Every finding on record at Sumter East Health & Rehabilitation Center

Based on observation, interview, and facility policy review, the facility failed to ensure food was stored off the floor, failed to label, date, and cover stored food, and failed to discard food with expired use by or best by dates in two of two facility kitchens. These failures had the potential to create an environment for food-borne illnesses which could affect 165 residents who consumed food prepared from the facility's two kitchens.Findings include:Review of the facility's undated policy titled, Date Marking for Food Safety, indicated, Policy: The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food. Policy Explanation and Compliance Guidelines for Staffing: 1. Refrigerated, ready-to-eat, time/temperature control for safety food (i.e. perishable food) shall be held at temperatures of 41 [degrees] F [Fahrenheit]. for a maximum of 7 days. 2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded . 4. The marking system shall consist of a food label, the day/date of opening, and the day/date the item must be consumed or discarded. 5. The discard day or date may not exceed the manufacturer's use-by date, or three days, whichever is earliest. The date of opening or preparation counts as day 1. (For example, food prepared on Tuesday shall be discarded on or by Thursday.) . Review of the facility's undated policy titled, Food Safety Requirements, indicated, Policy: It is the policy of this facility to procure food from sources approved or considered satisfactory by the federal, state, and local authorities. Food will also be stored, prepared, distributed, and served in accordance with professional standards for food service safety . Policy Explanation and Compliance Guidelines: . 3b. Dry food storage - keep foods/beverages in a clean, dry area off the floor . c. Refrigerated storage - . iv. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded; and v. Keeping foods covered or in tight containers .1. Observation on 03/08/26 from 6:50 AM to 7:20 AM, during the initial inspection of the facility's [NAME] kitchen revealed the following food storage concerns:a. In the kitchen's dry storage room a crate which housed 24 four-ounce containers of thickened cranberry juices was stored directly on the floor.b. The kitchen's walk-in refrigerator contained an opened and undated package of American cheese slices, two opened and undated packages of Swiss cheese, an opened and undated one gallon container of mayonnaise, two large opened and cut fully cooked hams which were labeled with an opened date of 02/17/26, but were not labeled with a use-by or discard date, and four five pound containers of cottage cheese with expired manufacturer's use by dates of 03/07/26. c. The kitchen's walk-in freezer contained three large plastic bags of dumplings and one large box of garlic bread that were stored open to air and not protected from possible contamination.On 03/08/26 at 7:25 AM DD1 was shown each of the above food storage concerns that were identified in the facility's [NAME] kitchen and he observed and confirmed each concern.During an interview on 03/08/26 at 7:35 AM, DD1 stated when staff placed food into storage, the food should be completely covered, dated, labeled, and stored off the floor. DD1 also stated food with expired use by, or expiration dates should be discarded.During an interview with on 03/10/26 at 12:05 PM, DD1 stated the two large fully cooked hams that were observed on 03/08/26 stored in the [NAME] kitchen's walk-in refrigerator that were labeled as opened on 02/17/26 should have been discarded by staff seven days after their open date.2. Observation on 03/08/2026 from 9:50 AM to 10:10 AM, during the initial inspection of the facility's East kitchen, with DD2 present, revealed the following food storage concerns:a. The kitchen's walk-in refrigerator contained one opened and undated package of shredded Swiss cheese, three large plastic packages of cut lettuce, which had slight browning on some of the lettuce, that had expired manufacturer's best by dates of 03/03/26 on each bag, one five-pound container of cottage cheese with an expired manufacturer's use by date of 03/07/26, and one box of egg patties that were stored opened to air and not protected from possible contamination.During an interview on 03/08/26 at 10:00 AM, DD2 stated staff should check stored food and discard any food found with an expired expiration date. DD2 also stated staff should date food when opened and completely close food when stored.

Based on interviews, record review, and facility policy review, the facility failed to complete an assessment of the building to determine where Legionella and other opportunistic waterborne pathogens can grow and spread. Additionally, there was no diagram of the water maintenance as it flows through the facility. This had the potential to affect 168 of 168 residents who resided at the facility. These failures had the potential to allow for the growth of waterborne pathogens to be unnoticed and placed residents at risk for the spread of infections. Findings include:Review of the facility's Infection Prevention and Control Program under number 17, indicated, Water Management, provided by the facilities, infection preventionist, revealed an assessment of the building was not completed where Legionella could grow and spread. a. A water management program has been established as part of the overall infection prevention and control program. b. Control measures and testing protocols are in place to address potential hazards associated with the facility's water systems. c. The Maintenance Director serves as the leader of the water management program.During an interview on 03/09/26 at 3:42 PM, the Maintenance Director (MD) provided a drawing that showed where water entered both buildings of the facility and indicated where the shut-off valves were for the water supply. The drawing did not indicate the water flow throughout the facility or areas of potential stagnation where the growth of waterborne pathogens, including Legionella could occur. The MD confirmed he had not completed a building assessment and was unaware one was needed for the water management programDuring an interview on 03/09/26 at 4:10 PM, the MD provided blueprints of the two buildings that made up the facility. Review of the blueprints revealed the blueprints were original and had not been updated to show the current water flow in the buildings.During an interview on 03/10/26 at 12:29 PM, the Administrator confirmed the drawings provided by the MD only showed the shut-off locations for the water supply. The Administrator confirmed there was not a building assessment completed to show areas where waterborne pathogens could grow.

Based on observation, interview, record review, and policy review, the facility failed to ensure one of 20 supplemental residents was assessed for self-administration of medications Resident (R) 177. R177 had seizure medications at her bedside; however, she had not been assessed for or ordered by her physician to be able to self-administer her medications. This failure placed the resident at an increased risk of seizure activity if the medications were not administered as ordered by the physician. Findings include:Review of the facility's policy titled, Resident Self-Administration of Medication, dated 2025, revealed, A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely . When determining if self-administration is clinically appropriate . the results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment Form, which is placed in the resident's medical record . Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the other resident's rooms or to confused roommates of the resident who self-administers medication.Review of R177's admission Record, located under the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with a diagnosis of altered mental status.Review of R177's Brief Interview for Mental Status (BIMS) assessment dated [DATE], located under the Assessments tab of the EMR revealed the facility assessed the resident to have a BIMS score of eight of 15 which indicated she was moderately cognitively impaired. During an observation on 03/08/26 at 10:37 AM of R177's room revealed on the resident's bedside table was a small souffle cup that contained two large blue and white medication capsules. R177 was not in her room and was observed walking down the hallway. At 10:42 AM, R177 entered the room and stated she had forgotten about her medications on the table and was supposed to take them earlier.During an observation and interview on 03/08/26 at 10:43 AM in R177's room, Licensed Practical Nurse (LPN) 1 confirmed the souffle cup with blue and white medication capsules was present on R177's bedside table. LPN1 stated the medication should not have been left in the resident's room unattended. LPN1 encouraged R177 to take her medications, and R177 swallowed the pills. LPN1 stated the pills were Depakote [anti-seizure medication] and were given to R177 around 9:30 AM. LPN1 stated she thought R177 had taken the pills and did not realize they were left in her room unattended. LPN1 stated R177 was unable to self-administer medications. Review of R177's physician Order, dated 03/05/26 and located in the resident's EMR under the Orders tab revealed an order for 125 milligrams of Depakote capsules to be administered twice daily for seizures The order specified the morning dose should be given at 9:00 AM.Review of R177's EMR under the Assessments tab revealed no assessment of the resident's ability to self-administer medications or safety with keeping medications at her bedside.During an interview on 03/10/26 at 5:00 PM, the Director of Nursing (DON) stated it was her expectation the nursing staff watch residents swallow their medication. The DON also stated she expected nurses never to leave medications at the bedside unattended unless a resident had been assessed to be able to self-administer medications.

Based on record review, interview, and facility policy review, the facility failed to ensure one of five residents Resident (R)18 reviewed for unnecessary medications out of a total sample of 35 had adequate indication for the use of an antipsychotic medication. R18 was ordered Seroquel (Quetiapine), an antipsychotic medication for schizophrenia, without documented evidence of the diagnosis. This failure placed the resident at risk of receiving unnecessary medications. Findings include:Review of the facility undated policy titled, Restraint Free Environment revealed, . If a medication was initially administered for a medical symptom and continues to be administered in the absence of such symptom, the facility should re-evaluate the need for such medication to ensure that it does not sedate the resident or make it easier for the staff to care for the resident . Review of R18's admission Record, located under the Profile tab of the EMR, revealed the resident was admitted on [DATE] with diagnoses that include senile degeneration of brain, dementia with behavioral disturbance, and psychosis not due to substance or known physiological condition.Review of R18's Preadmission Screening and Resident Review (PASARR) with a screening date of 06/25/25 and located under the Miscellaneous tab of the electronic medical record (EMR) revealed no documented evidence of a mental illness.Review of R18's Order Summary Report, located under the Orders tab of the EMR, revealed a physician's order for Quetiapine Fumarate Oral Tablet 100 milligrams (mg) one tablet by mouth two times a day for schizophrenia. Review of R18's Care Plan, dated 07/16/25 and located under the Care Plan tab of the EMR, revealed the resident was not care planned for schizophrenia. It was documented that R18 was receiving antipsychotic medications related to psychosis/ behavior management. Review of the Consultant Pharmacist Recommendations to Physician, dated 12/07/25 and provided by the facility, revealed R18 had been taking quetiapine 100mg twice a day since 07/09/25 without a Gradual Dose Reduction (GDR). Pharmacist recommendation was to attempt a dose reduction at this time to quetiapine 50 mg once in the morning and 100mg once at night to verify the resident was on the lowest possible dose. It was recorded the physician agreed with recommendation to have the resident's dose reduced to 75mg twice daily. Review of R18's Order Summary, located in the EMR revealed no documented evidence the gradual dose reduction was initiated. Review of R18's of Progress Notes, dated 02/08/26 through 03/07/26 and located under the Progress Notes tab of the EMR, revealed no documentation of R18 experiencing behaviors.Review of R18's Medication Administration Record (MAR), dated 03/01/26 through 03/09/26 and located under the Orders tab of EMR, indicated R18 had behaviors. R18 was observed not having any behaviors during the survey process.During an interview on 03/10/26 at 10:48 AM, the Director of Nursing (DON) confirmed the resident did not have a proper schizophrenia diagnosis and that a GDR should have been started. The DON also confirmed the GDR recommended for R18 was not followed. The DON revealed she would look for PASARR results when a resident is prescribed an antipsychotic but missed R18. During an interview on 03/10/26 at 3:18 PM, the Registered Pharmacist Consultant (RPHC) confirmed she was not familiar with R18 and that R18's Seroquel order noted the resident had schizophrenia. The Pharmacist confirmed she did not question the use of Seroquel in the monthly reviews because the order was signed by the provider for schizophrenia.An attempt was made to contact the Medical Director during the survey, but he was unreachable.

Based on review of the facility policy, interviews and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected a facility fall for one of three residents reviewed for falls Resident (R)150 out of a total sample of 35. This failure had the potential to lead to lack of care plan interventions to prevent falls. Findings include:Review of the facility's undated policy titled, MDS 3.0 Completion revealed, . Persons completing part of the assessment must attest to the accuracy of the section they completed by signature and indication of the relevant sections.Review of R150's admission Record, located under the Profile tab of the electronic medical record (EMR), indicated R150 was admitted on to the facility on [DATE] with diagnoses of acquired absence of right leg below knee (BKA), lack of coordination and abnormalities of gate and mobility.Review of R150's Progress Note, dated 01/17/26 at 1:39 PM and located under the Progress Notes tab of the EMR, revealed, Staff was alerted that resident was on the floor. Upon entering staff observed resident lying on his left side parallel to his bed. The resident's head was resting against the nightstand beside his bed . Review of R150's admission MDS, with an Assessment Reference Date (ARD) of 01/19/26 and located under the MDS tab of the electronic medical record (EMR), revealed the assessment did not indicate the resident had a fall while in the facility. During an interview on 03/10/26 at 10:48 AM, the Director of Nursing (DON) confirmed R150 had a fall in the facility on 01/17/26 and the admission MDS dated [DATE] was inaccurate and should have reflected R150's fall in the facility.During an interview on 03/10/26 at 2:53 PM, the MDS Coordinator (MDSC) 2 confirmed R150 had a fall in the facility on 01/17/26 and the MDS with an ARD date of 01/19/26 was inaccurate and should have reflected R150's fall in the facility.

Based on interview, record review, and review of the facility's policy, the facility failed to ensure the comprehensive care plan was developed to accurately reflect the indication of the resident's use of an antipsychotic medication for one of five sampled residents Resident (R)18 reviewed for unnecessary medications out of a total sample of 35. This failure placed the resident at risk of staff not meeting the resident's care needs. Findings include:Review of the facility's undated policy titled, Comprehensive Care Plan, revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality . The care planning process will include an assessment of the resident's strengths and needs . The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .Review of R18's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R18 was admitted on [DATE] with diagnoses that included major depressive disorder.Review of R18's Care Plan, dated 05/01/25 and located under the Care Plan tab of the EMR, revealed R18 received an antipsychotic medication related to insomnia. Review of R18's Order Summary Report, located under the Orders tab of the EMR, revealed and order dated 12/09/25 for Risperdal (an antipsychotic medication) one milligram (mg) one tablet orally at bedtime for depression. Review of R18's Order Note, dated 12/09/25 and located under the Progress Notes tab of the EMR, revealed the resident was ordered Risperdal one mg tablet to be given at bedtime for depression. Review of R18's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/15/26 and located under the MDS tab of the EMR, revealed R18 had a Staff Interview for Mental Status (SAMS) score of three, which indicated the resident was severely cognitively impaired. It was recorded the resident received antipsychotic medications during the lookback period.During an interview on 03/10/26 at 2:50 PM, the MDS Coordinator (MDSC) 2 confirmed that R18 was ordered Risperdal for depression and care planned for Risperdal with insomnia. MDSC2 confirmed the care plan should match the physician's order and be specific to the diagnosis.

Based on record review, interview, and policy review, the facility failed to ensure one of 35 sampled residents Resident (R)6 care plan was revised to reflect the resident's end of life wishes. R6's wishes was to be a Do Not Resuscitate (DNR); however the resident's care plan documented the resident wanted to receive life saving measures of cardio-pulmonary resuscitation (CPR) in the event her heart stopped or she stopped breathing. This failure placed R6 at risk to receive CPR against her wishes for a natural death, potentially causing serious injury from compressions or psychosocial harm related to her preference not being honored. Findings include:Review of the policy titled, Comprehensive Care Plans, dated 2025, revealed, The comprehensive care plan will describe, at a minimum, the following:a. The services that are to be furnished to attain or maintain the resident's highest practicablephysical, mental, and psychosocial well-being'b. Any services that would otherwise be furnished, but are not provided due to the resident'sexercise of his or her right to refuse treatmentc. The resident's goals for admission, desired outcomes, and preferences for future discharge.d. Discharge plans. as appropriate.e. Resident specific interventions that reflect the resident's needs and preferences and align withthe resident's cultural identity, as indicated.Review of R6's admission Record, located under the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including stroke, diabetes, heart failure, and encephalopathy.Review of R6's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] and located under the MDS tab of the EMR, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS), score of three out of 15 which indicated the resident was severely cognitively impaired. Review of R6's EMR home page revealed her code status was DNR [Do Not Resuscitate]. Review of R6's National POLST [Portable Orders for Life-Sustaining Treatment] Form, located under the Miscellaneous tab of the EMR dated [DATE], revealed R6's representative with legal decision-making authority elected DNR status.Review of R6's EMR under the Orders tab revealed a physician's order, dated [DATE], for Do Not Resuscitate - DNR.Review of R6's Care Plan initiated [DATE], revised [DATE], and located under the Care Plan tab of the EMR revealed, I . choose to have CPR [cardio-pulmonary resuscitation]. The goal was, I will have all of my wishes and advanced directives honored until I request otherwise, or until the next review period. The approaches included, Please provide CPR.During an interview on [DATE] at 10:14 AM, Licensed Practical Nurse (LPN) 4 stated R6's code status was DNR. She stated the first place to look was the report sheet or code status book, which showed R6 had a DNR status. LPN1 stated she could also look in the EMR under the resident's home page, which also indicated DNR status.During an interview on [DATE] at 11:36 AM, the MDS Coordinator (MDSC) stated R6's Care Plan was done on [DATE] and her DNR order was dated [DATE], so the Care Plan should have been updated at that time to reflect a DNR status. The MDSC stated typically, the Social Services Director (SSD) would update the DNR paperwork and the Care Plan.During an interview on [DATE] at 11:53 AM, the SSD stated she was responsible for ensuring all the DNR paperwork was completed, then she presented the code status change to the interdisciplinary team. The SSD stated the nursing staff would obtain the order for the code status and the MDSC would update the Care Plan accordingly. The SSD stated the Care Plan should have been updated to reflect the DNR with the code status change.During an interview on [DATE] at 5:20 PM, the Director of Nursing (DON) stated the MDSC was responsible for updating the Care Plan with any code status changes; however, the MDSC was not working the day R6's code status was changed. The DON stated the Care Plan should have been updated to DNR.

Based on observation, interview, record review, and policy review, the facility failed to implement care to prevent pressure ulcer development for one of four residents reviewed for pressure ulcers Resident (R)6 out of 35 sampled residents. R6's interventions for the prevention of pressure ulcers were not being implemented. This failure placed R6 at risk for development of pressure ulcers.Findings include:Review of R6's admission Record, located under the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including stroke, diabetes, heart failure, and encephalopathy.Review of R6's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/19/26 and located under the MDS tab of the EMR revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS), score of three out of 15 which indicated there resident was severely cognitively impaired. The MDS also revealed the resident did not exhibit any behavioral symptoms, was dependent on staff for putting on footwear, and she was at risk of developing pressure ulcers but had no current pressure ulcers.Review of R6's EMR under the Orders tab revealed a physician's order, dated 11/25/25, to Apply offloading boot 1 time each shift as tolerated by resident. Okay to float bilateral legs on pillows if better tolerated by resident for wound care/protect skin integrity. Review of R6's Care Plan dated 12/11/25 and located under the Care Plan tab of the EMR revealed, I . have potential for pressure ulcer development . r/t [related to] diabetes, CVA [stroke] w/ [with] hemiparesis, incontinence, multiple comorbidities, and recently healed Right great toe area. The approaches included, Apply offloading boot 1 time each shift as tolerated by resident. Okay to float bilateral legs on pillows if better tolerated by resident. Per MD [physician] orders. Review of R6's Medication Administration Record (MAR) dated March 2026 and located under the Orders tab of the EMR, revealed the order for an offloading boot or pillows to float heels was signed off as completed twice daily from 03/01/26 through 03/09/26.During every 15 minutes observation on 03/08/26 from 7:25 AM to 10:00 AM in R6's room, R6 was observed asleep in bed with no boots on or pillows under her legs.During an observation on 03/08/26 at 11:44 AM in R6's room, R6 was lying in bed with no boots or pillows under her legs/feet.During an observation on 03/09/26 from 9:21 AM to 10:00 AM in R6's room, R6 was lying in bed with bare feet. Her feet were in direct contact with the mattress and there were no boots or pillows in place.During an observation on 03/09/26 from 2:31 PM to 4:00 PM in R6's room, R6 was lying in bed with bare feet. Her feet were in direct contact with the mattress and there were no boots or pillows in place.During an observation on 03/10/26 at 9:52 AM in R6's room, R6 was lying in bed with bare feet. Her feet were in direct contact with the mattress and there were no boots or pillows in place.During an interview and observation on 03/10/26 at 4:31 PM in R6's room, Licensed Practical Nurse (LPN) 4 stated she had ensured R6 had her boots on earlier that morning, but R6 must have removed them since then. LPN4 confirmed there were no boots or pillows in place, and she stated she was unaware R6's feet were not being floated. LPN4 stated the boots sometimes agitated R6, as she liked to move her feet and rub them together.During an interview on 03/10/26 at 4:35 PM, LPN1 stated R6 sometimes would not cooperate with wearing boots but a pillow should be in place to float her heels. LPN1 stated she or the wound nurse would put boots on R6's feet about three times a week but it was not done every day. LPN1 stated she did not know why the MAR was signed for this every day but thought maybe the nurses assumed the boots were on because she or the wound nurse would typically put them on.During an interview on 03/10/26 at 5:00 PM, the Director of Nursing (DON) stated R6 was at risk for pressure ulcers and the staff should have been floating her heels with boots or pillows at all times.Review of the policy titled, Pressure Injury Prevention and Management, dated 2025, revealed, Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include but are not limited to: . Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.).

Based on observations, record reviews, interviews, and policy review, the facility failed to honor known food preferences for one resident Resident (R)155 of four residents reviewed for food out of 35 sampled residents. This failure had the potential to cause R155's nutritional needs to go unmet. Findings included:Review of R155's undated admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed an original admission date of 03/10/25 and diagnoses which included, type 2 diabetes mellitus with hyperglycemia, and chronic kidney disease.Review of R155's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/19/26 and located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated R155 was cognitively intact.Review of R155's current Care Plan, provided by the facility and most recently revised on 03/02/26, contained a Focus, which indicated, I [Resident #155's name] have an actual nutritional problem or potential nutritional problem r/t [related to] Diabetes, S/P [status post] Left BKA [below the knee amputation], PVD [peripheral vascular disease], Hypertension, CAD [coronary artery disease], Renal Insufficiency . Care plan Interventions/Tasks included, Provide, serve diet as ordered . Honor my diet preferences.Review of R155's current Physician Orders, located in the EMR under the Orders tab, revealed an order for a CCHO [controlled carbohydrate] (Diabetic) diet, Mechanical Soft consistency, Regular texture. Directions for this diet order included no oatmeal, no eggs, double portions, and no meat. The diet order had a revision date of 02/26/26.Observation on 03/08/26 at 1:31 PM revealed R155 was in his room eating lunch. Observation of R155's meal revealed he was served carrots, potatoes, a roll, a fruit dessert, iced tea, and water. Review of the tray slip that was served with R155's meal revealed he was a vegetarian, and no meat was to be served. The tray slip specified the featured menu included pot roast and the second choice was chicken breast for this meal.During the observation, interview with R155 revealed he was a vegetarian and had informed facility staff of this when he was admitted to the facility about a year ago. R155 voiced a concern that he was not always served a protein source in place of the meat that he did not eat the meals. R155 stated he did not eat pot roast or chicken and again was not served an alternative for these foods with his lunch meal. R155 specified he would eat cheese, cottage cheese, pimento cheese, salmon, and other types of fish.Observation on 03/10/26 at 8:44 AM revealed staff served R155's breakfast meal in his room. Observations of R155's meal revealed he was served grits on a plate, a four-ounce carton of apple juice, a eight-ounce carton of milk and a cup of coffee. R155 placed a can of sardines that he had in the room on the grits that were served with the breakfast meal. Review of the resident's tray slip served with this meal specified no oatmeal, no eggs, no meat, vegetarian. The tray slip also specified the Featured menu included two-ounce scrambled eggs and two ounces of sausage and contained the following: Instructions: No toast, grits, fruits breakfast only. During an interview on 03/10/26 at 8:44 AM, R155 stated he did not eat eggs and sausage and was not served alternatives with his breakfast meal for these foods that he did not eat. R155 stated his family had provided cans of sardines that he kept in the room and he ate them with grits at breakfast each morning. The resident stated he would eat cheese on his grits if it was served with the breakfast meal. R155 also stated he had requested fruit to be served with his breakfast each morning but was not served any fruit with the breakfast today. R155 specified that he enjoyed eating any type of fruit but was only served fruit at breakfast a couple times a week.On 03/10/26 at 8:55 AM Licensed Practical Nurse (LPN) 3 came to R155's room and observed the resident's breakfast meal. LPN3 confirmed R155 was not served a protein source in place of the scrambled eggs and sausage that was planned on the featured menu and was not served any fruit with the breakfast meal. LPN3 stated she would inform Dietary Director (DD) 2 of these omissions and provide R155 with fruit to eat with his breakfast meal.During an interview on 03/10/26 at 12:10 PM, DD2 stated she was aware R155 was a vegetarian and the resident should be served a meat alternative at meals for foods he would not eat. DD2 stated R155 should have been served an alternative during the 03/08/26 lunch meal in place of the pot roast and chicken that was being served at this meal. DD2 also stated during the breakfast meal on 03/10/26, R155 should have received a substitute for the scrambled eggs and sausage that were served at this meal and should have received fruit with his/her breakfast meal that the resident had previously requested.During an interview on 03/10/26 at 2:22 PM, the facility's Registered Dietitian (RD) stated R155 was a vegetarian and his food preferences should be honored. The RD stated he was unable to find R155's original admission food preference documentation that would have been completed during the resident's 03/10/25 admission. The RD stated he did find a 04/21/25 reentry RD Nutritional Assessment for R155 which specified the resident was a vegetarian and a 08/05/25 diet requisition form which specified that R155 was vegetarian and was not to be served meat or eggs.Review of the facility's undated policy titled, Policy and Procedure, provided by the facility, indicated, Procedure . Personal Food Preferences, allergies, idiosyncrasies, and intolerances are addressed on an individual basis and assessment.

Based on review of facility policy, record review and interview, the facility failed to protect Resident (R)1 from physical abuse by Certified Nursing Assistant (CNA)1. Specifically, CNA1 slapped R1's bilateral stumps to ensure his stumps were flat on the bed, for 1 of 3 residents reviewed for abuse. On 03/20/25 at 2:00 PM the Administrator and the Director of Nursing were notified that the failure to protect a resident from physical abuse constituted Immediate Jeopardy (IJ) at F600. On 03/20/25 at 2:00 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 03/02/25. The IJ was related to 483.12 Freedom from Abuse, Neglect, and Exploitation. On 03/20/25 at 7:20 PM, the facility provided an acceptable IJ Removal Plan. On 03/20/25, the survey team, validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F600 at a lower scope and severity of D. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F600, constituting substandard quality of care. Findings include: Review of the facility policy titled Abuse, Neglect and Exploitation, states, Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse including abuse facilitated or enabled through the use of technology . Physical Abuse includes but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. The facility admitted R1 on 06/27/24, with diagnoses including but not limited to: respiratory failure with hypoxia, dependent on renal dialysis for ESRD (End Stage Renal Disease), peripheral vascular disease and left and right below the knee amputations. R1 has a dialysis catheter to his right upper chest area. Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 01/22/25, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicates R1 was cognitively intact. Review of R1's Care Plan revealed R1 has a self care deficit related to activities of daily living (ADLs), impaired mobility, muscle weakness, and lack of coordination, with pulmonary edema, and incontinence of bowel and bladder. R1 is receiving oxygen therapy related to acute and chronic congestive heart failure, restrictive lung disease and cardiomyopathy. During an interview on 03/17/25 at 11:58 AM, the Social Services Director (SSD) stated that R1 had told her that CNA1 was rough with him and overly aggressive. The SSD further stated R1 has bilateral amputations and when he lays back his stumps will raise up a little, CNA1 slapped R1s legs for him to put them down. When CNA1 slapped his legs, R1 swung at him. Then the CNA1 grabbed both of the resident's hands, held them and and pressed them against R1's upper chest and neck area. The SSD further stated CNA1 told the resident, You are not going to hit me. The SSD stated that CNA1 held down R1's hands while he performed incontinent care for R1. The SSD concluded that R1 became distressed and was very upset and felt abused by the act. During an interview on 03/17/25 at 12:18 PM, the Director of Nursing (DON) stated, The CNA is arrogant and out spoken and is in the military Reserves. The DON further stated that CNA1 had informed the DON that he grabbed both of the resident's hands and with one of his hands he held them down across his upper chest and neck area. CNA1 said to the DON, I had no choice but to restrain him. During an interview on 03/17/25 at 2:25 PM, CNA1 stated, The resident [R1] put on his call light, as he does several times during the night and was whining. I was not assigned to the resident, his CNA was busy taking care of another resident. I went in to see if I could help him. I was turning him over to loosen his brief and he swung at me and hit me. I tried blocking his hand with my hands and he stopped for a minute and I continued changing him and left the room. CNA1 did not mention the slapping of R1's legs and restraining him by holding his hands pressed against his upper chest. Review on 03/17/25 at 2:35 PM, of the original statement written by CNA1 documented, Resident put on his call light, I, myself went in and asked what was wrong and he said he needed a brief change. So, I told him the CNA working with him would be with him and he said ok. I left the room to finish my rounds, and the resident started to whine. His CNA for the night was falling behind so I went in his room and told him I was going to change him and he swung at me so I restrained him until he cooled down. He let me change him and I left the room. He threatened me and disrespected me physically and vocally. During an interview on 03/17/25 at 3:28 PM, R1 stated, The CNA came in my room when I rang the call bell, he just started hitting my stumps. My left stump is still tender because it has not been long since I had the amputation. The CNA went out of the room so I called again. He came back in and grabbed me and held my hands down around the upper part of my chest. I was scared he would pull out my dialysis catheter, so I just quit struggling with him. In a little while he quit holding me down. I never hit him or pushed him. I could not believe he was doing me like that. My CNA, a female, that usually helped me was helping someone else at the time. That is why he came in my room in the first place. During an interview on 03/20/25 at 10:40 AM, Licensed Practical Nurse (LPN)1 stated she was the nurse coming on duty for the day shift on 03/02/25. R1 started calling for this nurse as soon as he saw she was there. LPN1 stated that R1 was very upset and it took a few minutes to calm him down. She stated that R1 was not crying, but he was very upset. I informed him that he was safe and that the CNA would not be back and could not hurt him. After he appeared calmer, I left the room for a few minutes to go and report what the resident had told me. The resident was adamant about calling his family and wanting to press charges against the CNA. On 03/20/25 at 7:20 PM, the facility provided an acceptable IJ Removal Plan, which included the following: Please accept this as our plan for abatement of the Immediate Jeopardy with a date of compliance of 03/20/25. Actions taken for the affected resident: On 03/02/2025 at approximately 07:15 AM, Resident #1 reported to the Licensed Practical Nurse #1 (LPN1) the he (R1) wanted to call the police to press charges against CNA #1. The resident then went on to disclose how CNA#1 was rough with him and smacked his leg. LPN1 informed the Unit Manager and the Director of Nursing. On 03/02/2025 at approximately 07:30 AM, the Director of Nursing (DON) was contacted by LPN1 and was notified of the allegation. LPN1 remained with the resident pending the arrival of the DON to start the investigation. On 03/02/2024 at approximately 07:45 AM, the DON contacted CNA1 via phone and suspended him. The DON requested that CNA1 provide a written statement regarding his interactions with R1. The DON interviewed CNA1 in which he admitted that he (CNA1) restrained the resident. On 03/02/2025 at approximately 08:04 AM, the DON provided notification to the South Carolina Department of Public Health of the allegation of abuse. On 03/02/2025 at approximately 08:30 AM, the DON interviewed resident (R1) as a part of the investigation. She completed a body audit that was negative for marks or bruises. Resident (R1) disclosed that he was lying on his back with his legs bent. He (R1) demonstrated and it was observed that due to amputations his legs point up into the air. Resident #1 states that when CNA1 entered the room. CNA1 hit his (R1s) legs and told him to put them down if he wanted to be changed. The resident did not disclose pain or injury from the open-handed contact but it made him mad and then he, R1, took a swing at CNA1. The resident then demonstrated how CNA1 crossed the residents arms on his upper chest and held his arms. On 03/02/2025 at approximately 09:30 AM, the DON notified the local police authorities. Officers responded and statements were taken and a report was filed. On 03/02/2025 at approximately 08:45 AM, the DON contacted the family and left a message. At approximately 09:00 AM the family returned the call and spoke with LPN1 regarding the allegations. On 03/02/2025 at approximately 07:25 AM, LPN1 notified the Attending Physician of the allegation of abuse. On 03/02/2025 at approximately 9:00 AM, the DON began providing education to staff regarding Abuse Neglect and Restraints. The SDC took lover the training after arriving to the facility. On 03/02/2025, the Social Service Director began to monitor the resident (R1) for residual and latent effects. She reports no latent effects and that the resident (R1) is glad that CNA1 not longer works here. Actions taken to identify other residents potentially affected: On 03/05/2025, the Social Services Director interviewed other residents able to be interviewed and no pattern was noted. No residents reported abuse or being restrained. Systemic Changes: Based on the following facts: 1) Resident interviews indicated that this was an isolated event. 2) Resident #1's skin audit was negative for marks or bruises. 3) CNA1 admitted both verbally and in his written statement to having restraining R1. The allegation was substantiated. On 03/02/2025, the Staff Development Coordinator (SDC) began education on Abuse, Neglect and Exploitation for staff. Education will be provided upon hire, annually and as needed. All education will be completed by Staff on or before 03/20/2025. Staff will not be allowed to work without completing the training. On 03/20/2025, The Abuse, Neglect and Exploitation Policy was reviewed by the DON, the Administrator and the Corporate Nurse Consultant. No Policy Revision needed at this time. The SDC will audit new hire Orientation Packets Monthly x 6 months and then quarterly to ensure that employees were provided training on restraints. The SDC will track and trend and report the results of the audits monthly x 6 months and then quarterly. Annually, the SDC, DON, or Designee will provide education to staff regarding Restraints. Annually, the SDC will audit all employee training records to ensure that all staff have received annual training. The SDC will track and trend her annual education audit and report to QAPI at least annually. QAPI On 03/20/2025, an Ad Hoc QAPI Committee meeting was held with the Medical Director attending via phone. The plan of actions taken were reviewed and it was determined that the appropriate preventative actions had been take. The Committee approved the addition of restraints as a focus to the new hire process and annual education. The Committee will monitor the results of the new hire and the annual training audits and make recommendations and modifications as needed to ensure continued compliance.

Based on review of facility policy, record review and interview, the facility failed to protect Resident (R)1 from being physically restrained by Certified Nursing Assistant (CNA)1. Specifically, CNA1 grabbed both of R1's hands, held them crossed against R1's upper chest during incontinence care, for 1 of 3 residents reviewed. On 03/20/25 at 2:00 PM the Administrator and the Director of Nursing were notified that the failure to protect a resident from being physically restrained constituted IJ at F604. On 03/20/25 at 2:00 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 03/02/25. The IJ was related to 483.12 Freedom from Abuse, Neglect, and Exploitation. On 03/20/25 at 7:20 PM, the facility provided an acceptable IJ Removal Plan. On 03/20/25, the survey team, validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F604, at a lower scope and severity of D. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F604, constituting substandard quality of care. The findings include: Review of the facility policy titled, Restraint Free Environment, documents, It is the policy of this facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of physical or chemical restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints . Physical Restraint, refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove and restricts freedom of movement or normal access to one's body. Physical restraints may include but are not limited to . Holding down a resident in response to behavioral symptoms, during the provision of care if the resident is resistive or refusing the care. The facility admitted R1 on 06/27/24 with diagnoses including but not limited to, respiratory failure with hypoxia, dependent on renal dialysis for ESRD (End Stage Renal Disease), peripheral vascular disease and left and right below the knee amputations. Further review revealed, R1 has a dialysis catheter to his right upper chest area. Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/22/25, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R1 was cognitively intact. Further review of the MDS revealed R1 is not scored for moods and behaviors. Review R1's Care Plan revealed R1 had a self care deficit related to activities of daily living (ADLs) and impaired mobility, muscle weakness, and lack of coordination, with pulmonary edema, and incontinence of bowel and bladder. R1 is receiving oxygen therapy related to acute and chronic congestive heart failure, restrictive lung disease and cardiomyopathy. During an interview on 03/17/25 at 11:58 AM, the Social Services Director (SSD) stated that R1 told her that CNA1 was rough with him and overly aggressive. The SSD stated that R1 has bilateral amputations and when he lays back his stumps will raise up a little. The SSD stated CNA1 grabbed both of the resident's hands, held them in one of his hands and pressed them against R1's upper chest and neck area. The SSD further stated that CNA1 told the resident, You are not going to hit me. The SSD stated that CNA1 held down R1's hands while he performed incontinent care for R1. The SSD concluded that R1 became distressed, was very upset and felt abused by the act. During an interview on 03/17/25 at 12:18 PM, the Director of Nursing (DON) stated, [CNA1] is arrogant and out spoken and is in the military Reserves. CNA1 had informed the DON that he grabbed both of the resident's hands and with one of his hands, he held them down across R1's upper chest and neck area. CNA1 said to the DON, I had no choice but to restrain him. During an interview on 03/17/25 at 2:25 PM, CNA1 stated, The resident put on his call light, as he does several times during the night and was whining. I was not assigned to the resident, his CNA was busy taking care of another resident. I went in to see if I could help him. I was turning him over to loosen his brief and he swung at me and hit me. I tried blocking his hand with my hands and he stopped for a minute and I continued changing him and left the room. CNA1 did not mention restraining R1 by holding his hands pressed against his upper chest. Review on 03/17/25 at 2:35 PM, of the statement written by CNA1 revealed, Resident put on his call light, I, myself went in and asked what was wrong and he said he needed a brief change. So, I told him the CNA working with him would be with him and he said ok. I left the room to finish my rounds, and the resident started to whine. His CNA for the night was falling behind so I went in his room and told him I was going to change him and he swung at me so I restrained him until he cooled down. He let me change him and I left the room. He threatened me and disrespected me physically and vocally. During an interview on 03/17/25 at 3:28 PM, R1 stated, The CNA came in my room when I rang the call bell, he just started hitting my stumps. My left stump is still tender because it has not been long since I had the amputation. The CNA went out of the room so I called again. He came back in and grabbed me and held my hands down around the upper part of my chest. I was scared he would pull out my dialysis catheter, so I just quit struggling with him. In a little while he quit holding me down. I never hit him or pushed him. I could not believe he was doing me like that. My CNA, a female, that usually helped me was helping someone else at the time. That is why he came in my room in the first place. During an interview on 03/20/25 at 10:40 AM, Licensed Practical Nurse (LPN)1 states, she was the nurse coming on duty for the day shift on 03/02/25. R1 started calling for this nurse as soon as he saw she was there. LPN1 stated that R1 was very upset and it took a few minutes to calm him down. LPN1 stated that R1 was not crying, but he was very upset. LPN1 stated she informed him that he was safe and that the CNA would not be back and could not hurt him. After he appeared calmer, LPN1 left the room for a few minutes to go and report what the resident had said. The resident was adamant about calling his family and wanting to press charges against the CNA. On 03/20/25 at 7:20 PM, the facility provided an acceptable IJ Removal Plan, which included the following: Please accept this as our plan for abatement of the Immediate Jeopardy with a date of compliance of 03/20/25. Actions taken for the affected resident: On 03/02/2025 at approximately 07:15 AM, Resident #1 reported to the Licensed Practical Nurse #1 (LPN1) the he (R1) wanted to call the police to press charges against CNA #1. The resident then went on to disclose how CNA#1 was rough with him and smacked his leg. LPN1 informed the Unit Manager and the Director of Nursing. On 03/02/2025 at approximately 07:30 AM, the Director of Nursing (DON) was contacted by LPN1 and was notified of the allegation. LPN1 remained with the resident pending the arrival of the DON to start the investigation. On 03/02/2024 at approximately 07:45 AM, the DON contacted CNA1 via phone and suspended him. The DON requested that CNA1 provide a written statement regarding his interactions with R1. The DON interviewed CNA1 in which he admitted that he (CNA1) restrained the resident. On 03/02/2025 at approximately 08:04 AM, the DON provided notification to the South Carolina Department of Public Health of the allegation of abuse. On 03/202/2025 at approximately 08:30 AM, the DON interviewed resident (R1) as a part of the investigation. She completed a body audit that was negative for marks or bruises. Resident (R1) disclosed that he was lying on his back with his legs bent. He (R1) demonstrated and it was observed that due to amputations his legs point up into the air. Resident #1 states that when CNA1 entered the room. CNA1 hit his (R1s) legs and told him to put them down if he wanted to be changed. The resident did not disclose pain or injury from the open-handed contact but it made him mad and then he, R1, took a swing at CNA1. The resident then demonstrated how CNA1 crossed the residents arms on his upper chest and held his arms. On 03/02/2025 at approximately 09:30 AM, the DON notified the local police authorities. Officers responded and statements were taken and a report was filed. On 03/02/2025 at approximately 08:45 AM, the DON contacted the family ad left a message. At approximately 09:00 AM the family returned the call and spoke with LPN1 regarding the allegations. On 03/02/2025 at approximately 07:25 AM, LPN1 notified the Attending Physician of the allegation of abuse. On 03/02/2025, the Social Service Director began to monitor the resident (R1) for residual and latent effects. She reports no latent effects and that the resident (R1) is glad that CNA1 not longer works here. Actions taken to identify other residents potentially affected: On 03/05/2025, the Social Services Director interviewed other residents able to be interviewed and no pattern was noted. No residents reported abuse or being restrained. Systemic Changes: Based on the following facts: 1) Resident interviews indicated that this was an isolated event. 2) Resident #1's skin audit was negative for marks or bruises. 3) CNA1 admitted both verbally and in his written statement to having restrained R1. The allegation was substantiated. On 03/20/2025, the Staff Development Coordinator, DON and or Unit Manager/Coordinator began providing education to staff regarding restraints to include holding a resident's hands down. Education will be provided upon hire, annually and as needed. All education will be completed by Staff on or before 03/20/2025. Staff will not be allowed to work without completing the training. On 03/20/2025 the Restraint Policy was reviewed by the DON, the Administrator and the Corporate Nurse Consultant. No Policy Revision needed at this time. The SDC will audit new hire Orientation Packets Monthly x 6 months and then quarterly to ensure that employees were provided training on restraints. The SDC will track and trend and report the results of the audits monthly x 6 months and then quarterly. Annually, the SDC, DON, or Designee will provide education to staff regarding Restraints. Annually, the SDC will audit all employee training records to ensure that all staff have received annual training. The SDC will track and trend her annual education audit and report to QAPI at least annually. QAPI On 03/20/2025, an Ad Hoc QAPI Committee meeting was held with the Medical Director attending via phone. The plan of actions taken were reviewed and it was determined that the appropriate preventative actions had been take. The Committee approved the addition of restraints as a focus to the new hire process and annual education. The Committee will monitor the results of the new hire and the annual training audits and make recommendations and modifications as needed to ensure continued compliance.

Based on review of facility policy, interview, and record review, the facility failed to provide appropriate supervision for Resident (R)78, resulting in R78 successfully eloping from the facility. On 10/09/24 at 11:28 AM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 09/26/24. The IJ was related to 42 CFR 483.25 - Free of Accidents Hazards/Supervision/Devices. On 10/10/24 at approximately 1:40 PM, the facility provided an acceptable IJ Removal Plan. The survey team validated the facility's corrective actions and determined the facility put forth good faith attempts to address the non-compliance. The IJ is considered at Past Non-Compliance with a correction date of 09/30/24. An Extended Survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care. Findings Include: Review of an undated facility policy titled Elopements and Wandering Residents documented under Definitions, elopement occurs when a resident leaves the premises or a safe area without authorization. Further review, documented under Policy Explanation and Compliance Guidelines, 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner . 4 a. residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team, d. adequate supervision will be provided to help prevent accidents or elopements. Review of R78's Face Sheet revealed R78 was admitted to the facility on [DATE], with diagnoses including but not limited to: Dementia, cognitive communication deficit, and abnormalities of gait and mobility. Review of R78's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/21/24, revealed that a Brief Interview for Mental Status (BIMS) was not conducted because the resident is rarely/never understood. Further review of the MDS revealed R78 was moderately impaired regarding Cognitive Skills for Daily Decision Making. Additionally, R78's assessment for Rejection of Care and Wandering indicated that these behaviors did not occur. Review of R78's Progress Notes revealed a note dated 09/26/24 at 6:34 PM, which documented, resident wondered out of building and was found on the ground by staff. no injuries or broken skin noted. Resident stated that she did not hit her head. wonder guard was administered, and resident is in bed resting with eyes open. MD and family notified. will continue to monitor During my shift. During an interview on 10/08/24 at 12:04 PM, Dietary [NAME] (DC)1 stated, on 09/26/24 at approximately 5:20 PM, I went out to the trash can of the west building to throw away some boxes and that's when I saw the resident on the ground next to a tree. DC1 stated it was raining and [R78] was wet and looked like she had been out there for a while. DC1 then notified staff members who came and assisted [R78] back into the building. During an interview on 10/08/24 at 2:50 PM, Receptionist 1 stated at approximately 4:45 PM, she heard the door alarm going off in the east building, however she was assisting a family member and could not respond to the alarm. Receptionist 1 further stated that after about 15 seconds the alarms stopped and then a few minutes later a CNA [certified nursing assistant] asked if she had let a resident out and she said no. Receptionist 1 stated it was raining that day because it was the day before Hurricane [NAME]. During an interview on 10/08/24 at 2:57 PM, Certified Nursing Assistant (CNA)1 stated around 4:40 PM dinner trays came to the unit, and then around 5:00 PM is when R78 was noticed to be missing and not in her room. CNA1 stated that all rooms and inside areas of the east building were searched and R78 could not be found. CNA1 further stated that R78 was found outside the west building on the fence line near a tree. CNA1 was not able to determine how R78 exited the building. During an interview on 10/08/24 at 3:20 PM, the Director of Nursing (DON) stated she was not on duty when R78 went missing, however she received a call stating that they could not find her (R78) and that they had looked everywhere inside. The DON stated R78 was not an elopement risk due to her being immobile at the time of admission and that an updated assessment was not done until after R78 eloped from the facility. The DON concluded R78 would walk the halls but had not previously attempted to elope. During an interview on 10/08/24 at 3:30 PM, the Administrator stated that R78 was not an elopement risk prior and that they had been unable to determine which door R78 had used to elope. The Administrator stated that elopement assessments are done upon admission. According to the Weather Channel, on 09/26/24 at 5:20 PM, the high was 73 F with heavy rain and fog. On 10/10/24 at 1:40 PM, the facility provided an acceptable IJ Removal Plan, which included the following: Action taken for the affected residents: On 9-26-24 at appx. 5:20 PM, Resident # 78 was returned to the facility and experienced no injury while outside of the facility. The Director of Nursing (DON) completed the initial report to South Carolina Department of Public Health for the elopement of Resident #78. On 9-26-24, when Resident# 78 returned to the facility an Elopement Assessment, Head to Toe Skin Assessment and an Incident Report were completed by the charge nurse including notification to the Physician and Responsible Party/Family of the incident and safe return. On 9-26-24, facility nursing staff initiated q 15-minute checks x 72 hours on Resident #78. Checks were completed without any negative occurrences. Based upon the elopement assessment, a wander guard bracelet was placed on Resident #78 by the charge nurse on 9-26-24 with the Attending Physician and Family notified by the charge nurse. Resident #78's CP has been updated with intervention for wander guard by MDS on 9-27-24. Resident #78's Care Plan (CP) was updated to reflect this incident and her increased exit seeking behavior on 9-27-24 by the MDS Director. On 9-27-24, The Administrator completed a post incident Brief interview Mental Status (BIMS) on Resident #78. Actions taken to identify other residents potentially affected: On 9-26-24, Nursing Supervisor accounted for all residents listed on 24-hour census. All residents were accounted. On 9-26-24, Nursing Supervisor check all resident with wander guard bracelet. On 9-27-24, All doors with wander guard alarms were audited by Maintenance Director or designee determined to be in good working order. Systemic Changes: Wander guard door in the EAST building will be monitored by staff to ensure residents at risk do not elope from the buildings started on 9-27-24 in the East Building. On 9-27-24, Administrator provided education to the Central Supply Clerk, DON and Unit Managers on a Par System for Wander guard Bracelets. On 9-27-24, Administrator provided education to the Central Supply Clerk regarding the maintaining adequate supply of Wanderguard bracelets. PAR level was established of at least 5 and she was educated and verbalized understanding. She placed an order for 20 wander guards on to meet current needs and exceed PAR Level. On 9-27-24, the DON completed an Audit of residents identified as an elopement risk and needing a WanderGuard Bracelet. The DON created log to track which resident was issued a wander guard bracelet and the expiration of date of the Bracelet. The DON will update the log as wander guard bracelets are issued or as they expire. New wandering and elopement assessments will be completed by the DON, IDT Team and charge nurse on all residents and care plans will be updated as needed by 9-30-24. On 9-30-24, the Elopement Policy has been reviewed by the DON, Administrator and Corporate Nurse Consultant to include supervision for residents with increased behaviors/exit seeking behaviors. On 10-1-24, Door Vendor assessed wander guard doors and in the assessment process the vendor caused disruption of normal working and was not able to restore normal operations. Doors were already being watched by staff post elopement. On 10-8-24, a second vendor was able to assist Maintenance Director in replacing equipment that had been damaged and doors returned to normal operations. Door watch continues pending abatement of IJ. On 10-1-24, wander guard bracelets were received by Central Supply Clerk and nurses place bracelets on newly identified residents determined to be at risk and the bracelet removed by the resident and the bracelet found not to be operating by nursing staff. Staff will be educated on the elopement policy to include management of exit seeking behaviors beginning on 9-27-24 and continuing until 10-3-24. Any staff member who has not completed training by 5 PM on 10-3-24 will not be allowed to work util training is complete. The training is conducted by the DON, Staff Development Coordinator and the Administrator. Staff will be educated on the elopement policy and how to manage exit seeking behaviors upon hire, annually and as needed by the Staff Development Coordinator, Administrator, Director of Nursing or Designee on going. Elopement drills will be conducted weekly for 4 weeks on each shift beginning on 9/27/24 and continuing through week ending 10-25-24 by the Maintenance Director or Designee. Monthly elopement drills will be done for two months beginning in November 2024 and then at least quarterly by the Maintenance Director or Designee. The corporate regulatory consultant will do monthly random audits of behavior care plans and assessments for 90 days beginning October 2024 and continuing for 90 days. The DON/Designee will audit binder monthly and alert the central supply clerk of the number of bracelets to expire in the next 30 days in order to ensure PAR is maintained. QAPI On 9-30-24, an Ad Hoc QAPI Committee Meeting was held with the DON, Administrator and Medical Director. The plan of actions taken were review and the it was determined that all necessary actions had been taken at this time. The results of the audits, drills and wander guard documentation will be reported to the QAPI Committee for review and assessment to assure continued compliance. . date of compliance of 09/30/24.

Based on review of facility policy, observation and interview, the facility failed to ensure 3 of 3 clothes dryers in the East Building did not contain an excessive amount of lint. The lint was located above the lint baskets and onto the wiring. Findings include: Review of the facility policy titled Care of Equipment states, To review the use and care of all equipment used by the Laundry Department to perform their daily duties. Laundry departments work with 2 types of equipment. Large pieces (washers/dryers, etc). Larger equipment must be maintained on a regular basis. Preventative Maintenance (PM) work may be the responsibility of the Maintenance Department in some buildings, but the Laundry Supervisor must still be familiar with the daily cleaning and simple maintenance. Laundry Equipment - Dryers Lint screens must be cleaned every two or three loads. The bottom of the dryers must also be lint free. The drums of dryer should be cleaned after each load to prevent any type of trash or lint from heating up and melting to the inside. The area between the drum and walls of the dryers should be blown clean of lint on a regular basis. The area at the top of the dryers by the control panel and around the pilot should be kept free of lint at all times. The area behind the dryers as well as the vent work coming from the dryers should be kept free of lint. Always document the dryer cleaning. An observation on 10/10/24 at 7:40 AM, of the laundry room in the East Building revealed 3 clothes dryers with an excessive amount of lint on top of the lint baskets and around the wiring. This was confirmed by the laundry worker and the maintenance director. Review of the Work History Report: Listed is the Building, East or West, the Due Date, the Task Description and Task Completion date and time and by whom. The dryer vent cleaning was completed in the East Building on 10/01/24. The dryer vents in the East Building were scheduled to be cleaned on 08/31/24 and was completed on 09/18/24. On 07/31/24 the dryer vent cleaning was due to be competed but was marked as completed on 07/30/24. During an interview on 10/10/24 at 7:45 AM, the Maintenance Director confirmed the excessive amount of lint over the lint baskets and hanging from the wiring for 3 clothes dryers in the East Building. The Maintenance Director stated that the area above the lint baskets and on the wiring is removed monthly.

Based on review of facility policy, record review, and interview, the facility failed to provide services and interventions to prevent significant weight loss for 3 of 4 resident's reviewed for nutrition, Resident (R)3, R 17, and R78. Findings Include: Review of an undated facility policy titled, Weight Monitoring, revealed, . The facility will ensure that all residents maintain acceptable parameters of nutritional status . Further review of the Compliance Guidelines section, revealed, 1. The facility will utilize a systemic approach to optimize a resident's nutritional status 2. A comprehensive nutritional assessment will be completed upon admission on residents ., 3. Information gathered from the nutritional assessment and current dietary standards of practice are used to develop an individualized care plan ., 4. Interventions will be identified, implemented, monitored and modified (as appropriate), consistent with the residents' assessed needs and current professional standards to maintain acceptable parameter of nutritional status. 7. Documentation: a. The physician should be informed of a significant change in weight and may order nutritional interventions, c. Meal consumption information should be recorded and may be referenced by the interdisciplinary team as needed, e. The Registered Dietitian, Dietary Manager should be consulted to assist with interventions: actions are recorded in the nutrition progress notes, g. The interdisciplinary plan of care communicates care instructions to staff. Review of an undated facility policy titled Menu and Adequate Nutrition revealed, The purpose of the policy is to assure menus are developed and prepared to meet resident choices including their nutritional, religious, cultural and ethnic needs, while using established guidelines. 1. Review of R78's Face Sheet revealed R78 was admitted to the facility on [DATE], with diagnoses including but not limited to: Dementia, protein calorie malnutrition, type 2 diabetes mellitus, dysphagia and gastro-esophageal reflux disease. Review of R78's Weights located in the Electronic Medical Record (EMR) revealed the following weights: On admission (05/17/2024), R78 weighed 145 pounds. On 06/07/2024, R78 weighed 145 pounds. On 07/05/2024, R78 weighed 142 pounds. On 07/12/2024, R78 weighed 123 pounds. On 08/16/2024, R78 weighed 120 pounds. On 08/30/2024, R78 weighed 118 pounds. On 09/13/2024, R78 weighed 116 pounds. On 10/04/2024, R78 weighed 115 pounds. Review of R78's Physician Orders revealed the following: On 05/17/2024, weekly weights on Fridays. On 05/21/2024, Diabetic diet, pureed texture, regular consistency. On 05/21/2024, [Speech-Language Pathologist] (SLP) to see patient 5x a week for 5 weeks to increase PO [by mouth] intake. On 05/22/2024, Glucerna three times a day for inadequate energy intake x1 with meals. Review of the Registered Dietitians (RD) Monthly Weight Report dated 08/23/24, revealed, R78 had a 15.5 % weight loss over the last 30 days and a 16.8% weight loss over 90 days. Further review revealed, the following interventions: Med pass [a fortified nutritional shake] 120ml TID r/t significant [weight] loss. Review of R78's Electronic Medical Record (EMR) revealed that this intervention was never ordered. During an interview on 10/11/24 at 10:02 AM, the Registered Dietitian (RD) reported that she had noticed a significant weight change for R78 and had requested a re-weigh from staff, however RD did not follow up afterwards. RD states that she wrote interventions for R78 in August, 2024 and she sent them to the facility, but she is responsible for entering orders that do not include medications. RD confirmed interventions for R78 were not entered and never put in place. 2. Review of R3's Face Sheet reveled R3 was admitted to the facility with diagnoses including, but not limited to: dementia, cognitive communication deficit, fracture of left femur, and a wedge compression fracture of the second lumbar vertebra. Review of R3's Weight revealed an unplanned weight loss. On 05/01/24, R3 weighed 154.2 pounds. On 06/06/24, R3 weighed 131.3 pounds. On 07/04/24, R3 weighed 125.4 pounds and on 08/01/2024 R3 weighed 120.0 pounds. On 10/01/24, R3 weighed 133.8 pounds. Review of R3's Physician Orders revealed R3 is receiving a dietary supplement, Magic Cup, and a cardiac diet with regular texture and regular consistency. Review of R3's Comprehensive Plan of Care, revealed that R3 has potential for nutritional deficits and the following interventions are in place: Resident to maintain adequate nutritional status as evidenced by maintaining weight, no signs or symptoms of malnutrition and consuming meals daily. Determine individual likes and dislikes and serve preferences as able. Invite to activities that promote additional intake. Meal assistance: Provide set up assistance and offer snacks at bedtime and as requested. Weigh per orders/protocol. Registered Dietician to to evaluate and make diet change recommendations as needed. Provide and serve diet as ordered and record intake of each meal. During an interview on 10/10/24 at 3:19 PM, the Registered Dietician (RD) stated that R3 had a 13.75% weight loss. The RD stated that the scales are calibrated and may or may not be accurate. The RD further stated she is in the facility one day a week and sometimes she will request a reweigh. The RD concluded that R3 has a body mass index of 20 and feels like some of the previous weights are not correct due to the broken scale, the RD will check her again on the following Tuesday. During an interview on 10/11/24 at 11:20 AM, the attending Physician stated he does not like to be too aggressive with the elderly and sometimes the staff will let him know of weight loss but he checks it himself while reviewing the record. The Physician stated sometimes he will order lab work or a supplement and he does not always trust the scales. 3. Review of an admission record revealed the facility admitted R19 on 02/02/24, with diagnoses including but not limited to: acute respiratory failure with hypoxia, unspecified protein-calorie malnutrition, and muscle wasting and atrophy in left and right lower leg, and left and right upper arm not elsewhere classified. Review of R19's Orders dated 10/09/24 revealed Pro-Stat AWC Oral Liquid (Amino Acids-Protein Hydrolysate) Give 30 ml by mouth three times a day for advanced care wound healing, dated 09/12/24 Med-Pass give 30ml by mouth three times a day for advanced care wound healing. Review of R19's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/04/24, revealed R19 had a Brief Interview for Mental Status (BIMS) of 15 out of 15, which indicated R19 was cognitively intact. During an interview on 10/08/24 at 11:17 AM, R19 stated, I seen the nutritionist about two weeks ago, they do not have nondairy ensure. So, I must order mine from Amazon when I have the money. I get my niece to order it for me. During an interview on 10/08/24 at 2:43 PM, R19's Daughter-in-law stated, He is losing weight. I know he is a picky eater. He doesn't like grits, but he will eat oatmeal. During an interview on 10/10/24 at 10:49 AM, the Registered Dietician (RD) stated, I have a note on 09/10/2024 my intervention was to increase med pass a concentrated source and change prostat awc 30ml BID. I don't know if they were able to get [R19] on it or not. We tried to initiate tube feeding to meet additional needs. I am planning on doing a report on my recommendations. The weights are not accurate, it is questionable. The conversation needs to start with the resident and if he refuses the recommended tube feeding all I can do is supplement him. During an interview on 10/11/24 at 9:05 AM, Certified Nursing Assistant (CNA)3 stated, [R19] doesn't always like the food. We feed him too. He is a total care. He buys his own supplements because he is lactose free. If he doesn't eat the food, someone from his family will bring him something to eat. His brothers will bring him food. He likes breakfast foods and sandwiches, and fast-food items. He does look like he is losing weight. During an interview on 10/10/24 at 1:02 PM, the Director of Nursing (DON) stated, [R19] is lactose intolerant. We can order the nondairy supplements. He gets up quite a bit. Every day or every other. He has a friend in this building so he will come over here and they will sit on the porch. During an interview on 10/11/24 at 9:52 AM, Licensed Practical Nurse (LPN)5 stated, [R19] has had several appointments. He is followed by RD and wound MD. He is alert and oriented. A lot of the food he doesn't like. Even the staff goes out and get him food. We have lactose intolerant supplements, but he still thinks it has dairy in it. During an interview on 10/11/24 at 11:05 AM, the Medical Director (MD) stated, I am aware of the situation, [R19] is a picky eater. I talk to him many times. It's related to GI. [R19] bounces back a few months. I knew him before. I look at the residents' weights myself to follow up. I review the weights. Sometimes I review the charts before I document my notes. I order weekly or biweekly instead of monthly. The first number of weights I don't trust. So, I always ask them to reweigh and get PO intakes. Any true nutritional decline like eating less than half. I ask when I make rounds how they are eating, sleeping and etc. I usually go by their look and go with that. So, the staff may or may not tell me, but I usually assess that when I come to the facility. 48214 49918

Based on the facility policy, record review and interview, the facility failed to provide the required documents to notify Resident (R)63 and R125 regarding medicare eligibility and coverage for 2 of 3 residents reviewed for advance beneficiary notices. Findings include: Review of the facility policy titled, Advance Beneficiary Notices, states: 4. The facility shall inform Medicare beneficiaries of his or her potential liability for payment. A liability notice shall be issued to Medicare beneficiaries of his or her potential liability for payment. A liability notice shall be issued to Medicare beneficiaries upon admission or during a resident's stay. 5. The current CMS-approved version of the forms shall be used at the time of issuance to the beneficiary (resident or resident representative). Contents of the form shall comply with related instructions and regulations regarding the use of the form. a. For Part A items and services, the facility shall use the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), Form CMS-10055. c. A Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123, shall be issued to the resident/representative when Medicare covered service (s) are ending, no matter if the resident is leaving the facility or remaining in the facility. This informs the resident on how to request an appeal or expedited determination from their Quality Improvement Organization (QIO). Review of R63's Electronic Medical Record (EMAR) revealed R63 was admitted to the facility for rehab services. After the last covered day of Part A Medicare services, R63 remained in the facility with benefit days remaining. R63 received the form Notice of Medicare Non-Coverage, (NOMNC) Form CMS-10123 but not the required CMS form 10055. R63 received Form CMS-R-131 for Medicare Part B services. Review of R125's EMAR revealed R125 was admitted to the facility for rehab services. After the last covered day of Part A Medicare services, R125 remained in the facility with benefit days remaining. R125 received 2 notices of non coverage, however did not receive form CMS-10055. During an interview on 10/10/24 at 1:10 PM, the Social Services Assistant stated she was not aware that the incorrect forms were being used. She stated that the CMS-10123 and the CMS-R-131 form are the only forms the facility has and uses.

Based on review of facility policy, observation, interview, and record review, the facility failed to ensure that Resident (R)18 who needed respiratory care was provided with such care that was consistent with professional standards of practice for 1 of 2 residents reviewed for oxygen therapy. Findings include: Review of the undated facility policy titled Oxygen Administration revealed, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the residents' goals and preferences. 1. Oxygen is administered under orders of a physician . Review of R18's Face Sheet revealed R18 was admitted to the facility on [DATE], with diagnoses including but not limited to: chronic respiratory failure, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD). Review of R18's Quarterly Minimum Data Set with an Assessment Reference Date of 08/26/24, revealed that R18 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment. Further review of the MDS revealed R18 has dyspnea (shortness of breath). Review of R18's Physician Orders did not reveal any orders for oxygen therapy. Review of R18's Care Plan revealed, R18 has an altered respiratory status and has the potential for difficulty breathing and/or shortness of breath related to acute respiratory failure with hypoxia, COPD, CHF. Further review revealed R18 requires oxygen use. During an observation and interview on 10/09/24 at 1:00 PM, revealed R18 lying in bed receiving oxygen at 2 liters per minute (LPM) via nasal cannula (NC). R18 stated that she had always been on oxygen and was waiting for someone to change her NC. During an observation and interview on 10/10/24 at 10:21 AM, Licensed Practical Nurse (LPN)2, stated R18 was currently receiving oxygen via NC at 2 LPM. LPN2 was unable to find or produce an order for oxygen therapy for R18, and stated she should have one, but she would need to go check. During an interview on 10/10/24 at 10:39 AM, the Director of Nursing (DON), stated when residents are admitted from the hospital any orders are automatically populated into the system and then the medical director will review and sign off on them. The DON states that she will update R18's orders to correctly reflect oxygen therapy. The DON was unaware of how often orders are reviewed by the physician.

Based on review of facility policy, observations, and interviews, the facility failed to ensure that all drugs and biologicals used in the facility were labeled in accordance to professional standards including expiration dates for 3 of 3 Medication Storage Rooms, 1 out of 4 Medication Carts , and 1 out of 3 Treatment Carts. Findings include: Review of the facility policy, copyright 2024 (The Compliance Store, LLC), titled, Medication Storage, states It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. 8. Unused medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our Destruction of Unused Drugs Policy. An observation on 10/09/24 at 9:17 AM, of [NAME] Front Medication Storage Room (#1) for 100 & 200 Hall revealed the following: CareFusion MaxPlus Clear needleless connector Ref # MP1000-C Lot (10) 18065214 exp 2023-06-02, EZ Huber Safety Infusion Set 22G x 1.0 in with needless Y site exp 2024 05-31 Manufacturer BARD Sterile Lot REFU0162. An interview on 10/09/24 at 9:31 AM, Licensed Practical Nurse (LPN)5 stated, I went through the cabinets 10 times. I don't know why it is still expired items in there. This is my unit, so I am responsible for checking the cabinets on this unit for expired medications. An observation on 10/09/24 at 3:34 PM, of the South Medication Storage Room (#2) revealed: Dressing change kit w/Chloraprp @ Triple swab sticks manufacturer Wolf-Pak Lot No 221586506, Expired 2024 01-31. An observation on 10/09/24 at 3:50 PM revealed Storage room [ROOM NUMBER] refrigerator logs for August 2024, days 20-23 days temperature was not recorded. An interview on 10/09/24 at 3:50 PM, LPN1 stated the refrigerator is checked by the manager but we are in the process of hiring a manager. I've been trying to check for expirations. An observation on 10/10/24 at 11:50 AM, of the [NAME] Back Medication Storage Room (#3) revealed the following: BD max Plus clear needless connector Ref MP1000C Lot # (10) 19075266 exp 2024 07-10, Care fusion clear needless connector Ref MP1000-C Lot (10)18065214 Exp 2023 06 02, CareFusion MaxPlus Ref MP10000-C Lot# (10) 18055492 Exp 2023 05 30, EZ Huber Safety Infusion Set 22G x 1.0 in (0.7 mm x 25 mm) with needless Y site Lot REFX3523 Exp 2024 09 30 Sterile open, Medline Insulin safety syringe 0.5 ml (50 units), 29 G x 0.5' Ref SYRSl193292 Lot # 897190700001 Exp 2024 06 30, [NAME] Point Syringe 3ml 25G x 1 (0.50 mm x 25 mm) Ref 10391 exp 2024 09 28 x2. On 10/10/24 at 12:20 PM reviewed expired medication with LPN3 who discarded in needle box. An interview on 10/10/24 at 12:30 PM, LPN3 stated, The unit managers usually check the medication storage rooms for expirations we are in transition now. An observation on 10/10/24 at 7:40 AM, of the Medication Cart 2 600 Hall (#3) revealed ExcelGinate Sterile Non-Woven Calcium Alginate 4 x 5 Dressing 1 Dressing, Manufactured MPM Medical, Lot # 21010151, Expired 2024 02 19. An interview on 10/10/24 at 7:40 AM, LPN4 stated, I never used that before. It is usually kept in the treatment cart. Expired medication was also reviewed by DON. An interview on 10/11/24 at 7:22 AM, the Director of Nursing (DON) stated, They are supposed to throw the expired medications away. The Staff Development Coordinator (SDC) does education on all treatment supplies and dressings. The wound MD usually instructs if it is different from the norm.

Based on review of facility policy, observations, interviews, and record review, the facility failed to properly clean a glucometer machine. Findings include: Review of the facility's policy titled, Blood Glucose Monitoring copyright date 2023 revealed, It is the policy of this facility to preform blood glucose monitoring to diabetic residents as per physician's orders. Policy Explanation and Compliance Guidelines 2. The nurse will perform the blood glucose test utilizing the facility's glucometer as per manufacturer's instructions. 3. The nurse will abide by the infection control practices of cleaning and disinfection of the glucometer as per the manufacturer's instructions and in accordance with the facility's glucometer disinfection policy. Procedure 18. Clean and disinfect the glucometer as per manufacturer's instructions. During an observation on 10/10/24 at 8:16 AM, Licensed Practical Nurse (LPN)2 cleaned a glucometer machine with an alcohol wipe. During an interview on 10/10/24 at 10:00 AM, Director of Nursing (DON) stated, Glucometer machines are cleaned with our Bleach Wipes.

Based on observation, interview, record review, and facility policy review, the facility failed to properly supervise 1 of 2 residents to prevent a fall, resulting in injury. Specifically, Resident (R)3 wandered into a staff break room and tripped and fell over a hole in the floor, resulting in R3 suffering a closed head injury and pain. This failure constituted actual harm. Findings include: A review of the un-dated facility's policy titled, Accidents and Supervision indicated, The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes Identifying hazards and risks, implementing interventions to reduce hazards and risks, monitoring for effectiveness, and modifying interventions when necessary. 1.) Identification of Hazards and Risks- the process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident. A.) All staff are to be involved in observing and identifying potential hazards in the environment while taking into consideration the unique characteristics and abilities of each resident. B.) The facility should make a reasonable effort to identify the hazards and risk factors for each resident. 3.) Implementation of Interventions- A.) Communicating interventions to all relevant staff. E.) Ensuring that the interventions are put into action. 4.) Monitoring and Modification-A. Ensuring that the interventions are implemented correctly and consistently. 5.) Supervision- Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Review of R3's Face Sheet revealed R3 was admitted to the facility on [DATE] with diagnoses of dementia, history of falling, diabetes mellitus, and hypothyroidism. Review of R3's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/25/23, revealed R3 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating R3 was moderately cognitively impaired. Review of R3's Care Plan dated 07/27/23 with a target completion date of 9/30/23 revealed the following: impaired cognitive function related to dx (diagnosis) of dementia, at risk for falls related to my impaired, decreased mobility, History of falls, impaired vision, impaired cognition. Interventions include, I need a safe environment with: (SPECIFY: even floors free from spills and/or clutter); Nursing to monitor resident when ambulating in the hall. Encourage the resident to wait for assistance before ambulating. Please remind me to call for assistance with the call bell prior to transfers and ambulating. Staff education. Review of R3's progress note dated 09/07/2023 at an unspecified time reveaeld, Note Text: The writer observed a closed bruise on the left side of the resident's forehead. When asked if she fell , the resident denied falling 3 times. Resident finally admitted falling when asked again, multiple times by the Unit Manager (On duty at the time a bruise was observed and reported). It is unknown exactly when the resident fell , but neuro checks and vital signs have been initiated. Review of R3's emergency room After Visit Summary Report dated 09/24/23 states the diagnoses are, Closed head injury, initial encounter, Rib pain on the right side, Right-hand pain, Right hip pain, and urinal tract Infection. Imaging tests performed were, CT head w/o contrast, XR chest, XR hand, XR hip, and XR spine lumbar 2 or 3 View. Review of an email conversation from the Director of Nursing (DON) to Agency management dated 09/08/23 states I have spoken with [unidentied staff] about this. However, there were two patients who fell during her shift, and she was instructed by a manager to complete incident reports. She stated to her manager I am not putting my anything that I may have to go to court for later. When the manager told her that one of the patients had a bruise she stated, Oh well that's a day shift problem. If the manager had been at work, I would have had to deal with a state reportable due to an injury of an unknown origin. I cannot have nurses working in my building who do not care about the patients. Review of the facility Fall Incidents printout dated 06/01/23 - 09/28/23 revealed R3's fall was not listed for the month of September 2023. During an interview on 09/29/23 at 11:47 AM, R3 revealed I was walking out one day, and I went to the dining room, and I don't know, I went into a little room off to the side, I open the door and I fell in a hole and I hit my head real bad. I guess I was looking for something. I don't remember how I got out of there, I didn't go to the hospital. My sister told me this place didn't call her. My sister found out a few days later when she came to visit me. An interview with the Director of Nursing, DON on 09/29/23 at 12:09 PM, revealed she was on vacation when she got a call from LPN2 on 09/09/23 stating that she believed R3 had a fall on 09/06/23 during the third shift. LPN2 told the DON she saw R3's cane and eyeglasses in the hole that was located in the break room. The DON states that LPN2 told her she removed the items from the hole, removed R3 from the breakroom, put a table in front of the door, and took R3 back to her room. The DON stated that R3 likes to go to the dining room to look for loose change in the vending machines. The DON further stated that the hole in the breakroom had been there for quite some time due to some repairs that were needed under the building. The job has not been completed so she was unsure of when the hole would be fixed. The DON stated that upon return from her vacation a few days later, R3's representative was not contacted, the incident report had not been completed, and staff in-service was not done. The DON stated that the resident eventually went out to the hospital a few days later, when R3's family came to the facility and requested for R3 to be sent out. R3 did not have any broken bones, just a lot of discoloration to the face. R3 went out twice to the hospital according to R3's records, however, could not locate the after-visit summary for the first hospital encounter at the beginning of the month of September. The DON stated that her expectation of staff is to be doing frequent 2-hour checks, residents who are care planned as wanderers, to keep a close eye on them. The DON stated that staff is to complete incident reports when a resident falls, or suspects a fall, and she and the Medical Director should be notified immediately along with the resident representative, regardless of time. During an interview on 09/29/23 at 12:47 PM, R3's sister revealed I went to visit my sister the morning of the 6th and my sister was fine, normal self. I then go back to visit on the 10th, and my sister is all banged up. I go see my sister a few times a week. My sister told me that she was curious about what was in the room that night, walked in, fell in the hole, and hit her head with the pipe that was sticking up from the hole. My sister then took me to the dining room and showed me the door, which was beside the vending machine, and it had a padlock on it. My sister was not acting right, when she sat up on the bed, she had bruises and a big lump on the left side of her face. I attempted to speak with staff, and nobody had any knowledge about the fall. Nobody called me about the fall, didn't send my sister out to the hospital until I told the staff to send her out. The Administrator told somebody, I can't remember her name, that staff didn't need to call the family. I found out from several employees that the hole in the staff break room has been there for weeks. The staff refused to allow me to see the hole in the break room because they didn't have a key. When I asked the Administrator why I wasn't notified about my sister's fall, he told me that she was doing okay, and it wasn't deemed necessary to call.

Based on review of facility policy, interview, observation, and record review, the facility failed to protect 7 of 19 residents from misappropriation of medications. Specifically, Licensed Practical Nurse (LPN)2 diverted medications from Residents (R)5, R6, R13, R14, R15, R16, and R17 during the months of August and September 2023. Findings include: Review of the undated facility policy titled Abuse, Neglect and Exploitation revealed, misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. Review of R5's Face Sheet revealed R5 was admitted to the facility on [DATE] with diagnoses including, but not limited to: muscle weakness, gout, and chronic kidney disease. Review of R5's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/28/23, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R5 was cognitively intact. Review of R6's Face Sheet revealed R6 was admitted to the facility on [DATE] with diagnoses including, but not limited to: vascular dementia, depression, and fracture of superior rim of right pubis. Review of R6's quarterly MDS with an ARD of 07/11/23, revealed a BIMS score of 7 out of 15, indicating R6 was moderately cognitively impaired. Review of R13's Face Sheet revealed R13 was admitted to the facility on [DATE] with diagnoses including, but not limited to: dementia, chronic obstructive pulmonary disease, and history of healed pathological fracture. Review of R13's quarterly MDS with an ARD of 07/19/23, revealed a BIMS score of 15 out of 15, indicating R13 was cognitively intact. Review of R14's Face Sheet revealed R14 was admitted to the facility on [DATE] with diagnoses including, but not limited to: paraplegia, spina bifida, epilepsy, and anxiety. Review of R14's annual MDS with an ARD of 07/06/23, revealed a BIMS score of 14 out of 15, indicating R14 was cognitively intact. Review of R15's Face Sheet revealed R15 was admitted to the facility on [DATE] with diagnoses including, but not limited to: schizophrenia, pain in right and left leg, dementia, and anxiety. Review of R15's quarterly MDS with an ARD of 08/29/23, revealed a BIMS score of 99 out of 15, indicating R15 could not be interviewed. Review of R16's Face Sheet revealed R16 was admitted to the facility on [DATE] with diagnoses including, but not limited to: cerebral palsy and displaced bicondylar fracture of the left tibia. Review of R16's annual MDS with an ARD of 08/02/23, revealed a BIMS score of 12 out of 15 indicating R16 was moderately cognitively impaired. Review of R17's Face Sheet revealed R17 was admitted to the facility on [DATE] with diagnoses including, but not limited to: osteoarthritis of left ankle and foot and Alzheimer's dementia. Review of R17's quarterly MDS with an ARD of 09/03/23, revealed a BIMS score of 6 out of 15 indicating R17 was severely cognitively impaired. Review of Care Plans for R5, R6, R13, R14, R15, R16, and R17 revealed all residents had care plan interventions for pain and required pain management. Review of R5's narcotic reconciliation sheets and Medication Administration Record (MAR) for Oxycodone 5 mg every 6 hours as needed revealed several discrepancies. The narcotic reconciliation sheet had several sign-outs without corresponding MAR entries. This includes the following dates: 09/18/23 at 10:30 PM by LPN2, 09/19/23 at 5:45 AM by LPN2, 09/19/23 at 12:00 PM by LPN1, 09/19/23 at 6:00 PM by LPN1, 09/20/23 at 12:30 AM and 6:30 PM by LPN7, 09/21/23 at 6:55 AM by LPN2, 09/21/23 at 1:00 PM by LPN4, 09/21/23 at 8:00 PM by LPN2 and 09/22/23 at 2:00 AM by LPN2. During an interview on 09/28/23 at an unspecified time, the DON confirms that all entries, other than LPN2, were likely forgeries as the staff in question were not working those days. Review of R6's MAR and narcotic reconciliation cards for Norco 5-325 mg every 8 hours as needed revealed several discrepancies. R6 was missing a narcotic pill card from 09/05/23 to 09/08/23, the narcotic reconciliation card was also missing. The narcotic reconciliation card attached to R6's second narcotic pill card had several sign-outs with no corresponding MAR entries. This includes 09/06/23 at 7:00 PM by LPN2, 09/12/23 at 9:00 PM by LPN2, 09/15/23 at 9:00 PM with an illegible signature, 09/20/23 at 7:45 PM by LPN2, 09/21/23 at 8:30 AM by LPN1, 09/21/23 at 6:30 PM by LPN1, 09/22/23 at 7:45 AM by LPN7, 09/22/23 at 11:00 PM by LPN2, 09/23/23 at 7:00 AM by LPN2, 09/23/23 at 3:00 PM and 5:00 AM by LPN4, 09/21/23 at 9:00 AM by LPN2, 09/22/23 at 5:00 AM by LPN2, and 09/22/23 at 5:00 PM by LPN2. During an interview on 09/28/23 at an unspecified time, the DON revealed that all LPNs, other than LPN2, were likely forgeries as many staff did not work the shifts for which they allegedly signed out. The DON further stated that LPN4's name was misspelled during her entries on the narcotic reconciliation sheets. Review of R13's narcotic reconciliation sheet and MARs revealed one discrepancy on 09/02/23 at 5:00 AM signed by LPN2. Review of R14's narcotic reconciliation sheets and MAR for the month of September 2023, revealed multiple illegible signatures. R14's September 2023 narcotic reconciliation sheet entries 3, 6, and 8 had illegible signatures. Entries 17 and 18 were signed by LPN2, but she was not scheduled to work at that time. Entry 20 was signed by LPN8. Entry 28 had an unrecognizable signature. Review of R16's revealed no corresponding MAR entries for Tramadol 40 mg every 6 hours as needed on 09/22/23 at 11:00 PM and 6:00 AM. Review of R17's narcotic reconciliation sheet revealed R17 was missing two pills of Ativan 0.5 mg scheduled at the hour of sleep. Observation revealed the pill card was empty, but the narcotic reconciliation card indicated there should be two remaining after the last pill was signed out on 09/21/23 by LPN6. Review of staffing schedules revealed that LPN1 did not work 09/21/23, LPN7 did not work 09/22/23, and LPN4 was not working on 09/23/23 until 7:00 AM. Further review of staffing schedules revealed that LPN1 did not work 09/19/23, LPN7 did not work 09/20/23, and LPN4 did not work 09/21/23. Review of LPN4's statement to the facility written on 09/08/23 revealed, 3 packs of Norco were received by the facility on 09/05/23. The first pack contained 27 narcotic pills and the other two packs contained 30 each. When LPN4 returned to work on 09/08/23, she noticed the facility was working off a second pack, meaning the remainder of the pack of narcotics with 27 pills had gone missing. LPN4 alerted the DON. During an interview on 09/28/23 at approximately 12:00 PM, LPN4 confirmed her statement to the facility. One of the narcotic reconciliation sheets and the narcotic pill packages intended for R6 had gone missing between 09/05/23 and 09/08/23. During an interview on 09/29/23 at 11:25 AM, LPN1 confirmed the signatures attributed to her on days where she did not work were forgeries. LPN1 states she always uses the same pen to write which creates bold ink strokes, and the false entries had less pronounced strokes from the pen. Attempted interviews with LPNs 2, 6, 7, and 8 were unsuccessful. During an observation and interview with R5, R6, R15, R16 and R17 on 09/28/23 revealed no concerns with pain management. During an observation and interview with R13 on 09/28/23 at 11:18 AM, revealed no concerns with pain management. R13 stated they were never in pain due to lack of medication and generally did not request his Tramadol. R13 concluded that he did not even notice the pain medication was missing. During an observation and interview with R14 on 09/28/23 at 11:49 AM revealed no concerns with pain management. R14 stated they were never in pain due to lack of medication and the most she had to wait for pain medication was 30 minutes. R14 stated she believed the facility was providing good care. During an interview on 09/28/23 at 2:44 PM, the Director of Nursing (DON) revealed R15 was missing at least 81 pills of Oxycodone HCl 5 milligrams, ordered every 8 hours as needed. The DON confirmed the missing medications because the facility received 90 pills in the month of August. A package of 30 came on 08/01/23, another package of 30 arrived on 08/13/23 and a final package of 30 arrived on 08/22/23. The DON stated all three packages and narcotic reconciliation cards went missing by the end of the month, and review of R15's MAR indicated only 9 pills were signed out. During an interview on 09/29/23 at 11:03 AM, the Director of Nursing (DON) revealed that LPN2 was the alleged thief. On 09/08/23 the DON received a call from LPN4 alerting her that a card of narcotics meant for R6 went missing between 09/05/23 and 09/08/23. The DON stated the facility began investigating and discovered that R15 was also missing an entire narcotics pill card. Further investigation revealed that R13 and R14 were also missing narcotics.

Based on review of facility files and interview, the facility failed to implement a comprehensive person-centered care plan for each resident. Resident #1 was noted to receive a laceration while being transferred by CNA (certified nurse aide) #1. CNA #1 did not use the appropriate transfer method while transferring Resident #1 at the time the laceration occurred per the resident's plan of care. Resident #1's care plan for [MEDICAL CONDITION] medication was not followed related to attempted gradual dose reductions. One of three residents reviewed for care plans. The findings included: The facility reported an injury of unknown source to the State Agency for Resident #1 on 11/29/17. Review of the facility's Five-Day Follow-Up Report dated 12/4/17 indicated Resident #1 was being transferred from the wheelchair to the bed for care. The resident's left leg caught on the bracket of the wheelchair leg rest, causing a laceration. Resident #1 was sent to the emergency room for evaluation and treatment. The resident's laceration was approximately 2 cm x 0.5 cm. Review of Resident #1's medical record revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] coded the resident as having a Brief Interview for Mental Status score of 6. The Quarterly MDS coded Resident #1 as requiring extensive assistance for transfers with 2+ person physical assist. Review of the CNA Kardex for Resident #1 revealed under transfer status to provide gait belt and assistance of two as necessary for transfers/mechanical lift with two as necessary depending upon ability. Provide mechanical lift as necessary for transfers depending on resident ability: full body lift. Review of Resident #1's care plan revealed impaired ability to transfer self due to weakness was identified as a problem area on the care plan. Resident was noted to require 2 assistance to/from bed/chair, use mechanical lift to assist as necessary. Interventions and approaches to the problem were listed on the care plan and included provide gait belt and assistance of two as necessary for transfers/ mechanical lift with two as necessary depending upon ability. Provide mechanical lift, as necessary for transfers depending on resident ability: full body lift. Review of the SBAR Communication Form dated 11/29/17 indicated the CNA stated that during transfer from the bed to the wheelchair after ADL (activities of daily living) care, the resident's lower left leg was caught on a metal piece of the wheelchair causing a laceration. The resident had a deep laceration that required sutures. CNA #1's facility-obtained statement dated 11/29/17 indicated s/he was transferring Resident #1 from the bed back to the chair. The resident's leg got caught on the inside of the wheelchair. When CNA #1 saw blood, s/he notified the nurse immediately. In an interview with the surveyor on 1/30/18 at approximately 2:10 PM, CNA #1 stated s/he was assigned to Resident #1 at the time of the incident. S/he was transferring the resident from the bed to the wheelchair and his/her leg got caught inside the wheelchair. CNA #1 stated s/he transferred Resident #1 by him/herself, CNA #1 transferred the resident as a stand and pivot. CNA #1 stated the shoes Resident #1 had on did not have grip and they slid. The resident's leg got caught on a groove on the inside of the wheelchair. CNA #1 notified the nurse when it happened. CNA #1 stated s/he transferred the resident by him/herself. CNA #1 stated the transfer information for each resident is on the kardex on the kiosk. CNA #1 stated s/he did not look at the kardex prior to transferring the resident, s/he did go back and look at the information after the incident and the resident was listed as a 2 person transfer. CNA #1 stated s/he usually works days and is usually assigned to Resident #1. CNA #1 has worked on the same unit for [AGE] years. LPN (Licensed Practical Nurse) Unit Coordinator's facility-obtained statement dated 11/29/17 indicated a description of action taken in regards to CNA #1. A verbal warning was giving to CNA #1 for not following the Kardex plan of care on Resident #1's transfer status. Also, discussion as to importance of checking the Kardex on all residents prior to caring for them to see how they transfer, eat, toilet, how they do with ADL's and any other safety concerns or issues that are listed in each individual Kardex. In an interview with the surveyor on 1/30/18 at approximately 2:20 PM, RN #1 stated s/he was working on 11/29/17 and s/he was assigned to Resident #1. RN #1 was passing medications and s/he heard an aide looking for him/her. They told RN #1 to bring the treatment cart. Resident #1 was sitting in his/her wheelchair and his/her leg was bleeding. RN #1 cleaned the area because there was a lot of blood. S/he saw the laceration and sent for the unit manager. The resident's leg kept bleeding. The unit manager came and looked at the leg and went and got the DON (director of nursing). The DON said the resident needed sutures and needed to go out to the hospital. In an interview with the surveyor on 1/31/18 at approximately 11:30 AM, the DON stated s/he completed the reportable and investigation for Resident #1 because it was a significant injury. They checked the kardex and the care plan to make sure they matched and Resident #1's did match. Resident #1 was a 2 person stand/pivot transfer at the time of the incident. CNA #1 had a coaching and s/he was re-educated on the kardex and looking at the kardex to safely transfer a resident. Review of Resident #1's medical record revealed the pharmacist's Medication Regimen Review on 12/17/17 indicated irregularities and/or recommendations. Review of the Consultation Report dated 12/17/17 revealed Resident #1 received two [MEDICAL CONDITION] medications: [REDACTED]. The recommendation was to please evaluate if a gradual dose reduction of either of the medications was possible at the time, perhaps decreasing [MEDICATION NAME] to 2.5 milligrams three times daily, while monitoring for re-emergence of target and/or withdrawal symptoms. If this therapy is to continue it is recommended that a) the prescriber document an assessment of risk versus benefit, indicating that it continues to be a valid therapeutic intervention for this individual; AND b) the facility interdisciplinary team ensure ongoing monitoring for effectiveness and potential adverse consequences. Further review of the Consultation Report dated 12/17/17 revealed there was no response or signature from the physician. The Consultation Report contained an area for the physician to sign to accept the recommendations and an area for the physician to sign to decline the recommendations. Review of the Doctor's Progress Notes revealed no documentation between 12/17/17 and 1/31/18 related to the pharmacist recommendations for a gradual dose reduction. Review of the pharmacist's Gradual Dose Reduction Tracking Report dated 1/22/18 indicated the last gradual dose reduction request for Resident #1 for [MEDICATION NAME] and [MEDICATION NAME] was on 12/17/17. The report indicated there was no current documentation of clinical contraindications. In an interview with the surveyor on 1/31/18 at approximately 11:30 AM, the Director of Nursing stated the physician would look at the pharmacy consultation report but may not sign it. S/he stated they print out a copy of the report and put it in the physician's mailbox. Review of Resident #1's care plan revealed the resident required administration of psychoactive medications was identified as a problem area on the care plan. Interventions and approaches to the problem were listed on the care plan and included periodic reviews of medications by the interdisciplinary team to determine potential dose reductions.

Based on review of facility files and interview, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents. Resident #1 was noted to receive a laceration while being transferred by CNA (certified nurse aide) #1. CNA #1 did not use the appropriate transfer method while transferring Resident #1 at the time the laceration occurred. One of three residents reviewed for incidents. The findings included: The facility reported an injury of unknown source to the State Agency for Resident #1 on 11/29/17. Review of the facility's Five-Day Follow-Up Report dated 12/4/17 indicated Resident #1 was being transferred from the wheelchair to the bed for care. The resident's left leg caught on the bracket of the wheelchair leg rest, causing a laceration. Resident #1 was sent to the emergency room for evaluation and treatment. The resident's laceration was approximately 2 cm x 0.5 cm. Review of Resident #1's medical record revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] coded the resident as having a Brief Interview for Mental Status score of 6. The Quarterly MDS coded Resident #1 as requiring extensive assistance for transfers with 2+ person physical assist. Review of Resident #1's Transfer Evaluation forms dated 9/7/17 and 12/5/17 revealed the resident's transfer evaluation score was a category 3, caregiver performs 50% or more of task. Equipment was indicated as mechanical lift (total body/sling or stand assist as appropriate). Review of the Nursing Monthly Summary dated 9/26/17 revealed the nurse indicated Resident #1 required extensive assistance with one person physical assist for transfers. Review of the Nursing Monthly Summaries dated 11/24/17 and 12/25/17 revealed Resident #1 was also coded as requiring extensive assistance with one person physical assist for transfers. Review of the Nursing Daily Skilled Charting note dated 12/5/17 revealed Resident #1's transfer status was documented as requiring extensive assistance with two+ persons physical assist. Review of the care plan revealed requires two assistance to/from bed/chair, use mechanical lift to assist as necessary was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included to provide gait belt and assistance of two as necessary for transfers/mechanical lift with two as necessary depending on ability. Review of the SBAR Communication Form dated 11/29/17 indicated the CNA stated that during transfer from the bed to the wheelchair after ADL (activities of daily living) care, the resident's lower left leg was caught on a metal piece of the wheelchair causing a laceration. The resident had a deep laceration that required sutures. CNA #1's facility-obtained statement dated 11/29/17 indicated s/he was transferring Resident #1 from the bed back to the chair. The resident's leg got caught on the inside of the wheelchair. When CNA #1 saw blood, s/he notified the nurse immediately. In an interview with the surveyor on 1/30/18 at approximately 2:10 PM, CNA #1 stated s/he was assigned to Resident #1 at the time of the incident. S/he was transferring the resident from the bed to the wheelchair and his/her leg got caught inside the wheelchair. CNA #1 stated s/he transferred Resident #1 by him/herself, CNA #1 transferred the resident as a stand and pivot. CNA #1 stated the shoes Resident #1 had on did not have grip and they slid. The resident's leg got caught on a groove on the inside of the wheelchair. CNA #1 notified the nurse when it happened. CNA #1 stated s/he transferred the resident by him/herself. CNA #1 stated the transfer information for each resident is on the kardex on the kiosk. CNA #1 stated s/he did not look at the kardex prior to transferring the resident, s/he did go back and look at the information after the incident and the resident was listed as a 2 person transfer. CNA #1 stated s/he usually works days and is usually assigned to Resident #1. CNA #1 has worked on the same unit for [AGE] years. LPN (Licensed Practical Nurse) Unit Coordinator's facility-obtained statement dated 11/29/17 indicated a description of action taken in regards to CNA #1. A verbal warning was giving to CNA #1 for not following the Kardex plan of care on Resident #1's transfer status. Also, discussion as to importance of checking the Kardex on all residents prior to caring for them to see how they transfer, eat, toilet, how they do with ADL's and any other safety concerns or issues that are listed in each individual Kardex. In an interview with the surveyor on 1/30/18 at approximately 2:20 PM, RN #1 stated s/he was working on 11/29/17 and s/he was assigned to Resident #1. RN #1 was passing medications and s/he heard an aide looking for him/her. They told RN #1 to bring the treatment cart. Resident #1 was sitting in his/her wheelchair and his/her leg was bleeding. RN #1 cleaned the area because there was a lot of blood. S/he saw the laceration and sent for the unit manager. The resident's leg kept bleeding. The unit manager came and looked at the leg and went and got the DON (director of nursing). The DON said the resident needed sutures and needed to go out to the hospital. In an interview with the surveyor on 1/31/18 at approximately 11:30 AM, the DON stated s/he completed the reportable and investigation for Resident #1 because it was a significant injury. They checked the kardex and the care plan to make sure they matched and Resident #1's did match. Resident #1 was a 2 person stand/pivot transfer at the time of the incident. CNA #1 had a coaching and s/he was re-educated on the kardex and looking at the kardex to safely transfer a resident. The DON stated CNAs can decide if they need to use a lift or the nurse may make the call and let the CNAs know to use a lift. The Nursing Monthly Summary is completed by the nurse assigned to the resident and the DON was not sure what their thought process was for assessing Resident #1 as a 1 person assist for transfer status. The nurses should have assessed the resident as a 2 person assist since that is what was on the care plan. The DON stated the Transfer Evaluations are completed by MDS (minimum data set) nurses and they look at the plan of care documentation from the CNAs to complete the evaluation. If Resident #1 was coded as a Category 3, s/he would require a lift unless therapy assessed that s/he did not require a lift for transfers. In an interview with the surveyor on 1/31/18, Occupational Therapist #1 stated s/he started working with Resident #1 on 12/1/17, after the incident. They assess residents on the therapy case load for transfer status, they do not assess all residents in the facility.

Based on review of facility files and interview, the facility failed to prevent further potential abuse/neglect while an investigation was in progress. Resident #1 was noted to receive a laceration while being transferred by CNA (certified nurse aide) #1. CNA #1 did not use the appropriate transfer method while transferring Resident #1 at the time the laceration occurred. CNA #1 continued to work the rest of his/her shift on the day of the incident and was not suspended during the investigation. One of three residents reviewed for incidents. The findings included: The facility reported an injury of unknown source to the State Agency for Resident #1 on 11/29/17. Review of the facility's Five-Day Follow-Up Report dated 12/4/17 indicated Resident #1 was being transferred from the wheelchair to the bed for care. The resident's left leg caught on the bracket of the wheelchair leg rest, causing a laceration. Resident #1 was sent to the emergency room for evaluation and treatment. The resident's laceration was approximately 2 cm x 0.5 cm. Review of Resident #1's medical record revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] coded the resident as having a Brief Interview for Mental Status score of 6. The Quarterly MDS coded Resident #1 as requiring extensive assistance for transfers with 2+ person physical assist. Review of the care plan revealed requires two assistance to/from bed/chair, use mechanical lift to assist as necessary was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included to provide gait belt and assistance of two as necessary for transfers/mechanical lift with two as necessary depending on ability. Review of the SBAR Communication Form dated 11/29/17 indicated the CNA stated that during transfer from the bed to the wheelchair after ADL (activities of daily living) care, the resident's lower left leg was caught on a metal piece of the wheelchair causing a laceration. The resident had a deep laceration that required sutures. CNA #1's facility-obtained statement dated 11/29/17 indicated s/he was transferring Resident #1 from the bed back to the chair. The resident's leg got caught on the inside of the wheelchair. When CNA #1 saw blood, s/he notified the nurse immediately. In an interview with the surveyor on 1/30/18 at approximately 2:10 PM, CNA #1 stated s/he was assigned to Resident #1 at the time of the incident. S/he was transferring the resident from the bed to the wheelchair and his/her leg got caught inside the wheelchair. CNA #1 stated s/he transferred Resident #1 by him/herself, CNA #1 transferred the resident as a stand and pivot. CNA #1 stated the shoes Resident #1 had on did not have grip and they slid. The resident's leg got caught on a groove on the inside of the wheelchair. CNA #1 notified the nurse when it happened. CNA #1 stated s/he transferred the resident by him/herself. CNA #1 stated the transfer information for each resident is on the kardex on the kiosk. CNA #1 stated s/he did not look at the kardex prior to transferring the resident, s/he did go back and look at the information after the incident and the resident was listed as a 2 person transfer. CNA #1 stated s/he usually works days and is usually assigned to Resident #1. CNA #1 has worked on the same unit for [AGE] years. LPN (Licensed Practical Nurse) Unit Coordinator's facility-obtained statement dated 11/29/17 indicated a description of action taken in regards to CNA #1. A verbal warning was giving to CNA #1 for not following the Kardex plan of care on Resident #1's transfer status. Also, discussion as to importance of checking the Kardex on all residents prior to caring for them to see how they transfer, eat, toilet, how they do with ADL's and any other safety concerns or issues that are listed in each individual Kardex. In an interview with the surveyor on 1/30/18 at approximately 2:20 PM, RN #1 stated s/he was working on 11/29/17 and s/he was assigned to Resident #1. RN #1 was passing medications and s/he heard an aide looking for him/her. They told RN #1 to bring the treatment cart. Resident #1 was sitting in his/her wheelchair and his/her leg was bleeding. RN #1 cleaned the area because there was a lot of blood. S/he saw the laceration and sent for the unit manager. The resident's leg kept bleeding. The unit manager came and looked at the leg and went and got the DON (Director of Nursing). The DON said the resident needed sutures and needed to go out to the hospital. A review of the Time Detail report dated 11/29/17 revealed CNA #1 was in the facility from 7:09 AM to 3:10 PM on that date. CNA #1 worked the 7:00 AM - 3:00 PM shift on 11/30/17, 12/1/17, and 12/4/17. In an interview with the surveyor on 1/31/18 at approximately 11:30 AM, the DON stated s/he completed the reportable and investigation for Resident #1 because it was a significant injury. They checked the kardex and the care plan to make sure they matched and Resident #1's did match. Resident #1 was a 2 person stand/pivot transfer at the time of the incident. CNA #1 had a coaching and s/he was re-educated on the kardex and looking at the kardex to safely transfer a resident. Review of the facility's Abuse & Neglect Prohibition policy revealed each resident has the right to be free from neglect. Neglect was defined as failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Based on review of facility files and interview, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse/neglect. Resident #1 was noted to receive a laceration while being transferred by CNA (certified nurse aide) #1. CNA #1 did not use the appropriate transfer method while transferring Resident #1 at the time the laceration occurred. This incident was an allegation of neglect and CNA #1 was not suspended during the investigation. One of three residents reviewed for incidents. The findings included: The facility reported an injury of unknown source to the State Agency for Resident #1 on 11/29/17. Review of the facility's Five-Day Follow-Up Report dated 12/4/17 indicated Resident #1 was being transferred from the wheelchair to the bed for care. The resident's left leg caught on the bracket of the wheelchair leg rest, causing a laceration. Resident #1 was sent to the emergency room for evaluation and treatment. The resident's laceration was approximately 2 cm x 0.5 cm. Review of Resident #1's medical record revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] coded the resident as having a Brief Interview for Mental Status score of 6. The Quarterly MDS coded Resident #1 as requiring extensive assistance for transfers with 2+ person physical assist. Review of the care plan revealed requires two assistance to/from bed/chair, use mechanical lift to assist as necessary was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included to provide gait belt and assistance of two as necessary for transfers/mechanical lift with two as necessary depending on ability. Review of the SBAR Communication Form dated 11/29/17 indicated the CNA stated that during transfer from the bed to the wheelchair after ADL (activities of daily living) care, the resident's lower left leg was caught on a metal piece of the wheelchair causing a laceration. The resident had a deep laceration that required sutures. CNA #1's facility-obtained statement dated 11/29/17 indicated s/he was transferring Resident #1 from the bed back to the chair. The resident's leg got caught on the inside of the wheelchair. When CNA #1 saw blood, s/he notified the nurse immediately. In an interview with the surveyor on 1/30/18 at approximately 2:10 PM, CNA #1 stated s/he was assigned to Resident #1 at the time of the incident. S/he was transferring the resident from the bed to the wheelchair and his/her leg got caught inside the wheelchair. CNA #1 stated s/he transferred Resident #1 by him/herself, CNA #1 transferred the resident as a stand and pivot. CNA #1 stated the shoes Resident #1 had on did not have grip and they slid. The resident's leg got caught on a groove on the inside of the wheelchair. CNA #1 notified the nurse when it happened. CNA #1 stated s/he transferred the resident by him/herself. CNA #1 stated the transfer information for each resident is on the kardex on the kiosk. CNA #1 stated s/he did not look at the kardex prior to transferring the resident, s/he did go back and look at the information after the incident and the resident was listed as a 2 person transfer. CNA #1 stated s/he usually works days and is usually assigned to Resident #1. CNA #1 has worked on the same unit for [AGE] years. LPN (Licensed Practical Nurse) Unit Coordinator's facility-obtained statement dated 11/29/17 indicated a description of action taken in regards to CNA #1. A verbal warning was giving to CNA #1 for not following the Kardex plan of care on Resident #1's transfer status. Also, discussion as to importance of checking the Kardex on all residents prior to caring for them to see how they transfer, eat, toilet, how they do with ADL's and any other safety concerns or issues that are listed in each individual Kardex. In an interview with the surveyor on 1/30/18 at approximately 2:20 PM, RN #1 stated s/he was working on 11/29/17 and s/he was assigned to Resident #1. RN #1 was passing medications and s/he heard an aide looking for him/her. They told RN #1 to bring the treatment cart. Resident #1 was sitting in his/her wheelchair and his/her leg was bleeding. RN #1 cleaned the area because there was a lot of blood. S/he saw the laceration and sent for the unit manager. The resident's leg kept bleeding. The unit manager came and looked at the leg and went and got the DON (Director of Nursing). The DON said the resident needed sutures and needed to go out to the hospital. In an interview with the surveyor on 1/31/18 at approximately 11:30 AM, the DON stated s/he completed the reportable and investigation for Resident #1 because it was a significant injury. They checked the kardex and the care plan to make sure they matched and Resident #1's did match. Resident #1 was a 2 person stand/pivot transfer at the time of the incident. CNA #1 had a coaching and s/he was re-educated on the kardex and looking at the kardex to safely transfer a resident. Review of CNA #1's Time Detail Report revealed s/he worked in the facility from 7:09 AM until 3:10 PM on 11/29/17. CNA #1 worked the 7:00 AM - 3:00 PM shift on 11/30/17, 12/1/17, and 12/4/17. CNA #1 was employed at the facility on the days of the survey and was interviewed while on duty. Review of the facility's Abuse & Neglect Prohibition policy revealed the facility will timely conduct an investigation of any alleged abuse/neglect. Any employee alleged to be involved in an instance of abuse and/or neglect will be suspended immediately and will not be permitted to work unless and until such allegations of abuse/neglect are unsubstantiated.

Based on review of facility files and interview, the facility failed to ensure each resident remained free from neglect. Resident #1 was noted to receive a laceration while being transferred by CNA (certified nurse aide) #1. CNA #1 did not use the appropriate transfer method while transferring Resident #1 at the time the laceration occurred. One of three residents reviewed for incidents. The findings included: The facility reported an injury of unknown source to the State Agency for Resident #1 on 11/29/17. Review of the facility's Five-Day Follow-Up Report dated 12/4/17 indicated Resident #1 was being transferred from the wheelchair to the bed for care. The resident's left leg caught on the bracket of the wheelchair leg rest, causing a laceration. Resident #1 was sent to the emergency room for evaluation and treatment. The resident's laceration was approximately 2 cm x 0.5 cm. Review of Resident #1's medical record revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] coded the resident as having a Brief Interview for Mental Status score of 6. The Quarterly MDS coded Resident #1 as requiring extensive assistance for transfers with 2+ person physical assist. Review of the care plan revealed requires two assistance to/from bed/chair, use mechanical lift to assist as necessary was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included to provide gait belt and assistance of two as necessary for transfers/mechanical lift with two as necessary depending on ability. Review of the SBAR Communication Form dated 11/29/17 indicated the CNA stated that during transfer from the bed to the wheelchair after ADL (activities of daily living) care, the resident's lower left leg was caught on a metal piece of the wheelchair causing a laceration. The resident had a deep laceration that required sutures. CNA #1's facility-obtained statement dated 11/29/17 indicated s/he was transferring Resident #1 from the bed back to the chair. The resident's leg got caught on the inside of the wheelchair. When CNA #1 saw blood, s/he notified the nurse immediately. In an interview with the surveyor on 1/30/18 at approximately 2:10 PM, CNA #1 stated s/he was assigned to Resident #1 at the time of the incident. S/he was transferring the resident from the bed to the wheelchair and his/her leg got caught inside the wheelchair. CNA #1 stated s/he transferred Resident #1 by him/herself, CNA #1 transferred the resident as a stand and pivot. CNA #1 stated the shoes Resident #1 had on did not have grip and they slid. The resident's leg got caught on a groove on the inside of the wheelchair. CNA #1 notified the nurse when it happened. CNA #1 stated s/he transferred the resident by him/herself. CNA #1 stated the transfer information for each resident is on the kardex on the kiosk. CNA #1 stated s/he did not look at the kardex prior to transferring the resident, s/he did go back and look at the information after the incident and the resident was listed as a 2 person transfer. CNA #1 stated s/he usually works days and is usually assigned to Resident #1. CNA #1 has worked on the same unit for [AGE] years. LPN (Licensed Practical Nurse) Unit Coordinator's facility-obtained statement dated 11/29/17 indicated a description of action taken in regards to CNA #1. A verbal warning was giving to CNA #1 for not following the Kardex plan of care on Resident #1's transfer status. Also, discussion as to importance of checking the Kardex on all residents prior to caring for them to see how they transfer, eat, toilet, how they do with ADL's and any other safety concerns or issues that are listed in each individual Kardex. In an interview with the surveyor on 1/30/18 at approximately 2:20 PM, RN #1 stated s/he was working on 11/29/17 and s/he was assigned to Resident #1. RN #1 was passing medications and s/he heard an aide looking for him/her. They told RN #1 to bring the treatment cart. Resident #1 was sitting in his/her wheelchair and his/her leg was bleeding. RN #1 cleaned the area because there was a lot of blood. S/he saw the laceration and sent for the unit manager. The resident's leg kept bleeding. The unit manager came and looked at the leg and went and got the DON (Director of Nursing). The DON said the resident needed sutures and needed to go out to the hospital. In an interview with the surveyor on 1/31/18 at approximately 11:30 AM, the DON stated s/he completed the reportable and investigation for Resident #1 because it was a significant injury. They checked the kardex and the care plan to make sure they matched and Resident #1's did match. Resident #1 was a 2 person stand/pivot transfer at the time of the incident. CNA #1 had a coaching and s/he was re-educated on the kardex and looking at the kardex to safely transfer a resident. Review of the facility's Abuse & Neglect Prohibition policy revealed each resident has the right to be free from neglect. Neglect was defined as failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Based on review of facility files and interview, the facility failed to immediately inform the resident's physician when there was a significant change in the resident's physical status. Resident #92 was noted with complaints of pain and his/her arm was observed to be red and swollen on 12/18/16 at approximately 9:00 PM. The resident's physician and responsible party were not notified until 12/19/16. One of resident reviewed for notification. The findings included: The facility submitted an allegation of physical abuse for Resident #92 on 12/19/16. Resident #92 was noted to have a painful, swollen, reddened left elbow. Review of the Radiology Report dated 12/19/16 revealed Resident #92 had a supracondylar elbow fracture. Review of the medical record revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] coded Resident #92 as having a Brief Interview for Mental Status score of 6. Review of the Incident/Accident Report revealed the resident's physician was notified at 8:40 AM and the resident's responsible party was notified at 9:20 AM. The report was signed but not dated. The Incident/Accident Report indicated the date of incident was 12/18/16 at 9:00 PM, the resident complained of pain and his/her left elbow was discolored and swollen. Review of Resident #92's Nurses' Notes revealed no entries between 12/5/16 and 12/19/16. A SBAR Summary was completed on 12/19/16 at 10:28 AM that indicated the resident was noted to have a swollen red elbow. Review of the SBAR dated 12/19/16 at 10:28 indicated resident was noted to have a swollen red elbow to the left and discoloration to the left heel. Resident's left elbow observed to be swollen, painful to touch, and discolored. Verbal order received per MD for x-ray of left elbow, apply skin prep to left heel. Tylenol 325 mg 2 tablets was administered for pain on 12/19/16 at 9:00. CNA # 3's facility-obtained statement dated 12/19/16 indicated on 12/18/16 at 9:00 PM s/he went to check on Resident #92. As s/he went to turn the resident, the resident said ouch my arm my arm. CNA #3 went to get LPN #1 and s/he came in to talk with the resident. LPN #1's facility-obtained statement indicated on 12/18/16 at approximately 9:00 PM, CNA #3 told him/her that Resident #92 complained of arm pain. LPN #1 stopped what s/he was doing and went to the resident's room. LPN #1 observed both arms and noted the left elbow was red and a little bigger than the right. LPN #1 indicated s/he went to the medication cart and administered 325 mg Tylenol. LPN #1 then continued with his/her medication pass. In an interview with the surveyor on 4/4/16 at approximately 6:10 PM, the ADON (Assistant Director of Nursing) reviewed Resident #92's nurses' notes and confirmed there was no documentation related to the resident's arm on 12/18/16. The ADON stated LPN #1 should have notified the physician at the time the arm was noted to be red and swollen. Review of the facility's policy on Changes in Resident Condition indicated the attending physician and resident's legal representative are notified when changes in the resident's condition occur. The policy indicated prompt notification is required when there is a significant change in the resident's physical status.

Based on review of facility files and interview, the facility failed to ensure each resident remained free from physical restraints imposed for purposed of convenience, and not required to treat the resident's medical symptoms. Resident #142 was noted to been restrained in his/her wheelchair with a gait belt. One of 1 resident reviewed for restraints. The findings included: The facility reported an allegation of physical abuse for Resident #142 on 9/17/16. Review of the facility's Five-Day Follow-Up Report dated 9/21/16 revealed a nurse was walking through the unit on 9/16/16 at approximately 11:35 PM and Resident #142 asked the nurse if s/he had a pair of scissors. The nurse asked the resident what s/he needed scissors for. Resident #142 said to cut this thing off of me. The nurse examined the chair and noticed the gait belt around the resident. The nurse called the ADON (Assistant Director of Nursing) to report. When the ADON and the DON arrived at the facility around midnight, Resident #142 was in the bed. CNA #2 was assigned to Resident #142 on the 11-7 shift. When CNA #2 took Resident #142 to his/her room s/he noticed the gait belt around him/her. CNA #2 removed the gait belt and asked the nurse, LPN #4, if s/he knew anything about the situation. LPN #4 said (CNA #1) must have put it on him/her. The 3-11 shift CNA, CNA #1, stated that s/he put his/her gait belt around Resident #142 to prevent him/her from falling. CNA #1 told LPN #4 and brought the resident to the nurses station where s/he could be closely monitored. Further review of the medical record revealed the Initial Minimum Data Set ((MDS) dated [DATE] coded Resident #142 as having a Brief Interview for Mental Status score of 6. The Initial MDS coded Resident #142 as requiring extensive assistance for transfers, dressing, hygiene and bed mobility with no behaviors coded as occurring during the assessment period. The Initial MDS coded Resident #142 as having no restraints. Review of the care plan revealed resident exhibits behavioral symptoms as evidenced by yelling out, resists care, and verbally/physically abusive to staff/others at times was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included to modify environment to minimize external stressors. Review of Resident #142's September 2016 Physician order [REDACTED]. Review of the Nurses' Notes dated 9/15/16 indicated resident made several attempts to stand and get up out of wheelchair unassisted. Alert alarm intact and functioning. Resident refuses to be redirected, yells at staff and is very aggressive. LPN #2's facility-obtained statement dated 9/16/16 indicated at approximately 11:25 PM, s/he saw Resident #142 sitting in the wheelchair at the nurses' station. Resident #142 asked him/her for scissors because s/he was tied to his/her chair. LPN #2 said you are not tied, then looked closer to find resident tied to wheelchair with a gait belt and covered up with a fitted bedsheet. LPN #2 called the ADON. CNA #1's facility-obtained statement dated 9/17/16 indicated s/he was assigned to Resident #142 on 9/16/16 on the 3-11 shift. Resident #142 kept trying to get up out of bed and his/her alarm kept going off. CNA #1 put Resident #142 in the wheelchair around 9:30 PM and the resident was trying to get up out of the wheelchair. At about 10:00 PM, the resident continued to try to get out of the chair so CNA #1 decided to put his/her gait belt around him/her to keep them from getting up out of the chair so s/he would not fall. When CNA #1 took the resident to the front of the nurses' station s/he told LPN #4 that s/he had put the gait belt on the resident. Resident #142 was saying s/he was cold so the CNA took a draw sheet off the bed and draped it around the resident. CNA #1 stated s/he did not tie the sheet around the resident and did not put the sheet on the wheelchair handles. CNA #1 meant to take off the gait belt before s/he left but forgot. CNA #1 did not know how the resident got a fitted sheet wrapped around him/her or hooked to the wheelchair handles. In an interview with the surveyor on 4/4/17 at approximately 7:15 PM, CNA #1 stated Resident #142 was following him/her around in the hallway. CNA #1 put the resident in the wheelchair so s/he could go up and down the hall. Then the resident started getting up from the wheelchair and walk around the hall. CNA #1 took his/her gait belt and put it around Resident #142 in the wheelchair. S/he used the hook on the gait belt to secure it. CNA #1 fastened the gait belt behind the wheelchair seat. That was around 10:00 PM. CNA #1 worked the 3-11 PM shift. CNA #1 told the nurse, LPN #4, that s/he put the gait belt around the resident in the chair because s/he couldn't watch the resident and care for the other residents. LPN #4 didn't say anything, but CNA #1 stated s/he knows s/he heard him/her. CNA#1 meant to remove the belt when s/he left at 11:00 but got busy and forgot. CNA #1 stated Resident #142 followed him/her around that night. Resident #142 would knock on a resident's door and ask CNA #1 when s/he was going to be done. Resident #142 CNA tell CNA #1 to hurry up. CNA #1 stated Resident #142 did not usually follow him/her around like they did that night. CNA #2's facility-obtained statement dated 9/16/16 indicated at approximately 11:00 PM s/he observed Resident #142 in the wheelchair at the nurses' station with a sheet wrapped over him/her. At around 12:30 AM, the resident said s/he was tired and ready to go to bed. CNA #2 took the resident to his/her room and assisted him/her to bed. When CNA #2 was putting the resident to bed s/he noticed that the resident had a gait belt on as s/he removed the sheet that was over the resident's waist and legs. When s/he finished putting the resident to bed, she took the gait belt to the nurses' station and asked the nurse if s/he knew that it was on the resident. The nurse said CNA #1 must have placed it on the resident to avoid him/her from falling. In an interview with the surveyor on 4/4/16 the Interim DON (Director of Nursing) stated s/he would not expect the nurse to document the incident. When asked about LPN #2 finding the resident restrained at approximately 11:25 PM and the resident still being tied with a gait belt at 12:30 AM per CNA #2's statement, the Interim DON stated s/he would expect the nurse who called the ADON to follow the ADON's direction as to what to do. Review of the facility's Abuse & Neglect Prohibition policy revealed each resident has the right to be free from mistreatment, neglect, abuse, exploitation, involuntary seclusion, corporal punishment, physical or chemical restraint not required to treat the resident's medical symptoms, injuries of unknown origin, and misappropriation of resident property.

Based on review of facility files and interview, the facility failed to ensure services provided by the facility meet professional standards of care. Resident #92 was noted with complaints of pain and observed to have a swollen red elbow on 12/18/16 at 9:00 PM. There was no follow up to the resident's condition until 12/19/16 at approximately 9:00 AM. One of resident reviewed for professional standards. The findings included: The facility submitted an allegation of physical abuse for Resident #92 on 12/19/16. Resident #92 was noted to have a painful, swollen, reddened left elbow. Review of the Radiology Report dated 12/19/16 revealed Resident #92 had a supracondylar elbow fracture. Review of the Incident/Accident Report revealed the resident's physician was notified at 8:40 AM and the resident's responsible party was notified at 9:20 AM. The report was signed but not dated. The Incident/Accident Report indicated the date of incident was 12/18/16 at 9:00 PM, the resident complained of pain and his/her left elbow was discolored and swollen. Review of Resident #92's Nurses' Notes revealed no entries between 12/5/16 and 12/19/16. A SBAR Summary was completed on 12/19/16 at 10:28 AM that indicated the resident was noted to have a swollen red elbow. There were no entries on 12/18/16 when Resident #92's arm was noted to be swollen and red, with the resident complaining of pain. There was no documentation that the resident's condition was monitored. Review of the SBAR dated 12/19/16 at 10:28 indicated resident was noted to have a swollen red elbow to the left and discoloration to the left heel. Resident's left elbow observed to be swollen, painful to touch, and discolored. Verbal order received per MD for x-ray of left elbow, apply skin prep to left heel. Tylenol 325 mg 2 tablets was administered for pain on 12/19/16 at 9:00. Review of Resident #92's Medication Administration Record revealed the resident was not administered Tylenol 325 mg for pain on 12/18/16. The resident received Tylenol 325 mg for pain on 12/19/16 at 9:00 AM. CNA #3's facility-obtained statement dated 12/19/16 indicated on 12/18/16 at 9:00 PM s/he went to check on Resident #92. As s/he went to turn the resident, the resident said ouch my arm my arm. CNA #3 went to get LPN #1 and s/he came in to talk with the resident. LPN #1's facility-obtained statement indicated on 12/18/16 at approximately 9:00 PM, CNA #3 told him/her that Resident #92 complained of arm pain. LPN #1 stopped what s/he was doing and went to the resident's room. LPN #1 observed both arms and noted the left elbow was red and a little bigger than the right. LPN #1 indicated s/he went to the medication cart and administered 325 mg Tylenol. LPN #1 then continued with his/her medication pass. In an interview with the surveyor on 4/4/16 at approximately 6:10 PM, the ADON (Assistant Director of Nursing) reviewed Resident #92's nurses' notes and confirmed there was no documentation related to the resident's arm on 12/18/16. The ADON stated LPN #1 should have notified the physician at the time the arm was noted to be red and swollen. The ADON stated the nurse should have monitored and documented the resident's condition in the nurses' notes. The ADON reviewed Resident #92's December 2016 MAR and confirmed there was no documentation that the nurse administered Tylenol for pain on 12/18/16. The ADON reviewed the nurses' notes and confirmed there was no documentation related to Resident #92's arm on 12/18/16. Review of the facility's policy on Changes in Resident Condition indicated the attending physician and resident's legal representative are notified when changes in the resident's condition occur. The policy indicated prompt notification is required when there is a significant change in the resident's physical status. The policy also indicated the SBAR Communication Form and the Progress Note are used to: assess and document changes in condition in an efficient and effective manner, provide assessment information to the physician, and provide clear comprehensive documentation.

On the days of the complaint inspection based on record review and interviews, the facility failed to revise the care plan related to falls for Resident #4 to include interventions implemented after a fall in November 2012. Resident #4 had a second fall with injury in January 2013, there was no evidence that the interventions put in place following the fall in November 2012 were in place. The findings included: The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes from 4/4/12 through 2/12/13 revealed a Change of Condition form dated 11/8/12 at 10:58 AM that stated, "Resident on floor in room, R (right) side of head on closet. Lying on R side. Goose egg bump to R forehead (and) gash (upper) R eye. Resident denies pain. Moderate amount of blood noted from gash." The Interdisciplinary Post Fall Review dated 11/9/12 stated in the section Summary of Interdisciplinary Team: "...Place chair alarm to wheelchair..." Further review revealed a Nurse's Note dated 1/20/13 at 5:05 (?) "...Res(ident) was observed lying on floor on LT (left) side c (with) w/c (wheelchair) behind her. S/he had blood come (sic) from her LT (upper) eye (with) a hematoma 2. cm (centimeters) x 2. cm. Further review revealed a Change of Condition form dated 1/20/13 with no documentation that safety devices were in place prior to the fall. Review of the Interdisciplinary Post Fall Review revealed "Shoes" was checked in the box for Footwear/Assistive Devices at the Time of Fall. No other safety devices were listed. On 2/12/13 at 10:26 AM, record review revealed a Report from the hospital dated 1/20/13 for a laceration to the scalp. Further review revealed a physician order [REDACTED]. Review of the care plan dated 7/31/12 and updated 1/25/13 revealed a care plan for Risk for Falls. Chair Alarm was not checked. The care plan had been updated to reflect the falls on 11/8/12 and 1/20/13 but had not been revised to reflect the need for a chair alarm. Review of the Resident Care Specialist Assignment Sheet, the Certified Nursing Assistants (CNA) care plan, dated 2/3/13 revealed a chair alarm was not listed for Resident #4. On 2/6/13 at approximately 12:15, the Director of Nursing confirmed that the chair alarm was not listed on the nursing care plan. During an interview on 2/6/13 at approximately 1:30 PM, the Assistant Director of Nursing confirmed that the chair alarm had not been listed on the 2/3/13 CNA care plan.

On the days of the complaint inspection based on observation, record review and interviews, the facility failed to provide safety devices or adequate supervision to prevent fall with injury for Resident #4, 1 of 1 Resident reviewed for falls. The findings included: The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes from 9/18/12 through 2/12/13 revealed two falls with injury. A Change of Condition form dated 11/8/12 at 10:58 AM stated, "Resident on floor in room, R (right) side of head on closet. Lying on R side. Goose egg bump to R forehead (and) gash (upper) R eye. Resident denies pain. Moderate amount of blood noted from gash. ...to send resident to ER (emergency room ) for evaluation... The Interdisciplinary Post Fall Review signed by the team members on 11/9/12 stated in the section Summary of Interdisciplinary Team: "Resident c decreased safety awareness. Place chair alarm to wheelchair. ...monitor resident's whereabouts in room and in facility." 1/20/13 at 5:05 stated, "...res(ident) was observed lying on floor on LT (left) side c (with) w/c (wheelchair) behind her. S/he had blood come (sic) from her LT (upper) eye c a hematoma 2. cm (centimeters) x 2. cm..." There was no documentation that a chair alarm was in use at the time of the fall. Review of the Change of Condition form revealed no documentation of any safety devices in place at the time of the fall. The Interdisciplinary Post Fall Review signed by the team members on 1/21/13 indicated under the section Footwear/Assistive Devices At Time Of Fall "shoes". Stated in the section Summary of Interdisciplinary Team: Encourage resident to ask for assistance as needed. Monitor resident's whereabouts in facility. Incontinent care q (every) 2 hr (hours) and prn (as needed)." No other safety devices were listed. Further review of the Nurse's Notes revealed documentation in the Nursing Daily Skilled Summary dated 1/14/13 that indicated "Other safety Devices" and a Nursing Daily Skilled Summary dated 1/18/13 that stated an "alert alarm to w/c (wheelchair)." The Director of Nursing was unable to provide any further documentation that the alarm was being used. During an interview with the surveyor on 2/12/13 at approximately 12:15 PM, the Director of Nursing (DON) confirmed there was no documentation that the chair alarm was in use at the time of the fall on 1/20/13. S/he further confirmed that the only documentation that the alarm had been used was on 1/14 and 1/18/13. The DON also verified that the alarm was not listed on the nursing care plan. During an interview at approximately 1:32 PM, the Assistant DON (ADON) confirmed that the Certified Nursing Assistants (CNAs) use the Resident Care Specialists Assignment Sheet (CNA care plan) to know what care to provide to their residents. S/he further confirmed that the chair alarm was not listed on the CNA care plan and that it had been added on the day of the survey. The ADON also stated that s/he had responded to a call when Resident #4 fell on [DATE] but did not recall whether the chair alarm was in use or alarming at the time.