Every finding on record at Pruitthealth - Athens Heritage

Based on observations, resident and staff interviews, and review of the facility's policy titled Oxygen Administration, the facility failed to ensure oxygen was administered according to the physician's orders for two of 25 residents (R) (R5 and R34) receiving oxygen treatment. This deficient practice had the potential to place R5 and R34 at risk for respiratory complications. Findings include: Review of the facility's policy titled Oxygen Administration, revised 8/2/2023, revealed the Policy Statement section stated, It is the policy of [name of corporation] to provide oxygen safely and accurately to appropriate patients/residents. The Procedure section included, . 4. Regulate liter flow to ordered/desired flow rate. If using portable e-tank, check for full tank, and regulate flow. Turn main control valve on completely and then regulate liter flow meter to ordered/desired flow rate. 1. Review of the electronic medical record (EMR) for R34 revealed diagnoses, including but not limited to, unspecified systolic (congestive) heart failure, ischemic cardiomyopathy, old myocardial infarction, and dysphagia, oropharyngeal phase, with Klebsiella pneumoniae as the cause of diseases classified elsewhere. Review of the Quarterly Minimum Data Set (MDS) assessment for R34, dated 7/10/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 3 (indicating severe cognitive impairment). Section GG (Functional Abilities and Goals) documented impairment in both upper and lower extremities, and required assistance with Activities of Daily Living (ADLs). Section J (Health Conditions) documented shortness of breath or trouble breathing with exertion, at rest, and when lying flat. Section O (Special Treatments, Procedures, and Programs) documented that the resident received oxygen therapy. Review of the care plan for R34 revealed a Problem area for oxygen use at 2 liters per minute related to heart failure, chronic left frontal lobe infarction, and a history of myocardial infarction. The Goal was to maximize oxygen levels through the next review period. Approach included oxygen at two liters. Review of the physician orders for R34 revealed an order dated 2/26/2024 for oxygen at 2 liters per minute (LPM) via nasal cannula (NC) every shift. Observation on 9/2/2025 at 11:33 am revealed R34 was receiving oxygen via an NC. The oxygen concentrator flow rate was set at 3 LPM. In an interview, R34 stated that the oxygen should be set on 2 LPM. Observation on 9/3/2025 at 10:45 am revealed R34 was receiving oxygen via an NC. The oxygen concentrator flow rate was set at 2.5 LPM. In a concurrent observation and interview on 9/4/2025 at 10:00 am, with Licensed Practical Nurse (LPN) EE confirmed R34 was receiving oxygen at 2.5 LPM via an NC, and the physician's order was for 2 LPM. LPN EE stated the nurses were responsible for reviewing physician orders and ensuring oxygen was administered as ordered. 2. Review of the EMR for R 5 revealed diagnoses, including but not limited to, pulmonary embolism, acute and chronic respiratory failure with hypoxia, pulmonary fibrosis, and dyspnea. Review of the Quarterly MDS assessment for R5, dated 8/27/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 15 (indicating little to no cognitive impairment). Section GG (Functional Abilities and Goals) documented impairment in both upper and lower extremities, and required assistance with Activities of Daily Living (ADLs). Section J (Health Conditions) documented shortness of breath or trouble breathing with exertion, at rest, and when lying flat. Section O (Special Treatments, Procedures, and Programs) documented that the resident received oxygen therapy. Review of the care plan for R5 revealed a Problem area of respiratory failure, history of pulmonary embolism, and active diagnosis of congestive heart failure, osteoarthritis, and pulmonary fibrosis. She requires oxygen at 2 liters continuously. The Goal was for the resident to not exhibit signs of respiratory distress as evidenced by no episodes of shortness of breath or low saturations. Approach included administering oxygen at 2 LPM. Review of the physician orders for R5 revealed an order dated 5/12/2022 for oxygen at 2 LPM via an NC continuous. Observation and interview on 9/2/2025 at 12:10 pm revealed R5 was receiving oxygen via an NC. The oxygen concentrator flow rate was set at 1 LPM. R5 stated her oxygen was ordered at 2 LPM. Observation on 9/3/2025 at 10:45 am revealed R5 was receiving oxygen via an NC. The oxygen concentrator flow rate was set between 1 and 1.5 LPM. In a concurrent observation and interview on 9/4/2025 at 10:15 am, with LPN FF, observation revealed R5 receiving oxygen via an NC. The oxygen concentrator flow rate was set at 1 LPM. LPN FF confirmed the oxygen flow rate was set at 1 LPM, and the physician's order was for 2 LPM. LPN FF stated it was the nurse's responsibility to review the physician's orders and ensure oxygen was administered per the physician's orders. In an interview on 9/4/2025 at 10:40 am, the Director of Health Services (DHS) stated her expectations were for nursing staff to verify oxygen settings were accurate per physician orders each shift. In an interview on 9/4/2025 at 3:45 pm, the Administrator stated her expectations for oxygen administration practices included adhering to physician orders, ensuring the care plan was followed, and verifying that settings were correct.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled Occurrences, the facility failed to ensure hazardous chemicals were not stored in one of 34 sampled residents' (R) (R9) rooms. This deficient practice had the potential to place R9 at risk of medical complications related to hazardous chemicals. Findings include: Review of the facility's policy titled Occurrences, revised 1/11/2024, revealed the Policy Statement section included, .To prevent occurrences, each patient/resident will be observed and assessed for risks. Appropriate, realistic interventions will be implemented in accordance with their plan of care. Review of the electronic medical record (EMR) for R9 revealed diagnoses including, but not limited to, muscle weakness, end-stage renal disease, dependence on renal dialysis, unspecified symptoms and signs involving cognitive functions, dysphagia following cerebral infarction, and aphasia following cerebral infarction. Review of the Quarterly Minimum Data Set (MDS) assessment for R9, dated 6/17/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 4 (indicating severe cognitive impairment). Section GG (Functional Abilities and Goals) documented that R9 required substantial to maximal assistance with Activities of Daily Living (ADLs). Observation on 9/2/2025 at 12:45 pm, in R9's room, revealed a pink organizational bin resting on her bedside table next to her lunch meal tray with an aerosol disinfectant spray container. In an interview, R9 stated it was her spray but did not remember where it came from. She stated she needed to use it when she cleaned her table and area. She stated it had been on her table for a while. Observation on 9/2/2025 at 12:53 pm revealed Certified Nurse Aide (CNA) CC picking up R9's lunch meal food tray, which was sitting on the bedside table next to the pink organizational bin with a can of aerosol disinfectant spray. In a concurrent interview observation on 9/2/2025 at 1:17 pm, in R9's room, Licensed Practical Nurse (LPN) AA confirmed the aerosol disinfectant spray container resting on R9's bedside table and stated the resident should not have it in the room. In an interview on 9/2/2025 at 1:20 pm, Registered Nurse (RN) BB stated R9's family member always came in and cleaned up her room, and brought cans of disinfect sprays. In an interview on 9/2/2025 at 1:25 pm, CNA CC stated he noticed the aerosol disinfectant spray in R9's room when he picked up the lunch meal tray. He confirmed he did not remove the aerosol disinfectant spray from the room when he picked up R9's lunch meal tray.

Based on observations, staff interviews, and review of the facility-provided document titled Housekeeping: Discharge and Monthly Deep Cleaning of the Resident Room, the facility failed to maintain a clean, homelike environment in two of 12 resident rooms (rooms [ROOM NUMBERS]) on the 300 Hall. This deficient practice had the potential to place the residents residing in the rooms at risk of living in an unsanitary living environment and a diminished quality of life.Findings include: Review of the undated facility-provided document titled Housekeeping: Discharge and Monthly Deep Cleaning of the Resident Room revealed the Purpose section stated To detail the proper steps for the discharge and monthly deep cleaning of resident rooms in order to create a sanitary and comfortable environment for the resident. The Procedure section included, 1. Before beginning the deep/discharge clean, confirm with Maintenance Director and Housekeeping Supervisor that all Maintenance and floor care needs ( .PTCA [Packaged Terminal Air Conditioner] units/clean coils, .) have been addressed.Observations on 9/2/2025 at 12:01 pm and 9/3/2025 at 9:54 am in resident room [ROOM NUMBER] revealed debris in the PTAC unit grill.Observation on 9/2/2025 at 10:42 am and 9/3/2025 at 9:52 am in room [ROOM NUMBER] revealed debris in the PTAC unit grill.In a concurrent interview and observation on 9/4/2025 at 10:59 am, the Interim Maintenance Director confirmed debris on the PTAC units in resident rooms [ROOM NUMBERS]. The Interim Maintenance Director stated he was unsure how long the debris had been present and noted that debris on PTAC units could be from burned-off coils and heating elements. He stated that housekeeping performed daily cleaning and that standardized cleaning included monthly deep cleaning. He stated that residents should feel like the facility was their home and that housekeeping should be monitoring PTAC units.In an interview on 9/4/2025 at 1:26 pm, the Administrator stated that housekeeping was responsible for cleaning the PTAC grills, and if further attention was needed, maintenance would be involved. She stated that regular dusting was completed daily, deep cleaning was completed monthly, and items that housekeeping could not reach were to be reported to maintenance. She confirmed the expectation was to maintain a clean, homelike environment with monthly deep cleaning.

Based on observations, resident and staff interviews, record review, and review of the facility policy titled Self-Administration of Medications by Patients/Residents, the facility failed to ensure unauthorized and unsecured medications were not left at the bedside for two of 41 sampled residents (R) (R17 and R86). This deficient practice had the potential to place R17 and R86 at risk of medical complications related to unauthorized medication use. Findings include:Review of the facility's policy titled Self-Administration of Medications by Patients/Residents, revised 1/28/2020, revealed the Procedure section included . 6. All nurses and aides are required to report to the Charge Nurse on duty any medications found at the bedside not authorized for bedside storage and to give unauthorized medications to the Charge Nurse for return to the family or responsible party. Families or responsible parties are reminded of this procedure and related policy when necessary.1. Review of the electronic medical record (EMR) for R17 revealed diagnoses including, but not limited to, chronic systolic and diastolic heart failure, major depressive disorder with psychotic features, and type 2 diabetes mellitus.Review of the Quarterly Minimum Data Set (MDS) assessment for R17, dated 8/7/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 15 (indicating little to no cognitive impairment). Section GG (Functional Abilities and Goals) documented R17 required assistance with Activities of Daily Living (ADLs). Review of the care plan for R17 revealed no care plan for self-administration of medications. Review of the EMR for R17 revealed no assessment for self-administration of medications.Observations on 9/2/2025 at 11:44 am, 9/3/2025 at 10:47 am, and 9/4/2025 at 9:54 am revealed one blue container of medicated vapor rub and one blue container of medicated chest rub on R17's bedside table.Observation on 9/3/2025 at 10:02 am revealed a clear pill container containing two white pills on R17's bedside table.In an interview on 9/4/2025 at 9:56 am, Certified Nursing Assistant (CNA) GG revealed that no residents were authorized to self-administer medication and stated that if she saw medication at the bedside, she would report it to the nurse.In an interview and observation on 9/3/2025 at 10:02 am, CNA HH confirmed the identified medication on R17's bedside table. She stated she would notify a supervisor. 2. Review of the EMR for R86 revealed diagnoses including, but not limited to, major depressive disorder, recurrent, mild, unspecified dementia, and age-related physical debility.Review of the Quarterly MDS assessment for R86, dated 8/3/2025, revealed Section C (Cognitive Patterns) documented a BIMS score of 14 (indicating little to no cognitive impairment). Section GG (Functional Abilities and Goals) documented R86 required assistance with ADLs. Review of the care plan for R86revealed no care plan for self-administration of medications. Review of the EMR for R86 revealed no assessment for self-administration of medications.Observations conducted on 9/2/2025 at 10:39 am and 9/3/2025 at 9:51 am revealed one bottle of medicated eye drops on R86's bedside table. In an interview on 9/3/2025 at 9:56 am, CNA GG revealed there were no residents who self-administer medication and stated that over-the-counter medications found at the bedside were reported to the nurse.In an interview and observation on 9/3/2025 at 10:02 am, CNA HH confirmed the presence of the medicated eye drops at R86's bedside table. She stated she would report medications found at a resident's bedside to a supervisor, and residents were not authorized to self-administer.In an interview on 9/3/2025 at 10:13 am, Licensed Practical Nurse (LPN) EE stated she checked resident rooms to ensure medications were not left unsecured at the bedside. She confirmed that the medications found at R17's and R86's bedsides were not administered by staff and identified potential negative outcomes, including accidental ingestion by another resident or allergic reactions.In an interview on 9/4/2025 at 11:44 am, the Director of Health Services (DHS) revealed that residents must have an order to self-administer medications. She stated that staff were expected to administer medications before leaving the room and identify and report any medications found at the bedside. She stated residents could have adverse outcomes from having unauthorized medications at the bedside. In an interview on 9/4/2025 at 1:22 pm, the Administrator revealed that medications were not allowed at the bedside unless residents had authorized orders for self-administration. She stated that staff were expected to assess the room and remove medications found unsecured at the bedside. She identified potential negative outcomes from leaving medications at the bedside, including incorrect use and a risk of the wrong resident accessing medications.

Based on observations, staff interviews, and review of the facility's policy titled, Labeling, Dating, and Storage, the facility failed to ensure food stored in the main kitchen and in the unit kitchenette's, were labeled, dated, and not expired. The failure had the potential to increase the prevalence and spread of foodborne illness and infection for all residents. The facility census was 83 residents. Findings include: Review of the facility's policy titled, Labeling, Dating, and Storage, revised [DATE], indicated, Food and beverage items will have an identifying label as well as a received date and opened date . for items prepared onsite, a 'use by' date will be indicated. 1. Observation on [DATE] at 9:20 am revealed the following items in the walk-in refrigerator during the initial kitchen tour: A bag of shredded cheese and a block of cheese with no use by date. Nineteen cartons of chocolate milk dated [DATE]. Four ,d+[DATE] (one-half) gallon of buttermilk, dated [DATE]. A container labeled puree turkey, dated [DATE]-[DATE]. A container of cubed potatoes dated [DATE]-[DATE]. A container with meat patties, unlabeled and not dated. A container of Macaroni and Cheese dated [DATE]. A container with a gelled substance which was not labeled and dated [DATE]-[DATE]. Three bags of sliced ham with no date. A container of mechanical chopped turkey sausage dated [DATE]. A whole ham wrapped in foil with no label or date and stored above a case of fresh strawberries and a case of watermelon. Observation on [DATE] at 12:40 pm revealed the following items in the walk-in refrigerator: Fourteen cartons of thawed health shakes with no date. Instructions on the side of the carton indicated the product was to be used within 14 days of thawing. Interview on [DATE] at 1:41 pm with the Dietary Manager (DM) confirmed that all items should be dated with a use by date and no outdated items should remain in the walk-in refrigerator. The DM stated that left over should be saved for only 72 hours and have a discard date on them. The DM stated that the staff should follow the storage diagram for items in the walk-in refrigerator. 2. Observation on [DATE] at 3:50 pm of the nourishment room on unit two revealed a carton of chocolate milk, dated [DATE], and a quart of prune juice, dated [DATE]. Observation on [DATE] at 4:10 pm of the nourishment room on unit one revealed an opened tube feeding bottle of Nepro 1.8 with a best by date of February 2024 and two cartons of yogurt with no visible date. Interview on [DATE] at 10:24 am with the DM stated that the nourishment rooms should be checked daily for cleanliness by the dietary staff. The DM stated she was not aware of the outdated items in the nourishment rooms and confirmed that they should not have remained in the refrigerators. The DM stated that she expects the staff assigned to the nourishment rooms to discard them.

Based on record review, staff interviews, and review of the facility's policies titled, Pneumococcal Vaccinations and Influenza (Flu) Vaccinations for Health Care Center Residents, the facility failed to provide documentation the pneumococcal and influenza vaccines had been offered, given, or previously received outside of the facility for five of five Residents (R) (R286, R23, R12, R72, and R76) reviewed for immunizations. The sample size was 29 residents. Findings include: Review of a policy provided by the facility titled, Pneumococcal Vaccinations, dated 8/29/2023 revealed All residents who reside in this healthcare center are to receive the pneumococcal vaccine(s) within the current CDC guidelines unless contraindicated by their physician or refused by the resident or residents family. If the resident is cognitively impaired, the responsible party will be contacted, and their wishes will be followed in this matter. Review of a policy provided by the facility title, Influenza (Flu) Vaccinations for Health Care Center Residents, dated 12/4/2023 revealed All residents who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with the vaccinations against influenza. 1. Review of R286's undated Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed R286 was admitted to the facility on [DATE]. Review of R286's Vaccines located under the Immunizations tab in the EMR revealed no documentation for pneumonia or influenza that had been offered, given, or previously received outside of the facility. 2. Review of R23's undated Face Sheet located in the EMR under the Profile tab revealed R23 was admitted to the facility on [DATE]. Review of R23's Vaccines located under the Immunizations tab in the EMR revealed no documentation for pneumonia or influenza that had been offered, given, or previously received outside of the facility. 3. Review of R12's undated Face Sheet located in the EMR under the Profile tab revealed R12 was admitted to the facility on [DATE]. Review of R12's Vaccines located under the Immunizations tab in the EMR revealed no documentation for pneumonia or influenza that had been offered, given, or previously received outside of the facility. 4. Review of R72's undated Face Sheet located in the EMR under the Profile tab revealed R72 was admitted to the facility on [DATE]. Review of R72's Vaccines located under the Immunizations tab in the EMR revealed no documentation for pneumonia or influenza that had been offered, given, or previously received outside of the facility. 5. Review of R76's undated Face Sheet located in the EMR under the Profile tab revealed R76 was admitted to the facility on [DATE]. Review of R76's Vaccines located under the Immunizations tab in the EMR revealed no documentation for pneumonia or influenza that had been offered, given, or previously received outside of the facility. Interview on 5/15/2024 at 1:33 pm with the Infection Preventionist (IP) stated, I have been in this position for two months and the immunizations are not up to date. No one in the facility has access to the Georgia Registry of Immunization Transactions and Services (GRITS). We are trying to get access to the system. The five residents (R286, R23, R12, R72, and R76) for whom immunizations were requested, were not in the EMR. There is no documentation that they were offered or given. We do not have a system upon admission to document immunizations. During an interview on 5/16/2024 at 9:50 am with the Director of Nursing stated, Residents should be interviewed and asked about their immunizations and have it recorded in our documents. If they decline an immunization, then document that they declined. The former IP was to be working on immunizations before she left and obviously that did not happen. Interview on 5/16/2024 at 10:27 am with the Administrator revealed Immunizations need to be offered to each resident and documented if refused.

Based on staff interview, record review, and review of the facility's policy titled Advance Beneficiary Notics (ABNs), the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) or Notice of Medicare Non-Coverage (NOMNC) for two out of three Residents (R) (R23 and R76) who were reviewed after being discharged from Medicare Part A Services and remained in the facility. The sample size was 29 residents. Findings include: Review of the facility's policy titled Advance Beneficiary Notics (ABNs) with a revised date of 7/19/2016 revealed, Policy Statement: The company recognizes the residents have the right to be informed in writing. in a timely fashion, about their liability for payment not of services prior to the provisions of those services if Medicare is expected to pay. The purpose of an Advance Beneficiary Notice (ABN) is to inform the resident that Medicare will probably not pay for a certain item or service in a specific situation, even if Medicare might pay for the item or service under different circumstances. This allows the resident to make an informed decision about whether or not to receive the item or service for which he/she may have to pay out of pocket or through other insurance. 3. A copy of the Advance Beneficiary Notice will be issued to the resident for his/her records and a copy will be maintained in the resident's record. 1. Review of the undated Resident Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab for R23 revealed admission to the facility on [DATE] and readmitted on [DATE]. R23 had Medicare benefits and was discontinued from skilled therapy services on 1/24/2024 per the information provided by the facility. R23 had exhausted the Medicare benefit days. Further review of the EMR revealed no documentation that SNFABN or NOMNC was issued to R23 and/or R23's representative. 2. Review of the undated Resident Face Sheet located in the EMR under the Face Sheet tab for R76 revealed admission to the facility on [DATE]. R76 had Medicare benefits and was discontinued from skilled therapy services on 2/22/2024 per the information provided by the facility. R76 had exhausted the Medicare benefit days. Further review of the EMR revealed no documentation that a SNFABN or NOMNC was issued to R76 and/or R76's representative. During an interview on 5/14/2024 at 2:45 pm, the Administrator stated he was unable to locate a completed NOMNC or SNF ABN forms for two of the three residents. He stated the Social Worker was completing the notifications; however, the Business Office Manager had taken over the process. The Administrator stated he had contacted the Social Worker, who said she had provided the notification; however, did not have any copies of the notice. The Administrator confirmed there were no notes in the residents' record to indicate if or when the notices were provided.

Based on record review, staff and resident interviews, the facility failed to accommodate a resident's allergies for one of 29 sampled Residents (R) (R286). Specifically, the facility served R286 foods that were documented as allergies. This deficient practice had the potential to result in harm with an allergic reaction and reduced consumption for R286. Findings include: Review of R286's Face Sheet tab of the Electronic Medical Record (EMR) revealed he was admitted to the facility with diagnoses that included chronic obstructive pulmonary disease (COPD), type II diabetes (DMII), depression, anxiety, Parkinson's disease, and renal dialysis. R286's allergies were listed as black pepper, cayenne pepper, onions and strawberries. Review of R286's Admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 5/4/2024 and located in the MDS tab of the EMR, revealed he scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated intact cognition. Review of R286's Care Plan dated 5/5/2024 and located in the Care Plan tab of the EMR, revealed [R286] has allergies to . black pepper, cayenne pepper, onions and strawberries. Goals were listed as [R286] will not receive any medication or food with allergies ingredients. The approaches included List all allergies on the chart, monitor and document allergy changes .monitor medication and food for allergy ingredients. Interview on 5/13/2024 at 3:10 pm with R286 revealed that he received strawberry shortcake on his lunch tray. R286 stated that he knew what it was and didn't even open the container. R286 stated that he was also allergic to all peppers including black pepper and cayenne pepper. R286 stated that he was also allergic to fish and has had that served on his meal trays. Review of the meal tray ticket for R286, dated 5/13/2024, revealed that strawberries were listed as an allergy. Further review revealed that angel food cake with strawberry topping was on the tray ticket and not replaced with a suitable substitution. Interview on 5/15/2024 at 2:28 pm with R286 revealed that he got chicken chili for dinner and had to tell the staff he could not eat it because of the ingredients. Review of the undated Consistency Census Report provided by the Dietary Manager (DM) revealed R286 diet was on a liberal renal diet and documented no onions, peppers (seasoning included) or fish should be served to R286. There was no mention of strawberries on this report. Interview on 5/15/2024 at 4:24 pm with the Director of Health Services (DHS) revealed that there was no facility policy addressing resident allergies but expected all allergies to be documented in the resident charts. Interview on 5/16/2024 at 10:15 am with the DM revealed that she was aware of R286 allergies and dislikes. The DM stated that staff should be aware of the residents' allergies and dislikes and those foods should not be on the meal trays. The DM stated that staff should be aware of the ingredients in the food to be sure those foods could be served safely to the residents. The DM was not aware that strawberries or onions had been served to R286. The DM stated that she expects the staff on tray line to make sure the meal trays contain only the foods the residents are able to consume.

Based on observations, resident and staff interviews, and record review, the facility failed to provide podiatry services to one out of 29 sampled Residents (R) (R38). This failure had the potential to affect one resident's bilateral foot health. Findings include: Review of R38's undated Face Sheet, provided by the facility, revealed R38 was readmitted with diagnoses that included but not limited to diabetes, hypertension, and frequent falls. Review of R38's quarterly Minimum Data Set (MDS), located in the EMR under the MDS tab, with an Assessment Reference Date (ARD) of 3/5/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of seven out of 15, which indicated R38 had moderate cognitive impairment. Further review of the MDS revealed, R38 required substantial or maximal assistance from helper for personal hygiene. Observation conducted on 5/13/2024 at 3:47 pm revealed R38's toenails were long and unkept. Observation conducted on 5/14/2024 at 9:28 am revealed R38's toenails were long and unkept. During an interview on 5/15/2024 at 9:02 am, Licensed Practical Nurse (LPN)1 stated, Her [R38] toenails are too long. During an interview on 5/15/2024 at 9:11 am, Certified Nursing Assistant (CNA)1 stated, Her [R38] toenails are too long. The CNA went directly to the nurse to report the R38 had long toenails. LPN1 stated I will put her on the list to see the podiatrist the next time he comes. During this interview with CNA1, R38 stated, My toes hurt me so bad because my toenails are too long. During an interview on 5/15/2024 at 1:48 pm, the Director of Health Services (DHS) confirmed R38's toenails were too long. When asked when was the last time R38 had seen the podiatrist, the DHS stated, I don't remember but I will find out. Follow up interview with the DHS on 5/15/2024 at 5:00 pm stated, R38 has not seen the podiatrist since she had been admitted here. I have put her on the list to be seen in June. When asked the process in which the resident's are put on the podiatrist list to be seen, the DHS stated, If the CNA sees this is a problem, the CNA reports this to the nurse and then the nurse can put the residents on the list or they can talk to the social worker and they will put the resident on this list. Cross Reference F677

Based on observations, resident and staff interviews, and record review, the facility failed to perform nail care for one out of 29 sampled Residents (R) (R38) requiring substantial or maximal assistance from staff for personal hygiene needs. Findings include: Review of R38's undated Face Sheet, revealed R38 was readmitted with diagnoses that included diabetes, hypertension and frequent falls. Review of R38's quarterly Minimum Data Set (MDS), located in the EMR under the MDS tab, with an Assessment Reference Date (ARD) of 3/5/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of seven out of 15, indicating R38 was moderately cognitively impaired. R38 was also coded as requiring substantial or maximal assistance from staff for personal hygiene. Review of R38's care plans revealed there was no documentation regarding nail care. Observations on 5/13/2024 at 3:47 pm and on 5/14/2024 at 9:28 am revealed R38's fingernails were long with brown debris visualized under them. During an interview on 5/15/2024 at 9:02 am, Licensed Practical Nurse (LPN)1 stated, Her .fingernails are too long. When asked who was responsible for making sure the resident's fingernails were cut or trimmed on a regular basis LPN1 stated, I guess it would be the CNA's [Certified Nursing Assistants] responsibility to do this. During an interview on 5/15/2024 at 9:11 am, CNA1 stated, I don't know if I can cut her [resident's] nails. During this interview, R38 stated, My fingernails are too long and need to be cut. Can you cut them for me? On 5/15/2024 at 1:48 pm, the Director of Health Services (DHS) went to R38's room and confirmed the resident's fingernails were long and had brown debris under them. The DHS stated, It is the responsibility of each CNA to clean and file the resident's fingernails as needed and if there is a problem, then they [CNA] are to report this to their nurse. Follow up interview on 5/15/2024 at 4:30 pm with the DHS stated, We don't have a policy on activity of daily living but instead we have a procedure on how nail care is to be performed. Cross Reference F687

Based on observations, staff interviews, and record review, the facility failed to ensure the call button to activate the emergency call light was accessible for one out of 29 sampled Residents (R) (R53) . This failure placed the resident at risk of accident, injury, and/or unmet needs related to an inability to call for staff assistance. Findings include: Review of R53's Face Sheet tab of the electronic medical record (EMR) revealed she was admitted with diagnoses that included heart disease, stage 3 (three) chronic kidney disease, hemiplegia and hemiparesis, contracture of right knee, dysphagia, ataxia, aphasia, vascular dementia, mood disturbance and anxiety, depression disorder and post-traumatic stress disorder (PTSD). Review of R53's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 4/29/2024 and located in the MDS tab of the EMR, revealed she scored six out of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. R53 required total assistance with toileting, dressing and maximal assistance with personal hygiene. R53 required total assistance with chair to bed transfer and sit to lying position. Review of R53's Care Plan, dated 3/21/2024, and located in the Care Plan tab of the EMR, revealed, [R53] was at risk for falls related to decreased mobility, diagnose (dx) of dementia R53 was a high risk for falls. The approaches included Place call light within reach when in room and encourage use. During the initial tour of the facility on 5/13/2024 at 10:29 am R53 was sitting in the wheelchair and the call light was observed on the bed and out of the reach of the resident. An observation of R53 on 5/14/2024 at 11:31 am revealed R53 lying in bed with her eyes open there was no call light observed in or near the bed. An interview on 5/14/2024 at 11:31 am with Certified Nurse Assistant (CNA) 2 revealed that R53 was able to use the call light and has used it on occasions. CNA2 located R53's call light on the floor behind the bed. An observation of R53 on 5/15/2024 at 12:03 pm revealed R53 sitting in her wheelchair watching television. The call light was observed on the floor behind the bed. An interview on 5/15/2024 at 2:51 pm with the Director of Health Services (DHS) revealed that her expectations are that all residents have their call lights within reach while in their rooms. Additionally, the DHS stated that staff should make sure call lights are placed within the reach of the residents after all care has been provided. A call light policy was requested but was not provided during survey.

Based on observation, staff interviews, record review, and review of the facility's policy titled Self-Administration of Medications by Patients/Residents, the facility failed to evaluate and determine if it was appropriate for a resident to self-administer medications for one of 29 sampled Residents (R) (R51). This failure placed the resident at risk for inappropriate and unsafe medication use. Findings include: Review of the facility's policy titled Self-Administration of Medications by Patients/Residents, dated 1/28/2020 revealed, Each patient/resident who desires to self-administer medication is permitted to do so if the healthcare center's Licensed Nurse and physician have determined that the practice would be safe for the patient/resident and other patients/residents of the healthcare center . Review of R51's undated Face Sheet, revealed R51 was readmitted with a diagnosis that included chronic obstructive pulmonary disease. Review of R51's quarterly Minimum Data Set (MDS), located in the EMR (electronic medical record) under the MDS 3.0 Assessment tab, with an Assessment Reference Date (ARD) of 4/8/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R51 was cognitively intact. Review of R51's Physician's Orders located in the EMR, under the Order tab revealed on 3/27/2024 the physician ordered dextromethorphan-guaifenesin liquid 10 ml (milliliters) by mouth three times a day for cough, dorzolamide solution 2% (two percent) one drop in each eye twice a day which was ordered by the physician on 3/27/2024, and Wixela inhub 250-50 mcg/dose (microgram per dose) one puff by mouth which was ordered on 10/3/2023. During the medication administration observation on 5/15/2024 at 9:06 am, Licensed Practical Nurse (LPN)1 left the eye drops, cough medicine and inhaler on the over the bed table as LPN1 went out into the hallway to get another medication that was forgotten. LPN1 returned to the resident's room and administered the medications. During an interview on 5/15/2024 at 9:06 am, LPN1 stated, There is no order for her to self-administer her medication. I should not have left the inhaler; eye drops or cough medicine in the room. I should have brought them out with me. During an interview on 5/15/2024 at 1:15 pm with the Director of Health Services (DHS), who stated, If a nurse has to leave the room and the medications have not been taken, the nurse is to ask the resident if they can take the medication at that time and if not, then the nurse is to take the medications out of the room with them. The DHS confirmed R51 did not have an order to self-administer medications. During an interview on 5/15/2024 at 1:25 pm, with the MDS nurse who stated, She doesn't have an order to do this. The MDS nurse confirmed R51 was not to self-administer medications to herself.

Based on record review, interviews, and review of the policy titled Occurrence Reduction Program, the facility failed to provide adequate supervision to prevent accidents for one of three sampled residents (R) (R1). Actual harm occurred on 12/29/2022, when R1 fell out of bed and suffered a compression fracture of T2/T3 vertebrae, a laceration on her forehead which required sutures, skin tears and multiple bruises to bilateral upper extremities. Findings include: Review of the policy titled Occurrence Reduction Program reviewed 12/9/2021, revealed the policy documents in an effort to prevent occurrences, each patient/resident will be assessed for risk and appropriate and realistic interventions will be implement upon identification of risk and after a fall. These interventions will be included in the care plan. Review of the clinical record revealed R was admitted to the facility on [DATE] with diagnoses including morbid obesity, chronic obstructive pulmonary disease (COPD), chronic kidney disease, major depressive order, and chronic diastolic heart failure. Review of Progress Note dated 12/29/2022 at 7:20 am written by Licensed Practical Nurse (LPN) NN, documented resident observed lying on the floor in her room next to bed face down. Resident was responsive when called. Resident left in same position while 911 was called and then returned to her room. The physician was notified, and responsible party (RP) was called but could not get the RP on the phone. Review of a document titled Post Fall Observation hand dated 12/29/2022, revealed a potential factor contributing to the fall was that Hospice had a new air loss mattress delivered and placed on the resident's bed. The air mattress shifts the weight of the resident. Review of the delivery ticket from the Durable Medical Equipment (DME) provider, dated 12/29/2023 documented the air loss mattress was delivered and set up on 12/28/2023 at 10:30 a.m. Further review of the delivery receipt revealed CNA/CMA SSS was identified to be the staff member that signed receipt of the air mattress. Review of Progress Note dated 1/6/2023 at 1:46 pm written by LPN VVV revealed the resident returned from hospital. Multiple bruising to bilateral arms and thighs. Bruising to chest. closed healing laceration to scalp, sutures removed one day ago. Steri-strips to right hand with noted bruising and swelling. Interview on 12/28/2023 at 9:48 am with Registered Nurse (RN) RR revealed that he was performing 6:00 am medication pass when R1 was found on the floor beside her bed. He stated blood was observed on the floor coming from R1's forehead and stated resident was responsive to staff's questions, indicating she was on the floor for a long time, so she fell asleep. RN RR stated R1 informed him she was reaching for something when she fell out of the bed. During further interview, he stated another nurse called 911 while he stayed with the resident. Interview on 12/28/2023 at 11:15 am, the Administrator revealed the air loss mattress was placed on R1's bed while she was receiving a shower from Hospice Certified Nursing Assistant (CNA) SS. The Administrator stated the pressure relieving mattress was ordered in October 2022, but was on back order. She stated it didn't arrive in the facility until December 2022, and was placed on R1's bed without staff's knowledge. She stated the mattress was removed after the residents fall. Interview on 12/28/2023 at 1:15 am, the Administrator stated R1 fell out of bed while reaching for something. She stated resident was out of reach from the call light and didn't have any roommates that could call for assistance for her. The Administrator stated R1 preferred to have her door shut and stated staff was not sure how long she was on the floor, but stated it was long enough for R1 to fall asleep on the floor. The Administrator confirmed R1 was found on the floor by the nurse during 6:00 am medication pass. Phone interview on 1/3/2024 at 3:13 pm, the Patient Affairs Coordinator from the hospital, stated she called the State Agency to report the fall due to Emergency Medical Services (EMS) personnel communicating that the resident was on the floor for over an hour before she was found. Interview on 1/4/2024 at 10:20 am Certified Nursing Assistant/Certified Medical Assistant (CNA/CMA) PP, stated that R1 was in the bed that evening at the beginning of the shift. She stated that R1 preferred to have the door to her room shut and the lights turned off after care had been provided. During further interview, CNA/CMA PP stated resident requested to not be disturbed after care was provided and therefore, she did not go back to check on resident anymore. She stated R1 usually did not wake up until breakfast. Interview on 1/4/2024 at 11:47 am with Senior Certified Nursing Assistant (Sr. CNA), MM revealed it is the expectation for all CNAs to do rounds every two hours, and walking rounds done with the oncoming shift. Sr. CNA MM stated some residents may not turn their call light on for hours, but the expectation is for the staff to check and make eye contact with each resident every two hours. In a follow-up interview on 1/4/2024 at 2:46 pm, RN RR stated R1 requested the door be closed through the night. RN RR stated however, it is the expectation that CNAs perform two-hour checks on each resident. He stated R1 had a pressure relieving mattress on her bed, stating that the air flow moves the mattress every now and then to prevent any pressure sores. Interview on 1/9/2024 at 10:45 am, the DME delivery representative RRR stated upon arrival to the facility, he notified the facility of the delivery for the respective resident. He stated he demonstrated to a staff member how the use of the mattress settings work before he could leave the facility. He stated he could not recall who he spoke to, or who he showed the demonstration to. Phone interview on 1/9/2024 at 1:24 pm with CNA/CMA SSS denied remembering signing for the air loss mattress for R1's bed. She stated it had been over two years since working at the facility and she subsequently hung up the phone during the interview.

Based on record review, staff and resident interviews, and review of the policies titled, Admission Orders and Peripherally Inserted Central Catheters (PICC), the facility failed to review, verify, document, and transcribe physician orders for one of three sampled residents (R) (R24). Specifically, R24 was admitted to facility with a PICC line, but there were no physician orders for use or care of the device. Findings include: Review of the policy titled Admission Orders dated September 2022, indicated the policy in order to assure quality patient/resident care and to comply with Federal law, it is necessary that completed and accurate physician orders for the patient/resident's immediate care be obtained. Number 1: The orders must be reviewed by the admitting nurse and should at least address the patient/resident's dietary needs, medications (if applicable), and routine care to maintain or improve the patient/resident functional abilities. Number 2. The admitting nurse will make every effort to obtain admission orders prior to the patient/resident's arrival. All hospital orders should be reviewed and authorized by the patient/resident's attending physician, prior to admission to healthcare facility. Number 5. Once all admission orders have been verified and documented appropriately, they are to be transcribed by the admitting nurse on the appropriate documents in the records. Review of the policy titled Peripheral Inserted Central Catheters (PICC) reviewed 10/16/2023, revealed the policy statement defines PICC line is a central venous catheter that is inserted peripherally by a physician or a certified registered nurse. Because this is a special infusion access device, [named facility] requires that a qualified nurse must be knowledgeable regarding the PICC infusion access device. Review of the clinical record revealed R24 was admitted to the facility on [DATE] with diagnoses which included malignant neoplasm of the bladder, dysphagia, and depression. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed R24 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Section O did not reveal resident to have any type of IV access device. Review of the hospital After Visit Summary dated 12/5/2023-12/18/2023 revealed no evidence that R24 would be discharged with a PICC line and did not have physician orders to care for the PICC line. Review of the Observation Detail List Report-Admission Observation dated 12/19/2023 completed by Registered Nurse (RN) RR documented for Physical Observation-Cardiovascular did not reveal that R24 was observed to have a PICC line to the left upper arm. Alterations in skin documented resident upper extremities were noted to have scattered bruises on both upper extremities. Review of the Observation Detail List Report-Skin Note dated 12/20/2023 and completed by Licensed Practical Nurse (LPN) CC documented PICC line in left upper arm with no open areas noted. Review of the Skin Note dated 1/1/2024 completed by RN BB revealed the PICC line was not captured on the assessment. Observation on 1/2/2024 at 9:32 am in R24's room, revealed R24 had a PICC line in the left upper arm. There was an old dressing dated 12/12/2023 that was coming apart from the skin. Interview on 1/2/2024 at 9:32 am, R24 stated she had not received any IV (intravenous) antibiotics since admission to the facility. When asked about the care of the PICC line, she stated the nurses were not caring for the line. Observation on 1/2/2024 at 10:06 am in R24's room, RN GG verified R24 had a PICC line in her left upper arm with a dressing dated 12/12/2023. Telephone interview on 1/4/2024 at 2:47 pm, RN RR stated he did not remember admitting R24 to the facility. He stated the protocols for admitting residents with a PICC line is double check with the resident's physician regarding orders for care of the device, or to discontinue the PICC line. During further interview, he stated the nurses were responsible to make sure the PICC line was intact and patent. Interview on 1/5/2024 at 12:04 pm, the Director of Health Services (DHS) stated that R24's PICC line was assessed upon admission. She indicated the admitting nurse, or the UM should have notified the physician about the PICC line since there were no discharge orders for the device.

Based on record review, interviews, and review of the policy titled Quality Assurance and Performance Improvement Policy (SNF), the facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) Program that identified ongoing concerns related to resolving resident grievances and concerns related to dietary services and call light responses. The census was 89. Findings Include: Review of the Quality Assurance and Performance Improvement Policy (SNF) reviewed on 6/2/2022 revealed the purpose of the Quality Assurance and Performance Improvement (QAPI) Program is to continually take a proactive approach to assure and improve the way we provide care and engage with our patients, partners, and other stakeholders so that we may fully realize our vision, mission, and commitment to caring pledge. The process is that all partners and contracted staff are responsible for the quality of care and services within their respective departments and are expected to participate in the QAPI program. Each center must develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of care, quality of life, and resident choice. Review of the QAPI meeting minutes from January 2023 revealed that the issues with call lights was not documented as being resolved. Under the section, Resident Council Meeting, showed that the New concerns and Old Business concerns from the January 10, 2023, meeting were marked as need improvement. A review of the QAPI meeting minutes dated January 10, 2023, showed that the Resident Council Meeting Minutes Report Form was reviewed by the QAPI Committee. The form showed that residents voiced concerns that Certified Nursing Aides (CNAs) and nursing staff would turn off the call lights and state that they would return or find someone to help the resident and would not return. The form indicated an in-service was provided for staff. Review of the April 2023 QAPI meeting minutes showed that under the section under Resident Council Meeting showed that the New concerns and Old Business concerns were marked as addressed and resolved. During further review of the Resident Council Meeting Minutes that were attached from the April 2023 meeting documented residents stated that the call light issue from March was not resolved. The form indicated an in-service was provided for staff. Review of the May 2023 QAPI meeting minutes showed that under the section under Resident Council Meeting showed that the New concerns and Old Business concerns were marked as need improvement. Review of the Resident Council Meeting Minutes that were attached from the May 9, 2023, meeting revealed that residents stated the call light issue from March was not resolved. The form indicated an in-service was provided for staff during the month of May. Review of the August 2023 QAPI meeting minutes showed that under the section Resident Council Meeting documented that the New concerns and Old Business concerns were marked as need improvement. Review of the Resident Council Meeting Minutes showed that the call light issues voiced during the July Resident Council Meeting had not been resolved. Resident Council Meeting Minutes for meeting held on August 8, 2023, documented residents voiced that staff was sitting at the nurse's station, talking loudly, and laughing while call lights were going off. Further review revealed that education was provided to staff regarding proper etiquette and answering call lights in a timely manner. Review of the QAPI meeting minutes from September 2023 to December 2023 showed that the issue of call lights was not documented as being resolved. Interview on 12/28/2023 at 10:58 am, the DHS stated that call light audits are randomly performed by herself and two Unit Managers (UM). She stated they would speak with the resident to get details about their complaints regarding the call lights not being answered in a timely manager. She stated that she would find out from the resident and the staff who would answer the call light but did not address the actual issue that was call light was used for. During further interview, she stated she had to do a lot of verbal disciplining. Interview on 1/9/2024 at 2:55 pm, the Administrator stated that the QAPI team had initiated random call light audits, by having the UM press the call light, and time how long it takes to be answered. She stated that her expectation was that the call lights would be answered within 10 minutes. During further interview, she stated that all staff have been educated on answering the call lights, and that they must address the issue that the resident used the call light, before turning it off. She further stated that she feels the call lights are an ongoing issue. Cross Refer F585

Based on record review, interviews, and review of the facility policy titled Grievances: Healthcare Centers, the facility failed to ensure prompt and thorough efforts to resolve continued resident grievances regarding call light response time, and lack of staff's response to residents unmet needs. The census was 89. Findings Include: Review of the policy titled Grievances: Healthcare Centers, revised date11/21/2022 defined a grievance as complaints with respect to care and treatment furnished to a patient, as well as that which has not been furnished. The policy is for the facility to process grievances and complaints in a prompt, reasonable, and consistent manner. All partners shall take an active part in efforts to resolve grievances and complaints without discrimination or retaliation against a person filing a grievance or complaint. Grievances and complaints should be resolved within three business days and be presented to the monthly Quality Assurance and Performance Improvement Committee. The Administrator is responsible for overseeing the grievance process. Review of the facilities past 12 months of Patient/Resident Council/Family Council Department Response Forms documented residents voiced grievances/complaints regarding call lights and dietary services as follows: 1/10/2023 - Resident's stated that some CNA's and nurses turn off call lights saying they will return or find someone to help and do not return. Residents continue to have concerns about dietary. Department Investigation, Response, Solution documented Please see attached inservice signed and dated 1/11/2023 by the Director of Nursing (DON) and the Administrator. 3/14/2023 - Council members stated they are having to wait a long period of time to have their call light answered. Others are saying their call light is being turned off with CNA's saying they will be back, or they will tell their CNA, and no-one returns. Department Investigation, Response, Solution documented staff have been in-serviced on teamwork, will begin having huddles in the morning to discuss tasks for the day and discuss resident changes. The Administrator signed the document, but there is no date of the resolution. 4/11/2023 - Resident's stated that the call light issue from March Resident Council was not resolved. Call's {sic} lights being turned off, staff stating they will let their CNA (Certified Nursing Assistant) know. Department Investigation, Response, Solution documented inservice to all staff: Is not responding to a patients call light in a timely manner considered nursing home neglect? The document was dated 5/7/2023 and signed by the DON. There was no evidence the facility Administrator signed the response. 5/9/2023 - Council stated April issues related to call lights and beds not being made are unresolved. Department Investigation, Response, Solution was blank. The Administrator signed the document, but there is no date of the resolution. 5/9/2023 - CNA's playing music out loud in their pockets in the hallways and in patient rooms during care. Department Investigation, Response, Solution was blank. The Administrator signed the document, but there is no date of the resolution. 5/9/2023 - Council stated they are not receiving condiments that go with the meals. For example, Fish, but no tartar sauce. Department Investigation, Response, Solution documented the only time they do not get condiments is if we do not have it, or the truck does not bring it. We can go to the store and try to get it. The Administrator signed and dated the document on 6/7/2023. 5/9/2023 - Council stated the issue with heavy pepper from the last meeting has not been resolved. Residents also stated that vegetables are overcooked. Department Investigation, Response, Solution documented I had a talk with all the cooks. They are not using pepper in the food too much anymore. We do get things already seasoned on the truck. The Administrator signed and dated the document on 6/7/2023. 6/13/2023 - Residents met with Administrator to go over call light issues with staff turning off call light saying they will go get their CNA or saying they will be back and no {sic} returning. There was no evidence the facility Administrator signed the response. 7/11/2023 - Resident stated staff are still turning off the call light stating they will come back, or they will tell their CNA. Department Investigation, Response, Solution documented see attachment. The document was signed by the Administrator and dated 8/4/2023. 8/8/2023 - Call light issue from July Resident Council has not been resolved. Residents stated staff still turn off call light without addressing residents needs stating they will return or find their CNA. Department Investigation, Response, Solution documented All staff are aware that call lights are to be answered promptly, within five minutes. Unit Managers are also auditing to ensure residents needs are being met. The document was signed by the DON and Administrator and dated 8/15/2023. 8/8/2023 - Resident complained that unit one CNAs behavior is not acceptable for a nursing home setting. Resident stated CNA's are running up and down the halls and sitting at the nurse's station loud talking and laughing while call lights are going off. Department Investigation, Response, Solution documented education was provided to staff regarding proper etiquette. Education also provided on answering call lights in a timely manner. The document was dated and signed by the Administrator on 8/15/2023. 8/8/2023 - Resident Council asks Why can't the CNA's work as a team? For example, if another CNA answer's their call light, why can't the CNA help them even if it's not their patient? Department Investigation, Response, Solution documented teamwork is encouraged by management. Staff is educated that responsibilities are equally shared. All staff are encouraged to assist all residents with required needs and ADL's (activities of daily living). The Administrator signed and dated the document on 8/15/2023. 8/8/2023 - Issue about all three meals running late from July Council meeting has not been resolved. Department Investigation, Response, Solution documented meals have been on time. Will continue to sit on the halls after trays have been brought down to unit to monitor. The Administrator signed and dated the document on 9/8/2023. 8/8/2023 - Issue about all residents not receiving weekly menus and dietary not following residents meal tickets has not been resolved. Department Investigation, Response, Solution documented we only have to substitute meals when things do not come in on the truck. Dietary Manager will make sure menus are being passed out. There was no evidence the facility Administrator signed the response. 8/8/2023 - Council stated the food has become worse. The food is not appetizing. They stated it is either too salty, undercooked, or overcooked. Council also stated the food is so bad, they are asking family members to bring them meals. Department Investigation, Response, Solution documented Dietary Manager spoke to all the cooks about food preparation. There was no evidence the facility Administrator signed the response. 10/10/2023 - Residents expressed dissatisfaction as condiments were consistently omitted from their meal trays, receiving cold meals, and their meal tickets not being followed. The residents expressed grievances regarding overall food preparation particularly citing overcooked vegetables. Department Investigation, Response, Solution documented was not completed, nor signed by the Administrator. Interview on 12/29/2023 at 7:45 am, R22 stated that it takes over 30 minutes for her call light to be answered. Interview on 12/29/2023 at 7:56 am, R17 stated it has taken close to an hour for the call light to be answered. She was asked how she knew it was an hour and resident stated she was getting ready for her physical therapy session and wanted to be changed before her appointment. R17 stated it was very close to her appointment time before she finally got changed. Interview on 1/8/2024 at 10:10 am, Resident Council President stated that call light response time has been a persistent problem for a long time and is brought up in Resident Council meetings. She stated it takes 30 to 40 minutes for her own call light to be answered. She stated there is a little improvement while the State Surveyors are in the building. During further interview, she stated she fears it would go back to worse once the surveyors leave the facility. Interview on 1/9/2024 at 2:55 pm, the Administrator stated her expectation is that the call lights be answered within 10 minutes. She stated staff have been educated on answering call lights, and stated the staff are not to turn off the call light until the residents needs are taken care of. During further interview, she stated that the Unit Managers have done audits on call light response time, and stated the issue with call lights is an ongoing issue.

Based on observations and staff interview, the facility failed to ensure that the daily nurse staffing information was posted daily and readily accessible to residents and visitors on three of three survey dates, 9/30/22, 10/1/22 and 10/2/22. The facility census was 81. Findings include: Observation on 9/30/22 at 8:34 a.m. during initial tour of the facility, revealed that the required daily nurse staffing information could not be located. Observation on 9/30/22 at 4:11 p.m. revealed the daily nurse staffing information could not be located. Observation 10/1/22 at 10:18 a.m. and 10/1/22 at 3:25 p.m. revealed the required daily nurse staffing information could not be located. Observation on 10/2/22 at 7:57 a.m. and 10/2/22 at 2:23 p.m. revealed the required daily nurse staffing information could not be located. Interview on 10/2/22 at 2:25 p.m., Staffing Coordinator (SC) revealed she has never been told staffing schedule or the staffing hours are supposed to be posted in a high visible area for staff and visitors. Interview on 10/2/22 at 2:35 p.m., the Director of Health Services (DHS) revealed where the nurse staffing hours are supposed to be posted. She confirmed it was not posted in a highly visible area and that she is aware that the staffing hours have not been posted.

Based on observations, interviews, and record review, the facility failed to ensure there was sufficient staffing to provide the assistance residents needed with activities of daily living (ADLs). This deficient practice had the potential to affect all 81 residents in the facility. Findings include: Review of the 'Residents Census and Conditions of Residents' form revealed the facility had a census of 81 residents on 9/30/22. Of these 81 residents, 33 residents were dependent on staff for bathing, 30 were dependent on staff for dressing, 35 were dependent on staff for transferring, 35 were dependent on staff for toileting, and 12 were dependent on staff for eating. It also revealed 43 residents required the assistance of one or two staff for bathing, 46 residents required the assistance of one or two staff for dressing, 43 residents required the assistance of one or two staff for dressing, 41 residents required the assistance of one or two staff for toilet use, and 65 residents required the assistance of one or two staff for eating. Review of the 'Pruitthealth-[NAME] Heritage-Staffing Assignment (Nursing Department) revealed the following assignments: *9/30/22: two Certified Nursing Assistants (CNA) for Unit One from 7:00 a.m. to 3:00 p.m. which has 31 rooms, and two CNA's for Unit Two from 7:00 a.m. to 7:00 p.m. which has 31 rooms. *10/1/22: one CNA and three TNA's (temporary nursing assistants) on Unit One from 7:00 a.m. to 3:00 p.m. which has 31 rooms, and two CNA's and one TNA on Unit Two which has 31 rooms. *10/2/22: two CNA's and two TNA's on Unit One which has 31 rooms, and one CNA and one TNA on Unit Two which has 31 rooms. 1. Review of R#56's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Interview on 9/30/22 at 10:11 a.m., R#56 revealed there are not enough CNA's, especially on the weekends. R#56 stated it takes 30 minutes for someone to answer the call light. 2. Review of R#74's Quarterly MDS dated [DATE] revealed a BIMS score of 15 out of 15, indicating intact cognition. Interview on 9/30/22 at 11:06 a.m., R#74 revealed she has gone up to 23 hours without her call light being answered. States this occurred recently. Further revealed daughter called the corporate offices. During further interview, she stated it is worse on nights and weekends, and at one time, the nursing staff was not able to find a CNA anywhere to help her. 3. Review of R#185's Admission MDS dated [DATE] revealed a BIMS score of 13 out of 15, indicating intact cognition. Interview on 9/30/22 at 11:08 a.m., R#185 revealed it takes staff a while to answer the call light. 4. Review of R#45's Quarter MDS dated [DATE] revealed a BIMS score of 15 out of 15, indicating intact cognition. Interview on 9/30/22 at 4:29 p.m., R#45 revealed there is not enough staff to take care of the residents and stated that it has taken as long as two hours before someone would come see what she needed. Interview on 10/1/22 at 10:45 a.m., TNA JJ revealed he has been working independently this morning without a CNA. Further revealed he has been providing care to residents but is not comfortable working alone. Interview on 10/1/22 at 11:06 a.m., Staffing Coordinator revealed each TNA is supposed to work under the supervision of a CNA. States anytime they are providing care to a resident they are required to get their assigned CNA prior to providing any care that is outside their scope of training. Interview on 10/2/22 at 11:32 a.m., R#47's family member (FM) revealed she has been complaining to staff concerning the ADL care her daughter is receiving. She states there have been several times she has waited so long for assistance that she has had to change her daughter herself. She also stated that she has complained twice within the last two weeks about her daughter not being changed in a timely manner. R#47's FM further revealed when she complains, things will get better for a little while, then go back to being bad again. She also stated in her opinion there is a severe lack of staff to care for the residents. Interview on 10/2/22 at 1:05 p.m., CNA II revealed she has had no training since being employed at the facility for approximately three weeks. She stated that she shadowed another CNA for 3 days. She also stated that she does not feel she has sufficient time to assist her residents properly with ADL care because there is not sufficient staff and she feels rushed to move on to the next resident. Interview on 10/2/22 at 1:30 p.m., CNA PP revealed she is 600 hall and part of 500 hall. She stated she generally has 14 residents. She also revealed that she did not receive any training when hired and works independently because there is not enough help assist her on her halls. Interview on 10/2/22 at 2:12 p.m., TNA QQ revealed she does not feel there is enough help to assist the residents properly. She stated it takes a long time to get things done for residents in a timely manner. Interview on 10/2/22 at 2:15 p.m., Licensed Practical Nurses (LPN) NN and LPN OO revealed they do not feel there is sufficient staff to meet resident needs. They stated that there are not enough CNAs to help with resident care and revealed that residents have to wait a long time to get assistance they need because of the staffing shortage. Interview on 10/2/22 at 2:25 p.m., Staffing Coordinator (SC) revealed she does not base the number of staff she schedules based on the needs of the resident or the census. She also stated that she was not trained to schedule that way. The SC stated that the staff post their availability in the scheduling online software, and she makes her schedule based on who signs up to work. During interview on 10/2/22 at 2:52 p.m. Assistant Director of Health Services (ADHS) revealed TNAs are teamed with a CNA that has been working at the facility for a while. The ADHS further stated that TNAs are teamed with a CNA one on one and that TNAs are monitored closely if they are working independently. She revealed that she does not feel that there are sufficient staff members to meet the resident needs and that the facility closed down a hall so the residents would not be spread out as much due to staffing.

Based on observations, staff interviews, and review of the policy titled Labeling, Dating, and Storage, the facility failed to label, and date opened food items. This deficient practice had the potential to effect 74 of 88 residents receiving an oral diet. Findings include: A review of the policy titled Labeling, Dating, and Storage, revised 1/8/21, revealed that the policy did not address the labeling of items with the date after opening. A further review revealed that foods would be stored in their original containers, wrapped tightly with film, foil, etc., and clearly labeled with the name of the item and the use by date. Observation on 9/30/22 at 7:50 a.m., of the dry goods in the kitchen revealed the following items were unlabeled and undated after opening: Sahara Burst Lemon Juice Reconstituted, 32 ounces, no expiration date. Imperial Instant Food Thickener, eight ounces, Best by Date 8/8/24. Sahara Teriyaki Sauce, one gallon, delivery date 9/5/22. Arrezzio Cooking Oil, one gallon, delivery date 7/11/22. Sysco Imitation Vanilla, 32 ounces, delivery date 9/19/22. House Recipe Quick Oats, 42 ounces, expiration date 7/18/24. [NAME] Parsley Flakes, 12 ounces, no lid or open date. [NAME] Durum Wheat Semolina Pasta, 160 ounces, expiration date 12/15/24. Interview on 9/30/22 at 7:50 a.m., the Assistant Dietary Manager (ADM) acknowledged the dry goods items in the kitchen were unlabeled and undated after being opened. The ADM indicated that it was all staff members' responsibility to ensure that food items were labeled with the date they were opened. Observation on 9/30/22 at 8:03 a.m. of the walk-in refrigerator the following items were noted unlabeled, uncovered, and undated after opening: Sysco Imperial Lemon Flavored Water, 46 ounces, expire date 12/13/22. Sysco Reliance Mayonnaise, one gallon, no expiration date noted. Sysco Classic Golden Italian Dressing, one gallon, no expiration date noted. One bag of lettuce One box of cucumbers (all noted to be rotten) One bag of two-count celery Interview on 9/30/22 at 8:10 a.m., the Dietary Shift Lead (DSL) acknowledged the items in the walk-in refrigerator were unlabeled, undated, and uncovered after opening. Observation on 9/30/22 at 8:14 a.m., of the walk-in freezer revealed the following items were noted as uncovered and unsealed after opening. Continued observation revealed the uncovered and unsealed items were noted with a white, crystalized, ice substance. One box of smoked ham hocks dated 9/19/22. One box of grilled chicken breast fillets dated 9/23/22. One box of beef patties dated 9/26/22. One box of corn on the cob dated 8/29/22. One box of green beans dated 9/26/22. One box of green beans dated 9/19/22. Interview on 9/30/22 at 8:20 a.m. the DSL acknowledged the following items in the walk-in freezer were unsealed and uncovered after opening. Observation on 9/30/22 at 8:23 a.m., in the dry storage area a package of La Bandeira, 12 tortillas, was observed on the shelf. The tortillas were opened, undated, and unsealed. Interview on 9/30/22 at 8:23 a.m., the Dietary Manager (DM) explained it was all staff members' responsibility to ensure food items were labeled with the date they were opened. He acknowledged the food items in the walk-in refrigerator, walk-in freezer, and dry goods were unlabeled. He acknowledged the foods that were not sealed after opening. Additionally, he acknowledged that an unlabeled package of La Bandeira 12 Tortillas was opened and unlabeled in the dry storage area. He added that all the items should have been dated and sealed after opening.

Based on record review, interviews, and review of the facility policy titled Advanced Directives: Georgia, the facility failed to ensure that the health records which included the physician orders, accurately reflected the code status wishes for two residents (R) (R#7 and R#17). The sample size was 33 residents. Findings include: A review of the policy titled Advanced Directives: Georgia last revised [DATE], revealed revocation of any advance directive for health care will become effective only upon communication to the attending physician by the patient/resident or by a person acting at the patient/resident's direction. The attending physician shall record in the patient/resident's medical record the time and date when the attending physician received notification of the written revocation. 1. Review of the electronic medical record (EMR) for R#7 revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the EMR for R#7 revealed that on [DATE] the residents responsible party (RP) signed a Physician's Orders for Life Sustaining Treatment (POLST) in which the resident's RP elected to attempt resuscitation should the resident have no pulse and is not breathing, and comfort measures. The POLST was signed by the resident's physician on [DATE]. A form titled State of Georgia Physician's Do Not Resuscitate (DNR) order for Adult Patient/Resident without Decision Making Capacity with Authorized Person was signed by residents RP on [DATE] which indicated, No Cardiopulmonary Resuscitation (CPR) is to be used to keep the above mentioned alive in the event of a cardiac or respiratory arrest. The DNR was signed by the attending physician on [DATE]. A review of the current physician's order dated [DATE] revealed R#7 had an order to be a full code status. Interview on [DATE] at 11:16 a.m., Licensed Practical Nurse (LPN) NN revealed that R#7's status in the electronic medical record was DNR and she was on hospice. DNR was read on the banner on her electronic medical record. Interview on [DATE] at 11:19 a.m., the Director of Health Services (DHS) revealed that she would follow the DNR order if the resident was to stop breathing. The surveyor then asked the DHS, to view the physician orders for R#7. Once the DHS reviewed the most recent orders, and confirmed the resident had physician orders to be a full code dated [DATE], she retracted her previous statement and stated that she was not clear what she would do. She also stated that she would reach out to the nurse consultant and the hospice nurse for clarification. The DHS then looked in R#7's EMR for the DNR dated [DATE]. She stated that she was not familiar with the person who signed off the order dated [DATE] for full code. Interview on [DATE] at 12:35 p.m., the DHS revealed that she had spoken to the nurse consultant who had noticed a discrepancy with the code status for R#7. She further mentioned that R#7's code status as of now has been changed to full code status and has been updated in the care plan and banner on the electronic medical record reflecting the new code status of full code. Review of the EMR revealed that the banner on the resident's EMR reads 'full code' and her care plan dated [DATE] has been updated to 'full code' status. Interview on [DATE] at 1:08 p.m., the RP for R#7 revealed that he has not received any recent updates or notifications from the facility on R#7's code status. He further mentioned that he wishes to have R#7's code status remain at the DNR code status that he signed on [DATE]. 2. Review of the EMR revealed that R#17 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#17's admission packet revealed page titled GA Advanced Directive for Healthcare box B checked which states I have not executed an advance directive but would like to obtain additional information and resources to complete an advance directive. Further review of document titled DNR revealed box B checked which states I do not have a DNR order or POLST in place . Both documents dated [DATE]. Review of R#17's EMR revealed a code status of Do Not Resuscitate dated [DATE], however there is not a signed DNR or POLST in the EMR. Interview on [DATE] at 1:12 p.m. the Social Worker (SW) was performing an audit of resident charts. The SW stated that R#17 does not have a DNR in place and should be listed as a full code. Interview on [DATE] at 1:17 p.m. the Director of Nursing (DON) revealed R#17 is coded as a DNR in error. She stated that she is not sure why he is listed as a DNR and confirms there is not a DNR in his record signed by resident or RP.

Based on record review and staff interview, the facility failed to revise the care plan to address the need for two person assistance during the provision of a shower for one resident (R) (R#4) of three residents reviewed for falls. This failure to revise the care plan for two person assistance during the provision of a shower resulted in harm with R#4 rolling off the shower bed onto the floor and sustaining a laceration to her head that required five staples and a right foot fracture. Findings include: Review of the medical record for R#4 revealed that she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed that R#4 was totally dependent for bathing with support assessed as a 2 indicating the need for one person assistance. Review of the Quarterly MDS dated [DATE] revealed that R#4 was totally dependent for bathing with support assessed as a 3 indicating the need for two person assistance. Review of the resident's care plan dated 1/9/2020 revealed that the resident had a self-care deficit and required assistance with activities of daily living (ADLs) related to limited mobility and her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no indication that staff revised her care plan after the 7/20/20 MDS assessment to reflect her new need for two person assistance during bathing. Review of the resident's medical record since 12/9/2019 to the present (7/21/2021) revealed that she had one fall. Review of the Nurse's Note dated 9/29/2020 at 7:31 a.m. revealed that R#4 fell out of the shower chair during her shower resulting in a laceration to the back of her head. Pressure was applied to stop the bleeding, the Physician was notified, and the resident sent to the Emergency Department (ED). The resident's Responsible Party was notified. Continued review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed that R#4 was assessed by the Nurse Practitioner on her return to the facility on [DATE]. Review of the Nurse Practitioner's Progress Note dated 9/29/2020 at 12:28 p.m. revealed that the hospital CT scan showed a laceration to the resident's scalp. An x-ray of her right foot showed a closed non-displaced fracture of the calcaneus (heel) bone. An x-ray of her pelvis was negative for fracture. Review of the facility investigation dated 9/29/2020 revealed that that there was only one staff person, a Certified Nursing Assistant (CNA), who assisted R#4 during her shower. Review of the CNA's statement revealed that the resident was lying on a shower bed and that the wheels were locked. Continued review revealed that R#4 was pushing against the CNA with her right hand during care. The CNA rolled R#4 onto her left side to dry her back while the resident continued to reach with her right hand and the momentum of the resident's body caused her to roll over the rail of the shower bed onto the floor. The CNA notified the Licensed Practical Nurse (LPN) of the resident's fall. Further review of the facility investigation revealed that Maintenance staff assessed the shower bed and found that it was in working order. The facility identified that two staff should have been assisting the resident with her shower and an in-service was provided to nursing staff on 9/29/2020. On 9/29/2020 staff revised the resident's care plan to address her fall from the shower bed with an intervention for two persons to assist the resident with her showers. Interview with CNA AA on 7/21/21 at 8:50 a.m. revealed that two staff provided baths/showers for R#4. Continued interview revealed that to her knowledge there was no documentation for her to review that indicated how many staff persons a resident required for bathing. CNA AA stated, at that time, that the nurse or the CNA on the previous shift would notify her if a resident required more than one CNA for care. Telephone interview with Registered Nurse/MDS Coordinator BB on 7/21/21 at 3:36 p.m. revealed that R#4 was assessed on the 7/20/2020 Quarterly MDS as requiring two person assist with bathing which also included showers. She confirmed at that time that two staff persons should have provided the resident's showers. The facility failed to revise the care plan for R#4 after the 7/20/20 MDS Assessment to address her need for two person assistance during bathing. During the provision of a shower by one CNA on 9/29/20, R#4 rolled off the shower bed onto the floor and sustained a laceration to her head and a right foot fracture. Cross Refer to F689.

Based on observation, review of the facility Occurrences policy (effective date 7/1/2012 and reviewed 5/4/2016), record review, and staff interview, the facility failed to ensure that two staff persons were present during the provision of a shower for one resident (R) (R#4) of three residents reviewed for falls. This failure to ensure two persons were present during the provision of a shower resulted in R#4 rolling off the shower bed onto the floor and sustaining a laceration to her head that required five staples and a right foot fracture. Findings include: Review of the facility Occurrences policy (effective date 7/1/2012 and reviewed 5/4/2016) revealed that the facility recognizes that due to the frailty of the residents served, there is an increased risk for occurrences that may result in injury to the resident and/or others. In an effort to prevent occurrences, each resident will be observed and assessed for risks. Appropriate, realistic interventions will be implemented in accordance to their care plan. Review of the Medical Record for R#4 revealed that she was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)] (CVA) with [CONDITION(S)], dysphagia with gastrostomy tube, [CONDITION(S)], dementia, and diabetes. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed that R#4 had a Brief Interview for Mental Status (BIMS) score of 99, indicating that she had cognitive impairment. Continued review revealed that she had limited range of motion of her upper and lower extremities on one side of her body. She was non-ambulatory and was assessed as totally dependent for bathing with support assessed of a 3 indicating the need for two plus persons to assist the resident. Review of the resident's care plan dated 1/9/2020 revealed that the resident had a self-care deficit and required assistance with activities of daily living (ADLs) related to limited mobility and her diagnosis of CVA. Her care plan included an intervention for staff to provide bath/shower as indicated; however, there was no indication as to the number of staff required to provide her bath/shower. Review of the resident's medical record since 12/9/2019 to the present (7/21/2021) revealed that she had one fall. Review of the Nurse's Note dated 9/29/2020 at 7:31 a.m. revealed that R#4 fell out of the shower chair during her shower resulting in a laceration to the back of her head. Pressure was applied to stop the bleeding, the Physician was notified, and the resident sent to the Emergency Department (ED). The resident's Responsible Party was notified. Continued review of the resident's medical record revealed that she returned to the facility the same day at 11:50 a.m. with five staples to the laceration on the back of her head and her right foot in a soft cast. R#4 was assessed by the Nurse Practitioner on her return to the facility on [DATE]. Review of the Nurse Practitioner's Progress Note dated 9/29/2020 at 12:28 p.m. revealed that the hospital CT scan showed a laceration to the resident's scalp. An x-ray of her right foot showed a closed non-displaced fracture of the calcaneus (heel) bone. An x-ray of her pelvis was negative for fracture. Review of the facility investigation dated 9/29/2020 revealed that statements were obtained from the Certified Nursing Assistant (CNA) who provided the resident's shower and the Licensed Practical Nurse (LPN) who assessed the resident after her fall. Review of the CNA's statement revealed that the resident was lying on a shower bed and that the wheels were locked. Continued review revealed that R#4 was pushing against the CNA with her right hand during care. The CNA rolled R#4 onto her left side to dry her back while the resident continued to reach with her right hand and the momentum of the resident's body caused her to roll over the rail of the shower bed onto the floor. The CNA notified the LPN of the resident's fall. Further review of the facility investigation revealed that Maintenance staff assessed the shower bed and found that it was in working order. The facility identified that two staff should have been assisting the resident with her shower and an in-service was provided to nursing staff on 9/29/2020. On 9/29/2020 staff revised the resident's care plan to address her fall from the shower bed with an intervention for two persons to assist the resident with her showers. Interview with CNA AA on 7/21/21 at 8:50 a.m. revealed that two staff provided baths/showers for R#4. Continued interview revealed that to her knowledge there was no documentation for her to review that indicated how many staff persons a resident required for bathing. CNA AA stated at that time that the nurse or the CNA on the previous shift would notify her if a resident required more than one CNA for care. Telephone interview with Registered Nurse/MDS Coordinator BB on 7/21/21 at 3:36 p.m. revealed that R#4 was assessed on the 7/20/2020 Quarterly MDS as requiring two person assist with bathing which also included showers. She confirmed at that time that two staff persons should have provided the resident's showers. Observation of R#4 on 7/14/21 at 8:32 a.m., 10:05 a.m., and 1:15 p.m.; on 7/15/21 at 8:30 a.m. and 11:10 a.m.; and on 7/20/21 at 4:15 p.m. revealed that the resident was clean, neat and without odors. Staff had applied bilateral [NAME] boots on her feet to prevent additional skin breakdown and heal existing heel wounds. The resident appeared well hydrated and well nourished. The facility failed to ensure that two staff persons provided R#4 her shower on 9/29/2020 resulting in the resident rolling off the shower bed and onto the floor and sustaining injuries to her head and right foot.