Every finding on record at Sullivan County Health Care

Based on interview and record review, it was determined that the facility failed to ensure resident care plans were revised for 2 residents in a final sample of 24 residents. (Resident Identifiers are #34 and #121). Findings include:Resident #34 Review on 12/10/25 of Resident #34's nursing notes revealed the following note dated 10/17/25: Spoke this shift with DPOA [Durable Power of Attorney] about this resident found in another male residents room lying on the bed with [pronoun omitted] pants off, still had a brief on and a bra half on . The DPOA states [pronoun omitted] was sexually active at the last facility and as long as [pronoun omitted] and the other resident are willing participants they do not want us to try and stop the interactions between the two residents. Review on 12/11/25 of Resident #34's care plans revealed that there was no care plan implemented for sexual expression. Interview on 12/11/25 at approximately 10:00 a.m with Staff F (Director of Nursing) confirmed the above findings. Review on 12/9/25 of Resident #34's nursing notes in his/her medical record, revealed that Resident #34 had an unwitnessed fall on 11/28/25. Further review revealed that Resident #34 did not have any footwear on his/her feet. Interview on 12/10/25 at approximately 2:00 p.m. with Staff E (Unit Manager) revealed that the root cause of the fall was improper footwear and that no new interventions were put into place after the fall. Review on 12/11/25 of Resident #34's care plans revealed, no new interventions were added after Resident #34's fall to ensure Resident #34 proper footwear. Review on 12/11/25 of the facility policy titled, Falls, Dated 8/5/20, revealed: . m. update the resident's care plan and add new interventions to prevent a fall or injury. Interview on 12/11/25 at approximately 9:00 a.m. with Staff F (Director of Nursing) confirmed that there was no new intervention initiated in Resident #34's care plan after his/her fall on 11/28/25. Resident #121 Interview on 12/09/25 at approximately 9:51 a.m. with Resident #121 revealed they have hearing loss and use hearing aids. Review on 12/10/25 11:05 a.m. of Resident #121's medical record revealed an audiology note, dated 10/20/25, that stated .fit hearing aids, fits well; Patient hearing well; Nurse will insert and remove hearing aid; Nurse will change hearing aid batteries . Further review of Resident #121's medical record revealed the care plan was not revised to include the use of hearing aids. Interview on 12/10/2025 at approximately 12:19 p.m. with Staff A (Unit manager) confirmed their were no updates to Resident #121's comprehensive care plan to identify that he/she used bilateral hearing aids.

Based on observation, interview, and record review, it was determined that the facility failed to ensure that a resident was assisted with meals in accordance with the resident's care plan for 2 of 2 dining observations. (Resident identifier is #31.)Findings include: Observation on 12/9/25 at approximately between 12:08 p.m. to 1:00 p.m. in the 4000 unit during lunch dining observations revealed that Resident #31 was in bed in their room with his/her eyes closed and his/her lunch was in front of him/her, untouched. Further observation revealed that there was no staff assisting Resident #31 with his/her lunch. Review on 12/10/25 of Resident #31's ADL care plan with a revision date of 10/27/25 revealed the following ADL care plan interventions: Resident #31 requires moderate assistance by one staff to eat, initiated 12/8/25; One staff assist with all meals, initiated 12/9/25; Offer feeding assistance and encourage upright head of bed position during meals, initiated 12/9/24; If the resident refuses care, notify the nurse to attempt to intervene, initiated 9/25/24. Observation on 12/10/25 at approximately between 8:10 a.m. to 9:06 a.m. in the 4000 unit during breakfast dining observations revealed that in Resident #31 was in bed in their room with his/her eye closed and his/her breakfast was in front of him/her, untouched. Further observation revealed that there was no staff assisting Resident #31 with his/her breakfast. Observation in the 4000 unit also revealed that the 4 of 5 Licensed Nursing Assistants (LNA) on the unit were assisting other residents with their breakfast. Interview on 12/10/25 at approximately 9:06 a.m. with Staff J (Unit Manager) revealed that Resident #31 had a recent decline in eating that he/she would need staff assistance with meals. Staff J was not aware if anyone was assisting Resident #31 with his/her breakfast. Interview on 12/10/25 at approximately 9:06 a.m. with Resident #31 and Staff J revealed that Resident #31 stated that he/she wanted to eat his/her breakfast. Interview on 12/10/25 at approximately 9:15 a.m. with Staff K (Registered Nurse) revealed that he/she was Resident #31's nurse and had not received any report that Resident #31 declined to eat breakfast. Staff K was not aware if anyone was assisting Resident #31 with his/her breakfast. Interview on 12/10/25 at approximately 9:15 a.m. with Staff L (LNA) revealed that he/she was Resident #31's LNA and that Resident #31 needed one staff assist with meals. Staff L had not offered Resident #31 with assistance with breakfast and was not aware if anyone was assisting Resident #31 with his/her breakfast.

Based on interview and record review, it was determined that the facility failed to ensure residents were free from exposure to bloodborne pathogen transmission when staff used a resident's insulin pen to administer insulin to another resident (Resident identifiers are #1 and #2.) Findings include: Interview on 6/6/25 at approximately 10:03 a.m. with Staff A (Licensed Practical Nurse (LPN)) revealed that on 6/3/25 he/she administered insulin to Resident #2 using Resident #1's used insulin pen. Interview on 6/6/25 at approximately 10:09 a.m. with Staff C (LPN) revealed that on 6/3/25 he/she received shift report from Staff A that Resident #2 ran out of insulin and Staff A used Resident #1's insulin pen to administer insulin to Resident #2. Staff C stated that he/she reported to the night supervisor and both resident's providers about the above mentioned incident on 6/3/25. Resident #1's insulin pen was discarded on 6/3/25. Review on 6/6/25 of Resident #1's June 2025's Electronic Medication Administration Record (EMAR) revealed an active physician's order for Basaglar Kwikpen (insulin glargine) and was signed as given on 6/3/25. Review on 6/6/25 of Resident #2's June 2025 EMAR revealed an active physician's order for Semeglee (insulin glargine) one time a day and was signed as given on 6/3/25. Interview on 6/6/25 at approximately 10:30 a.m. with Staff B (Director of Nursing) revealed that he/she was made aware of the above mentioned incident on 6/4/25. An Adhoc Quality Assurance meeting was held by Staff B, Assistant Director of Nursing, and Administrator about the incident and developed a corrective action plan on 6/4/25. Staff B stated that corrective actions taken included staff interviews on safe insulin administration and facility policy for unavailable medication and found no deviation to facility policy, education was provided to Staff A on safe insulin administration and facility policy on unavailable medications on 6/4/25 and 6/5/25, Staff B assigned online education to Staff A on understanding blood-borne pathogen and avoiding common medication errors before returning to work, and Staff A will have random insulin administration observations during the next 2 weeks. Further interview with Staff B also revealed that both resident's providers were notified on 6/3/25 and blood-borne pathogen testing was ordered on 6/5/25 for Resident #1 and Resident #2. Review on 6/6/25 of the Basaglar (insulin glargine) manufacturer's instruction dated 2015, revealed: .Instructions for use .Do not share your BASAGLAR KwikPen with other people, even if the needle has been changed. You may give other people a serious infection or get a serious infection from them . Review on 6/6/25 of the facility's policy titled, Medication Administration-General Guidelines, effective date of May 2018, revealed .Medications supplied for one resident are never to be administered to another resident . Review on 6/6/25 of the Centers for Disease Control and Prevention (CDC) website titled, Considerations for Blood Glucose Monitoring and Insulin Administration, dated 8/7/24, retrieved 6/6/25, from https://www.cdc.gov/injection-safety/hcp/infection-control/index.html#:~:text=medications%20in%20pockets.-,Insulin%20administration,Training%20and%20oversight revealed: .Insulin pens are pen-shaped injector devices that contain a reservoir for insulin or an insulin cartridge. These devices permit self-injection, but healthcare providers may also use them to administer insulin. Each pen is designed to be safe for just one patient to use multiple times with a new, fresh needle for each injection. Pens must never be used for more than one patient because blood may be present in the pen after use . Review on 6/6/25 of the facility's documentation of corrective action revealed the following: Staff A was educated on safe insulin administration on 6/4/25; all staff were interviewed to ensure staff had knowledge of safe insuling administration; blood-borne pathogen testing was performed on 6/5/25 for Resident #1 and Resident #2, and an ad hoc Quality Assurance meeting was held on 6/4/24 to initiate a Quality Assurance Performance Imporvement plan that included monitoring.

Based on interview and record review it was determined that the facility failed to follow professional standards after a fall with identified hip pain for 1 of 1 resident reviewed for falls (Resident Identifier #120) Findings include: Review on 10/14/2024 of Resident #120's nursing note written by Staff F (Licensed Practical Nurse), dated 8/24/24 revealed: Resident was found on the floor lying on her left side close to [pronoun omitted] bed. Assessment done. AROM [active range of motion] on BUE [bilateral upper extremities], PROM [passive range of motion] on BLE [bilateral lower extremities], resident c/o [complained of] pain. Tender to touch on resident's left hip. Resident holds [pronoun omitted] side. Assisted resident back to bed with 2-3 person .Received order to send resident to ER [emergency room ] for further evaluation. Interview on 10/16/2024 at approximately 11:00 a.m. with Staff F revealed that Resident #120 was found on the floor. Staff F assessed Resident #120 for injury. Staff F revealed that Resident #120 was complaining of pain and pointing to his/her left hip. Staff F further revealed that Resident #120 was transferred back to bed with assist of three staff. The provider was notified after the resident was transferred to bed and an order was obtained to send the resident to the emergency room for evaluation. Review on 10/16/2024 of Resident #120's hospital discharge summary, dated 8/29/24, revealed: . [pronoun omitted] left pubic fracture . Review on 10/16/2024 of facility policy titled, Falls, dated 8/5/20, revealed: .(2) The charge nurse present performs a complete physical assessment to determine injury. She/he will use sound nursing judgement to determine necessary actions, first aid, transfer etc. Should the resident show evidence of a fracture or pain, keep him/her immobilized .Do not move the injured limb . Review on 10/16/2024 of the Journal of Nursing, Post Fall Care Nursing Algorithm, accessed on 1/21/20 revealed: The general scheme of the algorithm is as follows: the post-fall algorithm begins with a decision diamond that requires the nurse to . the next step is to determine whether serious injury has occurred; in this case, serious injury is defined as an injury involving the neck or spine, or any other major trauma. The attending nurse should not move the patient, but should call for assistance from another nurse and immediately notify a physician .The musculoskeletal system should be assessed for any deformities, pain, swelling, weakness, strength, and range of motion .

Based on record review and interview, it was determined that the facility failed to accurately code Minimum Data Set (MDS) assessments for 3 residents reviewed for MDS in a final sample of 25 residents (Resident identifiers are #8, #29, and #118). Findings include: Resident #29 Review on 10/16/24 of Resident #29's current orders revealed an order dated 3/19/24 for dialysis three days a week. Review on 10/16/24 of Resident #29's Quarterly MDS with an Assessment Reference Date (ARD) of 9/21/24, Section O, Special Treatments, Procedures, and Programs, dialysis was coded as no. Interview on 10/16/24 at approximately 10:35 a.m. with Staff A (MDS Coordinator) confirmed that the resident was on dialysis, and that the MDS was coded incorrectly. 48515 Resident #118 Review on 10/14/2024 of Resident #118's Quarterly MDS assessment, dated 8/20/2024, Section N revealed that antipsychotic medications were received on a routine basis. Resident #118 was not receiving antipsychotic medications during the assessment reference period. Review on 10/16/2024 of Resident #118's August 2024 Medication Administration Record (MAR), revealed that Resident #118 was not receiving antipsychotic medications. Interview on 10/16/2024 at approximately 1:02 p.m. with Staff A confirmed the above findings. 26364 Resident #8 Review on 10/16/24 of Resident #8's hospice records revealed Resident #8 was admitted to hospice on 8/26/24. Review on 10/16/24 of Resident #8's Significant Change MDS Assessment with an ARD of 9/5/24, revealed that under Section OO0110, Special Treatments, Procedures, and Programs, Hospice care while a resident was not indicated. Interview on 10/16/24 at approximately 11:45 a.m. with Staff A confirmed that Resident #8 was receiving Hospice services, and the assessment was coded incorrectly.

Based on interview and record review, the facility failed to ensure that staff reported allegations of abuse to the administrator, or designee, within 2 hours after the allegation, to prevent further abuse for 1 of 3 residents reviewed for abuse (Resident Identifier is #2). Findings include: Review on 1/4/24 of Resident #2's nursing note, dated 12/25/23 at 11:47 a.m., revealed Resident #2 stated the following: A few days ago he came and paused at the door and he was scratching himself when he came in. He was covered, but scratching at his balls. I asked him if he was here for my roommate, he did not talk but was moaning. He continued to scratch his balls and moved towards me and stood in front of me. I gestured for him to leave and told him you need to scratch somewhere else. He left the room and as he was leaving he stated I'll be back. I reported this occurrence when it happened, I actually told a number of people about this. I did not know if he was a visitor or who he was. When I saw him and recognized him the next day (12/24/2023), I rang my call bell to identify him to staff. I talked to a [NAME] young girl. She told me that they knew who he was and that he had done this before. Today, ([DATE]th, 2023) I'm sitting here on my computer and I saw him stop at the door. He came in with his fly down and got in front of my TV looking at me. This time he had his hands in the hole of his pants playing with himself and masturbating. I saw his penis this time. I told him to get out several times and reported this to [Licensed Nursing Assistant name removed]. I'm worried that he's a roaming predator, and thank god I know what is going on because other people may not be able to tell him to leave like I did. Interview on 1/4/24 at 11:15 a.m. with Staff K (Charge Nurse) and Staff L (Social Services) revealed that Resident #2 was alert and oriented and recalled the above event. Interview also revealed that the visitor was the spouse of another resident, Resident #1, and that there was another event where the visitor was allegedly touching Resident #1's roommate, that resulted in Resident #1 being moved to a single room near the nurses' station. Interview on 1/4/24 at approximately 1:00 p.m. with Staff B (Director of Nursing) confirmed the above findings. Staff B investigated the above incident and the investigation had revealed that the visitor had entered Resident #2's room on 12/23/23. Staff B confirmed that he/she was not aware of the incident on 12/23/23 and the investigation did not begin until the 12/25/23 incident.

Based on interview and record review, the facility failed to ensure that staff reported allegations of abuse to the administrator, or designee, within 2 hours after the allegation for 1 of 3 residents reviewed for abuse (Resident Identifier is #2) Findings include: Review on 1/4/24 of Resident #2's nursing note, dated 12/25/23 at 11:47 a.m., revealed the following Resident #2 stated the following: A few days ago he came and paused at the door and he was scratching himself when he came in. He was covered, but scratching at his balls. I asked him if he was here for my roomate, he did not talk but was moaning. He continuted to scratch his halls and moved toward me and stood in front of me. I gestured for him to leave and told him you need to scratch somewhere else. He left the room and as he was leaving he stated I'll be back. I reported this occurrence when it happened, I actually told a [NAME] of people about this. I did not know if he was a vistor or who he was. When I saw him and recognized him the next day (12/24/2023), I rang my call bell to identify him to staff. I talked to a [NAME] young girl. She told me that they knew who he was and that he had done this before. Today, ([DATE]th, 2023) I'm sitting here on my computer and I saw him stop at the door. He came in with his fly down and got in front of my TV looking at me. This time he had his hands in the hole of his pants playing with himself and masturbating. I saw his penis this time. I told [NAME] to get out several times and reported this to [Licensed Nursing Assistant name removed]. I'm worried that he's a romaing predator, and thank god I know what is going on because other people may not be able to tell him to leave like I did. Interview on 1/4/24 at 11:15 a.m. with Staff K (Charge Nurse) and Staff L (Social Services) revealed that Resident #2 was alert and oriented and recalled the above event. Interview also revealed that the visitor was the spouse of another resident, Resident #1, and that there was another event where the visitor was allegedly touching Resident #1's roommate, that resulted in Resident #1 being moved to a single room near the nurses station. Interview on 1/4/24 at appoimatley 1:00 p.m. with Staff B (Director of Nursing) confirmed the above findings. Staff B investigated the above incident and the invesitgation had revealed that the visitor had entered Resident #2's room on 12/23/23. Staff B confirmed that he/she was not aware of the incident on 12/23/23 and the invesitgation did not begin until the 12/25/23 incident.

Based on interview and record review, it was determined that the facility failed to ensure that the residents were seen face-to-face by a physician, at least once every 30 days, for the first 90 days after admission, and at least every 60 days thereafter for 7 out of 7 residents reviewed for physician visits in a final sample of 25 residents (Resident Identifiers are #1, #40, #62, #73, #113 and #117). Findings include: Resident #1 Review on 10/18/23 of Resident #1's physician visit notes revealed the following encounters: On 1/10/23, a 60 day recertification telemedicine encounter; On 3/23/23, a 60 day recertification telemedicine encounter; On 5/18/23, a 60 day recertification telemedicine encounter; On 7/28/23, a 60 day recertification telemedicine encounter On 9/26/23, a 60 day recertification telemedicine encounter. Resident #62 Review on 10/19/23 of Resident #62's physician visit notes revealed the following encounters: On 7/21/23, an admission telemedicine encounter; On 9/12/23, an admission telemedicine encounter; On 10/10/23, an admission telemedicine encounter. Interview on 10/19/23 at approximately 9:30 a.m. with Staff C (Unit Manager (UM) confirmed the above information. 43002 Resident #40 Review on 10/18/23 of Resident #40's physician visit notes revealed the following; On 4/27/23 a 30 day recertification by telemedicine; On 6/23/23 a 30 day recertification by telemedicine; On 7/28/23 a 30 day recertification by telemedicine; On 9/12/23 a 30 day recertification by telemedicine. Further review of Resident #40's physician notes revealed that there were no in-person visits conducted during the above timeframe by the physician or a practitioner who was not employed by the facility. Interview on 10/19/23 at 9:25 a.m. with Staff F (UM) confirmed the above findings. Staff F revealed that Staff E (Medical Director) had only come to the facility a handful of times. 26364 Resident #113 Review on 10/19/23 of Resident #113's physician visit notes revealed the following encounters: On 3/9/23, an admission visit was completed via telemedicine encounter; On 9/12/23, a 60 day visit was via telemedicine encounter Further review on 10/19/23 of Resident #113's medical record revealed that Staff J (Advanced Practice Registered Nurse) did visits on 2/22/23, 8/21/23, 9/1/23, 9/6/23, 10/2/23, 10/11/23, and 10/12/23. Further review of Resident #113's physician notes revealed that there were no in-person visits conducted during the above timeframe by the physician or a practitioner who was not employed by the facility. Interview on 10/19/23 at approximately 10:00 a.m. with Staff C confirmed the above findings. Resident #117 Review on 10/19/23 of Resident #117's physician visit notes revealed the following encounters: On 8/3/23, an admission visit was completed via telemedicine encounter; On 9/19/23, a 30 day visit was completed via telemedicine encounter; Further review of Resident #117's physician notes revealed that there were no in-person visits conducted during the above timeframe by the physician or a practitioner who was not employed by the facility. Interview on 10/19/23 at approximately 10:00 a.m. with Staff C confirmed the above findings. 28881 Resident #73 Review on 10/19/23 of Resident #73's physician visit notes revealed the following encounters: On 4/13/23, a 60 day recertification telemedicine encounter; On 6/15/23, a 60 day recertification telemedicine encounter; On 8/8/23, a 60 day recertification telemediciine encounter; On 10/13/23, a 60 day recertification telemediciine encounter. Further review of Resident #73's physician notes revealed that there were no in-person face-to-face visits conducted during the above timeframe by the physician or a practitioner who was not employed by the facility. Interview on 10/19/23 at 9:11 a.m. with Staff H (Medical Records Clerk) confirmed the above findings. Interview on 10/19/23 at 10:20 a.m. with Staff I (Administrator) further confirmed Staff E had not met with residents face-to-face, and that Staff J met with residents on an incidental basis.

Based on observation, interview, and policy review it was determined that the facility failed to ensure that the residents' environment remained as free of accident hazards as possible on 1 of 4 units (Stern 3 Unit). Findings include: Observations on 10/17/23 at 11:50 a.m. and 2:10 p.m. on the Stern 3 Unit revealed the bath room (where residents shower/bathe) door was open and unlocked in the resident hallway with one bottle of [NAME] facility cleaning solution on an open shelf and a container of bleach wipes on a Personal Protective Equipment (PPE) station left unsecured. Interview on 10/17/23 at 2:20 p.m. with Staff B (Registered Nurse) revealed that 11 residents on Stern 3 Unit have been identified to wander. Interview on 10/18/23 at 9:30 a.m. with Staff A (Licensed Practical Nurse) confirmed the above finding. Observation on 10/18/23 at 10:35 a.m. revealed the treatment room door was open on the Stern 3 Unit in the resident hallway with a sign that stated, Door Must Be Locked At All Times, with the following items: 3 pairs of scissors in an unlocked treatment cart, 2 oxygen tanks, and 8 bottles of alcohol-based hand sanitizer on an open shelf. Interview on 10/18/23 at 10:45 a.m. with Staff B confirmed the above finding. Review of the facility's policy titled, Incident/Accidents, dated 10/24/22 revealed: POLICY: To provide a safe and healthful living environment for all residents and staff of the facility. Review of the facility's policy titled, Tub Bath, dated 1/22/98 revealed: 6. Clean the tub .& return supplies to their proper place. Review of Safety Data Sheets revealed: Midlab-[NAME] Facility Peroxide Disinfectant - Hazard Statements - Causes eye irritation - Serious eye damage/eye irritation -Category 2B. Storage Conditions .Keep locked up . Clorox Healthcare Bleach Germicidal Wipes - Eye Contact - Liquid may cause irritation .Ingestion - Ingestion of liquid may cause slight irritation to mucous membranes and gastrointestinal tract. Purell Hand Sanitizer - Hazard Statements - H319 Causes serious eye irritation .

Based on observation, interview, and record review, it was determined that the facility failed to ensure that expired medications and biologicals were removed from supply and were not given for 1 of 2 medication rooms and 1 of 4 medication carts observed. Findings include: Medication Cart: Observation on 10/17/23 at 10:20 a.m. of the [NAME] Unit, South Medication Cart with Staff G (Registered Nurse) revealed the following expired medications. 1 open bottle of Aspirin enteric coated 325 milligrams (mg), with a manufacturer's expiration date of 9/23; 1 glucagon kit 1mg with a manufacturer's expiration date of 9/23. Observation on 10/17/23 at 10:30 a.m. of the [NAME] Unit, Medication Room with Staff G (Registered Nurse) revealed the following expired medications: Medication room: 2 unopened bottles of aspirin enteric coated 325 mg, with a manufacturer's expiration date of 9/23; 1 bottle MI-Acid relief (Simethicone) with a manufacturer's expiration date of 09/23; 1 open vial of tuberculin purified protein derivative aplisol with an open date of 8/22/23, review on of manufacturer's instructions that read discard after 30 days of opening. Interview on 10/17/23 at approximately 10:40 a.m. with Staff G (Registered Nurse) confirmed the above findings. Review on 10/17/23 of the facility's policy titled Medication Storage In The Facility dated May 2018, revealed under expiration dating . B. Drugs dispensed in the manufacturer's original container will be labeled with the manufacturer's expiration date. C. Certain medications(Manufacturer for Tuberculin) .once opened require an expiration date shorter than manufacturer's expiration date to ensure medication purity and potency.

Based on observation, record review, and interview, it was determined that the facility failed to assess a resident's ability to self-administer medications for 1 out of 1 residents reviewed for self-administration of medication in a final sample of 24 residents. (Resident Identifiers is #318.) Findings Include: Resident #318 Observation on 10/3/22 of Resident #318's room at approximately 10:49 a.m. revealed two bottles of [MEDICATION(S)] eye gel on the bedside table. Interview on 10/3/22 with Resident #318 at approximately 10:50 a.m. revealed that he/she uses the eye drops throughout the day when his/her eyes get dry. Review on 10/4/22 of Resident #318's medical record revealed no assessment for self-administration of medication and no order for self-administration of medications. Interview on 10/5/22 at approximately 1:49 p.m. with Staff B (Director of Nursing) confirmed that Resident #318 did not have any self-administration orders and there was no self-administration assessment done for Resident #318.

Based on observation, interview, and record review, it was determined that the facility failed to ensure that alleged violations of abuse were reported to the State Survey Agency within 24 hours for 2 of 6 residents reviewed for abuse in a final sample of 24 residents. (Resident identifiers are #23 and #75.) Findings include: Resident #23 Review on 10/4/22 of Resident #23's medical record revealed the following nursing notes: Nursing note, dated 9/8/22: LNA (Licensed Nursing Assistant) came to get this nurse to look at residents left side of stomach, [pronoun omitted] has a purplish bruise about the size of a baseball. Resident has pain when touching [pronoun omitted] anywhere. Will inform NP (Nurse Practioner) and family later in morning. Nursing note, dated 9/15/22: Resident experiencing pain with any care or movement, minimal relief from pain interventions, abdomen firm and pain to touch, two areas of bruising increased in size from previous days, bruise on LLQ (Left Lower Quadrant) 5cm (centimeter) x 5cm, bruise on left flank area 13cm x 5cm, . Interview on 10/4/22 at approximately 3:00 p.m. with Staff B (Director of Nursing) and Staff D (Social Worker) revealed there was no investigation into Resident #23's bruised areas, as Staff B and Staff D felt that it was related to Resident #23 being combative with care. Staff B and Staff D confirmed that these were not reported to the state agency. Resident #75 Review on 10/5/22 of Resident #75's medical record revealed the following notes under the social work section: Social Service Note dated, 10/3/22 revealed: Intermittent note Writer and another staff member met with [pronoun omitted] after [pronoun omitted] made statements regarding a male LNA. Interview on 10/5/22 at approximately 8:30 a.m. with Staff B and Staff D revealed that Resident #75 made a sexual allegation against 2 male LNAs. Further interview revealed that the allegation was not reported to the state agency within 24 hours from the allegation being made. Review on 10/5/22 of the investigation timeline into the accusation revealed the following: The Staff E (Night Supervisor) emailed the accusation to Staff D on 10/1/22. Interview on 10/5/22 at approximately 9:00 a.m. with Staff D revealed that Staff D did not read the email until 10/3/22 when he/she arrived to work. Interview on 10/5/22 at approximately 11:30 a.m. with Staff E confirmed that he/she sent email to the Staff D as notification of the allegation of abuse. Review on 10/4/22 of the facility policy titled, Abuse Reporting & Investigation, Dated 3/6/17 revealed: For the purpose of Definition and Investigation: . i. Injuries of unknown source should be classified as an injury of unknown source when both of the following conditions are met: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time . III. Identification . B. All staff are to immediately report any suspected abuse to their Supervisor or Charge Nurse, This will include, but not limited to, bruising, skin tears, . IV. Investigation A. All incidents of suspected abuse must be reported to your immediate Supervisor who then notifies the DON (Director of Nurses) and the Administrator. An incident resulting in physical abuse, sexual abuse, neglect, misappropriation of property/funds and any other serious abuse issue shall be immediately reported to the Administrator and Director of Nursing. The Administrator will then determine whether or not local law enforcement authorities shall be notified. The Supervisor or Charge Nurse will complete an Alleged Resident Abuse Incident Report on any incident which is not consistent with the routine operation of the facility, . V. Reporting A. An initial notification of the incident involving suspected abuse will be faxed to the Ombudsman as directed by the Administrator or designee.

Based on observation, interview, and record review it was determined that the facility failed to ensure that suspected violations of allegations involving abuse were thoroughly investigated to ensure that the residents were free from abuse and neglect for 2 of 6 residents reviewed for alleged abuse and neglect in a final sample of 24 residents. (Resident identifiers are #115 and #23.) Findings include: Resident #115 Observation on 10/3/22 at approximately 10:00 a.m. of Resident #115's bilateral forearms revealed bruises to both arms. Interview on 10/3/22 at approximately 10:00 a.m. with Resident #115 revealed that he/she could not elaborate on what had happened to his/her forearms. Observation on 10/4/22 at approximately 3:30 p.m. with Staff C (Unit Manager) confirmed the bruising to bilateral forearms. Interview on 10/4/22 at approximately 3:30 p.m. with Staff C revealed that Staff C was unaware of the bruising noted to Resident #115's bilateral forearms. Further interview revealed that the facility had not done an investigation into the cause of the bruising to Resident #115's bilateral forearms. Resident #23 Review on 10/4/22 of Resident #23's medical record revealed the following nursing notes: Nursing note, dated 9/8/22: LNA (Licensed Nursing Assistant) came to get this nurse to look at residents left side of stomach, [pronoun omitted] has a purplish bruise about the size of a baseball. Resident has pain when touching [pronoun omitted] anywhere. Will inform NP (Nurse Practioner) and family later in morning. Nursing note, dated 9/15/22: Resident experiencing pain with any care or movement, minimal relief from pain interventions, abdomen firm and pain to touch, two areas of bruising increased in size from previous days, bruise on LLQ (Left Lower Quadrant) 5cm (centimeter) x 5cm, bruise on left flank area 13cm x 5cm, . Interview on 10/4/22 at approximately 3:00 p.m. with Staff B (Director of Nursing) and Staff D (Social Worker) revealed there was no investigation into Resident #23's bruised areas, as Staff B and Staff D felt that it was related to Resident #23 being combative with care. Review on 10/4/22 of the facility policy titled, Abuse Reporting & Investigation, Dated 3/6/17 revealed: . For the purpose of Definition and Investigation: . i. Injuries of unknown source should be classified as an injury of unknown source when both of the following conditions are met: * The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and * The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. . III. Identification . B. All staff are to immediately report any suspected abuse to their Supervisor or Charge Nurse, This will include, but not limited to, bruising, skin tears, . . IV. Investigation A. All incidents of suspected abuse must be reported to your immediate Supervisor who then notifies the DON (Director of Nurses) and the Administrator. An incident resulting in physical abuse, sexual abuse, neglect, misappropriation of property/funds and any other serious abuse issue shall be immediately reported to the Administrator and Director of Nursing. The Administrator will then determine whether or not local law enforcement authorities shall be notified. The Supervisor or Charge Nurse will complete an Alleged Resident Abuse Incident Report on any incident which is not consistent with the routine operation of the facility, . V. Reporting A. An initial notification of the incident involving suspected abuse will be faxed to the Ombudsman as directed by the Administrator or designee.

Based on interview and record review, it was determined that the facility failed to ensure that licensed nurses contracted through nursing agencies had demonstrated competencies and skills necessary to care for residents' needs as identified in the facility assessment for 1 out of 1 agency staff reviewed for nursing competencies. (Staff identifier is Staff A) Findings include: Review on 10/4/22 of the facilities' facility assessment, updated date of 1/2022, revealed .Staff training/education and competencies 3.5 The following outlines the staff education and competencies required by SCHC [[NAME] County Healthcare] Upon hire and annual review: Resident's rights and facility responsibilities. Abuse, neglect, and exploitation, including identification and reporting requirements. Fire Safety/ Emergency Preparedness/ Material Safety Data Sheets. Infection Control/ Blood Bourne Pathogens. HIPAA [Health Insurance Portability and Accountability Act] Overview. False Claims Act and Whistleblower Protection. Compliance Policy. Additional Trainings and Competencies SCHC [[NAME] County Healthcare] Code of Ethics. Caring for Persons with Alzheimer's and Dementia. Therapeutic Activities . Review on 10/4/22 of Staff A's (agency nurse) training and competency records revealed that had no documentation of demonstrated competencies as mentioned in the facility assessment. Interview on 10/4/22 at approximately 11:00 a.m. with Staff B (Director of Nursing) revealed that the facility does not conduct training/education and competency checks for agency nurses before they work independently in the facility. Interview on 10/3/22 at approximately 12:30 p.m. with Staff A (Agency Nurse) revealed that he/she started working at the facility on 10/3/22 and there had been no training, education, or competencies done with Staff A by the facility prior to his/her start of employment.

Based on interview and observation, it was determined that the facility failed to ensure that insulin pens that have expired were disposed of after the expiration date for 1 out of 2 medication carts observed. (Resident identifiers are #25, and #69) Findings include: Resident #25 Observation on [DATE] at 09:10 a.m. of the [NAME] I medication cart 1 revealed the following: One [MEDICATION(S)] Injection KwikPen insulin pen open with a label that stated discard after 28 days date [DATE] for Resident #25. Resident #69 One [MEDICATION(S)] Injection KwikPen insulin pen open with a label that states discard after 28 days date [DATE] for Resident #69. Interview on [DATE] with Staff I (Medication Nursing Assistant) confirmed the above expiration date. Staff I also stated that the insulin pens should for Resident #25 and #6 had been used since expired and shuld have been discarded. Interview on [DATE] with Staff J (Registered Nurse) confirmed that the insulin pens were expired and should not be in the cart and discarded. Review on [DATE] of the Eli Lilly and Company's [MEDICATION(S)] Insulin injection KwikPen revealed that .In use Pens .Throw away the Insulin [MEDICATION(S)] injection pen you are using after 28 days, even if it has insulin left in it . Resident #75 Observation on [DATE] at approximately 10:10 a.m. on Resident #75's night stand revealed [MEDICATION(S)] Mouth Spray. Observation on [DATE] at approximately 1:15 p.m. on Resident #75's night stand revealed [MEDICATION(S)] Mouth Spray. Interview on [DATE] at approximately 1:15 p.m. with Staff C (Unit Manager) revealed that Resident #75 could not physically use the mouth spray. Further interview revealed that the mouth spray should not be locked in the medication cart.

Based on interview and record review, it was determined that the facility failed to ensure that the minimum required committee members attended meetings at least quarterly for 3 of 4 quarterly meetings reviewed. Findings include: Review on 10/5/22 of the last 4 quarterly Quality Assurance and Performance Improvement (QAPI) meeting attendance sheets revealed the following: January 2022 - The Medical Director or designee was not in attendance. April 2022 and August 2022 - no QAPI meeting attendance sheets were available to review to assure the minimum required committee members were in attendance at either meeting. Interview on 10/6/22 at approximately 2:00 p.m. with Staff H (Administrator) confirmed that the medical director or designee was not in attendance per the attendance sheet for the January 2022 QAPI meeting. Staff H stated that they could not locate a sign-in sheet for the April 2022 and the August 2022 QAPI meetings to verify who was in attendance.

Based on interview and record review, it was determined that the facility failed to implement policies and procedures in regard to the facility's contingency plan for staff who are not fully vaccinated for COVID-19 for 1 out of 3 contracted staff reviewed. (Staff identifier is Staff G.) Findings include: Review on 9/4/22 of the facility's policy titled, Employee COVID-19 Vaccination Policy, revised on 2/23/22, revealed .SCHC {[NAME] County Health Care] requires, as a condition of employment, that all [NAME] County Employees who provide services to or are located at the [NAME] County Health Care be fully vaccinated with an FDA [Food and Drug Administration] approved (either under Emergency Use Authorization or final approval) COVID-19 vaccine .This requirement includes, but is not limited to: .Health Care contracted providers and consultants .SCHC must also explore possible reasonable accommodations for those employees who have a documented medical condition or a sincerely held religious belief that keeps them from getting the vaccine .Request for exemption for receiving the COVID-19 vaccine must be made through the Human Resources Department. Medical reasons must include a note from a qualified medical practitioner .Request for exemption must be made on an annual basis . Review on 10/4/22 at approximately 10:30 a.m. of Staff G's (contracted Medical Provider) revealed that Staff G had received only one of the two recommended COVID-19 vaccinations on 11/12/21. Interview on 10/4/22 at approximately 11:a.m. with Staff B (Director of Nursing) confirmed that Staff G is not fully vaccinated for COVID-19. Staff B stated that Staff G does not have a medical or religious exemption request on file and has not provided proof of COVID-19 testing while employed by the facility. Staff B stated that Staff G was new to the facility and had only been in the facility to see residents on 9/12/22, 9/14/22, 9/19/22, 9/21/22, 9/26/22, and 9/28/22.

1.Based on observation, interview and policy review, the facility failed to ensure that drugs were labeled and stored in accordance with accepted professional standards for 2 out of 8 medication carts observed and 2 out of 3 medication rooms observed. Findings include: Observation on 6/22/21 at approximately 9:15 a.m. of 3rd floor North Side medication cart with Staff D (Registered Nurse) revealed 1 [MEDICATION(S)] Emergency 1 mg Kit with a manufacturer's expiration date of 5/2021. Further observation revealed 1 bottle of Mineral Oil Lubricant [MEDICATION(S)] with a manufacturer's expiration date of 5/2021. Observation of the 3rd floor medication room revealed 1 vial of [MEDICATION(S)] High-Dose Quadrivalent vaccine with a manufacturer's expiration date of 6/2/21. Interview on 6/22/21 at approximately 9:15 a.m. with Staff D confirmed the above findings. Observation on 6/22/21 at approximately 9:30 a.m. of the 2nd floor North Side medication cart with Staff A (Licensed Practical Nurse) revealed 1 [MEDICATION(S)] Emergency 1 mg Kit with a manufacturer's expiration date of 5/2021, a box of Omeprozole with no expiration date opened on 6/16/21 and 1 vial of [MEDICATION(S)] 10 mg/1ml with a manufacturer's expiration date of 6/6/20. Interview on 6/22/21 at approximately 9:30 a.m. with Staff A confirmed the above findings. Observation on 6/22/21 at approximately 9:40 a.m. of the first floor medication room revealed an open [MEDICATION(S)] with no open date and a manufacturer's expiration date of 2/2022. Interview on 6/22/21 at approximately 9:40 a.m. with Staff E confirmed the above findings. Review on 6/25/21 of [MEDICATION(S)] High-Dose Quadrivalent manufacturer's instructions revealed .Do not use after the expiration date shown on the label . Review on 6/25/21 of [MEDICATION(S)] manufacturer's instructions revealed .Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency . Review on 6/25/21 of facility policy titled 5.3 Storage and Expiration of Medications, Biologicals, Syringes and Needles revised 01/01/13 revealed .3.1 Facility should store Schedule II controlled substances and other medications deemed by Facility to be at risk for abuse or diversion in a separate compartment within the locked medication carts and should have a different key or access device . and .3.3 Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors . Review on 6/24/21 of the facility's policy titled Self Administration of Drugs approved 4/28/93 revealed that .It is the policy of this facility to permit residents to self-administer their drugs and medications unless such practice for the resident is deemed unsafe .Procedure 2. a. The manner of storage shall prevent access by other residents . Review on 6/25/21 of facility policy title 5.3 Storage and Expiration of Medications, Biologicals, Syringes and Needles revealed .Facility should ensure that medications and biologicals: 4.1 Have an Expiration Date on the label; 4.2 Have not been retained longer than recommended by manufacturer or supplier guidelines . and .Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. 5.1 Facility staff may record the calculated expiration date based on date opened on the medication container . 2. Based on medical record review, observation and interview, it was determined that the facility failed to provide a secure storage method for medications used for self- administration at resident bedside for 2 of 2 residents. (Resident identifiers are #103 and #53) Findings include: Resident # 103 Review of medical records for Resident #103 revealed orders for self-administration of [MEDICATION(S)] MDI (metered dose inhaler). Review on 6/24/21 of the facility's policy titled Self Administration of Drugs approved 4/28/93 revealed that .It is the policy of this facility to permit residents to self-administer their drugs and medications unless such practice for the resident is deemed unsafe .Procedure 2. a. The manner of storage shall prevent access by other residents . Observation on 6/22/21 at aproximately 1:42 p.m. revealed Resident #103 sitting in chair with a [MEDICATION(S)] inhaler on the bedside table next to them with no staff in the room. Observation on 6/23/21 at aproximately 8:53 a.m. revealed no one in Resident #103's room and a [MEDICATION(S)] inhaler on bedside table in room unsecured. Interview with Resident #103 on 6/22/21 corfirmed that they self-administer the [MEDICATION(S)] inhaler as needed for their asthma. Resident #103 also confirmed that the medication is not secured or locked up when not in use. Interview on 6/23/21 with Staff J (Licenced Practical Nurse) revealed that they were unaware of facility process for securing self-administered medications. Resident #53 Observation on 6/23/21 at approximately 2:40 p.m. revealed Resident #53 had nasal saline spray 44 milliliters on their over bed table. Interview on 6/23/21 at approximately 2:40 p.m. with Resident #53 revealed that they keep the the saline solution on the over bed table at all times. Interview on 6/23/21 at approximately 2:45 p.m. with Staff A (Licensed Practical Nurse) confirmed that Resident #53's nasal saline spray remains out on the overbed table at all times for their comfort.

Based on interview and record review, it was determined that the facility failed to ensure that services provided met professional standards for following physcian orders for 5 of 9 residents reviewed for medication management in a final sample of 22 residents. (Resident identifiers are #305, #54, #15, #25, and #102.) Findings include: Professional reference: Potter, Patricia A., and Anne Griffin Perry. Fundamentals of Nursing. 7th Edition, St Louis, Missouri: Mosby Elsevier, 2009. Chapter 23 Legal Implications Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Chapter 35 Medication Administration Page 699-Prescriber's Role Prescriber must document the diagnosis, condition, or need for use for each medication ordered Page 706-709-Standards The prescriber often gives specific instructions about when to administer a medication Resident #305 Review on 6/23/21 of Resident #305's physician's orders revealed the following orders: Acetaminophen 325 mg (milligrams) by mouth every 4 hours as needed for pain. [MEDICATION(S)] 0.5 ml (milliliters)/10 mg by mouth as needed for pain. There was no direction or instruction on when to give which medication versus the other. Interview on 6/24/21 at 12:05 p.m. with Staff I (Registered Nurse) confirmed that Resident #305's physician's orders did not have parameters on when to give acetaminophen versus [MEDICATION(S)]. Staff I stated that the nursing staff would use nursing judgement on which medication to give. Resident #54 Review on 6/23/21 of Resident #54's physician's orders revealed the following orders: Acetaminophen 325 mg two tablet (650 mg) by mouth every 4 hours as needed for pain. [MEDICATION(S)] 0.5 ml/10 mg by mouth every 2 hours as needed for pain. There was no direction or instruction on when to give which medication versus the other. Interview on 6/24/21 at 12:05 p.m. with Staff I confirmed that Resident #54's physician orders did not have parameters on when to give which medication. Resident #15 Review on 6/23/21 at approximately 2:30 p.m. of Resident #15's MAR (Medication Admininstration Record) revealed the following PRN (as needed) orders with no pain parameters for administration: Acetaminophen 325 MG TabletDose: (2 tablet/650mg) by mouth every 4 hours as needed For: Pain Administration Instructions: not to exceed 3 grams per 24 hours. [MEDICATION(S)]-Acetaminophen 5MG-325MG Tablet Dose: (1 tablet) by mouth daily prn for: Pain As needed for MODERATE TO SEVERE PAIN. There were no parameters as to when to admininister Acetaminophen versus [MEDICATION(S)]-Acetaminophen. Resident #25: Review on 6/23/21 at approximately 2:40 p.m. of Resident #25's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] Tablet (1 tablet/200mg) by mouth every 6 hours as needed for Back Pain Arthritis. Take with food. Acetaminophen 650MG Suppository Dose: 1 suppository/650mg) rectal every 4 hours as needed for Pain, Fever not to exceed 3000mg/24hr. [MEDICATION(S)] 20MG Tablet (1 tablet/50mg) by mouth every 6 hours as needed for Pain. Give for Moderate to Severe pain. oxyCODONE HCl 100MG/5ML Concentrate Dose: 0.125 ml/2.5mg by mouth every 4 hours as needed for Acute Pain. There were no parameters indicating when to administer [MEDICATION(S)] versus Acetaminophen Suppository versus [MEDICATION(S)] versus oxyCODONE. Resident #102 Review of records found an order start dated 2/19/21 for [MEDICATION(S)] (cardiovascular medication) to be given by mouth daily, if the systolic blood pressure (SBP) is greater than 100 mmHg. There was no documentation of daily blood pressure (BP) measurements prior to dosing for this medication since 2/19/21. Interview on 6/24/21 with unit manager Staff F (LPN) at aproximately 2:46 p.m. confirmed that there is no BP documentation on the record since 2/19/21.

Based on interviews and record review it was determined that the facility failed to document resident grievances for 2 of 5 residents reviewed for grievances/concerns in a final sample of 22 residents (Resident identifiers are #53 and #41.) Review on 6/22/21 of the grievance log revealed 3 grievances in the last 3 years (7/9/19, 2/24/20 and 6/19/20.) Interview on 6/23/21 at approximately 11:30 a.m. with Staff O (Social Services Director) and Staff P (Social Worker) revealed that grievances were coordinated through the social services department. Staff O (Social Services Director) and Staff P (Social Worker) confirmed the above 3 grievances were the only documented grievances that they had. They said that issues that residents bring forward are usually just handled on the spot and not documented. Interview on 6/24/21 at approximately 9:05 a.m. with Resident #53 revealed that within the last two weeks the resident had rosary beads missing. The Resident had alerted staff and they looked for the rosary beads. They did find the rosary beads within one day. Review on 6/24/21 of resident #53's nurses notes revealed that on 6/12/21 an entry was made about the missing rosary beads but no grievance form was completed. Interview on 6/24/2 with Resident #41 on 6/24/21 at approximately 9:10 a.m. revealed that the resident had concerns about ink stains on their clothes and let the staff know. Resident #41 had let staff know about a complaint about missing glasses, as well, that had occurred in the last couple of weeks. Review of the nurses notes on 6/24/21 noted that on 6/18/21 that the Resident was concerned about their glasses. No grievance form was completed. No notation was documented regarding the ink stains in the nurses notes. Review on 6/23/212 of the resident grievance procedure approved 6/1/17 revealed that .2. the resident has the right to prompt efforts by the Facility to resolve grievances .6. Social Services is responsible for ensuring that all written grievance decisions include; .any corrective action taken or to be taken by the Facility as a result of the grievance .8. The Facility is required to maintain evidence of the results of all grievances for a period of no less than three years from the issuance of the grievance decision.

Based on interview and record review, it was determined that the facility failed to provide the necessary transfer services outlined in a resident's care plan which resulted in harm for 1 resident who sustained fractures to their face for 1 resident reviewed. (Resident identifier is #1.) Findings include: Review on 11/16/17 of Resident #1's care plan revealed an intervention dated 8/28/17 Two assist for transfers . Review on 11/16/17 of Resident #1's care plan revealed an intervention dated 8/31/17 2 assist with bed mobility. Use Hoyer (mechanical lift) . Review on 11/16/17 of the facility's Incident/Accident Investigation report, dated 9/15/17 revealed that Resident #1's care plan had been updated on 8/31/17 with Resident #1's transfer status of 2 assist and a mechanical lift for all transfers but that the Kiosk used by LNA's (Licensed Nursing Assistants) and the LNA tickets had not been updated with this new information. Review on 11/16/17 of the facility's Incident/Accident Investigation report, dated 9/15/17 revealed that on 9/8/17, Staff A (Licensed Nursing Assistant) transferred Resident #1 without the use of a mechanical lift and without the assistance of another staff member. During this transfer, Staff A lost balance and Resident #1's head hit a Broda chair resulting in fractures to Resident #1's right maxillary sinuses, orbital wall and an oblique fracture to the anterior inferior C2 (Cervical 2) vertebral body. Interview on 11/16/17 at approximately 1:00 p.m. with Staff B (Director of Nursing) confirmed that Staff A did transfer Resident #1 on 9/8 /17 without the use of a mechanical lift and without having a second staff member for assistance.