Every finding on record at White Oak Manor - Newberry

Based on interviews, record review, and review of facility policy, the facility failed to ensure resident safety and prevent avoidable accidents for 1 of 1 residents (R)124) reviewed for accidents/hazards. Specifically, on 10/15/2025, while a staff member was providing ADL care, the resident fell from the bed to the floor and sustained injuries, including bilateral femur fractures. Further, the resident required a two person assist for care, yet only one staff member was providing care at the time of the incident.Findings Include:A review of the facility policy titled Fall Management Program with no revision date states that [NAME] Oak Management, Inc. considers all newly admitted residents to be at risk for falls, as residents entering the facility have experienced some degree of decline and are transitioning into a new environment. The policy notes that fall risk determination may also be made by the Interdisciplinary Team or Safety Committee. The policy outlines recommended steps for implementing the Fall Management Program, including completion of the Fall Risk Data Collection Tool (electronic UDA) during the admission or readmission process and quarterly thereafter; conducting medication reviews and clinical condition assessments as needed; assessing each resident for a history of falls; performing environmental checks of the resident's immediate surroundings based on identified environmental factors; and developing an interim plan of care during the admission process for each resident.A review of R124's Face Sheet revealed the resident was admitted to the facility on [DATE] at 1:45 AM with diagnoses including, but not limited to, unspecified severe protein calorie malnutrition; osteoarthritis; other specified disorders of bone density and structure; unspecified fracture of the lower end of the right femur, subsequent encounter for closed fracture with routine healing; unspecified fracture of the lower end of the left femur, subsequent encounter for closed fracture with routine healing; and pathological fracture of the unspecified tibia and fibula, subsequent encounter for fracture with routine healing.A review of R124's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/14/2025 revealed a Brief Interview for Mental Status (BIMS) score of 04 out of 15, indicating the resident was severely cognitively impaired. Further review of the MDS showed the resident was dependent for all ADLs, including personal hygiene and toileting, and transfers were not attempted. In addition, the resident was coded with a prognosis of life expectancy less than six months, and Section O indicated the resident was receiving hospice services.A review of R124's care plan revealed a documented problem stating that the resident has a history of falls with major injuries and is at risk for re occurrence related to muscle weakness, cognitive impairment, and the medication regimen secondary to hypertension, diabetes mellitus, vascular dementia, degenerative joint disease, and osteoporosis. The care plan approach included assisting the resident in completing safe transfers per the facility's safe handling tool.A review of R124's Safe Resident Handling Data Collection Form dated 08/15/2025 revealed the resident required a total lift, which required two staff members to turn and reposition the resident in bed. The form also indicated that a lift sheet may be used.A review of R124's Fall Event Details Form dated 10/15/2025 revealed the fall was documented as a witnessed fall. The report stated the resident was being bathed by a hospice CNA and flipped out of the bed while being turned on her side during a sheet change. The form further indicated that prior to the fall, the resident was receiving a bath and the staff member was in the process of changing the bed linens.A review of R124's Hospital Summary dated 10/15/2025 revealed the chief complaint was documented as a fall. The summary stated the 91 year old nonambulatory female presents to the ED from [NAME] Oaks Manor secondary to a witnessed fall. Patient is DNR on hospice care currently. According to staff, patient rolled out of bed while being bathed. There is concern for lower extremity injury at this time. Denies any head injury, loss of consciousness, nausea, or vomiting. Patient has severe dementia at baseline. Bilateral knee X rays showed distal femur fractures bilaterally, while hip and pelvis X rays were essentially negative. The resident remained neurovascularly intact. The case was discussed with the orthopedic surgeon, who recommended non operative outpatient treatment with bilateral knee immobilizers and follow up in two weeks. Hospice nurses were present at the bedside, and precautions were discussed with them.A review of R124's Hospice Clinical Note Post Fall, charted by the hospice nurse and dated 10/15/2025, revealed the hospice [Certified Nursing Assistant (CNA)] contacted the nurse at 6:14 AM, reporting she was very distraught. The CNA stated she had been providing morning care to R124 and, when she walked around the bed to loosen the sheets for a linen change, the resident began moving and rolled off the bed. The CNA reported she attempted to grab the resident to prevent the fall but was unable to hold her, and the resident fell to the floor. The hospice nurse notified the resident's son and began traveling to the facility. While en route, the nurse was informed that the resident was being sent to a local hospital for evaluation and X rays due to crying out in pain when her legs were touched. The nurse attempted to notify the facility that X rays could be completed onsite, but the resident had already been transported. The hospital is located one parking lot away from the facility. The hospice nurse met the resident in the emergency department. X rays were taken, and the nurse requested 50 mg of Tramadol, which was part of the resident's routine medication regimen, to address pain. The physician reported that both femurs were fractured above the patella and stated the orthopedic surgeon would also review the X rays. The physician noted the bones appeared twisted, but the hospice nurse and the resident's son confirmed the leg positioning was affected by a previous fracture that had not healed in a straight alignment. The note documented that, prior to this incident, R124 required only one staff member for assistance with ADLs; however, hospice and the facility agreed the care plan would be updated to reflect a two person assist for all ADLs except feeding. Hospice assigned two CNAs to the resident's care, and the facility nurse practitioner was asked to add an additional scheduled dose of Tramadol and an extra PRN dose to address increased pain during healing. The resident was provided bilateral leg immobilizers, which could be removed for bathing or if skin breakdown was noted. The hospital physician requested a two week orthopedic follow up. The hospice nurse contacted the orthopedic office to determine whether X rays completed at the facility and placed on a disc would be acceptable; the orthopedic office confirmed that X rays must be provided on a disc for review. The hospice nurse ensured safe transport back to the facility and discussed potential care plan changes with facility leadership. The team agreed that the low air loss mattress, placed on the resident's bed the previous evening to reduce the risk of skin breakdown, may have contributed to the incident, as such mattresses have a [NAME] and less stable surface for providing care. This was a new surface for both the resident and staff. The hospice nurse documented the following changes to the resident's plan of care: 1. Change from a one person assist to a two person assist for all ADLs except feeding for both facility and hospice staff. 2.Addition of longer side rails, replacing individual half rails. 3.Application of bilateral leg immobilizers for pain control and healing. 4.Temporary increase in scheduled pain medication. 5.Addition of an extra PRN pain medication dose for breakthrough pain.6.Increased nursing visits for the next two weeks, including three nursing visits and three weekly CNA visits performed by two CNAs, to provide additional monitoring and safety oversight. 7.Ensuring side rails are raised and the bed is in the lowest position when staff leave the room. 8.Hospice to order fall mats for placement beside the bed, pending facility approval.An interview conducted on 06/03/2026 at 12:52 p.m. with the resident's son and responsible party revealed he had no complaints regarding the facility and described it as a good facility. He stated the resident was on hospice services and was a DNR at the time of the incident. He reported that on 10/15/2025, the facility notified him that the resident had reportedly fallen and that both of her legs appeared to be injured. He stated he did not believe the resident fell but believed she was dropped by a hospice CNA during a bed bath and linen change. He explained the resident was bedbound, unable to get up, and declining due to multiple comorbidities and being in the final days of life. He stated the resident had previously been dropped at another facility and believed the injuries sustained at this facility were a reinjury of prior injuries. He reported he had no concerns with the quality of care at this facility and could not recall whether one or two staff members were required to provide care. He stated there were no surgical interventions related to the injuries and that the resident had soft casts applied to both legs.An attempt was made to contact CNA 1 on 06/03/2026 at 1:11 p.m. A detailed voicemail message was left requesting a return call.An interview on 06/03/2026 at 1:41 PM, CNA 2 reported she had been employed with the hospice agency for over one year and was familiar with the resident. She stated she provided care to the resident three times per week and that the resident was bedbound and required a one person assist at the time. She reported that on the morning of 10/15/2025, she was providing the resident's morning care. She stated she had turned the resident onto her left side and then walked around to the opposite side of the bed. She observed the resident beginning to move and attempted to grab her but was unable to hold onto her, and the resident fell behind the bed onto the floor. She stated she had no additional staff present in the room at the time. CNA 2 stated she immediately pressed the call light and notified the nurse. She reported that staff used a Hoyer lift to assist the resident from the floor and return her to bed after the nurse completed an assessment. She stated she contacted her supervisor, who met her at the hospital. She reported she had the resident on her side while attempting to change the bed linens when the fall occurred and noted the resident's bed was not positioned against the wall. She stated she was not aware that the resident had a new mattress. She reported that following the incident, the resident was changed to a two person assist for care. She confirmed she received an in service related to lift use after the event.An Interview conducted on 06/04/26 at 12:25 PM, the Director of Nursing (DON) stated that reportable's are handled by herself and the Administrator. She confirmed she is familiar with the R124 and the circumstances surrounding the reportable incident from October 2025. The DON stated she does not recall exactly how she was notified of the event, only that it occurred on a weekday. She recalled being informed that the resident had experienced a fall from the bed during care and was being transferred to the hospital. stated that the day prior to the incident, an air reducing mattress had been placed on the resident's bed. She explained that the hospice nurse's assessment triggered the addition of the mattress, noting that this was a hospice intervention rather than a facility initiated change. Facility staff were aware of the mattress change; however, it was unclear whether the hospice company communicated this change to their CNA staff. She reported that the contracted hospice CNA was providing care at the time of the incident. The resident had been turned onto her side, and the CNA was removing the sheet from one side of the bed. DON stated that this may have shifted the resident's weight to the opposite side, contributing to the fall and resulting injuries. She described the resident as a routine CNA care resident with consistent care patterns. She noted the mattress was similar to an air mattress in texture and movement. DON stated the resident sustained bilateral femur fractures. Based on hospital records, the resident reinjured a previous fracture originally sustained at another facility prior to admission to this facility. She confirmed that the witnessed fall on 10/15/2026 was the only fall the resident experienced during her stay at this facility. She reported that the resident required a total two person assist for transfers and repositioning. At the time of the fall, two staff members were not present in the room. Hospice staff came onsite the same day and provided in service training to the CNA involved, as well as to all other hospice CNAs, as a precautionary measure. The resident was transferred to the hospital on [DATE] and did not undergo surgical intervention. Knee immobilizers were applied. The resident was already on hospice care at the time, and the responsible party was notified of the event. DON stated the resident returned to the facility the same day.Attempts were made to contact LPN 5 (Licensed Practical Nurse) on 06/04/2026 at 1:27 p.m. and again at 1:57 p.m. via phone. Both attempts were unsuccessful. A detailed voicemail message was left requesting a return call.A phone interview with Hospice Registered Nurse (RN) on 06/04/2026 at 1:34 PM revealed she is the clinical operations manager, she's familiar with R124 and the incident that occurred on 10/15/2025. Hospice RN stated it was an unfortunate situation. Hospice RN states that per the documentation she has, the resident was a 1 person assist during that time. She has been a 1 person since admission to the facility. The decision at that time was based on the current status of the patient during that time of assessment. She wasn't a patient that required a 2 person assist. Prior to the fall on 10/15/2025, the hospice company ordered the a pressure reliving mattress, however once the mattress is ordered the company does not notify the staff once its installed, that's a communication that the facility staff should have communicated to the CNA. The Hospice RN confirmed she received the call from CNA4 and confirmed what was written in her clinical note. As far as the in-service, it was a verbal in-service. The RN states that the hospice staff were invited to care plan meeting by the son back in February 2025 and that was the only meeting hospice staff were in attendance for. Any changes or updates made after February 2025, such as resident becoming a 2 person assist instead of 1, the hospice staff were not made aware of by facility staff. When hospice aides arrive at the facility, they are to check in at the nurses station, and any type of communication, should be done at that time. An interview with the Facility Nurse Consultant on 06/04/2026 at 2:29 p.m. revealed that communication between the facility and hospice staff requires the facility nursing department to verbally communicate any updates to the resident's current plan of care to hospice staff, and hospice staff are likewise expected to verbally communicate updates to the facility.An interview with the Facility Administrator on 06/04/2026 at 3:17 p.m. revealed she was notified of the incident after the nurse who first received the report, and the reportable process was initiated at that time. She stated that, to the best of her knowledge, the hospice CNA who routinely provided care to the resident had been changing the bed linens when the resident slid off the mattress and the CNA was unable to catch her. She reported that the day prior to the incident, a pressure relieving air mattress had been placed on the resident's bed, which may have contributed to the fall. She stated the resident was admitted to the facility already on hospice services at the request of the family, under a one time hospice contract. The Administrator stated that door tags identify the resident's transfer and repositioning status, and both hospice staff and facility staff are expected to review the door tag. She stated that hospice staff are required to report to the nurse's station upon arrival, and any communication regarding the resident's status should occur at that time. She reported that facility staff instructed hospice staff to check with the resident's son to determine whether he wished to continue care with the same CNA following the incident. She stated that any changes in transfer status are updated on the door tag, which serves as the reference point for all staff. The Administrator reported the resident was transported to the emergency department located next to the facility, did not undergo surgical intervention, and returned to the facility later the same day. Review of the facility's corrective actions, revealed the facility put forth due diligence in addressing the non-compliance, considering this citation at past non-compliance.

Based on review of the facility policy, observations and interviews, the facility failed to ensure expired medications and uncontaminated medications were removed and not stored with current medications in use for residents in 2 of 5 med carts and 1 of 3 medication rooms.Findings Include: Review of the facility policy titled, Medication Storage In The Facility, revised September 21, 2022 revealed, Policy: Medications and biologics are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. 9. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction, and reordered from pharmacy, if a current order exists.During an observation on 06/04/2026 at 12:37 PM of medication cart 300C revealed, Medichoice Povidone- Iodine Prep Pad expired on 06/15/2025. Dermal Wound Cleanser First Aid Antiseptic spray with an expiration date of 07-2028 however, there was a black substance floating around in the bottle. An interview on 06/04/2026 with Licensed Practical Nurse (LPN)2 at approximately 01:40 PM revealed that the medications were confirmed to be expired and contaminated. During an observation on 06/04/2026 at 01:05 PM of medication cart 300A revealed, Dermal Wound Cleanser First Aid Antiseptic spray expired 09/2025. An interview on 06/04/26 with LPN1 at approximately 02:05PM revealed that the medications were confirmed to be expired. During an observation on 06/04/2026 at 01:10 PM of the 300 unit medication room revealed, Children's Acetaminophen 160mg per 5 ml Pain Reliever- Fever Reducer 4 fluid ounces floor stock that expired in October 2025. An interview on 06/04/2026 with LPN1 at approximately 02:05 PM revealed that the medications were confirmed to be expired. During an interview on 06/04/2026 at 01:15PM with the Director of Nursing revealed, I expect there to be no expired medications on the medication carts or in the medication rooms. The pharmacist does a monthly audit of the medication carts and the medication rooms. I cannot believe that he missed that.

Based on observation, record review, and interviews, the facility failed to ensure Resident (R6)'s care plan was reviewed and revised to include catheter care related to the resident's indwelling catheter. This failure affected 1 of 3 residents reviewed for catheter care.Findings include:Review of the facility's policy titled RAI and Care Plan Process, revised 06/08/17, revealed that a comprehensive resident assessment and the development of the resident's plan of care shall be initiated on the day of admission and completed by representatives from Activities, Dietary, Nursing, the Restorative Nurse, Social Services, Therapies, and any other disciplines involved in the resident's care. The policy states that on admission day, the assessment and data collection process begins with all team members gathering resident information. The Business Office Manager/admission Coordinator initiates the electronic record by entering resident information into the computer. The admission Coordinator/Social Services enters the Entry Tracking Item Set upon admission or re admission. The RAC then opens the electronic admission MDS by entering the reason for assessment into Section A0310 with signature and date, and by entering the assessment reference date into the system.Review of R6's Electronic Medical Record (EMR) Face Sheet revealed R6 was admitted to the facility on [DATE] at 2:32 PM with the following diagnoses: nontraumatic subarachnoid hemorrhage, vascular dementia, unsteadiness on feet, abnormalities of gait and mobility, and retention of urine, unspecified.Review of R6's admission Minimum Data Set (MDS) dated [DATE] revealed R6 was moderately impaired and scored 06 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. The assessment also indicated the presence of an indwelling catheter, coded under H0300. Urinary continence was not rated, as the resident had a catheter (indwelling or condom), urinary ostomy, or no urine output for the entire seven day look back period.Review of R6's active orders revealed the following: The resident had orders for the catheter bag to be changed as needed for leaking or clogging (PRN), and an additional order for the catheter bag to be changed every two weeks between 07:00 AM and 03:00 PM, initiated on 05/22/2026. There was an order to change the indwelling catheter as needed for clogging every shift (PRN). Another order directed that the indwelling catheter be changed monthly, specifying a #16 Fr Foley catheter with a 10 mL balloon, with instructions to change the catheter on the 20th of each month between 11:00 PM and 07:00 AM, effective 06/20/2026. Additional PRN orders included irrigating the indwelling catheter with 30 mL of normal saline as needed for clogging (PRN 1, PRN 2, PRN 3). The record also documented that the resident had an indwelling #16 Fr catheter with a 10 mL balloon related to urinary retention, with monitoring every shift (AM, PM, NOC). Nursing orders included providing daily catheter care by cleansing with a warm moist towelette once per day between 11:00 PM and 07:00 AM, starting 05/22/2026. Staff were also ordered to empty the catheter and document output at the end of each shift (AM 07:00 AM-03:00 PM, PM 03:00 PM-11:00 PM, NOC 11:00 PM-07:00 AM), effective 05/22/2026. An additional nursing order directed the use of a Foley 3 way StatLock, with special instructions to change the StatLock placement weekly on Mondays between 07:00 AM and 03:00 PM, alternating legs as tolerated.Review of R6's care plan revealed there was no problem, goal, approach, or discipline identified related to R6's indwelling catheter or catheter care.Observation on 06/02/2026 at 3:04 PM revealed R6 had an indwelling catheter in place. The catheter bag was covered with a privacy bag. The resident's husband, who was present in the room, reported that the resident was admitted with a catheter, had it removed a few days after admission, and had it reinserted in May 2026. No attempt was made to interview R6, as the resident was deemed un interviewable.A follow up observation on 06/03/2026 at 2:44 PM showed the catheter bag remained intact with the privacy bag in place and the resident was observed sleeping.An interview conducted on 06/03/2026 at 11:00 AM with Licensed Practical Nurse (LPN 1) revealed she was the resident's assigned nurse and was knowledgeable about the resident's catheter status. She stated the resident was admitted to the facility in March 2026 with an indwelling catheter. LPN 1 explained that the facility does not utilize a baseline care plan form and instead begins the care plan based on the assessment completed upon admission. LPN 1 reported there was an order dated 05/26/2026 from the Nurse Practitioner related to the catheter. LPN 1 further stated that a urinalysis was completed on 05/22/2026 due to the resident exhibiting symptoms consistent with a possible urinary tract infection (UTI). She reported that, based on her review of the progress notes, the resident was admitted from the hospital with an indwelling catheter, which was removed at some point during the stay and later reinserted. LPN 1 confirmed she did not see a problem, goal, or intervention in the resident's care plan addressing the resident's catheter status and stated that this should be included. She also reported that, to her knowledge, the resident did not currently have a UTI.An interview conducted on 06/04/2026 at 11:07 AM with the MDS Coordinator revealed he works full time and has been employed at the facility for approximately five to six years. He stated that his partner, who typically completes the resident's MDS assessments, CAAs, and care plan updates, was currently out on leave. Based on his review of the physician orders and the resident's medical record, the MDS Coordinator confirmed that the resident does have an indwelling catheter. He also confirmed that the resident's care plan does not contain a problem, goal, or intervention addressing the resident's catheter status. The MDS Coordinator stated that upon admission, the facility does not use a baseline care plan; instead, the care plan is initiated at the time of admission, and based on the resident's records, the catheter related information should have been reflected. He acknowledged this was an oversight and stated he would add the catheter related problem and interventions to the care plan.An interview conducted on 06/04/2026 at 12:14 PM with the Director of Nursing (DON) revealed the resident was admitted with an indwelling catheter, had the catheter in place for three days, and then underwent a trial of voiding, which was successful at that time. The DON stated the catheter was reinserted on 05/22/2026. She reported that the facility holds morning meetings each day during which new orders are reviewed. She explained that upon admission, the MDS department conducts a review of the resident's information, including the 24 hour form for skilled residents, and that MDS staff have access to all documentation. The DON stated the care plan is reviewed during QAPI meetings; however, she acknowledged that interventions related to the resident's catheter were not being addressed. She reported that one of the MDS staff members had a medical issue and was out, leaving the department operating with only one person instead of the usual two. The DON stated that moving forward, the facility would conduct audits and develop a checklist to prevent similar oversights.An interview conducted on 06/04/2026 at 3:15 PM with the Facility Administrator revealed her expectation is that care plans are completed accurately and in a timely manner to reflect the resident's current care and status. She stated that the MDS staff member had been out on medical leave, and the resident's care plan may have been overlooked as a result.

Based on review of the facility policy, record reviews, and interviews, the facility failed to notify the ombudsman for (Resident (R)122')s discharge from the facility, for one of one residents reviewed for discharge. Findings include:Review of the facility policy titled Discharge Planning revised 2/19 documented, Transfer/Discharge to a Distinct certified unit /Facility: Notice of facility-initiated transfers and discharges are also sent to the local Ombudsman.Review of R122's Face Sheet revealed the facility admitted R122 on 02/20/26 with diagnoses including but not limited to; displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, and gastro-esophageal reflux disease without esophagitis.Review of R122's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 02/26/26 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R122 's cognition was intact.Review of R122's progress notes revealed the following:Nursing Progress Note - 03/17/26 at 3:56 PM: [R122] was discharge, I told his brother about his discharge and medications. The belongings paper was signed by his family member. He was discharge to go home and stay with his brother. Told the brother if they have any questions they are more than welcome to call. by Nursing.Social Services Progress Note - 03/18/26 at 11:02 AM: [R122] went home with his brother. He will be getting PT, OT, Nurse He went home last evening. by Social Services.During an interview on 06/03/26 at 1:21 PM the Social Services Director (SSD) reports that she and the Social Worker (SW) share the workload for the facility. The SSD reports that R122 was one of the residents on her caseload. SSD reports the discharge process for R122 involved contacting the Home Health agency for PT/OT/Nursing and securing equipment as needed, and documenting in the progress notes. SSD reports she did not send discharged information for R122 to the Ombudsman and has not been sending residents' discharged information to the Ombudsman. SSD states that going forward, she will send residents' discharge information to the ombudsman.During an interview on 06/04/26 at approximately 10:07 AM, the SSD confirmed again that she has not been contacting the ombudsman regarding resident discharges. During an interview on 06/04/26 at 10:16 AM, the Administrator reports her expectations is SS should contact the Ombudsman's office when residents are discharged from the facility. The Administrator acknowledged the SSD made her aware yesterday that they did not contact the Ombudsman office for R122 's 03/17/26 discharge from the facility.

Based on review of facility policy and procedures, observations, record reviews and interviews, the facility failed to ensure proper infection control practices as it relates to a foley bag remaining off of the floor for Resident (R)112, 1 of 3 residents observed for catheters. Findings Include: Review of the facility procedure titled, Closed Urinary Drainage, revised September 21, 22 revealed: Procedure: 3. Attach drainage bag to bed frame, below level of resident's bladder, not touching the floor; cover with a dignity bag (unless fig leaf bag used).Review of R112's Face Sheet revealed the facility admitted R112 on 11/17/25 with diagnoses including but not limited to, Vascular dementia, moderate, with psychotic disturbance (Admission), Acute embolism and thrombosis of unspecified deep veins of lower extremity, Neuromuscular dysfunction of bladder, and hesitancy of micturition.Review of R112's physician orders revealed Catheter Dx: Patient has an indwelling catheter #16 FR 5 ml bulb related to urinary retention.An observation on 06/02/26 at 11:49 AM of R112 revealed resident lying in bed watching television. Bed was in low position. Catheter bag noted resting on floor. During an observation on 06/02/26 01:30 PM revealed resident lying in bed watching television. Bed was in low position. Catheter bag noted resting on floor. During an interview on 06/02/26 at 04:10 PM Certified Nursing Assistant (CNA)3 confirmed that resident's catheter bag was resting on the floor. On 06/04/26 at 08:30 AM an interview with the Director of Nursing (DON) revealed, staff should always place the foley catheter bag on the bed frame below the bladder and the tubing should be placed across the resident's leg. The catheter bag should never be on the floor.On 06/04/26 at 02:05 PM an interview with Licensed Practical Nurse (LPN)4 revealed, the DON just gave us an in-service. The foley Catheter bags should be hooked to the bedframe off of the floor. The tubing should be draped over the resident's legs.

Based on interviews and record review, the facility failed to ensure effective coordination of care and communication with the contracted hospice provider for 1 of 1 residents (R)124) receiving hospice services. The facility did not ensure that hospice staff had accurate, up to date information necessary to safely provide care. These failures resulted in the hospice CNA providing care without knowledge of the newly installed pressure relieving mattress and without updated information regarding the resident's assist level, contributing to a witnessed fall with injury. Findings Include:A review of R124's Face Sheet revealed the resident was admitted to the facility on [DATE] at 1:45 AM with diagnoses including, but not limited to, unspecified severe protein calorie malnutrition; osteoarthritis; other specified disorders of bone density and structure; unspecified fracture of the lower end of the right femur, subsequent encounter for closed fracture with routine healing; unspecified fracture of the lower end of the left femur, subsequent encounter for closed fracture with routine healing; and pathological fracture of the unspecified tibia and fibula, subsequent encounter for fracture with routine healing.A review of R124's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/14/2025 revealed a Brief Interview for Mental Status (BIMS) score of 04 out of 15, indicating the resident was severely cognitively impaired. Further review of the MDS showed the resident was dependent for all ADLs, including personal hygiene and toileting, and transfers were not attempted. In addition, the resident was coded with a prognosis of life expectancy less than six months, and Section O indicated the resident was receiving hospice services.A review of R124's care plan revealed a documented problem stating that the resident has a history of falls with major injuries and is at risk for re occurrence related to muscle weakness, cognitive impairment, and the medication regimen secondary to hypertension, diabetes mellitus, vascular dementia, degenerative joint disease, and osteoporosis. The care plan approach included assisting the resident in completing safe transfers per the facility's safe handling tool.A review of R124's Safe Resident Handling Data Collection Form dated 08/15/2025 revealed the resident required a total lift, which required two staff members to turn and reposition the resident in bed. The form also indicated that a lift sheet may be used.A review of R124's Fall Event Details Form dated 10/15/2025 revealed the fall was documented as a witnessed fall. The report stated the resident was being bathed by a hospice CNA and flipped out of the bed while being turned on her side during a sheet change. The form further indicated that prior to the fall, the resident was receiving a bath and the staff member was in the process of changing the bed linens.A review of R124's Hospital Summary dated 10/15/2025 revealed the chief complaint was documented as a fall. The summary stated the 91 year old non ambulatory female presents to the ED from [NAME] Oaks Manor secondary to a witnessed fall. Patient is DNR on hospice care currently. According to staff, patient rolled out of bed while being bathed. There is concern for lower extremity injury at this time. Denies any head injury, loss of consciousness, nausea, or vomiting. Patient has severe dementia at baseline. Bilateral knee X rays showed distal femur fractures bilaterally, while hip and pelvis X rays were essentially negative. The resident remained neurovascularly intact. The case was discussed with the orthopedic surgeon, who recommended non operative outpatient treatment with bilateral knee immobilizers and follow up in two weeks. Hospice nurses were present at the bedside, and precautions were discussed with them.A review of R124's Hospice Clinical Note Post Fall, charted by the hospice nurse and dated 10/15/2025, revealed the hospice CNA contacted the nurse at 6:14 AM, reporting she was very distraught. The CNA stated she had been providing morning care to R124 and, when she walked around the bed to loosen the sheets for a linen change, the resident began moving and rolled off the bed. The CNA reported she attempted to grab the resident to prevent the fall but was unable to hold her, and the resident fell to the floor. While enroute, the nurse was informed that the resident was being sent to a local hospital for evaluation and X rays due to crying out in pain when her legs were touched. The physician reported that both femurs were fractured above the patella and stated the orthopedic surgeon would also review the X rays.The note documented that, prior to this incident, R124 required only one staff member for assistance with ADLs; however, hospice and the facility agreed the care plan would be updated to reflect a two person assist for all ADLs except feeding. Hospice assigned two CNAs to the resident's care, and the facility nurse practitioner was asked to add an additional scheduled dose of Tramadol and an extra PRN dose to address increased pain during healing. The team agreed that the low air loss mattress, placed on the resident's bed the previous evening to reduce the risk of skin breakdown, may have contributed to the incident, as such mattresses have a [NAME] and less stable surface for providing care. This was a new surface for both the resident and staff. The hospice nurse documented the following changes to the resident's plan of care: 1. Change from a one person assist to a two person assist for all ADLs except feeding for both facility and hospice staff. 2.Addition of longer side rails, replacing individual half rails. 3.Application of bilateral leg immobilizers for pain control and healing. 4.Temporary increase in scheduled pain medication. 5.Addition of an extra PRN pain medication dose for breakthrough pain.6.Increased nursing visits for the next two weeks, including three nursing visits and three weekly CNA visits performed by two CNAs, to provide additional monitoring and safety oversight. 7.Ensuring side rails are raised and the bed is in the lowest position when staff leave the room. 8.Hospice to order fall mats for placement beside the bed, pending facility approval.An interview conducted on 06/03/2026 at 12:52 PM with the resident's son and responsible party revealed that on 10/15/2025, the facility notified him that the resident had reportedly fallen and that both of her legs appeared to be injured. He stated he did not believe the resident fell but believed she was dropped by a hospice CNA during a bed bath and linen change. He explained the resident was bedbound, unable to get up, and declining due to multiple comorbidities and being in the final days of life. He reported he had no concerns with the quality of care at this facility and could not recall whether one or two staff members were required to provide care. An interview on 06/03/2026 at 1:41 PM from CNA 2, reported she had been employed with the hospice agency for over one year and was familiar with the resident. She stated she provided care to the resident three times per week and that the resident was bedbound and required a one person assist at the time. She reported that on the morning of 10/15/2025, she was providing the resident's morning care. She stated she had turned the resident onto her left side and then walked around to the opposite side of the bed. She observed the resident beginning to move and attempted to grab her but was unable to hold onto her, and the resident fell behind the bed onto the floor. She stated she had no additional staff present in the room at the time. CNA 2 stated she immediately pressed the call light and notified the nurse. She reported that staff used a Hoyer lift to assist the resident from the floor and return her to bed after the nurse completed an assessment. She stated she contacted her supervisor, who met her at the hospital. She reported she had the resident on her side while attempting to change the bed linens when the fall occurred and noted the resident's bed was not positioned against the wall. She stated she was not aware that the resident had a new mattress. She reported that following the incident, the resident was changed to a two person assist for care. She confirmed she received an in service related to lift use after the event.06/04/26 at 12:25 p.m. - Interview with RN, Director of Nursing (DON) who stated that reportable's are handled by herself and the Administrator. She confirmed she is familiar with the R124 and the circumstances surrounding the reportable incident from October 2025. The DON stated she does not recall exactly how she was notified of the event, only that it occurred on a weekday. She recalled being informed that the resident had experienced a fall from the bed during care and was being transferred to the hospital. stated that the day prior to the incident, an air reducing mattress had been placed on the resident's bed. She explained that the hospice nurse's assessment triggered the addition of the mattress, noting that this was a hospice intervention rather than a facility initiated change. Facility staff were aware of the mattress change; however, it was unclear whether the hospice company communicated this change to their CNA staff. She reported that the contracted hospice CNA was providing care at the time of the incident. The resident had been turned onto her side, and the CNA was removing the sheet from one side of the bed. DON stated that this may have shifted the resident's weight to the opposite side, contributing to the fall and resulting injuries. She described the resident as a routine CNA care resident with consistent care patterns. She noted the mattress was similar to an air mattress in texture and movement. DON stated the resident sustained bilateral femur fractures. She reported that the resident required a total two person assist for transfers and repositioning. At the time of the fall, two staff members were not present in the room. Hospice staff came onsite the same day and provided in service training to the CNA involved, as well as to all other hospice CNAs, as a precautionary measure. The resident was transferred to the hospital on [DATE] and did not undergo surgical intervention. Knee immobilizers were applied. The resident was already on hospice care at the time, and the responsible party was notified of the event. DON stated the resident returned to the facility the same day.A phone interview with Hospice Registered Nurse (RN) on 06/04/2026 at 1:34 PM revealed she is the clinical operations manager, she's familiar with R124 and the incident that occurred on 10/15/2025. Hospice RN stated it was an unfortunate situation. Hospice RN states that per the documentation she has, the resident was a 1 person assist during that time. She has been a 1 person since admission to the facility. The decision at that time was based on the current status of the patient during that time of assessment. She wasn't a patient that required a 2 person assist. Prior to the fall on 10/15/2025, the hospice company ordered the a pressure reliving mattress, however once the mattress is ordered the company does not notify the staff once its installed, that's a communication that the facility staff should have communicated to the CNA. The Hospice RN confirmed she received the call from CNA4 and confirmed what was written in her clinical note. As far as the in-service, it was a verbal in-service. The RN states that the hospice staff were invited to care plan meeting by the son back in February 2025 and that was the only meeting hospice staff were in attendance for. Any changes or updates made after February 2025, such as resident becoming a 2 person assist instead of 1, the hospice staff were not made aware of by facility staff. When hospice aides arrive at the facility, they are to check in at the nurses station, and any type of communication, should be done at that time. An interview with the Facility Nurse Consultant on 06/04/2026 at 2:29 p.m. revealed that communication between the facility and hospice staff requires the facility nursing department to verbally communicate any updates to the resident's current plan of care to hospice staff, and hospice staff are likewise expected to verbally communicate updates to the facility.

Based on interview, record review, and facility document review, the facility failed to ensure a Head Trauma Protocol was completed after an unwitnessed fall for 1 (Resident (R)2) of 3 residents reviewed for accidents. Findings include: Review of a facility protocol titled Head Trauma, revised on 12/07/2010, revealed under the section titled Objective included, 1. To provide close observation of any resident sustaining a suspected or actual blunt trauma to the head. 2. To provide early medical intervention in the event of brain injury. Under the section titled Procedure included, 2. Take baseline vital signs and record. Monitor vital signs as follows: q. [every] 1 hour x [times] 4 hours, then q. 2 hours x 4 hours, then q. 4 hours x 24 hours, then q. shift x 48 hours. 3. Complete neuro [neurological] documentation. Further review revealed, 4. Notify physician immediately if any of the following symptoms occur: Dizziness Nausea/Vomiting Increased pain Change in neuro determination Convulsions Inappropriate behavior Temp [temperature] elevation above 100 [degrees Fahrenheit]. Under the section titled Key Points included Wake q. 2 hours x 24 hours. Review of R2's Resident Face Sheet revealed the facility admitted R2 on 09/04/2025. According to the Resident Face Sheet, the resident had a medical history that included but was not limited to diagnoses of difficulty walking, lack of coordination, history of malignant neoplasm of bladder, and overactive bladder. Review of R2's Discharge (return anticipated) Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/14/2025, revealed R2 had short- and long-term memory problems and modified independence with cognitive skills for daily decision-making, per a Staff Assessment for Mental Status (SAMS). The MDS revealed the resident required supervision or touching assistance with toileting hygiene and was independent with toilet transfers. Review of R2's Care Plan included a problem area, initiated on 09/05/2025, that indicated the resident had a history of falls prior to arrival at the facility and was at risk for re-occurrence. Review of an Event Report dated 09/14/2025 revealed R2 sustained a fall on 09/11/2025. The Event Report revealed the resident was observed on the floor around 2:12 AM. Per the report, the resident was sitting in the doorway against the wall. The report revealed the resident stated they slid down while using the bathroom and crawled to the door. The report revealed that the fall was not witnessed, and the facility's head trauma protocol was initiated. Review of R2's Head Trauma Protocol form for the timeframe from 09/11/2025 through 09/13/2025 revealed that the neurological and symptoms section for the 4:15 AM and 5:15 AM checks on 09/11/2025 were blank. The Head Trauma Protocol form revealed that the vital signs, neurological, and symptoms section for the second shift on 09/13/2025 were blank. During an interview on 12/06/2025 at 10:31 AM, Licensed Practical Nurse (LPN)2 stated that when R2 fell on [DATE] she was the nurse assigned to provide care to the resident. She stated that she found the resident on the floor near their door. LPN2 stated that the fall was unwitnessed, so she initiated the head trauma protocol. She stated that she always completed the neurological checks but could not remember why she did not fill out the Head Trauma Protocol form for the checks at 4:15 AM and 5:15 AM on 09/11/2025. She stated it was possible the resident had just calmed down or was sleeping, and she did not want to disturb the resident, or she completed them and forgot to write them down. She stated that the resident was very irritable, and she would not want to wake them. LPN2 stated that she could not remember the reason for not completing the form. During an interview on 12/06/2025 at 4:44 PM, LPN3 stated that on 09/13/2025 at 7:15 PM, she switched assignments to work on the medication cart and care for residents, which included R2. She stated that she worked on that assignment for approximately two and a half hours. She stated that the nurse she received the assignment from did not inform her that R2 had experienced a fall that required the Head Trauma Protocol form to be completed. She stated she did not complete the required checks because she was unaware they were needed. LPN3 further stated that she did not report or pass on the need to complete the checks to the next shift because she did not know they were in place. She stated that nurses were aware of the required checks through passing down the information from shift to shift. During an interview on 12/06/2025 at 11:21 AM, the Director of Nursing (DON) stated she was responsible for reviewing the Head Trauma Protocol form for accuracy. She stated that she missed R2's Head Trauma Protocol form for the resident's fall on 09/11/2025. She stated that if the resident was sleeping, she would not expect the staff to wake the resident up, especially if they finally got the resident to rest, even though the protocol said to wake the resident. She then stated that she expected staff to follow the protocol.

Based on review of the facility policy, observation, interview, the facility failed to ensure foods that are stored in the walk-in freezer, refrigerator and unit refrigerators were labeled and discarded after manufacturer's expiration date. Findings include: Review of facility's policy titled, Storage of Food and Supplies dated ,d+[DATE], revealed Procedure 5: Staple, frozen and refrigerated foods are stored with the new product to the back of the older products. Foods removed from the original packaging will be labeled with the received date, either individually or as a unit. Procedure 6: Potentially hazardous foods are stored in the refrigerator in a manner to prevent cross-contamination. When meat/poultry/fish products require simultaneous refrigerated storage, the items are stored from bottom shelf to top in this under poultry, meat, fish, then ready-to-eat. All items are labeled with a use-by date as well as the contents (if not readily identifiable). Procedure 7: All opened items are securely wrapped or stored in a secure storage container and labeled to identify the product (if not readily identifiable) as well as a use by date no greater than 72 hours after opening unless documentation available for a longer shelf life is available. Staple products such as flour, sugar, cornmeal, dried pasta, etc., may be stored in designated secured bins, staple bin scoops may be stored in the product if the handle is out of the product in a manner to prevent touching the food. Review of facility's policy titled, Food brought into facility for residents dated ,d+[DATE], revealed Procedure 2: Foods requiring refrigeration and stored as outlined about may be stored in the unit refrigerator for up to 3 days unless approved by the Dietary Director. Foods that are improperly stored or labeled or stored for more than 3 days will be discarded by nursing staff. Review of facility's policy titled, Responsibility for Ensuring Infection Control (Sanitation/Infection Control) dated ,d+[DATE] revealed, The Dietary Director is responsible for oversight of infection control processes to ensure food served by the Dietary Department is safe. Review of a Dietary In-Service dated [DATE] presented by the Kitchen Manager (KM) revealed training on labeling and documentation and rotation of foods. During an observation on [DATE] at approximately 10:45 AM, in the walk-in refrigerator lying on the shelves were the following: unlabeled, undated, and not in the original box/container; an 8 ounces (oz) bag of low moisture Mozzarella cheese, 8 oz [NAME] Shredded Cheese, 8 oz bag of Pimento Cheese. Kitchen Staff (KS)1 confirmed the items had no date nor were they in the original packaging. Further observations in the walk-in refrigerator revealed two (2) spiral hams on a long silver serving tray. One of the spiral hams packaging had a hole on the top right-hand side, the size of a fist, with a white circle like substance where the opening was located and an expiration date of [DATE]. KS1 stated the ham was taken out of the freezer and placed in the refrigerator to be served this week. The Cook acknowledged the opening and the expiration date of [DATE]. In the walk-in freezer, an opened box of [NAME] Choice [NAME] (one package) undated, an opened box with an expiration date of [DATE] with the contents of a plastic bag full of breadsticks and an opened box of pureed shaped seasoned fish, undated. KS1 acknowledged that an open date should have been listed somewhere on the box. During an observation on [DATE] at approximately 11:41 AM of the Unit 300 Refrigerator, revealed an open 46 fl oz. box of Thickened Sweetener (Ready Care) with an expiration date of [DATE]. In an interview with Licensed Practical Nurse (LPN)1, she acknowledged the expiration date of the Thickener, and stated items in refrigerator are monitored by Nursing and normally they throw the expired items in the trash. Further observation of Unit 100 Hall at 12:11 PM with the Consulting Dietician (CD) revealed an unlabeled McDonald's Cup with a frozen product and a Vitamin Water frozen that were unlabeled/undated. A pink water jug was discovered with no name or date. The CD and staff at the nurses station confirmed that it was a staff's water jug and not a resident's. The CD further stated that the refrigerator temperatures are not recorded on a log, but are monitored by the nurses on the unit. In an interview with the Kitchen Manager on [DATE] she stated she has been with the facility for one week. She stated she completed some in-services with the staff on proper labeling and documentation of foods and provided a recent in-service sheet completed on [DATE].

Based on clinical record review, staff and family interviews and facility policy review, the facility failed to notify the family of one (1) Resident #16 of a significant weight loss in accordance with Notification of Change. This affected one (1) of 23 sampled residents. Findings include: Review of facility's policy titled Education (effective date 4/18/2017) noted the following: Education is provided to staff, residents, family members, visitors and volunteers on as needed basis related to newly diagnosed conditions and/or communicable diseases that warrant special precautions (may be verbal, or written or both). Through, verbal and instruction, nurse initially makes staff aware of special precautions indicated for an individual resident's care and updating of the resident plan of care. Unit nurses notifies family members of change in the resident's condition, care, and treatment plan. Clinical record review for Resident #16, revealed the resident was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the progress notes dated 12/18/2020, revealed the resident was charted as having a weight of 142lbs (pounds). Further review of the progress notes dated 5/27/2021, revealed the resident was charted as having a weight of 129lbs (pounds) for a total of 9.15% in five (5) months. There was no documentation that the family had been notified about the weight loss. A review of the Dietician progress notes dated 12/2020 through 5/27/2021, revealed Resident #16's weight loss was addressed with additional measures put in place, but there was no documentation the family was notified. An interview was conducted on 6/7/21 at approximately 6:59 p.m. with Resident #16's daughter. The daughter revealed, I saw my family member a week ago and felt s/he was going down due to advanced stage Alzheimer's. Before COVID-19, I would visit once a week. I never heard from the Dietician or Nurses about his/her weight loss; or given the opportunity to make a decision about Hospice or any alternative things related to his/her care. An interview was conducted on 6/8/21 at 1:20 p.m. with the Dietician revealed, The nurses are responsible for calling the families about any weight loss. The dietician stated, I'm usually given a note or informed by the nurses of any weight loss in the building and follow up from there. I am not sure who is responsible for reporting weight loss to the family. An interview was conducted on 6/8/21 at 1:25 p.m. with the Corporate Dietician. The Corporate Dietician revealed, Usually the nurses are responsible for reporting the weight loss to the family, we are not sure who makes the call, but we will find out. An interview conducted on 6/8/21 at 1:30 p.m. with License Practical Nurse #7 revealed, I am not the one responsible for informing the family about any weight loss, I call them about medication changes and physician orders. An interview was conducted on 6/8/21 at 1:45 p.m. with the Social Worker (SW). The SW revealed, I spoke with Resident #16's family on the phone about the last care plan meeting, but I did not inform him/her about the resident's weight loss; The SW stated: I do not call the families to inform them of weight loss. An interview was conducted on 6/8/21 at 2:01 p.m. with Resident Assessment Nurse #5. The nurse revealed, We had a quarterly assessment done recently and the family was not notified at that time about Resident #16's weight loss. An interview conducted on 6/8/21 at 2:11 p.m. with the SW revealed, a post card was sent out to the family on 3/23/2021 to attend the care plan meeting, we do not call. The SW stated, the family member called after receiving the post card invite, but we did not discuss the weight loss from May of 2021. I have not notified the family of Resident's #16's weight loss, but we have a care plan meeting next Tuesday and will discuss it then. An interview was conducted on 6/9/21 at 9:07 a.m. with the Director of Nursing (DON). The DON revealed, it is his/her expectation that the family is to be notified of any weight loss and that unit nurses are responsible for informing the family. An interview was conducted on 6/9/21 at 9:17 a.m. with the Administrator, who revealed, it is my expectation that the Dietician be responsible for informing the family of the weight loss the nurses have enough to do, and we will make sure from now on.

Based on observations, record review, interviews, and facility policy review, the facility failed to assess and receive a physicians order for the use of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of facility's policy entitled Physical Device Data Collection Tool/Restraint Reduction Plan: dated 11/2019 revealed, nursing staff completes this form for all devices/restraints. It assists in determining whether a device is a restraint and if there are appropriate indications for use and identifies alternatives when possible. Information for the completion of this form will be obtained by observation, interview of the resident or family, the admission data collection, the history and physical, other discipline specific data collection, physician orders, therapy evaluations, the Minimum Data Set (MDS) and selected Care Area Assessment (CAA) reviews, dependent on the length of stay of the resident at the time a resident is considered. The Restraint Reduction Plan portion of the form is completed at least quarterly in conjunction with the Minimum Data Set (MDS) schedule. Review of the Social/Activity history along with the customary daily routine information (MDS) section F. The information may be useful in determining appropriate alternatives to restraint usage. Safety Committee Review: The safety committee should consider the information gathered and recommended alternatives to the restraint (device) or the least restrictive type of restraint (device). The team is also responsible for determining the conditions under which it is to be used. The device must be the least restrictive of all choices The risks and benefits must be specifically identified and described to the resident There must be indications that use of the restraint (device) enables or promotes greater functional independence A specific care plan must be developed that addresses the potential risks associated with the selective device. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A specific physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . All devices used as restraints must have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The type of device/restraint The reasons for using/medical symptom being treated When it may be used How and when the restraint is to be monitored When the restraint must be released and the type of care to be provided when released. A review of the Resident's Face Sheet revealed Resident #40 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE] revealed, Resident #40 had a Brief Interview for Mental Status Score (BIMS) of three (3) indicating severe cognitive impairment and rejection of care none during the seven (7) day observation period. The resident required extensive assistance with bed mobility, transfers, toileting and personal hygiene, walking on and off the unit did not occur and the resident required extensive assistance with locomotion full staff performance over the entire seven (7) day observation period. The Physical Restraint Care Area Assessment (CAA) part for the Annual MDS dated [DATE], documented Resident #40 as not using any Restraint devices during the seven (7) day observation period. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation was made on 6/7/21 at 10:45 a.m. Resident # 40 was sitting up in his/her wheelchair with the seatbelt restraint around the waist and the anti-slip belt restraint across the top of his/her legs. The resident was observed trying to release the seatbelt but could not. An observation was made on 6/7/21 at 11:30 a.m. Resident #40 remained sitting up in the wheelchair in his/her room with the seatbelt around the waist and the anti-slip belt across the top of his/her legs. The resident was unable to release the restraints. An interview was conducted on 6/9/21 at 8:49 a.m. with Certified Nursing Assistant #10 revealed he/she was informed by the unit charge nurse not to get Resident #40 up and place him/her in the wheelchair today, because the facility does not have an order or assessment for the use of the seatbelt. An interview was conducted on 6/9/21 at 9:00 a.m. with License Practical Nurse (LPN) #7, revealed Resident #40 has not been assessed or has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] An interview was conducted on 6/9/21 at 9:07 a.m. with the Director of Nursing, revealed that it is the expectation that staff should have assessed and received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] An interview was conducted on 6/9/21 at 9:17 a.m. with Administrator, revealed, I agree with you, we should have completed the assessment and got an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview conducted on 6/10/21 at 9:36 a.m. with the RN Safety Nurse revealed, he/she was informed on 6/9/21 about Resident #40's wheelchair with seatbelt restraint. The RN stated once a wheelchair or any device is delivered, he/she should be notified as soon as the device or wheelchair is brought through the front door, so that the resident can be assessed prior to use. The facility failed to ensure an assessment and physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to have a medical justification for the use of the restraint.

Based on observations, record review, interviews, and facility policy review, the facility failed to review and revise a care plan for one (1) of 23 sampled residents, (Resident #40). The care plan for Resident #40 was not reviewed or revised with goals or interventions, to reflect the use of a wheelchair with a seat belt restraint. Findings include: Review of facility's Policy entitled Care Plan Policy Comprehensive Team Care Planning dated 1/9/2012 and revised 6/8/2017 revealed, it is the policy of White Oak Management Inc, to provide care planning for all residents; to formulate individualize plans of care for each resident that will be an effective and useful approach for providing quality care and to help the resident meet his/her mental, emotional, social, and physical needs during his stay. This shall be a team approach for resolving the resident's problems or needs with emphasis on normalization of daily life to the highest level of dignity and ability. The residents plan of care guides the necessary care and services based on the findings of the Resident Assessment Instrument (RAI). The services are implemented and updated on the care plan. Outcome evaluation and revisions for interventions/approaches are an ongoing process. Review of the facility's Policy entitled Physical Device Collection Tool/Restraint Reduction Plan dated 11/2019 revealed, the safety committee should consider the information gathered and recommended alternatives to the restraint (device) or the least restrictive type of restraint (device). The team is also responsible for determining the conditions under which it is to be used. A specific care plan must be developed that addresses the potential risks associated with the selective device. A review of the resident's Face Sheet revealed Resident #40 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual Minimum Data Set (MDS) Assessment; dated 4/7/21 revealed Resident #40 to have a Brief Interview Mental Status (BIMS) score of three (3) indicating severe cognitive decline. The resident was assessed not to resist or reject care and/or treatments. The assessment identified the resident as having no impairment to the upper and lower extremities and required extensive assistance with all Activities of daily living (ADL's). Under the restraint section the resident was assessed to not have use of any restraint devices. Review of Resident #40's plan of care dated 4/15/21 revealed, provide pressure reducing surfaces on bed and chair assist with repositioning on rounds and as needed (PRN). There was no care plan goal or intervention for the use of a wheelchair with seatbelt restraint. An interview conducted on 6/10/21 at 8:55 a.m. with Resident Assessment Nurse #11 revealed, the start date of the care plan dated for 4/15/21 does not have a care plan goal, or intervention for the use of a wheelchair with a seatbelt restraint for Resident #40. An interview conducted on 6/10/21 at 9:27 a.m. with Resident Assessment Nurse #12 revealed, Resident # 40's care plan was just updated on 6/9/21 to reflect the use of the wheelchair with a seat belt restraint. An interview conducted on 6/10/21 at 10:00 a.m. with the Assistant Director of Nursing (ADON) revealed, it is my expectation that the Resident Assessment Nurses update the care plans and any information that is discussed in the morning meetings; the care plan was not updated to reflect the use of the wheelchair with the seatbelt restraint. The facility failed to review, revise and update Resident #40's Care Plan to include, approaches, goals and interventions for the use of a wheelchair with a seatbelt restraint.

Based on observations, interviews, and record reviews, the facility failed to treat residents with dignity for 1 of 3 residents reviewed for abuse and on 1 of 3 units (Hall 300 Rooms 316-323) observed during the dining experience. Certified Nursing Assistant (CNA) #2 lost composure and argued with Resident #136 while providing care for his/her roommate. Staff was observed entering rooms during meal delivery without knocking. All residents in room [ROOM NUMBER] were not served sequentially and privacy curtain was not pulled closed while a resident was eating and another resident was not served or eating. The findings included: Resident #136 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review facility investigation of abuse allegation for Facility Reported Incident (FRI) #SC 482 on 12/11/19 at approximately 3:46 PM revealed the following: 1. Resident #136 was upset about a dirty linen bag that had been left in the room. 2. CNA #2 was arguing back with the resident, stating they would get the bag out and Resident #136 did not have to yell at them. 3. CNA #2 stated that s/he was tired of all this laughing up and cutting up with us one minute, then yelling and fussing at us the next. S/he must be [MEDICAL CONDITION] or something. 4. CNA #3, Resident #136, and the resident's roommate (at that time) confirmed what CNA #2 said during the facility's investigation. 5. Facility did not substantiate abuse but found CNA #2 to be inconsiderate to the resident. Interview with Director of Nursing (DON) and Administrator on 12/12/19 at approximately 9:39 PM revealed that both concluded CNA #2 was commenting to CNA #3 about a separate, non-work, topic and was misunderstood by all parties. During a previous interview, CNA #2 made a similar claim. Interview with CNA #2 on 12/12/19 at approximately 9:52 AM confirmed that both Resident #136 and CNA #3 were arguing back and forth, but s/he could not recall the content of the argument. Review of Dignity Policy on 12/12/19 at approximately 12:39 PM revealed that staff are to Maintain composure during care . (Don't lose it). During random meal observation on 12/10/19 at approximately 12:36 PM a food cart was delivered to the 300 hall rooms 316-323. At approximately 12:27 and 12:39 PM CNA #1 was observed entering rooms [ROOM NUMBERS] without knocking when delivering lunch trays. The CNA further did not voice knock knock to seek permission to enter the residents room due to having food tray in hands. An interview on 12/10/19 at approximately 12:40 PM with CNA #1 acknowledged he/she entered resident rooms without knocking. On 12/10:19 at 12:40 PM, a resident was in room [ROOM NUMBER] in the first bed with food tray and eating while another in the room in bed near the window was not served or eating. The privacy curtain was not pulled while the resident in bed near the window was not eating or served. An observation and interview on 12/10/19 at 12:42 PM with Licensed Practical Nurse (LPN) #1 confirmed the observation and pulled/closed the privacy curtains since the resident in the bed by the window was not served or eating. At approximately 12:48 PM, LPN #1 was observed reminding staff to pull/close privacy curtains when all residents in the room were not served.

Based on interviews, observation, and record review, the facility failed to ensure that clinical paper and electronic records were complete and accurate for 1 of 25 sampled resident reviewed. Resident #87 had no dietary/nutritional notes in his/her medical record. The findings included: The facility admitted Resident #87 on 7/30/19 with [DIAGNOSES REDACTED]. During individual interview on 12/10/19 at approximately 9:55 AM Resident #87 stated he/she would like a variety of foods in his/her diet. When asked if anyone has specifically addressed his/her diet the resident stated he/she would like to talk to someone about his/her diet. A review of the electronic medical record on 12/11/19 at approximately 1:07 PM revealed the resident was on a regular renal diet with no fluid restrictions noted. A meal delivery observation on 12/11/19 at 1:18 PM revealed Resident #87 received diet as ordered. Staff had to encourage the resident to wake up to eat. Staff placed the food tray on the bedside table and raised the resident's bed. A review of the medical record on 12/11/19 at 2:40 PM revealed no dietary/nutritional notes in paper or electronic medical records. The paper chart had multiple yellow sheets indicating diet changes with no accompanying notes or dietary consults/assessments. The facility staff could not locate any dietary/nutritional notes in the paper chart or electronic records and referred the surveyor to the registered dietitian. An interview on 12/11/19 at 8:25 AM with the Registered Dietitian (RD) revealed he/she had a system in place to ensure documentation was completed and stated he/she had meet with Resident #87 on 10/30/19 to address his likes and dislikes but could not find the documentation. The RD further stated he/she looked through the electronic medical records under multiple tabs and could not find any dietary/nutritional notes to indicate a dietary consult/assessment had been done for Resident #87.

Based on observation, interview and record review, the facility failed to provide the restorative range of motion (ROM) program for one of two residents, (Resident (R) 35), selected for review. Findings include: Review of R35's admission Minimum Data Set (MDS), an assessment tool completed by the facility staff used to identify resident care problems and assist with care planning, with an Assessment Reference Date (ARD), the end-point of the evaluation period, of 06/20/18, specified under Section G: Functional Status, R35 had functional limitation in ROM to bilateral upper and lower extremities. Review of a Functional Range of Motion form, dated 06/14/18 and found in R35's medical record under the Therapy tab identified limitations of varying degrees to bilateral upper and lower extremities. All of the limitations were noted to interfere with R35's daily function and/or put him at risk for injury. Review of R35's care plan, found in R35's electronic medical record (EMR) under the Care Plan section, dated 07/11/18, identified the potential for decline in upper extremity strength and ROM. The identified goal was for the resident to participate in the exercise activities without complication. Approaches included direction for restorative active ROM upper extremity exercises three days a week to maintain strength. A second care plan identified R35 with the potential for decline in lower extremity strength and ROM, with a goal for the resident to complete seated exercises. Approaches included directions for restorative active ROM, seated exercises as well as right knee hamstring stretches, three days a week. These care plans were noted as resolved/achieved 08/29/18. In addition, care plans dated 06/14/18, identified R35 with the potential for falls and with a self-care deficit. Both of these care plans included the approach Restorative therapy as ordered. Review of the Restorative - CNA (Certified Nurse Aide) Data Collection form, provided by the Assistant Director of Nursing (ADON), on 08/29/18 at 2:15PM revealed between 7/11/18, when the restorative program was initiated and 08/28/18, R35 participated in the program one time on 07/11/18. It was also noted on 07/11/18 the resident refused the restorative program. On every other date, staff documented Activity Did Not Occur. In an interview on 08/29/18 at 2:50 PM, the ADON explained the facility was without a program coordinator for the restorative program and she was covering until someone was hired. She stated she reviewed the attendance records for R35 and discussed the lack of attendance with the restorative aide. She explained R35 apparently had refused the restorative program each time it was offered, and the restorative aide inaccurately documented the activity did not occur, instead of refused. The ADON stated she had not been notified R35 had refused the program for the past six weeks. In an interview on 08/30/18 at 9:29 AM, R35 stated he had been asked to attend an exercise program one time. He explained he had participated in therapy prior to that but did not find value in the exercises they had him do, so he had refused to attend when asked by the restorative aide. He stated he had not understood the program was different than skilled therapy and that the exercises could be customized to his desires. The resident denied having been invited to the restorative program recently. In an interview on 08/30/18 at 12:40 PM, Restorative Aides 78 and 13 explained what they would do if a resident refused the restorative program. Both agreed they would offer the program several times in a day, and if the resident still refused, they would notify the resident's nurse and the ADON. They stated they would then enter refused in the record. Restorative Aide 78 then explained R35 was on her caseload. She recalled that when she first offered the program to the resident, he got very upset so she told him to just come down to the therapy room when he wanted to do something. She stated she notified his nurse but did not recall notifying the ADON. She stated she had not gone back and offered the program to R35 because he had been so upset. She said the resident participated in some exercises one time but never returned, and she had not offered him the program again. In an interview on 08/30/18 at 1:48 PM, the ADON stated she thought R35 was being offered the program three times a week and consistently refusing. She explained based on that belief, she discontinued the restorative program 08/29/18.

Based on observation, interview and record review, the facility failed to accurately document an identified allergy for one resident, (Resident (R) 61), and failed to document the implementation and resident response to the weaning of oxygen as ordered by the physician for one resident, R54, of the 25 residents selected for review. As a result of this deficient practice, staff were unable to identify and/or determine R61's allergy status and were unable to determine if the weaning of oxygen was successful for R54. Findings include: 1. Review of a Prescriber Recommendation Form, dated 07/12/18 and found in R61's medical record under the Consultation tab revealed the consulting pharmacist identified a doctor's note from an outside provider that indicated the resident had an allergy to nonsteroidal anti-[MEDICAL CONDITION] drugs (NSAIDs). The pharmacist documented, . Should NSAIDS be added to her allergy list? On 7/30/18, the physician signed the form and indicated he agreed with the recommendation. Review of the resident's hard chart revealed the allergy sticker on the front cover noted the resident had no known allergies. The Face Sheet, at the front of the hard chart identified No Known Drug Allergies. According to the electronic medical record (EMR), under the Diagnosis & Allergy tab, No Known Drug Allergies were noted. In no other place in the EMR or hard chart was this allergy identified. In an interview on 08/29/18 at 1:16 PM, Registered Nurse (RN) 36 reviewed the resident's record and stated when the physician signed the Recommendation form, the nurse on duty should have entered the allergy into the computer and added the information to the cover of the record. In an interview on 08/30/18 at 3:15 PM the Director of Nursing (DON) stated when a physician accepted a pharmacy recommendation, nursing staff were expected to document or implement the change. The DON acknowledged that the process had not been followed as staff should have either documented the allergy or contacted the physician to discuss the accuracy of the data. Review of the facility's policy titled, Provider Pharmacy Requirements dated (MONTH) 1, (YEAR), revealed The consultant shall ensure that all known allergies and adverse effects are documented in plain view in the resident's medical record . 2. Observation on 08/27/18 at 11:00 AM revealed R54 lying in bed with oxygen on via nasal cannula. She stated she had used the oxygen for many months. Review of the (MONTH) (YEAR) Treatment Administration Record (TAR), found in the EMR under the eMAR/eTAR tab, revealed a physician's orders [REDACTED]. A physician's orders [REDACTED]. Staff placed a check mark on each of the three shifts between 06/01/18 and 06/24/18, except for 6/10/18 at 6:30 AM and 06/17/18 at 2:30 PM, when they recorded an N. There was no indication of what rate the oxygen had been reduced to or what the resident's oxygen saturations were as a result of the ordered reduced rate. In an interview on 08/29/18 at 10:53 AM, RN 36 stated she would document the oxygen rate and resulting saturation rate in the TAR. In an interview on 08/29/18 at 1:29 PM, Administrative Nurse 142 stated typically there would be a nurse's note that identified staff either decreased or discontinued the oxygen and what was the resident's response and the saturation rate. She stated if it was successful, staff would discontinue the oxygen, however R54 had previously failed at having the oxygen weaned. She acknowledged staff had not documented in a manner sufficient to allow the facility to determine if the weaning had been successful. A policy regarding the documentation of oxygen therapy was requested, however at the time of exit the facility did not provide a policy.

Based on review of facility files and interview, the facility failed to establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf. The Business Office Manager was noted to misappropriate money from resident accounts. No receipt books could be located after the Business Office Manager resigned. There were 121 residents' accounts that were affected by the Business Office Manager's misappropriation between (MONTH) (YEAR) and (MONTH) (YEAR). One of one Business Office Manager reviewed for accounting principles. The findings included: The facility reported an allegation of misappropriation of funds by the former Business Office Manager to the State Agency on 9/7/17. Review of the South Carolina Victim Impact Statement revealed the financial loss was noted as $161,622.53. The administrator and the corporate accounts receivable manager gave conflicting statements to the surveyor on how the misappropriation was identified. In an interview with the surveyor on 12/5/17 at approximately 10:25 AM, the facility administrator stated they had someone from corporate office at the facility training the new Business Office Manager and they noted there was a discrepancy between the system when they pulled a financial file for a resident. The corporate staff decided to do an audit and started to note suspicious zero deposits. They confirmed the Business Office Manager was responsible when they pulled the former Business Office Manager's direct deposit account number from Human Resources and it matched an account number on one of the checks that was created. The former Business Office Manager had resigned and was no longer working at the facility when the discrepancy was found. In an interview with the surveyor on 12/5/17 at approximately 11:05 AM, the corporate accounts receivable manager stated a resident's family had called and stated the check they received was not the right amount. The check was a refund for the amount they had private paid, the resident had passed away. The consultant looked up the information and the information was correct in the computer, but when s/he looked in the billing file it was not right. S/he noted the discrepancy and called the corporate accounts receivable manager. They started looking to find out what was wrong and saw some cash that was receipted but never posted for a different resident. The former Business Office Manager posted the cash received from another resident to the resident whose check was incorrect, that was to try to make the account look right. The corporate accounts receivable manager stated there were no set time frame for audits, generally an audit would be done if there was a change in Business Office Manager or if something flagged at the corporate office. The Business Office Manager was responsible for everything - taking money, disbursing money, and the resident trust fund. At the end of the month, the Business Office Manager does an accounting for resident fund accounts. The problem was everything was balancing because the Business Office Manager was using funds from one resident's account to make another resident's account look correct. This way it balanced when the corporate office looked at the funds information. The former Business Office Manager was writing checks out of resident fund accounts to him/herself and putting it into his/her personal account and 4 other accounts. The former Business Office Manager was using the checks to make payments to those accounts. The former Business Office Manager was using his/her credit cards to buy things for their children and family, then s/he would come back and reimburse him/herself from a resident fund account. Some of those receipts were signed, some were not. The Business Office Manager would have a resident sign a petty cash receipt for example $15 from their account, then the social worker would sign and then the Business Office Manager would go back and put a 3 in front of the 15 to make it $315.00. If a resident can't sign a receipt for cash, they will put an X, the Business Office Manager would sign that s/he gave the money. No one had to witness the transaction. All the receipt books could not be found after the Business Office Manager left. There were some receipts attached in the files, but they were not consecutive receipt numbers. There is a copy of the bogus checks included with the investigation. They pulled up all resident accounts and audited from the time the former Business Office Manager started, as well as receivable accounts. They have no idea how much cash s/he actually took, there is no way to know how much may have been affected by cash that came in that should have been credited to resident accounts. The facility hired a forensic account to audit the resident accounts. Residents were made whole with interest. The facility notified residents and families, whoever is in the system to get financial information is who was notified. They notified them by letter, some were also notified over the phone if there were any questions. They sent the letters out with the reimbursement checks with interest. Review of the Resident's Funds policy revealed the facility will hold, safeguard, manage and account for the resident's funds deposited with the facility. The resident fund account should always be up-to-date; all transactions should be accounted for and entered daily. Review of the Resident's Funds procedures revealed every cash disbursement must be recorded on the Resident Fund Monthly Cash Ledger. A receipt should be signed by the resident requesting the disbursement. If the resident can only make a mark (X), two witnesses must sign the receipt. The receipts should be entered into the resident trust fund software (RFMS) daily and be attached to the Transaction Report printed after the transactions have been transmitted. A resident fund numbered receipt book should be used for all cash transactions. Review of the section for Resident Fund Monthly Reconciliation revealed auditors recommend separation of duties when it comes to managing the resident fund account. One person should disburse cash and complete the resident fund transactions. Another person should complete the bank account reconciliation's.

Based on review of facility files and interview, the facility failed to ensure residents remained free from misappropriation of resident property. The Business Office Manager was noted to misappropriate money from resident accounts. There were 121 residents' accounts that were affected by the Business Office Manager's misappropriation between (MONTH) (YEAR) and (MONTH) (YEAR). One of one reportable allegation of misappropriation. The findings included: The facility reported an allegation of misappropriation of funds by the former Business Office Manager to the State Agency on 9/7/17. Review of the facility's Five-Day Follow-Up Report dated 9/14/17 revealed suspicious deposits were noted on a resident's account. The investigation had not been concluded. Review of the South Carolina Victim Impact Statement revealed the financial loss was noted as $161,622.53. In an interview with the surveyor on 12/5/17 at approximately 11:05 AM, the corporate accounts receivable manager stated a resident's family had called and stated the check they received was not the right amount. The check was a refund for the amount they had private paid, the resident had passed away. The consultant looked up the information and the information was correct in the computer, but when s/he looked in the billing file it was not right. S/he noted the discrepancy and called the corporate accounts receivable manager. They started looking to find out what was wrong and saw some cash that was receipted but never posted for a different resident. The former Business Office Manager posted the cash received from another resident to the resident whose check was incorrect, that was to try to make the account look right. The Business Office Manager was using funds from one resident to make another resident's account look correct. The former Business Office Manager was writing checks out of resident fund accounts to him/herself and putting it into his/her personal account and 4 other accounts. The former Business Office Manager was using the checks to make payments to those accounts. The former Business Office Manager was using his/her credit cards to buy things for their children and family, then s/he would come back and reimburse him/herself from a resident fund account. Some of those receipts were signed, some were not. The Business Office Manager would have resident sign petty cash receipt for example $15 from their account, then the social worker would sign and then the Business Office Manager would go back and put a 3 in front of the 15 to make it $315.00. They pulled up all resident accounts and audited from the time the former Business Office Manager started. They have no idea how much cash s/he actually took, there is no way to know how much may have been affected by cash that came in that should have been credited to resident accounts. The facility hired a forensic account to audit the resident accounts. Residents were made whole with interest. The facility notified residents and families, whoever is in the system to get financial information is who was notified. They notified them by letter, some were also notified over the phone if there were any questions. They sent the letters out with the reimbursement checks with interest. Review of the facility's Abuse Policy revealed misappropriation of resident property was defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. Review of the Resident's Funds policy revealed the facility will hold, safeguard, manage and account for the resident's funds deposited with the facility. The resident fund account should always be up-to-date; all transactions should be accounted for and entered daily.

Based on review of facility files and interview, the facility failed to ensure residents remained free from misappropriation of resident property. The Business Office Manager was noted to misappropriate money from resident accounts. No receipt books could be located after the Business Office Manager resigned. There were 121 residents' accounts that were affected by the Business Office Manager's misappropriation between (MONTH) (YEAR) and (MONTH) (YEAR). One of one reportable allegation of misappropriation. The findings included: The facility reported an allegation of misappropriation of funds by the former Business Office Manager to the State Agency on 9/7/17. Review of the facility's Five-Day Follow-Up Report dated 9/14/17 revealed suspicious deposits were noted on a resident's account. The investigation had not been concluded. Review of the South Carolina Victim Impact Statement revealed the financial loss was noted as $161,622.53. The administrator and the corporate accounts receivable manager gave conflicting statments to the surveyor on how the missapropriation was identified. In an interview with the surveyor on 12/5/17 at approximately 10:25 AM, the facility administrator stated they had corporate office here training the new Business Office Manager and they noted there was a discrepancy between the system and when they pulled a financial file for a resident. The corporate staff decided to do an audit and started to note suspicious zero deposits. It was confirmed when they pulled the former Business Office Manager's direct deposit account number from Human Resources and it matched an account number on one of the checks that was created. The former Business Office Manager had resigned and was no longer working at the facility when the discrepancy was found. In an interview with the surveyor on 12/5/17 at approximately 11:05 AM, the corporate accounts receivable manager stated they had a resident's family that called and said the check they received was not the right amount. The check was a refund for the amount they had private paid, the resident had passed away. The consultant looked up the information and the information was correct in the computer, but when s/he looked in the billing file it was not right. S/he noted the discrepancy and called the corporate accounts receivable manager. They started looking to find out what was wrong and saw some cash that was receipted but never posted for a different resident. The former Business Office Manager posted the cash received from another resident to the resident whose check was incorrect, that was to try to make the account look right. The corporate accounts receivable manager stated there were no set time frame for audits, generally if there was a change in Business Office Manager or if something flagged at the corporate office. The Business Office Manager was responsible for everything - taking money, disbursing money, and the resident trust fund. At the end of the month, the Business Office Manager does an accounting for resident fund accounts. The problem was everything was balancing because the Business Office Manager was using funds from one resident to make another resident's account look correct. This way it balanced when the corporate office looked at the funds information. The former Business Office Manager was writing checks out of resident fund accounts to him/herself and putting it into his/her personal account and 4 other accounts. The former Business Office Manager was using the checks to make payments to those accounts. The former Business Office Manager was using his/her credit cards to buy things for their children and family, then s/he would come back and reimburse him/herself from a resident fund account. Some of those receipts were signed, some were not. The Business Office Manager would have resident sign petty cash receipt for example $15 from their account, then the social worker would sign and then the Business Office Manager would go back and put a 3 in front of the 15 to make it $315.00. Receipts for cash, if the resident can't sign they will put an X, the Business Office Manager would sign that s/he gave the money. No one had to witness the transaction. All the receipt books could not be found after the Business Office Manager left. There were some receipts attached in the files, but they were not consecutive receipt numbers. There is a copy of the bogus checks included with the investigation. They pulled up all resident accounts and audited from the time the former Business Office Manager started, as well as receivable accounts. They have no idea how much cash s/he actually took, the amount from the resident funds was $109,000. That was actual resident money that they know was tampered with. There is no way to know how much may have been affected by cash that came in that should have been credited to resident accounts. The facility hired a forensic account to audit the resident accounts. Residents were made whole with interest. The facility notified residents and families, whoever is in the system to get financial information is who was notified. They notified them by letter, some were also notified over the phone if there were any questions. They sent the letters out with the reimbursement checks with interest. Review of the facility's Abuse Policy revealed misappropriation of resident property was defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent.

Based on observation, interview, and review of the facility policy, the facility failed to prepare, distribute, and serve food under sanitary conditions for 1 of 1 kitchen reviewed and has the potential to affect 129 of 129 residents with ordered diets as evidenced by failing to do the following: Dispose of expired food items. The findings included: On 7/17/17 at 9:20 AM, an initial tour of the kitchen with the Food Service Director /Certified Dietary Manager (CDM) revealed: Walk-in refrigerator: 1.) (4) gallons of reduced fat milk (2) dated 7/4/17 and (2) dated 7/9/17. 2.) (1) gallon of skim milk dated 7/16/17. 3.) Leftover vegetable soup in a clear container dated 7/13/17. 4.) Bowl of peaches undated. 5.) Clear container of grape jelly undated. Walk-in freezer: 6.) (4) bags of chicken legs frozen in liquid open and undated. 7.) (1) bag of chopped beef that had freezer burn and was undated. 8.) (4) 32 ounce cartons of V8 Smoothie Mix Fusion with a Best by date of 11/18/16. 9.) (4) 32 ounce cartons of V8 Smoothie Watermelon Raspberry with a Best by date of 9/29/16. Following the initial tour observations, the CDM verified the above (9) listed expired/undated items in the walk-in refrigerator/freezer and indicated the expired and unlabeled items should have been re-moved from storage. Review of the facility policy entitled, Storage of Food and Supplies, revealed under procedure (7.) All opened items are securely wrapped or stored in a secure storage container and labeled to identify the product (if not readily identifiable) as well as a use-by date of no greater than 72 hours after opening (unless documentation available for a longer shelf life is available). Staple products such as flour, sugar, cornmeal, dried pasta, etc. may be stored in designated, secure bins. Staple bin scoops may be stored in the product if the handle is out of the product in a manner to prevent touching of the food product. Also, the facility policy, Leftover Foods states under procedure (5.) Refrigerated leftovers are discarded after 72 hours and frozen leftovers discarded after 30 days.

Based on interview and record review, the facility failed to ensure restorative services were provided for 1 of 3 sampled residents reviewed for range of motion. Resident #147 with physician's orders [REDACTED]. The findings included: The facility admitted Resident #147 with [DIAGNOSES REDACTED]. A review of the medical record on 7/18/17 at approximately 10:48 AM revealed a physician's orders [REDACTED]. Further record review revealed a care plan that indicated resident was to receive PROM five (5) days a week to bilateral upper extremities every shift with a problem onset date of 9/2/16 with the next review target date of 10/03/17. The care plan also addressed Resident #147 receiving PROM to lower extremities times 10 reps three (3) days a week every shift. Further review of the medical record revealed PROM documentation for the months of 4/17/17 to 7/18/17 that indicated documented PROM services was provided to Resident #147 on 4/17/17 one shift, 4/18/17 one shift, 4/25/17 one shift and 4/27/17 one shift. The PROM for the month of May 2017 revealed documented services for 5/01/17 one shift, 5/02/17 one shift, and 5/03/17 one shift. The PROM for the month of June 2017 revealed services were provided on 6/15/17 one shift, 6/21/17 and 6/22/17 one shift. The PROM for the month of July 2107 revealed services were provided on 7/04/17 one shift, 7/11/17 and 7/12/17 one shift. An interview on 7/19/17 at approximately 11:40 AM with the Director of Nursing confirmed the restorative documentation as noted and further stated the blanks noted on the PROM documentation indicated the Certified Nursing Aide may not have been able to provide the services due to being called away.