Bishop Gadsden Episcopal Health Care Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, policy review, and staff interview, the facility failed to individualize comprehensive plans for urinary catheter bulb size for two (2) of two (2) residents reviewed for catheter care (Resident (R)11 and R123). This failure could place the residents at risk for discomfort and/or pain.
Findings include:
A review of the facility policy titled Physician Orders, with a revision date of October 2024, documented:
1. Policy
It is the policy of [NAME] to obtain, document, and implement physician (or other licensed practitioner) orders in accordance with federal and state regulations, facility protocols, and standards of clinical practice.
It is the policy of [NAME]'s SNF [skilled nursing facility] to review charts for any changes in Physician Orders. This will be done by the charge nurse every shift using the 24-hour alerts or 'Display New Orders' feature.
2. Procedure
Order Documentation
All orders must be documented in the resident's medical record, either electronically or in written form.
Orders must include:
*Medication
*Dosage
*Frequency
*Route
*Reason for administration
*Date and time of the order
*Resident identification
*Specific Instructions
*Provider name & Electronic signature
*Indication for any PRN [as needed] medications
*Oxygen orders should include rate of flow, route, and rationale .
A review of the facility policy titled Comprehensive Care Plans, with a review date of September 2024, documented:
1. Policy:
The facility develops a comprehensive care plan for each resident that includes measurable goals and timetables to meet the resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment.
2. Procedure:
-2. The comprehensive care plan is prepared by an interdisciplinary team (IDT), including the attending physician, a registered nurse, and other appropriate staff in disciplines as determined by the resident's needs.
1. A review of the clinical record revealed R11 was admitted to the facility on [DATE], with diagnoses to include Retention of Urine.
A review of R11's admission Minimum Data Set (MDS) assessment dated [DATE] revealed a score of four (4) out of fifteen (15) on the Brief Interview for Mental Status Cognition (BIMS), indicating the resident had severe cognitive impairment.
A review of R11's current Physician Orders found an order dated 04/09/25, which noted: Insert Urinary Catheter: [18] Fr [French] [5] cc [cubic centimeter] bulb as needed for Occlusion or Leakage As Needed [sic], with the French (Fr) scale referring to the catheter's diameter, and the cc referring to the size of the bulb or balloon used to retain the catheter in the urinary bladder.
A review of R11's Care Plan revealed the following focus area, dated 04/09/25: The resident has Indwelling Catheter: Atonal bladder and urinary retention. [sic] Interventions associated with the focus are included: CATHETER: The resident has 18 Fr 10 cc balloon indwelling catheter. The balloon size described in the resident's Care Plan did not match the bulb/balloon size noted in the Physician Order.
2. A review of the clinical record revealed R123 was admitted to the facility on [DATE] with diagnoses to include History of Prostate Cancer and History of Bladder Cancer with Chronic Self-Categorization.
A review of the admission MDS dated [DATE] revealed a score of 15 out of 15 on the BIMS, indicating the resident's cognition was intact.
A review of R123 current Physician Order found an ordered dated 04/14/25, which noted: Urinary Code Catheter: [16] F [10 cc] bulb in place. Patient manages catheter clamping and releasing to void.
A review of a Provider Visit Note, dated 04/07/25 at 5:17 p.m., found the following:
. Gross hematuria [blood in urine].
History of prostate cancer, bladder cancer.
Chronic self-catheterization.
Given hx [history], most concerning malignant etiology. Per patient, this has been relatively chronic since starting AC [anticoagulant], and he has self-held his Eliquis [an anticoagulant] at home for hematuria. Self caths 5-6 x/day [self-catheterizes five to six times daily]. Foley [urinary catheter] placed 3/31 given bleeding, diuresis, frequent I/O's [in and out catheterizations]. Hematuria improved w/ foley, likely trauma from frequents I/O's on Eliquis. Urology consulted. Recommended discharge with Foley in place and will f/u [follow-up] as outpatient. Patient wishes to keep foley capped and empty ~4x/day [approximately four times daily]. Urology agreeable to this plan.
A review of the R123's Care Plan, dated 04/07/25, revealed the following focus area: The resident has 14fr/10ml [milliliter] Indwelling Catheter. Patient manages catheter clamping and releasing to void.
In an interview with the Director of Clinical Excellence on 04/25/25 at 10:29 a.m., he/she confirmed the residents' Care Plan should have the same bulb/balloon size as noted in the residents' Physician Orders for the indwelling catheters, as this was a standard of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and staff interview, the facility failed to follow physician orders for oxygen therapy prescribed for one (1) of one (1) sampled resident (Resident (R)14).
Findings included:
A review of the clinical record revealed that R14 was most recently admitted to the facility on [DATE], with diagnoses to include Acute and Chronic Respiratory Failure with Hypoxia, chronic obstructive pulmonary disease (COPD), Acute Pulmonary Manifestations Due to Radiation, Pneumonia, and Influenza.
Review of an admission Minimum Data Set (MDS) dated [DATE], revealed Section O, Special Treatments, Procedures, and Programs, revealed that the resident was receiving oxygen therapy.
A review of the R14's Care Plan revealed a focused area for oxygen therapy, date initiated April 8, 2025, with interventions to include give medications as ordered by physician, monitor for signs/symptoms of respiratory distress and report to Medical Doctor (MD) as needed, and oxygen settings via nasal cannula (NC) at 4 liters (L) per minute (/min) during ambulation and 2 L/min at rest.
A review of the current physician order dated April 7, 2025, for oxygen to be delivered at four (4)L/min during ambulation, and two (2)L/min at rest via nasal cannula (NC) every shift.
An observation on April 22, 2025, at approximately 11:55 a.m., revealed R14 sitting in a wheelchair in his/her room. R14's oxygen concentrator was turned on and ran at one (1)L/min which was not consistent with physician's orders.
A second observation on April 23, 2025, at approximately 11:30 a.m., revealed R14 sitting in a wheelchair in his/her room. R14's oxygen concentrator was turned on and running at one (1)L/min.
A third observation on April 23, 2025, at approximately 12:30 p.m., in the presence of the Director of Clinical Excellence (DCE), revealed R14 sitting in a wheelchair in his/her room. R14's oxygen concentrator was turned on and running at 1 L/min.
Interview with the DCE on April 23, 2025, at approximately 12:35 p.m., confirmed that the physician's order for supplemental oxygen was not followed for R14.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, review of facility policy and clinical records, the facility failed to monitor and/or document the use of a wander guard device according to standards of practice for one (1) of one (1) sampled resident (Resident (R)3), and toprovide care and services consistent with professional standards for the management of pain related to a resident's frequent request for an opioid pain medication prescribed as needed (PRN) and or to ensure the consistent administration of pain medication for one (1) of two (2) residents (R4) sampled for pain.
Findings include:
1.) A review of facility policy titled, Wander Management System, reviewed September 2024, revealed 1. Policy- A wander management system will be used for those residents/patients who are assessed to be an elevated risk to wander or elope. 2. Procedure 1. A tag will be assigned to each resident/patient who qualifies for increased monitoring, per wrist band if ambulatory or to wheelchair if unable to ambulate. 2. The system function will be checked to ensure proper working order on a daily basis by the evening shift charge nurse, checking both the wall sensors and the resident/patient tags.
A review of R3's clinical record revealed admission to the facility on April 7, 2025, with diagnoses to include Traumatic Subarachnoid Hemorrhage without loss of Consciousness, Fracture of Fifth Metacarpal Bone in Right Hand, Dementia, and Depression.
Review of an admission Minimum Data Set assessment (MDS) dated [DATE], revealed that the resident was severely cognitively impaired, and that R3 has wandering behaviors.
A review of the resident's Care Plan revealed a focus area forrisk for wandering and therefore has a wander guard (a device that alerts staff when the resident reaches a certain perimeter/exit) in place left ankle, date-initiated April 11, 2025, with interventions to include check skin around wander guard for any irritation and report to Director of Nursing (DON) if noted. Check wander guard daily for placement and function.
An observation of R3 on April 22, 2025, at approximately 12:10 p.m., found him/her ambulating in the common area between the East and [NAME] unit looking out the window. At this time, a wander guard was observed on his/her left ankle.
During an observation on April 22, 2025, at approximately 1:11 p.m., R3 was seen ambulating on the East unit pleasantly confused. At this time, the wander guard was observed on his/her left ankle.
A Social Services note dated April 11, 2025, at 12:32 p.m., revealed a Wanderguard place on patient's left ankle. Patient's daughter is aware. SS [Social Services] will follow up as needed.
A Daily Skilled Note dated April 11, 2025, at 2:47 p.m., stated no wander guard was present.
An additional Daily Skilled Note dated April 12, 2025, at 3:09 p.m., stated a wander guard was in place. Frequent rounding on patient, attempts to leave unit and ambulate without assistive device.
Further review of the resident's Daily Skilled Notes revealed that on April 15, 16, 18 and 20, 2025, staff documented that a wander guard was not in place. And on April 13, 14, 17, 19, 21 and 22, 2025 staff documented that a wander guard was in place.
A Physician's Order dated April 22, 2025, at 12:20 p.m., prescribed placement of a wander guard to the left (L) ankle of R3 and to check for placement and function every day and every night shift.
A Discharge summary dated [DATE], at 9:50 a.m., indicated the resident was discharged to a memory care assisted living facility.
During an interview on April 23, 2025, at approximately 12:20 p.m., the Director of Clinical Excellence (DCE) verified that the current Physician's Order for the wander guard was not obtained timely, and that the facility's documentation of the wander guard's presence was inaccurate. Furthermore, the DCE was unable to provide documentation of the skin checks for any irritation, or daily checks for placement and function as stated in the residents' care plan. and the DCE also confirmed the facility failed to follow facility policy as well as accepted standards of practice for management and monitoring of a wander guard.
2.) A review of facility policy titled, Pain Management, last reviewed by the facility March 2025, indicated that the facility shall provide adequate management of pain to ensure that residents attain or maintain the highest practicable physical, mental, and psychological well-being. The clinical team shall evaluate the resident for pain upon admission, during periodic scheduled assessments, and with changes in condition or status. Assessment and evaluation by the appropriate members of the Inter Disciplinary Team (IDT) may include: asking the resident to rate the intensity of his/her pain using a numerical pain scale or a verbal or visual descriptor that is appropriate for the resident. Current prescribed pain medications, dosage, and frequency. Note all treatments, including non-pharmacological interventions. Non-pharmacological pain management interventions include but are not limited to: exercises, ROM, physical modalities such as warm compress, cold compress. Turning and repositioning, smoothing linens, adjusting room temperature, cognitive/sensory interventions such as diversions, pain education or music, and massage. The IDT is responsible for developing a pain management regimen. The following are general principles for prescribing analgesics in the long-term care setting: Evaluate the resident's medical condition regimen to determine the most appropriate therapy for pain. Opioid treatment for pain shall be appropriately assessed and individualized for each resident. Reassess and adjust the dose to optimize pain relief while monitoring and trying to minimize or manage side effects.
A review of the clinical record revealed R4 was most recently admitted to the facility on [DATE], with diagnoses to include Fracture of Left Femur (leg), and Left Humerus (arm), Falls, and Malignant Neoplasm of Bladder.
An admission Minimum Data Set assessment (MDS) dated [DATE], revealed that the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13. Review of the MDS indicated the resident has had frequent pain rated at an eight (8) on a scale of zero (0) - 10, within the last 5 days.
Review of the resident's Care Plan revealed a focus area for potential for pain, date-initiated April 14, 2025, with interventions to administer medication as ordered, if PRN, monitor for effectiveness, assess pain per 0-10 numerical scale or PAINAD, and position for comfort, date-initiated April 14, 2025.
A review of current Physician Orders dated April 11, 2025, revealed an order for Tylenol Extra Strength (a non-narcotic analgesic) oral tablet 500 milligrams (mg),one (1) tablet by mouth every six (6) hours as needed (PRN) for left hip pain.
A review of Physician Orders dated April 11, 2025, revealed an order for Tramadol HCL (an opioid - narcotic pain medication) oral tablet 50 mg give two (2) tablets by mouth every six (6) hours PRN for pain related to displaced intertrochanteric fracture of the left femur for 14 days. The order was discontinued April 14, 2025.
A review of Physician Orders dated April 14, 2025, revealed an order for Tramadol HCL oral tablet 50 mg , give one (1) tablet by mouth every four (4) hours PRN for pain related to displaced intertrochanteric fracture of left femur for 14 days. The order was discontinued April 21, 2025.
A review of R4's April 2025, Medication Administration Record (MAR), revealed that nursing administered PRN Tramadol HCL to the resident nine (9) of 11 days, and on five (5) of 11 days, it was administered multiple times a day, for a total of 14 doses, from April 11, 2025, through April 21, 2025.
Continued review of the April 2025 MAR revealed the pain scale (0-10 [0 indicating no pain, and 10 the worst pain]) nursing staff had documented the opioid pain medication, Tramadol, was provided to the resident for a pain score range of four (4) to eight (8). The April 2025 MAR further revealed staff administered Tylenol Extra Strength (a non-narcotic analgesic) also for a pain scaled range of four (4) to eight (8).
A closer review of the April 2025 MAR revealed the Tramadol HCL, and Tylenol Extra Strength was being administered for pain, without any pain scale parameters.
Review of the clinical record, lacked documentation of non-pharmacological interventions (NPI) attempted prior to the administration of the opioid pain medication, Tramadol.
During an interview with the DCE on April 23, 2025, at approximately 12:25 p.m., he/she confirmed that nursing administered the PRN opioid pain medication (Tramadol HCL) to the resident 9 of 11 days, and on 5 of 11 days, multiple times a day, for a total of 14 doses, from April 11, 2025, through April 21, 2025. The DCE further stated the physician orders for both the Tramadol and Tylenol failed to include the parameters for the usage. The DCE further confirmed that the pain scale nursing staff had documented for the opioid pain medication, Tramadol, was provided to the resident for the range from a 4 to 8, and Tylenol Extra Strength (a non-narcotic analgesic) ranged of four (4) to eight (8). When questioned how the nursing staff was to determine which medication, Tramadol or Tylenol, to provide the resident, the DCE stated the resident could request the medication desired and/or clinical nursing judgement would be made. The facility failed to clarify the physician's order for the Tramadol and or Tylenol, which as written, was to be used for pain as needed without parameters, which may lead to a possible opioid dependence related to a resident's frequent use, and the resident's Care Plan failed to address the resident's use of the opioid - narcotic pain medication.
During an additional interview with the DCE on April 24, 2025, at approximately 9:13 a.m., he/she was unable to provide documentation of the NPIs used prior to the administration of the opioid - narcotic pain medication (Tramadol) and or the parameters used for opioid administration, which was not consistent with facility policy and/or accepted standards of practice for pain management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the facility failed to ensure the kitchens were maintained and operated in a safe manner to minimize the chances for potential spread of foodborne illness to all 21 residents in the facility. Failures included not storing food properly, handling ready to eat foods with gloves that had been in contact with potentially contaminated surfaces, failure to air dry pans and food containers before storage, and failure to ensure employee hair restraint while in the kitchens.
Findings include:
Review of the facility's policy titled Storing Staples, revised September 2016, revealed: .2. Procedure.2.1 All dry staples food items are stored in the dry storage area. Certain food items are stored off the floor on clean racks for ventilation and cleaning purposes. 2.2 Other staple items are stored in containers to be protected from splashes and other contamination. 2.3 Food items are rotated frequently. New stock is stored behind older stock to prevent deterioration and spoilage .
Review of the facility's policy titled Storing Perishable Food Items, revised November 2016, showed: 1. Policy. All perishable food items are stored in either refrigerator or freezer equipment. Perishable food items are stored above the floor on clean shelves for cleaning purposes and to prevent contamination (6 inches above the floor). Leftover food items are stored in covered containers. Each container is labeled as to the contents and dated.
Review of the facility's policy titled Sanitary Conditions, effective April 2016, showed: A. Policy. It is the policy of [NAME] to prevent the spread of foodborne illness and abstain from those practices that result in food contamination and compromised food safety. Sanitary conditions are defined as proper storage, preparation, distribution and serving food in order to prevent food borne illness.B. Procedure Dishwashing.Manual: Compartment sink (wash, rinse, and sanitize): Sanitizing solution used according to manufacturer's instructions. -Scrape, remove all food -Wash and thoroughly rinse surfaces -Immerse in sanitizer solution 150-400 ppm (machine automatically dispenses proper amount. ----All surfaces should be exposed to sanitizer solution for no less than one minute. -Allow to dry before storage .
Review of the facility's policy titled Labeling, effective February 2008, showed: Purpose: The purpose of this policy is to ensure the safety and quality of food served in our skilled nursing facility by implementing guidelines for labeling and dating all food items stored in the kitchen. Scope: This policy applies to all staff members responsible for handling, storing, and preparing food within the kitchen premises of the skilled nursing facility. Responsibility: It is the responsibility of the kitchen staff to adhere to this policy and ensure proper labeling and dating of all food items in accordance with CMS [Centers for Medicare and Medicaid] regulations. Labeling Guidelines: a. All food items, including raw ingredients, prepared meals, leftovers, and perishable items, must be labeled with the following information: -Name or description of the food item; -Date of preparation or opening; -Use-by or expiration date, if applicable. b. Labels should be clear, legible, and affixed to the container or packaging of the food item using a permanent marker or adhesive label. c. Dating Procedure: -Food items should be dated at the time of opening or preparation. -Use the following format for dating: Month/Day/Year -If a food item has been opened, transferred to another container, or repackaged, it should be dated with the current date.
Review of the facility's policy titled Hair Restraints, effective June 2002, showed: Policy: 1. Food employees shall wear hair restraints such as hats, hair covering and nets, beard restraints, and clothing that covers body hair that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, linens, and unwrapped singe-service or single-use articles.
Review of the facility's policy titled Food Preparation & Handling, effective July 2016, showed: .D. Food employees should wash their hands immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: a. After touching bare human body parts other than clean hands and clean, exposed portions of arms; b. After using the toilet room; c. After caring for or handling animals; d. After coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, or drinking; e. After handling soiled equipment or utensils; f. When switching between working with raw food and working with ready-to-eat food; g. Before donning gloves to initiate a task that involves working with food; h. After engaging gin [sic] other activities that contaminate the hands.
During the initial tour of the first-floor kitchen on 03/18/24 at 10:50 AM, the Executive Chef (EC) introduced himself and was noted to not have his hair restrained. During the tour, five blue tied plastic bags were observed on the top shelf of the walk-in cooler with no identification as to contents or date of storage. The EC confirmed at 11:05 AM the bags contained flatbread and were not labeled. The EC stated the flatbreads had been removed from the original box that morning. Continued observation revealed a commercial size [NAME] mixer was noted to have the bowl stored uncovered and in the lowered position with the paddle blade attached. When asked the last time the mixer was used, the EC stated that was unknown and confirmed debris and organic matter could settle in the bowl. At 11:15 AM observation of racks of clean pans and acrylic food storage containers revealed a stack of nine full shallow steam table pans stacked with moisture in between the pans and a stack of five acrylic containers with moisture in between. The EC confirmed the moisture and removed the two stacks to be rewashed. At 11:20 AM, the Robo Coupe (food processor) was noted assembled with the blade inside with moisture in the interior. The EC confirmed the presence of moisture and took the bowl/blade to the dishwasher room.
During an interview on 03/18/24 at 11:24 AM, the EC was questioned as to whether he was required to restrain his hair while he was in the kitchen and responded (as he fished a hairnet out of his pocket), When I heard you were here I just left the office and forgot to put it on.
During an observation on 03/19/24 at 11:53 AM, of the second-floor kitchen revealed a staff member in a gray jacket walking through the kitchen without a hair restraint on. At 11:65 AM, the Certified Dietary Manager (CDM) joined the observation tour. A bin labeled Flour Sugar Powder Leavener was noted to have an expiration date of 02/11/24. At 12:02 PM the CDM stated It's full so it tells me he didn't change the sticker. At 12:03 PM another bin labeled chocolate candies and flavored chips was noted to have an expiration date of 02/11/24, when pointed out to the CDM, she picked up the bin and passed it through the window to the dishwasher. At 12:08 PM the staff member in the gray jacket walked out of the dishwash room and through the kitchen again. The CDM identified him as a title of Utility Healthcare (UHC)3 and instructed him to go to the office and get a hair restraint. At 12:10 PM when asked about the evening service time for the Rehab unit, the CDM stated that evening trays could be served from downstairs [first floor kitchen] occasionally. When asked how often per week that occurred, the CDM responded, Right now, every evening as we are short line cooks. The surveyor entered the dishwasher room by the three-compartment sink to observe UHC1 towel drying a sheet pan at 12:12 PM. When asked if he was trained to towel dry pans, UHC1 stated no. The CDM walked up as UHC1 was answering and stated, Not supposed to dry with a towel, air dry. UHC4 confirmed the sheet pan being towel dried had been washed in the three-compartment sink.
During an observation 03/20/24 at 11:29 AM, of the Rehab mid-day meal service, [NAME] 1 was observed wearing gloves and slicing scallions. At 11:38 AM, meal service started and [NAME] 1 was observed to remove two portions of chicken with tongs from the steam table pan; held the chicken with gloved hands and sliced them on the cutting board, picked each portion up with gloved hands and placed them onto a plate. After serving the other food items, used the same gloved hands to place scallions and an orange slice on the plates as garnish. [NAME] 1 then went over by the cooler table and opened a bread wrapper, removed 4 slices of bread, uncovered the tuna salad in a deep 1/8 acrylic pan covered with plastic wrap, and placed tuna salad on the bread with a spoon. [NAME] 1 then opened the lettuce container, picked up two slices of lettuce and placed it on top of the tuna, cut the sandwich with a knife, and placed it on to a plate. [NAME] 1 then uncovered the pickle spears, picked up a spear and placed it on the plate, turned back by the griddle and removed the plastic wrap from a 1/3 deep steam table pan that contained potato chips, used his gloved hands, and then placed potato chips onto the plate with gloved hands. [NAME] 1 then retrieved a large jar of peanut butter from the shelf above the cold deli items, opened it, spread peanut butter on the bread while held in gloved hand, put the bread down, put the lid back on the peanut butter, opened the two-door refrigerator under the deli item cooler and retrieved a Smucker's grape squeezable jelly. The [NAME] then squeezed the jelly onto a slice of bread, spread the jelly with a spoon, picked up the knife, turned on the water in the sink to the right of the deli cooler items, rinsed the knife under the water, dried the knife with a towel at his waist, cut the sandwich, placed it on a plate, and served potato chips with his gloved hands onto plate. At 11:41 AM, [NAME] 1 changed his gloves and served the next plate which was sweet & sour shrimp. [NAME] 1 removed three shrimp from the steam table pan, chopped the shrimp and placed them in a bowl with his hand, ladled in sauce and mix, and then poured onto a plate. Next [NAME] 1 removed two pot stickers with tongs and chopped them with the same knife on the same cutting board, placed the chopped pot stickers onto the plate with gloved hands and knife, then chopped egg rolls in the same place with the same knife. All plates were garnished with orange slices and scallions via gloved hands. At 11:50 AM, [NAME] 1 left the steam table area to retrieve tongs, then opened a black zippered bag with orange handles, withdrew a squeeze bottle, used the tongs to open a steam table pan to pick up a hamburger, place it on the griddle, cover with a stainless-steel bowl, and squirt water (confirmed by Cook1) to steam the burger. [NAME] 1 then opened a bag of hamburger buns, removed one, squirted oil onto the griddle, opened the bun and placed down onto the oiled griddle. [NAME] 1 then opened the bread wrapper and removed two slices, laid them on the shelf by the deli cooler, commented if there were a lot of sandwiches ordered he would prep them in advance and keep them in the refrigerator, if not a lot he will make to order. At 11:52 AM, the [NAME] served a plate with stir fry vegetables using a spoodle (a serving utensil) and placed two egg rolls onto the plate by hand. [NAME] 1 proceeded to slice a serving of chicken with gloved hands, placed the sliced chicken on plate, and garnished with scallions and an orange slice. At 11:55 AM, [NAME] 1 removed lettuce and tomato with gloved hands, placed them onto a bun, held the other half of the bun in his other hand, added the hamburger patty, placed the hamburger onto a plate, and then added a pickle spear and potato chips with gloved hands. The last plate was served with two egg rolls placed on the plate by the gloved hand, sliced a serving of chicken, placed the chicken on plate with the same gloved hand and garnished the plate with scallions and a orange slice with same gloved hands. The service ended at 11:56 AM.
During an interview on 03/20/24 at 12:42 PM, the CDM stated it was her expectation staff, depending on their station, if working prep or plating, [then staff] require a hair restraint. Dining room servers do not need a hair restraint, and the dishwashers usually wear a hat - but he (UHC3) had a lot of hair. The CDM also stated it was her expectation When handling ready to eat, cutting/chopping meat, using gloved hands to put food on plate, ready to eat defined anything not going to be cooked further, would be picked up with gloved hands or tongs. When queried if touching the bread product wrappers and door handles contaminated gloves, the CDM stated, if touching handles of things should definitely change gloves. The CDM did not confirm that touching bread wrappers would contaminate gloves.
During an observation on 03/20/24 at 3:15 PM, of the first-floor kitchen prepping the evening meal items for the second floor Rehab, revealed UHC2 was preparing cantaloupe with no hair restraint. When mentioned to the EC at 3:19 PM, the EC stated the fruit was for the Rehab unit. The EC told UHC2 to go put his cap on and explained to him that whenever out here [kitchen area] [you] need that [hat] on when working with food.
During an interview on 03/20/24 at 4:31 PM, regarding the number of Rehab residents that receive meals from the kitchen, the Director of Nursing (DON) stated, All residents on rehab receive their meals from the kitchen; nobody is NPO [nothing by mouth] or receiving tube feedings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews the facility failed to assure a medication error rate of less than 5% (percent) based on medication pass observations for 1 of 3 residents. There were two medication administration errors resulting in an error rate of 7.67%.
related to medication administration to Resident (R)224 who was admitted to the facility on [DATE] with diagnoses including, but not limited to acute respiratory failure with hypoxia.
Findings include:
During observation of Medication Administration on 03/18/24 at approximately 4:00 PM, Registered Nurse (RN)1 stated she was going to give Azelastine Nasal Spray to R224 and took a pharmacy labeled dispensing vial for R224 from the medication cart which had been labeled by pharmacy as Azelastine Nasal Spray for R224. RN1 then removed a container of Fluticasone Nasal Spray from the pharmacy labeled Azelastine vial. After punching other medications for R224 from medicine cards, she started toward the resident's room when the Surveyor stopped her asking that she review the name of the container of nasal spray in her hand as being the intended medication. After looking at the dispensing vial and bottle of nasal spray RN1 stated I have the wrong medicine, she is supposed to get Azelastine, not Fluticasone and someone put the wrong medicine in the pharmacy labeled Azelastine vial. At approximately 4:06 PM, RN1 proceeded to the resident's room and administered all oral medications, then at approximately 4:11 PM, RN1 administered 2 sprays of the Azelastine Nasal Spray into each of R224's nostrils.
On 03/18/24 at approximately 4:19 PM during medication reconciliation, a review of the March 2024 physicians orders revealed an order for Azelastine 137 mcg (microgram) (0.1%) nasal spray aerosol 1 spray in NASAL twice a Day for ALLERGIC RHINITIS, UNSPECIFIED and an order for Fluticasone Allergy Relief 50 mcg/actuation nasal spray, suspension [Fluticasone propionate] Nasal 2 sprays into each NASAL Every Day for Allergic RHINITIS, UNSPECIFIED.
During an interview on 03/18/24 at approximately 4:27 PM, RN1, after reviewing the medication administration record and medications for R224, stated she had given too many sprays of Azelastine to R224.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, manufacturer' guidelines and review of the facility's policy and procedures, the facility failed to ensure the Medical Director worked with the facility to completely assess 1 of 5 residents (Resident (R)75) for unnecessary medications. Specifically, an antipsychotic and psychoactive medication was used by the facility without an attempted gradual dose reduction (GDR), proper medical rationale or proper indication for use.
Findings include:
Review of the facility's policy titled Psychotropic Medication Guideline revised March 2022 revealed, The Medical Director will act in an administrative and supervisory capacity by A. Contributing to the establishment of the Medical Policies in to the establishment of the Medical Policies B. Supervising the medical care given C. Ensuring that the medical policies are carried out D. Participating in the Quality Improvement Program to identify areas of improvement of patient care E. Approving medical care procedures as set forth in the procedures Manual. and The Medical Director shall act as a liaison between attending physicians and the Directors of the respective healthcare areas, assuring compliance with regulations.
Review of the Centers for Medicare and Medicaid S&Q Memo Ref 13-35-NH dated May 24, 2013 revealed, .The problematic use of medications, such as antipsychotics, is part of a larger, growing concern. This concern is that nursing homes and other settings (i.e., hospitals, ambulatory care) may use medications as a quick fix for behavioral symptoms or as a substitute for a holistic approach that involves a thorough assessment of underlying causes of behaviors and individualized, person-centered interventions . When antipsychotic medications are used without an adequate rationale, or for the purpose of limiting or controlling behavior of an unidentified cause, there is little chance it will be effective. In addition, they commonly cause complications such as movement disorders, falls, hip fractures, cardiovascular events (cardiovascular accidents and transient ischemic events) and increased risk of death .
Review of the manufacturer's guideline for the use on Seroquel last updated 03/27/20 revealed under the section titled, Indications, Seroquel is used specifically for the treatment of bipolar disease and schizophrenia with a Black Box Warning Increased mortality in elderly patients with dementia-related psychosis.
Review of R75's Face Sheet revealed R75 was admitted to the facility on [DATE] with diagnoses including but not limited to: pneumonia, unspecified organism, (idiopathic) normal pressure hydrocephalus and unsp (unspecified) dementia, unspecified severity, without beh/psych/mood/anx (behaviors/psychiatric/mood/anxiety).
Review of R75's Electronic Medical Record (EMR), Physician Orders and Medication Administration Record (MAR) dated March 2024, revealed orders dated 03/12/24 for Seroquel 25 mg (milligram) tablet (Quetiapine) 1 tablet ORAL Twice a Day for UNSPECIFIED MOOD [AFFECTIVE] DISORDER being administer daily starting 03/13/24, as prescribed, at 09:00 (9:00 AM) and 16:00 (4:00 PM); Seroquel 25 mg (Quetiapine) - 2 tablets ORAL Hour of Sleep. (Take with Quetiapine 200 mg to equal 250mg) For UNSPECIFIED MOOD [AFFECTIVE] DISORDER and Seroquel 200mg [Quetiapine] - 1 tablet ORAL Hour of Sleep. (Take with Quetiapine 50mg to equal 250mg) For UNSPECIFIED MOOD [AFFECTIVE] DISORDER being administered daily starting 03/12/24, as prescribed, at 21:00 (9:00 PM) with the exception of not having been administered on 03/13/24.
On 03/19/24 at approximately 1:52 PM review of the [NAME] St. [NAME] Physician Partners discharge plan revealed continue .Seroquel .
Review of R75's entry Minimum Data Set (MDS) did not indicate R75 had a psychiatric/mood diagnosis or that R75 was receiving a psychotherapeutic agent .
Review of R75's March 2024 EMR failed to reveal the physician's rationale for prescribing Seroquel and there were no behaviors or psychosis documented on the MAR or in progress notes.
On 03/19/24 at approximately 4:02 PM and on 03/20/24 at 11:55 AM, attempts were made to contact the Medical Director but were unsuccessful.
On 03/20/24 at approximately 1:15 PM review of R75's Baseline Careplan revealed Administer medications as ordered and Dementia Care with no reference to a specific medication.
During an interview on 03/20/24 at approximately 1:21 PM, the Administrator and Director of Nursing (DON) confirmed that R75 was receiving high doses of Seroquel during his recent hospitalization and subsequent to his admission to the facility on [DATE] and that this particular Medical Director was not working with the facility to have a complete assessment for continued use of psychotherapeutic agents. The reason being not wanting to mess with orders for long standing psychotherapeutic medications during a short term stay at the facility. The Administrator and DON stated that their expectation was for a complete and documented assessment by the Medical Director or prescribing physician to occur.

Based on observations, record reviews, interview and facility Departmental Procedure, the facility failed to ensure expired medications were removed from active storage in 1 of 1 medications rooms.
The findings include:
On 2/14/22 at approximately 10:38 AM, inspection of the medication room refrigerator revealed one opened vial of Tuberculin, Purified Protein Diluted, Diluted, Aplisol by Par Pharmaceuticals 5 TU (test units)/0.1 ml (milliliter) 1ml (10 tests) approximately 1/4 full, dated as opened by the facility on 1/9/22. This medication was labeled by the manufacturer Once entered, vial should be discarded after 30 days and the manufacturer package insert states Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency.
The Departmental Procedure, revised October 2021, states under 2.3 Expired or discontinued medication shall not be stored with current medications. On 2/14/22 at approximately 10:48 AM, these findings were confirmed by Registered Nurse 1 and on 2/17/22 at approximately 9:05 AM, the Director of Nursing stated that the night shift nurses and pharmacy are responsible for checking accuracy of storage in the medication room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interview, review of the manufacturer's guidelines for medication use, and review of the facility's policy and procedure, the facility failed to ensure that one of five residents (Resident (R) R10) reviewed for unnecessary medication use did not receive psychoactive medication without a clinical risk versus benefit assessment and analysis, appropriate indication for use of the medication, attempting gradual dose reductions, identifying and routinely monitoring specific target behavior, and developing and implementing resident specific non-pharmacological interventions. This deficient practice had the potential for serious harm and/or death for all residents who reside in the facility.
Findings include:
Review of the facility's policy titled, Psychotropic Medication Guidelines dated May 2021, revealed the facility was to ensure that .Residents who have not used psychotropic medications would not be prescribed psychotropic medications unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record.
-Residents who use psychotropic medications receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. -Residents do not receive psychotropic medications pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. -PRN orders for psychotropic medications are limited to 14 days. Except as provided in 438.45(e)(5). If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration of the PRN order .
Further review of the facility's psychotropic medication policy revealed that the procedure was .the ordering provider will document the rationale and diagnosis for the use of the medication. -the ordering provider will discuss with the resident and/or responsible party the risk versus benefits of the medication, including any black box warnings. -A gradual dose reduction (GDR) decrease, or discontinuation of the medication will be attempted after no more than 3 months unless clinically contraindicated. -the facility's contracted psychiatrist will be consulted as resident's clinical condition requires .The nursing team will monitor the psychotropic drug use, noting any adverse effects such as functional decline or increase somnolence. -The nursing team will monitor for the presence of target behaviors on a daily basis, charting by exception .
Review of the manufacturer's guidelines for the medication Seroquel (An antipsychotic medication) dated 10/20 revealed that Seroquel was prescribed to treat specific conditions, which did not include insomnia, psychosis, anxiety, drowsiness, and agitation. In addition, use of this medication for residents with dementia placed the resident at increased risk of harm, injury, or death.
Review of the manufacturer's guidelines for the use of the medication Seroquel last updated 10/20 revealed, .Approved Uses Seroquel is a once-daily tablet approved in adults for major depressive disorder (MDD) who did not have an adequate response to antidepressant therapy; bipolar disorder; acute manic or mixed episodes in bipolar disorder alone or with lithium or divalproex; long-term treatment of bipolar disorder with lithium or divalproex; and schizophrenia .Elderly patients with dementia-related psychosis (having lost touch with reality due to confusion and memory loss) treated with this type of medicine are at an increased risk of death, compared to placebo (sugar pill). Seroquel is not approved for treating these patients .
On 02/14/22 at 10:32 AM, R10 was observed in his room in the chair watching television. R10 stated that he felt good today and was not having any issues. R10 appeared calm and was not exhibiting hallucinations or negative behaviors.
On 02/15/22 at 2:10 PM, R10 was observed in his wheelchair located in the common area. When asked R10 stated that he was having a good day. R10 was not exhibiting any hallucinations or negative behaviors.
On 02/16/22 at 12:27 PM, R10 was observed eating lunch meal at the dining hall at a table with three other residents. R10 was calm, talkative, and not exhibiting hallucinations or negative behaviors.
On 02/16/22 3:21 PM revealed R10 was observed sitting in his room in the recliner watching television. R10 was not exhibiting hallucinations or negative behaviors.
On 02/17/22 at 9:06 AM, R10 was observed in his room in the recliner watching television and was not exhibiting hallucinations or negative behaviors.
Review of the electronic medical record (EMR) Face Sheet for R10 revealed R10 was admitted on [DATE] with a re-admission date of 11/29/21 with diagnoses of Parkinson's disease, Dementia without behavioral disturbances, and pneumonia.
Review of R10's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 09/08/21 revealed R10 exhibited mild cognition impairment with symptoms of depression (feeling down, tired, bad about self, and trouble concentrating). It was documented R10 had no hallucinations and no behaviors. R10 was administered seven days of antidepressant medication.
Review of R10's discharge MDS assessment with an ARD of 11/19/21 revealed R10 had no behaviors, no hallucinations, and was administered six days of antidepressant medication. R10 required extensive staff assistance with activities of daily living (ADL).
Review of R10's quarterly MDS assessment with an ARD of 12/05/21 revealed R10 exhibited mild cognition impairment with symptoms of depression (feeling tired, and trouble concentrating). It was documented R10 had no behaviors or hallucinations. R10 was administered seven days of an antipsychotic medication with no gradual dose reduction (GDR) attempted, and no documented clinical rationale for the use of an antipsychotic medication.
Review of R10's EMR Medication Record for the month of November 2021, revealed on 11/29/21 R10 was started on Seroquel 25 mg (milligrams) by mouth for circadian rhythm sleep disorder, irregular sleep wake type, at hour of sleep routinely. There was an order to monitor target behavior each shift, however, it was not stated what the target behavior was.
Review of R10's EMR Physician's Orders for the month of February 2022, revealed R10 was prescribed an antipsychotic medication (Seroquel) 25 mg by mouth for circadian rhythm sleep disorder, irregular sleep wake type hour of sleep that started on 11/29/21. In addition to, R10 had an order to monitor target behavior for MDD, Single Episode, Severe W [sic] Psych
Review of R10's EMR Diagnoses tab revealed no listed diagnosis of circadian rhythm sleep disorder, irregular sleep wake type.
Review of R10's EMR current comprehensive Care Plan with a Category: Behavior Problem dated 11/29/21 revealed R10 had hallucinations related to the Parkinson's disease. The non-pharmacological interventions were to re-direct the resident if able, attempt to determine cause and trigger of behavior, be mindful of the resident and treat with respect and dignity while providing care, and reassure and provide comfort to the resident. Further review of R10's plan of care revealed a Category: Psychotropic Drug use dated 11/29/21 revealed interventions for monitoring adverse effects of the psychotropic medication. The interventions listed were: Medication as ordered, Monitor resident for any side effects related to psychotropic medication - to include drowsiness, restlessness, muscle spasms, tremor, dry mouth, blurring of vision or tardive dyskinesia, Notify MD of any problems noted, AIMS quarterly, and Pharmacy review monthly and notify MD of GDR recommendations.
Review of R10's hospital Discharge Summary dated 11/29/21 revealed R10 had been prescribed Seroquel medication 25 mg 1 tablet oral (given by mouth) every 6 hours as needed for agitation . R10's discharge diagnoses were toxic metabolic encephalopathy, pneumonia, leukocytosis, Parkinson's disease, and dehydration. There was no diagnosis indication for the use of an antipsychotic medication (Seroquel).
Review of R10's psychiatric note titled, Nursing Home Follow-Up Visit dated 11/19/21 indicated R10 was last seen in 2017 and was being followed by psych services for depression. The note stated: .Both staff and daughter have been concerned for depression due to recent death of son and his (R10) own health decline. Per staff (R10) has been less interactive and engaged. Pt. [sic] (patient) seen and examined . Further review revealed R10 had been feeling weak, anxious, tired, and trouble falling asleep, and denied being depressed. It was indicated the physician ordered laboratory tests and clinical assessment to rule out any acute physical illness that may be causing R10's symptoms. A medication review was noted, and it was documented that R10 was prescribed Aricept 20 mg (milligrams), Trazadone 50 mg, and melatonin 5 mg qhs [sic] (every day at hour of sleep). It was documented R10's appearance and behavior during the visit was ill in appearance, cooperative, and had frequent coughing spasms throughout the interview. R10's speech was fast, somewhat mumbled, and mostly fluent. R10's thought process was tangential and with loose associations off the topic from the question at hand. R10 was oriented to person and place, not time and judgement was impaired during the interview. It was documented that the psychiatric physician's summary of findings included delirium, MNCD (Mild neurocognitive disorder) due to PD (Parkinson's disease), r/o (rule out) vascular component, and anxiety. The psychiatric physician recommended a concern that R10 may have been experiencing acute delirium based on R10's presentation during the visit. It was documented the psychiatric physician coordinated care with the Nurse Practitioner (NP) and the clinic and due to an increase in temperature and the change in mental status R10 was sent to the emergency department for further evaluation. The psychiatric physician stated, Will be happy to reassess once medical condition stabilizes.
Review of R10's physician assessment progress note dated 12/02/21 provided by the Director of Nursing upon request on 02/16/22 revealed R10 was seen by the physician for a skilled 3-day follow up from a hospital stay. The medications listed on the assessment indicated R10 was prescribed Seroquel medication 25 mg 1 tablet orally every 6 hours as needed. It was documented under the Assessments that R10's hospital metabolic encephalopathy (A medical term used to describe a disease that affects brain structure or function. It causes altered mental state and confusion) was clinically resolved and the goal for the Seroquel medication was to taper off over the next 2-3 weeks.
Review of R10's physician assessment progress note dated 01/06/22 provided by the Director of Nursing upon request on 02/16/22 revealed R10 was seen by the physician for a skilled 4 week follow up from a hospital stay. The medication listed on the assessment indicated R10 was prescribed Seroquel medication 25 mg 1 tablet orally every 6 hours as needed. Under the Symptoms note it was documented .From review of records and talking to staff, there are no current issues. There have been no incidents in the past 4 weeks . Under the Treatment note the documentation stated R10 .did have significant metabolic encephalopathy during his acute respiratory illness (hospital stay for pneumonia) .Seroquel was started .on low dosing of Seroquel and appears to be overall sleeping well and generally awake and active during the day, with brief naps, as per nursing staff . Remains cooperative .
Review of R10's daily behavior monitoring documentation from 10/2021 through 02/2022 revealed R10 exhibited no hallucinations or behaviors.
Review of the pharmacy Consultation Report for R10 dated November 30, 2021, revealed the pharmacy made a recommendation that stated: .Please reassess Seroquel use with the end goal of discontinuation. Individualized non-pharmacological interventions are recommended throughout this process. Rationale for this recommendation: There is inadequate evidence supporting the effectiveness of antipsychotic medications in insomnia. If therapy is to continue, it is recommended that a) the prescriber document an assessment of risk versus benefit describing why continued use of this medication continues to be a valid therapeutic approach for this individual, b) the record contain documentation of the dose reduction history and individualized non-pharmacological interventions including the outcomes; and c) the facility interdisciplinary team ensures ongoing monitoring for effectiveness, potentially reversible causes, and potential adverse consequences . The physician's response: I decline the recommendation above and do not wish to implement any changes due to the reasons below: Pt. [sic] (patient) doing well on Seroquel HS (hour of sleep) but will try to wean in near future.
Review of the pharmacy Consultation Report for R10 dated January 28, 2022, revealed the pharmacy made a recommendation that stated: .Please reassess Seroquel use with the end goal of discontinuation . The rationale and statement were the same as the above reference. The physician's response: I decline the recommendation . pt.[sic] (patient) delirium related to PD (Parkinson's disease) well controlled on present dosing. Delirium (A short term effect from either acute illness, infection, intoxication, psychoactive medication, and sleep deprivation and usually resolves once the trigger is resolved).
Interview with Licensed Practical Nurse (LPN) 2 on 02/15/22 at 3:30 PM revealed she stated that R10 was an easy-going person and liked to talk about his bugs and what his occupation was before retirement. LPN 2 stated R10 does not exhibit any behavioral or hallucination symptoms and was a joy to care for.
Interview with Certified Nursing Assistant (CNA) 2 on 02/15/22 at 3:50 PM revealed R10 was a quiet person who loved to read and watch television. CNA 2 stated when caring for R10 he had not exhibited any behavioral or hallucination symptoms.
Interview with LPN 1 on 02/17/22 at 9:09 AM revealed R10 was a polite, quiet, and sweet man. LPN 1 stated R10 had a few hallucinations a few months back, however, there had been none since. LPN 1 stated she had noticed that R10 was prescribed Seroquel medication at night and thought it was due to sleep issues.
Interview with the Consulting Pharmacist (CP) on 02/16/22 at 11:46 AM revealed she stated that she sent pharmacy recommendations to the facility in November 2021 to reassess R10's Seroquel for hallucinations and behaviors with the end goal to discontinue. The CP stated on the follow up in January 2022 R10 had continued on the Seroquel 25 mg daily. The CP further stated, she had been trying to get the physician to wean R10 off the Seroquel medication with no success. The CP stated review of R10's progress notes for earlier in the month showed documentation that R10 exhibited .daytime fatigue, sleeping fairly well with occasional wake up at 2am and most the time can get back to sleep . There was no documentation that R10 had exhibited negative behaviors or hallucinations.
Interview with R10's Medical Doctor (MD) on 02/16/22 at 12:47 PM revealed she stated that R10's Seroquel medication had continued after admission due to having reported symptoms of hallucinations. The MD stated R10 needed the psychotropic antipsychotic medication for the Parkinson's diagnosis. The MD stated R10 had attended the mood clinic at the Medical University of South Carolina (MUSC) for mental health treatment. The MD further confirmed R10 should be weaned off the Seroquel medication and that it was not an appropriate medication for Parkinson's disorder. There was no documentation in R10's EMR related to a history of mental health treatment as described by the MD.
During the Quality Assurance Process Improvement (QAPI) meeting with the Administrator held on 02/17/22 at 11:42 AM revealed the Administrator stated she agreed that the facility had not identified through the QAPI process any concerns with the use of psychotropic medications or pharmacy services.

Based on observations, interviews and review of the facility Departmental Procedure, Food Storage in Country Kitchen Refrigerator, the facility failed to ensure an expired item was removed from the reach in cooler and failed to ensure open items in the cooler, freezer and the dry storage were labeled with an open date and resealed. The facility further failed to ensure food splatter was removed from the microwave in the Bistro and failed to ensure a covered trash receptacle was provided at the hand washing sink in the Bistro. This deficient practice has the potential to affect all 34 residents eating foods prepared and stored in the Bistro.
The findings included:
An observation on 2/24/22 at 10:40 AM during initial tour of the Bistro revealed the following:
Food splatter in the top of the microwave.
A covered trash receptacle not provided at the hand washing sink in the Bistro.
A small carton of milk in the reach in cooler with an expired date of 2/12/22.
A tub of mixed fruit opened and not labeled with an open date.
An open bag of 2 frozen hamburger patties in the reach in freezer in the Bistro with no open date and not sealed.
A bag of fried Clams in the freezer opened with no open date and not sealed.
A bag of brown sugar opened in the dry storage with no open date.
A bag of spaghetti noodles opened and partially used with no open date.
A bag of chipped cashews opened with no open date.
An interview on 2/14/22 at 10:45 AM with the Chef confirmed the above findings. The missing trash receptacle at the hand washing sink was confirmed by the Culinary Services Manager.
Review on 2/15/22 at 1:40 PM of the facility Departmental Procedure titled, Food Storage in Country Kitchen Refrigerator. revealed:
1. Policy - It is the policy of this facility to ensure that perishable, refrigerated items stored in the country Kitchen are discarded appropriately.
2. Procedure - All items stored in the refrigerator need to be dated when opened.
1.2 Discarding items: b. Milk products are to be discarded based on the expiration date printed on the product.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review the facility failed to maintain an effective infection control and prevention program by failing to monitor COVID 19 screening process logs to ensure accurate and within normal limit temperature measurements of 97 degrees Fahrenheit (F) to 99.5 degrees F. Specifically, all residents, staff members, vendors, and visitors entering the facility campus were checked for an increase in temperature over 99.5 F. and symptoms of COVID 19. Review of the temperature measurements recorded on the screening process logs revealed there were temperature measurements out of normal range that could indicate a symptom of COVID 19 illness. The deficient practice had the potential to increase the risk of exposure and/or contracting the COVID 19 virus or its variants.
On 02/14/22 at 3:15 PM, the Administrator was provided a copy of the CMS Immediate Jeopardy (IJ) Template and notified that the failure to ensure the infection control and prevention program was implemented correctly to prevent exposure and the spread of the COVID 19 virus by improperly screening staff, visitors, and vendors prior to entering the facility campus, constituted an IJ at F880.
The immediate jeopardy was determined to first exist on February 14, 2022 when the facility failed to identify errors in the COVID 19 screening process through February 15, 2022.
The deficient practice remained at a E (pattern with no actual harm and potential for more than minimal harm) scope and severity following the removal of the immediate jeopardy.
The facility presented an Allegation of Compliance (AOC) plan of correction on February 15, 2022 at 11:20 AM indicating that the facility put a plan into place to remove the immediacy. Staff interviews, record reviews, policy and procedure reviews and review of the training, and education was completed during the survey to verify the immediate corrective actions taken by the facility were implemented.
The Credible Allegation of Compliance included the following:
Criterion 1:
Screening long for 2/14/22 was audited and all individuals with a temperature above the threshold were rechecked. All temperatures rechecked were within normal range.
All screening team members currently working were immediately educated on the correct screening procedures to include correct temperature ranges and explaining the screening procedure to everyone being screened. They were also immediately educated on the correct cleaning process before and after each use per manufacturer's guidelines.
All staff currently working educated on the screening process including to notify screener if they answer yes to any of the questions and the steps they need to take if their temperature is above the threshold.
All thermometers were replaced with new ones and the open date recorded to be able to follow manufacturer's guidelines for calibration.
Criterion 2:
Screening logs for the past 7 days were audited and no other temperatures above the threshold were noted during that period of time.
Criterion 3:
Team members who work the check point, but were not working on 2/14/22, the team members on vacation, out on leave or out sick will receive additional training prior to the start of their next shift. Training to include:
. The appropriate procedure to follow when temperatures read greater than 99.5 degrees Fahrenheit.
. The appropriate way to calibrate the thermometers per manufacturer's guidelines.
. Instructed to verbally alert all arrivals to read screening questions and alert screener if they answer yes to any
questions.
. The appropriate cleaning process before and after each use per manufacturer's guidelines.
All team members who were not working on 2/14/2022, team members on vacation, out on leave or out sick, will receive the additional training prior to the start of their next shift.
All team members will receive training on the screening upon hire.
Updated the screening form to include space to document temperature re-checks.
Criterion 4:
The Assistant Director of Environmental Services or designee will audit the screening logs for compliance per day for two weeks, then once a day for one week and then weekly.
Results of the audits will be reported through the QAPI program on a monthly basis.
Criterion 5:
Date of Compliance 2/15/22
Findings include:
Based on a review of the manufacturer's guidelines for the Extech Non-Contact Forehead IR Thermometer Model IR200 dated 2015 indicated:
.For the most accurate results, make reading with an ambient (room) temperature of 73 to 82, make sure skin is dry and no hair interferes with the measurement, avoid touching and/or scratching the infrared surface, always use clinical thermometer to verify abnormal temperature measurements, and clean the lens area by gently blowing with compressed air and use a damp swab to wipe the lens . If the meter has been stored in a cold or hot environment, allow it at least 20 minutes to acclimate to room temperature before making measurements . Steam, dust, smoke, frost, oil, grime, etc. can obscure measurements . Please disinfect the housing and lens of this device before and after use .Allow the device to dry for at least 10 to 15 minutes after cleaning before use . Annual calibration should be performed to verify meter performance and accuracy .
Review of the manufacturer's guidelines for the [NAME] No touch plus forehead NTF3000 thermometer dated 2015 indicated: .The thermometer is intended for household use only . Temperature elevation may signal a serious illness, especially in adults who are old, frail, or have weakened immune system. Please seek professional advice immediately when there is a temperature elevation and if you are taking temperature on: Patients over 60, Patients having diabetes mellitus or a weakened immune system, cancer, etc . Fever guidance feature . The screen displays green suggests no fever, a yellow screen suggests moderate fever, and a red screen suggests high fever. 10 audible beeps indicate temperatures above 99.4 to alert that the patient may have a fever . Patient should be inside 30 minutes before taking a measurement, the patient should not drink, eat or be physically active before/while taking the measurement, remove dirt, or hair from forehead before taking measurement; hair fringes may cause higher readings . The thermometer is initially calibrated at the time of manufacture. If the thermometer is used according to the use instructions . Care and Cleaning - the thermometer should be cleaned in between uses .
According to review of the electronic version John Hopkins Medicine dated 2022 it was indicated .Normal body temperature varies by person, age, activity, and time of day. The average normal body temperature is accepted as 98.6°F (37°C). Some studies have shown that the normal body temperature can have a wide range, from 97°F (36.1°C) to 99°F (37.2°C)
Review of the facility's COVID-19 Security Check Point Screening Refresher training dated 03/19/21 revealed the screening process was .All team members, vendors, and visitors entering the facility campus must be screened upon arrival, every time they come in. Upon arrival, it is the security check point team's responsibility to check the individual's temperature and ask the screening questions .Screening individuals before they enter the campus is an effective strategy for reducing the risk of exposure to the virus throughout the community, screening has proven to help prevent the spread of disease within a community, screening is a requirement of both CMS and DHEC . Visitors - As of 03/10/21 visitors were permitted to visit healthcare areas . Per CMS and DHEC guidelines, all visitors are required to go through screening process . Individuals observed to have any symptoms related to COVID-19 should not be permitted on campus . Temperature Check - If the temperature reads 99.5 degree or higher: Ask the individual to pull over to the side, wait 2-3 minutes and recheck the temperature, If the 2nd check is still above 99.5 call the Charge Nurse and ask them to come out to check an oral temperature, The Charge Nurse will take the temperature orally. If the temperature remains 99.5 degrees or higher, the individual will not be allowed to enter campus. If it is a visitor, inform them that they will not be able to access the campus and then notify the Charge Nurse in the area they were going to visit. Please make sure the thermometer is cleaned in between each use . If the individual's temperature is below 99.5 degrees and they have answered No to all of the screening questions, give them a dot sticker with the prescribed color of the day, indicating the individual had passed the screening . Vendors - In addition to asking the screening questions and checking temperature, please complete the vendor check in log with their name, temperature reading, and company, for visitors, complete on the visitor log .
Review of the facility's policy titled, Infection Control and Response COVID-19 not dated, indicated .Screening - All traffic into the campus is diverted to the East side, where security station will be in place. All team members, visitors, and vendors will have their temperature checked, as well as be screened with questions regarding potential exposure, upon arrival on campus.
-Those whose temporal reading registers higher than 99.5 degrees Fahrenheit will be checked via an oral thermometer by a nurse. At this second stage, those who register higher than 99.5 degrees will not be granted access to the community.
-Team members will document by signature that they have been asked the screening questions and that their temperature is recorded.
Team members who report to work with signs and symptoms of acute respiratory illness or influenza-like illness will be instructed to return home and to seek medical evaluation via telemedicine .
Review of the facility's policy titled, COVID-19 Testing Policies and Procedures dated 09/27/21 indicated .In an effort to mitigate the risk of exposure and transmission of COVID-19 within licensed healthcare areas, the facility (name) has developed the following procedures. These procedures align with the requirements of 42 CFR 483.80 (h) .
Review of the facility's policy titled, Infection Control and Communicable Disease Prevention dated October 2016 indicated the purpose of the policy was .promote resident and employee safety at all times. All employees will promote the prevention of infections, contagious, and communicable diseases by following precautions set forth by the CDC, DHEC, and the facility (name) .
The facility failed to ensure visitors, vendors, and residents were properly screened according to CDC/CMS guidelines for COVID 19 virus and its variants. Specifically, on 02/14/22 at 10:00 AM, five surveyors in separate vehicles, were stopped at the campus entrance for COVID 19 screening, while remaining inside the vehicle. The attendant asked the drivers to sign a form with the driver's name and record the temperature after being measured by the attendant. The attendant had not asked any COVID 19 exposure or symptom questions before removing the sign in form from the driver.
The first surveyor driver measured a temperature of 99.1, the second driver measured a temperature of 99.7, the third driver measured a temperature of 99.8, the fourth driver measured a temperature of 100.0, and the fifth driver measured a temperature of 101.0. All five surveyor drivers were then directed to enter the campus for parking and then enter the facility. No other guidance or questions were provided. The survey team was met by facility staff at the skilled Nursing building entrance door and escorted to the conference room, located outside the resident care area. There was no resident contact made during that time. After entering the conference room, infection control and Prevention investigation was started to determine if there had been potential deficient practice.
In review of the screening sign in sheets used to record the measured temperatures dated for 02/14/22 revealed a vendor vehicle that had entered prior to the first surveyor vehicle had a measured temperature of 100.2 F. Further investigation revealed per the facility policy when a driver had a measured temperature over 99.5 F., the attendant should ask the driver to pull to the side of the entrance, outside of the campus and call the charge nurse and the charge nurse would then orally recheck the driver's temperature. If the driver's temperature remained above 99.5 F., the driver would not be allowed to enter the campus. In further review of the screening sign in sheets it was revealed that the facility had multiple abnormal measured temperatures documented that had not been rechecked and the driver was permitted to enter the campus.
On 02/14/22 at 11:17 AM, in an interview with Registered Nurse (RN) 1 and RN 2 stated that COVID 19 screening on all residents, staff and visitors were performed daily. They stated the screening consisted of temperature measurement and sign in form completed at the campus gate. They stated there were no COVID-19 positive residents in the facility at the time of survey and on admission, the resident would be placed in isolation for five days as a precautionary measure. RN 1 and RN 2 stated the facility had 100 percent of the residents vaccinated.
On 02/14/22 at 11:54 AM, an observation was made at the screening gate outside of the facility at the entrance of the campus. Six cars were observed, and the following was identified:
The first car observed was a staff member and the attendant approached the car, handed the clipboard to the driver, and asked the driver to sign in, then the attendant obtained the drivers temperature via no touch thermometer scan and recorded the temperature on the sign in form.
The second car observed was a staff member and the same process as above was performed by the attendant.
The third car observed was a staff member and the same process as above was performed by the attendant.
The fourth car observed was a visitor and the same process as above was performed by the attendant.
The fifth car was a visitor, and the same process as above was performed by the attendant.
The six car was a vendor, and the same process was performed as above and in addition there was no key badge offered.
The thermometer was not cleaned in between each use as recommended by the manufacturer care instructions. Ref: Extech user's manual dated 2015.
On 02/14/22 at 11:54 AM, in an interview with the Screening Gate Attendant (SGA) 1 it was stated the first step of the process was to have the driver of the vehicle sign in on the proper form (vendor form, visitor form, or healthcare form). The SGA 1 stated the next step was to take the driver's temperature and record the temperature on the designated form. The SGA 1 stated resident's residing in the Assistant Living (AL), cottages, and housing on the campus did not have to be screened. It was stated some of the cars have stickers to show which cars can be let through the campus without being screened and the attendants use more than one thermometer in case one is damaged. The SGA 1 further stated she had not calibrated the thermometers and had not been trained on how to calibrate the thermometers or what to do if a thermometers were not working properly. The SGA 1 stated she was not aware of how to tell if the thermometer was not working properly. She further stated she only filled in when security needed help and not everyone performing the screenings know how to troubleshoot the thermometers. The SGA 1 stated she was trained informally on what to do by the other staff that worked at the screening gate.
It was observed at the time of the interview there was a total of five thermometers located in the screening station (Extech brand and [NAME] brand).
Interview with the Assistant Director of Environmental Services (ADES) at 12:16 PM on 02/14/22 in the conference room revealed not all screening gate attendants were trained on the screening process, calibration, and troubleshooting of the thermometers. The ADES stated the policy was if the temperature measured 99.5 or higher it was policy to call the charge nurse and re check the temperature prior to letting the driver enter the campus. The ADES stated he was not aware of when and how often the thermometers were calibrated or checked for proper working order. The ADES stated he was responsible for the screening station at the entrance of the campus. The ADES stated it would be up to the attendant's personal judgement to determine if the thermometers were working properly or not. He further stated if the temperature was too low or too high continually that should show it was not working properly. When asked was there a range for too low and too high the ADES stated it was a personal judgement on the screener to determine that information. The ADES stated the healthcare staff should enter through the [NAME] entrance because there was a screening kiosk with a concierge staff present. The ADES stated all healthcare staff that would be interacting with residents should enter through the [NAME] entrance and the survey team should have also been directed to enter at that entrance. When asked about the other residents residing on the campus who did not have to be screened, he stated there were only a few on campus and those people were not screened because they were not residents in the skilled Unit. When asked if those residents could enter the skilled area of the building without staff knowledge, the ADES stated yes, they could.
In interview with Director of Operations on 02/14/22 at 12:17 PM revealed he stated if the temperature measurements were out of range, the attendant would cross out the first temperature recorded on the form and recheck the temperature and record the new one under the crossed-out temperature and initial.
Interview on 02/14/22 at 3:15 PM with the Administrator, Director of Operations (DOO) in the conference room revealed they were not aware of the infection control screening concerns identified by the survey team. They stated they agreed that the drivers entering the campus whose temperatures were out of range per facility policy should have been asked to pull the vehicle to the side of the entrance and have the charge nurse re check/assess the driver prior to entering the campus. The Administrator and the DOO stated the survey team findings did show there was a problem with the facility's process. They both stated they have always received alerts when a staff or visitor's temperature was out of range, and that was how they knew the process was working. However, the Administrator and the DOO expressed they had not been formally monitoring the screening process logs related to the temperature recordings on the sign in form. They further stated they no longer asked COVID 19 symptom questions because they had placed those questions on the sign in forms and that meant when the driver signed the form, they were attesting to not having symptoms of COVID 19. When asked how the facility ensured symptoms of COVID 19 were reported to the appropriate person and that the questions listed on the sign in forms were read and understood, they stated, We see your point and was not sure how that could be ensured.
On 02/15/22 at 10:38 AM in an interview with the Administrator, DOO, and President in the Administration office it was revealed the President and the DOO wanted to ask questions and offer additional information related to the facility's screening process. The DOO stated he felt the vendors and the visitor screening forms should not have been reviewed by the survey team because those forms were irrelevant to the identified concerns. He furthered stated the reason for not including the vendors and the visitors in the review of the screening process was that the vendors were given badges to only enter certain areas of the building and the vendors would not be around skilled residents. The Administrator confirmed that the facility administration could not ensure that the vendors and/or the visitors would not enter the area of the building where residents reside without anyone's knowledge. The DOO stated he felt there was no deficient practice because of substantial compliance of the process. It was explained to the Administrator, DOO, and the President that the deficient practice identified was that the screening process had not worked efficiently according to the regulation and facility policy and potentially placed residents residing in the facility at risk for exposure and contracting the COVID 19 virus or its variants.
Based on a review of the Daily Screening forms- dated from 02/07/22 through 02/14/22 the following information was identified:
Normal Temperature range per best practice. For a typical adult, body temperature can be anywhere from 97 F to 99 F.
02/07/22
22 out of 233 temperatures were measured under 97 F. and one of 233 was measured over 99.5 at 100.7 F. with no re-checks documented on the forms.
02/08/22
29 out of 319 temperatures were measured under 97 F. and one temperature was not recorded.
02/09/22
40 out of 297 temperatures were measured under 97 F.
02/10/22
27 out of 287 temperatures were measured under 97 F. and one temperature was not recorded.
02/11/22
38 out of 261 temperatures were measured under 97 F.
02/12/22
23 out of 136 temperatures were measured under 97 F.
02/13/22
30 out of 130 temperatures were measured under 97 F.
02/14/22
34 out of 210 temperatures were measured under 97 F. one temperature was not recorded, and seven were measured over 99.5 F. with no re-checks documented on the forms.
Visitor Sign In forms dated from 02/07/22 through 02/13/22
27 out of 224 were measured under 97 F. four were not recorded, and one was measured over 99.6 F. without rechecks recorded.
286 total of 2097 = 14% error rate
Healthcare Sign In forms dated from 02/07/22 through 02/13/22
22 out of 178 were measured under 97 F. two were measured over 99.5 F. without rechecks recorded and one was not recorded. 12% error rate
Vendor Sign In forms dated from 02/07/22 through 02/13/22
43 out of 391 measured under 97 F. nine were measured over 99.5 F. without rechecks recorded, and seven were not recorded. 11% error rate
Total of 2663 screenings over a seven-day period, 370 were abnormal or not recorded. 14% overall.
On 02/16/22 the Allegation of Compliance (AOC) for the IJ in infection control COVID 19 screening was verified and there were no identified concerns. A request was made for screening sign in forms from 02/14/22 through 02/16/22 to verify compliance. The following items were verified:
-The Daily Screening - Team Members sign in forms dated from 02/15/22 through 02/16/22 were reviewed and the following was noted:
On 02/15/22 there were a total of 326 screenings performed. Out of the 326 screenings; 27 temperatures measured under 97 F. and out of those 27; 2 were not rechecked. There were 6 temperatures measured over 99.5 F. and out of those 3; 1 was not rechecked.
The Visitor Sign In forms dated 02/15/22 revealed a total of 56 screenings. Out of the 56 screenings; 4 temperatures measured under 97 F., and all were rechecked. There were no temperatures that measured over 99.5 F.
The Vendor Sign In forms dated 02/15/22 revealed a total of 58 screenings. Out of the 58 screenings; 1 temperature measured under 97. F and was rechecked. There were no temperatures measured over 99.5 F.
There was a total of 440 screenings and out of the 440 there were 38 abnormal temperatures. Out of the 38; 3 temperatures were not rechecked which resulted in a 0.6% error rate, with much improvement from the initial survey findings.
On 02/16/22 there were no abnormal temperatures left without being rechecked.
Observations and random staff interviews were completed and retraining for the COVID 19 screenings and facility policy revisions were provided by Administration as stated in the AOC.
Educational material and staff sign in sheets were reviewed and were complete.
Observation on 02/16/22 at 9:00 AM at the entrance gate of the campus, the screening staff were reminding drivers of the symptom questions, measuring temperatures, and recording. The information was recorded on the forms and signed by the driver. There were five staff members at the entrance screening gate.
Observation on 02/16/22 at 10:06 AM at the entrance of the campus, screening staff were reminding drivers of the symptom questions listed and measuring and recording temperatures on the screening forms. Screening staff were observed cleaning thermometers after each use.
Transportation Staff 1 was interviewed on 02/16/22 at 10:11 AM and it was stated that he received additional screening in-service training on 02/15/22 of the new screening policy updates.
Certified Nursing Assistant (CNA) 1 was interviewed on 2/16/22 at 10:15 AM and she stated that she was designated to take oral temperatures if any driver entering the gate had a temperature above 99.5 degrees or below 97 degrees. CNA 1 stated that she received in-service training on the new screening policy updates.
Interview with the Administrator in the conference room on 02/16/22 at 10:18 AM revealed the facility had not been monitoring for temperatures below 97 F and confirmed that it would be a good idea to monitor for temperatures below 97 to determine if the thermometer were in proper working order. She stated there were Assisted Living (AL), Human Resource staff, Security and IT staff that were being screened in the main building at the concierge desk. The Administrator stated there were AL residents that want to visit residents in the skilled unit, and those persons would be screened in the AL area at the kiosk next to the concierge desk and would be given a printed badge after passing the screening to show the person had been screened. The Administrator confirmed all staff were educated on the screening policy and procedure, old thermometers were replaced with new ones, and the screening sign in sheets were being monitored daily since the survey findings.
A QAPI interview with the Administrator held on 02/17/22 at 11:42 AM revealed the Administrator confirmed the facility had failed to identify a quality deficiency related to the Infection Control and Prevention Program by not monitoring the effectiveness of the COVID 19 screening process which could have created a risk to resident's health and wellbeing by potentially exposing and/or spreading the COVID 19 virus and its variants. The Administrator confirmed that the facility was aware that there were staff recorded low temperatures measuring under 97.0 F. and had not been aware there were any concerns with the functioning of the thermometers. She further stated all of the thermometers had been replaced as part of the AOC.