Every finding on record at White Oak Manor - Spartanburg

Based on observations, interviews, record review, and facility policy review, the facility failed to administer oxygen (O2) as ordered by the physician for 1 of 4 residents (Resident (R)7) reviewed for respiratory care out of a total sample of 17 residents. This failure had the potential to cause respiratory issues including shortness of breath for residents.Findings include:Review of the facility's policy titled, Oxygen Concentrator, dated 05/11/18, indicated, Objective 1. To provide oxygen to resident in need of supplement. 2. To provide continuous oxygen. 3. To promote ease and efficient oxygen delivery . Procedure . 5. Record oxygen therapy on TAR [treatment administration record] or in EMR. Include rate of flow.Review of R7's undated Face Sheet, located under the Resident tab in the electronic medical record (EMR), revealed R7 was admitted to the facility on [DATE], with diagnoses including but not limited to, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and acute and chronic respiratory failure with hypoxia (too little oxygen reaching the body's tissues). Review of R7's physician's orders located under the Orders tab in the EMR revealed a current order, with a start date of 03/08/26, for R7 to receive oxygen at two liters per minute via nasal cannula continuously as ordered as the resident tolerates every shift related to shortness of breath.Review of R7's significant change Minimum Data Set (MDS), located in the EMR under the MDS 3.0 tab with an Assessment Reference Date (ARD) of 03/09/26, revealed the resident received O2 therapy, and had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated R7 was severely cognitively impaired.Review of R7's current care plan, located under the Care Plan tab in the EMR with a last reviewed/revised date of 03/10/26, revealed the following, Problem: RESPIRATORY: [R7's name] is at risk for shortness of breath r/t [related to] allergies, COPD, CHF. She is at risk of recurrent pneumonia. An approach included in this care plan directed nursing staff to: Administer oxygen therapy as ordered.During observations on 03/25/26 at 8:30 AM, 9:47 AM, and 4:15 PM, revealed R7 was in bed receiving O2 from a concentrator via a nasal cannula at a rate of one and a half liters per minute (L/min). During an observation and interview on 03/25/26 at 4:20 PM, Registered Nurse (RN)1 observed R7 and confirmed oxygen was being administered to the resident from a concentrator via a nasal cannula at a rate of one and a half L/min. RN1 checked R7's EMR and stated the resident had a current physician's order to receive oxygen at 2 L/min, and R7 was not receiving oxygen at the prescribed rate. During an interview on 03/26/26 at 12:40 PM, Licensed Practical Nurse (LPN)2 stated R7's Medication Administration Record (MAR) was where staff documented the administration of the resident's oxygen. LPN2 checked R7's MAR and stated that it specified the resident was to receive oxygen at a rate of 2 liters per minute, and the order was initiated on 03/08/26.During an interview on 03/26/26 at 1:45 PM, the Director of Nursing (DON) stated she was aware that R7 was observed on 03/25/26 not receiving oxygen at 2 L/min as ordered. The DON stated she expected oxygen to be administered to residents at the rate as ordered by their physician.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure a medication error rate below five percent during observation of medication administration. The facility had two medication errors out of 27 opportunities, which resulted in a medication error rate of 7.41%.Findings include:Review of the facility's policy titled, Pharmaceutical Services Policies and Procedures Manual, dated 09/21/22, indicated, . 6 For solid medications: . b. Medications not otherwise indicated may be crushed. If Do Not Crush is added to a medication order and the resident needs to have medication crushed, please consult the pharmacy. Review of Meds That Should Not Be Crushed and Pharmacy Technician's Letter/Prescriber Insights, updated April 2025 and located at https://pharmacist.therapeuticresearch, revealed that tamsulosin capsules should not be crushed, chewed, or opened. It is a sustained-release medication designed to be released slowly and crushing it can cause too much of the drug to be absorbed at once, increasing side effects like severe dizziness or hypotension. Capsules must be swallowed whole. Enteric-Coated/Delayed Release aspirin 81 mg should not be crushed. The coating is designed to prevent stomach irritation by preventing the drug from releasing until it reaches the intestines.Review of Resident (R)39's Face Sheet located under the Profile tab in the electronic medical record (EMR) revealed R39 was originally admitted to the facility on [DATE], with the diagnoses including but not limited to, non-ischemic myocardial injury (non-traditional heart attack) and retention of urine, unspecified.Review of R39s Physician Orders provided by the facility revealed an order dated 05/02/25, for aspirin delayed release/enteric coated (DR/EC) 81 milligrams (mg) one tablet by mouth daily. Ordered on 02/25/25 was tamsulosin 0.4 mg one capsule by mouth after breakfast. Do not crush.During observation of medication administration on 03/25/26 at 8:56 AM, License Practical Nurse (LPN)1 crushed a delayed release aspirin 81 mg tablet, placed it in apple sauce, and administered it to R39. In addition, LPN1 crushed R39's tamsulosin capsule 0.4 mg, placed it in applesauce, and administered it to R39. During an interview on 03/25/26 at 4:10 PM, the Director of Nursing (DON) was asked if an aspirin tablet, delayed release, and a tamsulosin capsule should be crushed. The DON stated, No, none of those medications are to be crushed. During an interview on 03/26/26 at 8:36 AM, LPN1 was asked why R39's medications were crushed. LPN1 replied, It's what we all do; it's easier to get her to take them when crushed and placed in applesauce.

Based on observation, interview, and record review, the facility failed to ensure that oxygen concentrators were maintained in a clean condition and free of debris for 1 of 6 concentrators in use (Resident (R)31) out of a sample of 17 residents. This failure posed a risk of cross-contamination, contaminated oxygen flow, and healthcare-associated infections. Findings include:The facility reported there was no policy on the cleaning and maintenance of oxygen concentrators and no documentation where an outside company came in and serviced the concentrators.Review of R39's Face Sheet located under the Profile tab in the electronic medical record (EMR) revealed R31 was admitted to the facility on [DATE], with diagnoses including but not limited to, respiratory failure and congestive heart failure.During an observation on 03/24/26 at 8:56 AM, during first day facility rounds in R31's room, the oxygen concentrator had a brown unidentified substance down the front and other debris on the top and down the front and sides. The concentrator was in use delivering oxygen at two liters by nasal cannula to R31.During an observation on 03/25/26 at 1:50 PM, during facility rounds in R31's room, the oxygen concentrator had a brown unidentified substance down the front and other debris on the top and down the front and sides. The concentrator was in use delivering oxygen at two liters by nasal cannula to R31.During an observation and interview on 03/25/26 at 2:34 PM, the Director of Nursing (DON) and Assistant Director of Nursing/Infection Preventionist (IP), accompanied surveyor to R31's room and to the concentrator with serial number 05C63182 delivering oxygen to R31. The concentrator continued to have a brown substance that was running down the front and sides and other debris. The DON stated, it should not look like that and should be clean.

Based on record review, interview, and facility policy review, the facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) when residents completed Medicare A therapy services for 2 of 2 residents (Residents (R)22 and R32) reviewed for beneficiary notices out of a sample of 33 residents. This failure to provide the SNF ABN prevented the residents from knowing how many days were remaining under Medicare A. Findings include: Review of the facility's undated policy titled, Skilled Nursing Facility Advance Beneficiary Notice indicated, . The Business Office is to initiate and deliver the SNF-ABN (CMS-10055) form when a Medicare resident is, or will be, receiving a service normally covered by Medicare, but the Provider believes is not (a) medically necessary or (b) is custodial care and the technical requirements for the coverage are met. The SNF-ABN form is required to be issued no later than 2 days before the resident's Medicare coverage is ending . 1. Review of R22's Face Sheet, located in the Face Sheet tab of the electronic medical record (EMR), revealed R22 was admitted to the facility for long-term care and was receiving skilled in therapy on 11/27/24. Review of the SNF Beneficiary Notice Form, completed by the facility, indicated R22's last day of Part A service was 02/06/25. The form indicated the SNF ABN, Form CMA 10055 was not provided to the resident because of a mistake on the business office part. 2. Review of R32's Face Sheet, located in the Face Sheet tab of the EMR, revealed R32 was admitted to the facility for long-term care and was receiving skilled in therapy on 10/08/24. Review of the SNF Beneficiary Notice Form, completed by the facility, indicated R32's last day of Part A service was 11/15/24. The form indicated the SNF ABN, Form CMA 10055 was not provided to the resident because of a mistake on the business office part. During an interview on 03/13/25 at 11:23 AM, the Administrator confirmed the residents did not receive the ABN.

Based on observations, interviews, and review of facility policy, the facility failed to follow appropriate infection control practices for hand hygiene and glove wearing for 1 out of 1 resident (Resident (R)211), observed during wound care and 1 out of 5 residents (R37), observed during medication administration out of a total sample of 33 residents. These failures increased the risk of the spread of infections. Findings include: Review of undated facility policy provided by the facility titled Hand Hygiene indicated, Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: . After removing gloves or aprons . Putting on and Taking off Personal Protective Equipment (PPE) . Types of PPE and Purpose Gloves: Protect hands from body fluids and other contaminates . PPE Guidelines - Wash or sanitize hands prior to donning PPE . - Remove PPE at resident doorway and perform hand hygiene immediately . - During removal of PPE, if at any time your hands become contaminated, perform hand hygiene immediately and then proceed with removal of the other articles of PPE . 1. During wound care observation for R211 on 03/13/25 at 12:22 PM, Registered Nurse (RN)2 and the Infection Preventionist (IP). The IP was assisting to hold R211. The IP donned a pair of gloves with a gown. During the observation, the IP removed the pair of gloves and donned a new pair of gloves without performing hand hygiene between the glove change. During an interview on 03/13/25 at 1:30 PM, the IP acknowledged that she had changed gloves without performing hand hygiene in between glove changes. 2. During medication administration observation on 03/14/25 at 9:15 AM, with Licensed Practical Nurse (LPN)2, LPN2 entered R37's room carrying a wrist blood pressure cuff, a cup of oral medications, a cup of water, and a lidocaine patch. Once in the room, LPN2 donned a pair of gloves without first performing hand hygiene. While applying the lidocaine patch, LPN2 removed the right glove briefly and laid the glove on the bedside table. LPN2 put the same glove back on to continue applying the lidocaine patch. After applying the lidocaine patch on R37, LPN2 removed gloves, gathered all her supplies (medication cup, water cup, and wrist blood pressure machine) in one hand and touched the wall hand sanitizer dispenser to apply sanitizer on the other hand. LPN2 exited R37's room. LPN2 laid the supplies on her medication cart and rubbed her hands together to apply the hand sanitizer. During an interview on 03/14/25 at 9:20 AM, LPN2 acknowledged she had removed one glove, put the same glove back on, and had failed to sanitize her hands before gloving and immediately after ungloving. During the closing conference on 03/14/25 at 4:00 PM, the IP, DON and Administrator were informed of and acknowledged the above findings.

Based on review of facility policy, interview, and record review, the facility failed to report an incident of alleged abuse involving 1 of 5 residents reviewed for unnecessary medications. Specifically, on 05/12/2023, Resident (R)34 struck R14 on her arm and the incident was not reported. Findings include: Review of the facility policy titled Protocol for Reporting Abuse, updated on 05/2017 revealed, If you have reason to believe, as a reasonable person, that abuse, neglect, exploitation, or mistreatment . has occurred . then that person is obligated to notify the Administrator and other officials in accordance with state law through established procedures. Furthermore, all forms of resident - to - resident abuse must be reported to the appropriate state agency(s) within 2 hours. Review of R34's Face Sheet revealed, R34 was admitted to the facility on [DATE] with diagnoses including, but not limited to, severe hypoxic ischemic encephalopathy, delusional disorders, major depressive disorder, unspecified psychosis, and unspecified dementia. Review of R34's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/28/23 revealed, R34 received a Brief Interview for Mental Status (BIMS) score of 04 out of 15, indicating the resident was severely cognitively impaired. Review of R14's Face Sheet revealed, R14 was admitted to the facility on [DATE] with diagnoses including, but not limited to, metabolic encephalopathy and lack of coordination. Review of R14's quarterly MDS with an ARD 04/11/23 revealed, R14 received a BIMS score of 03 out of 15 indicating the resident was severely cognitively impaired. Review of R34's progress note dated 05/12/23 at 4:31 PM by the Director of Nursing (DON) revealed, The patient with a BIMS of 4 observed another resident with a baby doll and rolled over and hit the resident on her arm. The patient was told she should not hit the resident. Review ofa document titled Confidential Occurrence Statement or Interview written by the Medical Supply Manager (MSM), regarding an occurrence on 05/12/23 at 3:35 PM revealed, Certified Nursing Assistant (CNA)1 observed R34 roll over to R14 and hit her on the arm. The resident was told not to hit and she then told R14 she was sorry. During an interview with the MSM on 06/07/23 revealed, she was at the desk, ready to go home when she saw R34 tap R14 to get her attention. The MSM confirmed that in her statement to the facility she used the word hit rather than tap because she was in a hurry to leave the facility. The DON was not available for interview.

Based on observations, interviews, and facility policy review, the facility failed to ensure 1 (Unit 2) of 2 medication rooms had a permanently affixed compartment for the storage of controlled drugs inside the medication refrigerator. Additionally, the facility failed to monitor 1 (Unit 2) of 2 medication room refrigerator temperatures to ensure it was in safe operating condition. Findings included: 1. Review of the facility's policy titled, Ordering and Receiving Medications from Pharmacy, dated 08/16/2021, indicated, 5. Controlled Substances: When a controlled substance is ordered, the Pharmacist is to send a labeled Medication Count Sheet. The Nurse will sign for receipt of medication on the Form. The medication will then be placed under double lock. Further review of the policy indicated, Upon receipt of the medication shipment, medications will be placed in the locked medication room for secure storage until such medications are distributed to the appropriate location for individual resident use. The policy did not indicate that controlled drugs were to be stored in a permanently affixed compartment. Review of the Drug Enforcement Administration (DEA) Lists of: Scheduling Actions Controlled Substances Regulated Chemicals, dated June 2023, revealed the medication named lorazepam, also known as Ativan, was a Schedule IV controlled substance. During a concurrent observation and interview on 06/07/23 at 10:55 AM, Licensed Practical Nurse (LPN)1 entered the Unit 2 medication room, located behind the Unit 2 nurses' station. LPN1 opened the medication refrigerator door and stated the facility placed the refrigerated controlled substances in a box. LPN1 then retrieved a small red toolbox with a lock from the refrigerator and stated controlled medications were kept inside the toolbox. LPN1 stated this was the only facility where she had seen a controlled substance box not secured (permanently affixed) in the refrigerator and stated, I could put that in my bag and take it. LPN1 did not have a key to the controlled substance box but stated LPN2 did. During a concurrent observation and interview on 06/07/23 at 11:01 AM, LPN2 entered the Unit 2 medication room with the surveyor, pulled the controlled substance medication box out of the refrigerator, placed it on the counter, and unlocked the box. The toolbox contained two 30 milliliter (mL) bottles of liquid lorazepam 2 milligram (mg) per mL for Resident (R)6. One bottle was unopened and contained 30 mL, while the second bottle contained eight milliliters. LPN2 stated controlled substances should be double locked and secured, and she felt like the red toolbox inside the refrigerator was secured because it was behind a locked medication room door and the toolbox had a lock on it as well. When asked by the surveyor what was to stop a staff member from taking the toolbox, LPN2 stated only nurses had keys to the medication room/controlled substance box, and someone would notice if a staff member tried to walk out of the facility with the red toolbox. During an interview on 06/07/23 at 1:50 PM, the Administrator, Corporate Nurse Consultant (CNC), Social Service Consultant (SSC), and Corporate Registered Dietician (CRD) were in the Administrator's office and stated they could be interviewed together. The CNC stated she was filling in for the Director of Nursing (DON) while the DON was out of the country. The CNC stated resident medications were under lock and key in the medication cart, and there was a locked storage box located inside the medication refrigerator. The CNC stated the controlled substances located in both the medication cart and medication room were double locked. When asked how the red toolbox was secured inside the medication refrigerator, the CNC stated the second lock on the red toolbox secured the box. The CNC further stated the controlled medications must be counted each shift, so the facility would know if any medication was missing. When asked if the controlled substance box located inside the medication refrigerator was permanently secured (permanently affixed so it could not be removed), the Administrator responded, Nothing is permanently secured anywhere. 2. Review of the facility's policy titled, Medication Storage in the Facility, dated 08/16/2021, revealed, 7. Medications requiring 'refrigeration' or 'temperatures between 36 [degrees] F [Fahrenheit] and 46 [degrees] F are kept in a refrigerator with a thermometer to allow temperature monitoring. Review of a medication package insert for lorazepam oral concentrate, revealed the medication should be stored between the temperatures of 36 degrees F to 46 degrees F. During a concurrent observation and interview on 06/07/23 at 10:55 AM, LPN1 entered the Unit 2 medication room, located behind the Unit 2 nurses' station. LPN1 stated the night shift staff was responsible for monitoring the refrigerator temperatures. The surveyor and LPN1 exited the medication room and stood at the nurses' station when LPN2 approached. LPN2 stated the refrigerator temperature log was completed by the day shift nurse. Registered Nurse (RN)1 then approached the nurses' station. RN1, LPN1, and LPN2 were unable to locate a refrigerator temperature log. During an interview on 06/07/23 at 11:50 AM, LPN2 approached the surveyor and again stated the staff could not locate a refrigerator temperature log. LPN2 stated she previously trained new nurses, and monitored refrigerator temperatures and logging the temperatures were not part of the training. During an interview on 06/07/23 at 12:00 PM, the Administrator stated the facility did not have a log for the medication refrigerators, it was not part of the facility policy, and the facility was not required to log the refrigerator temperatures daily. The Administrator stated he expected the nurses to look at the refrigerator thermometer when they opened the refrigerator. The Administrator was unable to state how he ensured staff monitored the refrigerator temperatures since there was no log available and stated the previous Director of Nursing (DON) monitored the refrigerator temperatures. During an interview on 06/07/23 at 1:50 PM, the Administrator, Corporate Nurse Consultant (CNC), Social Service Consultant (SSC), and Corporate Registered Dietician (CRD) were in the Administrator's office and stated they could be interviewed together. The CNC stated she was filling in for the DON while the DON was out of the country. The Administrator stated the facility monitored the medication refrigerator and they [refrigerator thermometers] are looked at when they are approached. The CNC stated the nursing staff must count the controlled medications in the refrigerator each shift and looked at the thermometer then. The SSC stated the facility did not complete any audits to ensure staff monitored the medication refrigerator temperatures, and the facility would not complete an audit unless there was a problem. The CNC stated if there was an issue with the refrigerator, the nursing staff would let administration and maintenance know.

Based on record reviews, interviews, and review of facility policy, the facility failed to ensure that the Ombudsman was notified of the transfer of residents (R) 38 and 296 to the hospital for 2 of 2 residents that were reviewed for hospitalization . Findings include; The facility admitted Resident (R) 38 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of nurse's notes, on 10/13/21 at 1:21 PM, revealed R38 was transferred to the hospital on 8/30/21 due to a decline in condition. The resident was admitted to the hospital and returned to the facility on [DATE] per the nurse's notes. Further review of nurse's notes and social worker notes revealed no documentation to indicate the facility sent a copy of the transfer notice to the State Long-Term Care Ombudsman. Record review of nurse's notes on 10/14/21 at 9:30 AM revealed R296 was sent out to the hospital. Further review of the medical record showed no documentation of notification to the Ombudsman. During an interview with the Nursing Home Administrator (NHA), on 10/14/21 at 10:08 AM, the NHA stated the Ombudsman was not sent a notice of the resident's transfer to the hospital. The NHA stated when the waiver for notifying the Ombudsman of resident transfers ended in May, the facility did not resume sending notice to the Ombudsman. The NHA stated their census had been so low it would not have been an issue to re-admit any resident that was transferred to the hospital. The NHA stated Social Services was responsible for sending the Ombudsman a copy of the Notice of Transfer/Discharge form after transfer to the hospital. The NHA stated the facility had not been doing that and would resume sending notification to the ombudsman for all transfers and discharges. Review of the facility's policy titled Discharge Planning, last revised 02/2019 revealed: Transfer/Discharge to a Distinct Certified Unit/Facility When a transfer or discharge is necessary and requires transfer or discharge of a resident to another facility or from one certified unit to another, written notification shall be given to the resident and the resident's representative stating effective date of transfer and reasons for transfer. Notice of facility initiated transfers and discharges are also sent to the local Ombudsman .

Based on record review, interview and review of facility policy, the facility failed to develop and implement baseline care plans within 48 hours of admission for Residents (R) 38, 41, and 146, 3 of 12 sampled residents reviewed for baseline care plans. The baseline care plans had no completion date and the baseline care plan for R38 failed to include the minimum healthcare information to properly care for the resident. The findings included: The facility admitted R38 on 8/26/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of nurse's notes, on 10/13/21 at 3:47 PM, revealed an admission note from 8/26/21. The note indicated the resident was admitted with bilateral nephrostomy tubes. Record review of the baseline care plan, on 10/13/21 at 3:28 PM, revealed the resident's base line care plan did not indicate the resident was admitted with bilateral nephrostomy tubes and had no interventions listed for the care of the nephrostomy tubes. Further review of the baseline care plan revealed there was no date to indicate when the care plan had been developed and implemented. The area of the form for the completion date was left blank. Record review of the Treatment Administration Record, on 10/14/21 at 8:50 AM, revealed treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with Registered Nurse (RN) 1 and the Director of Nursing (DON), on 10/14/21 at 9:50 AM, RN1 and the DON confirmed the resident's bilateral nephrostomy tubes were not included on the baseline care plan. RN1 and the DON also confirmed the baseline care plan completion date had been left blank. RN1 stated some problem areas on the baseline care plan were dated 8/26/21 and this indicated the baseline care plan was developed and implemented on this date and within 48 hours of admission. It was pointed out to RN1 the baseline care plan also listed other problem areas with dates beyond 48 hours of admission. RN1 confirmed the additional dates on the baseline care plan. RN1 agreed had the completed date been listed on the form instead of left blank it would have been clear when the baseline care plan was developed and implemented. The Baseline Care Plan policy was also reviewed with RN1 and the DON on 10/14/21 at 9:50 AM. After review of the policy, the DON stated the facility did not follow their policy for completing the baseline care plan, The DON stated it is facility policy to complete the baseline care plan within 24 hours of admission. The DON stated they could not show that this was done due to no completion date was listed on the baseline care plan in the space indicated. The baseline care plans for R41 and R146 were also reviewed with the DON and RN1 on 10/14/21 at 9:50 AM. The DON and RN1 observed and confirmed that the completion date was left blank on both baseline care plans. Per Baseline Care Plan policy: Purpose: To assure the immediate provision of person-centered essential care to the resident. Procedure: Admission physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The admitting nurse must complete a baseline care plan within 24 hours following admission.

Based on review of facility files, facility policy and interview, the facility failed to report a potential violation involving misappropriation of resident property for Resident #1, 1 of 1 sampled residents reviewed for misappropriation of resident property. Resident #1 was missing medication that was not reported to the State Agency within the 2 hour and 5 day reporting time frames. The findings included: The facility admitted Resident #1 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility investigation records, on 6/14/21 at 10:57 AM, revealed during a count of Resident #1's [MEDICATION(S)] tablets, on 5/7/21 at 2:45 PM, the resident was missing 2 [MEDICATION(S)] tablets. Review of narcotic count sheets revealed 2 nurses signed the record confirming the missing tablets. Later in the shift, a third nurse was notified of the discrepancy. The investigation also revealed the Director of Nursing (DON) was not notified of the discrepancy until 11:30 AM the following day, on 5/8/21. Further review of the investigation file revealed a 24 Hour Report was not sent to the State Agency until 5/13/21 and the 5 Day Follow Up Report was not sent until 5/17/21. During an interview with the DON, on 6/14/21 at 2:18 PM, the DON confirmed the missing narcotic medication was not reported to the State Agency in a timely manner. The DON stated s/he should have been notified of the missing medication immediately, but was not notified until the following day (5/8/21). In addition, the DON stated the initial report s/he received, on 5/8/21 (Saturday), indicated the discrepancy had been corrected. The DON felt no further action was required at the time. On 5/10/21, after returning to work, the DON stated s/he discovered the missing medication was still missing and immediately started an investigation. The DON stated all nurses had been re-educated on facility policy related to controlled substances. Review of the facility's abuse policy revealed It is the responsibility of our employees, workforce, facility consultants, physicians, family members, etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, theft or misappropriation of resident property to facility management. In addition .the Administrator or designee will notify the appropriate State agency(s) immediately, but not later than two (2) hours after the allegation is made if the events that cause the allegation involve abuse .

Based on observations and interview, the facility failed to ensure residents rights were honored when staff failed to knock on doors to residents' rooms before entering their room. Staff was observed entering residents' rooms on the Unit 3 without knocking. 1 of 2 Units observed. The findings included: Random observations on Unit 3 on 6/24/19 at approximately 12:37 PM revealed staff entering rooms [ROOM NUMBERS] without knocking. The doors to both rooms were opened with resident's present. At approximately 12:44 PM on 6/24/19 a different staff member was observed entering rooms [ROOM NUMBERS] without knocking. An interview on 6/24/19 at approximately 12:47 PM with Certified Nursing Aide (CNA) #1 confirmed he/she entered residents' rooms without knocking. CNA #1 further stated he/she generally enter residents' rooms without knocking when the door to the resident's room was opened. An observation on 6/24/19 at approximately 12:50 PM revealed a laundry/housekeeping staff entering residents' rooms without knocking. The doors were opened to the resident's rooms and the resident was present.

Based on record review and interview the facility failed to act upon, in a timely manner, pharmacy recommendations for laboratory blood work to monitor related medications for 2 of 5 residents reviewed for unnecessary medications. (Residents #29 and #45) The findings included: Resident #29 was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #29's medical record on 06/25/19 at approximately 3:00 PM revealed The Pharmacist Progress note showed the pharmacy performed a medication record review on 04/26/19. The pharmacist progress note made the following recommendations under nursing, Labs (laboratory) recommended, Complete Blood Count (CBC) and Magnesium level for Magnesium oxide and Eliquis use. The pharmacist progress note was dated by the pharmacist on 04-29-19. Review of doctor's orders on 6/25/19 at approximately 3:10 PM revealed, the order for the CBC and Magnesium level was not written until 06-02-19. The blood work was done on 06/03/19. During an interview with the Director of Nursing (DON) on 06-25-19 at approximately 4:00 PM, s/he confirmed the blood work was done on 06-03-19. Resident #45 was admitted [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #45's medical record on 06/25/19 at approximately 3:30 PM revealed, The Pharmacist Progress Note showed the pharmacy performed a medication record review on 04/26/19. The pharmacist made the following recommendation under Nursing, Labs (laboratory) recommended, Potassium level for Micro-K use (dose changed 03.25.19). The Pharmacist Progress Note was dated by the pharmacist on 04/29/10. Review of doctor's orders on 6/25/19 at approximately 3:35 PM revealed the order for the potassium level was not written until 06/02/19. The laboratory work was done on 06/03/19. During an interview with the Director of Nursing (DON) on 06-25-19 at approximately 4:00 PM, h/she confirmed the blood work was done on 06-03-19. Review on 06/25/19 at approximately 4:15PM of the facility policy Medication Regimen Review #3 revealed, Recommendations should be addressed within 30 days of receipt of the recommendation.

Based on record review and interview the facility failed to give 1 of 13 residents the opportunity to formulate their advance directive. Resident #16 was declared incapable of making his/her own decisions by one physician but not a second per South [NAME]ina law (Adult Health Care Consent Act). The findings included: Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #16's Record on 6/24/19 at approximately 2:14 PM revealed the resident was signed Do Not Resuscitate by a resident representative. Review of capacity form revealed only one physician had assessed the resident as incapable of making his/her own decisions. Interview with Social Services Director on 6/25/19 at approximately 2:50 PM confirmed the capacity form of Resident #16 was missing a second physician signature. Review of Advance Directive Policy on 6/26/19 at approximately 10 AM revealed if a physician is to order that life sustaining measures be withheld; the resident must be declared mentally incapacitant by state law. Interview with the Administrator on 6/26/19 at approximately 10:37 AM confirmed the capacity form of Resident #16 second missing a second physician signature. The administrator said the physician was correcting it. Review of the Adult Health Care Consent Act revealed A patient's inability to consent must be certified by two licensed physicians, each of whom has examined the patient.

Based on observation, record review and interview the facility failed to insure the participation of all required disciplines in the Care Plan Conferences for Residents #2, #3, #30 and #45, 4 of 16 sampled residents reviewed for Care Plans. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Record review on 06/06/18 at approximately 2:42 PM revealed signature sheets for Care Plan Review meetings held on 02/24/18 and 09/20/17 did not verify representation from Dietary at the meetings. The facility admitted Resident #45 with [DIAGNOSES REDACTED]. Disease. Record review on 06/07/18 at approximately 10:11 AM revealed Care Plan Conference signature sheets for 02/24/18 with no documentation of attendance by a Certified Nursing Assistance (CNA) or Dietary representative and no documentation of attendance by a CNA on 05/10/18, 11/21/17, 08/25/17. In an interview 06/06/18 Registered Nurse #1, the Resident Assessment Coordinator, stated that all disciplines do not attend the Care Plan Review meeting. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. Record review on 06/08/18 revealed the required staff participation was not evident x 5 care plan meetings, dated 06/15/17, 09/14/17, 12/15/17, and 02/27/18. Resident #30 was admitted to the facility with [DIAGNOSES REDACTED]. Record review on 06/08/18 revealed the required staff participation was not evident x 3 care plan meetings, dated 01/23/18, 02/15/18 and 04/17/18. The provided RAI (Resident Assessment Instrument) Process Review, Care Plan Review forms with missing signatures for Residents #3 and 30 were reviewed and confirmed by the Administrator on 06/08/18 at 6:02 p.m. Review of the provided RAI and Care Plan Process revised on 05/08/17, policy indicates on page 11, line item 10, states, TEAM CONFERENCE: Everyone present should sign the RAI Process Review Sheet to evidence attendance and/or participation in the care planning process.

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 2 kitchens reviewed and has the potential to affect 19 of 53 residents with ordered diets as evidenced by failing to avoid cross contamination of food items during temperature taking (temping) on unit 4. The findings included: On 6/5/18 at 11:45 AM, during an observation of the unit 4 lunch line temping with Cook #1, the cook first placed a food temperature probe into rice, then into mixed vegetables, followed by chicken and finally into pureed rice before being stopped by the surveyor. Cook #1 did not sanitize the temperature probe between each food item s/he was temping and was asked, Were you trained to sanitize the temperature probe between food items. S/he stated, Yes, I forgot. Review of the facility policy, Thermometer Calibration/Food Temps stated under (5.) To check food temperatures: bullet (5) rinse, sanitize and air dry the thermometer between foods unless the same food in another consistency is checked and the previous temperature was within desirable range.

Based on observation, record review and interview the facility failed to notify the family/ resident representative for Resident #2, 1 of 1 sampled resident reviewed for Accidents. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Record review on 03/09/18 at approximately 2:42 PM revealed a Nurse's Note dated 03/09/18 stating, Continue on antibiotic related to fever. No noted signs/symptoms of adverse reactions. A Febrile with no complaint of pain or discomfort. No documentation of new order or notification of Resident Representative related to change in medication noted in the Nurse's Notes. In an interview on 06/06/18 at approximately 2:42 PM the Director of Nursing (DON) provided a copy of a telephone order from the thinned chart records for 1 gram [MEDICATION NAME] by injection x 4 days. The DON also confirmed that there was no documentation of notification to the family/ resident representative of the new medication.

Based on record review and interview, the facility failed to ensure assessment accuracy for Resident #21 for 1 of 5 residents reviewed for unnecessary medication. The findings included: Resident #21 was admitted to the facility with [DIAGNOSES REDACTED]. Record review of the resident's care plan, on 06/08/18, revealed the resident to be participating in a Urinary toileting program. During an interview with the Registered Nurse #1, on 06/08/18 at 2:55 pm, s/he indicated s/he is not responsible for the toileting program but pulls that information from 'Smart Charting' - the clinical input from the Certified Nursing Assistants. The date onset of the toileting program is 09/08/17, on page 17 of 27 of the resident's provided care plan. MDS nurse provided smart charting documentation that did indicate Resident #21 was on the toileting program during the dates of the assessment, 03/20/18 and should have been coded as such.

Based on observation, record review and interview the facility failed to provide a written summary of the baseline care plan to Resident #29, 2 of 3 sampled residents reviewed for hospitalization . The findings included: The facility admitted Resident #29 with [DIAGNOSES REDACTED]. Record review on 06/08/18 at approximately 2:49 PM revealed an Interim (Baseline) Care Plan dated 01/05/18. There was no written summary of the Baseline Care Plan in the medical record. In an interview on 06/08/18 at approximately 3:26 PM Registered Nurse #1, the Resident Assessment Coordinator, stated that if there was no copy of the summary in the record, it was not completed.

Based on observation, record review and interview the facility failed to ensure accuracy of medical records related to completion of Incident Reports for a fall for Resident #2, 1 of 1 sampled resident reviewed for Accidents. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Record review on 06/06/18 at approximately 2:42 PM revealed a Nurse's Note dated 03/08/18 stating, A visitor notified this nurse that this resident was sitting on the floor in his/her room. When this nurse entered the room the Resident was sitting on the cushion from his/her wheelchair in front of his/her wheelchair with his/her legs stretched out and feet going across the rails of his/her side table. When this nurse tried to assess the Resident, s/he became verbally abusive and tried to strike me with the side table but failed. When other staff entered the room to assist, the resident continued to curse and attempt to be combative. The Resident refused to allow staff to use a lift to get him/her from the floor. When asked could s/he get him/herself off the floor, the resident did so on his/her own without any assistance. The resident refused a body audit but stated that s/he was not in pain and had not hit his/her head. This surveyor requested a copy of the incident report documenting this fall and any interventions implemented to prevent reoccurrence. In an interview on 06/06/18 at 10:51 AM the Administrator confirmed s/he was unable to locate an incident report. In a subsequent interview on 06/08/18 at 1:41 PM the Director of Nursing confirmed that staff would be expected to complete an incident report for a fall.

Based on observations, interviews and review of the facility's Resident Meal Service policy, the facility failed to ensure that residents who ate in their rooms were served/eating at the same time their roommates were served/eating and failed to pull privacy curtains for residents that were not served/eating for 2 of 2 units observed. Residents who ate in their rooms were served milk out of milk cartons due to no extra glasses being available on the opened food cart for residents who eat in their rooms for 2 of 2 units observed. The findings included: During a random meal observation of Unit 3 on 6/05/17 at approximately 5:35 PM the food carts were not delivered to unit per schedule. At 5:45 PM the first opened food cart was delivered to the unit and remained near room [ROOM NUMBER] unit around 5:55 PM. The opened food cart was noted with liquid beverages in glasses while milk was served in milk cartons. There were no extra glasses on the opened food cart for the milk. At approximately 6 PM during random meal observation on Unit 3, a second opened food cart was delivered to the unit. The resident seated near the door in room [ROOM NUMBER] was served a food tray while his/her roommate was not served. The roommate was positioned in his/her bed facing the resident who had been served and eating in room [ROOM NUMBER]. The privacy curtains were not pulled while the resident near the door was seated in his/her wheelchair and eating when the roommate was seated in bed facing him/her and not served or eating. A nurse entered room [ROOM NUMBER] and delivered the resident who was eating an additional request on his/her food tray. Staff did not attempt to provide the resident in bed a food tray/or pull privacy curtains while the resident in the wheelchair continued to eat. Staff which included the Director of Nursing and Administrator were observed delivering meals to other residents in their rooms on the unit near room [ROOM NUMBER] before the resident in bed was served. On 6/05/17 at approximately 6:17 PM, a facility consultant walked pass and looked in room [ROOM NUMBER] where one resident was served and eating while the roommate was seated in bed and not served or eating. The resident not served or eating continued to be positioned facing his/her roommate with the privacy curtains not drawn while the roommate seated at the door had nearly completed his/her meal. During an interview, the facility consultant confirmed the findings and stated he/she would find out why the resident seated in bed had not be served while the resident/roommate near the door had been served. The resident seated in bed did not get served until approximately 6:20 PM and the privacy curtains remained open. Review of the facility's Resident Meal Service policy dated 08-2010 revealed under the procedures section #9 For residents who chose to eat in their room on a routine basis, roommates will be served their meal trays at the same time as possible. If this is not possible, the curtain will be pulled before tray service. An interview on 6/08/17 at approximately 9:49 AM with the Dietary Manager confirmed that the kitchen staff did not provide extra glasses on food carts during the evening meal on 6/05/17 in order for residents on the unit who ate in their rooms to be served milk in glasses instead of the carton. An interview on 6/08/17 at approximately 9:55 AM with the Administrator confirmed one resident in room [ROOM NUMBER] was served/eating while the other resident was not served/eating and the privacy curtain not pulled. During the supper meal observation on 6/5/17 at 5:30 PM, there were 16 residents served milk on their food trays without glasses provided to pour the milk into. Staff did not ask residents if they preferred their milk in a glass or carton. While observing the meal pass to the rooms in the downstairs unit, a resident in room [ROOM NUMBER] was observed finishing her supper meal, which had been brought in by family. The other resident in the room had not been served her supper meal . The staff did not pull the privacy curtain between the two residents.