Every finding on record at PruittHealth- Barnwell

Based on record review, interview, and policy review, the facility failed to provide four of four residents (Resident (R) 1, R3, R5, and R2) and/or their resident representative with a written transfer notice that included required information regarding appeal rights and contact information for the Long-Term Care Ombudsman. This failure had the potential to prevent residents and their representatives from understanding their right to appeal the transfer, if desired, and from contacting the ombudsman. Findings include:Review of the facility's policy titled, Bed Hold Authorization Form: South Carolina, revised on 01/11/24, provided to R1, R3, R5, and R2 at the time of transfer to the hospital, indicated, Any patient/resident who is transferred or discharged from the healthcare center is allowed to be re-admitted , in accordance with applicable regulations, including there are no medical care issues that the medical staff believes the healthcare center will be unable to treat. Two notices related to the healthcare center's bed hold policy will be issued . The second notice, which specifies the duration of the bed hold policy, will be issued at the time of any transfer . The policy did not include information related to the notice of transfer, the appeals process, or contact information for the ombudsman. 1. Review of R1's admission Record revealed R1 was admitted to the facility on [DATE]. Review of R1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/29/26, located under the Resident Assessment Instrument [RAI] tab in the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated R1 was cognitively intact. Review of R1's Progress Notes dated 07/11/26, revealed R1 was transferred to the hospital due to an irregular heartrate, oxygen saturation of 81 percent, and hypertension. R1 returned to the facility on [DATE]. 2. Review of R3's admission Record, revealed R3 was admitted to the facility on [DATE]. Review of R3's Progress Notes dated 03/13/26, revealed that R3 was directly admitted to the hospital from the physician's office due to a peri-rectal abscess and returned to the facility on [DATE]. Review of R3's Annual MDS with an ARD of 05/21/26, located under the RAI tab in the EMR, revealed a BIMS score of 13 out of 15, which indicated R3 was cognitively intact. 3. Review of R5's admission Record revealed R5 was admitted on [DATE]. Review of R5's admission MDS with an ARD of 06/15/26, located under the RAI tab in the EMR, revealed a BIMS score of three out of 15, which indicated R5 was severely cognitively impaired. Review of R5's Progress Notes dated 07/16/26, revealed R5 was sent to the hospital on [DATE] for evaluation following a fall with head involvement and returned to the facility on the same day. Review of the Transfer/Bed Hold Notice Prior to Hospitalization or Therapeutic Leave forms, provided by the facility for R1, R3, and R5, revealed that the document did not include the appeals process or the ombudsman's contact information. 4. Review of R2's Face Sheet revealed R2 was admitted to the facility on [DATE] with the diagnoses of fracture of left femur and heart failure. Review of R2's quarterly MDS with an ARD of 06/24/26, located under the RAI tab showed a BIMS score of five out of 15, indicating R2 was severely cognitively impaired. Review of R2's Progress Notes dated 04/27/26 indicated, Resident transferred to [name of hospital removed] via [name of emergency medical service removed] for evaluation due to gross hematuria and CHF [congestive heart failure] exacerbation. RP [Responsible Party] and MD [Medical Doctor] aware. Transfer packet sent with EMS. Review of R2's Progress Notes dated 06/10/26 indicated, Orders received to transfer Res [Resident] to ER [Emergency Room] for eval R/T [related to] left hip dislocation. Res without pain or discomfort at this time, no complaints voiced. 911 called and present for transport . R2 returned to the facility on [DATE]. Review of the facility's form letters, untitled and undated for each of R2's transfers to the hospital, indicated, To Whom it May Concern: This letter is to inform you that R2 was sent to the hospital . The Appeal Process is as follows: [no directions provided] The Office of the State Long Term ombudsman information is listed below: [nothing was listed] . This form was provided to R2 and their responsible party at the time of transfer. During an interview on 07/23/26 at 10:00 AM, the Social Service Director (SSD) stated she was not aware that she needed to provide the ombudsman's contact information and the appeal process information to the resident and resident's responsible party when a resident was transferred to the hospital. During an interview on 07/23/26 at 10:40 AM, the Administrator stated she was not aware the ombudsman's contact information and the appeal process information needed to be provided in writing to residents and the resident's responsible party when a resident was transferred to the hospital.

Based on observation, interview, record review, and facility policy review, the facility failed ensure the proper personal protective equipment (PPE) was used during wound care to maintain Enhanced Barrier Precaution (EBP) for one resident (Resident (R) 37) of one resident observed during wound care. This had the potential for the resident's wound to become infected. Findings include: Review of the facility policy titled, Enhanced Barrier Precautions (EBP), with a revised date of 05/27/25 indicated, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Under Definition states, Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities .PPE for enhanced barrier precautions is only necessary when performing high-contact care activities. High-contact resident care activities include: h. Wound care: any skin opening requiring a dressing. Review of R37's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) revealed R37 was admitted to the facility on [DATE] with the diagnosis of peripheral vascular disease with atherosclerosis (plaque in the artery walls) of the right and left leg with ulceration of both feet and partial amputation. Review of R37's Physician Order located under the Orders tab in the EMR revealed an order dated 05/24/24 for Enhanced Barrier Precautions every shift. Review of R37's Care Plan with a problem start date of 05/09/24 indicated, Resident is at risk for contacting MDRO [Multi Drug Resistant Organism] r/t [related to] presence of open chronic PAD [Peripheral Artery Disease] wounds. An approach with a start date of 05/09/24 stated use gown and gloves during high contact resident care activities, including but not limited to dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, wound care and any skin opening requiring a dressing. During an observation on 06/10/25 at 12:55 PM revealed the Unit Manager (UM) preparing to complete wound care for R37. R37 had Stage IV Pressure Ulcers to the right and left heel/ankle area. A barrier was not placed under the residents' feet. A sponge was used to raise the lower half of the legs, but R37's heel hit the bed covers while the UM was washing her hands. The wounds were cleaned individually and clean dressings applied. The UM did not wear a gown while completing care to R37's wounds. During an interview with the UM on 06/10/25 at 1:29 PM, the UM stated, I did not put on my EBP. I knew halfway through that I forgot my gown. We have drapes to put down on the surface of the bed, and I did not use one. I am very aware of what I did. During an interview with the Director of Nursing (DON) on 06/12/25 at 11:27 AM revealed It is my expectation that nursing follows policy and procedures for EBP and that they know the orders before entering the room and put on the necessary PPE required.

Based on review of facility procedure, record review, observations, and interview, the facility failed to ensure 1 of 1 resident (R)2, reviewed for Positioning and Mobility, was provided assistance to apply splints per his plan of care. Findings include: The facility's splinting policy was requested on 08/25/22 at approximately 10:00 AM and was not received prior to survey exit on 08/25/22. The facility's Applying and Removing the Dynamic Splint Procedure, dated 2019, read, in pertinent part, Splints are used to: Prevent deformities and contractures of the joint . relieve pain . Maintain and improve mobility and range of motion. R2 was admitted to the facility on [DATE], per the undated Resident Face Sheet found in the electronic medical record (EMR) under the Admissions tab, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/23/22, indicated R2 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 99, indicating the assessment could not be completed due to R2's poor cognition. This MDS indicated R2 had Range of Motion (ROM) impairment to his upper and lower extremities (arms and legs) on one side of his body, and that a splint or brace was not in use for the resident during any of the seven day look back period. Review of R2's Contracture Risk Assessment, dated 08/23/22 and found in the EMR under the Observations tab, indicated a risk score of 13 (moderate risk for developing contractures). Contractures are fixed stiffening of a joint due to muscle or tendon shortening. Review of R2's Activities of Daily Living (ADL) Care Plan, dated 04/20/22 and found in the EMR under the Care Plan tab, indicated R2 received extensive assistance from staff to complete his ADLs due to his metabolic [CONDITION(S)], dementia, and history of [CONDITION(S)] (TBI). Approaches included: Resident to wear bilateral elbow braces/orthotics as indicated/tolerated to assist with prevention of contractures and Assist resident with putting on and taking off bilateral elbow braces/orthotics as indicated. Review of R2's Orders Report, dated 08/01/22 through 08/25/22 and found in the EMR under the Orders tab, indicated an order to Wear left and right elbow braces for 8 hours per day to reduce elbow contracture. The orders indicated the elbow braces were to be worn during the day shift. R2 was observed lying in his bed and awake on 08/23/22 at 3:41 PM, and on 08/24/22 at 11:58 AM, 1:53 PM, 2:32 PM, and 3:41 PM. R2 was not wearing his elbow splints during any of these observations. During an interview on 08/25/22 at 9:47 AM, Licensed Practical Nurse (LPN)/Unit Manager (UM)1 stated R2 was to be wearing his elbow splints as ordered. During an interview on 08/25/22 at 11:22 AM, Certified Nursing Assistant (CNA)1 verified that she had been taking care of R2 on 08/24/22, but had not been told R2 was supposed to have splints applied to his elbows during the day, and so did not apply them. During an interview with the Clinical Care Coordinator (CCC)/Infection Preventionist (IP), who was representing the Director of Nursing (DON) during the survey, on 08/25/22 at 11:54 AM, she stated, He [R2] should have the elbow protectors on per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on limited record review and interview, the facility failed to ensure 3 of 3 residents identified on the Minimum Data Set (MDS) 3.0 Missing Omnibus Budget Reconciliation Assessment (OBRA) Report and 2 of 3 residents triggered for review in the Facility Assessment Task had assessments electronically transmitted and accepted into the Centers for Medicare and Medicaid (CMS) system database as mandated (Resident #1, 2, 3, 91 & 92). The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Record review on 2/20/19 revealed the last MDS assessment received was on 9/6/18. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Record review on 2/20/19 revealed the MDS assessment was over 120 days old. The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Record review on 2/20/19 revealed the last MDS assessment was over 120 days old. The facility admitted Resident #91 with [DIAGNOSES REDACTED]. Record review on 2/20/19 revealed the last MDS assessment received was on 5/8/18. The facility admitted Resident #92 with [DIAGNOSES REDACTED]. Record review on 2/20/19 revealed the last MDS assessment received was on 3/7/18. Interview with the MDS Coordinator on 2/20/19 at 2:20 PM revealed the facility computer system had indicated assessments were accepted but the validation report indicated some assessments had been rejected. S/he continued by stating there was some type of glitch in the system and some assessments were never accepted and was unsure why those assessments did not show up on the report.

Based on record review and interview, the facility failed to ensure all physician ordered medications were transcribed onto the Medication Administration Record [REDACTED]. The findings included: During reconciliation of the medication pass on 2/22/19, record review of Resident #140's physician orders [REDACTED]. Further record review revealed the medication had not been transcribed to the MAR indicated [REDACTED] During an interview with Licensed Practical Nurse (LPN)#1 on 2/22/19 at approximately 12:30 PM, s/he confirmed the order for the medication. Further interview with LPN #1 on 2/22/19 revealed the resident's husband had brought the medication from home for the resident and the order had been written. S/he continued by stating since there was no [DIAGNOSES REDACTED]. The physician was notified and discontinued the medication on 2/22/19 due to no [DIAGNOSES REDACTED].

Based on record review, observation, and interview, the facility failed to care for each resident in an environment or manner that promotes maintenance or enhancement of his or her quality of life for one of one resident reviewed for dignity. Resident #5 was observed with facial hair. The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Record review on 2/21/19 at 5:57 PM of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #5 was coded as having a Brief Interview for Mental Status (BIMS) score of 6. Observation of Resident #5 on 2/20/19 at 10:36 AM revealed multiple white chin hairs. During an observation on 2/22/19 at 10:36 AM of Resident #5 with Licensed Practical Nurse (LPN)#1, s/he confirmed the facial hair on the resident's chin. S/he agreed using a reasonable person concept, a resident would want the facial hair removed. On 2/22/19 at 1:00 PM, LPN #1 stated s/he had asked the resident's Certified Nursing Assistant (CNA) to ask the resident if s/he would like the facial hair removed. Per LPN #1, Resident #5 stated s/he would like the facial hair removed. On 2/22/19 at 2:17 PM, CNA #1 stated s/he had asked Resident #5 if s/he would like the facial hair removed and the resident had stated yes. S/he continued by stating usually facial hair is removed during the bath and s/he had not noticed the hair on the resident's chin that morning. During the survey, no policy was provided related to removal of facial hair and/or dignity.

Based on observation and interview, the facility failed to provide reasonable accommodation related to call bell usage for one of 2 residents reviewed. Resident #27 when asked to demonstrate his/her call bell, could not operate his/her call bell provided by the facility. The findings included: The facility admitted Resident #27 with [DIAGNOSES REDACTED]. During observation of Resident #27 on 2/21/19 at approximately 10:35 AM, s/he was asked to demonstrate the use of the call bell system provided by the facility. During the demonstration, Resident #27 exhibited difficulty in the manipulation of the call bell. At the time of the attempted demonstration, Licensed Practical Nurse (LPN) #2 confirmed Resident #27 had difficulty and instructed staff to obtain a different call bell device for easier manipulation. No assessment for call bell usage for Resident #27 was provided during the survey process.

Based on record review and interview, the facility failed to ensure residents and/or their representatives received in writing and in a language they could understand the reason for transfer to the hospital for 2 of 2 residents reviewed for hospitalization . The facility failed to provide a written Notice of Transfer for Resident #41 and Resident #27. The findings included: The facility admitted Resident #41 on 11/15/18 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes dated 11/27/18 indicated the facility transferred Resident #41 to the hospital for evaluation related to critical lab results. The facility received the order to send Resident #41 to the hospital at 2:45 PM after the physician evaluated Resident #41 at 12:00 PM and ordered repeat labs. Documentation indicated the facility notified the resident's Responsible Party (RP) and readmitted Resident #41 on 12/4/18. There was no documentation in the medical record to indicate the facility sent a written Notice of Transfer with the resident or sent a written notification of the reason for the transfer to the resident's representative. The surveyor requested documentation related to the written Notice of Transfer. During an interview on 2/20/19 at approximately 3:00 PM, the Social Services Director stated that he/she does not send a written Notice of Transfer when a resident is transferred to the hospital. The facility admitted Resident #27 with [DIAGNOSES REDACTED]. Record review on 2/20/19 at 1:20 PM revealed Resident #27 was transferred to the hospital on [DATE] due to increased congestion and decreased oxygen saturation levels. In addition, Resident #27 was transferred to the hospital on [DATE] due to respiratory distress and elevated body temperature. Further record review revealed there was no documentation to reflect the resident and the resident's representative received in writing the reason for the transfer. During an interview with the Social Service Director on 2/22/19 at 2:28 PM, s/he confirmed there was no evidence to show written written notification of the transfer was given to the resident and the resident's representative.

Based on record review, interview, and review of the facility's policy entitled Bed Holds, the facility failed to ensure residents and/or their representatives received a copy of the facility's Bed Hold Policy upon transfer/discharge to the hospital for 2 of 2 residents reviewed for hospitalization . (Residents #41 and #27) The findings included: The facility admitted Resident #41 on 11/15/18 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes dated 11/27/18 indicated the facility transferred Resident #41 to the hospital for evaluation related to critical lab results. The facility received the order to send Resident #41 to the hospital at 2:45 PM after the physician evaluated Resident #41 at 12:00 PM and ordered repeat labs. Documentation indicated the facility notified the resident's Responsible Party (RP) and readmitted Resident #41 on 12/4/18. Further record review revealed no documentation that the facility sent a written notice of the Bed Hold Policy that included the amount of the Bed Hold to Resident 41's representative. During an interview on 2/20/19 at approximately 3:00 PM, the Social Worker stated that he/she goes over the bed hold policy at the time of admission but does not send a written Bed Hold Policy to the residents' representatives upon transfer/admission to the hospital. Review of the facility's policy entitled Bed Holds revealed, Two notices related to the healthcare center's bed hold policy will be issued. The first notice of bed hold policies is given during this admission, which is well in advance of any transfer. The second notice, which specifies the duration of the bed hold policy, will be issued at the time of any transfer. In cases of emergency transfer, notice 'at the time of transfer' means that the family and/or undersigned parties, not to include the healthcare center, is provided with written notification within 24 hours of the transfer. The requirement is met if the patient/resident's copy of the notice is sent with other papers accompanying the patient/resident to the hospital. The facility admitted Resident #27 with [DIAGNOSES REDACTED]. Record review on 2/20/19 at 1:20 PM revealed Resident #27 was transferred to the hospital on [DATE] due to increased congestion and decreased oxygen saturation levels. In addition, Resident #27 was transferred to the hospital on [DATE] due to respiratory distress and elevated body temperature. Further record review revealed there was no documentation to reflect the resident and/or the resident's representative received in writing the bed hold policy. During an interview with the Social Service Director on 2/22/19 at 2:28 PM, s/he confirmed there was no evidence to show written the bed hold policy was distributed to the resident and/or the resident's representative.

Based on record review and interview, the facility failed to ensure that a Level 2 screening was done as required for 1 of 2 residents reviewed for PASARR (Pre-Admission Screening and Resident Review). The facility failed to complete a PASARR Level 2 screening following a new [DIAGNOSES REDACTED].#30. The findings included: The facility admitted Resident #30 on 9/14/13 with [DIAGNOSES REDACTED]. Review of the medical record revealed the PASARR Level 1 screening dated 7/16/98. Review of the medical record revealed the Physician's Progress Notes dated 9/11/18 indicated the physician prescribed [MEDICATION NAME] 0.25 mg related to the resident's yelling, cursing, paranoia, and visual auditory hallucinations. The Nurses Notes dated 9/14/18 indicated, on 9/11/18 resident seen by MD (Medical Doctor) with a new order for [MEDICATION NAME], dx (diagnosis): [MEDICAL CONDITION] disorder with auditory and visual hallucinations. Review of the Antipsychotic Prior Authorization Form confirmed the [DIAGNOSES REDACTED]. Further record review revealed there was no Level 2 PASARR in the medical record. During an interview on 2/22/19, the Unit Manager reviewed the medical record and confirmed that a Level 2 PASARR was not completed following the new [DIAGNOSES REDACTED].

Based on observation, interview, and review of the facility policy titled Infection Control-Linen and Laundry Services, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to prevent development and transmission of disease and infection. Observation of the laundry revealed laundry staff touched the door between the sorting area and the washer area with a soiled gloved hand and after loading the washer, closed the washer door and started the washer with a soiled gloved hand. The findings included: During observation of the laundry on 2/21/19 at 9:55 AM, Laundry Staff #1 was observed after sorting soiled laundry to touch the door between the sorting room and washer room with his/her soiled gloved hand. After loading the washer, Laundry Staff #1 was observed to close the washer door and start the washer with his/her soiled gloved hand. After removal of Personal Protective Equipment and washing hands, Laundry Staff #1 was asked if there was anything else to be done and s/he stated no. Further interview revealed the washer was sanitized during the day but not after every load washed. Review of the facility policy on 2/21/19 titled Infection Control-Linen and Laundry Services revealed it did not address sanitizing the machine after touching the machine with soiled gloves or after loading the washer, but did indicate all areas should be cleaned on a regular schedule.

Based on observation, interview, and review of the facility policies titled Food Storage, Food Temperature, and Cleaning Procedures: Major Equipment, the facility failed to appropriately store, label and date opened food items stored in the kitchen freezer and dry storage areas. The facility also failed to maintain kitchen equipment in good working conditions and good appearance. The findings included: During the initial tour of the kitchen observation on 02/05/2018 at 6:24 PM a clear bag of what looks like breaded chicken of approximately 10lbs without a date or label. Two brown paper without a label or date on it, the dietary manager stated that the bags contain French Fries. A clear bag of chicken of approximately 10-15lbs and a bag of beef patties half full without label and date on it. A half-full bag of uncooked macaroni without label and date. A box containing a blue bag with approximately 20lbs of rice fully opened. Continuing kitchen observation on the same date at 6:41 PM a mop-bucket containing mop and dirty water placed next to clean drinking cups in the kitchen. The hand washing sink did not work properly and appeared soiled. Stand still dirty water was observed in the sink, which could create a potential for bacterial growth. The ice maker had extensive lime buildup all around it, and a tear in the left top corner of the door/front was observed. Throughout the kitchen floor, large brown to black stain was observed, and the floor appeared uncleaned. On 02/07/2018 at 3:49 PM during an interview with the dietary manager s/he confirmed findings. S/he also stated that s/he has been asking for a bigger freezer so items can be stored appropriately since s/he has to take items off their original package to store them in the freezer due to limited space. During an interview with the maintenance and the environmental managers, the maintenance manager stated the lime buildup had been there for a long time, and staff has not been able to take it off despite numeral attempts. S/he also state that the facility has scheduled deep cleaning for the kitchen floor but the stains don't come off. The environmental manager stated that s/he have been trying to have the kitchen floor changed for five years now with no success.

Based on observations, records review and interviews the facility failed to implement the care plan related to continent care for one of five sampled residents reviewed for unnecessary medication. The findings include: The facility admitted Resident # 19 with [DIAGNOSES REDACTED]. Review of Resident #19's comprehensive care plan on 02/07/2018 at 2:13 PM revealed that the resident is at risk for falls related to the [DIAGNOSES REDACTED]. According to care plan on 1/30/18, the resident had a fall and as a prevention intervention, incontinent care every two hours was added to the care plan. Based on observation during the second phase of the survey process, continent care was not observed being performed. On 02/07/18 at approximately 03:15 PM, the resident, was observed in his/her room laying on his/her bed. On 02/08/18 at 10:05 AM the resident was observed in his/her room applying lotion to face. The resident seems in good spirit. On 02/08/18 at 10:05 AM during an interview, Resident #19 stated that s/he had not gotten continent care every 2 hours at all. S/he stated that when s/he needs to go to the bathroom s/he pushes the call light button but if staff takes too long to respond s/he tries on his/her own. During an interview with the director of nursing (DON) on 02/08/2018 at 10:25 AM s/he stated that the resident got and gets continent care every 2 hours but was not able to provide documentation to support claims.

Based on observation, record review and interview the facility failed to provide scheduled supervised continent care to prevent avoidable accidents for one of five residents reviewed for unnecessary medication. The findings include: The facility admitted Resident # 19 with [DIAGNOSES REDACTED]. According to Medical doctor (MD)/Nurse Practical (NP) Note reviewed on 02/07/2018 at approximately 2:30 PM on 1/30/18 resident # 19 fell in the bathroom. According to note abrasion to midline and lower back occurred and the care plan intervention included toileting scheduled every 2 hours during the day. On 12/24/17 the resident fell in the bathroom during self-transferring. Left abdominal abrasion. Denies hitting the head and experiencing pain. On 9/13/17 the Resident closed toilet seat down onto left hand. Swelling discolored area. X-Ray obtained and icepack as ordered. No fracture or discomfort. On 8/6/17 the resident fell in the bathroom during self-transfer-no injury observed-denied pain-neuro check as ordered. Intervention- sensor pad to the wheelchair. On 5/9/17 resident placed a hand between toilet seat and lid and sat down resulting in hematoma and skin tear top left hand. On 5/8/17 x-rays to view hand obtained. On 3/28/17 the resident was observed sitting on the floor in the room between the bed and wheelchair .a urinalysis (UA) cast obtained urination .no growth in 48 hours. On 2/17/17 and 2/18/17 resident slid from wheelchair to floor.No injury noted, and the resident denied pain. UA cast was obtained-cast pending. On 2/18 alarm placed in wheelchair seat-intervention-injury screen sent. On 1/4/17 resident fell from the toilet to floor. Pain in the right side. X-ray obtained with no fracture and no breaks noted. Nurse's note reviewed on 02/07/2018 at approximately 3:30 PM stated that staff when in Resident #19's bathroom to answer the call light. According to note, the resident was found sitting upright on the bathroom floor beside the toilet. The resident denied hitting the head, but abrasion to mid and lower midline back was observed. The note also states that the resident-oriented to the toilet by two staffs for activity of daily living (ADL) care, the MD notified, and orders received. The resident's representative was also notified. The note does not reveal the indications or instructions of the order received. Based on observation during the second phase of the survey process, continent care was not observed being performed. On 02/07/18 at approximately 03:15 PM, the resident, was observed in his/her room laying on her bed. On 02/08/18 at 10:05 AM the resident was observed in his/her room applying lotion to face. The resident seems in good spirit. On 02/08/18 at 10:05 AM during an interview, Resident #19 stated that s/he had not gotten continent care every 2 hours at all. S/he stated that when s/he needs to go to the bathroom s/he pushes the call light button but if staff takes too long to respond s/he tries on his/her own. During an interview with the director of nursing (DON) on 02/08/2018 at 10:25 AM s/he stated that the resident got and gets continent care every 2 hours but was not able to provide evidence to support claims.

Based on interviews and record reviews, the facility failed to ensure resident's meals are served at a preferred temperature. Resident# 11 and #16 had concerns of meals being served cold for 2 of 2 residents reviewed for food. The findings included: The facility admitted Resident #11 with [DIAGNOSES REDACTED]. During an interview with Resident#11 on 2/06/18 at 10:20 AM, the surveyor asked Does the food taste good and look good. The resident stated the food is cold once received. During meal observation on 2/6/18 at 12:27PM, meal trays were on a cart being served by the Certified Nurse Aide that would knock on the door before entering the room. On the wall near the nurse station with the Meal Time it documented 11:45 AM. During record review of Patient/Resident Council Minutes on 2/7/18 at 8:40 AM revealed concerns with food being cold was discussed during the September 2017, November 2017, and December 2017, where Resident #11 attended. The facility admitted Resident #16 with [DIAGNOSES REDACTED]. During an interview with Resident#16 on 2/06/18 at 01:22PM, the surveyor asked Does the food taste good and look good. Resident #16 stated the food is cold. During another observation and interview with Director of Nursing and Certified Dietary Manager on 2/7/18 at 11:59AM, confirmed residents' tray sitting on the cart not being served on the hall. Resident #11 and #16 tray was on the cart near the dining room.

Based on record review, resident and staff interviews,and review of the facility policy entitled Grievances-Healthcare Center, the facility failed to follow the grievance policy and satisfactorily resolve a complaint related to resident behavior for one of one sampled resident reviewed for grievances. Resident #17's grievance about another resident's verbal abuse was not recorded, followed up on, or resolved. The findings included: The facility admitted Resident #17 with [DIAGNOSES REDACTED]. Review of the 9-7-16 Admission-5 Day Minimum Data Set (MDS) Assessment at 3:24 PM on 11-8-16 revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating s/he was cognitively intact. No [MEDICAL CONDITION] or behaviors were noted. During an interview on 11/07/2016 at 4:12 PM, when asked if staff, a resident or anyone else at the facility had abused her/him, Resident #17 responded, Yes. S/he stated, (Resident #1) blocked the door to my room so I couldn't get to the bathroom. I asked her (him) to move. She (He) said she (he) was busy talking to someone right then. She (He) called me a [***] . When asked if s/he had told staff, Resident #17 stated, I told the nurses and (Social Services). When asked if anyone had gotten back with her/him regarding resolution to the concern, the resident stated that no one had spoken with her/him further about the issue and that it was not resolved. The resident became tearful when relating what had occurred. S/he also reported that the other resident would not leave her/him alone-that s/he had followed her/him into the dining room and outside. S/he felt stalked. Review of the Grievance Log at 2:33 PM on 11-8-16 revealed that the resident's complaint/concern had not been entered into the log. Review of Nurses Notes on 11-8-16 at 2:51 PM revealed no documentation regarding an incident of verbal abuse by Resident #1. Review of Social Service Notes at 3:10 PM on 11-8-16 revealed no mention of the altercation with Resident #1. During an interview on 11-8-16 at 3 PM, Licensed Practical Nurse (LPN) #2 stated s/he had been told to monitor the situation & be sure everyone stays safe. S/he did not recall who had given that instruction. The nurse stated that Resident #1 had behavioral issues due to a prior head injury. LPN #3 stated s/he had been on duty but did not witness the incident. During an interview at 3:15 PM on 11-8-16, LPN #1 stated s/he had not been at the facility at the time of the incident. S/he heard that Resident #17 was trying to get to the bathroom and (Resident #1) was in the way-wouldn't move. I don't think there were any witnesses. LPN #1 reviewed the medical record and confirmed that there was no documentation of the incident in the Nurses Notes or Social Service Notes. During an interview at 4 PM on 11-8-16 with LPN #1 in attendance, Social Services stated the incident was reported to me. It happened on October 25th or 26th. (Resident #17) was trying to get to the bathroom, but (Resident #1) was in the way. (Resident #1) called her (him) a [***] . When asked if the report had been entered in the Grievance Log, LPN #1 and Social Services reviewed and verified that the incident had not been entered in the log. Social Service admitted s/he had not recorded the incident on the grievance form or the log when it was reported. At approximately 5 PM, Social Services provided a completed copy of the Grievance/Complaint Form which documented the date of occurrence/report and date of completion as 10-27-16. The form noted Actions taken: Spoke with both residents. (Resident #1) apologized to resident. They were both on friendly terms the next day. Discuss with (Resident #17) & she (he) agreed to above outcome. During an interview at 1:40 PM on 11-9-16, Resident #17 stated the complaint had not been resolved. S/he stated that Social Services had not followed up with her/him after the incident was initially reported. The as s/he repeated that Resident #1 had followed me and my sister outside and another time into the dining room. I don't want her (him) near me. She (he) did not apologize to me. I don't need an apology. I need her (him) to stay away from me. S/he adamantly denied being on friendly terms with Resident #1. The facility's policy entitled Grievances: Healthcare Centers provided by Social Services states: ''Policy Statement: It is the policy .for healthcare centers to follow an established process whereby patients .may have their grievances and complaints resolved in a prompt, reasonable, and consistent manner . Procedure: 1 . the staff person receiving the information will assist with completing the . Grievance/Complaint Form . 2 .The Social Services or Senior Care Partner will track the grievance on the Grievance/ Complaint Log Form . refer the grievance to the appropriate department for investigation .3.the responsible discipline will make prompt efforts to resolve the grievance. The action taken should be recorded . 4. The Social Services Partner/Senior Care Partner will be responsible for follow-up with the patient/resident. to determine the grievance has been resolved . 5. The Grievance/ complaint is to be resolved within 3 business days .

Based on observations and interviews, the facility failed to promote an environment that maintains or enhances each resident's living space. Findings include: Observed a black biological substance in grout around the base of the toilet area for resident rooms (104, 110 and 123) during a tour on 11/09/2016 at approximately 10:07 AM. A subsequent observation on 11/09/16 at approximately 11:10 AM revealed the same issues with Director of Maintenance, who indicated that the grout was missing in resident's rooms (104, 110, and 123) around the base of the toilet area. The Director of Maintenance was asked if a work order had been submitted to correct the problem, and he indicated that he did not receive any orders for repairs. In an interview with Administrator on 11/09/2016 1:20 PM, the Administrator indicated that she was not aware of the missing grout and the Director of Maintenance has only been at this position for about three weeks. The Administrator confirmed that a work order has not been submitted to correct the problem.

Based on record review and interviews, the facility failed to provide timely preventive care to one of three sampled residents reviewed for range of motion (ROM). An Occupational therapy (OT) recommendation for ROM was not implemented for 5 weeks for Resident #47. The findings included: The facility admitted Resident #47 with [DIAGNOSES REDACTED]. Review of the 8-5-16 Occupational Therapy Plan of Care (Evaluation Only) at 12:01 PM on 11-9-16 revealed that Skilled OT recommends Restorative Rehab to maintain CLOF (current level of function) and ROM in BUE (bilateral upper extremities) .would benefit from Restorative rehab to maintain ROM for ADL's (activities of daily living) and transfers to prevent contractures and promote skin integrity. Continued review revealed that restorative services were not implemented until 9-14-16, five weeks later, after a Physician's Interim Order was obtained on 9-13-16. During an interview on 11-9-16 at 12:49 PM, Licensed Practical Nurse #1 reviewed the OT recommendations and restorative documentation. S/he stated, We follow recommendations. I don't know why they were not followed for over a month. Sometimes I don't receive the recommendation right away when they come off (therapy).

Based on observation, interview, and review of the policy entitled, Ice Chest / Scoop Disinfection, the facility failed to ensure that the ice scoop used in the kitchen's ice machine was stored with proper drainage for 1 of 1 kitchen reviewed. The findings Included: Observation in the kitchen on 11/9/15 at approximately 11:30 am revealed the ice scoop used for the ice machine was observed stored without proper drainage causing a black, mold-like substance build-up in the ice scoop container. During an interview with the Dietary Manager on 11/9/15, he/she confirmed that the ice scoop holder had not been cleaned and did not contain holes in the bottom to ensure proper drainage. Review of the Ice Chest / Scoop Disinfection policy on 11/11/15 at approximately 11:40 am revealed, It is the policy of Pruitt Health to maintain safe and sanitary conditions when serving ice to prevent cross contamination and the spread of bacteria. This applies to all dietary partners employed by Pruitt Health or others as designated by the Administrator.

Based on record reviews and interviews, the facility failed to develop and/or individualize care plans for 4 of 4 sampled residents reviewed with pacemakers (Residents #9, #14, #33, #73). Resident #9 had no care plan for pacemaker checks or specific interventions to monitor pacemaker function. The Care Plans for Residents #14, #33, and #73 did not include frequency of pacemaker checks and were not individualized. The findings included: Cross Refer CFR.483.25 F309 Related to facility failure to monitor the function of 3 of 4 sampled residents with pacemakers. The facility admitted Resident #9 with [DIAGNOSES REDACTED]. Record review on 11-11-15 at 1:05 PM revealed no Physician's Orders for frequency/schedule of pacemaker checks though 2015 MD (Medical Doctor)/NP (Nurse Practitioner) Progress Notes demonstrated awareness of pacemaker placement. No evidence could be located in the record that any pacemaker checks had been done or that the resident had seen a cardiologist. Review of the Care Plan on 11-11-15 at 1:31 PM revealed a Problem/Need of Pacemaker' with a 9/14 hand-written entry: Unable to obtain pacemaker information. Res(ident) from out of state. Unable to give history of pacemaker placement-per family. Unable to have routine checks at this time due to inability to have model number. The Care Plan Goal was: Pacemaker will cont (inue) to function (without) s(igns)/sx (symptoms) defects. Approaches included: Vital signs as ordered. Monitor medications and give as ordered. Labs as ordered. Monitor for [MEDICAL CONDITION]. Diet as ordered. Interventions did not include what signs and symptoms to monitor for to determine pacemaker malfunction. Record review revealed no Physician's Orders for vital signs. During an interview at 2:50 PM, Registered Nurse (RN) #1 stated s/he had reviewed the record and confirmed s/he could find no evidence of family contact or attempts to obtain pacemaker information. S/he reviewed the Care Plan and when asked how the resident was being monitored to determine pacemaker function, RN #1 noted that the pulse should be monitored at least daily. When asked if the resident had seen a cardiologist since admission, RN #1 stated the resident had not. During an interview at 1:57 PM on 11-11-15, the monitoring services representative provided a copy of a communication including instructions and contact numbers for the five pacemaker manufacturers. The facility admitted Resident #33 with [DIAGNOSES REDACTED]. Based on record review and interview, the facility failed to develop a care plan to address frequency of pacemaker checks for this resident. Review of the Care Plan at 10:56 AM on 11-11-15 revealed a Problem/Need of Resident has pacemaker . The goal was: Will be free from pacemaker malfunctioning X 3 months. Approaches included: Check pacemaker per MD recommendations to ensure maintenance and proper functioning . Perform V/S as ordered indicated . Record review on 11-11-15 at 10:15 AM revealed Physician's Orders to assess the pacemaker site monthly and monitor the apical pulse daily for a full minute. Neither of these orders were incorporated into the Care Plan. There were no orders for frequency of pacemaker checks or vitals signs (other than pulse, as noted). During an interview on 11-11-15 at 4:40 PM, RN #1 reviewed and verified the Physician's Orders and Care Plan. The facility admitted Resident #14 with [DIAGNOSES REDACTED]. Review of the medical record on 11/10/15 revealed the admission orders [REDACTED]. Further record review indicated there were no orders to check the status of the pacemaker and no information related to the last time the pacemaker was checked or when the next pacemaker check was due. Review of the care plan indicated Pacemaker/Defibrillator was identified as a problem area. Interventions included, Pacemaker check as ordered. The care plan contained no specific information related to Resident #14's pacemaker and was not individualized to address monitoring the resident's pacemaker or follow-up care. During an interview on 11/12/15 at approximately 9:14 am, the Director of Nursing (DON) confirmed the care plan did not address specific information related to the care and monitoring of Resident #14's pacemaker. The DON indicated at that time that the facility's Interdisciplinary Team is responsible for reviewing assessments upon admission and individualizing care plans to meet residents' specific needs. The facility admitted Resident # 73 with [DIAGNOSES REDACTED]. Review of the medical record on 11/10/15 revealed no documentation of Type, Model Number or Serial Number for the pacemaker. There was no physician order as to when or how often the pacemaker checks should be done, and no listing of the Cardiologist for this resident. No information could be found as to when the last or next pacemaker check should be done. An interview with Licensed Practical Nurse ( LPN) # 1 on 11/10/15 at 3:50 PM confirmed none of the above information required was contained in the resident's medical record. He/She also stated that he/she did not know when the resident had had a pacemaker check nor what the results were. Further review of medical record confirmed in Hospital Discharge Summary printed on 9/.8/15, Physician's History and Physical dated 9/16/15, and Physician's Cumulative Order Sheets for September, October, and November noted under diagnosis pacemaker. The admission nursing assessment also documented pacemaker. Review of the care plan 11/10/15 for Pacemaker documented the following Approaches: Pacemaker check as ordered; vital signs as ordered; Monitor medications and give as ordered;labs as ordered; monitor for [MEDICAL CONDITION]; and diet as ordered. The care plan was not individualized to include specific physician's orders for pacemaker checks. There was no information as to when the last check had been done nor when the next check was due. The physician had not written any orders for pacemaker checks for this resident.