Every finding on record at Christian Care Center of Unicoi County

Based on facility policies, medical record review, observations, and interviews, the facility failed to provide a clean and homelike environment for 1 resident (Resident #53) of 46 residents reviewed for a homelike environment.The findings include: Review of the undated facility's policy titled, A Safe, Clean, Comfortable, and Homelike Environment, revealed .the resident has a right to a .homelike environment .the facility provides .maintenance services necessary to maintain a sanitary, orderly, and comfortable interior . Review of the facility's policy titled, Wheelchairs-Transfer and Transport, reviewed 10/25, revealed .Clean wheelchair weekly and PRN [As Needed] . Resident #53 was admitted to the facility on [DATE] with diagnoses including Cerebral Palsy, Speech and Language Deficits, and Dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of the Equipment Cleaning Schedules showed no documentation Resident #53's electric wheelchair had been cleaned and sanitized. Review of the Maintenance Logs from January 2026-April 2026 showed no work order had been submitted for the left-handed vanity cabinet door. During an observation in room [ROOM NUMBER], on 4/13/2026 at 10:10 AM, revealed a 2-door vanity cabinet with a left-handed door missing. Continued observation revealed Resident #53 sitting in an electric wheelchair which had a large amount of dust and thick debris on the rear of the wheelchair. During an interview on 4/14/2026 at 12:40 PM, Registered Nurse (RN) A stated all staff completed a work order to notify maintenance of any concerns related to equipment that needed repaired. RN A stated wheelchairs should be cleaned weekly on night shift. RN A confirmed the left-handed vanity cabinet door was missing and the wheelchair had large amounts of dust and thick debris on the rear. During an interview on 4/15/2026 at 10:50 AM, the Maintenance Director confirmed the left-handed cabinet door was missing on the vanity cabinet and maintenance was responsible for ensuring the room was properly maintained and repaired. During an interview on 4/15/2026 at 11:00 AM, the Director of Nursing (DON) confirmed the left-handed cabinet door was missing and the wheelchair had large amounts of dust and thick debris on the rear of the wheelchair.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure 1 of 2 nurses administered medications with a medication error rate of less than 5% (percent). A total of 2 errors were observed out of 27 opportunities, resulting in a medication error rate of 7.41%. The findings include:Review of the facility's policy titled, Medication Administration - Unit Dose Cart System, dated 1/2026, revealed .To correctly administer medications as prescribed .Verify the right ordered medication .Read label three times before administering medication .Check label against Medication Administration Record .Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] with diagnoses including Urinary Tract Infection, Essential Hypertension, Benign Prostatic Hyperplasia, and Obstructive and Reflux Uropathy. Review of a Physician's Order dated 4/3/2026, revealed .FLORASTOR 250 MG [milligram] CAPSULE [a medication used to prevent the growth of harmful bacteria in the stomach and intestines] .1 cap [capsule] Oral for Preventative Give while on ABT [antibiotic] and 7 days post ABT completion .Review of a Physician's Order dated 4/6/2026, revealed .ASPIRIN 81 MG TABLET, ENTERIC COATED .1 TABLET Oral One time daily .Essential .hypertension . During an observation of medication administration on 4/14/2026 at 7:28 AM, Registered Nurse (RN) A administered 1 Aspirin 81mg chewable tablet and 1 Acidophilus Probiotic Dietary Supplement (a dietary supplement that helps maintain a healthy balance of friendly bacteria in the digestive tract) 1 Billion Per Serving capsule to Resident #28. During an interview on 4/14/2026 at 12:41 PM, RN A confirmed she administered Aspirin 81 mg chewable tablet and Acidophilus Probiotic 1 Billion Per Serving capsule to Resident #28. RN A confirmed the Physician Orders for Resident #28 included Aspirin 81 mg tablet enteric coated and Florastor 250 mg capsule, and confirmed the incorrect medications were administered to Resident #28. During an interview on 4/15/2026 at 12:49 PM, the Assistant Director of Nursing confirmed Aspirin 81 mg enteric coated tablet and Florastor 250 mg capsule were not administered to Resident #28 as ordered by the physician.

Based on facility policy review, record review and interview, the facility failed to document evidence the resident had received information to formulate an advance directive for 1 resident (Resident #42) of 17 residents reviewed for advance directives. The findings include: Review of the facility policy titled, Advance Directives, dated 10/2022, showed .On admission .facility will determine if the resident has executed an Advance Directive .provide information concerning the right to formulate an Advance Directive . Resident #42 was admitted to the facility with diagnoses including Chronic Obstructive Pulmonary Disease, Acute and Chronic Respiratory Failure and Opioid Dependence. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #42 was cognitively intact and was on hospice care. Record review showed no documentation Resident #42 was educated on formulating an Advance Directive. During an interview on 8/29/2023 at 10:51 AM, the Patient Liaison confirmed there were no Advance Directive documents and no documentation of education to formulate an Advance Directive in Resident #42's medical record.

45837 Based on medical record review and interview, the facility failed to refer 2 residents (Residents #20 and #31), of 4 residents reviewed for Pre-Admission Screening and Resident Review (PASARR), to the state-designated authority for a Level II PASARR after the residents were identified with possible serious mental disorders. The findings include: Resident #20 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Unspecified Dementia, Depression, Generalized Anxiety Disorder and Cognitive Communication Deficit. Review of Notice of PASRR (PASARR) Level I Screen Outcome dated 3/21/2022, showed .No PASRR Level II Required .DIAGNOSIS .No mental health diagnosis is known or suspected .Does the individual have a diagnosis of dementia/neurocognitive disorder .No .PSYCHOTROPIC MEDICATIONS .Xanax .Anxiety Disorder .Buspar .Anxiety Disorder .ADDITIONAL COMMENTS .Pt has not taken any medications in a number of months but unsure .Level I Outcome: No Level II Condition-Level I Negative . Record review showed Resident #20 had diagnoses of Depression added 3/21/2022, Unspecified Dementia with Behavioral Disturbance and Adjustment Disorder added 5/6/2022 and Psychotic disorder with Hallucinations added 5/20/2022. Resident #31 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Unspecified Dementia, Major Depressive Disorder and Generalized Anxiety Disorder. Review of a PASRR dated 11/17/2022 showed Resident #31 had diagnoses of Anxiety and Depression. Record review showed Resident #31 had a new mental health diagnosis of Psychotic Disorder with Hallucinations added 1/5/2023. During an interview on 8/29/2023 at 2:19 PM, the Patient Liaison stated she was responsible for PASARR. She stated Resident #20 had a PASARR dated 3/21/2022 with no mental health diagnoses noted and had diagnoses of Depression added 3/21/2022, Unspecified Dementia with Behavioral Disturbance and Adjustment Disorder added 5/6/2022 and Psychotic disorder with Hallucinations added 5/20/2022. The Patient Liaison also stated Resident #31 had a PASARR dated 11/17/2022 and had a new mental health diagnosis of Psychotic Disorder with Hallucinations added 1/5/2023, and new PASARRs should have been submitted after the new diagnoses were ordered. During an interview on 8/29/2023 at 3:03 PM, the Director of Nursing (DON) confirmed new PASARRs were not submitted with the new mental health diagnoses for Residents #20 and #31.

Based on medical record review and interview, the facility failed to maintain a complete and accurate medical record for 1 resident (Resident #199) of 17 residents reviewed. The findings include: Resident #199 was admitted to the facility on [DATE] with diagnoses including Atrial Fibrillation, Hypertension, Dementia, Arthritis, and Hypothyroidism. Review of Resident #199's admission Minimum Data Set assessment dated [DATE] showed a Brief Interview for Mental Status score of 3, which indicated the resident had severe cognitive impairment. Continued review showed, resident required extensive assist of 1 person for bed mobility, transfers, toileting, dressing, bathing, and required supervision for eating. Review of a weekly skin assessment for Resident #199 dated 5/16/2023 showed .bumps and redness noted to perineal area . Review of a nurse progress note for Resident #199 dated 5/16/2023 showed .no skin issues or break down at this time . Review of a Nurse Practitioner (NP) progress note dated 5/16/2023 showed .nurse reported irritated rash to groin area .irritated red rash with individual red satellite [red spots or small blister -like lesions] pustules .Cutaneous Candidiasis [fungi on the skin] .Lotrisone [medicated cream to treat fungi] twice a day for 10 days to manage Cutaneous Candida infection . During an interview on 8/30/2023 at 3:34 PM, the Director of Nursing confirmed the nurse progress note on the medical record dated 5/16/2023 was inaccurate for Resident #199.

Based on medical record review, facility policy review, observation, and interviews, the facility failed to ensure signage was posted which indicated what personal protective equipment (PPE) was required for 1 resident (Resident #20) of 7 residents observed for Enhanced Barrier Precautions and Transmission Based Precautions. The findings include: Review of the facility's policy titled, Enhanced Barrier Precautions, with a revised date of 4/2023, showed .It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multi-drug resistant organisms .Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO [Multi-Drug Resistant Organism] as well as those at increased risk of MDRO acquisition .Implementation of Enhanced Barrier Precautions .Staff will don gown and gloves immediately prior to entering the room for high-contact resident care activities .PPE will be discarded at the door upon exit of the room .Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves . Resident #20 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Urinary Tract Infection. Review of a physician's order dated 8/3/2023, showed an order for Enhanced Barrier Precautions due to Resident #20's history of Extended Spectrum Beta-Lactamase (ESBL) (bacteria that can't be killed by many of the antibiotics that doctors use) infection. Review of the comprehensive care plan dated 8/13/2023, showed .Enhanced Barrier Precautions r/t [related to] .Hx [history] of ESBL .Goals .Reduce transmission of multi-drug resistant organisms .Place sign on door or wall outside resident room indicating the type of precautions and required PPE .PPE will consist of gloves and gown .Apply PPE prior to providing care . During the initial facility tour resident screening on 8/28/2023 at 10:41 AM, there was no signage posted on Resident #20's door to indicate the resident was in isolation. Certified Nursing Assistant (CNA) #1 entered the room and wore a gown and gloves to provide care. This surveyor asked CNA #1 if the resident was on isolation and the CNA answered, .yeah . During an observation and interview, outside Resident #20's room on 8/28/2023 at 10:45 AM, the Infection Preventionist (IP) stated the resident was in Enhanced Barrier Precautions for a history of MDRO in the urine. The IP stated signage was to be posted on the outside of Resident #20's door to let anyone who entered the room know what PPE was to be worn in what circumstances. The IP confirmed no signage was posted on Resident #20's door to indicate the required PPE to provide care for the resident. During an interview on 8/28/2023 at 3:28 PM, the Director of Nursing (DON) stated Resident #20 required Enhanced Barrier Precautions due to history of MDRO in the urine. The DON confirmed signage was to be posted outside the resident's door to make anyone who entered the room aware of what PPE was required for resident care.

Based on facility policy review, medical record review, and interview the facility failed to ensure a [CONDITION(S)] contract was in place for 1 resident (#46) of 27 residents reviewed. The findings include: Review of the facility policy Care of Residents Receiving [CONDITION(S)] Treatments revised date 3/24/2020 revealed .4. Arrange for [CONDITION(S)] as ordered . Resident #46 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of a Physicians order dated 8/7/2021 revealed .[CONDITION(S)] .Tuesday, Thursday, Saturday .at [named [CONDITION(S)] center] . Medical record review of the resident Plan of Care dated 8/9/2021 revealed, .I'm on [CONDITION(S)] treatments .3 times per week .my chair time is 10:45 AM . Interview and review of the [CONDITION(S)] communication records with the Director of Nursing (DON) on 8/30/2021 at 9:40 AM, in the DON office, revealed resident is transferred to [CONDITION(S)] 3 times per week per the Physician order with communication between the [CONDITION(S)] center and facility. Interview with the Administrator on 8/31/2021 at 8:02 AM, in the Administrators office, revealed the Resident #46 was going to the [CONDITION(S)] center as ordered. Further interview confirmed the facility failed to have a contract with the [CONDITION(S)] center to provide [CONDITION(S)] services to residents in the facility.

Based on review of facility policy, medical record review, review of a facility investigation, and interviews, the facility failed to report an allegation of Misappropriation of Property to the State Survey Agency timely for 1 resident (Resident #1) of 5 residents reviewed. The findings included: Review of the facility policy titled Abuse Protocol, last revised 11/2019, showed .The facility must .Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made .in accordance with State Law . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a physician's order dated 8/15/19 showed .[MEDICATION NAME] ([MEDICATION NAME]) 325 mg (milligrams) 5 mg tablet .every 4 hours .pain . Review of a facility investigation dated 1/1/2020 showed Licensed Practical Nurse (LPN) #6 contacted the facility pharmacy for a refill of Resident #1's [MEDICATION NAME] (pain medication). The pharmacy informed the LPN that the pharmacy had dispensed 1 card containing 30 tablets of the medication to the facility on [DATE] (5 days earlier) for Resident #1. The facility completed an investigation but was unable to locate the missing medication. The resident was refunded the cost of the medication. During an interview on 1/28/2020 at 12:00 PM, the Regional Director of Administration stated .(the facility) was unable to determine what happened to the missing narcotics and that was why (the facility) had not reported the missing narcotics to the local or state agencies . In summary, the facility was unable to locate 30 tablets of [MEDICATION NAME] dispensed by the pharmacy for Resident #1 on 1/1/2020. As of 1/28/2020 the facility had not reported the missing medication to the State Survey Agency (28 days later).

Based on facility policy review, medical record review, observation, and interview, the facility failed to implement a fall intervention for 1 resident (#18) and failed to develop a care plan to include the use of a lap belt for 1 resident (#33) of 21 sampled residents. The findings include: Review of the facility policy Care Plans, revised 11/2018, revealed .Identify needs .Include Physicians .orders Care Plans will be updated as changes occur . Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition. Further review revealed the resident required extensive assist of 2 staff members for bed mobility and transfers. Medical record review of a fall investigation dated 5/19/19 revealed the resident had a fall from the bed on 5/18/19. Further review revealed .New Intervention Description .Bed bolsters (long pillow used for support) in place . Medical record review of the care plan dated 3/8/2019 and revised 5/18/19 revealed .I may fall because of .my cognitive impairment .floor mat added to left side of bed and bed bolster . Observation of Resident #18 on 6/3/19 at 11:40 AM, in the resident's room, revealed the resident lying on the bed with an alarm on the bed and mats at the bedside. Further observation revealed no use of bed bolsters. Observation of Resident #18 on 6/4/19 at 1:47 PM, in the resident's room, revealed Resident #18 lying on the bed with an alarm on the bed and mats at the bedside. Further observation revealed no use of bed bolsters. Observation and interview of Resident #18 with Licensed Practical Nurse (LPN) #2 on 6/5/19 at 8:21 AM, in the resident's room, revealed the bed bolsters were not in use. Further interview confirmed .(Resident #18) .is supposed to have them . Interview with the MDS Coordinator on 6/5/19 at 8:39 AM, in the MDS office, confirmed the resident was care planned for the use of bed bolsters. Continued interview and observation, in the resident's room, confirmed the bed bolsters were not in use. Interview with the Executive Director (ED) on 6/5/19 at 10:38 AM, in the ED's office, confirmed the facility failed to follow the care plan for the use of bed bolsters for Resident #18. Medical record review revealed Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Continued review revealed the resident needed extensive assist of 2 staff members for bed mobility, transfer, toileting and had limited range of motion to all extremities. Medical record review of the Physician's Orders revealed .Self release lap belt in electric w/c (wheel chair) per resident request .4/10/19 . Medical record review of the care plan revealed no documentation of the use of a self release lap belt. Observation of Resident #33 on 6/3/19 at 3:19 PM, in the resident's room, revealed the resident sitting in an electric w/c with a self release lap belt in use. Observation of Resident #33 on 6/4/19 at 1:41 PM, in the resident's room, revealed the resident sitting in an electric w/c with a self release lap belt in use. Interview with the MDS Coordinator on 6/4/19 at 3:44 PM, in the MDS office, confirmed the lap belt had been in use since 4/10/19. Further interview confirmed the use of the self release belt had not been addressed on the resident's care plan. Interview with the ED on 6/5/19 at 7:35 AM, in the conference room, confirmed the facility failed to develop a care plan for Resident #33's use of a self release lap belt.

Based on facility policy review, medical record review, observation, and interview, the facility failed to implement a fall intervention to prevent accidents for 1 resident (#18) of 3 residents reviewed for falls of 21 sampled residents. The findings include: Review of the facility policy Fall Prevention Program, last revised 3/2017, revealed .Document the fall risk measures in the resident care plan .Assess for safety devices a minimum of once per shift for placement and functioning . Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition. Further review revealed the resident required extensive assist of 2 staff members for bed mobility and transfers. Medical record review of a fall investigation dated 5/19/19 revealed the resident had a fall from the bed on 5/18/19. Further review revealed .New Intervention Description .Bed bolsters (long pillow used for support) in place . Medical record review of the care plan dated 3/8/2019 and revised 5/18/19 revealed .I may fall because of .my cognitive impairment .floor mat added to left side of bed and bed bolster . Observation of Resident #18 on 6/3/19 at 11:40 AM, in the resident's room, revealed the resident lying on the bed with an alarm on the bed and mats at the bedside. Further observation revealed no use of bed bolsters. Observation of Resident #18 on 6/4/19 at 1:47 PM, in the resident's room, revealed Resident #18 lying on the bed with an alarm on the bed and mats at the bedside. Further observation revealed no use of bed bolsters. Observation and interview of Resident #18 with Licensed Practical Nurse (LPN) #2 on 6/5/19 at 8:21 AM, in the resident's room, revealed the bed bolsters were not in use. Further interview confirmed .(Resident #18) .is supposed to have them . Interview with the MDS Coordinator on 6/5/19 at 8:39 AM, in the MDS office, confirmed the resident was care planned for the use of bed bolsters. Continued interview and observation, in the resident's room, confirmed the bed bolsters were not in use. Interview with the Executive Director (ED) on 6/5/19 at 10:38 AM, in the ED's office, confirmed the facility failed to implement care planned intervention to prevent accidents for Resident #18.

Based on observation and interview the facility failed to properly label and store medications for 1 of 2 medication carts observed. The findings include: Observation and interview of the station 2 medication cart with Licensed Practical Nurse (LPN) #1 on 6/5/19 at 11:15 AM, on the station 2 hallway, revealed 2 medication cups in the medication cart with opened and unlabeled medications in the cups. Continued observation and interview confirmed LPN #1 had prepared the medications and placed the medications in the cups for administration to residents, and had then left the cart to do another task. Interview with the Executive Director (ED) on 6/5/19 at 12:34 PM, in the ED's office, confirmed the facility failed to properly label and store the medications in the medication cart.

Based on review of the Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review, and interview the facility failed to submit a discharge Minimum Data Set (MDS) discharge assessment timely for one resident (#2) of 1 resident reviewed for discharge MDS assessments of 21 sampled residents. The findings include: Review of the RAI Version 3.0 Manual Chapter 2: Assessments for the RAI revealed .Discharge assessment .Must be submitted .within 14 days after the MDS completion date . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed Resident #2 was discharged home on[DATE]. Medical record review of the MDS assessments revealed a discharge assessment was completed on 1/1/19. Interview with Registered Nurse (RN) Information Nurse Consultant on 06/05/19 at 1:50 PM, in the Executive Director's office revealed .discharge assessment was completed but was never transmitted . Continued interview confirmed the facility failed to submit a discharge assessment for the 1/1/19 discharge for Resident #2.

Based on medical record review and interview the facility failed to ensure the Minimum Data Set (MDS) was accurate for 1 (#6) of 26 residents reviewed. The findings included: Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Hospice Certification of Terminal Illness signed by the physician on 1/16/18 revealed .This is to certify that the beneficiary, named below, is terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course . Medical record review of the quarterly MDS dated [DATE], revealed .section J1400 Prognosis. Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? (Requires physician documentation) . Continued review of the quarterly MDS dated [DATE] revealed the response to section J1400 was no. Interview with the MDS Coordinator on 6/12/18 at 11:00 AM, at the nursing station, confirmed the MDS dated [DATE] was not accurate and did not reflect the resident had a condition or chronic disease that might result in a life expectancy of less than 6 months.

Based on medical record review and interview, the facility failed to develop a baseline care plan to address the use of antipsychotic and antianxiety medications for 1 resident (#16) of 5 residents reviewed who were admitted in the past 30 days. The findings included: Resident #16 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the readmission physician's orders [REDACTED]. Medical record review of the baseline Care Plan dated 5/31/18 revealed no documentation to address the resident's use of antipsychotic and antianxiety medications. Interview with the Director of Nursing (DON), on 6/13/18 at 9:10 AM, in the DON's office, confirmed a baseline Care Plan had not been developed to address the use of the antipsychotic and antianxiety medications.

Based on medical record review and interview, the facility failed to develop a care plan to address Diabetes for 1 resident (#37) of 26 residents reviewed. The findings included: Medical record review revealed Resident #37 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the readmission physician's orders [REDACTED]. Medical record review of the current Care Plan dated 5/31/18 revealed no documentation to address the resident's Diabetes with the need for insulin. Interview with the Director of Nursing on 6/12/18 at 2:35 PM, in the Minimum Data Set office, confirmed a Care Plan was not developed to address the resident's Diabetes or insulin.

Based on medical record review and interview, the facility failed to revise the Care Plan for 1 resident (#31) of 26 resident's reviewed. The findings included: Medical record review revealed Resident #31 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a nursing note dated 6/8/18 revealed the resident's family was concerned the resident was sick and had expiratory wheezing. Continued review of the nursing note revealed the physician was notified and orders were received. Medical record review of a chest x-ray dated 6/8/18 revealed Impression: 1. Density in the right infrahilar region which may be due to atelectasis versus developing infiltrate .2. Persistent small left pleural effusion with persistent left basilar atelectasis . Medical record review of a physician's orders [REDACTED]. Medical record review of the Care Plan dated on 5/9/18 revealed no documentation to address the resident's current Pneumonia and treatment. Interview with the Director of Nursing (DON) on 6/12/18 at 5:40 PM, in the Minimum Data Set office confirmed the Care Plan dated 5/9/18 was not revised to address the resident's treatment for [REDACTED].

Based on medical record review,review of the facility skin assessment schedule, interview and observation the facility failed to complete a skin assessment in a timely manner prior to the development of a pressure ulcer for 1 resident (#29) of 2 residents reviewed for pressure ulcers. The findings included: Medical record review revealed Resident #29 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Skin assessment dated [DATE] revealed a picture with bilateral heels circled with a note .red blanchable . Medical record review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident was at risk for developing a pressure ulcer. Continued review of the MDS revealed the resident did not have a pressure ulcer. Medical record review of a Braden scale dated 5/25/18 revealed a score of 14, indicating the resident is at moderate risk for developing a pressure ulcer. Medical record review of a skin assessment dated [DATE] (Friday) revealed a picture of the right heel circled and a note Red heel/blanchable. Medical record review of the facility skin assessment schedule revealed the resident was scheduled to have a weekly skin assessment every Friday. Medical record review of a note on a skin assessment dated [DATE] (Friday), revealed refused skin assessment Medical record review of a nurse's note dated 6/11/18 revealed .Noted during treatment .resident had area of dark/non blanchable skin to Right heel measuring approximately 3.4 x 2 cm (centimeter), middle area more red/purple, surrounding skin more brown in appearance . Area dry and intact . Medical record review of a physician's orders [REDACTED].Float heels while in bed . Interview with the Director of Nursing on 6/12/18 at 1:35 PM, in the MDS office, confirmed if a resident refused a skin assessment the nurse should have returned later to attempt to complete the skin assessment or pass it on for the next shift to complete. Continued interview confirmed the facility failed to complete a skin assessment in a timely manner for Resident #29. Interview with the Wound Nurse on 6/12/18 at 1:40 PM, in the MDS office revealed the resident had a scheduled skin assessment to be completed every Friday. Continued interview confirmed the residents skin assessment was refused by the resident on 6/8/18 and not completed until 6/11/18 and a deep tissue injury was noted at that time. Further interview confirmed the facility failed to complete a skin assessment in a timely manner resulting in the development of a deep tissue injury. Observation of the resident's pressure ulcer with the Wound Nurse on 6/13/18 at 9:10 AM, in the resident's room revealed a dry deep tissue injury, approximately quarter size, purple in color to the right heel.

Based on review of the manufacturer's recommendations, medical record review, observation and interview the facility failed to appropriately disinfect a glucose meter (a meter to check blood sugar) after use for 1 resident (#3) of 1 resident observed after use of a glucose meter. The findings included: Review of the manufacturer's instructions for Sani-Cloth, Germicidal Disposable Wipe undated revealed .Areas of Use .Hospital, Healthcare, and Critical Care use .May be used on hard non-porous surfaces of; Bed railings; blood glucose meters .To disinfect nonfood contact surfaces only: Unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for a full two (2) minutes. Let air dry . Review of the facility Adult Sliding Scale Insulin Protocal dated 1/31/18 revealed .Fingerstick Blood Sugar .QID (4 times per day) . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of Certified Nursing Assistant (CNA) #1 on 6/12/18 at 11:08 AM, in Resident #3's room revealed the CNA completed a blood glucose check on the resident in his room; brought the glucose meter to a rolling table outside of the resident's room; disinfected the glucose meter for approximately 5 seconds and returned the meter to the case. Interview with CNA #1 on 6/12/16 at 11:15 AM, at the nurse's station confirmed the facility used sani-wipes to disinfect the glucose meter after each use. Continued interview confirmed the CNA was not aware of the manufacturer's instructions for the sani-cloth and failed to appropriately disinfect the glucose meter. Interview with the Director of Nursing on 6/12/18 at 12:50 PM, in the Minimum Data Set (MDS) office confirmed the facility failed to appropriately disinfect the glucose meter and failed to follow the manufacturer's recommendations.

Based on medical record review, observation, and interview, the facility failed to follow the plan of care for 1 of 4 sampled residents (Resident #1). The facility's failure to follow the plan of care for transfers resulted in actual harm to Resident #1. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] for palliative care. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] indicated the resident was completely dependent upon staff to conduct all Activities of Daily Living (ADL's) and required maximum assist of 2 staff for transfers. Medical record review of the resident's Plan of Care dated 2/12/17 revealed .Alteration in ADL's related to dementia, immobility .total dependent care .transfer (with) max assist x (of) 2 (staff) . Medical record review of the Departmental Notes for Nursing dated 6/6/17 at 12:30 PM revealed the Hospice Certified Nursing Assistant (CNA) was getting the resident out of bed and transferring to a shower chair when the resident slid down the CNA's leg to the floor. The transfer was conducted solely by the Hospice CNA. Interview with the Administrator on 4/11/18 at 1:15 PM, by phone, confirmed the Hospice CNA did not follow the plan of care for a 2-person transfer.

Based on facility policy review, medical record review, observations, and interview, the facility failed to ensure 1 of 4 residents (Resident #1) was kept safe from falls by contracted staff caring for residents. The facility's failure to ensure a safe transfer resulted in actual harm to Resident #1. The findings included: Review of the facility's policy titled Fall Risk Evaluation, Prevention, and Intervention reviewed 1/17/17 revealed .VII Procedure .D. When a fall occurs: 1. Assess for injuries, and provide treatment as necessary . The policy did not address not moving the resident. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the resident's Plan of Care dated 2/12/17 revealed .Alteration in ADL's related to dementia, immobility .total dependent care .transfer (with) max assist x (of) 2 (staff) . Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was severely cognitively impaired and was totally dependent on staff for all Activities of Daily Living (ADL's) and required the extensive assistance of 2 people for transfers. Medical record review of a Fall Risk Evaluation dated 3/21/17 revealed the resident was assessed as a high risk for falls. Review of the Departmental Notes for Nursing dated 6/6/17 and timed 12:30 PM revealed the contracted Hospice Certified Nursing Assistant (CNA) was getting the resident out of bed to transfer to a shower chair when the resident slid down the CNA's leg to the floor. The Hospice CNA called for assistance. The resident was examined in the shower room with no apparent injury .no redness or bruising noted . The family and physician were notified. Medical record review of Departmental Notes for Nursing dated 6/6/17 and timed 1:53 PM revealed .Noted right lateral ankle bruising/blueness with [MEDICAL CONDITION] and scratch. Resident frowns when ankle is touched . Continued review revealed the family was at bedside. Further review revealed the physician was notified and x-rays were ordered. Review of the Resident #1's x-rays completed on 6/6/17 indicated non-displaced fractures of the left distal femur, right trimalleollar, left distal tibia and distal fibula, and the right distal femoral. The x-ray reports further indicated the bones were diffusely severely osteopenic. Medical record review of Departmental Notes for Nursing dated 6/12/17 revealed the Nurse Practitioner had discussed the patient's status with the resident's family including .no need for inpatient evaluation if patient cannot undergo surgery, cancel transfer to hospital . Continued review revealed the Administrator had also discussed obtaining additional x-rays which must be performed at the hospital and the family declined .due to pain in moving her . Review of the investigation by the facility, dated 6/6/17 indicated the Hospice CNA attempted to transfer the resident to a shower chair. The resident was heavier than the CNA expected and the resident slid down the CNA's leg to the floor as an assisted fall. The Registered Nurse (RN) assessed the resident in the shower room and did not identify any injuries. The facility identified the Hospice CNA was not familiar with the resident or the care plan to determine how many people needed to assist the resident for transfer. A Post Fall Assessment Huddle was completed on 6/16/17 and identified that the Hospice CNA is to call for assistance. The huddle concluded that the resident initially did not have any injuries but was later found to have multiple injuries after x-rays were completed for the resident. Review of the (name) Hospice Education for the Hospice CNA revealed the last documented training for Resident Lifting and Transfers was completed on 1/31/12 and the last competency checks provided were dated (MONTH) and (MONTH) of 2011. Review of the contract between the hospice and the facility dated 5/2/07 indicated that all staff possessed the education, skills, and training necessary to provide facility services. Review of the Nursing Facility Services Agreement between hospice and the facility dated 5/2/07, revealed .Qualifications of Personnel (b) (i) are duly licensed, credentialed, certified and/or registered as required under applicable state laws (ii) possess the education, skills, training, and other qualifications necessary to provide Facility Services . Observations on 4/2/18 at 8:45 AM and 4/4/18 at 8:05 AM revealed Resident #1 was in her room. The resident was lying in bed with her arms contracted to her chest and her right leg was bent at the knee. Interview with the Administrator on 4/2/18 at 10:30 AM, in the MDS office, indicated all falls were investigated by Risk Management. Interview with Registered Nurse (RN) #19 on 4/3/18 at 8:00 AM, by phone, revealed when she was notified of the fall, the resident had already been transferred to the shower chair and was in the shower room. The RN assessed the resident at that time and did not see any obvious deformities or swelling. The resident was nonverbal and did not appear to be in any distress at the time. Further interview revealed the RN was approached by the resident's family member approximately 1 to 2 hours later and the resident appeared to be in pain when her lower extremities were touched. Continued interview revealed the RN then reassessed the resident and noticed swelling and discoloration to lower extremities. Interview with the Director of Nursing (DON) on 4/3/18 at 1:10 PM, in the MDS office confirmed if a fall occurs in the facility the resident should be assessed by a nurse before moving. Interview with Family Member #2 on 4/4/18 at 8:05 AM, in the resident's room, indicated the family comes to the facility at meals times to assist the resident with eating. Family Member #2 indicated the resident had been bed ridden at home for approximately [AGE] years prior to becoming a resident at the facility and had been mostly cared for by family at home. The family stated the resident was lying in bed on the day of the fall, and when they came to feed her the family member sat on the bed next to the resident and the resident made a face and groaned. The family member pulled the cover back and noticed the leg was swollen and discolored. The nurse was notified and x-rays were ordered. The family member stated the resident had increased pain but this has been controlled with a change in medications. Interview with Certified Nursing Assistant (CNA) #20 on 4/4/18 at 8:10 AM, by phone, revealed when she answered the call light the resident was on the floor in a sitting position with her legs bent beside her. Continued interview revealed she helped the Hospice CNA transfer the resident into the shower chair, and then immediately notified the charge nurse of the incident. Further interview revealed the resident had not appeared to be in distress due to the resident had not exhibited any crying or moaning at the time of the fall. Interview with the Hospice CNA on 4/4/18 at 10:30 AM, by phone revealed she was attempting to give the resident a shower. She sat the resident up on the side of the bed and locked the shower chair next to the bed for transfer. When she realized the resident was too heavy to lift by herself she slid the resident down her leg to the floor and put the call light on for assistance. When assistance from a facility CNA came, they transferred the resident to the shower chair and she took the resident to the shower prior to the resident being assessed by the nurse. She stated this was the first time she had worked with the resident and was not aware of the need for a 2 persons assist, and was not aware of where to look to find the information. Interview with the Administrator on 4/4/18 at 11:30 AM, in the MDS office, indicated the training for the Hospice CNA's were required prior to them assisting residents at the facility, along with a background check and proof of certification. Continued interview with the Administrator revealed the facility does not require the hospice agency to provide updated training documentation. Interview with the Administrator on 4/11/18 at 1:15 PM, by phone revealed the Hospice CNA was not using a gait belt to transfer the resident. The Administrator stated that they have numbers above each resident's bed who need help with transferring; 1 would need assistance of 1 person, 2 would need assistance of 2 people.