Every finding on record at Rosecrest Rehabilitation and Healthcare Center

Based on review of the facility policy, observations, and interview, the facility failed to ensure foods were properly labeled, stored, and discarded in 1 of 1 main kitchens. Findings include: Review of the undated facility policy titled Food Storage, documented, Policy: . Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Procedure: 7. All stock must be rotated . Rotating stock is essential to assure the freshness and highest quality of all foods. B. Food should be dated as it is placed on the shelves . c. Date marking should be visible of all high risk food to indicate the date by which a ready-to-eat TCS food should be consumed, sold or discarded. d. Food will be stored and handled to maintain the integrity of the packaging until ready for use . 13. Refrigerated food storage: E. Cooked foods must be stored above raw foods to prevent contamination. Raw animal foods should be separated from each other and stored on lower shelves . and in drip proof containers. F. All foods should be covered, labeled and dated . 14. Frozen Foods: c. All foods should be covered, labeled and dated . During an observation on 02/25/25 at 10:44 AM, the walk-in refrigerator revealed the following: 4 bags of shredded cheese not sealed and not labeled. 2 silver pans of cooked ground meat, covered in plastic, not labeled. 1 container of a white creamy substance, not labeled. 1 large metal container of raw pork chops not labeled and stored on top of a box of raw bacon. 1 pit ham opened and not labeled. 1 container of sliced fruit not labeled. 2 trays of assorted vegetables not labeled. 1 container of parfait not labeled. 1 clear plastic container of a chunky white substance not labeled. 1 silver pan of ground cooked meat stored on top of raw meat. 1 silver pan containing cooked bacon and cooked sausage not labeled. 1 box of tomatoes with the tomatoes having fuzzy black and white spots. During an observation on 02/25/25 at approximately 11:00 AM, the dry storage revealed the following: 1 bottle of Worcestershire sauce opened and not dated. 1 6 pound 5 ounce can of Monarch [NAME] Beans, dented and stored with usable cans. During an interview on 02/25/25 at 11:09 AM, the Dietary Director stated anything not labeled should not be in the refrigerator and items should be pulled and discarded.

Amended [DATE] Based on review of the facility policy, observations, and interviews, the facility failed to: 1. properly lock and secure two medication carts on the Overlook Point Unit for one of the two units. This failure created a situation where residents, staff, or visitors could have accessed medications without the nurse's awareness. 2. ensure the emergency kit contents were replaced, and medications were not expired in one of the two medication rooms and one of the three medication carts. Findings include: Review of the facility policy titled, Medication Labeling and Storage dated February 2023, states under the policy: Compartments, including but not limited to drawers, carts . containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. If the facility has outdated medications, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Review of the facility policy titled, Administering Medications, records under the policy Medications are administered in a safe and timely manner. During administration of medications, the medication cart is kept closed, locked when out of sight of the medication nurse or aid . Review of the facility policy titled, Emergency Pharmacy Service and Emergency Kits (E-Kits) dated ,d+[DATE], revealed under the policy: If the facility has discontinued medications the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. The provider pharmacy supplies emergency or stat medications according to the provider pharmacy agreement. Emergency medications are kept secure, checked periodically for integrity and dating . 1. During an observation on [DATE] at 12:40 PM, Licensed Practical Nurse (LPN)1 was observed administering medication. After retrieving an as-needed medication, she left the medication cart unattended without locking it. She walked past the nurse's station, near the medication room, and into the hallway. When asked if she had locked the medication cart, she turned around, apologized, and returned to lock it. She acknowledged, We're not supposed to leave the medication cart unlocked. During an observation of medication administration on [DATE] at 8:37 AM, Registered Nurse (RN)1 was observed preparing medication and then RN1 left the medication cart unattended without locking it. No staff or residents were observed in the hallway. The third drawer was open, not flush with the other drawers. RN1 exited the room at 8:41 AM and returned to the medication cart. When asked about the unlocked medication cart and after it was observed by her, RN1 stated, I forgot to lock the cart. I am supposed to lock the med cart after each resident if I don't have my eye on it. During an Interview on [DATE] at 10:18 AM, the Director of Nursing (DON) stated, for medication administration, you make sure the cart is locked when you are not right there with it. So anytime you walk away you ensure it is locked. If you are not right there it better be locked. She said her nurse; LPN 1 told her yesterday that she left the cart unlocked and unattended. I gave her education about the medication cart, it was verbal. When asked if she have provided education about securing the medication to other nurses, she stated, no. Record review of a list of residents on the Overlook Point Unit that have the potential to wander revealed, one resident was recorded as a wanderer. The list of potential wanderers on the Orchard View Unit recorded 4 residents who have the potential to wander on the unit. She confirmed the Units are usually open and they can wander between them. 2. During an observation with LPN1 on [DATE] at 2:00 PM, the following was noted: a) An open undated vial of Humulin R Insulin in an emergency kit in the medication room refrigerator. The slip inside the kit was dated [DATE]. LPN 1 said, The form is the white and the yellow (carbon copy), both medication confirmation slips. This hasn't been refilled since [DATE], that was me who pulled the insulin out. b) Insulin Glargine Lantus 10 milliliters (ml) and Insulin Lispro Humalog 10 ml both missing from the emergency kit. LPN 1 stated, There is supposed to be 3 different insulins in here. c) An intravenous (IV) start kit was open, with an expiration date of [DATE] was also observed in the drawer of the medication room. LPN 1 confirmed it was expired. An observation on [DATE] at 11:15 AM of medication cart 2 located on the Overlook Unit revealed the following: 1. Epinephrine 0.3 milligrams (mg) auto inject that expired [DATE] with lot number G230602X. Record review of the pharmacist consultant findings of the Overlook Unit dated [DATE] revealed Emergency Medication Services, kits conform with regulation and securely stored/sealed. During an interview on [DATE] at 11:25 AM LPN1 stated, the night nurse goes through the cart to check the kits, and pharmacy usually comes out once a month and checks the kits. During an interview on [DATE] at 5:18 PM with the DON and the Administrator, they said, The pharmacist comes quarterly, a nurse consultant quarterly, they won't come in the same month. January was the last time they came in and reviewed the carts. They review the med rooms as well. We immediately corrected the insulin yesterday. We call the pharmacist, and they immediately changed it out, (the kit). We were made aware of the Epi Pen expired. The DON said, I would have expected the pharmacist that did the review to find it.

Based on observation, record review, interviews, and facility policy review, the facility failed to provide adequate supervision and assistive devices to prevent accidents for 1 (Resident (R)25) of 2 residents reviewed for accidents. Specifically, R25 sustained a fall when two staff failed to utilize a mechanical lift to transfer the resident. Findings include: A review of the facility's policy/procedure titled, Lifting Machine, Using a Mechanical with a revision date of July 2021, revealed, The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. The policy indicated, 1. Mechanical lifts may be used for tasks that require: b. Transferring a resident from bed to chair; c. Lateral transfers. The policy further revealed, 2. Types of lifts that may be available in the facility are b. Sit-to-stand lifts. A review of R25's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/16/2023, revealed the facility admitted the resident on 10/21/2021. The resident had active diagnoses including but not limited to; anemia, heart failure, diabetes, hemiplegia (paralysis) or hemiparesis (partial weakness). The MDS indicated R25 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating that the resident was cognitively intact. According to the MDS, R25 required extensive assistance of two or more staff for transfers and was not steady moving from a seated to standing position nor with transfers. The MDS revealed R25 had sustained no falls since the previous assessment. A review of R25's Care Plan, revealed the resident was at risk for falls related to decreased mobility, weakness, and left hemiplegia. Interventions established on 11/02/2022 directed staff to remind the resident to call for assistance before moving from the bed-to-chair and from the chair-to-bed and provide reminders to use ambulation and transfer assist devices. A review of R25's Safe Patient Handing/Transfer Algorithm dated 03/09/2023, revealed two staff were required to assist the resident with transfers with a sit-to-stand lift. During an interview on 05/22/2023 at 1:12 PM, R25 stated approximately three weeks earlier three staff assisted the resident with standing. Staff did not use the sit-to-stand lift and during the transfer the resident fell and sustained bruising and small cuts to the left arm. A review of a Fall Details Report, dated 03/31/2023, revealed R25 sustained a fall on 03/31/2023. According to the report, R25 told staff the resident could transfer with the assistance of one staff and declined using the sit-to stand lift. R25 sustained a skin tear to the back of the left upper arm. The facility concluded staff education was needed regarding utilizing the transfer algorithm as a guide to assist with transfers. A review of the facility's Educational In-service Sign-in, dated 04/01/2023, directed staff of the following: When assisting residents with a transfer ensure you are using the transfer status algorithm in the wardrobes. Do not transfer a resident based on the resident telling you how they transfer. When in doubt ask your nurse. **Note if a resident requires any lift to be used it is MANDATORY TO HAVE 2 STAFF AT ALL TIMES** Failing to safely transfer a resident can put the resident in harm, and will result in further disciplinary action. A review of R25's quarterly MDS, with an ARD date of 04/16/2023, revealed the resident's BIMS score was 14 out of 15, indicating R25 was cognitively intact. The MDS indicated the resident continued to require two or more staffs' assistance with transfers and was unsteady. However, even though the resident sustained a fall on 03/31/2023, according to the MDS, R25 had not sustained any falls since the previous assessment on 01/16/2023. A review of the facility's Safe Patient Handing/Transfer Algorithm, dated 05/04/2023, revealed R25 was able to bear partial weight and was cooperative. The transfer algorithm continued to direct two staff to assist the resident with transfers utilizing a sit-to-stand lift. During an observation on 05/22/2023 at 1:11 PM, Certified Nursing Assistant (CNA)6 assisted R25 from a wheelchair to a recliner with no assistance from staff nor a sit-to-stand lift. CNA6 placed the wheelchair next to the recliner, assisted the resident to a standing position, completed a pivot transfer to the left, and assisted the resident to a recliner. During a phone interview on 05/24/2023 at 8:45 AM, CNA6 stated the facility placed a transfer sheet in each resident's room, which directed staff how to transfer a resident. CNA6 stated she was aware R25 required the use of a sit-to-stand lift. Regarding the transfer on 05/22/2023, CNA6 stated the resident did not like to use the sit-to-stand lift and she assisted the resident to stand and pivot to transfer from the wheelchair to the recliner. During an interview on 05/24/2023 at 7:10 AM, Licensed Practical Nurse (LPN)7 stated R25 required a sit-to-stand lift due to the resident's history of falls and unreliability. LPN7 stated for resident safety, two staff were required when a sit-to-stand lift was being utilized. During an interview on 05/04/2023 at 9:20 AM, the Director of Nursing (DON) stated information on how to transfer a resident was listed on a transfer sheet in the resident's room and on the resident's care plan. Regarding the fall on 03/31/2023, R25 told staff he/she could transfer without the lift. Staff tried to assist the resident with the transfer, and the resident fell . The DON stated her expectation was if a resident refused to use the lift, staff were to notify the nurse. In addition, two staff were required when using the sit-to-stand lift, and staff were to look at the transfer sheet before transferring a resident. During an interview on 05/24/2023 at 9:42 AM, the Administrator stated the transfer status of residents were noted in the residents' care plans and in the Kiosk. Her expectation was for staff to follow the requirement. She stated she was not surprised by the 03/31/2023 incident because R25 was vocal about his/her refusal. The Administrator stated residents had rights, and when a resident refused to use a lift, the resident had the right to refuse and fall. She stated there was a balance and residents had a say in their care plan. However, if a resident refused, staff should notify the nurse, and the nurse should have a discussion with the resident about risks and benefits of their decision.

Based on record review, interviews, and facility policy review, the facility failed to ensure a psychotropic medication ordered to be administered pro re nata (PRN; as needed) had a stop date after fourteen days or physician justification for extension of the PRN order beyond fourteen days for 1 (Resident (R)20) of 5 residents reviewed for unnecessary medications. Findings included: Review of a facility policy titled, Medication Monitoring Medication Management dated 2007, specified, Additional specific guidelines are applied to Psychotropic drugs which are defined as any drug that affects brain activities associated with mental processes and behavior. This includes, but are not limited to Antipsychotics; Antidepressants; Anti-anxiety; and Hypnotics. Based on a comprehensive assessment of a resident, the facility must insure: Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. PRN orders for psychotropic drugs are limited to 14 days. Exception: If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. The intent of this requirement is that: each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial wellbeing; the facility implements gradual dose reductions (GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. A review of R20's Face Sheet indicated the facility admitted the resident on 10/24/2019 with diagnoses including but not limited to; hemiplegia following cerebral infarction affecting the left nondominant side. A review of R20's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/06/2023, revealed a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating R20 had moderately impaired cognition. A review of R20's Care Plan Report with a goal date of 07/20/2023, revealed a problem area regarding a history of anxiety. An undated intervention directed staff to administer medications as ordered. A review of R20's physician orders, with an order date of 05/08/2023, indicated staff were directed to administer alprazolam 0.5 milligram (mg) to the resident PRN two times daily. No stop date after 14 days (05/21/2023) was indicated. A review of R20's Progress Notes dated 05/08/2023, indicated, Changed [Xanax; alprazolam] to [twice daily] as needed instead of scheduled. There was no stop date indicated or rationale provided by the physician indicating a reason why staff should extend the availability of PRN alprazolam past fourteen days. A review of R20's May 2023 Medications revealed the resident was administered PRN alprazolam 0.5 mg on 05/22/2023 and 05/23/2023, 15 and 16 days after the 14-day stop date, respectively. During an interview on 05/24/2023 at 1:12 PM, Licensed Practical Nurse (LPN)3 stated Medical Doctor (MD)4 changed R20's order for alprazolam from scheduled twice a day to twice a day as needed on 05/08/2023. LPN3 stated the proper stop date for PRN alprazolam was 14 days after ordered unless extended by a provider. LPN3 noted MD4 did not provide a stop date for R20's PRN alprazolam order. During an interview on 05/24/2023 at 3:36 PM, the Director of Nursing (DON) stated the expectation for a PRN psychotropic medication's stop date was 14 days after the order date unless a physician documented a reason to extend the stop date. The DON confirmed there was no stop date for R20's PRN alprazolam and there were no notes in the system from MD4 to rationalize not having a stop date. During an interview on 05/25/2023 at 9:50 AM, MD4 stated PRN psychotropic medications were to have a stop date after 14 days with a reassessment of the medication conducted in order to justify its continuation. MD4 noted that continuation of a PRN psychotropic medication required documentation of the justification for continuation beyond 14 days of available administration. MD4 stated there was no stop date for R20's alprazolam order, dated 05/08/2023, because she had intended to reassess R20 before the 14 days were over.

Based on observation, record review and interview the facility failed to maintain complete and accurate medical records for Resident #7, 1 of 3 sampled residents reviewed for Skin Conditions. Resident #7 sustained a skin tear to the right hand. There was no documentation in the resident's medical record related to the skin tear. The findings included: The facility admitted Resident #7 with [DIAGNOSES REDACTED]. During an observation and interview of Resident #7, on 9/3/19 at 2:38 PM, a clean, intact dressing was observed in place on his/her right hand. When asked about the dressing, Resident #7 stated s/he received an injury when a staff member moved the over the bed table away from his/her bed. S/he stated his/her hands were under the table and when the table was moved, s/he sustained a skin tear to the top of the right hand. Record review of Resident #7's weekly skin audits for the past month, on 9/4/19 at 10:59 AM, revealed no documentation of any skin alterations to the resident's right hand. Record review of Resident #7's physician's orders [REDACTED]. Record review of Resident #7's nurse's notes on 9/4/19 at 11:12 AM revealed no notes related to the injury to the resident's 's right hand. There was no documentation in Resident #7's medical record related to the cause of or treatment of [REDACTED]. During an interview with the Director of Nursing (DON), on 9/4/19 at 2:07 PM, the DON confirmed there was no documentation in Resident #7's medical record related to the injury. In addition, the DON stated s/he was unaware the resident had sustained a skin tear and would initiate an investigation immediately. During an interview with the DON, on 9/4/19 at 3:30 PM, the DON stated s/he had determined that Resident #7 received a skin tear to the right hand on 8/31/19 on the 7 AM -7 PM shift. An Incident Report, completed on 9/4/19, was reviewed and revealed that Resident #7 received a skin tear to the right hand when the certified nursing assistant (CNA) moved the over the bed table.

Based on observation, record review and interview the facility failed to notify the physician and Resident Representative (RR) of an accident resulting in a skin tear to Resident #7, 1 of 3 sampled residents reviewed for Skin Conditions. The findings included: The facility admitted Resident #7 with [DIAGNOSES REDACTED]. During an observation and interview of Resident #7 on 9/3/19 at 2:38 PM a clean, intact dressing was observed in place on his/her right hand. When asked about the dressing, Resident #7 stated s/he received an injury when a staff member moved the over the bed table away from his/her bed. Record review of Resident #7's physician's orders [REDACTED]. Record review of Resident #7's nurse's notes on 9/4/19 at 11:12 AM revealed no notes related to the injury to the resident's right hand. In addition, there were no notes indicating the physician or RR had been notified of the injury. During an interview with the Director of Nursing (DON), on 9/4/19 at 3:30 PM, the DON confirmed that Resident #7 sustained a skin tear to the right hand on 8/31/19. The DON stated the physician and RR had not been notified of the injury. In addition, the DON stated s/he was unaware the resident had sustained an injury. The DON stated the nurse who identified or was notified of the injury should have initiated treatment, notified the physician and the RR, obtained treatment orders, completed an Incident Report and nurse's note, and notified her/him immediately, per facility protocol. During an interview with Resident #7's RR, on 9/4/19 at 2:30 PM, the RR stated s/he was not notified of the resident sustaining a skin tear. The RR stated s/he found out about it when visiting the resident over this past weekend and observed the dressing to the resident's right hand.

Based on interview and record review the facility failed to protect 1 of 3 residents from physical abuse. Resident #146 was physically struck by Companion #1, a contracted sitter by the facility, during routine AM care. The findings included: Resident #146 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility Incident Report dated 4/5/19 on 9/4/19 at approximately 3:06 PM revealed that Certified Nursing Assistant (CNA) #1 and Companion #1 were toileting and dressing Resident #146 at approximately 6:50 AM - 7 AM on 4/5/19. While Companion #1 was putting on the resident's slacks, s/he began to hit the companion. Companion #1 hit Resident #146's thigh with back of open hand. The incident was reported to Director of Nursing (DON), Resident Representative, Executive Director, Police, and Primary Care. Companion #1 was removed from assignment and will no longer be assigned to the facility. Review of CNA #1 statement on 9/4/19 at approximately 3:41 PM confirmed Companion #1, who worked for a contract company, struck Resident #146's thigh with the back of his/her hand. During an interview with CNA #1 on 9/5/19 at approximately 9:25 AM s/he confirmed that Companion #1 struck Resident #146. Resident #146 was unable to be interviewed by the surveyor due to poor cognition and a Brief Interview for Mental Status (BIMS) of 3. Review of Companion #1's facility obtained statement on 9/4/19 at approximately 3:33 PM revealed I (name of companion #1) was assisting (CNA) this morning with (name of resident) in the process of trying to get (him/her) dressed (s/he) was hitting both of us and refusing to let us get (him/her) dressed. While I was at (his/her) feet trying to put (his/her) pants on (s/he) hit me in my face and arm. CNA said (s/he) does that to us all the time. I started putting (his/her) leg in pants again and (s/he) tried to hit me again. And I popped (him/her) with my inside of my hand on (his/her) left thigh like I would my grandbaby to stop that During an interview with the Administered on 9/5/19 at 8:44 AM s/he stated that the contracted companion is to provide 1 on 1 attention, they do not give care to the resident they assist the CN[NAME]

Based on interview and record review the facility failed to implement the facility Abuse Policy to protect 1 of 3 residents from physical abuse. Resident #146 was physically struck Companion #1, a contracted sitter by the facility, during routine AM care. The findings included: Resident #146 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility Incident Report dated 4/5/19 on 9/4/19 at approximately 3:06 PM revealed that Certified Nursing Assistant (CNA) #1 and Companion #1 were toileting and dressing Resident #146 at approximately 6:50 AM - 7 AM on 4/5/19. While Companion #1 was putting on the resident's slacks, s/he began to hit the companion. Companion #1 hit Resident #146's thigh with back of open hand. The incident was reported to Director of Nursing (DON), Resident Representative, Executive Director, Police, and Primary Care. Companion #1 was removed from assignment and will no longer be assigned to the facility. Review of CNA #1 statement on 9/4/19 at approximately 3:41 PM confirmed Companion #1, who worked for a contract company, struck Resident #146's thigh with the back of his/her hand. During an interview with CNA #1 on 9/5/19 at approximately 9:25 AM s/he confirmed that Companion #1 struck Resident #146. Resident #146 was unable to be interviewed by the surveyor due to poor cognition and a Brief Interview for Mental Status (BIMS) of 3. Review of Companion #1's facility obtained statement on 9/4/19 at approximately 3:33 PM revealed I (name of companion #1) was assisting (CNA) this morning with (name of resident) in the process of trying to get (him/her) dressed (s/he) was hitting both of us and refusing to let us get (him/her) dressed. While I was at (his/her) feet trying to put (his/her) pants on (s/he) hit me in my face and arm. CNA said (s/he) does that to us all the time. I started putting (his/her) leg in pants again and (s/he) tried to hit me again. And I popped (him/her) with my inside of my hand on (his/her) left thigh like I would my grandbaby to stop that During an interview with the Administered on 9/5/19 at 8:44 AM s/he stated that the contracted companion is to provide 1 on 1 attention, they do not give care to the resident they assist the CN[NAME] Review of the facility Abuse Policy on 9/5/19 at approximately 10:08 AM revealed Administration will protect residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual.

Based on observation, record review and interview the facility failed to provide treatment and care per professional standards of practice and facility protocol for Resident #7, 1 of 3 sampled residents reviewed for Skin Conditions. Resident #7 sustained an injury to the right hand, and it was unclear when treatment was initiated or by whom. The findings included: The facility admitted Resident #7 with [DIAGNOSES REDACTED]. During an observation and interview of Resident #7, on 9/3/19 at 2:38 PM, a clean, intact dressing was observed in place on his/her right hand. When asked about the dressing, Resident #7 stated s/he received an injury when a staff member moved the over the bed table away from his/her bed. S/he stated his/her hands were under the table and when the table was moved, s/he sustained a skin tear to the top of the right hand. Resident #7 stated the staff member felt really bad that it happened. In addition, Resident #7 believed it was accidental and the staff member did not intend to cause the injury. Record review of Resident #7's weekly skin audits for the past month, on 9/4/19 at 10:59 AM, revealed no documentation of any skin alterations to the resident's right hand. Record review of Resident #7's physician's orders [REDACTED]. Record review of Resident #7's nurse's notes on 9/4/19 at 11:12 AM revealed no notes related to the injury to the resident's right hand. There was no documentation in Resident #7's medical record related to the cause of or treatment of [REDACTED]. There was no documentation that the physician or Resident Representative (RR) had been notified of the injury. During an interview with the Director of Nursing (DON) on 9/4/19 at 2:07 PM the DON confirmed there was no documentation in Resident #7's medical record related to the injury. In addition, the DON stated an Incident Report had not been completed related to Resident #7's injury. The DON stated facility protocol for any resident injury included completing an Incident Report and notifying the physician and RR promptly following the injury. The DON stated the nurse who identified or was notified of the injury should have initiated treatment, notified the physician and the RR, obtained treatment orders, completed an Incident report and nurse's note, and notified her/him immediately. The DON stated all the nurses know to notify her/him of any resident injury immediately. In addition, the DON stated facility protocol related to resident injuries and the action to take is posted at all the nursing stations. The DON stated every morning nursing leadership meets to review notes, orders and Incident Reports to identify any resident injuries. The DON stated if there is no documentation or verbal report of a resident injury the team would be unaware an injury occurred. The DON stated this was the first s/he was hearing about the resident's injury and would investigate immediately. During an interview with the DON on 9/4/19 at 3:30 PM the DON stated s/he had determined that Resident #7 received a skin tear to the right hand on 8/31/19 on the 7 AM -7 PM shift. The DON provided names of witnesses and witness statements. An Incident Report, completed on 9/4/19, was reviewed and revealed that Resident #7 received a skin tear to the right hand when the certified nursing assistant (CNA) moved the over the bed table. The Incident Report also revealed the physician and RR were notified of the skin tear on 9/4/19 at 12:40 PM. During an interview with Resident #7, with his/her RR present, on 9/4/19 at 2:30 PM, the resident provided details of how s/he received the skin tear consistent with the same account s/he gave on 9/3/19. The resident could not recall an exact date or time but stated it had happened over the past weekend. When asked if a nurse had provided treatment at the time of the injury, the resident stated a nurse had treated the injury and put a dressing on it. The resident could not recall which nurse provided the treatment. The resident was able to recall CNA #1 was the staff person who accidentally caused the skin tear. The RR stated s/he visits daily and also stated the skin tear happened over the past weekend. The RR stated while visiting Saturday or Sunday s/he noticed the dressing to the resident's hand and asked him/her what happened. The RR stated the facility had not notified her/him of the injury. S/he stated the dressing appeared to be loose or coming off and went to ask the nurse about it. The RR stated the nurse told her/him Well, maybe they want it left open to air. The RR stated the nurse did not tell her/him who they were. The RR stated when s/he came to visit the next day, the dressing again appeared that it needed to be changed. The RR stated s/he went to ask the nurse about changing the dressing and the nurse stated s/he would have to call the provider first. During the interview Resident #7 was observed with a new dressing in place dated 9/4/19. During an interview with Resident #7's Hospice nurse, Registered Nurse (RN) #1, on 9/4/19 at 2:38 PM, RN #1 stated s/he completed a scheduled visit with the resident on 8/30/19. RN #1 stated the visit was completed at 4:42 PM. RN #1 stated the resident did not have a skin tear to the right hand and no dressing was in place during her/his visit. During an interview with CNA #2, on 9/4/19 at 3:57 PM, CNA #2 stated around 6:00 PM on 8/31/19 s/he went to pick up the resident's dinner tray. CNA #2 stated s/he pulled the over bed table away from the resident and caused a skin tear to the back of his/her hand. CNA #2 stated the resident must have been holding on to the table when s/he pulled it away. CNA #2 stated she immediately reported the injury to Licensed Practical Nurse (LPN) #1. CNA #1 stated s/he returned to the resident's room about 30 minutes later to help with oral care. CNA #1 stated a dressing was in place to the resident's right hand. CNA #1 stated s/he did not observe LPN #1 provide care for the skin tear. In addition, s/he stated the RR was not present when the injury happened or when s/he went back to help the resident with oral care. During an interview with LPN #2, on 9/5/19 at 8:55 AM, LPN #2 stated s/he was the resident's nurse on the 7 PM-7 AM shift on 8/31/19. LPN #2 stated while providing care to the resident s/he noticed the dressing to his/her right hand. LPN #2 stated s/he asked the resident what happened, and s/he stated, that is where I hurt my hand and the nurse put a dressing on it. LPN #2 stated the dressing was initialed and dated. LPN #2 stated LPN #1's initials were on the dressing but could not recall what date was on the dressing. LPN #2 stated the dressing in place was a Polymem dressing, a dressing the facility typically uses for skin tears. LPN #2 stated Polymem dressings are typically left in place for 3-5 days. During an interview with LPN #1, on 9/5/19 at 11:18 PM, LPN #1 stated s/he was the resident's nurse on the 7 AM to 7 PM shift on 8/31, 9/1 and 9/2/19. LPN #1 stated a dressing was in place to the resident's right hand the morning of 8/31/19 and remained intact and in place throughout her/his shift that day, as well as all day on 9/1/19 and 9/2/19. LPN #1 stated s/he did not know what type of injury the resident sustained [REDACTED]. LPN #1 stated s/he did not place the dressing or provide any care or treatment for [REDACTED].#1 stated it wasn't until 9/2/19 that s/he was informed by LPN #3 the resident had a skin tear to the right hand. LPN #1 stated multiple times during the interview s/he had not seen the skin tear because the dressing was in place on all her/his shifts. LPN #1 stated s/he did not question anyone about the dressing because s/he assumed protocol had already been followed. LPN #1 stated the DON and Administrator were saying s/he is the nurse that provided treatment and placed the dressing after the resident sustained [REDACTED].#1 again denied treating the skin tear or placing the dressing. LPN #1 stated had s/he been the nurse to identify and treat the skin tear, s/he would have followed protocol for notification, completing an Incident Report, notifying the DON, etc. LPN #1 stated s/he had never not followed facility protocol. LPN #1 stated the skin tear did not occur on her/his shifts. During an interview with LPN #3 (the unit manager), on 9/5/19 at 12:37 PM, LPN #3 stated on 9/2/19 LPN #4 told him Resident #7's RR had asked her/him several times about changing the dressing. LPN #3 stated s/he was unaware of any injury or dressing at that time. LPN #3 stated s/he went to see the resident and asked to see his/her hand. LPN #3 stated a Polymem dressing, dated 9/1/19 with LPN #1's initials, was in place to the right hand. LPN #3 stated the dressing appeared to be coming loose. LPN #3 stated s/he then went to LPN #1 and told her/him that s/he needed to change the resident's dressing. LPN #3 also asked if anything was written up about the skin tear. LPN #3 stated LPN #1 told him/her that s/he had nothing to do with the skin tear and had not written anything up. LPN #3 stated s/he re-educated LPN #1 on protocol and what needed to be done and instructed LPN #1 to take care of it. LPN #3 stated s/he should have double checked to ensure protocol was followed but did not. In addition, LPN #3 stated CNA #2 had told him/her s/he had reported the skin tear to LPN #1 after it happened on 8/31/19. Review of Resident #7's nurse's notes on 9/5/19 at 12:50 PM revealed a wound assessment had been completed on 9/5/19 at 7:03 AM. The skin tear showed signs of healing with no signs or symptoms of infection.

Based on interview and record review, the facility failed to invite resident representatives to participate in care plan meetings for 1 of 1 family interviewed. The family of Resident #34 had not been invited to care plan meetings since 10/17. The findings included: Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with family of Resident #34 on 7/9/18 revealed it had been months since the last care plan meeting invitation. Review of a hospice interdisciplinary note dated 6/19/18 on 7/10/18 at approximately 3:33 PM revealed the family's attendance or invitation was not documented. Interview with the administrator and director of nursing (DON) on 7/10/18 at approximately 3:55 PM revealed they could not find invitations / attendance sheets for care plan meetings since the family last attended a meeting on 10/19/17.

Based on record review and interview, the facility failed to notify the physician that Resident #174 was refusing Pro-Stat, a protein supplement. Resident #174 refused Pro-Stat on multiple occasions over 3 months, 1 of 3 sampled residents reviewed for Pressure Ulcers. The finding included: The facility admitted Resident #174 with [DIAGNOSES REDACTED]. Record review of the RD (Registered Dietician) notes on 3/22/2017 at 10:12 AM, revealed that Resident #174 was assessed by the RD on 12/11/2016 and started on Pro-Stat 30 ml (milliliters) daily. The RD assessed the resident on 1/15/2017 and noted that the resident had a 5.7% weight loss in the past 30 days. Resident #174 was started on Med Pass 2.0 (nutritional supplement) 120 ml three times daily and the Pro-Stat was increased to 30 ml twice daily. On 2/13/2017, the RD noted that arterial dysfunction was complicating healing of the resident's Pressure Ulcers. Record review of the Medication Administration Records (MARs) for January, 2017-March, 2017 on 3/23/2017 at 9:09 AM, revealed that the resident's Pro-Stat was not administered on multiple occasions due to resident refusal. The MARs indicated the Pro-Stat was increased to 30 ml two times daily on 1/16/2017 and ordered to be given at 8:00 AM and 8:00 PM. Resident #174 refused the PM dose of Pro-Stat on 3 occasions in January. In February, Resident #174 refused the PM dose of Pro-Stat on 19 occasions. In March, the resident refused the PM dose of Pro-Stat on 7 occasions. Record review of the Care Plan on 3/23/2017 at 9:11 AM, revealed a problem area of Pressure Ulcers to feet. An intervention listed for this problem was to Perform nutritional screening. Adjust diet/supplements as indicated to reduce the risk of skin breakdown. The Care Plan had not been revised to indicate that the resident was frequently refusing the PM dose of Pro-Stat. No new interventions were implemented related to the resident's refusals. Additional record review of the RD and Nurse's Notes from January, 2017-March, 2017, on 3/23/2017 at 9:13 AM, revealed no documentation that the physician or the RP (Responsible Party) were notified of the resident's refusals of Pro-Stat. There were no RD notes addressing the resident's refusal of Pro-Stat and no RD notes after 2/13/2017. Record review of the Lab Reports on 3/23/2017 at 9:19 AM, revealed the resident's [MEDICATION NAME] level on 12/20/2016 was 17. The resident's [MEDICATION NAME] level on 2/14/2017 was 15. Per the Lab Reports, normal range for [MEDICATION NAME] is 17.0-34.0. [MEDICATION NAME] is a protein. Record review of the physicians notes on 3/23/2017 at 9:26 AM, revealed that the physician was evaluating and treating Resident #174's Pressure Ulcers weekly. There was no documentation in the physician's notes from January, 2017-March 2017 indicating he/she was aware the resident was refusing Pro-Stat. The physician's note from 2/16/2017 indicated he/she was aware of the [MEDICATION NAME] results from 2/14/2017. The physician's note from 1/27/2017 indicated that the physician met with the family to recommend a vascular consult and surgery to increase blood flow to aid in healing. A lab test on 1/17/2017 indicated the resident had severe arterial disease. The family declined the vascular consult and surgery. There was no sign of deterioration of the wounds in the weekly Pressure Ulcer assessments. During an interview with the DON (Director of Nursing) on 3/23/2017 at 10:08 AM, the DON confirmed the multiple refusals of Pro-Stat. During an interview at 10:37 AM the DON confirmed that the physician and RP had not been notified of the resident's refusal of Pro-Stat. In addition, the DON confirmed that no new treatment or interventions had been implemented related to the resident's refusal of Pro-Stat. The DON confirmed there were no RD notes or recommendations related to the resident's refusals. The DON stated that all nurses would be re-educated, starting today, regarding resident's who refuse any treatment, medication or supplement. During an interview with the RD on 3/23/2017 at 10:56 AM, the RD stated he/she could not recall if he/she was told by staff the resident was refusing Pro-Stat. The RD stated she/he was aware of inconsistencies in the resident's intake of Pro-Stat, but this would not have been a big factor in changing the treatment plan. The RD stated the resident was getting a lot of protein from the Med Pass supplement and the resident's weight was stable during the last review. The RD stated the resident's multiple disease processes were inhibiting wound healing and the low [MEDICATION NAME] level could be an indicator of Metabolic Stress. The RD also stated that [MEDICATION NAME] could be drawn 3 times in one week and could sway as much as 2 points each time it was drawn.

Based on observation and interview the facility failed to properly store scoops, restrain hair in food preparation area, date canned food products in storage room, and clean deep fryers frequently in 1 of 1 main Kitchen. Staff handled resident's food two times with bare hands in 1 of 4 dining areas. The findings included: Initial tour of the main kitchen on 3/21/17 at 6:30 AM revealed 1 scoop stored inside the sugar bin and 1 scoop on top of the cornmeal bin open to air. In the dry storage room the food cans were not dated when the cans came into the facility and the 3 deep fryers had large amounts of crumbs covering the oil and had not been changed in several days. At 8 AM on 3/21/17 in the Orchard View dining room CNA #1 ( Certified Nursing Assistant) handled bread with bare hands for 2 different residents. On 3/22/17 at 12 Noon 3 dietary employees were serving food in the diet kitchen on Overlook Unit with hair not constrained completely and hair out from under nets. The Dietary Manager and Assistant Dietary Manager confirmed these concerns were present.

Based on record review and interview the facility failed to have Hospice information related to Resident # 135 in the facility at the time of the survey. ( 1 of 1 Hospice resident reviewed) The findings included; Record review for Resident # 135's chart on 3/22/17 revealed that no Hospice information was included in the record. The Director of Nursing ( DON) stated the facility had a separate book which contained all the Hospice information and she/he would get it. The next morning the DON was again asked for the information. The DON stated that the book had not been in the facility and that the Hospice company had faxed over all the information that morning to be placed into a book. This contained copies of notes from the staff visits, assessments, and care plans. The Physicians's recertification form for service was later signed and faxed over to the facility. The DON and Administrator confirmed the book had not been in the facility at the time of the survey .

Based on record review and interviews, the facility failed to ensure electronic medical records were maintained accurately for 2 of 5 residents reviewed for unnecessary medications. Resident #28's electronic medical record (EMR) had inconsistent information related to oxygen level given as ordered. Resident #61's electronic charting had inconsistent information in regard to the resident's Advance Directive being Full Code or Do Not Resuscitate. The findings included: The facility admitted Resident #28 with [DIAGNOSES REDACTED]. Review of a physician's order dated 5/06/16 indicated Resident #28 was to receive Oxygen by nasal cannula at 3 LPM (Liters Per Minute). Further review of the electronic record revealed a nurse's note dated 5/26/16 that indicated the resident received Oxygen at 2 LPM at 10:38 AM. A nurse's note dated 5/28/16 at 12:40 AM indicated the resident received Oxygen at 3 LPM. A nurse's note dated 5/30/16 at 5:54 PM indicated the resident continued on Oxygen at 2 LPM via nasal cannula. A nurse's note dated 5/31/16 @ 12:06 PM indicated the resident continued to receive Oxygen at 2 LPM. A nurse's note dated 6/01/16 at 10:43 AM revealed the resident remains on 2L ( liters) O2 (oxygen) via NC (nasal cannula) to maintain O2 Sat (Saturate) > (less) 90. During an interview on 6/02/16 at approximately 9:30 AM with Registered Nurse (RN) #2, s/he confirmed the findings that the nurses notes dated 5/26/16, 5/30/16, 5/31/16 and 6/01/16 indicated the resident received oxygen at 2 LPM (Liters Per Minute). Further review of the electronic record revealed there was no physician's orders to give the resident oxygen at 2 LPM. During an interview on 6/02/16 at approximately 10:03 AM RN #2 stated he/she called the nurse who wrote the nurse's notes on the dates the oxygen was given at 2 LPM and was informed the notes were written in error. At approximately 10:45 AM, RN #2 then created an addendum to the electronic charting to make the corrections to the documentation. The facility admitted Resident #61 with [DIAGNOSES REDACTED]. Review of the Medication Administration Record [REDACTED]. During an interview on 6/02/16 at approximately 12:27 PM, the Administrator stated there should be only one notation on the MAR indicated [REDACTED]. The Administrator stated the facility had been using the electronic charting system since August 2015 and further stated the facility discussed concerns in February 2016 about documentation issues. The Administrator stated a plan of correction was put in place on 5/24/16 due to a recent licensing survey that indicated concerns with the electronic charting. The Administrator provided documentation to indicate their plan of correction addressed scanning documentation accurately. The plan of correction did not address documentation written or provided directly in the electronic records by staff.

Based on observations and interviews, the facility failed to keep the area around 3 of 3 dumpster's free of trash and food waste, keep the upper lid of 1 of 3 dumpster's closed and 1 of 3 dumpster's sat on a broken concrete surface. The facility also has 1 of 1 grease traps which was leaking onto the soil and concrete. The findings included: On 2/3/15 at approximately 3:03 PM, 3 dumpster's were observed sitting one in front of the other with the third pushed against the building wall on the dock area behind the facility kitchen. The concrete was noted to be broken and un-level under the first dumpster with soiled, used gloves on the ground, 2 of the 3 had doors/lids open and trash was stacked up behind the third dumpster. On 2/3/15 at approximately 4:35 PM, 2 dumpster's remained open with gloves and trash on the ground. On 2/4/15 at approximately 8:50 AM, the dumpster area was observed. The lids/doors were closed at that time but the concrete remained broken, soiled gloves, trash, and a gallon plastic carton was under the first dumpster and trash and food were observed stacked up behind the third dumpster. A grease trap was observed sitting across the lot on a concrete slab. The area in front of the trap was covered in grease as well as an area of the road approximately 20 feet long in front of the trap. Further observation revealed a crack in the weld along the bottom left side of the grease trap approximately six (6) inches long which had a heavy build up of grease. No other area on the outside of the grease trap had a build up of grease. On 2/5/15 at approximately 12:10 PM, the Executive Chef observed and verified the dumpster and grease trap. The maintenance Director also verified the areas. On 2/5/15 at approximately 2:10 PM, the dumpster lid nearest the facility wall, #3, was again observed with the lid open.

Based on record review, interview, and review of South Carolina Code of Law, Title 44, Chapter 7, Article 23, Section 44-7-2910, the facility failed to obtain criminal background checks in the state of residency for 2 of 2 licensed nurses not living in South Carolina for the 12 months preceding employment at the facility in accordance with State Law. The findings included: On 2/4/15 at 9:20 AM, review of personnel records revealed the Director of Nursing and Licensed Practical Nurse #5 were living in another state at the time of hire. Further review revealed a South Carolina State Law Enforcement Division (SLED) check had been obtained prior to the date of hire but there was no North Carolina criminal background check in either employees' file. During an interview on 2/4/14 at 10:10 AM, the Director of Human Resources confirmed North Carolina background checks had not been done and stated "I didn't know I was supposed to." Review of South Carolina Code of Law Title 44, Chapter 7, Article 23 Section 44-7-2910 revealed "(2) A direct care entity unable to verify South Carolina residency for a direct care applicant for the preceding twelve months shall conduct a state criminal record check on the applicant prior to employment and shall commence a federal criminal record check after employment. However, if the direct care entity can verify residency in another state for the preceding twelve months, the direct care entity may conduct only a state criminal record check in the applicant's resident state or jurisdiction where the applicant previously resided."

Based on observations, record review, interviews, manufacturer labeling and Facts & Comparisons the facility failed to follow a procedure to ensure that expired floor stock medications were not stored with other medications in 2 of 2 medication rooms. The finding includes: On 2/3/15 at approximately 4:15 PM inspection of the Orchard View Medication Room refrigerator revealed the following: -One opened vial of Tuberculin Purified Protein Derivative, Aplisol, 5 TU (test units)/0.1 ml (milliliter), lot 27 containing approximately 0.4 ml was found on the second shelf of the refrigerator. This vial had been dated by the facility as opened 12/21/14. The manufacturer label stated: "Once entered vial should be discarded after 30 days." This finding was verified by LPN (Licensed Practical Nurse) # 1 on 2/3/15 at approximately 4:22 PM. !! On 2/3/15 at approximately 4:30 PM inspection of the Overlook Point Medication Room refrigerator revealed the following: -One opened vial of Tuberculin Purified Protein Derivative, Aplisol, 5 TU (test units)/0.1 ml (milliliter), lot 9 containing approximately 0.7 ml was found on the second shelf of the refrigerator. This vial had been dated by the facility as opened 12/22/14. The manufacturer label stated: "Once entered vial should be discarded after 30 days."

Based on observations, record reviews, interviews and manufacturer package inserts the facility failed to assure that opened Novolog Insulin belonging to two residents was accurately labeled as to expiration date in 2 of 4 medication carts The findings include: On 2/3/15 at approximately 4:40 PM inspection of the Orchard View Medication Cart #1 revealed one opened 10 ml (milliliter) vial of Novolog Insulin 100 U (units)/ml belonging to Resident A. This vial contained approximately 9 ml and had been dispensed 9/5/14 and had not been dated as to date opened. On 2/3/15 at approximately 4:45 PM LPN (Licensed Practical Nurse) # 1 verified that the Novolog Insulin had been opened and had not been dated as to date of opening. !! On 2/4/15 at approximately 9:25 AM inspection of the Overlook Point Medication Cart #2 revealed one opened 10 ml vial of Novolog Insulin 100 U/ml belonging to Resident B. This vial contained approximately 9.5 ml and had been dispensed 1/16/15 and had not been dated as to date opened. On 2/3/15 at approximately 9:35 AM LPN (Licensed Practical Nurse) # 3 verified that the Novolog Insulin had been opened and had not been dated as to date of opening. The package insert of Novolog Insulin, manufactured by Novo Nordisk), package states that opened vials of Novolog Insulin should be used within 28 days.

On the days of the Recertification Survey and Complaint Inspection, based on record reviews and interviews, the facility failed to notify the physician of Fingerstick Blood Sugar (FSBS) results less than 60 for Residents #2, #5 and #9, (3 of 4 Residents reviewed for FSBS, who had orders to notify the physician for FSBS less than 60.) In addition, the facility failed to notify the physician of low Blood Pressure (BP) for Resident #13, (1 of 3 Residents reviewed for Orthostatic BP monitoring.) The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Record review of the physician's orders [REDACTED].< (less than) 60 or > (greater than) 350". Record review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Record review of the Nurses Notes and Telephone orders on 3/25/2014 at 12:28 PM revealed no documentation of MD notification for the blood sugar of less than 60. During an interview on 3/25/14 at 2:23 PM, Registered Nurse (RN) #1 verified the FSBS of 59 for Resident #2 and stated the MD should have been notified. After reviewing the clinical record, RN #1 verified, at 2:40 PM on 3/25/2014, that the MD had not been notified of the low blood sugar for Resident #2. The facility admitted Resident #5 with [DIAGNOSES REDACTED]. On 3/24/14 at 3:45 PM, review of the current monthly physician's orders [REDACTED]. Review of the MAR (Medication Administration Record) revealed the SSIC protocol included instructions to "give juice/Glucostat/[MEDICATION NAME] 1 mg (milligram) IM (intramuscularly) and call MD" for FSBS 0-59 and was discontinued on 2/10/14 as ordered. Further review revealed another order was written on 3/20/14 for FSBS BID call if less than 60 or greater than 250 after a week of obtaining the FSBS 4 times a day before meals and at bedtime, the results of which were reviewed by the Nurse Practitioner on 3/20/14. On 3/25/14 at 8:55 AM, review of the Nurse's Notes revealed a note dated and timed for 3/22/14 at 12 PM that stated "Resident returned from therapy (with) c/o (complaint of) weak, "feel funny" checked Resident's BGL (Blood Glucose Level), BGL 54, juice given to Resident & PB (Peanut Butter) crackers." There was no documentation that the physician was notified as ordered. During an interview on 3/25/14 at 12:27 PM, RN (Registered Nurse) #1 confirmed the FSBS was documented as 54 on 3/22/14 and that there was no documentation on physician notification. The RN stated that the nurse might not have thought the physician had to be notified because the FSBS was not done as one of the "scheduled" finger sticks. The RN further stated that the facility had a protocol as part of the SSIC but also stated "I guess that wouldn't apply since (the resident's) had been D/Cd (discontinued)." In addition, when asked if the physician was to be notified when a routine schedule FSBS was less that 60, then shouldn't the physician also be notified with a result less that 60 when the resident was symptomatic? RN #1 stated the nurse should have notified the physician and further stated "I would have called the doctor." Resident #9 was admitted to the facility in 2010 and diagnosed with [REDACTED]. On 3/25/14 at 2:52 PM, review of the current monthly Physician order [REDACTED]." Review of the Telephone Orders revealed the original order was written on 1/9/14. At approximately 3:50 PM, review of the 2/1/14-2/28/14 MAR indicated [REDACTED]. Review of the Nurse's Notes revealed no documentation for 2/9/14. On 3/25/14 at 3:59 PM, Licensed Practical Nurse (LPN) #1 confirmed the FSBS on 2/9/14 at 4:30 PM was documented as 22. The LPN also confirmed there was no documentation of the blood sugar in the Nurse's Notes and no documentation of physician notification. The LPN also confirmed the MD should have been notified. A policy related to Finger Stick Blood Sugars was requested from the facility. The facility provided a copy of "Standard Sliding Scale for FSBS per Facility Policy" which stated "< (less than) 60 if responsive give 8oz. juice or glucostat. If unable to swallow or unresponsive give [MEDICATION NAME] 1 mg IM. Then notify MD/Provider." Additional information was provided by the facility related to entering FSBS Sliding Scale into the EZ MAR indicated [REDACTED]." The facility admitted Resident #13 with [DIAGNOSES REDACTED]. Resident #13's care was reviewed as part of a closed record review. Record review on 3/25/14 revealed a hospital Discharge Summary dated 10/30/13 (admitted [DATE]) which stated the patient lived at the nursing facility and was brought to the emergency room after s/he had hit his/her head and back after falling from a standing position. The resident complained of left rib pain and was found to have a nondisplaced rib fracture. According to the summary, the discharge [DIAGNOSES REDACTED]. The resident's medications were adjusted and s/he was discharged back to the facility in stable condition; with possible further medication adjustment by his/her primary care provider. A review of Physician Telephone Orders revealed an entry dated 10/31/13 which stated, "Check orthostatic BP's (Blood Pressures) daily x 1 week (Lying, sitting, standing)...". A review of the resident's Vital Sign & Weight Flow Sheet revealed that on 11/3/14 (time unknown), the resident's standing blood pressure was 82/60; lower than the documented BP of 112/52 (taken with the resident lying down) and BP of 131/84 (taken with the resident sitting up). According to documentation provided by the Director of Nursing (DON), the blood pressure had been entered into the Care Tracker system on 11/3/14 at 1:11 PM. A review of Nurse's Notes documentation revealed there was no documentation to indicate the Physician had been notified of the resident's decreased blood pressure upon standing. There was no documentation that indicated the resident had been assessed relative to possible causes for this low blood pressure or any associated signs or symptoms the resident may have had at the time the blood pressures had been taken. During an interview on 3/25/14 at 1:35 PM, the DON was made aware of the surveyor's concerns related to the lack of notification of the Physician for Resident #13's low BP upon standing; along with the lack of documentation about the time the blood pressure had been taken or an assessment of the resident's condition.

On the days of survey, based on information provided by the facility and staff interview, the facility failed to assure background checks were completed prior to hire. Four of five personnel records revealed the results of criminal background checks for CNAs' A and D and Licensed Nurses' B and C were not completed timely. The findings included: The personnel record for CNA (Certified Nursing Assistant) #A revealed a hire date of 12/16/13 with a criminal background check dated 12/17/13. The personnel record for CNA #D revealed a hire date of 2/17/14 with a criminal background check also dated 2/17/14. The personnel record for RN (Registered Nurse)#B revealed a hire date of 12/30/14 with a criminal background check also dated 12/30/14. The personnel record for LPN (Licensed practical Nurse)#C revealed a hire date of 1/6/14 with a criminal background check also dated 1/6/14. On 3/25/14 at 12 Noon, the Director of Nursing confirmed the dates were accurate as cited.

On the days of the complaint inspection, based on record review and interviews, the facility failed to revise Resident #1 (1 of 1 resident reviewed for burns) care plan after s/he sustained a burn from spilling hot tea on him/herself. The findings include: Resident #1 admitted with [DIAGNOSES REDACTED]. During the initial tour on 3/12/13 at 9:45 AM, Resident #1 was not at the facility. S/he had been admitted to the hospital for testing, on 3/11/13 following a doctor's appointment. The hospital admission per the facility was not related to the incident with the hot tea. Review of the facility Admission History and Physical dated 2/13/13 stated, "...His/her past medical history includes chronic arthritis, mostly of his/her hands and feet... The patient also underwent multiple back surgeries in the past with residual left footdrop and s/he has more chronic symptoms of [MEDICAL CONDITION] in his/her feet and hand for which s/he continues on [MEDICATION NAME] therapy..." Review of the 24 Hour Report dated 3/4/13 stated in the conclusion, "...Our investigation concluded that the CNA's (certified nurse aide's) actions were neglectful in nature. The tea was too hot to be handled by a resident especially in the case of a resident with documented arthritis and [MEDICAL CONDITION] of his/her hands. It is believed that the resident's medical conditions put him/her more at risk to spill the tea, however the CNA should have not offered such a hot liquid to a resident under any circumstances..." Review of the resident's care plan dated 2/14/13 revealed that the facility had not care planned the resident's desire for "hot" tea or any precautions related to his/her [DIAGNOSES REDACTED]. Following the incident on 3/2/13 the care plan was updated to include "burn from tea" "[MEDICATION NAME] cream to area on abd q (every) shift till healed"; no other interventions were in place. In an interview with the Director of Nursing (DON) on 3/12/13 at 3:12 PM, the policy/procedure related to food temperatures from the kitchen was provided. The DON stated that they do not have a policy related to reheating foods in microwaves and they do not check the temperature for items that are reheated in the microwaves. The DON also stated they do not have anything in place related to policy/procedure for heating/reheating in microwaves following the incident with Resident #1 and that they were not going to change anything.

On the days of the complaint inspection, based on record review and interviews, the facility failed to ensure that the resident environment remained as free of accident hazards as possible. Resident #1 (1 of 1 resident reviewed for burns) sustained a burn after spilling hot tea on him/herself. The findings include: Resident #1 admitted with [DIAGNOSES REDACTED]. During the initial tour on 3/12/13 at 9:45 AM, Resident #1 was not at the facility. S/he had been admitted to the hospital for testing, on 3/11/13 following a doctor's appointment. The hospital admission per the facility was not related to the incident with the hot tea. Review of the facility Admission History and Physical dated 2/13/13 stated, "...His/her past medical history includes chronic arthritis, mostly of his/her hands and feet... The patient also underwent multiple back surgeries in the past with residual left footdrop and s/he has more chronic symptoms of neuropathy in his/her feet and hand for which s/he continues on gabapentin therapy..." Review of the 24 Hour Report dated 3/4/13 stated in the conclusion, "...Our investigation concluded that the CNA's (certified nurse aide's) actions were neglectful in nature. The tea was too hot to be handled by a resident especially in the case of a resident with documented arthritis and neuropathy of his/her hands. It is believed that the resident's medical conditions put him/her more at risk to spill the tea, however the CNA should have not offered such a hot liquid to a resident under any circumstances..." Review of the resident's care plan dated 2/14/13 revealed that the facility had not care planned the resident's desire for "hot" tea or any precautions related to his/her [DIAGNOSES REDACTED]. Following the incident on 3/2/13 the care plan was updated to include "burn from tea" "Silvadene cream to area on abd q (every) shift till healed"; no other interventions were in place. Review of the Nurse's Note from 3/2/13 through 3/11/13 revealed the following: 3/2/13 at 2:45 AM "... Around 0215 pt. (patient) waste hot tea on his/her abdomen area. Stf (staff) was called to resident room. Stf observed a red area on abdomen, hands, and pubic area. Stf. applied triple antibiotic ointment to areas. Areas were left open to air... Notified Bump and Bruise line. New order written to apply triple antibiotic ointment twice a day to reddened areas. Resident placed in MD book for evaluation. 1:20 PM Called NP (nurse practitioner) and obtained order for Silvadene cr (cream) to abd (abdomen). Area remains pink." 3/3/13 at 1100 "...Silvadene to abd (abdomen). Some blistered (closed) below belly button..." There was no documented in the nurse's notes regarding the blistered area on Resident #1's abdomen after 3/3/13. Review of the Treatment Record indicated that Silvadene Cream was applied twice a day to Resident #1's abdomen from 3/2/13 until 3/11/13 when s/he was admitted to the hospital. The Treatment Record revealed no assessment of the resident's injury from the hot tea; the only description of the blistered area was found in the nurse's notes dated 3/2 and 3/3/13. During an interview with Certified Nurses Assistant (CNA) #3 on 3/12/13 at 11:50 AM s/he stated that s/he cared for Resident #1 all the time and s/he likes hot tea. CNA #3 stated that on 3/2/13 Resident #1 was given his/her fourth cup for that evening. The resident stated that his arms were shaky and s/he spilled the hot tea. The CNA stated the light had been on in the bathroom and the television was playing. The CNA was unsure of the exact time, but believed it was around 5:30 AM. When the resident informed the CNA that s/he had spilt the hot tea on his/herself the CNA notified the nurse. The nurse assessed Resident #1 and applied some cream to his/her stomach. The CNA stated s/he usually heats the tea for 1 1/2 minutes and stood at the bed for him/her to taste. The resident put honey in the tea and said it was ok and then the CNA left the resident's room. The resident apparently had problems with other CNA's and so CNA #3 was assigned to the resident and s/he informed the CNA just how s/he liked the hot tea. The CNA continued to work with Resident #1 to get the hot tea right. The cups with lids were too hot for the resident and s/he asked for a thick plastic mug without a lid. The resident stated s/he did not want a lid. An interview with Registered Nurse (RN) #1 on 3/12/13 at 1:15 PM revealed s/he had been called to Resident #1's room because s/he spilled hot tea on him/herself and had a bruised/red area on his/her abdomen. RN #1 completed an incident report and applied Neosporin on Resident #1's abdomen. The resident stated s/he was not in any pain and RN #1 then notified the resident's wife. RN #1 stated this occurred during the night approximately around 1:00 AM in the morning, s/he was not sure of the time. RN #1 stated that this was the first occurrence that s/he was aware of. S/he did state that they give Resident #1 hot tea all the time. RN #1 stated the resident was able to feed him/herself with a tray setup. An interview with CNA #1 on 3/12/13 at 1:30 PM, revealed that CNA #3 had the hall with Resident #1 and that s/he was at the nurse's station when CNA #3 came running out and said the nurse needed to come see Resident #1 because s/he had spilled hot tea on his/her chest. CNA #1 stated that s/he does heat liquids for residents and s/he had done this for Resident #1 before. To prepare hot tea CNA #1 placed a tea bag in a cup of water and heat it for 1 1/2 minutes. S/he stated the resident never complained of it being to hot. CNA #1 stated s/he stayed with the resident while s/he puts honey in the tea and waited for the resident to taste it. An interview with Licensed Practical Nurse (LPN) #1 revealed that CNA #3 made Resident #1 a cup of tea and came back to the desk saying the tea had spilled on the resident's belly. The resident had red areas on his/her hands and belly. The LPN then asked the CNA how hot s/he made the tea. The CNA replied that s/he "heated it for 2 minutes like I usually do". LPN #1 stated that s/he then heated a 16 ounce cup of tea for 2 minutes and showed RN #1 how hot it was; s/he stated, "It was boiling". An interview with CNA #2 on 3/12/13 at 2 PM revealed that the call light for Resident #1 came on and s/he said that s/he wasted tea on him/herself. CNA #2 remembered that CNA #3 asked the resident if s/he wanted a lid? S/he said, " No." CNA #3 helped Resident #1 change clothes and bed linens. CNA #2 heard CNA #3 tell the resident that s/he wanted to put a lid on the tea for him/her, but the resident refused the lid. CNA #2 stated that s/he made tea a lot for Resident #1 and s/he would send the CNA back to reheat the tea if it was not hot enough. CNA #2 stated that sometimes they would not heat the tea because they were scared it would be too hot. S/he stated s/he would also put the tea in a white cup with a lid and had seen the resident remove the lid. In an interview with the Director of Nursing (DON) on 3/12/13 at 3:12 PM, the policy/procedure related to food temperatures from the kitchen was provided. The DON stated that they do not have a policy related to reheating foods in microwaves and they do not check the temperature for items that are reheated in the microwaves. The DON also stated they do not have anything in place related to policy/procedure for heating/reheating in microwaves following the incident with Resident #1 and that they were not going to change anything. The DON stated they did discuss with the CNA/Staff the incident with Resident #1 about heating foods and water temperatures and being careful not to serve hot. The surveyor informed the DON that during interviews with 9 staff members only 2 had attended the group inservice titled Abuse/Neglect conducted 3/4/13, as evidenced by their signatures. Also none of the staff remembered an inservice related to the incident with Resident #1. Review of the information presented at the inservice conducted 3/4/13 indicated topics discussed failed to address the incident with Resident #1. The inservice was about abuse, neglect and exploitation; including definitions of all three, indicators of abuse and financial exploitation and the clinical protocols related to abuse/neglect. .

On the days of the Recertification survey, based on observations, interviews and review of the facility's policy entitled Wound Care Guidelines, the facility failed to notify the physician of treatment changes and signs of infection for 2 of 2 residents reviewed with wounds with significant changes/the need to alter treatments. The physician was not notified of order changes from the wound clinic nor signs of wound infection for Resident #5. The physician was not notified of order changes for Resident #13. The findings included: Resident #5 was admitted to the facility with a right heel wound. On 11/8/12 at 7:30 PM nursing documented the treatment for [REDACTED]. There was no documentation to indicate notification of the physician related to the change. On November 1 and November 2, 2012, there was no documentation that wound care to the heel was provided. Treatment was signed as provided November 3, 4, & 5, 2012. The morning treatment of [REDACTED]. Subsequently, there was no further evidence the facility provided the resident with treatment to the heel wound. The resident was admitted to the hospital from the Wound Clinic on 11/13/12 for "possible limb loss due to infection of the wound". There was no evidence the physician was notified the treatments were not being administered per order. Information received from the wound center for the 11/13/12 visit indicates the resident had a stage 4 ulcer measuring 4.5 x 8 x .2 with a large amount of extremely foul odor. Additionally the consult stated; "deteriorated, this is much worse.." The Hospital admission note indicated the resident was admitted to the hospital for a "nonhealing ulcer of the right heel; may have osteo[DIAGNOSES REDACTED]". On 11/13/12 in an interview with the Director of Nursing (DON), the DON stated that per policy, the physician was not always notified and pointed out the section of the policy which stated "...All orders will be reviewed by the clinical management team and may be changed at their discretion". During an interview with the Wound Nurse on 11/15/12 at 11:45 AM the Wound Nurse stated that s/he had written the order on 11/8/12 to discontinue Dakin's Solution to Resident #5's left heel wound. The Wound Nurse stated that the resident had started going to the Wound Clinic on 11/6/12 and s/he stated s/he had not notified the physician of such. During an interview with the Medical Director on 11/15/12 at 3:30 PM, the Medical Director stated that s/he was not aware that Resident #5 had been admitted to the hospital from the wound center on 11/13/12. The Medical Director also stated that s/he would expect a decline in a wound's status if treatments were missed. S/he further stated it would be expectation for facility staff to notify the physician if the wound center sent orders for a resident and for the attending physician to verify/approve those orders prior to starting a treatment. The Medical Director reviewed the facility's protocol for wound care and stated that s/he did not agree with the protocol and would not agree with the facility beginning treatment without contacting the physician and to do so would be [MEDICATION NAME] without a license. The facility admitted Resident #13 with right groin wounds with a wound vac (vacuum) in place. Record review on 11/15/12 revealed Skilled Daily Nurses Notes dated 11/10/12 and 11/11/12 which documented signs and symptoms of possible infection in the groin wounds. The note dated 11/10/12 at 2:00 AM stated "Dsg (Dressing) to R(ight) groin (changed), Foul odor present (with) Blue-green drainage...". A note dated 11/11/12 at 2:00 AM stated "...Dsg to R(ight) groin (changed)...Area remains beefy red (with) Bluegreen drainage (with) foul odor". There was nothing in the notes to indicate the Physician had been notified of this change. A note dated 11/12/12 at 4:00 PM revealed the Nurse Practitioner was there for an acute visit with new orders received. A review of Physician Telephone Orders revealed no new orders related to the groin wounds for 11/12/12. There was no documentation of a Physician/Nurse Practitioner note related to a visit on 11/12/12 or documentation provided that information related to the drainage and foul odor had been communicated to the Nurse Practitioner or Physician. During an interview on 11/15/12 at 1:00 PM, the Director of Nursing (DON) verified the above information. The DON was asked to provide any documentation related to the Nurse Practitioner's visit in relation to notification of the wound but later stated there was none. During an interview on 11/15/12 at 3:30 PM, the Medical Director was asked if s/he would expect to be notified if for 2 consecutive nights the nursing staff documented blue green drainage with a foul odor from a surgical wound. The Medical Director stated that if this was a change, then s/he would expect to be notified.

On the days of the Recertification Survey, based on observation, staff interview, and review of the facility provided policy entitled, "Skin and Wound Management", the facility failed to ensure staff were following physician orders [REDACTED].#5, #13, 20 ( 3 of 3 sampled residents reviewed with pressure ulcers which declined and required hospitalization /were not present on admission.) Resident # 20 entered the facility without a pressure ulcer. There was no evidence preventative measure were put in place and the resident developed a pressure ulcer 17 days after admission measuring 10 x 5 cm (centimeter) to the right heel. Resident # 5, with a known pressure ulcer did not receive treatments as ordered and was subsequently admitted to the hospital. Resident # 13 did not receive wound care as ordered by the physician. The findings included: Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission care plan indicated the resident was continent of bowel and bladder, required assistance with transfers, bed mobility and toileting. The admission care plan did not identify the resident as having or being at risk for the development of a pressure ulcer. A discharge summary from a previous rehabilitative stay dated 10/15/12 noted "areas of breakdown on both lateral legs" but noting was documented related to a pressure area of the heel. Admission physician orders [REDACTED]. Review of the resident's medical record on 11/15/12 indicated the resident had a physician's orders [REDACTED]. Documentation on 11/6/12 (one day after orders were received and treatment initiated) indicated the resident had an area measuring 10 x 5 cm (centimeter) to the right heel not previously noted. The weekly wound tracking sheet indicated the area was a stage II pressure ulcer, moist with red- granulating tissue. On 11/13/12, the area measured 5.8 x 4.5 cm. Review of the resident's interim (admission) care plan did not indicate the facility identified the resident as having an actual or a potential for pressure ulcers and the comprehensive care plan was not updated to reflect the resident developing a pressure ulcer or currently receiving a treatment for [REDACTED]. Resident #5 was admitted to the facility on [DATE] with right Heel Wound. A facility Skin Assessment Form completed on 10/17/12 indicated that Resident #5 had a 4.5 X 5.2 X 0.4 centimeter (cm) wound on the right heel. An Admission Nursing Evaluation dated 10/17/12 also documented a right heel ulcer as 4.5 X 5.2 X 0.4 with the treatment noted as "clean with DWC (wound cleanser), Santyl applied, covered with 4 X 4". A Braden Scale was completed on 10/19/12 documented a score of 14, indicating that the resident was at high risk for skin breakdown. Review of the Physician's Telephone Orders (TO) revealed that on 10/24/12 an order had been written to cleanse the right heel would with Normal Saline or wound cleanser, apply Santyl to wound bed, cover with foam dressing ([MEDICATION NAME]) daily and as needed. A Skin Assessment Form completed on 10/20 and 10/25/12 documented no measurements of the wound and the right heel was circled on the form. . On 10/26/12 a late nurses note entry for 10/24/12 stated per the physician, the Resident had a Stage 3 area approximately 3.5 X 3.0 cm. with 75% slough and 25% granulation. 10/28/12 nursing notes stated the right heel was still "severely ulcerated" and was being treated. On 11/3/12 nursing notes stated that nursing had assessed the right heel and obtained a new order for Dakin's Solution, wet to dry dressings twice a day related to "foul odor noted". The facility Pressure Ulcer Healing Chart documented on 11/5/12 the area was 8.5 x 5 [MEDICAL CONDITION] with moderate exudate and granulation,slough and necrotic tissue was present. The Nurse's Notes dated 11/5/12 stated the dressing was changed as ordered. Additional Weekly Wound Tracking forms completed by the facility Wound Nurse were dated 11/6/12 indicated that on 11/6/12 the wound was "8.5 X 5.5 cm. with 25 % beefy red granulating tissue, foul odor, 25% yellow slough, 50% eschar with red intact peri-wound" On 11/8/12 a new order was written to discontinue Dakin's Wet to Dry to right heel "related to resident attends Wound Center". Documentation of the care to the wound indicated treatment was provided on 11/6/12 (not done in the AM, done in the PM), and then no further treatments were documented as being done by facility staff after this date. At 5:45 PM on 11/13/12 the surveyor was informed by the facility Wound Nurse that the resident had gone to the Wound Clinic, subsequently transferred and admitted to the hospital from the clinic. Review of the documentation from the Wound Clinic showed Resident #5 had scheduled for appointments on 11/6/12 and 11/9/12. The Wound Clinic notes provided by the wound clinic that were not available in the facility but requested by the surveyor and received on 11/14/12 stated: On 11/6/12 the resident stated s/he had been wearing a regular shoe on the right foot and had noted tenderness and had placed a Band-Aid on a blister. On 11/6/12 the wound center documented the resident had a stage 4 pressure ulcer of the right heel measuring 4.5 x 7 x .2. The plan was for the patient to continue dressing changes twice a day as ordered x 2 weeks, (wound notes as orders faxed to facility). On 11/13/12 the Wound Clinic's documentation for Impression and Recommendations: "Problem #1 Deteriorated much worse-foul odor and larger despite our best efforts at offloading: pt. (patient) does not want to be admitted but agrees, given the risk of limb loss." Review of the facility's policy entitled Skin and Wound Management revealed "...Treatment/Management: 1. The physician will authorize pertinent orders related to wound treatments..." The facility's policy entitled .... Wound Care Guidelines stated "Directions 1. Assess the area and determine to appropriate treatment as listed below. All orders will be reviewed by the clinical management team and may be changed at their discretion..." During an interview with the Director of Nursing (DON) on 11/15/12 at 11:25 AM, the DON stated that the wounds were reviewed weekly in the stand up meeting and documented on the Weekly Wound Tracking Sheet. The DON provided tracking forms for the weeks of 9/10,10/4/12, 10/11/12, 10/16, 10/30, 11/6 and 11/13/12. Review of the tracking worksheets indicated no evidence of review by the stand up team. During an interview with the Medical Director on 11/15/12 at 3:30 PM, the Medical Director stated that he/she was not aware that Resident #5 had been admitted to the hospital from the wound center on 11/13/12. The Medical Director also stated that s/he would expect a decline in a wound's status if treatments were missed. S/he would expect the facility staff to notify the physician if the wound center sent orders for a resident and for the attending physician to verify those orders prior to starting a treatment. The Medical Director reviewed the facility's protocol for wound care and stated that he/she did not agree with the protocol and would not agree with the facility beginning a treatment without contacting the physician and to do so would be [MEDICATION NAME] without a license. The facility admitted Resident #13 with [DIAGNOSES REDACTED]. According to the facility's admission History and Physical dated 9/19/12, bilateral stage 3 heel ulcers, pressure related, were present on admission. Review on 11/15/12 of Physician's Telephone Orders dated 9/14/12 revealed an order to "1. D/C (Discontinue) [MEDICATION NAME] to bilateral heels, 2. Apply skin prep to bilateral heels bid (twice daily)...". However, review of the September 2012 Treatment Record revealed skin prep had been applied only once daily on the 7-3 shift (instead of twice daily) from 9/15/12 through 9/30/12 with no documentation of the treatment having been done on 9/19/12 and 9/28/12 at all. There was no documentation on the back of the record to indicate why the treatment had not been initialed as having been done. Review of the October 2012 Treatment Record revealed skin prep had been applied twice daily, however, there were blanks for the evening application on 10/1/12, 10/19/12, and 10/26/12; and blanks for the morning application on 10/27/12 and 10/28/12, indicating the treatment had not been done. There was nothing on the back of the record to indicate why the treatment had not been initialed as having been done. Further review revealed a Physician's Telephone Order dated 10/30/12 which stated "...Non Wgt (Weight) Bearing L(eft) heel, Drsg (Dressing) (change) BID Wet to Dry L(eft) heel ..". This information had not been carried over to the November 2012 cumulative physician's orders [REDACTED]. During an interview on 11/15/12 at 11:50 AM, the wound nurse (nurse that measured the wounds) was asked and did not know why the treatment had not been done as ordered from 11/1/12 through 11/7/12. On 11/8/12, the order for the treatment was changed to clean the left heel with Normal Saline, pat dry, apply Santyl Ointment with foam dressing and kling daily. Review of the Treatment Record revealed the treatment had been scheduled daily for the 7 AM through 7 PM shift. Further review revealed blanks on the record indicating the treatment had not been done on 11/9/12, 11/11/12, and 11/13/12. The above findings were reviewed with the Director of Nursing (DON) on 11/15/12 at 1:00 PM who stated there were "concerns related to the wound care" . The National Pressure Ulcer Advisory Panel, Pressure Ulcer Prevention & Treatment, Clinical Practice Guideline 2009, states: "An initial holistic assessment should be performed on all patients with pressure ulcers. Reassess the patient and treatment plan if the ulcer fails to show signs of healing within two weeks. The pressure ulcer should be assessed at least weekly...Simple documentation of the pressure ulcer status is not enough. ...Prevention, early diagnosis, and effective treatment of [REDACTED]. Assess and accurately document physical characteristics such as location, stage, tissue type, wound bed and periwound condition, wound edges, undermining, tunneling, exudate, necrotic tissue, and odor".

On the day of the complaint inspection, based on record review, interviews, and review of Perry and Potter's Clinical Nursing Skills and Techniques, 7th Edition, the facility nursing staff failed to adhere to accepted professional standards of practice for one of one sampled residents reviewed for medication administration. On 9/26/12 Licensed Practical Nurse (LPN) #1 gave Resident #1's daughter a bottle of [MEDICATION NAME] Acetic Acid Ear Drops instead of the ordered Artificial Tears. The drops administered to Resident#1 ' s right eye by his/her daughter caused burning, redness, and irritation. LPN #1 then failed to report the incident to the oncoming shift so the resident could be monitored for any complications. The nurse also failed to notify the facility Physician. The incident and the assessment of the resident's condition were not documented in the Nurse's Notes. Once notified by the resident's family of the incident, LPN #2 failed to assess Resident #1, document findings, and report to the oncoming shift relative information regarding Resident #1's eye injury. There was no documentation in the Nurse's Notes of an assessment of Resident #1's eye until 9:30 PM on 9/27/12. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. On 9/28/12, the facility self-reported an incident to the State Agency that alleged that Licensed Practical Nurse (LPN) #1 "...handed what was supposed to be eye (drops) to (the) resident's family member to administer. Unfortunately the (drops) were ear (drops) containing (a) mild solution of acetic acid which burned the right eye on contact." According to the report, the incident occurred on 9/26/12 at 1:30 PM. Review of the facility's Five Day Follow-Up Report revealed under "Characteristics of Injury", that the resident's eye was injected (red) and painful and the eyelids were slightly swollen. Under "Interventions in place prior to the Reportable Incident" was written that the nurse administers the eye drops. The "Immediate Corrective action/assessment following the Reportable Incident" revealed information that the eyes were flushed and natural tears put in. The Physician was notified. Under "Interventions by facility to prevent future injury..." was written, "Nurse must administer meds (medications) and must be careful to choose correct bottle". During an interview on 10/10/12 at 8:45 AM, the Director of Nursing stated that s/he had interviewed LPN #1 who admitted s/he had done this. The DON stated that s/he completed a medication error report and incident report. The nurse was subsequently terminated for the medication error and failure to document. According to the DON, the nurse shouldn't have given the daughter the medication to administer. Review of Nurse's Notes on 10/10/12 at 10:15 AM revealed there was no mention of the incident documented. The first documentation assessment of the resident's eye was noted on 9/27/12 at 9:30 PM. The note stated that there was no redness noted to the right eye and that the resident stated, "it feels better". A note dated 9/28/12 stated that the resident was seen by the Nurse Practitioner for right eye redness and that the resident was without complaints of pain or burning to his/her eyes at the time of the visit. During an interview on 10/10/12 at 2:00 PM, Resident #1's daughter stated that on 9/26/12, she asked LPN #1 for the resident's eye drops since his/her eyes were itching. She and the resident were at the nurses' desk and LPN #1 gave her a bottle. The resident's daughter stated the bottle didn't look like the other bottle of eye drops but had her father's name on it. She stated she then gave her father one drop in the right eye and immediately the resident became distressed stating, "Ow Ow Ow, it's burning, those are the wrong drops". The resident's daughter stated that she asked for eyewash to flush his eyes and went and got a wet paper towel to hold to his eye. She stated that she looked closer at the bottle and somewhere on the bottle it said eardrops and she told the nurse. She stated the nurse took him to a room and started flushing his eyes with water from a washcloth. She stated she called her father's eye doctor who told her it should be ok, just to watch and if it got worse to bring him in. She stated that after the incident she left the facility but called back later that same afternoon after shift change to check on her father. She stated she spoke with the resident's CNA (Certified Nursing Assistant) who was not aware of the incident with her father's eye. She stated that she asked to speak with the head nurse (LPN #2), and s/he was also not aware of the incident. She stated that LPN #2 asked her if a report had been done. Resident #1's daughter stated that she was not upset with LPN #1 that the incident had occurred, but that she was upset because the information was not relayed to the next shift so they could monitor her father for any complications. During a phone interview on 10/11/12 at 9:40 AM, LPN #2 was asked how s/he heard about the incident that occurred with Resident #1 getting an eardrop administered to the eye. LPN #2 stated that one of the nurses told him/her about it that night, but that the resident was also talking about it. S/he stated that the incident was not reported to him/her by the day shift nurse and s/he wasn't sure exactly what had happened when the resident's daughter called (9/26/12) and told him/her that a mistake had been made; that the resident's eye had to be flushed; and that we (nursing staff) had to keep a check on it. When asked if s/he had kept a check on it, s/he stated "not that same day". S/he stated that they had put the resident on acute charting for 72 hours the following day (9/27/12). S/he stated that it was not until the next day that the DON told him/her what had actually occurred. When asked if anyone else knew about the incident, s/he stated not that s/he knew of. During a phone interview on 10/11/12 at 4:37 PM, LPN #1 stated the incident with the medication error had taken place on 9/26/12 around 9:20 AM when s/he was getting another patient's paperwork ready. S/he stated that s/he was busy, wasn't paying attention and passed the eardrops to the daughter instead of the eye drops. S/he stated that the bottle of eardrops was in a plastic zip lock bag and s/he looked at the bag, saw the resident's name on it, and grabbed it thinking it was the eye drops. When asked, s/he stated that this was the first time s/he had given any drops to the family to administer, and that this was not her/his usual practice. LPN #1 verified s/he did not report the incident to the oncoming nurse (LPN #2) and stated that s/he thought the resident's eye was fine after it had been flushed out and the eye drops had been applied. LPN #1 verified s/he did not document the incident or an assessment of the resident's eye and stated s/he should have documented that s/he continued to check the resident's eye throughout her/his shift. LPN #1 stated that the resident's daughter called Resident #1's eye doctor while s/he was flushing the resident's eye. LPN #1 stated s/he was not aware that any other Physician that was notified by the facility of the incident on that day. According to LPN #1, s/he did not fill out a medication error report until 9/27/12 when the DON asked her/him to fill one out. Review of Perry and Potter's Clinical Nursing Skills and Techniques, 7th Edition, Copyright 2010, revealed on page 523 under 'Nursing Process in Medication Administration-Implementation' that Preadministration Activities included "1. Minimize distractions during medication preparation-ask colleagues to not interrupt you, ...and do not try to perform other tasks while preparing a medication. ...4. Read the label on the medication container and compare it with the MAR (medication administration record) at least three times: before removing the container from the supply drawer, when placing the medication in an administration cup/syringe, and just before administering the medication to the patient..." Under Postadministration Activities on page 524 "After administering a medication, record the following information on the MAR indicated [REDACTED]. nurses' notes) required by the institution: Medication name, Dose, Route of administration, Time of administration, Any unexpected patient responses (see evaluation), Pertinent data or assessment collected at the time of administration, Signature and title of nurse administering medication..." Under 'Reporting Medication Errors' on page 525, "... When an error occurs, the patient's safety and well being become the top priority. The nurse assesses and [MEDICATION NAME] the patient's condition and notifies the physician or prescriber of the incident as soon as possible. Once the patient is stable, the nurse reports the incident to the appropriate person in the institution (e.g. manager or supervisor). The nurse is also responsible for preparing a written incident or occurrence report that must be filed usually within 24 hours of the incident..."

On the day of the complaint inspection, based on record review and interviews, the facility failed to ensure that residents remained free of significant medication errors for one of one resident reviewed for medication administration. The facility nurse gave Resident #1's daughter a bottle of [MEDICATION NAME] Acetic Acid Ear Drops instead of the ordered Artificial Tears. The eardrops administered by Resident #1's daughter caused burning, redness, and irritation to the resident's right eye. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. On 9/28/12, the facility self-reported an incident to DHEC Certification in which it was alleged that Licensed Practical Nurse (LPN) #1 "...handed what was supposed to be eye (drops) to (the) resident's family member to administer. Unfortunately the (drops) were ear (drops) containing (a) mild solution of acetic acid which burned the right eye on contact." According to the report, the incident occurred on 9/26/12 at 1:30 PM. Review of the facility's Five Day Follow-Up Report revealed under "Characteristics of Injury", that the resident's eye was injected (red) and painful and the eyelids were slightly swollen. Under "Interventions in place prior to the Reportable Incident" was written that the nurse administers the eye drops. The "Immediate Corrective action/assessment following the Reportable Incident" revealed information that the eyes were flushed and natural tears put in. The Physician was notified. Under "Interventions by facility to prevent future injury..." was written, "Nurse must administer meds (medications) and must be careful to choose correct bottle". During an interview on 10/10/12 at 8:45 AM, the Director of Nursing stated that s/he had interviewed LPN #1 who admitted s/he gave Resident #1's daughter eardrops instead of eye drops. The DON stated that LPN #1 told her s/he was very busy trying to get someone out for an appointment, that s/he picked up the drops, and handed them to the resident's daughter. The DON stated that LPN #1 thought she picked up the eye drops. When asked where the eardrops were now, the DON stated s/he removed them from the med cart on 9/27/12 when s/he became aware of the incident. S/he had kept the bottle and provided it for inspection. The bottle was labeled as containing [MEDICATION NAME] and Acetic Acid Otic Solution and a yellow sticker attached to the label included the resident's name along with "acetic acid". (There was no zip lock bag provided along with the medication bottle). During an interview on 10/10/12 at 2:00 PM, Resident #1's daughter stated that on 9/26/12, she asked LPN #1 for the resident's eye drops since the resident's eyes were itching. S/he and the resident were at the nurse's desk and LPN #1 gave her a bottle of drops. The resident's daughter then gave her father one drop in the right eye and immediately the resident became distressed stating, "Ow Ow Ow, it's burning, those are the wrong drops". The resident's daughter stated that she asked for eyewash to flush his eyes and went and got a wet paper towel to hold to his eye. She stated that somewhere on the bottle it said eardrops and she told the nurse. Review of an Acute Care Visit dictated by the Nurse Practitioner on 9/28/12 revealed the following: "This is an acute care visit for a resident we are seeing today following complaints of eye pain. S/he reports that his/her eyes were burning a few days ago after administration of eardrops put in his/her eyes. S/he reports they have been cleaned out and, over the last two days, it has resolved. There is no burning at this time. S/he denies any change in his/her vision... S/he denies any ongoing pain or discomfort. S/he states that the stinging only lasted about a day... S/he is a good historian as far as the events that have occurred. Looking at his/her eyes, both eyes sclerae (sic) are white. His/her right eye is good; it did seem to be slightly drooped, however. On evaluation, his/her pupils did react sluggishly; however, they did react to light. There were no signs of redness. No signs of discharge or discomfort. Again, s/he denied any other issues... At this time, we will continue to monitor..." During an interview on 10/10/12 at 3:20 PM, the facility Physician stated that the eardrops were diluted Acetic Acid and would not have caused permanent eye surface damage since the eye had been rinsed right away. S/he stated that corneal abrasions could develop if the irritant wasn't removed. S/he stated that the incident concerned him/her, however, the nursing staff flushed the eye and got the irritant out of the eye right away. During a phone interview on 10/11/12 at 4:37 PM, LPN #1 confirmed the incident with the medication error took place on 9/26/12 around 9:20 AM when s/he was getting another patient's paperwork ready. S/he stated that s/he wasn't paying attention and passed the eardrops to the daughter instead of the eye drops. S/he stated that the bottle of eardrops was in a plastic zip lock bag and s/he looked at the bag, saw the resident's name on it, and grabbed it thinking it was the eye drops. When asked, s/he stated that this was the first time s/he had given any drops to the family to administer, and that this was not her/his usual practice.

On the days of the survey, based on observations, interviews, record reviews and review of the facility's protocol for Care Of Skin Abrasions, the facility failed to provide services for the residents which met the professional standards of quality for 1 of 9 residents sampled for professional standards and random observations during medication pass. Resident #9 had documented allergies [REDACTED]. The findings included: The facility admitted Resident #9 on 1/25/2008 with [DIAGNOSES REDACTED]. Review of the resident's medical chart on 9/7/2010 at 3:20 PM revealed that the resident had multiple allergy inconsistencies documented. The allergy sticker on the inside of the chart listed [MEDICATION NAME], Sulfa, [MEDICATION NAME], Amox. ([MEDICATION NAME]), E-Mycin ([MEDICATION NAME]), [MEDICATION NAME], Keflex, Beta Blockers and TAO (Triple Antibiotic Ointment) (adverse reaction) as well as *No sleeping pills*, OpSite Dsds (dressings), Tapes and Band-Aids. The Cumulative Orders for August and September 2010 listed Sulfa (Sulfonamide Antibiotics), [MEDICATION NAME], Ambien, [MEDICATION NAME] and [MEDICATION NAME]. The facility's Nursing Home History and Physical dated 8/5/2010 listed the resident's allergies [REDACTED]. A Nursing Home Admission History and Physical dated 8/25/2010 listed her/his allergies [REDACTED]. A hand written note was included which stated Tapes, OpSite, *No sleeping Pills Per POA (Power Of Attorney). Review of the Nurses' Notes dated 8/2/2010 at 0630 (6:30 AM), indicated that the resident had rubbed a scab off of the right side of her/his face. The nurse cleaned the area and applied "TAO (Triple Antibiotic Ointment) and a band-aid". At 5:00 PM, the Nurses' Notes revealed that the area on the right side of the resident's face was "red & (and) irritated. Res. (resident) states is painful to touch. On MD (physician) book for eval. (evaluation)." No other entries related to the resident's face were noted until 8/10/2010 at 4:40 PM which indicated that the physician had seen the resident and written new orders related to the "area on side of face." Review of the Treatment Administration Record (TAR) for Resident #9 for the month of August 2010 contained no documentation of the TAO being administered prior to the new order on 8/11/2010. On 9/7/2010 at 6:00 PM, during an interview with Licensed Practical Nurse (LPN) #4, she/he stated that a Telephone Order (TO) for the TAO should have been written and the TAO should have been documented on the TAR. Review of the TO dated 8/2/2010 stated per protocol apply TAO ointment to R (right) cheek abrasion and cover with dressing until healed. A TO dated 8/10/2010 indicated that the TAO had been discontinued on 8/10/2010. Review of the facility's protocol for Care Of Skin Abrasions revealed "...Preparation: 1. Verify that there is a physician's order for this procedure. (Note: This may be generated from a facility protocol) 2. Review the resident's care plan, current orders and [DIAGNOSES REDACTED]. 3. Check the Treatment Record...." Review of a Physician's Progress Note dated as dictated on 8/10/2010 contained documentation indicating ..."Allergic Reaction"...and to stop the topical antibiotics. On 9/8/2010 at 8:30 AM, during an interview with the Director Of Nursing (DON) and the Assistant Director Of Nursing (ADON), both verified the allergy information. The DON and ADON also verified the Nurses' Notes stating that the resident had received the TAO and that it was not documented as to how long and how often the resident received the treatment. On 9/8/2010 at 11:50 AM, during an interview with Resident #9, the resident's daughter, the Nurse Practitioner (NP) and the ADON present, the resident and her/his daughter stated that the resident had received the TAO for 3 days that they were sure of stating maybe 4 days. The NP stated that she/he was reviewing the resident's allergies [REDACTED]. During a random observation of the Medication Pass on 9/7/10 at 3:30PM, Licensed Practical Nurse # 6 was observed to leave a bottle of [MEDICATION NAME] on top of the medication cart when s/he entered the room to administer medications. The medication cart was not able to be seen from the resident's bedside. After entering the resident's room, the nurse was observed to leave the medication filled syringe on the bedside table as s/he left the room the wash his/her hands. After checking the resident's blood sugar and determining the need to call the physician for further direction, the nurse returned to the medication cart where s/he left both the bottle of insulin and the medication filled syringe on top of the cart unattended as s/he returned to the bathroom to wash his/her hands. On 9/8/10 at approximately 7:40AM, during observation of medication pass, Licensed Practical Nurse # 7 was observed to enter a resident's room and leave a medication cup containing nine medications and a bottle of [MEDICATION NAME] Nasal Spray on the bedside table when s/he left the room to wash his/her hands. The medications were not visible to the nurse as s/he washed his/her hands. On 9/8/10 at 10:30AM, the findings were shared with the Director of Nursing, who verified it was not facility policy to leave medications unattended.