Every finding on record at Union Post Acute

Based on observation, interview, and facility policy review, the facility failed to store foods in accordance with professional food storage standards for labeling and dating for 1 of 1 resident refrigerator observed. Findings included: A facility policy titled, Food Receiving and Storage, revised November 2022, revealed, Refrigerated/ Frozen Storage. 1. All foods stored in the refrigerator or freezer are covered, labeled, and dated ('use by' date). The policy revealed, 7. Refrigerated foods are labeled, dated and monitored so they are used by their 'use-by' date, frozen, or discarded. The policy revealed the section titled Foods and Snacks Kept on Nursing Units indicated, 2. All foods belonging to residents are labeled with the resident's name, the item and the 'use by' date. A tour of the facility D-Wing Nursing Station was conducted with the Dietary Director (DD) on 01/15/2025 at 6:37 AM, revealed the following unlabeled, undated food items, were observed in the refrigerator designated for residents' food: - Two transparent, plastic bowl containers of beef stew. - One gallon-sized bag of cheese slices. - Four brown paper bags containing hamburgers and French fries. - Two plastic bags of fresh fruit. - One transparent, plastic bowl container of chicken and pasta. - One opened carton of Egg Nogg. During an interview on 01/15/2025 at 6:39 AM, the DD stated the food items noted in the refrigerators should have been dated and labeled and did not know why these food items were not disposed of. During an interview on 01/16/2025 at 3:33 PM, Certified Nursing Assistant (CNA)15 stated staff who put a food item in the refrigerator for a resident were to label the item with the resident's name, date, and resident room number. CNA15 further stated that it was everyone's responsibility to make sure it was done. During an interview on 01/16/2025 at 3:39 PM, CNA16 stated that all foods should be labeled with the resident name and the date and that it was everyone's responsibility. CNA16 further stated that she can admit it hasn't been getting done. During an interview on 01/16/2025 at 4:15 PM, Licensed Practical Nurse (LPN)16 stated that residents' personal food items were supposed to be labeled with the resident's name, date, and room number. During a follow-up interview on 01/16/2025 at 4:36 PM, the DD stated that prior to that week it was her understanding that the third shift nurse was responsible for cleaning out the resident refrigerator. During an interview on 01/17/2025 at 3:11 PM, the Director of Nursing (DON) stated that when food was brought in it should be labeled with the resident's name and date. The Administrator was interviewed on 01/17/2025 at 3:55 PM. The Administrator stated that he expected all food to be dated and labeled prior to being placed in the resident refrigerator.

Based on observation, interview, and facility policy review, the facility failed to ensure 1 (Resident (R)16) of 19 sampled residents was assessed to determine whether the resident could safely self-administer medications prior to keeping the medication at the resident's bedside. Findings included: A facility policy titled, Self-Administration of Medications, revised February 2021, revealed, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. The policy revealed, 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. The policy revealed, 3. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. An Admission Record revealed the facility admitted R16 on 08/29/2023. According to the Admission Record, the resident had a medical history that included diagnoses of chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), acute on chronic diastolic (congestive) heart failure (CHF), and a need for assistance with personal care. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/19/2024, revealed R16 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had shortness of breath or trouble breathing with exertion and when lying flat. R16's Care Plan, included a focus area revised on 11/26/2024, that indicated the resident was at risk for altered respiratory status/difficulty breathing related to diagnoses of COPD, chronic respiratory failure, CHF, and pleural effusion. Interventions directed staff to administer medications/puffers (inhalers) as ordered and to monitor for effectiveness and side effects (initiated 01/12/2024). The Care Plan also indicated that the resident May have inhaler on person (initiated 05/09/2024). The Care Plan did not address whether the IDT had assessed to determine whether self-administration of the inhaler had been deemed safe and clinically appropriate for R16. R16's Order Summary Report for active orders as of 01//15/2025, contained an order dated 08/29/2023 for albuterol sulfate HFA (hydrofluoroalkane) inhalation aerosol solution, inhale two puffs every six hours as needed for shortness of breath/wheezing. The Order Summary Report revealed R16 did not have an order to self-administer any medication. An observation on 01/14/2025 at 11:26 AM revealed an albuterol inhaler lying on R16's bedside table. During a concurrent interview R16 stated that they kept the inhaler on their table and used the inhaler every six hours. R16 further stated the staff left the inhaler with the resident and picked it up when the resident was done. During an interview on 01/16/2025 at 2:20 PM, Certified Nursing Assistant (CNA)20 stated the nursing staff gave R16 their inhaler and left it with the resident to self-administer the medication. CNA20 stated staff picked up the inhaler during their next medication pass. During an interview on 01/16/2025 at 3:54 PM, Licensed Practical Nurse (LPN)21 stated she was aware that R16 had an inhaler in their possession but was not certain whether any resident had been assessed for self-administration of medication. During an interview on 01/16/2025 at 3:58 PM, LPN4 stated she was not aware R16 had albuterol at the bedside until the previous day when R16 mentioned the medication. LPN4 stated she asked the resident where the albuterol came from, and the resident stated they needed it for their breathing but did not tell her where they got the medication. LPN4 stated the resident had not been assessed for self-administration of the medication. During an interview on 01/16/2025 at 4:20 PM, the Director of Nursing (DON) stated that no resident of the facility had been assessed for self-administration of medications. During a follow-up interview on 01/17/2025 at 3:14 PM, the DON stated R16 should not have been self-administering medication without being assessed and having a physician's order to self-administer. The Administrator was interviewed on 01/17/2025 at 3:55 PM. The Administrator stated he expected residents to be evaluated or assessed prior to self- administering medication. The Administrator stated R16 should not have self-administered medication without first being assessed.

Based on observation, interview, record review, and facility policy review, the facility failed to develop and implement a comprehensive person-centered care plan to address contractures, which affected 1 (R29) of 1 resident reviewed for limited range of motion (ROM) concerns. Findings included: A facility policy titled, Care Plans, Comprehensive Person-Centered, revised 03/2022, indicated, 7. The comprehensive, person-centered care plan: included b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment and (3) which professional services are responsible for each element of care. The policy revealed the comprehensive, person-centered care plan also e. reflects currently recognized standards of practice for problem areas and conditions. A facility policy titled, Resident Mobility and Range of Motion, revised 07/2017, revealed the Policy Statement included, 1. Residents will not experience an avoidable reduction in range of motion (ROM). 2. Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. 3. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. The Policy Interpretation and Implementation revealed, 4. The care plan will be developed by the interdisciplinary team based on the comprehensive assessment, and will be revised as needed. 5. The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. 6. Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts. 7. The care plan will include the type, frequency, and duration of interventions, as well as measurable goals and objectives. The resident and representative will be included in determining these goals and objectives. An Admission Record revealed the facility admitted R29 on 05/08/2019. According to the Admission Record, R29 had a medical history that included a diagnosis of unspecified Alzheimer's disease. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/19/2024, revealed R29 had severe impairment in cognitive skills for daily decision-making and had a short-term and long-term memory problem per a Staff Assessment of Mental Status (SAMS). The MDS revealed R29 was dependent upon staff for eating, oral hygiene, toileting hygiene, showers/baths, upper and lower body dressing, putting on and taking off footwear, and personal hygiene. The MDS indicated the resident was dependent on staff for rolling to the left and right, chair/bed-to-chair transfers, and with tub/shower transfers. R29's care plan included a focus area revised on 11/13/2023, that indicated the resident was at risk for general pain evidenced by verbal and nonverbal expressions due to decreased mobility and osteoarthritis. Interventions directed staff to encourage and assist the resident with repositioning frequently to achieve comfort (initiated 08/21/2022). The care plan revealed no documentation that revealed R29 had contractures. An observation on 01/14/2025 at 11:25 AM revealed R29's left hand was contracted. There was nothing observed in the resident's palm to protect their palm from their long fingernails. The resident's legs were observed to be drawn up under sheets. Restorative Nursing Assistant (RNA)3 was interviewed on 01/16/2025 at 10:20 AM. RNA3 stated R29 was on the restorative nursing caseload for feeding. She stated R29's legs and arms were contracted and stated she provided ROM for the resident's legs and arms. Certified Nursing Assistant (CNA)5 was interviewed on 01/16/2025 at 4:50 PM. CNA5 stated she provided care to R29 on the 3:00 PM to 11:00 PM shift. She stated R29 had contractures in their left leg and arms and stated their hands were contracted a little as well. She stated the resident's contractures started within the past year. She stated she was not sure if the resident received any therapy services but stated that at one time restorative aides worked with the resident. CNA5 stated she did not use any devices in the resident's hands to protect the resident's palms but did place pillows between the resident's legs. CNA6 was interviewed on 01/16/2025 at 5:15 PM. CNA6 stated she had worked at the facility for a year and R29 had contractures when she started. CNA6 stated R29's legs and hands were contracted. She stated the resident had a wedge, but the wedge had been lost, so she used pillows to place between the resident's legs. CNA6 stated that when she was assigned to provide care to R29, she placed a folded cloth in the resident's hands. Licensed Practical Nurse (LPN)2 was interviewed on 01/16/2025 at 3:16 PM. LPN2 stated R29 had contractures in their left leg. During a concurrent observation LPN2 went to the resident's room and was unable to open the resident's right hand and was able to open their left hand slightly. LPN2 stated the expectation was for the certified nursing assistants (CNAs) to place a washcloth in the resident's hands to keep the nails from touching the resident's palms. LPN2 stated she was not aware of R29 receiving therapy services or restorative services for their contractures. The MDS Coordinator was interviewed on 01/17/2025 at 10:54 AM. The MDS Coordinator stated she was responsible for addressing nursing issues on the care plan and stated the Director of Nursing (DON) and the Assistant DON (ADON) also added to the care plan. She stated she reviewed orders daily and received verbal reports from staff regarding issues that required care planning. The MDS Coordinator stated contractures were care planned. The MDS Coordinator reviewed R29's care plan and stated the resident's care plan had not included the resident's contractures until the day prior, when she updated it, but stated that she had not added interventions yet. She stated the lack of addressing the contractures in the care plan was an oversight. The DON was interviewed on 01/17/2025 at 3:19 PM. The DON stated she expected contractures, contracture management, and interventions to provide comfort to be addressed in the care plan. The Administrator was interviewed on 01/17/2025 at 4:01 PM. The Administrator stated he expected contractures and any interventions for the resident to be addressed in the care plan.

Based on interview, record review, and facility policy review, the facility failed to ensure a quarterly care plan meeting was held for 1 (Resident (R)37) of 19 sampled residents. Findings included: A facility policy titled, Care Planning- Interdisciplinary Team, revised 03/2022, indicated, 1. Resident care plans are developed according to the timeframes and criteria established by S483.21 [public health code of federal regulations for comprehensive person-centered care planning] The policy revealed, 5. Care Plan meetings are scheduled at the best time of the day for the resident and family when possible. An Admission Record revealed the facility admitted R37 on 06/24/2024. According to the Admission Record, the resident had a medical history that included diagnoses of myotonic muscular dystrophy, unspecified anxiety disorder, unspecified depression, chronic congestive heart failure, and presence of a cardia pacemaker and automatic cardiac defibrillator. R37's IDT [Interdisciplinary Team] Conference Notes, dated 07/11/2024, revealed an admission conference was held. According to the notes, the resident, the resident's guardian, and a family member attended the conference. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/19/2024, revealed R37 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. A quarterly MDS, with an ARD of 12/19/2024, revealed R37 had a BIMS score of 12, which indicated the resident had moderate cognitive impairment. R37's Care Plan, initiated 06/25/2024 revealed the Last Care Plan Review Completed was 12/27/2024. R37's electronic medical record line listing for IDT conference notes revealed there was no documented evidence a quarterly care plan meeting had been held since 07/11/2024. During an interview on 01/14/2025 at 9:45 AM, R37 stated they had not been invited to discuss their care and was unaware there was anything like that (care plan meetings) in place. The Social Services Director (SSD) was interviewed on 01/17/2025 at 7:20 AM. The SSD stated she was responsible for inviting residents to care plan meetings. The SSD stated she kept a log that included the month that each resident's care plan meeting was due. She stated that at the end of the month, she set up a schedule for the following month and sent a list of the residents who were due for a care plan meeting to the receptionist. The SSD stated the receptionist mailed meeting information and delivered a card with care plan meeting information to each resident who was alert and oriented. The SSD reviewed the IDT notes for R37 and revealed the resident did not have a quarterly care plan meeting in 10/2024. The SSD stated it was an oversight. The DON was interviewed on 01/17/2025 at 3:31 PM. The DON stated care plan meetings were held quarterly and as needed. The DON stated she expected residents to be notified of care plan revisions and meetings. The DON stated she was unaware R37's quarterly care plan meeting was missed in 10/2024. The Administrator was interviewed on 01/17/2025 at 4:06 PM. The Administrator stated care plan meetings were expected to be held quarterly, and he expected residents to be invited.

Based on observation, interview, record review, and facility policy review, the facility failed to provide interventions to prevent the development or worsening of contractures for 1 (Resident (R)29) of 1 resident reviewed for limited range of motion concerns. Findings included: A facility policy titled, Resident Mobility and Range of Motion, revised 07/2017, indicated, 1. Residents will not experience an avoidable reduction in range of motion (ROM). 2. Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. 3. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. An Admission Record revealed the facility admitted R29 on 05/08/2019. According to the Admission Record, R29 had a medical history that included a diagnosis of unspecified Alzheimer's disease. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/19/2024, revealed R29 had severe impairment in cognitive skills for daily decision-making and had a short-term and long-term memory problem per a Staff Assessment of Mental Status (SAMS). The MDS revealed R29 was dependent upon staff for eating, oral hygiene, toileting hygiene, showers/baths, upper and lower body dressing, putting on and taking off footwear, and personal hygiene. The MDS indicated the resident was dependent on staff for rolling to the left and right, chair/bed-to-chair transfers, and with tub/shower transfers. R29's care plan included a focus area revised on 11/13/2023, that indicated the resident was at risk for general pain evidenced by verbal and nonverbal expressions due to decreased mobility and osteoarthritis. Interventions directed staff to encourage and assist the resident with repositioning frequently to achieve comfort (initiated 08/21/2022). The care plan revealed no documentation that revealed R29 had contractures. An Admission/Readmission Evaluation, dated 01/24/2023, indicated R29 could move all their extremities and indicated the resident had no impairment in ROM of their upper extremities or their lower extremities. The evaluation also indicated R29 was independent with transferring from a sitting position to a standing position. The Care planning decision indicated the resident was to be transferred with a gait belt. A PT [Physical Therapy] Plan of Care, dated 01/24/2023, indicated R29 had difficulty walking and had generalized muscle weakness. The PT Plan of Care indicated the resident's prognosis was Fair and indicated the resident had impaired balance and impaired mobility. The PT Plan of Care indicated the resident's lower extremities were weak, and R29 received assistance with bed mobility, transfers, and gait [walking style]. The PT Plan of Care revealed the Plan included Gait training and PT was to be provided six times a week for an Expected Treatment Duration of four weeks. Per the PT Plan of Care, R29's prior level of functioning indicated the resident required minimum to moderate assistance from one staff member with their gait, was able to maintain balance when sitting, required moderate assistance from one staff member for transfers, and used a rolling walker and required assistance from one staff member to walk. A hospice Visit Note Report, dated 12/20/2023, revealed R29 had a recent functional decline and was in bed most of the time. The record revealed that previously, the resident had been in a wheelchair most of the day. The note indicated R29 no longer had balance when sitting. The note indicated the resident was unable to walk, was unable to sit up, and was bedbound. An observation on 01/14/2025 at 11:25 AM revealed R29's left hand was contracted. There was nothing observed in the resident's palm to protect their palm from their long fingernails. The resident's legs were observed to be drawn up under sheets. Restorative Nursing Assistant (RNA) #3 was interviewed on 01/16/2025 at 10:20 AM. RNA #3 stated R29 was on the restorative nursing caseload for feeding. She stated R29's legs and arms were contracted and stated she provided ROM for the resident's legs and arms. RNA3 stated she was part-time, and the full-time RNA was on vacation, so there was no one providing restorative services that day. Licensed Practical Nurse (LPN)2 was interviewed on 01/16/2025 at 3:16 PM. LPN2 stated R29 had contractures in their left leg. During a concurrent observation LPN2 went to the resident's room and was unable to open the resident's right hand and was able to open their left hand slightly. LPN2 stated the expectation was for the certified nursing assistants (CNAs) to place a washcloth in the resident's hands to keep the nails from touching the resident's palms. LPN2 stated she was not aware of R29 receiving therapy services or restorative services for their contractures. She stated when the resident was admitted , they were able to stand and get out of their wheelchair. LPN4 was interviewed on 01/16/2025 at 3:37 PM. LPN4 stated that at one time, R29 was up in a wheelchair, walking with the use of handrails, and propelling independently in their wheelchair. LPN4 stated the resident had declined. She stated that at one time the resident received therapy services, but the services were discontinued because the resident had met their potential. LPN4 stated now that R29 was on hospice services and therapy staff would not provide treatment. CNA5 was interviewed on 01/16/2025 at 4:50 PM. CNA5 stated she provided care to R29 on the 3:00 PM to 11:00 PM shift. She stated R29 had contractures in their left leg and arms and stated their hands were contracted a little as well. CNA5 stated R29 had not always had contractures. She stated that at the time of the resident's admission, the resident was able to walk to the bathroom with assistance. She stated the resident's contractures started within the past year. She stated she was not sure if the resident received any therapy services but stated that at one time restorative aides worked with the resident. CNA5 stated she did not use any devices in the resident's hands to protect the resident's palms but did place pillows between the resident's legs. CNA6 was interviewed on 01/16/2025 at 5:15 PM. CNA6 stated she had worked at the facility for a year and R29 had contractures when she started. She stated R29's legs and hands were contracted. CNA6 stated the resident had a wedge, but the wedge had been lost, so she used pillows to place between the resident's legs. CNA6 stated that when she was assigned to provide care to R29, she placed a folded cloth in the resident's hands. The Director of Rehabilitation (DOR) was interviewed on 01/17/2025 at 9:20 AM. The DOR stated residents were screened for services annually and quarterly dependent upon MDS information. She stated the annual screening included contracture management. The DOR stated even if a resident were not receiving therapy services or restorative services, the expectation was for the nursing staff to place something in the resident's hands to prevent the nails from touching the palm, protect the palm, and to help reduce the risk of the contracture worsening. The DOR stated R29 had not had any recent therapy screenings due to the resident being on hospice. The DOR stated therapy staff were unable to screen residents who were on hospice unless permission was given by the hospice company. She stated it had been a year and a half or more since R29 had been screened for any type of therapy services. The DOR stated the nursing staff had not mentioned that R29 had contractures. During a concurrent observation the DOR observed R29 and stated the resident's legs and hands were contracted. She stated that prior to receiving hospice services, R29 had been out of bed more and sat in the wheelchair and was not as contracted as they were currently. The DOR stated that when R29 was admitted , the resident had been able to walk with assistance. Hospice Registered Nurse (HRN)7 was interviewed by telephone on 01/17/2025 at 9:46 AM. HRN7 stated the primary objective of hospice was to assure comfort and safety. HRN7 stated she first started seeing R29 in August 2024. She stated that both of the resident's legs, their right arm, and both hands were contracted. She stated there had been no change in the resident's contractures since she had first seen the resident. She stated the resident started receiving hospice services on 12/22/2023 and stated that if the resident's contractures had worsened since admission to hospice, she would have expected the facility staff to notify her. She stated she expected the facility staff to make sure the resident was comfortable by keeping the areas padded, assessing for pain, and expected a washcloth to be used in the resident's hands. HRN7 stated she had not seen any interventions used for R29's contractures, such as using a rolled cloth in their palms or pillows for positioning. HRN7 stated it was reasonable for nursing staff to ask the hospice provider for a therapy screen/evaluation for contracture management and stated that she had not received any requests for the hospice provider to provide orders for a therapy evaluation. The Director of Nursing (DON) was interviewed on 01/17/2025 at 3:19 PM. The DON stated that when a resident had contractures, she expected staff to be aware of positioning and pain management and to provide passive ROM. She stated she expected nurses or CNAs to use rolled washcloths or some device to prevent any damage to the palms of the hands. The DON stated for R29, the rolled washcloths in their hands would be a comfort measure. She stated the resident declined after they had a stroke and returned to the facility after being hospitalized . The Administrator was interviewed on 01/17/2025 at 4:01 PM. The Administrator stated he expected any interventions implemented to address contractures to be the decision of the hospice staff, therapy staff, the physician, and nursing staff. He stated therapy staff did not usually make recommendations when a resident was on hospice.

Based on interview, record review, and facility policy review, the facility failed to accurately monitor and document the amount of fluid consumed by a resident with a physician ordered fluid restriction. The deficiency affected 1 (Resident (R)62) of 2 residents reviewed for nutrition. Findings included: A facility policy titled, Resident Hydration and Prevention of Dehydration, revised 10/2017, indicated, 3. Physician orders to limit fluids will take priority over calculated fluid needs. The policy revealed, Fluid restrictions will be assessed by RD [Registered Dietician] and orders to include breakdown by dept [department] and shift. The policy revealed, 12. Nursing will monitor and document fluid intake and the dietitian will be kept informed of status. An Admission Record revealed the facility admitted R62 on 12/12/2023. According to the Admission Record, the resident had a medical history that included diagnoses of end stage renal disease, dependence on renal dialysis, kidney transplant status, and unspecified systolic congestive heart failure. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/05/2024, revealed R62 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident did not reject evaluation or care during the assessment timeframe. The MDS revealed R62 required set-up or clean-up assistance from staff with all activities of daily living (ADLs). The MDS revealed the resident received hemodialysis services while a resident at the facility. R62's care plan included a focus area initiated 12/27/2024, that indicated the resident was at risk of dehydration or electrolyte imbalance related to a fluid restriction. Interventions directed staff to provide the resident with a diet per the physician's order (initiated 12/27/2024) and monitor the resident's intake and output (initiated 12/27/2024). The care plan included a focus area initiated 12/14/2023 and revised 01/15/2025, that indicated the resident received dialysis. Interventions directed staff to promote the resident's fluid restriction as ordered (initiated 02/06/2024). R62's Order Summary Report, with active orders as of 01/15/2025, revealed an order dated 06/20/2024 for a renal diet, regular texture, thin liquids, with a 1,500 milliliters (mL) fluid restriction for Resident needs low potassium low phosphorus diet. The Order Summary Report revealed an order dated 01/07/2024 for a 1,500 mL fluid restriction every shift. The Order Summary Report revealed the orders did not include a breakdown of the amount to be provided by each department. R62's Progress Notes revealed a Nutrition Narrative Note, dated 09/06/2024, that indicated the resident received a renal diet and had a 1,500 mL fluid restriction. The note indicated staff should monitor for fluid gain/edema and continue the current nutrition plan of care. R62's Medication Administration Record [MAR], for the timeframe from 01/01/2025 through 01/31/2025, revealed a transcription of an order for 1,500 mL fluid restriction every shift, with an order date of 01/07/2024 and a discontinued date of 01/16/2025. The MAR revealed it did not include a space for staff to record the resident's actual intake of fluids. The MAR revealed a transcription of an order dated 01/17/2025 for 1,500 mL fluid restriction, with instructions for nursing staff to provide 780 mL, and dietary staff to provide 720 mL every shift. R62's meal tray card, dated 01/17/2025, indicated the resident received a renal diet. The meal tray card revealed Alerts indicated a 1,500 mL fluid restriction. R62 was interviewed on 01/14/2025 at 1:50 PM. R62 stated staff gave them one large foam cup of ice water daily and added that they (R62) knew to limit their fluids. Restorative Nursing Assistant (RNA)3 was interviewed on 01/16/2025 at 10:20 AM. RNA3 stated any resident on a fluid restriction was listed on an assignment sheet. RNA3 pointed out R62's name on the sheet and stated the resident had fluid restriction of 1500 mL. She stated that when she passed ice water to residents, she gave R62 a 16-ounce (oz) foam cup of ice water that was filled with ice and about a half a cup of water. She stated she returned to ask the resident how much was consumed and documented that amount in the EMR. RNA3 stated the fluids documented in the EMR included fluids consumed at breakfast, lunch, and any additional fluids given to the resident by the CNAs. Licensed Practical Nurse (LPN)2 was interviewed on 01/16/2025 at 4:05 PM. LPN2 stated R62 had been ordered a fluid restriction. LPN2 stated a certain amount of fluid was provided by dietary staff, and the resident was given between 60 mL and 90 mL with medication administration. She stated there were two medication administrations on her shift, which meant the resident received between 120 mL and 180 mL from the medication administrations but stated that she did not document the amount given. LPN2 stated the nurses were responsible for adding the total fluid consumed by R62 in a 24-hour timeframe but stated that there was nowhere to document the amount. LPN #4 was interviewed on 01/16/2025 at 4:31 PM. LPN #4 stated that when a resident had an ordered fluid restriction, the order should indicate how much fluid was to be given by dietary staff and how much fluid was to be given by nursing staff. She stated that the amount of fluid given to a resident with medication administration was documented on the MAR. LPN #4 stated no staff had been assigned to total the 24-hour fluid intake for the resident. The Dietary Director (DD) was interviewed on 01/17/2025 at 7:53 AM. The DD stated that she documented the amount of fluid to be given to a resident on their meal tray ticket. She stated the staff knew to only give the amount of fluids listed on the meal tray ticket. The DD stated that when a resident was admitted on a fluid restriction, she notified the Registered Dietician (RD), and the RD entered the fluid restriction order into the EMR, which included how much would be given by the dietary staff and how much would be given by the nursing staff. The DD stated fluid overload could occur, which may require the resident to need more time on the dialysis machine. The Dialysis Registered Nurse (DRN) was interviewed by telephone on 01/17/2025 at 8:17 AM. The DRN stated the dialysis RD was not available, but she was familiar with R62 and was able to answer questions about the resident's diet, fluid restriction, and overall condition. The DRN stated it was important that R62 adhered to the ordered fluid restriction to limit the amount of extra fluid the resident retained. The DRN stated retaining too much fluid could cause the resident problems during dialysis and added it was hard to remove extra fluid, causing fluid overload and an increased blood pressure. The Physician's Assistant (PA) was interviewed on 01/17/2025 at 8:35 AM. The PA stated it was important for a resident receiving dialysis to adhere to a fluid restriction to avoid fluid overload and flushing out of electrolytes. The PA stated he expected the facility to maintain an accurate record of what fluids R62 consumed. The RD was interviewed by telephone on 01/17/2025 at 1:52 PM. The RD stated if a resident was on a fluid restriction, she used a fluid restriction guideline that was available to both the dietary department and the nursing department and stated the nursing department responsible for dividing their portion of the fluid restriction as they saw fit. The RD stated she expected the nurses to have documentation of the fluid consumed so nurses knew how much fluid the resident received. The Director of Nursing (DON) was interviewed on 01/17/2025 at 3:34 PM. She stated she expected the fluids to be divided between the dietary department and the nursing department. The DON stated there was a fluid cheat sheet that divided the amount of fluid nursing staff provided per shift. The DON stated she expected the nurses to document the amount of fluid consumed during medication administration and expected the CNAs to document what fluids were consumed during meals. The DON stated the 7:00 PM to 7:00 AM nurse was responsible to total the fluid intake for the 24-hour timeframe and document the amount of fluid consumed in the nurse's notes. She stated that she had not been aware the nurses were not documenting the amount of fluid consumed by R62. The Administrator was interviewed on 01/17/2025 at 4:09 PM. The Administrator stated he expected the amount of fluid given to a resident who had an ordered fluid restriction to be documented accurately, adding that otherwise there was no point in the fluid restriction.

Based on observation, interview, record review, and facility policy review, the facility failed to provide oxygen therapy in accordance with professional standards of practice and the comprehensive care plan for 2 (Resident (R)37 and R38) of 4 residents reviewed for respiratory care. Specifically, the facility failed to administer R38's supplemental oxygen per physician orders and failed to obtain a physician's order for supplemental oxygen for R37. Findings included: A facility policy titled, Oxygen Administration, revised 10/2010, indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration. The policy revealed, 1. Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration. 1. An Admission Record indicated the facility admitted R38 on 12/24/2024. According to the Admission Record, the resident had a medical history that included diagnoses of acute and chronic respiratory failure and chronic obstructive pulmonary disease (COPD). An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/31/2024, revealed R38 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had received oxygen therapy within the last 14 days of the assessment look-back period. R38's Care Plan, included a focus area initiated 12/26/2024, that indicated the resident was at risk for altered respiratory status/difficulty breathing related to acute on chronic respiratory failure, COPD, and sleep apnea. Interventions directed staff to provide oxygen as ordered (initiated 12/26/2024). R38's Order Summary Report, for active orders as of 01/17/2025, contained an order dated 12/24/2024, for supplemental oxygen at two liters per minute (LPM) via nasal cannula every shift for low oxygen saturation. An observation on 01/14/2025 at 11:18 AM revealed R38's oxygen concentrator was set at 1.5 LPM. During a concurrent interview R38 stated their supplemental oxygen should be at 2 LPM. An observation on 01/14/2025 at 11:00 AM revealed R38 was out of the room. The observation revealed the resident's oxygen concentrator was on and their oxygen tubing was lying on the resident's bed. During an interview on 01/14/2025 at 11:18 AM, R38 stated they had just returned from the shower and was struggling to catch their breath. R38 stated they needed supplemental oxygen when they went to the shower; however, staff did not take any supplemental oxygen with them. During an interview on 01/14/2025 at 1:15 PM, Certified Nursing Assistant (CNA)13 revealed he was aware that R38 was dependent on supplemental oxygen. CNA13 stated he took R38 to the shower that morning but did not take supplemental oxygen for the resident. CNA13 stated the facility did not have portable oxygen tanks to use when transporting a resident. During an additional interview on 01/14/2025 at 1:33 PM, CNA13 stated he should have taken supplemental oxygen with R38 to the shower that morning to prevent anxiety or shortness of air. An observation on 01/16/2025 at 4:40 PM of the oxygen storage room revealed an ample supply of tanks along with oxygen haulers and concentrators. An observation on 01/16/2025 at 2:33 PM revealed R38's oxygen concentrator was set at 1.5 LPM. During an interview on 01/16/2025 at 4:40 PM, Licensed Practical Nurse (LPN)14 observed R38's oxygen concentrator and stated the oxygen concentrator was set at 1.75 LPM. LPN14 stated that the resident's supplemental oxygen should be set to 2 LPM. During an interview on 01/16/2025 at 3:21 PM, LPN14 stated she was told that R38 was dependent on supplemental oxygen and that it benefited the resident to take supplemental oxygen with them to the shower. During an interview on 01/17/2025 at 8:27 AM, the Physician Assistant (PA) stated he expected staff to follow the orders and to make sure supplemental oxygen was being delivered at the correct rate. The PA stated R38 should be provided supplemental oxygen when taken to the shower. During an interview on 01/17/2025 at 3:32 PM, the Director of Nursing (DON) stated she expected staff to administer supplemental oxygen at the correct rate. During an interview on 01/17/2025 at 4:14 PM, the Administrator stated he expected staff to follow physician orders for oxygen therapy and to make sure it was being delivered at the correct rate. 22445 2. An Admission Record revealed the facility admitted R37 on 12/05/2018 and most recently readmitted the resident on 06/24/2024. According to the Admission Record, the resident had a medical history that included diagnoses of myotonic muscular dystrophy, unspecified anxiety disorder, unspecified depression, and chronic congestive heart failure. A Transition of Care form dated 06/24/2024, the date of R37's most recent readmission from the hospital, indicated the resident received oxygen at two liters per minute by nasal cannula. The form indicated the resident's oxygenation decreased on room air. The form revealed no documented evidence related to which facility staff nurse completed the form. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/19/2024, revealed R37 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident had an active diagnosis of pneumonia. According to the MDS, the resident did not receive oxygen therapy during the assessment look-back period. R37's Care Plan, with a revision date of 07/09/2024, revealed the resident was at risk for an altered respiratory status/difficulty breathing related to pneumonia, dysphagia, and congestive heart failure. Interventions directed staff to administer medication/puffers (inhalers) as ordered, monitor for signs/symptoms of respiratory distress, and report to the physician as needed (initiated 06/25/2024). R37's Order Summary Report, with active orders as of 01/15/2025, revealed an active order started on 06/24/2024 to monitor the resident's oxygen saturation every shift and notify the medical doctor if the resident's oxygen saturation was less than 90 percent. The Order Summary Report revealed R37 had no active physician's order to administer oxygen to the resident. R37's Treatment Administration Record [TAR] for 01/2025 revealed a transcription of an order dated 06/24/2024 that instructed staff to monitor the resident's oxygen saturation every shift and notify the medical doctor if the resident's oxygen saturation was less than 90 percent. The TAR revealed that prior to 01/16/2025, there was no documentation that staff were administering supplemental oxygen to the resident. An observation on 01/14/2025 at 9:52 AM revealed R37 was receiving supplemental oxygen at two liters per minute via nasal cannula. Licensed Practical Nurse (LPN) #2 was interviewed on 01/16/2025 at 3:45 PM. LPN #2 stated a physician's order was required for the use of supplemental oxygen and should specify the amount of oxygen to be delivered. LPN #2 reviewed the physician's orders for R37 and stated the resident had no order for supplemental oxygen administration. LPN #2 stated R37 transferred to her unit from another unit within the facility and was wearing oxygen on arrival. LPN #2 stated someone should have noticed there was no order for supplemental oxygen for the resident. The Physician's Assistant (PA) was interviewed on 01/17/2025 at 8:33 AM. The PA stated that prior to administering supplemental oxygen an order for oxygen therapy was needed. He stated he expected the nurses to ask for supplemental oxygen orders. The Director of Nursing (DON) was interviewed on 01/17/2025 at 3:32 PM. The DON stated that prior to administering oxygen therapy, there had to be a physician's order. The Administrator was interviewed on 01/17/2025 at 4:07 PM. The Administrator stated he expected orders to be obtained prior to initiating oxygen therapy for a resident.

Based on interview, record review, and facility policy review, the facility failed to ensure the attending physician documented a clinical rational when declining pharmacy recommendations, which affected 1 (Resident (R)29) of 6 residents reviewed for unnecessary medications. Findings included: A facility policy titled, Antipsychotic Medication Use, revised 07/2022, indicated, Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject gradual dose reduction and re-review. The policy revealed, 9. Diagnoses alone do not warrant the use of antipsychotic medication. In addition to the above criteria, antipsychotic medications will generally only be considered if the following conditions are also met: a. The behavioral symptoms present a danger to the resident or others; AND: (1) the symptoms are identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations; delusions, paranoia or grandiosity); or (2) behavioral interventions have been attempted and included in the plan of care, except in an emergency. The policy revealed, 19. The physician shall respond appropriately by changing or stopping problematic doses or medications, or clearly documenting (based on assessing the situation) why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences. An Admission Record revealed the facility admitted R29 on 05/08/2019. According to the Admission Record, R29 had a medical history that included a diagnosis of unspecified Alzheimer's disease, dementia, bipolar disorder, generalized anxiety disorder, and major depressive disorder. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/19/2024, revealed R29 had severe impairment in cognitive skills for daily decision-making and had a short-term and long-term memory problem per a Staff Assessment of Mental Status (SAMS). The MDS revealed R29 had no hallucinations or delusions, exhibited no physical or verbal behavioral symptoms towards others, did not reject evaluation or care, and did not exhibit behaviors of wandering during the assessment timeframe. The MDS revealed the resident received antianxiety medication, antidepressant medication, and antipsychotic medication during the assessment timeframe. The MDS revealed a physician documented that a gradual dose reduction was clinically contraindicated on 05/09/2024. R29's care plan included a focus area revised on 05/23/2023, that indicated the resident was at risk for behavior symptoms related to Alzheimer's disease/dementia, anxiety disorder, bipolar disorder, and depression. Interventions directed staff to administer medications per physician orders (initiated 07/22/2019), observe the resident for mental status/behavior changes with new medications and changes in dosage (initiated 07/22/2019), provide non-pharmacological interventions for symptom management (revised 11/24/2023), and use consistent approaches when providing care (initiated 07/22/2019). The care plan also revealed a focus area initiated 05/14/2019, that indicated R29 exhibited verbal and physical aggression, including hitting at staff and resisting care. Interventions directed staff to administer medications as ordered (initiated 05/14/2019), provide diversional activity (initiated 05/14/2019), allow the resident time to respond to staff directions or requests (initiated 05/14/2019), and be aware of not invading the resident's personal space (initiated 05/14/2019). The care plan revealed a focus area initiated 05/14/2019 and revised 03/05/2023, that indicated the resident was at risk for adverse effects related to the use of antipsychotic medication, antidepression medication, and antianxiety medication. Interventions directed staff to evaluate the effectiveness and side effects of medications for a possible decrease/discontinuation of psychotropic medications (initiated 05/14/2019). R29's Order Summary Report, with active orders as of 01/15/2025, revealed R29 was admitted to hospice services on 12/22/2023 related to a diagnosis of Alzheimer's disease. The Order Summary Report revealed the following medication orders: - Citalopram hydrobromide (an antidepressant) tablet, 10 milligrams (mg) daily for depression, with a start date of 01/25/2023. - Clonazepam (a benzodiazepine) oral tablet, 0.5 mg twice a day for anxiety, with a start date of 08/28/2023. - Divalproex sodium (an anticonvulsant) delayed release sprinkle capsule 125 mg, one capsule twice a day for mood alteration, with a start date of 11/06/2023. - Lamotrigine (an anticonvulsant) oral tablet 25 mg, two tablets twice a day for bipolar disorder/seizure, with a start date of 11/27/2024. - Risperidone (an antipsychotic) oral tablet 0.5 mg, one tablet once a day for bipolar disorder/anxiety, with a start date of 06/24/2023. - Risperidone oral tablet 1 mg, one tablet once a day for bipolar disorder, with a start date of 12/17/2023. A consultant pharmacist Consultation Report, with a Recommendation date of 11/04/2024, revealed a comment that the resident had several medications that were due for a gradual dose reduction (GDR) assessment. The report revealed that as of 11/04/2024, the resident was receiving the following medications: - Risperidone 0.5 mg every morning and 1 mg every night for bipolar/dementia, noting that the medication was last increased on 06/24/2023. - Lamotrigine 50 mg twice daily for bipolar/dementia, noting that it was last reduced on 03/25/2024. - Divalproex 125 mg twice daily for bipolar/dementia, noting that it was last reduced on 11/06/2023. - Clonazepam 0.5 mg twice daily for anxiety, noting that no changes in dosage had been made since starting the medication on 08/30/2023. - Citalopram 10 mg daily, noting that it was last reduced on 01/23/2020. The Consultation Report revealed a recommendation to reevaluate the medications and consider attempting a GDR of any of the referenced medications and to consider discontinuing citalopram. The Consultation Report revealed the provider declined the recommendation, and revealed, Hospice NP [nurse practitioner] declined, was handwritten in the signature line and did not have a physician signature. The Consultation Report revealed the response was dated 11/06/2024. The report revealed no clinical rationale for rejecting the recommendation. The Physician's Assistant (PA) was interviewed on 01/17/2025 at 8:25 AM. The PA stated the psychotropic medications received by a resident was dependent upon the discharge medications from the hospital and then psychiatric services determined the routine. The PA stated diagnoses including anxiety disorder, bipolar disorder, and mood disorders supported the use of an antipsychotic medication. The PA stated if a GDR was needed on R29 the facility should reach out to the hospice provider, and the reason a GDR had not been attempted for R29 was due to the resident receiving hospice services. Hospice Registered Nurse (HRN)7 was interviewed by telephone on 01/17/2025 at 9:46 AM. HRN7 stated R29 had started hospice services on 12/22/2023. HRN7 stated that in November 2024 she and the hospice physician discussed R29's medication with the Director of Nursing (DON) to determine if the medications were still appropriate for the resident and to prevent destabilization. HRN7 stated that during the November discussion with the DON, the DON did not request a risk versus benefit statement or a reason from the hospice physician to support the declined GDR recommendation. The DON was interviewed on 01/17/2025 at 3:23 PM. The DON stated receiving hospice services did not support R29's use of an antipsychotic medication and stated the resident's primary physician declined a GDR. The DON stated she had made the hospice agency aware that they must follow rules and regulations for long-term care facilities.

Based on observation, interview, record review, and review of facility policy, the facility failed to maintain a medication error rate of less than 5 percent. Observation of medication administration revealed staff made two errors during 27 medication opportunities, resulting in a medication error rate of 7.41 percent. Findings included: A facility policy titled, Administering Medications, revised 04/2019, indicated, 4. Medications are administered in accordance with prescriber orders, including any required time frame. The policy revealed, 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. An Admission Record revealed the facility admitted R3 on 01/26/2018. According to the Admission Record, the resident's medical history included an unspecified vitamin D deficiency and chronic idiopathic constipation. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/28/2024, revealed R3 had a Brief Interview for Mental Status score of 15, which indicated the resident had intact cognition. R3's Care Plan, included a focus area initiated 01/30/2018, that indicated the resident had an alteration in bowel elimination and constipation related to anxiety, lack of exercise, and medications. Interventions directed staff to administer medications per the physician's orders and observe effectiveness (initiated 01/30/2018). The resident's Care Plan also included a focus area revised 12/06/2022, that indicated the resident was at nutritional risk. Interventions directed staff to administer medications (initiated 02/09/2021) and supplements (initiated 01/31/2018) as ordered. During an observation of medication administration on 01/15/2025 at 8:05 AM, Licensed Practical Nurse (LPN) #1 placed one capsule of docusate sodium, 100 milligrams (mg) into a medication cup. LPN1 removed one cholecalciferol tablet from a bottle that indicated the dosage of the cholecalciferol tablet was 400 international units (IU). LPN1 administered the medications to R3. R3's Order Summary Report for active orders as of 01/15/2025 revealed an order dated 04/12/2024, for cholecalciferol tablets 1000 units, with instructions to give one tablet one time per day for a vitamin D deficiency. The Order Summary Report revealed an order dated 12/02/2020 for docusate sodium 100 mg, with instructions to give 200 mg one time per day for constipation. During an interview on 01/15/2025 at 10:07 AM, LPN1 revealed she administered one docusate sodium and one cholecalciferol tablet to R3. During the interview, LPN1 reviewed R3's physician's orders and stated she needed to give the resident another capsule to equal 200 mg of docusate sodium the physician had ordered. LPN1 stated she also needed to give R3 another cholecalciferol to equal the amount the physician had ordered. When LPN1's attention was brought to the ordered cholecalciferol dosage, she stated she was not able to give half a tablet because the tablets were not scored and would have to check to see if the facility had the correct dosage available. LPN1 revealed she had made two medication errors because she did not check the medication labels and the medication orders carefully. The Director of Nursing (DON) was interviewed on 01/15/2025 at 10:54 AM. The DON stated LPN1 made medication errors when the correct dosage of docusate sodium and cholecalciferol were not given to R3. The DON stated she expected nurses to check dosages prior to giving medication to make sure the right dose was administered to the right resident. The DON stated if the right dosage of a medication was not available, she expected the nurse to contact the physician and follow the physician's directions. The DON stated medication errors were unacceptable. The Administrator was interviewed on 01/17/2025 at 4:12 PM. The Administrator stated that prior to giving medications, she expected nurses to check orders to make sure the medications administered to the resident matched the physician's orders.

Based on observation, interview, and record review, the facility failed to maintain and store oxygen equipment in a manner to prevent the development or spread of infection for 1 (Resident (R)37) of 4 residents reviewed for respiratory care. Findings included: A facility policy titled, Oxygen Administration, revised 10/2010, revealed, The purpose of this procedure is to provide guidelines for safe oxygen administration. The policy did not address storage or changing oxygen tubing. On 01/17/2025 at 5:53 PM, the Regional Director of Clinical Services (RDCS) revealed the facility had no policy for the storage of oxygen tubing. The Director of Nursing (DON) was interviewed on 01/17/2025 at 3:32 PM. The DON stated oxygen tubing should be stored in a bag when not in use to decrease contamination. The DON stated third shift staff should change oxygen tubing weekly. An Admission Record revealed the facility admitted R37 on 06/24/2024. According to the Admission Record, the resident had a medical history that included diagnoses of myotonic muscular dystrophy, unspecified anxiety disorder, unspecified depression, chronic congestive heart failure, and presence of a cardia pacemaker and automatic cardiac defibrillator. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/19/2024, revealed R37 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. A Transition of Care form dated 06/24/2024, indicated R37 received oxygen at two liters per minute by nasal cannula. R37's Care Plan, with a revision date of 07/09/2024, revealed the resident was at risk for an altered respiratory status/difficulty breathing related to pneumonia, dysphagia, and congestive heart failure. An observation on 01/14/2025 at 9:52 AM revealed R37's oxygen tubing, connected to a portable oxygen tank, was wrapped around the arms of a wheelchair and was dated 12/05/2024. There was no covering over the nasal cannula portion of the tubing. During a concurrent interview R37 stated staff did not cover the tubing, and the tubing was always hanging free and uncovered. Licensed Practical Nurse (LPN)2 was interviewed on 01/16/2025 at 3:45 PM. LPN2 stated tubing for oxygen was changed weekly and stored in a plastic bag between uses. LPN2 stated third shift staff were responsible for changing tubing, and any staff member could change the tubing when needed. LPN2 stated all nurses were responsible for making sure the tubing remained covered when not in use. LPN2 observed R37's oxygen tubing and stated the tubing was dated 12/30/2024 (not 12/05/2024), which had been more than one week and should have been changed. The Physician's Assistant (PA) was interviewed on 01/17/2025 at 8:33 AM. The PA stated it was important to change oxygen tubing and to keep oxygen tubing covered when not in use to decrease the risk of germ transmission. The Administrator was interviewed on 01/17/2025 at 4:07 PM, and stated he expected oxygen tubing to be covered when not in use and expected for it to be changed per the facility policy.

Based on interview, record review, and facility policy review, the facility failed to report an allegation of sexual abuse to the state agency that involved 1 (Resident (R)2) of 4 sampled residents reviewed for abuse. Findings include: Review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised in September 2022, indicated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation Reporting Allegations to the Administrator and Authorities 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The policy specified, 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Review of an Admission Record revealed the facility admitted R2 on 06/05/24. According to the Admission Record, R2 was admitted with diagnoses including but not limited to: nontraumatic intracranial hemorrhage (stroke), thyrotoxicosis (excessive thyroid hormones), chronic obstructive pulmonary disease (COPD), type 2 diabetes, chronic kidney disease, and major depressive disorder. Review of an Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/11/2024, revealed R2 had a Staff Assessment for Mental Status (SAMS) that indicated the resident had severely impaired cognitive skills for daily decision making. The MDS indicated the resident was dependent for all activities of daily living (ADLs) and was always incontinent of bladder and bowel. Review of R2's Care Plan, initiated on 06/05/24, indicated the resident was at risk for ADL/mobility decline and required assistance related to recent hospitalization due to intracranial hemorrhage. Interventions directed staff to monitor for changes in condition or declines in ability to participate in ADLs, decreased strength, increased weakness, or changes in cognition, and to notify the physician if occurs. Review of the facility investigation file revealed a urine test performed on R2, who was in a non-verbal, unresponsive, and vegetative state, revealed the resident had a sexually transmitted disease (STD), trichomonas. The Investigation Report, dated 06/12/24, did not reveal evidence to indicate the state survey agency was notified of the abuse allegation. Review of an addendum from the emergency department, dated 06/11/24 at 9:50 PM, revealed a urinalysis revealed a result of cloudy, small traces of blood, 30 protein, and moderate urine leukocyte. The microscopic showed a few bacteria, an STD, and an urine culture was in process. During an interview on 06/21/24 at 11:56 AM, the Director of Nursing (DON) stated the allegation was not reported to the state agency because when she spoke with the Ombudsman, it was presented as a notification that the resident had tested positive for an STD, not an allegation of abuse. During a follow-up interview on 06/21/24 at 3:42 PM, the DON stated R2 had multiple cerebral hemorrhages while in the hospital. The DON stated the Ombudsman called and informed the facility that the hospital notified Adult Protective Services (APS) that the resident tested positive for an STD. The DON stated the facility also got a call from the hospital that the resident tested positive for an STD. The DON stated the facility started an investigation. During an interview on 06/21/24 at an unspecified time, the Administrator stated no one ever relayed the information regarding R2 to him as an allegation of abuse. It was relayed as a notification that the resident tested positive for a STD. The Administrator stated when any allegations are made, it is relayed to the facility's regional staff, who were responsible for reporting. The Administrator stated because the test was not done at the facility and no allegations of abuse were made, thus the determination was made that they did not feel it needed to be reported.

Based on observations, staff interviews, and record review, the facility failed to ensure food stored in the main kitchen was labeled, dated, and had not expired. Additionally, staff failed to utilize safe food handling. The failures had the potential to increase the prevalence, spread of foodborne illness, and cross contamination for all 82 residents residing in the facility. Findings include: Review of the facility's policy titled Food and Nutrition Services dated ,d+[DATE] documented, Foods are labeled for food safety. Information on the label tells staff when food is approaching dates when it would be removed from service. On [DATE] from 8:49 AM to 9:25 AM, the following items were observed during the initial kitchen tour: -A dirty and rusted-looking can opener. -The countertop next to the sink with food debris, and underneath the sink noted stained floor. -Pantry with non-labeled and non-dated bag of pasta, grits, cornbread mix and angel food cake. An interview on [DATE] at 9:10 AM with the Dietary Manager (DM), acknowledged the can opener was dirty and rusted. DM stated that she will wash it and pre-soaked the can opener. An interview on [DATE] at 9:15 AM with the DM, acknowledged all foods that are opened should be labeled and dated when opened. DM removed the non-labeled and non-dated pasta, grits, cornbread mix and angel food cake from the pantry. The DM stated she instructed staff to date and label all opened food items. During an observation and interview on [DATE] at 9:25 AM with the DM revealed, the DM did not know how to use the sanitizing test strips to test the sanitization of the dishwasher. The DM stated, we ordered the dishwashing test strips, since the thermometer broke last week, and were not able to test temperatures. Review of the facility's Dishwasher Temperature Log dated ,d+[DATE] documented, [DATE] - [DATE] noted dish machine down for 5 days. Review of the facility's Sanitation Audit dated [DATE] documented, Discussed with Certified Dietary Manager (CDM) importance of ensuring high and low areas of the kitchen are cleaned regularly . corrected opportunity immediately. An observation on [DATE] at 12:15 PM of the tray line service revealed, Cook1 placed a tong on top of the lettuce, tomatoes, and onions. An interview on [DATE] at 2:50 PM with the DM revealed, we talked to Ecolab and will just use the dishwasher with higher temperature. The DM further explained the can opener was dirty and rusted; however, the rust was old tomato soup, after she cleaned it, the rust was gone.

Based on observation, record review, and interviews, the facility failed to ensure one Resident (R)12 reviewed for behavior management received the appropriate behavioral health care and management to attain her highest practicable well-being. Findings include: Review of the facility's policy titled Psychotropic Medication Use dated 08/2018, documented, Medication dose adjustments are periodically considered based on person centered factors. During an observation conducted on 05/09/23 at 5:00 PM, R12 was observed beside her bed, seated in her wheelchair, and noted with hand tremors. R12 acknowledged she could not calm down when she was anxious, and she had to ask for her Ativan medication. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/17/23, located in the electronic medical record (EMR), under the MDS tab, indicated R12 was admitted to the facility on [DATE] with diagnoses of anxiety, depression, and Parkinson's disease. Review of R12's Plan of Care dated 05/18/23, located in the EMR under the Care Plan tab, documented, at risk for changes in mood related to (r/t) depression and/or anxiety. The approaches included: Administer medication per physician orders. Observe mental status/mood state changes when new medication is started or with dose changes. Review of R12's Medication Administration Record (MAR) dated 05/01/23 through 05/31/23, documented, Ativan (an anti-anxiety medication) 0.5 MG (milligram), Give 0.5 mg by mouth (po) as needed (PRN) for anxiety for 14 Days, 3 x(times) a day (TID). Further review documented administered one-time dose of Ativan 0.5 mg from 05/02/23 through 05/06/23. Review of the R12's Behavioral Health Services, Psychiatry Follow-Up Note, dated 04/26/23 documented, Primary Psychiatric (diagnosis) is panic disorder [episodic paroxysmal anxiety] without agoraphobia (fear in open or enclosed places or situation). Patient (Pt) is visibly anxious today . Pt requested to see this nurse practitioner for anxiety today. Pt complaining of severe anxiety and hyperness[sic]. Pt reports she is unable to soothe herself and she feels jittery. Further review of the 04/26/23 Behavioral Health Services, Psychiatry Follow-Up Note documented, Psychomotor agitation present and Pt states I can't calm down. Pt is visibly anxious today. Pt reports be[sic] helpful to be able to take the Ativan more often. All depressive symptoms are under control. Pt complaining of difficulty initiating sleep 7 nights a week . Plan is to increase Buspar to 5 mg by mouth 3 times a day . we can increase the Ativan to 0.5 mg by mouth 3 times a day as needed. Review of R12's nursing Progress Note dated 05/03/23 at 23:27(11:27 PM), located in the EMR under the Progress notes tab, documented, R12 had panic attack after supper . C/O [complained of] about shaking, anxiety, nausea, jitteries[sic] . Asked for Ativan. Explained that it was ordered every 12 hours and it was not time for another dose. During an interview on 05/09/23 at 4:53 PM with Licensed Practical Nurse (LPN)1, stated as needed (PRN) Ativan dose was administered for R12's anxiety on 5/03/23 at 8:00 AM, per physician (MD) order. R12 was jittery and anxious at that time. LPN 1 added she could not speak for PM [evening/night] shift nurse on 05/03/23, as to why R12's Ativan 0.5 mg PRN TID dose was not administered; however, the PM nurse documented R12 was experiencing a panic attack, jitteriness' and anxious. During an interview on 05/10/23 at 3:18 PM with LPN 2, stated she was assigned to the resident, and that R12 was familiar with scheduled meds. LPN 2 stated on the night of 05/03/23, R12 asked for Ativan. LPN 2 stated we do not know what brings R12 panic attacks, anxiety and resident needs to calm down. R12 stated I'm shaking all over. LPN 2 stated I wish to have more time to sit with R12, instructed to deep breath, but I would try to calm R12 instead of giving medication. During an interview on 05/10/23 at 3:35 PM with the Director of Nursing (DON), confirmed the assigned PM shift nurse did not check R12's Ativan PRN order, and needed to give 3x's a day on 05/03/23. DON stated medication must be given as ordered, unless the medication is unavailable, and non-pharmacologic interventions did not work. DON stated staff must contact MD [physician] to administer the one-time PRN med dose.

Based on record reviews and interviews, the facility failed to ensure Resident (R)1 did not have access to solid foods while on a pureed diet for 1 of 3 residents reviewed for accidents/incidents. On [DATE] at 8:00 AM, R1 was found unresponsive by facility staff in the dining area. Specifically, the facility failed to monitor R1, who had known behaviors of taking others food to eat, while on a pureed diet. This failure resulted in Immediate Jeopardy (IJ) to resident health or safety. On [DATE] at approximately 8:24 AM, Emergency Medical Services (EMS) arrived at the facility and pronounced R1 deceased at approximately 8:30 AM. Based on full and/or limited record reviews and interviews, it was determined on [DATE] at 2:29 PM that an Immediate Jeopardy existed. The Administrator was provided with copies of the Immediate Jeopardy template on [DATE] at 2:45 PM. The facility provided an IJ Removal Plan that was accepted on [DATE] at 2:27 PM and the IJ at F689 was removed with an effective completion date of [DATE] and lowered to scope and severity of D. Additionally, the failure constituted substandard quality of care, warranting the completion of an extended survey on [DATE]. The facility's removal plan for F689 included: 1) The Medical Director was contacted and informed of the initial report on [DATE]. The Medical Director has been updated daily as changes have occurred. 2) Resident and staff interviews were completed on [DATE] to investigate occurrence with no findings as to where the food originated. A timeline of events was created. 3) A review of residents was completed on [DATE] to identify those with cognitive impairment who were mobile. Diet consistency reviewed for those residents on ground or pureed diet to create like residents list. These residents were then reviewed to identify behaviors related to food. Like resident care plans were reviewed and updated as appropriate. No behaviors related to food were identified on these residents. Completed [DATE]. 4) All facility staff (including nursing, therapy, housekeeping, dietary, and IDT members) were educated on the importance of not leaving food, drinks, and personal items in patient care areas on [DATE] by the Director of Nursing or designee. Staff who were not in the facility on [DATE] were educated by the Director of Nursing or designee via phone. This education was completed in it's entirety on [DATE]. New hires will be educated during orientation and any individuals on leave will be educated prior to receiving an assignment when returning to work. 5) Initial observation of common areas was conducted Friday and Saturday of dining rooms to validate no food was present on [DATE] and [DATE]. 6) The DON or designee will conduct observations of common areas to validate food was not left unattended weekly x 4 weeks, then monthly x 2 months. 7) The QAPI Committee will meet and determine further actions and audits based on trend and analysis. 8) Alleged Date of Compliance: [DATE] The findings included: The facility admitted R1 on [DATE] with diagnoses including, but not limited to; [CONDITION(S)], Oropharyngeal Phase, Dysphagia, [CONDITION(S)], Conduct Disorder and Major Depressive Disorder. Review of Quarterly Minimum Data Sets (MDS) dated [DATE] and [DATE] indicated R1 had short and long term memory problems. He had a Brief Interview for Mental Status (BIMS) score of 99 indicating he was severely cognitively impaired and never/rarely made decisions. R1 was determined to be a Do Not Resuscitate (DNR) on [DATE] with two physicians signatures for decisional capacity, indicating inability to make decisions. Review of R1's monthly cumulative Physician's orders revealed the R1 was placed on a pureed texture diet on [DATE]. Review of the Annual MDS dated [DATE] and Quarterly MDS dated [DATE] in the Aspen MDS Viewer screen revealed R1 was not checked for having swallowing concerns under Section K. Review of the Quarterly MDS dated [DATE] indicated under Section K: R1 was checked for having swallowing difficulties Coughing or choking during meals or swallowing medications. A Behavioral Symptoms assessment dated [DATE] under Identified Behavioral Symptoms revealed R1 wanders into other resident's room and takes/eats there [sic] food. A nurse's note dated [DATE] at 2:38 PM states, At approximately 7:45 AM patient was noted at nurse's desk eating pudding. Around 8 AM I was called to C-Wing dining room where it was noted patient laying on back in wheel chair unresponsive with mouth open and food particles visible. I called for assistance and performed finger sweep to clear mouth. Physician's Assistant (PA) came in and quickly assessed patient and initiated abdominal thrust. 911 called. EMS arrived at approximately 8:20 AM and started care. Patient pronounced at 8:28 AM. Family notified per staff 8:30 AM. Coroner notified and arrived at 9:30 AM. Funeral home here to get resident at 10:05 AM. A review of the Emergency Medical Service (EMS) report on [DATE] at 3:26 PM, which was dated [DATE], indicated the facility called due to resident choking. Reportedly staff had been pulling food out of resident's airway and not sure if they got it all. Resident was not breathing. Pt [patient] laid in supine on floor. #3 [NAME] blade used to look in airway and found to be clear. Advise staff to start CPR. RN advised pt is DNR. Once DNR paperwork was presented to EMS, CPR discontinued. Monitor showing Agonal to Asystole. Staff stated they would call doctor and coroner. An interview on [DATE] at 11:25 AM with the Administrator Assistant revealed R1 had a habit of eating others food and it was believed that a staff member on the 7 AM to 3 PM shift left the meal in the dining room, that they intended to eat for lunch. The meal the resident had access to was described as shredded turkey, macaroni and cheese and dressing. The Administrator Assistant stated staff was aware resident could not eat solid foods. An interview on [DATE] at 12:09 PM with the Director of Nursing (DON) revealed she was not in the facility at the time the resident was discovered non responsive, but she observed the solid food in the area and it looked as if the food had been chewed. The DON further stated no staff member has acknowledged that they left the food tray in the dining room. The DON stated that staff was aware R1 had a behavior of taking foods that was not physician's ordered. An interview on [DATE] at 12:17 PM with Laundry/Housekeeping Aide (L/H) revealed, on [DATE] at approximately 8:00 AM, she saw R1 seated in his wheelchair in the dining with the food tray. The resident was leaning back with legs stretched out. The resident's eyes were opened and food was in his mouth. Per the L/H staff the food did not look as if it had been chewed. The L/H stated when she called out the resident's name he grunted one time and that she could see macaroni and dressing on the table. She realized it was food the resident could not eat and called out for assistance. An interview on [DATE] at 12:57 PM with LPN (Licensed Practical Nurse) 1 revealed, on [DATE] at approximately 8:10 AM she heard someone screaming for help. Per LPN1 when she arrived she saw food on the floor. The food looked like turkey and dressing. LPN 1 stated she was aware the resident should not have access to solid foods. LPN1 further stated R1 was noted to go in other resident rooms and take food as well as being found opening the food cart to take food, he should not have been eating. Per LPN1, the staff was aware of R1's behavior of taking foods. An interview on [DATE] at 1:20 PM with RN (Registered Nurse) 1 revealed, on [DATE] at approximately 8:15 AM, she was told of the incident that R1 was discovered non responsive in the dining room with solid foods. RN1 further stated that staff was aware the resident was on a pureed diet and should not have access to solid foods. An interview on [DATE] at 10:05 AM with the Physician's Assistant (PA) revealed he and staff at the facility was aware that R1 was on a pureed diet, had behaviors of taking others food and that the resident should not be eating solid foods. The PA further stated on [DATE] at approximately 8:15 AM, he could see some of the food chewed and a chunk of turkey in R1's mouth. The PA stated he did abdominal thrust while the nurse did a sweep of the resident's mouth to remove food. EMS arrived and briefly attempted to revive the resident until the DNR order was located. An interview on [DATE] at 11:40 AM with LPN2 revealed, on [DATE] at approximately 8:03 AM, she heard a staff member yelling out for assistance stating something was wrong with a resident (R1). LPN2 stated she checked R1 and he was not breathing. LPN2 stated another nurse came and provided assistance. LPN2 stated she saw regular dressing and mac and cheese in the food tray. LPN2 further stated she was aware resident should not have solid foods.

Based on interviews and record reviews, the facility failed to revise the comprehensive care plan for 1 of 3 residents reviewed for accident hazards/ supervision/ devices. On [DATE] at 8:00 AM, Resident (R)1 was found unresponsive by facility staff in the dining area. Specifically, the facility failed to monitor R1, who had known behaviors of taking others food to eat, while on pureed diet. This failure resulted in Immediate Jeopardy (IJ) to resident health or safey. On [DATE] at approximately 8:24 AM, Emergency Medical Services (EMS) arrived at the facility and pronounced R1 deceased at approximately 8:30 AM. Based on full and/or limited record reviews and interviews, it was determined on [DATE] at 2:29 PM that an Immediate Jeopardy existed. The Administrator was provided with copies of the Immediate Jeopardy template on [DATE] at 2:45 PM. The deficiencies involved were as follows: CFR 483.10 F657 was identified at a scope and severity of (J). The Immediate Jeopardy existed on [DATE] when R1 care plan was not revised to ensure that solid foods were out of resident's reach while on physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The facility provided an Immediate Jeopardy Removal Plan that was accepted on [DATE] at 2:27 PM and the Immediate Jeopardy at F657 was removed with an effective completion date on [DATE] and lowered to scope and severity of D. The facility provided an IJ Removal Plan that was accepted on [DATE] at 2:27 PM and the IJ at F657 was removed with an effective completion date of [DATE]. After the IJ removal, the noncompliance remained at a lower scope and severity of D. The facility's removal plan for F657 included: 1) The Medical Director was contacted and informed of the initial report on [DATE]. The Medical Director has been updated daily as changes have occured. 2) Resident and staff interviews were completed on [DATE] to identify those with behaviors related to food and no residents were identified. Like resident care plans were reviewed and updated as appropriate. Completed [DATE]. 4) All facility staff (including nursing, therapy, housekeeping, dietary and IDT members) were educated on the importance of not leaving food, drinks, and personal items in patient care areas on [DATE] by the Director of Nursing or designee via phone. This education was completed in it's entirety on [DATE]. New hires will be educated during orientation and any individuals on leave will be educated prior to receiving an assignment when returning to work. 5) Licensed nursing staff will be educated on timely updating and revising of care plans and appropriate care plan interventions related to unsafe behaviors regarding food. This education will be completed in person or via phone on [DATE] by the Director of Nursing or designee. Any staff who were not able to be educated will not be allowed to work until education is completed. 6) The DON or designee will audit residents with unsafe behaviors related to food for appropriate care plans weekly x4 weeks, then monthly x 2 months. 7) The QAPI committee will meet and determine further actions and audits based on trends and analysis. 8) Date of Compliance [DATE]. The findings include: The facility admitted R1 on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Quarterly Minimum Data Sets (MDS) dated [DATE] and [DATE] indicated R1 had short and long term memory problems. He had a Brief Interview for Mental Status (BIMS) score of 99, indicating he was severely cognitively impaired and never/rarely made decisions. R1 was determined to be a Do Not Resuscitate (DNR) on [DATE] with two physicians signatures for decisional capacity, indicating he was unable to make his own decisions. Review of R1's monthly culminative physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R1's care plan, last revised on [DATE], revealed the resident was resistive to treatment/care related to: late stage dementia, disbelief in value of treatment will take solid foods of his liking that peers have left on their plates and eat them-ie chicken, breads, milk, and other meats. will try to drink any liquids he can reach. Further review of R1's care plan, last revised [DATE], revealed resident at risk for altered nutritional status and actual weight changes due to changes in PO (by mouth) intake- mechanically altered diet, risk for aspiration related to being non compliant: Provide diet as ordered: Pureed- 2x all portions. R1's care plan interventions were to use consistent approaches when giving care, escort resident to and from dining room, will educate resident on non compliance, will encourage resident to leave the dining area when he finish his meal and provide resident with food to go finger foods that can be eaten while walking. An interview with Registered Nurse (RN) 1 on [DATE] at 1:20 PM, revealed R1 was care planned for behaviors of trying to take food and liquids from other resident's food trays on [DATE]. RN1 was asked to review the care plan and determined if interventions were in place to ensure resident did not get access to solid foods while on a pureed diet. RN1 stated she will review the care plan further and let the surveyor know what additional information was documented in the electronic medical record. An interview on [DATE] at 2:15 PM with RN1 revealed there was no documentation on the care plan to address what interventions should be in place to prevent R1 from having access to other residents or staff solid foods. RN1 further stated R1 was cognitively impaired and required supervision. When asked what kinds of finger foods were available for a resident on a pureed diet? RN1 stated she was not aware of any and that finger foods should not have been on the resident's care plan.

Based on observation, policy review, and interviews, the facility failed to ensure that foods were used/consumed prior to the expiration date. During the initial tour of the facility on [DATE] at 10:56 a.m., it was observed that 10 cartons of eight (8) ounces of Sysco Imperial Thickened Dairy Drink had a manufacturer's expiration date of [DATE] and five (5) cartons of 32 ounces of Sysco Imperial Thickened Dairy Drink had a manufacturer's expiration date of [DATE]. It was also observed that one (1) gallon of Pet milk was observed with a manufacturer's expiration date of [DATE]. A review of the Labeling Food and Date Marking policy dated ,d+[DATE] showed that foods are labeled following delivery, preparation or opening to identify the item and to provide date, time and, or temperature information. The identification of the date of preparation and the date by which the food is to be used or consumed is often referred to as date marking. During an interview on [DATE] at 10:59 a.m., Registered Dietitian (RD) #1 stated that the items were expired and should not be available for use. RD #1 discarded the items.

Based on observation, policy review, and interview, the facility failed to ensure that food temperatures met holding temperature requirements prior to lunch meal service. During an observation of the steam table in the kitchen on 10/12/21 at 11:36 a.m., it was revealed that pork chops were 133 degrees Fahrenheit, pureed greens were 120 degrees Fahrenheit, and fish was 133 degrees Fahrenheit. During a subsequent observation of the steam table in the kitchen on 10/12/21 at 12:35 p.m. showed pork chops at 143 degrees Fahrenheit and fish at 142 degrees Fahrenheit. A review of the Food Temperatures During Holding Policy dated 11/20 showed that guidelines state that food temperatures are checked and recorded; upon completion of cooking, prior to start of meal services, whenever a new pan of food is put in use, if food has remained on the steam table for over two (2) hours, any other time if needed. Hot food are held at 135 degrees but below 180 degrees Fahrenheit and cold foods below 41 degrees Fahrenheit. A review of the temperature logs submitted showed temperature logs dated from 9/01/21 to 10/11/21 and did not include the date of 10/12/21, the day of observation. During an interview on 10/12/21 at 11:36 a.m., Lead Cook (LC) #1 stated that pork chops, fish, and pureed greens were not at the required temperature. LC #1 stated that protocol requires foods temperature to be taken prior to placing in steamtable trays and before being plated to serve to residents. LC #1 stated that if foods do not meet the required temperature, then the items are placed in the convection oven to heat up prior to going back on the steam table. Staff also stated that convection stove was not working properly because foods would not be heated evenly and not at high temperature. During an interview on 10/13/21 at 3:32 p.m., Registered Dietitian (RD) #1 stated the procedure for ensuring that foods are served at the correct temperature includes that staff would take the temperature prior to plating the food. RD #1 stated that if foods are not at the correct temperature, then the staff is to put the food back into the oven to get the foods to the correct temperature. RD #1 stated that s/he was not sure why the food was not at the correct temperature during the lunch meal on 10/12/21. RD #1 stated that s/he along with LC #1 would let maintenance know verbally or through an email if kitchen equipment is not working properly. RD #1 stated that s/he was not aware of the convection oven was not working properly.

Based on observation, record review, policy review and interviews, the facility failed to ensure that all kitchen appliances were working properly. During the initial tour of the facility on 10/10/21 at 10:47 a.m., it was observed that a reach in upright cooler was the only kitchen appliance to be labeled in non-working order. A review of the Inspect Kitchen Small Appliances policy showed that small appliances should be inspected, and non-working appliances should be noted and a repair request should be sent to maintenance in TELS equipment log. A review of the work orders for the past three (3) months did not show a work order for a convection oven. During an interview on 10/12/21 at 11:36 a.m., Lead Cook (LC) #1 stated that the convection oven was not working properly because foods would not be heated evenly and not at high temperature. LC #1 stated that s/he was aware of the oven not working properly for approximately one (1) month. During an interview on 10/13/21 2:04 p.m., Maintenance Supervisor (MS) #1 stated that the protocol for a work order for a repair is either given to him/her when staff sees him/her, or staff will inform him/her through using TELS by writing a work order. MS #1 stated that s/he has current orders for steam table and it has been ongoing since July 2021, and a reach in cooler; however, s/he did not have a work order for a convection oven. During an interview on 10/13/21 at 3:32 p.m., Registered Dietitian (RD) #1 stated the procedure for ensuring that appliances in the kitchen is to inform maintenance of broken appliances. RD #1 stated that s/he along with LC #1 would let maintenance know verbally or through an email if kitchen equipment is not working properly. RD #1 stated that s/he was not aware of the convection oven not working properly, and she had not reported any equipment being broken to maintenance.

Based on observation, policy review, and interviews the facility failed to ensure that menus were posted to be viewed by residents. During the initial tour of the facility on 10/10/21 at 10:47 a.m., it was observed that the menus were not posted throughout the facility, but only in the main two (2) dining rooms. A review of the Menu Posting policy dated 11/2020 showed that menus are posted in public areas to inform staff and patients about meal items being served throughout the day. Dietary staff use posted menus for reference of diets during meal preparation and service. Guidelines showed that current menus in large legible print are posted at eye level for residents to view. During an interview on 10/10/21 at 10:53 a.m., Registered Dietitian (RD) #1 stated that menus are not posted outside of the dining room. RD #1 stated that residents are informed by staff of what the menu consists of, if it is an item that residents don't prefer. RD #1 stated that activity staff is responsible for posting menus. During an interview on 10/12/21 at 11:06 a.m., Lead Cook (LC) #1 stated that activities staff is responsible for posting menus. LC #1 stated that residents' food preferences are learned during admission. LC #1 stated that each week, residents are asked about his/her choices and residents are informed of menu if items that he/she does not prefer is going to be served. During an interview on 10/13/21 at 3:22 p.m., Activity Staff (AS) #1 stated s/he is not responsible for posting menus in the facility. During an interview on 10/13/21 at 3:32 p.m., RD #1 stated that it was his/her responsibility to post menus in the facility. RD #1 further stated that s/he was supposed to place menus at each nurse's station to be distributed to the residents. RD #1 stated that s/he had not been getting the menus out to the residents. RD #1 further stated that s/he had heard the residents complaining about not knowing what the menu was for mealtimes. RD #1 stated that distribution of the menus started on 10/13/21 along with a Food Council Advisory team for residents.

Based on Medical Record review, and Interviews, the facility failed to keep resident free from Abuse. Findings Include: On 11/30/20 Allegations that CNA # 1 Abused resident #1 Interview with Licensed Practical Nurse #1 (LPN#1) via telephone on 2/3/21 at 12:05, employee states that s/he was performing medication pass when s/he heard Resident #1 (R#1) yelling. S/he went into the room to see what was happening. R#1 had received a bath by Certified Nursing Assistant (CNA) #1. LPN#1 stated when s/he entered the room, R#1 was sitting up in the chair with his/her pants halfway down. LPN#1 said s/he asked what happened and CNA #1 stated that s/he was about to get ghetto with this [***] . LPN#1 stated that R# 1 swatted at CNA #1's arm and missed and swatted again and hit CNA #1 on the arm. That's when s/he witnessed CNA #1, closed fisted punched resident #1 in the chest. LPN#1 stated that R#1 passed out. LPN#1 said that s/he immediately assessed R#1 and took his/her vital signs and tried to arouse her. CNA #1 immediately ran from the room. LPN#1 stated s/he asked CNA#2 to stay in the room with R#1 while s/he went to get the Administrator and Director of Nursing. Interview with CNA #2 on 2/3/2021 at 12: 15 p.m. CNA#2 said she entered the resident's room to help CNA#1 with R#1 because s/he was being combative. LPN#1 told her CNA #1 hit R#1 in the chest. CNA #2 stated s/he did not see CNA #1 hit R #1. CNA #2 also said R #1 looked at him/her and asked for help. S/he helped R #1 finish dressing. The Administrator and Director of Nursing arrived, police were called, CNA#1 was questioned by the police and suspended by Administrator and Director of Nursing pending investigation. The Director of Nursing (DON) stated on 2/3/2021 that when s/he arrived to R#1's room the resident was responsive and assessed, vital signs were stable, CNA# 1 was immediately suspended, Abuse training initiated for all staff, Internal QAPI PIP initiated. Audit and Investigation of all like residents conducted. Trauma assessment completed on identified patients. Care plan up-dated. When asked about R#1 passing out, the DON said R#1 would act like s/he passed out often. CNA #1 was called for an Interview on 2/3/21 at 12: 25 p.m. and at 1:15 with no success. Numbers were disconnected.

On the day of the complaint inspection based on observations, record review and interview the facility failed to ensure a staff member involved in an allegation of neglect was removed from the resident care areas. The facility also failed to ensure supervisory staff reported allegations of neglect. Certified Nursing Assistant #1 (CNA #1) was allowed to work for 5 hours after neglect was alleged for Resident #1. Licensed Practical Nurse (LPN) #1 failed to report CNA #1's alleged neglect. Resident #1 was transferred inappropriately resulting in a fracture. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #1 scored a "10" on the Brief Interview for Mental Status indicating moderate cognitive impairment. The resident also was coded as requiring two person extensive assistance with transfers and toilet needs. Resident #1 used a scoot wheelchair that was propelled by staff. Review of the Care Plan dated 5/23/2011 revealed the resident had a problem area related to activities of daily living (ADL) self care deficit with approaches including for staff to "assist with daily hygiene, grooming, dressing and eating as needed" and to "observe for and report significant changes in ADL or cognitive status to physician." Review of the CNA Kardex (Care Guide) revealed under ADL Assist "Usually two person with Stand up lift." Review of the Staff Assignment Sheet revealed under ADL Assist the resident was to have "2 Person Stand Up." Review of the Nurse's Notes revealed on 5/26/12 at 5:14 PM, "complains of left hip and left thigh pain. Per (Physician): mobile x-ray of left hip and left thigh..." At 10:12 PM, "Acute appearing left femur fracture as described per report of left hip and thigh x-ray...resident sent to hospital..." There were no Nurse's Notes documented prior to 5:14 PM on 5/26/12. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"complaints of left leg pain." There was no documentation of follow up or further pain management until 7:30 PM when the resident received another 325 mg of Tylenol for left leg pain. Review of the Radiology Report dated 5/26/12 revealed the Conclusion of the 2 View Femur x-ray was: "acute appearing left femur fracture." The results of the x-ray were reported to the facility at 7:31 PM. Review of the 5 Day Report dated 5/30/12 revealed on 5/26/12 at 2 PM, "while patient on standing lift, hands let go of grips L (left) leg buckled foot slipped. Patient c/o pain L thigh area. Received order x-ray showed intertrochanteric fracture." Review of the facility obtained statement from CNA #1 dated 5/26/12 revealed: "was changing resident on stand up lift. Resident released grips and left leg slipped a bit. Resident did not fall out of sling. Let resident slowly down with button of stand up lift." Review of the facility obtained statement from CNA #1 dated 5/27/12 revealed: "Tell me what happened yesterday? I had her up on the stand up lift to change her on my last round. She had a hold of the bars with her hands. Her hand kind of let go and grabbed back onto it. Her left leg slipped forward. When she did that I let her back down into her chair. Did her leg hit anything? Not that I noticed but I was more worried about her slipping and falling, so I was trying to get her down into her chair. What happened after that? I took her out of the sling and she was saying her left leg was hurting her. She was in the scoot chair. I went to get the nurse to look at her. How many people were in the room while using the lift? Just one I'm not going to lie about that. Did you know she should have had two in room with lift per the kardex? Yes I did. Why didn't you? I'm not really sure to be perfectly honest." During a telephone interview on 6/5/12 at 11:10 AM, CNA #1 stated that she was assigned to Resident #1 from 7 AM-3 PM on 5/26/12. She stated that she was changing the resident at approximately 1:30-2 PM. CNA #1 stated that the resident was on the stand up lift when her leg buckled and her foot slipped off the platform. CNA #1 stated that she lowered the resident back into her chair and wheeled the resident to her room. CNA #1 stated that Resident #1 cried out when her foot slipped and then complained of pain to her left leg. After the resident was back in her room, CNA #1 stated that she went and informed the nurse of the incident and reported the left leg pain. CNA #1 stated that she transferred the resident by herself and stated that she knew the resident's Kardex indicated the resident was to have a two person assist and a lift for transfers. CNA #1 stated that she informed LPN #1 that she had transferred the resident by herself. CNA #1 also stated that she finished the remainder of her shift on 5/26/12 and stated that she had a resident assignment on 5/27/12 from 7 AM- 11:10 AM. Review of the Time Card for CNA Williams revealed CNA Williams clocked in at 6:54 AM on 5/26 and clocked out at 3 PM. CNA Williams then clocked in at 6:57 AM on 5/27/12 and clocked out at 11:10 AM. Review of the facility obtained statement from LPN #1 dated 5/27/12 revealed: "I was sitting at my desk finishing up work. (CNA #1) came to the desk and said that (Resident #1) had a skin tear and was complaining of left leg hurting. Was she complaining of pain before this? No. What happened next? I asked her what happened. She said she had her on the stand lift to do incontinent care. Her hands slipped off the grip bar and she (the patient) reached and grabbed them again. That's how she got the skin tear on the thumb. She said her leg slipped on the platform and kind of buckled. That's when she set her back into the scoot chair. What was your assessment of the patient? I looked at her thumb and seen skin tear. I moved her leg, when she lifted her leg she said it was hurting in her left thigh. Her verbal expression was mild pain, I recorded. I gave her Tylenol. No bruising or redness. I reported skin tear to physician. The second shift nurse arrived and the physician was called and order obtained for the x-ray while I was there." During an interview on 6/5/12 at 11:30 AM, LPN #1 confirmed her statement and confirmed that she was assigned to the resident from 7 AM-3 PM on 5/26/12. LPN #1 stated that at approximately 2 PM, CNA #1 reported that the resident's leg slipped off of the lift. LPN #1 stated that CNA #1 informed her at that time that she was using the lift by herself. LPN #1 stated that she went and assessed the resident. She stated that the resident was sitting up in her scoot chair and complained of pain to her left thigh. LPN #1 stated that she looked at the resident's leg and did not see any bruising or swelling. LPN #1 stated that she administered Tylenol for pain. She then stated that the second shift nurse arrived and was told that the resident was still in pain, LPN #2 assessed the resident and noted her hip was misaligned. LPN #1 stated that the physician was called an x-ray was obtained. LPN #1 stated that she notified the physician via the "bump and fall" line. LPN #1 also stated that she could not remember who called the Director of Nurses regarding the incident. Review of the facility obtained statement from LPN #2 dated 5/29/12 revealed: "(LPN #1) was working on report for skin tear between thumb and forefinger. (LPN #1) said patient was complaining of pain in her left leg. She advised me to monitor her. Shortly after that (CNA #2) brought her to the desk. She was complaining of pain. (CNA #2) took her back to room to put her to bed. I went to look at her leg. It did look like it may be out of alignment on the left side. So I went back to the desk and told (LPN #1) I was going to call for x-ray. She also agreed. So I called (Attending physician), he said to have x-ray completed. X-ray was completed, we received report, I called back and spoke with (Nurse Practitioner). She said to send her to hospital for evaluation." During a telephone interview on 6/5/12 at 3 PM, LPN #2 stated that she was assigned to Resident #1 from 3-11 PM on 5/26/12. LPN #2 stated that she received report from LPN #1 and was informed the resident had complaints of pain to her left leg. LPN #2 stated that CNA #2 brought the resident to the desk and informed her that the resident was complaining of left leg pain. LPN #2 told the CNA to put her in the bed. LPN #2 stated that this occurred between 3:15 and 3:30 PM. LPN #2 stated that she then went and assessed the resident and noted that her left leg looked out of alignment. She stated that she went back to the desk and informed LPN #1 of her findings. She stated that LPN #1 agreed that an x-ray should be ordered and the physician was notified. LPN #2 stated that she "did not think of neglect or think of investigating the incident and was more concerned with the issue at hand." During an interview on 6/5/12 at 2 PM, the Director of Nurses (DON) and the Administrator confirmed the discrepancy in the CNA Kardex, ADL Sheet and Nursing Care Plan. The DON also confirmed LPN #1 did not follow up after she administered Tylenol to Resident #1 for left leg pain. The DON stated that she was contacted at approximately 8 PM on 5/26/12 and informed of the leg fracture. She stated that she was not informed CNA #1 transferred the resident inappropriately until the next day. The DON confirmed that LPN #1 was aware of the alleged neglect and confirmed that she did not report the incident. The DON also confirmed that CNA #1 continued with her assignment on 5/26/12 and confirmed that she had a patient assignment on 5/27/12.

On the days of the complaint inspection based on observations, record review, interview and review of the facility's policy on Abuse, Neglect and Misappropriation of Patient Property Prevention, the facility failed to ensure their policies and procedures were implemented related to resident protection and reporting. Certified Nurse Assistant (CNA) #1 was not immediately suspended after an allegation of neglect. Licensed Practical Nurse (LPN) #1 failed to report the alleged incident. The findings included: Cross Refer to F 224 as it relates to the facility's failure to protect residents and the facility's failure to ensure all incidents of neglect were reported. Resident #1 was transferred inappropriately resulting in a left femur fracture. Certified Nursing Assistant #1 admitted to transferring the resident inappropriately. Licensed Practical Nurse #1 failed to report the allegation of neglect. Review of the facility's policy on Abuse, Neglect and Misappropriation of Patient Property Prevention revealed: "Protect Abuse, Neglect and misappropriation of property can occur among various people within the center. The center supports and protects patients, family members and staff from harm during an investigation of alleged abuse. Protective actions depend on the people involved. Any allegation of abuse must be immediately reported to the supervisor and abuse prevention coordinator. The administrator follows the quality assurance and assessment occurrence investigation process in investigating the allegation of abuse, neglect and or misappropriation of patient property."

On the days of the Complaint and Extended Inspection based on observations, record reviews and interviews, the facility failed to ensure the safety for one of four residents reviewed for specialized rehab. Resident #1 received hot pack therapy via a makeshift rice sock that resulted in a third degree burn to her mid thoracic region. The findings included: The facility admitted Resident #1 on 6/16/2010 with [DIAGNOSES REDACTED]. Review of the Initial Minimum Data Set ((MDS) dated [DATE] coded the resident as having no short-term or long-term memory problems and as not needing assistance in daily decision-making. No behaviors were coded for the assessment period. Review of the Quarterly MDS dated [DATE] indicated that the resident was not experiencing pain. The Quarterly MDS coded Resident #1 as having a burn. Review of Resident #1's Care Plan revealed no care plan for therapy services, however at the time of the survey the resident was not currently on therapy's caseload. No old care plans were produced at the time. Further review revealed the resident's Care Plan updated on 12/15/2010 to reflect the burn on her back as a result of a hot pack. Observation of Resident #1 on 2/28/2011 revealed a dark red colored, burned area, approximately 5 centimeters by 2.5 centimeters (cm) to the mid thoracic region of the back. The center of the burn was a small area of friable tissue measuring approximately 0.5 cm by 0.5 cm. The center area skin was intact but extremely fragile in appearance. Review of the Nurses Notes revealed the following entries: On 12/14/2010 at 10:00 PM "Resident is noted to have a redden (sic) area on back, slightly raised. When asked how it happened, resident stated when she was in therapy today, will continue to monitor..." On 12/15/2010 at 8:30 AM, "Resident is noted to have a burn area to back, area is noted to be 2.5 cm x 3.0 cm with serous drainage family is notified and MD, new orders are written for Silvedeen (sic), incident report will be completed by primary nurse." Further review of the notes revealed the resident complained of pain to her back. The physician ordered Tramadol for the pain along with the scheduled Tylenol. Review of the Skin Alteration Record initiated on 12/15/2010 measured the burn as 2.5 cm x 3.0 cm, reddened in color with no drainage. The record indicated that the burned area was decreasing in size. On 2/11/2011, the burn measured 2 cm x 1.5 cm with scant amount of serosanguinous drainage. On 2/17/2011, the burn was 1 cm x 1 cm with serous drainage. On 2/26/2011 the burn was recorded as measuring 0.5 cm x 0.5 cm with no drainage. Review of the Wound Notes revealed the "burn was healing well." Review of the Physician's Orders revealed the following: On 12/15/2010 a telephone order was written for "Silverdeen (sic) to area on back q (every) day and cover c (with) border gauze." On 1/5/2011 a telephone order was written for "1. D/C (discontinue) Silverdene (sic) and border gauze to area on back q day. 2. Cleanse area to back c NS (normal saline), pat dry c 4 x 4, apply Santyl and cover c border gauze q day and PRN." The order was clarified on 1/20/2011, "D/C previous tx (treatment) to back wound start on 1/21: clean area c NS, pat dry c 4 x 4, apply Santyl, cover c Border Gause. change daily and prn (as needed) x 14 days, then reevaluate." There was no documentation located as to why the dressing order was changed and Santyl was ordered. The following telephone order written on 1/21/2011 indicated, "D/C previous to back: start 1/21 clean area c NS pat dry c 4 x 4, apply hydrogel and cover c Border Gause change daily and PRN until healed." Review of the "Physician Orders Physical Therapy" dated 12/8/2010 revealed "cold packs" were checked as a treatment. Nowhere on the form were hot packs listed as a modality. Review of the Therapy "Consultation Evaluation" indicated under treatment approaches, "hot/cold" pack was listed as a modality. Review of the Rehabilitation Summary form revealed a weekly status update dated 12/15/2010 that stated, "patient on 12-14-10 reported low back pain @ +10, after treatment no pain; ...patient received heat to low back x 12 minutes f/b (followed by) rub down of pain relieving cream to low back region..." No other documentation was located related to the use of a hot pack. Review of the Physician's Progress Notes revealed an entry dated 12/15/2010 by the Attending Physician that documented, "I was asked to evaluate a lesion on her back that is attributed to a burn from a heating pad. This appears shallow. I estimate its maximum dimensions at 2 cm or less. These usually heal in 7-14 days. A bandage for comfort is my only suggestion. Antibiotic creams or bland ointments are optional." An entry dated 1/16/2011 documented, "Burned area on back has not completely healed. Appropriately tx (treated) c protective bandage, which is all that she needs..." During an interview on 2/28/2011, Resident #1 stated that the burn occurred during therapy. Resident #1 stated that the therapist placed a hot pack on her shoulder and it fell over. She stated that it was "very hot" and on a "long time." She also stated that she did not tell anyone in the therapy department that the hot pack was too hot. Resident #1 stated that she informed the nurses that that evening of what happened. Resident #1 was asked, on three separate occasions to show the surveyor exactly where the hot pack was placed. Each time Resident #1 pointed to the right shoulder, mid shoulder blade region and said that the hot pack fell down towards the left shoulder. She stated that the hot pack was "held in place" by her leaning back in the wheelchair. During an interview on 2/28/2011, the Physical Therapy Assistant (PTA) #1 stated that he placed the hot pack on Resident #1. He stated that the hot pack was placed on her lower back region not her shoulder. He stated that he used the makeshift rice sock because that was what was used. PTA #1 stated that in order to use heat as a modality a physicians order must be written. He stated that the Rehab Director "encouraged" the use of makeshift hot packs. PTA #1 stated that he placed the makeshift hot pack into the microwave for 3-5 minutes then placed the hot pack in towels and placed the pack on Resident #1. PTA #1 stated that the nursing department reported the burn the next day. He stated that he assessed the wound and that it was "not a burn." He stated that the Rehab Director destroyed the hot packs and stated that they were not to be in use. He then stated that the Rehab Director stated that the hot packs were not even supposed to be in the building due to a Corporate Policy. Three therapists were interviewed on 2/28/2011, all three stated that the makeshift hot packs made from socks and rice were in use in the building prior to 12/15/2010. All three stated that the Rehab Director was aware of the use. They stated that a physician's order must be written prior to using heat. All stated that they would not heat the sock in the microwave for more than 1 minute. All three stated that using the rice socks was a routine practice; however none could remember specific patients the rice socks were used on. During an interview on 2/28/2011, the Rehab Director stated that she was aware the makeshift hot packs were in use prior to 12/15/2010. She stated that they had been in use prior to her position as the manager in November 2009. The Rehab Director stated that she supported the use of all modalities and did not encourage the use of one over another and was "ok" with the use of the hot packs. The Rehab Director stated that she was not aware of the Corporate Policy related to the use of heat and hot packs. The Rehab Director confirmed the Physician's Order did not have "hot packs" or "heat" as a modality ordered. She stated that since hot/cold pack was on the evaluation form and signed by the physician that it was the therapist's discretion as to which modality to use. During an interview on 2/28/2011, the Attending Physician stated that the burn sustained on Resident #1's mid thoracic region was a third degree burn. He stated that he was not aware the burn was sustained while using a makeshift rice sock that was heated in the microwave. During an interview on 2/28/2011, the Medical Director stated that he was aware of the Corporate Policy related to not using hot packs or heat as a modality. He stated that he was not aware that heat was being used in the facility. He stated that he was not aware the makeshift hot packs that were in use were made from tube socks and rice. He stated that it "wouldn't be a good thing to use." He further stated that in order to use the product it must be standardized, reproducible and predictable in order to establish safety. He confirmed that the makeshift rice socks were none of the above. During an interview on 2/28/2011, the Regional Rehab Director stated that it was the policy of HCR ManorCares that heat was not to be used as a modality. She stated that the policy went into effect 3/4/2009. She further stated that a memo was sent to all Administrators, Directors of Nursing and Rehab Directors. She stated that heat should not have been used in the facility. She also stated that the Rehab Director at this facility was "not aware" of the memo and the memo should have been communicated to her. However, she stated, "accountability was not clear." Review of the Memo dated 3/4/2009 and sent to "Directors of Rehabilitation, Rehab Services, ADNS (Directors of Nurses) and Administrators." The memo documented: "Effective immediately, the Skilled Nursing Center Rehabilitation Departments will no longer be providing hot pack treatments... Do not substitute the hydrocollator unit and hot packs with any type of electric, microwaveable, or chemically activated heating pads..." Cross Refers to F-281 as it relates to the failure of the facility to provide specialized rehab services that met professional standards of practice. Cross Refers to F-407 as it relates to providing specialized rehabilitative services by qualified personnel to Resident #1 and the failure of the facility to provide rehabilitative services as prescribed by a physician. Cross refers to F-520 as it relates to the failure of the Quality Assessment and Assurance Committee to appropriately act on an identified concern related to a third degree burn sustained by Resident #1 as a result of the use of a makeshift hot pack. On 2/28/2011 at 2:15 PM the Administrator was notified that Substandard Quality of Care and Immediate Jeopardy were identified at F-323 at a scope and severity level of "J" and existed in the facility as of 12/14/2010. Following a review of the facility Allegation of Compliance documentation, inservice content and staff inservice completion sign off sheets, staff interviews, and record review of residents with therapy orders, the Immediate Jeopardy was removed and the citation at F-323 was lowered to a scope and severity level of a "D" as of 3/1/2011 at 11:30AM.

On the days of the Complaint and Expanded Inspection based on record reviews, interviews, observations, review of a March 4, 2009 HCR ManorCare memo related to the use of hot pack treatments, and review of the South Carolina Licensing, Labor and Regulation Code of Ethics for Physical Therapy Assistants 101-14, the facility failed to ensure that one of four residents reviewed for specialized rehab received the appropriate standards of care related to the use of a hot pack. Resident #1 sustained a third degree burn to her mid [MEDICATION NAME] region when a hot pack made from a tube sock filled with an unknown amount of rice, was heated in the microwave for an undetermined amount of time and then placed on her mid [MEDICATION NAME] region. The findings included: The facility admitted Resident #1 on 6/16/2010 with [DIAGNOSES REDACTED]. Observation of Resident #1 on 2/28/2011 revealed a dark red colored, burned area, approximately 5 centimeters by 2.5 centimeters (cm) to the mid [MEDICATION NAME] region of the back. The center of the burn was a small area of friable tissue measuring approximately 0.5 cm by 0.5 cm. The center area skin was intact but extremely fragile in appearance. Review of the "Physician Orders Physical Therapy" dated 12/8/2010 revealed "cold packs" were checked as a treatment. Nowhere on the form were hot packs listed as a modality. Review of the Therapy "Consultation Evaluation" indicated under treatment approaches, "hot/cold" pack was listed as a modality. Review of the Rehabilitation Summary form revealed a weekly status update dated 12/15/2010 that stated, "patient on 12-14-10 reported low back pain @ +10, after treatment no pain; ...patient received heat to low back x 12 minutes f/b (followed by) rub down of pain relieving cream to low back region..." No other documentation was located related to the use of a hot pack. Review of the Nurse's Notes revealed the following entries: On 12/14/2010 at 10:00 PM "Resident is noted to have a redden (sic) area on back, slightly raised. When asked how it happened, resident stated when she was in therapy today, will continue to monitor..." On 12/15/2010 at 8:30 AM, "Resident is noted to have a burn area to back, area is noted to be 2.5 cm x 3.0 cm with serous drainage family is notified and MD, new orders are written for Silvedeen (sic), incident report will be completed by primary nurse." Further review of the notes revealed the resident complained of pain to her back. The physician ordered [MEDICATION NAME] for the pain along with the scheduled Tylenol. During an interview on 2/28/2011, Resident #1 stated that the burn occurred during therapy. Resident #1 stated that the therapist placed a hot pack on her shoulder and it fell over. She stated that it was "very hot" and on for a "long time." She also stated that she did not tell anyone in the therapy department that the hot pack was too hot. Resident #1 stated that she had informed the nurses that evening of what happened. Resident #1 was asked, on three separate occasions to show the surveyor exactly where the hot pack was placed. Each time Resident #1 pointed to the right shoulder, mid shoulder blade region and said that the hot pack fell down towards the left shoulder. She stated that the hot pack was "held in place" by her leaning back in the wheelchair. During an interview on 2/28/2011, the Physical Therapy Assistant (PTA) #1 stated that he placed the hot pack on Resident #1. He stated that the hot pack was placed on her lower back region not her shoulder. He stated that he used the makeshift rice sock because that was what was used in the facility. PTA #1 stated that in order to use heat as a modality a physician's order must be written. He stated that the Rehab Director "encouraged" the use of makeshift hot packs. PTA #1 stated that he placed the makeshift hot pack into the microwave for 3-5 minutes then placed the hot pack in towels and placed the pack on Resident #1. PTA #1 stated that the nursing department reported the burn the next day. He stated that he assessed the wound and that it was "not a burn." He stated that the Rehab Director destroyed the hot packs and stated that they were not to be in use. He then stated that the Rehab Director stated that the hot packs were not even supposed to be in the building due to a Corporate Policy. Three therapists were interviewed on 2/28/2011, all three stated that the makeshift hot packs made of socks and rice were in use in the building prior to 12/15/2010. All three stated that the Rehab Director was aware of the use. The three therapists stated that a physician's order must be written prior to using heat and all stated that they would not heat the sock in the microwave for more than 1 minute. All three stated that using the rice socks was a routine practice; however none could remember specific patients the rice socks were used on. During an interview on 2/28/2011, the Rehab Director stated that she was aware the make shift hot packs were in use prior to 12/15/2010. She stated that they had been in use prior to her position as the manager in November 2009. The Rehab Director stated that she supported the use of all modalities and did not encourage the use of one over another and was "ok" with the use of the hot packs. The Rehab Director stated that she was not aware of the Corporate Policy related to the use of heat and hot packs. The Rehab Director confirmed the Physician's Order did not have "hot packs" or "heat" as a modality ordered. She stated that since hot/cold pack was on the evaluation form and signed by the physician that it was the therapist's discretion as to which modality to use. During an interview on 2/28/2011, the Attending Physician stated that the burn sustained on Resident #1's mid [MEDICATION NAME] region was a third degree burn. He stated that he was not aware the burn was sustained while using a makeshift rice sock that was heated in the microwave. During an interview on 2/28/2011, the Medical Director stated that he was aware of the Corporate Policy related to not using hot packs or heat as a modality. He stated that he was not aware that heat was being used in the facility. He stated that he was not aware the makeshift hot packs that were in use were made from tube socks and rice. The Medical Director stated that it "wouldn't be a good thing to use." He further stated that in order to use the product it must be standardized, reproducible and predictable in order to establish safety. He confirmed that the makeshift rice socks were none of the above. During an interview on 2/28/2011, the Regional Rehab Director stated that it was the policy of HCR Manor Cares that heat was not to be used as a modality. She stated that the policy went into effect 3/4/2009. She further stated that a memo was sent to all Administrators, Directors of Nursing and Rehab Directors. She stated that heat should not have been used in the facility. She also stated that the Rehab Director at this facility was "not aware" of the memo and the memo should have been communicated to her. However, she stated, "accountability was not clear." Review of the memo sent March 4, 2009 from the Vice President, for Rehabilitation Services, HCR ManorCare, addressed to Directors of Rehabilitation, Rehab Services, ADNS (Director of Nursing), and Administrators stated, "Effective immediately, the Skilled Nursing Center Rehabilitation Departments will no longer be providing hot pack treatments. With the increasing acuity of the patients entering our centers, many patients present with contraindications to superficial moist heat. Our Rehabilitation Departments have other effective methods of deep tissue heating, such as diathermy and ultrasound. The Director of Rehabilitation should unplug, drain and dispose of [MEDICATION NAME] units and hot packs in your department effective immediately. The [MEDICATION NAME] units should be placed in a dumpster, rather than put in storage. Do not substitute the [MEDICATION NAME] unit and hot packs with any type of electric, microwaveable, or chemically activated heating pads..." Review of the LLR 101-14 Code of Ethics for Physical Therapy Assistants revealed the following: Standard 1: Physical Therapist Assistants provide services under the supervision of a physical therapist. Standard 2: Physical Therapist Assistants respect the rights and dignity of all individuals. Standard 3: Physical Therapist Assistants maintain and promote high standards in the provision of services, giving the welfare of patients their highest regard. Standard 4: Physical Therapist Assistants provide services within the limits of the law. Standard 5: Physical Therapist Assistants make those judgments that are commensurate with their qualifications as physical therapist assistants. Standard 6: Physical Therapist Assistants accept the responsibility to protect the public and the profession from unethical, incompetent, or illegal acts. Cross Refers to F-407 as it relates to providing specialized rehabilitative services by qualified personnel to Resident #1 and the failure of the facility to provide rehabilitative services as prescribed by a physician. Cross Refers to F-323 as it relates to the facility failure to provide an environment free of hazards as is possible and the facility failure to provide adequate supervision to prevent accidents for Resident #1 who sustained a third degree burn as a result of the use of a make shift hot pack. Cross Refers to F-520 as it relates to the failure of the Quality Assessment and Assurance Committee to appropriately act on an identified concern related to a third degree burn sustained by Resident #1 as a result of the use of a makeshift hot pack. On 2/28/2011 at 2:15 PM the Administrator was notified that Immediate Jeopardy was identified at F-281 at a scope and severity level of "J" and existed in the facility as of 12/14/2010. Following a review of the Allegation of Compliance documentation, inservice content and staff inservice completion sign off sheets, staff interviews, and record review of residents with therapy orders, the Immediate Jeopardy was removed and the citation at F-281 was lowered to a scope and severity level of a "D" as of 3/1/2011 at 11:30AM.

On the days of the Complaint and Expanded Inspection based on observations, record reviews, interviews, review of the South Carolina Licensing, Labor and Regulation Code of Ethics for Physical Therapy Assistants 101-14, and review of the facility's Corporate Memo dated 3/4/2009, the facility failed to provide the appropriate rehabilitation services in accordance with facility policy, standards of practice for therapists, and as prescribed by the physician. Resident #1 sustained a third degree burn to her mid [MEDICATION NAME] region from a makeshift hot pack made from a tube sock and an undetermined amount of rice. The findings included: The facility admitted Resident #1 on 6/16/2010 with [DIAGNOSES REDACTED]. Observation of Resident #1 on 2/28/2011 revealed a dark red colored, burned area, approximately 5 centimeters by 2.5 centimeters (cm) to the mid [MEDICATION NAME] region of the back. The center of the burn was a small area of friable tissue measuring approximately 0.5 cm by 0.5 cm. The center area skin was intact but extremely fragile in appearance. During an interview on 2/28/2011, Resident #1 stated that the burn occurred during therapy. Resident #1 stated that the therapist placed a hot pack on her shoulder and it fell over. She stated that it was "very hot" and on a "long time." She also stated that she did not tell anyone in the therapy department that the hot pack was too hot. Resident #1 stated that she informed the nurses that evening of what happened. Resident #1 was asked, on three separate occasions to show the surveyor exactly where the hot pack was placed. Each time Resident #1 pointed to the right shoulder, mid shoulder blade region and said that the hot pack fell down towards the left shoulder. She stated that the hot pack was "held in place" by her leaning back in the wheelchair. Review of the Nurse's Notes revealed the following entries: On 12/14/2010 at 10:00 PM "Resident is noted to have a redden (sic) area on back, slightly raised. When asked how it happened, resident stated when she was in therapy today, will continue to monitor..." On 12/15/2010 at 8:30 AM, "Resident is noted to have a burn area to back, area is noted to be 2.5 cm x 3.0 cm with serous drainage family is notified and MD, new orders are written for Silvedeen (sic), incident report will be completed by primary nurse." Further review of the notes revealed the resident complained of pain to her back. The physician ordered [MEDICATION NAME] for the pain along with the scheduled Tylenol. Review of the "Physician Orders Physical Therapy" dated 12/8/2010 revealed "cold packs" were checked as a treatment. Nowhere on the form were hot packs listed as a modality. Review of the Therapy "Consultation Evaluation" indicated under treatment approaches, "hot/cold" pack was listed as a modality. Review of the Rehabilitation Summary form revealed a weekly status update dated 12/15/2010 that stated, "patient on 12-14-10 reported low back pain @ +10, after treatment no pain; ...patient received heat to low back x 12 minutes f/b (followed by) rub down of pain relieving cream to low back region..." No other documentation was located related to the use of a hot pack. Review of the Physician's Progress Notes revealed an entry dated 12/15/2010 by the Attending Physician that documented, "I was asked to evaluate a lesion on her back that is attributed to a burn from a heating pad. This appears shallow. I estimate its maximum dimensions at 2 cm or less. These usually heal in 7-14 days. A bandage for comfort is my only suggestion. Antibiotic creams or bland ointments are optional." An entry dated 1/16/2011 documented, "Burned area on back has not completely healed. Appropriately tx (treated) c protective bandage, which is all that she needs..." During an interview on 2/28/2011, the Attending Physician stated that the burn sustained on Resident #1's mid [MEDICATION NAME] region was a third degree burn. He stated that he was not aware the burn was sustained while using a makeshift rice sock that was heated in the microwave. During an interview on 2/28/2011, the Medical Director stated that he was aware of the Corporate Policy related to not using hot packs or heat as a modality. He stated that he was not aware that heat was being used in the facility. He stated that he was not aware the makeshift hot packs that were in use were made from tube socks and rice. He stated that it "wouldn't' t be a good thing to use." He further stated that in order to use the product it must be standardized, reproducible and predictable in order to establish safety. He confirmed that the makeshift rice socks were none of the above. During an interview on 2/28/2011, the Physical Therapy Assistant (PTA) #1 stated that he placed the hot pack on Resident #1. He stated that the hot pack was placed on her lower back region not her shoulder. He stated that he used the makeshift rice sock because that was what was used in the facility. PTA #1 stated that in order to use heat as a modality a physicians order must be written. He stated that the Rehab Director "encouraged" the use of makeshift hot packs. PTA #1 stated that he placed the makeshift hot pack into the microwave for 3-5 minutes then placed the hot pack in towels and placed the pack on Resident #1. PTA #1 stated that the nursing department reported the burn the next day. He stated that he assessed the wound and that it was "not a burn." PTA #1 stated that the Rehab Director destroyed the hot packs and stated that they were not to be in use. He then stated that the Rehab Director stated that the hot packs were not even supposed to be in the building due to a Corporate Policy. Three therapists were interviewed on 2/28/2011, all three stated that the makeshift hot packs made of socks and rice were in use in the building prior to 12/15/2010. All three stated that the Rehab Director was aware of the use. They stated that a physician's order must be written prior to using heat. All stated that they would not heat the sock in the microwave for more than 1 minute and that using the rice sock was a routine practice; however none could remember specific patients the rice socks were used on. During an interview on 2/28/2011, the Rehab Director stated that she was aware the makeshift hot packs were in use prior to 12/15/2010. She stated that they had been in use prior to her position as the manager in November 2009. The Rehab Director stated that she supported the use of all modalities and did not encourage the use of one over another and was "ok" with the use of the hot packs. The Rehab Director stated that she was not aware of the Corporate Policy related to the use of heat and hot packs. The Rehab Director confirmed the Physician's Order did not have "hot packs" or "heat" as a modality ordered. She stated that since hot/cold pack was on the evaluation form and signed by the physician that it was the therapist's discretion as to which modality to use. During an interview on 2/28/2011, the Regional Rehab Director stated that it was the policy of HCR Manor Cares that heat was not to be used as a modality. She stated that the policy went into effect 3/4/2009. She further stated that a memo was sent to all Administrators, Directors of Nursing and Rehab Directors. She stated that heat should not have been used in the facility. She also stated that the Rehab Director at this facility was "not aware" of the memo and the memo should have been communicated to her. However, she stated, "accountability was not clear." Review of the Memo dated 3/4/2009 and sent to "Directors of Rehabilitation, Rehab Services, ADNS (Directors of Nurses) and Administrators." The memo documented: "Effective immediately, the Skilled Nursing Center Rehabilitation Departments will no longer be providing hot pack treatments... Do not substitute the [MEDICATION NAME] unit and hot packs with any type of electric, microwaveable, or chemically activated heating pads..." Review of the LLR 101-14 Code of Ethics for Physical Therapy Assistants revealed the following: Standard 1: Physical Therapist Assistants provide services under the supervision of a physical therapist. Standard 2: Physical Therapist Assistants respect the rights and dignity of all individuals. Standard 3: Physical Therapist Assistants maintain and promote high standards in the provision of services, giving the welfare of patients their highest regard. Standard 4: Physical Therapist Assistants provide services within the limits of the law. Standard 5: Physical Therapist Assistants make those judgments that are commensurate with their qualifications as physical therapist assistants. Standard 6: Physical Therapist Assistants accept the responsibility to protect the public and the profession from unethical, incompetent, or illegal acts. Cross Refers to F-281 as it relates to the failure of the facility to provide specialized rehab services that met professional standards of practice. Cross Refers to F-323 as it relates to the facility' s failure to provide an environment free of hazards as is possible and the facility' s failure to provide adequate supervision to prevent accidents for Resident #1''s third degree burn sustained as a result of the use of a makeshift hot pack. Cross Refers to F-520 as it relates to the failure of the Quality Assessment and Assurance Committee to appropriately act on an identified concern related to a third degree burn sustained by Resident #1 as a result of the use of a makeshift hot pack. On 2/28/2011 at 2:15 PM the Administrator was notified that Immediate Jeopardy was identified at F-407 at a scope and severity level of "J" and existed in the facility as of 12/14/2010. Following a review of the Allegation of Compliance documentation, inservice content and staff inservice completion sign off sheets, staff interviews, and record review of residents with therapy orders, the Immediate Jeopardy was removed and the citation at F-407 was lowered to a scope and severity level of "D" as of 3/1/2011 at 11:30AM.

On the days of the Complaint and Expanded Inspection based on observations, record reviews, interviews and review of the facility's Quality Assurance (QA) committee meeting minutes, the facility failed to appropriately act upon a known deficiency. A Corporate policy implemented in 2009 mandated that heat would not be a part of therapy utilized in the facility. The facility Rehab Director was aware that makeshift rice socks were in use to provide heat packs as a part of therapy. A Plan of Action was put in place when a resident was burned on 12/14/10 but the QA meeting minutes revealed the facility was aware the plan of action put into place on 12/15/2010 had not been completed. The findings included: The facility admitted Resident #1 on 6/16/2010 with [DIAGNOSES REDACTED]. Observation of Resident #1 on 2/28/2011 revealed a dark red colored, burned area, approximately 5 centimeters by 2.5 centimeters (cm) to the mid [MEDICATION NAME] region of the back. The center of the burn was a small area of friable tissue measuring approximately 0.5 cm by 0.5 cm. The center area skin was intact but extremely fragile in appearance. During an interview on 2/28/2011, Resident #1 stated that the burn occurred during therapy. Resident #1 stated that the therapist placed a hot pack on her shoulder and it fell over. She stated that it was "very hot" and on a "long time." She also stated that she did not tell anyone in the therapy department that the hot pack was too hot. Resident #1 stated that she informed the nurses that evening of what happened. Resident #1 was asked, on three separate occasions to show the surveyor exactly where the hot pack was placed. Each time Resident #1 pointed to the right shoulder, mid shoulder blade region and said that the hot pack fell down towards the left shoulder. She stated that the hot pack was "held in place" by her leaning back in the wheelchair. Review of a Memo dated 3/4/2009 and sent to "Directors of Rehabilitation, Rehab Services, ADNS (Directors of Nurses) and Administrators." The memo documented: "Effective immediately, the Skilled Nursing Center Rehabilitation Departments will no longer be providing hot pack treatments... Do not substitute the [MEDICATION NAME] unit and hot packs with any type of electric, microwaveable, or chemically activated heating pads..." After Resident #1 received the burn, a Plan of Action was put in place that included inservicing all staff of the facility policy related to "no heat therapy". Review of the Inservice Sign in sheet for the inservice conducted on 12/15 and 12/16/2010 as a result of the burn Resident #1 sustained revealed that not all of the therapy and licensed nursing staff attended the inservice. Review of the facility's QA meeting minutes dated 1/28/2011 revealed "DHEC reports- (Resident #1) therapy to complete inservices." During an interview on 3/1/2011, the Director of Nursing confirmed the inservice sign in sheets showed that all of the therapy staff and licensed nursing staff had not completed the inservice related to the plan of correction put in place following a burn to Resident #1 on 12/14/2010. The DON confirmed that the plan of correction submitted to the Bureau of Certification on 12/15/2010 included staff inservicing. The DON also confirmed that the Memo sent on 3/4/2009 was sent to the Administrator. She stated, however that she was not the DON at the time and the Rehab Director was not the Director at the time the memo was sent. The DON stated that the nursing staff was aware that heat was not to be used as a modality. She further stated that the therapy department "should have known" not to use the hot packs. Cross Refers to F-281 as it relates to the failure of the facility to provide specialized rehab services that met professional standards of practice. Cross Refers to F-407 as it relates to providing specialized rehabilitative services by qualified personnel to Resident #1 and the failure of the facility to provide rehabilitative services as prescribed by a physician. Cross Refers to F-323 as it relates to the facility failure to provide an environment as free of hazards as possible and the facility failure to provide adequate supervision to prevent accidents for Resident #1 who sustained a third degree burn due to the use of a make shift hot pack. On 2/28/2011 at 2:15 PM the Administrator was notified that Immediate Jeopardy was identified at F-520 at a scope and severity level of "J" and existed in the facility as of 12/14/2010. Following a review of the Allegation of Compliance documentation, inservice content and staff inservice completion sign off sheets, staff interviews, and record review of residents with therapy orders, the Immediate Jeopardy was removed and the citation at F-520 was lowered to a scope and severity level of a "D" as of 3/1/2011 at 11:30AM.