Every finding on record at Simpsonville Post Acute

Based on observation, interview, record review, and facility policy review, the facility failed to assess 1 of 1 residents reviewed (Resident (R)1) for self administration of medications. This failure resulted in medications being left in the resident's room/possession, where they could be accessed by other residents or could place the resident at risk of being overly medicated. Findings include:Review of the facility's policy titled, Self-Administration of Medications, last revised February 2021, revealed As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident.Review of the facility's policy titled, Storage of Medications, dated 2001, revealed Policy Interpretation and Implementation 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. 3. The nursing staff is responsible for maintaining medication storage.Review of R1's Face Sheet located in the electronic medical record (EMR) under the Resident tab revealed R1 was admitted to the facility on [DATE] with a primary diagnosis of wedge compression fracture of fifth lumbar vertebra, subsequent encounter for fracture with routine healing.Review of R1's annual Minimum Data Set (MDS) located in the EMR under the Resident Assessment Instrument (RAI) tab with an Assessment Reference Date (ARD) of 02/20/26, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 was cognitively intact.Review of R1's Care Plan located in the EMR under the RAI tab, did not include a care plan related to self-administration of medications.Review of R1's Evaluations located in the EMR under the Evaluations tab did not include an assessment/evaluation for self-administration of medications.Review of R1's Orders located under the Orders tab of the EMR revealed R1 did not have an order for self-administration of medications. Additionally, R1 had orders for Gabapentin Oral Capsule 300 MG give one table by mouth every 12 hours for Neuropathy, Tums Oral Tablet Chewable 500 MG (Calcium Carbonate Antacid) give 500 mg by mouth every 6 hours as needed for indigestion, Lexapro Oral Tablet 20 MG (Escitalopram Oxalate) give 1 tablet by mouth one time da day for depression, Ondansetron HCI Oral Tablet 4 MG ( Ondansetron HCI) give 1 table by mouth every 8 hours as needed for Nausea Vomiting.During an observation on 06/09/26 at 11:04 AM, R1 was sitting in her wheelchair in the hallway in front of the nursing station with a white bag with four (4) prescription bottles which included: Pantoprazole Sodium, Gabapentin, Ondansetron HCL, Escitalopram Oxalate.During an interview on 06/09/26 at 11:04 AM, Resident (R)1 revealed that she received medications from her doctor's appointment with her pain doctor the day before. R1 states that she took one of her Protonix pills because the nurse did not give her a tums as she requested.During an interview 06/09/26 at 11:10 AM, The Unit Manager (UM) confirmed the medications in the resident possession and stated that the resident went out to the pain doctor yesterday and she should have turned the medications in to the nurse along with the orders for the medications.During a follow up interview on 06/09/26 at 11:50 AM, The UM checked the prescription bottles for broken seals and confirmed that the seal was broken for Pantoprazole Sodium.During a 2nd follow up interview on 06/09/26 at 2:03 PM, The UM counted the contents for prescription Pantoprazole Sodium and confirmed a count of 29 pills and confirmed there should have been 30 pills in the bottle. The UM revealed that the resident does not have an order to self-administer her own medications, and that she is not supposed to self-administer any medications. The UM explains that the resident should have given the medications to the nurse on the med cart when she returned from the doctor as she usually does but she is not sure why she didn't yesterday.During an interview on 06/09/26 at 2:11 PM, the Director of Nursing (DON) revealed that they do not have any residents in the facility with orders to self-administer medications. The DON explains that residents are usually transported by facility transportation to appointments and they usually handle all the paperwork and medications and return it to the nurses on the cart. The DON continues to explain that if family members transport the residents, they are supposed to turn in paperwork and medications to the nurse when they return from appointments. The DON states that R1 had a friend to take her to her appointment yesterday and R1 usually turns in her paperwork and medications to the nurse when she returns from appointments, but she is not sure why she didn't do that yesterday.

Based on interview, record review, document review, and facility policy review, the facility failed to ensure a certified nursing assistant (CNA) transferred a resident according to the resident's care plan for 1 (R2) of 4 sampled residents reviewed for accidents. Certified Nursing Assistant (CNA)1 used a sit to stand lift with one person instead of a mechanical sling lift with two people as specified by the resident's care plan. The failure resulted in R2 sustaining a fractured femur. Findings included: A facility policy titled, Lifting Machine, Using a Mechanical, revised 07/2017, indicated, Purpose The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions. General Guidelines 1. A least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. A facility policy titled, Safe Lifting and Movement of Residents, revised 07/2017, indicated, Policy Statement In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. The policy specified, 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. An Admission Record revealed the facility admitted R2 on 10/17/2022. According to the Admission Record, the resident had a medical history that included diagnoses of late onset Alzheimer's disease, anxiety disorder, unspecified dementia with other behavioral disturbance, unspecified psychosis, and vitamin D deficiency. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/25/2024, revealed R2 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was dependent on staff for chair/bed-to-chair transfers. R2's Care Plan, included a focus area initiated 10/25/2022, that indicated the resident required assistance with activities of daily living related to limited range of motion and weakness. Interventions directed staff to utilize a Mechanical/Hoyer lift with the assistance of two people to transfer the resident (initiated 08/12/2024). R2's Nurse's Note, documented by Registered Nurse (RN)2 and dated 11/18/2024 at 5:00 PM, indicated R2 was observed grimacing during patient care, swelling was noted to the resident's left femur, and an order was received to complete an x-ray. A Visit Note Report, dated 11/18/2024, revealed RN2 notified hospice that R2 complained of pain in their left leg. Per the Visit Note Report, there had been no reported falls, but the resident's leg was swollen, and RN2 thought the resident's leg might be dislocated. Per the Visit Note Report, RN6 visited the facility on 11/18/2024 at 8:47 PM and noted the resident's left ankle was turned out. The Visit Note Report indicated, the resident had pain and swelling in their left lower hip area, with pain seemingly present only when their leg was moved, and RN6 applied a soft splint. R2's Order Summary Report, contained an order dated 11/19/2024, for an x-ray of the resident's left knee and hip. The Radiology Results Report, dated 11/19/2024 at 9:20 AM, revealed R2 had an acute appearing femoral fracture. Contained within the facility's investigation was CNA1's Witness Statement, dated 11/18/2024, which indicated CNA1 acknowledged she alone transferred R2 to the bed by using a stand up lift. The Five-Day Follow-Up Report, dated 11/22/2024, revealed R2 had a fracture of the mid femoral shaft with malalignment. Per the Five-Day Follow-Up Report, a CNA transferred the resident to the bed by usage of a stand-up lift. The Five-Day Follow-Up Report, while the CNA had been trained on resident transfers, the CNA did not transfer the resident per the resident's plan of care and the CNA's employment with the facility was terminated. The Post Falls Assessment and Root Cause Investigative Report, dated 11/20/2024, revealed R2 was improperly transferred with a mechanical lift and the assistance of one staff. An Employee Counseling Form, signed by CNA1 and dated 11/28/2024, revealed the nature of the infraction was the CNA transferred a resident without assistance. Per the Employee Counseling Form, CNA1 was terminated. During an interview on 01/02/2025 at 1:31 PM, RN2 stated she was in the room with another resident on 11/18/2024 and was called to come and check R2. RN2 stated she noticed something was wrong with the resident's leg and asked the resident what happened. RN2 stated the resident said they did not know, and it was not like that earlier that morning. RN2 stated the resident required a sling type mechanical lift and she was not present with the resident to know how the resident was transferred. RN2 stated there had not been any issues with transfers prior to the incident because everyone knew with a mechanical lift, there always needed to be two people for assistance. During an interview on 01/02/2025 at 1:22 PM, CNA3 stated she was working on the day of the incident, but she did not recall anything unusual. CNA3 stated R2 had not had any falls or anything of which she was aware. CNA3 stated for residents that required a mechanical lift for transfers, there should always be two people. During an interview on 01/02/2025 at 1:43 PM, CNA #4 stated she did restorative, trained the CNAs on the mechanical lift, and instructed them to make sure they always had two people with them, especially for safety reasons. During an interview on 01/02/2025 at 3:50 PM, the Administrator stated he contacted the Director of Nursing (DON), and she stated CNA1 did not give a reason for why she did not have two people present for the transfer of R2. During a follow-up interview on 01/02/2025 at 5:04 PM, the Administrator stated he expected residents to be transferred per their care plan, with the correct number of staff for assistance. On 01/02/2025 at 12:42 PM and 1:54 PM and 01/03/2025 at 8:35 AM, a telephone interview was attempted with CNA1. There was no answer and each time a voicemail message was left, and no return telephone call was received. CN

Based on interview, record review, document review, and facility policy review, the facility failed to implement their Quality Assurance and Performance Improvement (QAPI) plan following an incident of an improper transfer for 1 (Resident (R)2) of 4 sampled residents reviewed for accidents. Findings included: A facility policy titled, Quality Assurance and Performance Improvement (QAPI) Program-Analysis and Action, revised 03/2020, specified, Quality deficiencies that are identified through feedback and data and will undergo appropriate corrective action. Corrective actions are monitored against established goals and benchmarks by the QAPI committee. An Admission Record revealed the facility admitted R2 on 10/17/2022. According to the Admission Record, the resident had a medical history that included diagnoses of late onset Alzheimer's disease, anxiety disorder, unspecified dementia with other behavioral disturbance, unspecified psychosis, and vitamin D deficiency. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/25/2024, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was dependent on staff for chair/bed-to-chair transfers. R2's Care Plan, included a focus area initiated 10/25/2022, that indicated the resident required assistance with activities of daily living related to limited range of motion and weakness. Interventions directed staff to utilize a Mechanical/Hoyer lift with the assistance of two people to transfer the resident (initiated 08/12/2024). Contained within the facility's investigation was Certified Nursing Assistant (CNA)1's Witness Statement, dated 11/18/2024, which indicated CNA1 acknowledged she alone transferred R2 to the bed by using a stand up lift. R2's Order Summary Report, contained an order dated 11/19/2024, for an x-ray of the resident's left knee and hip. The Radiology Results Report, dated 11/19/2024 at 9:20 AM, revealed Resident #2 had an acute appearing femoral fracture. The Five-Day Follow-Up Report, dated 11/22/2024, revealed R2 had a fracture of the mid femoral shaft with malalignment. Per the Five-Day Follow-Up Report, a CNA transferred the resident to the bed by usage of a stand-up lift. The Five-Day Follow-Up Report, while the CNA had been trained on resident transfers, the CNA did not transfer the resident per the resident's plan of care and the CNA's employment with the facility was terminated. The Post Falls Assessment and Root Cause Investigative Report, dated 11/20/2024, revealed R2 was improperly transferred with a mechanical lift and the assistance of one staff. The Quality Assurance Committee Meeting Agenda and Guide, dated 12/19/2024, indicated R2's injury was reviewed, and an action plan was implemented. The QAPI/Action Plan, dated 11/18/2024, revealed the issue was an inappropriate transfer. The action plan revealed an audit would be initiated by the Director of Nursing/nurse management weekly for four weeks and monthly for two months to ensure transfer methods were accurate and reflected on a resident's care plan and information guide used by CNA staff. During an interview on 01/03/2025 at 3:19 PM, the Administrator stated the facility had not yet started the audits for the QAPI plan related to the inappropriate transfer. The Administrator stated the QAPI team met on 12/19/2024 and the week of 12/23/2024, he was off work and the DON was off the week of 12/30/2024. The Administrator stated the audits would start the week of 01/06/2025, when the DON returned. During an interview on 01/03/2025 at 5:07 PM, the Administrator stated he expected when something was presented to QAPI, the facility would make a plan and follow through with the implementation of it.

Based on observation, interview, and facility policy, the facility failed to provide dignity to Resident (R)68 by failing to knock prior to entering the resident's room. The facility further failed to provide dignity to R68 with his urinal,1 of 5 residents reviewed for dignity. Findings include: Record review of facility policy titled Dignity last revised 02/28/21, revealed Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy interpretation and implementation include residents are treated with dignity and respect at all times; when assisting with care, residents are supported in exercising their rights for example residents are provided with a dignified dining experience. Staff are expected to knock and request permission before entering resident's rooms. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents by promptly responding to resident's request for toileting assistance. R68 was admitted to the facility on [DATE] with the diagnosis including but not limited to type 2 diabetes, hypertension, and acquired absence of left and right legs above knee. Review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed R68 has a Brief Interview of Mental Status (BIMS) score of 15 out of 15, which indicates that he is cognitively intact. Further review of the Quarterly MDS revealed that R68 is dependent on staff for toileting hygiene and personal hygiene. An observation and interview on 08/26/24 at 9:06 AM with R68 revealed the resident in bed and he had just finished breakfast. Further observation revealed a urinal lying on it's side, almost full with urine. R68 stated that staff had just left out of the room to take up the his plate/utensils, but did not offer to empty his urinal. R68 further stated that staff do not offer to provide him assistance with Activities of Daily (ADL) care, unless he asks. An observation on 08/26/24 at 9:14 AM with R68 revealed that he pressed his call light for assistance for staff to empty his urinal. An observation on 08/26/24 at 9:14 AM revealed Certified Nursing Assistant (CNA)1 entered the room without knocking or permission to enter the room, to empty R68 urinal. An observation on 08/26/24 at 9:15 AM revealed CNA1 exiting R68's room and entered another resident room across the hall without knocking or waiting for permission to enter the room. An interview on 08/26/24 at 9:18 AM with CNA1 revealed that they did not knock on R68 and door because it was open then CNA1 stated staff are expected to knock prior to entering rooms regardless of the door was open. CNA1 further admitted that she did not knock on the door across the hallway as well. CNA1 finally stated that she is assigned to R68 for the day, but was not the staff member who picked up his breakfast tray and was unsure of who that staff member was. An interview on 08/28/24 at 5:30 PM with the Director of Nursing (DON) revealed that staff are expected to knock and wait for permission prior to entering residents rooms and that staff are expected to offer resident's assistance with their urinals when they observe that they need to be emptied. Record review of R68 Care Plan last revised 08/26/24 revealed I am at risk for chronic Urinary Tract Infection (UTI). Prefers urinal on bedside table at all times, I will not have a UTI through next review. Interventions include: administer medications and treatments as ordered, observe and document responses; encourage fluid intake; I will need post incontinent care every two hours and as needed; monitor and obtain labs as ordered and as needed; notify the Medical Director/ Nurse Practitioner as needed; monitor for signs and symptoms of UTI.

Based on observation, interview, and facility policy the facility failed to ensure that Resident (R)102 had the right to exercise automy/self-determination related to her preferred sleeping schedule. 1 of 1 reviewed for self-determination. Findings include: Record review of facility policy titled Resident Self-Determination and Participation last revised 08/31/22 revealed Our facility respects and promotes the right of each resident to exercise his or her autonomy regarding what the resident considers to be important facets of his or her life. Policy interpretation and implementation include each resident is allowed to choose activities, and schedule health care and healthcare providers that are consistent with his or her interests, values, assessments, and plans of care, including: daily routine, such as sleeping and waking, eating, exercise and bathing schedules. In order to facilitate resident choice, the administration and staff: inform the residents and family members of the resident's right to self-determination and participate in preferred activities. R102 was admitted to the facility on [DATE] with the diagnosis including but not limited to dementia with severe agitation, hypertension, major depressive disorder, and psychotic disorder with hallucinations due to a known physiological condition. According to the Quarterly Minimum Data Set (MDS) dated [DATE] revealed R102 has a Brief Interview of Mental Status (BIMS) score of 3 out of 15, which indicates she is not cognitively intact. An observation on 08/27/24 at 8:30 AM revealed a Certified Nursing Assistant (CNA) attempting to wake R102 and encouraging her to eat her breakfast. A phone interview on 08/28/24 at 1:56 PM with R102 Resident Representative (RR) revealed that the resident often sundown's and does not go to bed at times until after midnight. During the interview the RR had concerns with the facility not allowing to the resident self-determination due to them attempting to provide ADL care to R102 at 6:30 AM this morning (08/28/24). RR further stated that at times the resident does not want to be awaken before 9:00 AM and has had this pattern prior to admission to the facility. An interview on 08/28/24 at 2:18 PM with CNA2 revealed that the resident was very agitated this morning and refused to get up, when the resident is agitated CNA2 stated that she leaves the resident alone and gives her time to calm down and notifies the nurse of the behavior so they can chart it in the Electronic Medical Record (EMR). CNA2 stated that she attempted to provide the resident ADL care around 9:00 AM this morning and resident began to curse at her. CNA2 finally stated that R102 has never hit them when she gets agitated, she curses at staff and will ball up her fists but has not witnessed R102 be physically aggressive with staff. A phone interview on 08/28/24 at 3:37 PM with the Psychiatric Nurse Practitioner (NP) revealed that they were informed by a 3rd shift CNA that the resident was attempting to fight staff this morning during their last round when the attempted to provide Activities of Daily Living (ADL) care for R102. A phone interview on 08/28/24 at 5:05 PM with CNA3 (3rd shift CNA) revealed that the resident at times can be combative but has never physically hit them or any other staff that they are aware of. Interview with CNA3 further revealed that staff assist resident to bed around 8:00 PM - 9:00 PM and at times resident will get back up and will become verbally aggressive with staff if they attempt to redirect. CNA3 further stated that they were R102 assigned CNA for last night/this morning (08/28/24) when they attempted to get the resident up for the day around 6:30 AM the resident refused to be provided ADL care and became verbally aggressive with him and the nursing staff. An interview with the Director of Nursing (DON) on 08/28/24 at 5:36 PM revealed that residents have a right to self-determination and refusal of treatment and services. Record review of R102 Care Plan last revised 11/20/23 revealed Refusal of Care - Resident refuses care and services within their rights as manifested by non-compliance/refusal of nursing care, has episodes of removing brief. Interventions include: behavioral and psychological services as indicated; determine resident's experiences and preferences to eliminate/mitigate triggers to the extent possible; encourage active participation in care; reapproach when refusing care to the extent possible.

Based on review of the facility policy, interviews and record review, the facility failed to implement its abuse policies with regards to an allegation of verbal abuse involving 2 of 3 residents sampled. On 05/21/2023 Resident (R)2 verbally abused R3. The facility did not follow its set policies with regards to reporting or investigating alleged abuse allegations. Findings include: Review of facility policy titled Resident-to-Resident Altercations, revised on December 2016 revealed that, in the event two residents are involved in an altercation, staff will - among other measures - identify what happened, including what might have led to aggressive conduct on the part of one or more individuals; notify each resident's representative and the Attending Physician; consult with the Attending Physician to identify treatable conditions; make any necessary changes in the care plan approaches to any or all involved individuals; document in the resident's clinical record all interventions and their effectiveness; consult psychiatric services for assistance in assessing the resident, complete a Report of Incident / Accident form and document the incident, findings, and corrective measures taken in the resident's medical / clinical record; and report incidents, findings, and corrective measures to appropriate agencies as outlined in our facility's abuse reporting policy. Review of facility policy titled Abuse and Neglect - Clinical Protocol, revised on March 2018 revealed that the staff, with the physician's input as needed, will investigate alleged abuse to clarify what happened and identify possible causes. The physician will provide adequate documentation regarding negative outcomes that have resulted form a resident's underlying medical illnesses or conditions, despite appropriate care. Furthermore, the staff and physician will monitor individuals who have been allegedly abused to address any issues regarding their medical conditions, mood, and function. Review of facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised on April 2021 revealed prevention program consists of a facility-wide commitment and resource allocation to support following objectives: protect residents from abuse, neglect, exploitation, or misappropriation of property; develop and implement policies and protocols to prevent and identify abuse or mistreatment of residents, neglect of residents, and / or theft, exploitation, or misappropriation of resident property; establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive, or emotional problems; identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property; investigate and report any allegations within timeframes required by federal requirements; involve the resident council in monitoring and evaluating the facility's abuse prevention program. Review of facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised on April 2021 revealed that if resident abuse, neglect, exploitation, misappropriation of property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator. The administrator or the individual making the allegation reports to the following agencies: state licensing / certification agency, local / state ombudsman, resident's representative, adult protective services, law enforcement officials, the resident's attending physician, and the facility medical director. Immediately, is defined as within two hours of an allegation involving abuse. All allegations are thoroughly investigated, and the administrator initiates investigations. The individual conducting the investigation at a minimum: reviews documentation and evidence; reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and the time since the incident; observes the alleged victim, including his or her interactions with staff and other residents; interviews the person(s) reporting the incident; interviews any witnesses to the incident; interviews the resident or the resident's representative; interviews the resident's attending physician as needed to determine the resident's condition; interviews staff members who have had contact with the resident during the period of the alleged incident; interviews the resident's roommate, family members, and visitors; interviews other residents to whom the accused employee provides care or services; reviews all events leading up to the alleged incident; and documents the investigation completely and thoroughly. R2 was admitted to the facility on [DATE] with diagnoses including, but not limited to, memory deficit following cerebral infarction, dementia, major depressive disorder, and behavioral disorders. The resident scored a Brief Interview for Mental Status (BIMS) of 0 out of 15 on his admission Minimum Data Set with an Assessment Reference Date (ARD) of 05/24/2023, indicating the resident could not complete the interview. R3 was admitted to the facility on [DATE] with diagnoses including, but not limited to, hemiplegia and hemiparesis affecting the right dominant side, aphasia following brain infarction, epilepsy, major depressive disorder, and generalized anxiety disorder. The resident scored a BIMS of 02 out of 15 on his admission MDS with an ARD 5/23/2023, indicating severe cognitive impairment. Review of a 05/21/2023 behavior note written by Licensed Practical Nurse (LPN)1 at approximately 11 PM revealed that R2 was heard yelling racial slurs at his roommate. The facility contacted the Director of Nursing (DON) for a room change approval. The resident did state that it was good he was moving for his roommate's sake. Review of R3's Care Plan revealed the abuse incident was not addressed, nor were any interventions added to protect the resident from, or mitigate, psychosocial harm related to the verbal abuse allegation. Interview with the DON on 06/20/2023 at approximately 12:20 PM revealed that R2 directed racial slurs at R3, his previous roommate. The facility did not consider the incident abuse because R3 did not appear offended. When asked how a reasonable person might react to being called a racial slur in their own home, she was unable to answer. Interview with the Administrator on 06/20/2023 at approximately 12:32 PM revealed he was not notified of the abuse incident except in passing as to why the residents were moved. He confirmed the incident was not viewed as abuse. Interview with the Director of Social Services on 06/20/2023 at approximately 12:40 PM revealed that she was not aware of the verbal abuse incident between R2 and R3 prior to the date of the survey. As such, she had not followed up with either resident regarding the incident. When asked to define verbal abuse, she answered it could include derogatory remarks, name calling, and inappropriate remarks - among others. Interview with LPN1 on 06/20/2023 at 1 PM confirmed she authored the 05/21/2023 note regarding the abuse incident between R2 and R3. She did not directly witness the incident, however, and could not name the CNA who reported it to her. She did contact the DON at the time of the incident for permission to move the roommates to separate rooms. She did not follow it up as a verbal abuse incident. Interview with CNA1 on 06/20/2023 at 2 PM revealed she could not recall the specifics of the abuse incident between R2 and R3. She heard the residents yelling but did not hear what they said. The nurse moved the residents after the incident. Review of Nurse Practitioner's progress note for R3 with Date of Service (DOS) of 05/22/2023 revealed there was no mention of the abuse incident on 05/21/2023. Interview with the Nurse Practitioner on 06/20/2023 at approximately 2:20 PM revealed she met with R3 following the abuse incident on 05/22/2023. However, the visit was related to his admission, and she was unaware of the verbal abuse incident the resident was involved in the day prior. As she was not aware, she did not make a note of it in the progress note. Had she been notified of the incident, she would have made a note of it in the note and gone over the resident's psychosocial health with regards to the verbal abuse incident. Interview with CNA2 on 06/20/2023 at approximately 2:30 PM and again at 3 PM revealed the two residents (R2 and R3) were going back and forth arguing with each other. Though she could not remember what was specifically said, she characterized both of their language as verbally abusive.

Based on review of the facility policy, interviews and record review, the facility failed to report an allegation of verbal abuse involving 2 of 3 residents sampled. On 05/21/2023 Resident (R)2 verbally abused R3, using a racial slur. The facility did not report the incident to the appropriate state agencies. The findings include: Review of facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised on April 2021 revealed that if resident abuse, neglect, exploitation, misappropriation of property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator. The administrator or the individual making the allegation reports to the following agencies: state licensing / certification agency, local / state ombudsman, resident's representative, adult protective services, law enforcement officials, the resident's attending physician, and the facility medical director. Immediately, is defined as within two hours of an allegation involving abuse. R2 was admitted to the facility on [DATE] with diagnoses including, but not limited to, memory deficit following cerebral infarction, dementia, major depressive disorder, and behavioral disorders. The resident scored a Brief Interview for Mental Status (BIMS) of 00/15 on his admission Minimum Data Set with Assessment Reference Date (ARD) of 05/24/2023, indicating the resident could not complete the interview. R3 was admitted to the facility on [DATE] with diagnoses including, but not limited to, hemiplegia and hemiparesis affecting the right dominant side, aphasia following brain infarction, epilepsy, major depressive disorder, and generalized anxiety disorder. The resident scored a BIMS of 02/15 on his admission MDS with ARD 5/23/2023, indicating severe cognitive impairment. Review of a 05/21/2023 behavior note written by Licensed Practical Nurse (LPN)1 at approximately 11 PM revealed that R2 was heard yelling racial slurs at his roommate. The facility contacted the Director of Nursing (DON) for a room change approval. Interview with the DON on 06/20/2023 at approximately 12:20 PM revealed that R2 directed racial slurs at R3, his previous roommate. The facility did not consider the incident abuse because R3 did not appear offended. As such, the abuse was not reported to DHEC, the South Carolina State Agency. Interview with the Administrator on 06/20/2023 at approximately 12:32 PM confirmed the incident was not viewed as abuse or reported to DHEC as a potential abuse incident. Interview with LPN1 on 06/20/2023 at 1 PM confirmed she authored the 05/21/2023 note regarding the abuse incident between R2 and R3. She did not directly witness the incident, however, and could not name the CNA who reported it to her. She did contact the DON at the time of the incident for permission to move the roommates to separate rooms. Interview with CNA1 on 06/20/2023 at 2 PM revealed she could not recall the specifics of the abuse incident between R2 and R3. She heard the residents yelling but did not hear what they said. The nurse moved the residents after the incident. Interview with CNA2 on 06/20/2023 at approximately 2:30 PM and again at 3 PM revealed the two residents (R2 and R3) were going back and forth arguing with each other. Though she could not remember what was specifically said, she characterized both of their language as verbally abusive.

Based on interview and record review, the facility failed to run an ordered laboratory test in a timely manner for 1 of 4 residents reviewed. Resident (R)1 was ordered for stool testing of antibodies for Helicobacter pylori (a bacteria that infects the stomach and may cause ulcers) on 03/23/22. The specimen was to be collected for testing after two weeks of held medications, however there was no laboratory result until 05/24/22. Findings include: R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R1's laboratory results revealed a stool sample for antibody testing of H. Pylori was collected 05/19/22 and reported 05/24/22 as negative. Review of R1's care plan revealed the resident was care planned for gastrointestinal issues. Interventions included the facility conducting laboratory tests as ordered. Interview with Nursing Consultant on 10/24/22 at approximately 11:50 AM revealed a 03/23/22 order for R1 to hold [MEDICATION(S)] (medication that decreases stomach acid production) for two weeks and then retest stool for antibodies of H. Pylori. Interview with Nursing Consultant on 10/24/22 at approximately 12:30 PM revealed that R1's April Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Pylori testing on 04/05/22. There is no further documentation in the record until 05/19/22. Review of facility grievances indicates the resident representative for R1 filed a grievance on 05/18/22 regarding H. Pylori. This was prior to the 05/19/22 collection. Interview with Operations Manager on 10/24/22 at approximately 2 PM indicated that all laboratory orders are reviewed in morning clinicals. He could not provide a rationale as to why R1's missing H. Pylori laboratory test was not caught by the facility.

Based on record review, facility policy review, and staff interviews, the facility failed to ensure 2 out of 2 residents (Residents (R) 36 and R86) reviewed for resident-to-resident abuse out of a total sample of 30 residents were free from abuse. R37 was the aggressor in two resident-to-resident altercations, one which resulted in harm when R86 sustained a [CONDITION(S)] from a fall after being pushed. Findings include: Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, showed: Policy Statement Residents have the right to be free from abuse . This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse . Policy Interpretation and Implementation The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff; b. other residents;. Review of R37's Admission Record from the electronic medical record (EMR) Profile tab showed a facility admitted [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R37's admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 06/01/22 revealed R37 had a Brief Interview for Mental Status (BIMS) score of 06 out of 15, indicative of severe cognitive impairment. Review of a Behavior Care Plan, dated 08/24/22 and located in the Care Plan tab of the EMR showed documentation that R37, has risk for combative or aggressive behaviors. history and or potential to demonstrate verbally abusive behavior towards others. Review of R86's Admission Record from the EMR Profile tab showed a facility admitted [DATE], a readmitted [DATE], with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R86's admission MDS with an ARD of 07/12/22 revealed R86 had a BIMS score of 00 out of 15, indicative of severe cognitive impairment. The MDS revealed R86 was assessed by staff as needing only supervision when ambulating and steady at all times when walking. Review of R37's Progress Notes EMR tab showed: 8/23/2022 20:34 [8:34 PM] Behavior Note Note Text: Resident highly agitated stating 'Get out of her house.' Entered another residents [sic] room and attempted to physically strike him with closed fist. This nurse was able to redirect hands and resident angrily exited room on own stating this was her house. Resident currently requiring 1:1 [one on one] care for other resident safety. 8/23/2022 21:28 [9:28 PM] Alert Note Note Text: On call, [Nurse Practitioner], notified of patients behavioral issues. On call ordered 2.5mg [milligrams] IM [intramuscular] [MEDICATION(S)] x1 [one time]. UA [urinary analysis] C&S [culture and sensitivity]. Will continue to observe. 8/23/2022 21:47 [9:47 PM] Behavior Note Note Text: NP on call contacted about resident's agitated behavior. N/O [new order] received. Attempt to contact family resulted in busy signal will cont [continue] to attempt contact. Then an SBAR (Situation, Background, Assessment, Recommendation) on 08/23/22 at 10:15 PM that stated: .Resident has had increased behavior (wandering and argumentative speech with staff) in past 24 hours. This shift resident swearing at staff and other residents. Placed hands on another resident and pushed her causing a fall. Then attempted to enter other residents' rooms, when staff attempted to redirect resident became belligerent yelling loudly and cursing but exited room. 1:1 required this shift for other residents' safety. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: [MEDICATION(S)] 2.5mg IM x 1 dose now. Attempt to obtain UA C&S prior to injection. If unable to obtain or resident resistant obtain on 8/24. If resident is asleep do not wake to obtain. Review of R86's EMR Progress notes tab showed: 08/23/2022 20:17 [8:17 PM] Alert Note Note Text: Pt [patient] was approached by agitated resident. Agitated resident placed hands angrily on patients [sic] chest and pushed causing her to fall on left side. Patient and agitated resident separated. Staff assisted pt X2 [two staff] from floor to chair. Patient placed at nurses station for safety and observation. Pt was visibly upset, crying and grimacing. Pt vital signs . No visible skin discoloration or alternation [sic] noted at this time. Pt complains of pain in left leg. Pt unable to specify where pain is located. Pt refusing to weight bear and favoring left side. Pt grimacing and visibly upset with tears streaming down face when staff attempted a two person assist stand from chair. Pt given Tylenol PRN [as needed], standing order. DON [Director of Nursing] notified. Family Notified. Hospice Notified. Hospice physician en route to further evaluate pt for adverse reaction to fall. Will continue to observe. 08/23/2022 21:37 [9:37 PM] Alert Note Note Text: Hospice [name] arrived to evaluate patient following incident. Hospice suggests patient be sent to ED [emergency department] for further evaluation. Family notified of condition. EMS [emergency medical services] called for transer [sic]. Will continue to monitor. 08/24/22 02:06 [2:06 AM] Alert Note Note Text: Patient returned to facility via EMS at 0205 [2:05 AM]. Patient has a fractured trochanter, non-operable. Pt nonweight [sic] bearing. DON notified. Will continue to observe. A voicemail message was left for Registered Nurse (RN) 62 regarding the incident notes for R37 on 09/09/22 at 4:03 PM. No return call received. During an interview on 09/09/22 at 8:15 PM with the Administrator and Operations Manager (OM), neither was in the facility at the time of the incident but they were notified by staff. The two agreed there were no signs prior to the day of the incident that R37 would become physical with another resident. Both residents were independently ambulatory at the time of the incident and there had been no incidents with R37 and R86 prior to the event and no other incidents with R37 other than the one involving R38. The Administrator stated, We changed [R37's] room and ordered a psychiatric evaluation, which, unfortunately, did not occur prior to the incident with [R38]. Staff have been educated to keep [R37] away from other residents. The Administrator expressed an expectation that she absolutely positively prefers to never have resident to resident altercations. A voice mail message was left for RN6 on 09/09/22 at 8:37 PM and returned on 09/10/22 at 6:04 PM. RN6 stated she was working the night of the incident and R37 gave no indication that she would have an altercation with another resident. RN6 stated the two residents (R37 and R86) were just passing in the hall and she pushed her. RN6 examined R86 after the fall and noted pain; she contacted hospice and R86 was sent to the emergency room . R86 returned later that night with a trochanter fracture and was not a candidate for surgery so she is now non-weightbearing and in bed. 2. Review of the Admission Record located in the Profile tab of the EMR revealed R38 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the quarterly MDS assessment with and ARD of 06/04/22 revealed a BIMS score of seven out of 10 which indicated R38 was impaired in cognition for daily decision-making and had no behaviors. R38 was not interviewable. Review of the investigation provided by the facility for an incident on 08/28/22 at 8:49 PM, revealed, .Staff member reported that resident, [R37], was with resident, [R38] in the doorway of their [room]. [R38] stated that resident, [R37] wanted to close the door to the room and R38 wanted the door left open [R37] then hit R38 in the face. Staff separated residents. Resident, [R38] was assessed for injury with a scratch to the bridge of her nose and a scratch to left eyelid. During an interview on 09/09/22 at 8:15 PM with the Administrator and OM, they confirmed that R37 had not been involved in any other incidents since the incident with R38. The Administrator stated, We changed [R37's] room and ordered a psychiatric evaluation, which, unfortunately, did not occur prior to the incident with [R38]. Staff have been educated to keep [R37] away from other residents. In a follow up interview on 09/09/22 at 9:00 PM, the OM confirmed R37's behavior health evaluation occurred on 08/30/22.

Based on review of facility policy, menu review, observations and interviews, the facility failed to ensure that food was prepared in a form to meet individual needs for 7 of 116 current facility residents (Resident (R) 35, R10, R223, R85, R88, R224, R225). Multiple residents stated they had difficulty consuming food served as substitutions to the menu. The deficient practice has the potential to create a choking risk and result in decreased resident intake. Findings include: Review of the facility's undated policy titled, Therapeutic Diets, indicated All residents have a diet order, including regular, therapeutic, and texture modification, that is prescribed by the attending physician, physician extender, or credentialed practitioner in accordance with applicable regulatory guidelines. 'Therapeutic diet' is defined as a diet ordered by a physician, or delegated registered or licensed dietitian, as part of the treatment for a disease-e or clinical condition. The purpose of a therapeutic diet is to eliminate or decrease specific nutrients in the diet (e.g. sodium), or to increase specific nutrients in the diet (e.g. potassium), or to provide food that a resident is able to eat (e.g. mechanically altered diet). 'Mechanically altered diet' means one in which the texture of the diet is altered. When the texture is modified, the type of texture must be specific and part of the physicians' or delegated registered or licensed dietitian's order. The Week-At-A-Glance menu provided by the facility revealed the following planned lunches: For 09/07/22, BBQ Pork Loin, Black-Eyed Peas, Seasoned Okra, Cornbread, Mandarin Oranges, Tea of Choice, or Salisbury Steak, Herbed Rice, Braised Cabbage. For 09/08/22, Chicken Soft Taco with Flour Tortilla, Cilantro Rice, Mexican Corn, Deluxe Fruit Salad, and Tea of Choice; or Citrus Fish, Oven Roasted Potatoes, Capri Vegetable Blend and Dinner Roll/Bread. During an observation of the main kitchen on 09/07/22 at 9:30 AM, the Dietary Manager (DM) and the Kitchen Manager (KM) stated foods were ordered on Thursdays for lunch through Tuesday and on Mondays for Tuesday's dinner through Friday's lunch. The KM said it had been hard to get some products in, so substitutions were made. The KM stated, when substitutions were made the Registered Dietitian (RD) signed off on the substitutions. The KM indicated they did not have the black-eyed peas and okra for today's lunch so corn on the cob would be substituted. The following observations were made on 09/07/22 during lunch service from 11:55 AM - 12:50 PM on the 100 hall. At 11:55 AM, lunch trays were brought to the floor and the certified nurse aides (CNAs) passed out trays to the residents. At 11:56 AM, R88 was trying to cut the corn off the cob. R88 said it would be better if she had some teeth to eat the corn with. R88's meal ticket on the tray indicated, Please enjoy the substitution of Corn on the Cob in place of Okra if appropriate. At 11:59 AM, R35 was observed sitting on her bed trying to eat her lunch. R35 was observed trying to eat the corn on the cob and her dentures fell out. R35 stated, I was trying to eat my corn and my teeth fell out, and pointed to her dentures. R35's meal ticket on the tray indicated, Please enjoy the substitution of Corn on the Cob in place of Okra if appropriate. At 12:07 PM, R85, referring to the corn on the cob stated she did not like it and she could not eat it. R85's meal ticket on her tray indicated an advanced dysphagia texture, chopped okra, and Please enjoy the substitution of Corn on the Cob in place of Okra if appropriate. At 12:48 PM, R10 stated she was concerned about the corn on the cob on her plate, because she had no teeth and was not able to eat the corn. R10's meal ticket on the tray indicated, Please enjoy the substitution of Corn on the Cob in place of Okra if appropriate. During an observation of lunch service on 09/08/22 at 12:10 PM, R223, when asked if lunch was good, stated she could not eat lettuce or the tortilla because she had no teeth, so she only had a bite or two. R223's meal ticket on her tray indicated an advanced dysphagia diet texture, no lettuce, and Please enjoy the substitution of Nachos in place of Flour Tortilla's if appropriate. R223 asked the surveyor to ask the kitchen for some mashed potatoes or applesauce, so she had something to eat. The DM was informed and replied that tortillas were on a soft diet, but he would take care of the lettuce issue. During dining observations on 09/08/22 at 12:30 pm, R224 stated the food was good, but having to take time to eat the chips, it was difficult. R225 stated he did not have any teeth to eat the chip and lettuce so he ate what he could. R224's and R225's meal tickets on the trays indicated, Please enjoy the substitution of Nachos in place of Flour Tortillas if appropriate. During an observation on 09/08/22 at 12:42 PM, R10 had only completed about 15% of her lunch. She stated she could not chew the nacho chips, or the lettuce because she had no teeth. R10's meal ticket on the tray indicated, Please enjoy the substitution of Nachos in place of Flour Tortilla's if appropriate. During an interview on 09/08/22 at 2:47 PM, the DM and KM revealed they were trying to please everyone with the meals and the corn on the cob was one of the ways. The staff stated they were unaware residents found corn on the cob difficult to consume. They stated the food supply company had been out of stock on certain foods. The DM and KM stated they did not get much feedback directly from the residents. The information they used to determine if resident's were eating came from what staff charted in the computer. According to the DM, he stated his documentation for Resident 10, revealed she ate 75-100% of her meal. During an interview on 09/09/22 at 11:38 AM, the District Manager for the food service stated the facility used a four-week menus cycle. The District Manager stated when residents' dislikes were entered in the computer system, the system would automatically remove unliked items from the menu and that was what was followed for the residents. The District Manager stated menus were posted in the hallway with changes three days prior to service. The District Manager indicated he understood what the concerns are about the corn on the cob, the tortilla chips, and soft taco for the residents observed with difficulties eating. The District Manager stated it would be good to set up with the Speech Therapist and get a better understanding of resident and eating pattern. During an interview on 09/09/22 at 4:33 PM, the Registered Dietitian (RD), indicated when residents admitted to the facility the speech therapist evaluated them and it's up to them the down grade from regular, to soft mechanical, etc . The RD stated for the future this information would need to put on the resident dislike list, to avoid difficult foods. The RD stated from her knowledge there had not been an issue with these residents before. The RD felt residents could still eat the items in question because their gums are hard. The RD stated evaluations were done upon admission, annually, sufficient change, wounds and if staff see needs to be addressed.

Based on interview, record review, and review of facility policy, the facility failed to ensure that the code status (to resuscitate or not) for 1 of 32 residents (Resident (R) 222) reviewed in the initial pool survey process was accurately documented in all areas of the medical record to ensure the resident's code status was honored. This failure had the potential to negatively affect the dignity, designated wishes, and physical status of the resident in case of cardiac or respiratory arrest. Findings include: Review of the facility policy titled Advanced Directives, revised [DATE], showed: Policy Interpretation and Implementation 1. Upon admission, the resident will be provided with written 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. 15. In accordance with current OBRA definitions and guidelines governing advance directives, our facility has defined advanced directives as preferences regarding treatment options and include, but are not limited to:. e. Do Not Resuscitate - indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used. Review of R222's Admission Record on [DATE] at 9:01 AM, from the electronic medical record (EMR) Profile tab, showed an admitted [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Under the heading of Advance Directive, the Admission Record showed R222 as CPR [cardiopulmonary resuscitation]. Review of the heading on R222's EMR showed him to be a full code, indicating CPR would be performed. Review of the Documents did not show any signed paperwork regarding resuscitation code status. Review of R222's hard (paper) chart showed a red piece of paper at the front of the chart that stated DNR [do not resuscitate] Notify the physician of lack of vital signs; obtain order for time of death per state regulation. Behind the Advance Directives tab in the hard chart was a physician's certification that R222 was capable of making healthcare decisions and a Resident/Family Consent for Cardiopulmonary Resuscitation that showed an X by the choice I understand that cardiopulmonary resuscitation is an extraordinary measure and SHOULD NOT be done on [blank line with R222's name handwritten in]. This form was signed by R222 on [DATE]. On [DATE] at 9:00 AM, the Social Worker (SW) provided R222's chart showing the DNR information and was not sure where the disconnect was. After reviewing the EMR showing full code and the hard chart showing DNR, the SW asked if she could get back to you when asked if she was confirming there was a difference. At 9:07 AM, the SW confirmed the EMR had shown CPR, but there is no discrepancy now, and the hard chart was DNR status. During an interview on [DATE] at 7:15 PM, the Administrator stated, The procedure would be to talk to the resident and/or family during admissions and if there is no code status, the resident would be a full code until the physician could determine the capacity of the resident to make health care decisions, then would discuss the code status with family or the resident at which time the physician would fill out the code status and the EMR would be updated. The Administrator expressed an expectation that the chart and the EMR would match for a resident's code status.

Based on record review and interview, the facility failed to ensure that a surety bond provided adequate coverage for the residents' personal funds account. The facility's surety bond was less than the amount in the residents' funds account for 75 of 75 residents as documented on the trial balance sheet provided by the facility. The findings included: A review of the residents' personal funds account on 5/25/21 at approximately 1:56 PM revealed the total amount of residents funds to be $157,764.46 on a trial balance sheet provided by the facility. The facility's surety bond coverage was noted to be in the amount of $62,000 which was less than the money in the residents' personal funds account. An interview on 5/25/21 at approximately 2 PM with the Business Office Manager confirmed the findings. When asked if the facility had contacted their corporate office related to the facility's funds being more than the facility's surety bond? The Business Office Manager stated the corporate office was aware and further stated that residents' had a year to spend down the funds in the their account.

Based on observation, interview, and review of facility policy titled Coronavirus (COVID- 19) Precaution Plan the facility failed to provide visitation information that was accessible to all residents and resident representatives. An observation on 5/23/2021 at approximately 11:00 AM revealed that a Resident Representative was denied access to visit Resident #113. Resident Representative stated that they were unaware of the visiting hours for the facility. Staff explained to the Resident Representative that visiting hours are 12 PM - 4 PM on Sunday's and information was available online on the facility website and postings are on the front door and at each Nurses Station in the facility. An interview with the Administrator and Director of Nursing (D.O.N.) on 5/25/2021 at 10:26 AM revealed that Visitation Hours are Monday - Friday 9 AM - 5 PM, Saturday 11 AM - 3 PM, and Sunday 12 PM - 4:30 PM so that staff would have an appropriate amount of time to clean in between visitations and for social distancing precautions. The Administrator further revealed that residents can review visitation hours online (on the facility website), visiting the Nurses Station on each unit, and a channel on their television's that is in every resident's room that has facility information and updates. The D.O.N. revealed that the facility did not notify residents or resident representatives in writing or by phone information about visitation hours. On 5/24/2021 at approximately 12:00 PM, a review of the facility policy titled Coronavirus (COVID- 19) Precaution Plan revealed that The facility will communicate facility-specific visitation guidelines with resident family and keep them informed of changes to the visitation policy.

Based on observation and interview, the facility failed to ensure that the dietary staff wore appropriate hair restraints, maintained the kitchen and its equipment in good repair, and adequately clean. In addition, the facility failed to ensure all food items were properly labeled and dated, expired foods were removed from use, and dishware was dried and stored according to standard practice for 1 of 1 kitchen observed. The findings include: On [DATE] at approximately 10:49 AM, the cook was observed in the kitchen without a hair net. The ice-machine door was hard to open. It made a loud sound when opened and had a pink build-up inside of the door. A reach-in cooler contained a plate of salad without label or date, 8 brown plastic cups containing cooked food inside was without a label or date, a [NAME] steel container with approximately 6 fried kitchen patties dated ,d+[DATE], and 3 other foods without the label or the date on them. A Jar of mustard with an expiration date of [DATE]. The flour and sugar bins had no label or dates and appeared dusty. The kitchen floor felt sticky during the walkthrough. There was trash under the dishwasher floor and the edges and corners of the floor had brown buildup. There was trash in the walk-in cooler and freezer. Boxes in the freezer were stacked up to the ceiling. The kitchen's overall appearance was poor (it appeared greasy and not clean). On [DATE] at approximately 8:09 AM, the kitchen supervisor did not have a cover or hair net. S/he had a cap that was not covering [his/her] entire head. The top part of the ice machine on the east wing was unscrewed and loosed. On a third visit to the kitchen on [DATE] at approximately 08:29 AM, 10 wet nesting pans storage in the clean area were noticed. The findings were discussed and confirmed by the Certified Dietary Manager (CDM), kitchen supervisor, and the cook.

A random observation on 5/23/21 at approximately 11:51 AM revealed multiple bed pans/pans in an adjoining bathroom for resident rooms [ROOM NUMBERS]. There were 4 gray pans, 2 bed pans and a urinal in the bathroom. The bed pans were stacked on top of each other on a shelf above the commode. There was a urinal hanging from support rails bathroom. The pans were noted loosely in the shared bathroom. Two of the bed pans did not have a name on it. An interview on 5/23/21 at approximately 1:39 PM with Licensed Practical Nurse (LPD) #1 who confirmed the observations. A copy of the facility's infection control process related to bed pan storage was requested. An interview on 5/25/21 at approximately 3:08 PM with Facility Administrator, Facility Consultant and Director of Nursing (DON) revealed the facility does not have a policy on how bed pans should be stored but indicated an in-service was provided on 4/21/21. The DON stated the bed pans should be in individual plastic bags for infection control maintenance. Based on observation, interview and review of facility policy, the facility failed to store bedpans and urinals in a sanitary manner in 1 of 7 shared bathrooms observed. In addition, staff failed to perform hand hygiene after administering medications to Resident #212, 1 of 1 residents observed for Insulin administration. The findings included: The facility admitted Resident #212 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #212 was observed receiving an Insulin injection from Licensed Practical Nurse (LPN) #3 on 5/25/21 at approximately 11:31 AM. LPN #3 donned clean gloves, lifted the resident's shirt, exposed the abdomen and cleansed an area with an alcohol swab. LPN #3 then injected insulin into the resident's abdomen. LPN #3 then removed her/his gloves, left the room and returned to the medication cart. LPN #3 did not perform hand hygiene after removing the gloves or before returning to the medication cart. LPN #3 opened the cart and began to put supplies back into the cart. During an interview with LPN #3, on 5/25/21 at 11:38 AM, LPN #3 was asked at what point s/he performs hand hygiene after administering insulin to residents. LPN #3 continued to touch the medication cart and stated hand hygiene would be done after s/he finished storing the supplies. LPN #3 was asked what the facility policy was for hand hygiene after insulin administration. LPN #3 stated s/he would have to look it up. Review of the facility's Hand Hygiene policy revealed Employees must perform appropriate handwashing procedures after the following conditions: After handling items potentially contaminated with blood, body fluids, excretions, or secretions and After removing gloves .

Based on interview and record review, the facility failed to give 1 of 32 residents the opportunity to formulate their advance directive. Resident #11 was ruled incapable of making their own decisions by only one physician. There was no second physician assessment of the resident's decision-making capacity. The findings included: Resident #11 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #11's chart on 5/24/21 at approximately 9:25 AM revealed the resident had been made Do Not Resuscitate (DNR) by their representative, yet there was only one physician signature in the resident's inability to consent form. Interviews with Discharge Planner, Medical Record Supervisor, Licensed Practicing Nurse #1, and the Director of Nursing on 5/24/21 at approximately 9:35 AM confirmed there was no second physician signature on the resident's inability to consent form. Staff confirmed that, although the resident was not properly assessed for decision-making capacity by two physicians, the resident had not been part of the advance directive process.

Based on interviews, observations, and record reviewa, the facility failed to protect the dignity of 2 of 4 residents reviewed for dignity. Residents #35 and #97 were observed without privacy covers on their catheter bags, exposing their voided urine to those not responsible for their care to include other residents and visitors. The findings included: Resident #35 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident #35 on 5/23/21 at approximately 11:27 AM revealed the privacy cover for the resident's catheter bag was not securely fastened, exposing the urine in the catheter bag. Observation of Resident #35 on 5/23/21 at approximately 1:22 PM revealed the privacy cover for the resident's catheter bag was not securely fastened, exposing the urine in the catheter bag. Observation and interview with Licensed Practical Nurse (LPN) #1 on 5/23/21 at approximately 1:45 PM confirmed the privacy cover was not securely fastened to the catheter bag, exposing the urine. The LPN adjusted the privacy cover. Observation and interview with LPN #2 on 5/24/21 at approximately 3:55 PM revealed the privacy cover was not securely fastened to the catheter bag, exposing the urine. The LPN called for a Certified Nursing Assistant (CNA) to adjust the privacy cover. Resident #97 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident #97 on 5/23/21 at approximately 12:41 PM revealed the catheter bag had no privacy cover. From the doorway, the catheter bag and urine were clearly visible. Observation of Resident #97 on 5/23/21 at approximately 2:40 PM revealed the catheter bag had no privacy cover. From the doorway, the catheter bag - now emptied -- was clearly visible. Observation of Resident #97 on 5/23/21 at approximately 3:14 PM revealed the catheter bag had no privacy cover. From the doorway, the catheter bag and urine were clearly visible. Review of the facility's policy titled Resident Rights on 5/25/21 at approximately 2:28 PM revealed that residents are to be treated with consideration, respect, and in full recognition of [their] dignity and individuality, including privacy in treatment and in care for [their] personal needs.

The facility admitted Resident #58 on 8/21/09 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A random observation on 5/23/21 at approximately 10:59 AM revealed Certified Nursing Aide (CNA) #1 providing personal care to Resident #58. The door was opened when the surveyor knocked for permission to enter. When the surveyor heard permission to enter, Resident #58 was in the room in bed with the privacy curtains open, and the resident's body exposed. The surveyor exited the room and then CNA#1 closed the door. An interview on 5/23/21 at approximately 11:11 AM with Certified Nursing Aide (CNA) #1 confirmed the observation. CNA #1 then pointed to a resident in the hallway and stated he/she was the one who opened the door and he/she did not have time to close it again. The CNA was not wearing a name tag during the interview. The CNA further stated that the door should have been closed as well as the privacy curtains. Based on observation, interviews, and review of facility policy, the facility failed to provide personal privacy during medical treatment and personal care for Residents #212 and #58, 1 of 1 residents reviewed for Insulin administration, and 1 of 1 observed receiving personal care. Resident # 212 was not provided privacy while receiving an insulin injection in the abdomen. Resident #58's uncovered body was observed from the hallway. The findings included: The facility admitted Resident #212 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #212 was observed receiving an Insulin injection from Licensed Practical Nurse (LPN) #3 on 5/25/21 at 11:31 AM. LPN #3 knocked and entered the resident's room and explained the the procedure to the resident. LPN #3 did not close the resident's door to the hallway or pull the privacy curtain to provide full visual privacy. LPN #3 lifted the resident's shirt, exposed the abdomen and cleansed an area with an alcohol swab. LPN #3 then injected insulin into the resident's abdomen. During an interview with LPN #3, on 5/25/21 at 11:38 AM, LPN #3 confirmed s/he did not provide the resident with privacy during the injection. LPN #3 stated s/he would normally close the door or pull the curtain when giving an injection. Review of the facility's General Dose Preparation and Medication Administration Policy revealed Observe each resident's privacy and rights in accordance with applicable law (e.g., knocking before entering the room, pulling privacy curtains .).

Based on observation, interview, and review of facility policy titled Coronavirus (COVID- 19) Precaution Plan the facility failed to allow visitation at the facility. Resident #113 was admitted to the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation on 5/23/2021 at approximately 11:00 AM revealed that a Resident Representative (RP) was denied access to visit Resident #113. Resident Representative stated that they were unaware of the visiting hours for the facility. Staff explained to the Resident Representative that visiting hours are 12 PM - 4 PM on Sundays and information was available online on the facility website and postings are on the front door and at each Nurses Station in the facility. An interview with Resident #113 on 05/24/21 at 03:45 PM revealed that the facility would not allow their resident representative to enter the facility due to visitation hours. Resident #113 stated that they felt like this was a limitation and against their rights as a resident. An interview with the Administrator and Director of Nursing (D.O.N.) on 5/25/2021 at 10:26 AM revealed that Visitation Hours are Monday - Friday 9 AM - 5 PM, Saturday ' s 11 AM - PM, and Sunday ' s 12 PM - 4:30 PM so that staff would have an appropriate amount of time to clean in between visitations and for social distancing precautions. The Administrator further revealed that residents can review visitation hours online (on the facility website), visiting the Nurses Station on each unit, and a channel on their television 's that is in every resident 's room that has facility information and updates. A review of the facility rules for visitation on 5/23/2021 at approximately 3:00 PM revealed that Each visit is 15 minutes long and must be scheduled. Review of facility policy on 5/24/2021 at approximately 12:00 PM policy titled Coronavirus (COVID- 19) Precaution Plan revealed that Visitors who come to see vaccinated patients can come/go as they please during center's visiting hours. There are no set timeframes or time limits for the visit. Visitors must wear a face mask, be able to pass the screen, and sign the waiver to enter.

Based on record review and staff interview, the facility failed to ensure that a resident who experienced a significant change in functional status was comprehensively assessed for one of one sampled resident reviewed for the activity of daily leaving (ADL). Resident #77 had a significant decline in one or more areas of activity of daily leaving (ADL). Findings include: The facility admitted Resident # 77 on 3/28/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #77's quarterly minimum data set (MDS) assessment dated [DATE] and reviewed on 5/24/21 at 2:35 PM indicated [s/he] was able to perform personal hygiene, bathing, dressing, and toilet use with only supervision. Review of following quarterly MDS assessment dated [DATE] revealed that Resident #77's functional status changed from supervision to extensive assistance in personal hygiene, bathing, dressing, and toilet use. In an interview with the MDS Coordinator #1 [s/he] confirmed that the facility failed to conduct the required 14 days a significant change assessment for Resident #77.

Based on review of facility files and interview, the facility failed to ensure that the services provided by the facility meet professional standards of quality. Review of Resident #1's medical record revealed an x-ray result dated 8/21/18. Review of Resident #1's medical record revealed no documentation related to the x-ray until 8/23/18. There was no documentation in the resident's medical record related to why the x-ray was obtained. The facility reported an injury of unknown source to the State Agency for Resident #8, the CNAs failed to inform the nurse of the incident involving Resident #8. Two of fourteen residents reviewed for professional standards. The findings included: The facility reported an injury of unknown source to the State Agency on 8/23/18 for Resident #1 for a compression fracture of back. The Initial 23-Hour Report indicated the reportable incident was reported at 1:00 PM on 8/23/18. Review of the facility's Five-Day Follow-Up Report dated 8/27/18 revealed upon completion of investigation including staff interviews and review of medical record, resident has had no falls. Resident has a [DIAGNOSES REDACTED]. The surveyor requested a copy of the facility's complete investigation into the incident involving Resident #1. Review of the facility's investigation revealed only one witness statement. License Practical Nurse (LPN) #2's facility-obtained statement dated 8/23/18 indicated s/he received an x-ray report that showed suspicion of possible compression fracture in spine. A Computerized tomography (CT) Scan was ordered. Review of Resident #1's Radiology Report revealed the date of service as 8/21/18 and signed by the radiologist on 8/21/18 at 12:31 PM. The Radiology Report had alert results of poorly seen but suspected T 11 vertebral compression fracture with anterior wedging deformity of unknown age. CT scan was advised. The fax stamp across the top of the Radiology Report indicated 8/21/18 at 12:36 PM. Review of Resident #1's Progress Notes revealed an entry on 8/23/18 at 12:54 that indicated x-ray right hip and pelvis done with findings of suspected T 11 vertebral compression fracture with anterior wedging deformity of unknown age. Resident #1 seen by nurse practitioner and an order for [REDACTED]. The previous entry was dated 8/20/18 at 6:30 PM and indicated resident returned from [MEDICAL TREATMENT] with no distress noted. Appears stable and no distress. Review of Resident #1's medical record revealed no documentation related to the resident having a change in condition that would indicate why an x-ray was done. Review of the Daily Assignment Sheet revealed LPN #2 was assigned to Resident #1 on day shift on 8/23/18. Review of Resident #1's Medication Administration Record [REDACTED]. Resident #1 was administered [MEDICATION NAME] 5-325 mg 1 tablet as needed for pain on 4:45 PM on 8/21/18. During an interview on 1/18/19 at approximately 10:45 AM the Risk Manager stated Resident #1 complained of discomfort in his/her back to LPN #2 on 8/23/18. The nurse completed an x-ray and the result was a compression fracture. The Risk Manager stated s/he had no knowledge of the resident having prior complaints of back pain. The Risk Manager stated s/he spoke with LPN #2 and s/he said it was the first time the resident had complained of back discomfort. The Risk Manager stated s/he only got a statement from LPN #2, who the resident complained to. The surveyor reviewed the medical record with the Risk Manager related to the Radiology Report being dated 8/21/18 and no documentation of follow-up with the results until 8/23/18. The Risk Manager stated s/he would double check and make sure. The Risk Manager returned and stated s/he does not know why the Radiology Report was dated 8/21/18 but not reported or documented in the resident's Progress Notes until 8/23/18. The Risk Manager stated no incident report was completed for Resident #1. During an interview on 1/18/19 at approximately 2:05 PM the DON stated s/he could not locate anything on why the x-ray was done on 8/21/18 and not documented in Resident #1's Progress Notes until 8/23/18. The facility reported an injury of unknown source to the State Agency for Resident #8 on 10/15/18. Review of the facility's Five-Day Follow-Up Report dated 10/18/18 revealed upon completion of investigation including staff interviews and review of medical record, staff that was in the bathroom with resident did not witness her fall. Resident #8 has not had a fall in several months. Review of CNA #4's facility-obtained statement dated 10/16/18 revealed s/he and another CNA were getting Resident #8 out of the restroom. When they went to stand the resident up s/he tried to sit down to early and the chair was not behind him/her. Resident #8's legs then buckled, but s/he did not hit the floor. Review of CNA #5's facility-obtained statement dated 10/15/18 revealed on 10/11/8 Resident #8 was placed on the toilet using 2 person assist. CNA #4 and CNA #5stepped out of the room so the resident could use the bathroom. Resident #8's daughter/son-in-law and resident were arguing and s/he came out and asked CNA #4 and CNA #5 to get the resident off the toilet. CNA #4 and CNA #5 went in and asked Resident #8 to stand, as they stood the resident up his/her daughter/son-in-law began to talk with him/her. They were having words as the CNAs were cleaning the resident. Resident #8 thought the chair was behind him/her, s/he went down and CNA #4 and CNA #5 grabbed him/her and put them in the chair. Resident #8 never hit the floor. Review of LPN #2's facility-obtained statement dated 10/15/18 indicated s/he had no knowledge of Resident #8 having any falls. Review of RN #2's facility-obtained statement dated 10/15/18 indicated s/he did not know of any incidents with Resident #8. Review of RN #1's facility-obtained statement dated 10/16/18 indicated Resident #8 did not fall during shower. Resident's daughter/son-in-law was at the facility and made no report regarding a fall on 10/11/18. Review of Resident #8's Progress Notes revealed on 10/11/18 at 11:47 AM resident combative with care. Taken into shower room by nurse and CNA. When attempting to undress resident s/he punched the CNA. Daughter/son in law present and asked to come into the shower room. Eventually able to undress resident and begin bathing. On 10/11/18 at 9:50 PM resident pointing to right leg and wincing. Resident fighting staff and refused care at 9:30 PM. On 10/11/18 at 11:02 PM resident complained of nausea and complained of pain in right knee when s/he moves. Grandson/Granddaughter here and demands s/he has an injection for his/her nausea. Wants resident seen in AM by MD (Medical Doctor) or NP (Nurse Practitioner). Check both knees. Call placed to NP and received order for [MEDICATION NAME]. On 10/12/18 at 10:51 AM resident with swelling and pain noted to bilateral knees. Nurse practitioner in to examine with order to send resident to rheumatology. On 10/13/18 at 6:30 PM resident continues to refuse care. The nurse attempted to provide care but resident displayed signs of pain to right knee and would not allow peri care. Scheduled [MEDICATION NAME] was given. Responsible party notified of refusal of care at approximately 6:00 PM. On 10/13/18 at 9:36 PM responsible party requesting resident be sent to emergency room for evaluation to right knee due to increased pain related to swelling. On call clinician notified at 9:35 PM and order given to send to emergency room . Review of the Transfer to Hospital Form dated 10/13/18 revealed resident complained of increased pain to right knee with swelling noted to area. Resident stated pain started on 10/11/18. Review of the SBAR (Situation, Background, Assessment, Recommendation) Communication Form revealed resident with increased right knee pain and swelling that started on 10/11/18. Indicated resident's family requested ER (emergency room ) intervention. Review of the resident's (MONTH) MAR (Medication Administration Record) revealed the resident was monitored for pain TID (Three Times a Day). The resident had no pain noted from 10/1/18-10/11/18. On 10/11/18 on second shift the resident was coded as having mild pain. On 10/12/18 the resident was coded as having mild pain on all three shifts. On 10/13/18 the resident was coded as having severe pain on first shift. Resident had an order for [REDACTED].>Review of the Hospital History and Physical dated 10/14/18 revealed the resident presented with right knee pain. Resident stays at a SNF (Skilled Nursing Facility) and apparently had a fall 2 days ago (per reports) but was found today by family complaining of right leg pain. Resident was brought to ER and found to have a distal right femoral fracture. Review of the NP Progress Note dated 10/22/18 resident was being seen s/p hospitalization for right knee pain. Note resident reported falling 2 days prior to hospitalization . Resident was found to have a right femoral fracture. During an interview on 1/18/19 at approximately 11:10 AM, the Risk Manager stated on 10/15/18 s/he received a report the resident had a right femur fracture. LPN #2 reported the fracture to him/her at 9:45 AM. The Risk Manager was trying to investigate how the injury came about. Resident #8 stated s/he had a fall in the bathroom, that is what s/he told the grandson/granddaughter. The Risk Manager interviewed several staff and found two CNAs reported that while s/he was in the bathroom they had him/her up standing with 2 CNAs trying to clean the resident. Resident #8 buckled but did not touch the ground. There were two CNAs holding the resident up, and one of the CNAs were trying to clean the resident. The resident could bear weight at that time. The resident's daughter/son-in-law was behind the wheelchair at the time of the incident. When the resident buckled they transferred him/her back to the wheelchair. The incident occurred on 10/11/18. The Risk Managers stated the CNAs reported the incident to the nurse. The DON stated they did not do an incident report because the resident did not fall. The DON stated if the nurses knew about the resident buckling then they should have done an assessment. The DON stated s/he is not sure when the CNAs told the nurses about the incident. The DON said s/he is not sure what happened at the time of the incident when the resident buckled so s/he can't say if the CNAs should have reported it to the nurses. The Risk Manager stated Resident #8 was evaluated by the nurse practitioner and if s/he feels like the resident needs to be sent out then the resident will be sent out. Neither the DON nor Risk Manager know if the nurse practitioner was aware the resident buckled prior to complaining of knee pain.

Based on record review and interview, the facility failed to ensure Resident #1 received adequate supervision and assistance to prevent accidents/hazards, 1 of 5 sampled residents reviewed for Accidents/Hazards. Resident #1 had a documented food allergy to peanuts and was served peanut butter crackers. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Record review of the Telephone Orders on 7/9/2018 at 12:01 PM revealed a dietary order, dated 4/16/2018, indicating the resident should have no nut and no chocolate. Record review of a Diet Requisition Form on 7/9/2018 at 12:30 PM, revealed the resident was to have no nuts and no chocolate. Record review of the care plan on 7/9/2018 at 3:59 PM, revealed the resident had a peanut allergy. Record review of the Nurse Aide's Information Sheet on 7/9/2018 at 12:05 PM, revealed the resident had a food allergy to peanuts. Record review of the Nurse's Notes on 7/9/2018 at 12:45 PM, revealed a note, dated 4/25/2018, indicating Resident #1 called the nurse into her/his room and stated s/he placed a cracker into her/his mouth and did not realize it was a peanut butter cracker until it was in her/his mouth. The note indicated the resident did not eat the cracker. The Nurse Practitioner (NP) was notified and instructed the nurse to monitor for any reaction. A few minutes later the resident stated she/he was having an anaphylactic reaction with difficulty breathing and needed a dose of [MEDICATION NAME]. The NP was called again and gave orders for [MEDICATION NAME] and to send the resident to the emergency room . The [MEDICATION NAME] was given and E[CONDITION] was called. The note indicated the resident was lying in bed communicating with staff while waiting for E[CONDITION]. During an interview with the Risk Manager (RM) on 7/9/2018 at 2:51 PM, the RM confirmed the resident was given peanut butter crackers by a Certified Nursing Assistant (CNA). The Risk Manager confirmed the resident care plan and the Nurse Aide's Information Sheet indicated the resident had a peanut allergy. The RM also provided a staff in-service done on 4/26/2018 related to resident allergies [REDACTED].>During an interview with Registered Nurse (RN) #1 on 7/9/2018 at 3:05 PM, RN #1 stated the resident had asked for a snack and the CNA brought her/him crackers. RN #1 was called to the resident's room and the resident told RN #1 s/he did not eat the cracker and spit it out after s/he realized it was a peanut butter cracker. A few minutes later, RN #1 was called back to the room and the resident complained of difficulty breathing and going into anaphylactic shock. RN #1 stated orders were received for [MEDICATION NAME] and to send the resident to the emergency room . RN #1 stated the resident was stable and had no difficulty talking while waiting for E[CONDITION]. During an interview with CNA #1 on 7/9/2018 at 3:11 PM, CNA #1 stated on 4/25/2018 the resident asked her/him for a snack. CNA #1 asked what kind of snack and the resident told her/him anything with peanut butter. CNA #1 stated s/he was sure this is what the resident asked for because s/he asked the resident if s/he wanted a sandwich or crackers, since the facility had peanut butter and jelly sandwiches, also. CNA #1 stated the resident replied s/he would just have the crackers. CNA #1 stated s/he brought the resident the crackers and was unaware the resident had a peanut allergy. Review of a written statement by Resident #1, dated 5/7/2018, Resident #1 indicated s/he asked for a snack and told the CNA s/he could not have anything with nuts or chocolate. Review of the hospital History and Physical from 4/25/2018 revealed the resident complained of shortness of breath on admission, but displayed no symptoms of anaphylactic shock. The resident was admitted to the hospital for an unrelated matter.

Based on record review and interview, the facility failed to provide scheduled pain medication timely for Resident #1, 1 of 4 sampled residents reviewed for pain management. Resident #1's pain medication was administered 7 hours late due to the medication being out of stock at the facility. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Record review of the physician's orders [REDACTED]. Record review of the Medication Administration Record [REDACTED]. In addition, the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Further record review on 7/9/2018 at 11:57 AM revealed a faxed prescription, dated 4/17/2018, for [MEDICATION NAME] [MED] extended release 30 mg every 12 hours. The resident's date of birth was omitted from the prescription. The prescription was faxed to the pharmacy on 4/17/2018 at 3:25 PM. Record review of the Nurse's Notes on 7/9/2018 at 12:45 PM, revealed a note from 4/19/2018 at 4:30 AM, indicating the resident was given her/his 9:00 PM dose of [MEDICATION NAME] extended release at 4:00 AM. The Nurse's Notes also indicated the resident was very upset his/her [MEDICATION NAME] took so long to arrive from the pharmacy. There was no pain evaluation done at the time of administration. During an interview with the Assistant Director of Nursing (ADON) on 7/9/2018 at 2:35 PM, the ADON confirmed that the resident's scheduled pain medication was given 7 hours late due to waiting for it to come in from the pharmacy. During an interview with the Director of Nursing (DON) on 4/10/2018 at 10:40 AM, the DON stated the resident was admitted from the hospital with enough [MEDICATION NAME] to last through the 9:00 AM dose on 4/18/2018. The DON stated the physician saw the resident on 4/17/2018 and wrote a refill prescription which was faxed timely to the pharmacy. The DON also stated that the prescription was faxed without the resident's date of birth and this caused the delay in delivery of the medication. The DON stated eventually someone from the pharmacy contacted the facility about the discrepancy and the prescription was faxed again with the date of birth. During an interview with the DON on 4/10/2018 at 1:40 PM, the DON stated the facility keeps a supply of [MEDICATION NAME] immediate release in the Stat Box. The DON stated the resident could have been given this while waiting for the medication to be delivered. The DON also stated nurses are frequently educated on the availability of medications in the Stat Box. The DON provided Vital Signs Reports from the 2nd and 3rd shifts on 4/18 and 4/19. The DON stated the reports indicate the resident's vitals signs were stable and did not appear to be affected by the lack of pain medication. The DON also stated s/he was not denying that the resident was in pain due to the lack of pain medication. During an interview with the Nurse Practitioner (NP) on 7/10/2018 at 12:37 PM, the NP stated it was reasonable to believe that the resident was having increased levels of pain due to the long delay in receiving her/his scheduled pain medication. In a written statement provided by Resident #1 on 5/7/2018, Resident #1 indicated her/his pain level was nearing a 10 out of 10 on the pain scale when her pain medication was due on 4/18/2018. The resident also indicated that by midnight s/he was in severe pain. The resident statement indicated s/he had been up all night due to pain. In addition, after the resident received the [MEDICATION NAME] [MED], s/he indicated it was an hour before s/he felt any relief.

Based on record review and interview the facility failed to notify the physician for continued vomiting and pain for 1 of 3 residents reviewed for change in condition. Resident #3's physician was not notified of residents continued vomiting/spitting up and pain after an initial notification on the day shift. The findings included: On 12/22/17 resident #3 was vomiting/spitting up and complained of abdominal pain on the 7 AM - 3 PM shift, sometime after lunch. The resident continued to have vomiting/spitting up and abdominal pain throughout the day. The physician was not notified the resident continued with vomiting/spitting up and pain into the evening shift. The facility admitted resident #3 with [DIAGNOSES REDACTED]. Review of the medical record revealed a Nurse's Progress Note dated 12/22/17 at 2:54 PM, Family in to visit at lunch and fed resident. Resident has been coughing up phlegm and c/o (complained of) stomach pain. Dr. (Doctor) (name of physician) informed and new orders received. RP (responsible party) aware. Further review of the medical record revealed a Radiology Report for a Chest X-ray (CXR) was available for 12/22/17, with a faxed time of 5:44 PM. The chest x-ray conclusion was, No acute cardiopulmonary disease process. No documentation that the physician was notified of the CXR results. On 12/22/17 at 8:26 PM a SBAR (Situation-Background-Assessment/Appearance- Request) Report was completed for physician notification. Situation: Pain (uncontrolled) Since this started it has gotten worse. Vital signs: B/P (blood pressure): 124/72, Pulse: 72, Respirations: 14, Temp 98.8, Oximetry%: 97%. Abdominal/Gastro-intestinal (GI) Evaluation: Vomiting, abdominal pain, abdominal tenderness. Describe vomiting: Description checked was Persistent or recurrent (two or more episodes within 12 hours) vomiting, with or without abdominal pain, bleeding, distention, or fever. Describe abdominal pain: Description checked: Associated with fever, continuous GI bleeding, or other acute symptoms. Describe GI signs and symptoms: brown, then pink, then darker pink vomitous. Pain Evaluation: Facial grimacing, occasional moan or groan. New orders to send to emergency room (ER) for evaluation. On 1/18/18 Licensed Practical Nurse #1 was interviewed by the surveyor. I got in report that s/he had been sick and the doctor had ordered x-rays. I went first to check on her/him. It was clear phlegm. I told them we could not lay her/him down while s/he was vomiting and I could watch her/him in the day room. It took a while for the x-ray report to come back. When it did I called the on call and s/he said to send her/him out. The family wanted to give her/him some pain medicine, but the doctor didn't want to give her/him anything while s/he was vomiting to see what was wrong. The nurse stated the family remained with the resident the entire time.

Based on record review and interviews, the facility failed to maintain professional standards for treating residents in pain and for documentation of resident's condition for 2 of 3 residents reviewed for change in condition. Resident #1, and #3 with changes in their condition that required hospital transfer did not have documentation in their medical records to depict the changes. The findings included: The facility admitted resident #1 with [DIAGNOSES REDACTED]. Review of the medical record revealed Nurses' Notes of 12/11/17 at 3:21 PM: Nurse from emergency room (ER) called and stated resident will be coming back with new #4 trach. 12/20/17: ER called stated resident was on her way back.[MEDICAL CONDITION]#4 was replaced. Resident is in no respiratory distress. There was no documentation as to what had occurred to send the resident to the ER. On 1/18/18 at approximately 3:15 PM, Licensed Practical Nurse #2 was interviewed by the surveyor and asked what had occurred for the resident to be sent out. [MEDICAL CONDITION] only come out twice. Both times, s/he had a coughing spell and it came out. S/he went to the hospital both times. We kept a pulse ox on her/him the whole time until EMS (Emergency Medical Services) arrived. We notified the physician as well. We kept her/him upright, we stayed with her/him and assessed the whole time. S/he has the ambu bag, we had oxygen at the bedside in case her/his sats dropped, but they did not. S/he maintained. The Nurse Practitioner was in the building and stayed with the resident as well, s/he maintained sats at 96%. S/he maintained above 90% both times. I was here both times it occurred. S/he has to go to the hospital to change the trach. S/he can breathe. Originally s/he had a size 6 and now has a 4. They were going to remove [MEDICAL CONDITION] s/he has a polyp right behind the trach. The physician wants to remove the polyp, but not right now, then remove the trach. The facility admitted resident #3 with [DIAGNOSES REDACTED]. Review of the medical record revealed a Nurse's Progress Note of 12/22/17 at 2:54 PM, Family in to visit at lunch and fed resident. Resident has been coughing up phlegm and c/o (complained of) stomach pain. Dr. (Doctor) (name of physician) informed and new orders received. RP (responsible party) aware. There was no other documentation as to the monitoring, assessing or how resident's condition progressed. There was no documentation as to when the resident began vomiting or complained of abdominal pain. There was no assessment of the resident for the abdominal pain. The nurse failed to document the resident was not given any medication for pain or vomiting. There was a pain score noted on the Medication Administration Record [REDACTED]. Further review of the medical record revealed a Radiology Report for a Chest X-ray (CXR) was available for 12/22/17, with a faxed time of 5:44 PM. The chest x-ray conclusion was, No acute cardiopulmonary disease process. No documentation that the physician was notified of the CXR results. On 12/22/17 at 8:26 PM a SBAR Report was completed for physician notification. Situation: Pain (uncontrolled) Since this started it has gotten worse. Vital signs: B/P (blood pressure): 124/72, Pulse: 72, Respirations: 14. Temp 98.8, Oximetry%: 97%. Abdominal/Gastro-intestinal (GI) Evaluation: Vomiting, abdominal pain, abdominal tenderness. Describe vomiting: Description checked was Persistent or recurrent (two or more episodes within 12 hours) vomiting, with or without abdominal pain, bleeding, distention, or fever. Describe abdominal pain: Description checked: Associated with fever, continuous GI bleeding, or other acute symptoms. Describe GI signs and symptoms: brown, then pink, then darker pink vomitus. Pain Evaluation: Facial grimacing, occasional moan or groan. New orders to send to ER emergency room for evaluation. The surveyor interviewed Licensed Practical Nurse (LPN) #1 by phone on 1/18/2018 at approximately 4:50 PM. The LPN stated, I got in report that s/he had been sick and the doctor had ordered x-rays. I went first to check on her/him. It was clear phlegm. I told them we could not lay her/him down while s/he was vomiting and I could watch her/him in the day room. It took a while for the x-ray report to come back. When it did I called the on call and s/he said to send the resident out. I was checking on her/him. The family wanted to give her/him some pain medicine, but the doctor didn't want to give anything while s/he was vomiting to see what was wrong. I came on at 3:00 PM. S/He sat up in the geri chair so I could keep an eye on her/him. We couldn't put her/him in the bed. The girls (Certified Nursing Assistants (CNA's)) changed her/him. I was checking on her/him and they were checking her/him every 2 hours. I did vitals and listened to her/his lungs. S/He did tell me s/he was in pain, s/he was not yelling out. S/He was a little restless, no more than usual. More like spitting up than vomiting. You know like mucus you get in your mouth when you are getting nauseated. It (vomitus) was clear at first. No stomach contents. Around the time the tech got there to do the x-ray it (phlegm) was a pink color. I was keeping the sisters and the niece apprised of what was going on. The daughter came in and I talked with her. On 1/19/18 the surveyor attempted a phone interview with the physician named in the nurses' note. The physician stated s/he was not the physician on call on 12/22/2017 and was not able to say if the nurses should have called the physician to let her/him know the resident continued to complain of pain and vomiting.

Based on record review and interview, the facility failed to provide interventions for pain and vomiting/spitting up which persisted from sometime after lunch until evening. Resident #3 was vomiting/spitting up and complained of abdominal pain with no treatment. 1 of 3 residents reviewed for change in condition. The findings included: The facility admitted resident #3 with [DIAGNOSES REDACTED]. Review of the medical record revealed a Nurse's Progress Note of 12/22/17 at 2:54 PM, Family in to visit at lunch and fed resident. Resident has been coughing up phlegm and c/o (complained of) stomach pain. Dr. (Doctor) (name of physician) informed and new orders received. RP (responsible party) aware. No documentation of physician's orders [REDACTED]. Further review of the medical record revealed a Radiology Report for a Chest X-ray (CXR) was available for 12/22/17, with a faxed time of 5:44 PM. The chest x-ray conclusion was, No acute cardiopulmonary disease process. No documentation that the physician was notified of the CXR results. On 12/22/17 at 8:26 PM a SBAR (Situation-Background-Assessment/Appearance- Request) Report was completed for physician notification. Situation: Pain (uncontrolled) Since this started it has gotten worse. Vital signs: B/P (blood pressure): 124/72, Pulse: 72, Respirations: 14. Temp 98.8, Oximetry%: 97%. Abdominal/Gastro-intestinal (GI) Evaluation: Vomiting, abdominal pain, abdominal tenderness. Describe vomiting: Description checked was Persistent or recurrent (two or more episodes within 12 hours) vomiting, with or without abdominal pain, bleeding, distention, or fever. Describe abdominal pain: Description checked: Associated with fever, continuous GI bleeding, or other acute symptoms. Describe GI signs and symptoms: brown, then pink, then darker pink vomitous. Pain Evaluation: Facial grimacing, occasional moan or groan. New orders to send to ER emergency room for evaluation. The surveyor interviewed Licensed Practical Nurse (LPN) #1 by phone on 1/18/2018 at approximately 4:50 PM. The LPN stated, I got in report that s/he had been sick and the doctor had ordered x-rays. I went first to check on her/him. It was clear phlegm. I told them we could not lay her/him down while s/he was vomiting and I could watch her/him in the day room. It took a while for the x-ray report to come back. When it did I called the on call and s/he said to send the resident out. I was checking on her/him. The family wanted to give her/him some pain medicine, but the doctor didn't want to give anything while s/he was vomiting to see what was wrong. I came on at 3:00 PM. S/He sat up in the geri chair so I could keep an eye on her/him. We couldn't put her/him in the bed. The girls (Certified Nursing Assistants (CNA's)) changed her/him. I was checking on her/him and they were checking him every 2 hours. I did vitals and listened to her/his lungs. S/He did tell me s/he was in pain, s/he was not yelling out. He was a little restless, no more than usual. More like spitting up than vomiting. You know like mucus you get in your mouth when you are getting nauseated. It (vomitus) was clear at first. No stomach contents. Around the time the tech got there to do the x-ray it was a pink color. I was keeping the sisters and the niece apprised of what was going on. The daughter came in and I talked with her. Review of the Emergency Medical Services report stated the resident was in the day room sitting up when they arrived. On 1/19/18 the surveyor attempted a phone interview with the physician named in the nurses' note. The physician stated s/he was not the physician on call on 12/22/2017 and was not able to say if the nurses should have called the physician to let her/him know the resident continued to complain of pain and vomiting.

Based on record review and interviews services provided by the facility did not meet professional standards of quality. Resident #1 was administered Resident #5's 9:00 AM medications between noon and 1:00 PM and there was no documentation in the medical record of Resident #1 being monitored after the incident. Two of five residents reviewed for medication errors. The findings included: Review of Resident #1's medical record revealed the resident's [DIAGNOSES REDACTED]. Review of the Medication Error Report for Resident #1 dated 5/17/15 revealed medications were administered to the wrong resident. Resident #1 received Resident #5's medications. Factors contributing to the incident were documented and included not following policy or procedure and medication sheet not read or read incorrectly. The Medication Error Report indicated Resident #1 received in error Aspirin 81 mg (milligrams), Vitamin D3, Vitamin B12, Senna, [MEDICATION NAME] 40 mg, [MEDICATION NAME] XL 60 mg, [MEDICATION NAME] 100 mg, [MEDICATION NAME] 100 mg, Linsinopril 5 mg and [MEDICATION NAME] 25 mg. Review of Resident #1's SBAR Communication Form dated 5/17/15 indicated the resident received the wrong medications. Resident #1 was given salt tablets to counteract blood pressure medications. Pertinent history included Resident #1 normally has low blood pressure. Resident #1's blood pressure was documented as 98/50. Resident #1's vital signs were documented as pulse 72, respiration 18 and temperature 98.2. There was no documentation that indicated what time the vital signs were obtained or what time the SBAR Communication Form was completed. Review of Resident #1's SBAR Communication Form dated 5/18/15 indicated the resident had altered mental status and was unresponsive. The resident's vital signs were documented as pulse 67, respiration 20 and temperature 98.2. There was no blood pressure documented. Review of Resident #1's Nurse's Notes revealed an entry dated 5/15/15. The next entry was dated 5/18/15 and indicated at 2:00 AM the resident was alert and blood pressure was 90/50. At 4:30 AM the Nurse's Notes indicated This nurse observed resident being unresponsive to verbal stimuli and mid sternal rub: BS (blood sugar) - 151: notified EMS also night supervisor: night supervisor talked with (resident's daughter). The next entry was dated 5/17/15 at 6:55 as a late entry Pt (patient) was given roommates meds: [MEDICATION NAME] 60 mg XL, [MEDICATION NAME] 25 mg, [MEDICATION NAME] 100 mg by accident. Pt B/P (blood pressure) normally was low. Supervisor notified. This happened around 12-1 P. (S/he) was also given [MEDICATION NAME] 40 mg and Linsinopril 5 mg. Dr. was notified & at first recommended Ipecac but then changed order to salt tablets & high carb foods. B/P remained normal for the rest of my shift. Pt was A(lert) & O(riented) x 3 by the end of my shift. Review of Resident #1's Physician's Telephone Orders revealed an order dated 5/17/15 to encourage fluids and give sodium tablets. Give resident shake high in carbohydrate related to low blood pressure. There was no indication of how often to administer the sodium tablets or a time frame for how long to administer the sodium tablets. Review of Resident #1's vital sign sheet revealed an entry on 5/18/15 at 2:00 AM that indicated the resident's blood pressure was 90/50. There were three additional entries after the 5/18/15 entry that indicated on 5/17/15 Resident #1's blood pressure was 98/50, 94/48 and 112/45. There were no times to indicate when the 5/17/15 blood pressures were obtained. Review of Resident #1's May 2015 Medication Administration Record [REDACTED]. There was no documentation that sodium tablets were administered to Resident #1. A Physician's Telephone Order dated 5/18/15 indicated may transport Resident #1 to the emergency department. In an interview with the surveyor on 6/3/15 at approximately 11:55 AM, the facility Administrator stated that RN #1 realized almost immediately s/he had given the wrong medications. The physician and family were notified. The physician ordered ipecac and they did not have any in the facility. Staff went to the pharmacy to look for the ipecac and could not find. The physician then ordered sodium tablets and a high carbohydrate diet. Resident #1's blood pressure was monitored and there were no changes noted. Resident #1 has a history of altered mental status related to high ammonia levels. On 6/3/15 at approximately 1:25 PM, the facility Administrator stated that RN #1 stated s/he was running late and that is why Resident #1 was given his/her roommates 9:00 AM medications between 12:00-1:00 PM. RN #1 normally worked on a different unit and picked up a shift that day. The facility Administrator was not aware of any events on the unit that would have caused the nurse to be running so far behind. On 6/3/15 at approximately 1:40 PM the facility Administrator stated that the blood pressures for 5/17/15 that were listed on Resident #1's vital sign sheet were documented on staff 's cheat sheet and then later transcribed to the vital sign sheet. S/he was not sure what time the blood pressures were taken. The facility Administrator was also asked about the lack of documentation of a blood pressure when Resident #1 was found unresponsive on 5/18/15 and did not provide any information that the blood pressure was documented anywhere. In an interview with the surveyor on 6/3/15 at approximately 1:45 PM, the Nurse Practitioner stated that s/he was familiar with Resident #1. The Nurse Practitioner stated that [MEDICATION NAME] and Linsinopril could make the residents blood pressure lower. There would be no major side effects from the other medications given in error. Low blood pressure could cause Resident #1 to become unresponsive. The Nurse Practitioner stated that s/he would expect blood pressure to be documented when the resident was found unresponsive. S/he would also expect documentation related to the resident being monitored after the medication error. The Nurse Practitioner stated that s/he could not say that receiving the medications given would affect the resident after being given one time. Resident #1 would metabolize the medications differently related to his/her decreased renal function. Review of Resident #5's May 2015 Medication Administration Record [REDACTED]. In an interview with the surveyor on 6/3/15 at approximately 12:15 PM, Resident #5 stated that the nurse brought him/her the wrong medications one Sunday. S/he noticed they were not his/her medications and told the nurse. Resident #5's roommate (Resident #1) received his/her medications. The nurse brought both resident 's medications in at the same time in different medication cups. Review of Resident #5's Quarterly Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview for Mental Status score of 14.

Based on record review and interviews, the facility failed to ensure that residents are free of any significant medication errors. Resident #1 was administered Resident #5''s medications. Registered Nurse (RN) #1 brought Resident #1 and Resident #5's medications into the residents' room at the same time and handed each resident a medication cup. Resident #5 realized that the medications were not what s/he usually took and told RN #1. Resident #1 had already taken Resident #5's medications. Two of five residents reviewed for medication errors. The findings included: Review of Resident #1's medical record revealed the resident's [DIAGNOSES REDACTED]. Review of the Medication Error Report for Resident #1 dated 5/17/15 revealed medications were administered to the wrong resident. Resident #1 received Resident #5's medications. Factors contributing to the incident were documented and included not following policy or procedure and medication sheet not read or read incorrectly. The Medication Error Report indicated Resident #1 received Aspirin 81 mg (milligrams), Vitamin D3, Vitamin B12, Senna, [MEDICATION NAME] 40 mg, [MEDICATION NAME] XL 60 mg, [MEDICATION NAME] 100 mg, [MEDICATION NAME] 100 mg, Linsinopril 5 mg and [MEDICATION NAME] 25 mg. Review of Resident #1's SBAR Communication Form dated 5/17/15 indicated the resident received the wrong medications. Resident #1 was given salt tablets to counteract blood pressure medications. Pertinent history included Resident #1 normally has low blood pressure. Resident #1's blood pressure was documented as 98/50. Resident #1's vital signs were documented as pulse 72, respiration 18 and temperature 98.2. There was no documentation that indicated what time the vital signs were obtained or what time the SBAR Communication Form was completed. Review of Resident #1's SBAR Communication Form dated 5/18/15 indicated the resident had altered mental status and was unresponsive. The resident's vital signs were documented as pulse 67, respiration 20 and temperature 98.2. There was no blood pressure documented. Review of Resident #1's Nurse's Notes revealed an entry dated 5/17/15 at 6:55 as a late entry Pt (patient) was given roommates meds: [MEDICATION NAME] 60 mg XL, [MEDICATION NAME] 25 mg, [MEDICATION NAME] 100 mg by accident. Pt B/P (blood pressure) normally was low. Supervisor notified. This happened around 12-1 P. (S/he) was also given [MEDICATION NAME] 40 mg and Linsinopril 5 mg. Dr. was notified & at first recommended Ipecac but then changed order to salt tablets & high carb foods. B/P remained normal for the rest of my shift. Pt was A(lert) & O(riented) x 3 by the end of my shift. On 5/18/15 at 4:30 AM the Nurse's Notes indicated the resident was unresponsive to verbal stimuli and transferred to the emergency room . Review of Resident #1's Physician's Telephone Orders revealed an order dated 5/17/15 to encourage fluids and give sodium tablets. Give resident shake high in carbohydrate related to low blood pressure. There was no indication of how often to administer the sodium tablets or a time frame for how long to administer the sodium tablets. Review of Resident #1's May 2015 Medication Administration Record [REDACTED]. There was no documentation that sodium tablets were administered to Resident #1. A Physician's Telephone Order dated 5/18/15 indicated may transport Resident #1 to the emergency department. In an interview with the surveyor on 6/3/15 at approximately 11:55 AM, the facility Administrator stated that RN #1 realized almost immediately s/he had given the wrong medications. The physician and family were notified. The physician ordered ipecac and they did not have any in the facility. Staff went to the pharmacy to look for the ipecac and could not find. The physician then ordered sodium tablets and a high carbohydrate diet. Resident #1's blood pressure was monitored and there were no changes noted. Resident #1 has a history of altered mental status related to high ammonia levels. Review of Resident #5's May 2015 Medication Administration Record [REDACTED]. In an interview with the surveyor on 6/3/15 at approximately 12:15 PM, Resident #5 stated that the nurse brought him/her the wrong medications one Sunday. S/he noticed they were not his/her medications and told the nurse. Resident #5's roommate (Resident #1) received his/her medications. The nurse brought both resident 's medications in at the same time in different medication cups. Review of Resident #5's Quarterly Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview for Mental Status score of 14.

Based on review of facility files and interviews, the facility failed to ensure that each resident received adequate supervision to prevent accidents. Resident #1 was on 1:1 supervision related to having multiple falls. Resident #1 fell while CNA (Certified Nurse Aide) #1, who was assigned to watch the resident, was on their phone. One of four residents reviewed for falls. The findings included: The facility reported an incident to the State Agency on 3/4/15. The facility report indicated Resident #1 fell and sustained a right forehead hematoma and a laceration to the resident's right forehead reopened after falling face forward from a wheelchair to the floor. CNA #1 was distracted while providing 1:1 care for Resident #1 at the time of the fall. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Further review of the medical record revealed the Initial Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a short-term and long-term memory problem with severely impaired cognitive skills for daily decision-making. Review of the care plan revealed at risk for falls and/or serious injury related to history of falls was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included nursing will observe more frequently with 1:1 on 3:00-11:00 PM shift. Review of the Nurses' Notes dated 3/3/15 at 8:45 PM indicated Resident #1 was receiving one on one with a caregiver. The resident was sitting in a wheelchair and the caregiver was sitting beside the resident. Resident #1 leaned forward with his/her whole upper body and fell on the floor. One on one caregiver is to be within arms reach, hand on resident or wheelchair while out of bed, no exceptions. Education was provided to the caregiver. CNA #1's facility-obtained statement indicated his/her job assignment was to sit with Resident #1 on 3/3/15. During the time CNA #1 was with the resident s/he seemed agitated and upset. CNA #1 was sitting in a chair approximately 5 feet away from Resident #1 when the resident fell down on the floor face first. CNA #1 was not looking at Resident #1 when the incident happened. CNA #1 was looking at his/her phone. There were two other CNAs in the dayroom at the time and one of them said look s/he is falling. By the time CNA #1 reacted it was too late. In an interview with the surveyor on 4/7/15 at approximately 5:25 PM, CNA #2 stated that s/he saw CNA #1 sitting in a chair next to Resident #1. CNA #1 was intense looking at his/her phone. CNA #1 had been on the phone earlier in the day. CNA #2 stated CNA #1 had been on the phone the majority of the time s/he saw him/her. CNA #1 and Resident #1 were in the dayroom most of the day on 3/3/15. In an interview with the surveyor on 4/7/15 at approximately 5:00 PM, CNA #3 stated s/he was in the dayroom when the incident occurred on 3/3/15. Resident #1 was leaning over trying to stand up and fell . CNA #1 was on his/her phone and was too far from the resident to reach out and touch the resident. CNA #3 stated CNA # had been on the phone texting when Resident #1 fell . In an interview with the surveyor on 4/8/15 at approximately 4:00 PM, CNA #4 stated s/he was in the dayroom across the room from Resident #1 and CNA #1 when the incident occurred. CNA #4 stated s/he had been in the dayroom approximately 5 minutes when Resident #1 fell . CNA #4 stated CNA #1 was sitting across the table from Resident #1. CNA #1 was texting on his/her phone when CNA #4 came into the dayroom. CNA #1 stayed on the phone until CNA #3 yelled his/her name because Resident #1 was standing up. CNA #1 looked up but could not get to Resident #1 before he fell . In an interview with the surveyor on 4/8/15 at approximately 11:30 AM, the facility Administrator stated that CNA #1 stated s/he was having an argument with his/her spouse and was trying to resolve it at the time of the incident on 3/3/15. At approximately 4:40 PM, the facility Administrator stated that CNAs were not inserviced on 1:1 expectations prior to the incident on 3/3/15. CNAs should know that 1:1 means they cannot take their eyes off the residents.

Based on record review, interview and review of the facility's policy, Administering Medications, conducted during the complaint inspection, the facility failed to ensure that residents are free of significant medication errors. Resident # 6 received 10 medications that were not ordered for Resident #6, 1 of 5 residents reviewed for administration of medications. The findings included: The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Review of the closed medical record at approximately 2:50 PM on 7/21/14 revealed the following Nurse's Notes: 6/19/14 10:30 AM "Res (resident) received ...roommates 9 AM med's (medications). (Doctor) notified (with) orders rec'd (received) (and) processed..." 6/19/14 5:00 PM "Resident noted (with) low bp (blood pressure) 72/34 pulse 65 resp(irations) 20 O2 (oxygen) Sat(uration) 93% on 5 L (liters) O2. 6/19/14 5:30 PM "...bp 70/30 pulse 66 resp 21 O2 Sat 92% on 5 L/O2 resident remains alert respond easily (with) stimuli. Placed call to (doctor) again (with) update of condition. (Doctor) stated to give 1 liter of NS via IV (intravenous) if ok (with) hospice." 6/19/14 6:30 PM "Bolus (normal saline) complete Bp 88/46 pulse 72 resp 20 96% O2. Pt alert to stimuli. Moving around in bed." 6/19/14 7:05 PM "59/21 pulse 60 resp 20 O2 93% 6/19/14 7:10 PM "Call placed to on call physician. (Doctor) returned call gave order to given (sic) [MEDICATION NAME] if approved by hospice..." 6/19/14 7:25 "[MEDICATION NAME] administered IM 66/45 pulse 65 respiration 20 O2 Sat 93%." Documentation of the residents vital signs and mental status every 30 minutes continued until 1:30 AM on 6/20/14 when the nurse documented the resident was noted with "BBS (bilateral breath sounds) (with) pleural rub (and) (upper) lobes diminished. Clear (lower) lobes (No) urination noted..." and at 2:05 AM "Notified (Doctor) ...of residents status inability to (increase) BP, BP 58/37 P(ulse) 73 Resp 20 T(emperature) 96.2 (degrees) Sat 93 breathing (with) depth Rt. (right) lobes adventious (sic) (and) Lt. (left) diminished (and) clear. Noted with (decreased) alertness, noted lethargic ..." "...N/O (new order) to send resident to (hospital)..." At 2:15 AM the nurse documented the arrival of emergency medical personnel, that the resident's Blood Pressure was 52/42 Pulse 72 Respirations 22, breathing irregular and the resident was lethargic. The resident left the facility at 2:40 AM. Further review of the nurse's notes revealed a Nursing Home to Hospital Transfer Form that stated the most recent pain medication administered was [MEDICATION NAME] mg. which was not ordered for resident #6. Continued review of the resident's record revealed a Nursing Focus Note by the hospice nurse that stated the resident "was given 2 blood pressure medications and [MEDICATION NAME] 30 mg at 9 AM on 6/19/14. These were the roommates medication and not (the resident's). Pts. (patient's) BP has bottomed out at 67/37 even after a bolus of NS 1 liter and a dose of [MEDICATION NAME]" Review of the closed medical record revealed an un-timed Telephone Order dated 6/19/14 for neuro (neurological) checks every 15 minutes for 4 hours. A second order was noted, dated and timed 6/19/14 at 4:45 PM, for neuro checks every 15 minutes for 2 hours, every hour for 4 hours, then every 4 hours for 24 hours. Additional review revealed un-timed orders dated 6/19/14 for NS (normal saline) 1 liter now and another order for [MEDICATION NAME] (a drug that prevents or reverses the effects of opioids including respiratory depression, sedation and [MEDICAL CONDITION]) 1 milliliter IM (intramuscular) for 1 dose now. At 2:48 PM, review of the Medication Administration Record [REDACTED]. (milligrams) scheduled for 9:00 PM was "held for lethargy." On 7/21/14 at 1:59 PM, review of the Social Services Notes revealed a note dated 7/2/14 that stated "Res(ident) sent to hospital 6/20/14 (and) facility was informed that (the resident) passed away there 6/24/14." On 7/22/14 at 8:59 AM the Director of Nursing (DON) confirmed the resident had received the roommate's medications. The DON also stated the nurse that administered the medications was a new nurse on her/his third day of orientation. The DON also stated that the orienting nurse observed the new nurse pull the medications but did not observe her/him administer them. At approximately 10:00 AM on 7/22/14 review of the incident report provided by the facility revealed the resident received 10 medications that were not ordered for Resident #6 including, but not limited to, [MEDICATION NAME] 10 mg., [MEDICATION NAME] 6.25 mg., both used for hypertension and [MEDICATION NAME] mg., an extended release opoid pain reliever. Further review of the documentation revealed a One to One Inservice / Counselling (sic) Record for the orienting nurse. The record included a statement from the orienting nurse that stated "I watched (the orientee) double check the meds. I asked if (she/he) knew which resident (and) (she/he) confirmed (she/he) did. I stood by the cart the entire time. (She/he) passed meds to the same residents the day before." Review of the facility's policy entitled Administering Medications revealed "6. The individual administering medications must verify the resident's identity before giving the resident his/her medications. Methods of Identifying the resident may include: A. Checking identification band B. Checking photograph attached to medical record C. Calling resident by name D. If necessary, verifying resident identification with other facility personnel." The policy further stated "27. The Charge Nurse must accompany new nursing personnel on their medication rounds for a minimum of three (3) days to ensure established procedures are followed and proper resident identification methods are learned.}"