Every finding on record at Woodruff Manor

Based on observation, interview, record review, and facility policy review, the facility failed to ensure 1 (Resident (R)10) of 2 residents reviewed for respiratory care was assessed and a care plan was developed for self-management of supplemental oxygen therapy. Findings included:A facility policy titled, Oxygen Services, effective 07/25, revealed, For a resident receiving oxygen therapy, the resident's record must reflect ongoing assessment of the resident's respiratory status, response to oxygen therapy and include, at a minimum, the resident's care plan should identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: When to administer, such as continuous or intermittent and/or when to discontinue.An admission Record revealed the facility admitted R10 on 11/12/24. The admission Record identified the resident had a medical history that included diagnoses of respiratory failure, unspecified with hypoxia; pneumonia; chronic obstructive pulmonary disease (COPD); chronic combined systolic and diastolic heart failure; end-stage renal disease; dependence on dialysis; atrial fibrillation; cognitive communication deficit; and diabetes mellitus.A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/12/25, revealed R10 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. The MDS revealed the resident received oxygen therapy while a resident of the facility.R10's physician Order Summary Report for active orders as of 02/10/26 revealed an order started 11/12/24 for oxygen at 2 liters via nasal cannula every shift related to COPD.An observation on 02/10/26 at 3:14 PM revealed R10 was not present in the room, and the nasal cannula tubing for supplemental oxygen was hanging from the side of the bed.During an interview on 02/10/26 at 11:14 AM, R10 stated they (the resident) determined when they used supplement oxygen. The resident stated they removed their nasal cannula in the morning and reapplied it at approximately 8:00 PM. Per R10, the resident also turned the oxygen machine off in the morning and turned it back on at night by pressing the power button.R10's Care Plan Report, included a focus area revised 09/13/24, that indicated the resident was at risk for altered respiratory status/difficulty breathing related to chronic hypoxemia, respiratory failure, and COPD. Interventions directed staff to apply oxygen as ordered, 2 liters via nasal cannula (revised 12/20/25). The Care Plan Report did not address the resident self-managing their supplemental oxygen therapy.During an interview on 02/12/26 at 9:20 AM, Licensed Practical Nurse (LPN)4 stated that it was staff's responsibility to manage R10's oxygen therapy, including application and removal. LPN4 stated that the resident was forgetful at times, and that staff could not rely on the resident to manage their supplemental oxygen independently.During an interview on 02/11/26 at 10:32 AM, the Social Services Director (SSD) stated that residents were not permitted to independently manage medications unless it was specifically ordered, and the resident was assessed. The SSD stated that R10 had not been assessed for self-managing supplemental oxygen. The SSD also revealed that the interdisciplinary team had not discussed the resident removing their supplemental oxygen, and a care plan had not been developed to reflect independent oxygen management.During an interview on 02/14/26 at 5:54 PM, the Assistant Director of Nursing (ADON) revealed R10 removed their oxygen based on the resident's comfort and believed the resident could manage their supplemental oxygen. She stated the resident knew how to turn the oxygen machine on and off and the ADON could not control what the resident chose to do. Per the ADON, R10 had not been formally evaluated and did not have a care plan for independent oxygen management.During an interview on 02/14/26 at 12:04 PM, the Administrator stated that if a resident was alert and oriented enough to remove their supplemental oxygen, the facility could not prevent the resident from doing so. The Administrator stated that staff were expected to check whether oxygen was in use as ordered, and if oxygen was not in use, staff should remind the resident and attempt to reapply oxygen. The Administrator stated certified nurse aides (CNAs) were expected to notify a nurse if the resident removed their nasal cannula or if oxygen was not being worn. Per the Administrator, nursing staff were responsible for reapplying oxygen, managing oxygen therapy, and documenting as needed.

Based on observation, interview, record review, facility document review, and facility policy review, the facility failed to ensure medical records were complete and accurate for 2 (Resident (R)3 and R56) of 2 residents reviewed for pressure ulcers/injuries.Findings included: A facility policy titled, Documentation of Resident Care, dated 01/2026, revealed, The Skilled Nursing Facility shall document the care given to the resident utilizing and efficient and standardized method. The policy further revealed under the Procedure section, 2. Required Licensed Nursing documentation includes but is not limited to i. Surgical or wound site condition and care, s. Observations, t. Clinical Assessment, w. Skin Inspection. A facility policy titled, Pressure Ulcers, dated 09/2025, revealed, Procedure: All residents are assessed on admission and weekly for an entire body audit review which includes all body surface areas. The policy further revealed, The skin body audit contains clear documentation of all existing wounds and any areas that may have previous deep tissue injury. The policy also revealed, Documentation: At any time during the resident's stay on the Skilled unit a pressure related wound is recognized, a wound LDA [Lines, Drains, and Airways] is created which includes: Date of onset, site and location, size (location, size (length and width), depth, exudates, odor, wound bed, tunneling, undermining, surrounding skin color, surrounding tissue and wound edges, any cultures sent, response to treatment, provider and family notification, and pain. Dressing changes are documented in the electronic health record. Nursing progress notes are utilized for additional documentation. 1. An admission Record revealed the facility admitted R3 on 10/19/2017. According to the admission Record, the resident had a medical history that included diagnoses of anorexia, protein-calorie malnutrition, muscle weakness, and vitamin D deficiency. A comprehensive Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/19/2025, revealed R3 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was at risk for developing pressure ulcers but did not have ulcers at the time of the assessment. R3's Care Plan Report included a focus area revised 01/27/2026, that indicated the resident had impaired skin integrity, which included a Stage 2 (partial-thickness skin loss) pressure injury to the coccyx. Interventions directed staff to complete weekly body audits (initiated 08/18/2024); provide wound care as ordered; and document the wound, healing, and signs of infection and alert the provider of negative findings (revised 01/16/2026). R3's physician Order Recap Report for the timeframe from 02/01/2026 to 02/28/2026 contained an order started on 01/01/2026 and discontinued on 01/11/2026 to clean the wound with wound cleanser, pat the area dry, apply a xeroform (a germ prevention non-stick dressing used for wound healing) dressing, and cover the area with a foam bordered dressing daily and as needed. The Order Summary Report also revealed an active order dated 01/11/2026 to clean the wound with wound cleanser, pat the area dry, apply a Hydrofera Blue (an antibacterial foam dressing that promotes healing by removing germs from the wound) dressing, and cover the area with a foam bordered dressing every other day and as needed. R3's January 2026 Treatment Administration Record revealed staff documented that wound care was provided daily from 01/02/2026 to 01/11/2026 and was provided every other day from 01/13/2026 to 01/31/2026. R3's February 2026 Treatment Administration Record revealed staff documented that wound care was provided every other day from 02/01/2026 to 02/10/2026. R3's electronic medical record (EMR) was reviewed for the timeframe from 12/31/2026 through 02/06/2026. R3's EMR revealed there was no documentation containing weekly measurements or weekly descriptions of the resident's wound. R3's Skin Only Evaluation, dated 01/03/2026, indicated R3 had a pressure ulcer on the sacrum. R3's Skin Only Evaluation, dated 01/04/2026, 01/18/2026, and 02/01/2026, revealed Licensed Practical Nurse (LPN)2 documented that R3's skin was intact (no wounds), and the resident had no skin issues. R3's Skin Only Evaluation, dated 01/11/2026, 01/25/2026, 01/31/2026, and 02/07/2026, revealed LPN3 documented that R3 had no skin issues. During an interview and concurrent review of the Skin Only Evaluations on 02/13/26 at 6:18 AM, LPN2 stated that R3 had a wound on their sacrum that was not intact. The LPN stated that the wound care nurse assessed and documented regarding the resident's wound; however, the wound care nurse's notes were not in the resident's medical record. LPN2 that she documented that the skin was intact because the rest of the resident's skin (excluding the sacral wound) was intact. An attempt to interview LPN3 by telephone was made on 02/13/26 at 10:39 AM; however, LPN3 did not answer the call or return the call by the end of the survey. During an interview on 02/12/26 at 7:03 PM, Registered Nurse (RN)1 stated that she reviewed wounds in the facility weekly and sent the information on a wound report via electronic mail (e-mail) to the Director of Nursing (DON), the MDS nurse, the Assistant Director of Nursing (ADON), the dietician, and the Administrator (ADM). RN1 stated there was not a wound report form in the facility's electronic medical records (EMR); subsequently, she completed summaries weekly. RN1 stated the floor nurses conducted a skin assessment weekly, and wounds could be notated on that form. RN1 stated if a floor nurse needed information regarding the history of the wound, they had to ask someone in management because the information was not in the resident's medical record. During an interview on 02/13/26 at 2:29 PM, the DON stated RN1 obtained wound measurements and assessed the appearance of wounds weekly and expected RN1 to document all wound care notes in the resident's EMR. The DON provided e-mails which revealed that wound assessments were completed weekly. The DON stated that she was not previously aware that RN1 was not charting in residents' EMRs. The DON stated she was also not aware the floor nurses were documenting that Resident #3's skin was intact when the resident had a wound. The DON stated she spoke with the floor nurses, and they were confused. The DON stated that for some reason the floor nurses thought they should only document whether there were any new skin issues. During an interview on 02/14/26 at 10:04 AM, the Administrator stated that he expected all wound care notes to be in the resident's medical record and to be completed correctly. The Administrator stated that the DON or their designee was responsible for monitoring wound care documentation. 2. An admission Record revealed the facility admitted R56 on 01/25/24. According to the admission Record, R56 had a medical history that included diagnoses of cerebral aneurysm, non-ruptured; dementia with other behavioral disturbance; anxiety disorders; muscle weakness; difficulty walking; other lack of coordination; and unspecified psychosis not due to a substance or known physiological condition. A significant change of condition MDS, with an ARD of 01/06/26, revealed that R56 had severe impairment in cognitive skills for daily decision making and had short-term and long-term memory problems per a staff assessment for mental status (SAMS). The MDS also revealed that R56 had impairments on one side of their upper extremities and both sides of the lower extremities and utilized a wheelchair for mobility. An activity Progress Note, dated 01/12/26 at 11:04 AM, revealed that R56 was alert to self and confused, had physical decline and weight loss, and spent most of the time in bed. A health status Progress Note, dated 01/17/26 at 6:17 PM, revealed that a certified nurse aide (CNA) alerted the nurse of heel breakdown and a pink area to R56's buttocks. There was no documented evidence that staff assessed the breakdown/areas. A skin only Progress Note, dated 01/20/26 at 12:36 PM, for R56 revealed that areas were noted to the resident's heels and treatment was in place. The note did not address the measurements or an assessment of the area to the heels and buttocks. An electronic mail (e-mail) with a subject line of Wounds, dated 01/22/26 at 10:28 AM, sent by Registered Nurse (RN)1 to the Director of Nursing (DON), Assistant Director of Nursing (ADON), Administrator, and other staff members, revealed RN1 assessed R56's heels and the resident had a left heel deep tissue injury (DTI), which measured 3 centimeters (cm) by (x) 2 cm and was purple/red. Per the email, there was a new treatment for skin prep and a foam dressing every three days and as needed. The email revealed the resident was also wearing Prevalon boots and the heels were being floated when in bed. An e-mail with a subject line of Wound Report, dated 01/27/26 at 6:01 PM, sent by RN1, to the DON, ADON, Administrator, and other staff members revealed the RN assessed R56's heels. The email revealed that the resident had a left heel DTI, which measured 3 cm x 2 cm and was purple/red. R56's Care Plan Report revealed a focus area initiated on 01/27/26, that indicated the resident had a pressure ulcer and was at risk for a non-healing/infection. Interventions directed staff monitor/document/report as needed any changes in skin status (appearance, color, wound healing, signs/symptoms of infection, wound size, and stage), and weekly treatment documentation to include measurements of each area of skin breakdown's width, length, depth, type of tissue, and exudate. A skin only Progress Note, dated 01/28/26, and 02/10/26 revealed that there were no current skin issues but indicated the treatment to the heels continued. An e-mail with a subject line of Wounds, dated 02/04/26 at 1:35 PM, sent by RN1 to the DON, ADON, Administrator, and other staff members revealed the RN assessed R56's left heel DTI, which measured 7 cm x 4 cm and was purple. Per the email, staff would continue treating the area with skin prep and a foam dressing. An e-mail with a subject line of Wounds 02/11/2026, dated 02/10/26 at 12:30 PM, sent by RN1 to the DON, ADON, Administrator, and other staff members revealed the DTI to R56's left heel continued to measure 7 cm x 4 cm and was purple. The email also revealed that the area continued to be treated with skin prep and a foam dressing. An Order Summary Report, with orders effective as of 02/13/26, revealed an order dated 02/04/26 to apply skin prep to the left heel and apply a Mepilex foam dressing (a comfortable foam dressing used to absorb wound draining and minimize pain) every three days and as needed until healed. During an observation on 02/13/26 at 3:10 PM, the ADON provided wound care to R56's left heel. During an interview on 02/14/26 at 9:57 AM, the ADON, who was also the Infection Preventionist (IP) stated that she tracked wounds from an infection control standpoint. The ADON stated that RN1 assessed all wounds and documented and sent them a weekly report. The ADON stated that she had never looked in the EMR to see whether wound measurements were documented. Per the ADON, she had seen the nurses' documentation and measurements in the EMR but never investigated to make sure RN1's assessments were documented. During an interview on 02/14/26 at 10:11 AM, the DON stated that the resident's medical record should include the type of wound, a description and measurements, and the current treatment. She stated that R56's wound documentation should be in the resident's medical record. The DON further stated if they needed any changes to treatment, and if the resident went out of the facility to the wound center, all that information should be documented in the progress notes in the EMR. She stated that she became aware while the survey team was onsite that wound assessments were not documented in residents' EMRs. Per the DON, they received a weekly wound report, and they reviewed the report weekly in their Safe and Soundmeeting; however, she did not go back and verify the information was documented in the EMR. The DON stated that RN1 was a certified wound nurse. According to the DON, the facility used a different EMR before converting to the current EMR in August 2024. The DON stated RN1's wound reports were detailed, and she thought the RN was documenting wound assessments in the EMR. During an interview on 02/14/26 at 10:58 AM, the Administrator stated he expected wound assessments and treatments to be documented in residents' medical records. He stated the facility had not identified that documentation of wound summaries was an issue or concern prior to the survey.

Based on review of the facility policy, record review, and interviews, the facility failed to ensure that Resident (R)1 was free from being administered another resident's medication, for 1 of 1 resident reviewed.Findings include:Review of the facility's policy titled Administration of Medications Plan dated 07/2025 revealed the following: 7b. The following Ten Rights of Medication Administration practice should be Right patient Right drug Right route Right time Right dose Right documentation Right action (appropriate reason) Right form Right response Right to refuseReview of R1's Face Sheet revealed admission to the facility on [DATE] with diagnoses including, but not limited to, aftercare following joint replacement surgery, presence of left artificial hip joint, cerebral infarction, and pulmonary hypertension. Review of R1's Quaterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/26/25 revealed R1 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating he was cognitively intact.Review of R1's Care Plan with a revision date of 08/16/25 revealed R1 is at risk of adverse effects of antianxiety medication. A goal indicated R1 will show a decrease in anxiety/agitation over the next 90 days and will not experience adverse effects from medication through the next review date. Further review of the care plan listed interventions directing staff to monitor for adverse effects of antianxiety medications: insomnia, irritability, dizziness, headache, confusion, drowsiness, light-headedness, sedation, difficulty speaking, hypotension, chest pain, increased or decreased appetite, and redirect from the source of anxiety/agitation as able.Review of R1's Medication Administration Record (MAR) revealed R1 is allergic to statins.Review of R1's Progress Note dated 06/17/25 revealed R1's nighttime medication was administered by Licensed Practical Nurse (LPN)1. At 20:45 it was discovered that R1 received donepezil 10 mg, buspirone 10 mg, namenda 10 mg, and lipitor 40 mg by mouth. Upon review of signing the medications out, LPN1 realized the medications were administered to the wrong patient. During an interview on 09/02/25 at 12:27 PM, R1's Resident Representative (RP) stated, They called me as soon as it happened. The medication must not have been very strong, because she was fine. She told me she was fine.During an interview on 09/02/25 at 12:45 PM, Registered Nurse (RN)1 stated, [LPN1] informed me she made a medication error. I asked her who and which medication. I then went to assess the resident. I took a set of vital signs (VS). I had [LPN1] monitor the resident and call the on-call physician to let them know. The resident is allergic to Lipitor. I called the pharmacy to see the type of reaction that would occur if she received the medication. I looked in the system to see what the reactions were. The systems showed if there was any adverse reaction, [R1] would experience muscle pains. I called the Director of Nursing (DON) and RP. [R1's] VS were stable, and he was not experiencing any shortness of breath. The DON came into the facility. I watched the DON conduct a medication pass, a medication administration quiz, and review patient rights education. I made frequent rounds on [R1]. [LPN1] was shaken up by the incident.During an interview on 09/02/25 at 1:33 PM, R1 stated, I remember taking the wrong medications. I haven't had any problems with those pills.During an interview on 09/02/25 at 1:43 PM, Nurse Practitioner (NP) stated, I do remember that, and I remember telling them to call the pharmacy. I am a palliative nurse practitioner. So, when someone calls us we rely on what they say. I instructed them to call the practitioner.During an interview on 09/02/25 at 1:50 PM, the Pharmacist stated, We run 24 hours. No one mentioned this incident to me as the pharmacist director until today. This incident was probably called into our main office. All of the pharmacists who were working at that time and shift are no longer with us.During an interview on 09/02/25 at 3:15 PM, LPN1 stated, It was a total mix-up. I looked at Point Click Care (electronic medical record system) and told myself I was going to look at [R1]. I pulled the medications and popped them out of the container. When I went in the room, we started talking. I usually give the other resident her medications first, but I didn't. I ended up giving [R2's] medication to [R1]. When I went back to PCC, I realized I didn't. I reported the incident. I contacted my supervisor. We went through her allergies. She has a statin allergy. We immediately called the NP. The allergy she had to statins was muscle cramps. I monitored her all night. It was a big mix-up. We did education. We went over the six rights of education. The nurse supervisor watched me pull medications to make sure I was pulling medications correctly.During an interview on 09/02/25 at 2:03 PM, the DON stated, They called me when it happened. The supervisor called me and reported that the resident received the wrong medication. They had already called the provider and the pharmacist and were instructed on what to do and the signs and symptoms to look for. I conducted one-on-one education with [LPN1]. During an interview on 09/02/25 at 2:09 PM, the Administrator stated, We knew it was a medication error. We looked to see if it would have any side effects, and we did one-to-one education with that nurse. The night shift supervisor is good about going around and monitoring the nurses.

Based on observations, interviews, and facility policy review, the facility failed to ensure foods that were stored in the freezer, refrigerators, and dry food storage were appropriately sealed, labeled, dated with a use by date, and/or discarded after the manufacturer's expiration date.This deficient practice had the potential to affect all residents who received food items from the kitchen. Findings include: Review of the facility's policy dated ,d+[DATE] and titled, Food and Supply Storage, revealed associates shall ensure that food safety and sanitation guidelines are maintained during storage of food and supply items. Procedure: 1. Dry Food Storage items shall be stored by associates using the following guidelines: e. Discard food and supplies items for which the expiration date has expired. 2. Refrigerated items shall be stored by associates using the following guidelines: l .Label and date container with name and product and expiration date. 3. Freezer items shall be stored by associates using the following guidelines: b. Store buld materials in National Sanitation Foundation approved containers that hae tight fitting lids. Label with product name and expiration date. During an initial tour of the kitchen on [DATE] at 09:30 AM revealed Dry Food storage 18 - 2 ,d+[DATE] ounce (oz) boxes Barnum's Animal Crackers with manufacturer's use by date of [DATE] Walk in Freezer 2 - 32 oz containers Blueberries open/not sealed and not dated with an open date or an expiration date Walk in Cooler 1 - 5 pound (lb) bag parmesan cheese open and not dated with an open date or an expiration date 1 - 32 oz carton Thick & Easy open with no open date During an interview on [DATE] at 4:23 PM, the Dietary Manager (DM) revealed that staff complete deep investigations of the food items on Mondays and Thursdays, when orders come in to make sure that expired items are removed.

Based on observations, interviews and facility policy, the facility failed to ensure medications and biologicals were kept sterile and not expired in 2 out of 2 Medication and Treatment carts. The findings include: Review of the facility policy titled, Storage of Medication revealed that medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. 14. Outdated, contaminated, discontinued 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 disposal (Refer to Section 5- disposal of Medications, Syringes and needles), and reordered from the pharmacy (Refer to Section 3.2 - Ordering and Receiving Non-Controlled medications), if a current order exists. An observation on 10/16/24 at 09:43 AM (Unit 1 Treatment Cart) revealed 2 HydroferBlue Hydrofera Blue Ready-Transfer Antibacterial Foam Dressing Ref #HBRT2525 Lot#001505-1. Expired as of 05/01/24. An observation on 10/16/24 at 09:43 AM (Unit 1 Treatment Cart) revealed HydroferBlue Hydrofera Blue Ready-Transfer Antibacterial Foam Dressing Lot#001506-2. Expired as of 07/01/24. An observation on 10/16/24 at 09:43 AM (Unit 1 Treatment Cart) revealed Xeroform Occlusive Gauze Patch 4 x 4 (10.2cm x 10.2cm), Ref#8884433500, expires 2025 Lot#4011304 cut into and partially open x 2. An observation on 10/16/24 at 09:43 AM (Unit 1 Treatment Cart) revealed Kerlix Bandage Roll 4-1/2 x 4-1/8 yd (11.4cm x 3.7m) Ref#6715 Lot # 24E059462 Expired 2029 04 30 Manufacturer COVIDIEN, item open. An observation on 10/16/24 at 09:43 AM (Unit 1 Treatment Cart) revealed 10-Sage M-Care Meatal Cleansing cloths Fragrance free 2 wash cloths 5.5 in x 8 in Manufacturer [NAME] Lot# 92639. Expired as of 10/15/24. During an interview on 10/16/24 at 09:57 AM, the Director of Nursing (DON) stated, The nurses are responsible for checking for expired items every shift. During an interview on 10/16/24 at 10:09 AM, Registered Nurse (RN)3 stated, We do not have a set schedule, but we usually go through. When we have time, we review it and organize and remove items at that time. She stated, We do the dressing changes. The wound care nurse does the dressing changes. An observation on 10/16/24 at 03:45 PM (Unit 2 Treatment Cart) revealed 2- Triamcinolone 0.1% in Eucerin 1:1 cream CMP Lot # 240815-003. Expired as of 09/14/24. An observation on 10/16/24 at 03:45 PM (Unit 2 Treatment Cart) revealed opened Algiste M (10x10) 4in x 4 in manufacturer [NAME] & Nephew Lot (10)2049 Ref 59480200. During an interview on 10/16/24 at 03:47 PM, Licensed Practical Nurse (LPN)1 stated treatment carts are checked twice a week by the Lead Nurse or Supervisor on Monday & Friday. An observation on 10/17/24 at 09:36 AM (Unit 2 Medication Storage Room) revealed Airborne Lot =AEC 491, Expired 09/24 Tablet chewable House Supply x 4. During an interview on 10/17/24 at 09:36 AM, RN2 stated, We review the medications once we get something in and going over inventory. Everyone in general should check for expiration dates no specific day is this completed. An observation on 10/17/24 at 10:22 AM (Unit 1 Medication Storage Room) revealed Airborne Lot # ADY983 Expired 09/24 Tablet chewable House Supply x 3. During an interview on 10/17/24 at 09:38 AM, RN3 stated, I took all of the expired medications out earlier. There is no one assigned to go through the cabinets. During an interview on 10/17/24 at 10:47 AM, the DON stated, The Cream stays in the medication storage room until pharmacy comes and pick up expired medications. To fix that I ordered bins to eliminate any confusion of it sitting on the counter. Narcotics come to the DON and get locked in a lock box behind my desk. For off duty hours when I am not here the narcotics are kept in the medication cart and given to me when I am here to keep it locked up to go to pharmacy. Pharmacy sometimes comes twice a day to pick up. It depends on our needs. During an interview on 10/17/24 at 10:52 AM, DON stated, The nurse on the unit check for expirations when they need to restock. The Supervisor and Unit managers check for expirations on Mondays and Fridays every week. We will reeducate on how the treatment cart should be. We will do the same with the medication rooms.'

Based on review of the facility policy, observation, and interview, the facility failed to follow infection control practices to sanitize multi use medical equipment, and failed to perform hand hygeine during medication observation. Findings include: Review of the facility policy dated 05/2025 and titled, Hand Hygeine stated under the policy,Hand hygeine is performed after removing gloves and or other personal protective equipment. During a medication observation on 10/16/2024 at 08:18 AM, Registered Nurse (RN)3 openned the medication cart to obtain a pulse oximeter. She brought it into the room and used it to check the oxygen concentration of a resident's finger. After she completed giving the medication and performing hand hygeine, she then placed the pulse oximeter on the medication cart, then picked it up and placed it into the medication cart. On 10/16/2024 at 8:30 AM, an interview with RN3 revealed, I should have cleaned the pulse oximeter. We are taught to clean medical equipment when used for all residents. During a medication observation on 10/16/2024 at 8:36 AM with Licensed Practical Nurse (LPN)2, she was observed to apply gloves to pull all of her medications. After all of the medications were retreived from the medication cart, she removed the gloves before entering the room to give the medication. She did not sanitize or wash her hands after she removed the gloves. On 10/16/2024 at 8:45 AM, an interview with LPN2 revealed, I wore gloves because I was taught not to touch the pills. She confirmed she should have sanitized after removing her gloves. An interview with the Director of Nurses (DON) on 10/17/2024 at 4:38 PM. She stated, With medication passes, nurses are to sanitize hands between each resident. After glove removal, perform hand hygiene. The pulse oximeter must be cleaned first before placing back into a med cart after a nurse uses it on a patient.

Based on review of the facility policy, observation, record review, and interviews, the facility failed to ensure the medication error rate was less than 5%. The medication error rate was 28%. Findings include: Review of the facility policy dated 02/2004 and titled, Administration of Medications revealed under the policy, The following Ten Rights of Medication Administration Practice should be confirmed prior to administration: Right time. On 10/16/24 at 12:22 PM, an observation of Licensed Practical Nurse (LPN)2 during medication administration revealed the following; LPN1 drew the following medications for Resident (R)80; Vitamin B 12, 2 tablets of stock medication Vitamin B Complex 1 tablet of stock medication Levofloxin 500 milligram (mg)- 1 tablet Gabapentin 800 mg- 1 tablet Azithromycin 500 mg- 1 tablet Sertraline 50 mg- 1 tablet Ethambutol 400 mg- 2 tablets and Biktarvy 50/200/25 1 tablet po QAM 1 tab An interview with LPN2 on 10/16/24 at 12:23 PM revealed, These are his morning medications. He wasn't feeling well earlier and asked if I could come back later. Record review of R80's medication orders revealed Vitamin B12 was ordered at 0800, Levofloxin 500 mg was ordered for 0800, Gabapentin was ordered every 8 hours, and was to be given at 0900, Azithromycin 500 mg was ordered at 0800, Sertraline 50 mg was ordered at 0800, Ethambutol 400 mg was ordered at 0800 and Biktarvy 50/200/25 was ordered at 0800. An interview with LPN2 on 10/16/24 at 4:20 PM revealed, I spoke to the supervisor, I told her what was going on. She didn't advise me to get an order from the doctor or anything. An interview on 10/16/24 at 4:29 PM with Registered Nurse (RN)4 revealed The protocol is to call the doctor and explain what was going on. Ask if we can give the medication at a later time. I can't recall a nurse telling me this AM that a resident did not take their meds. I did not call the Nurse Practitioner (NP). An interview with the Director of Nurses (DON) on 10/17/24 at 2:21 PM revealed, If the resident wasn't feeling well that day, we could put it down as refused, medication not given. If it became routine, the nurse practioner or Physician would be called to get an order. The nurse would have called the provider prior to giving the medication, to request to give at a later time. The DON observed R80's Medication Administration Record (MAR). She said, The Gabapentin was signed as given at 2:00 PM, as well. It is not ok to give the Gabapentin as a nursing judgement that close to when the resident just received the other. On 10/18/24 at 10:00 AM, the DON stated, I printed the actual time stamp of the medication given yesterday. The Medication Admin Audit Report revealed the actual times the nurse administered the medication to R80 on 10/16/24. The DON verified all those medications were given late and there was not an order to give them at that time.

Based on review of the facility policy, observation, record review, and interview, the facility failed to ensure hand hygiene was followed during an observation of wound care for Resident (R)49, for 1 of 1 resident reviewed for pressure ulcers. Findings include: Review of the facility policy dated 11/03/2023 and titled, Hand Hygeine recorded under the policy, According to the World Health Organization, hand hygeine is performed at minimum, at the followng times. Before a clean procedure, after exposure to body fluids, after touching the residents surroundings including equipment and devices. Record review of R49's medical record revealed he was admitted to the facility on [DATE] with diagnoses that included but not limited to stenosis of carotid artery, diabetes mellitus with neuropathy, hypothyroid, hypertension, and pressure ulcer to the right heel. On 10/18/24 at 10:43 AM, an observation of a dressing change for R49 revealed the following: R49 consented to the observation. Registered Nurse (RN)2 prepared the overbed table and placed a barrier down before placing the supplies for the dressing change. Observed on the overbed table were normal saline, gauze, skin prep and 2 dressings pre dated and initialed. RN2 had the treatment order printed. RN2 donned a gown and washed her hands and donned gloves. She then closed the blinds. She removed R49's bunny boots to his bilateral feet. R49 was lying in bed. RN2 removed the sock and dressing from R49's left foot, dated 10/16/24. Using the same gloves, she cleaned the wound with normal saline. She then removed her gloves, sanitized her hands, and applied skin prep around the outer wound. Afterward, she applied the dressing and gathered all supplies and discarded them in the trash. On 10/18/24 at 10:52 AM, an interview with the RN2 revealed, When touching the dirty, I should have removed the gloves. I was kind of nervous. On 10/18/24 at 4:38 PM, an interview with the Director of Nurses (DON) revealed, For a dressing change, after removing the soiled dressing, glove removal, then hand hygeine. On 10/18/24 at 11:07 AM, an interview with the Infection Prevention Nurse revealed, For a dressing change, gather supplies, provide a clean field, sanitize hands until dry. Then don gloves, remove old dressing, then remove gloves, re-sanitize and apply new gloves.

Based on review of facility policy, record review, and interviews, the facility failed to properly supervise Resident (R)1, resulting in R1's successful elopement from the facility. Specifically, on 05/24/24 at approximately 9:00 PM, R1 crawled through the window in his room to elope from the facility. R1 was found by local law enforcement on a highway and sent to the local hospital. R1 suffered a skin tear to the right forearm, while crawling out of the window. On 05/29/24 at 1:07 PM, the Administrator and the Director of Nursing (DON) were notified that the failure to properly supervise a resident, resulting in a successful elopement from the facility, constituted Immediate Jeopardy (IJ) at F689. On 05/29/24 at 1:07 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 05/24/24. The IJ was related to 42 CFR 483.25 - Quality of Care. On 05/29/24 at approximately 2:30 PM, the facility provided an acceptable IJ Removal Plan. The survey team validated the facility's corrective actions and determined the facility put forth good faith attempts to address the non-compliance. The survey team considers the IJ at Past Non-Compliance as of 05/28/24. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care. Findings include: Review of the facility policy titled Resident Check/Elopement Policy with an effective date of 10/23, revealed, Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. A resident who leaves a safe area may be at risk of (or has the potential to experience) heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle . Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE], with diagnoses including but not limited to: acute respiratory failure with hypoxia, dementia, lack of coordination, bipolar disorder, anxiety disorder, major depressive disorder, Type 2 diabetes, and dizziness and giddiness. Review of R1's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/22/24, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating R1 was cognitively intact. Further review of the MDS revealed R1 wandering behaviors were not exhibited. Review of R1's Elopement Risk Took dated 02/29/24, revealed diagnoses that may increase the risk of elopement: depression, bipolar disorder with mania, and Dementia. Further review revealed, Resident has been found to be at risk for elopement . Review of R1's Progress Note dated 05/25/24 at 3:31 AM, revealed, Note entry for 1230 AM, Law enforcement from [local police dept.] arrived at front door of facility. The officer stated, We found [R1] on Hwy 101. Do you know him? This writer answered, Yes and asked if he was injured. Officer stated, He is ok, no injury. We have ems taking him to the hospital. Review of R1's Progress Note dated 05/25/24 at 5:22 AM, revealed, Late entry for 415 am. [R1] had returned from ER with son . Body audit completed . Skin assessed with findings of a discoloration to right outer aspect of forearm. It is irregular in shape, approx. 4 cm long. Per [R1], he hit it on the window sill. He is not c/o in that arm. The bottom of his feet are reddened, friction r/t wearing croc slip on shoes with no socks. Review of R1's Care Plan revealed no Care Plan, related to wandering/elopement, was in place prior to the elopement. Review of the facility's undated Resident Check/Elopement Policy revealed R1 was last seen at 9:30 PM, going to his room with a cup of ice. Immediate eyes on head count of all residents completed by staff. Facility parking lot and grounds search completed. R1 was not located during eyes on count. Elopement determined date documented 05/25/24 at 12:45 AM. Review of a Witness Statement dated 05/25/24, written by Nurse Supervisor revealed, Last saw [R1] going to his room at 915 PM after asking for water. I continued to chart at the desk on unit one. No activity was noted coming from room [ROOM NUMBER]P. No alarms for doors or beds were sounding. Review of a Witness Statement dated 05/25/24, written by an unidentified Nurse revealed, At about 1245 am I was sitting at the nurses station and saw blue lights piercing through the front double doors. A police officer was outside and notified us of resident found out there on the highway. As I entered the resident's room, noted his window was wide open and the gate outside was also open. Review of a Witness Statement dated 05/25/24, written by Certified Nursing Assistant (CNA)2 revealed, I witnessed the police at the door, the doorbell rung and I was headed to answer but the nurse beat me. As I was walking the police asked if we had a [R1] and we went to his room and he was gone and the window was open. Review of a Witness Statement dated 05/25/24, written by CNA1 revealed, I was assigned to [R1] I gave [R1] his meds and treatment at 804 PM. [R1] was calm and standing at nursing station when I left him and continued med pass. [R1] was last seen by nurse when he asked aide for water around 9:15 PM. Review of Google Maps revealed, the entrance to Highway 101 is approximately 3 miles from the facility, however the exact location that R1 was found on Highway 101 was undetermined. Review of the Weather Channel revealed on 05/24/24, the high was 88 degrees Fahrenheit and the low was 65 degrees Fahrenheit. And on 05/25/24, the high was 83 degrees Fahrenheit and the low was 61 degrees Fahrenheit. During an interview on 05/29/24 at 10:51 AM, R1 revealed, I went out the window in my room. The window slides open, and I got it to work. I hurt my arm; I got a little scratch on my arm crawling out the window. I walked from [NAME] down to McDonalds and got on Highway 101, there was a lot of traffic. I was trying to get home to [NAME] [[NAME], South Carolina]. A deputy sheriff stopped me and questioned me, and they took me to the [local hospital]. I left because I don't like this place. I feel like a puppy dog trapped in a cage. I've told several nurses. I walked for about 3 hours. It was about 9:00 PM when I left and the sheriff stopped me around 12:00 AM. I still feel like I want to leave, I want to be home. I was wearing a dark blue t-shirt, khaki shorts, and crocs with no socks. During an interview on 05/29/24 at 10:59 AM, Registered Nurse (RN)1 revealed that R1 does say that he wants to go home and be with his wife, but R1 seems happy and content. RN1 stated, I didn't take him (R1) seriously when he made those comments. During an interview on 05/29/24 at 11:02 AM, Licensed Practical Nurse (LPN)1 revealed that R1 likes it here, but he wants to be home. He always tells us that he is capable of being home. LPN1 further stated, I never thought he would try and do something like that. During an interview on 05/29/24 at 11:06 AM, Social Services (SS) revealed that after the elopement, R1 stated he was planning to do this. He wanted to go home with his wife and didn't understand why he was here. SS further stated, I never thought he would do that. During an interview on 05/29/24 at 11:37 AM, the Administrator and DON revealed R1 was found about 3 miles away. The DON stated, R1 had a small discoloration on his arm and R1 told her that his feet were hurting, but felt fine after about an hour. The DON revealed nurses are supposed to generally do rounds every 2-4 hours, depending on the need of the resident. The Administrator stated, [R1] is independent and he isn't one that they would have to check on very frequently. The DON stated R1 left the facility about 9:30 PM and the police notified the facility about 12:30 AM, that they found R1 on Highway 101. The Administrator stated that R1 did say that he would like to spend time with his family and go home every once in a while. During an interview on 05/29/24 at 11:45 AM, the Nursing Supervisor (NS) revealed, I was doing some charting on Unit 1, the Certified Nursing Assistants (CNA)s were putting residents to bed and nurses were passing meds. [R1] did not appear to be nervous or exit seeking or upset. Around 9:30 PM the resident asked for a glass of ice and the CNA got it for him. I was still charting and [R1] went to his room. Around 12:30 AM we hear the door bell ring. The staff answered the door and told me the police were here. The police officer asked if I know a [R1] and I said yes. I thought the resident called 911. The officer stated no and that we found him on Highway 101. The officer said they were taking him to the hospital. I asked the staff to check the residents and check his room. they came back to me and told me the window and gate were open. [R1] wasn't the happiest to be here. I didn't think he would try to elope. On 05/29/24 at approximately 2:30 PM, the facility provided a removal plan, which included the following: Resident sent to ER for evaluation when located. Resident assessed with no major injury. Resident returned safely to facility. Post-elopement procedures initiated on 05/25/24 and family at bedside. Resident window secured to prevent exit. Resident relocated to interior, courtyard-view room for safety. Resident care plan has been reviewed and revised as needed. Resident evaluated by in-house provider and Lifesource Psychiatry on 05/28/24 for follow up. All residents are at risk. Resident check completed for all residents at 12:45 am 5/25/24. All resident windows were assessed and secured to prevent exit by 10:30 am 5/25/24. This includes all resident room windows and common area windows. All resident and common area windows were assessed and secured to prevent resident exit on 5/25/24. Added a motion detector alarm to the exterior gate. Staff educated on motion detector alarm initiated on 5/29/24 by Administrator, DON, or designee. Staff education on Wander/Elopement risk; Precautions and missing resident powerpoint and Resident check/Elopement policy 100.149 initiated on 5/28/24 by SNF Educator or designee. Audits for window security were initiated on 5/25/24 and will continue daily for 4 weeks, then weekly by 4 weeks, then 3 times per week for 4 weeks. Continue elopement drills daily for 4 weeks, then weekly by 4 weeks, then 3 times per week for 4 weeks. Correction action will be completed 5/28/24.

Based on observations, interviews, record reviews and facility policy review, the facility failed to ensure that 1 of 3 sampled residents, Resident (R)1, was free from significant medication error. Specifically, the nurse administered medications to R1 that were ordered for R1's roommate, resulting in R1 being transported to the emergency room (ER) via Emergency Medical System (EMS). Findings include: On [DATE] at 9:52 AM, the Administrator was notified that the failure to administer the correct medications to a resident, based on physician orders, constituted Immediate Jeopardy (IJ) at F760. On [DATE] at 9:52 AM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of [DATE]. The IJ was related to 42 CFR 483.45 Pharmacy Services. On [DATE] at 3:15 PM, the facility provided an acceptable IJ Removal Plan. The survey team validated the facility's corrective actions and determined the IJ at F760 is considered at Past Non-Compliance. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F760, constituting substandard quality of care. Review of a policy titled The 10 Rights of Drug Administration updated [DATE], revealed understanding the 10 rights of Drug Administration helps prevent medication errors. Nurses at all times are responsible for ensuring safe and quality patient care. The policy indicates medication error rate is 60% in the form of wrong time, rate, or dose. However, some medication errors cause permanent disability and for others the errors are fatal. Nevertheless, the policy revealed following the 10 rights of drug administration will ensure safe patient care. The 10 rights to drug administration are: 1. Right Drug 2. Right Patient 3. Right Dose 4. Right Time and Frequency 5. Right Documentation 6. Right History and Assessment 8. Drug approach and Right to Refuse 9. Right Drug-Drug Interaction and Evaluation 10. Right Education and Information. Step #2 Right Patient reiterate ask the name of the resident and check his/her ID band before giving the medication. The policy notes: .if you know that resident you should still ask their name in order to verify. Review of R1's clinical record revealed an admitted [DATE] and re-admitted [DATE], with diagnoses including, but not limited to: Cellulitis of Left Lower Limb, Alzheimer's disease, Dementia, Type 2 Diabetes, and Chronic Kidney Disease. The facility had assessed the resident's code status as a Full Code. Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 6 out of 15, indicating R1 has severe cognitive impairment. Further review of the MDS revealed the facility assessed the resident to have no concerns with mood or behaviors. Review of R1's Physician Order dated ,d+[DATE] revealed schedule medications as follows: Vitamin D3 1250 microgram (mcg) one (1) tablet twice a month, Aspirin Enteric-Coated (EC) 81 milligram (mg) one (1) tablet daily, Namenda 10 mg (use to treat moderate to severe dementia of Alzheimer's) one (1) tablet twice a day, Keppra 500 mg (use to control epilepsy) one (1) tablet every 12 hours, Doxycycline Hyclate 100mg (use to treat bacterial infections) take one (1) capsule every 12 hours. Review of Licensed Practical Nurse (LPN)1's Personnel file revealed the facility employed LPN1 on [DATE]. LPN1 was provided orientation competency on [DATE] to include Medication Administration. Review of R1's Medication Error Report, dated [DATE], revealed the medication error occurred at 9:15 AM, when the resident received her/his roommate's medications. The report indicated that R1 received Lisinopril/Hydrochlorothiazide combination (used to treat high blood pressure), Amlodipine 10 mg (used to treat high blood pressure), Tylenol, Vitamin D3 5000 U and Ferrous Sulfate 325mg. The report revealed the resident became hypotensive (low blood pressure) and was transferred to the ER via Emergency Medical System (EMS). The facility suspended LPN1 pending investigation. She/he implemented medication pass audits. The facility assessed the medication error to be caused from failure to identify the resident. A phone interview was attempted on [DATE] at 9:30 AM, with LPN1, who acknowledged herself but declined to discuss any information and directed the surveyor to contact her attorney. During an interview on [DATE] at 10:40 AM, Certified Nursing Assistant (CNA)1 revealed caring for R1 consistently. CNA1 voiced that the resident was confused without any behaviors. CNA1 recalled working the day of the medication error. CNA1 verbalized, that at the start of morning shift (before breakfast) vital signs are obtained on residents. (Reviewed R1's V/S on [DATE] were 97.9, 02 saturation 93%, heart rate 72 and respirations 17, and blood pressure (b/p) ,d+[DATE]). CNA1 continued and recalled retrieving breakfast trays, and upon entering R1's room she noticed the resident was pale and did not respond to verbal stimuli. CNA1 went to the hall, requested and informed LPN1 something was wrong with R1. CNA1, at the same time, requested another CNA to assist with obtaining a set of vital signs. The vital signs were unobtainable, and LPN1 had not entered the resident's room to assist. CNA1 called for another nurse (LPN5) on unit 100 to assess R1. LPN5 immediately arrived to R1's room. During an interview on [DATE] at 11:00 AM, LPN5 revealed working in the facility for [AGE] years but as an LPN for the past year. LPN5 recalled on the morning of [DATE], he/she was requested to assess R1. Upon assessing R1 LPN5 informed R1's nurse (LPN1) that the crash cart (used to hold emergency medications and equipment) was needed. LPN5 informed the resident's nurse (LPN1) that the resident was not responding, and assistance was needed. LPN1 did not provide assistance. A sternal rub was implemented, and the resident responded slightly. By this time, the Director of Nursing (DON) had arrived to assist. LPN5 stated he/she was unsure who notified EMS. During an interview on [DATE] at 12:10 PM, the DON revealed, that upon arriving to R1's room, LPN1 was in the hallway by the medication cart. The DON requested LPN1 to provide copies of R1's medication administration record for EMS. At that time, LPN1 revealed that R1 received the roommate's morning medications. The DON immediately removed LPN1 from the floor. The resident was transferred to the emergency room . During the investigation, the DON revealed that LPN1 had prefilled his/her residents' medications. While the investigation was being conducted LPN1 resigned. The DON concluded that R1 expired. During an interview with the Administrator and DON on [DATE] at 12:00 PM, revealed they are both the Abuse Coordinator and were aware of the medication error. The Administrator stated immediate corrective action was taken and medication administration continues to be a part of Quality Assurance (QA). On [DATE] at 3:15 PM, the facility presented an IJ Removal Plan which included the following: The identified resident was sent to the ER for evaluation. The incident was reported to the state on [DATE]. All residents in the facility were identified as having the potential to be affected by the deficient practice. Involved nurse was placed on immediate administrative leave on [DATE] pending investigation. Education entitled Med Pass education was initiated by MSN, RN, Director of Nursing, which included policy 100.104 entitled Administration of Medication as well as 10 rights of medication administration on [DATE] and [DATE]. Immediate initiation of Medication pass observations on all nurses present in the building with ongoing observations as each nurse reported for shift until 100% was complete. 100% initial observations were completed on [DATE]. [NAME] Manor continues 3 medication observations per week by MSN, RN or designee since [DATE] with 100% compliance. Stand up education regarding resident identification utilizing wristbands initiated on [DATE] by MSN, RN, Education Coordinator or designee using policy 200.130 entitled Resident identification. Stand up education regarding medication administration and Abuse and Neglect was initiated by MSN, RN, Educator or designee on [DATE]. On [DATE] Social Worker, interviewed decisional residents regarding agreement to wear wristband. All decisional residents agreed on [DATE]. On [DATE], a wristband was placed on all residents currently admitted to the facility. [NAME] Manor continues 3 medication observations per week since [DATE] performed by MSN, RN, or designee with 100% compliance. These audits continue and are ongoing as of [DATE]. Audits for resident identification utilizing wristbands initiated on [DATE] to be included with med pass observations audit. These audits will continue 3 times per week for 4 weeks, then 3 times per week for 2 additional months. Education was complete on [DATE] and [DATE] for Medication administration. Stand up education regarding resident identification utilizing wristbands and medication administration/Abuse and Neglect was initiated on [DATE] with all RN and LPN associates present and any associates who will report for duty with 100% compliance. No associate will report for duty until education has been complete. On [DATE] Social Worker, interviewed decisional residents regarding agreement to wear wristband. All decisional residents agreed on [DATE]. On [DATE], a wristband was placed on all residents currently admitted to the facility.

Based on observations, interviews, record review, and facility policy review, the facility failed ensure residents remained free of neglect, for 1 of 3 residents. Specifically, a nurse administered medications to Resident (R)1 that belonged to another resident, resulting in R1 being sent to the emergency room (ER) via Emergency Medical System (EMS). On [DATE] at 9:52 AM, the Administrator was notified that the failure to administer the correct medications to a resident, based on physician orders, constituted Immediate Jeopardy (IJ) at F600. On [DATE] at 9:52 AM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of [DATE]. The IJ was related to 42 CFR 483.12 Freedom from Abuse, Neglect. On [DATE] at 3:15 PM, the facility provided an acceptable IJ Removal Plan. The survey team validated the facility's corrective actions and determined the IJ at F600 is considered at Past Non-Compliance. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F600, constituting substandard quality of care. Findings include: Review of the facility's policy titled Adult and Elder Abuse, Mistreatment and Neglect policy #200.119, effective date ,d+[DATE] revealed, Residents are to be free from mental, physical, sexual, and verbal abuse, neglect, corporal punishment, and involuntary seclusion. The policy defines neglect as the failure of the facility, its employees or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or medical care. The policy also defines abandonment as the desertion of an older adult by his or her designated caregiver. Review of R1's Physician Order, dated ,d+[DATE], revealed scheduled medications as: Vitamin D3 1250 microgram (mcg) one (1) tablet twice a month, Aspirin Enteric-Coated (EC) 81 milligram (mg) one (1) tablet daily, Namenda 10 mg (used to treat moderate to severe dementia of Alzheimer's) one (1) tablet twice a day, Keppra 500 mg (used to control epilepsy) one (1) tablet every 12 hours, Doxycycline Hyclate 100mg (used to treat bacterial infections) take one (1) capsule every 12 hours. Review of Licensed Practical Nurse (LPN)1's Personnel file revealed the facility employed LPN1 on [DATE]. LPN1 was provided orientation competency on [DATE] which included but was not limited to Medication Administration. Review of LPN1's time sheet for the week of [DATE] - [DATE], revealed LPN1 clocked out of the facility on [DATE] (date of medication error) at 11:07 AM and did not return. Review of R1's Medication Error Report, dated [DATE], revealed the medication error occurred at 9:15 AM, when the resident received her/his roommate's medications. The report indicated that R1 received Lisinopril/Hydrochlorothiazide combination (used to treat high blood pressure), Amlodipine 10 mg (used to treat high blood pressure), Tylenol, Vitamin D3 5000 U and Ferrous Sulfate 325 mg (milligrams). The report revealed that R1 became hypotensive (low blood pressure) and was transferred to the emergency room (ER) via Emergency Medical System (EMS). The facility assessed the medication error to be caused from failure to identify resident. A phone interview was conducted on [DATE] at 9:30 AM, with LPN1 who acknowledged herself and informed the surveyor to contact her attorney. During an interview on [DATE] at 10:40 AM, Certified Nursing Assistant (CNA)1 revealed caring for R1 consistently. CNA1 voiced that the resident was confused without any behaviors. CNA1 recalled working the day of the medication error. CNA1 stated that at the start of morning shift (before breakfast) vital signs are obtained on residents. (Reviewed R1's V/S on [DATE] were 97.9, 02 saturation 93%, heart rate 72 and respirations 17, and blood pressure (b/p) ,d+[DATE]). CNA1 continued to recall retrieving breakfast trays and upon entering R1's room the CNA noticed the resident was pale and did not respond to verbal stimuli. The CNA went to the hall, requested, and informed LPN1 that something was wrong with R1. CNA1 recalled, also at the same time requesting another CNA to assist with obtaining a set of vital signs. However, the vitals were unobtainable. During this time LPN1 had not yielded any assistance to the resident. CNA1 called for another nurse (LPN5) on Unit 100 to assess R1. LPN5 immediately arrived at R1's room. CNA1 defined neglect as not providing needed care to a resident such as not providing incontinent care. During an interview on [DATE] at 11:00 AM, LPN5 revealed working in the facility for [AGE] years but as an LPN for the past year. LPN5 recalled on the morning of [DATE], she was requested to assess R1. Upon LPN5's assessment of R1, it was revealed that the resident needed immediate assistance and informed the resident's nurse (LPN1) that the resident was not responding. LPN 1 did not provide assistance. Sternal rub was implemented, and the resident responded slightly. By this time, the Director of Nursing (DON) had arrived to assist. LPN5 revealed being trained on abuse and neglect yearly. She provided an example of neglect as leaving a resident who needs assistance. During an interview on [DATE] at 12:10 PM, the DON revealed upon arriving to R1's room, LPN1 was in the hallway by a medication cart. The DON requested LPN1 to provide copies of R1's medication administration record for EMS. At that time, LPN1 revealed that R1 received the roommate's morning medications. The DON immediately removed LPN1 from the floor. The DON stated from the initial investigation findings, LPN1 had prefilled her/his medications. While the investigation was being conducted, LPN1 resigned. The DON revealed that R1 expired on [DATE]. During an interview with the Administrator and DON on [DATE] at 12:00 PM. revealed they both are the Abuse Coordinator, and they were aware of the medication error. The Administrator stated immediate corrective action was taken and medication administration continues to be a part of Quality Assurance (QA). On [DATE] at 3:15 PM, the facility presented an IJ Removal Plan which included the following: The identified resident was sent to the ER for evaluation. The incident was reported to the state on [DATE]. All residents in the facility were identified as having the potential to be affected by the deficient practice. Involved nurse was placed on immediate administrative leave pending investigation on [DATE]. A DHEC reportable and related investigation was completed and submitted. Education entitled Med Pass education was initiated by MSN, RN, Director of Nursing, which included policy 100.104 entitled Administration of Medication as well as 10 rights of medication administration on [DATE] and [DATE]. Immediate initiation of Medication pass observations on all nurses present in the building with ongoing observations as each nurse reported for shift until 100% was complete. 100% initial observations were completed on [DATE]. [NAME] Manor continues 3 medication observations per week by MSN, RN, or designee since [DATE] with 100% compliance. Education entitled Change in resident condition, Abuse and Neglect, Resident's Right was initiated on [DATE], [DATE], [DATE], [DATE], and [DATE]. Stand up education regarding resident identification utilizing wristbands was initiated on [DATE] by MSN, RN, Education Coordinator, or designee using policy 200.130 entitled resident identification. Stand up education was initiated [DATE] for abuse and neglect all staff all shifts by MSN, RN, Educator or designee. [NAME] Manor continues 3 medication observations per week since [DATE] performed by MSN, RN or designee with 100% compliance. These audits continue and are ongoing as of [DATE]. Audits for resident identification utilizing wristbands was initiated on [DATE] to be included with med pass observations audit. These audits will continue 3 times per week for 4 weeks, then 3 times per week for 2 additional months. Audits for abuse and neglect initiated [DATE] will be conducted in conjunction with Med Pass observations 3 times per week for 4 weeks, then 3 times per week for 2 additional months. Education was complete on [DATE] for Medication administration. Stand up education for resident identification utilizing wristbands and abuse and neglect was initiated and complete on [DATE] with all associates present at 100% compliance. No associate will report for duty until education has been complete.

Based on record reviews, facility policy review, and interviews, the facility failed to ensure 1 of 1 resident's assistive device, wheelchair, was properly secured for transportation. Specifically, Resident (R)4's wheelchair was not properly secured for transportation, resulting in R4 experiencing medical injuries. Findings Include: Review of the policy titled, Fall Assessment and Fall Response, with an effective date of 07/2022 states, Procedure: Each resident shall have standard fall precautions in place Investigation: 1. Determine what may have caused or contributed to the fall, including ascertaining what the resident was trying to do before he/she fell . 2. Revise the Resident's plan of care and/or facility practices as needed to reduce the likelihood of another fall. Review of R4's face sheet revealed R4 was admitted to the facility on [DATE] with diagnoses of, but not limited to, type 2 diabetes, atherosclerotic heart disease, hyperlipidemia, chronic kidney disease, major depression, anxiety, and hypertension. Review of R4's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/15/23 revealed R4 had a Brief Interview for Mental Status (BIMS) score of 14 of 15, indicating R4 was cognitively intact. Further review of the MDS revealed R4 uses a wheelchair. Review of R4's progress notes on 07/13/23 at 5:07 PM revealed, Resident out to physician's appointment and was injured getting into transport van. He is no [sic] on his way to emergency room (ER). A progress note dated 07/15/23 at 9:16 PM revealed, Resident returned to facility approx. 8pm via ambulance staff. Res transferred to bed by ambulance staff. Body audit complete. No signs of skin breakdown. Small bruise in left inner antecubital area. Vital signs obtained. RP notified of return to facility and new orders. No concerns were voiced by RP at this time. At 9:52 PM Nurse walked by resident's room and noted him leaned over dry heaving. Resident stated he felt dizzy and nauseous. RP notified in agreement with sending resident to hospital. EMS arrived at 9:50 PM to transport resident. Review of R4's hospital records with an admitted [DATE] revealed R4 was presented to a local hospital after fall, patient was not properly secured in vehicle when started, patient fell directly back in wheelchair and hit his head and neck. R4 notes he did hit his head and believes he lost consciousness. R4 enters with a diagnosis of Subdural Hemorrhage. R4 was discharged on [DATE] with findings of a small subdural hematoma on imaging and neurosurgery was consulted. During an interview with Certified Nursing Assistant (CNA)2 on 07/19/23 at 1:32 PM revealed that she accompanied R4 to his doctor appointment. As they were being picked up from the appointment and they were pulling off, the van approached a red light, and she was looking through the windshield and saw the resident falling back and she tried to stop it but was blocked by her seatbelt. She then yelled for the driver to stop, by that time R4 was already on the floor. The driver stopped and came to the back of the van and helped aide the resident so that he was lying flat, the driver then contacted the Emergency Medical Services (EMS). CNA2 further revealed R4 was able to communicate with her and the driver. The driver sat him up because he was having a little trouble breathing. CNA2 included that she assumed the driver didn't have the chair buckled all the way down, but she did not pay attention to when he was strapping him in. She also states she went with him to the hospital and he was cognitive and able to answer the questions that the physician was asking. During an interview with R4 on 07/19/23 at 1:48 PM, R4 revealed that he was being transported from a doctor's appointment back to the facility and the next thing he knew, I was flat on my back. He included that the driver and CNA2 helped him because he had passed out for about ten minutes, and when he was alert again, he was at the hospital. R4 states he had a CT scan and since then he has had headaches of which they provide him Tylenol for his pain. He explains that he was not strapped in from the bottom where the wheelchair goes in, but he doesn't remember half of what happened. During an interview on 07/19/23 at an unspecified time, the Operations Coordinator of the contracted transportation company, revealed the securement for the wheelchair was not properly secured, it was on one end, but not the other. He includes they completed observations and safety procurement with their staff once to twice a month for the entire process. The driver has been employed for about a year and was off today and was not able to be reached or provide a phone number for interview either.

Based on review of facility policy, interview, and record review, the facility failed to prevent accidents/accident hazards for 1 of 5 residents reviewed for accidents. Specifically, Certified Nursing Assitant (CNA)1 removed fall safety precautions from Resident (R)1 prior to providing care. R1 was left unattended and fell from the bed resulting in a head injury. Findings Include: Review of the facility policy titled Fall Assessment and Fall Response with policy effective date of 07/2022 revealed, Each resident shall have standard fall precautions in place. R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to; diffuse traumatic brain injury (TBI), malnutrition, prior vertebral fracture, and muscle spasms. Review of the resident's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/14/2023 revealed R1 required extensive 2-person physical assistance for bed mobility. Review of the facility Five-Day Follow-Up report dated 03/09/2023 revealed, on 03/05/2023 at approximately 8:30 PM, CNA1 went into R1's room to provide care. CNA1 elevated the bed to give R1 a bath and continued with care. CNA1 left the bedside of R1 to find assistance to roll the resident, and during her absence the resident fell from the bed. R1 was discovered with a small hematoma to his left temple and some frothy, pink blood product coming from his mouth. Review of the Resident Incident Report dated 03/05/2023 at 9:00 PM revealed, R1 was found on the floor, lying on his left side. The bed was up in the air. He sustained a laceration and hematoma to the left temple. Review of the Emergency Department discharge note dated 03/05/2023 at 10:06 PM revealed, the resident's Computed Tomography (CT) of his head and cervical spine without contrast indicated no acute intracranial hemorrhage and no acute fracture or malalignment in the cervical spine. Review of R1's undated Care Plan revealed a care area regarding an increased risk for falls secondary to immobility, TBI (traumatic brain injury), impaired hearing and vision, and inability to make needs and wants known. Interventions included a high mat beside bed when unattended. Review of CNA1's Witness Statement dated 03/05/2023 revealed the CNA removed wedges and floor mat from the resident's room prior to providing care as well as raising his bed to its highest position. After giving the resident a bath, she left the resident unattended to see if there was another aide to help roll the resident. It was during this time that she heard a loud boom and ran back to the room. She yelled for help because the resident was lying on the floor with his face toward the restroom door. He was bleeding from his mouth. Interview with the Director of Nursing (DON) on 05/23/2023 at 11:31 AM revealed, CNA1 should have gotten a 2nd person prior to providing care. Furthermore, if CNA1 had to leave the room to find assistance, she should have replaced the high fall mat prior to leaving the resident unattended. Interview with Licensed Practical Nurse (LPN)1 on 05/23/2023 at 2:08 PM revealed, she came to R1's room after CNA1 called her. She saw the resident on the floor, and his fall mat was not in place. When asked what the procedure was for leaving the resident unattended, LPN1 stated CNA1 should not have removed the fall mat prior to leaving the resident unattended to find help. Interview with CNA1 on 05/23/2023 at 2:09 PM confirmed her statement to the facility. At the time of the incident, CNA1 went into the resident's room to give him a bed bath. She removed the wedges and fall mats to provide care. When it came time to roll the resident, she left him unattended to find assistance. She did not replace the wedge or fall mat prior to leaving the resident unattended, saying there was no excuse. She did not realize the resident had coughing fits that were violent enough to cause a fall from the bed.

Based on record review, interviews, and facility policy review, the facility failed to protect 1 Resident (R4) of 4 residents reviewed for abuse from further potential abuse after R4 reported an abuse allegation. Findings include: The facility's policy titled, Adult and Elder Abuse, Mistreatment and Neglect, dated June 2022, indicated, Residents have the right to be free from mental, physical, sexual and verbal abuse, neglect, corporal punishment and involuntary seclusion. The policy indicated the facility definition of neglect was the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Verbal abuse was defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to resident or their families, or within their hearing distances, regardless of their age, ability to comprehend, or disability. Further review of the facility's policy revealed the Procedure for Reporting, was The Director of Nursing shall: 4. If an employee is indicated in an alleged abuse, neglect, mistreatment, or exploitation the employee shall be suspended pending resolution of the alleged violation. A review of the annual Minimum Data Set (MDS), dated [DATE], revealed R4 had diagnoses that included non-Alzheimer's dementia, anxiety disorder, and bipolar disorder. The MDS indicated the resident had a Brief Interview for Mental Status (BIMS) score of 8, indicating the resident was moderately cognitively impaired. R4 required extensive, one-person assistance with bed mobility, transferring, hygiene, and toileting. The resident had no range-of-motion limitations. R4 was always incontinent of bladder and frequently incontinent of bowel. Review of the facility grievance titled Statement of Concern, dated 01/25/2023 at 3:30 PM, revealed R4 reported Certified Nursing Assistant (CNA)9 answered the resident's call light and stated, All you do is eat, [profanity], and sleep. The CNA told the resident, You should just wear a brief. The form indicated the concerns were reported to the Director of Nursing (DON) and Administrator. A review of CNA9's time clock data revealed the CNA clocked out of work on 01/25/2023 at 3:05 PM. Further review revealed CNA9 clocked in to work the next day, 01/26/2023, at 7:50 AM. A review of a facility Initial 2/24-Hour Report, dated 01/26/2023, indicated the incident with R4 occurred on 01/20/2023, but was not reported to the facility until 01/25/2023. According to the report, the facility notified the state agency of a neglect allegation on 01/26/2023 at 1:19 PM. According to the report, the facility removed CNA9 from the facility pending an investigation. Further review of CNA9's time clock data revealed the CNA clocked out of the facility on 01/26/2023 at 12:36 PM, after working approximately 4.5 hours the day after the resident reported allegations of abuse. During an interview with R4 on 03/16/2023 at 8:53 AM, the resident revealed some CNAs were just rude and that one (did not state which one) was always rude. During an interview with Social Services on 03/16/2023 at 11:06 AM, she stated R4 reported on 01/25/2023 that they did not like how CNA9 spoke to the resident. Initially, R4 made a statement regarding how the CNA stated that the resident only ate, pooped, and slept and should just wear a brief. The interview revealed Social Services filed a grievance and reported the allegation to the Administrator. She stated the next day the team discussed the grievance and decided to report the incident as alleged abuse. A review of the facility's 5 Day Follow Up Reportable Incident Allegation of Abuse, dated 01/30/2023, revealed the facility determined R4 was not neglected. The resident had no observable indicators of abuse or neglect and did not voice any concerns in the days following the alleged incident. The report indicated R4 had not suffered any psychosocial or emotional distress. According to the report, CNA9 was taken off R4's assignment. During an interview with the Director of Nursing (DON) on 03/16/2023 at 11:44 AM, she stated the allegation came in on 01/25/2023. Social Services discussed the issue with the Administrator, and they felt it was not reportable. The DON stated since the facility did not report the allegation on 01/25/2023, CNA9 came back to work on 01/26/2023 for day shift. Following the morning meeting when R4's grievance was discussed, the facility decided to report verbal abuse and CNA9 was sent home during the investigation by noon on 01/26/2023. According to the DON, CNA9 was terminated due to other negative comments and concerns during the investigation. During an interview with the Administrator on 03/16/2023 at 11:54 AM, he stated at the time on 01/25/2023, he did not feel that abuse happened, and it was only a care concern. However, when the facility team discussed the incident on the morning of 01/26/2023, they decided to report an allegation of neglect because the resident stated no one came in during the shift to care for the resident. The interview revealed the facility did not initiate an investigation or send CNA9 home until 01/26/2023.

Based on record review, interviews, and facility policy review, the facility failed to report an allegation of abuse timely for 1 Resident (R4) of 4 residents reviewed for abuse. Findings included: The facility's policy titled, Adult and Elder Abuse, Mistreatment and Neglect, dated June 2022, indicated, Residents have the right to be free from mental, physical, sexual and verbal abuse, neglect, corporal punishment and involuntary seclusion. The policy indicated the facility definition of neglect was the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Verbal abuse was defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to resident or their families, or within their hearing distances, regardless of their age, ability to comprehend, or disability. The facility policy indicated, Mental abuse includes but is not limited to, humiliation, harassment, threats of punishment or deprivation. Further review of the facility's policy revealed the Procedure for Reporting was The Director of Nursing shall: 1. Notify Nursing Home Administrator 2. Utilize the chart below for reporting. A review of the chart revealed allegations of abuse and neglect should be report within 2 hours. A review of the annual Minimum Data Set (MDS), dated [DATE], revealed R4 had diagnoses that included non-Alzheimer's dementia, anxiety disorder, and bipolar disorder. The MDS revealed R4 had a Brief Interview for Mental Status (BIMS) score of 8, indicating the resident was moderately cognitively impaired. R4 required extensive, one-person assistance with bed mobility, transferring, hygiene, and toileting. The resident had no range-of-motion limitations. R4 was always incontinent of bladder and frequently incontinent of bowel. A review of R4's Care Plan, initiated on 01/18/2022, indicated the resident needed extensive staff assistance with activities of daily living related to decreased independence with mobility and physical functioning and fluctuations in activity of daily living care was anticipated related to multiple disease processes. Interventions in place to meet the goal of being clean, dry, well groomed, dressed appropriately, and comfortable included staff were required to encourage the resident to participate in dressing and grooming, approach the resident calmly and explain procedures, assist only as necessary and encourage to try before offering assistance, allow sufficient time for dressing and undressing, and break tasks down into manageable segments. A review of R4's Care Plan, dated 05/18/2022, indicated the resident had behaviors including a history of false allegations and accusatory statements towards staff due to cognitive impairment. Interventions in meeting the goal of having a decrease in non-factual statements included requiring staff to offer diversional activities, administer medications as ordered, and provide psychiatric services as needed. Review of the facility grievance titled Statement of Concern, dated 01/25/2023 at 3:30 PM, indicated R4 had a complaint related to Certified Nursing Assistant (CNA)9 answering a call light and stating, All you do is eat, [profanity], and sleep. The CNA told the resident, You should just wear a brief. The form indicated the concerns were reported to the Director of Nursing (DON) and Administrator. A review of the Initial 2/24-Hour Report, dated 01/26/2023, indicated the incident occurred on 01/20/2023 but the resident did not report the incident to the facility until 01/25/2023. According to the report, the facility notified the state agency of neglect on 01/26/2023 at 1:19 PM, approximately 22 hours after the resident reported allegations of abuse. A review of the facility's Five-Day Follow-Up Report, dated 01/30/2023, revealed the report was being sent due to alleged abuse. Review of the Social Services witness statement, dated 01/26/2023, indicated R4 was interviewed in reference to neglect. The resident confirmed that CNA9 did not enter the room to offer care or assistance on 01/20/2023. The resident stated another staff member provided the resident's care and did not remember the staff member's name. R4 stated their needs were met and at no point did they feel neglected. However, R4 stated CNA9 was consistently hateful and rude during their interactions. During an interview with R4 on 03/16/2023 at 8:53 AM, the resident revealed they received needed care. The resident stated there were some CNAs that were just rude and that one (did not state which staff member) was always rude. During an interview on 03/16/2023 at 10:27 AM with CNA9, she stated she did not know where R4 came up with that statement because she never made that statement. CNA9 stated she was in and out all day on 01/20/2023 taking care of R4 and the resident's roommate because the roommate was totally dependent. She stated R4 requested care when the CNA was feeding the roommate and could not take care of R4 right then. CNA9 stated she told the resident she would get back with the resident after assisting the roommate. In the meantime, another CNA assisted R4. During an interview with Social Services on 03/16/2023 at 11:06 AM, she stated R4 reported the incident on 01/25/2023; however, Social Services did not document a grievance right away because she looked through the notes and got CNA statements. She stated that originally R4 stated the CNA told the resident that the resident only ate, pooped, and slept and should just wear a brief. When Social Services talked with R4 on 01/26/2023, the resident talked about care issues. She stated on 01/25/2023, she reported to the Administrator what the CNA allegedly stated, the next day the team discussed the grievance, and decided to report the incident as alleged abuse. During an interview with the Director of Nursing (DON) on 03/16/2023 at 11:44 AM, she stated the allegation came in on 01/25/2023. Social Services discussed the issue with the Administrator, and they felt it was not reportable. According to the DON, the allegation probably should have been reported on 01/25/2023. During an interview on 03/15/2023 at 3:42 PM with the Administrator, he stated the resident told the allegations to Social Services on 01/25/2023 and there was some debate whether the allegation was a care issue or abuse. The Administrator stated R4 did not say they were abused but that the CNA made a statement and did not provide care. During a follow-up interview with the Administrator on 03/16/2023 at 11:54 AM, he stated at the time on 01/25/2023, he did not feel that abuse happened, but the concern was a care concern. When their team discussed the incident on the morning of 01/26/2023, because it was reported that no one came in during the shift to care for the resident, they decided to report it as neglect. They began their investigation, and the CNA was sent home. The Administrator stated R4 alleged the care issue happened on 01/20/2023, but the resident never told staff until 01/25/2023. The Administrator stated they followed up with R4, and the resident did not feel humiliated and stated care was provided. According to the Administrator, the resident exhibited behaviors of making false allegations and had a care plan in place reflecting this behavior.

Based on record review, document review, interviews, and policy review, the facility failed to ensure a fall prevention intervention was consistently implemented for 1 Resident (R)9 of 6 samples residents reviewed for accidents. Specifically, the facility failed to ensure a care planned and physician-ordered sensor alarm was implemented for R9 to alert staff when the resident attempted to stand unassisted. The facility failed to ensure the alarm was in place on 02/02/22, and staff found R9 on the floor in front of the wheelchair. This resulted in a fractured femur (hip) for R9. Findings include: Review of a facility policy titled, Resident Alarm Devices, effective March 2022, revealed, Resident alarms may be used as a non-restraining device that alerts staff to a resident rising from a bed or chair without assistance. Review of a Face Sheet revealed R9 had diagnoses which included cerebral infarction (stroke), displaced intertrochanteric (between the two points on the thigh bone where the thigh and hip muscles attach) fracture of the left femur, [CONDITION(S)] [CONDITION(S)], [CONDITION(S)], and a history of falling. Review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed R9 had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. The MDS indicated the resident required extensive assistance with bed mobility and was totally dependent on the assistance of two people for transfer. According to the MDS, the resident had no functional limitation in range-of-motion but had unsteady balance and was only able to stabilize with staff assistance during surface-to-surface transfers. The MDS indicated the resident had not fallen since admission/readmission and had a chair alarm in use daily. Review of a Care Plan, dated 05/11/21, revealed R9 was at risk for injury related to falls secondary to a history of falls, decreased cognition, weakness, use of [CONDITION(S)] medications, incontinence, and a lack of insight related to safety needs. The goal was for the resident to have no injuries related to falls through the next 90 days. Interventions with a start date of 05/11/21 included ensuring the call light was within reach and answering it promptly, placing frequently used items within easy reach, and placing a sensor pad alarm in the resident's chair. Review of a Physician Orders List revealed R9 had a physician's order dated 10/16/20 for a sensor pad alarm to the wheelchair when out of bed related to poor safety awareness. A review of the revised Device Sheet (a pocket care guide for Certified Nursing Assistants to use in guiding each resident's care), dated 01/28/22, revealed R9 required a mechanical lift for transfers, was in a wheelchair when out of bed, and required a sensor pad alarm to the wheelchair. Review of an Accident/Incident Report, dated 02/01/22 at 9:30 PM, revealed Certified Nursing Assistant (CNA)1 found the resident in front of the wheelchair, sitting on the footrest. There was no sensor pad alarm in the wheelchair. The resident was assessed and stated he/she did not hit his/her head. The mechanical lift was used to place the resident back in bed. The resident complained of left leg/hip pain. The note indicated no bruising or abrasions were noted but the left leg appeared rotated. The responsible party, physician, Director of Nursing (DON), and Administrator were notified. The resident was sent to the emergency room for evaluation. Review of an Accident/Incident Reporting Form, dated 02/04/2022, revealed the facility completed an investigation of R9's unwitnessed fall. The report indicated the hospital alerted the facility at 4:45 AM that the resident had a left hip fracture. According to the report, the resident's sensor pad alarm was not in the wheelchair at the time of the fall but was noted on the device sheet. The reported revealed the resident had recently moved to the COVID-19 unit, and CNA2 was unaware of the need for the sensor pad alarm when he assisted the resident out of bed earlier in the day. The report revealed the facility was unable to determine from their investigation if the fracture was a result of the fall or a result of the transfer back to bed with the lift equipment; however, according to the report, when describing the lift procedure, all four staff involved in the resident's transfer back to bed were able to describe the appropriate transfer technique. Review of the February 2022 Treatment Administration Record (TAR) revealed R9's sensor pad alarm was to be in the wheelchair when the resident was out of bed and was to be checked every morning at 7:00 AM. Nursing staff initialed that the alarm was checked on 02/01/22 at 7:00 AM. Review of hospital ED [Emergency Department] Provider Notes, dated 02/01/22, revealed the resident had complaints of left leg pain, could move all four extremities spontaneously, had painful range of motion at the proximal femur region, and had a shortened leg. A review of the x-ray of the left femur revealed a left femur intertrochanteric fracture, osteopenia (decreased bone mineral density that is not low enough to meet diagnostic criteria for [CONDITION(S)]), and extensive [CONDITION(S)] calcifications in the vasculature (areas of plaque build-up in the arteries). Review of a hospital Discharge Summary, dated 02/05/22, revealed R9 underwent medullary nailing (repair of a bone by inserting a steel nail into the marrow cavity) on 02/03/22 and was discharged back to the facility on [DATE]. During an interview on 09/13/22 at 9:55 AM, R9 stated he/she broke his/her leg and could not walk well. Observation on 09/13/22 at 1:49 PM revealed R9 sitting in a Broda chair in the day room. During an interview on 09/14/22 at 10:14 AM, the Director of Nursing (DON) stated the purpose of the sensor pad alarm was to cue staff to check on the resident. She stated the Device Sheets were no longer used, as the facility had transitioned to electronic records, and the staff now viewed and documented in the electronic charting system. She stated R9's fall was prior to the transition to electronic charting. During an interview on 09/14/22 at 10:52 AM, CNA2 revealed that on 02/01/22, CNA staff were using Device Sheets that had information on how to care for each resident. The CNA stated the Device Sheet was a piece paper that could be kept in staff's pocket and was like a care guide that let staff know what needed to be done for each resident. CNA2 stated he did not remember having a Device Sheet in his pocket on 02/02/22. He stated he did not know R9 should have had a sensor pad alarm in the wheelchair when he assisted the resident to the wheelchair. He stated the alarm was to alert staff to check on the resident. During an interview on 09/14/22 at 3:52 PM, CNA1 revealed he usually worked nights, from 7:00 PM to 7:00 AM, and R9 was always in bed when he arrived for his shift. He stated he was assigned to care for the resident on the 7:00 PM shift on 02/01/22. He stated when he arrived for his shift, the resident was sitting in a wheelchair, which was not typical. He stated he was assisting a resident with a bed bath on the hallway where R9's lived and after finishing the bath, when he walked past R9's room, the resident was on the floor in front of his/her wheelchair. He stated he called for the nurse and another CNA. He indicated Resident #9 was alert and talking when he went into the room. He stated the brakes on the wheelchair were locked, but he did not see a sensor alarm pad in the wheelchair. He stated since he had never had to transfer the resident from or to the wheelchair prior to the incident, he did not know if the resident was supposed to have an alarm pad in the wheelchair. During an interview on 09/15/22 at 1:24 PM, the Nurse Practitioner (NP) revealed R9 was alert but confused. She stated the resident had a history of a fractured right hip before coming to the facility and had osteopenia (low bone density) and dementia. She stated R9's sensor pad alarm was for the resident's safety awareness and to alert staff to check on the resident if they heard the alarm. She indicated whether the sensor pad alarm was on or off, if R9 stood up, there was a possibility the resident would fall and given the resident's medical history and comorbidities, the resident was at risk for injury. The NP stated falls could happen instantaneously and, even with an alarm that sounds, staff could not always get there instantly. She further stated she would have expected if there was an order for a sensor pad alarm to the wheelchair that the alarm would have been in place when the resident was in the wheelchair. During an interview on 09/15/22 at 2:09 PM, the DON revealed she was the supervisor on the evening R9 fell and assessed the resident following the fall. The DON stated R9 was alert and complained of leg pain when staff assisted the resident to bed. The DON stated she observed obvious rotation of the resident's leg. According to the DON, Resident #9 did not complain of pain while on the floor or when being picked up by the lift until the sides of the sling lift were put down. The DON stated Resident #9 had co-morbidities, a history of a fall and fracture, and osteopenia. She stated the root cause of the fall was not determined because the resident's hip could have broken during the fall or when the lift was used. The DON stated she expected physician's orders to be followed. During an interview on 09/15/22 at 3:17 PM, the Administrator stated he expected physician's orders to be followed. He stated the facility recognized at the time of the incident that the sensor pad alarm was not in use for R9. He asserted that CNA2 and the entire staff was reeducated on the use of the device care guides and following care plans. He stated every sensor chair alarm pad was audited and monitoring was done. During an interview on 09/16/22 at 3:38 PM, the Staff Development Coordinator (SDC)/Infection Control Preventionist stated she conducted education on resident summaries and devices on 02/10/22 and 02/11/22 in response to the chair pad alarm that was not in place for R9 on 02/01/22. The SDC showed copies of the education documents to the surveyor. During an interview on 09/16/22 at 3:15 PM, the DON and MDS Coordinator stated they had no information about audits or monitoring related to R9's alarm not being implemented. The DON and MDS Coordinator indicated R9's fall occurred before they were in their current positions, and they did not see any documentation from the previous DON. The DON revealed she had no paperwork in the file to determine if other residents with alarms were reviewed to ensure their alarms were in place but stated the alarms were checked on the Treatment Administration Records (TARs) daily by the nurses.

Based on facility policy review, record review, and interviews, the facility failed to ensure a care planned fall prevention intervention was consistently implemented for 1 Resident (R)9 of 6 sampled residents reviewed for accidents. Specifically, on 02/01/22, the facility failed to ensure the sensor alarm pad was in place in R9's chair, per the care plan, and the resident was found on the floor in front of the wheelchair. This resulted in a fractured femur (hip) for R9. Findings include: Review of a facility policy titled, Care Planning Process and Conferences, dated 03/2022, revealed residents had the right to be informed of and participate in their treatment including, d. The right to receive the services and or items included in the plan of care. The policy also indicated, Baseline Care Plan Process: 1. A baseline care plan shall be developed and implemented for each resident on admission that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Review of a Face Sheet revealed R9 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/06/21, revealed R9 had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. The MDS indicated the resident required extensive assistance with bed mobility and was totally dependent on the assistance of two people for transfer. According to the MDS, the resident had no functional limitation in range-of-motion but had unsteady balance and was only able to stabilize with staff assistance during surface-to-surface transfers. The MDS indicated the resident had not fallen since admission/readmission and had a chair alarm in use daily. Review of a Care Plan, dated 05/11/21, revealed R9 was at risk for injury related to falls secondary to a history of falls, decreased cognition, weakness, use of [CONDITION(S)] medications, incontinence, and a lack of insight related to safety needs. The goal was for the resident to have no injuries related to falls through the next 90 days. Interventions with a start date of 05/11/21 included ensuring the call light was within reach and answering it promptly, placing frequently used items within easy reach, and placing a sensor pad alarm in the resident's chair. Review of a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Unit One Device Sheet, dated 01/28/22, revealed R9 required a sensor pad alarm to the wheelchair. Review of an Accident/Incident Report, dated 02/01/22 at 9:30 PM, revealed Certified Nursing Assistant (CNA)1 found the resident in front of the wheelchair, sitting on the footrest. There was no sensor pad alarm in the wheelchair. The resident was assessed and stated he/she did not hit his/her head. The mechanical lift was used to place the resident back in bed. The resident complained of left leg/hip pain. The note indicated no bruising or abrasions were noted but the left leg appeared rotated. The responsible party, physician, Director of Nursing (DON), and Administrator were notified. The resident was sent to the emergency room for evaluation. Review of hospital ED [Emergency Department] Provider Notes, dated 02/01/22, revealed the resident had complaints of left leg pain, could move all four extremities spontaneously, had painful range of motion at the proximal femur region, and had a shortened leg. A review of the x-ray of the left femur revealed a left femur intertrochanteric fracture, osteopenia (decreased bone mineral density that is not low enough to meet diagnostic criteria for [CONDITION(S)]), and extensive [CONDITION(S)] calcifications in the vasculature (areas of plaque build-up in the arteries). Review of a hospital Discharge Summary, dated 02/05/22, revealed R9 underwent medullary nailing (repair of a bone by inserting a steel nail into the marrow cavity) on 02/03/22 and was discharged back to the facility on [DATE]. During an interview on 09/14/22 at 10:52 AM, CNA2 revealed that on 02/01/22, he worked with R9 on day shift, until approximately 7:00 PM. CNA2 stated staff had device sheets with information on how to care for residents. He stated he kept the sheets in his pocket and that they were like a care guide that would let him know what needed to be done for each resident. He stated he did not remember having a Device Sheet in his pocket on the day of R9's fall. He stated he did not know there should have been a sensor pad alarm in the wheelchair. He indicated the alarm was to alert staff to check on the resident. During an interview on 09/14/22 at 3:52 PM, CNA1 revealed R9 was assigned to his care on the 7:00 PM shift on 02/01/22. He stated he walked past R9's room, and the resident was on the floor in front of the wheelchair. He stated he did not see a sensor alarm pad in the wheelchair seat. During an interview on 09/15/22 at 1:24 PM, the Nurse Practitioner revealed the resident was alert, but confused. She stated R9's sensor pad alarm was for the resident's safety awareness and to let the staff know to check on the resident if they heard the alarm. She stated she would have expected the care plan to be implemented. During an interview on 09/15/22 at 2:09 PM, the DON revealed she would expect the care plan for the alarm to be implemented. During an interview on 09/15/22 at 3:17 PM, the Administrator stated he would expect the care plan for the alarm to be implemented. He stated the facility recognized at the time of the incident that the sensor pad alarm was not in use. He asserted that CNA2 and the entire staff was reeducated on the use of the device care guides and following care plans. He stated every sensor chair alarm pad was audited and monitoring was done. During an interview on 09/16/22 at 3:38 PM, the Staff Development Coordinator (SDC)/Infection Control Preventionist stated she conducted education on resident summaries and devices on 02/10/22 and 02/11/22 in response to the chair pad alarm that was not in place for R9 on 02/01/22. The SDC showed copies of the education documents to the surveyor. During an interview on 09/16/22 at 3:15 PM, the DON and MDS Coordinator stated they had no information about audits or monitoring related to R9's alarm not being implemented. The DON and MDS Coordinator indicated R9's fall occurred before they were in their current positions, and they did not see any documentation from the previous DON. The DON revealed she had no paperwork in the file to determine if other residents with alarms were reviewed to ensure their alarms were in place but stated the alarms were checked on the Treatment Administration Records (TARs) daily by the nurses. During an interview on 09/16/22 at 3:32 PM, the Administrator again asserted the facility completed the investigation and provided education to staff. The Administrator stated the last Quality Assurance/Performance Improvement (QAPI) meetings were conducted in March and July 2022 and that the sensor pad alarm issue should have been taken to QAPI but, We were so focused on infection control that it was missed.

Based on review of the facility's policy titled, Administration of Medications, record review, observation, and interviews, the facility failed to ensure their medication error rate was less than 5%. On 09/15/22, three nurses were observed administering medications to 3 residents for a total of 31 opportunities with two errors, which yielded a medication error rate of 6.45%. This deficient practice affected Resident (R)47; one of three residents observed for medication administration. Findings include: A review of the facility's policy titled, Administration of Medications, dated 03/2022, indicated Medication(s) shall be verified with the provider's order prior to the initial dose being administered. The following 'Nine Rights of Medication Administration Practice' should be confirmed prior to administration: - Right patient - Right drug - Right route - Right time - Right dose - Right documentation - Right action - Right form - Right response. A review of R47's September 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Per the orders, the resident was to rinse his/her mouth with water and spit into a cup after the use of [MEDICATION(S)]. During medication administration observation on 09/15/22 at 9:02 AM, the surveyor observed Registered Nurse (RN)3 prepare and administer medications to R47. RN3 was observed to hand the resident a [MEDICATION(S)] inhaler. The resident took the inhaler, shook it, took one puff, and laid it back down. RN3 did not prepare and administer the [MEDICATION(S)] for R47 and did not offer or assist the resident to rinse and spit after using the [MEDICATION(S)] inhaler. During an interview on 09/16/22 at 10:32 AM, RN1 stated to ensure a medication was not missed during a medication pass, the computer had the staff click on each medication as it was being prepared, and then the computer made the staff review each medication again to ensure it was given. RN1 stated it was important to make sure the resident rinsed their mouth out after a steroid inhaler because it could cause yeast (fungal infection) to grow in the resident's mouth (thrush). During an interview on 09/16/22 at 1:10 PM, Licensed Practical Nurse (LPN)5 stated when she administered medications, she checked the medications against physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN5 stated residents must rinse after using steroid inhalers due to the risk of thrush. During an interview on 09/16/22 at 1:32 PM, the Director of Nursing (DON) stated nurses were supposed to check a medication against the associated order on a resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated nurses should have a resident rinse their mouth out after using a steroid inhaler. During an interview on 09/16/22 at 4:02 PM, the Administrator stated nurses should consult with the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The Administrator stated he was not aware of the requirements after the use of a steroid inhaler, but he expected nurses to follow orders and administer medications according to recommendations.

Based on facility policy review, record review, and interviews, the facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) when Medicare Part A services were ending for 1 (Resident (R)134) of 3 sampled residents reviewed for beneficiary protection notification. Findings include: Review of a facility policy titled, Notice of Medicare Non-Coverage, (NOMNC) Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) and Denial Letter, dated 08/2022, revealed, The SNFABN is a notice given to Skilled Nursing Facility beneficiaries in Original Medicare to convey that Medicare is not likely to provide coverage in a specific case, and to inform the beneficiary of potential liability for a non-Medicare covered stay. The policy further indicated, The SNFABN must be reviewed with the beneficiary or his/her representative and any questions raised during that review must be answered before it is signed. The SNFABN must be delivered far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice. Review of a Face Sheet revealed the facility admitted R134 to the facility on [DATE] with a payor source of Medicare and discharged the resident on 04/08/22 with return not anticipated. Review of a SNF Beneficiary Protection Notification Review form revealed R134's Medicare Part A Skilled Services Episode started on 03/22/22, and the resident's last covered day of Part A services was 04/08/22. The review indicated the facility initiated the discharge from Medicare Part A Services when the benefit days were not exhausted. The form indicated the SNFABN was not provided to the resident due to services are medically necessary, and the NOMNC was not provided to the resident due to a, missed opportunity with staff changes - unable to locate. During an interview with the Social Worker on 09/16/22 at 10:02 AM, she stated at the time R134 was discharged , the facility was going through a transition with therapy, so the paperwork (SNFABN and NOMNC) for R134, slipped through the cracks. During an interview with the Social Worker and the Administrator on 09/16/22 at 11:17 AM, the Administrator indicated the NOMNC for R134 was missed during a transition of management and therapy staff. In a follow-up interview on 09/16/22 at 4:02 PM, the Administrator acknowledged that he could not find the advanced beneficiary notices for R134.

Based on interview, record review, review of the Facility Reported Incident (FRI), and review of facility policy, the facility failed to ensure a resident was free from verbal and alleged physical abuse from a staff member. This affected one resident (Resident (R) 15) of three reviewed for abuse. Findings include: Review of facility policy titled Adult and Elder Abuse, Mistreatment and Neglect, effective 5/2020 revealed that all residents of the facility have the right to be free from mental, physical, sexual, and verbal abuse, neglect, corporal punishment, and involuntary seclusion. It is the policy of the facility to protect residents from abuse, neglect, mistreatment, or exploitation from anyone, including staff members. The policy provides the following definitions: Abuse - The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Verbal abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to resident or their families, or within their hearing distances, regardless of their age, ability to comprehend, or disability. A review of the FRI report dated 09/03/21 conducted by the Administrator revealed on 08/27/21 at about 6:00 AM Certified Nursing Assistant (CNA)1 went into R15's room to perform personal care. CNA1 grabbed at R15's brief and R15 swatted CNA1's hand away. According to CNA2, CNA1 then pinned R15's arms to avoid being hit by the resident. CNA2 further revealed CNA1 screamed in R15's face telling him he could not hit her. CNA1 was ushered out of the room by Licensed Practical Nurse (LPN)1, who was also in the room at the time and witnessed the incident. A review of the written statement by CNA2 dated 08/27/21 revealed she went to help in getting R15 up in chair; upon entering R15's room, CNA1 and LPN1 were already in the room. CNA1 got near R15, and R15 swatted CNA1's hand away. CNA1 then lunged at R15 and grabbed R15's hands and started screaming profanities, and how she would lose her license if he (R15) hit her. CNA2 got between CNA1 and R15, and LPN1 ushered CNA1 out of R15's room. A few minutes later, CNA1 returned to R15's room and continued to scream at R15. CNA1 was again removed from R15's room but continued to scream in the hallway. A review of the written statement by LPN1 dated 08/27/21 revealed she entered R15's room to assist CNA1 to get R15 out of bed. CNA1 became frustrated with R15. CNA1 grabbed at R15's brief and the resident pushed CNA1's hand away. CNA1 then began to yell at R15 that if he put his hands on her, she would lose her license today. LPN1 asked CNA1 to leave the resident's room to calm down. After about five minutes, CNA1 returned to R15's room still with anger and hostility toward R15. R15 asked CNA1 her to leave his room, and CNA1 began yelling at the R15 again. LPN1 physically removed CNA1 from R15's room until CNA1 could collect herself and then reported the incident to the Registered Nurse Supervisor (RNS). A review of the written statement by RNS revealed on 08/27/21, around six-ish (sic), RNS heard CNA1 coming down the hallway on unit one. CNA1 was very animated and upset. RNS heard CNA1 say I don't care if I lose my license; ain't nobody going to hit me in my face. CNA1 continued with a lot of profanities. RNS stated she was told by CNA2 and LPN1 that they had witnessed and incident between CNA1 and R15. CNA2 and LPN1 stated CNA1 grabbed R15's brief, and then R15 started to grab CNA1's arm. CNA1 then held R15's arms and yelled at R15 stating that she did not care what they did to her, and that she did not care if she lost her license, no one was going to hit her face. CNA2 and LPN1 gave written statements of the incident and CNA1 refused to write a statement. Continued review of the FRI, revealed the Director of Nursing (DON) was informed of the incident immediately by LPN1 via text message at 7:01 AM on 08/27/21 (confirmed by interview with DON on 10/6/2021 at 6:02 PM) Review of R15's most recent quarterly Minimum Data Set(MDS) dated [DATE], located in the EMR under the MDS tab revealed R15 has a Brief Mental Status Interview (BIMS) of 02, indicating severe cognitive impairment. The resident was not interviewable. During an interview with the Administrator on 10/06/21 at 3:00 PM the Administrator stated he did not receive the written witness reports of the allegations of abuse by CNA1 against R15 on 08/27/21. The Administrator stated the reports were submitted to the DON as a care concern and that he did not become aware of the incident until 08/31/21, at which time he immediately initiated an investigation and reported the incident to the State Agency, began education and in-services on abuse, suspended CNA1, and subsequently terminated CNA1. During an interview with the DON 10/06/21 at 3:15 PM, revealed she was informed by RNS on 08/27/21 at 7:01 AM of the incident that occurred on 08/27/21 regarding CNA1 and R15. The DON stated she called CNA1 on 08/27/21 at about 5:00 PM. DON stated CNA1 informed her when R15 swung at her she crossed R15's arms over and turned him away sideways, so that he could not hit her. The DON stated that she did not think any harm was done to R15 and she checked on him and he exhibited no signs that he had been harmed by the incident. The DON stated R15 was combative and had already hurt one of her staff. The DON confirmed that CNA1's behavior in yelling, screaming, and cursing at R15 was not appropriate behavior, however she did not recognize it as abuse because R15 did not suffer any effects from the behavior. During an interview with CNA2 on 10/06/21 at 4:15 PM, revealed when she went to respond to R15's alarm, CNA1 was already in the room. When CNA1 tried to take off R15's briefs he tried to push her away. CNA1 then lunged at R15, and CNA2 stated she got in between them to protect the resident. CNA1 then left the room, however, came back in the room and shouted at R15 again and had to be forcibly removed from the room. CNA2 stated that CNA1 continued to be loud in the hallway. She further revealed she reported the incident to RNS. RNS and LPN1 were unavailable for interview.

Based on observations, interviews, and record review; the facility failed to ensure the resident environment remains free of accident hazards and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents reviewed for injuries of unknown origin. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses including but not limited to, Alzheimer's disease, [CONDITION(S)] with depression, muscle weakness, dysphasia, lack of coordination, difficulty in walking, and [CONDITION(S)]. The facility submitted a reportable indicating on January 27, 2021, Resident #1 was found on the floor of the shower room, incontinent of stool, after sliding from the lift sling with Certified Nursing Assistant (CNA) #1 present. Review of the medical record on 3/3/2021 at 11:30 AM indicated a progress note dated 01/27/2021 at 4:24 PM, revealed that Resident #1 was in the shower room with a CNA when s/he slid from the mechanical lift sling down shower chair to floor. Resident was assessed after the incident by Registered Nurse (RN) #1 and showed no signs of pain or discomfort. Resident had a L shaped impression on the outside of his/her left hip from the shower chair lug connecter. The area was two- and one-half inches long and two- and one-half inches wide. An additional review of the progress note dated 01/28/2021 at 11:07 AM stated that Resident #1 was receiving care from CNA and RN #2. Resident was assessed by RN #1 and his/her left leg appeared to be larger in size than right. Resident showed no signs of pain or discomfort. RN #1 reported the findings to the Nurse Practitioner (NP) and an X-ray was ordered. Resident #1 received Tylenol and now scheduled BID (twice a day). A progress noted dated 01/28/2021 at 2:11 PM, revealed that Resident #1 X-ray report showed left hip fracture. NP was consulted and sent Resident #1 to the emergency room . RN #2 called resident's representative (RP) and updated him/her on the new findings. A radiology report dated 1/28/2021 at 12:42 PM noted there was an intertrochanteric fracture from the radiographic imaging taken of Resident #1's left hip. A quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #1's Brief Interview for Mental Status (BIMS) score of 0 out of 15. The resident required total staff assistance with bed mobility, dressing, toilet use, and personal hygiene. Resident #1's plan of care, initiated on 05/18/2020 and revised on 08/08/2020, indicated under the activities of daily living (ADL's) functional/rehabilitation potential portion of the plan of care that Resident #1 requires mechanical lift for all transfers. Resident #1's fall care plan also states; Resident is at risk for falls secondary to decreased cognition and impaired balance. Resident is non-ambulatory and unable to self-propel. Approaches are mechanical lift for transfers On 03/03/2021 at 12:00 PM during an interview with the Administrator, s/he stated, that when s/he was made aware of the incident with Resident #1, s/he immediately launched an investigation. The Administrator stated staff were interviewed and the interviews revealed that CNA #1 did not have the sling secured to the lift which allowed the resident to slide out of the lift sling. The Administrator did not take corrective action against CNA #1. The Administrator stated immediate re-education was provided to the nursing assistant and re-education was initiated to all clinical staff regarding mechanical lift competency. On 03/03/2021 at 12:20 PM, a follow-up interview was conducted with RN #2 with the Administrator present. RN #2 stated s/he assessed Resident #1 on 01/28/2021. The assessment of Resident #1 revealed the left leg appeared to be larger in size than the right leg. RN #1 then reported her/his findings to the NP and notified the resident's representative. (RP). On 03/03/2021 at 12:45 PM, a follow-up interview was conducted with RN #1 via telephone with the Administrator present. RN #1 stated s/he was alerted by CNA #1 that Resident #1 was on the floor in the shower room. RN #1 observed Resident #1 sitting on the floor leaning against a shower bench. RN #1 assessed Resident #1 for injuries and then lifted the resident into a reclined shower chair to complete shower. Multiple attempts were made to contact CNA #1 via telephone with no success. Review of CNA #1's Orientation Competency Assessment revealed s/he had been educated on Safe Transfers via demonstration. Further review of the facility's 5-day follow-up report investigation of the incident concluded that Resident #1's intertrochanteric fracture to the left hip resulted from CNA #1 not securing the sling to the mechanical lift.

Based on record review and interview, the facility failed to ensure the safety and protection of its residents from harm, to include physical abuse as evidenced by Resident #60's hospitalization following an incident with CNA #2 that resulted in a distal-humerus fracture, in addition to the nurse on duty neglecting to assess the resident's condition timely after being informed. Resident #60 was one of three reviewed for reportable incidents. The findings included: Resident #60 was admitted to the facility, with [DIAGNOSES REDACTED].On 07/19/17 , Resident #60 was hospitalized following an incident with CNA #1 that resulted in a distal - humerus fracture, in addition the nurse on duty neglected to assess the resident's condition timely after being informed. According to the facility's investigation, CNA #2 was said to have been providing care to Resident #60, on the last rounds of her/his shift. Per the CNA the resident was resisting care, at which time the resident's arms were pinned above her head by the CNA's forearm in an effort to complete the care that was being provided. The CNA informed the nurse on duty LPN #1, of the resident's complaints of pain, with a statement from the resident indicating the CNA as the individual who had caused the pain in her/his arm. Time lapse of approximately forty-five minutes, when the oncoming staff attempted to assist the resident to breakfast. The resident's arm was swollen and the resident was in pain. The oncoming nurse, for first shift, was notified and assessed the resident. The incident report on file was completed by the oncoming nurse. While reviewing the incident report and supporting documentation, it was revealed an injury to Resident #60, described as prominent bony area on Rt (right) arm at approximately 7:15 a.m. The nurse who completed the form assessed the resident at that time and notified the nurse practitioner, who was on call at that time, the resident's family, the administrator and the interim Director of Nursing. The resident was noted to be confused and disoriented. Emergency Medical Services was contacted and the resident was transported to the hospital at approximately 8:00 a.m., secondary to physician's orders [REDACTED]. The resident was admitted and had surgery. The administration of the facility contacted the appropriate various government agencies, to include the local law enforcement and State Bureau of Certification. An investigation began immediately to include obtaining statements concerning the incident from the resident's roommate and staff present. The resident's roommate was not an appropriate candidate for interview, secondary to cognitive deficits. Review of the voluntary statement provided by LPN # 1, it was revealed that the CNA had informed LPN # 1 of Resident #60's complaint of pain in her/his arm at approximately 6:30 - 6:45 a.m. S/he alleged to have been doing routine medication pass and asked the CNA what was wrong. S/he alleged that the CNA did not know what happened but did not explicitly state her/his involvement. LPN #, stated the CNA, did not asks her/him. The CNA that reported the resident's pain stated that s/he was not assigned to care for the resident but came to work on the morning of 7/19/17 and went to he resident's room to prepare her/his breakfast tray. It was at that time that the resident was noted to be crying in pain showing the CNA her/his elbow. The charge nurse was immediately notified, per her/his statement (CNA). Another oncoming nurse confirmed via her/his voluntary witness statement the occurrence described by the CNA above. Ten other voluntary witness statements were taken at that time but the individuals did not personally witness the incident, nor did they have any further information to provide. According to documentation provided by the facility, in-services and investigation began immediately. To ensure the safety of the residents, corrective actions were taken for both the staff members involved by way of suspension, pending the investigation of alleged abuse. During an interview on 10/3/17 at approximately 4:45 p.m., CNA #1 stated that s/he had nothing further to discuss with regard to the incident. The nurse could not be reached for comment.

Based on full and/or limited record reviews, interviews, and review of the facility policies, it was determined on 6/2/15 at approximately 5:02 PM Immediate Jeopardy and/or Substandard Quality of Care existed for CFR 483.75 F-520 which was identified at a scope and severity level of (L). The facility failed to ensure that the Quality Assurance (QA) process was utilized to identify, monitor and implement a plan of action to ensure routine monitoring of water temperatures to prevent potential injuries to residents. The findings included: Cross refer CFR 483.25 F-323 Free of Accident Hazards CFR 483.25 F-323 was identified at a scope and severity level of (L). The Immediate Jeopardy existed on 6/2/15 when water temperatures were checked on initial tour in thirteen resident bathrooms on Unit 2 and observed to be too hot. On 6/2/15 at approximately 9:30 AM Surveyor Team thermometers were used to check all facility bathrooms. Thirteen resident bathrooms on Unit 2 were found to have hot water temperatures of approximately 121-124 degrees F (Fahrenheit). During an interview on 6/4/15 at approximately 5:30 PM, the facility Administrator confirmed the facility had not identified the water temperatures as being a concern. The Administrator stated the facility had no QA in process relative to the concern. The Administrator stated that the QA Committee identified concerns through the Quality Measures, Bench Mark Reports the 24 Hour Reports, Incident Reports, Grievances, Customer Satisfaction Surveys, the Guardian Angel Program, and the Interact Stop and Watch to identify residents' changes in condition to prevent re-hospitalization s. The Administrator was notified at approximately 5:00PM on 6/2/2015 of the Immediate Jeopardy and/or Substandard Quality of Care related to excessive hot water temperatures in resident rooms. An Allegation of Compliance (AOC) was submitted by the facility on 6/3/15 at approximately 8:45 AM. The actions listed in the AOC included the following: I. Corrective Action taken to remove the Immediate Jeopardy: · On 6/2/2015 at approximately 5:00pm (sic), the survey team notified the facility that an Immediate Jeopardy situation was present in regards to Hot Water Temperatures on the 200 Unit. The survey team stated that resident room temperatures on the 200 Unit were in excess of 120 degrees (highest temperature reported was 124 degrees). It was stated by the survey team leader that excessive temperatures were limited to the 200 Unit and that the other Unit's temperatures (100 Unit) were in compliance. · The Administrator informed the nursing staff on the 200 Unit to cease using hot water on 6/2/15 at approximately 5:20pm (sic) until the situation was resolved. · On 6/2/15 The DON, in coordination with the Licensed Nursing Staff completed 100% body audits on all residents on both units to ensure that there was no evidence of any resident injury or bums due to hot water. The findings of the body audits concluded that there had been no injuries [MEDICAL CONDITION] residents. · The Maintenance Director contacted the facility's contracted plumber and they dispatched a plumber to the facility immediately. The plumber, along with the Maintenance Director and Regional Director of Operations visibly inspected the two hot-water heaters that control resident room temperatures on the 200 Unit. The two hot water heaters each have their own thermostats but are then connected by an adjustable mixing valve. The plumber adjusted the left thermostat to the lowest allowable setting. In addition, the mixing valve was adjusted approximately a 1/4 inch colder temperature to ensure compliance. · At 6:15, the plumber, Maintenance Director, and Regional Director of Operations conducted an initial test of a resident room where excessive temperatures had been noted by the survey team. At that time, the temperature at the resident sink was noted to be 117 degrees, indicating that the adjustments made to the thermostat had successfully removed the immediate jeopardy to the residents. · At 6:30pm (sic) the plumber signed a Teachable Moment form, indicating that he had educated the Maintenance Director on adjusting the thermostats and mixing valves to achieve the desired temperatures, as well as proper calibration of thermometers. At the plumber's recommendation, new Digital Thermometers were purchased by the facility Administrator on 6/2/2015. · At IOpm (sic), The Maintenance Director and Regional Director of Operations checked 100% (12 on each of 2 Units) of resident bathroom sinks and shower rooms on 6/2/2015. All temperatures were within regulatory limits (100 - 120 degrees). · The facility has no recorded grievances by residents that the room water temperatures were too hot. The facility has had no incidents of residents being burned or scalded by hot water. 2. Measures put into place or systemic changes made to ensure that the immediate jeopardy will not recur: · The Administrator and Regional Director of Operations inserviced the Maintenance Director on 6/2/2015 regarding the requirement to check resident room temperatures in accordance with facility policy. A log to record temperatures was provided and will be utilized to ensure ongoing compliance. The water temperature log will be completed daily for two weeks to ensure stability of temperature settings, and weekly thereafter. Any temperature readings in excess of 120 degrees will be corrected immediately and reported to the facility Administrator. · The Staff Development Coordinator began inservicing all nursing staff on 6/2/2015 on the facility's Safety of Water Temperatures policy. No nursing staff will be allowed to work until having received this inservice. This inservice includes: o Any time water feels excessively hot to the touch (i.e., hot enough to be painful or cause reddening of the skin after removal of the hand from the water), staff will report this finding to their immediate supervisor. o Risk factors for scalding/burns that are more common in the elderly, such as: · Decreased skin thickness; · Decreased skin sensitivity; · Peripheral [MEDICAL CONDITION]; · Reduced reaction time; · Decreased cognition; · Decreased mobility, and · Decreased communication. o Other factors that influence temperature tolerance (length Of exposure, amount of skin exposed, and the resident's current condition). o Signs and symptoms [MEDICAL CONDITION](first, second, and third degree) o If a resident is scalded or burned, nursing staff shall follow pertinent first aid and physician notification protocols and report the injury to his or her direct supervisor. · As a precaution, the hot water heaters that control resident room water temperatures on the 100 Unit were reviewed by the plumber, Maintenance Director, and Regional Director of Operations. The findings of the review indicated the left hot water heater was set on 120 degrees, and the right was set on 110. The water from the two hot-water heaters is combined prior to entering the facility. The thermostat of the left hot water heater was reduced to 115 degrees. There has been no reported temperatures on the 100 Unit in excess of 120 degrees. · All new nursing staff will be oriented regarding the Safety of Water Temperatures policy during orientation. Any new Maintenance personnel will also be oriented on this policy, and the log for tracking hot-water temperatures. · Results of hot-water temperature monitoring will be brought to the Quality Assurance Committee monthly to ensure ongoing compliance. However, any noted temperatures above the allowable range of 100-120 degrees will be corrected immediately and reported to the facility Administrator. Observations, review of policy, education and signature sheets on 6/3/15 revealed the Allegation of Compliance submitted by the facility on 6/3/15 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. The Administrator was informed of this on 6/3/15 at 5:25 PM. The citations at F-323, F-490, and F-520 remained at a lower scope and severity of F.

Based on observations, record reviews and interviews the Administrator failed to train and/or provide a job description for the facility Maintenance Director which contributed to immediate jeopardy and/or substandard quality of care. The findings include: Cross refer CFR 483.25 F-323 Free of Accident Hazards On 6/3/15 at approximately 10:00 AM a review of the Maintenance Director personnel file revealed the Date of Hire as Floor Tech: 8/16/13 and Promoted to Maintenance Director/Housekeeping Supervisor: 9/26/14. Further review failed to show a job description or evidence of training for the Maintenance Director. The Administrator stated that s/he was unable to locate a Maintenance Director job description or a record of training for the Maintenance Director. The Administrator was notified at approximately 5:00PM on 6/2/2015 of the Immediate Jeopardy and/or Substandard Quality of Care related to excessive hot water temperatures in resident rooms. An Allegation of Compliance (AOC) was submitted by the facility on 6/3/15 at approximately 8:45 AM. The actions listed in the AOC included the following: I. Corrective Action taken to remove the Immediate Jeopardy: · On 6/2/2015 at approximately 5:00pm (sic), the survey team notified the facility that an Immediate Jeopardy situation was present in regards to Hot Water Temperatures on the 200 Unit. The survey team stated that resident room temperatures on the 200 Unit were in excess of 120 degrees (highest temperature reported was 124 degrees). It was stated by the survey team leader that excessive temperatures were limited to the 200 Unit and that the other Unit's temperatures (100 Unit) were in compliance. · The Administrator informed the nursing staff on the 200 Unit to cease using hot water on 6/2/15 at approximately 5:20pm (sic) until the situation was resolved. · On 6/2/15 The DON, in coordination with the Licensed Nursing Staff completed 100% body audits on all residents on both units to ensure that there was no evidence of any resident injury or bums due to hot water. The findings of the body audits concluded that there had been no injuries [MEDICAL CONDITION] residents. · The Maintenance Director contacted the facility's contracted plumber and they dispatched a plumber to the facility immediately. The plumber, along with the Maintenance Director and Regional Director of Operations visibly inspected the two hot-water heaters that control resident room temperatures on the 200 Unit. The two hot water heaters each have their own thermostats but are then connected by an adjustable mixing valve. The plumber adjusted the left thermostat to the lowest allowable setting. In addition, the mixing valve was adjusted approximately a 1/4 inch colder temperature to ensure compliance. · At 6:15, the plumber, Maintenance Director, and Regional Director of Operations conducted an initial test of a resident room where excessive temperatures had been noted by the survey team. At that time, the temperature at the resident sink was noted to be 117 degrees, indicating that the adjustments made to the thermostat had successfully removed the immediate jeopardy to the residents. · At 6:30pm (sic) the plumber signed a Teachable Moment form, indicating that he had educated the Maintenance Director on adjusting the thermostats and mixing valves to achieve the desired temperatures, as well as proper calibration of thermometers. At the plumber's recommendation, new Digital Thermometers were purchased by the facility Administrator on 6/2/2015. · At IOpm (sic), The Maintenance Director and Regional Director of Operations checked 100% (12 on each of 2 Units) of resident bathroom sinks and shower rooms on 6/2/2015. All temperatures were within regulatory limits (100 - 120 degrees). · The facility has no recorded grievances by residents that the room water temperatures were too hot. The facility has had no incidents of residents being burned or scalded by hot water. 2. Measures put into place or systemic changes made to ensure that the immediate jeopardy will not recur: · The Administrator and Regional Director of Operations inserviced the Maintenance Director on 6/2/2015 regarding the requirement to check resident room temperatures in accordance with facility policy. A log to record temperatures was provided and will be utilized to ensure ongoing compliance. The water temperature log will be completed daily for two weeks to ensure stability of temperature settings, and weekly thereafter. Any temperature readings in excess of 120 degrees will be corrected immediately and reported to the facility Administrator. · The Staff Development Coordinator began inservicing all nursing staff on 6/2/2015 on the facility's Safety of Water Temperatures policy. No nursing staff will be allowed to work until having received this inservice. This inservice includes: o Any time water feels excessively hot to the touch (i.e., hot enough to be painful or cause reddening of the skin after removal of the hand from the water), staff will report this finding to their immediate supervisor. o Risk factors for scalding/burns that are more common in the elderly, such as: · Decreased skin thickness; · Decreased skin sensitivity; · Peripheral [MEDICAL CONDITION]; · Reduced reaction time; · Decreased cognition; · Decreased mobility, and · Decreased communication. o Other factors that influence temperature tolerance (length Of exposure, amount of skin exposed, and the resident's current condition). o Signs and symptoms [MEDICAL CONDITION](first, second, and third degree) o If a resident is scalded or burned, nursing staff shall follow pertinent first aid and physician notification protocols and report the injury to his or her direct supervisor. · As a precaution, the hot water heaters that control resident room water temperatures on the 100 Unit were reviewed by the plumber, Maintenance Director, and Regional Director of Operations. The findings of the review indicated the left hot water heater was set on 120 degrees, and the right was set on 110. The water from the two hot-water heaters is combined prior to entering the facility. The thermostat of the left hot water heater was reduced to 115 degrees. There has been no reported temperatures on the 100 Unit in excess of 120 degrees. · All new nursing staff will be oriented regarding the Safety of Water Temperatures policy during orientation. Any new Maintenance personnel will also be oriented on this policy, and the log for tracking hot-water temperatures. · Results of hot-water temperature monitoring will be brought to the Quality Assurance Committee monthly to ensure ongoing compliance. However, any noted temperatures above the allowable range of 100-120 degrees will be corrected immediately and reported to the facility Administrator. Observations, review of policy, education and signature sheets on 6/3/15 revealed the Allegation of Compliance submitted by the facility on 6/3/15 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. The Administrator was informed of this on 6/3/15 at 5:25 PM. The citations at F-323, F-490, and F-520 remained at a lower scope and severity of F.

Based on observations, record reviews and interviews the facility failed to assure safe water temperatures for 13 of 13 resident bathrooms on Unit 2 (Hall 200). The Maintenance Director failed to have adequate knowledge for checking temperatures and calibrating thermometers and there was no scheduled monitoring of water temperatures. The findings include: On 6/2/15 at approximately 9:00 AM during initial tour of the facility water temperatures were checked by hand in thirteen resident bathrooms on Unit 2 and observed to be too hot. On 6/2/15 at approximately 9:30 AM Surveyor Team thermometers were used to check all facility bathrooms. Thirteen resident bathrooms on Unit 2 were found to have hot water temperatures of approximately 121-124 degrees F (Fahrenheit). On 6/2/15 at approximately 9:55 AM the Maintenance Director was asked to provide a water temperature log and to take water temperatures for the Unit 2 resident bathrooms. He/she stated that no log was kept and obtained a Taylor stick thermometer from the kitchen. When asked about calibration he/she stated that the thermometer had been calibrated yesterday. The Surveyor asked for the thermometer to be calibrated again and the Maintenance Director took the thermometer to the kitchen and asked the Dietary Manager to calibrate. On 6/2/15 at approximately 10:10 AM the Maintenance Director used the kitchen thermometer calibrated by the Dietary Manager to check bathroom water temperatures on Unit 2. Water temperatures were check in bathrooms for room 201/203, 204/206, 209, 211/213, 216 and 215/217. The results obtained by the Maintenance Director were between approximately 100-110 degrees F. The Maintenance Director demonstrated considerable variability in technique when taking temperatures and stated several times that the water sure feels a lot hotter than this. The thermometer was held under the hot water stream at varying angles and the entire temperature sensitive portion of the thermometer was not exposed to the water. The Surveyor temperature reading taken at the same time were between approximately 122-124 degrees F. On 6/2/15 at approximately 10:57 AM the Maintenance Director stated during an interview that he/she did not keep a water temperature log. On 6/2/15 at approximately 11:50 AM the Maintenance Director stated in an interview that he/she had not checked water temperatures in 3-4 months. On 6/2/15 at approximately 11:55 AM inspection of the two hot water heaters for Unit 2 located in an outside room next to room 206 revealed a Honeywell digital controller reading 110 degrees F and an analog thermometer located past the controller reading 117 degrees F. The Maintenance Director was unable to explain the difference, speculated that the thermometer could be old and needed to be replaced and stated there were no logs kept for the two hot water heaters. On 6/2/15 at approximately 2:50 PM prior to rechecking water temperatures the Maintenance Director stated that he/she did not know how to calibrate a thermometer. The kitchen thermometer being used by the Maintenance Director and the Surveyor thermometer were then calibrated in the same ice bath, at the same time by the Dietary Manager and the Surveyor. Once calibrated, the maintenance Director and Surveyor checked water temperatures in bathrooms for rooms 201/203, 204/206, 209, 211/213, 206 and 215/217. Temperature readings for both the Facility thermometer and the Surveyor thermometer ranged from 121 degrees to 123 degrees F. On 6/2/15 at approximately 4:35 PM the Administrator verified that no water temperature logs were being kept by the Maintenance Director. The Administrator was notified at approximately 5:00PM on 6/2/2015 of the Immediate Jeopardy and/or Substandard Quality of Care related to excessive hot water temperatures in resident rooms. An Allegation of Compliance (AOC) was submitted by the facility on 6/3/15 at approximately 8:45 AM. The actions listed in the AOC included the following: I. Corrective Action taken to remove the Immediate Jeopardy: · On 6/2/2015 at approximately 5:00pm (sic), the survey team notified the facility that an Immediate Jeopardy situation was present in regards to Hot Water Temperatures on the 200 Unit. The survey team stated that resident room temperatures on the 200 Unit were in excess of 120 degrees (highest temperature reported was 124 degrees). It was stated by the survey team leader that excessive temperatures were limited to the 200 Unit and that the other Unit's temperatures (100 Unit) were in compliance. · The Administrator informed the nursing staff on the 200 Unit to cease using hot water on 6/2/15 at approximately 5:20pm (sic) until the situation was resolved. · On 6/2/15 The DON, in coordination with the Licensed Nursing Staff completed 100% body audits on all residents on both units to ensure that there was no evidence of any resident injury or bums due to hot water. The findings of the body audits concluded that there had been no injuries or burns to residents. · The Maintenance Director contacted the facility's contracted plumber and they dispatched a plumber to the facility immediately. The plumber, along with the Maintenance Director and Regional Director of Operations visibly inspected the two hot-water heaters that control resident room temperatures on the 200 Unit. The two hot water heaters each have their own thermostats but are then connected by an adjustable mixing valve. The plumber adjusted the left thermostat to the lowest allowable setting. In addition, the mixing valve was adjusted approximately a 1/4 inch colder temperature to ensure compliance. · At 6:15, the plumber, Maintenance Director, and Regional Director of Operations conducted an initial test of a resident room where excessive temperatures had been noted by the survey team. At that time, the temperature at the resident sink was noted to be 117 degrees, indicating that the adjustments made to the thermostat had successfully removed the immediate jeopardy to the residents. · At 6:30pm (sic) the plumber signed a Teachable Moment form, indicating that he had educated the Maintenance Director on adjusting the thermostats and mixing valves to achieve the desired temperatures, as well as proper calibration of thermometers. At the plumber's recommendation, new Digital Thermometers were purchased by the facility Administrator on 6/2/2015. · At IOpm (sic), The Maintenance Director and Regional Director of Operations checked 100% (12 on each of 2 Units) of resident bathroom sinks and shower rooms on 6/2/2015. All temperatures were within regulatory limits (100 - 120 degrees). · The facility has no recorded grievances by residents that the room water temperatures were too hot. The facility has had no incidents of residents being burned or scalded by hot water. 2. Measures put into place or systemic changes made to ensure that the immediate jeopardy will not recur: · The Administrator and Regional Director of Operations inserviced the Maintenance Director on 6/2/2015 regarding the requirement to check resident room temperatures in accordance with facility policy. A log to record temperatures was provided and will be utilized to ensure ongoing compliance. The water temperature log will be completed daily for two weeks to ensure stability of temperature settings, and weekly thereafter. Any temperature readings in excess of 120 degrees will be corrected immediately and reported to the facility Administrator. · The Staff Development Coordinator began inservicing all nursing staff on 6/2/2015 on the facility's Safety of Water Temperatures policy. No nursing staff will be allowed to work until having received this inservice. This inservice includes: o Any time water feels excessively hot to the touch (i.e., hot enough to be painful or cause reddening of the skin after removal of the hand from the water), staff will report this finding to their immediate supervisor. o Risk factors for scalding/burns that are more common in the elderly, such as: · Decreased skin thickness; · Decreased skin sensitivity; · Peripheral neuropathy; · Reduced reaction time; · Decreased cognition; · Decreased mobility, and · Decreased communication. o Other factors that influence temperature tolerance (length Of exposure, amount of skin exposed, and the resident's current condition). o Signs and symptoms of burns (first, second, and third degree) o If a resident is scalded or burned, nursing staff shall follow pertinent first aid and physician notification protocols and report the injury to his or her direct supervisor. · As a precaution, the hot water heaters that control resident room water temperatures on the 100 Unit were reviewed by the plumber, Maintenance Director, and Regional Director of Operations. The findings of the review indicated the left hot water heater was set on 120 degrees, and the right was set on 110. The water from the two hot-water heaters is combined prior to entering the facility. The thermostat of the left hot water heater was reduced to 115 degrees. There has been no reported temperatures on the 100 Unit in excess of 120 degrees. · All new nursing staff will be oriented regarding the Safety of Water Temperatures policy during orientation. Any new Maintenance personnel will also be oriented on this policy, and the log for tracking hot-water temperatures. · Results of hot-water temperature monitoring will be brought to the Quality Assurance Committee monthly to ensure ongoing compliance. However, any noted temperatures above the allowable range of 100-120 degrees will be corrected immediately and reported to the facility Administrator. Observations, review of policy, education and signature sheets on 6/3/15 revealed the Allegation of Compliance submitted by the facility on 6/3/15 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. The Administrator was informed of this on 6/3/15 at 5:25 PM. The citations at F-323, F-490, and F-520 remained at a lower scope and severity of F.

On the day of the complaint investigation, based on record review and interview, the facility failed to ensure clear and concise guidance was provided to facility staff related to resident transfers. Resident # 1 was receiving multiple types of assistance with transfers that occurred both prior to and following identification of an injury to the right leg. On 8/29/13 the resident was admitted to the hospital with [REDACTED]. The findings included: The facility reported to the State Agency that Resident #1 had sustained a fracture of unknown origin and had been admitted to acute care for treatment. The resident was ultimately discharged at the family's request. On 10/15/13 record review revealed the facility investigation into the incident had concluded that the "fracture occurred at the of the difficulties with the lift... and during repositioning... one of the fracture fragments protruded through the skin and resulted in an open wound." Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. On 8/24/13 a physician's order was written to change the method of transfer for the resident. The resident had previously been transferred using a stand-up lift. The new order stated: "May use Marissa lift for transfers per protocol." This was documented as occurring at approximately 4:00 PM. When interviewing Licensed Practical Nurse (LPN) #2 who wrote this order, it was explained that the resident had exhibited some swelling and discoloration at the [PROCEDURE] site and it was concluded that the lift was the possible cause. The nurse stated the information was passed on in report and written in the 24 hour report. On 8/24/13, at approximately 6:30 PM, Certified Nursing Assistant (CNA) #1 was documented as having transferred the resident using the stand up lift per his/her own written statement. In addition to using the standup lift, the CNA violated facility policy and transferred the resident alone, (without assistance from additional staff members). Per the CNA's statement as documented in the investigative file, the transfer "did not go well" and s/he had to "let her down on the bed". The CNA stated s/he asked for assistance from a nurse on duty (Registered Nurse #1) to reposition the resident into the bed and reported "it was not a good idea to use the stand up lift anymore." No apparent injury was noted at this time. As a result of the facility investigation, the inappropriate transfer was identified and on 9/6/13 the CNA received a written notice of corrective action for failing to follow mechanical lift procedures. The Certified Nursing Assistant and the Director of Nursing signed it on 9/6/13. On Sunday 8/25/13 the day shift receives the resident already out of the bed. Two CNA's use the Marissa lift to transfer the resident from the wheelchair to the bed and back to the chair at approximately 9 AM. At 2 PM a 2 person transfer is used the transfer the resident into bed. The Marissa lift is not used and the resident is transferred by lifting the resident under the arms. The CNA flow sheet documents a total dependant/assist on 2 transfer occurred on the evening shift. However, the investigation documented the resident remained in bed for the evening shift. . There is no documentation of injury being present on this date. On Monday, 8/26/13, the day shift again receives the resident out of bed. At 9 AM and again at 1:30 PM, two CNA's transfer the resident using a 2 man transfer (not the Marissa lift). The resident is not documented as being out of the bed for the remainder of the day. At 11:45 PM a body audit is documented and no concerns are identified with the lower extremity. On Tuesday 8/27/13, the resident is received out of bed by the day shift. At 9 AM, incontinence care is provided using the Marissa lift and the assistance of two staff members and the resident is again transferred back into the chair via the lift. At 2:30 PM, two CNA's complete a two person transfer from the wheelchair to the bed. There was no documentation of pain and or injury on this date. The resident remained in bed for the remainder of the day. On Wednesday 8/28/13 at 4 AM, one CNA transferred the resident to the shower chair to provide a shower. S/he noted discoloration and swelling to the right knee. The concern was reported to the nursing staff. Registered Nurse #2 documented the knee as "swollen approximately 3/4 the way up her right thigh. It was yellow with a small reddish discoloration in the middle of the kneecap. The skin was tight and shiny." A staff discussion took place and it was agreed that this was a change, previously not noted. On the day of the survey, when the Director of Nursing was questioned as to why the resident would have been transferred and showered based on the documented assessment, s/he could not explain. Neither the physician not the responsible party was notified at this time of the assessed findings. On 8/29/13, RN #2, who documented the findings, received a "teachable moment" related to assessment, physician notification, and appropriate documentation. On 8/28/13, the day shift receives the resident out of bed. Despite the documentation from the 11-7 shift, the resident continues to be repeatedly transferred in and out of bed. At 9 AM the resident is transferred using a two person CNA transfer for a brief change. The affected area was not visualized. At approximately 1 PM, using a two man transfer, the resident was returned to bed. CNA #2 indicated the bruise was between the size of a penny and a dime. At 4 PM, the resident was in bed and CNA #3 observes the bruise and states it is the size of a half dollar. The written investigation indicates at 5:30 PM, the resident ate supper in the dayroom. However, it also states the CNA also indicated s/he left the resident in bed. The ADL flow record documents that no transfer in or out of bed occurred on the evening shift. Incontinence care is provided in the bed at approximately 10 PM. Thursday, August 29, 2013 at 1:50 AM, the resident is found in the bed with blood on his/her gown and an open area on the right knee. The area was "oozing" blood and the leg lying in a flat position. When assessed by the nurse, a vertical laceration to the outer aspect of the right knee with a whitish protrusion was evident. There was "active bleeding" when the resident flexed the leg. The blood stains were fresh on the bed linens. The resident is subsequently transferred and admitted to acute care. Certified Nursing Assistant #1 was not available for interview and did not return the surveyors calls. On 10/15/13 at 12:10 PM, Certified Nursing Assistant #2 stated during an interview, when a two man transfer was done for the resident, the resident was lifted under the arms, stood and pivoted. S/he stated the resident could not follow directions nor participate in the transfer. The resident could not grasp with the left hand and could not move his/her feet upon command. When asked what determined how the resident was transferred, the CNA stated the facility did not have that many lift slings; therefore, they were not always available. Sometimes, the decision to use a two man transfer was based on the lack of available slings for the Marissa lift. At times, the decision of how to transfer a resident was based on the resident's cognitive status for the day. On 10/15/13 at 12:15 PM, during an interview with LPN #1, s/he was questioned about CNA's following instructions by the nurse. (E.g.. Not using the Marissa lift as instructed in report). S/he stated the nursing assistants should report any concerns as to why they could not follow the nurse's instructions. When asked about the lack of availability of slings, she also verified from "time to time, it does happen, Not very often but it does happen." At 12:50 PM, during an interview with the Certified Occupational Therapy Assistant (COTA), s/he stated per facility policy CNA's could use a 2 person transfer or the Marissa Lift. The explanation was that resident's cognitive status could vary from day to day. Depending on the day, a CNA could use their best judgment and decide how to transfer the resident. S/he stated the rehab department left it up to nursing whether the assistance of 1 or 2 persons was required. S/he explained the Marissa lift was the "lowest you can go." It is the safest of all transfers At 1 PM, The Director of Nursing also stated CNA's were allowed to make a judgment as to the type of transfers. S/he stated no physician order was necessary for using the Marissa lift because it "was the most assistance" a resident could require. When asked if she felt CNA's had the ability to make such decisions related to transfers, s/he stated, "Yes, I do." The CNA ADL Flow record (certified Nursing Assistant Activities of Daily Living) for August 2013 documented information related to transfers (how a resident moves to and from bed, chair, wheelchair, standing). The documentation consistently coded transfers as total dependence with assist of one person on the night shift (11-7) from the 16th through the 28th of August. Only one day (8/24) stated assistance of 2 persons was provided. The other shifts documented transfers occurred with assistance of two persons.