Every finding on record at The Reserve Healthcare And Rehabilitation

Based on observations, record reviews, interviews, and manufacturer labeling, the facility failed to ensure that medications were properly secured and stored in 2 of 8 medication carts. Findings included: The facility policy on Storage of Medication, dated 2007, states: Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall only be accessible to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medication. On 9/24/23 at approximately 10:33 AM during initial tour of the 300/400 Hall, one medication cart and one treatment cart were found unlocked and unattended with two wandering residents nearby. On 9/24/23 at approximately 10:38 AM these findings were confirmed by Licensed Practical Nurse (LPN)1, who stated the medication cart was his and the treatment cart was for staff use on the 300/400 Hall. On 9/24/23 at approximately 10:40 AM, inspection of the unlocked medication cart for Hall 300 revealed: -two capsules containing a creamy white granular substance were in a white medicine cup in the top drawer. -one Anora Ellipta 62.5 mcg (microgram)/25 mcg Inhaler by Glaxo [NAME] opened, in use, not dated as to date of opening and labeled Safely throw away ANORA ELLIPTA in the trash 6 weeks after you open the foil tray or when the counter reads 0, whichever comes first. Write the date you open the tray on the label on the inhaler. -one Fluticasone Propionate and Salmeterol inhaler, in use, not dated as to the date of opening and labeled discard 30 days after opening or when the counter reads 0, whichever comes first. On 9/24/23 at approximately 10:46 AM, LPN1 verified these two inhalers had not been dated, were in use and was unable to identify the two capsules in the medicine cup. On 9/24/23 at approximately 10:51 AM, inspection of the Treatment Cart for the 300/400 Hall revealed; -one partially filled 250 ml (milliliter) bottle of Sterile Water for Irrigation, USP (United States Pharmacopoeia) by SteriCare dated as opened 9/10/23 by the facility with the bottle labeled by the manufacturer as Sterile and for Single Use. On 9/24/23 at approximately 10:54 AM, LPN1 verified the finding and after reading the label acknowledged the opened bottle of Sterile Water for Irrigation was for single use only and should not have been returned to the treatment cart

Based on review of facility policy, record review, and interviews, the facility failed to be administered in a manner that enabled it to use its financial resources effectively and efficiently. Specifically, the facility failed to have a system in place to ensure all financial obligations are met to guarantee care and services are provided to the residents. This failure has the potential to affect all 86 residents residing in the facility. On 04/13/23 at 1:31 PM the Administrator was notified that the failure to keep up to date with payment to vendors, utility services, and critical services provided to the residents of the facility constituted Immediate Jeopardy (IJ) at F835. The facility was unable to present an acceptable plan of removal of the immediate jeopardy. Therefore, the survey team was not able to validate that the IJ was removed. The facility remained out of compliance at F835 at a scope and severity of L (widespread immediate jeopardy to residents' health and safety). The survey team exited the facility on 04/13/23 with an ongoing IJ. On 04/13/23 at 1:31 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 04/05/23. The IJ was related to 42 CFR 483.70 - Administration. On 04/13/23 the survey team exited the facility with an ongoing IJ. The facility was not able to provide an acceptable IJ Removal Plan. Findings Include: Review of a facility policy titled, Administrative Management (Governing Board) with a revision date of October 2017 revealed, The governing board shall be responsible for the management and operation of the facility. 2. The Administrator is appointed by and accountable to the governing board. 3. The governing board is responsible for, but not limited to: a. Oversight of facility care and services in accordance with professional standards of practice and principles; g. Provision of a safe physical environment equipped and staffed to maintain the facility and services;. Review of a facility policy titled, Vendor Selection with a revision date of November 2009 revealed, All vendors have an equal opportunity to bid or quote on supplies and equipment used by the facility. 1. The selection of vendors is the responsibility of the Purchasing Agent in cooperation with department supervisors. 4. All vendors must be referred to the Purchasing Agent. Review of a spreadsheet printed through Stampli (software that keeps track of vendor invoices), provided by the Administrator on 04/12/23 at approximately 11:00 AM revealed the following outstanding balances due to vendors: Agilit-$39,395.93 Allstate Medical- $3,685.15 American Health Associates- $10,588.94 AOAK Farms- $269.20 ARJO, Inc.- $222.33 ARM Solutions, Inc.- $2,434.36 Ashpa Management- $13,505.10 ATC Healthcare- $23,051.37 Cleaning Solutions and Supplies- $400.00 Concentra- $108.00 [NAME] Dizzia LLP- $62.97 Curana Health- $469,343.00 Dynalink Communications- $304.84 [NAME]- $5,994.65 Health Technologies- $1,920.00 ImageOne- $4,482.00 Industrial Chem Labs- $102.86 Innovative Supply Group- $11,238.01 Joerrns Healthcare- $2,547.80 [NAME] Controls- $3,615.00 Leader Stat- $107.76 LimRic Plumbing- $18, 830.53 MAS Medical Staffing- $11,224.25 Merch- $20,205.37 [NAME] Factors, Inc.- $1,315.00 NetSmart- $285.12 Personal Care Ambulance- $62,706.41 Pharmaceutical Healthcare- $480.00 Pioneer Technologies- $10,821.53 [NAME]- $505.68 [NAME]-[NAME] Fire & Safety- $566.97 [NAME] Collections Services-re:Med Pass- $62.87 Rotech- $1,420.00 Sapphire Background Check- $4,693.43 SC Healthcare Association- $10,192.50 Signal Technologies- $2,420.35 Stericycle- $1,720.00 Trident USA- $13,281.75 Vecmar- $305.00 Vital Records Control- $3,769.58 Totaling $758,185.61 Review of a Notice Of Motion And Motion For Appointment Of Receiver Expedited Hearing Requested with an electronic filing date of 03/28/23 revealed, [NAME] Sc Property Holdings, LLC, And [NAME] Sc Property Holdings, LLC, Plaintiffs, vs. [NAME] Op LLC, [NAME] Op LLC [NAME] Capital Management LLC, Sc Two Op Holdings LLC, And [Owner], Defendants noted: A. Defendants Are In Breach of Contract and Are Insolvent. 1. Plaintiffs are the owners of the real property located at 1137 [NAME] Boulevard, [NAME], South Carolina 29407 and 1800 Eagle Landing Boulevard, [NAME], South Carolina 29410, the legal descriptions of which appear in Exhibit A and B attached to the Verified Complaint and incorporated herein (collectively, the Properties). The Lessees lease these Properties from Plaintiffs and manage two skilled nursing facilities thereon known as Viviant Healthcare of [NAME] (the [NAME] Facility) and Viviant Healthcare of [NAME] (the [NAME] Facility, collectively, the Facilities). (Ex. A, [NAME] Aff., 4.) 3. Starting in October 2022, Defendants began failing to make timely payments of Rent under the Lease and have continued to fail to make timely Rent payments in November 2022, December 2022, January 2023, February 2023, and March 2023. The total amount that is currently past due and owing under the Lease is a sum of at least $2,250,436.13. 14. At least 3 staffing agencies have sued the Lessees in [NAME] County and [NAME] County for breach of contract and failure to pay the agencies, which raises very serious concerns and doubts as to whether the Facilities are adequately staffed to provide proper care for the residents. The following is a listing of the lawsuits filed by the staffing agencies, 1. [NAME] Medical Staffing, LLP v. [NAME] OP, LLC d/b/a Viviant Healthcare of [NAME], [NAME] County, Case # 2023-CP-08- 0067, filed Summons & Complaint on 3/1/2023. 2. [NAME] Medical Staffing, LLP v. [NAME] OP, LLC d/b/a Viviant Healthcare of [NAME], [NAME] County, Case # 2023-CP-10- 01057, filed Summons & Complaint 3/2/2023. 3. A&G Healthcare Staffing Agency, LLC v. [NAME] OP LLC d/b/a Viviant Healthcare of [NAME], [NAME] County, Case # 2022- CP-08-02853, filed Summons & Complaint on 11/22/2022. 4. Prime Staffing, LLC v. [NAME] OP LLC d/b/a Viviant Healthcare of [NAME] f/k/a West [NAME] Rehabilitation and Nursing Center-[NAME], SC, LLC, [NAME] County, Case # 2022-CP-10-02774, filed Summons and Complaint 6/21/2022. 24. Therefore, not only do Lessees lack the money to pay Plaintiffs, Lessees also lack money to pay vendors providing medical supplies and services to the residents at the Facilities, which is a particularly dangerous situation. 26. As such, Defendants 'insolvency puts the residents at the Facilities in serious risk. Review of an Order Appointing Receiver with an electronic filing date of 04/14/23 revealed, [NAME] Sc Property Holdings, LLC, And [NAME] Sc Property Holdings, LLC, Plaintiffs, Vs. [NAME] Op LLC, [NAME] Op LLC, [NAME] Capital Management LLC, Sc Two Op Holdings LLC, And [Owner], Defendants. Based on the record in this case, the Court finds and concludes: 2. Under South Carolina's Receivership Act, the Court has the statutory power to order the appointment of a receiver to protect a party's business and property interests in commercial real property and personal property related to or used to operate the business. 4. Plaintiffs have met their burden to appoint a receiver for the Lessees, the Facilities, and the Personal Property, which includes the assets and Operations described in the Motion. 6. Good cause exists for issuing this Order, appointing a receiver over the Lessees, the Facilities, and the Personal Property and Operations. Defendants have failed to meet their obligations under the Lease, and Plaintiffs are entitled to enforce their rights and remedies, including, without limitation, the right to have a receiver appointed. A receiver is necessary to protect both the residents of the Facilities and the rights of Plaintiffs because the Facilities and the Personal Property are being subjected to or are in danger of impairment, waste, loss, substantial diminution in value, misappropriation, and dissipation, and a further delay would cause an injustice to the Plaintiffs and the residents. Moreover, the Lessees appear to be insolvent or in imminent danger of insolvency. Based upon the foregoing, it is hereby, ORDERED AND ADJUDGED: 1. The Motion is GRANTED. 2. Appointment. [Receiver] is qualified to act as Receiver in this action and is appointed Receiver over the Lessees, the Facilities and the Personal Property and Operations. The appointment of the Receiver is effective as of April 17, 2023 and continues until further order of this Court. As previously ordered by the Court on April 6, and pending the April 17, 2023 Effective Date for the appointment of the Receiver, the parties shall not dispose of any property or do anything adverse with any property, real, financial, or otherwise, except such actions as would occur during the normal course and scope of business. The Receiver shall schedule weekly meetings with Plaintiffs to provide information on the status of the receivership. 3. Powers of Receiver. As of the Effective Date, and ending upon termination of such appointment by further Order of the Court, Receiver is authorized to take possession, custody and control of the Facilities and Lessees' business operations, assets, and property, of whatever nature, including, without limitation, the Personal Property (collectively, the Personal Property and Operations), and is authorized, but not required, to perform all services and take all actions necessary or advisable to oversee, carry on, manage, care for, maintain, repair, insure, protect, and preserve the Personal Property and Operations, without further order of the Court, including, but not limited to, the following: a. To take immediate possession of, custody of, and control over the Facilities and all of the Personal Property and Operations and all other property and assets of Lessees. For the avoidance of doubt, the Personal Property and Operations shall include all business operations and all personal property of any kind owned by the Lessees used in connection with the Facilities, including all intellectual property, fixtures, equipment, inventory, books and records, bank accounts, keys, combinations for locks, passwords or other access to information, and intangibles. d. To direct Defendants and their officers, agents, employees or other representatives immediately to turn over and deliver or cause to be delivered to the Receiver or his designee all personalty which is owned by the Defendants and relates in any manner to the Facilities or the Personal Property and Operations including, without limitation, all keys, combinations for looks, passwords or other access codes, books, records, accounts, operating statements, reserve accounts and the like pertaining to the Personal Property and Operations. e. To negotiate all bills, drafts, loan documents (with Plaintiff or others), notes or other instruments in the name of the Lessees. g. To retain and pay professionals to advise and assist Receiver with the Facilities and the management and administration of the Personal Property and Operations . h. To collect and receive all earnings, rents, issues, income, profits, and other revenues of the Facilities and Lessees' Personal Property and Operations now due and unpaid or that may be earned after entry of this Order. i. To (a) continue to maintain and utilize Lessees' deposit accounts, which shall be used exclusively for deposits and disbursements of the Revenues and (b) direct payors to deposit funds due and owing to Defendants in the bank accounts related to the Facilities. Receiver shall be expressly authorized to operate the Facilities as a single business enterprise, including commingling the revenues generated from both Facilities and to use such revenues to pay the liabilities incurred by both Facilities during the course of the Receivership. m. To maintain existing or open new accounts with, or negotiate, compromise or otherwise resolve Lessees' existing obligations to utility companies or other service providers or suppliers of goods and services to Lessees or to otherwise enter into such agreements, contracts or understandings with such utility companies or other service providers or suppliers as are necessary to maintain, preserve and protect the Personal Property and Operations. During an interview with the Ombudsman on 04/12/23 at 10:45 AM revealed, This has been going on since last year. We've been aware and it's been reported. We knew there was a lot of debt, but we didn't know how much it was. The Ombudsman further stated, A lot of the facilities in the [NAME] region are close to capacity. During a virtual meeting with the Viviant Leadership team which included Chief Executive Office (CEO), Nurse Consultant (NC), Administrator of Viviant of [NAME], and the Administrator of Heartland of West [NAME], on 04/12/23 at 1:00 PM revealed, It is a Jewish holiday, holy week, and we have no corporate staff or management to provide the information requested. All the previous invoices have been paid except for the transportation company. There were some invoices that needed to be approved and submitted this last Sunday. I sent approval but there is no one that I can call to get this information facilitated. We are current on payroll, there is no invoice for agency staff, we don't use agency staff. There are no services that are currently shut off. Since there are no documents to review, you can see the supplies that we have on hand. A PCC representative is working on facility access to the system (PCC). I received an email stating PCC was down. I will provide the survey team with the contact information for the technician helping us get PCC back up. Not all the invoices have been paid. The electric bill is current. I don't have access to provide the information showing the electricity bills have been paid. I don't have the ability to see anything, invoices. The accounts that I said were paid was only transportation. I didn't find out about the transportation until yesterday. We have payment agreements with other vendors who are pass due, but I don't have documentation to show we have payment plans set up with them. My intention to the past due vendors is to reimburse them, decisions to move on to new vendors is done by our quality team and at the facility level. We never dropped a new vendor because of an outstanding balance. Switching of vendors was before my time. The utility company is not going to provide us with a letter saying the services are not going to be cut off. During an interview with the Administrator on 04/13/23 at 4:30 PM, he stated he was unaware of the full financial status of the facility due to the failure of upper management to provide documentation and full transparency. He stated he did not have access to the billing from Electric Company #1, nor was he aware of the payment status. The Administrator stated since he arrived at the facility, almost a month ago, he had made high efforts to change the culture and outlook of the facility, but he does not have full corporate support when it comes to finances. During a follow-up virtual call with the CEO, Administrators, Company representatives and State Agency Representatives on 04/13/23 at 10:15 AM, the CEO stated if there were a threat to services being disconnected while the quality office was closed, he would pay the bills out of his pocket. During a telephone interview with Sewer Company #1, provider of the facility's sewer services, the representative indicated the facility had a past due balance of $3,893.74 and a current bill due of $3,963.83 additional. She indicated that autopay draft services had not been initiated. During a telephone interview with Water Company #1 on 04/13/23 at 2:15 PM, the automated teller line indicated the facility had a past due balance of $5,711.90 and a payment of $3,638.60 must be made by 05/02/23 to avoid an interruption in services. A phone interview with the Medical Director (MD) on 04/13/23 at 2:35 PM revealed, the MD was unaware of the financial status of the facility. The MD stated she felt like her orders were being followed regarding residents being transported for appointments. The MD concluded, I work for SC House Calls which Viviant has contracted with, and SC House Calls pays me. A returned phone call after the exit of the survey on 04/19/23 at 10:04 AM from a representative from Transport Company #1 indicated the facility was past due $64,618.95.

Based on review of facility policy, record review, and interviews, the facility failed to have an effective governing body in place to ensure proper management and operation of the facility's financial resources. Specifically, the facility's governing body failed to have a system in place to ensure all financial obligations were met to guarantee care and services are provided to the residents. This failure had the potential to affect all 86 residents residing in the facility. On April 13, 2023, at 1:31 PM, the Administrator was provided with an Immediate Jeopardy (IJ) Template indicating IJ existed at F837 with a scope and severity level of L. The facility was unable to present an acceptable plan of removal of the immediate jeopardy. Therefore, the survey team was not able to validate that the IJ was removed. The facility remained out of compliance at F837 at a scope and severity of L (widespread immediate jeopardy to residents' health and safety). The survey team exited the facility on 04/13/23 with an ongoing IJ. On 04/13/23 the survey team exited the facility with an ongoing IJ. The facility was not able to provide an acceptable IJ Removal Plan. Findings include: Review of a facility policy titled, Administrative Management (Governing Board) with a revision date of October 2017 revealed, The governing board shall be responsible for the management and operation of the facility. 1.The facility's governing board is the supreme authority and has all legal authority and responsibility for the management and operation of our facility. 2. The Administrator is appointed by and accountable to the governing board. 3. The governing board is responsible for, but not limited to: a. Oversight of facility care and services in accordance with professional standards of practice and principles; b. Delineation of the powers and duties of the officers and committees of the governing board; d. Establishment and ongoing review of all administrative programs governing facility management and operations, including: (1) Corporate Compliance Program; (3) Quality Assurance and Performance Improvement program; g. Provision of a safe physical environment equipped and staffed to maintain the facility and services; j. Establishment of a system whereby the Administrator reports to the governing body . 5. The Governing Board, with the assistance of the Administrator and legal/medical consultants, have developed bylaws/medical practices that outline specific responsibilities, privileges and authority assigned to designated individuals. 7. Copies of the Articles of Incorporation, bylaws, agreements and other legal documents pertaining to the ownership and operation of the facility are on file in the administrative office, and a copy of such information has been provided to appropriate federal and state agencies. During a virtual meeting on 04/12/23 at 1:00 PM, the Chief Executive Officer (CEO) stated, this is a Jewish holiday, so we have no staff or management available to provide information requested related to financials. All the previous invoices have been paid except for the transportation company. There were some invoices that needed to be approved and submitted this last Sunday, so I sent them for approval but there is no one that I can call to get this information facilitated. We are current with payroll, there is no invoices for agency staff, we don't use agency staff. There are no services that are currently pending shut off that I am aware of. Since there are no documents to review, you can see the supplies that we have on hand. Not all the invoices have been paid. The electric bill is current; however, I don't have access to provide the information showing the electricity bills have been paid. I don't have the ability to see anything related to invoices. The accounts that I said were paid was only transportation. I didn't find out about the transportation until yesterday. The quality staff was available on Sunday, Monday, and Tuesday of this week. We have payment agreements with other vendors who are past due, but I don't have documentation to show we have payment plans with them. My intention to past due vendors is to reimburse them. Decisions to move on to new vendors is done by our Quality team in the Corporate Office and at the facility level. We never dropped a new vendor because of an outstanding balance. Switching of vendors was before my time. The utility company is not going to provide us with a letter saying the services are not going to be cut off. During a follow up call with the Administrators, CEO, and other corporate officials on 04/13/23 at 9:46 AM, the CEO stated there is no system in place if cash is needed or anyone in charge of operations with the Corporate Office being closed due to observation of holidays. He stated the facility has a debit card and petty cash that can be used but does not have access to large amounts of cash present to settle bills. During an interview with the Administrator on 04/13/23 at 11:15 AM, he stated he did not have access to large amounts of cash, the facility's billing and invoices and that upper management had not educated him on what systems to use, or given him access to systems within the facility to monitor its financial status. A phone interview with the Medical Director (MD) on 04/13/23 at 2:35 PM revealed, the MD was unaware of the financial status of the facility. The MD stated she felt like her orders were being followed regarding residents being transported for appointments. The MD concluded, I work for SC House Calls which Viviant has contracted with, and SC House Calls pays me.

Based on random observations and interviews, the facility failed to assure that Resident (R)3 was not improperly exposed during investigation occurring with 1 of 4 complaint investigations involving R2. Cross refer F 921. Findings include: R3 was admitted to the facility on [DATE] with diagnoses including, but not limited to; retention of urine, benign prostatic hypertrophy and cerebral infarct. R 2 has a BIMS (Brief Interview for Mental Status) score of 15 with 13-15 meaning intact cognitive response. Observation from the hallway on 4/13/23 at approximately 10:46 AM, showed the door to R2's room open with R3 lying in the bed next to the door, partially uncovered with an incontinent undergarment and pubic hair exposed and three urinals containing a yellow substance hanging from a trash can, which was facing the open doorway. In addition, R3's bed was angled away from the wall, with his wheelchair at the base of bed and the bedside table beside the bed were partially blocking access and egress to R2, near the window. During an interview on 04/13/23 at approximately 10:51 AM, R3 who has a BIMS of 14 stated that he prefers to leave his wheelchair at the foot of his bed along with his night stand and a trash can from which he hangs his urinals. During an interview on 04/13/23 at approximately 11:00 AM, Certified Nursing Assistant (CNA)2 stated that the three urinals hanging from R3's trash can contained a yellow substance and were visible through the open door to the hallway. She confirmed that R3 was lying in bed, uncovered with exposed incontinent brief and pubic hair and that the room was congested with R 3 's wheelchair and belongings blocking R 2 from moving his high-rise electric wheelchair from area near his bed to the door. C.N.A. 2 further stated that she frequently has to move R 3's wheelchair and belongings in order to maneuver a Hoyer lift (mechanical lift) to R 2's bed so that he can be lifted into his wheelchair and that R 3 has been repeatedly asked not to block the way with his wheelchair and to not placed urinals so they can been seen from the hallway.

Based on random observations, record reviews, interviews and policy review, the facility failed to follow their policies and procedures and did not assure that Resident (R)2 could maneuver safely throughout his room for 1 of 4 complaint investigations involving R2. Cross refer F 550. Findings include: Review of the facility's policy revised March 2018 titled, Activities of Daily Living (ADLs), Supporting showed Residents will ((sic) (as written)) provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). and Appropriate care and services will be provided for residents who are unable to carry out ADLs independently .including support and assistance with .Mobility (transfer and ambulation ) R2 was admitted to the facility on [DATE] with diagnoses including but not limited to cerebral infarct, paraplegia and polyneuropathy. Review of an unspecified Mininum Data Set (MDS) revealed R2 has a BIMS (Brief Interview for Mental Status) score of 15, indicating he is cognitively intact. During an interview on 04/13/23 at approximately 10:46 AM, R2 stated that once lifted from his bed into his high-rise electric wheel chair, that he frequently cannot get from his end of the room to the door, so he can be out and about because his roommate's (R3)wheelchair and other stuff blocks him from getting out of the room, until someone can come and moves things. During an interview on 04/13/23 at approximately 11:00 AM, Certified Nursing Assistant (CNA)2 stated that the room is congested with R3's wheelchair and belongings blocking R2 from moving his high-rise electric wheelchair from the area near his bed to the door. CNA2 further stated she has to move R3's wheelchair and belongings in order to maneuver a Hoyer lift (mechanical lift) to R2's bed so that he can be lifted into his wheelchair and that R3 has been asked repeatedly not to block the way with his wheelchair.

Based on review of the facility policy and interviews, the facility failed to employ a qualified dietician or other clinically qualified nutrition professional either full-time, part-time or on a consultation basis. Findings include: Review of the facility policy titled, Food and Nutrition Services revealed, Policy Interpretation and Implementation: 1) The multidisciplinary staff including nursing staff, the attending physician, and the facility dietician will assess each resident's nutritional needs, food likes, dislikes, and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake information. On 03/07/2023 at 12:45 PM, interview with the CDM (Certified Dietary Manager) revealed that the facility Registered Dietician quit the facility a few weeks ago and as a result, the CDM had to fulfill the role until the facility finds a replacement. The CDM confirmed he is not a dietician. On 03/07/2023 at 3:51 PM in the conference room, the DON (Director Of Nursing) confirmed that the facility currently has no registered dietician.

Based on a 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, and 3) Dry Storage area was free of pests. Findings include: Review of the 2017 facility policy and procedure titled, Food and Nutrition Services states: Policy Statement- Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation states 1. Food services, or other designated staff, will maintain clean food storage at all times. 5. Non-refrigerated foods, disposable dishware, and napkins will be stored in a designated dry storage unit which is temperature and humidity controlled, free of insects and rodents, and kept clean. 7. Dry foods stored in bins will be removed from their original packaging, labeled, and dated (use by date). Such foods will be rotated using a first in First out system. During the initial kitchen tour on [DATE] at 11:00 AM, an observation revealed throughout the kitchen floor, large brown stains were observed, and the floor appeared uncleaned. The hand washing sink located in the entry of the kitchen did not work correctly and appeared soiled. There was no availability of hairnets and no paper towels available for hand drying. During the initial kitchen tour on [DATE] at 11:15 AM, an observation of the facility's dry storage area revealed, 28 ounces (oz.) of Quaker Creamy Wheat with no open date or expiration date noted on the box, a 5-pound Muffin Mix opened on the shelf with no open date or expiration date observed, 32 oz/ 2-pound bag of Pioneer White Sugar on shelf opened with no open or expiration date, and 32 oz. of Iodized Salt, left open with no open date or expiration date. During the initial kitchen tour on [DATE], an observation revealed in the dry storage area contained a massive number of flies. Follow-up observation of the kitchen on [DATE] at 09:46 AM revealed the kitchen floors, dry storage area, and flies remained in the same conditions. On [DATE] at 12:45 PM, an interview with the CDM (Certified Dietary Manager) revealed he has been employed with the facility since October of 2022. CDM stated that the previous kitchen manager was not consistent with duties that were assigned such as menus, cleaning, and ordering, and since he's been with the facility, he has been making schedules with designated duties for each staff member in the kitchen. The CDM stated that it's everyone's job to make sure that food that gets opened receives a sticker with an open and end by date on it. On [DATE] at 09:36 AM, the CDM stated that Pest Control came out last week, sprayed the dry storage area, behind equipment such as stoves, etc. The CDM stated that the pest control company told him that they would have to come and fog the whole kitchen after hours once they receive payment, however there were concerns that the pest control bill was not paid, delaying services.

Based on review of facility policy, record review and interviews, the facility failed take action and make decisions to ensure vendors, contractors, and services were paid in full. Specifically, the facility had muliple outstanding balances due to services provided to the facility, which directly affected all residents residing in the facility. Findings Include: Review of the facility policy titled, Facility Responsibilities with a revision date of October 2022 revealed, It is the policy of this facility to uphold and comply with the facility responsibilities. The facility will ensure that staff members are educated on the rights of the residents and the responsibilities of a facility to properly care for its residents. Review of the undated facility policy titled, AP Escalation Process revealed, 4. Communicating with Administrators and AP Specialist at the facility level regarding Bill Pay Updates when said updates are received. 5. All regular AP functions need to be completed at the Facility Level as far as uploading invoices into the AP System. a. Administrators still need to be approving the invoices. On 03/06/23 the State Survey Agency (SSA) received a complaint alleging the facility failed to pay their water and sewage bill and services will be disconnected. An interveiw with the Administrator on 03/06/23 at 11:11 AM revealed, We paid the past due amount. Any past due balance was paid on Friday (03/03/23), for the water and sewer. The payment is still pending. I don't know how they paid it, it could have been a bank transfer or credit card. On Friday (03/03/23) I reached out to the Finance Department for [NAME] County Sewage (company that provides sewage services to the facility), but she was not in the office. I was trying to verify the payment was received. I also called her this morning and left a voicemail. I am not sure if the payment has posted. I don't know the user name and password to see if the payment has posted. I was aware the bill was past due since the facility was in Change of Ownership (CHOW) around June of 2021. This has been ongoing for months after the CHOW. The Administrator further stated, I don't receive a statement or bill, it all goes straight to corporate's system. I believe it is all electronic. I have asked vendors that submit invoices to send it to me also. There hasn't been much communication between the vendors and corporate. The Administrator concluded, This facility was chosen as the Special Focus Facility (SPFF) for a reason. This facility has a lot of things going on. I keep sending my concerns to the Cheif Executive Officer (CEO). The corporate level doesn't understand the risk involved to the residents. The CEO started back in January 2023, and he used to visit frequently. But now that they have added Tennessee to the portfolio, I've only seen him maybe twice since January 2023. I was forwarding him emails about the invoice situation and that's when he hired some to do Accounts Payable (AP) to help to sequence the payment system. An interview with the Business Office Manager (BOM) on 03/06/23 at 1:21 PM revealed, I do accounts receivable. I take in the money. I don't pay out any bills. I got a call from Dominion Energy (provides electicity services to the facility), I don't recall what date, but it was about a past due bill. She (Representaive from Dominion Energy) told me the past due balance was about $19,000.00. She didn't say they were going to terminate it, but she wanted payment. I believe a gentleman showed up here from Dominion Energy about a couple months ago. I am aware the water and sewage bills are overdue. All the bills are overdue. I've seen a pharmacy bill that was past due last month. This all started when the new company took over. We do receive statements for certain utility bills here. I know we get the sewage bill here. I am not sure if the water bill comes here. The Medical Records Clerk (MRC) usually receives all the bills by mail. She scans them in and sends them to the Administrator and Corporate. An interview with the MRC on 03/06/23 at 1:42 PM revealed, I email invoices to the Administrator and Corporate. Whenever something appears in the AP box I send it up to corporate. I open the mail, I scan it, and I send it to the Administrator and to Corporate. I never received a sewage bill or light bill. I can't remember what the bills were, but I got a lot. I've seen a lot of bills that come in say overdue or past due. But I can't remember where they came from, I was just being nosey. An interview with the Kitchen Manager (KM) on 03/07/23 at 11:08 AM revealed, Clean Start handles the chemicals. Ecolab did our pest control for laundry and kitchen. Ecolab provided us with the dishwasher and chemicals. We were leasing the dishwasher. The new dishwasher was delivered and sat outside until we got the old one out. The same day they uninstalled the old one and they installed the new one. The old dishwasher was leaking, the company made the decision to end the contract with Ecolab due to the cost of the chemicals. Ecolab told me I couldn't order anymore chemicals from them; I am not sure if Ecolab sent notification to take the dishwasher back or cancel services due to nonpayment. We always had a dishwasher in service. An phone interview with the Director of Collections (DOC) for PharMerica (company that provides pharmacy services to the facility) on 03/08/23 at an unspecified time revealed, the facility's oustanding balance with PharMerica is $59,133.00 and are over contract by $38,247.00. The DOC further stated the facility is in a forebarance agreement with PharMerica and will be transitioning to a cash on delivery payment process. If the facility does not provide past due payment or adhere to the cash on delivery payment system, PharMerica will be terminating services with the facility. The DOC concluded PharMerica would ensure the facility has another pharmacy service before termination occurs and at this time, no notification of termination of services has been sent to the facility. An phone interview with a representative from Dominion Energy on 03/07/23 at 2:01 PM revealed, they could not release any information without authorization from the account holder. Attempts were made to gain authorization for release of information with no success. Review of the facility's Quality Assurance and Performance Improvement (QAPI) meeting minutes dated 06/09/22 revealed, reviewed our Profit and Loss with approximate $402K loss in April, $382K loss in March, and $202K loss in February. Labor costs contributed to most as February and March we had agency in building and April was shift bonuses and overtime. The following invoices were provided by the facility and had an outstanding. Multiple attempts were made to request additional invoices with outstanding balances with no success: [NAME] Gas and Equipment Inc. $19,402.22 [NAME] Water System $16,489.96 (invoice indicated we plan to shut off the water in 60 days) [NAME] Sales and Services $764.49 ECOLAB $3,560.24 (indicated account is seriously delinquent) American Health Associates $19,552.63 An interview with the Administrator on 03/06/23 at an unspecified time revealed, We have outstanding balances with multiple vendors and contractors. Renovation companies, Transport companies, Pest contorl, Oxygen, and many more. No documentation was provided.

Based on interviews, record review and review of the facility's policy titled, Care Plan Revisions Upon Status Change, the facility failed to review and revise the comprehensive care plan for Resident (R)21 and R31 for weight loss, R22 for a diagnosis of Schizophrenia, and R71 for pain management. Additionally, facility failed to ensure R1 and R33 were invited to care plan meetings, 2 of 3 residents reported not being invited to care plan meetings. Findings include: Review of facility's policy titled, Care Plan Revision Upon Status Change dated 02/01/2023 revealed Policy Explanation and Compliance Guidelines reads, the comprehensive care plan will be reviewed and revised as necessary, when a resident has a status change. Review of R21's Face Sheet on Electronic Medical System (EMR) revealed the admitted [DATE] and the diagnoses include muscle weakness, osteoarthritis; hypertension, hyperlipidemia, parasitic diseases, renal dialysis, chronic kidney disease stage 5, gastro-esophageal reflux disease, chronic atrial fibrillation, absence of left leg below knee, urinary tract status, chronic obstructive pulmonary disease, infectious and parasitic diseases, obesity. Review of R21's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/6/2022 documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R21 is cognitively intact. Review of R21's weights on the EMR revealed weight documented at 281.8 lbs. on 07/14/2022 and 235.6 lbs. on 12/30/2022 revealing a -16.39-weight loss over six months. The EMR listed R21's weight as outlined: 07/14/2022 281.8 lbs 08/22/2022 269.6 lbs 09/19/2022 258.2 lbs 10/21/2022 252.1 lbs 11/23/2022 251.2 lbs 12/30/2022 235.6 lbs In an interview with the Physician on 03/07/2023 at approximately 3:41 PM, she stated the facility does not have an active Dietician, the Dietician quit in December 2022 and there will not be another Dietician on staff for another few weeks. The facility admitted R31 on 03/21/22 with diagnoses including, but not limited to, metabolic encephalopathy, major depressive disorder, vitamin D deficiency and cognitive communication deficits. Review on 03/07/23 at 08:42 AM of the medical record for R31 revealed a weight loss. On 11/23/22, R31 weighed 163.0 pounds, on 12/12/22 he weighed 151.2 pounds and on 01/24/23, R31 weighed 146.6 pounds indicating a 16.4 pound weight loss in 2 months. There were no weights for February 2023 nor March 2023. Further review of the medical record for R31 revealed a note by the Registered Dietician dated 01/24/23 reads, diet order for mechanical soft with thin liquids, po (by mouth) intake varies, weight loss of 10 pounds in 30 days. Recommendations to continue with current plan of care, dietary will add double portions with lunch and dinner. Currently on Magic cup bid (two times daily. RD (registered dietician) to monitor and follow up prn (as needed). Review on 03/07/23 at 12:57 PM of the physician orders which state active orders as of 03/08/23 does not include the double portions with lunch and dinner nor the Magic Cup 2 times daily. The orders do include Ensure 2 times daily started 09/22/22 and a frozen nutritional treat 2 times daily started 12/22/22. An observation on 03/08/23 of the lunch meal received by R31 did not include double portions. The Ensure two times daily was not observed. Review on 03/07/23 at 1:10 PM of the Comprehensive Plan of Care revealed the double portions with lunch and dinner and the Magic Cup were not included in the interventions to decrease weight loss or to prevent further weight loss. An interview on 03/07/23 at 3:00 PM with the DON verified that the interventions for the double portions during lunch and dinner and the Magic Cup 2 times daily were not on the care plan to aid in reduction of further weight loss. The care plan had not been reviewed and revised for weight loss. During an interview on 03/08/23 at 9:25 AM with the Certified Dietary Manager (CDM), he stated that he had followed up on R31's preferences. He also stated he came to work with this facility in October 2022 and since then the registered dietician had resigned. b. Review of R22's Face Sheet revealed the admitted [DATE] and the diagnosis of multiple sclerosis, schizophrenia, urinary tract infections, constipation, panic disorder, auditory hallucinations, anxiety, depressed mood, muscle weakness, encephalopathy, sepsis without septic shock, bi-polar disorder. Review of R22's Medical psychiatric diagnoses listed under Physician Orders on Electronic Medical Record (EMR) revealed the onset start date for psychiatric diagnoses documented: panic disorder onset 05/06/2021; Auditory Hallucinations onset 09/14/2021; Bi-Polar onset 05/04/2017 and Schizophrenia onset 10/18/2021. Additionally, R22's current medications prescribed are listed under the black box warning medications-: Bupropion; Xarelto, Lorazepam, Asenapine Transdermal Patch; Lorazepam Oral Tabled; Lexapro and Depakote. Review of R22's Quarterly Minimum Data Set (MDS) and Assessment Reference Date (ARD) of 12/10/2022 revealed a Behavior Interview Mental Status (BIMS) of 15 which means cognitively intact. No behaviors were documented. MDS listed R22 as totally dependent with self help skills and active daily living skills. R22 has an indwelling catheter. No bowel toileting program and received scheduled pain regimen. Review of R22's Care Plan dated 9/22/2021 revealed no revision for newly diagnosis of Schizophrenia. c. Review of facility's policy titled, Pain-Clinical Protocol, revised March 2018 revealed The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. Review of R71's Face Sheet revealed an admitted [DATE] and the diagnoses of chronic obstructive pulmonary disease. type 2 diabetes, congestive heart failure, muscle weakness, major depressive disorder, blindness, and seizures. Review of R71's MDS with an ARD of 11/24/2022 revealed a BIMS score of 15 which, which indicated R71 is cognitively intact. Review of R71's Care Plan dated 11/18/2022 revealed no revision to plan to monitor pain management or monitor for resident for adverse effects. Review of R71's progress note dated 02/17/2023 revealed the following medical dictation, Pt is a long term resident of Viviant who is being seen today for f/u ER visit s/p fall and chronic conditions to include HTN, CKD, DM2, COPD and insomnia. Per dtr do not send pt to the hospital if she falls out of bed. Daughter states mom is doing that for attention. I told her I was leaving and stood by the door and watched her try to pull herself over to the left side of the beds edge and I stopped her. Pt very anxious on exam which could be contributing to high BP. Will add xanax 2mg qhs x 14 days along with xanax 0.25mg qhs and daily prn. Review of R71's Medication Administration Record (MAR) for March 2023 revealed resident is prescribed the following medications for pain: Acetaminophen 325 milligrams (mg), 2 tablets every 6 hours; Aspirin Tablet 81 mg, 4 tablets every 24 hours; Hydrocodone-Acetaminophen tablet 10-325MG every 12. Review of R71's Medication Administration Record (MAR) for March 2023 revealed resident is prescribed the following medications for pain: Acetaminophen 325mg, 2 tablets every 6 hours; Aspirin Tablet 81 mg, 4 tablets every 24 hours; Hydrocodone-Acetaminophen tablet 10-325MG every 12. An interview with the MDS Coordinator on 03/09/2023 at approximately 10:00 AM revealed when she reviewed the care plan and MDS, R71's care plan did not contain the pain management medication regimen. She stated that she is working between two buildings, but she will add this to her plan. An interview with the Director of Nursing (DON) at 1:10 PM on 03/09/2023 revealed she was aware that R71 was on an Opioid and Benzodiazepines. She acknowledged R71 is on medication for pain. 46992 Based on medical record review, R1 was admitted to the facility with diagnoses including but not limited to anemia, anxiety disorder, chronic pain, and hypotension. A review of R1's quarterly MDS with an ARD of 12/17/22, revealed the resident has a BIMS score of 15, indicating the resident was cognitively intact. During an interview with R1 on 03/07/23 at 09:09 AM, she stated that since the facility had a change in ownership, she has not been invited to a care plan meeting. During an interview with the Social Worker (SW) on 03/07/23 at 09:48 AM, she stated she initiates the care plans and has made a sheet to help with care plans and mailing letters. She stated residents are generally included in the care plan meetings, but as of lately, she is not sure if they have been. During an interview with the MDS Coordinator on 03/09/2023 at 1:11 PM, she stated residents and families do sometimes have input into the care plans, but they have not invited nor included many residents or families in the care plan meetings. 31846 The facility admitted R33 with diagnoses including, but not limited to, diabetes mellitus type II, hypertension, insomnia and bilateral above the knee amputation. During an interview on 3/06/23 at 1:56 PM with R33, he stated that he had not been invited to care plan conferences. R33 is deemed able to make decisions for himself but was not included in the care planning process. Review of the medical record on 03/07/23 at 08:15 AM revealed no documentation to ensure R33 was invited to attend or that his input was sought to formulate and update the Comprehensive Plan of Care. During an interview on 03/07/23 at 2:00 PM with the Social Service Director, she confirmed that there was no documentation to ensure R33 was invited to attend the care plan conference.

Based on observations, review of medical records, interviews and facility policy titled, Activities of Daily Living (ADLs), and Promoting/Maintaining Resident Dignity, the facility failed to ensure Resident (R)31, R75, and R21 were provided ADLs to include showers, nail care and removal of facial hair for 2 of 3 residents reviewed for Activities of Daily Living. Findings include: Review of the facility policy titled, Activities of Daily Living (ADLs) states, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care; The policy explanation and compliance guidelines: A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of the facility policy titled, Promoting/Maintaining Resident Dignity, states: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Compliance Guidelines: 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. 9. Groom and dress residents according to resident preference. 15, Random observations and/or verifications are conducted by the Director of Nursing Services (DNS), or designee, to ensure compliance with this policy. The facility admitted R31 with diagnoses including, but not limited to, cerebrovascular accident, hemiplegia and hemiparesis, contracture of muscle of left arm, fractured femur with left hip replacement and cognitive communication deficit. An observation on 03/06/23 at 11:50 AM revealed R31 resting in bed, his nails were long and he had several days of facial hair growth. He had not received ADL care on this date. Review on 03/07/23 at 12:57 PM of the medical record for R31 revealed an ADL sheet dated 02/28/23 states a shower was given on this date signed by the Certified Nursing Assistant (CNA) and the nurse. The sheet included nail care, hair washed and feet cleaned, none of these were addressed on the sheet as being done on 2/28/23. R31 is scheduled to receive showers on Tuesday and Friday mornings. No other shower sheets were in the ADL book provided by the Director of Nursing (DON). She stated the facility had the sheets out of the book, and the ADLs were documented as done daily. She did not provide any other ADL sheets for (R31). Review on 03/07/23 at 2:55 PM of the quarterly Minimum Data Sheet (MDS) assessment dated [DATE] section G for ADL assistance is coded for: Bed mobility 3/3 - Extensive assistance with 2 assist Transfer 3/3 - Extensive assistance with 2 assist Locomotion on unit 3/3 - Extensive assistance with 2 assist Locomotion off unit 3/3 - Extensive assistance with 2 assist Dressing 3/3 - Extensive assistance with 2 assist Eating 1/1 - Self performance with set up only Toilet 3/3 - Extensive assistance with 2 assist Personal Hygiene 3/3 - Extensive assistance with 2 assist Bathing 4/2 - Total dependence - full staff performance every time with one assist. Review on 03/07/23 at 3:40 PM of the Comprehensive Plan of Care for R31 indicated that he has self care deficits related to history of stroke, recent left femur fracture, paranoid schizophrenia, and right eye retinal detachment. The interventions include to, report changes in ADL performance, shower 2 to 3 times per week and as needed, and utilize task segmentation as indicated to help improve ADL participation. He is care planned for refusing care, being combative, and verbally abusive toward staff during care. The facility admitted R75 with diagnoses including, but not limited to, cerebrovascular, hemiplegia and hemiparesis, aphasia, memory deficit and cognitive communication deficit. An observation on 03/06/23 at 11:30 AM of R75 revealed long and dirty fingernails, facial hair growth of several days. An observation on 03/07/23 at 9:00 AM of R75 revealed he was wearing the same clothes from the day before and his fingernails were still long and dirty. He was unshaven. Review on 03/07/23 at 10:00 AM of the shower schedule for R75 revealed that he receives a shower on Wednesday and Saturday mornings. The last shower or bath documented was dated 03/01/23 and he had refused a shower and received a complete head to toe bath. Nail care was documented as completed, along with hair washed and feet cleaned. No other sheets were in the shower book and no other sheets or documentation were provided for showers or baths since 03/01/23. Review of the medical record on 03/07/23 at 10:30 AM for R75 indicated that he is total care with ADLs. Review on 03/07/23 at 10:33 AM of the quarterly MDS assessment dated [DATE] is coded as follows: Bed Mobility 3/3 - Extensive assistance with 2 assist Transfer 4/3 - Total dependence with 2 assistance Locomotion on and off unit 4/2 - total dependence with 1 assist Dressing 3/2 - Extensive assistance with 1 assist Eating 1/1 - Supervision with set up Toilet 3/2 - Extensive with 1 assist Personal Hygiene 3/2 - Extensive assistance with 1 assist Bathing 4/3 - Total dependence with 2 assist. 46991 Review of R21's Face Sheet on Electronic Medical System (EMR) revealed the admitted [DATE] and the diagnoses include muscle weakness, osteoarthritis; hypertension, hyperlipidemia, parasitic diseases, renal dialysis, chronic kidney disease stage 5, gastro-esophageal reflux disease, chronic atrial fibrillation, absence of left leg below knee, urinary tract status, chronic obstructive pulmonary disease, infectious and parasitic diseases, obesity. Review of R21's MDS with an Assessment Reference Date (ARD) of 12/6/22 documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R21 is cognitively intact. Resident requiring two-person physical assistance with self-help skills and activity of daily living skills. Review of R21's Care Plan dated 12/27/22 revealed a goal for activities of daily living self-care performance deficit related to bilateral weakness and pain. The goal is for resident to show no decline in current level of function in active daily living skills through next review date. The following approaches are listed, praise all efforts of self-care; requires 1 person assist with bed mobility, 2 person assist with transfers, requires set up assist with eating; encourage her to discuss feelings about self-care deficit, encourage to use bell to call for assistance, encourage to participate to the fullest extent possible with each interaction. Review of Grievance Log for 11/29/22 filed by Ombudsman office for Certified Nursing Aide (CNA) concerns. Review of Shower Steets provided for the month of December 2022 revealed shower was provided on 12/2/2022; 12/5/2022; 12/14/22; 12/20/2022. Shower sheet for 01/03/2022 was provided however no signature on sheet noting show was given. Shower was provided on 1/10/23 and 1/20/23. The form submitted for February 2023 was listed for February 2022. No other forms were provided upon request for the month of February 2023 and March 2023. An interview with R21 on 03/07/23 at approximately 8:42 AM revealed she had complaints about her not getting her showers. R21 stated she still is not getting her showers. She stated she is supposed to get a shower on Tuesdays and Fridays, because she goes to dialysis. She stated she has informed the Administrator and they said they were going to do better, and they did for a minute, but now she is back to not getting her showers. In an interview with the Ombudsman Representative at approximately 4:22 PM on 03/07/23 revealed she had filed a complaint with DHEC on behalf of R21 for investigation on her not getting her showers and cleanliness. She stated she had filed a grievance previously with the facility, but conditions are still the same. In an interview 03/08/23 with the DON at 11:40 AM revealed after review of shower logs for December 2022, January 2023 and February 2022 presented for R21, she stated if these form is not signed by a CNA or a LPN, this does not mean there was no shower given. However, she states she believes the showers were given. She stated these are all the forms they have at this time, so she could not acknowledge if showers were received.

Based on record reviews, interviews, and review of the daily staffing posted, the facility failed to ensure a Registered Nurse (RN) was included on the daily posting for at least 8 consecutive hours for 7 days a week for multiple days in January 2023 and February 2023. Findings include: Review of the daily staffing posted for January and February 2023 revealed no documentation to ensure a RN was in the facility for at least 8 consecutive hours 7 days a week. The dates are as listed: 01/02/23, 01/03/23, 01/04/23, 01/05/23, 01/09/23, 01/10/23, 01/11/23, 01/12/23, 01/16/23, 01/17/23, 01/18/23, 01/19/23, 01/23/23 and 01/24/23. In February 2023, the dates are as listed: 02/01/23, 02/02/23, 02/03/23, 02/06/23, 02/07/23, 02/08/23, 02/09/23, 02/10/23 and 02/12/23, 02/16/23, 02/22/23, and 02/23/23. During an interview on 03/09/23 at 9:20 AM, the Scheduler stated, that she was told not to include the Registered Nurse on the daily staff posting sheet. When asked how residents and families know that a registered nurse is in the building for at least 8 hours a day, she stated she was unsure.

Based on observations, record reviews, manufacturer's package insert and interviews the facility failed to ensure that medications were properly stored and secured in 2 of 3 medication rooms and 2 of 8 medication carts. Findings included: Review of the facility policy titled, Medication Storage, implemented on [DATE], 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. Number 1 under the policy explanation and compliance guidelines states: a. All drugs and biological's will be stored in locked compartments (i.e., medications carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. On [DATE] at approximately 11:15 AM, inspection of the 200 Hall medication room refrigerator revealed a locked clear plastic box with 3 containers of Lorazepam 2 mg (milligram)/ml (milliliter) by Westward with the clear plastic box not attached to the inside of the refrigerator. On [DATE] at approximately 11:21 AM, this finding was confirmed by LPN (Licensed Practical Nurse)1, who stated it is supposed to be permanently attached to the inside of the refrigerator On [DATE] at approximately 2:46 PM inspection of the ,d+[DATE] Hall medication room refrigerator revealed a soaking wet box containing three Trulicity Pens 0.75 mg/0.5 ml belonging to Resident # 13. Further inspection of the medication room revealed a sink which was dirty with red stains, black crusty material and strands of hair. These two findings were verified on [DATE] at approximately 2:51 PM by RN (Registered Nurse)1. On [DATE] at approximately 3:25 PM inspection of the 100 Hall medication cart revealed one opened, in-use and undated Advair Diskus 250 mcg. (microgram)/50 mcg. Inhaler. The manufacturer and Pharmacy had applied labels to indicate opened and expiration date. On [DATE] at approximately 3:25 PM this finding verified by LPN1. The GlaxoSmithKline manufacturer package insert states The device should be discarded 1 month after removal from the moisture-protective foil overwrap pouch . On [DATE] at approximately 9:40 AM inspection of the ,d+[DATE] Hall treatment cart revealed that it was unlocked for over ten minutes with a wandering resident in the area. On [DATE] at approximately 9:48 am this finding was verified by RN #1, who was returning a container of Diclofenac Gel to the cart, who stated she had left the cart unlocked. Further inspection of this treatment cart revealed eight, expired as of ,d+[DATE], Lubricating Gel packets by Medline and one opened bottle of Curad Iodoform Packing Strip 1 (inch) x 5 yd (yard) dated on the bottle cap by the facility as opened [DATE] and labeled by the manufacturer Sterile in unopened, undamaged package. These findings were verified by LPN2. 31846 An observation on [DATE] at 2:17 PM of the treatment cart on the 300 Unit revealed the cart unlocked and unattended. A resident was observed walking in the hallway in the vicinity of the unlocked treatment cart. The cart contained medications and biological's used in the treatment of wounds and skin irritations. During in interview on [DATE] at 2:18 PM with RN1, she confirmed that the treatment cart was left unlocked and unattended while she went to do wound care down the hallway.

Based on observation, interview, and policy review, the facility failed to ensure palatable food was served to 5 sampled residents' (Resident (R)21, R17, R71, R46, R41). Residents complained foods were not flavorful and were not hot when they received their meals. Findings include: Review of the facility's policy titled, Food and Nutrition Services dated October 2017 revealed, Policy Statement- Each resident is provided with a nourishing, palatable, Well balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Policy Interpretation and Implementation states: 7) The food and nutrition staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. During an interview on 03/07/23 at 09:56 AM, R21 stated the food (breakfast) is not good and always cold. Observation revealed, R21 did not consume breakfast tray and called Certified Nursing Assistant (CNA) in the room to remove tray from bed side table. Review of R21's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/16/22, located in the electronic medical record (EMR) under the MDS tab revealed R21 was intact in cognition with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (score of 13 - 15 indicates intact cognition). During an interview on 03/06/23 at 11:58 AM, R17 revealed food is always cold. An observation on 03/09/23 at 08:11 AM, revealed R17's food tray contained Grits, Bacon, Toast. R17 consumed about 25 % of tray. An interview with R17 confirmed that the food was cold and did not taste good. Review of R17's Quarterly MDS with an ARD of 01/27/23, located in the EMR under the MDS tab revealed R17 was intact in cognition with a BIMS score of 15 out of 15. During an interview on 03/07/23 at 10:09 AM with R71 revealed R71 did not eat her breakfast. R71 revealed sometimes she does not eat her food due to taste, or temperature. Review of R71's Quarterly MDS with an ARD of 11/24/22, located in the EMR under the MDS tab revealed R71 was intact in cognition with a BIMS score of 15 out of 15. During an interview on 03/06/23 at 11:18 AM, R46 revealed food is not good, most times cold. R46 stated facility has given her food that she should not have. Review of R46's Quarterly MDS with an ARD of 12/18/22, located in the EMR under the MDS tab revealed R46 was intact in cognition with a BIMS score of 15 out of 15. During an interview on 03/06/23 at 02:12 PM, R41 stated that the food provided is never hot or warm. Review of R41's Quarterly MDS with an ARD of 12/25/22, located in the EMR under the MDS tab revealed R41 was intact in cognition with a BIMS score of 15 out of 15. Observations of the tray line meal service and distribution of meals was made on 03/07/2023 at 11:39 AM for lunch. Observation of the tray line revealed foods included Baked Turkey, Chopped Turkey, Puree Turkey, Potato Scalloped, Broccoli, Puree Broccoli, Rice, Baked Chicken, Chopped Chicken, and a small pan of Brown Gravy. The following concerns were noted; there was no ice or refrigeration in place to keep the beverages cold during meal service, Drinks were out of the packaged box, unopened, with the plastic ring, observed on top of the table beside the refrigerator. All carts observed, were not enclosed carts. Facility meal carts were sheet pan racks that were open to air and had no mechanism in place to keep the hot foods hot. Interview with the CDM (Certified Dietary Manager) on 03/06/2023 at 12:45 PM revealed if the resident misses breakfast due to being sleep, staff on the unit will come in the kitchen and notify staff that the resident would like a warm meal due to being cold by the time the resident wakes up and decides to eat, and kitchen staff will cook a warm meal for them. On 03/09/2023 at 09:36 AM, the CDM confirmed the meal carts were sheet pan racks and were not enclosed and had no mechanism in place to keep the meals warm. The CDM stated he can't order, due to facility management not paying bills, so the kitchen is suffering as a result. The CDM verified the beverages should be kept cold during meal service, on ice for example, and should not be at room temperature while trays were being dished up and served. The CDM stated that he has attended meeting in regard to grievances with complaints about meals and is asking residents weekly about how the food is and what could be better.

Based on interviews, record reviews, and the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to implement an infection prevention and control program (IPCP) designed to provide a safe and sanitary environment to help prevent the possible development and transmission of communicable diseases and infections for all residents by not providing education on pneumococcal and influenza vaccines and did not offer pneumococcal vaccines to residents. Findings include: Review of the policy titled, Pneumococcal Vaccine, revised October 2019 revealed Policy Statement: All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Review of the policy titled, Influenza Vaccine, revised October 2019 revealed Policy Statement: All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. Record Review on 03/07/23 at 9:35 AM of the tracking and trending logs revealed pneumococcal vaccines were not offered to residents and no education of pneumococcal and influenza vaccines were provided to residents. Interview on 03/07/23 at 3:07 PM with Infection Preventionist (IP) stated, no residents were offered education on the Pneumococcal and Influenza Vaccines and the facility failed to offer the pneumococcal vaccine to any residents.

Based on observation, interview, and review of the facility policy, the facility failed to ensure an effective pest control program for the environment to remain free from pests. Findings include: Record review of facility policy titled Pest Control Program dated 02/01/2023 revealed, Policy: It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. Definition: Effective pest control program is defined as measures to eradicate and contain common household pests (e.g, bed bugs, lice, roaches, ants, mosquitos, flies, mice, and rats). Compliance Guidelines: 1) Facility will maintain a written agreement with a qualified outside pest service to provide comprehensive pest control services on a regular and schedueled basis. On 03/08/2023 4:19 PM, an observation and interview was conducted with Maintenance Director and the DON (Director Of Nursing). On the 100 and 400 unit by the nurses station revealed the Maintenance Director was unaware of the pest infestation in the facility. The Maintenance Director revealed it was not brought to his attention and he will look into it. The Maintenance Director revealed that he started his employment at the facility 3 months ago after the holidays and the previous maintanence person quit unexpectedly and got rid of alot of documentation. The DON confirmed pest (flies and fruit flies) in the facility, as the DON has witnessed them in the 100 and 400 unit in the hall ways. On 03/09/2023 at 1:55 PM, the Administrator brought documentation to the conference room in regards to the pest control program. The following documentation provided were the proposals from Elam's Pest Control Company that stated treatment and preventable pest treatment and prevention of general pest (Roaches, Ants, Bed Bugs, Spiders, Fleas, Ticks, Rodents). The documentation also indicated the company would only spray rooms that need treatment. The Administrator provided invoices dated 09/19/2022, 12/06/2022, 02/24/2023. There was no documentation of what the company had done or which areas had been treated. There was no record of invoices for the current month of March 2023.

Based on review of the facility policy titled, Promoting/Maintaining Resident Dignity, observations and interviews, the facility failed to maintain resident privacy by first knocking on resident room doors prior to entering with meal trays on the 300 Hall during 2 observations of the lunch meal service. Findings include: Review of the facility policy titled, Promoting/Maintaining Resident Dignity, implemented on 02/01/23, states, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Number 11 states, Respect the resident's living space . Number 12 states, Maintain resident privacy. An observation on 03/06/23 at 12:05 PM revealed Certified Nursing Assistants (CNAs) entering resident rooms with meal trays and not knocking, just walking in or yelling, knock, knock. A second observation of the lunch meal service on the 300 Hall on 03/08/23 at 12:30 PM revealed CNAs entering resident rooms with meal trays, and not first knocking and waiting for a response before entering. During an interview on 03/08/23 at 12:40 PM, CNA1 stated, if the doors are already open, we do not knock.

Based on review of the facility policy titled, Advance Directives, record reviews, and interviews, the facility failed to afford Resident (R)75 the opportunity to formulate an advance directive. The facility further failed to ensure R142 was accurately coded as a full code, specifically, R142 was coded as a Do Not Resuscitate (DNR) by the Nurse Practitioner for 2 of 3 residents reviewed for Advance Directives. Findings include: Review of the facility policy titled, Advance Directives, states, Advance Directives will be respected in accordance with state law and facility policy. The policy interpretation and implementation, states, under number 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate and advance directive if he or she chooses to do so. 2. Written information will include a description of the facility's policies to implement advance directives and applicable state law. 3. If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative. 15. In accordance with current OBRA definitions and guidelines governing advance directives, our facility has defined advanced directives as preferences regarding treatment options and include, but are not limited to: a. Advance Directive - a written instruction, such as a living will or durable power of attorney for health care, recognized by state law, related to the provisions of health care when the individual is incapacitated. The facility admitted R75 on [DATE] with diagnoses including, but not limited to, cerebrovascular accident, aphasia, memory deficit, and cognitive communication deficit. Review of the medical record revealed no documentation to ensure R75 nor his personal representative was afforded the opportunity to formulate and advance directive. The medical record did contain a form titled, Physician's Determination of Capacity, and is signed by 2 physician's stating the the R75 is without capacity to make decisions regarding his medical care and treatment. During an interview on [DATE] at 11:28 PM with the Director of Nursing (DON) she stated that all the facility needed was a note written by the physician indicating that the code status was discussed with the resident or the personal representative. No other documentation was needed. 25335 Resident (R)142 was admitted to the facility on [DATE] with diagnoses including, but not limited to chronic heart failure, pseudobulbar effect and symptomatic epilepsy. On [DATE] at approximately 2:05 PM review of the electronic medical record for R142 revealed his code status as DNR with progress notes stating Code Status as per facility EMR: DNR/No CPR (cardiopulmonary resuscitation) and that he had been care planned as DNR and the miscellaneous section of the electronic medical record containing an EMR DNR signed by the Family Nurse Practioner on [DATE]. On [DATE] at approximatley 3:56 PM LPN (Licensed Practical Nurse)4 nurse reviewed the electronic medical record for R142 and confirmed that his code status was DNR, that Main Street Physicians SC (South Carolina) House Calls had stated on [DATE] that R142 had no advance directives and was full code. In addition, LPN # 4 stated she could find no evidence of the resident having been deemed competent or incompetent by a physician. [DATE] at approximately 4:04 PM the Social Service Director stated she was unable to find a physician statement deeming R142 incompetent. The Social Services Director stated the physician had stated on [DATE] that R142 was full code and that the FNP (family nurse practioner) had stated on [DATE] that R142 was DNR on the DHEC (Department of Health and environmental Control) EMS DNR (Emergency Medical Services Do not Resuscitate) form 3462 (,d+[DATE]). On [DATE] at approximately 4:13 PM, the DON reviewed the electronic medical record for R142 and stated the FNP did not have the authority to complete a DNR form.

Based on record review and interview, the facility failed to use the required CMS 10055 form to notify 3 of 3 residents of their Skilled Nursing Facility Advanced Beneficiary Notice (ABN) of Non-coverage. Findings include: The facility was asked to provide a copy of their Beneficiary Notices policy. However, during the duration of the survey, the policy was not provided. Review of the SNF Beneficiary Notice Protection Notification Review of residents discharged from a Medicare covered Part A stay with benefit days remaining in the past 6 months revealed 3 of 3 residents reviewed were not provided with a written notice of Medicare non-coverage, a CMS 10055 and a CMS 10123 form. In an interview on 03/09/23 at approximately 4:00 PM, the Director of Nursing (DON) revealed when she reviewed the SNF Beneficiary Protection Notification Review that these were all the forms provided to these three residents at the time of discharge.

Based on record review and interview, the facility failed to ensure Resident (R)81 and her responsible party (RP) received in writing, in a language they could understand, of the reason for discharge to the hospital in a timely manner for 1 of 2 residents reviewed for hospitalization . Findings include: The facility admitted R81 with diagnoses including, but not limited to, acute pulmonary edema, end stage renal disease, major depressive disorder and schizophrenia. Review of the medical record for R81 revealed a hospitalization on [DATE] and returning on 02/22/23. No documentation was found in the medical record to ensure R81 and their RP received in writing and in a language they could understand of the reason for transfer to the hospital not at discharge to the hospital and not in a timely manner. During an interview on 03/07/23 at 3:28 PM, the Director of Nursing (DON) stated that at the time of discharge, the facility sends a packet with the resident to the hospital and it was her understanding the packet contained all the information needed by the facility for the resident. The DON could not confirm that the RP or Resident received this information when it is sent, however, the facility does not mail the documents either.

Based on record reviews, interviews and review of the facility policy titled, Bed-Holds and Returns, the facility failed to ensure Resident (R)81 and/or their responsible parties (RP) received a copy of the facility bed hold policy with the bed hold amount upon discharge or within a practical amount of time for 1 of 2 residents reviewed for hospitalization . Findings include: Review of the facility policy titled, Bed-Holds and Returns, states, Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. The policy interpretation and implementation states, 1.Residents may return to and resume residence in the facility after hospitalization or therapeutic leave as outlined in this policy. 2. The current bed-hold and return policy established by the state (if applicable) will apply to Medicaid residents in the facility. 3. Prior to transfer, written information will be given to the residents and the resident representatives that explains in detail: a. The rights and limitations of the resident regarding bed-holds; b. The reserve bed payment policy as indicated by the state plan )Medicaid residents); c. The facility per diem rate required to hold a bed (non-Medicaid residents), or to hold a bed beyond the state bed-hold period )Medicaid residents); and d. The detains of the transfer (per the Notice of Transfer). 4. Medicaid residents who exceed the state's bed hold limit amount and/or non-Medicaid residents who request a bed-hold are responsible for the facility's basic per diem rate while his or her bed is held. The facility admitted R81 with diagnoses including, but not limited to, acute pulmonary edema, end state renal disease, congestive heart failure, cognitive communication deficit and dependent on renal dialysis. Review of the medical record for R81 revealed a hospitalization dated 02/17/23 and returning to the facility on [DATE]. No documentation could be found in the medical record for R81 to ensure she nor her personal representative received a copy of the bed hold policy which included the bed hold amount if the hospitalization went past the 10 days to hold the bed. During an interview on 03/07/23 at 3:28 PM with the Director of Nursing, (DON) she stated that a copy of the Bed-Hold and Returns policy is sent with the resident to the hospital and it was her understanding the packet contained all the information needed by the facility for the resident. The DON could not confirm that the RP or Resident received this information when it is sent, however, the facility does not mail the documents either.

Based on record reviews, staff interviews, and review of the facility policy, the facility failed to provide adequate supervision for 1 of 3 residents reviewed for accidents related to wandering. Resident (R)1 had a successful elopement on June 15, 2022, between 10:30 PM and 10:55 PM. Failure to establish, maintain and implement written policies and procedures regarding supervision places an individual's health and safety at risk for serious injury, harm, impairment, or death. On June 15, 2022, at approximately 10:30 PM, R1 was last seen on the 300 Unit attempting to exit the side door. Her wanderguard, located on her left ankle set the alarm off. As staff was responding, Certified Nursing Assistant (CNA)1 redirected R1 away from the door and down the hall. After staff successfully disarmed the alarm door at the 300 Unit, another alarm was heard sounding. It was then noted that the 400 Unit exit door was sounding. On June 15, 2022, at approximately 10:55 PM, R1 was found outside the facility, in approximately 300 feet from the facility, in a bushy/leafy area. When found, there was a small stick on her forehead, but she had no open injuries, or identified pain. The weather was noted to be dry and cool. On June 20, 2022, at 3:18 PM, the survey team provided the Administrator with a copy of the Centers for Medicare and Medicaid Services (CMS) Immediate Jeopardy (IJ) Template, notifying the facility IJ existed at F689 due to the facility's failure to adequately monitor R1, who had a diagnosis of Dementia with an effective date of June 15, 2022. On June 20, 2022, at 5:00 PM, the facility provided an acceptable IJ Removal Plan related to F689. The immediacy of the IJ was removed as of June 16, 2022. Further review of the facility's implemented plan showed substantial evidence that the facility took all necessary actions to remove the immediacy prior to the start of the survey, warranting the IJ to be justified as Past noncompliance with a confirmed compliance date of June 16, 2022. This was confirmed via observations, random staff interviews and review of audits and education. Additionally, the failure constituted substandard quality of care, warranting the completion of an extended survey on June 20, 2022. Findings include: Review of the facility's undated policy titled, Elopements and Wandering Residents, revealed, This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk .The facility is equipped with door locks/alarms to help avoid elopements. 4d. Adequate supervision will be provided to help prevent accidents or elopements . R1 was admitted to the facility on [DATE], with diagnoses including, but not limited to dementia with behaviors, major depressive disorder, anxiety, hypertension, and palliative care related to dementia. Review of R1's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of March 9, 2022, indicated she has a Brief Interview of Mental Status (BIMS) score of 99, indicating she is severely cognitively impaired. Review of R1's most recert quarterly MDS with an ARD of April 28, 2022, indicated a BIMS score of 0 with cognitive skills coded as severely impaired. Her activities of daily living for locomotion for on and off the unit was coded as supervision only, indicating she could ambulate on her own. R1 was not coded for the use of assistive devices. Review of R1's medical records revealed R1 was assessed via a telehealth visit on June 16, 2022, at 1:33 AM. Summary of findings indicate: 87 y/o F with h/o dementia with behavior disturbance, major depressive disorder, anxiety disorder, [CONDITION(S)], and HLD, made successful egress out a side door of facility this evening, while another door was alarming. She has a wander guard, but it only triggers an alarm in proximity to the front door of the building. She managed to get to some nearby woods and was ultimately found on her back by a dumpster. She sustained a slight abrasion to her forehead, but no other injuries found on nursing assessment. She was seen on video and did not appear in any acute distress. She was unable to articulate what happened. She is not on antiplatelet or anticoagulation therapy. Further review of the progress notes indicates on June 16, 2022, at 1:49 AM, R1 was immediately placed on 1:1 supervision and daughter was notified of the incident. On June 16, 2022, R1 was moved to a room closer to the nurses' station for increased monitoring. R1 was noted to have adjusted well to the move. As of a progress note dated June 18, 2022, R1 continued to have stable vitals and neuro checks remained at R1's baseline. Review of R1's Wandering/Elopement Risk assessment dated [DATE], indicated a wandering risk score of 14, indicative of high risk for wandering. The assessment codes R1's mobility as ambulates with one assist or independent. It also codes a diagnosis of Alzheimer's disease. In the section for history of wandering, it codes R1 as a known wanderer/hx(history) of wandering. An additional Wandering/Elopement Risk Assessment, completed on June 16, 2022, indicated a wandering risk score of 11, indicative of at risk for wandering. The assessment codes R1 as oriented to person, mood/behavior-combative, severely agitated, exhibits/expresses fear and/or anxiety, having wandering behaviors, able to ambulate or move about the facility without the use of an assistive device, cognitively impaired with poor decision-making skills and history of wandering/elopement from a previous location. Review of R1's care plan with an initiation date of June 28, 2019, and revision date of November 17, 2021, indicated a focus: R1 wanders throughout the facility. Ambulates while carry baby doll at times socializing with staff and others. Goals are for R1 to remain safe within environment through the review date and R1 will not leave the center unattended. Interventions are to accompany to meals and scheduled activities, alert bracelet on left ankle, calmly redirect to an appropriate area, check alert bracelet placement every shift and functioning every day, close observation, educate family/visitors to advise staff when leaving patient following visit, encourage socialization with others and provide recreational programming, and engage in activities/tasks to keep occupied Interventions added on June 16, 2022 indicate, line of sight with 30 minute documentation and request family provide familiar objects from home. R1 is also care planned with an initiation date of January 14, 2019, with a focus area of: Use of wanderguard for safety related to cognitive deficit. Goal is patient will have no ill effects of wanderguard such as skin irritation and or distress with use of wanderguard over the next review. Interventions are to assist patient to ambulate/reposition, wanderguard/alert bracelet per physician's order, report change in skin integrity, and provide observation of residents where about at all times. Interventions added with an initiation date of June 15, 2022, are assure resident's picture is in elopement book with updated information, body audit completed once when outside, lumbar x-ray completed, room change to be closer to nurses' station for clear proximity observation and staff education on elopement policy. Review of R1's Physician Orders revealed an order for a secure alert bracelet to be applied to the left leg. Check functioning and placement each shift. Review of R1's Treatment Adminstration Record (TAR) revealed documentation of checks completed as ordered. Additional review of the medical record revealed a Radiology Report dated June 16, 2022, which revealed no fracture or subluxation seen, as a result of the incident. During an interview with the Director of Nursing (DON) on June 20, 2022, at 1:22 PM, she stated she received a phone call on June 15, 2022, and 10:55 PM from a staff member indicating they could not find R1. She stated she lives 25 minutes from the facility, so she immediately was in route to the facility. Around 11 PM on June 15, 2022, she received another telephone call stating R1 had been found outside the facility, having exited the back door of Unit 400. She stated upon her arrival to the facility at approximately 11:20 PM on June 15, 2022, she immediately assessed R1 and found no injuries. She then began gathering statements from all staff on the units, observed the area R1 was found, re-interviewed R1, who did not recall the incident and immediately began in-servicing all staff that was in the building. During an additional interview and facility tour with the DON on June 20, 2022, at 1:40 PM, she showed the surveyors where R1 had been found outside of the facility, in the back of the building, approximately 300 feet from the facility, in a bushy/leafy area. She stated the back parking lot is lit but was unsure if the lights reached that far back. In addition, the DON stated she was unable to determine if R1 had fallen or if she had gotten tired and laid down in the bushes. When found, she had a stick on her forehead, but there were no open injuries. During a telephone interview with CNA1 on June 20, 2022, at 1:46 PM, she stated, I heard the alarm and ran out of my resident's room and asked where is R1. R1 was walking towards me, so I tried to attempt to get her to bed. R1 became combative and refusing to go to bed. R1 then walked away from me, so I went back to assist another staff member in turning the alarm off. We were yelling out door codes until we finally got the alarm to stop. Once we got the door to stop alarming, I then heard another alarm going off. I immediately thought, Oh no, that's R1 again. I proceeded down to the 400 Unit and saw staff looking, so I came back and told the Nurse. He then called a Code Purple, and I saw two other CNAs heading out the 400 Unit door to look for her. Finally, someone said they had found her out back in the bushes, and when I looked, it was her pink sweatsuit that she had on. During a telephone interview with CNA2 on June 20, 2022, at 2:20 PM, she stated, I work 11p-7a. I arrived to work around 10:50 PM on June 15, 2022, and when I got to the door, everyone was looking and saying R1 was missing. I immediately threw down my stuff at the door and started checking the parking lot. It was dark and I didn't see or hear R1. I headed back towards the facility to get my car keys so that I could drive and check the subdivision behind the building. By the time I made it back to the parking lot to my car, I heard someone say they'd found her. When I looked, staff was walking her down the hall. She had on a pink sweatsuit and was still appearing to be combative and trying to get away from them, which is her usual behavior. When asked if there had been any training or in-services related to elopement, CNA2 stated the facility had recently done training prior to this incident and immediately the night of the incident as well. During a telephone interview with Licensed Practical Nurse (LPN)1 on June 20, 2022 at 2:22 PM, she stated, Around 10 PM, she noticed that the door to the Magnolia Unit was closed. She then saw an elderly lady walking in the hall by herself. She stated she walked towards R1 and introduced herself, offered her hand and led R1 back to the Magnolia Unit until she came across LPN2. LPN1 stated she asked LPN2 if she was missing a resident, and she replied, yes. About 20 minutes later, Registered Nurse (RN)1 came running through the building and she asked him what was wrong. He replied, R1 was missing. A few minutes later, R1 was found and brought back into the building. When asked if there had been any staffing education, LPN1 replied, Yes, we were immediately in-serviced that night. Multiple attempts were made to contact LPN2 via telephone, with no success. A written statement from RN1 taken on the night of the elopement revealed the following: I had walked to the end of the 300 hallway to encourage R1 away from the door. She had tripped the alarm. After she turned and started walking away, I started to close the door and shut the alarm off. I tried the code **** multiple times, but it wasn't working. I turned around to ask CNA1 if she knew another code. She told me to try ****. That code worked to shut the alarm off. At this time, I could hear another alarm so I headed back to the nurses station to discover the 400 hallway alarm going off. So I went to that door and the other nurse and CNAs were outside and they didn't see her so I told one to stay outside and the others check rooms and bathrooms. I then called a code purple. I explained to staff that it was R1 and she was wearing a pink sweatsuit. After searching, the CNAs called me and had found R1 in the back of the parking lot near the rear of the building. She was brought back into the facility by the CNAs and myself. On this day, I was the nurse on the Magnolia 400 hallway. Multiple attempts were made to contact RN1, with no success. A written statement from CNA3, dated June 16, 2022 revealed, I was headed out of the building to take the trash to the dumpster and a Code Purple was called about 10:55 PM. A nurse then directed myself, and two other CNAs to go check outside to the back of the facility. As we were walking in the back of the facility, we began yelling out resident's name. As we were yelling, we heard a voice and continued to follow the voice, that led to the edge of the woods. Resident was laying on the ground on her back with a small stick on her forehead, looking at us. Immediately notified RN1 to come out to assess her before moving the resident. The nurse arrived and assessed the resident and the resident was taken back into the facility. Multiple attempts were made to contact CNA3, with no success. During a telephone interview with R1's daughter, her Responsible Party (RP), on June 20, 2022 at 3:15 PM, she stated she is aware of her mother's wandering behaviors. She stated this is not the first time her mother had gotten out of the building, but it has been a few years since she last got out. The RP stated the facility was previously providing a sitter, however, since the new company has taken over the building, they were no longer providing that service. She stated approximately two weeks ago, she paid for her own personal private sitters to come into the building to sit with her mother. She stated her mother has began wandering around the facility more since the onset of COVID, however, because her mother is familiar with the staff and facility, she does not want to move her to another unit or facility with a memory care unit. She stated R1 is also receiving Hospice services, and this is another reason why she does not wish to move her mother somewhere else, however, she does feel her mother will get out of the building again, because she is determined and enjoys walking around, although it is aimlessly. During an interview with the Administrator on June 20, 2022 at 3:45 PM, he stated, he was unaware of the facility previously providing sitters, as the facility recently became under new management. He stated this was something he would look into, however, he feels on the night of the incident, staff immediately implemented the elopement plan as soon as R1 was noted to not be in the building. Additional review of the facility's plan of compliance revealed a 100% audit completed of all residents in the building. There were 12 residents identified as having a risk of elopement. All residents were re-assessed and care plans were updated as necessary. A 100% audit of door alarm functioning was completed, beginning on June 15, 2022 and was ongoing at the time of the survey. 1:1 documentation was reviewed with a start date of June 15, 2022, immediately after the return of R1 to the facility. The facility's removal plan included the following: 1. Resident was found within 6 minutes and returned to the facility safely. Family and Physician were notified.1:1 staff was implemented on 6/15/22. Body audit was conducted immediately. X-ray was completed with no positive results. The resident was relocated to a room in closer proximity to the nurses' station. Re-education of staff began immediately. Met with family and IDT to discuss interventions. The care plan for resident was updated 6/16/2022. Placement and function of wanderguard bracelet confirmed on 6/15/22 by the Director of Nursing. 2. Residents currently in the facility with a BIMS score of 10 or less were assessed by 6/16/2022 using the elopement evaluation. There were no newly identified residents at risk for elopement. The Wander/Elopement Risk book was reviewed by the Director of Nursing on 6/16/22 to ensure all residents that were assessed as at risk for wandering/elopement were identified in the book. The book was found to be accurate and up to date. 3. The Administrator checked 100% of the facility doors on 6/15/22 and found all doors and alarms functioning correctly. Staff education on procedures for managing residents at risk for wandering and elopement started on 6/15/22 and was completed with staff by 6/16/22. 120Db alarms were installed on all doors exiting the care area. 4. 3 Exit seeking behavior drills will be conducted weekly for 4 weeks across various shifts then 2 times per week for 4 weeks then weekly for 4 weeks or until substantial compliance is continuously received. Facility doors will be checked by the Maintenance Director (Manager on Duty on the weekends) daily for 4 weeks then 3 times per week for 4 weeks then weekly for 4 weeks to ensure all doors within the facility lock/release and alarm appropriately. 5. Administrator will review the results of all audits in QAPI monthly x 3 months or until substantial compliance is achieved. Allegation of Compliance- 6/16/22

Based on review of the facility's policy titled, Abuse, Neglect and Exploitation, record review, and interviews, the facility failed to ensure Resident (R)1 was free from abuse and/or neglect. Specifically, facility staff failed to prevent R1 from elopement from the facility on 1/4/22 at 4:30 AM. The facility's failure constituted substandard quality of care. R1 exited the rear exit door of the 200 Hall (COVID quarantine unit) on 1/4/22 at approximately 4:30 AM. During the time outside the facility (estimated to be 30-45 minutes), R1 walked out the back entrance of the 200 Hall (COVID quarantine unit) on 1/4/22 around 4:30 AM and was wearing a wander guard that did not alarm with an assortment of clothes with no jacket or shoes. Per an interview with the Laundry Aide (LA), the staff member who found R1, the weather was noted to be in the mid-30s and chilly. R1 was observed in the parking lot of the facility and knocked on the Laundry Aide's driver side door stating, I'm cold. R1 was brought back into the facility and assessed by Certified Nursing Assistant (CNA)2 and Registered Nurse (RN) 1 with no signs or symptoms of harm. On 1/6/22 at 2:05 PM, the Administrator was notified of Immediate Jeopardy (IJ) at F600: Free from Abuse and Neglect related to the failure to adequately monitor residents with wanderguards, in an effort to prevent elopement The immediate jeopardy at F600 was determined to first exist on 1/4/22 at 4:30 AM, when R1 was observed outside of the facility unsupervised by a staff member. The facility presented a removal plan for IJ at F600 on 1/7/22. The IJ was removed on 1/7/22 at 3:13 PM. The deficient practice remained at F600 at a lower scope and severity of D. The findings include: Review of facility policy titled Abuse, Neglect and Exploitation last reviewed 6/23/21 revealed, it is the policy to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect exploitation and misappropriation of resident property. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. R1 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 had not tested positive for COVID-19. Review of R1's Quarterly Minimum Data Set, dated dated dated [DATE] revealed she had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, which indicated she was not cognitively intact. Review of R1's Care Plan dated 11/19/21 revealed R1 is an elopement risk/wanderer as evidenced by impaired safety awareness. The goals are to assess for fall risk, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books. Following the elopement on 1/4/22, her care plan was updated to include during late evenings and during nights, staff to be stationed at exit door area. Wander guard bracelet applied to left ankle. An interview on 1/5/22 at approximately 2:05 PM with the Laundry Aide (LA) revealed that she (Laundry Aide) was in the back parking, having just arrived to start her shift when she saw someone near Hall 400 and thought it was a ghost. As I was getting my wits, there was knocking on my car window. I lowered window and the person stated, I'm cold. At first, I wasn't sure that it was a real person, but I touched her, and it was a woman who was wearing an odd assortment of items but was not wearing shoes or a jacket. It was in the mid-30s, no rain or wind, but very cold and there had been frost on my wind shield. She (the resident) was wearing a wander guard and I took her to the nearby kitchen entrance because I knew the cook would be in there. I entered the code number to get inside, but the wander guard did not trigger an alarm when we entered. The Cook went to the 300/400 Hall and returned with a nurse. The nurse stated R1 was not one of her residents and escorted us to the 200 Hall. At this time, it was noted she was R1 from the 200 Hall (COVID quarantine unit). I took her to the double doors of the 200 Hall where there were 2 CNAs on duty and an Agency Nurse. LA then stated, None of them even knew that R1 was missing. When asked what happened after R1 was returned to the unit, she stated, I think the Agency Nurse took her to her room. R1 did not appear to be hurt, only saying she was cold. An interview on 1/5/22 at approximately 2:25 PM with the Director of Nursing (DON) revealed they notified me about the elopement at home at approximately 6:00 AM and I immediately made an assignment that all exit doors be manned since I didn't know if the alarm system was functioning or not. The DON stated that the electronic monitoring systems are checked daily on wandering residents and later that morning it was determined that the alarm system was working. During a walk through with the Surveyor, the DON showed there is only one Hall 200 exit door to the outside and explained how she thought R1 found her way to the parking lot from the exit door, down a ramp with handrail to the area where the LA encountered R1. Distance was determined to be approximately 75 feet. The DON stated that the Resident Representative frequently visits and always likes to take R1 around the building. The DON then stated, I had asked her not to do this because her mother was an elopement risk. The DON stated, she definitely eloped. The DON stated that CNA1, CNA2 and the Agency Nurse had not returned her phone calls. An interview with the Maintenance Director (MD) on 1/5/22 at approximately 2:40 PM revealed that he had been informed that alarms might not be working by 1st shift staff on 1/4/22 at approximately 7:00 AM. He checked all doors throughout the building and found they were working, as well enunciators near all nursing stations. He checks all door weekly, and Signal Technologies last checked during July 2020, but further checks were put on hold because of the pandemic. The MD stated that the alarm system does not record the time of alarm. The MD and Surveyor toured the 200 Hall (COVID quarantine with closed entrance doors). There was no antenna on exit door to detect a wander guard and the exit door could only be opened by pressing against it for 15 seconds. The MD did so, and the alarm sounded loudly and could be easily heard full length of 200 Hall, as well as down the adjacent open hallway for approximately 75-100 feet. The MD stated that the enunciator sound and blinking light is set up to occur near every nursing station in the building. This was verified to be the case by the Surveyor. The MD walked back to the exit door to turn off the alarm and stated, it cannot be turned off from anywhere else in the building. A phone interview on 1/6/22 at approximately 11:00 AM with the Resident Representative for R1 stated she had not been informed of her mother's elopement and became very irate. She further stated that she visited R1 almost daily prior to the COVID outbreak and has had ongoing concerns about the facility and quality of care but did not elaborate further on her concerns. On 1/6/22 at 11:20 AM, the Maintenance Director stated he checks door alarms monthly, but because of the recent change in ownership he could not access those records and that the new company's record keeping system had just been implemented this month. A phone interview with CNA2 on 1/6/22 at approximately 1:05 PM revealed R1 was outside the building for approximately 30-45 minutes before being discovered in the back parking lot by the LA. CNA 2 stated that she did a quick body audit on the resident then put her back into bed. When asked what the nurse did to assist the R1, CNA2 stated that Agency Nurse 1 did absolutely nothing. Attempts were made to contact Agency Nurse 1 with no success. The facility's removal plan for F600 included the following: 1. 1:1 staff implement on 1/4/2022. This 1:1 was discontinued after an assigned staff member was placed at the exit door to eliminate potential elopement risk. This staff member can view the entire hallway and all exit doors on the hall. The care plan for Resident #1 was updated on 1/5/2022 by the Director of Nursing to reflect the addition of a staff member posted at the exit door. Resident #1 will continue to receive psychiatric services. Resident #1 is scheduled to be seen by a Psychiatric Doctor on 1/7/2022 to evaluate the current plan of care related to exit-seeking behaviors. Placement and function of wander guard bracelet on Resident #1 confirmed on 1/4/2022 by the Director of Nursing. 2. Residents currently in the facility with a Brief Interview for Mental Status (BIMS) score of 8 or less were assessed by 1/6/2022 using the elopement evaluation. 10 residents currently in the facility have a BIMS score of 4 or less and 4 of those 10 residents were determined to be at potential risk for elopement. The Wander/Elopement Risk book was reviewed by the Director of Nursing on 1/4/2022 to ensure all residents that were assessed as at risk for wandering/elopement were identified in the book. The book was found to be accurate and up to date. Resident with wander guard bracelets will have monitoring of placement daily by a Licensed Nurse and documentation added to an electronic record with a start date of 1/5/2022. 3. The Maintenance Director checked 100% of the facility doors on 1/4/2022 and found all doors and alarms function correctly. Staff education on Abuse, Neglect and Exploitation procedures for managing residents with risk for wandering and elopement, notification, process, and response to door alarms and resident safety started on 1/4/2022 and will be continued with staff by 1/7/2022. Any staff members not scheduled between 1/4/2022 and 1/7/2022 will be educated before they return to work. 3 Elopement drills will be conducted weekly for 4 weeks across various shifts, then 2 times per week for 4 weeks, then weekly for 4 weeks, or until substantial compliance is achieved. Facility doors will be checked by the Maintenance Director (Manager on Duty on the weekends) daily for 4 weeks then 3 times per week for 4 weeks then weekly for 4 weeks to ensure all doors within the facility lock/release and alarm appropriately. This task will be conducted weekly, moving forward, by the Maintenance Director. New admission referrals will be screened prior to admission to determine the resident's history of wandering and elopement. New admissions will be assessed at the time of admission using the Wandering/Elopement Evaluation section of the All-Inclusive Admission Evaluation. A resident identified as at-risk will be added to the Elopement/ Wandering book, have a wander guard placed if appropriate, and a wandering/elopement care plan with individualized intervention. The facility will install a contract staff orientation process that will include, at minimum a- Incident reporting procedures b- Notification process for resident events c- List of door codes d- Overview of the Emergency Operation Plan e- Location of Elopement Book/How to identify residents that are at risk for wandering/elopement f- Managing residents that are at risk for wandering/elopement- The Director of Nursing will audit any event and interventions taken to prevent further elopements. The administrator will review the results of all audits in QAPI monthly for 3 months or until substantial compliance. Allegation of Compliance: 1/7/2022

Based on review of the medical record and interviews, the facility failed to ensure Resident (R)1 was free from accident hazards related to wandering/elopement. Specifically, facility staff failed to prevent R1 from elopement from the facility on 1/4/22 at 4:30 AM. The facility's failure constituted substandard quality of care. R1 exited the rear exit door of the 200 Hall (COVID quarantine unit) on 1/4/22 at approximately 4:30 AM. During the time outside the facility (estimated to be 30-45 minutes), R1 walked out the back entrance of the 200 Hall (COVID quarantine unit) on 1/4/22 around 4:30 AM and was wearing a wander guard that did not alarm with an assortment of clothes with no jacket or shoes. Per an interview with the Laundry Aide (LA), the staff member who found R1, the weather was noted to be in the mid-30s and chilly. R1 was observed in the parking lot of the facility and knocked on the Laundry Aide's driver side door stating, I'm cold. R1 was brought back into the facility and assessed by Certified Nursing Assistant (CNA)2 and Registered Nurse (RN) 1 with no signs or symptoms of harm. On 1/6/22 at 2:05 PM, the Administrator was notified of Immediate Jeopardy (IJ) at F689: Free of Accident Hazards/Supervision/Devices related to the failure to adequately monitor residents with wanderguards, in an effort to prevent elopement The IJ at F689 was determined to first exist on 1/4/22 at 4:30 AM, when R1 was observed outside of the facility unsupervised by a staff member. The facility presented an acceptable removal plan for the IJ at F689 on 1/7/22. After confirmation of implementation of the removal plan by interview and observations, the IJ was removed on 1/7/22 at 3:13 PM. The deficient practice remained at F689 at a lower scope and severity of D following the removal of the immediate jeopardy. The findings include: R1 was admitted to the facility on [DATE] and had diagnoses including, but not limited to [CONDITION(S)] disease: Chronic, progressive with [CONDITION(S)], Questionable [CONDITION(S)], had been assessed as being a wanderer and was quarantined to the quarantine unit due to contact with a COVID positive roommate. R1 had not tested positive for COVID-19. Review of R1's Quarterly Minimum Data Set, dated dated dated [DATE] revealed she had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, which indicated she was not cognitively intact. Review of R1's Care Plan dated 11/19/21 revealed R1 is an elopement risk/wanderer as evidenced by impaired safety awareness. The goals are to assess for fall risk, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books. Following the elopement on 1/4/22, her care plan was updated to include during late evenings and during nights, staff to be stationed at exit door area. Wander guard bracelet applied to left ankle. An interview on 1/5/22 at approximately 2:05 PM with the Laundry Aide (LA) revealed that she (Laundry Aide) was in the back parking, having just arrived to start her shift when she saw someone near Hall 400 and thought it was a ghost. As I was getting my wits, there was knocking on my car window. I lowered window and the person stated, I'm cold. At first, I wasn't sure that it was a real person, but I touched her, and it was a woman who was wearing an odd assortment of items but was not wearing shoes or a jacket. It was in the mid-30s, no rain or wind, but very cold and there had been frost on my wind shield. She (the resident) was wearing a wander guard and I took her to the nearby kitchen entrance because I knew the cook would be in there. I entered the code number to get inside, but the wander guard did not trigger an alarm when we entered. The Cook went to the 300/400 Hall and returned with a nurse. The nurse stated R1 was not one of her residents and escorted us to the 200 Hall. At this time, it was noted she was R1 from the 200 Hall (COVID quarantine unit). I took her to the double doors of the 200 Hall where there were 2 CNAs on duty and an Agency Nurse. LA then stated, None of them even knew that R1 was missing. When asked what happened after R1 was returned to the unit, she stated, I think the Agency Nurse took her to her room. R1 did not appear to be hurt, only saying she was cold. An interview on 1/5/22 at approximately 2:25 PM with the Director of Nursing (DON) revealed they notified me about the elopement at home at approximately 6:00 AM and I immediately made an assignment that all exit doors be manned since I didn't know if the alarm system was functioning or not. The DON stated that the electronic monitoring systems are checked daily on wandering residents and later that morning it was determined that the alarm system was working. During a walk through with the Surveyor, the DON showed there is only one Hall 200 exit door to the outside and explained how she thought R1 found her way to the parking lot from the exit door, down a ramp with handrail to the area where the LA encountered R1. Distance was determined to be approximately 75 feet. The DON stated that the Resident Representative frequently visits and always likes to take R1 around the building. The DON then stated, I had asked her not to do this because her mother was an elopement risk. The DON stated, she definitely eloped. The DON stated that CNA1, CNA2 and the Agency Nurse had not returned her phone calls. An interview with the Maintenance Director (MD) on 1/5/22 at approximately 2:40 PM revealed that he had been informed that alarms might not be working by 1st shift staff on 1/4/22 at approximately 7:00 AM. He checked all doors throughout the building and found they were working, as well enunciators near all nursing stations. He checks all door weekly, and Signal Technologies last checked during July 2020, but further checks were put on hold because of the pandemic. The MD stated that the alarm system does not record the time of alarm. The MD and Surveyor toured the 200 Hall (COVID quarantine with closed entrance doors). There was no antenna on exit door to detect a wander guard and the exit door could only be opened by pressing against it for 15 seconds. The MD did so, and the alarm sounded loudly and could be easily heard full length of 200 Hall, as well as down the adjacent open hallway for approximately 75-100 feet. The MD stated that the enunciator sound and blinking light is set up to occur near every nursing station in the building. This was verified to be the case by the Surveyor. The MD walked back to the exit door to turn off the alarm and stated, it cannot be turned off from anywhere else in the building. A phone interview on 1/6/22 at approximately 11:00 AM with the Resident Representative for R1 stated she had not been informed of her mother's elopement and became very irate. She further stated that she visited R1 almost daily prior to the COVID outbreak and has had ongoing concerns about the facility and quality of care but did not elaborate further on her concerns. On 1/6/22 at 11:20 AM, the Maintenance Director stated he checks door alarms monthly, but because of the recent change in ownership he could not access those records and that the new company's record keeping system had just been implemented this month. A phone interview with CNA2 on 1/6/22 at approximately 1:05 PM revealed R1 was outside the building for approximately 30-45 minutes before being discovered in the back parking lot by the LA. CNA 2 stated that she did a quick body audit on the resident then put her back into bed. When asked what the nurse did to assist the R1, CNA2 stated that Agency Nurse 1 did absolutely nothing. Attempts were made to contact Agency Nurse 1 with no success. The removal plan included for F689 included: 1. 1:1 staff was implemented on 1/4/2022. This 1:1 was discontinued after an assigned staff member was placed at the exit door to eliminate potential elopement risk. This staff member can view the entire hallway and exit doors on the hall. The care plan for resident # was updated on 1/5/2022 by the Director of Nursing to reflect the addition of a staff member posted at the exit door. Resident # will continue to receive psychiatric services. Resident is scheduled to be seen by the Physician on 1/7/2022 to evaluate the current plan of care related to exit seeking behaviors. Placement and function of wander guard bracelet on Resident # confirmed on 1/4/2022 by the Director of Nursing. 2. Residents currently in the facility with a BIMS score of 8 or less were assessed by 1/6/2022 using the elopement evaluation. 10 residents currently in the facility have a BIMS score of 4 or less and 4 of these 10 residents were determined to be at potential risk for elopement. The Wander/Elopement Risk book was reviewed by the Director of Nursing on 1/4/2022 to ensure all residents that were assessed as at risk for wandering/elopement were identified in the book. The book was found to be accurate and up to date. Residents with wanderguard bracelets will have monitoring of placement daily by a Licensed Nurse and documentation added to electronic record with a start date of 1/5/2022. 3. The Maintenance Director checked 100% of the facility doors on 1/4/2022 and found all doors and alarms functioning correctly. Staff education on procedures for managing residents at risk for wandering and elopement, notification, process and response to door alarms and resident safety started on 1/4/2022 and will be completed by staff by 1/7/2022. Any staff members not scheduled between 1/4/2022 and 1/7/2022 will be educated before they return to work. 4. 3 elopement drills will be conducted weekly for 4 weeks across various shifts then 2 times per week for 4 weeks then weekly for 4 weeks or until substantial compliance is achieved. Facility doors will be checked by the Maintenance Director (Manager on Duty on the weekends) daily for 4 weeks then 3 times per week for 4 weeks then weekly for 4 weeks to ensure all doors within the facility lock/release and alarm appropriately. This task will be conducted weekly, moving forward, by the Maintenance Director. New admission referrals will be screened prior to admission to determine resident's history for wandering and elopement. New admissions will be assessed at the time of admission using the Wandering/Elopement Evaluation section of the All-Inclusive Admission Evaluation. Residents identified at risk will be added to the Elopement/Wandering book, have a wanderguard placed if appropriate and a wandering/elopement care plan with individualized interventions. The facility will install a contract staff orientation process that will include, at a minimum: a. Incident reporting procedures b. Notification reporting procedures c. List of door codes d. Overview of the emergency operations plan e. Location of Elopement Book/ How to identify residents that are at risk for wandering/elopement f. Managing residents that are at risk for wandering/elopement The Director of Nursing will audit any event requiring an incident report daily x 4 weeks, then weekly x 8 weeks to ensure notification to family and physician occurs timely. 5. Ad hoc QAPI meeting held on 1/6/2022 to discuss the event and interventions taken to prevent further elopements. Administrator will review the results of all audits in QAPI monthly x 3 months or until substantial compliance is achieved. Allegation of Compliance: 1/7/2022

Based on observation, record review, and interview, the facility failed to ensure 2 of 2 sampled residents remained free from physical abuse (rough handling). Resident #63 reported abuse by agency personnel to a staff nurse which was not reported to the administrator or State agency and therefore not investigated. Resident #40 reported rough handling by staff member which was not fully investigated by the facility or reported to State Agency. The findings included: Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an interview on 4/09/18 at approximately 10:41 AM, Resident #40 reports, Sometimes staff are not nice. The Administrator comes to check in on me since my wound issue and said that it wasn't acceptable. Resident #40 continued stating, Agency aides are not nice, they are belligerent. My roommate was not handled well by them and he/she hollers in pain, he/she didn't get to come to room when he/she wanted to due to pain. They put him/her in a room and shut the door. (RN #3) came in at night and made my leg worse, he/she said that he/she needed to do something to get checked off on it, I said I would call my lawyer if he/she came back in. My leg did not have any open areas on it anymore, just 3 little scabs, until that nurse got hold of it. Nurse Practitioner (NP) progress notes reviewed on 4/10/18 at approximately 03:10 PM, revealed Skin is observed to be warm, dry, and intact. Bilateral lower extremities remain pinkish-red in coloration and skin is very thin. The abrasion to the patient's right lower abdomen has closed. Patient's skin is free from any signs/symptoms of pressure areas. Behavioral Health progress notes reviewed on 04/09/18 at approximately 11:54 AM, revealed the resident to be oriented to person, place, and time during the session on 3/22/18. The resident complained that she (he) did not want (RN #3) the wound nurse, doing her (his) left leg. She (He) noted that RN #3 took care of her (his) leg either at night or over the weekend- she (he) is not sure which. Explained that she (he) needs to bring these concerns up with her (his) Nurse Practitioner (NP). Behavioral Health progress notes from the session on 4/5/18, revealed the resident to be oriented to person, place, and time. She (He) noted that she (he) was seen by her (his) wound care doctor yesterday; and, she (he) expressed some concern regarding the wound on her (his) leg. She (He) stated that she (he) does not like it when (RN #3), the wound nurse, attends to her (him) and would rather deal with her (his) physician. She (He) states that she (he) spoke with administrator and was advised by this clinician that she (he) should leave it in his (her) hands. During an interview on the morning of 4/11/18, Resident #40 complained of pain. The Resident described the incident that happened on 3/13/18, stating, I was asleep and all of the sudden that nurse was doing something on my leg and it really hurt. I yelled and said I would call my lawyer if it didn't stop. That nurse never even asked my permission. During an interview on 4/11/18 at approximately 10:10 AM regarding the incident that occurred 3/13/18, RN #3 stated, On the day of the incident I went in to do a skin sweep at about 10 PM. I saw a dressing on the left lower leg and said that I was worried about a tear occurring from it pulling on her (his) leg, probably placed by a floor nurse. When asked about providing pain medication before the dressing change, RN #3 stated, S/he always gets a pain medication at night, even though it is as needed, s/he always asks for it. RN #3 continued stating, I removed the foam dressing and noticed a few small open areas of dark pink tissue, no drainage but it needed to be covered. So, I recovered the area with a non-adherent gauze and wrapped in Kerlix. Then I notified the Nurse Practitioner (NP) through the on-call service and the NP gave an order for [REDACTED].>Record review on 04/10/18 at approximately 03:29 PM, revealed Resident #40 had an appointment with the Wound Center on 4/3/18 at 2:30 PM for a Left Lower Leg Posterior venous leg ulcer. the Wound Center documentation shows the Wounding Event as trauma with zero weeks of treatment prior. The wound (#12) is open, measuring 14 x 8 x 0.1 centimeters (cm) with a medium amount of serosanguinous drainage. Order for a dressing of Xeroform gauze, absorbent bandage and Kerlix, change daily and as needed. Return to clinic in 2 weeks. Review of the grievance report on 04/14/18 at approximately 12:02 PM, revealed the incident occurred on 3/13/18 at approximately 10 PM. The investigation is dated 3/16/18, incident report dated 3/18/18, and the Director of Nursing (DON) completed the incident report and investigation. The DON interviewed RN #3, whose statement included a Certified Nursing Assistant (CNA) that was present during the incident. The DON also interviewed the resident. The DON then signed the off the incident as resolved because RN will no longer do treatments to resident, however, the incident was not fully investigated by the facility or reported to State Agency. The CNA in the incident was not contacted. The facility did not fully investigate the incident or report it to State Agency. During an interview the morning of 04/14/18, the DON and Administrator verified the investigation was complete after reviewing the incident. The DON verified no contact was made with the CNA. During a follow up interview on 04/14/18 at 11:40 AM, when asked about the incident follow up, Resident #40 stated, I don't think the DON was honest in her (his) report. The facility admitted Resident #63 with [DIAGNOSES REDACTED]. Review of the 3-17-18 Quarterly Minimum Data Set assessment on 4-14-18 at 1:29 PM revealed that Resident #63 had a Brief Interview for Mental Status (BIMS) score of 15, indicating s/he was cognitively intact. During an interview on 4-11-18 at 9:36 AM, when asked about the bruises on her/his forearms, Resident #63 stated s/he had hand prints on her/his arm and leg from an agency Certified Nursing Assistant (CNA) being rough. S/he pulled back the covers to show the areas where s/he stated the CNA had grabbed her/him. There did not appear to be any bruising on the resident's upper leg where s/he indicated. However, when Resident #63 pulled the sleeve of her/his gown up and over her/his left shoulder, there were bruises on the upper left arm that appeared to be resolving yellow and red fingerprints. When asked about when this had occurred, the resident stated weeks ago. S/he was unable to specify the date or shift. When asked if s/he had reported the incident to anyone, the resident stated s/he had reported it to the nurse on duty and the CNA never came back. When asked, the resident was unable to recall the name of the nurse to whom s/he had reported the incident. During a second interview on 4-12-18 at 2:32 PM, Resident #63 reported the same information, but stated, It's no big deal. Review of (MONTH) through (MONTH) Nurses Notes at 1:25 PM on 4-12-18 revealed no documentation of reported rough handling. Review of the grievance log on 4-11-18 at 10:28 AM revealed no entry for this resident related to rough handling. The incident was reported to the Administrator immediately after review of the grievance log. The Administrator stated s/he had not been advised of the incident and therefore had not reported the allegation to the State Agency or initiated an investigation to date. S/he stated, I will talk with the resident and initiate an investigation today. Review of the Agency Orientation Checklist and packet on 4-14-18 revealed that the orientation did include 24. Resident Rights/Abuse and Neglect. Review of 52 files of temporary agency staff (licensed nurses and Certified Nursing Assistants) on the current availability/use roster on 4-14-18 revealed the following: (1) 28 files had no evidence of completion of orientation or lacked completion prior to start date. (2) 50 files had no evidence of State-required background checks prior to start date. (3) 11 files had no verification of current license or certification. During an interview on 4-14-18 at 4:15 PM, the above information was reviewed and verified by the Administrator and/or Human Resources. No further information was provided. Review of the policy entitled Abuse, Neglect, and Misappropriation of Patient Property Prevention (4-21-06) provided by the facility revealed it had not been updated with the 11-16 and 11-17 changes in regulations. It did not address screening and orientation of agency personnel. The policy stated: The center must ensure that all alleged violations involving mistreatment .or abuse .are reported immediately to the administrator of the center and to other officials in accordance with state law .

Based on observation, record reviews, interviews, and review of the policy entitled Abuse, Neglect, and Misappropriation of Patient Property Prevention (4-21-06), staff failed to implement written policies and procedures related to reporting allegations of abuse for 1 of 2 sampled residents reviewed for abuse. Resident #63 reported an incident of rough handling to the nurse which was not documented and reported to the Administrator. The findings included: The facility admitted Resident #63 with [DIAGNOSES REDACTED]. Review of the 3-17-18 Quarterly Minimum Data Set assessment on 4-14-18 at 1:29 PM revealed that Resident #63 had a Brief Interview for Mental Status (BIMS) score of 15, indicating s/he was cognitively intact. During an interview on 4-11-18 at 9:36 AM, when asked about the bruises on her/his forearms, Resident #63 stated s/he had hand prints on her/his arm and leg from an agency Certified Nursing Assistant (CNA) being rough. S/he pulled back the covers to show the areas where s/he stated the CNA had grabbed her/him. There did not appear to be any bruising on the resident's upper leg where s/he indicated. However, when Resident #63 pulled the sleeve of her/his gown up and over her/his left shoulder, there were bruises on the upper left arm that appeared to be resolving yellow and red fingerprints. When asked about when this had occurred, the resident stated weeks ago. S/he was unable to specify the date or shift. When asked if s/he had reported the incident to anyone, the resident stated s/he had reported it to the nurse on duty and the CNA never came back. When asked, the resident was unable to recall the name of the nurse to whom s/he had reported the incident. During a second interview on 4-12-18 at 2:32 PM, Resident #63 reported the same information, but stated, It's no big deal. Review of (MONTH) through (MONTH) Nurses Notes at 1:25 PM on 4-12-18 revealed no documentation of reported rough handling. Review of the grievance log on 4-11-18 at 10:28 AM revealed no entry for this resident related to rough handling. During an interview at this time, the Administrator stated s/he had not been advised of the incident and therefore had not reported the allegation to the State Agency. Review of the Agency Orientation Checklist and packet on 4-14-18 revealed that the orientation did include 24. Resident Rights/Abuse and Neglect. Review of 52 files of temporary agency staff (licensed nurses and Certified Nursing Assistants) on the current availability/use roster on 4-14-18 revealed that 28 files had no evidence of completion of orientation or lacked completion prior to start date. During an interview on 4-14-18 at 4:15 PM, the above information was reviewed and verified by the Administrator and/or Human Resources. No further information was provided. Review of the policy entitled Abuse, Neglect, and Misappropriation of Patient Property Prevention (4-21-06) provided by the facility revealed it had not been updated with the 11-16 and 11-17 changes in regulations. It did not address screening and training of agency personnel. The policy did state: The center must ensure that all alleged violations involving mistreatment .or abuse .are reported immediately to the administrator of the center and to other officials in accordance with state law . Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an interview on 4/09/18 at approximately 10:41 AM, Resident #40 reports, Sometimes staff are not nice. The Administrator comes to check in on me since my wound issue and said that it wasn't acceptable. Resident #40 continued stating, Agency aides are not nice, they are belligerent. My roommate was not handled well by them and he/she hollers in pain, he/she didn't get to come to room when he/she wanted to due to pain. They put him/her in a room and shut the door. (RN #3) came in at night and made my leg worse, he/she said that he/she needed to do something to get checked off on it, I said I would call my lawyer if he/she came back in. My leg did not have any open areas on it anymore, just 3 little scabs, until that nurse got ahold of it. Nurse Practitioner (NP) progress notes reviewed on 4/10/18 at approximately 03:10 PM, revealed Skin is observed to be warm, dry, and intact. Bilateral lower extremities remain pinkish-red in coloration and skin is very thin. The abrasion to the patient's right lower abdomen has closed. Patient's skin is free from any signs/symptoms of pressure areas. Behavioral Health progress notes reviewed on 04/09/18 at approximately 11:54 AM, revealed the resident to be oriented to person, place, and time during the session on 3/22/18. The resident complained that she (he) did not want (RN #3) the wound nurse, doing her (his) left leg. She (He) noted that RN #3 took care of her (his) leg either at night or over the weekend- she (he) is not sure which. Explained that she (he) needs to bring these concerns up with her (his) Nurse Practitioner (NP). Behavioral Health progress notes from the session on 4/5/18, revealed the resident to be oriented to person, place, and time. She (He) noted that she (he) was seen by her (his) wound care doctor yesterday; and, she (he) expressed some concern regarding the wound on her (his) leg. She (He) stated that she (he) does not like it when (RN #3), the wound nurse, attends to her (him) and would rather deal with her (his) physician. She (He) states that she (he) spoke with administrator and was advised by this clinician that she (he) should leave it in his (her) hands. During an interview on the morning of 4/11/18, Resident #40 complained of pain. The Resident described the incident that happened on 3/13/18, stating, I was asleep and all of the sudden that nurse was doing something on my leg and it really hurt. I yelled and said I would call my lawyer if it didn't stop. That nurse never even asked my permission. During an interview on 4/11/18 at approximately 10:10 AM regarding the incident that occurred 3/13/18, RN #3 stated, On the day of the incident I went in to do a skin sweep at about 10 PM. I saw a dressing on the left lower leg and said that I was worried about a tear occurring from it pulling on her (his) leg, probably placed by a floor nurse. When asked about providing pain medication before the dressing change, RN #3 stated, S/he always gets a pain medication at night, even though it is as needed, s/he always asks for it. RN #3 continued stating, I removed the foam dressing and noticed a few small open areas of dark pink tissue, no drainage but it needed to be covered. So, I recovered the area with a non-adherent gauze and wrapped in Kerlix. Then I notified the Nurse Practitioner (NP) through the on-call service and the NP gave an order for [REDACTED].>Record review on 04/10/18 at approximately 03:29 PM, revealed Resident #40 had an appointment with the Wound Center on 4/3/18 at 2:30 PM for a Left Lower Leg Posterior venous leg ulcer. The Wound Center documentation shows the Wounding Event as trauma with zero weeks of treatment prior. The wound (#12) is open, measuring 14 x 8 x 0.1 centimeters (cm) with a medium amount of serosanguinous drainage. Order for a dressing of Xeroform gauze, absorbent bandage and Kerlix, change daily and as needed. Return to clinic in 2 weeks. Review of the grievance report on 04/14/18 at approximately 12:02 PM, revealed the incident occurred on 3/13/18 at approximately 10 PM. The investigation is dated 3/16/18, incident report dated 3/18/18, and the Director of Nursing (DON) completed the incident report and investigation. The DON interviewed RN #3, whose statement included a Certified Nursing Assistant (CNA) that was present during the incident. The DON also interviewed the resident. The DON then signed the off the incident as resolved because RN will no longer do treatments to resident, however, the incident was not fully investigated by the facility or reported to State Agency. The CNA in the incident was not contacted. The facility did not fully investigate the incident or report it to State Agency. During an interview the morning of 04/14/18, the DON and Administrator verified the investigation was complete after reviewing the incident. The DON verified no contact was made with the CNA. During a follow up interview on 04/14/18 at 11:40 AM, when asked about the incident follow up, Resident #40 stated, I don't think the DON was honest in her report.

Based on observation, limited record review, and interview, the facility failed to report allegations of abuse to the State Agency for 1 of 2 residents reviewed for abuse. Resident #40 reported rough handling by a staff member. The findings included: Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an interview on 4/09/18 at approximately 10:41 AM, Resident #40 reports, Sometimes staff are not nice. The Administrator comes to check in on me since my wound issue and said that it wasn't acceptable. Resident #40 continued stating, Agency aides are not nice, they are belligerent. My roommate was not handled well by them and he/she hollers in pain, he/she didn't get to come to room when he/she wanted to due to pain. They put him/her in a room and shut the door. (RN #3) came in at night and made my leg worse, he/she said that he/she needed to do something to get checked off on it, I said I would call my lawyer if he/she came back in. My leg did not have any open areas on it anymore, just 3 little scabs, until that nurse got hold of it. Nurse Practitioner (NP) progress notes reviewed on 4/10/18 at approximately 03:10 PM, revealed Skin is observed to be warm, dry, and intact. Bilateral lower extremities remain pinkish-red in coloration and skin is very thin. The abrasion to the patient's right lower abdomen has closed. Patient's skin is free from any signs/symptoms of pressure areas. Behavioral Health progress notes reviewed on 04/09/18 at approximately 11:54 AM, revealed the resident to be oriented to person, place, and time during the session on 3/22/18. The resident complained that she (he) did not want (RN #3) the wound nurse, doing her (his) left leg. She (He) noted that RN #3 took care of her (his) leg either at night or over the weekend- she (he) is not sure which. Explained that she (he) needs to bring these concerns up with her (his) Nurse Practitioner (NP). Behavioral Health progress notes from the session on 4/5/18, revealed the resident to be oriented to person, place, and time. She (He) noted that she (he) was seen by her (his) wound care doctor yesterday; and, she (he) expressed some concern regarding the wound on her (his) leg. She (He) stated that she (he) does not like it when (RN #3), the wound nurse, attends to her (him) and would rather deal with her (his) physician. She (He) states that she (he) spoke with administrator and was advised by this clinician that she (he) should leave it in his (her) hands. During an interview on the morning of 4/11/18, Resident #40 complained of pain. The Resident described the incident that happened on 3/13/18, stating, I was asleep and all of the sudden that nurse was doing something on my leg and it really hurt. I yelled and said I would call my lawyer if it didn't stop. That nurse never even asked my permission. During an interview on 4/11/18 at approximately 10:10 AM regarding the incident that occurred 3/13/18, RN #3 stated, On the day of the incident I went in to do a skin sweep at about 10 PM. I saw a dressing on the left lower leg and said that I was worried about a tear occurring from it pulling on her (his) leg, probably placed by a floor nurse. When asked about providing pain medication before the dressing change, RN #3 stated, S/he always gets a pain medication at night, even though it is as needed, s/he always asks for it. RN #3 continued stating, I removed the foam dressing and noticed a few small open areas of dark pink tissue, no drainage but it needed to be covered. So, I recovered the area with a non-adherent gauze and wrapped in Kerlix. Then I notified the NP through the on-call service and the NP gave an order for [REDACTED].>Record review on 04/10/18 at approximately 03:29 PM, revealed Resident #40 had an appointment with the Wound Center on 4/3/18 at 2:30 PM for a Left Lower Leg Posterior venous leg ulcer. The Wound Center documentation shows the Wounding Event as trauma with zero weeks of treatment prior. The wound (#12) is open, measuring 14 x 8 x 0.1 centimeters (cm) with a medium amount of serosanguinous drainage. Order for a dressing of Xeroform gauze, absorbent bandage and Kerlix, change daily and as needed. Return to clinic in 2 weeks. Review of the grievance report on 04/14/18 at approximately 12:02 PM, revealed the incident occurred on 3/13/18 at approximately 10 PM. The investigation is dated 3/16/18, incident report dated 3/18/18, and the Director of Nursing (DON) completed the incident report and investigation. The DON interviewed RN #3, whose statement included a Certified Nursing Assistant (CNA) that was present during the incident. The DON also interviewed the resident. The DON then signed the off the incident as resolved because RN will no longer do treatments to resident, however, the incident was not fully investigated by the facility or reported to State Agency. During an interview on 04/14/18 at approximately 12:16 PM with the DON and Administrator, it was verified that the CNA was not contacted, it was not reported to the State Agency and no further investigation of the incident was done. During a follow up interview on 04/14/18 at 11:40 AM, when asked about the incident follow up, Resident #40 stated, I don't think the DON was honest in her (his) report.

Based on observation, limited record review, and interview, the facility failed to do a complete investigation for allegations of abuse for 1 of 2 resident's reviewed for abuse. Resident #40 reported rough handling by a staff member. The findings included: Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an interview on 4/09/18 at approximately 10:41 AM, Resident #40 reports, Sometimes staff are not nice. The Administrator comes to check in on me since my wound issue and said that it wasn't acceptable. Resident #40 continued stating, Agency aides are not nice, they are belligerent. My roommate was not handled well by them and he/she hollers in pain, he/she didn't get to come to room when he/she wanted to due to pain. They put him/her in a room and shut the door. (RN #3) came in at night and made my leg worse, he/she said that he/she needed to do something to get checked off on it, I said I would call my lawyer if he/she came back in. My leg did not have any open areas on it anymore, just 3 little scabs, until that nurse got hold of it. Nurse Practitioner (NP) progress notes reviewed on 4/10/18 at approximately 03:10 PM, revealed Skin is observed to be warm, dry, and intact. Bilateral lower extremities remain pinkish-red in coloration and skin is very thin. The abrasion to the patient's right lower abdomen has closed. Patient's skin is free from any signs/symptoms of pressure areas. Behavioral Health progress notes reviewed on 04/09/18 at approximately 11:54 AM, revealed the resident to be oriented to person, place, and time during the session on 3/22/18. The resident complained that she (he) did not want (RN #3) the wound nurse, doing her (his) left leg. She (He) noted that RN #3 took care of her (his) leg either at night or over the weekend- she (he) is not sure which. Explained that she (he) needs to bring these concerns up with her (his) Nurse Practitioner (NP). Behavioral Health progress notes from the session on 4/5/18, revealed the resident to be oriented to person, place, and time. She (He) noted that she (he) was seen by her (his) wound care doctor yesterday; and, she (he) expressed some concern regarding the wound on her (his) leg. She (He) stated that she (he) does not like it when (RN #3), the wound nurse, attends to her (him) and would rather deal with her (his) physician. She (He) states that she (he) spoke with administrator and was advised by this clinician that she (he) should leave it in his (her) hands. During an interview on the morning of 4/11/18, Resident #40 complained of pain. The Resident described the incident that happened on 3/13/18, stating, I was asleep and all of the sudden that nurse was doing something on my leg and it really hurt. I yelled and said I would call my lawyer if it didn't stop. That nurse never even asked my permission. During an interview on 4/11/18 at approximately 10:10 AM regarding the incident that occurred 3/13/18, RN #3 stated, On the day of the incident I went in to do a skin sweep at about 10 PM. I saw a dressing on the left lower leg and said that I was worried about a tear occurring from it pulling on her (his) leg, probably placed by a floor nurse. When asked about providing pain medication before the dressing change, RN #3 stated, S/he always gets a pain medication at night, even though it is as needed, s/he always asks for it. RN #3 continued stating, I removed the foam dressing and noticed a few small open areas of dark pink tissue, no drainage but it needed to be covered. So, I recovered the area with a non-adherent gauze and wrapped in Kerlix. Then I notified the NP through the on-call service and the NP gave an order for [REDACTED].>Record review on 04/10/18 at approximately 03:29 PM, revealed Resident #40 had an appointment with the Wound Center on 4/3/18 at 2:30 PM for a Left Lower Leg Posterior venous leg ulcer. The Wound Center documentation shows the Wounding Event as trauma with zero weeks of treatment prior. The wound (#12) is open, measuring 14 x 8 x 0.1 centimeters (cm) with a medium amount of serosanguinous drainage. Order for a dressing of Xeroform gauze, absorbent bandage and Kerlix, change daily and as needed. Return to clinic in 2 weeks. Review of the grievance report on 04/14/18 at approximately 12:02 PM, revealed the incident occurred on 3/13/18 at approximately 10 PM. The investigation is dated 3/16/18, incident report dated 3/18/18, and the Director of Nursing (DON) completed the incident report and investigation. The DON interviewed RN #3, whose statement included a Certified Nursing Assistant (CNA) that was present during the incident. The DON also interviewed the resident. The DON then signed the off the incident as resolved because RN will no longer do treatments to resident, however, the incident was not fully investigated by the facility or reported to State Agency. During an interview on 04/14/18 at approximately 12:16 PM with the DON and Administrator, it was verified that the CNA was not contacted, it was not reported to the State Agency and no further investigation of the incident was done. During a follow up interview on 04/14/18 at 11:40 AM, when asked about the incident follow up, Resident #40 stated, I don't think the DON was honest in her (his) report.

Based on record review and interview, the facility failed to provide sufficient nursing staff coverage on 30 of 51 days reviewed. The findings included: Resident #444 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On (MONTH) 23, (YEAR), a complaint was filed to the State Agency by a concerned family member of Resident #444 indicating the resident had been left for an hour or more in soiled clothes and is not receiving proper care. Record review on 04/13/18 at 2:47p.m. revealed documentation of the resident's toileting attempts or checks revealed inconsistent time frames, potentially leaving the resident in soiled clothing, for extended periods of time. Review of the POS [REDACTED]. During an interview with LPN#1, s/he indicated there had been times in the past, where the facility was short-staffed, resulting in delay of care. S/he could not recall amy incidents related to Resident #444. Cross Refer CFR 483,10(a)(1)(2)(b)(1)(2) F550 The facility failed to provide care and services in a manner that maintained residents' dignity for 4 of 7 actively participating members in the Resident Council meeting and 3 random observations on 2 of 3 units. Resident #16, #46, and #442 had to wait extended periods of time to be assisted to the bathroom resulting in incontinence and/or wait to be assisted with incontinent care. Resident #50 was observed from the corridor, fully exposed except for a towel across his/her midsection for a period of 15 minutes without staff intervention. Resident #8 was observed from the corridor, exposed from the waist down with a disposable brief visible for a period of 15 minutes without staff intervention. Resident #73 was observed being transported in the corridor on a shower gurney with his/her catheter drainage bag in full view. During the Resident Council meeting on 4-11-18 at 2 PM, Residents #16, #46, and #442 stated they had to wait 30 minutes to 3 hours to be assisted to the bathroom, resulting in incontinence. Residents #16, #46, #442, and #55 also stated they had to wait the same amount of time to be assisted with incontinent care. Resident #55 stated s/he did not get pullups when s/he needed them, resulting in remaining wet/soiled for long periods of time. Residents #16 and #46 stated that it was embarrassing and uncomfortable to be left wet for a long time. Resident #16 stated her/his issue was that s/he doesn't get changed in a timely manner. They say that they can do it after lunch or dinner. The CNAs (Certified Nursing Assistants) say they cannot change you during breakfast, lunch or dinner. It does not matter what hall you are on. My call light was on for an hour and there was nobody. There was one CNA for the entire floor on the 200 hall on 11-7. This happened on Saturday night, three nights ago. There were two nurses at the nurses station and it was past shift change time. Resident #16 stated s/he had waited so long s/he finally had to struggle to use a transfer board to get out of bed to go to the nurses station her/himself to get help. During an interview on 04/13/18 at 09:45 AM, Resident #16 stated s/he was incontinent due to spinal problems. S/he had multiple fusions, back surgeries. The resident re-stated that it was embarrassing when s/he was left wet. It affects your self image when you cannot get help when you need it. Resident #9 stated,There's not enough staff if someone calls in sick. If they get in agency people, they don't know anything. They cannot keep any people. On 04/14/18 at 10:12 AM, Resident #50 was observed for a period of 15 minutes with his/her room door open. S/he appeared to be bathing him/herself, sitting on the bed, facing the door with only a towel draped across his/her genitals. The curtain was not pulled to afford the resident privacy. Two staff members were standing in the corridor talking at a medication cart without acknowledging the condition of the resident. The resident was visible to any passersby in the hallway. On 04/12/18 at 08:23 AM, Resident #8 was in the bed nearest the doorway and observed from the corridor with the lower half of his/her body fully exposed from feet to waist. A disposable brief was visible. Two Certified Nursing Assistants (CNAs) were passing out breakfast trays, passing the room multiple times as the tray cart was located between this and the neighboring room in the hallway. Registered Nurse (RN) #2 was also noted in the hall, supervising and assisting with tray delivery. CNA #1 delivered trays to both residents in this room without pulling the privacy curtain, covering the resident or speaking to the resident about the condition. All staff were repeatedly passing the room without addressing this condition for over 15 minutes. During an interview on 4-13-18 at 3:43 PM, the Senior Administrator stated s/he would expect staff to address the exposed residents immediately. During Resident Council, when asked if residents got baths when they needed or wanted them, Resident #16 stated,We get a bath every 2 days if there is someone there to help you on the 300 hall. If there is an emergency then there is simply not enough staff. If something is going on with another resident then you do not get your bath. 5 of 7 residents actively participating in the Resident Council stated they did not get their medications in a timely manner on both day and evening shifts. Resident #39 stated s/he has received his/her long acting 8 AM insulin as late as 11 AM. Residents #13 and #9 stated that the 9 AM medications sometimes came at almost 12 noon. Resident #9 stated evening medicine they have received as late as 2 or 3 in the morning. Cross Refer CFR 483.10(f)(1)-(3)(8) F561 Facility staff failed to ensure that 2 of 2 residents attending Resident Council who smoked had the opportunity to exercise his or her choices to participate in this activity that was important to them. The facility failed to support and accommodate Residents #16 and #47 with their smoking choices/preferences. During the Resident Council meeting on 4-11-18 at 2 PM, Residents #16 identified her/himself as a smoker and stated that facility staff did not adhere to established smoking times. They do not take us out to smoke when they are supposed to. Resident #47 shook his/her head obviously in agreement. When asked about the designated times, Resident #16 stated, 10 AM for 15 minutes, 2 PM for 15 min and 7 PM for 15 minutes. When asked how often they did not get to go on time, Resident #16 responded s/he almost always had to go find someone to take them out. There's no lighting out there and there's no covered area for the smokers, so staff don't want to take us out at all when it's dark or raining. Resident #39, who was not a smoker, agreed the staff did not follow the policy. S/he stated, When you go to look for people to take them out to smoke, the staff response is I am too busy. S/he stated that the units rotated responsibility but they should probably just assign someone to take the smokers out. Resident #16 said, I always go and get someone when I want to smoke and I am going to keep on doing that until I leave here. During an observation on 4-12-18 from 10-10:25 AM, no residents or staff were observed in the smoking area. Resident #47 was observed in the front lobby in a wheelchair. Later, Resident #47 was observed seated in the front lobby in a wheelchair prior to 2 PM. Resident #16 returned from an appointment and came into the lobby at 2:10 PM. At 2:15 PM, the Receptionist stated, I have been trying to call the unit to take (Resident #47) to smoke but no one is answering. At 2:18 PM, staff arrived to assist the residents to the smoking area. During the survey, no other residents were observed in the smoking area. When Resident Council members were asked if they got their beds made, 2 of the 7 active participants stated they had to make their own bed if they wanted it done. Three residents stated they never got their beds made. When the Council members were asked about meal service, 5 of the 7 stated they were served in their rooms. Residents #9 and #39 stated they had gotten their breakfasts as late as 10 AM. Resident #9 stated, It's hard to eat lunch when just finished breakfast. Resident #9 stated s/he has received her/his dinner tray at late as 7 PM. Review of the facility assessment on 4/13/18 at 10:00 AM revealed that the C.N.A. to resident ratios are as follows for each shift: 7-3 shift: 1 C.N.A. for every 9 residents. 3-11 shift: 1 C.N.A. for every 13 residents 11-7 shift: 1 C.N.A. for every 22 residents. Review of documentation provided by facility of Posted Nursing Hours staffing completed on 4/13/18 at 11:30 AM revealed that the State mandated ratios of Certified Nursing Assistant to Resident ratios failed to meet both regulatory compliance and guidelines outlined in the facility assessment during 13 shifts between 1/18/18 and 1/26/18 and during 30 shifts between 3/1/2018 and 4/11/2018. Specific information regarding the dates 1/18/18-1/26/18 as follows: 1/18/18: night shift-Census 88 residents, #C.N.A.'s=3 / ratio of C.N.A. to resident=1:29.3 1/19/18: evening shift-Census 92 residents, #C.N.A.'s=4 / ratio of C.N.A. to resident=1:23 1/20/18: day shift-Census 91 residents, #C.N.A.'s=9 / ratio of C.N.A. to resident=1:10.11 1/21/18: day shift-Census 91 residents, #C.N.A.'s=9 / ratio of C.N.A. to resident=1:10.11 1/21/18: night shift-Census 91 residents, #C.N.A.'s=4 / ratio of C.N.A. to resident=1:22.75 1/22/18: day shift-Census 89 residents, #C.N.A.'s=8 / ratio of C.N.A. to resident=1:11.12 1/22/18: evening shift-Census 89 residents, #C.N.A.'s=5/ ratio of C.N.A. to resident=1:17.8 1/24/18: day shift-Census 90 residents, #C.N.A.'s=7/ ratio of C.N.A. to resident=1:12.85 1/24/18: night shift-Census 90 residents, #C.N.A.'s=3 / ratio of C.N.A. to resident=1:30 1/25/18: day shift-Census 92 residents, #C.N.A.'s=8 / ratio of C.N.A. to resident=1:11.5 1/25/18: evening shift-Census 92 residents, #C.N.A.'s=6 / ratio of C.N.A. to resident=1:15.3 1/25/18: night shift-Census 92 residents, #C.N.A.'s=4 / ratio of C.N.A. to resident=1:23 1/26/18: evening shift-Census 92 residents, #C.N.A.'s=6 / ratio of C.N.A. to resident=1:15.3 Specific information regarding the dates 3/1/18-4/11/18 as follows: 3/5/18: day shift-Census 80 residents, #C.N.A.'s=8/ ratio of C.N.A. to resident=1:10 3/6/18: day shift-Census 86 residents, #C.N.A.'s=8/ ratio of C.N.A. to resident=1:10.75 3/7/18: day shift-Census 87 residents, #C.N.A.'s=8.5 / ratio of C.N.A. to resident=1:10.2 3/8/18: day shift-Census 86 residents, #C.N.A.'s=8 / ratio of C.N.A. to resident=1:10.75 3/10/18: day shift-Census 86 residents, #C.N.A.'s=9 / ratio of C.N.A. to resident=1:9.5 3/10/18: night shift-Census 86 residents, #C.N.A.'s=3 / ratio of C.N.A. to resident=1:28.67 3/11/18: evening shift-Census 84 residents, #C.N.A.'s=6 / ratio of C.N.A. to resident=1:14 3/14/18: day shift-Census 87 residents, #C.N.A.'s=8.5 / ratio of C.N.A. to resident=1:10.2 3/15/18: day shift-Census 89 residents, #C.N.A.'s=9 / ratio of C.N.A. to resident=1:9.89 3/15/18: evening shift-Census 89 residents, #C.N.A.'s=6.5 / ratio of C.N.A. to resident=1:13.69 3/16/18: evening shift-Census 88 residents, #C.N.A.'s=6.5 / ratio of C.N.A. to resident=1:13.5 3/22/18: day shift-Census 89 residents, #C.N.A.'s=9 / ratio of C.N.A. to resident=1:9.88 3/23/18: day shift-Census 87 residents, #C.N.A.'s=7 / ratio of C.N.A. to resident=1:12.4 3/24/18: day shift-Census 88 residents, #C.N.A.'s=8.5 / ratio of C.N.A. to resident=1:10.35 3/24/18: evening shift-Census 88 residents, #C.N.A.'s=6/ ratio of C.N.A. to resident=1:14.6 3/25/18: day shift-Census 88 residents, #C.N.A.'s=9 / ratio of C.N.A. to resident=1:9.77 3/25/18: night shift-Census 88 residents, #C.N.A.'s=2/ ratio of C.N.A. to resident=1:44 3/26/18: day shift-Census 88 residents, #C.N.A.'s=7.5 / ratio of C.N.A. to resident=1:11.73 3/28/18: evening shift-Census 85 residents, #C.N.A.'s=6/ ratio of C.N.A. to resident=1:14.16 3/31/18: day shift-Census 87 residents, #C.N.A.'s=7 / ratio of C.N.A. to resident=1:12.42 4/2/18: day shift-Census 88 residents, #C.N.A.'s=8 / ratio of C.N.A. to resident=1:11 4/2/18: evening shift-Census 88 residents, #C.N.A.'s=6.5 / ratio of C.N.A. to resident=1:13.5 4/5/18: night shift-Census 93 residents, #C.N.A.'s=3 / ratio of C.N.A. to resident=1:31 4/6/18: night shift-Census 93 residents, #C.N.A.'s=4 / ratio of C.N.A. to resident=1:23.31 4/7/18: day shift-Census 92 residents, #C.N.A.'s=8 / ratio of C.N.A. to resident=1:11.5 4/7/18: night shift-Census 92 residents, #C.N.A.'s=4 / ratio of C.N.A. to resident=1:23 4/8/18: day shift-Census 92 residents, #C.N.A.'s=9 / ratio of C.N.A. to resident=1:10.22 4/8/18: evening shift-Census 92 residents, #C.N.A.'s=6.5 / ratio of C.N.A. to resident=1:14.15 4/8/18: night shift-Census 92 residents, #C.N.A.'s=4 / ratio of C.N.A. to resident=1:23 4/11/18: day shift-Census 87 residents (for 7-3 shift), #C.N.A.'s=9 / ratio of C.N.A. to resident=1:9.88 During interview with Director of Nursing (DON) and Staffing Coordinator on 4/13/18 at 12:45 PM, both verified that according to the Heartland Nursing Service Daily Staffing Control Sheets for the dates identified above and the Posted Nursing Hours documentation provided for review on 4/12/18, the facility did not meet the requirement for C.N.A. to resident ratios over all shifts between the dates of 3/1/18 and 4/11/18. Both DON and Staffing Coordinator reported that the facility utilized licensed nurses functioning in the role of C.N.A. for some of the identified shifts, however they could not provide evidence of this on either staffing control sheets or with daily assignment documentation for those identified dates with inadequate C.N.A. to resident ratios. DON verified in later interview on 4/13/18 at 2:30 PM that the facility did not meet the requirement for C.N.A. to resident ratios over all shifts between the dates of 1/18/18 and 1/26/18.

Based on review of facility files and interviews, the facility failed to ensure each resident remained free from physical abuse. Resident #1 was observed to be physically abused by Certified Nursing Assistant (CNA) #1. CNA #1 hit Resident #1 in the resident's room. The incident was witnessed by an employee. One of five residents reviewed for abuse. The findings included: The facility reported an allegation of physical abuse for Resident #1 by CNA #1 to the State Agency on 3/27/17. Review of the facility's Five Day Follow-Up Report dated 4/3/17 indicated after review of statements it was determined that the incident did occur. Staff observed CNA #1 hit Resident #1 on his/her forearm. House Keeping Staff's facility-obtained statement indicated s/he saw and heard CNA #1 hit resident real hard on the hand and forearm. Resident #1 said Ow real loud. During an interview on [DATE] at 11:31 AM with House Keeping Supervisor it was revealed housekeeping staff came to her immediately to report the incident that occurred with Resident #1 and CNA #1. The Housekeeping Supervisor reported the incident to the Administrator and the Director of Nursing. The Administrator and Director of Nursing took CNA #1 and began an investigation. In a telephone interview with housekeeping staff on [DATE] at 4:25 PM. S/He stated the CNA #1 was transferring Resident #1 and Resident #1 hit CNA #1 and CNA #1 hit the resident twice on the hand. CNA #1's facility obtained statement indicated that Resident #1 was making a swatting motion and CNA #1 did the same. CNA #1 admitted s/he hit the resident. In a telephone interview with the surveyor on [DATE] at 4:43 PM, CNA #1 stated s/he did not want to further discuss the situation that occurred. Have moved on and what is done is done.

Based on review of facility files, interviews and the facility's policy entitled Patient Protection, the facility failed to implement policies to ensure each resident remained free from abuse. Resident #1 was observed to be physically abused by Certified Nursing Assistant (CNA) #1. CNA #1 hit Resident #1 in the resident's room. The incident was witnessed by an employee. One of five residents reviewed for abuse. The facility reported an allegation of physical abuse for Resident #1 by CNA #1 to the State Agency on 3/27/17. Review of the facility's Five Day Follow-Up Report dated 4/3/17 indicated after review of statements it was determined that the incident did occur. Staff observed CNA #1 hit Resident #1 on his/her forearm. House Keeping Staff's facility-obtained statement indicated s/he saw and heard CNA #1 hit the resident real hard on the hand and forearm. Resident #1 said Ow real loud. During the interview on [DATE] at 11:31 AM with House Keeping Supervisor it was revealed housekeeping staff came to her immediately to report the incident that occurred with Resident #1 and CNA #1. Housekeeping Supervisor reported the incident to the Administrator and the Director of Nursing. The Administrator and Director of Nursing took CNA#1 and began an investigation. In a telephone interview with housekeeping staff on [DATE] at 4:25 PM. s/he stated the CNA #1 was transferring Resident #1 and Resident #1 hit CNA #1 and CNA #1 hit the resident twice on the hand. CNA #1's facility obtained statement indicated that Resident #1 was making a swatting motion and CNA #1 did the same. CNA #1 admitted s/he hit the resident. In a telephone interview with the surveyor on [DATE] at 4:43 PM, CNA #1 stated s/he did not want to further discuss the situation that occurred. Have moved on and what is done is done. Review of the facility's Patient Protection on page 4 under 4[AGE].12 Freedom from abuse, neglect, and exploitation: The resident has the right to be free from abuse . defined in this subpart.

Based on observations, record review, and resident and staff interviews, the facility failed to assure 2 of 4 residents reviewed for pain recognition and management (R22 and R260) were able to promptly access ordered medications to control pain symptoms, and the facility failed to ensure skin concerns were identified, treated and monitored until resolved for 1 of 34 sampled residents (R126). The failure resulted in R260 being transported to a hospital emergency room for treatment of [REDACTED]. Findings include: According to Resident (R)260's profile page of his electronic medical record (EMR), R260 was a male who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R260's Medication Administration Review (MAR) for January 2017, revealed R260 received [MEDICATION NAME] ER (extended release) 20 milligrams (mg) 2 times a day routinely for pain. The MAR further revealed the resident had an order for [REDACTED]. A nursing progress note in R260's clinical record, dated 1/7/17 at 5:26 a.m. indicated the resident reported he had fallen. An assessment of his surgical wound to his right leg stump revealed some bleeding from the site. The next progress note assessing the resident's wound was not until 1/11/17 at 2:00 p.m. when the nurse removed his staples. The note did not include a description of the wound. Record review of the Nursing Progress Notes in R260's clinical record dated 1/17/17 at 12:08 a.m. indicated the resident complained of excruciating pain to his stump. The note revealed there was no available narcotic at that time. Another note on the same day at 12:51 a.m. revealed the resident was transported to the emergency room for pain, per the physician's orders [REDACTED]. On 1/17/17 at 9:38 a.m., Resident (R)260 was interviewed. R260 reported he was not getting the care he needed. According to R260, he ended up at the hospital last night (1/16/17). He said he was in a lot of pain. R260 said the facility was out of the pain medicine ordered for him. He said instead of re-ordering when they knew he was running out, they let it run out. R260 said the emergency room physician told him he might end up having more amputation on his stump. R260 revealed on a scale of 1-10 (10 representing severe/ excruciating pain) his pain was at 20 on the night he was transported to the emergency room . A review of the hospital's Emergency Provider Report, dated 1/17/17 at 1:19 a.m., revealed R260 arrived at the emergency room with complaints of pain related to his recent below the knee right leg amputation. The report revealed the resident also complained that his dressing to his stump had not been changed in 3 days. The hospital report further indicated the resident received [MEDICATION NAME] (a narcotic pain medication) for his moderate pain to his right leg (stump) and [MEDICATION NAME] (an antibiotic) for an infection to his stump, assessed by the emergency room physician. The report further revealed, R260's pain was listed at a severity of moderate. The assessment of the resident's surgical wound on his right stump was assessed as mild wound dehiscence (opening up of the incision). Mild [DIAGNOSES REDACTED] (redness). A review of the nursing progress notes revealed no indication this had been assessed or reported to the resident's physician prior to the emergency room visit for pain. During an interview, on 1/19/17 1:41 p.m. with Unit Manager (UM)114 regarding R260's pain med running out, she said they were unable to locate the medication. She explained that meant they ran out of R260's [MEDICATION NAME]. Note: [MEDICATION NAME] is a narcotic [MEDICATION NAME] used for pain management. She said they had no new prescription or the ability to get one immediately. UM114 indicated the procedure for reordering narcotics was to place the request in the book when there were only 10 tablets remaining, for the provider/ physician/ prescriber to see and write the prescription. She said this was put in the book on 1/15/17 but no prescription was written. According to UM114, a provider (physician) was at the facility on the 1/16/17, but she was not sure why the prescription was not written. UM114 said any physician could have written the prescription. She said since they were unable to resolve the issue with the prescription quickly, R260 was sent out to the emergency room . When asked about the antibiotic the resident returned from the emergency room with, she said she had performed the wound dressing change on R260's stump the day prior to his transport and there were no signs or symptoms of an infection on 1/16/17. An interview with Unit Manager (UM)115, on 1/20/17 at 9:20 a.m., who was over the unit R260 lived on, and observations of the facility Pyxis available medications, revealed there was no [MEDICATION NAME] in their emergency medications stored in the Pyxis machine (Pyxis is a medication dispensing machine). She said it was the responsibility of the resident's nurse to monitor the medication to ensure a new prescription for the pain medication was obtained. She confirmed, though the nurse would place the medication label on the Narcotic Request Log for the physicians to see and leave a prescription, it is ultimately up to the nurse assure the prescription is obtained. She shared that physicians are in the building all the time and if the prescription is not obtained, the nurse could let her know so she can retrieve the prescription. She said all other routine medications were on an automatic renewal. 2. R22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was documented to have scored a 14/15 on her Brief Interview for Mental Status, which indicated no cognitive impairment. In regard to pain, the 30 Day MDS documented R22 had frequent pain and received scheduled pain medication. In the 5 days prior to her pain assessment, R22 stated the worst her pain had been was an 8/10 (with 0 being no pain and a 10 the worst pain ever experienced). She was also documented to have non medication pain interventions and no specific signs of pain were noted. The Staff Assessment of Pain Indicators portion of the MDS was not completed. An initial interview with R22 took place on 1/17/17 at 10:45 a.m. When asked about her pain control, she stated only the red pill worked for pain. She also stated she got pain medication every 6 hours, but only if she asked. R22 said due to some short term memory loss, she forgets and winded up waiting for them to just bring it. She stated that she sometimes fell asleep and woke up with same horrible headache because she did not get anything for it. The resident was observed to place both hands on the sides of her head and moan three times during the interview. When asked if she wanted to continue, she stated yes. A second interview with R22 on 1/18/17 beginning at 8:45 a.m. occurred in the presence of a family member who knew R22 well. Both stated they thought her pain was getting worse. R22 was observed holding her head on each side with her hands and moan. She was ready to leave for [MEDICAL TREATMENT] and was waiting on transportation. She stated the pain was excruciating and that she had told a CNA (Certified Nurse Aide) at least 30 minutes ago. At this time, the unidentified medication nurse was contacted and asked if she had been advised of R22's pain complaint. She stated, no; she was advised R22 stated her pain was excruciating. The nurse stated she would be right there. Then R22 was notified the nurse would bring her medication. Next the paramedics arrived to transport R22 to [MEDICAL TREATMENT]. They stated they would wait until R22 received her pain medication. It had been approximately 10 minutes since the nurse was contacted. The medication nurse was again contacted and advised of the resident's pain level, as well as letting her know R22's transport was waiting. The nurse delivered pain medication to R22 approximately 3 minutes later, and at least 40 minutes after letting the CNA know she had excruciating pain and wanted prn pain medication. The facility had completed a PAINAD (Pain/Pain Assessment in Advanced Dementia) evaluation dated 1/7/17. It documented her highest level of pain had been an 8/10 and that her pain goal was a 0/10 - she wanted to have no pain. Pain was documented to occur in the frontal part of her head, both lower legs and lower mid back. Exacerbating conditions were position changes. Relieving factors were repositioning, sleep, change in environment (dark, quiet) and medications. The care plan response section read, in pertinent part: Focus: (R22) c/o (complains of) H/A (headache) s/p (status [REDACTED]. Intervention: Notify physician if pain frequency/ intensity is worsening or if current [MEDICATION NAME] regimen has become ineffective . monitor nonverbal expressions of pain such as moaning, striking out, grimacing, crying, thrashing, change in breathing. Review of the care plan showed the following documentation in R22's clinical record, in pertinent part: Focus: (R22) c/o H/A s/p craniotomy, fungal meningitis. Date Initiated: 12/01/2016 . Goal: Will express that pain management is within acceptable limits. Date Initiated: 12/01/2016 . Interventions/Tasks: -Monitor nonverbal expressions of pain such as moaning, striking out, grimacing, crying, thrashing, change in breathing, etc. Date Initiated: 12/09/2016 -Administer pain medication per physician's orders [REDACTED]. Date Initiated: 12/01/2016 -Notify physician if pain frequency/ intensity is worsening or if current [MEDICATION NAME] . R22s pain medication management regimen was documented via Medication Administration Records (MARs): a. December Medication Administration Record [REDACTED] [MEDICATION NAME] (an anticonvulsant, sometimes ordered as an off-label medication used for neurological pain) 100 mg twice a day for pain (ordered on [DATE]). [MEDICATION NAME] (a combination [MEDICATION NAME]/ barbiturate combination drug) 50/325/40 mg (50 mg [MEDICATION NAME]/ 325 mg [MEDICATION NAME]/ 40 mg caffeine) give 1 tablet by mouth every 6 hours as needed for headache. Do not exceed greater than 3 grams of APAP ([MEDICATION NAME]) in a 24 hr period. Medication discontinued on 12/27/16. Midrin (combination [MEDICATION NAME] medication) give 2 capsules by mouth every hour as needed for the onset of headache, followed by 1 capsule every hour until relieved. Max 5 capsules in 12 hour period (ordered on [DATE] and started on 12/28/16). [MEDICATION NAME] (opiod [MEDICATION NAME]) 50 mg, give half a tablet by mouth every 6 hours as needed for pain (ordered on [DATE]). Tylenol 325 mg ([MEDICATION NAME]), give 2 tablets by mouth every 4 hours as needed for pain (ordered on [DATE] and discontinued on 12/11/16). b. January Medication Administration Record [REDACTED] [MEDICATION NAME] (an anticonvulsant, sometimes ordered as an off-label medication used for neurological pain) 100 mg twice a day for pain (ordered on [DATE]). Tylenol 325 mg ([MEDICATION NAME]), give 2 tablets by mouth every 4 hours as needed for pain (ordered on [DATE] and discontinued on 12/11/16). NOTE: while documented as having been given to R22 on 1/5/17 and 1/8/17, the medication had been previously discontinued on 12/11/16. A second order to discontinue the medication was received on 1/9/17. Midrin (combination [MEDICATION NAME] medication), give 2 capsules by mouth every hour as needed for the onset of headache, followed by 1 capsule every hour until relieved. Max 5 capsules in 12 hour period (ordered on [DATE] and started on 12/28/16). [MEDICATION NAME] (opioid [MEDICATION NAME]) 50 mg, give half a tablet by mouth every 6 hours as needed for pain. It was ordered on [DATE] and the MAR indicated [REDACTED]. Review of the December 2016 Pain Assessment - revealed that R22 was assessed for pain during each of the three shifts (Day, Evening and Night Shifts) upon admission 12/1/16. Her pain was assessed 91 times and was documented to be greater than 5/10 (0 being no pain and 10 being the worst pain ever experienced) on 9 occasions. Review of the January 2017 Pain Assessment - revealed that R22 was assessed for pain during each of the three shifts (Day, Evening and Night Shifts) from 1/1/17 through days shift on 1/19/17. Her pain was assessed 54 times and was documented to be greater than 5/10 (0 being no pain and 10 being the worst pain ever experienced) on 14 occasions. An interview with the facility Medical Director (who was also the primary care physician for R22) occurred on 1/19/17 at 1:09 p.m. She stated neither she nor her Nurse Practitioner (NP) had been advised that R22 felt her pain was not well controlled. She was not aware the nursing staff had documented an increase in her pain levels. She acknowledged the nursing staff were to notify her (or her NP) of ineffectiveness of pain medication and/or any increase in pain. When asked about R22's care plan reflecting a goal of pain being within an acceptable level for R22, which was zero, the Medical Director stated she was not specifically aware R22 had a goal of zero pain and that might not be realistic. The Medical Director also stated that an ophthalmology referral, a neurology referral and a psychiatric referral had all been ordered for R22. Record review revealed those orders had been made by the primary care physician on 1/19/17 for neurology and ophthalmology. The referral for a psychiatric evaluation was written on 1/20/17. 3. According to the Admission Record Report viewed on 1/20/17, R126 had the following pertinent Diagnoses: [REDACTED]. The 12/12/16 annual Minimum Data Set (MDS) documented in section C (Cognitive Patterns) that the resident had a Brief Interview of Mental Status (BIMS) score of 15/15 indicating no cognitive impairment. Section G functional status identified that she required total assist of one for bathing. Section M (Skin Conditions) documented that there were no current skin issues. Review on 1/19/17 of the current care plan initiated on 2/17/14 identified the following: Focus: R126 was identified at risk for complications related to [MEDICAL CONDITION]. Goal: Will not experience acute exacerbation requiring hospitalization . Interventions/ Tasks: Administer medications/ treatments as ordered. Obtain Lab results as ordered and notify physician of results. Report evidence of fresh bruising. Review of the January 2017 computerized physician orders [REDACTED]. According to R126's January 2017 MAR, body audits were completed on 1/2/17, 1/9/17 and 1/16/17; no skin concerns were documented. The January 2017 progress notes for 1/2/17, 1/9/17 and 1/16/17 revealed there were no nursing notes on those days which addressed the resident's skin condition or findings from the body audit. Review of the Shower/ Skin Observation Report dated 12/16/16, 12/19/16, 12/21/16, 12/23/16-refused, 12/26/16, 12/28/16, 12/30/16, 1/2/17, 1/4/17-refused, 1/6/17, 1/9/17 and 1/16/17 revealed nothing was documented on the report regarding R126's right forearm discoloration. R126 was observed and interviewed on 1/16/17 at 2:09 p.m. with a brown discoloration approximately 1.5 inches long by .5 inches wide on her right forearm below the elbow. She said the discoloration had been there for a long time and it was because her arm rubbed against her wheelchair arm rest that was cracked and rough. She stated she has told multiple staff members about it. On 1/19/17 at 10:35 a.m. nursing staff 108 was interviewed. She was unaware R126 had the discoloration, and she went to R126's room. The resident was again observed at this time with the same brown discoloration on her right forearm below the elbow. The resident showed the nurse her elbow, informed the nurse that it was due to her cracked arm rests and that she had the discoloration for a long time now. On 1/19/17 at1:55 p.m. nurse staff 108 confirmed nursing should have been documenting the discoloration on the weekly skin sheet/ body audit and the CNA staff should have documented on the Shower/ Skin Observation Report the resident had a discoloration on her right forearm. R126 was subsequently interviewed on 1/19/17 at 3:50 p.m. She said her arm did not bother her and she had reported it to a CNA who said it would be documented on the shower sheet, and she said the CNA was no longer working there. She stated the arm rest had been cracked for a long time, but today she was given new arm rests. Review of the CPO's (Computerized Physician Orders) for January 2017 revealed a new order to monitor discoloration to the right elbow every shift. Every shift- ordered on [DATE] at 7:00 a.m. On 1/20/17 10:53 a.m. the Quality Assurance Coordinator (QAC) stated that it was her expectation that nursing staff identify a skin issue on the resident shower days or on their weekly skin audit whichever came first and that they document it on the sheets. On 1/19/17 during an interview with central supply staff 39 she stated she replaced resident #126's arm rests today as nursing staff informed her they needed to be replaced. She discussed that they usually try to keep wheelchair parts such as arm rests in stock. She had approximately 13 on hand.

Based on record review and staff interviews, the facility failed to ensure ordered medications were maintained in adequate supply and available for 1 of 22 core sampled residents (R260). Even though Resident (R)260's pain to his recent right leg below the knee amputation was frequent and severe, the facility did not maintain a stock of his prn (as needed) medication to address his breakthrough pain. This failure resulted in R260 experiencing excruciating pain which required his transportation by ambulance from the facility to a local emergency room for treatment of [REDACTED]. Findings include: According to Resident (R)260's profile page of his electronic medical record (EMR), R260 was a male who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During an interview with R260, on 1/1716 at 9:38 a.m. R260 said he was not getting the care he needed. According to R260, he ended up at the hospital last night (1/16/17). He said he was in a lot of pain. R260 said the facility was out of the pain medicine ordered for him. He said instead of re-ordering when they knew he was running out, they let it run out. R260 said the emergency room physician told him he might end up having more amputation on his stump. R260 revealed on a scale of 1-10 (10 representing severe/ excruciating pain) his pain was at 20 on the night he was transported to the emergency room . Record review of the Nursing Progress Notes in R260's clinical record dated 1/17/17 at 12:08 a.m. indicated the resident complained of excruciating pain to his stump. The note revealed there was no available narcotic at that time. Another note on the same day at 12:51 a.m. revealed the resident was transported to the emergency room for pain, per the physician's orders [REDACTED]. According to the resident's Medication Administration Review (MAR) for January 2017, R260 received Oxycodone ER (extended release) 20 milligrams (mg) 2 times a day routinely for pain. The MAR further revealed the resident had an order for [REDACTED]. An interview with Unit Manager (UM)115, on 1/20/17 at 9:20 a.m., who was over the unit R260 lived on, and observations of the facility Pyxis available medications, revealed there was no Endocet in their emergency medications stored in the Pyxis machine (Pyxis is a medication dispensing machine). She said it was the responsibility of the resident's nurse to monitor the medication to ensure a new prescription for the pain medication was obtained. She confirmed, though the nurse would place the medication label on the Narcotic Request Log for the physicians to see and leave a prescription, it is ultimately up to the nurse assure the prescription is obtained. She shared that physicians are in the building all the time and if the prescription is not obtained, the nurse could let her know so she can retrieve the prescription. She said all other routine medications were on an automatic renewal. A review of the facility's policy on New Orders for Schedule II Controlled Substances dated 12/1/07 and last revised 1/1/13, indicated a new written prescription was required to dispense Schedule II, III, and IV controlled substances, unless there was an emergency. In emergencies, in the States where permitted, the medication could be retrieved from the emergency box if a written prescription was faxed to the pharmacy. However, as noted in the above interview, R260's prn medication was not included in the drugs maintained in the emergency supply of the Pyxis machine. Instead, R260 had to be transported by emergency ambulance to the local emergency room to be medicated for his pain.