Every finding on record at Sandpiper Post Acute

Based on record review, interview, and facility policy review, the facility failed to protect 3 of 3 residents (Resident (R)2, R51 and R159) from physical abuse, out of a sample of 33 residents. Specifically, the facility enabled R68 to physically abuse R2, R51, and R159 by not properly supervising R68.On 06/29/26, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 06/29/26 at 9:30 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 01/25/26. The IJ was related to 42 CFR 483.12 - Freedom from Abuse, Neglect, and Exploitation.On 06/30/26 at 1:06 PM, the facility provided an acceptable IJ Removal Plan. On 06/30/26 at 4:30 PM, the survey team, validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F600 at a lower scope and severity of E.An extended survey was conducted in conjunction with the Recertification and Complaint Survey for non-compliance at F600, constituting substandard quality of care.Findings include: Review of the facility's policy titled, Abuse and Neglect-Clinical Protocol revised 03/2018 revealed it is the policy of this facility for management and staff to institute measures to address the needs of the residents and minimize the possibility of abuse. Further review of the policy revealed Abuse is defined as the willful infliction of injury . Instances of abuse of all resident, irrespective of any mental or physical condition . It includes verbal abuse, sexual abuse, physical abuse . 1. Review of R2's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted on [DATE], with diagnosis including but not limited to cognitive communication deficit. Review of R2's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/09/26 and located under the MDS tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which indicated the resident was severely cognitively impaired. 2. Review of R51's Face Sheet located in the EMR under the Profile tab revealed the resident was admitted on [DATE], with diagnosis including but not limited to dementia. Review of R51's quarterly MDS with an ARD of 05/23/26 and located under the MDS tab of the EMR revealed a BIMS score of 10 out of 15 indicating a moderately impaired cognition. 3. Review of R68's Face Sheet located in the EMR under the Profile tab revealed the resident was admitted on [DATE], with diagnosis including but not limited to cognitive communication deficit. Review of R68's quarterly MDS with an ARD of 03/06/26 and located under the MDS tab of the EMR revealed a BIMS score of 15 out of 15 indicating cognitively intact. 4. Review of R159's Face Sheet located in the EMR under the Profile tab revealed the resident was admitted on [DATE] with diagnosis including but not limited to hyperlipidemia. Review of R159's quarterly MDS with an ARD of 05/06/26 and located under the MDS tab of the EMR revealed a BIMS score of 15 out of 15 indicating cognitively intact. Review of the facility's investigative file revealed that on 01/25/26, R68 hit R159. The file indicated that R159 was yelling and cursing at a female resident when R68 said to R159 to stop. R159 confronted R68 by cursing and replying with it's a black conspiracy. R68 struck R159 in the face. Review of R68's EMR Care Plan under the Care Plan tab indicated R68 had been educated that, I cannot hit or touch another resident even if I am defending another resident dated 01/25/26. Review of the facility's investigative file revealed that on 04/27/25, R68 punched R51 in the nose. R68 overheard R51 yelling and cursing at his roommate. R68 told R51 to stop yelling. R51 began yelling at R68. R51 stated that R68 punched him in the nose. Review of R68's EMR Care Plan under the Care Plan tab indicated R68 education and reminders that I have to stay in my room and not touch or address concerns with other residents and alert staff to my concerns dated 04/27/26. Review of the facility's investigative file revealed that on 05/25/26, R68 hit R2 who was yelling and cursing at a female resident. R68 told R2 to stop. R2 continued to point his finger in the female resident's face and curse; that is when R68 struck R2 once. Review of R68's Care plan in the EMR under the Care Plan tab indicated that Resident may customize smoking time to avoid being in group setting with other smokers dated 05/05/24 and revised on 06/29/26. During an interview on 06/29/26 at 2:35 PM, the Social Services Director (SSD) stated that R68 was still in the facility. The SSD stated that several attempts have been made to find placement at another facility that could better meet his needs. During an interview on 06/29/26 at 3:00 PM, the Director of Nursing (DON) confirmed that the facility did not place R68 on a one-to-one supervision as an intervention after each of the physical altercations involving R68 and R2, R51 and R159, because the residents were moved to other hallways away from R68. The DON stated that R68 was also put on one-to-one for smoke breaks to ensure there wasn't any contact between R68 and the other residents. During an interview on 06/29/26 at 8:29 PM, the DON stated that the incidents were described by R68 so there was no way the facility could prove that the others involved cursed another resident. The one female resident that R159 was accused of cursing was interviewed and told the DON when asked if R159 was being mean and cursing at her, the female resident stated, s**t no. During an interview on 06/29/26 at 4:32 PM, Nurse Practitioner (NP)1 stated that she does not think that R68 was a danger to himself or others. She had been working with R68 on communication instead of reaction. Has also provided R68 with self-awareness exercises to help with anxiety and impulse control. NP1 stated that she has also educated staff on monitoring for R68 signs of agitation and interventions such as the self-awareness reminders. NP1 stated that she does not feel R68 would benefit from adding any other medications to his regimen. On 06/30/26 at 1:06 PM, the facility provided an acceptable IJ Removal Plan, which included the following: Summary of Incident: Resident 68 was involved in three resident to resident altercations with three other residents. He was involved in altercations on three separate occasions and with each altercation the facility acted accordingly and separated the residents and assessments were complete with no injuries noted. Plan of care was reviewed and revised each time and adjustments made to care plans. Psych NP f/u with Resident 68. Resident 68 does not participate in smoke breaks with the group and is provided separate smoke breaks and 1:1 supervision while smoking. Immediate Action Taken 1) Resident 68 was placed on 1:1 supervision on 6-29-26 @ 10pm following the IJ - care plan updated to reflect 1:1 and order in PCC. 2) Resident 159 was followed up with by DON on 6-29-26 for psychosocial support and states that he feels safe and I'm not afraid of anyone. No concerns voiced. 3) Resident 51 was followed up with by DON on 6-29-26 and he had no recollection of the altercation that occurred in April with another resident. When asked if he feels safe he says yes he does and voiced no concerns. 4) Resident 2 was seen by the DON for follow up on 6-29-26. He has no recollection of altercation that ocured in May with another male resident. He has no concerns and when asked if he feels safe he laughed and said yes. 5) Psych NP evaluated resident 68 on 6-30-26 to evaluate his physical aggression towards other residents. 6) Abuse policy reviewed by DON and Administrator. No revisions indicated. 7) 1:1 Supervision policy reviewed by DON and Administrator and revision indicated. ADHOC QA Meeting Held on 6-30-26 Members present were: [name] LNHA, [name] RN, DON, [name] SSD, Unit Managers and [name] NP Members via phone: [name] MD, Medical Director Root Cause: Staff failed to protect residents from abuse by Resident 68 with subsequent altercations with other residents. Education and training was provided to DON and Administrator by Regional Director of Clinical Services on 6-30-26 regarding Abuse and Abuse reporting and De-escalating behaviors and intervening with behaviors. Education was initiated on 6-30-26 by DON and Administrative Nursing staff for all staff regarding abuse and abuse reporting and intervening when any resident is anxious, yelling and cursing to deescalate the situation . As of 11:15 am on 6-30-26- 114 employees out of 176 have received the education. All newly hired staff and or agency staff will receive the education during next scheduled shift. Staff will also be educated on process of 1:1 supervision and documenting that supervision for Resident 68. Resident 68 was placed on 1:1 supervision effective 10pm on 6-29-26 and has had no concerns. 1:1 supervision Observation Checklist created for staff to provide documentation during supervision. Plan of care reviewed and revised for Resident 68 to include 1:1 supervision. SSD/Administrator and DON will continue to meet with Resident 68 and his daughter and referrals will continue to be made to other facilities for discharge planning . Audits by DON/designee will be complete daily Mon-Fri as part of Clinical meeting process to review all nursing notes to ensure any behaviors or verbal altercations were handled and documented appropriately Audit of 1:1 supervision documentation will be reviewed daily by DON/designee . Resident 68 was seen by Psych NP on 6-30-26 to educate and evaluate him regarding physical aggression towards other residents. Results of QAPI will be reviewed by QA committee weekly x 2 weeks then monthly x1 then quarterly as needed to ensure no further need for monitoring. The above components have been implemented as of 6-30-26 by 1:46pm

Based on interview, record review, and facility policy review, the facility failed to provide a timely notification to the provider or nurse practitioner (NP) of the delayed delivery of a medication for 1 of 1 resident (Resident (R)172) in the sample of 33 residents. Specifically, R172 missed two doses of intravenous (IV) medication and there was no evidence in the medical record the provider or NP was notified. This deficient practice had the potential to affect the resident's health and recovery from sepsis.Findings include: Review of the facility's policy titled Reconciliation of Medication on admission dated 2017 revealed, Any medications not received timely from pharmacy the physician will be notified. Review of R172's electronic medical record (EMR) Face Sheet under Profile tab revealed an admission date of 06/02/26 and a discharge date of 06/05/26, with diagnoses including but not limited to Hepatic Biliary Necrosis (the localized death of bile duct tissues) and Septic Shock (a life-threatening immune system response to infection). Review of R172's Orders tab of the EMR revealed an order dated 06/02/26 for Piperacillin Sod-Tazobactam So Solution Reconstituted 4-0.5 GM (Use 4.5 gram intravenously every 6 hours for sepsis for 13 days). Review of the EMR Medication Administration Record (MAR) dated June 2026 revealed that the first dose of Piperacillin had been scheduled to be given on 06/02/26 at 6:00 PM. Further review of the MAR revealed that the Piperacillin Sod-Tazobactam So Solution Reconstituted 4-0.5 GM medication was scheduled for midnight on 06/03/26, however was documented by Licensed Practical Nurse (LPN)1 on 06/02/26 at 11:26 PM as medication on order. On 06/03/26 the medication was scheduled for 6:00 AM however was documented by LPN1 on 06/03/26 at 6:16 AM as pending arrival from pharmacy. The MAR indicated that on 06/03/26 at 1:42PM, the IV antibiotic was administered. Review of R172's EMR Progress Notes under the Progress notes tab dated 06/02/26 through 06/03/26 revealed no documentation that the provider or Nurse Practitioner (NP)1 was notified that the IV antibiotic medication Piperacillin was not available to be administered on 06/02/26 for the 6:00 PM dose, on 06/03/26 for the 12:00AM and 6:00 AM dose. During an interview on 06/29/26 at 10:22 AM, the Director of Nursing (DON) explained that R172's admission was on 06/02/26 at 7:00 PM. The DON explained the orders for all of R172's medications had been sent to the pharmacy on the admission date of 06/02/26. During a second interview on 06/29/26 at 6:10 PM, the DON explained that pharmacy acknowledged an error regarding the Piperacillin specifically that the order was not seen in the queue when it came in and consequently was missed. The pharmacist emailed the DON on 06/29/26 at 2:06 PM, a timeline which indicated, Order came in at 5:55 PM on 06/02/26, order was routed on the IV queue 06/02/26, order was entered as STAT [immediate] on 06/03/26 at 9:12 AM, order was delivered at 1:20 PM on 06/03/26 During a follow-up interview on 06/30/25 at 10:00 AM, the DON discussed the missed doses of Piperacillin saying, . the facility does not have an inhouse pharmacy or a pyxis. The DON stated that as soon as she got in on 06/03/26, a STAT (immediate delivery) was processed for the medication, and it was at that time the pharmacy acknowledged the mistake. During an interview on 06/30/26 at 10:00 AM, Registered Nurse (RN)1, who had been on duty for R172 the evening of his admission on [DATE], acknowledged the antibiotic was not available the evening of admission. On 06/30/26 at 3:30 PM an attempt to speak with LPN1 who had been on duty for R172 on 06/02/26 and 06/03/26. A phone message was left requesting a return call that was not returned during survey. During an interview on 06/30/26 at 6:10 PM, the DON explained that there had been no expectation of the medication coming in during the evening of 06/02/26 due to the lateness of the admission and entry of orders. The DON explained when she came in the following day and found out the medication had not come in immediate action was taken to notify NP1 and get the order entered as STAT. The DON said the medication was given as soon as it arrived. During a telephone interview on 06/30/26 at 6:31 PM, NP1 recalled the situation and explained there would have been no expectation for medication delivery the night of admission and that the DON had provided timely notification of delay the following day.

Based on record review, interview, and facility policy review, the facility failed to ensure 1 of 1 resident (Resident (R)116) reviewed for care plan participation from a sample of 33 residents was afforded the opportunity to participate in the development and implementation of her person-centered plan of care. The facility's failure to invite and include R116 in the care planning process limited her opportunity to be informed of and participate in decisions regarding her care.Findings include: Review of the facility's policy titled, Resident Participation-Assessment/Care Plans revised 11/2025 revealed, The resident is encouraged to attend and participate in the resident's assessments and in the development of the resident's person-centered care plan. Review of R116's electronic medical record (EMR) undated admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE], with diagnosis including but not limited to Multiple Sclerosis. Review of R116's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ADR) of 06/19/26 located in the EMR with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which revealed the resident was cognitively intact. Review of the LTC (Long Term Care) Care Conference Sign In Sheet dated 03/10/26, revealed R116 was not in attendance. Review of the LTC (Long Term Care) Care Conference Sign In Sheet dated 06/09/26, revealed R116 was not in attendance. During an interview on 06/28/26 at 1:30 PM, R116 stated she was not aware of a care plan conference. She said it was important to her to attend since they are talking about me. During an interview on 06/29/26 at 2:42 PM, the Social Services Director (SSD) confirmed R116 was notified verbally regarding the 06/09/26 care conference and was not made aware of the 03/10/26 care conference. During an interview on 06/29/26 at 3:02 PM, the Director of Nursing (DON) stated it was important for residents to attend their care conference.

Based on observation, interview, record review, and facility policy review the facility failed to follow the facility's policy and ensure signage for Enhanced Barrier Protection (EBP) was posted for residents who had a urinary catheter, gastrostomy tube (G-tube), dialysis, and/or open wounds for 13 of 34 residents (Resident (R) R113, R412, R16, R151, R126, R88, R119, R75, R38. R10, R22, R114, and R101) reviewed for EBP. As a result of this deficient practice the staff had the potential to spread infections from one resident to another. Findings include: Review of the facility's policy titled Enhanced Barrier Precautions, revised 03/24, revealed EBP's are (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). b. Personal protective equipment (PPE) is charged before caring for another resident. c. Face protection may be used if there was also a risk of splash or spray. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. 1. Review of R113's Admission Record located in the EMR under the Profile tab revealed an admitted [DATE] with medical diagnosis that included chronic kidney disease, stage three. Review of R113's physician's orders in the EMR under the Orders tab confirmed an order for dialysis three times a week. Observation on 04/08/25 at 1:30 PM, the door for R113 lacked a sign for EBP indicating the personal protective equipment (PPE) to be applied for direct resident care. During an observation on 4/10/25 at 9:33 AM, Licensed Practical Nurse (LPN)13 confirmed the central venous catheter (CVC) catheter was located on the right chest wall by moving the resident's clothing to reveal the dressing. LPN13 was not wearing gloves at the time of the observation of the dressing. 2. Review of R412's Admission Record located in the EMR under the Profile tab revealed an admitted [DATE] with a readmitted [DATE] with medical diagnosis that included end stage renal disease (ESRD). Observation on 04/08/25 at 10:30 AM, the door lacked a sign for EBP indicating the PPE to be applied for direct resident care. Observation on 04/08/25 at 5:06 PM, Certified Nursing Assistant (CNA)1 came into the room for R412 for brief change, applied gloves, and did not apply any other personal protective equipment (PPE) prior to changing the brief. 3. Review of R16's Admission Record located in the EMR under the Profile tab revealed an admitted [DATE] with a readmitted [DATE] with medical diagnosis that included neuromuscular disfunction of the bladder. Review of R16'sphysician's orders revealed an order for a suprapubic urinary catheter. During a tour of 200 hallway on 04/10/25 at 7:50 AM, R16's room lacked a sign for EBP indicating the PPE to be worn when providing direct resident care. 4. Review of R151's Admission Record located in the EMR under the Profile tab revealed an admitted [DATE] with medical diagnosis that included gastroesophageal reflux disease. Review of R115'sphysician's order revealed an order for G-tube. Tour of the 100 hallway on 04/10/25 at 7:34 AM, R151's room lacked a sign for EBP indicating PPE to be worn when providing direct resident care. 5. Review of R126's Admission Record located in the EMR under the Profile tab, revealed an admitted [DATE] with medical diagnosis that included a pressure ulcer stage three. Review of R126'sphysician's orders revealed orders for wound care on right above knee amputation (AKA) wound and an order dated 03/16/25 for EBP for high contact resident care activities secondary to wound (care) every shift. Tour of the 400 hallway on 04/10/25 at 7:40 AM, R126's room lacked a sign for EBP indicating PPE to be worn when providing direct resident care. 6. Review of R88's Admission Record located in the EMR under the Profile tab revealed an admitted [DATE] with a readmitted [DATE] with medical diagnosis that included ESRD. Review of R88's physician's orders revealed orders for dialysis three times a week and EBP every shift. Tour of the 300 hallway on 04/10/25 at 7:30 AM, R151's room lacked a sign for EBP indicating PPE to be worn when providing direct resident care. 7. Review of R119's Admission Record located in the EMR under the Profile tab revealed an admitted [DATE] with a readmitted [DATE] with medical diagnosis that included neuromuscular dysfunction of the bladder. Review of R119's physician's orders revealed an order for suprapubic catheter and EBP for high contact resident care activities secondary to wound (care)and urinary catheter every shift. Tour of the 400 hallway on 04/10/25 at 7:40 AM, R119's room lacked a sign for EBP indicating PPE to be worn when providing direct resident care. 8. Review of R 75's Admission Record located in the EMR under the Profile tab revealed an admitted [DATE] with a readmitted [DATE] with medical diagnosis that included obstructive and reflux uropathy. Review of R75'sphysician's orders revealed an order for a indwelling urinary catheter and for EBP for high contact resident care activities secondary to urinary catheter every shift. Tour of the 300 hallway on 04/10/25 at 7:30 AM, R75's room lacked a sign for EBP indicating PPE to be worn when providing direct resident care. 9. Review of R38's Admission Record located in the EMR under the Profile tab revealed an admitted [DATE] with medical diagnosis that included dysphasia. Review of R38'sphysician's orders revealed orders for enteral feedings through a G-tube. Tour of the 400 hallway on 04/10/25 at 7:40 AM, R38's room lacked a sign for EBP indicating PPE to be worn when providing direct resident care. 10. Review of R10's Admission Record located in the EMR under the Profile tab revealed an admitted [DATE] with a readmitted [DATE] with medical diagnosis that included ESRD. Review of R110'sphysician's orders for dialysis three days a week and an order dated 03/19/25 for EBP related to dialysis. Tour of the 400 hallway on 04/10/25 at 7:40 AM, R10's room lacked a sign for EBP indicating PPE to be worn when providing direct resident care. 11. Review of R22's Admission Record located in the EMR under the Profile tab revealed an admitted [DATE] with medical diagnoses that included benign prostatic hyperplasia and indwelling catheter complications. Review of R22'sphysician's orders revealed orders for a urinary catheter. Tour of the 100 hallway on 04/10/25 at 7:45 AM, R22's room lacked a sign for EBP indicating PPE to be worn when providing direct resident care. 12. Review of R114's Admission Record located in the EMR under the Profile tab revealed an admitted [DATE] with medical diagnosis that included dementia. Review of R114's physician's orders revealed orders for wound care on both heels. Tour of the 300 hallway on 04/10/25 at 7:30 AM, R114's room lacked a sign for EBP indicating PPE to be worn when providing direct resident care. 13. Review of R101's Admission Record located in the EMR under the Profile tab revealed an admitted [DATE] with medical diagnosis that included neuromuscular dysfunction of the bladder. Review of R101'sphysician's orders revealed orders for a suprapubic catheter and EBP for high contact resident care activities secondary to suprapubic catheter care every shift. Tour of the 200 hallway on 04/10/25 at 7:50 AM, R101's room lacked a sign for EBP indicating PPE to be worn when providing direct resident care. During an interview on 04/10/25 at 11:00 AM, the Director of Nursing (DON) and the Infection Preventionist/Unit Manager (IP) both confirmed residents for dialysis, with wound care, with urinary catheters and with G-tubes were to be on EBP indicating staff were to be wearing gown and gloves during direct resident contact.

Based on interview, record review, review of the Centers for Disease Control and Prevention (CDC) recommendation pneumococcal vaccination for all adults [AGE] years or older, and facility policy review, the facility failed to offer pneumovax recommended updates for five of five residents (Residents (R)49, R39, R86, R53, and R83) reviewed for pneumonia vaccinations out of a total sample of 34 residents, the opportunity for the resident to be vaccinated in accordance with nationally recognized standards. This practice had the potential to increase the risk for these residents to contract pneumonia. Findings include: Review of the facility's policy titled Pneumococcal Vaccine dated 10/19 indicated, All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current CDC recommendations at the time of the vaccination. Review of CDC recommendation pneumococcal vaccination for all adults [AGE] years or older revealed: Not previously received a dose of PCV13, PCV15, or PCV20 or whose previous vaccination history is unknown: l dose PCV15 or 1 dose PCV20. If PCVl5 is used, this should be followed by a dose of PPSV23 given at least 1-year after the PCV15 dose. Review of R49's Admission Record located in the electronic medical record (EMR) under the Profile tab revealed an admitted [DATE]. The resident was over the age of 65 at the time of admission. Review of R49's Immun tab for immunizations located in the EMR indicated the resident received Pneumococcal polysaccharide vaccine (PPSV23) on 04/11/22. The facility failed to offer one dose of Pneumococcal 15-valent Conjugate Vaccine (PCV15) or one dose of Prevnar 20 (PCV20) or PCV21 at least one year after last dose of PPSV23. Review of R39's Admission Record EMR under the Profile tab revealed an admitted [DATE]. The resident was over the age of 65 at the time of admission. Review of R39's Immun tab for immunizations located in the EMR indicated the resident received PPSV23 on 11/08/19. The facility failed to offer one dose PCV15 or one dose of PCV20 or PCV21 at least one year after last dose of PPSV23. Review of R86's Admission Record EMR under the Profile tab, revealed an admitted [DATE]. The resident was over the age of 65 at the time of admission. Review of R86's Immun tab for immunizations located in the EMR indicated the resident received PVC13 on 10/29/15. The facility failed to offer one dose of PCV20 or PCV21 at least one year after the last dose of PCV13. Review of R53's Admission Record EMR under the Profile tab, revealed an admitted [DATE] and readmitted on [DATE]. The resident was over the age of 65 at the time of admission. Review of R53's Immun tab for immunizations located in the EMR indicated the resident received PVC13 on 01/30/18. The facility failed to offer one dose of PCV20 or PCV21 at least one year after the last dose of PCV13. Review of R83's Admission Record EMR under the Profile tab, revealed an admitted [DATE]. The resident was over the age of 65 at the time of admission. Review of R83's Immun tab for immunizations located in the EMR indicated the resident refused pneumovax vaccinations in the past. The facility failed to offer one dose of PCV15, PCV20, or PCV21. During an interview on 04/09/25 at 4:14 PM, the Regional Director of Clinical Services (RDCS) explained the facility did not follow up on the pneumovax and it was the expectation if the pneumovax update was to be given, the provider would order it. During an interview on 04/10/25 at 4:50PM, the Infection Preventionist (IP) verbalized that the facility did not follow up with the residents about the pneumovax update. During the admission process the residents would be asked if they wanted an updated pneumovax and confirmed the admission person would not know if it was recommended by CDC or not.

Based on observation, interview, record review, document review and policy review, the facility failed to have menu spreadsheets and/or follow menu spreadsheets for portion sizes for three (Resident (R)51, R61 and R92) of three residents reviewed for menus and therapeutic diets for 81 residents reviewed for menus. This deficient practice could cause residents to choke on food and/or lose weight. Findings include: Review of the facility's policy titled Menus dated 2001 revealed, 1. Menus meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board (National Research Council and National Academy of Sciences). 2. Menus for regular and therapeutic diets are written at least two (2) weeks in advance and are dated and posted in the kitchen at least one (1) week in advance. Review of the facility's diet roster dated 04/10/25 located in the EMR under the Report tab revealed 37 residents were prescribed a mechanical soft diet, 14 residents were prescribed a pureed diet, 42 residents were prescribed a CCHO [carbohydrate-controlled] diet, and eight were prescribed a renal diet. Review of the facility's spreadsheets for the 2024 Menus for the week of 04/07/25 through 04/13/25 revealed diets were planned for regular, pureed, mechanical soft ground, CCD and Renal. Review of the facility's Week 4 general menu dated 04/06/25 through 04/12/25 provided by the facility did not match the 2024 Menu spreadsheets and did not include therapeutic diets or portion sizes. 1. Observation of the tray line on 04/08/25 at 4:43 PM, the Kitchen Manager (KM) pointed to the Week 4 general menu posted in the kitchen that included Asian Stir Fry (chicken), egg roll, rice, mixed vegetables, and a cookie. Dietary Aide (DA) plated the pureed chicken, pureed baked beans, pureed green beans, regular textured green beans, regular textured mixed vegetables, ground chicken, and chopped chicken using a blue long handled serving utensil. During an interview on 04/09/25 at 4:27 PM, the KM confirmed the blue long handle serving spoon was two ounces and there was no menu spreadsheets for the Asian Stir Fry meal on 04/08/25 at supper. The KM then reviewed another similar menu spreadsheets and stated four ounces should have been served for the above menu items. 2. Review of R61's significant change Minimum Data Set (MDS,) with an Assessment Reference Date (ARD) date of 02/25/25 located in the MDS tab of the Electronic Medical Record (EMR) revealed an admitted [DATE], a Brief Interview for Mental Status (BIMS) of 00, indicating he was cognitively impaired, received a mechanically altered diet and therapeutic diet, and had diagnosis of dysphagia following cerebral infarction, hemiplegia or hemiparesis, and chronic kidney disease. Review of R61's diet order dated 10/22/24 located in the EMR under the Order tab revealed Liberal Renal, Large Portions diet, Pureed texture, Thin Liquids consistency. On 04/09/25 at 8:27 AM, R61 was served his breakfast tray that included a large portion of pureed eggs, pureed hot cereal, and pureed sausage. Review of the general breakfast menu used for 04/09/25 revealed Baked Cheesy Omelet, English muffin, strawberry yogurt, bacon or sausage, and cold cereal. The breakfast menu did not include a menu for a pureed textured diet or a renal diet. On 04/09/25 at 1:32 PM, R61 was served his lunch tray. Certified Nurse Aide (CNA)3 confirmed the meal included a large portion of pureed meat, apple sauce, tea, peas, and mashed potatoes. Review of the general lunch menu used by dietary for the 04/09/25 lunch meal revealed country fried steak, mashed potatoes, peas, Hamburger steak renal, noodles , warm apples. The lunch menu did not include a menu for a pureed textured diet. 3. Review of R51's annual MDS with an ARD date of 03/01/25 located in the MDS tab of the EMR revealed an admitted [DATE], a BIMS score of five out of 15 which indicated R51 was cognitively impaired, received a mechanically altered diet and therapeutic diet, and had diagnosis of non-Alzheimer's dementia, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of R51's diet order dated 06/17/24 located in the EMR under the Order tab revealed, NAS [No Added Salt] diet, Mechanical Soft Chopped texture, Thin Liquids consistency. On 04/09/25 at 1:21 PM, R51 was served his lunch tray that included ground country fried steak, peas, mashed potatoes, baked apples, and milk. Review of the general lunch menu used for 04/09/25 revealed, country fried steak, mashed potatoes, peas, and warm apples. The lunch menu did not include a menu for a mechanically altered texture diet. 4. Review of R92's annual MDS with an ARD date of 02/10/25 located in the MDS tab of the EMR revealed an admitted [DATE], a BIMS score of 15 out of 15, indicating he was cognitively intact, received a therapeutic diet, and had diagnosis of obesity due to excess calories. Review of R92's diet order, dated 12/19/24 located in the EMR under the Order tab revealed, CCHO, NAS diet, Regular texture, On 04/09/25 at 1:00 PM, R92 was served his lunch tray that included a country fried steak, mashed potatoes, a roll, peas, a beverage, and no dessert. Review of the general lunch menu used for 04/09/25 revealed, country fried steak, mashed potatoes, peas, and warm apples. The lunch menu did not include a menu for a CCHO diet. During an interview on 04/08/25 at 6:30 PM, the Registered Dietitian (RD) was asked why the Week 4 general menus for 4/7/25-4/13/25 didn't match the 2024 menu spreadsheets for 04/08/25-4/13/25. The RD stated the facility was changing over to new menus and they are still discussing if they should develop their own or use another company. The RD stated the spreadsheets for the 04/06-12/25 menus were still being developed and the general menus have been in use for about one month. The RD stated that for lunch and dinner on 04/08/25, she approved a substitution. The RD provided the substitution list for lunch on 04/08/25 which reflected a lunch entree, BBQ chicken was substituted for turkey and dinner on 04/08/25 fried sweet and sour chicken was substituted for deli sandwiches. The RD was asked about the substitution for the side dishes these two meals and RD confirmed the list didn't include side dishes. During an interview on 04/09/25 at 4:27 PM, the RD and KM were asked if the spreadsheets haven't been developed for the diets how does dietary know what portions to serve. The RD stated it's based on the old menu portions, and they are mixed and matched with recipes. The KM was asked how dietary knew what foods to puree as not all foods puree and did the pureed diets get bread today at breakfast, 04/09/25. The KM stated, No, not sure. The KM checked and confirmed an English muffin should have been provided. The KM was asked if there are no spreadsheets to follow for 04/09/25 lunch, what foods should be served for the therapeutic diets such as mechanical soft, renal or CCHO for R51, R61, and R92. The KM stated they were using old menus as a reference. During a follow-up interview on 04/10/25 at 8:07 AM, the KM was asked for the lunch menus used for the country fried steak, on 04/09/25 which wasn't included in the previous set of spreadsheets provided. The KM stated he didn't have a menu to follow for country fried steak menu, but the RD approved it but didn't include the side dishes. The KM stated he used the Salisbury steak menu as a reference. When the Salisbury steak menu was reviewed, the menu included corn, green beans, dinner roll, and a chocolate brownie. The KM went on to say the breakfast menu always stayed the same for the most part. The KM reviewed an old breakfast pureed menu spreadsheet and confirmed a bread item should be provided but hadn't been. The KM stated he doesn't have spreadsheets for staff to follow for portion sizes, just does a pre meal set-up, telling his staff what serving size utensils to use. The KM stated he was currently working on new menus.

Based on observation, staff interview, and facility document review, the facility failed to maintain a safe and homelike environment, including but not limited to ensuring maintenance services were conducted as necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, the bedroom walls were gauged and scraped and the bathroom door had scuff marks and was unable to open fully. This deficient practice affected eight resident (R)76, R141, R147, R17, R82, R35, R145 and R96) in the census of 151. The facility failed to provide a homelike environment and easy access in and out of resident rooms and bathrooms. Findings include: The undated Common Area Checklist revealed, General and Common Area items to review daily. These items include monitoring doors, walls, trims, baseboards, and flooring. During an observation on 04/08/25 at 10:00 AM, R76's room revealed extensive and deep wall scrapings along the side of the resident bed. During an observation on 04/08/25 at 10:08 AM, the bathroom door for R82 and R35's room could not open more than approximately half-way before being jammed along the floor, leaving large scuff marks on the resident room floor. During an observation on 04/08/25 at 11:53 AM, R141's room revealed extensive and deep wall scrapings along the side of the resident's bed. During an observation on 04/08/25 at 12:40 PM, R147's room revealed extensive and deep wall scrapings across the majority of the resident's wall. During an observation on 04/08/25 at 1:30 PM, the front door to R145 and R96's room could not open more than approximately half-way before being jammed along the floor, leaving large scuff marks on the resident room floor. During an observation on 04/09/25 at 8:45 AM, R17's room revealed extensive and deep wall scrapings across the resident room walls. Interview during a facility tour on 04/10/25 from 5:12 PM through 5:35 PM, the Maintenance Director (MD) stated he used an electronic system to complete work orders. He stated that if the nurses and certified nurse aides (CNA) found a concern, the nurses had access to this system. During the facility tour the MD confirmed that the doors had shifted and some had become damaged, and that they needed replaced or repaired. He confirmed the room walls needed repaired and painted. He stated that he had a checklist that he used each day to ensure facility building needs were met.

Based on observation, interview, resident record, and facility policy, the facility failed to ensure residents receiving dialysis treatments, staff were using Enhanced Barrier Protection (EBP) when providing direct resident care for two of three residents (Resident (R) 113 and R412) reviewed for dialysis care. The facility failed to ensure physician orders were in place for dialysis treatment and accurate interventions were documented in the care plan. The deficient practice has the potential for the residents to not receive dialysis care in the facility. Findings included: Review of the facility's policy titled End-Stage Renal Disease, Care of a Resident dated 09/19 revealed, Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. Education and training of staff includes, specifically: the care of grafts and fistulas. The resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care. Review of the facility's policy titled Enhanced Barrier Precautions revised 03/24, revealed EBPs are (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. 1. Review of R113's Admission Record located in the EMR under the Profile tab revealed an admitted [DATE] with medical diagnosis that included chronic kidney disease, stage three. Observation on 04/08/25 at 1:30 PM, R113 was in bed and pointed to his right chest when questioned about where the dialysis clinic accessed for dialysis. No signs on the door or near the resident room indicating the need for EBP. During an observation on 4/10/25 at 9:33 AM, Licensed Practical Nurse (LPN)13 confirmed the central venous catheter (CVC) catheter was located on the right chest wall by moving the resident's clothing to reveal the dressing. LPN13 was not wearing gloves at the time of the observation of the dressing. During an interview on 04/10/25 at 9:50 AM, LPN1/Unit Manager confirmed 113 should be on EBP and was not. 2. Review of R412's Admission Record located in the EMR under the Profile tab revealed an admitted [DATE] with a readmitted [DATE] with medical diagnosis that included end stage renal disease (ESRD) Review of R412's physician orders in the EMR under the Orders tab lacked documentation for an order for dialysis to include place and days for dialysis treatment. Review of R412's physician orders under the Orders tab in the EMR documented an order dated 03/26/25 for Gentamicin Sulfate external ointment 0.1 percent (%). Apply to peritoneal dialysis (PD) catheter topically every evening shift. Use gauze to apply Q tip sized amount. Review of R412's EMR MAR for March 2025 documented the gentamicin applied to PD catheter on five evening shifts and the MAR for April 2025 documented the gentamicin applied to PD catheter on nine evening shifts Review of R412's care plan under the Care Plan tab in the EMR dated 03/26/25, revealed, Resident requires peritoneal dialysis . and is at risk for bleeding at the access site, deficient/excess fluid volume, hypertension, occlusion, and shortness of breath. Interventions included monitor peritoneal access site [every] shift for redness, swelling, discharge, odor of pain. The care plan lacked focus and interventions for hemodialysis. During an interview on 04/08/25 at 2:00 PM, R412's family member (FM)1 explained that the resident went out for dialysis treatment because the PD catheter had been removed from the abdomen during the hospitalization prior to being admitted to the facility. Observation on 04/08/25 at 5:06 PM, Certified Nursing Assistant (CNA)1 came into R412's room for brief change. CNA1 applied gloves and did not apply any other personal protective equipment (PPE) prior to changing the brief. During an interview on 04/09/25 at 1:40 PM, Licensed Practical Nurse (LPN)3 verified the order for gentamicin for R412 and confirmed the PD catheter had been removed. LPN3 verified the site was healed and no longer needed the order for gentamicin to be applied. LPN3 verbalized documentation of the application of gentamicin being applied was not correct documentation. LPN3 confirmed R412 needed to be on EBP. During an interview on 04/10/25 at 11:00 AM, the Director of Nursing (DON) and the Infection Preventionist/Unit Manager (IP) both confirmed R113 had a CVC inserted in the right chest wall for dialysis access. Residents with CVC do not have a bruit or thrill present to be monitored. Monitoring needed was for dressing to be dry and clear, catheter secure. Documentation for presence of bruit and thrill for R113 was inaccurate, false documentation since with a CVC catheter the resident does not have a thrill or bruit. The DON and IP confirmed R412 did not have a peritoneal dialysis catheter and the order to apply gentamicin to the PD site on the abdomen was incorrect. Both confirmed the documentation about application of gentamicin to the PD catheter was inaccurate documentation. The DON and IP confirmed residents for dialysis were to be on EBP wearing gown and gloves during direct resident contact and residents requiring dialysis treatment required a physician's order.

Based on observation, record review, interviews, and facility policy review, the facility failed to implement a person-centered comprehensive plan of care with measurable goals for one of 34 sampled residents (R) 16) reviewed for care plans. The failure to implement the care plan intervention for pressure ulcers of a cushion to the resident's wheelchair placed the resident at risk of an ongoing decline in healing of the pressure ulcers. Findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered dated March 2022 indicated, .A comprehensive, person-centered care plan should include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs . The care plan interventions should be derived from information obtained from the resident and his/her family/responsible party, with possible discretionary modifications resulting from the comprehensive assessment .The comprehensive, person-centered care plan should: Describe the services that are to be furnished in an attempt to assist the resident attain or maintain that level of physical, mental, and psychosocial wellbeing that the resident desires or that is possible. Review of R16's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 03/20/25 located in the MDS tab of the Electronic Medical Record (EMR) revealed an admitted [DATE], a Brief Interview for Mental Status (BIMS) score of twelve out of 15, indicating he had moderate cognitive impairment. R16 was admitted with diagnoses including multiple sclerosis and muscle weakness. R16 was documented to require partial/moderate assistance for sitting to lying and was dependent for sit to stand and chair/bed-to-chair transfer. R16 was documented to have a stage three pressure ulcer. Review of R16's EMR titled physician Orders located under the Orders tab dated 01/09/23 indicated the resident was ordered a DEVICE: ROHO cushion to wheelchair (per wound specialist). Review of R16's EMR titled Care Plan located under the Care Plan tab initiated 08/04/17 revealed, the resident was at risk for skin impairment and/or breakdown .had a history of an open area to left toes and a wound to right/left buttock. Interventions included having a ROHO cushion on his wheelchair. During an interview on 04/08/25 at 10:20 AM, R16 stated that his current wheelchair was being replaced because the back support was not functioning properly anymore. His wheelchair was placed directly next to the resident bed. There was no cushion observed in the resident's wheelchair as care planned. During an interview and observation on 04/08/25 at 12:45 PM, R16 was observed seated in his new wheelchair. He stated he liked to be out of bed as much as possible, and stated the wheelchair could be more comfortable since he did have a wound on his bottom. He confirmed he did not have a cushion underneath him. None was visible. During an interview and observation on 04/09/25 at 2:20 PM, R16 was noted in his wheelchair without a cushion. He stated he did not have a cushion in his wheelchair. During a concurrent interview on 04/09/25 at 2:30 PM, Licensed Practical Nurses (LPN)8 and LPN11 stated that R16 had a pressure ulcer on the sacrum. LPN8 stated that R16 would benefit from a wheelchair cushion since he liked to get out of bed. LPN8 reviewed the EMR and stated that it appeared an order had been placed into the chart, but it was not on the Medication Administration Record or Treatment Administration Record. During an interview and observation on 04/09/25 at 2:30 PM, Licensed Practical Nurse/Unit Manager (LPN)15 stated that R16 had a sacral wound. Upon observation of R16, LPN15 confirmed R16 was not using a cushion in his wheelchair. During an interview on 04/10/25 at 4:57 PM, the Director of Nursing stated that she expected the nursing staff to follow the resident's care plan and physician orders for the ROHO cushion for R16's wheelchair.

Based on observation, interview, resident record, and facility policy, the facility failed to ensure residents receiving dialysis treatments had accurate documentation of care provided for the dialysis site for two of three residents (Resident (R) 113 and R412) reviewed for dialysis care. The deficient practice has the potential for the residents to not receive dialysis care in the facility. Findings include: 1. Review of R113's Admission Record located in the EMR under the Profile tab revealed an admitted [DATE] with medical diagnosis that included chronic kidney disease, stage three. Review of R113's physician orders under the Orders tab in the EMR documented an order dated 03/26/25 indicating, Resident has arteriovenous (AV) fistula (shunt) located on [right]chest wall. Monitor for presence of bruit (auscultation) and thrill (palpation of vibration) [every] shift. Notify MD [Medical Doctor] if unable to auscultate of palpate. Monitor [each] shift for bleeding. Drainage, excessive warmth, pain, redness, numbness in fingers, tenderness, or swelling. Check circulation [each] shift by palpating distal pulses, observing capillary refill, assessing numbness, tingling, altered sensation, coldness, and pallor. Notify MD of abnormal findings, every shift document if bruit is present (+) absent (-) also document if thrill is present or absent. Review of R113's EMR Medication Administration Record (MAR) for March 2025 documented the presence on bruit and thrill on four shifts and the MAR for April documented the presence on bruit and thrill 17 shifts. During an interview on 04/10/25 at 6:20 PM, Registered Nurse (RN) 3 confirmed R113 had a central venous catheter (CVC) located on the right chest wall and secured with a dressing. RN3's practice was to check for redness, drainage, and intact dressing. There was no bruit or thrill to check for and when documenting there was no other place to document the condition of the CVC dressing. RN3 did confer with RN1 about the documentation confusion and did not inquire with the unit manager about the confusion in the documentation and decided to document what was available on the MAR even if it was not what was being done. During an interview on 04/10/25 at 6:40 PM, RN1 acknowledged knowing the difference between a CVC and arteriovenous (AV) fistula for dialysis access. RN1 confirmed R113 had a CVC for dialysis access. RN1 confirmed documenting presence of thrill and bruit for R113 and aware that assessment was not accurate. RN1 spoke to RN3 about the inaccurate documentation in the MAR and chose to mark in the MAR even though the assessment was for dressing being intact and dry. During an interview on 04/10/25 at 9:50 AM, LPN1/Unit Manager confirmed there was no AV fistula for documentation of thrill and bruit. 2. Review of R412's Admission Record located in the EMR under the Profile tab revealed an admitted [DATE] with a readmitted [DATE] with medical diagnosis that included end stage renal disease (ESRD) Review of R412's physician orders under the Orders tab in the EMR documented an order dated 03/26/25 for Gentamicin Sulfate external ointment 0.1 percent (%). Apply to peritoneal dialysis (PD) catheter topically every evening shift. Use gauze to apply Q tip sized amount. Review of R412's EMRMAR for March 2025 documented the gentamicin applied to PD catheter on five evening shifts and the MAR for April 2025 documented the gentamicin applied to PD catheter on nine evening shifts During an interview on 04/08/25 at 2:00 PM, R412's family member (FM)1 explained that the resident went out for dialysis treatment because the PD catheter had been removed from the abdomen during the hospitalization prior to being admitted to the facility. During an interview on 04/09/25 at 1:40 PM, Licensed Practical Nurse (LPN)3 verified the order for gentamicin for R412 and confirmed the PD catheter had been removed. LPN3 verified the site was healed and no longer needed the order for gentamicin to be applied. LPN3 verbalized documentation of the application of gentamicin being applied was not correct documentation. During an interview on 04/10/25 at 11:00 AM, the Director of Nursing (DON) and the Infection Preventionist/Unit Manager (IP) both confirmed R113 had a CVC inserted in the right chest wall for dialysis access. Residents with CVC do not have a bruit or thrill present to be monitored. Monitoring needed was for dressing to be dry and clear, catheter secure. Documentation for presence of bruit and thrill for R113 was inaccurate, false documentation since with a CVC catheter the resident does not have a thrill or bruit. The DON and IP confirmed R412 did not have a peritoneal dialysis catheter and the order to apply gentamicin to the PD site on the abdomen was incorrect. Both confirmed the documentation about application of gentamicin to the PD catheter was inaccurate documentation.

Based on observation, interview, record review, and policy review, the facility failed to ensure a baseline care plan was accurate and complete within 48 hours of admission to the facility for one of nine residents (Resident (R)412) reviewed for care plans in the sample of 34 residents. The deficient practice had the potential for the lack of care planning for the specific needs of the residents. Findings include: Review of the facility's policy titled Care Plans-Baseline revised 12/22 revealed, A baseline plan of care should be developed for each resident within forty-eight (48) hours of admission. The baseline care plan should include instructions needed to provide effective, person-centered care of the resident . Review of R412's Admission Record located in the EMR under the Profile tab, revealed an admitted [DATE] with a readmitted [DATE] with medical diagnosis that included end stage renal disease (ESRD) Observations on 04/08/25 at 5:30 PM revealed R412 had a gastrostomy tube (G-tube) inserted in the abdomen, a central venous catheter (CVC) inserted in the right chest wall, and a continuous positive airway pressure (CPAP) machine located on the nightstand near the resident bed. Review of R412's Care Plan under the Care Plan tab in the EMR documented a care plan focus for dialysis with interventions for peritoneal dialysis with an initiation date of 03/26/25 and lacked care plan for a G-tube and for CPAP. During an interview on 04/09/25 at 1:36 PM, Licensed Practical Nurse (LPN)3 reviewed the EMR and confirmed the care plan indicated the wrong type of dialysis. R412 was receiving hemodialysis not peritoneal dialysis since R412 had CVC for dialysis treatment. LPN3 verified R412 had a G-tube and CPAP and there was no care plan. During an interview on 04/10/25 at 7:59 AM, Infection Preventionist/Unit Manager (IP) confirmed R412 had been wearing the CPAP machine at 5:50 AM that day. During an interview on 04/10/25 at 11:13 AM, Director of Nursing (DON) and IP verified the care plan did not reflect R412's care needs. The DON confirmed the dialysis focus was incorrect, there was no care plan for the G-tube or CPAP and should be.

32513 Based on interview, record review, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the Minimum Data Set (MDS) was coded accurately for two (Residents (R)87 and R135) in a total sample of 34. The facility failed to accurately code a significant change assessment for prognosis of terminal illness for R87 and for mental status for R135. These failures placed the residents at risk of unmet care needs and a diminished quality of life. Findings included. Review of the October 2024 RAI manual, page 1-5 revealed, .An accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations .It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy (what the resident's actual status was during the observation period) by the IDT (interdisciplinary team) completing the assessment . Review of the October 2024 RAI Manual, page C-1, revealed: Cognitive Patterns.Steps for Assessment, 1. Interact with the resident using their preferred language . Be sure they can hear you and/or have access to their preferred method for communication. If the resident needs or requires an interpreter, complete the interview with an interpreter. If the resident appears unable to communicate, offer alternatives such as writing, pointing, sign language, or cue cards. 2. Determine if the resident is rarely/never understood verbally, in writing, or using another method . 1. Review of R87'sAdmission Record located in the Profile tab of the electronic medical record (EMR) revealed R87 was readmitted to the facility on [DATE] with a diagnosis of anoxic brain injury and blood clots to both upper extremities. Review of the Order Summary located in the Orders tab of the EMR revealed, Admit to [hospice name ] dated 11/26/24. Review of R87's significant change MDS located in the MDS tab of the EMR with an ARD of 12/05/24 revealed, R87 had a Brief Interview of Mental Status (BIMS) score of six out of 15 which indicated R87 was severely impaired in cognition, was not coded for prognosis of six months or less but was on hospice care. Review of the Certification of Terminal Illness (CTI) located in the Documents tab of the EMR revealed, R87 had a terminal diagnosis of six months or less which was signed by the physician. The CTI was dated 11/26/24 to 02/19/25. During an interview on 04/10/25 at 10:57 AM, the MDS Director (MDSD) was asked why the prognosis of six months or less was not coded but hospice care was coded. The MDSC stated, I did not see the hospice documentation because it was not uploaded to the computer until 12/31/24. The MDSD further stated she was not aware that to be on hospice care required a terminal diagnosis of six months or less. 2. Review of R135's Admission Record from the EMR Profile tab showed a facility admitted [DATE] with medical diagnoses of senile degeneration of the brain, cognitive communication deficit, and history of cerebral infarction. Review of R135's annual MDS in the EMR MDS tab with an ARD of 10/04/24 showed a BIMS score of 12 out 15, indicative of moderate cognitive impairment. Review of R135's quarterly MDS with an ARD of 01/02/25 was coded as Rarely or Never Understood. Section C200 to C400 was not scored and Section C500 BIMS summary score was not completed. Section C600, should the staff assessment for mental status be conducted, it was not scored for either No (resident was able to complete interview) or Yes (resident was unable to complete interview). Review of R135's MDS with an ARD of 04/01/25 showed a BIMS score of 13 out of a possible 15, indicative of being cognitively intact. During an interview on 04/10/25 at 11:40 AM, the MDS Director (MDSD) reviewed R135's assessments and stated, I don't know what happened. That one [01/02/25] was a mistake; he is with it. When asked if R135 was cognitively intact in January, the MDSD responded Yes. When queried if the facility had an MDS accuracy policy, the MDSD stated, No, we use the RAI [Resident Assessment Instrument] manual. I didn't verify the MDS information. I just sent it out.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure a significant change Minimum Data Set (MDS) was completed for one resident (Resident (R)87) of two sampled residents reviewed for hospice in a total sample of 34. The facility failed to complete the significant change assessment when R87 revoked hospice services due to an improvement in his condition. This failure placed residents at risk of unmet care needs and a diminished quality of life. Findings included. Review of the RAI manual version 3.0 dated October 2024, page 2-25 revealed, .An SCSA [significant change in status assessment] is required to be performed when a resident is receiving hospice services and then decides to discontinue those services (known as revoking of hospice care). The ARD [assessment reference date] must be within 14 days from one of the following: 1) the effective date of the hospice election revocation (which can be the same or later than the date of the hospice election revocation statement, but not earlier than); 2) the expiration date of the certification of terminal illness; or 3) the date of the physician's or medical director's order stating the resident is no longer terminally ill . Review of the Admission Record located in the Profile tab of the electronic medical record (EMR) revealed R87 was readmitted to the facility on [DATE] with a diagnosis of anoxic brain damage (lack of oxygen to the brain). Review of the Order Summary located in the Orders tab of the EMR revealed, Admit to [hospice name withheld] dated 11/26/24. Review of the significant change MDS located in the MDS tab of the EMR with and ARD of 12/05/24 revealed R87 had a Brief Interview of Mental Status (BIMS) score of six out of 15 which indicated R87 was severely impaired in cognition and was receiving hospice care. Review of the quarterly MDS located in the MDS tab of the EMR with an ARD of 03/02/25 revealed, R87 had a BIMS score of nine out of 15 which indicated R87 was moderately impaired in cognition and was receiving hospice services. Review of the provider visit note dated 03/27/25 in the EMR under the Progress Notes tab revealed that R87 revoked hospice services due to Being stable and gaining weight. During an interview on 04/08/25 at 10:46 AM, R87 was asked if he was still on hospice services. R87 stated, No, I quit hospice. They told me I had six months left to live but that has been over a year ago and I am still here. During an interview on 04/10/25 at 10:57 AM, the MDS Director (MDSD) was asked when had R87 had revoked hospice services. The MDSD stated, He went off hospice on 02/19/25. The MDSD was asked why a quarterly assessment was completed instead of a significant change assessment. The MDSD stated, I was not aware that a significant change assessment needed to occur when a resident goes off hospice. During an interview on 04/08/25 at 4:06 PM, the Director of Nursing (DON) stated, R87 came off hospice care on 02/29/25. The DON confirmed that a significant change assessment had not been completed.

Based on interviews, record reviews, and policy review, the facility failed to ensure that one out of five residents (Resident (R) 145) out of a total sample of 33 residents reviewed for unnecessary medication use. Specifically, the facility failed to follow adequate monitoring of blood pressure parameters before the unnecessary administration of blood pressure medications, according to physician orders. This failure had the potential to increase the risk for serious adverse effects. Findings include: Review of the facility's policy titled, Administering Medications dated April 2019 indicated, Medications are administered in a safe and timely manner, and as prescribed .Medications are administered in accordance with prescriber orders, including any time frame.1. Review of R145's Admission Record found in the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses of atrial fibrillation, localized hypertensive chronic kidney disease, and edema. Review of R145's quarterly Minimum Data Set (MDS) assessment located in the MDS tab in the EMR with an Assessment Reference Date (ARD) of 03/14/25 revealed a Brief Interview for Mental Status (BIMS) score of five out of 15 which indicated severe cognitive impairment. R145 received a diuretic. Review of R145's Care Plan in the EMR under the Care Plan tab initiated 12/14/24, revealed R145 was at risk for complications related to a diagnosis of congestive heart failure as manifested by confusion, elevated blood pressure, and localized edema. Interventions included to administer medications as ordered. Record review revealed a cardiology appointment dated 02/20/25 that stated R145 was mild-moderately volume overloaded during exam and that the facility should complete vital signs daily. Review of R145's EMR under the Orders tab revealed an order, dated 12/16/24, for Vital Signs Q shift [every shift] while skilled every shift. This order was discontinued 03/01/25. Review of R145's February 2025 Medication Administration Record (MAR) in the EMR revealed resident received Amlodipine Besylate Oral Tablet 10 milligrams (mg). Give one tablet by mouth one time a day for hypertension at 9:00 AM. Hold if systolic blood pressure (SBP) less than 100. The medication was documented as administered, but SBP was not documented each day prior to administration. Record review of R145's March 2025 MAR in the EMR revealed resident received Amlodipine Besylate oral tablet 10 mg one tablet daily. The medication was documented as administered, but SBP was not documented each day prior to administration. Record review of R145's April 2025 MAR in the EMR revealed resident received Amlodipine Besylate oral tablet 10 mg one tablet daily. The medication was documented as administered, but SBP was documented only on 04/09/25, as of 04/09/25. Record review of R145's February 2025 MAR in the EMR revealed resident received Furosemide oral tablet 40 mg. Give one tablet by mouth one time a day for congestive heart failure at 9:00 AM. Hold if SBP (systolic blood pressure) less than 100. The medication was documented as administered, but SBP was not documented each day prior to administration. Record review of R145's March 2025 MAR in the EMR revealed resident received Furosemide oral tablet 40 mg one tablet daily. The medication was documented as administered, but SBP was not documented each day prior to administration. Record review of R145's April 2025 MAR in the EMR revealed resident received Furosemide oral tablet 40 mg one tablet daily. The medication was documented as administered, but SBP was documented only on 04/09/25. Record review of R145's February 2025 MAR in the EMR revealed resident received Losartan Potassium oral tablet daily. The medication was documented as administered, but SBP was not documented each day prior to administration. Record review of R145's March 2025 MAR in the EMR revealed resident received Losartan Potassium oral tablet daily. The medication was documented as administered, but SBP was not documented each day prior to administration. Record review of R145's April 2025 MAR in the EMR, revealed resident received Losartan Potassium oral tablet daily. The medication was documented as administered, but SBP was documented only on 04/09/25. Record review of R145's February 2025 MAR in the EMR, revealed resident received Carvedilol oral tablet 3.125 mg. Give one tablet by mouth two times a day for congestive heart failure at 9:00 AM and 8:00 PM. Hold for SBP less than 100 or heart rate less than 50. The medication was documented as administered, but SBP nor heart rate was not documented each day prior to administration. Record review of R145's March 2025 MAR in the EMR, revealed resident received Carvedilol oral tablet 3.125 mg. Give one tablet by mouth two times a day. The medication was documented as administered, but SBP nor heart rate was not documented each day prior to administration. Record review of R145's April 2025 MAR in the EMR, revealed resident received Carvedilol oral tablet 3.125 mg. Give one tablet by mouth two times a day. The medication was documented as administered, but the SBP and heart rate was documented only on 04/09/25. Record review of R145's February, March, April 2025 Blood Pressure Summary revealed the resident received blood pressure monitoring on infrequent days and infrequent times, not documented in collaboration with the administration of the identified medications that required parameter monitoring, nor noted in the MARs. During an interview on 04/10/25 at 12:04 PM, Registered Nurse (RN)4 stated that she completed vitals prior to the administration of medications. She stated that for R145 if the resident's systolic (blood pressure) was below 100 or his pulse was low, she would hold his blood pressure medications. RN4 said that if a resident's vitals were below parameters, you would hold the medication and would document that in the EMR and would be required to document in the progress note. During an interview on 04/10/25 at 3:35 PM, Licensed Practical Nurse/Unit Manager (LPN) 15 stated that when a resident was on skilled care, they would have their vitals done daily. She confirmed that they might not all be documented in the EMR. LPN15 said that if a resident had parameters for some medications, she would expect to see those vitals taken, and if they were outside the correct levels, the medication should not be given. She confirmed there should be a progress note, as well. Upon review of R145's MAR she confirmed that R145 had not had all vitals taken prior to the administration of medications that required parameter monitoring. During an interview on 04/10/25 at 4:58 PM, the Director of Nursing (DON) stated that she was not sure why the physician order to discontinue vitals was discontinued on 03/01/25 for R145. She stated she would expect to see medication orders followed to ensure medications were given according to the parameters. Upon review of R145'sMARshe confirmed the resident did not have regular vital checks prior to the administration of these medications. She stated she would expect the parameters to be followed.

Based on observations, interviews, record review, and review of facility policy, the facility failed to maintain a medication error rate of less than 5% when two oral medications were not administered according to the physician's order for two (Residents (R)20 and R80) of seven residents observed during medication pass. This consisted of two medications errors in 30 opportunities for a 6.67% error rate. Findings included. Review of the facility's policy titled, Administering Oral Medications dated 2001 revealed, .Medications are administered in accordance with prescriber orders, including any required time frame .The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) before giving the medication . 1. During a medication pass observation on 04/10/25 at 8:39 AM. Licensed Practical Nurse (LPN) 8removed a multivitamin (MVI) with iron tablet from a bottle in the top drawer of the medication and placed the medication into the medication cup. In addition, there was one Ferrous Sulfate (Iron replacement medication) 325milligram (mg) tablet which had been placed into the medication cup earlier. Review of the April Medication Administration Record (MAR) located in the Orders tab of the electronic medical record (EMR) revealed, Multi-Vitamin/Minerals. Give one tablet by mouth one time a day for dietary supplement. Start Date 07/28/23. Review of the April MAR located in the Orders tab of EMR revealed, Ferrous Sulfate 325mg. Give one tablet by mouth one time a day related to IRON DEFICIENCY. Start Date, 03/13/19. During an interview on 04/10/25 at 8:40 AM, LPN 8 was asked if the physician had been notified that R20 was receiving both an iron replacement and a MVI with iron. LPN 8 stated, This was the bottle on the medication cart. LPN 8 acknowledged that R20 may have been given too much iron. 2. During a medication pass observation on 04/10/25 at 8:54 AM, LPN 1 removed a Vitamin D 10 mcg [micrograms] (400 IU-International Units) one tablet and placed it into the medication cup with R80's other morning medications and then administered them to R80. Review of the MAR located in the Orders tab of the EMR revealed, Vitamin D 100 mcg (4000 IU). Give one tablet by mouth one time a day for supplement. Dated 06/05/24. During an interview on 04/10/24 at 10:15 AM, LPN 1 was asked why the 10 mcg Vitamin D was administered instead of the 100 mcg Vitamin D. LPN1 looked through the top drawer of the medication cart and could not find a bottle of Vitamin D 100 mcgs. LPN 1 then went to the medication room and found a bottle of D3 (Vitamin D) which was labeled 50 mcg (2000 IU) and stated, I should have given two of these to equal the 100 mcg (4000 IU) per the physician order. During an interview on 04/10/25 at 1:15 PM, the Director of Nursing (DON) was told about the 6.67% medication error rate and the two medication errors in 30 opportunities. The DON acknowledged that these were medication errors.

Based on observation, interview, record review, and policy review, the facility failed to investigate the possible underlying issue for significant weight loss and assessed the resident before the use of a psychotropic drug for weight loss for one (Resident (R)51) of 10 sampled residents reviewed for nutritional status. This had the potential to cause further weight loss. Findings include: Review of the facility's policy titled, Weight Assessment and intervention revised 03/22 revealed, Weight Assessment .3. Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. a. If the weight is verified, nursing will immediately notify the dietitian in writing.Evaluation, 1. Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met. 2. The physician and the multidisciplinary team identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. Review of the facility's policy titled, Nutritional Assessment revised 10/17 revealed, 2. As part of the comprehensive assessment, the nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition. Review of R51's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 03/01/25 located in the MDS tab of the Electronic Medical Record (EMR) revealed an admitted [DATE], a Brief Interview for Mental Status (BIMS) score of five out of 15, indicating he was severely cognitively impaired, weight at 195 pounds, no weight loss, and had diagnosis of non-Alzheimer's dementia, schizophrenia, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of R51's 50% or less meal consumption and/or refusal: (Alternate meal/nourishments) located in the EMR under the Task tab revealed no nutritional supplement for 03/09/25 to 04/08/25. Review of R51's orders located in the EMR under the Order tab revealed the April 2025 Medication Administration Record (MAR)/Treatment Administration Record (TAR) and physician orders revealed no nutritional supplementation. Review of R51's progress notes dated 03/10/25 to 04/02/25 in the EMR under the Progress Note tab revealed no nutritional supplementation. Review of R51's orders located in the EMR under the Order tab revealed NAS [No Added Salt] diet, Mechanical Soft Chopped texture, Thin Liquids consistency dated 06/17/24 and Mirtazapine Oral Tablet 7.5 MG [milligram] (Mirtazapine) Give 7.5 tablet by mouth one time a day for appetite, dated 03/31/25. Review of R51's care plan revised 01/11/24 located in the EMR under the Care Plan tab revealed, Resident is at risk for malnutrition r/t [related to] h/o [history of] significant changes, therapeutic diet, dysphagia, dementia, Dx [diagnosis] Subdural hemorrhage, CVA [cerebral vascular accident] late effects, HTN [hypertension], HLD [hyperlipidemia], Mild cognitive deficit, ETOH [alcohol] abuse, Peptic ulcer disease (PUD), Hepatitis C, constipation, diuretic therapy, malnutrition risk. Interventions included, Provide and serve supplements as ordered .RD [Registered Dietician] to evaluate and make diet and nutrition-related recommendations PRN [as needed]. Review of R51's Nutritional Risk Review dated 06/03/24, located in the EMR under the Evaluation tab revealed Order for 1:1 feeding assistance started 5/31. He has dysphagia and is receiving mech [mechanically] altered diet. Pureed diet started 5/28/24 per hospital recommendations. Receives meds [medications] crushed per 5/30 nursing note. Review of R51's Nutritional Risk Review dated 03/20/25 located in the EMR under the Evaluation tab revealed, Has dysphagia and is receiving mech altered diet. Noted to need assistance with meals.Flagged for significant weight loss of -10% x30 days. Question accuracy of 3/10 weight. Other weights have been stable. Review of R51's weight history located in the EMR under the Weight/Vitals tab revealed a 17.8-pound (8%) weight loss in three months: On 01/03/25 at 198.0 pounds (Lbs.) via wheelchair On 02/04/25 at 195.2 Lbs. via [name of mechanical lift] On 03/10/25 at 175.6 Lbs. via wheelchair On 04/02/25 at 178.0 Lbs. via [name of mechanical lift] On 04/10/25 at 180.2 Lbs. On 04/09/25 at 8:24 AM, R51 was asleep in bed with his breakfast tray on an overbed table. R51's breakfast tray included a carton of milk, an English muffin, grits, egg omelet, chopped sausage, juice, and coffee. Zero percent of the food was consumed. On 04/09/25 at 8:30 AM, Certified Nurse Aide (CNA)4 was in R51's room standing at his bedside spoon feeding R51. On 04/09/25 at 8:33 AM, CNA4 was observed bringing R51's breakfast tray out of the room and onto the cart. CNA4 was asked about R51's meal consumption. CNA4 stated R51 ate 50% and then uncovered the plate to reveal 50% of the meal consumed. On 04/09/25 at 1:21 PM, CNA6 brought R51's lunch tray into his room and CNA spoon fed R51 in bed while standing at his bedside. R51 was served ground country fried steak, peas, mashed potatoes, baked apples, and milk. R51 ate 50% of the food and only bits of the ground country fried steak. During an interview on 04/09/25 at 5:02 PM, the RD was asked about R51's significant weight loss and his weights not taken consistently as sometimes a mechanical lift was used and other times a wheelchair. The RD stated she had asked nursing about the weights when she started working at the facility in late December 2024 and education was started for weigh consistency. The RD was asked if reweights should be completed if weights varied from the previous weight. The RD stated she asks nursing to do them. The RD stated R51 was someone she would have wanted reweighed and to conduct a deeper investigation as to why he is losing weight. The RD was asked about the Mirtazapine and if R51 was receiving supplements. The RD stated she had not yet recommended a supplement as she will consider a supplement after R51 was reweighed and investigate if it may be beneficial. The RD stated she also wanted to observe R51 while eating a meal. During an interview on 04/10/25 at 2:52 PM, the Nurse Practitioner (NP) was asked if she was aware of R51's recent significant weigh loss. NP stated she was aware R51 was steadily losing weight. NP was asked why R51 was losing weight. NP stated R51 was small, and then reviewed EMR quoting a weight from 2021. NP stated she put R51 on Mirtazapine as a response to R51's weight loss. NP had no further comment. During a follow up interview on 04/10/25 at 3:04 PM, the RD stated R51 was reweighed at 180.2 Lbs. on 04/10/25 and confirmed the reweight should have been sooner. The RD was asked why the NP used pharmacological intervention first. The RD stated she didn't know as she wasn't contacted. The RD confirmed nonpharmacological interventions (NPI) such as nutritional interventions should be attempted first before considering pharmacological interventions. During an interview on 04/10/25 at 5:00 PM, the Director of Nursing (DON) was asked if she was aware of R51's weight loss. The DON stated, don't know off the top of my head. The DON stated they didn't have a process to identify weight loss or at risk for weight loss but one was being developed. The DON was asked if she was aware R51's 2024 hospital discharge instructions recommended R51 have a pureed diet but R51 was on a mechanical soft diet. The DON stated, No. The DON was asked about the kitchen not having menu extensions for therapeutic diets. The DON stated she had heard something about that. The DON stated her expectation would be for staff to promptly inform her of weight loss and staff to follow their policy for reweighing a resident when the weight differed from the previous weight. The DON stated she was aware that weights should be taken consistently. During a follow up interview on 04/10/25 at 6:30 PM, the DON was asked why R51 was prescribed Mirtazapine first and not NPI as well as conducting an evaluation before using a psychotropic medication. The DON reviewed the EMR, and confirmed no evaluation was found. The DON stated she could not say why.

Based on observations, interview, and record review, the facility failed to ensure the Comprehensive Care Plan was revised/updated for one resident (Resident (R)87) in a total sample of 34 care plans reviewed. Specifically, the facility failed to update the care plan when R87 revoked hospice services, had the gastrostomy tube (G-tube-a tube placed into the abdomen for medications and nourishment) removed and had the enhanced barrier precautions (EBP) removed. This failure placed the resident at risk of unmet care needs and a diminished quality of life. Findings included. Review of the Admission Record located in the Profile tab of the electronic medical record (EMR) revealed R87 was readmitted to the facility on [DATE] with a diagnosis of anoxic brain injury (lack of oxygen to the brain). Review of the quarterly Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 03/02/25 revealed a Brief Interview of Mental Status (BIMS) score of nine out of 15 which indicated R87 was moderately impaired in cognition, was independent with eating, required partial assistance with toileting, bed mobility and transfers, had weight gain, no tube feedings, and was receiving hospice services. Review of the End-of-Life Care Plan dated 11/25/24 revealed, Resident requires comfort care and is at risk for rapid decline in ADL [activities of daily living] function, sudden onset or worsening skin integrity, weight loss, nausea/vomiting, pain, abnormal breathing, impaired psychosocial well-being related to terminal illness. Interventions included, Coordinate residents' needs with hospice staff, hospice service as ordered and notify hospice of change of condition. During an interview on 04/08/25 at 10:46 AM, R87 was alert, able to communicate and make his needs known. R87 was asked if he was currently in hospice. R87 stated, No, I quit hospice as they told me I had six months to live and that has been over a year ago, and I am still here. During an interview on 04/08/25 at 4:06 PM, the Director of Nursing (DON) confirmed R87 revoked hospice services 02/19/25. The DON confirmed that the Care Plan was not updated/revised when he went off hospice. Review of the Aspiration/Choking/Swallowing Care Plan dated 11/25/24 revealed, Resident is at risk for aspiration, choking, or difficulty swallowing related to chewing problems, coughing or choking during meals or when swallowing medications, Dysphagia [difficulty swallowing], G-tube, Gastroesophageal reflux disease (GERD), history of aspiration pneumonia, holding food in mouth/cheeks or residual food in mouth after meals, loss of liquids/solid from mouth while eating or drinking, swallowing problems .continue enteral feedings (nourishment via G-tube) for nutritional needs, allowed pleasure foods per hospice. Review of a discontinued/completed Order Summary located in the Orders tab of the EMR revealed, .PEG [percutaneous endoscopic gastrostomy] tube to remain out. Give all medications orally . dated 12/28/24. During an observation on 04/08/25 at 12:38 PM, R87 was observed at the dining table during the noon meal, feeding himself a regular meal and no swallowing issues were observed. Review of the Enhanced Barrier Precautions Care Plan dated 11/24/24 located in the Care Plan tab of the EMR revealed, .Resident requires enhanced barrier precautions during high-contact resident care activities due to the presence of .feeding tube . During an interview on 04/10/25 at 11:01 AM, the MDS Director (MDSD) reviewed R87's current care plan and stated, When R87 came off hospice, the care plan should have been revised as he no longer has the feeding tube and does not need EBP.

Based on interviews, document review, and review of the facility policy, the facility failed to ensure narcotic counts were initialed by the on-coming nurse (7:00AM to 7:00PM) and the off-going nurse (7:00PM to 7:00AM) at the change of shift to ensure the narcotic count was accurate for eight of eight medications carts reviewed. This failure had the potential for drug diversion. Findings included. Review of the facility's policy titled, Controlled Substances dated 2001 revealed, .Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count .The nurse coming on duty and nurse going off duty make the count together and document and report any discrepancies to the director of nursing services . 1. Review of the medication cart identified as 100 hall-cart 1 on 04/09/25 at 9:23 AM with Licensed Practical Nurse (LPN) 4 revealed on 04/07/25 the on-coming and off-going nurse did not identify how many narcotic cards were in the narcotic box at the end of the shift. In addition, on 04/08/25 the off-going nurse did not initial that the narcotic count was correct or document how many narcotic cards were in the narcotic drawer at the end of the shift, as required on their narcotic sheet, as required on the narcotic sheet. 2. Review of the medication cart identified as 100 hall-cart 2 on 04/09/25 at 9:36 AM with LPN 6 revealed on 04/05/25 and 04/06/25 the off-going nurse did not initial the narcotic was correct. On 04/07/25 the on-coming nurse did not document how many narcotic cards were in the narcotic box and on 04/09/25 the on-coming nurse did not initial that the narcotic count had occurred or how many narcotic cards were in the narcotic box, as required on the narcotic sheet. 3. Review of the medication cart identified as 200 hall-cart 1 on 04/09/25 at 9:42 AM with LPN 11 revealed on 04/02/25 there were no initials that the on-coming nurse had counted the narcotics with the off-going nurse, as required. 4. Review of the medication cart identified as 200 hall-cart 2 on 04/09/25 at 9:46 AM with LPN 8 revealed on 04/03/25 there were no initials that the on-coming nurse or the off-coming nurse had counted the narcotics, as required. 5. Review of the medication cart identified as 300 hall-cart 1 on 04/09/25 at 9:50 AM with LPN 12 revealed no documentation to show the on-coming nurse had initialed that there was a narcotic count was done with the off-going nurse. During an interview on 04/09/25 at 9:52 AM, LPN12 stated, That was a mistake as I don't usually work this shift. LPN 12 further stated, I did not realize I had done this. 6. Review of the medication cart identified as 300 hall-cart 2 on 04/09/25 at 10:44 AM with Registered Nurse (RN) 1 revealed on 04/04/25 the number of narcotic cards in the narcotic drawer was not documented for the start of the shift and at the end of the shift. In addition, on 04/07/25 the off-going nurse did not initial the narcotic count as being correct. 7. Review of the medication cart identified as 400 hall-cart 1 on 04/09/25 at 10:56 with LPN 3 revealed, there was no documentation at the end of shift to show how many narcotic cards were in the narcotic drawer. On 04/02/25 the end of shift documentation did not show the number of narcotic cards that were in drawer, despite having documentation to show three cards were removed during the shift. On 04/03/25 there were no initials to indicate the start of the shift, and the end of shift narcotic count was performed. 8. Review of the medication cart identified as 400 hall-cart 2 on 04/09/25 at 11:09 AM with LPN 3 revealed on 04/01/25, 04/02/25, 04/04/25, 04/05/25, 04/07/25 and 04/08/25 the end of shift nurse did not document the number of narcotic cards that were in the drawer, per the narcotic sheet. In addition, the on-coming nurse on 04/09/25 did not initial that the narcotic count was performed. Interview on 04/09/25 at 11:10:00 AM, when LPN3 was asked why she did not document that a narcotic count was performed, she did not answer. During an interview on 04/09/25 at 11:24 AM, the Director of Nursing (DON) was shown the blanks in documentation. The DON confirmed that the narcotic sheets contained blanks and stated, The staff are to count the meds and in addition, to document their initials at the start of the shift and at the end of the shift.

Based on interview and record review, the facility failed to ensure the previous three years of surveys, complaint investigations and any plans of corrections were made readily accessible to residents, families, or visitors. This failure placed all the residents, families, and visitors at risk of not being provided with information on the facility's quality of care. Findings included: During a tour of the facility on 04/08/25 at 4:29 PM, the survey book, which was located on the wall at the entrance to the activity room, revealed no previous surveys, certifications, complaint investigations and any plans of correction between 2022 and present. Review of the [NAME] [an acronym for Certification and Survey Provider Enhanced Reporting] report revealed the following surveys and complaint investigations occurred at the facility since 2022: May 2023 a federal survey with citations and the plan of correction; 08/27/24 complaint investigation which was substantiated and the plan of correction; 10/09/24 complaint investigation which was unsubstantiated; 11/21/24 complaint investigation which was substantiated and the plan of correction; 01/28/25 complaint investigation which was substantiated and the plan of correction; and an 04/18/24 federal survey with citations and the plan of correction. During an interview on 04/08/25 at 4:38 PM, the Administrator and Director of Nursing (DON), who reviewed the survey book, confirmed that it had not been updated with the required information for the past three years.

Based on review of facility policy, observation, and interview, the facility failed to protect residents private health information, for 3 of 8 residents. Specifically, a nurse did not secure the computer screen while administering medications. Findings include: Review of the facility's undated policy titled Protected Health Information (PHI), Uses and Disclosures of documented, The facility will make reasonable efforts to limit the use or disclosure of PHI to only the minimum necessary use to accomplish the intended purpose of the use, disclosure or request. During an observation on 01/28/25 at 5:16 PM, revealed a nurse's medication cart was left unattended, while the nurse was administering medications. Further observation revealed, the Electronic Medication Administration Record (EMAR) was still open on the computer screen, revealing multiple residents listed on the screen. During an interview on 01/28/25 at 5:18 PM, Licensed Practical Nurse (LPN)1 stated, You are interviewing me about my screen being open. I was gone for three minutes. I went to give morphine to a resident. The policy is to lock your screen when you step away from it. I know better, I do. It is not my first rodeo, I just had too many things to do at once. During an interview on 01/28/25 at 7:48 PM, the Director of Nursing (DON) revealed her expectation is that all staff protect patient information. The DON stated they (nurses) have two options; they could either close the laptop or press the privacy HIPPA button to hide the screen. We often remind them to do better, it is a habit they have to change within themselves.

Based on observation, interview, record review, and review of facility policy, the facility failed to assess, supervise, and provide proper safety protocols for residents that smoke, for 2 of 6 residents (Resident (R)123 and R101) reviewed for accidents/hazards. On 04/16/24 at 5:17 PM, the Administrator was notified that the failure to conduct smoking assessments, ensure residents were adequately supervised during smoking, ensuring safety protocols, and providing a safe environment for residents that smoke constituted Immediate Jeopardy (IJ) at F689. On 04/16/24 at 5:17 PM, the survey team provided the Administrator with a copy of the Center of Medicare and Medicaid (CMS) IJ Template and informed the facility IJ existed as of 04/10/24 at 4:33 PM. The IJ was related to 42 CFR 483.25 - Quality of Care. On 04/17/24 the facility provided an acceptable IJ Removal Plan. On 04/18/24 at 8:40 AM the survey team, validated the facility's corrective actions and removed the IJ as of 04/16/24. The facility remained out of compliance at F689 at a lower scope and severity of D. An extended survey was conducted in conjunction with the Recertification Survey for non-compliance at F689, constituting substandard quality of care. Findings include: Review of the facility policy titled Smoking Policy - Residents last revised on 10/31/23 revealed, This facility has established and maintain safe resident smoking practices. Prior to, and upon admission, residents are informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. Smoking is only permitted in designated resident smoking areas, which are located outside of the building. Smoking is not allowed in the facility under any circumstances. Metal containers with self-closing devices are available in smoking areas. Resident smoking status is evaluated upon admission. If a smoker the evaluation includes current level of tobacco consumption; method of tobacco consumption; desire to quit smoking; ability to smoke safely with or without supervision. A resident's ability to smoke safely is re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff. Residents who have independent smoking privileges are permitted to keep cigarettes/smoking items in their possession. Only disposable safety lighters are permitted and all other forms of lighters including matches are prohibited. Residents are not permitted to give smoking items to other residents. Residents without independent smoking privileges may not have or keep any smoking items, including cigarettes, tobacco, etc. except under direct supervision. Staff members and volunteers are not permitted to purchase and/or provide any smoking items for residents. Review of R123's Face Sheet revealed R123 was admitted to the facility on [DATE], with diagnoses including but not limited to: nicotine dependence cigarettes uncomplicated, generalized anxiety disorder, alcohol dependence with alcohol induced mood disorder, and cognitive communication deficit. Review of R123's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 01/10/24, revealed R132 had a Brief Interview of Mental Status (BIMS) score of 13 out of 15 which indicates R123 is cognitively intact. Review of the Release of Responsibility for Leave of Absence for R123 revealed R123 signed himself out of the facility to smoke on 02/28/24 at 10:22 PM and signed himself back into the facility on [DATE] at 10:35 PM. Review of the Release of Responsibility for Leave of Absence for R123 revealed R123 signed himself out of the facility to smoke on 04/16/24 at 9:55 there was no documentation of AM or PM and no sign in time when the resident returned back inside the facility. Review of R123's Admission Smoking Observation assessment dated [DATE], revealed R123 is a smoker or user of tobacco. R123 smokes 1 - 2 times a day and smokes whenever he wants and can light his own cigarette safely. Review of R123's Electronic Medical Record (EMR) revealed no documentation that R123 was assessed for smoking prior to the assessment dated [DATE]. Review of R123's Care Plan last revised for Smoking on 01/05/24 revealed that R123 is a current/former smoker. Interventions include assessing the ability to smoke safely; explaining the risks and consequences of smoking; explaining smoking policy and times to resident and family; respect the resident's wishes about smoking within the facility guidelines. Review of the facility's History of Smoking list did not indicate R123 as a smoker at the facility. Review of an email correspondance titled Smoking Policy and Education Implementation at Sandpiper Post Acute dated 04/10/24 revealed communication between the facility and corporate regarding smoking. The email revealed, We are finally at the point where we feel we could offer supervised smoking times at Sandpiper . Could you and [Regional Consultant] take a look at the revised Policy specific to Sandpiper and our Protocols/Reminders that we created to assist with this transition? As an FYI, [name] ordered the smoking aprons today, next is lock box order with at least 2 keys. During an observation on 04/16/24 at 9:51 AM, R123 was smoking alone, unsupervised while sitting at a picnic table beneath an oak tree to left of entrance to facility parking lot. There were 4 cars parked in parking lot, blocking view to the resident. When approached, R123 put out the cigarette. During an observation and interview on 04/16/24 at 10:00 AM, R123 was in a shaded area near the facilities parking lot. R123 revealed that he signs himself out of the facility to smoke alone. R123 stated he gets the cigarettes and lighter from another resident that is his friend at the facility but refused to disclose the resident specifically. R123 further stated at times his family comes in and brings him cigarettes as well. R123 concluded that he has had 3 strokes over the past few years but enjoys coming outside to smoke. I have to take my time to get through the leaves to make sure I don't fall but I haven't any falls while coming outside. During an interview on 04/16/24 at 10:07 AM, Licensed Practical Nurse (LPN)2 and LPN4 revealed that the policy for the facility is that residents are not allowed to keep cigarettes or lighters in their personal possession. Residents must inform the nursing staff that they would like to smoke and nursing staff will provide residents with smoking materials and ensure that residents are signed out of the facility, cigarettes and lighters are kept in the medication cart with the nurses. During an interview on 04/16/24 at 10:13 AM, LPN5 revealed they were unaware that R123 was a smoker and were unsure of where he received his smoking materials. LPN5 stated they were also unsure of the facilities policies related to residents smoking because she does not have residents that smoke, but is aware of a resident on the C-Wing of the facility that smokes independently and will smoke with other residents at times. LPN5 concluded that some residents smoke outside under the tree but others smoke in the courtyard area of the facility. Review of R101's Face Sheet revealed R101 was admitted to the facility on [DATE], with diagnoses including but not limited to: difficulty in walking, cognitive communication deficit, dysphagia, and psychoactive substance dependence. Review of R101's Quarterly MDS with an ARD of 03/22/24, revealed R101 had a BIMS score of 15 out of 15 which indicates R101 is cognitively intact. Review of R101's Smoking Observation/assessment dated [DATE], revealed R101 is a smoker or user of tobacco products. R101 smokes 2 - 5 times a day in the afternoons, can light his own cigarette and needs a smoking apron for adaptive equipment while smoking. R101 has the potential for injury related to smoking. Review of R101's Care Plan last revised for Smoking on 02/24/24 revealed R101 is a smoker, and the Interdisciplinary team (IDT) has determined that the resident can smoke outside independently. Interventions include explain the risks and consequences of smoking; resident had been educated that this is a nonsmoking facility and staff will continue to educate the resident on the hazards associated with smoking; resident will sign self out prior to going outside the facility to smoke. During an interview on 04/16/24 at 11:07 AM, R101 revealed that he is a smoker and at times provides other residents at the facility with cigarettes but refused to identify any specific residents. R101 stated that he keeps his cigarettes and lighter in his room and showed the area where he hides his cigarettes. During an observation on 04/16/24 at 1:43 PM, of the area that residents smoke at, which is approximately 248 feet from the facility, revealed no ash trays. There were numerous cigarettes on the ground around the picnic bench. During an observation on 04/16/24 at 1:50 PM, the facility's courtyard area revealed no commercial ash trays. During an interview on 04/16/24 at 3:11 PM, the Director of Nursing (DON), Regional Nurse, and Administrator revealed that the facility is currently a non-smoking facility but are in the process of transitioning to being a smoking facility. We started emailing on 04/10/24 to look at polices from other sister facilities that currently allow smoking to address how to notify residents and families. Currently the facility requires residents that smoke to sign out of the facility at the front desk because it is a non-smoking facility, we are not currently supervising residents when they sign out to smoke. Smoking aprons arrived today at the facility for the residents smoking. On 04/17/24 the facility provided an acceptable IJ Removal Plan, which included: -Education provided to all residents known to smoke or have a history of smoking on 04/16/24. Process for keeping cigarettes at reception desk not keeping them on their person reviewed as well as process to sign out with receptionist prior to going out to smoking are and that staff would accompany them and supervise. -Smoking evaluations will be completed 04/16/24 for all residents known by staff who currently smoke or have a history of smoking. Previous smoking evaluations were noted to be conflicting related to safety status while smoking. -100% audit on residents known to smoke or have a history of smoking complete to ensure care plans accurately reflect current smoking evaluation. -Education sent to all staff via COVR message on 04/16/24 to ensure understanding of procedure for residents who smoke and that they must sign out at a reception and a staff member will accompany them out to smoking are. -Education provided to all Resident Representatives via message on 04/16/24 to ensure understanding of procedure for residents that a staff member will accompany them out to the smoking area. ADHOC QA Meeting Held on 4-16-2024: -Root cause of issue: Residents are signing out and go outside to smoke. Facility has identified a concern with smoking however the smoking program has not yet been implemented. Facility will ensure safety until smoking program implemented. -Education to resident who have a history of smoking on 4-16-24 to ensure that all are understanding the process for smoking: go to receptionist and sign yourself out and get your smoking items if you have them and you will be accompanied out to smoking area by a staff member to ensure your safety. -Education provided to all staff to ensure understanding of process above and that staff member must accompany resident to smoking area and sit with them and ensure they are safe. A smoking apron will be taken out with them. -Any resident noted smoking any concern of safety related to holding cigarettes, dropping them etc. will be reported to Administrator and Director of Nursing (DON) immediately and smoking evaluation will be completed to ensure current status is correct. -Education/notification will be sent to all RR's on 04/16/24 via COVR message to inform of above process and that smoking will be supervised until smoking program is implemented. -All smoking materials have been gathered by Admin Staff on 4-16-24 and are located at the reception desk in a locked box to be given to resident at the time they sign out and returned to lock box upon reentry of facility. Ongoing Monitoring: Administrator along with RDCS and DON will provide oversight daily to ensure that all residents who smoke are adhering to process and are always accompanied by staff at all times when outside smoking. This will continue until the smoking program is implemented. All newly admitted residents and newly hired staff will be educated to this process to ensure compliance. Monitoring of the smoking program and implementation of new program will be ongoing and taken to Quality Assurance (QA) for evaluation of need to continue the monitoring. Monitoring will be weekly for four weeks then monthly three months then random thereafter. Review of monitoring will be discussed in QA and need for further monitoring evaluated. The above components have been implemented as of 4-16-24 by 7pm.

Based on review of the facility policy, interviews and record review, the facility failed to develop a comprehensive person-centered care plan related to Resident (R)1's usage of bedrails. On [DATE] at 3:25 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On [DATE] at 3:25 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of [DATE]. The IJ was related to 42 CFR 483.21 - Comprehensive Resident Centered Care Plan. On [DATE] at 6:32 PM, the facility provided an acceptable IJ Removal Plan. On [DATE] at 7:00 PM, the survey team validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F656 at a lower scope and severity of D. Findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, with a revision date of [DATE] revealed a comprehensive, person-centered care plan should include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. The comprehensive, person-centered care plan should: a. Include measurable objectives and time frames; b. Describe the services that are to be furnished in an attempt to assist the resident attain or maintain that level of physical, mental, and psychosocial well-being that the resident desires or that is possible, including services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights . Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including but not limited to: major depressive disorder, dysphagia, and muscle weakness. Review of R1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] indicated R1 had a Brief Interview of Mental Status score of 00, indicating R1 could not complete the assessment. Review of R1's Care Plan revealed a comprehensive care plan developed for other areas of care for R1. Further review of R1's Care Plan revealed there was no development of a care plan related to R1's usage of bedrails. During an interview on [DATE] at 12:40 PM, Registered Nurse (RN)1 was asked if there was a care plan for R1's usage of bedrails and she replied, No. She stated R1's bed rail usage was due to his frequent falls. Additional review of R1's comprehensive care plan provided by RN1 revealed a care plan related to falls. However, the listed interventions did not include the use of bedrails or the risk of entrapment. During an interview on [DATE] at 12:55 PM, the Director of Nursing (DON) stated there was no care plan completed for bed rails for R1. During a telephone interview with a representative from the [NAME] County Coroner's Office on [DATE] at 1:14 PM, she confirmed preliminary findings of R1's death indicated R1 had signs of something with pressure being placed on his neck, indicating asphyxiation. On [DATE] at 6:32 PM the facility presented a removal plan which included: Summary of Incident: R1 is an [AGE] year male admitted to the facility on [DATE] for hospice/palliative care r/t thoracic aortic aneurysm and pararenal abdominal aortic aneurysm, hypertensive heart disease, atherosclerosis of coronary artery bypass grafts, muscle weakness, cognitive communication deficit, long term use of anticoagulants, paroxysmal atrial fibrillation, GERD, obstructive sleep apnea, major depressive disorder and cardiomegaly. He was under the care of MUSC Hospice r/t the two AAA. He had hospital stay in [DATE] with back pain and noted AAAs were significantly larger since diagnosis in 2020. Per Hospital notes and discharge summary- Rupture at anytime would be life ending. Family and resident wishes to not have any type of invasive procedure. He was aware of significant risk for rupture and decided to go under hospice/palliative care. Per MD should his AAA bleed or rupture he would have significant mortality rate. R1 admitted to Sandpiper Post Acute following the hospital stay on [DATE] under MUSC Hospice. He tested positive for COVID on [DATE]. He was in bed on [DATE] and per his usual per staff he liked to lay on his side over near edge of bed near the grab bar. At approximately 515 am he was noted by CNA near the edge of the bed and was turned and repositioned back to his back and repositioned to the center of the bed. The nurse entered the room at 630 am and he was noted lying on his side and upper body lying between the grab bar and lower body was off of the bed on the floor. He has no vital signs. Bed was in the lowest position almost to the floor. Nurse went out and got help from another nurse and CNA who entered the room and moved him from the position he was in from between the grab bar and mattress and was placed on the floor. Nurse states she was trying to move him herself and had a hard time with the position he was in getting him down to the floor. He was confirmed to be without vital signs by RN. Nurse states he has some redness noted to his head and neck area where he was lying but no apparent signs of any struggle or discoloration. He was placed back into the bed and Hospice was notified of his death. Timeline of Events: [DATE]- admitted to Sandpiper Post Acute for LTC under Hospice r/t dx of two AAA with significant risk for rupture [DATE]- tested positive for COVID and place on droplet precautions [DATE] 5:15 AM- CNA provided care and turned and repositioned resident from lying on his side at edge of bed to his back in the center of the bed. [DATE] 6:30 AM- Nurse enters room to administer his medication and he is noted lying on his side at the edge of the bed. His upper body was noted between the grab bar and the mattress and his lower body/legs were noted on the floor. Bed was in low position. He appeared to have no vital signs. Fingers and hands were bluish in color. She yelled and got another nurse and CNA in the room and the other nurse then started to remove him from the bed and stated that he was difficult to move by herself and he was stuck the way he was lying. She states she was pulling to try and free him from the position in which he was lying but when asked about some details she stated it all happened fast and really couldn't remember all exact details just that she had a difficult time moving him and getting him to the floor. She moved him to the floor and at this time an RN came into room as well and she confirmed no vital signs. Both nurses say he had redness to his head and neck from trying to get him moved to the floor, but no discoloration or signs of any struggle noted. [DATE] 6:40 AM (approximately)- Call placed to MUSC Hospice to inform of death. [DATE] 9:00 AM- The Hospice nurse from MUSC Hospice was at facility. He notified family of resident death. At 0945, he informed ADON that MUSC would come to pick up the body which had been donated to science. [DATE] 10:07 AM- Call received from MUSC and info requested regarding resident. They declined to accept his body into the program r/t his COVID diagnosis. [DATE] 10:15 AM- MUSC Hospice was informed that he was declined to be accepted into the science program and he stated he would notify the family and get funeral home information and notify the funeral home. [DATE] 10:30 AM- ADON was informed that Simplicity Low Country would be coming to get his body. [DATE] 1:50 PM- Call received from Simplicity Low Country and stated that Hospice had not notified them to get the body, but they had just heard from his wife. Stated they would be there soon. [DATE] 4 PM- Simplicity called facility again and stated they were having issues getting a driver to come. Stated someone should arrive around 5:30 PM. [DATE] 6:10 PM- Simplicity arrived to pick up body. [DATE] 6:20 PM- Simplicity left facility with body. Immediate Action Taken: -Statements were written by nurses and CNAs present on [DATE]. RDCS called and was informed resident expired and that he was lying between the grab bar and mattress. -On [DATE] based on review of statements, interviews were conducted by RDCS' and Administrator with nurses and CNA and asked to demonstrate position in which he was noted at time of death. -All siderails/grab bars were removed from beds in facility on [DATE] and confirmed as removed by Administrator. -Education was initiated with all staff on [DATE] by ADON, DON, and designees regarding use of alternatives to siderails and or grab bars, completion of evaluation of siderails and consent and order required prior to use of any as well as care plan to indicate use and need. Education for all staff to never put siderails up without confirming they have order and all documentation needed. -Education also provided that if a resident has a siderail and is noted to by lying close to the edge of bed or that rail to immediately notify the nurse. -Education was provided to MDS team by RDCS on [DATE] to ensure the care plans are up to date and current and reflect the current status of the resident. -ADHOC QA Meeting held on [DATE] at 2 PM with Administrator, DON, ADON, and Medical Director as well as other members of the QA committee to discuss situation and f/u measures conducted. Actions Taken as a Result of ADHOC QA Meeting: -Audit of all care plans for 100% of residents completed on [DATE] to ensure all care plans are reviewed and revised to be accurate regarding use of siderails/grab bars. -Audits will be conducted of all care plans weekly by MDS team to ensure all care plans are accurate and up to date. Audits will be weekly x4 then monthly x2 then random thereafter. Findings of audits will be reported to QA committee to determine need for continued monitoring. -Education regarding development and implementation will be provided to MDS with any change in MDS positions and as needed with concerns based on audits. -Education provided to MDS by RDCS to ensure care plans are accurate and updated as needed to reflect the current status of the resident. Allegation of Compliance - [DATE]

Based on review of facility policy, interviews and record review, the facility failed to ensure Resident (R)1 was properly assessed for the usage of bedrails to prevent entrapment, educated on the risks and benefits of bed rails with R1 and/or his Resident Representative, and to ensure consents were in place prior to the use of bedrails. On [DATE] at 3:23 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On [DATE] at 3:27 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of [DATE]. The IJ was related to 42 CFR 483.25: Quality of Care. On [DATE] at 6:38 PM, the facility provided an acceptable IJ Removal Plan. On [DATE] at 7:00 PM, the survey team validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F700 at a lower scope and severity of D. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F700, constituting substandard quality of care. Findings include: Review of the facility's policy titled, Bed Safety and Bed Rails with a revision date of [DATE], revealed Bedrails are properly installed and used according to the manufacturer's instructions, specifications and other pertinent safety guidance to ensure proper fit . The facility's education and training activities will include instruction about risk factors for resident injury due to beds, and strategies for reducing risk factors for injury, including entrapment. The policy also states under Use of Bed Rails, Section 3: The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. Section 4: Prior to the installation or use of a side or bed rail, alternatives to the use of side or bed rails are attempted. Alternatives may include a. roll guards, b. foam bumpers, c. lowering the bed; and/or d., use of concave mattresses to reduce rolling off the bed. Section 8: Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The following information will be included in the consent: a. The assessed medical needs that will be addressed with the use of bed rails; b. The resident's risks from the use of bed rails and how these will be mitigated; c. The alternatives that were attempted but failed to meet the resident's needs; and d. The alternatives that were considered but not attempted and the reasons. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including but not limited to: major depressive disorder, dysphagia, and muscle weakness. Review of R1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] indicated R1 had a Brief Interview of Mental Status score of 00, indicating R1 could not complete the assessment. Review of R1's medical record revealed no Physician order, consents, or assessments for the usage of siderails. During an interview on [DATE] at 12:40 PM, Registered Nurse (RN)1 was asked if there were any Physician orders, consents or assessments for R1's usage of bedrails and she replied, No. During an interview on [DATE] at 12:55 PM, the Director of Nursing (DON) stated there were no Physician orders, consents for the use of side rails or side rail assessments completed for R1. During a telephone interview with a representative from the [NAME] County Coroner's Office on [DATE] at 1:14 PM, she confirmed preliminary findings of R1's death indicated R1 had signs of something with pressure being placed on his neck, indicating asphyxiation. During a telephone interview on [DATE] at 1:45 PM, Licensed Practical Nurse (LPN)1 stated, I arrived to work around 6:20 AM, the night nurse was still passing medications, so I sat at the nurses' station with 2 other staff members. At that time, another nurse came and asked if they could look at something with her. LPN1 further stated, the staff then proceeded to R1's room to find him (R1) with his body partially off the floor and his head entrapped between the mattress and the siderail. LPN1 stated she then went to maneuver R1's head from the siderail so that he could be assessed because she was unsure if he was breathing or not. LPN1 then instructed the other staff to go and get RN1 for assistance. LPN1 confirmed there should have been consents, a physician order and monitoring for the use of siderails for R1. Review of the facility's preliminary investigation indicated three handwritten witness statements were obtained: Witness Statement #1, written by Certified Nursing Assistant (CNA)1 and dated [DATE] indicated, At around 0630 I was called by the nurse and R1 was found with his head stuck between the bars. Witness Statement #2, written by CNA2 and dated [DATE] indicated, At approximately 5:15 am I went into rm. 120 to perform patient care. Resident was in bed. I moved patient to middle of bed and exited room. Witness Statement #3, written by LPN1 and dated [DATE] revealed, At about 6:30 AM, I was called in to room [ROOM NUMBER] by night nurse. Resident observed with his head stuck in the side rail. Night nurse and I called ADON to unit. Multiple attempts were made to contact CNA1 and CNA2 for an interview, but were unsuccessful. During a telephone interview with R1's spouse on [DATE] at 3:01 PM, she stated the Coroner arrived at her home and notified her of R1's death, stating it was death by asphyxiation due to R1's head being in the bedrail. R1's spouse confirmed the bedrails were present on the bed at the time of his admission on [DATE] and that she had not signed consents for the usage or been explained the risks and benefits for the use of the siderails. She stated R1 had bedrails on both sides of his bed. During an interview on [DATE] at 5:15 PM, the Administrator stated that neither maintenance nor nursing had been monitoring for the use of bedrails in the facility. On [DATE] at 6:38 PM, the facility presented a removal plan which included: Summary of Incident: R1 is an [AGE] year male admitted to the facility on [DATE] for hospice/palliative care r/t thoracic aortic aneurysm and pararenal abdominal aortic aneurysm, hypertensive heart disease, atherosclerosis of coronary artery bypass grafts, muscle weakness, cognitive communication deficit, long term use of anticoagulants, paroxysmal atrial fibrillation, GERD, obstructive sleep apnea, major depressive disorder and cardiomegaly. He was under the care of MUSC Hospice r/t the two AAA. He had hospital stay in [DATE] with back pain and noted AAAs were significantly larger since diagnosis in 2020. Per Hospital notes and discharge summary- Rupture at anytime would be life ending. Family and resident wishes to not have any type of invasive procedure. He was aware of significant risk for rupture and decided to go under hospice/palliative care. Per MD should his AAA bleed or rupture he would have significant mortality rate. R1 admitted to Sandpiper Post Acute following the hospital stay on [DATE] under MUSC Hospice. He tested positive for COVID on [DATE]. He was in bed on [DATE] and per his usual per staff he liked to lay on his side over near edge of bed near the grab bar. At approximately 515 am he was noted by CNA near the edge of the bed and was turned and repositioned back to his back and repositioned to the center of the bed. The nurse entered the room at 630 am and he was noted lying on his side and upper body lying between the grab bar and lower body was off of the bed on the floor. He has no vital signs. Bed was in the lowest position almost to the floor. Nurse went out and got help from another nurse and CNA who entered the room and moved him from the position he was in from between the grab bar and mattress and was placed on the floor. Nurse states she was trying to move him herself and had a hard time with the position he was in getting him down to the floor. He was confirmed to be without vital signs by RN. Nurse states he has some redness noted to his head and neck area where he was lying but no apparent signs of any struggle or discoloration. He was placed back into the bed and Hospice was notified of his death. Timeline of Events: [DATE]- admitted to Sandpiper Post Acute for LTC under Hospice r/t dx of two AAA with significant risk for rupture [DATE]- tested positive for COVID and place on droplet precautions [DATE] 5:15 AM- CNA provided care and turned and repositioned resident from lying on his side at edge of bed to his back in the center of the bed. [DATE] 6:30 AM- Nurse enters room to administer his medication and he is noted lying on his side at the edge of the bed. His upper body was noted between the grab bar and the mattress and his lower body/legs were noted on the floor. Bed was in low position. He appeared to have no vital signs. Fingers and hands were bluish in color. She yelled and got another nurse and CNA in the room and the other nurse then started to remove him from the bed and stated that he was difficult to move by herself and he was stuck the way he was lying. She states she was pulling to try and free him from the position in which he was lying but when asked about some details she stated it all happened fast and really couldn't remember all exact details just that she had a difficult time moving him and getting him to the floor. She moved him to the floor and at this time an RN came into room as well and she confirmed no vital signs. Both nurses say he had redness to his head and neck from trying to get him moved to the floor, but no discoloration or signs of any struggle noted. [DATE] 6:40 AM (approximately)- Call placed to MUSC Hospice to inform of death. [DATE] 9:00 AM- The Hospice nurse from MUSC Hospice was at facility. He notified family of resident death. At 0945, he informed ADON that MUSC would come to pick up the body which had been donated to science. [DATE] 10:07 AM- Call received from MUSC and info requested regarding resident. They declined to accept his body into the program r/t his COVID diagnosis. [DATE] 10:15 AM- MUSC Hospice was informed that he was declined to be accepted into the science program and he stated he would notify the family and get funeral home information and notify the funeral home. [DATE] 10:30 AM- ADON was informed that Simplicity Low Country would be coming to get his body. [DATE] 1:50 PM- Call received from Simplicity Low Country and stated that Hospice had not notified them to get the body, but they had just heard from his wife. Stated they would be there soon. [DATE] 4 PM- Simplicity called facility again and stated they were having issues getting a driver to come. Stated someone should arrive around 5:30 PM. [DATE] 6:10 PM- Simplicity arrived to pick up body. [DATE] 6:20 PM- Simplicity left facility with body. Immediate Action Taken: -Statements were written by nurses and CNAs present on [DATE]. RDCS called and was informed resident expired and that he was lying between the grab bar and mattress. -On [DATE] based on review of statements, interviews were conducted by RDCS' and Administrator with nurses and CNA and asked to demonstrate position in which he was noted at time of death. -All siderails/grab bars were removed from beds in facility on [DATE] and confirmed as removed by Administrator. -Education was initiated with all staff on [DATE] by ADON, DON, and designees regarding use of alternatives to siderails and or grab bars, completion of evaluation of siderails and consent and order required prior to use of any as well as care plan to indicate use and need. Education for all staff to never put siderails up without confirming they have order and all documentation needed. -Education also provided that if a resident has a siderail and is noted to by lying close to the edge of bed or that rail to immediately notify the nurse. -Education was provided to MDS team by RDCS on [DATE] to ensure the care plans are up to date and current and reflect the current status of the resident. -ADHOC QA Meeting held on [DATE] at 2 PM with Administrator, DON, ADON, and Medical Director as well as other members of the QA committee to discuss situation and f/u measures conducted. Actions Taken as a Result of ADHOC QA Meeting: -All siderails/grab bars were removed from all beds by [DATE] in the facility pending investigation. -One alert and oriented resident in facility who continues to utilize a grab bar has been audited to ensure presence of evaluation, consent, order and care plan. -Moving forward the need for use of siderails/grab bars will be completed by IDT team to ensure that evaluations are complete and need is confirmed with therapy, consents obtained, orders written and care plan complete. -Education for all staff initiated on [DATE] for use of siderails and all documentation needed, alternatives to use instead of siderails or grab bars as well as notifying the nurse of anyone noted lying on edge of bed near a rail or grab bar and never putting siderails or grab bars up on a bed without first confirming with the nurse. Education will be provided to all staff prior to next shift worked if unable to reach on [DATE]. Allegation of Compliance- [DATE]

Based on review of facility policy, record review and interviews the facility failed to ensure adequate supervision was provided to prevent accidents/hazards for 1 of 3 residents. Specifically, on 08/10/23, Resident (R)1 had a successful elopement from the facility. On 08/15/23 at 6:06 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 08/15/23 at 6:06 PM, the Administrator in Training (AIT) and the Regional Director of Clinical Services (RDCT) were notified that the failure to prevent a resident from successfully eloping the facility constituted Immediate Jeopardy (IJ) at F689, at Past Non-Compliance (PNC) On 08/15/23 at 6:06 PM the survey team provided the AIT and the RDCT with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 08/10/23. On 08/16/23 at 12:47 PM, the facility presented an acceptable plan of removal of the IJ. The survey team validated that the IJ was removed on 08/11/23 following the facility's implementation of the plan of removal of the IJ. Due to the facility's due diligence of recognizing the non-compliance and implementing a removal plan on 08/11/23, prior to the start of the survey. The IJ is indicated at Past Non-Compliance (PNC). Findings include: Review of the facility policy titled Wandering and Elopements with a revised date of December 2019 documented, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrive [sic] environment for residents. Review of the facility policy titled Elopements with a revised date of December 2007 documented, Staff shall investigate and report all cases of missing residents. Review of R1's Face Sheet located in the Electronic Medical Record (EMR) revealed, R1 was admitted to the facility on [DATE]. Further review of the Face Sheet revealed R1's diagnoses included but was not limited to: muscle wasting and atrophy, bilateral osteoarthritis of knee, Pick's disease, aphasia, cognitive communication deficit, anxiety disorder, COPD (chronic obstructive pulmonary disease) and alcohol dependency with alcohol induced dementia. Review of R1's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/07/23 revealed a Brief Interview for Mental Status (BIMS) score of 2 out of 15 which indicates R1 has severe cognitive impairment. Review of R1's Wandering and Elopement Assessment with an evaluation date of 08/07/23, indicated R1 to be a low risk for wandering/elopement with no history of wandering. During an interview on 08/15/23 at approximately 10:35 AM, the RDCS and the AIT revealed on 08/10/23, R1 had tested positive for COVID and was upset with staff because he was asked to stay in his room related to this diagnosis. On 08/10/23 at approximately 8:25 PM, staff observed him standing in the doorway of his room. On 08/10/23 at approximately 10:15 PM the facility was contacted by R1's son-in-law stating that Emergency Medical Service (EMS) had notified him that R1 was found walking in a neighborhood. Then the [Local Police Department] notified the facility they had found R1 walking in a neighborhood near the facility and R1 had provided them with the name and telephone number for his son-in-law. The [Local Police Department] further informed the facility that EMS would be transporting R1 to the [local emergency room ]. Finally, EMS notified the facility that they would be transporting R1 to the [local emergency room ] for evaluation and that he did not appear to have any injuries. The AIT further stated, on 8/10/23 soon after arriving at the facility at approximately 10:45 PM, the AIT reviewed camera footage and observed R1 on camera exiting the facility through the front entrance which was not yet locked for the night. During review of the camera footage on 08/15/23 at approximately 2:15 PM, revealed R1 was wearing glasses, short knee length pants, a t-shirt, shoes and socks, and was carrying several pieces of clothing over his left arm. R1 exited the front door into the facility parking lot. Review of the local weather report, revealed the temperature outside was approximately 85 degrees Fahrenheit on 08/10/23. During the survey, multiple attempts were made to contact R1's Resident Representative (RR), Licensed Practical Nurse (LPN)1, Certified Nursing Assistant (CNA)1 with no success. The facility's Removal Plan included the following: This letter constitutes a removal plan by Sandpiper Post Acute that the Immediate Jeopardy identified by DHEC on August 15, 2023 for failure to protect Resident #1 from Freedom of Accidents and Hazards. The submission of this information does not constitute an admission on the part of the facility that the findings cited are accurate or that and scope and severity regarding the deficiencies cited are correctly applied. The facility considers any cited deficiency serious and will respond accordingly. The following information constitutes Sandpiper Post Acute - Removal Plan of Immediate Jeopardy. Summary of Incident: R1 is a [AGE] year male admitted to the facility on [DATE] for a respite stay. He is alert with BIMs of 2/15. His medical diagnosis include: muscle wasting and atrophy, Bilateral osteoarthritis of knee, Pick ' s disease, aphasia, cognitive communication deficit, anxiety disorder, COPD and alcohol dependence with alcohol induced dementia. R1 was evaluated on 8-7-23 and determined to be a low risk for wandering/elopement r/t no history of wandering. He tested positive for COVID on 8-10-23 and was upset with staff because he was asked to stay in his room r/t this diagnosis. Staff observed him standing in the doorway of his room at approx. 825pm on 8-10-23. At approximately 827pm resident was observed on camera to exit the facility through the front entrance which was not locked yet for the night. The facility was contacted by R1's son stating that the EMS had notified him that R1 was found walking in a close neighborhood. EMS then notified the facility immediately after as well informing facility that R1 had been located and that EMS was transporting him to [local hospital] for evaluation however he appeared to have no injuries. Operations Manager and ADON and DON were informed immediately and responded to the facility. Timeline of Events: 8-7-23 Resident admitted to Sandpiper Post Acute for respite stay. 8-7-23 Wander risk evaluation complete. Score of 2 for R1 and indicated low risk for wandering /elopement. 8-10-23 R1 tested positive for COVID and verbalized frustration with staff when he was informed he would need to stay in his room. 8-10-23 Staff report seeing R1 standing in doorway to his room at approximately 825pm. At approximately 10:15 pm facility received a call from R1's son-in-law who stated that EMS (Emergency Medical Service) notified him that R1 was picked up walking in a neighborhood close to the facility and he had provided them with his phone number. EMS notified the facility as well at approximately 10:15pm that they had found R1 walking in a neighborhood close to the facility and he had been able to provide his name and son-in-law ' s phone number. Stated EMS would be transporting him to [local hospital] for evaluation however he did not appear to have any injuries. Nurse at facility notified ADON (Assistant Director of Nursing) at approximately 10:20pm and ADON notified AIT at approximately 10:25pm. DON and nursing administration team notified at 10:30pm. AIT (Administrator in Training) and ADON arrived at facility at 10:45pm and immediately initiated a 100% (percent) audit of all residents complete by ADON to ensure all residents were present and accounted for. 100% audit of all doors initiated immediately upon arrival to facility at 10:45pm by AIT to ensure that all doors were locked and secure. Interviews were conducted with all staff on duty by ADON beginning at approx. 11:20pm to establish a timeline. Staff reported seeing him in his doorway just before 8:30pm Camera footage was watched by AIT at approximately 12:30am upon completion of door audits and some interviews. R1 was seen on camera exiting the facility through the front entrance at approximately 8:27pm. The door was not yet locked for the night. 8-11-23 @0525 R1 returned from the ER. No new orders noted. Wander evaluation complete and wander guard bracelet placed to his left ankle. Immediate Actions Taken: Interviews conducted with his roommate as well as other residents on the unit with BIMs>8 by ADON and DON (Director of Nursing). Interviews initiated at approx. 12:30am, his roommate was unaware that he had left and stated that he knew nothing. Education initiated with all staff on duty by ADON and DON after completion of resident interviews to ensure understanding of elopement and ensuring all residents are safe and accounted for as well as maintaining doors locked and secure. ADHOC QA meeting held on 8-11-23 @10am with Admin, Operations Manager, AIT, DON and medical director as well as other members of QA (Quality Assurance) committee to discuss event and follow up measures conducted. Actions Taken as a Result of ADHOC (when necessary or needed) QA meeting: Wander evaluations complete on 8-11-23 for all residents to ensure all are current and accurate for the risk of wandering /elopement by Nursing management team. All residents identified at risk for wandering/elopement checked to ensure wander guard bracelets present on 8-11-23 by DON/ADON. Elopement binder audited to ensure all residents identified at risk for wandering/elopement are in the binder on 8-11-23 by DON/ADON. Education for all staff initiated on 8-11-23 for Elopement by DSD (Director Staff Development). Education for all staff initiated on 8-11-23 for Abuse /neglect by DSD. Education for all staff initiated on 8-11-23 for resident rights by DSD. Education for all staff initiated on 8-11-23 for monitoring of residents and frequency of rounding by DSD. Elopement drill conducted by AIT/DON on 8-11-23 and 8-14-23. Door locking procedure was reviewed and changed on 8-11-23 at 10:15am to front door will be locked manually at 8pm (was previously 9pm) by Reception prior to leaving. Staff and receptionists were educated on door procedure. Plan of care for R1 reviewed and revised by MDS (multiple data set) on 8-11-23. Plan of care for all residents identified at risk reviewed and revised as needed by SS (Social Service) on 8-11-23. Q 2hr checks will be complete by nursing staff to ensure all residents are present and accounted for beginning 8-11-23 through 8-17-23. All exit doors in facility will be checked q 2 hours by Maintenance/nursing/designees to ensure all are secure and locked. Audits will begin 8-11-23 through 8-17-23. R1 will be discharging per plan with his family on 8/17/23.

Based on observations, interviews, record review, and review of manufacturer guidelines, the facility failed to ensure a multi-use glucometer was cleaned between residents with an EPA (environmental protection agency) registered disinfectant when performing fingerstick blood glucose (sugar) testing on 4 of 4 residents (Resident (R) 109, R16, R125 and R38) observed for blood glucose testing. One of three residents (R99) residing in the facility had a bloodborne pathogen, was diabetic and had daily blood glucose testing. This failure placed the residents at risk for the transmission of bloodborne pathogens. In addition, the facility failed to ensure Personal Protective Equipment (PPE) was appropriately donned prior to caring for a resident on contact precautions on 2 of 4 units observed. On 08/24/21 at 7:29 PM the Administrator and the Director of Nursing were notified that the failure to disinfect the multi-use glucometer between residents with an EPA registered disinfectant effective against blood borne pathogens such as [CONDITION(S)] ([CONDITION(S)]), [CONDITION(S)], and [CONDITION(S)] C constituted Immediate Jeopardy (IJ) at F880. The facility presented an acceptable plan of removal of the immediate jeopardy on 08/26/21 at 8:33 AM. The survey team validated that the immediate jeopardy was removed on 08/26/21 at 5:00 PM following the facility's implementation of the plan of removal of the immediate jeopardy. The facility remained out of compliance at F880 at a lower scope and severity of D (pattern with potential for minimal harm) following removal of the IJ. The facility's abatement plan included identification of all residents with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Systemic changes put in place included these changes in procedure. In-service of agency nurses to include individual glucometer cleaning to be given before commencing their first shift. In-service includes Competency-Glucometer review and a review of the Blood Sampling-Capillary (Finger Sticks) Policy and Procedure. In-services are to be given one-on-one and conducted by the unit managers, ADON, or DON. All other staff nurses are to receive glucometer cleaning in-service via telephone, in person, and/or in the training room. The Administrator will be responsible for auditing and monitoring the effectiveness of the corrective actions and systemic changes on a weekly basis and record audit findings weekly. Administrator to report results of audits to the QAPI committee monthly for a minimum of 6 months or until a pattern or compliance is achieved and then quarterly thereafter for a minimum of 1 year. The QAPI committee to review, analyze and make recommendations for any needed changes in policy, procedure, and/or facility practice. Findings include: Review of the manufacturer's guidelines titled, Assure Platinum Blood Glucose Monitoring System dated 10/2019 revealed, To minimize the risk of transmitting blood-borne pathogens, the cleaning and disinfecting procedure should be performed as recommended in the instructions below. The Assure® Platinum Blood Glucose Monitoring System may only be used for testing multiple patients when standard precautions and the manufacturer's disinfecting procedures are followed. The meter should be cleaned and disinfected after use on each patient. The cleaning procedure is needed to clean dirt, blood and other bodily fluids off the exterior of the meter before performing the disinfecting procedure. The disinfecting procedure is needed to prevent the transmission of blood-borne pathogens. ARKRAY has tested and validated the durability and functionality of the Assure Platinum meter with the most commonly used EPA-registered wipes. Those wipes include: Clorox Professional Products Company (Clorox® Healthcare Bleach Germicidal Wipes, Dispatch® Hospital Cleaner Disinfectant Towels with Bleach), Professional Disposables International (Super Sani-Cloth® Germicidal Disposable Wipes), Metrex Research (CaviWipes (Trademark)). Review of R109's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation of medication administration for R109 on 08/24/21 at 4:18 PM with agency Registered Nurse (RN) 1, RN1 gathered supplies to perform a fingerstick blood glucose check on the resident. RN1 sanitized her hands, gathered supplies, and donned clean gloves. R109 was sleepy, and RN1 knelt down beside the bed and placed the fingerstick supplies and glucometer on R109's bed without a barrier; she then used the glucometer to test R109's blood sugar. After testing, RN1 then discarded all supplies in the sharp's container, exited R109's room, discarded her gloves, and placed the glucometer on top of the medication cart. Review of R16's EMR MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation of medication administration for R16 (400 Hall) on 08/24/21 at 4:25 PM with RN1, RN1 went to R16's room and the resident was not there. RN1 went to get resident and rolled R16 to their room via his/her wheelchair. RN1 Nurse sanitized hands, donned clean gloves, gathered supplies, and placed the glucometer on the resident's bedside table without a barrier. Post testing R16's blood sugar, RN1 placed the glucometer back on the bedside table without a barrier, discarded supplies in the sharp's container, discarded his/her gloves, exited R 16's room, and placed the glucometer on top of the medication cart without a barrier. Post administration of insulin, RN1 returned to the medication cart and placed the glucometer in the drawer without disinfecting the glucometer. During an observation of RN1's medication cart (400 Hall) on 08/24/21 at 4:30 PM, RN1 had one glucometer available in RN1's medication cart for blood glucose testing. Review of R125's EMR MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation of medication administration for R125 (100 Hall) on 08/24/21 at 4:52 PM with agency Licensed Practical Nurse (LPN) 1, LPN1 took R125's scheduled medication, glucometer supplies and glucometer machine into the resident's room. LPN1 placed the glucometer on R125's bedside table without a barrier. Post blood sugar testing for R125, LPN 1 discarded the glucometer supplies in the sharp's container, exited the resident's room, placed the glucometer on top of the medication cart without a barrier and discarded her gloves. LPN1 sanitized her hands and then placed the glucometer in the medication cart without disinfecting the glucometer. During an observation of LPN1s medication cart (100 Hall) on 08/24/21 at 5:00 PM, LPN1 had one glucometer available for blood glucose testing. On 8/25/21 at approximately 5:00 PM LPN 2 failed to clean and disinfect the Assure Platinum glucometer before or after performing a finger stick blood sugar check on R38. LPN 2 stated that blood touches the test strip not the glucometer and that glucometers are cleaned every shift. Review of an untitled and undated document provided by the Director of Nursing on 08/24/21 (time not noted) revealed three residents residing in the facility had a bloodborne pathogen. One of the three residents (R99) admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R99's Order Recap Report revealed Check FSBS one time a day related to Type 2 Diabetes Mellitus with unspecified complications. During an interview with RN1 on 08/24/21 at 4:25 PM, RN1 stated, I placed the (insulin) flex pen and glucometer back into the medication cart. I should have cleaned the glucometer after each patient. I would clean it with sani-wipes® and allow to dry completely. I was nervous as to why I didn't do it. The agency provides my competency, and I didn't do one during orientation on glucometer usage in this facility. During an interview with LPN1 on 08/24/21 at 4:52 PM, LPN1 in an interview with LPN1 stated, I did not clean it (glucometer), it should be cleaned with a CaviWipe®. The glucometer should be cleaned after each use. Unsure if it should be cleaned before and after use. The glucometer was used once prior to this resident and unsure if cleaned prior to usage. The facility did not provide any training, but I should know that because I have been a nurse for a long time. My orientation was for three hours about Covid-19 and the software. I have been working here for three weeks now. During an interview with Unit Manager (UM) 1 on 08/24/21 at 5:15 PM, UM1 stated, The ADON (assistant director of nursing) does the orientation for the contract staff. They (contract staff) get on the schedule, and they work with someone at least twice before they go off on their own. Staff should be using the CaviWipes® on the medication carts. During an interview with the ADON on 08/24/21 at 6:00 PM, the ADON stated, They (contract staff) are provided POC (point of care), EMAR (electronic medication administration record) training, TAR (treatment administration record) training, and charting requirements on paper. They have a check-off list with skill set sent to us provided prior to hire .Glucometers are to be cleaned after each resident. Staff are to use the bactericidal, purple top, wipes located on the hallways next to the gloves and the medication rooms. Each cart does not have wipes because our Unit Managers didn't want to have them on the carts. If no purple top wipes (are available) then they are to use any germicidal. We disinfect between each resident due to best practice and to keep down infection control. During an interview with the Director of Nursing (DON)/Infection Preventionist (IP) on 08/24/21 at 6:28 PM, the DON/IP stated, The expectation is between use of the glucometers that the nurses will use the purple top sani-wipes® which is located on all of the units, or they use the white top germicidal for the glucometers to clean them. The agency staff get a full program orientation on infection control. The skill sets for the contract staff is checked off prior to them coming here by their agency. We have a core staff check off list. The disinfection for the glucometer is a two-minute wet time. If staff is not cleaning properly there is a concern of transmitting diseases. We haven't initiated any procedures for conducting audits of the agency staff to ensure they are competent. 2. Review of facility policy titled, Isolation-Categories of Transmission-Based Precautions dated 10/2018, .4. Staff and visitors will wear gloves (clean, non-sterile) when entering the room .5. Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed During an observation on the 400 unit on 08/24/21 at 8:50 AM, resident room [ROOM NUMBER] was observed with posted signage stating, Full PPE required. The Staffing Coordinator and certified nursing assistant (CNA) 5 observed going into the room with bed linen without full PPE donned. During an interview with the Staffing Coordinator on 08/24/21 at 9:07 AM, the Staffing Coordinator stated The resident in room [ROOM NUMBER] is on contact precautions due to an infection in their urine. Full PPE is required when care is provided to the resident. An observation on 8/23/2021 at approximately 5:14 PM revealed staff, Licensed Practical Nurse (LPN) and Certified Nursing Assistants (CNAs) entering resident rooms on the 100 Hall without first applying full Personal Protective Equipment (PPE) as required for residents that are not fully vaccinated. During an interview on 8/23/2021 at approximately 5:20 PM with LPN #12, he/she stated, I did not notice the sign outside the door, this resident was most likely just admitted . An observation on 8/26/2021 at approximately 12:20 PM during meal the lunch meal service on the 100 Hall revealed CNA #4 entering resident rooms with lunch trays without applying the Full PPE as described on the outside of resident's room doors for residents that are not fully vaccinated. An interview on 8/26/2021 at approximately 12:30 PM with CNA #3 confirmed that he/she was not applying the Full PPE as listed on the outside of resident rooms that are not fully vaccinated. CNA #3 stated, he/she did not notice the sign outside the resident rooms that required Full PPE to be applied before entering the room. Review on 8/26/2021 at approximately 1:40 PM of the facility policy titled, Isolation - Categories of Transmission - Based Precautions, states under policy statement, Transmission - Based Precautions are initiated when a resident develops signs and symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Number 5. states, When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. a. The signage informs the staff of the type of Center for Disease Control (CDC) precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room. b. Signs and notifications comply with the resident's right to confidentiality or privacy.

Based on record review, interviews, and facility policy, the facility failed to maintain and implement written policies and procedures regarding the residents' right to formulate an advance directive for 3 of 3 sampled residents (Residents (R) 99, R59, and R125). Failure to establish, maintain, and implement written policies and procedures regarding the residents' right to formulate an advance directive and provision of health care when the individual is incapacitated places the residents at risk to receive, failure to receive, or delay in receiving Cardio-Pulmonary Resuscitation (CPR). On [DATE] at 5:30 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On [DATE] at 6:40 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of [DATE]. The IJ was related to 42 CFR 483.10 - Right to request, refuse, and or discontinue treatment. On [DATE] at 11:47 PM, the facility provided an acceptable IJ Removal Plan. On [DATE] at 4:31 PM, the survey team, validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F578 at a lower scope and severity of D. The acceptable IJ Removal Plan included a 100% resident audit for code status. The audit included; most recent quarterly social services assessment and interview, decisional capacity form, physician order, paper DNR form in chart, point click care code status, and care plan. Systematic changes put into place included in-service for Nurse Managers and Social Workers to include; policy will change so that code status procedure for a re-admission choosing to change code status is managed with a different process. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Social workers are to enter code status changes on the care plan. Quarterly, social services will continue to assess and interview residents and include choice of code status in the interview conversation. Any changes identified in quarterly assessments to be communicated from social services to the nurse manager. Nurse manager to enter Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse manager to then check decisional capacity form, paper DNR form in chart, Point Click Care Code status and Care plan for consistency. Procedures for admission code status will remain unchanged. The Director of Nursing or designee will be responsible for conducting a weekly code status audit, reviewing at least 5 residents per unit and monitoring the effectiveness of the corrective actions and systemic changes on a weekly basis and record audit findings weekly. DON or designee to report results of audits to the QAPI committee monthly for a minimum of 3 months or until a pattern of compliance is achieved and then deficiency reviewed monthly thereafter for a minimum of 1 year. The QAPI committee to review, analyze and make recommendations for any needed changes in policy, procedure, and/or facility practice. Findings for Resident 99 include: Review of the facility's policy titled Advance Directives, dated [DATE], revealed, Advance directives will be respected in accordance with state law and facility policy . 1. Upon admission, the resident will be provided with information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so . 3. If a resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative . 6. Prior to or upon admission, the Social Services Director or designee will inquire of the residents, his/her family members, and/or his or her legal representative about the existence of any written advance directive . 10. The plan of care for each resident will be consistent with his or her documented treatment preferences and/ or advance directive . 17. The Interdisciplinary Team will conduct ongoing review of the resident's decision-making capacity and communicate significant changes to the resident's legal representative. Such changes will be documented in the care plan and medical record. Further review of the facility's policy did not include procedures for obtaining or verifying advance directives upon readmission to the facility. Review of the facility's policy titled Readmission to the Facility, last revised ,d+[DATE], did not include procedures for obtaining or verifying advance directives upon readmission to the facility. Review of the facility's Face Sheet revealed R99 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] and [DATE]. The facility face sheet did not include the resident's readmission to the facility on [DATE]. The section titled Advance Directive revealed R99's code status was CPR. Review of R99's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of [DATE] revealed R99 was readmitted to the facility from an acute care hospital on [DATE]. Further review revealed R99 had a Brief Interview of Mental Status Score (BIMS) of 15 out of 15, which indicated R99 was cognitively intact. Review of the Medical Decisional Capacity form, signed by two physicians (one physician signed the form on [DATE] and a second physician signed the form on [DATE]), revealed R99 required assistance for making health care decisions. Review of a physician's Verbal Order dated [DATE] revealed R99 was a DNR. Review of R99's hard chart clinical record revealed staff placed a DNR sticker on the inside cover indicating the resident's code status was a DNR. The Emergency Medical System (EMS) form dated [DATE], located under the Advance Directive tab, in the resident's clinical record revealed R99 did not want CPR in the event of cardiac or respiratory arrest. Further review revealed the resident, surrogate, or agent signed the EMS Do Not Resuscitate (DNR) form, but a physician did not sign the form. The Comprehensive Care Plan, last revised on [DATE], revealed R99 wished to be a Do Not Resuscitate (DNR). The care plan interventions indicated I/responsible party will be informed of any changes in my condition and benefits, risk and possible choices of treatment ., my [R99] stated desires will be honored and physician notified of my desires, and any needed physicians order obtained Review of R99's Discharge tracking records ranging from ,d+[DATE] through ,d+[DATE] revealed R99 discharged (return anticipated) to an acute care hospital on [DATE], [DATE], and [DATE]. Review of R99's Entry tracking records ranging from ,d+[DATE] through ,d+[DATE] revealed R99 was readmitted to the facility from an acute care hospital on [DATE], [DATE], and [DATE]. Review of the Hospital Discharge Summary ranging from [DATE] and [DATE] revealed R99's Resuscitation Status was full resuscitation (i.e., CPR). On [DATE] at 3:15 PM and [DATE] at 10:45 AM, the facility was asked to provide a copy of the hospital discharge summary dated [DATE]; however, the facility was unable to obtain and did not provide a copy for review. Review of R99's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Verbal Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed an order dated [DATE] (prior to readmission on [DATE]) for a Social Services consult for code status one time only for one day. Review of the Psychosocial Progress Note dated [DATE] indicated an ARD of [DATE]; the BIMS score for [R99] is 15, he is cognitively intact, alert, and organized thinking. There was no evidence of an acute change in cognition . There were no concerns with mood, no noted behaviors . he remains as CPR and as Long-Term Care (LTC) resident. Care Plan (CP) mtg (meeting) scheduled for [DATE]. Further review of the psychosocial progress notes revealed that on [DATE] (while hospitalized ), the facility reviewed the resident's current care plan (participants unknown) and revealed, continue with plan of care. However, the current care plan (see above) shows R99 is a DNR. There is no indication that the Social Service spoke to the resident and or resident representative regarding the resident's desire to change his code status from a DNR to CPR. Review of the Progress Note dated [DATE] by LPN #12 revealed R99 returned to the facility from an acute care hospital and that R99 was a full code. Review of the Psychosocial Progress Note dated [DATE] indicated ARD [DATE], the BIMS score for [R99] is 15, and he is cognitively intact. There was no evidence of an acute change in cognition . There were no concerns with mood, no noted behaviors . he remains as CPR and as Long-Term Care (LTC) resident. Care Plan (CP) mtg (meeting) scheduled for [DATE]. Further review of the psychosocial progress notes from [DATE] through [DATE] did not reveal any notes that the facility conducted a care plan meeting with the resident and or resident representative between [DATE] through [DATE]. During an interview on [DATE] at 10:29 AM with Licensed Practical Nurse (LPN) #8, LPN #8 stated that if staff transfers a resident to the hospital, staff provide a copy of the resident's face sheet, list of medications, communication form, and advanced directives to the paramedics. LPN #8 stated that if a resident has a current DNR, staff also send a copy of the DNR form. LPN #8 verified R99's code status as a DNR according to the resident's clinical record. During an interview on [DATE] at 10:55 AM with Unit Manager (UM) #3, she stated that if a resident has a code status of a DNR, the DNR EMS form is given to medics (paramedics) and sent with the resident to the hospital. UM #3 verified R99's code status as a DNR according to the resident's clinical record. During a second interview with LPN #8 on [DATE] at 8:46 AM, LPN #8 stated R99 was a DNR according to his clinical record; if R99 were to code (i.e., cardiac arrest or stop breathing), she would not perform CPR. During an interview on [DATE] at 8:51 AM with Certified Nurse Aide (CNA) #2, CNA #2 confirmed R99's code status was a DNR and stated that if R99 coded, she would get a nurse. During an interview with CNA #8 on [DATE] at 8:55 AM, CNA #8 confirmed resident's code status was a DNR and stated that if R99 coded, she would go and get the nurse. During an interview with CNA #9 on [DATE] at 9:00 AM, CNA #9 confirmed R99's code status was a DNR and stated that if R99 coded, she would go and get a nurse. During a telephone interview on [DATE] at 9:12 AM with R99's representative, she stated that she was unsure of R99's code status, but she believed R99 was a DNR the last time they spoke. R99's representative further stated that she was unaware when R99 was readmitted to the facility from the hospital on [DATE] and [DATE] and that the facility staff obtained physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE] at 10:42 AM with UM #3 revealed R99's code status of DNR. UM #3 stated the electronic health record did not get updated when the resident was readmitted to the facility. UM #3 further said she called R99's representative on [DATE] to verify R99's code status, who advised her (UM#3) that R99's was a DNR. During an interview on [DATE] at 11:40 AM with R99, R99 stated that he wanted everything done to save him if something were to happen to him. R99 further stated that if he were to code, he would like to be saved. R99 said the facility never asked him about his advance directives. During a second telephone interview on [DATE] at 11:58 AM with R99's representative, R99's representative stated the facility staff (not identified) called her this morning to try and verify R99's code status. R99's representative said she was unsure and would call R99 to verify his code status and call the facility after speaking to R99. R99's representative further stated from what she can remember, this was the first-time facility staff called to verify R99's code status. During a telephone interview with LPN #12 on [DATE] at 4:51 PM, LPN #12 stated that she could not confirm R99's code status because she no longer worked at the facility. LPN #12 said that when residents were readmitted to the facility, she confirmed the resident's code status by reviewing the resident's profile or admission paperwork. Findings for Resident 59 include: On [DATE] at approximately 5:28 PM a review of the computerized medical record for Resident 59 revealed that the resident had a BIMS score of 15 out of 15 with a code status of DNR, the paper chart contained a South Carolina Emergency Medical Service Do Not Resuscitate form dated [DATE] signed by one physician and the resident's representative and a care plan initiated on [DATE] and revised on [DATE] which stated I/RP (personal representative) wish to be a DNR. The Surveyor was unable to locate a Medical Decisional Capacity form which had been assessed and signed by two physicians. Resident 59 had been admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at approximately 12:48 PM Resident 59 stated he/she makes all of his/her decisions, but was unsure of whether he/she code or DNR. On [DATE] at approximately 1:08 PM Unit Manager 2 was asked to find the medical decisional capacity form signed by 2 physicians. On [DATE] at approximately 2:47 PM Unit Manager 2 provided a Medical Decisional Capacity form signed by the Attending Physiciqn (Medical Director) on [DATE] at approximately 2:24 PM stating All Decisions Made by Others Reason/diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at approximately 3:15 PM, LPN 10 and Registered Nurse 2 each stated that to determine code status they would go to the computer first and if there were any questions, they would double check the paper chart. LPN 10 was asked to walk the Surveyor through how he/she would determine code status for Resident 59. He/she went to the computer and stated that Resident 59 was DNR and also stated most residents on 300 Hall, were DNR. He/she then checked the paper chart and found a paper copy of the EMS DNR Form signed by one physician stating DNR, but could not locate a Medical Decisional Capacity form. On [DATE] at approximately 3:59 PM Unit Manager 2 brought a copy of a Medical Decisional Capacity form signed by a second physician who had deemed All Decisions Made by Others with a reason stated and dated [DATE] at approximately 3:01 PM, (after inquiry during the survey). This completed form stated According to the Adult Health Care Consent Act, all health care decisions will be made in order of priority by: the name of daughter as the Relationship and Phone #. Of note, the facility did not have a completed Medical Decisional Capacity form signed by two physicians until [DATE]. On [DATE] at approximately 2:43 PM the Medical Director stated in a telephone interview that he expects to have code status clarified upon admission and be accurate and to be informed of any changes that occur. The Medical Director stated that he had been notified yesterday by the facility about a change in code status on Resident 59. The facility admitted R125 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on [DATE] at approximately 2:00 PM of the paper medical record for R125 revealed a signed, DNR Order, Notice to EMS Personnel, signed by R125. Further review on [DATE] at approximately 2:00 PM of the paper medical records for R125 revealed a form titled, Medical Decisional Capacity, signed by R125's attending physician on [DATE], stating that R125 was independent in making his/her own health care decisions. Review on [DATE] at approximately 3:10 PM of the electronic medical record for R125 revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed a Comprehensive Plan of Care dated [DATE] indicating R125 was a Full Code. During an interview on [DATE] at approximately 9:45 AM with R125 concerning his code status, when asked, Do you know what your code status is now and he stated, I chose to be a DNR status the day I was admitted to this facility in [DATE]. When asked, how would it make you feel if you chose a DNR status and the facility initiated CPR, if you were to stop breathing or your heart would stop beating? R125 replied, I would feel as if the facility failed to abide by my wishes. During an interview on [DATE] at approximately 10:15 AM with LPN 9, when asked, How would you know a residents code status? Where would you go to find it? LPN 9 stated he/she would look in the paper chart. He/she was not familiar with the Kardex. LPN 9 did agree that when a resident is not breathing and their heart has stopped beating, you would have to leave the resident, go to the nurse's desk and look at the paper medical record, under the Advance Directive tab, to ensure the code status. If the paper records and the electronic records reflected the same information it would save valuable time during a code situation.

Based on observations, record review, interview and facility policy, the facility failed to ensure 1 of 4 residents (Resident (R) 113) was free from abuse and/or neglect. Specifically, facility staff left R113 naked and exposed in bed on two occasions within the same day. As a result, R113 was upset, crying, felt humiliated. Findings include: Review of facility's policy titled Sandpiper Rehab and Nursing Abuse Policy last revised 09/27/2018 revealed, Sandpiper Rehab and Nursing will seek to prohibit neglect, mental or physical abuse, including involuntary seclusion and the misappropriation of the property of residents. Sandpiper Rehab and Nursing will conduct an investigation of alleged or suspected abuse, neglect, or misappropriation of property, and, will provide notification of information to the proper authorities according to the state and federal regulations. Staff members will identify and assess suspected or alleged reports of abuse and neglect. Types of abuse include mental abuse (humiliation, harassment, threat, or punishment or deprivation). Verbal abuse (oral, written, gestured language including, but not limited to, disparaging or derogatory terms directed to or within hearing distance of the resident). Neglect, the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. During the Resident Council meeting on 08/24/21 at 2:14 PM, several residents voiced concerns regarding staff treatment. When asked, Do staff treat you with respect and dignity so that you do not feel afraid, humiliated, or degraded? Many residents stated, No, only certain staff treat me with respect. When asked Do you feel a resident or family group can complain about care without worrying that someone will 'get back' at them? Many residents stated, No, I would not feel safe after reporting someone (facility/agency staff). Due to various concerns voiced during the Resident Council meeting, individual interviews were conducted with residents. During an observation and interview with R113 on 08/25/21 at 10:00 AM in their room, R113 stated staff left her exposed and felt humiliated a few Sundays ago (8/15/21). She said Certified Nurse Aide (CNA) 4 was in her room and was getting ready to help her with a shower and CNA4 left the room to get a shower chair leaving her totally naked and exposed. About 10 minutes go by and she pressed the call light. An hour later, (R113 keeps track of time by the TV shows) CNA13 entered her room and stated, in a rude tone, did you need something?' She said she replied, Yes, don't you see me here sitting naked? CNA13 replied, I'll go find your CNA walked out of the room and closed the door. About 10 minutes go by and both CNA4 and CNA 13 returned to her room. CNA4 apologized and stated they (CNA4) got pulled to another unit (Magnolia) and did not think they would be gone for so long. CNA4 and CNA13 offered to give her a shower, but I just wanted to be covered up because I was cold. They covered me up with my nightgown, but they didn't tie the straps tight enough, which caused her nightgown to fall off about an hour after CNA4 and CNA13 left, leaving her breast exposed. Unlike the first time, her privacy curtain wasn't pulled, and her door was open. She heard and saw staff laughing at her instead of helping her. She said, the next day she overheard CNA2 and Licensed Practical Nurse (LPN) 14 talking and laughing about the incident in the hallway. R113 said she told Unit Manager (UM) 3 about the incident, and we (i.e., R113 and UM3) had a meeting with the Director of Nursing (DON), Social Services, and the Administrator regarding the incident where they apologized to her, filed a grievance, and obtained the names of those involved. R113 bed is near the window in her room, when the privacy curtain is not pulled and door is open they are able to both hear and see residents or staff that walk by their room. Resident #113 was admitted to the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R113's annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 05/10/21 revealed R113 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated she was cognitively intact. R113 did not display any behaviors toward staff or residents and did not reject evaluation or care during the review period. R113 required total assistance from two staff members for bed mobility and transfers, total assistance from one staff member for toileting, personal hygiene, and showers, and extensive assistance from one staff member for eating and dressing. Review of R113's quarterly Minimum Data Set (MDS) assessment with an ARD of 08/02/21 revealed R113 had BIMS score of 15 out of 15, which indicated she was cognitively intact. R113 did not display any behaviors toward staff or residents and did not reject evaluation or care during the review period. R113 required extensive assistance from one staff member for bed mobility and eating, total assistance from two staff members for transfers, and total assistance from one staff member for dressing, toileting, personal hygiene, and showers. Review of R113's Care Plan, dated 05/25/21, revealed R113 is resistive to care, refusing showers, non-adherence to catheter care treatment orders related to anxiety disorder. The care plan interventions directed staff to allow R113 to make decisions about treatment regimen to provide a sense of control, if possible; Negotiate a time for Activities of Daily Living (ADLS) and participate in the decision-making process; If R113 resists ADLs reassure her, leave her, and return in five to ten minutes and try again; Encourage as much participation/interaction by R113 as possible; Provide consistency in care to promote comfort with ADLs; Maintain consistency in timing of ADLs, care giver, and routine as possible. Review R113's Shower Log and Activities of Daily Living (ADL's) forms dated 08/2021 revealed R113 received showers on 8/3, 8/5, 8/6, 8/7, 8/10, 8/12, 8/13, 8/14, 8/17, 8/20, and 8/24. Review of a facility Grievance dated 08/16/21 revealed, R113's aide [CNA4] was moved to the A Wing right when she [R113] was getting ready for a shower. No one came in to replace them [CNA4] or cover R113 up [resident left entirely exposed with door and privacy curtain open] and was never showered. Then staff were loudly talking about this at the nurse's station and laughing. Review of a CNA4's Statement Form dated 08/16/21 revealed CNA4 stated, I worked at [NAME] from 7am - 3 pm, I was supposed to work [NAME] 3-11, but [NAME] was short [I was asked] to come back since [NAME] was overstaffed. I had already started [R113's last name] shower, so I came back to tell the CNAs and a nurse I was leaving to go to [NAME]. A CNA came back and said [R113's last name] was crying and naked with her call bell on for 30 minutes. I came back to help her and [R113's last name] get situated, [R113's last name] said she wanted to wait to do her shower and I told the CNA if she needed help to come get me from [NAME] and I would help ([R113's last name] heard this). I never saw that CNA that night, so I figured her shower was done and someone assisted her with the shower. That day I was left to do her shower alone because no one would assist me with it, that is why I told her that I would come from [NAME] to help her, but she never came. Review of CNA12's Statement of Witness form dated 08/16/21 (date signed by LPN14) and 08/18/21 (date signed by interviewer) revealed CNA12 stated, Mrs. [last name] refused her shower from [CNA4's] On Monday, that's all I heard from [CNA4's]. She said she didn't want it because [CNA4] wouldn't have any help. The nurse volunteered to help with her [R113] shower. Review of CNA2's Statement of Witness form dated 08/18/21 revealed CNA2 stated, I wasn't there to witness anything I was doing patient care. I heard what had happened, but I wasn't there to witness anything. I only helped the nurse and her CNA hold her over to put in a suppository and that's all I know. Review of CNA11's Statement of Witness form dated 08/23/21 revealed CNA11 stated, On the evening of attending I came on shift to check all my residents and begin my work. When I approached Ms. [last name] room her light was on. When I entered the room Ms. [last name] was laying naked with no clothes on her body, no covers, or sheets on her body nothing was on the bed but her laying on top of a lift pad. A lift machine was left over her and her air conditioning going (air conditioner was left on and blowing on R113). She was very cold to touch (her skin) and was very sad, mad, and crying for help. I was very shocked to see her this way. She asked me to help her and put her in a gown. A CNA was supposed to give her a shower and left (her) like that for a long period of time. I put a gown on her and covers, turned off air and removed lift (the Hoyer lift from the room). Ms. [last name] requested the nurse. I offered to give her a shower. Ms. [last name] said she did not want it at the time and maybe later or something. I went to track down her CNA who left her that way. She [CNA4] was moved over to [NAME]. I asked the CNA to come and assist me with Ms. [last name] and why did she leave her that way. CNA4 Stated she had to go to another unit and told a nurse. We [CNA4 and CNA11] went to [R113's last name] room. Ms. [last name] questioned her, (about why she left [R113] exposed naked) but [R113] told her [CNA4] and myself she may want a shower later. The CNA explained what happened to Ms. [last name] and told her she was sorry. She offered to shower Ms. [last name]. Ms. [last name] refused and said maybe later. I told the nurse about it. Later on, at the end of shift Ms. [last name] wanted a shower. I was unable because shift was ending, and I was going to another unit. Nurse was notified the other CNA [CNA4] (and they were unable to give R113 a shower at the time still). She (Unit Manager) then told me she was going to report to night supervisor, and to unit manager the next day. Review of R113's Progress Note dated 08/16/21 revealed Resident refused their shower this evening. Tech report that resident did not want their shower today and would get it Wednesday evening. Resident reported to this nurse that they refused because it takes two (staff members) to bathe them and that the aide would have no help. Nurse explained to resident that they were down to have a shower tonight and could have it. Resident continued to refuse. Review of R113's Progress Note dated 8/18/2021 revealed Unit Manager spoke with Resident Representative about resident's behaviors and cursing at staff. Explained concerns of hallucinations and need for psych consult. Resident #113 Resident Representatives were both supportive. Plan to meet with resident, Social Services, and DON today. Review of R113's Progress Note dated 08/22/21 (created on 08/23/21), revealed Resident refused shower, due to having to wait for nurse to assist with shower. Resident was rude and cussing at aide. Of note, the witness statements dated 08/16/21, 08/18/21, and 8/23/21 did not indicate R113 was rude or cussing at the aide. During an interview with the DON on 08/26/21 at 9:28 AM, the DON stated that he and other staff apologized to R113 for this incident and that they were still in the process of getting interviews and witness statements together regarding the investigation (11 days after R113 reported the alleged abuse). During a phone interview with LPN14 on 08/26/21 at 10:38 AM, regarding the incident on 08/15/21, LPN14 stated they weren't working that day but heard about the incident and denied ever laughing and humiliating the resident. They further stated that it's hard to get staff to want to help out R113 because of the way they talk to and treat staff sometimes. During an interview with Unit Manager (UM) 3 on 08/26/21 at 4:14 PM, UM3 stated R113 can be hard to deal with at times, they constantly curse at staff and make them uncomfortable. I don't believe that staff was laughing at R113, and it's impossible to hear what staff specifically saying from their room to the nurse's station. I do believe that this incident happened, and that staff left them uncovered but I don't believe that it was for that long of time period. R113 has told lies on staff and that's why some staff don't like to help them. During a phone interview with R113's Resident Representative (RR) 1 on 08/27/21 10:53 AM, RR1 stated, Things at Sandpiper have gone downhill over the last two to three years. The staff treat R113 like they are incompetent or like they have dementia, but they know exactly what's going on. There needs to be more compassion, especially with the weekend staff. That incident the other Sunday was unacceptable, there have been times where I was on speakerphone with R113 and have timed how long it takes staff to answer the call light and it can be up until an hour of wait time. They [staff] say that R113 makes up things but that's not true and they have legitimate concerns, they can hear when staff are laughing at them. They [staff] will only start laughing when they walk past R113 door. Overall, the quality of care is my main concern, and this is because of the changes with management and staff which causes the good staff to leave. During an interview with Social Services (SS) on 08/27/21 at 11:16 AM, SS stated this incident with R113 being left exposed is neglect and they were upset that it happened in the first place. When asked who is responsible for reporting these types of incidents to the state agency, they stated the DON. During an interview with the DON on 08/27/21 at approximately 3:00 PM revealed that the facility terminated CNA4 on 08/27/21 (upon inquiry during the survey). During an outdoor visitation interview and observation with Resident #113, RR1, and RR2 on 8/27/2021 at approximately 4:45 PM, RR2 stated She (R113) was looking into assisted suicide after being left naked that day (8/15/21) and has been sad ever since. During a follow up interview with R113 on 08/31/21 at 2:13 PM, R113 stated I do not feel safe here, a lot of the staff here I do not trust to properly take care of me.

Based on record reviews, interviews and review of the facility policy titled, Acute Condition Changes - Clinical Protocol, the facility failed to notify the Physician, Hospice Nurse nor the Personal Representative for Resident #1 related to pain, with no relief, for 1 of 1 residents reviewed for pain. The findings included: The Facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review on 4/23/2018 at approximately 12:10 PM of the medical record for Resident #1 revealed a nurses note dated 2/20/2018 at 6:04 AM and states, Resident continue to howl and moan in pain. Have tried topical [MEDICATION NAME] and repositioning. Resident continues to moan and howl for nurse, Says, I need you to send me to the hospital because I'm sick. No documentation could be found where in the medical record for Resident #1 to ensure the physician, hospice nurse nor the personal representative were notified of resident wanting to go to the hospital due to severe pain. Review on 4/23/2018 at approximately 12:25 PM of the MAR (Medication Administration Record) for Resident #1 for the month of February 2018 revealed that Resident #1 had ordered for pain, Biofreeze Gel 4 % (Menthol Topical [MEDICATION NAME]) to affected joints topically every 4 hours as needed for pain. Resident #1 had ordered [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg (milligrams) 1 tablet by mouth every 6 hours as needed for pain and [MEDICATION NAME] (Concentrate) Solution 20 mg/ml (milliliter) and to give 0.25 mls sublingually every 1 hour as needed for mild pain, and 0.5mls sublingually every 1 hour as needed for moderate pain and 1 ml sublingually every 1 hours as needed for severe pain. Resident #1 also had [MEDICATION NAME] HCT tablets 50 mg and to give 1 tablet by mouth every 8 hours as needed for pain. No documentation in the nurses' notes nor on the MAR for Resident #1 to ensure he/she received any of these pain medications as ordered for pain. Resident #1 has received pain medication at 12:47 AM on 2/20/2018 and not again until 9:00 AM on 2/20/2018. Resident #1 did not receive any pain medication on 2/20/2018 at 6:04 AM when the nurse documented that this resident continued to howl and moan in pain and requested to go to the hospital. During an interview on 4/24/2018 at approximately 10:30 AM, the DON (Director of Nursing) confirmed that the physician, the hospice nurse nor the personal representative were notified of the unrelieved pain and the resident's request to go to the hospital. The DON also confirmed that Resident #1 had not received any pain medication since 12:47 AM on 2/20/2018. The DON stated that the expectation was for the nursing taking care of the resident to administer pain medication as ordered and to notify the physician/hospice nurse and the personal representative of the severe pain and the residents request to go the hospital. On 4/24/2018 at approximately 1:20 PM during an interview with LPN (Licensed Practical Nurse) #1, the nurse taking care of Resident #1 on the night shift. LPN #1 stated that he/she had tried different approaches to alleviate the pain and included the topical [MEDICATION NAME] and repositioning. This surveyor read the nurses note written by LPN #1 and he/she did remember the note but did not remember exactly what medication was given. This surveyor stated none were documented on the MAR. This surveyor also asked about notifying physician/hospice nurse and the personal representative and he/she stated, that was one of those nights when I did not have time to document everything. LPN #1 did not confirm whether or not a pain medication was given or if the hospice nurse, the physician or the personal representative were notified of the severe pain and Resident #1's request to go the hospital. Review on 4/24/2018 at approximately 2:20 PM of the facility policy titled, Acute Condition Changes - Clinical Protocol, number 5 states, The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less). Number 6 states, The attending physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status. Number 1 under Treatment/Management, states, The physician will help identify and authorize appropriate treatments.

Based on record reviews, and interviews the facility failed to ensure Resident #1 received physician ordered medication for pain in a timely manner for 1 of 1 residents reviewed for pain. The findings included: The Facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review on 4/23/2018 at approximately 12:10 PM of the medical record for Resident #1 revealed a nurses note dated 2/20/2018 at 6:04 AM and states, Resident continue to howl and moan in pain. Have tried topical [MEDICATION NAME] and repositioning. Resident continues to moan and howl for nurse, Says, I need you to send me to the hospital because I'm sick. No documentation could be found where in the medical record for Resident #1 to ensure the physician, hospice nurse nor the personal representative were notified of resident wanting to go to the hospital due to severe pain. Review on 4/23/2018 at approximately 12:25 PM of the MAR (Medication Administration Record) for Resident #1 for the month of February 2018 revealed that Resident #1 had ordered for pain, Biofreeze Gel 4 % (Menthol Topical [MEDICATION NAME]) to affected joints topically every 4 hours as needed for pain. Resident #1 had ordered [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg (milligrams) 1 tablet by mouth every 6 hours as needed for pain and [MEDICATION NAME] (Concentrate) Solution 20 mg/ml (milliliter) and to give 0.25 mls sublingually every 1 hour as needed for mild pain, and 0.5mls sublingually every 1 hour as needed for moderate pain and 1 ml sublingually every 1 hours as needed for severe pain. Resident #1 also had [MEDICATION NAME] HCT tablets 50 mg and to give 1 tablet by mouth every 8 hours as needed for pain. No documentation in the nurses notes nor on the MAR for Resident #1 to ensure he/she received any of these pain medications as ordered for pain. Resident #1 has received pain medication at 12:47 AM on 2/20/2018 and not again until 9:00 AM on 2/20/2018. Resident #1 did not receive any pain medication on 2/20/2018 at 6:04 AM when the nurse documented that this resident continued to howl and moan in pain and requested to go to the hospital. During an interview on 4/24/2018 at approximately 10:30 AM, the DON (Director of Nursing) confirmed that the physician, the hospice nurse nor the personal representative were notified of the unrelieved pain and the resident's request to go to the hospital. The DON also confirmed that Resident #1 had not received any pain medication since 12:47 AM on 2/20/2018. The DON stated that the expectation was for the nursing taking care of the resident to administer pain medication as ordered and to notify the physician/hospice nurse and the personal representative of the severe pain and the residents request to go the the hospital. On 4/24/2018 at approximately 1:20 PM during an interview with LPN (Licensed Practical Nurse) #1, the nurse taking care of Resident #1 on the night shift. LPN #1 stated that he/she had tried different approaches to alleviate the pain and included the topical [MEDICATION NAME] and repositioning. This surveyor read the nurses note written by LPN #1 and he/she did remember the note but did not remember exactly what medication was given. This surveyor stated none were documented on the MAR. This surveyor also asked about notifying physician/hospice nurse and the personal representative and he/she stated, that was one of those nights when I did not have time to document everything. LPN #1 did not confirm whether or not a pain medication was given or if the hospice nurse,the physician or the personal representative were notified of the severe pain and Resident #1's request to go the hospital. Review on 4/24/2018 at approximately 2:20 PM of the facility policy titled, Acute Condition Changes - Clinical Protocol, number 5 states, The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less). Number 6 states, The attending physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status. Number 1 under Treatment/Management, states, The physician will help identify and authorize appropriate treatments.