onset 11/8/15 (Resident) is at risk for cardiopulmonary complications related but not limited to recent [MEDICAL CONDITION] with left upper lobe resection and post surgical pleural effusion, [MEDICAL CONDITION] with need for supplemental O2, Fib and TN with dx of heart murmur/palpitations, Goal &Target Date- (Resident) will have no noted cardiopulmonary complications that causes a change in overall health status resulting in hospitalization through next review date. (2/8/16). Approaches: check oxygen saturation (02 sat) as ordered, monitor for increased respiratory symptoms (productive or non-productive coughing, shortness of breath (SOB), wheezing, cyanosis, etc .) and report to provider for further orders/interventions, monitor for complaints of chest pain, shortness of breath . Review of the Nurses Note (Free text) dated 11/16/15 states, 8:00 PM - Patient (Pt) alert and oriented times three (A&O x 3). Resting in bed with eyes open. Shortness of breath noted (SOB). O2 saturation 83%on 2 liters of oxygen (2 lpm). Wheezes and crackles noted. Meds given as ordered. Nebulizer treatment (neb tx) administered. However, Resident #173 was not re-assessed by the Registered Nurse caring for her until 11/16/15 at 11:00 PM- three hours later, in a nursing note which states, Pt requested as needed (PRN) [MEDICATION NAME] for anxiety. Administered per request. At 11:45 PM on 11/16/15, the nursing note states, Certified Nursing Assistant (CNA) notified me that pt was unresponsive. Upon assessment, pt found unable to follow verbal commands. Eyes would open but unable to stay awake. O2 sat 91%, heart rate 78, blood pressure 130/54, Temperature 92.9 ax (axillary), fasting blood sugar 184. MD (medical doctor) notified and ordered transfer to emergency room (ER). At 12 AM midnight, the nurse documents in the Nurses Medication Notes that the result/response from the [MEDICATION NAME] as effective. Record review of Physician's Telephone Orders dated 11/16/15 at 11:45 PM revealed the resident was transferred to the Piedmont Medical Center with the [DIAGNOSES REDACTED]. Interview with the current facility Medical Director on 7/28/16 at 2:30 PM in the Conference Room revealed, I would expect a nurse to follow up with a re-assessment no less than thirty minutes after any treatment, however, I would expect to be notified immediately anytime a resident's oxygen saturation dropped below 90%. Interview on 7/28/16 at 3:00 PM with the facility's current Director of Nurses (DON) revealed, A nurse should immediately called 911 services whenever a resident's oxygen saturation drops to 83% and they can't breathe. This is considered a medical emergency. Record review of the document Physicians Order charting for 11/1/15 thru 11/30/15 states, Notify MD if shortness of breath develops ., Notify MD if evaluation of lungs reveals wheezes or rales, Notify MD if assessment reveals abnormalities post treatment or as needed. The nurse administering care to Resident #173 failed to follow any of these orders in order to provide the necessary care and services for this resident.

Based on record review and interview the facility failed to provide the necessary care and services in a timely manner for one (1) of one (1) reviewed for Quality of Care and Assessment. Resident #173 experienced a decline in respiratory condition resulting in a hospitalization as a result this deficiency is cited at a harm level. The findings include: Review of the facility policy and procedure titled, Policy/Procedure- Nursing Administration, Section: Care and Treatment, Subject: Change of Condition Reporting Policy Number: NACT 05 (5/2007) states, Policy: It is the policy of this facility that all changes in resident condition will be communicated to the physician. Purpose: To clearly define guidelines for timely notification of a change in a resident condition. Procedure: Life Threatening Change 1. Licensed nurse will initiate appropriate first aid measures until emergency response personnel arrive on the scene. 2. Licensed nurse will inform the primary physician (alternate physician or Medical Director) of resident status as soon as possible before, during or after the change of condition. 3. Licensed nurse will inform family of change of condition and document notification. 4. All nursing actions, physician contacts and resident assessment information will be document in the nursing progress notes. 5. The nursing supervisor should be notified immediately of life threatening changes of condition. The nursing supervisor (or licensed nurse) will inform the Director of Nursing Services or Executive Director,as appropriate. Record review of Resident #173 closed medical chart revealed the resident was admitted to Agape Rehabilitation of Rock Hill on 10/20/15 at 11:14 AM with the [DIAGNOSES REDACTED]. Review of the document titled, Minimum Data Set (MDS) Version 3.0 For Nursing Home Resident Assessment and Care Screening - Admission Assessment, signed and dated by the facility on 11/2/15, scores Resident #173 to be cognitively intact and without behaviors. The resident is assessed by the facility to need limited assistance of one (1) staff person with walking, dressing and toilet use. He/She is scored to utilize supplemental oxygen (O2). Review of the document titled, Physicians Orders charting for 11/1/15 through 11/30/15 revealed Resident #173 to be on the following medications; [MEDICATION NAME] 150 mg by mouth twice a day (treatment for [REDACTED]. one tablet by mouth once a day, [MEDICATION NAME] 50 mg (anti-depressant) one tablet once a day for anxiety, Prostat 30 milliliters (ml) (nutritional supplement) by mouth twice a day, [MEDICATION NAME] one vial via nebulizer four times a day for shortness of breath, [MEDICATION NAME] 18 micrograms (mcg) (used to treat [MEDICATION NAME]) one puff daily, [MEDICATION NAME] 1 mg tablet (a sedative use to treat anxiety and panic disorder)three times a day as needed, Proair HFA AER (treatment for [REDACTED].>Review of Resident #173's Individualized Plan of Care states, Problem Onset 11/8/15 (Resident) is at risk for cardiopulmonary complications related but not limited to recent [MEDICAL CONDITION] with left upper lobe resection and post surgical pleural effusion, [MEDICAL CONDITION] with need for supplemental O2, Fib and TN with dx of heart murmur/palpitations, Goal &Target Date- (Resident) will have no noted cardiopulmonary complications that causes a change in overall health status resulting in hospitalization through next review date. (2/8/16). Approaches: check oxygen saturation (02 sat) as ordered, monitor for increased respiratory symptoms (productive or non-productive coughing, shortness of breath (SOB), wheezing, cyanosis, etc .) and report to provider for further orders/interventions, monitor for complaints of chest pain, shortness of breath . Review of the Nurses Note (Free text) dated 11/16/15 states, 8:00 PM - Patient (Pt) alert and oriented times three (A&O x 3). Resting in bed with eyes open. Shortness of breath noted (SOB). O2 saturation 83%on 2 liters of oxygen (2 lpm). Wheezes and crackles noted. Meds given as ordered. Nebulizer treatment (neb tx) administered. However, Resident #173 was not re-assessed by the Registered Nurse caring for her until 11/16/15 at 11:00 PM- three hours later, in a nursing note which states, Pt requested as needed (PRN) [MEDICATION NAME] for anxiety. Administered per request. At 11:45 PM on 11/16/15, the nursing note states, Certified Nursing Assistant (CNA) notified me that pt was unresponsive. Upon assessment, pt found unable to follow verbal commands. Eyes would open but unable to stay awake. O2 sat 91%, heart rate 78, blood pressure 130/54, Temperature 92.9 ax (axillary), fasting blood sugar 184. MD (medical doctor) notified and ordered transfer to emergency room (ER). At 12 AM midnight, the nurse documents in the Nurses Medication Notes that the result/response from the [MEDICATION NAME] as effective. Record review of Physician's Telephone Orders dated 11/16/15 at 11:45 PM revealed the resident was transferred to the Piedmont Medical Center with the [DIAGNOSES REDACTED]. Telephonic interview with Resident #173 on 7/28/16 at 8:49 AM revealed, My left lung was removed before I came into the facility (Agape Rehabilitation). I was exercising and doing good-but I started to feel bad. I told the doctor, the therapists, and the nurses. He (the physician) did a chest x-ray (CXR) and some bloodwork. He said I was having a bad day, and it (CXR and bloodwork) was all okay. I became so short of breath (SOB) anytime I moved, even when I was lying still. I had been telling them (facility staff) a couple of weeks prior to 11/16/15 that I didn't feel good. I was so sick the day they (Agape Rehabilitation) finally moved me to the hospital, I don't even remember it. I was on life support for two (2) days, I did not return there (Agape Rehabilitation) after I got out of the hospital. Interview with the current facility Medical Director on 7/28/16 at 2:30 PM in the Conference Room revealed, I would expect a nurse to follow up with a re-assessment no less than thirty minutes after any treatment, however, I would expect to be notified immediately anytime a resident's oxygen saturation dropped below 90%. Interview on 7/28/16 at 3:00 PM with the facility's current Director of Nurses (DON) revealed, A nurse should immediately called 911 services whenever a resident's oxygen saturation drops to 83% and they can't breathe. This is considered a medical emergency. Record review of the document Physicians Order charting for 11/1/15 thru 11/30/15 states, Notify MD if shortness of breath develops ., Notify MD if evaluation of lungs reveals wheezes or rales, Notify MD if assessment reveals abnormalities post treatment or as needed. The nurse administering care to Resident #173 failed to follow any of these orders in order to provide the necessary care and services for this resident.

On the day of the complaint inspection, based on record review and interview, the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being. Resident #1 was found on the floor beside her/his bed with the bed alarm sounding. The x-ray's obtained related to the fall were reported to a nurse as negative for a fracture, the x-ray's in fact showed a fractured wrist and hip. The facility failed to timely address Resident #1's injury. The findings included: Review of the facility investigation summary stated that a nurse received a verbal negative x-ray result called in to her/him for Resident #1. Because s/he received a negative verbal report, s/he did not thoroughly read the written reports when they arrived, instead placing them in the physician's box for review. Review of Resident #1's Nurse's Notes from 5/4/13 through 5/6/13 revealed the following: 5/4/13 8:00 AM indicated the resident was observed lying on his/her right side on the floor in his/her room beside the bed and the bed alarm was sounding. The nurse assessed the resident for injuries and noted the resident cried when moving his/her upper and lower right extremities. A new order for x-ray of the right side was received. 12:00 PM x-ray of resident's right side and the resident was medicated for pain. 3:00 PM x-ray results were back and no fracture was noted to the right side, the resident was medicated for pain. 10:00 PM Resident #1 was medicated for pain to the right side of the body. Tender to touch or move. 5/5/13 4:00 AM "attempted to give [MEDICATION NAME] but refused to take. Appears in much pain during ADL's. 6:00 PM Resident in bed resting with eye's closed. Rt (right) side tender to touch. Pt (patient) medicated x 2 @ 7:00 AM and 2:00 PM with some effectiveness. Pt is unable to mover his/her (RLE) right lower extremities without having pain". 5/5/ - 5/6/13 at 8:00 PM medicated for pain and at "1:45 AM the doctor notified of (R) right [MEDICAL CONDITION]. Orders given to call family and tell them we can sent to ER (emergency room ) for evaluation and treatment or make an ortho (orthopedist) appt (appointment) ASAP on Monday. 2:10 AM left voice mail (for the resident's responsible party) have not heard back. 5/6/13 7:00 AM No returned call from family. Note to (staff) to plan on making ortho appt. ASAP. 5 AM [MEDICATION NAME] and [MEDICATION NAME] 1 mg (milligram) give 10:15 AM Off going nurse stated res had rt hip fx had spoken to MD and MD gave TO (telephone order). 9:10 AM order given to send res to ER..." Review of Resident #1's Controlled Drug Record revealed the resident received [MEDICATION NAME] 5-500 milligrams on 5/4/13 at 8:00 AM, 2:00 PM, and 10:00 PM. Resident #1 received [MEDICATION NAME] 5-500 milligrams on 5/5/13 at 4:00 AM, 7:00 AM, 2:00 PM, and 8:00 PM. Resident #1 received [MEDICATION NAME] 5-500 milligrams on 5/6/13 at 5:00 AM. Resident #1 had an order for [REDACTED]. Review of Resident #1's Physician's Telephone Orders' dated 5/6/13 indicated at 7:00 AM "May send to ER to evaluate and treat if family prefers or make appointment with ortho ASAP." A Physician's Telephone Order dated 5/6/13 at 9:10 AM indicated to transfer the resident to the emergency room for a right [MEDICAL CONDITION] and a right wrist fracture. Review of the Radiology Reports dated 5/4/13 indicated Resident #1 had an acute right [MEDICAL CONDITION] and a distal right radius fracture. Review of the Discharge Summary from the hospital dated 5/10/13 indicated Resident #1 had a right wrist fracture and a right [MEDICAL CONDITION]. Resident #1 underwent surgery for [REDACTED]. Licensed Practical Nurse (LPN) #1's facility-obtained incident statement indicated that Resident #1 had eight x-rays taken of his/her right side. LPN #1 received a phone call from the company that performed the X-rays and was given a verbal report stating that no fractures were found. S/he then retrieved the transmittal from the office fax machine and filed it in the doctor's communication book without reading it. On 5/5/13 LPN #1 updated the Director of Nursing (DON) on the incident and told the DON that s/he truly believed there was a fracture. Throughout the day s/he continued to monitor the resident and keep the resident as comfortable as possible until the end of his/her shift. In a telephone interview with the surveyor on 6/19/13 at approximately 4:55 PM LPN #1 confirmed the accuracy of her/his statement as written. Registered Nurse (RN) #1's facility-obtained statement indicated that s/he was told by the day shift nurse that several x-rays had been taken and they were all negative for fracture for Resident #1. RN #1 found a result of a right [MEDICAL CONDITION] for Resident #1 on the copier near the medication room at 1:45 AM. S/he called the doctor and received orders to send Resident #1 to the emergency room to evaluate and treat if the family preferred or to make an orthopedist appointment ASAP. The oncoming nurse (LPN #2) found a wrist fracture x-ray in the doctor's book. RN #1 did not think to look at those x-rays because s/he had already been told there were no fractures. Licensed Practical Nurse (LPN) #2's facility-obtained statement dated 5/9/13 indicated that on 5/6/13 s/he received report from the off going nurse that Resident #1 had fallen out of bed. The off going nurse stated that s/he had found an x-ray report on the fax machine that stated the resident had a right [MEDICAL CONDITION]. The off going nurse called the physician and received an order to notify the family to see if they wanted the resident sent out and if they didn't to have an orthopedist appointment ASAP. In a telephone interview with the surveyor on 6/19/13 at approximately 4:40 PM LPN #2 confirmed the accuracy of his/her statement as written. LPN #2 stated that the off going nurse noted in his/her statement was RN #1. LPN #2 stated s/he found the wrist fracture x-ray report while looking through the x-rays to show the supervisor the [MEDICAL CONDITION] x-ray report that RN #1 had found.

On the days of the complaint inspection, based on record review and interviews, the facility failed to ensure that one of one sampled residents reviewed with a [MEDICAL CONDITION] received appropriate care and services. The facility failed to implement interventions timely to prevent dislodgement of the [MEDICAL CONDITION] cannula for Resident #7. The findings included; The facility admitted /readmitted Resident #7 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set assessment dated [DATE] revealed the resident had short and long term memory problems. Review of the hospital Discharge Summary dated 4/23/13 revealed Resident #7 initially was treated at the hospital for a decline in mental status. Imaging on day 2 demonstrated an increase in ventricular size ([DIAGNOSES REDACTED]), and the resident was transferred for neurosurgical care. The resident underwent [REDACTED]. The resident required reintubation within 48 hours for hypoxic [MEDICAL CONDITION] and [DIAGNOSES REDACTED], and subsequently required a [MEDICAL CONDITION] on 4/2/13. According to the summary, "On date of discharge, (Resident #7) is alert [MEDICAL CONDITION]. (S/he) is able to speak a few words and follow commands with the LUE (left upper extremity). (S/he) has an old right [MEDICAL CONDITION] as well as facial weakness.[MEDICAL CONDITION] in place with no plans to decannulate given poor functional status and mental status...". Review of nursing facility documentation revealed a Daily Skilled Nurse's Note dated 4/26/13 at 10:00 PM, which included information that the suction catheter would not go into [MEDICAL CONDITION] the inner or outer cannula with resistance met at every attempt. "Noted [MEDICAL CONDITION] turned to the R(ight) side instead of forward, this was different from 2 days ago. Outer cannula head or neck plate was not flush to the skin and outer cannula was showing protruding out of the [MEDICAL CONDITION] opening in a R(ight) direction instead of straight out. No mucus was found in the inner cannula. (S/he) was coughing mucus into his/her throat and was unable to spit it out easily or swallow it. (S/he) bit the [MEDICATION NAME] suction tube when I attempted to clear his/her throat by suction. I contacted -- NP (Nurse Practitioner) and informed her/him. O2 sats (saturation) 92 % on O2 at 28%...". After evaluation of the resident by a Registered Nurse (RN), the NP gave an order to send the resident to the emergency room (ER) for evaluation and treatment for [REDACTED]. Review of the hospital's Admission History and Physical dated 4/27/13 revealed an Admitting [DIAGNOSES REDACTED]. According to the note, vital signs were stable on arrival except for the pulse which was [MEDICAL CONDITION] at 106 with an O2 saturation of 96% with a lot of gurgling and congestion heard in the patient's throat and chest. Respiratory Therapy was called but the catheter could not be advanced more than 4 cm before it hit hard resistance. Review of the CT (Computerized Tomography) scan report and an ENT (Otolaryngology) Consult dated 4/27/13 revealed that the [MEDICAL CONDITION] tip was flat against the anterior wall of the [MEDICAL CONDITION], not positioned well in the trachea. According to the Consult note, the impression was "Dislodged [MEDICAL CONDITION]". According to the note, [MEDICAL CONDITION] removed and easily replaced with another. Review of the facility's physician progress notes [REDACTED]. According to the note, the resident's family member was present when the resident had been evaluated by ENT at the hospital. "They stated that part of the [MEDICAL CONDITION] apparatus was turned the wrong way inside him. Pt. had pulled out his [MEDICAL CONDITION] set a few times before s/he was readmitted to the hospital. It was thought that floor nursing put it in the wrong way... They mentioned to (the family member) that (the resident) may need a mitten on his/her L(eft) hand... to keep from pulling out his/her [MEDICAL CONDITION] set". According to the "Current Plans:", the resident was doing well and [MEDICATION NAME] was ordered to thin secretions. Also noted was- "Will see if (facility) is okay with a mitten on L(eft) hand to prevent him/her from pulling out [MEDICAL CONDITION], and future trips to the ER for this. F/U (Follow up) prn (As Needed)". Review of the medical record revealed no indication that the possible use of mittens had been discussed or addressed by the facility until 5/11/13. During an interview on 6/18/13, the Director of Nursing (DON) was asked about documentation of an interdisciplinary team meeting relative to any interventions considered for the resident's behavior. The DON stated that they have discussed issues in morning meetings, but stated the facility did not have anything specifically documented for this resident. The surveyor requested to see any documentation in general related to these morning meeting discussions, but the DON did not provide this for review prior to exit. Review of Daily Skilled Nurse's Notes dated 5/1/13 - 5/11/13 revealed the following documentation of continued incidents in which the [MEDICAL CONDITION] was dislodged and/or partially dislodged along with incidents where the resident had removed his/[MEDICAL CONDITION] through which s/he had been receiving Oxygen. There was no evidence that interventions for these behaviors had been implemented by the facility until 5/11/13, when it was documented that orders had been obtained for scheduled [MEDICATION NAME] and hand mitts. 5/1/13 7A-7P "...res (resident) takes O2 off + had to be replaced, res reminded to leave it on.... suctioned several times this shift..". Another note dated 5/1/13 at 11:00 PM revealed information that the resident was "coughing up a large amount of clear to pink/yellow mucus from trach. Suctioned...S/he removed (trach) collar x 1...". 5/2/13 3:00 PM "...suctioned x 2 earlier this shift. ADON (Assistant Director of Nursing) + floor nurse went in to clean trach,[MEDICAL CONDITION] dislodged. ADON able to [MEDICAL CONDITION] obturator.....5/2/13 11P- Lethargic but pulling [MEDICAL CONDITION] off periodically ...suctioned...Large amount of ...phlegm from trach". 5/3/13 9:00 AM "...Noted [MEDICAL CONDITION] displaced...Supervisor [MEDICAL CONDITION] in place...". 5/3/13 6:00 PM "Nurse in to assess pt. Noticed that [MEDICAL CONDITION] lying on his/her chest (with) balloon deflated. Notified Dr. --. New order to send pt to (hospital) for displacement [MEDICAL CONDITION]+ to replace...pt sent to (hospital) via 911...". 5/5/13 3:00 PM "Resident pulled [MEDICAL CONDITION] out while sitting (up) in Geri-chair.[MEDICAL CONDITION] (with) obturator...Dr.-- notified. New order refer pt to pulmonologist for [MEDICAL CONDITION] (please try to wean off trach)...". 5/6/13 7A-7P "...Continues to take O2 mask (off), res reminded to keep mask on, O2 sat (saturation) 96%..." 5/6/13 11:00 PM "...Takes [MEDICAL CONDITION] off frequently and throws on floor. Found [MEDICAL CONDITION] his abdomen when entered the room....". 5/7/13 7A-7P "...Continues to pull O2 mask off trach, has to be reminded to leave in place..". 11:00 PM "[MEDICAL CONDITION] off and put on floor...O2 [MEDICAL CONDITION] @ 28%...". 5/8/13 "...No attempt to [MEDICAL CONDITION] continues to [MEDICAL CONDITION] collar...No acute distress..." On 5/10/13 Resident #7 had a [MEDICAL CONDITION] consult. Review of the consult note dated 5/10/13 revealed the pulmonologist was asked to give his/her opinion regarding the feasibility for decannulation (removal of the trach). According to the Assessment/Plan, the pulmonologist doubted that the resident could clear secretions or maintain an airway at present and that s/he would not consider downsizing or decannulation of [MEDICAL CONDITION] hospitalized in a facility where immediate emergent airway management was available. A Daily Skilled Nurse's Note dated 5/11/13 at 9:30 AM revealed that at 8:30 AM, the nurse went into the resident's room and found [MEDICAL CONDITION] dislodged laying on the resident's neck. An attempt to put [MEDICAL CONDITION] in was unsuccessful, and 911 was called. EMS was unable to replace [MEDICAL CONDITION] the resident was transported to the hospital. Upon return to the facility at 1:40 PM, it was documented that a size 4 [MEDICAL CONDITION] placed in the ER and the resident was now on 35% Oxygen. At the time of readmission, the DME (durable medical equipment) provider was called to bring in smaller suctioning catheters since the facility only had 14 french catheters. According to the note, the DME provider brought 12 french catheters that the facility was unable to use; and 10 french catheter(s) had been obtained from the hospital's emergency room . Continued review of Nurse's Notes revealed that at 7:00 PM, a sitter was with the resident and at 8:00 PM, s/he had left. The 7:00 PM note documented that a telephone order had been received from the physician for scheduled [MEDICATION NAME] (1 mg every 8 hours) and hand mitts. During an interview on 6/10/13 at 8:00 PM, the DON (Director of Nursing) stated the reason the resident had pulled out [MEDICAL CONDITION] because s/he didn't want it. When asked if any sitters had been provided for the resident, the DON stated that the resident's family member had been referred to a private pay Home Health Agency and had met with them to set up services for a sitter to come at night. According to the DON, since the resident pulled out [MEDICAL CONDITION] the family present, the resident would do the same with a sitter. The DON stated that the family would have to pay for this service, but before it could be started, the resident was sent out to the hospital and [MEDICAL CONDITION] been removed. During an interview on 6/18/13 at 3:10 PM, the DON provided documentation of a contract between Resident #7's RP (Responsible Party) and the home health agency for sitter services (to prevent [MEDICAL CONDITION] being pulled out) to start 5/10/13 at an hourly rate. The DON stated that they had no documentation of when the sitter came or didn't, and that the facility did not have a sign in/sign out sheet for this. The DON stated that the resident was still able to dislodge the [MEDICAL CONDITION] with the mitts on by using hand movements. The DON had been under the impression that [MEDICAL CONDITION] the resident and that s/he would rub it causing it to be dislodged. Further review of Daily Skilled Nurse's Notes revealed the following: 5/12/13 7A-7P "...Sitter @ bedside from 4P-8P...Will not keep mitts on hands. Unable to make needs known". 5/15/13 11:00 PM "...Continuously removes mittens from hands...". 5/16/13 11:00 PM "...Continues to take mittens off of hands. No attempts to remove trach/trach collar...". 5/17/13 at 10:30 AM stated, "Resident pulled [MEDICAL CONDITION]. N.O. (New Order) received to send to (hospital) to [MEDICAL CONDITION]." According to the note, the resident returned to the facility with a 3.5 [MEDICAL CONDITION] place. Review of hospital documentation revealed Resident #7 presented to theER on [DATE] for an evaluation of a dislodged trach. "...Patient had a 4.0 Shiley that the patient accidentally pulled out". According to the note, "Based on the size of the [MEDICAL CONDITION] opening a 4.0 could not be passed it was replaced with a 3.5 Shiley. Patient will follow up with [MEDICAL CONDITION]". Further review of Nurse's Notes revealed that on 5/17/13 at 3:50 PM, the therapist reported that [MEDICAL CONDITION] out after the resident coughed and that the 3.5 [MEDICAL CONDITION] been reinserted [MEDICAL CONDITION] had been done. At 4:15 PM, it was documented by nursing that the 3.5 [MEDICAL CONDITION] been removed and replaced with a #[MEDICAL CONDITION](with a small amount of blood tinged mucus noted). The note did not indicate why the [MEDICAL CONDITION] been replaced with a #4 trach. At 5:00 PM it was documented that [MEDICATION NAME] 1 mg (milligram) had been given via [DEVICE] (Gastrostomy tube) for increased anxiety and was effective. 5/19/13 at 10:35 PM revealed "Resident lying bed, O2 concentrator tubing disconnected (after) looking @ resident [MEDICAL CONDITION] completely out and upside down. Unable to replace trach-911 called and resident sent to ED. Resident had sitter until 9:00 PM...". A note timed for 2:00 AM (on 5/20/13) revealed that the resident's family member called the facility to report "that they were keeping resident in hospital d/t (due to) swelling [MEDICAL CONDITION] and inability to [MEDICAL CONDITION] consulting pulmonology in am". Review of hospital records revealed a procedure note which documented a [MEDICAL CONDITION], Direct laryngoscopy, and [MEDICATION NAME] through [MEDICAL CONDITION] incision had been completed on 5/23/13. The note stated that "..The [MEDICAL CONDITION] fell out last week and was not replaced in a timely manner resulting in stenosis of his/her left [MEDICAL CONDITION] site. Since that time, s/he has had intermittent [MEDICAL CONDITION] and replacement of his/her [MEDICAL CONDITION] has been recommended...". The note documented a #8 cuffed Shiley [MEDICAL CONDITION] had been inserted into the airway without difficulty. A hospital Progress note dated 5/24/13 documented that the [MEDICAL CONDITION] had been replaced 5/23/13, and that the ENT recommended the patient remain in the hospital until the first [MEDICAL CONDITION] change which would occur after 72 hours. Review of the hospital Discharge Summary dated 5/28/13 (signed 5/31/13) revealed that the resident had been admitted to the hospital after s/he pulled out his/her [MEDICAL CONDITION]. The patient was seen by the ENT who was unable to replace the [MEDICAL CONDITION] at the bedside and it was recommended that the resident be admitted to the hospital for closer monitoring. According to the note, "...Patient has been having plenty of airway secretion and is not able to cough adequately to clear his/her secretions. Patient was admitted and had intermittent suctioning. The [MEDICAL CONDITION] was then subsequently changed, but the patient was recommended to be kept in the hospital for reevaluation per the ENT and patient will need another [MEDICAL CONDITION] change within 72 hours. Yesterday, the ENT physician was able to place and change the [MEDICAL CONDITION] to a #6 and s/he has recommended to discharge...". The discharge recommendations included, "...Recommend closer monitoring of patient to avoid dislodging [MEDICAL CONDITION]. May need continuous sitter or may try an arm immobilizer to see if this reduces the incidence of patient moving to dislodge medical devices, the nursing home to address this and possibly reduce his/her rehospitalization ". Review of the nursing facility's medical record documentation from 5/31/13 (when the resident was readmitted ) through 6/6/13 revealed multiple incidents where Resident #7 continued to dislodge his/her trach. Review of Nurse's Notes/Hospice Notes revealed the following: Review of the Hospice notes revealed the following: 5/31/13 (In 11:00 PM, Out 11:59 PM)- "...Pt. upon arrival very restless and kicking covers off himself, reaching [MEDICAL CONDITION]. Pt. arrived with wrist restraints which were immediately removed and placed in pt. closet. Verbal cues given to pt. not to place hand [MEDICAL CONDITION].[MEDICAL CONDITION] itching pt. [MEDICATION NAME] applied BID (twice daily).[MEDICAL CONDITION] given by hospice nurse to help alleviate discomfort. Pt. still reaching [MEDICAL CONDITION]. [MEDICATION NAME] 1 mg tid (three times daily) prn (as needed) via g tube...". Further documentation in the note stated that the family understood the purpose of hospice but wanted to [MEDICAL CONDITION] g tube and full code status...(Resident) is unable to make sound decisions related to [MEDICAL CONDITION] and stroke in the past...". During an interview on 6/18/13 at 1:35 PM, the DON stated that the resident returned from the hospital (readmitted to the facility on [DATE]) on Hospice. The DON stated that s/he told the resident's family member that they didn't do wrist restraints (when it was requested by the resident's family). According to the DON, s/he told the family member that the facility wouldn't take the resident back with restraints. The DON verified when the resident returned to the facility in June there were no restraints ordered. Review of the Nursing Notes for June, 2013 revealed the following related to [MEDICAL CONDITION] care: 6/1/13 "Resident [MEDICAL CONDITION]. Res was found by CNA during am care.[MEDICAL CONDITION] by RN on the floor." 8:00 PM "Res pulled out trach. Reinserted by RN on 100 hall". Additional Hospice Notes revealed the following: 6/1/13 (In 8:30 PM, Out 9:00 PM)- "...FS (Facility Staff) reports that pt. had [MEDICAL CONDITION] two times since early am...Pt. agitated during assessment. S/he keeps tugging [MEDICAL CONDITIONS] gets irritated when verbally cued to leave area alone. Wash cloth placed in pt. right hand to distract pt. from touching trach. Requested FS to give [MEDICATION NAME] for agitation". 6/2/13 3:00 AM "Resident [MEDICAL CONDITION]. Site cleaned,[MEDICAL CONDITION] + Reinserted by RN on the floor". 10:30 AM "Resident removed trach. Replaced without incident...". 6/2/13 (In 5:15 PM, Out 6:15 PM)- "...Pt. face flushed and s/he continues to pull [MEDICAL CONDITION] 2 today. Spoke with FS and ascertain(ed) [MEDICAL CONDITION] may be irritating him/her with the straps. Instructed to check on pt. [MEDICAL CONDITION] and to give [MEDICATION NAME] to see if that will help alleviate site agitation...Pt. [MEDICAL CONDITION] times two today...Also discussed using [MEDICATION NAME] to see if pt would [MEDICAL CONDITION] alone. Site is irritated and pt. is going [MEDICAL CONDITION]." Review of Physician orders/Telephone Orders along with the Medication/Treatment Administration Records for June 2013 revealed no orders for [MEDICATION NAME] and no evidence anything [MEDICAL CONDITION] irritation had been ordered/given. Review of the June 2013 Medication Record revealed [MEDICATION NAME] 1 mg TID (three times daily) PRN (As Needed) had been administered once on 6/1/13 (at 6AM); with no documentation of [MEDICATION NAME] having been administered during the early/morning hours on 6/2/13 around the time frames the resident pulled out his/her trach. Review of a 6/3/13 9:38 AM Physician's Progress Note revealed "...Pt. admitted to (the facility) under the hospice GIP (General Inpatient) program for anxiety. S/he had recently been hospitalized after s/he pulled out his/her [MEDICAL CONDITION] again...Agitation under control at this point, will discuss with hospice the next step. If hospice finds that s/he does not require GIP status any further, we can shift pt back to LTC (Long Term Care) at (facility)...". Hospice notes for 6/3/13 through 6/7/13 indicated the following: (In 4:00 PM, Out 5:30 PM) "...Discussed with facility nurse about pt's agitation and attempting to remove trach. RN verbalized s/he had to give pt his PRN [MEDICATION NAME] nurse -- updated on new order of [MEDICATION NAME] and interventions of OOB (out of bed) to gerichair and [MEDICAL CONDITION] band. (Family member) agreed to try pt on [MEDICATION NAME] 0.5 mg in addition to PRN [MEDICATION NAME] 1 mg...". A Physician's Telephone Order dated 6/3/13 at 5:15 PM stated, "1) [MEDICATION NAME] 0.5 mg TID Dx Agitation...". 6/(4)/13 1:30 AM "Sitter states resident needs to be suctioned. Noted [MEDICAL CONDITION] out. Replace outer trach..." (In 2:00 PM, Out 3:30 PM)- "Pt is oriented to self mainly. Unable to communicate most needs. Able to follow some directions...Pt is very forgetful and must constantly be reminded to [MEDICAL CONDITION]. Facility nurse --- verbalized that pt has not been attempting to pull [MEDICAL CONDITION] today. S/he stated pt continues [MEDICATION NAME] 0.5 mg TID and only had to have one PRN dose of [MEDICATION NAME] since yesterday...(Family member) and --- notified that if pt's symptoms are resolved tomorrow, pt will discharge (from hospice) to the facility as a LTC (long term care) pt...Facility staff also updated that pt will likely come off (hospice) tomorrow if symptoms are resolved. 6/5/13 (SNF (Skilled Nursing Facility) visit- "Pt is calm at this time. Facility nurse --- verbalized pt has been calm and has not been attempting to pull out trach. Pt. is up in geri chair at this time. Pt is discharged off GIP (General Inpatient) (hospice) ... (Facility staff member) updated on pt's condition". 6/6/13 "Resident sent to (hospital) after pulling out trach.[MEDICAL CONDITION] was attempted by RN -- + was unsuccessful...Res transported via (ambulance service) via stretcher....Per --- @ (hospital), Res is to be returned to (facility) (with) [MEDICAL CONDITION] place. ---stated they do not have his/her sz (size)[MEDICAL CONDITION]+ that s/he is in no distress @ this time...". 6/7/13 "Returned from hospital @ 1:20 A (with) no trach. Res states s/he does not want trach...". 6/7/13 8:30 PM- "Resident restless, removing Oxygen collar from neck. O2 sat 97%, stoma patent...". A Physician's Progress Note dated 6/7/13 revealed, "...S/he returned to the facility without a trach...(Family member) stated the ER did not have the size s/he needed (which was an 8), that it was not an emergency, and that s/he should be transferred back to the facility without it (trach). They wanted (the resident) to see a pulmonologist other than Dr. ---, but (family member) wants an appt with Dr. -- ASAP (As soon as possible) to [MEDICAL CONDITION] put back in again...". A Physician's Telephone Order dated 6/7/13 at 12:16 PM stated, "Refer to Dr. --- (pulmonologist) ASAP, Dx [MEDICAL CONDITION] pt (without)[MEDICAL CONDITION] this point. -O2 sat q (every) day, -change [MEDICATION NAME] to scheduled". An Physician's Progress Note signed by Dr. ---(ENT) dated 6/13/13 at 1:15 PM stated, "...f/u (follow up) trach. S/he has pulled it - again on 6/7/13...(No) airway obstruction. D/C (Discontinue trach)...". Further review revealed a Physician's Telephone Order had been written 6/13/13 to discontinue [MEDICAL CONDITIONS] Oxygen. During an interview on 6/18/13 at 3:10 PM, the DON reviewed the ENT Progress note dated 6/13/13. When asked if the resident had seen the pulmonologist, the DON stated the pulmonology appt had been scheduled for late June (6/28/13) when the resident had been discharged from the hospital. Review of Social Services Notes revealed a note dated 6/11/13 which stated, "SW (Social Worker) will speak to Dr.-- about a referral to a psychiatrist for resident for behaviors of pulling out his/her medical equipment." There was no documentation of a referral having been made prior to this date. A faxed referral dated 6/11/13 for Psychotherapy services stated, "pt keeps pulling out his [MEDICAL CONDITION], likely on purpose, please evaluate for possible depression + apply CBT (Cognitive Behavioral Therapy)...". During an interview on 6/18/13, the DON was asked about the Life Source referral and stated that the resident had been referred to this Psychology service on 6/11/13 for cognitive behavioral therapy. The DON stated that they only came once a month and had been here on 6/11/13 when the referral had been made, but did not see the resident at that time. Review of the Interim Care Plan dated 5/31/13 revealed the resident had a trach. There was no information included to indicate any interventions had been put into place to prevent the resident from dislodging his/her [MEDICAL CONDITION]. Review on 6/10/13 of the resident's current Care Plan revealed an entry dated 6/6/13 which stated the resident had a trach, and included information that the resident had repeatedly dislodged [MEDICAL CONDITION] required reinsertion of [MEDICAL CONDITION] readmission on 5/31/13. The entry stated the resident was at risk for significant complications. A handwritten entry dated 6/6/13 stated, "#8 [MEDICAL CONDITION] cannula, ambu bag +obturator @ bedside". There was no indication from the Care Plan that the resident had returned to the facility without [MEDICAL CONDITION] place on 6/7/13. Another Care Plan entry dated 6/6/13 stated the resident was at risk for altered mood with [DIAGNOSES REDACTED]. Listed approaches included that the resident "will likely attempt to [MEDICAL CONDITION]/or PEG tube if s/he becomes anxious without intervention or diversion/ 1:1 supervision. use calm demeanor and positive tone of voice when trying to redirect any behaviors; s/he responds best to calm approach".

On the days of the complaint inspection based on observations, records review and interviews the facility failed to ensure that 1 of 8 sampled residents received the necessary care and services to attain or maintain the highest practicable physical and/or psychosocial well being. Resident #2 was placed on isolation precautions without a [DIAGNOSES REDACTED]. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Observation of Resident #2 on 10/24/2011 at 10 AM revealed a sign on the door indicating Contact Precautions. A container was noted outside of the door with gowns, gloves and shoe covers. Review of the hospital admission History and Physical dated 10/05/2011 indicated Resident #2 was admitted to the hospital "... for evaluation and management of his nonhealing wounds... The patient also has had chronic problems with itching and has excoriated the wounds... Apparently, he was sent here in the hope that he could see another infectious disease specialist, and in the hope that he might benefit from inpatient assessment and treatment..." Review of the Hospital Discharge Summary dated 10/11/2011 revealed Resident #2 "was evaluated initially by... from infectious disease and it was felt that the multiple superficial excoriations with associated [MEDICAL CONDITION] were likely not in need of treatment with antibiotics. The patient has been afebrile except for a low-grade temperature and has had a history of [REDACTED]. Nonetheless, he did not have any dep wound infections, and it was felt that he was likely colonized. Nonetheless, it was felt that a treatment with antibiotics for several days would be worthwhile to see if there was any improvement. The patient was treated with imipenem and [MEDICATION NAME] for 72 hours and he was subsequently reevaluated. In addition, it was noted that there was likely an underlying [MEDICAL CONDITION]/allergic component to the patient's skin condition, as he had increased eosinophils of approximately 800. The patient was treated with antibiotics and had no significant improvement. Additionally, ... from dermotoloty was consulted and pictures were sent via phone. She will follow up Mr. ... as an outpatient and he will undergo a skin biopsy and immunofluorescence... At this time, the patient is being discharged to home/skilled nursing facility, and is being continued on his home medications. He should be seen by wound care and should follow up with... (dermatology)." Resident #2 returned to the facility on [DATE] and the isolation precautions which were in effect prior to his 10/05/2011 hospitalization , were continued. However, the resident was not under any treatment for [REDACTED]. Review of Resident #2's care plan dated 8/14/2011 revealed the care plan had not been updated to reflect the resident's Acinetobacter infection, the contact isolation, the resident's hospitalization or the resident's [MEDICAL CONDITION]/allergy. Review of the Telephone Orders revealed Resident #2 had an order written [REDACTED]." This order was in addition to the Discharge Summary dated 10/11/11 for the resident to follow up with Dermatology. The facility contacted the Dermatologist on 10/24/2011 during the inspection, to obtain an appointment for Resident #2. The appointment was made for 12/1/2011. In addition, an appointment for a Psychiatrist was scheduled for Resident #2 on 10/21/11. However, the appointment had been canceled due to the resident's "isolation precautions." Review of the physician's orders [REDACTED]. Upon return from the hospital the [MEDICATION NAME] was reduced to an as needed prescription. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further record review on 10/25/2011 revealed Resident #2 was prescribed another antibiotic on 10/24/2011 for "[MEDICAL CONDITION]" of his arm related to an open area caused by the resident scratching. During an interview on 10/24/2011 at 12 PM, the Medical Director and Attending Physician confirmed Resident #2 was sent to the hospital on 10/5 for IV antibiotics for [MEDICAL CONDITION]. The Physician confirmed Resident #2 was diagnosed with [REDACTED]. He also stated that he contacted the Infectious Disease Physician's who stated that the Acinetobacter infection was not of great concern. The Physician also confirmed that Resident #2 was considered colonized and was not under treatment for [REDACTED]. He also confirmed the resident was on isolation precautions and that there was not a [DIAGNOSES REDACTED]. During an interview on 10/25/2011 at 9:45 AM, Licensed Practical Nurse (LPN) #1 stated that Resident #2 had been on isolation precautions since prior to his hospitalization and continued upon his return. She stated that the reason for the isolation was the Acinetobacter infection. LPN #1 confirmed Resident #2 was not under any treatment for [REDACTED]. LPN #1 confirmed that Resident #2 scratched at his skin and caused open sores. LPN #1 also stated that the Physician placed Resident #2 on antibiotics for [MEDICAL CONDITION]. During an interview on 10/25/2011 at 10 AM, the Assistant Director of Nurses confirmed the Discharge Summary and physician's orders [REDACTED].#2 on 10/24/2011. The ADON confirmed the delay in obtaining the appointment. The ADON also confirmed Resident #2's Psychiatry appointment had been canceled. During a follow up interview on 10/25/2011 at 11 AM, the Attending Physician again stated that there was not a [DIAGNOSES REDACTED]. He also stated that outpatient doctor's offices would not accept patients on isolation therefore Resident #2's Psychiatry appointment was canceled. The Physician agreed that the appointment was canceled unnecessarily because the resident should not have been under any precautions. The Physician stated that he was not sure why the [MEDICATION NAME] was reduced to an as needed dose.