Every finding on record at The Preston Health Center

Based on record review, review of the facility investigation, interview, and facility policy review, the facility failed to ensure one (Resident (R)9) out of six residents reviewed for mechanical lift transfers out of a sample of 20 residents was safe when being transferred from a mechanical lift. This resulted in harm when R9 sustained a fractured clavicle when being transferred with a mechanical lift. This deficiency was cited as past non-compliance (PNC). Findings include: Review of the facility policy, revised July 2017, for utilizing the mechanical lifting machines stated at least two nursing assistants were needed to safely move a resident with a mechanical lift. Each resident is assessed the proper sling size according to manufacturer's instructions. Review of the Electronic Medical Record (EMR), Profile tab, revealed R9 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's disease, dementia, and generalized anxiety disorder. A review of R9's EMR, revealed a quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 04/17/24, indicated R9 required maximum assistance for all activities of daily living (ADL's) and utilized the sit to stand mechanical lift for mobility transfers. Review of the Facility Reported Incident (FRI) investigated and reported by Director of Nursing (DON), submitted to the State Agency (SA), revealed on 07/01/24 Certified Nursing Assistant (CNA)1 attempted to transfer for R9 by herself from the bed to the chair, with a stand-up lift using the wrong sling. R9 fell from the sling with her arm hanging in the sling that resulted in a fracture of her clavicle. The incident report indicated the physician and R9's family were notified of the accident, along with her Hospice Agency. During an interview with the DON on 08/29/24 at 3:53 PM, confirmed CNA1 did not get assistance from another staff member and used the wrong sling when transferring R9 with the stand up lift resulting in the resident sustaining a fracture of the clavicle. Following the investigation on 08/29/24, the facility's corrective actions included: There were multiple implementations and interventions had been documented including training and policy/procedure acknowledgement for mechanical lift usage, old slings were discarded, and new ones were purchased, new assessments were conducted of each resident requiring a mechanical lift for transfers. Random checks of caregiving staff for competency and proper utilization of the mechanical lift have and are being completed. Review of CNA1's personnel file indicated she was immediately terminated on the date of the reported accident, (06/30/24), for poor performance to follow facility policy and procedure for the mechanical lift. Her file also documented she was previously trained and acknowledged the policies in place to prevent mechanical lift accidents. She has not been allowed to return to facility employment. Review of facility staff training logs dated 07/03/24, for utilizing a mechanical lift revealed all facility caregivers received re-training and acknowledgement of properly utilizing the lift. Observations during survey on 08/28/24 at 9:36 AM and 1:46 PM revealed CNA2 and Licensed Practical Nurse (LPN)1 demonstrated competency using the mechanical lift device. Review of the facility's corrective actions and interviews completed with staff regarding their education revealed that the facility was in compliance with F689 on 08/29/24.

Based on review of facility policy, observation and interview, the facility failed to ensure proper disposal of refuse. Findings include: Review of the undated facility policy and procedure titled, KITCHEN AND FOOD STORAGE AREA states: Policy: The skilled Health Center's kitchen and nourishment kitchen will meet the same standards for quality for sanitation, cleanliness, and health as required by state regulations for the main kitchen and food serving area. 7) All garbage, trash, and rubberish shall be collected daily and taken to storage facilities. Wet waste which is not disposed of by mechanical means shall be kept in leak- proof nonabsorbent containers with close-fitting covers and be disposed of daily in a manner will prevent transmission of disease, a nuisance, a breeding place for flies, or a feeding place for rodents. During an observation on 11/13/22 at approximately 12 PM revealed 2 dumpsters with posted signage CARDBOARD ONLY with both doors opened. During an observation on 11/13/22 at approximately 12:05 PM revealed a 3 ft tall plastic bin with an abounding amount of grease, uncovered behind the grease trap, surrounded with flies. During an interview with the Director of Food and Beverages on 11/15/22 at 12:56 PM, when asked about the plastic bin with grease and flies, he stated,he wasn't sure what it was, but he would get staff to get rid of it.

Based on review of facility policy, observation, and interview, the facility failed to ensure: 1) Accurate labeling and dating of foods, 2) Removal of expired foods from refrigeration and storage. Findings include: Review of the undated facility policy and procedure titled, KITCHEN AND FOOD STORAGE AREA states: Policy: The skilled Health Center's kitchen and nourishment kitchen will meet the same standards for quality for sanitation, cleanliness, and health as required by state regulations for the main kitchen and food serving area. Procedure: 1) All rooms where food or drink is stored, prepared, or served or where utensils are washed shall be in good repair, clean, and protected from dust, flies, vermin, rodents, and other contamination. Review of the undated facility policy and procedure titled, FOOD DISPOSAL states: Policy: Foods shall be received and stored in a manner that complies with safe food handling practices. Policy interpretation and implementation state 3) Dry foods that are stored in bins will be removed from original packaging, labeled and dated. Dispose of foods on the use by date. 4)All foods stored in the refrigerator or freezer will be covered, labeled, and dated. Disposal of foods on the use by date. 5) Refrigerated foods will be stored in such a way that promotes adequate air circulation around food storage containers. Refrigerators/walk-ins will not be overcrowded. During the initial kitchen tour on [DATE] at 11:31 AM, an observation revealed in freezer one contained beef; individually wrapped, on the floor, undated. There were also 5 cases of turkey thighs on the floor and 2 cases of lamb on the floor. In addition, there were 3 containers of Breyer's ice-cream noted to be placed on the floor. There was a box of Crabmeat, also on the floor. There were 3 cases of She Crab, 1 box of Cobbler, 1 case of Corn on the Cob, 1 case of Crab Cakes, 1 case of wheat bread and 1 bag of Hushpuppies, undated, all noted to be stored on the freezer floor. There was also a variety of frozen vegetables scattered on the floor. During an observation of the walk-in refrigerator/dairy cooler on [DATE] at 11:45 AM, an observation was verified by the Executive Chef (EC). Findings in this area included; uncovered tossed salad and cheese with a grayish black substance, undated and wrapped in unoriginal packaging. There was also unlabeled and undated, covered shrimp. There was also an undated, opened, container of cornbread, approximately ,d+[DATE] eggs in a metal bowl undated and 4 blocks of cheese, undated with a mold like substance present. There was a package of Brioche buns, opened and unlabeled, along with a package of hotdog buns, opened and unlabelled. There was a clear container of unlabeled coleslaw and unlabeled salad. There were 13 cases of Blackberries covered in a grayish-fur-like substance and 3 cases of Strawberries with the same substance present. During an observation of the dry storage on [DATE] at approximately 12:00 PM, an observation of was verified by the EC. Findings in the dry storage included; opened and undated, [NAME] cereal and an opened and undated bag of dry noodles. There was also a bag of yellow onions, with approximately 15 onions, with a mold-like substance on the floor, with flies flying around them. There was a bag of red onions, with approximately 15 onions, with a mold-like substance on the floor with flies, flying around them, also. The dry storage also contained an opened and undated box of grits, 6 boxes of pie shells opened and undated and two cases of beef gravy on the floor. There was also multiple items stored above the red line, close to the ceiling. During an observation on [DATE] at approximately 12:05 PM, there was a tray of dessert located in the food delivery room, uncovered and clean plates ready for service with food debris present. An observation of the kitchen on [DATE] at 12:30 PM revealed the walk-in refrigerator and walk in freezer, still in the same conditions as the [DATE] observations. On [DATE] at 12:56 PM, an interview with Director of Food and Beverages (DFB) verified the cases of food stored on the floor in the dry storage, walk in refrigerator, and walk in freezer. Also, verified the molded berries in the walk-in refrigerator and red onions in the dry storage. The DFB stated that facility is in the process of getting another fridge and cooler, since feeding two facilities. The DFB stated, The facility had a receiver staff member that cleans the fridge on Sundays and receives the new shipment, however, that staff member was fired this past month due to not completing her duties. The facility is currently trying to fill the position.

Based on review of facility policy, observations, and interviews, the facility failed to ensure expired medications and biologicals were removed from 2 of 3 medication storage rooms. Findings Include: Review of the facility policy titled, Drug Storage, revealed no indication on the disposal of expired medications and biologicals. Multiple requests were made for policies regarding disposition of expired medication with no documentation provided by the facility during the survey. Observation of the Arbor Unit medication storage room on 11/14/22 at 3:16 PM revealed, three (3) [NAME] I.V. Starter Kits with an expiration date of 08/05/22. Also, one (1) of the [NAME] I.V. Starter Kits was opened and no longer sterile. Licensed Practical Nurse (LPN)1 confirmed the expired biologicals. Observation of the [MEDICATION(S)] Unit medication storage room on 11/15/22 at 8:57 AM revealed, eight (8) cartons of [MEDICATION(S)] Complete Balanced Nutritional Fiber 8 Fl ounces (oz) with an expiration date of 11/01/21. LPN2 confirmed the expired biologicals. In an interview with the Director of Nursing (DON) on 11/15/22 at 1:55 PM, she stated she was informed by her staff that the expired medical supplies and expired [MEDICATION(S)] were found in the medication storage rooms. She revealed it is her expectation for staff to dispose of expired medications in a timely manner.

Based on review of the facility policy titled, In Service Training Program, Nurse Aide, document review and interview, the facility failed to ensure all nurse aide personnel has completed the required 12 hours of training per employment year based on hire date for 11 out of 32 Certified Nursing Assistants (CNAs). Findings include: Review on 11/15/22 at 3:00 PM of the facility policy titled, In Service Training Program, Nurse Aide, revealed the policy statement which reads, All nurse aide personnel shall participate in regularly scheduled in-service training classes. The Policy Interpretation and Implementation states: 1. All personnel are require to attend regularly scheduled in service training classes. 2. The facility will complete a performance review of nurse aides at least every 12 months. In-service training will be based on the outcome of annual performance reviews, addressing weakness identified in the reviews. 3. Annual in service must: a. Be no less than 12 hours per employment year; b. Address the special needs of the residents, as determined by the facility staff; c. Include training in dementia management and abuse prevention. 6. All training classes attended by the employee shall be entered on the respective employee's Employee Training Attendance Record by the department supervisor or other persons as designated by the supervisor. 7. Records shall be filed in the employee's personnel file or shall be maintained by the department supervisor. Review on 11/15/22 at 2:10 PM of the required 12 hours of in services and training for each employed CNA revealed that 11 out of 32 did not have documentation to ensure they had received the training per employment year based on their hire date. During an interview on 11/15/22 at 2:35 PM with the Director of Nursing (DON) confirmed the findings after acknowledging understanding and proceeded to find further documentation of the required 12 hours of in services for all CNAs. The DON was unable to provide the documention to ensure the training for the 12 hours for each CNA.

Based on observation, interviews, and Centers for Disease Control (CDC) publication, it was determined the facility failed to ensure their employees were fit tested for the use of N95 respirator masks. Five staff were observed wearing an N95 mask. The facility had a total of 118 employees that were not fit tested . This deficient practice occurred during the COVID-19 pandemic. Findings included: Reference: CDC publication, titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, last updated 12/14/2020, indicated, Respirator use must be in the context of a complete respiratory protection program in accordance with OSHA Respiratory Protection standard (29 CFR 1910.134). HCP (healthcare personel) should be medically cleared and fit tested if using respirators with tight-fitting facepieces (e.g., a NIOSH-approved N95 respirator) and trained in the proper use of respirators, safe removal and disposal, and medical contraindications to respirator use. To work properly, FFRs (Filtering Facepiece Respirators) must be worn throughout the period of exposure and be specially fitted for each person who wears one. This is called fit testing and is usually done in a workplace where respirators are used. The Occupational Health and Safety Health Administration has published requirements to use N95 respirators. Respirators must be test fitted after the employee has an approved medical screening (https://www.osha.gov/coronavirus/control-prevention). On 01/08/2021 at 9:21 AM, an interview was completed with Registered Nurse (RN) #1. RN #1 was noted to be wearing a N95 respirator. RN #1 stated that there had not been any fit testing for N95 masks. On 01/08/2021 at 10:02 AM, an interview was completed with the Rehabilitation Director (Rehab Dir). Rehab Dir was observed to be wearing a N95 respirator. Rehab Dir. stated that the facility provides personal protective equipment (PPE) for therapy staff, but that no fit testing for N95 respirators had been provided. During the survey on 01/08/2021, the Activity Aide (AA) and Licensed Practical Nurse (LPN) #2 were observed wearing N95 respirators. On 01/08/2021 at 1:50 PM, an interview was completed with the Administrator (Admin). The Admin was observed wearing a N95 respirator. The Admin stated that the facility started using N95 respirators in the last couple weeks at the suggestion of an infection control source with the Department of Health and Environmental Control (DHEC). The Admin also said that fit testing was mentioned and that the plan was to look into fit testing after the holidays (Christmas).

Based on record review and interview the facility failed to ensure the Minimum Data Set (MDS) assessments were encoded and transmitted to CMS (Centers for Medicare and Medicaid Services) according to State and Federal time frames for five (5) of 18 sampled residents (Resident #2, Resident #82, Resident #132, Resident #133, and Resident #182). This deficient practice placed the residents at risk for having incomplete care plans and inadequate care and services resulting in physical and psychosocial decline. Findings include: Record review of the CASPER report for the facility's MDS 3.0 Missing OBRA Assessment report dated 1/9/2020 reflected that the facility had not submitted assessment information into the Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System as required for the following residents. 1. Record review of Resident #2's face sheet revealed that Resident #2 was admitted to the facility on [DATE]. Review of the CASPER report for the facility's MDS 3.0 Missing OBRA Assessment report dated 1/9/2020 reflected a Last Record Identifiers date of 7/28/19 for Resident #2, meaning that the last assessment received by CMS was on that date, and that current data was missing. Resident #2's Admission MDS dated [DATE] and Quarterly MDS dated [DATE] had not been transmitted to CMS. 2. Record review of Resident #82's face sheet dated reflected Resident #82 was admitted to the facility on [DATE]. Record review of the CASPER report for the facility's MDS 3.0 Missing OBRA Assessment report dated 1/9/2020 reflected a Last Record Identifiers date of 6/20/19 for Resident #82, meaning that the last assessment received by CMS was on that date, and that current data was missing. Resident #82's Quarterly MDS dated [DATE] and Quarterly MDS dated [DATE] had not been transmitted to CMS. 3. Record review of Resident #132's face sheet dated reflected the resident was admitted to the facility on [DATE]. Review of the CASPER report for the facility's MDS 3.0 Missing OBRA Assessment report dated 1/9/2020 reflected a Last Record Identifiers date of 11/7/19 for Resident #132, meaning that the last assessment received by CMS was on that date, and that current data was missing. Resident #132's Admission MDS dated [DATE] and end of Medicare MDS dated [DATE] had not been transmitted to CMS. 4. Record review of Resident #133's face sheet dated reflected the resident was admitted to the facility on [DATE]. Review of the CASPER report for the facility's MDS 3.0 Missing OBRA Assessment report dated 1/9/2020 reflected a Last Record Identifiers date of 4/25/19 for Resident #133, meaning that the last assessment received by CMS was on that date, and that current data was missing. Resident #133's MDS dated [DATE] and MDS dated [DATE] and MDS dated [DATE] MDS had not been transmitted to CMS. 5. Record review of Resident #182's face sheet reflected the resident was admitted to the facility on [DATE]. Review of the CASPER report for the facility's MDS 3.0 Missing OBRA Assessment report dated 1/9/2020 reflected a Last Record Identifiers date of 4/25/19 for Resident #182, meaning that the last assessment received by CMS was on that date, and that current data was missing. Resident #182's MDS dated [DATE] and Quarterly MDS dated [DATE] had not been transmitted to CMS. During an interview on 1/16/2020 at 3:40 PM Interim Administrator/Previous Director of Nursing said that it was her expectation that assessments be transmitted in a timely manner per regulatory standards. She stated that the facility was aware of their failure to meet these requirements, and that the facility had had a Quality Assurance/Process Improvement (QAPI) project in place previously but that they had thought that the problem was resolved. She stated that they had added personnel to assist with the task. She stated that they had recently recognized that the problem had not been resolved and had put another QAPI project in place to address the issue.

Based on record review, and interview, the facility failed to complete Quarterly Minimum Data Set (MDS) assessments for one (1) of 18 sample residents (Resident #82). Findings include: Review of Resident #82's record indicated the resident's original admitted was 12/22/15. The resident's [DIAGNOSES REDACTED]. According to the resident's Significant Change MDS assessment dated [DATE] (most current complete full MDS assessment), Resident #82 was intact in cognition, having scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Under the Mood Section, the resident was noted with tiredness/having little energy. She had no behavioral indicators. The resident required assistance with activities of daily living (ADLs). The MDS indicated the resident required extensive assistance from staff for transfers, dressing, and toilet use. Review of the clinical record revealed the last two (2) Quarterly MDS assessments with Assessment Reference Dates (ARD) of 9/12/19 and 12/5/19 were incomplete. The 9/12/19 and 12/5/19 Quarterly MDS sections were blank (no data entered) for the following sections: C - Cognitive Patterns and D - Mood. Section Z - Assessment Administration was not signed off. The 9/28/19 and 12/5/19 Quarterly MDS were incomplete as follows: Section C - The Cognitive Patterns section was blank for the Brief Interview for Mental Status (BIMs), the Staff Interview for Mental Status, and the [MEDICAL CONDITION] Section. There was no determination of the resident's level of cognition. Section D - The Mood section was blank for the Resident Mood Interview, Staff Assessment of Resident Mood, and Total Severity Score. There was no assessment of the resident's mood. The 9/12/19 Quarterly Assessment Section Z, Assessment Administration, revealed all sections of the MDS had been completed by 1/16/2020 (as late as three (3) months after the ARD (annual review date). However, the overall assessment had not been signed off as complete by the Registered Nurse (RN) Coordinator. Although sections C and D were signed off as complete; they were incomplete with a lack of data entered. The 12/5/19 Quarterly Assessment Section Z, Assessment Administration, revealed all sections of the MDS had been completed by 1/15/19. However, the overall assessment had not been signed off as complete by the Registered Nurse (RN) Coordinator. Although sections C and D were signed off as complete; they were incomplete with a lack of data entered. During an interview on 1/16/2020 at 10:05 AM the MDS Coordinator stated the resident interview sections such as sections C and D had not been completed on Resident #82's Quarterly MDS assessments because the MDS was completed after the ARD date. She stated the Resident Assessment Instrument (RAI) manual instructed the use of dashes these sections when it was completed late. The MDS Coordinator stated the most recent complete Quarterly MDS assessment for Resident #82 was dated 6/20/19. The MDS Coordinator stated the interviews could be completed a couple days prior to the ARD, but not after the ARD. She stated the facility had a total of seven (7) - 14 days to complete the Quarterly MDS assessment. The MDS Coordinator stated the Assistant Administrator/Previous DON signed the MDS assessments for completion under Section Z because she could not sign them due to being a Licensed Practical Nurse (LPN) instead of Registered Nurse (RN). The MDS Coordinator verified neither the 9/12/19 MDS nor the 12/ 19 MDS had been signed as complete. The MDS Coordinator stated she got behind with the assessments and it snowballed. She stated there was now an RN who was helping her catch up. When asked what the facility policy was regarding completion of MDS assessments, the MDS Coordinator indicated she followed the guidance in the RAI Manual. During an interview on 1/16/2020 at 4:45 PM the Assistant Administrator/Previous Director of Nursing (DON) stated when the MDS assessments were finished, either she or another RN signed them to indicate completion under Section Z. She stated the MDS Coordinator got behind completing the MDS assessments and the facility hired an RN to help them to get caught up. She verified the facility got behind completing and submitting MDS assessments and this had been an ongoing problem. Regarding a lack of documentation of the resident interview sections, she stated dashes had to be entered instead of interview responses if the interview was not conducted by the ARD. The Assistant Administrator/Previous Director of Nursing stated the facility utilized MDS Tracker so they were aware when MDS assessments were due. She stated the facility had a plan to catch up with the assessments and was working on it. Review of the Resident Assessment Instrument (RAI) Manual, Chapter 3, C0100 - Should the Brief Interview for Mental Status Be Conducted? indicated if a resident who was interviewable was not interviewed during the look back period and prior to the ARD, no data should be entered. Dashes should be entered; the staff interview should not be completed if the resident was interviewable.

Based on observation, record review, interview and policy review, the facility failed to report an allegation of misappropriation of resident property for Resident #82 to the State Survey Agency within the required timeframe of 24 hours. This failure was found for one (1) of seven (7) facility self-reported incidents reviewed during the survey. Findings include: Review of Resident #82's record indicated the resident's original admitted was [DATE]. The resident's [DIAGNOSES REDACTED]. According to Resident #82's Significant Change Minimum Data Set (MDS) assessment dated [DATE] (most current complete full MDS assessment), Resident #82 was intact in cognition, having scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #82 required assistance with activities of daily living (ADLs). The Inventory of Personal Effects form completed on [DATE] indicated Resident #82 had a gold ring in his/her possession when s/he was admitted to the facility. Review of the Concern Grievance Form dated [DATE] and completed by the Director of Social Services revealed Resident #82's son reported the concern/grievance on [DATE]. The son indicated Resident #82's wedding ring was missing. The son and family did not know exactly when it went missing. Documentation on the Concern/Grievance Form revealed it most likely fell off Resident #82's finger without him/her realizing it. The Administrator, Director of Nursing and Housekeeping staff were notified of the missing ring on [DATE]. The family was asked for photographs of the ring. A search for the ring was conducted in Resident #82's room and bathroom, in the spa, and in the vacuum cleaner bag (went through its contents). The search did not result in finding the ring. The report indicated the plan also included checking the trap in the vacuum cleaner, checking the resident's robes, laundry washers and dryers, and his/her recliner. The ambulance transport company was contacted to search their vehicles for the ring. The resident had been evacuated from the facility due to a hurricane shortly before the ring was noticed missing. At the son's request, a report was filed with the local sheriff's office. A case number was provided and the Concern Grievance Form indicated the officer would follow up with Resident #82's son regarding the value of the ring and identifying characteristics. The initial Report to the State Survey Agency, dated [DATE] revealed that on [DATE] Resident #82's son reported that his/her mother/father had lost his/her wedding ring. Although the form indicated there was no concern of misappropriation of resident property, staff could not know for certainty that it was lost rather than stolen without having completed the investigation. The allegation was not reported to the State Survey Agency within the 24 hour reporting requirement. A Five (5)-Day Follow-Up Report was dated [DATE]. The date of reportable incident was [DATE]. The Report indicated the resident had experienced weight loss and had a [DIAGNOSES REDACTED]. The resident was documented as being alert and oriented; however, requiring extensive assistance with activities of daily living (ADLs) and transfers and having weakness and debility. Statements from 15 staff members who had worked with the resident during the estimated timeframe the ring went missing were taken. Several staff remembered seeing the ring. A nurse remembered seeing the ring upon return from the facility evacuation on [DATE]. Two (2) staff members (both Certified Nursing Assistants, CNA's) remembered the ring but had not seen it recently. Another CNA indicated that the last time she saw the ring was during the evacuation. The remainder of the witness statements indicated that these staff members had not ever seen the ring or noticed it. The resident was interviewed and stated she did not know when the ring went missing. According to the Five (5)-Day Follow-Up Report interventions in place prior to the reportable incident included the resident being offered to secure valuables such as money, jewelry, credit cards etc. The Report indicated the resident's Physician was notified. The summary report of the investigation indicated there was no suspicion of misappropriation of resident property and the belief was that the ring had fallen off due to the resident's significant weight loss. The investigation was thorough with all relevant persons being interviewed and an extensive search being conducted. On [DATE] at 9:21 AM Resident #82 was sitting in the recliner chair in her room. Her legs were elevated; she was wearing a sleeping gown and socks. She was covered with a blanket. The resident was elderly, emaciated and frail in appearance. A staff member was in the room assisting the resident to drink a thickened beverage of which she took a sip. The resident was not wearing any rings. An attempt was made to interview the resident. The resident was hard of hearing and sleepy; interview with the resident was not successful. On [DATE] at 4:01 AM Resident #82 was sitting in the recliner in her room with her legs elevated. Her eyes were closed. A blanket covered her. The resident was sleeping and an interview could not be conducted. The resident was not wearing any rings. During an interview on [DATE] at 12:14 PM the resident's son stated he filed a grievance related to the resident's missing wedding ring. He stated the ring was still missing and had not been found. He stated he reported the incident to the facility and also talked to the local police. He stated the staff thought his mother had the ring when she came back to the facility after the hurricane. He stated the resident had lost a lot of weight. He stated his mother kept a garbage can by her chair and it may have fallen off and into the garbage can. He stated the ring was not in her chair or in her bed when these areas were searched. He stated the ring was the only possession of his deceased father that his mother had and it was unfortunate it was gone. He stated it was a, very nice large ring. He stated it had a ¾ inch gold band with lots of diamonds. During an interview on [DATE] at 1:16 PM the Director of Social Services reported one of the CNAs informed her the ring was missing. She stated it was during the time of the evacuation. She stated she talked with the resident and she did not know when it went missing. She stated she called the location of the evacuation and the transportation company and the staff looked everywhere for the ring and could not find it. She stated she called the resident's son and asked what else he would like done and stated he wanted a police report filed. She stated the facility filed the police report and the police then contacted the son. She stated the facility's policy for missing items such as laundry included replacing the items. However, they could not replace a wedding ring. She stated there had been nothing else of value missing over the course of the past year within the facility. During an interview on [DATE] at 4:45 PM the Assistant Administrator/Previous Director of Nursing (DON) and Administrator stated the resident's son reported he thought the resident lost the ring, not that someone took it. They stated they did not adhere to the two (2)/24 hour reporting requirement to the State Survey Agency because they viewed it as a lost item and did not view it as a potential allegation of misappropriation of resident property. Review of the undated Abuse/Grievance /Injury of Unknown Origin policy revealed it was the policy of the facility to protect residents from mistreatment, neglect, abuse, or misappropriation of resident property. Misappropriation of resident property was defined as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of residents' belongings or money without the consent of the resident. Review of the policy indicated allegations needed to be reported to the Charge Nurse on duty, the Director of Nursing (DON), the Administrator and to the State Survey Agency within 24 hours.

Based on record review and interview, the facility failed to ensure care plans for two (2) of 18 sampled residents (Resident #2 and Resident #5) were updated when changes in condition occurred. This failure delayed a reduction in antipsychotic medication and possible lack of wound care and bleeding precautions. Findings include: 1. Record review of Resident #2's face sheet dated 1/26/2020 reflected that Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 was admitted with medications including Quetiapine (an antipsychotic) and [MEDICATION NAME] (an antidepressant). Record review of the resident's Minimum Data Set ((MDS) dated [DATE] assessed the resident as having minimal cognition impairment as indicated the Brief Interview for Mental Status (BIMS) score of 13. The resident was not documented as receiving hospice services or antipsychotic medications. Record review of Resident #2's active Care Plan dated 7/8/19-present reflected that Resident #2 was actively care planned for hospice services and care planned for monitoring of antipsychotic medication side effects. Care plan notes reflected a request for hospice consult on 8/15/19 by the family. Record review of a physician order [REDACTED]. The orders reflected a certification start date of hospice services dated 8/20/2019. The care plan was not updated/revised to reflect the physician orders [REDACTED]. During an interview on 1/15/2020 at 5:45 PM the facility Medical Doctor (MD) stated that he did not know that Resident #2 was no longer on hospice services. He stated that if he had known that he would have attempted a Gradual Dose Reduction (GDR) of Resident #2's antipsychotic if indicated. He stated that when a resident is on hospice care that he treats the resident very differently with respect to diagnostic orders because the resident is being followed by hospice, and if the resident comes off of hospice, then he would order primary care diagnostic procedures and labs to treat the resident appropriately. During an interview on 1/16/2020 at 10:00 AM Registered Nurse (RN) #1 stated that she knew that Resident #2 was no longer on hospice services and had seen that he was still care planned for hospice services. She said that care plan should have been discontinued. She also stated that it was her expectation that the care plans be changed in a reasonable amount of time. When advised that the physician was not aware of the Resident #2's hospice status and that the information had impacted his treatment she said that this was significant. 2. Resident #5 was admitted to the facility on [DATE] following hospitalization for a [MEDICAL CONDITION] Femur. Additional [DIAGNOSES REDACTED]. The resident was hospitalized from [DATE] - 11/12/19; she was readmitted to the facility on [DATE]. Review of the Summary of Hospital Stay dated 11/12/19 revealed the resident was hospitalized with a right lower extremity hematoma, was on chronic anticoagulation for stroke prevention with chronic [MEDICAL CONDITION], and status [REDACTED]. Review of the operative report dated 11/10/19 revealed the procedure performed was incision and drainage of right hip hematoma with placement of negative pressure dressing. The hematoma was evacuated manually; the total depth and volume of the wound was six (6) cm (centimeters) in length by six (6) cm in depth by five (5) cm in width. Review of the hospital Order Requisition dated 11/11/19 revealed the resident's [DIAGNOSES REDACTED]. The resident was discharged with a wound VAC in place and dressing changes every Monday, Wednesday and Friday to the right hip. Review of the Admission Minimum Data Set assessment 11/19/19 revealed the resident was unimpaired in cognition with a Brief Interview for Mental Status (BIMS) score of 15. The resident required limited assistance of one (1) staff for most activities of daily living (ADLs). The resident was administered an anticoagulant medication and received this medication all seven (7) days in the assessment period. Review of the physician's orders [REDACTED]. Review of the care plan dated 11/13/19 - 1/16/20 did not address the resident's [DIAGNOSES REDACTED]. During an interview on 1/16/2020 at 4:30 PM the Assistant Administrator/Previous Director of Nursing (DON) stated the resident's [DIAGNOSES REDACTED]. She stated it was her expectation these issues would be care planned and it was important to make sure the important clinical issues were addressed.

Based on observation, interview and review of the facility policy titled, Perishables Storage, the facility failed to label with a date a food was opened and partially used prior to storing it in the walk up cooler in 1 of 1 walk up coolers observed. The findings included: An observation on 10/15/2018 at approximately 10:00 AM of the foods inside a walk up cooler revealed 2 packages of rolls that has been opened and not dated with opened date. Further observation on 10/15/2018 at approximately 10:00 AM of the foods inside the walk up cooler revealed 1 plastic container used for food storage with cut up fruit and not dated and sweet potato fries partially used with no opened date. An additional observation on 10/15/2018 at approximately 10:05 AM of the same walk up cooler revealed trash and debris on the bottom shelf of the cooler. An interview on 10/15/2018 at approximately 10:02 AM with the Chef confirmed the findings and he/she asked staff to apply an open date to the foods. The Chef went on to say at this time that staff had not cleaned the trash and debris from the bottom shelf of the walk up cooler as they should have. Review on 10/16/2018 at approximately 2:40 PM of the facility policy titled, Perishables Storage, states under Purpose: To ensure compliance with DHEC, maintain nutrient content, maintain aesthetic quality, and ensure food safety of all perishable food items through proper storage and labeling. Number 1 states, All perishables will be labeled with item name and date of preparation and will be used or discarded within 7 days. Date is prep date plus 6 days or less.

Based on record reviews and interview, the facility failed to ensure the CNA (Certified Nursing Assistant) most involved with the care for Resident #5, #11, #182, #26, #27, #15, #13 and Resident #332 had input into the care planning process for 8 of 16 residents reviewed for care plan participation. The findings included: The facility admitted Resident #182 with [DIAGNOSES REDACTED]. Review on 10/16/2018 at approximately 2:18 PM of the Plan of Care revealed an Interdisciplinary Care Plan Conference sheet dated (MONTH) 23, (YEAR) and (MONTH) 6, (YEAR) for Resident #182. No documentation could be found to ensure the CNA most involved with the care for Resident #182 had input into the care planning process. The facility admitted Resident #26 with [DIAGNOSES REDACTED]. Review on 10/16/2018 at approximately 2:30 PM of the Plan of Care revealed an Interdisciplinary Care Plan Conference sheet dated (MONTH) 7, (YEAR) and (MONTH) 23, (YEAR) for Resident #26. No documentation could be found to ensure the CNA most involved with the care for Resident #26 had input into the care planning process. The facility admitted Resident #11 with [DIAGNOSES REDACTED]. Review on 10/16/2018 at approximately 5:27 PM of the Plan of Care for Resident #11 revealed an Interdisciplinary Care Plan Conference sheet dated 7/19/2018. No documentation could be found to ensure the CNA most involved with the care for Resident #11 had input into the care planning process. The facility admitted Resident #27 with [DIAGNOSES REDACTED]. Review on 10/17/2018 at approximately 12:40 AM of the Plan of Care for Resident #27 revealed an Interdisciplinary Care Plan Conference sheet dated (MONTH) 10, (YEAR) and (MONTH) 16, (YEAR). No documentation could be found to ensure the CNA most involved with the care for Resident #27 had input into the care planning process. The facility admitted Resident #13 with [DIAGNOSES REDACTED]. Review on 10/17/2018 at approximately 10:32 AM of the Plan of Care for Resident #13 revealed an Interdisciplinary Care Plan Conference sheet dated 10/4/2018. No documentation could be found to ensure the CNA most involved with the care for Resident #13 had input into the care planning process. The facility admitted Resident #332 with [DIAGNOSES REDACTED]. Review on 10/17/2018 at approximately 12:58 PM of the Plan of Care for Resident #332 revealed an Interdisciplinary Care Plan Conference sheet dated 9/27/2017. No documentation could be found to ensure the CNA most involved with the care for Resident #332 had input into the care planning process. A CNA did not attend the care plan meetings for Resident # 5. This finding was verified on 10/15/18 at approximately 5:38 PM by Licensed Practical Nurse # 1.

Based on record review and interview the facility failed to ensure each CNA (Certified Nursing Assistant) received the required 12 hours of training annually from hire date based on performance for staffing reviewed. The findings included: Review on 10/17/2018 at approximately 10:30 AM of the staffing revealed the required 12 hours of annual in service training for the CNA's based on performance and the hire date was not completed in a timely manner. During an interview on 10/17/2018 at approximately 10:30 AM with the Director of Nursing confirmed that each CNA did not receive the 12 hours of required training based on performance reviews and hire date.

Based on observation, interview and review of the facility policy titled, Dumpster Sanitation, the facility failed to ensure paper trash and debris was not accumulated on the ground around the outside of the dumpsters and further failed to ensure bagged trash was put inside the dumpsters and not outside on 1 of 1 observations of the facility's refuse disposal system. The findings included: An observation on 10/15/2018 at approximately 10:30 AM of the outside dumpsters revealed paper trash and debris accumulated on the ground around the outside of the dumpters. Further observation on 10/15/2018 at approximately 10:35 AM of the outside of the dumpster revealed bagged trash next to the dumpster and not placed inside. An interview on 10/15/2018 at approximately 10:35 AM with the CDM (Certified Dietary Manager) confirmed the findings and stated, the trash should be inside the dumpsters and not on the outside. Review on 10/15/2018 at approximately 1:40 PM of the facility policy titled, Dumpster Sanitation, states, The facility will ensure that the dumpster, compactor and surrounding areas remains in sanitary condition. The Guidelines states, 1. Garbage and refuse containers will be kept in good condition with no leaks. 2. Waste will be properly contained in dumpsters or compactors with lids or otherwise covered. 3. Garbage storage areas will be maintained in a sanitary condition to prevent the harborage and feeding of pests.

Based on record review and interviews, the facility failed to ensure residents were informed of their right to have access to names, addresses and telephone numbers of all pertinent state regulatory and informational agencies, resident advocacy groups and information on filing a complaint and or reporting alleged abuse violations. The facility further failed to ensure residents knew where the above information was located within the facility as revealed by 7 of 7 residents during 1 of 1 resident council meetings. The findings included: Interviews on 10/16/2018 at approximately 11:15 AM, during a resident council meeting, 7 of 7 residents in attendance confirmed they were not aware of their right to have access to a list of names, addresses and telephone numbers of all pertinent state regulatory and informational agencies, resident advocacy groups and information on filing a complaint and or reporting alleged abuse violations and the whereabouts of this information in the facility. Review on 10/16/2018 at approximately 2:40 PM of the Resident Council Minutes for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) made no mention of informing residents or the resident's right to have access to a list of names, addresses and telephone numbers of all pertinent state regulatory and informational agencies, resident advocacy groups and information on filing a complaint and or reporting alleged abuse violations. The Resident Council Minutes did not mention the whereabouts of such information within the facility. During an interview on 10/17/2018 at approximately 3:45 PM with the Admissions Coordinator, he/she stated, the residents are informed of their rights during the move in process, and during the resident council meetings. No documentation could be found to ensure residents were informed of their right to have access to state regulatory and informational agencies and how to file a complaint and or reporting abuse.

Based on observations, interview and review of the facility policy titled, Laundry Services, the facility failed to ensure soiled linen was bagged at point of use and then transported to the soiled utility room and placed in bins for laundry service pick up on 3 of 3 Halls. The findings included: An observation on 10/16/2018 at approximately 10:15 AM during the sorting process of soiled linen from the halls revealed a large bin from the soiled utility room with soiled linen unbagged and placed in the bin for pick up by the laundry service workers. During interviews on 10/16/2018 at approximately 10:25 AM with Laundry Worker #1 and the Housekeeping Supervisor confirmed the unbagged soiled linen and stated, The soiled linen should be in bags prior to putting it in the bins in the soiled utility room but sometimes it is not. Review on 10/16/2018 at approximately 10:50 AM of the facility policy titled, Laundry Services, states under Purpose: To ensure a clean supply of linens and to protect employees who handle and process the laundry. Under Policy: 1 B states, All soiled linen should be bagged or put into carts at the location where used; it should NOT be sorted or pre-rinsed in patient care areas. Linen that is saturated with blood or body fluids should be deposited and transported in impervious bags. All staff use standard precautions in handling linen, therefore all linen is handled in the same manner.

Based on record review, interview and review of the facility policy titled, Bed Hold Policy, the facility failed to ensure Resident #27 and/or the Personal Representative received a copy of the Bed Hold Policy and the reserve bed payment in a timely manner. The findings included: The facility admitted Resident #27 with [DIAGNOSES REDACTED]. Review on 10/17/2018 at approximately 12:18 PM of the medical record for Resident #27 revealed a transfer to the hospital on [DATE]. Further review on 10/17/2018 at approximately 12:18 PM of the medical record for Resident #27 revealed a Bed Hold Policy given to Resident #27 without the bed hold amount dated 9/6/2018. During an interview on 10/7/2018 at approximately 1:30 PM with RN (Registered Nurse) #1 confirmed the bed hold amount was not on the Bed Hold Policy form and was not conveyed to Resident #27 nor the Responsible Party.

Based on observation, record review and interview the pharmacist failed to assure that 1 of 4 residents were free of unnecessary medications. (Cross refer F758) The findings include: Record review on Resident # 7 on 10/16/18 failed to show that the physician had been notified that a PRN (as needed) psychoactive drug order for [MEDICATION NAME] 5 mg had been in existence since 9/27/17. This finding was verified on 10/17/18 at approximately 09:29 AM by Licensed Practical Nurse #1.

Based on record review and interview, the facility failed to ensure Resident #11 received form CMS- as required to address liability for payment after skilled Medicare Part A services were terminated. Resident #11 remained in the facility with Medicare days remaining for 1 of 3 residents reviewed for Beneficiary Protection Notification Review. The findings included: The facility admitted Resident #11 with [DIAGNOSES REDACTED]. Review on 10/17/2018 at approximately 1:10 PM of the Beneficiary Protection Notification Review revealed a NOMNC (Notice of Medicare Non-Coverage) CMS that states Medicare Part A services will end on 8/6/2018. Resident #11 has days remaining and is to reside in the facility. Further review on 10/17/2018 at approximately 1:10 PM of the Beneficiary Protection Notification Review indicated that a CMS- form or a denial letter was not issued for Resident #11. During an interview on 10/17/2018 at approximately 2:30 PM with LPN (Licensed Practical Nurse) #1 he/she stated he/she could not locate the CMS- form, but would keep looking for it.

Based on record review and interview, the facility failed to notify Resident #27 and the Personal Representative for Resident #27 of the transfer to the hospital in writing and in a language they could understand of the reason for the transfer and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman in a timely manner. The findings included: The facility admitted Resident #27 with [DIAGNOSES REDACTED]. Review on 10/17/2018 at approximately 12:18 PM of the medical record for Resident #27 revealed no documentation to ensure Resident #27 and the Personal Representative received the reason for the transfer to the hospital in writing and in a language they could understand and send a copy to the Office of the State Long-Term Ombudsman. An interview on 10/17/2018 at approximately 1:38 PM with RN (Registered Nurse) #1 confirmed Resident #27 and his/her personal representative did not receive in writing and in a language they could understand of the reason for transfer to the hospital and confirmed that the Ombudsman did not receive a copy in a timely manner.