Every finding on record at NHC Healthcare, Athens

Based on facility policy review, medical record review, observation, and interview, the facility failed to properly store medications and medical supplies in 1 of 2 medication carts observed for medication storage. The findings include: Review of the facility's policy titled, Medication Storage in the Facility, dated 2/25/2025, revealed .Medications and biologicals are stored safely, securely, and properly .Drugs dispensed in the manufacturer's original container will expire upon manufacturer's expiration date .All expired medications will be removed from the active supply . Review of the medical record revealed Resident #49 was admitted to the facility on [DATE] with diagnoses including Essential Hypertension, Gastro-Esophageal Reflux Disease, and Low Back Pain. Review of the Physician's Orders for Resident #49, revealed .Start Date .03/31/2025 .ondansetron [medication used to treat nausea] .4 mg [milligrams] .1 tab .for nausea/vomiting Every 6 Hours- PRN [as needed] .Review of the Medication Administration Records (MARs) for Resident #49 dated from 3/1/2026-6/9/2026 revealed the resident had not received the ondansetron 4 mg.During an observation of the 200 long hall medication cart and interview with Licensed Practical Nurse (LPN) A on 6/9/2026 at 8:00 AM, revealed an ondansetron 4 mg tablet for Resident #49 with an expiration date of 12/3/2025. Further observation revealed an unopened package of 6 breathable adhesive skin closures, an opened package with 3 breathable adhesive skin closures with an expiration date of 4/16/2026. Continued observation revealed (3) 20 gauge by 1-inch intravenous (IV) needles with an expiration date of 3/2/2025, and (1) 20 gauge by 1-inch IV needle with an expiration date of 12/4/2025. LPN A confirmed Resident #49 had an ondansetron 4 mg tablet that expired on 12/3/2025, the skin closures and IV needles had expired, and were available for resident use.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure medical information was not visible for 1 resident (#24) of 24 residents reviewed for dignity. The findings include: Review of the facility's policy titled, PATIENTS RIGHTS, revised on 6/2006, showed .The resident has a right to a dignified existence .A facility must protect and promote the rights of each resident, including .Privacy and confidentiality .A center must promote the exercise of rights for each patient . Review of an undated document provided by the facility titled, Confidentiality Statement, showed .The care of a patient is always personal in nature, and therefore any protected health information about his/her condition, treatment or personal data is absolutely confidential .The information in a patient's medical record is confidential and cannot be disclosed without the patient's knowledge and consent .The confidentiality of patient protected health information .MUST be maintained . Resident #24 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Fracture of the Left Femur, Urinary Tract Infection, Communication Deficit, Dementia, and Anxiety. Review of Resident #24's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #24 had moderate cognitive impairment. During an observation on 8/21/2023 at 11:05 AM, there was sign a posted on the wall above the head of Resident #24's bed that read, .MIDLINE [a type of intravenous access used for medication delivery] .NOT A PICC [Peripherally inserted central catheter] .Please ask regarding medication appropriate for infusion .8/15 [8/15/2023] .left Basilic [a vein in the upper arm] . The sign was visible to anyone who entered the room. During an observation on 8/22/2023 at 7:39 AM, there was sign a posted on the wall above the head of Resident #24's bed that read, .MIDLINE .NOT A PICC .Please ask regarding medication appropriate for infusion .8/15 .left Basilic . The sign was visible to anyone who entered the room. During an observation and interview with the Director of Nursing (DON) and the Administrator on 8/22/2023 at 11:38 AM, in Resident #24's room there was a sign posted on the wall above the head of Resident #24's bed that read, .MIDLINE .NOT A PICC .Please ask regarding medication appropriate for infusion .8/15 .left Basilic . The DON stated the sign .must have been . posted by the company that placed the Midline. The DON and Administrator confirmed the sign was visible to anyone who entered the room. The DON confirmed resident health information was not to be posted in resident rooms. During an interview on 8/23/2023 at 12:51 PM, the DON confirmed there was no documentation in the medical record that indicated the sign had been requested by Resident #24 or Resident #24's responsible party.

Based on facility policy review, observation, and interview the facility failed to ensure appropriate personal protective equipment (PPE) was worn while providing care for a COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) positive resident. The findings include: Review of the facility policy titled, Infection Control Manual Volume 1 dated 6/2023 showed, .Core Principles of COVID-19 Infection Prevention .Centers should provide guidance (e.g., posted signs at entrances about recommended actions .Hand hygiene .Face covering or mask .in accordance with CDC [Center for Disease Control] guidance .Post visual alerts in strategic places .alerts should include instructions about current .recommendations . when to use source control .Appropriate staff use of Personal Protective Equipment .Droplet Precautions .In addition to Standard precautions, use Droplet precautions for a patient known or suspected to be infected with microorganisms transmitted by droplets .PPE .Facemasks should be used upon entry into the patient room .Based upon pathogen or clinical syndrome, there is a risk of exposure .spraying of respiratory secretions is anticipated, gloves and gown as well as goggles (or face shield in place of goggles) should be worn . During an observation on 8/21/2023 at 11:28 AM, outside of the COVID unit was a table which contained 5 packs of blue plastic gowns, 5 boxes of exam gloves of various size, 1 box of medical face masks, and 5 individual packaged N-95 masks. Signage for Contact Precautions was posted outside of the COVID unit on the left door, just below the glass. The highly visible sign read as follows: STOP .CONTACT PRECAUTIONS EVERYONE MUST .Clean their hands .PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit .Put on gown before room entry .Discard gown before room exit .Do not wear the same gown and gloves for the care of more than one person .Use dedicated or disposable equipment .Clean and disinfect reusable equipment before use on another person . The COVID unit was visualized through the glass of the 2 closed doors. Small clear plastic cabinets with multiple drawers were outside of each residents room in the COVID unit, these cabinets contained PPE for staff to obtain before caring for the residents. During an observation on 8/21/2023 at 11:30 AM, Certified Nursing Assistant (CNA) #1 entered a resident room in the COVID unit, CNA #1 was noted to wear a surgical face mask and a face shield on top of the head, not in the appropriate position to cover the face. CNA #1 entered a room which displayed a highly visible Droplet Precautions sign present on the front of the door to the room. The Droplet precaution sign posted in a fully visible area where each component of PPE is explained, and which type of PPE is to be worn by staff while providing care or coming in contact with a COVID positive resident. Staff were to wear gown, gloves, mask and face shield as stated on the Standard precaution sign and add the PPE component of a N-95 mask. CNA #1 confirmed a room was entered in the COVID unit without donning appropriate PPE while a lunch tray was delivered to a COVID positive resident. CNA #1 stated I should have put on PPE .I made a mistake . CNA #1 was in the immediate presence of 2 other resident care staff members who wore a gown, gloves, N-95 mask, and face shield in the proper position during the observation. During an interview on 8/21/2023 at 11:59 AM, the Administrator confirmed the expectation was resident care staff would wear full PPE (gloves, gown, N-95 face mask [a mask that filters from the air small particles to include droplets], and a face shield/goggles) when entering a room with a COVID positive resident. During an interview on 8/22/2023 at 2:55 PM, the Infection Preventionist (IP) stated the expectation was for resident care staff to wear full PPE when entering a room or coming in contact with COVID positive residents. The expectation is also for resident care staff to wear a face shield to fully cover the face while in in the room and providing care for COVID positive residents.

Based on facility policy review, medical record review, and interview, the facility failed to revise the Comprehensive Care Plan to include hospice services for 1 resident (#18) of 3 residents reviewed for hospice. The findings include: Review of the facility's policy titled, PATIENT ASSESSMENT AND CARE PLANNING, revised on 11/1/2013, showed .The Federally mandated Minimum Data Set .is the basis for the assessment component of the Comprehensive Patient Care System .The assessment information is used to develop the patient's care plan . Resident #18 was admitted to the facility on [DATE] with diagnoses including Hypertensive heart and chronic kidney disease with heart failure, Adult Failure to Thrive, Anorexia, Paroxysmal Atrial Fibrillation, Dysarthria following cerebral infarction, and Dysphagia. Review of the facility's policy titled, PATIENT CARE POLICIES, dated 2023, showed .Patients are assessed initially and at regular intervals using a Federal/State specified, standardized, comprehensive resident assessment instrument to identify functional capacity and health status .serve as the basis for planning individualized patient care .The center will include the attending physician in the development of the patient's plan of care by incorporating the physician's plan of care (orders) into the care plan. Decision making/planning is based on identified needs/problems and builds on patient strengths while taking into account the patient's preferences. The care plan serves as a guide for care decisions and is made available for use by all patient care personnel . Review of the medical record showed Resident #18 was admitted to hospice services on 7/29/2023. Review of Resident #18's significant change Minimum Data Set (MDS) assessment dated [DATE], showed Resident #18 had moderate cognitive impairment and had started receiving hospice care in the last 14 days. Review of Resident #18's Comprehensive Care Plan showed, Resident #18's code status was Do Not Resuscitate. The Comprehensive Care Plan did not reflect that Resident #18 received hospice services. During an interview on 8/23/2023 at 8:22 AM, the Director of Nursing (DON) confirmed Resident #18's care plan did not include hospice services. The DON stated it was her expectation that care plans were revised to include hospice services for residents admitted to hospice. During an interview on 8/24/2023 at 11:19 AM, the MDS Coordinator stated she was responsible for care plans. Resident #18 had a significant change MDS assessment on 8/4/2023 because she was admitted to hospice on 7/29/2023. The MDS Coordinator confirmed Resident #18's care plan should have been updated to include hospice services.

Based on facility documentation review and interview the facility failed to ensure that all required members attended the quality assessment and assurance committee (QAA) meetings on a quarterly basis. The findings include: Review of the facility policy titled, QAPI [quality assessment and performance improvement] PLAN undated, showed, .will strive to meet the following goals based on our purpose, guiding principles and scope for QAPI .will strive to meet or exceed the clinical outcome goals. Priority will be set for those goals that are considered high-risk, high-volume or problem-prone areas .Governance and Leadership .Accountability for QAPI .Ultimately the Administrator (ADM) and Director of Nursing (DON) are accountable for the success or failure of the program .The DON .will be the QAPI champion. This champion will be accountable for all nursing QAPI activities .Department Managers will be educated on the QAPI Plan and expectations . Review of QAPI meeting sign-in sheets from 7/27/2022 -7/26/2023, showed the DON was absent from 5 of the 13 meetings. Of the 5 QAPI meeting absences, the DON was not present for the first 3 consecutive meetings of the beginning quarter of 2023, dated 1/25/2023, 2/22/2023, and 3/22/2023. During an interview on 8/24/2023 at 8:48 AM, the ADM confirmed the DON did not attend the 1/25/2023 meeting because she was on vacation. The ADM confirmed the DON did not attend the 2/22/2023 meeting because she was at the Regional DON meeting. The ADM confirmed the DON did not attend the 3/22/2023 meeting and stated the DON was present in the facility earlier that day and was unsure why she did not attend.

Based on facility contract review, facility policy review, medical record review, and interview, the facility failed to ensure a coordinated plan of care with the hospice provider was available in the medical record for 1 resident (#18) of 3 residents reviewed for hospice. The findings include: Review of the facility's hospice contract with Resident #18's hospice provider dated 7/24/2008, showed .Plan of Care .the Skilled Nursing Facility shall provide services in accordance with the Hospice plan of care . Resident #18 was admitted to the facility on [DATE] with diagnoses including Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Adult Failure to Thrive, Anorexia, Paroxysmal Atrial Fibrillation, Dysarthria following cerebral infarction, and Dysphagia. Review of the facility's policy titled, PATIENT CARE POLICIES, dated 2023, showed .HOSPICE SERVICES .Physicians may request consultation for hospice care services .When a patient elects hospice services, the hospice will guide the plan of care in collaboration with the center . Review of the medical record showed Resident #18 was admitted to hospice services on 7/29/2023. There was no hospice plan of care in Resident #18's medical record. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], showed Resident #18 had moderate cognitive impairment and had started receiving hospice care within the last 14 days. During an interview on 8/23/2023 at 8:02 AM, Licensed Practical Nurse (LPN) #1 stated she was the designated person appointed from the facility to communicate with Resident #18's hospice provider. LPN #1 stated the hospice provider's plan of care was to be available for facility staff to review either in the computerized chart under resident documents or in the hospice binder located at the nurses' station. LPN #1 confirmed Resident #18's hospice plan of care was not available in the resident's computerized chart or in the hospice binder. During an interview on 8/23/2023 at 8:22 AM, the Director of Nursing (DON) stated it was her expectation that the hospice provider's plan of care was available in the resident's medical record either in the computerized chart or in the hospice binder at the nurses' station so that facility staff could provide coordinated care with the hospice company.

Based on medical record review and interview, the facility failed to resubmit a Pre-Admission Screening and Resident Review (PASARR) timely after a new mental health diagnosis for 2 residents (Residents #1 and #54) of 5 residents reviewed for PASRR. The findings include: Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder and Anxiety Disorder. Record review of the most recent PASARR Level 1 assessment dated [DATE], revealed Resident #1 had mental health diagnoses of Major Depression, Anxiety Disorder and Mood Disorder. Record review revealed Resident #1 received new diagnoses of Post-traumatic Stress Disorder (PTSD) on 1/4/2023 and Delusion Disorders on 1/24/2023. Record review revealed no new Level II PASARR had been submitted to include the new diagnoses of PTSD and Delusion Disorders with anti-psychotic medication use initiated on 2/21/2023. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had active diagnoses of .Anxiety .Depression .Delusions .PTSD . and received antipsychotic, antianxiety, and antidepressant medications during the last 7 days. During an interview on 8/22/2023 at 5:00 PM, the Director of Nursing stated, when a resident in the facility receives a new mental health diagnosis, a PASARR was to be resubmitted for the resident and confirmed a request for a PASARR II review had not been done. 41782 Review of Resident #54's PASARR Level I Form dated 9/7/2022, showed .No mental health diagnosis is known or suspected .Level I Outcome: No Level II Condition- Level I Negative . Resident #54 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Hemiplegia and Hemiparesis following cerebral infarction affecting left dominant side, Dysphagia following cerebral infarction, Hypertension, Hyperlipidemia, Seasonal allergic rhinitis, GERD, Constipation, and Osteoarthritis. Review of the medical record showed Resident #54 received a diagnosis of Depression on 9/13/2022. Review of the medical record showed Resident #54 received a diagnosis of Adjustment disorder with mixed anxiety and depressed mood on 3/9/2023. Review of the medical record showed Resident #54 received a diagnosis of Generalized Anxiety Disorder on 6/21/2023. Review of the medical record showed Resident #54 received a diagnosis of Post Traumatic Stress Disorder (PTSD) on 7/12/2023. Review of Resident #54's annual Minimum Data Set (MDS) assessment dated [DATE], showed the resident was cognitively intact with active diagnoses that included Anxiety Disorder, Depression, and PTSD. Resident #54 received antianxiety and antidepressant medications on all 7 days of the look back period. Review of Resident #54's Notice of PASARR Level I Screen Outcome dated 8/22/2023, showed .Your Level I screen was submitted for a potential status change. Your screen shows more PASRR screening is not needed .DIAGNOSIS .Anxiety Disorder (Current Diagnosis) .Trauma/Stress Related Disorder (Current Diagnosis) .Depression- mild or situational (Current Diagnosis) .Other mental health diagnosis .adjustment disorder mixed with anxiety and depressed mood-suspected, nightmares .Rationale: Documentation reviewed and reports adjustment disorder mixed with anxiety and depressed mood and nightmares and added to this review as suspected .This review is submitted to update the diagnoses and medications .A Level II evaluation is not required and this Level I is approved with a Level I No Status Change . During an interview on 8/23/2023 at 9:43 AM, the MDS Coordinator stated a Level I was submitted from the hospital on 9/7/2022 prior to Resident #54's admission and had no mental health diagnoses noted. A Diagnosis of Depression was added on 9/13/2022, General Anxiety Disorder was added on 6/21/2023, Adjustment Disorder with Mixed Anxiety and Depressed Mood was added on 3/9/2023, and PTSD was added on 7/12/2023. The new diagnoses required a new PASRR to be submitted. The MDS Coordinator confirmed a new PASARR was not submitted until 8/22/2023 to reflect the new mental health diagnoses. The MDS Coordinator stated .we realized yesterday when we were asked for the PASARR that we didn't do it and went ahead and done it . The MDS Coordinator confirmed the PASARR was not resubmitted timely after the addition of new mental health diagnoses.

Based on review of facility policy, medical record review, review of the facility investigation, and interview the facility failed to maintain resident privacy for one Resident (Resident #2) of 4 residents surveyed for resident rights. The facility violated Resident #2's right to personal privacy when a staff member used a cellular phone to photograph Resident #2, without her knowledge or consent, then transmitted the photo to another staff member by cellular phone. The findings included: Review of the facility policy, Use of Personal Cellular Phones/Camera Equipped Mobile Devices, revised 5/1/2012, showed .while a partner is performing job duties .personal cellular phone or .electronic device must be kept in their bag or locker, not on his/her person and must be turned off .Partners may not take digital or still photographs or record audio or video footage with personal .devices for personal use while on company premises .camera equipped or audio equipped recording devices are strictly prohibited from use anywhere on company property .partners .found to be in violation of any aspect of this policy will be subject to disciplinary action, up to and including termination from employment . Medical record review showed Resident #2 was admitted to the facility on [DATE] with diagnoses including Acute upon Chronic Respiratory Failure, Functional Paraplegia, Morbid Obesity, Type 2 Diabetes, Hypertension, Atherosclerotic Heart Disease, COVID 19 Pneumonia, Major Depression and Generalized Anxiety Disorder. On admission Resident #2 refused cognitive testing but was noted to be cognitively impaired, had severe depressive symptoms, and signs of generalized anxiety with verbal and physical behaviors directed at others. Resident #2 was dependent upon one person for all activities of daily living. Review of the facility investigation and witness statements showed on Saturday 4/22/2023 sometime before lunch (exact time unknown) a facility staff member (Certified Nurse Assistant) CNA #1, text messaged her peer, Dietary Worker (DW) #3 a photograph of Resident #2 lying in her bed, fully clothed with a blanket over her lower torso. Resident #2 was lying with her head near the footboard, and it appeared she was reading mail, with shredded papers in the bed atop the covers. The photo appeared to have been taken from a vantage point in the room behind the resident and the resident appeared unaware she was photographed. DW #3 who was on break at the time with a coworker DW #2, briefly showed the text to DW #2. Afterwards, DW #3 also showed the cook on duty at the time, (who was the assistant Dietary Manager) (DW#1) the text, informed DW #1 she had no idea why the text was sent to her, then deleted the text from her phone. Continued review of the facility investigation and witness statements revealed when the Administrator began the facility investigation and questioned CNA #1, she had already deleted the phone and text message from her phone as well. However, CNA #1 in a written statement, did admit she had taken to the photo, texted it to her peer in the dietary department, and stated she had done so with no ill intentions. CNA #1 reported in her statement she was concerned for the Resident due to several bouts of aggressive and confused behaviors that morning and had sent the photo to her peer in efforts to explain difficulties she had encountered redirecting Resident #2 that morning after breakfast. CNA #1 issued a written apology for her actions and acknowledged she was aware her actions violated facility policy. Interview with the Administrator on 7/17/2023 at 12:30 PM in the conference room confirmed the facility investigation determined CNA #1 had violated the facility mobile device use policy and violated Resident #2's right to privacy. Facility Corrective Actions included: 1. Resident #2 passed away on 4/24/2023 which was unrelated to the incident. 2. Ad Hoc QA (Quality Assurance) meeting of the incident by the Administrator, Director of Nursing (DON), Regional [NAME] President, Social Services Director, Regional Nurse and Corporate Compliance Officers was held on 4/26/2023 by teleconference. 3. CNA #1 was initially placed on administrative leave on 4/24/2023 pending investigation then formally terminated by Human Resources on 4/28/2023 at the conclusion of the investigation. 4. The partner who received the text (DW#3) was in-serviced on the facility's Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and the Mobile Device Policy on 4/27/2023. 5. The facility investigation revealed no other residents impacted by the incident. 6. The facility conducted interviews with all alert and oriented residents and family representatives of non-interviewable residents to assess for any additional noncompliance. No concerns were identified. This was completed by 4/27/2023. 7. To help ensure the deficient practice does not recur, all facility staff employed as of 4/26/2023 were in-serviced on the NHC Patient Protection and Response Policy for Allegations of Abuse, Neglect, Misappropriation of Property and Exploitation, and the Use of Mobile Device Policies. (All employees are trained on the policies during new hire orientation and are required to review them annually as a component of the facility corporate compliance program which was already in place prior to the incident). 8. The training was conducted by the DON, Nurse Manager, Social Work Director, Nurse Staffing Coordinator, Dietary Manager, Payroll Manager and/or Administrator. Any staff who were unavailable on 4/26/2023, were required to complete the training before their next shift and sign attestations the training was completed. 9. The facility validated all staff training was completed per the corrective action plan on 5/1/2023. 10. Beginning on 5/1/23 the Administrator, DON, Resident Care Coordinator, Nurse Staffing Coordinator, Social Worker or Designee performed a monthly audit of compliance with the above policies reviewed in staff retraining by interviewing 10 employees for 3 months (May to July) to ensure employees are aware of facility policy that the taking of pictures, recordings or texting resident information is inappropriate and are questioned if they are aware of any such actions ongoing to ensure resident privacy and dignity are maintained. 11. Results of the ongoing monitoring will be reported to the full QA committee during the July 2023 meeting. The QA committee consists of the Administrator, Director of Nursing, Medical Director, QA Physicians, Dietician, Social Services Director, Infection Preventionist, Director of Plant Operations and Health Information Director. The QA committee meets monthly. Additional staff training and/or monitoring will be determined as necessary by the Quality Assurance Committee. The first full review by the QA committee was held on 5/1/2023 and monitoring was ongoing. Review and validation of the facility corrective actions put in place in response to the incident was conducted during the onsite survey 7/12/23 to 7/17/23. Staff interviews were conducted with 14 employees from various departments across both shifts, included clinical and non-clinical employees. All had completed the required retraining as outlined in the corrective action documents and all could recite verbatim the facility polices related to resident rights, privacy, the facility prohibition on the possession or use of personal mobile devices outside authorized break areas as outlined in the policy. No employees were observed with personal devices on their persons or in use in the clinical or common areas throughout the survey. All staff interviewed could state why the facility corrective actions had been implemented and were aware of the facility expectations in relation to resident privacy as well as the consequences of noncompliance outlined in the facility policies. Interviews with 4 alert and oriented residents and 4 family representatives of cognitively impaired persons showed no concerns with resident rights, privacy or dignity concerns, abuse or neglect, or unresolved grievances.

Based on review of facility policy, medical record review, review of facility investigation, observation, and interviews, the facility failed to provide adequate supervision to prevent elopement for 1 of 5 residents (Resident #1) reviewed, resulting in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident) when Resident #1 exited the building through an egress door and was found by a visitor in the grass by the parking lot, approximately 8 feet from a 2-lane roadway in front of the facility, and 187 feet away from the facility building. The Administrator and Regional Nurse Consultants (RNC #1 and RNC #2) were notified of the IJ on 5/6/2021 at 1:35 PM, in the Administrator's office. The facility was cited F-689 at a scope and severity of J which constitutes Substandard Quality of Care. The IJ was effective on 2/26/2021. The IJ was removed onsite 2/26/2021 when the facility implemented a corrective action plan. Corrective actions were validated by the surveyor on 4/21/2021 - 4/23/2021 and 5/6/2021 - 5/7/2021. The Immediate Jeopardy (IJ) was cited as past noncompliance and the facility is not required to submit a Plan of Correction. The findings include: Review of the facility's policy titled, Exit Door Alarm Policy dated 2/2020, showed .At any time when an exit door alarm is sounding, staff should try to identify the cause of the alarm .Staff should check outside of door prior to resetting the alarm . Resident #1 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Dementia, Adjustment Disorder with Mixed Anxiety and Depressed Mood, and history of Traumatic Brain Injury. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #1 had severe cognitive impairment and exhibited behaviors, with no wandering behaviors. Resident #1 required assistance of 2 staff for activities of daily living and bathing and used a wheelchair for locomotion on the unit. Review of elopement risk evaluations dated 1/21/2021 and 2/9/2021, showed Resident #1 was at risk for elopement due to cognitive impairment, independent mobility, poor decision-making skills, exit-seeking behavior, decreased safety awareness, and the resident's ability to exit the facility. Resident #1 scored 3 on both elopement risk assessments, which indicated the resident was considered a moderate to high risk for elopement. A Wanderguard (electronic monitoring device to detect when a resident exits the building) was implemented on 1/21/2021. Medical record review showed a note written by the Nurse Practitioner (NP) dated 1/22/2021, .[Resident #1] discharged from this facility on 1/14/2021 .with family and home health .family requested she return for long term care .Today, she is seen sitting in dining room up in her wheelchair .she appears calm and in no acute distress .reports she was tearful, anxious and exit seeking last night . Review of Resident #1's current comprehensive care plan revised 2/9/2021, showed .at risk for complications-wandering, exit seeking .will demonstrate willingness to comply with care by having fewer episodes of behaviors .involve pt [patient] in activities of choice/interest .redirect pt when attempting to exit building .wanderguard to right ankle . Review of a facility investigation dated 2/26/2021, showed Resident #1 had eloped from the building and was found at 1:12 PM, at the edge of the facility parking lot. At 11:30 AM, Resident #1 had refused lunch, propelled in a wheelchair to the Station 1 hallway door, and asked staff if they could open the door. At 11:45 AM, Resident #1 was found by staff pushing on the dining room door to the outside and was redirected by staff. Around 12:26 PM, MDS Nurse #2 found the resident again pushing on the dining room exit door. Staff redirected Resident #1 and the resident began self-propelling the wheelchair in the hallway. At 12:45 PM, Resident #1 was in the front lobby attempting to exit the front double doors and was redirected by staff to the dining room. Resident #1 had verbalized statements of wanting to leave the facility. Review of the facility investigation showed Resident #1 had been redirected from egress doorways multiple times throughout the morning of 2/26/2021. At 1:10 PM - 1:12 PM, Resident #1 had pushed on a fire door for more than 15 seconds, the door lock deactivated, and the alarm sounded on the Station 1 long hall. Registered Nurse (RN) #1 responded to the door alarm, looked out the window, and then secured the door. RN #1 did not observe Resident #1 outside. The Staffing Coordinator (SC) noticed a man running past her office in front of the facility around 1:12 PM. The SC met the visitor in front of the building and the man stated, Patient was outside of facility. The SC notified the Administrator and RN #2. Resident #1's wheelchair was in the parking lot and Resident #1 was found supine [laying on her back] in the grass. Emergency Medical Services (EMS) was called and the resident was transported to the hospital at 1:32 PM. Resident #1 returned to the facility the same day. Medical record review of the hospital discharge summary dated 2/26/2021, showed Resident #1 did not sustain any fractures, but the resident had abrasions to the left knee and right shin. During an interview conducted on 4/21/2021 at 12:55 PM, the Administrator stated around 1:10 PM, the door alarm sounded and was checked by a Partner (staff member). The partner looked out the window of the door and did not see the resident. At 1:12 PM, it was reported by a visitor that a resident (Resident #1) was in the parking lot. At 1:13-1:14 PM, Resident #1 was found by staff in the grass at the edge of the parking lot. Observation on 4/21/2021 at 1:10 PM, revealed signage present on all egress doors that an alarm would sound within 30 seconds. During an observation on 4/22/2021 at 2:03 PM, Staffing Coordinator (SC) #1 showed the surveyor where Resident #1 was found after exiting the facility on 2/26/2021. Resident #1 was found in the grass, beside the parking lot on facility property, approximately 8 feet from a 2-lane roadway in front of the facility. During an interview conducted on 4/22/2021 at 3:05 PM, RN #1 confirmed she had attended staff in-service training on the door alarm policy and the missing patient policy. RN #1 confirmed she had looked out the Station 1 door window and did not observe Resident #1 in view from the window. RN #1 stated .I looked out the window and didn't see anything .I did not go outside .I secured the door and reset code to alarm and went back to work . RN #1 confirmed she failed to go outside the door to ensure a resident had not exited the building and failed to follow facility policy. During an interview conducted on 4/23/2021 at 11:51 AM, the Director of Nursing (DON) confirmed RN #1 did not follow facility policy by not going outside to check for a resident when the door alarm sounded. The facility's corrective action plan included the following: A. On 2/26/2021, after Resident #1 returned to the facility from the hospital, an elopement assessment was completed, and care plan updated with interventions. Review of the medical record confirmed the elopement assessment had been completed and the comprehensive care plan was updated. B. On 2/26/2021, all exit doors and door alarms were inspected and found to be in working order by the Director of Maintenance (DM). Review of the Door Alarm Inspection Log dated 2/26/2021, verified doors were re-inspected by DM and were found to be in working order. C. On 2/26/2021, the Administrator, Director of Nursing (DON), Staffing Coordinator (SC), Patient Care Coordinator (PCC), and Minimum Data Set Coordinator (MDS) conducted a review of residents to identify other residents who had exit seeking behaviors. During an interview on 5/7/2021 at 3:40 PM, the DON confirmed no additional residents were identified. D. On 2/26/2021, the Administrator conducted a root cause analysis with assistance from members of the Quality Assurance and Performance Committee to identify any systemic failures that may have contributed to this incident. During a review of facility documentation titled Root Cause Analysis dated 2/26/2021, actions implemented were Resident #1s elopement assessment was updated; care plan was updated; interventions were updated; and a medication review was completed. Staff were reeducated on the door alarm policy and procedures 2/26/2021 through 3/3/2021, ensuring everyone was educated prior to working their shift. During an interview on 5/7/2021 at 4:10 PM, the Administrator confirmed a Root Cause Analysis was completed on 2/26/2021 and findings were taken to the Quality Assurance Performance Improvement (QAPI) meeting. The elopement event for Resident #1 was discussed in daily level of care meetings with a focus on identifying elopement and behavioral changes in residents. The continued focus on identifying elopement behaviors in daily level of care meetings is ongoing per the Administrator. E. On 2/26/2021, the DON, PCC, QAPI Director, and/or nurse supervisor audited all resident records to ensure elopement assessments were completed and care plans reflected any residents who may be at risk for elopement, ensuring appropriate interventions. Audits of all new admissions and readmissions continue weekly for 12 weeks and then monthly for 2 months to ensure desired compliance rate of 100% (percent). Results are reported monthly to the QAPI committee. During review of documents and interview on 5/7/2021 at 5:03 PM, the DON confirmed 100% compliance of elopement risk assessments completed in the electronic medical record for admissions and readmits for 2/26/2021 - 5/6/2021. F. On 2/26/2021, the Maintenance Director or designee performed a quality assurance monitor of exit door alarms to ensure they were working properly. Audits of door alarms continue weekly for 4 weeks and then monthly for 2 months. Results are reported monthly to the QAPI committee. Review of facility documentation dated 2/26/2021 through 4/2/2021 showed audits were completed and documented as in working order. Review of facility documentation titled, 3/24/2021 URC [Utilization Review Committee] showed it was reported in QAPI meeting that all fire doors and door alarms were checked each Friday and found in working order. During an interview on 5/7/2021 at 10:06 AM, the DM stated he continued testing door alarms weekly and will be an on-going monitoring process. The DM confirmed there had not been any reports of performance problems with any of the facility doors or alarms. G. On 2/26/2021 - 3/3/2021, the Administrator and DON conducted in-service reeducation for staff on responding to door alarms and checking outside perimeter on any exit door alarms. Review of the facility's in-service records and employee lists confirmed 100% of employees received reeducation. Staff interviews conducted on 5/6/2021 - 5/7/2021 with 2 Registered Nurses (RN) working day shift (6:00 AM - 6:00 PM) and 2 working night shift (6:00 PM - 6:00 AM), 5 Licensed Practical Nurses (LPN) working day shift (6:00 AM - 6:00 PM) and 3 working night shift (6:00 PM - 6:00 AM), 4 Certified Nursing Assistants (CNA) working day shift (6:00 AM - 6:00 PM) and 4 working night shift (6:00 PM - 6:00 AM), 2 Therapy staff, 2 Dietary staff, 2 Housekeeping staff, and the Maintenance Director confirmed they were aware of the policy and procedures to follow when a door alarm sounds and when a resident is missing. All staff interviewed verbalized that it is the facility's policy for staff to go outside and perform a sweep of the premises to locate a resident after responding to a door alarm. H. On 2/26/2021 - 3/3/2021, admission elopement risk assessments from 12/1/2020 through 2/26/2021 were reviewed by the DON and designee and no residents were identified to have missing admission elopement assessments. Observation of facility documentation titled Elopement Assessment QA dated 3/3/2021 showed .Audits of all new admissions and readmissions will continue weekly for 12 weeks and then monthly for 2 months to ensure desired compliance of 100% .61 patient charts reviewed - All patient charts had completed Elopement assessment. 9 of the 61 patients admitted within the previous 2 weeks - All completed and documented in timely manner .Patients who had been returned to center .dated 12/1/2020 to 2/26/2021, 6 out of 7 patient elopement assessment completed at readmission .PCC to complete admission Elopement assessment audit to ensure completion .MDS Coordinator to complete quarterly and annual assessment . During an observation on 5/7/2021, the DON accessed all resident's electronic medical records and this surveyor verified 100% of elopement assessments were completed. During an interview conducted on 5/7/2021 at 4:10 PM, the DON stated she completed the 7th chart mentioned in the QA tool and the facility was in 100% compliance. Audits are continuing until at least 5/26/2021. I. In March 2021, Missing Patient Policy and Door Alarm Policy information slides were added for new partner (staff) orientation. Observation of the facility's new hire orientation education documentation confirmed the following topics were added to orientation material: Elopement, Wander Guards, Door Alarm Policy, and Missing Patient Policy. During an interview conducted on 5/7/2021 at 4:10 PM, the Administrator and DON confirmed they both educate new hire employees regarding these policies and procedures during the new hire orientation process. J. On 3/8/2021 - 3/9/2021, annunciators (alarm speakers) with increased volume were added to the existing exit door alarms and were wired to each nurse's station panel to extend alarm notification to more central locations. Observation of facility documentation invoices from a local contractor confirmed alarm equipment was ordered on 3/2/2021 and the alarm equipment was installed at the nurse's stations, with equipment hard wired in with the current alarm system, on 3/8/2021 - 3/9/2021. The system was tested and was found in working order after installation. During an observation on 5/7/2021 at 10:08 AM, the door alarm was tested , unannounced and the door alarm was found to be in working order. Staff responded to the door alarm in a timely manner and 2 staff exited the building to perform a sweep of the outside premises to locate a possible missing resident. K. On 3/8/2021, the sent a request to the State Agency a request to disable the delayed egress, that was approved 3/30/2021. The approved request was for the reprogramming of the locks to 30 seconds. During an interview on 4/23/2021 at 11:17 AM, the DM confirmed all egress door delays were set to 30 seconds on 4/2/2021. During an observation conducted on 4/23/2021 at 11:22 AM, DM performed an unannounced test of door alarms, the alarms were audibly loud from the door as well as the installed nurses station annunciators. Multiple staff responded timely to the alarm. L. On 3/8/2021, an Ad-Hoc QAPI Committee meeting was held and the following recommendations were made: Continue quality assurance monitor for elopement assessments and care plan interventions on all new admissions and readmissions; continue weekly monitoring of exit door alarms for proper functioning and that new annunciators at nurses stations are working properly; conduct missing patient drill on or before 3/20/2021; evaluate staff performance to assess education needs; and monitor any patient who is actively exit seeking to ensure needs are met. Review of the facility documentation Missing Person Drill dated 3/12/2021 at 3:00 PM, confirmed multidisciplinary facility staff participated in the drill to simulate a missing resident. During an interview on 5/7/2021 at 4:10 PM, the Administrator stated elopement drills will continue on a quarterly basis.

Based on facility policy review, medical record review, and interview, the facility failed to ensure 1 resident (#11) received routine dental services of 18 residents sampled. The findings include: Review of the facility's policy Dental Services, undated, revealed .To ensure patients are receiving the care and services necessary for proper denture and dental health .Build accountability into each process to ensure effectiveness .Establish process for communication of dental needs .of patients .Ensure all partners are aware of process for communication of dental needs . Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. Medical record review of the care plan dated 9/3/19 revealed .risk of altered nutrition status .Dental consult as warranted . Medical record review of a Food and Nutrition Services progress note dated 9/10/19 revealed .Staff contacted RD (Registered Dietician) to notify of (Resident #11's name) reporting she is having trouble with her dentures and needs new ones. She reports that she is getting choked on her food because she can't chew it. Diet change to Low Sodium, Mechanical with ground meats for ease of chewing. Reassess diet texture change as needed/when new dentures are obtained . Medical record review of a physician's orders [REDACTED]. Interview with Resident #11 on 11/18/19 at 2:47 PM, in the resident's room, revealed her dentures no longer fit and she wanted new dentures. Further interview revealed she had reported the issue to the facility but had not been seen by the dentist. Interview with the Social Services Assistant on 11/19/19 at 12:34 PM, in the social services office, revealed the nursing staff maintained the list of residents to be seen by the dentist. Interview with the Resident Care Coordinator (RCC) on 11/19/19 at 12:46 PM, in the RCC's office, revealed the nursing staff did not maintain the list of residents to be seen by the dentist and the RCC was not aware of which residents were on the list. Interview with the Administrator on 11/19/19 at 12:49 PM, in the Administrator's office, revealed he maintained the list of residents to be seen by the dentist. Continued interview confirmed he had not been made aware of the resident's need to be seen by the dentist and Resident #11 had not been added to the dental list. Further interview confirmed it was his expectation to be notified immediately of dental concerns so the resident can be added to the dental list to be seen at the next visit or sooner if needed. Interview with the Director of Nursing (DON) on 11/19/19 at 12:53 PM, in the Administrator's office, confirmed she was unaware Resident #11 had a need to see the dentist. Continued interview confirmed it was her expectation for the RD or the staff member who informed the RD of Resident #11's need to be seen by the dentist to have notified the Administrator or DON.

Based on facility policy review, observation, and interview, the facility failed to store beverages in a sanitary manner, and failed to maintain dietary equipment, in a clean and sanitary manner in 1 of 2 dietary observations made affecting 63 of 68 residents. The findings included: Review of a facility policy, Safety & Sanitation Best Practice Guidelines Sanitation Manual Ware Washing revised 1/2011, revealed .Remove all traces of food .utensils .shall be cleaned and sanitized .throughout the day at a frequency necessary to prevent recontamination of equipment and utensils . Review of a facility policy, Safety & Sanitation Best Practice Guidelines Cleaning Procedures revised 1/2011, revealed . Cleaning procedures .Ovens .Scrape burned particles from hearth, brush out interior .Mixer .Clean mixer beater shaft . Review of a facility policy Safety & Sanitation Best Practice Guidelines Sanitation Machine Washing revised 1/2011, revealed .Check the machine for cleanliness and clean at least once each day or more often .Use an acid cleaner on the machine at least once a week . Review of a facility policy Safety & Sanitation Best Practice Guidelines Sanitation Refrigerator and Freezer Storage revised 1/2011, revealed .To prevent cross-contamination, partner (facility employee) and patient personal food items may not be stored in refrigerator/freezer in Dietary . Observation/Interview with the Assistant Dietary Manager on 10/30/17 at 9:40 AM, in the kitchen, revealed A. A mixer with dried debris on the beater shaft B. A can opener with dried debris on the base, and under the blade C. Dried burnt debris on the interior bottom, sides, and doors in 1 of 2 ovens observed D. A microwave with dried flaky debris on the interior top Further observation in the kitchen revealed A. 4 of 6 ¼ pans and 1 of 2 baking pans with flaky debris on the rims and inside B. 1 of 8 knives with dried orange colored debris on the blade Interview confirmed all items were available for use. Observation with the Assistant Dietary Manager on 10/30/17 at 9:55 AM, in the dish room, revealed the dish machine with thick dried debris on the door, sides, and top of the machine. Observation with the Assistant Dietary Manager on 10/30/17 at 10:00 AM, in the kitchen, of a reach in cooler revealed an employee's personal beverage stored with patient beverages. Interview with the Assistant Dietary Manager on 10/30/17 at 10:05 AM, in the kitchen, confirmed the facility failed to maintain a sanitary environment in the kitchen and failed to follow facility policy.

Based on observation and interview, the facility failed to maintain the kitchen area in a clean, sanitary manner evidenced by food preparation equipment stored with dried debris; failed to store food in a safe, sanitary manner evidenced by opened and unlabeled food products stored in the freezer, and failed to serve food in a safe, sanitary manner for 68 residents receiving meals by mouth of 72 residents reviewed. The findings included: Observation and interview with the Dietary Manager (DM), during the initial tour of the dietary department on 11/28/16 from 9:30 AM to 10:15 AM, revealed 8 of 10 large cookie sheets had brown debris visible, and the mixer head had multi-colored debris also visible. Continued observation in the walk-in freezer revealed the following foods opened and undated: approximately 20 waffles; approximately 2 pounds of berries; approximately 1 pound of fried okra; 4 gallon sized bags of cooked meatloaf; 4 bratwurst; and approximately 8 pounds of chicken thighs left open to air. Interview with the DM during the tour confirmed the cookie sheets and the mixer head had debris of various colors; and the items in the freezer were opened, ready for resident use, and had not been dated after opening. Observation on 11/28/16 at 11:55 AM, of the steam table in the food serving room, revealed the DM (with the bare hands) sanitized the probe of the thermometer (not the handle) with an alcohol wipe. Continued observation revealed the DM held the unsanitized handle of the thermometer with bare hands to obtain the temperature of the soup. Continued observation revealed the DM dropped the unsanitized handle of the thermometer into the soup, and retrieved the thermometer from the soup with bare fingers. Continued observation revealed the DM continued to prepare the soup for resident consumption after dropping the thermometer into the soup. Interview with the DM on 11/28/16 at 2:45 PM, in the conference room, confirmed the facility had failed to store, serve and prepare food in a safe and sanitary manner.

Based on medical record review, observation, and interview, the facility failed to ensure fingernails were clean and well-manicured by providing nail care for 1 resident (#52) of 25 residents reviewed. The findings included: Medical record review revealed Resident #52 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum (MDS) data set [DATE], revealed Resident #52 had severly impaired cognition, required maximum to total assistance with Activities of Daily Living (ADL) including eating and personal hygiene. Review of the resident's care plan dated 9/27/16, revealed, .Assist with personal hygiene daily and prn (as needed) .Nail care prn . Observation on 11/28/16 at 12:15 PM, in the 200 hall dining room revealed Certified Nurse Assistant (CNA) #1 was assisting Resident #52 with the lunch meal. Further observation revealed CNA #1 encouraged Resident #52 to pick up the food with the fingers to eat. Continued observation revealed Resident #52's fingernails were long, and had dark debris under the nail tips. Observation and interview with CNA #1 on 11/28/16 at 12:17 PM, in the 200 hall dining room revealed Resident #52's food was prepared in balls to assist the resident with using the fingers to feed herself. Continued interview confirmed Resident #52 had fed herself, using her fingers and there was dark debris under the nail tips. Interview with the Director of Nursing and the Registered Nurse Supervisor on 11/30/16 at 10:00 AM, in the conference room confirmed the facility failed to ensure Resident #52 had received adequate nail care.

Based on observation and interview, the facility failed to provide sanitary storage areas in the kitchen and failed to cover hair to prevent food contamination. The findings included: Observation and interview during the inital tour in the dietary department, on July 29, 2013, at 9:15 a.m., with the facility Chef revealed: a red tinged substance on the white shield in the ice machine; a rack of trays of juice in the juice cooler had spilled juice dried on each rack and the sides of the rack; a brown/black substance on the back wall of the juice cooler; a drawer with utensils stored next to the juice cooler had food debris on the inside bottom of the drawer; a set of four plastic drawers with utensils stored had food debris inside the bottom of the drawers; and the drip tray for the stove burners had a large amount of food debris. Interview during the inital tour with the Chef confirmed the above areas were not sanitary. Observation on July 30, 2013, at 1:10 p.m., in the kitchen on the clean side of the dishwasher, revealed dietary worker#1 had a beard, and was wearing the beard net down under the chin. Observation and interview on July 30, 2013, at 1:12 p.m., with the facility Chef in the kitchen, revealed Dietary Worker #2 had a long braid hanging down the left side of the front of the uniform. Interview with the Chef confirmed the dietary workers were required to cover the hair to prevent food contamination.

Based on medical record review and interview, the facility failed to include two residents (#31, #79) in the resident's care plan meetings of thirty-nine residents reviewed. The findings included: Resident #31 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident scored an 11 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was moderately cognitively impaired. Medical record review of a Social Services note dated May 14, 2013, revealed "...Care Plan mtg (meeting): SW (Social Worker) attempted to reach pt's (patient's) daughter by phone with no success..." Medical record review of a Patient Care Plan Approval Form dated May 14, 2013, revealed "...3. If participation is by the legal representative rather than the patient, please check reasons why the patient did not participate:...b. level of confusion..." Observation and interview with the resident on July 29, 2013, at 3:40 p.m., in the resident's room revealed the resident was alert and oriented, and was able to fully participate in the Stage 1 resident interview without difficulty. Continued interview revealed the resident reported the resident had not been involved or invited to participate in care plan meetings. Interview with the Social Services Director and Social Worker #1 on July 31, 2013, at 10:38 a.m., in the Social Services Director's office revealed Social Worker #1 was responsible for inviting the resident and resident's family to participate in Care Plan meetings. Continued interview with Social Worker #1 revealed all residents are to be invited to participate in Care Plan meetings if the resident is cognitively intact and "...able to make their needs known..." Further interview with Social Worker #1 confirmed the resident was only moderately cognitively impaired and was able to make needs known. Continued interview confirmed the facility had failed to invite the resident to participate in Care Plan meetings. Resident #79 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the last two Minimum Data Sets (MDS) dated [DATE] and May 30, 2013, revealed the resident had scored a 15 out of 15 on the BIMS (Brief Interview for Mental Status) indicating the resident was cognitively intact. Medical record review of Social Services notes dated March 12, 2013 and May 30, 2013, revealed "...pt scored 15/15 on BIMS assessment indicating cognitively intact..." Medical record review of a Patient Care Plan Approval Form dated March 19, 2013 and June 6, 2013, revealed "...3. If participation is by the legal representative rather than the patient, please check reasons why the patient did not participate:...b. level of confusion..." Interview with the Social Services Director and Social Worker #1 on July 31, 2013, at 10:38 a.m., in the Social Services Director's office, revealed Social Worker #1 was responsible for inviting the resident and the resident's family to participate in care Plan meetings. Continued interview with Social Worker #1 revealed all residents are to be invited to participate in Care Plan meetings if the resident is cognitively intact and "...able to make their needs known..." Further interview with Social Worker #1 confirmed the resident was cognitively intact and was able to make needs known, and confirmed the facility had failed to invite the resident to Care Plan meetings.

Based on medical record review, observation, and interview, the facility failed to update the care plan for use of a mechanical lift for one resident (#2) of five sampled residents. The findings included: Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Minimum Data Set (MDS) dated [DATE], revealed the resident was severely impaired with decision-making skills, totally dependent on staff on all activities of daily living, and had skin tears. Medical record review of a facility care plan effective through December 20, 2012, revealed, "...Skin integrity...Assist of two for transfers...Dermasavers (skin protectors) to BLE (bilateral lower extremities)...9-27-12 wedge cushion under bil (bilateral) legs when up in gerichair..." Medical record review of a nurse's note dated September 20, 2012, revealed, "...bruises in various stages of healing to BLE..." Medical record review of a Hospice Aide Visit Note dated September 26, 2012, revealed, "...2 person A (assist) with max (maximum) assist...Pt had bruises on L and R (left and right) leg after using sit to stand lift...bruises...were larger..." Observation with the Director of Nursing (DON) and the Assistant Director of Nursing on October 24, 2012, at 12:45 p.m., revealed the resident seated in a geri-chair, a wedge cushion was under the resident's legs, and Dermasvers were on both legs. Interview with the Director of Nursing on October 24, 2012, at 12:45 p.m., in the Activity Room, revealed the resident's plan of care did not include use of a mechanical lift and confirmed the facility failed to update the care plan for Resident #2 on September 26, 2012. C/O: #

Based on medical record review, review of facility investigation, observation, and interview, the facility failed to supervise to prevent accidental bruising during the use of a mechanical lift for one resident (#2) of five sampled residents. The findings included: Medical record review revealed resident (#2) was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of an H&P dated July 19, 2011, revealed, "...thin wasted frail...plan of care hospice..." Medical record review revealed the resident had a history of [REDACTED]. Medical record review revealed care plan interventions included padded siderails, assist of two for repositioning and transfers, Dermasavers to the extremities (the Dermasavers could be removed for hygiene/bathing). Medical record review of a nurse's note dated August 27, 2012, revealed, "resisting care...hitting kicking. SR covers were in place res knocked them off." Medical record review of a social service note dated September 5, 2012, revealed, "...appears fidgety..." Medical record review of a nurse's note dated September 20, 2012, revealed, "...bruising in various stages of healing..." Medical record review of a hospice aide's note dated September 26, 2012, revealed, "...2 person assist with max assist...bruises on L and R leg after sit to stand lift bruises on L and R leg were larger..." Review of facility investigation dated September 27, 2012, revealed the bruises resulted from use of the lift during a transfer. Interview with the DON on October 24, 2012, confirmed the facility failed to ensure the resident was supervised to prevent injury (bruises) during the use of the lift. C/O #

Based on medical record review and interview, the facility failed to provide confidentiality of clinical records for one resident (#1) of seven residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident scored fifteen of fifteen on the Brief Interview for Mental Status (BIMS) with intact cognitive skills, no memory impairment, and no behaviors. Medical record review revealed resident #1 was transferred from the facility and admitted to the hospital on April 11, 2012, with [DIAGNOSES REDACTED]. The resident was discharged back to the facility on [DATE], following a three day hospital stay. Medical record review of a Discharge Planner note, from the local hospital, dated April 13, 2012, at 5:40 p.m., revealed "...verbal permission from pts (patients) daughter via phone call...first choice NHC (National Health Care of Athens)..." Interview with the Administrator on May 22, 2012, at 12:05 p.m., in the Administrator's office, confirmed when the resident went to the hospital in April, 2012, the resident's family member did not want the resident admitted to another nursing home facility following the hospital stay, but the facility had previously been in contact with another nursing home facility regarding possible placement at the other facility. Interview with the Social Service Director on May 22, 2012, at 4:45 p.m., in the Social Service office, confirmed the resident's clinical information had been faxed to another local nursing home on April 13, 2012, for possible placement in the other facility, and neither the resident nor family had not requested or given permission for clinical information to be sent. C/O #

Based on medical record review, review of facility documentation, and interview, the facility failed to provide written notice of the bed-hold policy within twenty-four hours of a transfer for one resident (#1) of seven residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident scored fifteen of fifteen on the Brief Interview for Mental Status (BIMS) with intact cognitive skills, no memory impairment, and no behaviors. Medical record review revealed resident #1 was transferred from the facility and admitted to the hospital on April 11, 2012, with [DIAGNOSES REDACTED]. The resident was discharged back to the facility on [DATE], following a three day hospital stay. Medical record review and review of facility documentation revealed no documentation the resident or the resident's representative had been given written notice of the facility's bed-hold policy within 24 hours of admission to the hospital. Interviews with the Social Service Director on May 22, 2012, at 4:15 p.m., and 4:45 p.m., in the Social Service office, confirmed a family member of the resident was notified verbally by the Administrator the resident had no bed hold days, after the resident was admitted to the hospital. Interview with the Administrator on May 23, 2012, at 12:05 p.m., in the Administrator's office, confirmed the facility failed to provide a written notice within twenty-four hours of transfer to the hospital of the bed hold policy. C/O #

Based on medical record review and interview, the facility failed to accommodate individual needs for one resident (#1) of seven residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident scored fifteen of fifteen on the Brief Interview for Mental Status (BIMS) with intact cognitive skills, no memory impairment, and no behaviors. Continued review of the MDS revealed the resident required total staff assistance for all transfers, eating, and activities of daily living (ADLS). Medical record review of an Interdisciplinary Care Plan, dated May 10, 2012, revealed "...dependent on staff for ADLS r/t (related to) [MEDICAL CONDITION] secondary to [MEDICAL CONDITION] will have all daily needs for ADL, met by staff...two person transfer w/ (with) total body lift to electric w/c (wheelchair) with chin control for mobility, tv (television) controls and computer access...total assist of two persons for toileting and position changes in bed and w/c...staff to totally assist with meals daily...reposition frequently as pt (patient) is unable to make even slight changes unassisted...residents needs and wants will be met daily without excess demands..." Interview with the resident on May 22, 2012, at 9:10 a.m., and 3:40 p.m., in the resident's room, revealed the Maxi Lift (mechanical lift resident needed to be moved from bed to chair and chair to bed) had broken on May 12, 2012, and had not been repaired until May 17, 2012. Further interview revealed the resident's electric chair would recline for sleeping and the resident stayed in the electric wheelchair from May 12, through May 17, 2012. Further interview revealed the resident did not use a facility supplied bed or mattress; the height of the resident's personal bed did not adjust and the Arjo lift (the facility's other mechanical lift) did not go up high enough to place the resident in the resident's bed. Further interview revealed the Administrator offered on the third or fourth day to change the resident's bed to a facility supplied bed, and the resident requested the resident's mattress be placed on the facility bed, but staff never changed the bed. Further interview confirmed the resident had not been offered another alternative. Interview with Certified Nurse Assistant (CNA) #1 on May 22, 2012, at 2:45 p.m., in the Nurse's Station, revealed the resident had been in the electric wheelchair from May 12, 2012, through May 17, 2012, and had not been placed in the resident's bed at night due to the Arjo Lift would not raise the resident high enough to place the resident on the resident's bed. Continued interview revealed the Arjo Lift would allow the staff to provide all ADLS the only change in routine care from May 12, 2012, through May 17, 2012, was the resident was not able to lie down on the resident's bed. Interview with Licensed Practical Nurse (LPN) #1 on May 22, 2012, at 3:15 p.m., in the Activity Room, confirmed the Maxi Lift broke on May 12, 2012, at 3:00 p.m., and was not operational until May 17, 2012, sometime in the morning. Further interview revealed the facility attempted to contact the Administrator and the Maintenance Director regarding the broken Maxi Lift and did not receive a return call on May 12 or May 13, 2012. Further interview confirmed the broken mechanical lift was the lift required to put resident #1 to bed, the resident was not offered any alternatives (manual lift or bed options) over the weekend and the resident stayed up in the electric wheelchair from May 12 through May 17, 2012. Interview with CNA #2 on May 23, 2012, at 9:15 a.m., in the Conference Room, revealed the Maxi Lift was broken when the CNA arrived at work on May 14, 2012, staff reported to the CNA the Maxi Lift had been broken since May 12, 2012, and the resident had been in the chair since May 12, 2012. Continued interview revealed the Arjo Lift had been in place, staff had been using the Arjo Lift to provide routine care, and the Arjo Lift would not raise the resident high enough to place the resident on the resident's bed. Further interview confirmed, on May 15, 2012, the Administrator offered to change the resident's bed to a facility bed so the resident could lie down, and the resident requested own personal mattress be placed on the facility bed, but nothing had been changed. Interview with CNA #3 on May 22, 2012, at 3:05 p.m., in the Activity Room, confirmed the resident required total care, while the Maxi Lift was broken the resident stayed in the electric chair all day, staff repositioned the resident, staff performed routine care with the Arjo Lift, but staff had not been able to lie the resident down in bed. Interview with the Administrator on May 22, 2012, at 11:30 a.m., in the Administrator's office, confirmed the mechanical lift was broken May 12, through 17, 2012, the resident had stayed in the chair without going to bed from May 12, 2012, through May 17, 2012, and the facility did not accommodate the resident's needs for five days. C/O #