Every finding on record at Pruitthealth - Fitzgerald

Based on observation, interview, and facility policy review, the facility failed to discard cucumbers, tomatoes, and hamburger buns that had signs of spoilage, chocolate milk with expired sell by dates, and failed to cover food that was stored in the kitchen's walk-in freezer. The facility also failed to keep two kitchen ovens, two frying pans, and microwave oven clean for one of one kitchen. These failures had the potential to create an environment for food-borne illnesses which could affect 67 residents who consumed food prepared from the facility's kitchen. Findings include:1. Observation during the initial kitchen inspection on 01/11/2026 from 8:45 AM to 9:25 AM, with the Dietary Manager (DM) present, revealed the following concerns with food storage:a. Observation of food stored in the kitchen's walk-in refrigerator revealed two boxes of cucumbers which contained numerous cucumbers that had signs of spoilage including mold growth, one box of tomatoes which contained 15 tomatoes that had signs of spoilage including mold growth, and 31 half pint cartons of chocolate milk with expired sell by dates of 12/31/2025.b. Observation of food stored in the kitchen's walk-in freezer revealed a 29.7-pound box of biscuit dough, two 20-pound boxes of okra, and a bag of hush puppies that were stored open to air and unprotected from possible contamination.c. Observation of bread stored on the kitchen's bread racks revealed one package of hamburger buns with mold growth on one of the buns stored inside the package and one undated package of hamburger buns which did not contain a use by or sell by date.During an interview on 01/11/2026 at 9:10 AM, the DM confirmed the above food storage concerns that were identified during the initial kitchen sanitation inspection. The DM stated staff should discard any food with signs of spoilage or with expired expiration dates, and food should be closed when stored by staff. The DM also explained when bread products were delivered to the facility, she only checked the top layer bread for expiration dates and signs of spoilage, not the entire delivery.2. Observation during the initial kitchen inspection on 01/11/2026 from 8:40 AM to 9:25 AM, with the DM present revealed the following unclean food preparation and service equipment that was stored and ready for use: two kitchen ovens, and two frying pans which had accumulated blackened dried food substances on them.During an interview on 01/11/2026 at 9:25 AM, the DM confirmed the two kitchen ovens, and two frying pans were not clean. The DM stated the kitchen ovens were last cleaned three weeks ago, and kitchen equipment should have been cleaned by staff prior to being stored for use.3. Observation during a follow-up inspection of the kitchen on 01/12/2026 at 10:15 AM, with the DM present, revealed the kitchen's microwave oven was unclean with a heavy accumulation of splattered dried food substances in the oven's interior cooking compartment.During an interview on 01/12/2026 at 10:15 AM, the DM confirmed the interior of the kitchen's microwave oven was unclean and needed to be cleaned. The DM stated staff should have cleaned the microwave oven each day and as needed.Review of the facility's policy titled, Foodborne Illness, with a review date of 01/08/2021, indicated It is the policy of [Name] that the [DM] to be ServSafe certified in accordance with local, state, and federal regulations. This ensures the proper preparation and serving of foods under safe and sanitary conditions to prevent the spread of bacteria which may lead to foodborne illnesses.Procedure.2. Foods will be used before the expiration date, use by date, best by date, and sell by date, indicated on the food item. Foods not used prior to the expiration dates, use by date, best by date or sell by date must be discarded.6. Hands, equipment, utensils, and work areas must be dismantled, cleaned, and sanitized between uses.Review of the facility's policy titled, Receipt and Storage of Food & Supplies, with a review date of 10/20/2025, indicated It is the policy of [Name] that all food and supplies will be checked in and stored immediately upon delivery to ensure food safety.Procedure: 1. The Dietary Manager or trained designee is accountable for receiving and storage of food and supplies.7. The first in, first out (FIFO) method must be used to ensure proper rotation of all food items to prevent spoilage.Review of the facility's policy titled, Cleaning Procedures: Kitchen Area, with a review date of 10/23/2025, indicated It is the policy of [Name] to maintain a clean and sanitary environment to prepare patient/resident meals.All soiled, dirty, dusty, surfaces and/or areas within the kitchen should be cleaned and/or sanitized (as needed) immediately upon identification.

Based on record review, interviews, and review of the Resident Assessment Instrument (RAI) Manual 3.0, the facility failed to ensure Minimum Data Set (MDS) assessments were transmitted within the required timeframes specified for five of 20 sampled residents (R) (R26, R48, R72, R56, and R46) reviewed for MDS. This failure had the potential for inaccurate or incomplete care planning and/or provision to the residents, and/or a lack of appropriate payment for services to the facility.Findings include: 1. Review of the facility census on 01/11/2026 revealed that R26 was not in the facility. Review of the facility electronic medical record (EMR) Progress Notes for R26 on 01/11/2026 revealed: 10/09/2025 03:23 PM Resident was discharged from the facility with family via private vehicle walking with rollator via private vehicle with all meds [medications] and belongings.Resident discharged with no incident. Review of R26's Face Sheet from the EMR Resident tab revealed a facility admission date of 09/25/2025 with a discharge date of 10/09/2025 with medical diagnoses that included altered mental status, repeated falls, and acute kidney injury. Review of R26's EMR RAI tab, and the MDS 3.0 Assessments tab revealed on 01/11/2026 a Discharge Return Not Anticipated (DCRNA) with an Assessment Reference Date (ARD) of 10/09/2025 was still In Process. During an interview on 01/12/2026 at 3:57 PM, MDS Coordinator (MDSC) 1 and MDSC 2 reviewed the EMR MDS screen, and MDSC2 stated R26's assessments might have been included in an emailed list of identified missing assessments. The email was reviewed and at 4:00 PM, MDSC2 stated R26 was not included on that list. 2. During an interview on 01/12/2026 at 9:40 AM, R48 stated he/she received dialysis services three times per week. Review of the survey software Resident Manager revealed R48 was only triggered from the MDS assessment data for one rehospitalization. Review of R48's Face Sheet from the EMR Resident tab revealed a facility admission date of 10/27/2025, with a readmission date of 01/10/2026, with medical diagnoses that included type II diabetes, end stage renal disease, hypertension, depression, left leg below knee amputation, and chronic obstructive pulmonary disease (COPD). Review of R48's EMR RAI tab, and the MDS 3.0 Assessments tab revealed an admission assessment, with an ARD of 10/31/2025, was still In Process. The Discharge Return Anticipated with an ARD of 11/16/2025 and the Entry with an ARD of 11/18/2025 showed a status of Production Accepted. During an interview on 01/12/2026 at 4:07 PM, MDSC2 reviewed the EMR MDS tab and stated that R48's admission MDS was shown as completed and submitted earlier today, it was completed and signed on 11/12/2025 and should have been submitted sometime in November. 3. Review of the facility census on 01/11/2026 revealed R72 was not in the facility. Review of R72's Progress Notes from the EMR Resident tab revealed: 11/08/2025 10:31 AM Resident discharged home, A/O [alert and oriented]. All medications and personal items sent home with resident. Review of R72's Face Sheet from the EMR Resident tab revealed a facility admission date of 10/20/2025; a discharge date of 11/08/2025; with medical diagnoses that included myocardial infarction (heart attack), type II diabetes, hypertension, and dyspnea with lung abnormalities. Review of R72's EMR RAI tab, and the MDS 3.0 Assessments tab revealed an admission assessment, ARD of 10/24/2025, and a DCRNA assessment, ARD of 11/08/2025, both had a status of In Process. During an interview on 01/12/2026 at 4:09 PM, MSDC2 stated R72's admission MDSs were submitted today and should have been submitted sometime in November. During an interview on 01/14/2026 at 3:19 PM, the Administrator stated the facility did not have MDS policies but used the RAI Manual for their MDS procedures. During an interview on 01/14/2026 at 4:20 PM, the Director of Nursing (DON) stated an expectation that they [MDS assessments] be submitted in a timely manner on or before the due date. 4. Review of R56's undated Face Sheet located under the Resident tab of the EMR revealed R56 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease and type two diabetes mellitus. Review of R56's significant change MDS with an ARD of 11/03/2025, located in the EMR under the RAI tab revealed the assessment's CAA Summary (Section V) and the Assessment Administration section (Section Z) to verify completion of the assessment were not signed as completed by MDSC2 until 01/12/2026. During an interview on 01/14/2026 at 11:05 AM, MDSC2 confirmed R56's significant change MDS assessment on 11/03/2025 was not signed as completed until 01/12/2026. MDSC2 stated she was not employed at the facility when R56's significant change MDS on 11/03/2025 was performed, but she noticed the assessment's CAA Summary (Section V) and the assessment had not been signed by the Registered Nurse (RN) Assessment Coordinator to verify completion (Section Z), so she signed the CAAs and the assessment as completed which then transmitted the MDS data to Centers for Medicare and Medicaid Services (CMS) on 01/12/2026. 5. Review of R46's undated Face Sheet located under the Resident tab of the EMR revealed R46 was admitted to the facility on [DATE] with a primary diagnosis of hypertensive heart disease with heart failure. Review of R46's quarterly MDS with an ARD of 10/30/2025, located in the EMR under the RAI tab, revealed it was signed by the Registered Nurse (RN) Assessment Coordinator as completed on 11/11/2025. However, the data for R46's 10/30/25 MDS was not electronically transmitted by the facility to the Centers for Medicare and Medicaid Services (CMS) system until 01/08/2026. During an interview on 01/14/2026 at 12:55 PM, MDSC2 confirmed R46's quarterly MDS assessment of 10/30/2025 was signed as completed by the RN Assessment Coordinator on 11/11/2025 but the MDS data was not transmitted to CMS until 01/08/2026. Review of the RAI Manual 3.0, dated 10/2019, revealed .OBRA [Omnibus Budget Reconciliation Act] required comprehensive assessments include the completion of both the MDS and CAA process, as well as care planning. Comprehensive assessments are completed upon admission, annually, and when a significant change in a resident's status has occurred or a significant correction to a prior comprehensive assessment is required.The MDS completion date (item Z0500B) must be no later than 14 days from the ARD [Assessment Reference Date].and no later than 14 days after the determination that the criteria for an SCSA [Significant Change in Status Assessment] were met. This date may be earlier than or the same as the CAA(s) completion date, but not later than.

Based on staff interviews, record review, review of the facility-provided document titled, PASRR (Preadmission Screening and Resident Review) Management Process, and review of the facility's policy titled, Collection of Pre-Admission Information, facility failed to ensure a PASRR Level II referral was made to ensure that individualized care and services were offered to meet resident needs for three of 25 sampled residents (R) (R22, R46, and R13) that were reviewed for PASARR. This failure had the potential for residents with mental disorders not to receive identified specialized services. Findings include: Review of the facility-provided document titled PASRR (Preadmission Screening and Resident Review) Management Process dated July 17, 2015, in the section titled, Level II Screening revealed, Transition Nurse must verify a Level II screening has been completed prior to admission. In the section titled, Morning Meetings revealed, All expected Admission should be discussed in the facility morning meeting. At this time, it must be confirmed that the pending admission does have a valid PASRR in the state system .Expected admission should be discussed including PASRR accuracy. Review of the facility's policy titled Collection of Pre-Admission Information dated September 2009 under Policy revealed, Prior to admission, the Admission Coordinator will obtain the following information and provide to the Financial Counselor: Copy of state specific PASSAR FORM (if applicable). 1. Review of R22's Face sheet revealed the resident admitted to the facility on [DATE] with diagnoses that include but are not limited unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, mood disorder due to known physiological condition, unspecified, bipolar disorder, current episode mixed, severe, with psychotic feature and major depressive disorder, single episode, unspecified. Review of R22's Admission Minimum Data Set (MDS) dated [DATE] revealed: Section A- Identification Information: indicated no PASRR Level II; Section C-Cognition: a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition; Section D-Mood: Total Severity score of 0 (zero); Section E-Behavior: indicated no behaviors; Section I-Active Diagnoses: indicated Non Alzheimer's, seizure disorder, depression, and bipolar; Section N-Medications: indicated resident received antipsychotic, antidepressant, and antipsychotic medications. Review of R22's care plans included but not limited to: (Resident Name) receives anti-depressant, and anti-psychotic to manage dx of depression, mood disorder, bipolar, dementia. Risk for falls and adverse side effect with problem start date of 7/19/2024; (Resident Name) adjustment difficulty to new environment related to recent admission. HX (history) of bipolar, dementia, mood disorder, dementia, etc. with problem start date of 7/19/2024; (Resident Name) is inpatient with staff, becomes easily angered if they are not on time with tasks or late with problem start date of 8/14/2024. Review of R22's physician orders included but not limited to, duloxetine capsule, delayed release; 60 mg (milligram); one capsule by mouth once a day; risperidone 0.5 mg; one tablet by mouth once a day; and risperidone 1 mg; one tablet by mouth at bedtime; all with start date of 7/22/2024. Review of R22's medical record revealed an approved PASRR Level I dated 1/23/2015, however there was no primary diagnosis of serious mental illness, developmental disability, or related condition indicated. Review of the facility provided list of residents at the facility with a PASRR Level II titled PASRR LEVEL II [Facility Name] August 2024 revealed, R22 did not have a PASRR Level II. Review of R22's Social Services Progress Note dated 7/19/2024 revealed the resident did not have any discharge plans and would require LTC (Long Term Care) at the facility. Review of R22's medical record revealed that R22 was not receiving psychiatric services. 2. Review of R46's Face sheet revealed the resident admitted to the facility on [DATE] with diagnoses that include but are not limited mood disorder due to known physiological condition, unspecified, bipolar disorder, current episode mixed, severe, without psychotic major depressive disorder, recurrent, moderate, unspecified mood [affective] disorder, and generalized anxiety disorder. Review of R46's Admission MDS dated [DATE] revealed: Section A- Identification Information: indicated no PASRR Level II; Section C-Cognition: a Brief Interview of Mental Status (BIMS) score of 14, indicating intact cognition; Section D-Mood: Total Severity score of 6 (six); Section E-Behavior: indicated no behaviors; Section I-Active Diagnoses: indicated anxiety disorder, depression (other than bipolar), bipolar disorder Section N-Medications: indicated resident received antipsychotic, antianxiety, antidepressant medications. Review of R46's care plans included but not limited to: (Resident Name) referred to Life Source for depressive symptoms with problem start date of 8/16/2024; (Resident Name) receives anti-anxiety, anti-depressant, and anti-psychotic medication. Also receives mood stabilizer medication. Risk for falls and adverse side effects. Has dx of Bipolar, MDD, Mood disorder, and alcohol dependence with unspecified alcohol induced disorder with problem start date of 8/15/2024. Review of R46's physician orders included but not limited to: buspirone 5 (five) mg, (two tablets) by mouth three times a day (TID) with start date of 8/20/2024; duloxetine 60 mg capsule, one capsule by mouth at bedtime with start date of 8/14/2024; divalproex 125 mg, one tablet by mouth TID with start date of 8/14/2024 and quetiapine 50 mg tablet extended release 24 hr, one tablet by mouth at bedtime with start date of 8/20/2024. Review of R46's medical record revealed an approved PASRR Level I dated 4/12/2023, however there was no primary diagnosis of serious mental illness, developmental disability, or related condition indicated. Review of the facility provided list of residents at the facility with a PASRR Level II titled PASRR LEVEL II [Facility Name] August 2024 revealed, R46 did not have a PASRR Level II. Review of R46's Social Services Progress Note dated 8/15/2024 revealed the resident was at the facility for LTC and was receiving psychiatric services for psychotherapy. Interview on 8/31/2024 at 12:17 pm with Social Service Director revealed she reviewed new admissions to ensure they have a PASRR Level I in place. She reported if a resident's stay were long-term, she would review their diagnoses to determine if they had qualifying diagnoses for a Level II PASARR and submit the screening application at that time. She revealed that both R22 and R46 was at the facility for long term care. She confirmed that a Level II screening application had not been submitted for R22 and R46 that included the residents' qualifying diagnoses. She stated they were in the process of auditing all residents with qualifying diagnoses to ensure Level II screenings had accurately submitted. Interview on 8/31/2024 at 12:40 pm with the Administrator revealed his expectations of staff were to review and ensure PASRR Level I screenings were completed accurately prior to residents' admission and to follow the facility's PASRR process. Interview on 9/1/2024 at 9:30 am with the Admission Director, revealed she was responsible for obtaining PASRR Level I screenings on residents prior to admission. She reported that she would review the residents' medical records to determine if they had qualifying diagnoses and would submit a Level I screen. She stated that the R46 had a Level I screen completed at another facility and did not think she had to complete another one. She confirmed that both R22 and R46 had qualifying diagnoses on admission that would have triggered a Level II. She confirmed that a Level II screening should have been completed that included the qualifying diagnosis. She acknowledged that it had been overlooked. 36377 3. Record review of R13 's medical record revealed an admitted to the facility on [DATE] with the following diagnoses, but not limited to, major depressive disorder, recurrent severe with psychotic symptoms and anxiety disorder. Record review of R13's PASRR Level I revealed an official approval date of 7/28/2023. Continued review of the form revealed no indications that resident had any medical diagnosis or criteria which would prevent ineligibility for a PASRR Level II. Record review of R13's Annual MDS dated [DATE] Section C revealed a BIMS score of eight, a score of 8 of 12 indicated moderate cognitive impairment. In Section D for Mood, R13 was assessed for feeling down or depressed and having little energy or feeling tired for 12-14 days (almost every day). Review of R13's medical record revealed no PASRR Level 2 found in the record. Review of the list of residents at the facility with a PASRR Level II provided by the facility and titled PASRR LEVEL II [Facility Name] August 2024, revealed R46 did not have a PASRR Level II. Review of R13's Physician Order Form (POF) and Medication Administration Record (MAR) revealed an order for a psych medication, Cymbalta (duloxetine). The order dated 8/22/2024 read, Cymbalta (duloxetine) capsule, delayed release (DR/EC); 20 mg (milligram); amt (amount): 1 CAP (one capsule); oral Once A Day Every Other Day. Interview with the Social Service Director (SSD) on 8/31/2024 at 1:06 pm, the SSD confirmed that a PASRR was not submitted for R13. She stated the last time that the facility residents were screened for a PASRR Level II was March 20, 2024. Interview on 9/1/2024 at 9:34 am, the Admission Coordinator confirmed that R13's PASRR Level II was not submitted. She reported that prior to any resident admission to this facility from a discharge facility, the process was to ensure that the resident had a PASRR Level II. Once the resident was admitted to a room, and on the facility census, the SSD would follow up with submitting the PASRR Level II.

Based on staff interviews, record review, and review of the facility policy titled, Care Plan the facility failed to ensure the care plan was implemented for one of five residents (R) (R48). The deficient practice had the potential to affect the care and services provided to R48. Findings include: Review of the facility policy titled, Care Plan revised date of 7/27/2023 revealed under policy statement: It is the policy of the health care center for each patient/resident to have a person-centered baseline care plan followed by a comprehensive care plan developed following completion of the Minimum Data set (MDS) and Care Area Assessment (CAA) portions of the comprehensive assessment according to the resident Assessment Instrument (RAI) Manual and the patient/resident choice. Under Admission Comprehensive Plan of care 4. The goal is an expected outcome the patients/residents should achieve by implementing specific interventions. Record review for R48 revealed resident was admitted to the facility with diagnoses of but not limited to the following: Acute and chronic respiratory failure with hypercapnia, Chronic systolic (congestive) heart failure, Morbid (severe) obesity due to excess calories, and Chronic obstructive pulmonary disease (COPD). Review of the physician orders revealed an order dated 8/5/2024 that indicated oxygen at five LPM (liters per minute) via nasal cannula (NC) continuous. Review of the Annual Minimum Data Set (MDS) dated [DATE] Section O (Special Treatments, Procedures, and Programs) indicated resident was utilizing supplemental oxygen. Review of R48's care plan revealed under problem, R48 required oxygen related to disease process: CHF, A-Fib, morbid obesity, and chronic resp. failure with hypoxia, COPD. The approach was to administer oxygen as ordered at five LPM via NC. Observation on 8/30/2024 at 10:22 am revealed R48 was receiving 3 liters of oxygen via NC with no humidifier bottle noted. Observation on 8/31/2024 at 1:15 pm revealed oxygen was set at 4.5 LPM. Interview on 8/31/2024 at 2:46 pm with the Director of Health Services (DHS) revealed her expectation was that staff follow the care plan as written.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Oxygen Administration the facility failed to ensure oxygen therapy was administered as ordered for two of eight Residents (R) (R48 and R19). Specifically, the facility failed to ensure oxygen was administered at five litters per minute (LPM) as ordered and a humidifier bottle was utilized during oxygen administration for R48; and failed to ensure R19's humidifier bottle was changed and contained the required humidifying solution. Findings include: Review of the facility policy titled, Oxygen Administration with revise date of 8/2/2023 revealed under Policy Statement: It is the policy of (Facility Name) Hospice and Healthcare Centers/Veteran Homes to provide oxygen safely and accurately to appropriate patients/residents. Under Procedure: Oxygen will be administered by licensed personnel only when ordered by the physician, PA or NP. The physician order may be written PRN for comfort/dyspnea or may specify the number of liters, method of administration and length of time the oxygen is to be administered. 4. Regulate liter flow to ordered/desired flow rate. Continued review under Infection Control Policy of 02 Humidifier Bottles: 1. 02 humidifier bottles should be used on all patients/residents receiving higher than 2 Liters/minute of oxygen flow. 1. Record review for R48 revealed resident was admitted to the facility with diagnoses of but not limited to the following: Acute and chronic respiratory failure with hypercapnia, Chronic systolic (congestive) heart failure, Morbid (severe) obesity due to excess calories, and chronic obstructive pulmonary disease (COPD). Review of the physician orders revealed an order dated 8/5/2024 that indicated oxygen at five LPM via nasal cannula (NC)continuous. Review of the Annual Minimum Data Set (MDS) dated [DATE] Section C (Cognitive Patterns) revealed Brief Interview for Mental Status (BIMS) score of 15 indicating resident had little to no cognitive impairment. Section O (Special Treatments, Procedures, and Programs) indicated resident was utilizing supplemental oxygen. Review of the care plan review under problem, R48 required oxygen related to disease process: CHF, A-Fib, morbid obesity, and chronic resp. failure with hypoxia, COPD. The approach was to administer oxygen as ordered at five LPM via NC. Observation on 8/30/2024 at 10:22 am revealed R48 was receiving oxygen at 3 liters per minute (LPM) via NC with no humidifier bottle noted. Observation on 8/31/2024 at 1:15 pm revealed oxygen was set at 4.5 LPM. Interview on 8/31/24 at 1:20 pm with Licensed Practical Nurse (LPN) AA revealed R48 is supposed to be on 5 liters of oxygen continuously but sometimes the settings get changed accidentally during care. Further interview revealed at the beginning of the shift the oxygen concentrators are checked against the physician's order. Sometimes there are water bottles put on the oxygen concentrators and sometimes they are not, depending on if the resident wants them on there or not. Interview on 8/31/2024 at 1:52 pm with the Director of Health Services (DHS) revealed residents must have a physician's order for oxygen and should be checked by the Charge Nurse before oxygen is administered. The Charge Nurses should also be checking to ensure that residents receiving oxygen are getting the correct amount as ordered by the physician throughout their shift. The DHS confirmed R48's oxygen was not set on the correct flow rate as ordered by the physician. 36377 2. Record review of R19's medical record revealed the following diagnoses but not limited to, chronic obstructive pulmonary disease and chronic kidney disease. Record review of R19's Quarterly MDS dated [DATE] Section C revealed a BIMS score of 15 (a score of 13 to 15 indicated little to no cognitive impairment). Section O, special treatments and therapy use assessed R19's for oxygen use. Observation on 8/30/2024 from 10:00 am until 10:30 am, revealed R19 was receiving oxygen by oxygen concentrator and nasal cannula with a setting of 4 LPM (liters per minute). Continued observation revealed the humidifier bottle (pre-filled humidifier bottle) attached to the oxygen concentrator was empty. Review of R19's Physician Order (POF) listed an order dated 10/17/2023 for Oxygen at 4 LPM via nasal cannula PRN SOB (as needed for shortness of breath). Special Instructions: SOB, < 90% every shift (shortness of breath, oxygen saturation less than 90 percent every shift). A second order dated 10/17/2023 stated oxygen: change respiratory circuit/supplies weekly prn once a day on Sunday nights. Review of R19's care plan created 8/23/2022 (last revised 8/30/2024) stated R19 requires supplemental Oxygen Use at times related to: COPD, CHF (congestive heart failure), morbid obesity, and chronic respiratory failure. Interventions included, my apply oxygen as needed at 4 LPM via NC for oxygen levels less than 90%. During an interview on 8/30/2024 at 11:39 am (at the time of observation) with Licensed Practical Nurse (LPN) II, she confirmed that the R19's humidifier bottle was empty. LPN II reported being aware that the humidifier bottle needed replacement earlier during her visit to R19's room, she stated that her plan was to replace the bottle. Interview on 8/31/2024 at 3:10 pm, the DON confirmed that humidifier bottle should be attached and filled to prevent the resident from intake of dry oxygen. She reported her expectation was for nursing staff to monitor oxygen supplies.

Based on observations, record review, staff and resident interviews, and review of the facility policy titled, MDS Assessment Accuracy, the facility failed to ensure three of 31 residents (R) (#5, #29, and #18) were accurately assessed on the Minimum Data Set (MDS) for physical restraints. The deficient practice had the potential to affect the accurate assessment of the facility's residents' care needs. Findings include: Review of facility policy titled, MDS Assessment Accuracy with a revision date of 12/06/2022 revealed under Policy Statement: it is the policy of this healthcare facility that each Minimum Data Set (MDS)reflect the acuity and the medical status of each patient/resident in accordance with acceptable professional standards and practices. 1. Clinical record review for R#5 revealed resident was admitted to the facility with diagnoses that included but not limited to, Alzheimer's disease with early onset, dementia in other diseases classified elsewhere with behavioral disturbance, paranoid schizophrenia, muscle weakness (generalized), difficulty in walking, abnormal posture, weakness, and lack of coordination. Review of current physician orders for R#5 included but not limited to, 1/2 Siderails for turning and repositioning dated 9/26/2019. Review of the Quarterly MDS dated [DATE] revealed R#5 with a Brief Interview of Mental Status (BIMS) score of seven indicating severe impairment. Section P (Restraints) - documented bed rails restraint was used daily. Record review revealed a Restraint/Adaptative Use Observation Form dated 1/09/2023 which indicated R#5 did not have restraints or adaptative equipment in use. Observations on 1/20/2023 at 2:26 p.m., 1/21/2023 at 9:10 a.m., and 1/21/2023 at 1:45 p.m., revealed two quarter bedrails on his bed being utilized for bed mobility. 2. Clinical record review for R#29 revealed resident was admitted to the facility with diagnoses that included but not limited to, cerebrovascular disease, Type 2 diabetes mellitus without complications, chronic obstructive pulmonary disease, chronic pain syndrome, acquired absence of right leg above knee, peripheral vascular disease, low back pain, contracture of muscle, left lower leg. Review of current physician orders for R#29 included but not limited to, Bilateral assistive 1/4 side rails for bed mobility, positioning, and turning per resident request - start date 9/28/2020. Review of the Quarterly MDS dated [DATE] revealed R#29 with a BIMS score of 15 indicating resident is cognitively intact. Section P - documented bed rails restraint was used daily. Record review revealed a Restraint/Adaptative Use Observation Form dated 1/04/2023 which indicated R#29 did not have restraints or adaptative equipment in use. 3. Clinical record review for R#5 revealed resident was admitted to the facility with diagnoses that included but not limited to, muscle weakness (generalized), difficulty in walking, abnormal posture, unsteadiness on feet, history of falling. Review of current physician orders for R#18 included but not limited to, 1/4 Siderails for turning and repositioning - start date 9/29/2022. Review of the Quarterly MDS dated [DATE] revealed R#18 with a BIMS score of four indicating severe impairment. Section P - documented bed rails restraint was used daily. Record review revealed a Restraint/Adaptative Use Observation Form dated 12/24/2022 which indicated R#18 did not have restraints or adaptative equipment in use. Interview on 1/21/2023 at 9:48 a.m. with MDS/Care Plan Coordinator revealed that she is responsible for the MDS assessments and Care plans. She states that the facility does not have any real restraints in the facility. She further stated that she coded that bed rails as a restraint because she understood restraints as any device that is adjacent to the resident which restricts the resident from moving freely or independently that the resident cannot remove on their own. She further stated that she is aware that resident uses the bedrails for bed mobility, and she has learned now that she was not supposed to code the siderails as restraints. Further interview also revealed that the siderails were care planned as an enabling device but coded it on the MDS as a restraint. She stated that she had very little training for the position and stated that mistake with coding was due to a lack of knowledge. MDS Coordinator confirmed that the bed rails were coded incorrectly. Interview on 1/21/2023 at 1:20 p.m. with the Director of Nursing (DON) revealed that currently there are not any restraints in the facility. She further stated that the MDS coordinator is new to the position and need additional training in the MDS process. DON stated that the facility does not have any restraints in the facility and all resident with bedrails uses them to assist with bed mobility and repositioning and it should not be coded on the MDS as a restraint. Interview on 1/22/2023 at 8:33 a.m. with Certified Nursing Assistant (CNA) AA revealed that resident uses the bedrails for positioning while in the bed. She further stated that the facility does not have restraints. She stated that resident can assist during care with the use of the bedrails. Interview on 1/22/2023 at 8:40 a.m. with CNA BB revealed that resident uses the bedrails also to assist with helping him to stand and it is not a restraint. Interview on 1/22/2023 at 9:04 a.m. with Licensed Practical Nurse (LPN) CC revealed that the facility is a restraint free facility and does not utilize restraints. She stated that residents with the quarter bedrails uses them for positioning. She further stated that the nurses are responsible for completing and documenting the Restraint/Adaptative Equipment Observation on Admission, readmission, quarterly and additionally as changes occur with the resident in the electronic record.

Based on record review and staff interviews, the facility failed to submit an application for Level II PASRR (Preadmission Screening and Resident Review) for evaluation and determination of specialized services for one (1) resident (R) #26. This deficient practice has the potential to effect residents requiring Level II PASARR specialized services. The census was 63 residents. Findings include: Record review revealed R#26 was admitted to the facility on [DATE] with diagnosis of but not limited to: Unspecified psychosis not due to a substance or known physiological condition, adjustment disorder with mixed anxiety and depressed mood, and Generalized anxiety disorder. Medications listed but not limited to: Celexa 10mg daily, and Seroquel 50mg daily. Record review for R#26 revealed a DMA-6 (Physician's Recommendation Concerning Nursing Facility Care or Intermediate Care for Mentally Retarded) form signed and dated by physician on 1/20/2020 with diagnosis not checked however admission diagnosis of Unspecified psychosis not due to a substance or known physiological condition, adjustment disorder with mixed anxiety and depressed mood, and Generalized anxiety disorder. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed the PASARR Level II assessment was not selected. Review of section C- cognitive patterns reveal the resident has a Brief Interview for Mental Status (BIMS) score of seven indicating the resident has severe cognitive impairment. Section D- Mood assessed that R#26 had a total severity score of two indicating minimal depression. Section I- Active Diagnosis coded that the resident had Anxiety disorder, Depression, and Psychotic disorder. Section N- Medications coded that R#26 received an antipsychotic seven days of the assessment look back period, and an antidepressant medication six days of the assessment look back period. Review of R#26 care plan with revision date of 11/23/2022 revealed the following documented behavioral symptoms: Resident refuses medications, history of being non-compliant with medications at times, Refuses to go to dialysis at times, displays aggressive behaviors towards staff at times related to diagnosis of psychosis, displays exit seeking behaviors, makes sexual/inappropriate comments towards staff, refuses his baths at times, and refuses lab draws at times. Review of resident progress notes dated 12/12/2022 3:28 AM revealed Resident refused his 9 pm medication and BS check this shift. Writer made several attempts to get resident to take meds and check his bs, resident refused, covered his head with his covers and stated he wants to go home. Will continue to monitor and encourage resident to take his medication. On 12/06/2022 08:40 AM As soon as staff exits room resident stopped hollering out. Writer checked on resident who was sitting up on side of bed at this time. Asked resident why he was hollering, and he states, what, damn when are yall going to let me go home, shit I want to leave and go to [NAME] where my apartment is. Resident is non-complaint with medications at times, and refuses dialysis at times. Interview on 1/21/2023 at 3:15 p.m. with the Social Services Director (SSD) revealed she is responsible for making the referral to the appropriate state-designated authority when a resident is identified as having an evident or possible Mental Disorder (MD), Intellectual Disorder (ID) or related condition. SSD stated if a resident is identified as having a newly evident or possible MD, ID, or a related condition after admission the facility's process for referring the resident to the appropriate state-designated authority is in house psych through Life Source. SSD stated if residents have behaviors after admission, she refers them to psych. SSD also stated that she did not have a response as to why a level 2 was not completed.

Based on interviews, record review, resident trust funds review, and review of policy titled Resident Trust Policy, the facility failed to ensure that resident trust funds were made available to one resident (R)A, from a total of 9 sampled residents. Findings include: The facility had a Resident Trust Policy, dated September 2009. The policy documented that upon written authorization of a resident, the healthcare center must safeguard, manage, and account for the personal funds of the resident deposited with the healthcare center. The policy also revealed that residents have access to petty cash on an ongoing basis and are able to arrange for access of larger funds. However, the facility failed to provide R A the funds requested from his Resident Trust account, in a timely manner, prior to his discharge from the facility. A review of the clinical record revealed that RA resided at the facility from 3/27/21 through 10/27/21. Review of the Resident Fund Management Service authorization and agreement to handle resident funds form, dated 5/25/21, revealed that RA had authorized the facility to manage his social security direct deposit funds. The form also included that the facility was RA's Representative Payee (Rep Payee). A review of RA's Resident Fund Management Service Statement for 10/1/21 through 1/10/22 revealed an opening balance of $2,387.97. The balance as of 10/26/21, the day before RA discharged from the facility, was $2,425.50. During an interview on 1/11/22 at 1:48 p.m., Ombudsman AA stated that R A decided he wanted to go home and wanted his money on discharge (from the facility). However, the Business Office Manager (BOM) told him the facility would have to return the money to social security, when he discharged . So, Ombudsman AA stated, RA began asking for the money (from this resident trust account) days before discharge, but the BOM would not give it to him. A review of an email from Ombudsman AA to Social Service Director EE, dated 10/21/21 (six days before discharge on 10/27/21), documented that RA reported to the Ombudsman that he was going home, and that the facility would not give him his resident trust money. During an interview on 1/11/22 at 10:00 a.m. with the BOM and Administrator BB, RA's 10/1/21 through 1/10/22 resident trust bank statement was reviewed. On the date of discharge, 10/27/21, the account reflects a cash withdrawal of $200, which left an account balance of $2225.50. The BOM stated that $200 was the amount agreed upon with Ombudsman AA to give RA. The BOM further stated that RA wanted all of the money from his account, but because it was a large amount, she called her corporate consultant. Administrator BB stated that corporate staff advised the BOM not to give RA all of the money from his resident trust account, citing social security guidelines as the reason. The BOM stated that the remaining money in RA's account was returned to social security after he discharged from the facility on 10/27/21. A copy of the 2014 Guide for Organizational Representative Payees was provided by the facility as support for not providing RA money from his resident trust account, as requested, prior to discharge on 10/27/21. The Conserved Funds After You Stop Being Payee section of the guide referenced as support, explained that conserved funds were unspent social security or SSI funds that you hold on behalf of a beneficiary that belong to that beneficiary. The section also documented that when you are no longer payee for the beneficiary, you must immediately return all conserved funds, including interest, as well as any cash on hand, to social security can transfer the funds to a new payee or to the beneficiary directly if he no longer needs a payee. However, these guidelines, provided by the facility as support for not giving RA his money as requested, did not apply to RA's situation. The guidance was for returning funds when the facility was no longer payee for a resident. RA began asking for all money from his resident trust account, while he resided at the facility, which was while the facility remained his payee.

Based on observations, facility Policy review entitled (Infection Control- Housekeeping), and staff interviews the facility failed to ensure that it was maintained in a safe clean and comfortable environment. Specifically, the facility failed to ensure privacy curtains were clean and in good repair for three out of 36 occupied resident rooms. In addition, the facility failed to ensure in room three that the base boards were clean and free of debris and black markings on the walls. The facility census was 62. Findings: Review of facility policy entitled (infection control - Housekeeping Services) revealed in policy statement; it is the policy of this facility to ensure housekeeping services will be performed on a routine and consistent bases to ensure an orderly, sanitary, and comfortable environment. Further review of policy under procedure - Routine cleaning of Horizontal Surfaces: In patient/resident care area cleaning of non-carpeted floors and other horizontal surfaces will be performed daily and more frequently of spillage or visible soiling occurs. Observation on 7/12/21 11:14 a.m. revealed the privacy curtain between bed A and B in room 4 had noted brown stains on the outer edge of the curtain as well as a hole in the netting at the top of the curtain as well as a tear in the crease of the curtain. Observation on 7/12/21 11:29 a.m. of room 6 (R#211) revealed privacy curtain for A bed had noted rust-colored spots that are in the middle of the curtain as well as stains noted to the outer aspect of the curtain as well. Observation of curtain for B bed revealed privacy curtain had noted brown stains at the bottom of the curtain as well as noted brown stains in the middle of the curtain on both sides. Observation on 7/12/21 11:01 a.m. of room 3 revealed privacy curtain for bed B has large rust colored stain in the middle of the curtain, base boards have debris buildup along wall of the perimeter of the room, black marks noted on the wall leading into the resident's bathroom. Observation on 7/13/21 7:40 a.m. of room 6 revealed privacy curtain continues to be in disrepair and visibly stained. Observation on 7/13/21 7:46 a.m. of room 3 revealed privacy curtains continue to be visibly stained, base boards have visible debris noted, as well as black marks on the wall leading into the bathroom. Observations on 7/13/21 10:00 a.m. with Administrator and Housekeeping Supervisor confirmed room 3 base boards had build up and debris noted around the perimeter of the room, black marks on the wall leading into the bathroom as well as brown stains noted on privacy curtains for bed B. Continued observation rounds also confirmed in room 4 the hole in the privacy curtain noted at the top of the curtain netting and in the middle of the curtain as well. Observation rounds of room 6 revealed and confirmed privacy curtain was stained and or soiled with a brown substance in the middle of the curtain for resident in bed B. Interview on 7/13/21 10:22 a.m. with the Administrator revealed that some of the brown stain that was noted in room 6 was from the chain that holds the curtain in place had rust on it which rubbed off on the curtain. Continued interview also revealed that staff had recently removed curtains that were soiled and laundered them and that the curtains would be replaced, and that maintenance would be notified of the condition of the base boards that needed painting. Interview on 7/13/21 10:26 a.m. with the Housekeeping Supervisor revealed that deep cleanings are randomly chosen by facility system (building engines) and during the deep clean everything in the room is be cleaned including the privacy curtains and the walls.

Based on observation, interviews, and review of facility policy titled, 'Medication Storage in Healthcare Centers' the facility failed to ensure all medication carts were locked when out of view of the nurse for one of three medication carts and failed to ensure medications were properly secured inside of the medication cart when out of view of the nurse. Findings include: Review of facility policy 'Medication Storage in Healthcare Centers' states '2. Only licensed nurses and pharmacy personnel are allowed access to medications. Respiratory Therapist may access medications used in the provision of respiratory services. Medications rooms, carts, and medication supplies are locked or attended by persons with authorized access.' Observation on 7/13/21 at 3:32 p.m. the west hall medication cart was observed sitting in the nursing station unlocked and unattended. At 3:39 p.m. Licensed Practical Nurse (LPN) DD returned to the nurse's station and locked the cart. LPN DD stated she had been at the front of the building and did not realize the cart was unlocked. Observation on 7/14/21 at 8:12 a.m. during medication administration revealed that LPN DD walked away from the medication cart into a resident's room, out of site of the medication cart, leaving two bottles of vitamins sitting on top of the cart. Upon exiting the resident's room LPN DD stated she should not have left the vitamins sitting on the cart. LPN DD then gathered a box of eye drops from the cart and removed two doses the box. She then placed the remaining eye drops inside of the box on top of the medication cart. LPN DD then locked the medication cart and entered a resident room, closing the door behind her. The box of eye drops remained on top of the cart until after LPN DD finished administering medication to a resident at which time LPN DD stated, 'I just keep forgetting'.

Based on observation, resident interviews, family interviews, staff interviews and policy review of the facility policy titled, Menu Planning, Cycles and Alternates, the facility failed to ensure food preferences were honored. This deficient practice affected two of 20 sampled residents (R#49 and R#32). Findings include: Review of the facility policy titled Menu Planning, Cycles and Alternates effective 09/01/2001 and revised on 10/16/2017 states: It is the policy of PruittHealth to develop menus in order to provide patients/residents with three meals plus a bedtime snack each day. Procedural guideline number eight states: Menus may be individualized by the Registered Dietitian to meet the food preferences and holiday traditions of the patients/residents of the healthcare center. Record review for R#49 revealed a Quarterly Minimum Data Set (MDS) assessment dated which documented a Brief Interview for Mental Status (BIMS) summary score of fifteen, indicating no cognitive impairment. Per physician orders dated 4/22/21, R#49 is to receive a Liberalized Diabetic NAS (no added salt) diet with special instructions of a high protein diet. Interview with R#49 on 7/12/21 at 9:27a.m. revealed that she has advised staff that she does not eat eggs, string beans, creamed potatoes nor drink orange juice, which these items continue to be placed on her tray. Observation of the breakfast tray revealed scrambled eggs, which were untouched by the resident. Interview with R#49 on 7/13/21 at 9:38 a.m. revealed her breakfast tray consisted of scrambled eggs again. Resident now states that she does eat eggs, but just does not like the powdered eggs served at the facility. She stated she likes fried eggs. Interview with R#49 on 7/14/21 at 9:30a.m. Resident advised that she was served powdered eggs again this morning. R#49 continued to voice her dislike of these eggs and how she has expressed this issue on numerous occasions to the staff including the dietary manager. Interview and observation on 7/15/21 at 1:15, R#49 is in the dining room R#49 stated breakfast consisted of powdered eggs, bacon, grits, and milk. R#49 stated that she is ready to leave this facility and return to Virginia with her son. She also advised that she is frustrated. Family Interview via telephone on 7/15/21 at 2:00 p.m. Family member of R#49 contacted to inquire of any concerns of the facility. Resident's son stated that his mother has complained about the food and the choices lack flavor or variety. He advised that his mother spoke to him about her breakfast choices as well as other food items disliked, yet the staff continues to send these items. 2. Record review for R#32 revealed Quarterly Minimum Data Set (MDS) assessment dated which documented a Brief Interview for Mental Status (BIMS) summary score of fifteen, indicating no cognitive impairment. Per physician orders, R#32 is to receive a Liberalized Diabetic NAS (no added salt) diet with special instructions of a high protein diet. Interview with R#32 on 7/12/21 at 9:40. She stated she does not like the eggs poured from a carton. R#32 stated she spoke with dietary a month ago regarding regular fresh, pasteurized eggs, which this issue has not been resolved. Interview with R#32 on 7/13/21 at 9:54 a.m. She stated she had the liquid eggs again this morning. According to this resident, she has written notes on the back of the meal tickets in addition to conveying this to staff including the dietary manager. Interview with R#32 on 7/14/21 at 9:18 a.m. R#32 advised she received powdered eggs, bacon, grits and a pancake. She stated that she wrote on her tray ticket again her concerns and preferences. R#32 also advised that each time she makes a request, she takes a picture on her mobile phone as proof that she has advised staff of the concerns. Interview with R#32 on 7/15/21 at 8:45. She advised that she had powdered eggs again though breakfast was palatable except for the eggs. Family interview via telephone on 7/15/21 at 2:03 p.m. via phone. R#32's family member advised that the resident complained about the powdered eggs two weeks ago. Interview with the Dietary Manager, Staff KK on 7/13/21 at 1:35p.m. revealed that she is aware of the two residents that have concerns about the eggs and named them. She also advised that the eggs are poured from a carton and that residents are vocal about their likes and dislikes. In addition to this, she stated residents write on their meal tickets and the contents of the notes are typed up as well as noted in their files. She also advised that care plan meetings are every Thursday, which updated information is conveyed. Staff KK revealed that when she became an employee of the facility October 2020, there were no updated food preferences, and she has made an effort to update the likes and dislikes on the meal tickets.

Based on interviews, medical record review, review of written statements, review of the facility policy titled, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property review of the facility policy titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property and review of the police report, it was determined that the facility failed to ensure that one of 14 residents (R#7) was free from sexual abuse, and the facility failed to provide protection for one of 14 residents (R#7) causing continued fear after an allegation of sexual abuse was made on 6/8/19. The facility census was 69 residents. On (MONTH) 25, 2019, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Health Services (DHS), Acting Assistant Director of Health Services (AADHS), the newly hired Assistant Director of Health Services (ADHS), and the Regional Vice President (VP) were informed of the Immediate Jeopardy on (MONTH) 25, 2019 at 5:25 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 8, 2019. The Immediate Jeopardy continued through (MONTH) 27, 2019 and was removed on (MONTH) 28, 2019. The facility implemented a Removal Plan related to the Immediate Jeopardy on 6/27/19. The Immediate Jeopardy is outlined as follows: On (MONTH) 8, 2019 Resident (R) #6, a cognitively intact male, was observed by two Certified Nursing Assistants (CNA) in R#7's (a cognitively impaired female) room with his hand under R#7's covers, and was kissing the resident on her face. Per staff interviews, review of written statements and review of the police report, R#7 was fearful, crying and complained of pain to her perineal area. The two CNA's immediately reported the incident to two Licensed Practical Nurses (LPN). However, the LPN's failed to immediately report the incident to Administration which lead to a failure to protect R#7 resulting in R#6 re-entering her room again on (MONTH) 9, 2019 which caused R#7 continued fear. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600), Scope/Severity: J and 42 C.F.R. 483.12(a)(1), Develop/Implement Abuse/Neglect Policies (F607), Scope/Severity: J). Additionally, Substandard Quality of Care was identified with the requirements at 483.12(a)(1), Free from Abuse and Neglect (F600, Scope/Severity: J); 42 C.F.R. 483.12(a)(1), Develop/Implement Abuse/Neglect Policies (F607, Scope/Severity: J). A Removal Plan was received on (MONTH) 26, 2019 related to 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600) and 42 C.F.R. 483.12(a)(1), Develop/Implement Abuse/Neglect Policies (F607). Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Removal Plan, it was validated that the corrective plans was implemented therefore, the immediacy of the deficient practice was removed on (MONTH) 28, 2019. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of ensuring that staff and residents are educated on the facility's abuse policy and know what abuse is, when to report abuse, and how to report abuse. This oversight process included the analysis of the facility staffs' conformance with the facility's abuse policies and procedures governing the timely and accurate reporting of abuse and implementing interventions in their abuse policy. In-service materials and records were reviewed. Observations and interviews were conducted with staff and residents to ensure they demonstrated knowledge of facility policies and procedures regarding what is abuse and when and how to report abuse. Findings include: A review of the facility policy titled, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property documented the definition of sexual abuse is non-consensual sexual contact of any type with a patient. A review of the facility policy titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property documented the following procedure: Any allegation, suspicious, or identified occurrence involving patient abuse, neglect, exploitation, mistreatment, and misappropriation of property, including injuries of an unknown source, should be immediately reported to the Administrator of the provider entity. Record review revealed that R#6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 30-day Minimum Data Set (MDS) assessment, dated 5/15/19, indicated that the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. The resident was also assessed as requiring minimal assistance from staff. The resident was independent for locomotion on and off the unit and utilized a wheelchair and walker for mobility. Record review revealed that R#7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further record review revealed that R#7 was assessed by the facility on the 5/4/19 MDS as having a BIMS score of six indicating that the resident was severely cognitively impaired with decision making skills and demonstrated inattention. The resident required extensive assistance of one person for bed mobility and was non-ambulatory. She was totally dependent on staff for dressing, hygiene and bathing. She was assessed as having functional limitation in range of motion of the upper extremity on one side and impairment on both sides of the lower extremities. Review of the care plans for R#7 revealed that the resident had a care plan dated 2/27/19 with a review date of 5/16/19 with the problem/need: Resident has difficulty expressing ideas or wants related to effects of disease process: mild intellectual disability and cognitive communication deficit. The approaches were to: Allow resident plenty of time to respond, speak to resident in a low, clear voice to increase chance of hearing, provide a quiet environment for resident when discussing important issues and resident can best understand simple, direct communication. There was also a care plan problem/need with a revision date of 2/27/19 for decreased ability to speak and understand due to poor cognitive ability with an approach for restorative nursing for training and skill practice for communication. During an interview with LPN BB (7 a.m.- 7 p.m. shift) on 6/18/19 at 4:08 p.m., revealed that on Saturday, 6/8/19, after 7:00 p.m., a CNA came and reported to LPN AA that R#6 was kissing R#7 on her face and that he had his hand under the covers. LPN BB stated she and the other nurse, LPN AA, went down to R#7's room and asked R#6 to leave. LPN BB stated that R#6 got mad and called them racists. Further interview with LPN BB revealed that on 6/9/19 around shift change she was walking by R#7's room and her eyes met R#7's eyes. LPN BB stated that R#7 looked fearful. LPN BB stated that she saw that R#6 was in the room talking to R#7's roommate and then R#6 went over to R#7's bed. LPN BB stated that R#7 continued to have a fearful look on her face. LPN BB stated she went into the room and asked R#7 if she wanted R#6 in her room, and R#7 responded, no. LPN BB stated she then asked R#6 to leave, and that R#6 got mad and left. Continued interview with LPN BB revealed that on 6/9/19 she told the Acting Assistant Director of Health Services (AADHS) that R#6 had been in R#7's room twice and that R#7 was fearful. After that, CNA DD told the AADHS what occurred on 6/8/19, when they saw R#6 in R#7's room kissing her on the face with his hand under the covers. LPN BB stated that the AADHS said Oh my God, that has to be reported. During an interview with Certified Nursing Assistant (CNA) CC on 6/18/19 at 5:05 p.m., she stated on Saturday evening, 6/8/19, she and CNA DD were passing out snacks and saw R#6 in R#7's room with his hand under the covers, whispering to the resident and kissing her on the face. She stated she went and reported it to LPN AA and went down to the room with another CN[NAME] LPN AA asked R#6 to leave the room. CNA CC stated R#6 got mad and called them racists. CNA CC stated that on 6/9/19, she talked to the police when they came to the facility. During an interview with CNA DD on 6/18/19 at 5:15 p.m., revealed that on 6/8/19, around 7:30 p.m., she and CNA CC were passing out snacks when they passed by R#7's room they saw R#6 in the room with his hand under the covers and he was kissing R#7 on the face. CNA DD stated after they went and reported this incident to LPN AA, they (CNA CC, CNA DD, LPN AA, and LPN BB) went back down to R#7's room. CNA DD stated that after R#6 was asked to leave, R#7 said she was scared, pointed to her privates and started crying. CNA DD stated that the next day, on 6/9/19, she had just clocked in when LPN BB stated she had just run R#6 out of R#7's room again. Further interview with CNA DD revealed that she was not told to keep an eye out for R#6 until after 6/9/19, when the Acting Assistant Director of Health Services (AADHS) told them to. During a telephone interview with LPN AA (7 p.m.-a.m. shift) on 6/19/19 at 11:35 a.m., revealed that LPN AA stated that she was taking report with the day shift nurse on 6/8/19, around 8:00 p.m., when the CNA's (CNA CC and CNA DD) came to her and said R#6 had his hands under R#7's covers. When LPN AA and LPN BB went to R#7's room she (LPN AA) asked R#6 to leave the room. LPN AA stated that R#7 told her that he touched her, but she did not specify where. LPN AA stated she examined R#7 and noticed her brief was on tight and there was no redness or swelling. LPN AA also stated that R#6 was in R#7's room morning, noon, and night but that she had never witnessed any behaviors prior to the 6/8/19 incident. LPN AA stated she did not report this to anyone because she thought the residents were boyfriend and girlfriend. Further interview with LPN AA revealed that the next night, on 6/9/19, when she came on duty LPN BB told her that R#6 had been in R#7's room again and that she (LPN BB) made him leave. Continued interview with LPN AA revealed that on 6/9/19, as they (LPN AA and LPN BB) were talking, the AADHS walked up and heard their conversation. LPN AA stated the AADHS called the Administrator who came out to the facility that night around 7:30 p.m. LPN AA stated the police also came out to the facility that night. Review of the written statement from the AADHS provided to the police department on 6/9/19 documented the following: R#7 informed this writer that a male resident, R#6, touched in private area while in her room last night. R#7 states I asked him to stop and he was kissing me on my face, saying don't be scared, I am not going to hurt you. R#7 states that she started to cry, and he told her he would give her some chips, actually she said he used the term pay her with some chips. Not to cry or be scared. R#6 complains of hurting in her privates. She (R#7) states, I am scared of him, he said he would be back in the weekend again. R#7 reported incident to two staff members on the night of Saturday, (MONTH) 8, 2019. Staff members walked into the room during said incident. A police report dated 6/9/19 documented the following: On 6/9/19 at 1951 hours (military time for 7:51 p.m.) 911 dispatched officers to (facility) in reference to a possible sexual assault. The AADHS walked with me (officer) to R#7's room where I asked her some questions about what had happened. I spoke softly and slowly to R#7 as I asked her questions. I asked if she could tell me what happened. She could not carry on a conversation, so I had to ask direct questions to get a response. She made the following statements. I love him, Told him to leave me alone, He was going to pay me back for the chips, He said he loved me, Told him to stop and he didn't stop, He was going to see me this weekend, I told him to stop touching me this morning, He didn't stop touching me, He was touching me with his hands and He was touching in the private. I then spoke with CNA's DD and CC. Both stated they were giving out snacks when they saw resident #6 standing by R#7's bed kissing her face while his hands were under the cover rubbing her. They stated they got nurse AA to come to the room and she told him to leave so they could check on the resident and he got upset. I then spoke with nurse BB and she stated she was walking by R#7's room around 6:00 p.m. this day 6/9/19 and saw R#6 in R#7's room. She stated she stood in the hallway and watched R#6 as he spoke with R#7's roommate about the Lord and gave her a honeybun. She stated R#6 started to talk to R#7 and she had a scared look on her face. She stated she asked her if she wanted the man in the room and she shook her head no. She stated she then asked R#6 to leave the room. Record review revealed that on 6/9/19, there was a physician's order to send R#7 to the emergency room for evaluation and treatment. Review of the Emergency Documentation dated 6/9/19, documented in the physical exam, a visual inspection of the patient's skin reveals no evidence of redness, skin tearing, bruising or abrasions on her head, neck, chest, abdomen, thighs, legs or perineal region. There was no blood or any type of discharge in the patient's diaper. There is no evidence that we see of any type of injury or forced trauma on this patient. I do not see any physical findings at this time that lead me to believe that the patient has been harmed in any way. Interview on 6/19/19 at 11:05 a.m., with the Acting Assistant Director of Health Services (AADHS) confirmed that she first became aware of the physical contact between R#6 and R#7, that had occurred on 6/8/19, and 6/9/19, after R#6 had re-entered R#7's room on 6/9/19. The AADHS stated that she was working the day shift, on Sunday (6/9/19), on the North hall and overhead a conversation at the nursing station between LPN AA and LPN BB and CNA CC and that she asked them what was going on. When they told her, about the incident that occurred on 6/8/19 and 6/9/19, the AADHS made them aware that the incident should have been reported right away. The AADHS stated that she would not have considered that R#6 and R#7 were having a relationship because R#7 could not consent to a sexual relationship. The AADHS stated that LPN AA should have known that the sexual contact initiated by R#6 was not consensual contact. Although the two LPN's (AA and BB) removed R#6 from R#7's room on 6/8/19, they failed to immediately notify the Administrator. The staff's failure to report this incident resulted in a failure to provide protection for R#7 which resulted in R#6 re-entering R#7's room again on 6/9/19 causing R#7 continued fear. The facility implemented the following interventions to remove the Immediate Jeopardy: 1. Resident #6 was put on one-on-one supervision until he was transferred to another facility on 6/11/19. Resident #6 will not be returning to the facility. On 6/9/19 both LPN's were suspended. LPN #1 (AA) was subsequently terminated for not timely reporting incident. LPN #2 (BB) received education on abuse and timely reporting by the DHS before returning to work on 6/17/19. Resident #7 had a Quarterly Minimum Data Set (MDS) Assessment on 5/4/19 with a Brief Interview for Mental Status (BIMS) score of 6. Resident #7 was assessed by the DHS on 6/9/19 regarding her emotional and physical well-being and sent to the ER for emergency evaluation as well. Resident #7 has been assessed daily for her emotional/behavioral health by the DHS since 6/9/19 and has been added to the Behavior Management Program on 6/10/19. Resident #7 is also scheduled for a behavioral health services check with outside Psychiatrist on 7/10/19. 2. All residents have the potential to be affected. The ADHS, DHS, and Social Worker has completed abuse interviews with cognitive residents that have a BIMS score between 10-15 to rule out any other abuse allegations. Questions included has staff, a resident, or anyone else here abused you and have you seen any resident here being abused? Residents with a BIMS score lower than a 10 will receive a body audit and assessed for any behavioral changes. All interviews and body audits were completed between 6:00 p.m. and 11:00 p.m. on 6/25/19. An interview was conducted with forty-three residents and the remaining twenty-two residents received a body audit for a total of 65 residents in house. No adverse findings were found. 3. All staff were in-serviced by the DHS and Clinical Competency Coordinator (CCC) on abuse, types of abuse, timely abuse reporting, who to report abuse to and when to report abuse; including state agency contact information, resident protection (one-on-one supervision). Scenarios were also provided to staff on abuse identification of abuse indicators with non-cognitive resident to observe for fearfulness, anger, stress, defensiveness, anxiety, worrying, or fear of being alone with staff. In-service education was initiated on 6/25/19 at 7:30 p.m. until 11:00 p.m. and completed 6/26/19 between 9:00 a.m. and 11:00 a.m. 5 of 5 RN's, 12 of 12 LPN's, 21 of 21 CNAs, 8 of 8 housekeeping, 7 of 7 administrative, 6 of 6 dietary, 4 of 4 therapy, and 1 of 1 maintenance 100% of staff have competed in-service on 6/26/19. 4. Newly hired staff will be in-serviced on abuse on the first day of hire during orientation and annually by the CCC. 5. The CCC and/or Social Worker will interview 5 residents a week for 6 weeks on abuse questions and for cognitively impaired residents the DHS and/or ADHS will complete the Weekly Head to Toe Assessment. The CCC will report any adverse findings to the administrator immediately. The Administrator will report adverse findings to the state agencies and the DHS or ADHS will report adverse findings to the physician. The CCC and/or Social Worker will also interview 5 staff members per week for 6 weeks, Monday through Friday on both shifts 7 a.m. to 7 p.m. and 7 p.m. to 7 a.m., on questions about abuse and abuse scenarios. The abuse scenarios will include cognitively impaired residents to observe for fearfulness, anger, stress, defensiveness, anxiety, worrying or fear of being alone with staff. Any adverse findings will be reported to the Administrator immediately for proper reporting to state agency. 6. The immediate jeopardy was communicated with the Senior Nurse Consultant, Area Vice President, Sr. Vice President of Clinical Services, and COO of Community Services on 6/25/19. An ad hoc meeting was held with the medical director, the administrator, DHS, ADHS, Licensed Practical Nurse, senior nurse consultant, area vice president, restorative nurse and certified nursing assistant on 6/27/19 to discuss the immediate jeopardy finding and the allegation of credible compliance. 7. The Administrator will take all findings to the QAPI committee for action as needed monthly beginning 06/26/19 x 3 months. All immediate corrective actions will be completed by 6/27/19. The State Agency Validated the following to remove the Immediate Jeopardy: 1. Record review revealed a Physician order for [REDACTED]. A Physician order dated 6/11/19 for R#6 that documented may transfer to DCH via 1013; Res (Resident) medically stable for transport. Review of a Nurses Note dated 6/11/19 at 2:00 p.m., documented Res transported to psych in-patient facility via 1013 . Record review of a One on One Monitoring form dated 6/9/19 at 8 p.m. revealed the following instructions documented: Staff member is to closely monitor res. If he leaves his room for any reason. Day 1 Sunday Res. Placed on 1:1 monitoring at 8 p.m. d/t (due to) alleged sexual assault. Immediately following incident, resident returned to his room and was monitored by CN[NAME] Night 1 Sun (Sunday): Stayed in bed all night did not leave his room. Day 2 Mon (Monday) 6-10 - Walked in hall for short time, returned to bed and didn't come out of room. Monitored him while out of bed. Night 2 Mon 6-10 Charge nurse monitored resident and was given instruction to observe if resident left room for any reason. I served as Charge Nurse (CN) and he did not leave his room. Day 3 Tuesday 6/11/19 Watched until discharged , walked only in room and returned to bed. Behavioral Symptom Screening Form for R#7 dated 6/9/19, 6/12/19, 6/19/19, 6/26/19, documented the following: Resident was the victim of an alleged sexual assault from another male resident. Resident appeared frightful and scared. Review of the list of residents that had a Brief Interview for Mental Stability (BIMS) of 10 or Greater revealed a list of 43 Residents with BIMS greater than 10. Census list dated 6/25/19 revealed that 43 residents are marked as being interviewed and that 22 residents are documented as having skin assessments. Forty-three resident interviews revealed no adverse findings were noted. Twenty-two skin assessments were completed. Review of the 22 skin assessments revealed that there were not any adverse findings noted. Record review of the Census list documents for each resident document that one on one education was provided to the resident and documented that letter was mailed to the responsible party and the date letter was mailed. 2. Record review revealed that Body Audit forms were completed for each of the 22 residents without any adverse findings noted. Further review revealed 43 Resident interviews regarding Abuse. Specific questions included: Has staff, a resident, or anyone else here abused you? Have you seen any resident here being abused? Each form documents that each of the 43 residents received education on how to report suspected abuse/neglect. There were no negative findings of abuse noted. Each form documented that education was provided regarding the facility abuse policy. Each form documented that education was provided regarding the facility abuse policy. 3. Record review of the Inservice Education Program Summary Record dated 6/27/19 revealed that the abuse policy and procedure was reviewed. In addition, symptoms of abuse in non-cognitive residents: fearfulness, anger, stress, defensiveness, anxiety, worry or fear of being alone with person. Forty-one staff members are noted to have signed this form. Record review of the Active Employee Listing revealed that the facility has 59 active employees. Fifty-nine employees signed Inservice Education Program Attendance Record Form. Review of the Inservice Education Program Summary Record Form dated 6/25/19 through 6/26/19 revealed that education was provided regarding abuse, what is abuse, types of abuse, any suspected abuse must be reported immediately to the Administrator, no matter what time of day or what time. Abuse scenario reviews. Interview with staff on 6/28/19 revealed that staff had been educated on the components of the abuse policy, and received in-services regarding what is abuse, types of abuse, signs of symptoms of abuse for cognitively impaired residents, who to report abuse to, when to report abuse, and how to report abuse. Interviews included the following staff and residents: LPN FF ( 6/28/19 at 11:00; CNA GG- 1:41 p.m.; at 11:49 a.m. Financial Counselor HH; 12:08 p.m. Speech language Pathologist II; at 12:51 p.m. with Floor Tech JJ; at 1:10 p.m. with CNA KK and CNA LL; at 1:16 p.m. with the DON; at 1:30 p.m. with HK (QQ); at 1:34 p.m. Maintenance & Housekeeper MM; at 1:37 p.m. Laundry Aide NN; at 1:40 p.m. with PTA OO; at 1:47 p.m. LPN Unit Manager PP; at 1:40 p.m. with HK RR; at 1:50 p.m. LPN SS (7A-7P) (SS); at 2:00 p.m. with Dietary TT; at 2:30 p.m. with Dietary UU; at 4:57 p.m. with Area Vice President, Senior Nurse Consultant, the DHS, and ADHS; at 3:55 pm- CNA VV (7P-7A); 6/28/19 at 4:10 p.m. with LPN WW (7P-7A); at 4:30 p.m. with LPN XX (7P-7A); 6/28/19 at 5:00 p.m. RE. Interview on 6/28/19 at 3:05 p.m. via telephone with a family member of resident C stated the SW called him on 6/27/19 to talk about abuse and the policy. She told him they would be mailing him a copy of the policy and was to sign the form and mail it back. Interview on 6/28/19 at 4:40 p.m. with R D stated the staff gave her a copy of the abuse policy and procedure yesterday and talked to her about abuse and the policy. R D stated the staff also gave her roommate a copy. Interview on 6/28/19 at 5:00 p.m. with R [NAME] stated she had a copy of the abuse policy which was sitting on her overbed table that they brought her yesterday. 4. Record review revealed the facility had two new employees. Interview with LPN FF on 6/28/19 at 11:00 a.m. revealed that her first day was Wednesday and that she had received the following training: Abuse training - types of abuse physical, verbal, mental, sexual; right not to be abused, report, report immediately within two hours. If you see, remove abuser immediately - and contact DHS and Administrator. Check on the abused monitor for fear, anxiety, can't talk - tense, flinching. Received on the first day and every day since then. I immediately report to Administrator or DHS. Phone numbers are on bulletins. Beside Abuse policy. I know how to get abuse policy. A copy of policy is posted. Always report. Person is safe. Even if resident is confused you treat as any allegation of abuse and you report immediately. Protect resident. Separate the residents and watch perpetrator. Protection is priority. Delegate staff members. 5. Record review revealed that The Clinical Care Coordinator (CCC) and Social Worker (SW) interviewed five residents for the week of 6/27/19 regarding abuse and five additional Head to Toe assessments were completed for cognitively impaired residents. No adverse findings were noted. Further review revealed five Staff Abuse Questionnaires that included the following questions: What training have you received at this facility regarding abuse and neglect? How often is training held, what would you do if a resident becomes agitated and physically aggressive while you were providing care? Per our policy who would you report alleged abused to? List two examples of abuse, what would you do if you discovered two residents fighting? What would you do if you saw a staff member hit a resident? What would you do if the staff member you saw hit a resident was back at work the next day performing care to the residents? Do you know where the numbers are to report abuse and neglect? Can you tell me per our abuse policy, how quickly does the facility have to report alleged abuse to the state? 6. Review of the Ad hoc QAPI meeting notes revealed an Ad hoc meeting was held on 6/27/19 at 3:00 p.m. and that the following were in attendance: Physician, three LPN's, one RN, Administrator, Area Vice President, Senior Nurse Consultant, one CNA and topics discussed were ongoing complaint survey/IJ tags. Interview on 6/28/19 at 1:47 p.m. with the Area Vice President, Senior Nurse Consultant, Director of Health Services, and Assistant Director of Health Services revealed that an Ad hoc QAPI meeting was held 6/27/19 to discuss the findings with the Immediate Jeopardy tags. 7. Interview on 6/28/19 at 1:47 p.m. with the Area Vice President, Senior Nurse Consultant, Director of Health Services, and Assistant Director of Health Services revealed that the findings for the Immediate Jeopardy will be taken to the QAPI committee for action as needed.

Based on interviews, medical record review, review of written statements, review of the facility policy titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation and review of the facility policy titled Abuse Prevention and Reporting and review of the facility policy titled, No Retaliation for Good Faith Reporting of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property it was determined that the facility failed to implement the protection and reporting component of their abuse policy when two LPN's failed to report an incident of sexual abuse for one of 14 residents (R#7) reviewed for abuse and the facility failed to provide protection for one of one residents ( R#7) after an allegation of sexual abuse was made on (MONTH) 8, 2019. The facility census was 69 residents. On (MONTH) 25, 2019, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Health Services (DHS), Acting Assistant Director of Health Services (AADHS), the newly hired Assistant Director of Health Services (ADHS), and the Regional Vice President (VP) were informed of the Immediate Jeopardy on (MONTH) 25, 2019 at 5:25 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 8, 2019. The Immediate Jeopardy continued through (MONTH) 27, 2019 and was removed on (MONTH) 28, 2019. The facility implemented a Removal Plan related to the Immediate Jeopardy on 6/27/19. The Immediate Jeopardy is outlined as follows: On (MONTH) 8, 2019 Resident (R) #6, a cognitively intact male, was observed by two Certified Nursing Assistants (CNA) in R#7's (a cognitively impaired female) room with his hand under R#7's covers, and was kissing the resident on her face. Per staff interviews, review of written statements and review of the police report, R#7 was fearful, crying and complained of pain to her perineal area. The two CNA's immediately reported the incident to two Licensed Practical Nurses (LPN). However, the LPN's failed to immediately report the incident to Administration which lead to a failure to protect R#7 resulting in R#6 re-entering her room again on (MONTH) 9, 2019 which caused R#7 continued fear. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600), Scope/Severity: J and 42 C.F.R. 483.12(a)(1), Develop/Implement Abuse/Neglect Policies (F607), Scope/Severity: J). Additionally, Substandard Quality of Care was identified with the requirements at 483.12(a)(1), Free from Abuse and Neglect (F600, Scope/Severity: J); 42 C.F.R. 483.12(a)(1), Develop/Implement Abuse/Neglect Policies (F607, Scope/Severity: J). A Removal Plan was received on (MONTH) 26, 2019 related to 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600) and 42 C.F.R. 483.12(a)(1), Develop/Implement Abuse/Neglect Policies (F607). Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Removal Plan, it was validated that the corrective plans was implemented therefore, the immediacy of the deficient practice was removed on (MONTH) 28, 2019. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of ensuring that staff and residents are educated on the facility's abuse policy and know what abuse is, when to report abuse, and how to report abuse. This oversight process included the analysis of the facility staffs' conformance with the facility's abuse policies and procedures governing the timely and accurate reporting of abuse and implementing interventions in their abuse policy. In-service materials and records were reviewed. Observations and interviews were conducted with staff and residents to ensure they demonstrated knowledge of facility policies and procedures regarding what is abuse and when and how to report abuse. Findings include: A review of the facility policy titled, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property documented the definition of sexual abuse is non-consensual sexual contact of any type with a patient. A review of the facility policy titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property documented the following procedure: Any allegation, suspicious, or identified occurrence involving patient abuse, neglect, exploitation, mistreatment, and misappropriation of property, including injuries of an unknown source, should be immediately reported to the Administrator of the provider entity. A review of the facility policy titled, No Retaliation for Good Faith Reporting of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property documented the following procedure under the section titled Protection: During an active investigation of patient abuse, neglect, exploitation, mistreatment or misappropriation of patient property, when there is substantial evidence that such has occurred, the provider should take all reasonable efforts to protect the affected patient(s) from harm. R#6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The 30-day Minimum Data Set (MDS) assessment, dated 5/15/19, indicated that the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. The resident was also assessed as requiring minimal assistance from staff. The resident was independent for locomotion on and off the unit and utilized a wheelchair and walker for mobility. R#7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R#7 was assessed by the facility on the 5/4/19, MDS as having a BIMS score of six indicating that the resident was severely cognitively impaired with decision making skills and demonstrated inattention. The resident required extensive assistance of one person for bed mobility and was nonambulatory. She was totally dependent on staff for dressing, hygiene and bathing. She was assessed as having functional limitation in range of motion of the upper extremity on one side and impairment on both sides of the lower extremities. During an interview with Licensed Practical Nurse (LPN BB), (a.m.- 7 p.m. shift) on 6/18/19 at 4:08 p.m., revealed that on Saturday, 6/8/19, after 7:00 p.m., a CNA came and reported to LPN AA that R#6 was kissing R#7 on her face and that he had his hand under the covers. LPN BB stated she and the other nurse, LPN AA, went down to R#7's room and asked R#6 to leave. LPN BB stated that R#6 got mad and called them racists. Further interview with LPN BB revealed that on 6/9/19 around shift change she was walking by R#7's room and her eyes met R#7's eyes. LPN BB stated that R#7 looked fearful. LPN BB stated that she saw R#6 was in the room talking to R#7's roommate and then R#6 went over to R#7's bed. LPN BB stated that R#7 continued to have a fearful look on her face. LPN BB went into the room and asked R#7 if she wanted R#6 in her room and R#7 responded, no. LPN BB stated she then asked R#6 to leave, and that R#6 got mad and left. Continued interview with LPN BB revealed that on 6/9/19 she told the Acting Assistant Director of Health Service (AADHS) that R#6 had been in R#7's room twice and that R#7 was fearful. After that, CNA DD told the AADHS what occurred on 6/8/19, when they saw R#6 in R#7's room kissing her on the face with his hand under the covers. LPN BB stated that the AADHS said Oh my God, that has to be reported. During an interview on 6/19/19 at 11:05 a.m., the Acting Assistant Director of Health Services (AADHS) confirmed that she first became aware of the physical contact between R#6 and R#7 on 6/9/19, after R#6 had re-entered R#7's room on 6/9/19. When they told her what occurred on 6/8/19 and 6/9/19, she made them aware that the incident should have been reported right away. During an interview with LPN SS on 6/19/19 at 11:05 a.m., she stated she had been off work when all of this happened. She stated she returned to work on 6/10/19, and was assigned to the floor that R#7 resided on but no one informed her of the incident until after R#6 left the faciity on [DATE]. LPN SS also stated nobody told her to watch to ensure that R#6 did not go near R#7. During a telephone interview with LPN AA (p.m.-a.m. shift) on 6/19/19 at 11:35 a.m., she stated that she was taking report with the day shift nurse on 6/8/19 around 8:00 p.m., when the CNA's came to her and said R#6 had his hands under R#7's covers. When she and LPN BB went to the room she asked R#6 to leave the room. R#7 told her that he touched her, but she did not specify where. She stated she examined R#7 and noticed her brief was on tight and there was no redness or swelling. She also stated that R#6 was in R#7's room morning, noon and night but she never saw any behaviors prior to this. She stated she did not report this to anyone because she thought the residents were boyfriend and girlfriend. LPN AA stated the next night, 6/9/19, when she came on duty LPN BB told her R#6 had been in R#7's room again and she made him leave. LPN BB said she did not call the physician on 6/8/19. LPN AA further stated that LPN BB told her when she worked on 6/9/19 that there were no special instructions given to them to start one-on-one monitoring with R#6 or to keep R#6 out of R#7's room. During an interview with the Administrator and the Director of Health Services (DHS) on 6/20/19 at 9:50 a.m., they stated that light duty CNA's were on the hall watching R#6 and would shadow the resident if he came out of his room. They stated one of the light duty CNAs would have been assigned to watch the resident. Further interview revealed that the Administrator and DHS were unable to show the surveyor on the actual assignment sheets for 6/9/19, 6/10/19 and 6/11/19 who was assigned to watch R#6. During an interview with LPN EE on 6/26/19 at 10:45 a.m., she stated that there were no light duty CNAs working the night shift (7 p.m.-7 a.m.) on 6/9/19, or on 6/10/19, and stated that there were no staff actually assigned to stand in the hallway and watch R#6. LPN EE stated staff would just note where the resident was as they were out doing their assignments. Review of the Pruitt Health Daily Nursing Assignment Form revealed the following: On 6/8/19 the 7 p.m.-7 a.m., shift had two LPN's and three CNA's working with assignments. On 6/9/19 the 7 a.m.-7 p.m., shift had two LPN's and four CNA's with one light duty CNA who made beds, answered call lights and assisted with meals. The 7 p.m.-7 a.m., shift had two LPN's and three CNA's with no light duty staff scheduled. All the staff had assignments. On 6/10/19 the 7 a.m.-7 p.m., shift had two LPN's, four CNA's who had assignments and one CNA in training who also had an assignment. There were two light duty CNA's who were either assigned to the hydration cart and to accompany residents to appointments on transport. The 7 p.m.-7 a.m., shift had two LPN's and five CNA's who all had an assignment. On 6/11/19 the 7 a.m.-7 p.m., shift had two LPN's and five CNA's who had assignments and two light duty CNA's who either were assigned hydration or to accompany residents to appointments on transport. During an interview and review of the assignment forms with the AADHS on 6/26/19 at 10:45 a.m., she stated she was responsible for making out the assignment sheets. In reviewing the assignment sheets, she stated there were no light duty CNA's scheduled on 6/8/19 on the 7 p.m.-7 a.m., shift. She stated on 6/9/19, there was only one light duty staff who worked from 7 a.m.-3 p.m., making beds, answering call lights and assisting with meals. She stated there were no light duty staff on the 7 p.m.-7 a.m., shift and all of the staff had an assignment. She stated on 6/10/19 a.m.-p.m., there were three light duty CNA's. One was assigned hydration who worked from 8:00 a.m.- 4:30 p.m. passing out ice, water and snacks, another CNA was on transport and the third CNA worked from 7:00 a.m. -3:00 p.m., with another CNA who had an assignment. She stated the 7:00 p.m. - 7 a.m. shift did not have light duty staff and all the staff had assignments that night. She stated on 6/11/19, 7 a.m.- 7 p.m., had two light duty CNA's. One was on transport and the other on hydration from 8:00 a.m. - 4:30 p.m. Although the facility indicated R#6 was put on one-on-one observation there was no evidence that the facility called in additional staff to provide this supervision, and there was no evidence that the facility had light duty CNA's scheduled for the 7 p.m. - 7 a.m., shift. from 6/8/19 through 6/11/19, when R#6 was transferred to a psychiatric hospital. The facility implemented the following to remove the Immediate Jeopardy: 1. Resident #6 was put on one-on-one supervision until he was transferred to another facility on 6/11/19. Resident #6 will not be returning to the facility. On 6/9/19 both LPN's were suspended. LPN #1(AA) was subsequently terminated for not timely reporting incident. LPN #2 (BB) received education on abuse and timely reporting by the DHS before returning to work on 6/17/19. Resident #7 had a quarterly Minimum Data Set (MDS) Assessment on 5/4/19 resulting in a Brief Interview for Mental Status (BIMS) score of 6. Resident #7 was assessed by the DHS on 6/9/19 regarding her emotional and physical well-being and sent to the ER for emergency evaluation as well with no reported negative outcome. Resident #7 has been assessed daily for her emotional/behavioral health by the DHS since 6/9/19 and has been added to our Behavior Management Program on 6/9/19 and reviewed weekly. Resident #7 is also scheduled for a behavioral health services check with an outside Psychiatrist on 7/10/19. 2. The abuse policy was reviewed by corporate on 1/8/19 and then again by the Area Vice President and Administrator on 6/25/19. Our review of the policy determined the policy was in good standing and well developed and included the seven components; abuse identification, types of abuse, right to be free of abuse, investigating abuse, prevention of abuse, protecting against abuse, and reporting of abuse (2-hour timeline). 3. All residents have the potential to be affected. The ADHS, DHS, and Social Worker completed interviews regarding our facility abuse policy with cognitive residents that have a BIMS score between 10-15 to rule out any questions or concerns. Questions include do you have any questions on our abuse policy? and per policy do you know who to report to if you or someone has been abused in our facility? All interviews were completed between 10:00 a.m. and 1:00 p.m. on 6/27/19 with no adverse findings reported. 4. At the time of the interviews all forty-three cognitive residents were educated on the facility abuse policy including the seven components; abuse identification, types of abuse, right to be free of abuse, investigating abuse, prevention of abuse, protecting against abuse, and reporting of abuse. On 6/27/19 all forty-three cognitive residents received a copy of the abuse policy. The families, responsible parties, and/or power of attorneys, of the twenty-two residents with a BIMS lower than 10 were mailed the abuse policy on 6/27/19. 5. All staff was in-serviced by the DHS and Clinical Competency Coordinator (CCC) on our abuse policy and the seven components; abuse identification, types of abuse, right to be free of abuse, investigating abuse, prevention of abuse, protecting against abuse, and reporting of abuse. Scenarios were also provided to staff on abuse identification of abuse indicators with non-cognitive residents to observe for fearfulness, anger, stress, defensiveness, anxiety, worrying, or fear of being alone with staff. In-service education was initiated on 6/25/19 at 7:30 p.m. until 11:00 p.m. and completed 6/26/19 between 9:00 a.m. and 11:00 a.m. 5 of 5 RN's, 12 of 12 LPN's, 21 of 21 CNAs, 8 of 8 housekeeping, 7 of 7 administrative, 6 of 6 dietary, 4 of 4 therapy, and 1 of 1 maintenance have all been in-serviced. 100% of staff was competed on 6/26/19. A copy of the abuse policy was posted on the bulletin board located at the front entrance and by the therapy department for all visitors and staff members to have for review. A list of names and contact numbers of the Administrator, DHS, and CCC were also posted. 6. Newly hired staff will be in-serviced on the abuse policy on the first day of hire during orientation and annually by the CCC. 7. The CCC and/or Social Worker will interview 5 residents a week, for 6 weeks on the above-mentioned abuse policy questions starting 6/27/19. The CCC will report any adverse findings to the administrator immediately. The Administrator will report adverse findings to the state agencies, Ombudsman at (phone number), and the Facility Regulation Division at (phone number). The DHS or ADHS will also report adverse findings to the physician and/or Medical Director. The CCC and/or Social Worker will also interview 5 staff members per week, Monday through Friday on both shifts 7 a.m. to 7 p.m. and 7 p.m. to 7 a.m., for 6 weeks. The interview questions are on our abuse policy to make sure staff is familiar with our abuse policy. Adverse findings will be reported to the Administrator immediately for proper reporting to state agency. 8. The immediate jeopardy was communicated with the Senior Nurse Consultant, Area Vice President, Senior Vice President of Clinical Services, and COO of Community Services on 6/25/19 4:40 p.m. An Ad hock meeting was held with the medical director, the administrator, DHS, ADHS, Licensed Practical Nurse, senior nurse consultant, area vice president, restorative nurse and certified nursing assistant on 6/27/2019 to discuss the immediate jeopardy finding and the allegation of credible compliance. 9. The Administrator will take all findings to the QAPI committee for action as needed monthly beginning 06/26/19, times 3 months. 10. All immediate corrective actions will be completed by 6/27/19. The State Agency validated the following to remove the Immediate Jeopardy: 1. Record review revealed a Physician order for [REDACTED]. A Physician order dated 6/11/19 for R#6 that documented may transfer to DCH via 1013; Res (Resident) medically stable for transport. Review of a Nurses Note dated 6/11/19 at 2:00 p.m., documented Resident transported to psych in-patient facility via 1013. Record review of a One on One Monitoring form dated 6/9/19 at 8 p.m., revealed the following instructions documented: Staff member is to closely monitor res. If he leaves his room for any reason. Day 1 Sunday Res. Placed on 1:1 monitoring at 8 p.m., d/t (due to) alleged sexual assault. Immediately following incident, resident returned to his room and was monitored by CN[NAME] Night 1 Sun (Sunday): Stayed in bed all night did not leave his room. Day 2 Mon (Monday) 6-10 - Walked in hall for short time, returned to bed and didn't come out of room. Monitored him while out of bed. Night 2 Mon 6-10 Charge nurse monitored resident and was given instruction to observe if resident left room for any reason. I served as Charge Nurse (CN) and he did not leave his room. Day 3 Tuesday 6/11/19 Watched until discharged , walked only in room and returned to bed. Behavioral Symptom Screening Form for R#7 dated 6/9/19, 6/12/19, 6/19/19, 6/26/19, documented the following: Resident was the victim of an alleged sexual assault from another male resident. Resident appeared frightful and scared. 2. Record Review of the facility's abuse policy revealed that it was last revised 1/8/19 the policy includes the seven components including: screening, training, prevention, identification, investigation, protection, reporting and response to abuse. The policy addresses misappropriation of property, exploitation, mistreatment, mistreatment and misappropriation of property. Investigating abuse, No retaliation, prevention of abuse, reporting. 3. Review of the Census list dated 6/25/19 revealed that 43 residents are marked as being interviewed and that 22 residents are documented as having skin assessments. Record review revealed that Body Audit forms were completed for each of the 22 residents without any adverse findings noted. Further review revealed 43 Resident interviews regarding Abuse. Specific questions included: Has staff, a resident, or anyone else here abused you? Have you seen any resident here being abused? Each form documents that each of the 43 residents received education on how to report suspected abuse/neglect. There were no negative findings of abuse noted. Each form documented that education was provided regarding the facility abuse policy. Interview on 6/28/19 at 3:05 p.m., via telephone with a family member of resident C stated the Social Worker (SW) called him on 6/27/19 to talk about abuse and the policy. She told him they would be mailing him a copy of the policy and was to sign the form and mail it back. Interview on 6/28/19 at 4:40 pm with R D stated the staff gave her a copy of the abuse policy and procedure yesterday and talked to her about abuse and the policy. R D stated the staff also gave her roommate a copy. Interview on 6/28/19 at 5:00 pm with R [NAME] stated she had a copy of the abuse policy which was sitting on her overbed table that they brought her yesterday. 4. Record review revealed 43 resident interviews regarding Abuse. Specific questions included: Has staff, a resident, or anyone else here abused you? Have you seen any resident here being abused? Each form documents that each of the 43 residents received education on how to report suspected abuse/neglect. There were no negative findings of abuse noted. Each form documented that education was provided to each resident regarding the facility abuse policy. Record review of the Census list revealed letters were mailed, on 6/27/19, to Family Members and/or Responsible Party, that the facility would like to ensure our family members, responsible parties, and residents are aware of our Abuse Policy & Procedure that details the types of abuse, who to report abuse to, time to report, investigation, possible staff disciplinary actions, protection of resident, facility will investigate all allegation of abuse. The letter also documents that the facility will be having a Family Council meeting on 7/10/19 to further discuss abuse policies. Record review of the Census list documents for each resident documented that one on one education was provided to the resident and documents that letters were mailed to the responsible party and the date the letters were mailed (6/27/19). 5. Record review of the Inservice Education Program Summary Record dated 6/27/19 revealed that the abuse policy and procedure was reviewed. In addition, symptoms of abuse in non-cognitive residents: fearfulness, anger, stress, defensiveness, anxiety, worry or fear of being alone with person. Forty-one staff members are noted to have signed this form. Record review of the Active Employee Listing revealed that the facility has 59 active employees. Fifty-nine employees signed Inservice Education Program Attendance Record Form. Review of the Inservice Education Program Summary Record Form dated 6/25/19 through 6/26/19 revealed that education was provided regarding abuse, what is abuse, types of abuse, any suspected abuse must be reported immediately to the Administrator, no matter what time of day or what time. Abuse scenario reviews. Interview with staff on 6/28/19 revealed that staff had been educated on the components of the abuse policy, and received in-services regarding what is abuse, types of abuse, signs of symptoms of abuse for cognitively impaired residents, who to report abuse to, when to report abuse, and how to report abuse. Interviews included the following staff and residents: LPN FF ( 6/28/19 at 11:00; CNA GG- 1:41 p.m.; at 11:49 a.m. Financial Counselor HH; 12:08 p.m. Speech language Pathologist II; at 12:51 p.m. with Floor Tech JJ; at 1:10 p.m. with CNA KK and CNA LL; at 1:16 p.m. with the DHS; at 1:30 p.m. with HK (QQ); at 1:34 p.m. Maintenance & Housekeeper MM; at 1:37 p.m. Laundry Aide NN; at 1:40 p.m. with PTA OO; at 1:47 p.m. LPN Unit Manager PP; at 1:40 p.m. with HK RR; at 1:50 p.m. LPN SS (7A-7P) (SS); at 2:00 p.m. with Dietary TT; at 2:30 p.m. with Dietary UU; at 3:05 p.m. via telephone with, son of resident C; at 4:40 p.m. with RD; at 4:57 p.m. with Area Vice President, Senior Nurse Consultant, the DHS, and ADHS; at 3:55 pm- CNA VV (7P-7A); 6/28/19 at 4:10 p.m. with LPN WW (7P-7A); at 4:30 p.m. with LPN XX (7P-7A); 6/28/19 at 5:00 p.m. RE. 6. Record review revealed the facility had two new employees. Interview with LPN FF on 6/28/19 at 11:00 a.m., revealed that her first day was Wednesday and that she had received the following training: Abuse training - types of abuse physical, verbal, mental, sexual; right not to be abused, report, report immediately within two hours. If you see, remove abuser immediately - and contact DHS and Administrator. Check on the abused monitor for fear, anxiety, can't talk - tense, flinching. Received on the first day and every day since then. I immediately report to Administrator or DHS. Phone numbers are on bulletins. Besides Abuse policy. I know how to get abuse policy. A copy of policy is posted. Always report. Person is safe. Even if resident is confused you treat as any allegation of abuse and you report immediately. Protect resident. Separate the residents and watch perpetrator. Protection is priority. Delegate staff members. 7. Record review revealed that The Clinical Care Coordinator (CCC) and Social Worker (SW) interviewed five residents for the week of 6/27/19 regarding abuse and five additional Head to Toe assessments were completed for cognitively impaired residents. No adverse findings were noted. Further review revealed five Staff Abuse Questionnaires that included the following questions: What training have you received at this facility regarding abuse and neglect? How often is training held, what would you do if a resident becomes agitated and physically aggressive while you were providing care? Per our policy who would you report alleged abused to? List two examples of abuse, what would you do if you discovered two residents fighting? What would you do if you saw a staff member hit a resident? What would you do if the staff member you saw hit a resident was back at work the next day performing care to the residents? Do you know where the numbers are to report abuse and neglect? Can you tell me per our abuse policy, how quickly does the facility have to report alleged abuse to the state? 8. Review of the Ad hoc QAPI meeting notes revealed an Ad hoc meeting was held on 6/27/19 at 3:00 p.m., and that the following were in attendance: Physician, three LPN's, one RN, Administrator, Area Vice President, Senior Nurse Consultant, one CNA and topics discussed were ongoing complaint survey/IJ tags. Interview on 6/28/19 at 1:47 p.m., with the Area Vice President, Senior Nurse Consultant, Director of Health Services, and Assistant Director of Health Services revealed that an Ad hoc QAPI meeting was held 6/27/19 to discuss the findings with the Immediate Jeopardy tags. 9. Interview on 6/28/19 at 1:47 p.m. with the Area Vice President, Senior Nurse Consultant, Director of Health Services, and Assistant Director of Health Services revealed that the findings for the Immediate Jeopardy will be taken to the QAPI committee for action as needed.

Based on observations, and staff interview, it was determined that the facility failed to provide adequate staff coverage to prevent the Director of Health Services (DHS) from having to work as a charge nurse when the census was greater than 60 residents for four of 17 days of the Complaint investigation survey. Review of the facility Resident Census and Conditions of Residents Form CMS-672 dated 6/11/19 revealed that the current facility census was 69 residents. Findings include: During observations on 6/12/19 at 10:30 a.m. and 6/13/19 at 10:00 a.m., the DHS was observed working on the medication cart on the North Hall. During an interview with the DHS on 7/3/19 at 10:00 a.m., she stated she was working the medication cart today on the North Hall. She stated she started working at the facility in (MONTH) 2019 and staffing was a concern then. She stated she has worked on the medication cart on 6/12/19, 6/13/19, 6/24/19 and 7/3/19 due to the facility being short staffed. She stated the staff were tired and she tries to assist with baths and feeding as well.

Based on observations, interviews, and record reviews, the facility failed to implement interventions to apply soft heel boots for two of four residents (R#1 and R#4) reviewed for pressure ulcers, failed to provide timely incontinence care for one of three residents (R#1) reviewed for incontinence, failed to provide a consistent bathing schedule for two of five residents (R#3 and R#12) reviewed for Activities of Daily Living (ADLs), failed to serve the correct diet for one of three residents (R#2) reviewed for diets, failed to obtain a diet consultation for one of three resident (R#5) reviewed for diet consultations, failed to provide assistance to get out of bed for one of five residents (R B) reviewed for ADL's, failed to provide restorative nursing services for one of four residents (R B) reviewed for restorative nursing, and failed to develop a care plan for the use and care of a peripherally inserted central catheter (PICC) line for one of one residents (R#11) reviewed that had a PICC line. Findings include: 1. Resident (R) #2 had a care plan in place since 11/30/15 for the potential for an alteration in nutrition related to the use of a therapeutic diet secondary to hypertension and diabetes. The care plan was updated on 2/27/19 to include the potential of alteration in nutrition related to the use of a therapeutic, mechanically altered diet. The care plan included an intervention for dietary staff to serve the diet as ordered. R#2 had a physician's orders [REDACTED]. However, during an observation on 6/11/19 at 1:00 p.m., R #2 was observed to have been served a regular consistency diet for lunch. The lunch tray contained fried chicken, carrots, mashed potatoes, banana pudding, iced tea and water. The fried chicken was not a mechanical soft consistency. During an interview on 6/11/19 at 2:39 p.m., the Dietary Manager stated that the resident was on a regular diet. However, there was not any evidence that the mechanically soft diet had been discontinued until after surveyor inquiry. On 6/12/19 a physician's orders [REDACTED]. Cross refer to F805 2. Resident (R) #5 had a care plan, dated 2/15/19, for the potential for alteration in nutrition related to effects of disease processes of diabetes, hypertension, [MEDICAL CONDITIONS] and [MEDICAL CONDITION] reflux disease. The care plan included an intervention for a Registered Dietician (RD) consultation as needed. There was also a care plan, dated 2/15/19, that R#5 desired to lose weight. The care plan included an intervention for the RD to evaluate as needed. However, further record review revealed that there was not any evidence in the clinical record that the dietician consultation was obtained as ordered until after surveyor inquiry on 6/25/19. During an interview on 6/25/19 at 2:00 p.m., the Assistant Director of Health Services (ADHS) confirmed that the physician's orders [REDACTED]. Cross refer to F808 3. Resident (R) B received skilled physical therapy services from 2/19/19 through 4/30/19 then was discharged to the Restorative Nursing Program on 5/1/19. Care plan problems were developed on 4/30/19 for requiring restorative assistance to maintain goals and for being at an increased risk for falls. The care plans included interventions for nursing staff to complete passive range of motion (PROM) exercises and ambulate with the resident, as she was able, with a bariatric walker for 15 to 80 feet, with staff following close behind with a wheelchair. During an interview on 6/24/19 at 12:35 p.m., the Assistant Director of Health Services (ADHS) stated that she oversaw the restorative program and restorative certified nursing assistant (CNA) BBB provided the restorative nursing services. The ADHS also stated that restorative services are usually set up to be provided three to five times per week or as tolerated. She added that currently restorative CNA BBB had been out of the facility, since last week, on leave, and that a list of all residents who received restorative nursing services would be given to the CNA's assigned to the residents that day (6/24/19). Review of the Restorative Therapy Referral form, with an effective date of 5/1/19, included the approaches of 15 to 30 repetitions of therapeutic exercises to the bilateral lower extremities and ambulation with a bariatric walker for 15 to 80 feet as able. A review of the Restorative Log, Restorative I CNA Role, Restorative II CNA Role, and Restorative Nursing Flow Record forms from 5/1/19 through 7/1/19 revealed that range of motion services were provided 21 times in May, only six times in (MONTH) and once in July. Restorative ambulation services were provided 21 times in (MONTH) and only four times in June. There was no additional evidence that restorative services were consistently provided, as care planned after (MONTH) 2019. Cross refer to F688 In addition, resident (R) B had a care plan, dated 2/15/19, for having a self-care deficit in Activities of Daily Living (ADL's) related to a limited physical status. The care plan documented that the resident required assistance with ADL's. There was care plan in place, dated 2/15/19, for being at risk for falls related to obesity and weakness. The care plan included an intervention for nursing staff to assist the resident with transfers. Additionally, there was a care plan, dated 4/30/19, for requiring restorative (nursing) assistance that included the resident was at an increased risk for falls. The care plan included an intervention for nursing staff to encourage the resident to get out of bed to maintain function. A review of the quarterly Minimum Data Set (MDS) assessment, dated 5/18/19, revealed that the resident needed extensive assistance from staff for transfers. However, interviews revealed that the resident was not being assisted out of bed, as care planned, as often as she preferred. During an interview on 6/24/19 at 10:24 a.m., RB was observed lying in bed. She stated that she would like to get out of bed daily, but she only gets up maybe once a week because the certified nursing assistant (CNA) staff did not have enough help and time to get her up. During an interview on 6/26/19 at 3:25 p.m., CNA YY, who was assigned to assist RB on the 7:00 a.m. to 7:00 p.m. shift, stated that she was aware that RB wanted to get out of bed that day, but that she had not had time to get her up. She stated the resident liked to get out of bed after lunch. CNA YY included that she needed additional staff assistance to get the resident out of bed. She further stated that when she needed help, she had to go to another hall to find another CNA to help her, and she had not had time to do that. Cross refer to F725 4. Resident (R) #12 resided at the facility from 1/8/19 through 3/30/19. A care plan was developed, dated 1/8/19, to address R#12's self-care deficit of Activities of Daily Living (ADL's) related to limited mobility, fracture and muscle weakness. The care plan included an intervention for nursing staff to provide a bath and/or shower as scheduled. A review of the 14-day Minimum Data Set (MDS) assessment, dated 3/18/19, revealed that the resident was dependent on nursing staff for personal hygiene and bathing. A review of the clinical record revealed that R#12 was not documented as being provided with a bath on a consistent basis. During interviews on 7/2/19 at 9:30 a.m. and 7/3/19 at 10:30 a.m., and review of R#12's bathing documentation with the Director of Health Services (DHS), she stated that the Certified Nursing Assistants (CNA's) are supposed to document the ADL care provided every shift. Cross refer to F677 5. R#1 had a care plan since 4/13/18 for alteration in elimination: incontinent of bowel and bladder with an intervention for nursing staff to change soiled or wet clothing promptly. A review of the Quarterly MDS dated [DATE] revealed the resident was totally dependent on staff for hygiene and bathing. During an observation of the resident on 6/12/19 at 11:35 a.m., the resident's incontinence brief was heavily saturated with urine. During an interview with CNA KK on 6/12/19 at 12:00 p.m., revealed that she had not changed the resident's brief on her shift (7 a.m.-7 p.m.) until 11:35 a.m. She stated the resident was probably last changed around 5:30 a.m. or 6:00 a.m. She stated the facility had been short of staff for the past couple of months. CNA KK stated she was able to get most things finished except she was not able to bathe her residents or get them out of bed. Further review revealed R#1 had a care plan since 4/17/18 for self-care deficit activities of daily living related to impaired cognition and physical condition. There was an approach for nursing staff to provide a bath of choice as scheduled. Review of the bath schedule revealed the resident was scheduled to receive a bath on Tuesdays, Thursdays, and Saturdays. Review of the computerized Bath Form revealed there was not any documentation that the resident consistently received a bath as care planned. During an interview with the DHS on 7/3/19 at 9:45 a.m., she stated the CNA's are expected to offer the residents a bath three times a week and fill out a refusal form if the resident refused a bath. Cross Refer to F677. R#1 had a care plan since 6/3/19 for having an unstageable pressure ulcer to the left ischium, sacrum, and right medial foot and a stage 1 to the right medial ball of foot with the following approaches: resident needs wound care as ordered by physician, soft heel boots to bilateral feet and pillow between legs to cushion between knees and heels. An observation on 6/11/19 at 3:45 p.m., revealed that there was only one heel boot observed on the resident's right foot and that there was not a pillow between the resident's knees. The treatment stated at that time the resident would have a heel boot to the left foot. In addition, R#1 had a 5/28/19 order from the wound care physician for wound care to the right inner, medial foot ulcers times three. Wash daily with mild soap and water, cushion with gauze/foam. Review of the Treatment Records for (MONTH) 2019 and (MONTH) 2019 revealed there was no documentation that the wound care had been completed as ordered by the wound care physician. Interview with the Treatment Nurse on 7/2/19 at 2:50 p.m., revealed that she did not provide the wound care as ordered by the wound care physician because the areas were scabs and were basically healed. She stated she did not call the wound care physician or the primary care physician to clarify if it was ok to discontinue wound treatment. R#1 also had a 4/30/19 physician's orders [REDACTED]. Review of the (MONTH) 2019 Treatment Record revealed there was no evidence of documentation the treatment had been completed as ordered. 6. R#3 had a care plan since 4/12/19 for self-care deficit with activities of daily living and required extensive assistance with activities of daily living. There was an approach for bed bath daily and as needed. Review of the 5/3/19 Significant Change Minimum Data Set (MDS) revealed the resident required extensive assistance with hygiene and was totally dependent on staff for bathing. Review of the electronic Bath Report revealed there was no evidence of documentation that the resident had received a bath from as care planned. Cross Refer to F677. 7. R#4 had a 5/22/19 care plan for a Stage 2 pressure ulcer for the left heel and at risk for future skin breakdown related to limited mobility, cognitive abilities, incontinence of bowels and disease process with an approach for a soft heel boot to left foot. The resident was observed without a heel protector to the left foot with the resident's foot resting directly on the mattress on 6/11/19 at 1:50 p.m., 6/13/19 at 2:10 p.m. and 6/18/19 at 10:00 a.m. Cross Refer to F686. 8. Review of the clinical record revealed resident #11 was admitted to the facility on [DATE] with the Peripherally Inserted Central Catheter (PICC) line in place upon admission. During an observation of R#11 on 6/24/19 at 12:30 p.m., the resident had a PICC line to the right upper arm with an undated transparent type dressing. The dressing was soiled with a dried brown drainage and was hanging half off of the resident's arm. Review of the clinical record revealed that there was no evidence of a care plan in place to address the presence of a PICC line in the resident's right upper arm until after surveyor inquiry on 6/24/19. During an interview with the DHS on 7/3/19 at 9:50 a.m., she confirmed there was not a care plan in place for the PICC line. Cross Refer to F694.

Based on staff interview and record review, the facility failed to ensure that six of 15 nurses reviewed maintained a current Cardiopulmonary Resuscitation (CPR) certification. Findings include: The facility had a Lippincott Procedure for Cardiopulmonary Resuscitation. A review of the procedure revealed that it did not include information on how the facility ensured there were an adequate number of staff present at all times, who were properly trained and or certified in CPR for healthcare providers, to be able to provide CPR until emergency medical services arrived. During interviews on [DATE] at 11:50 a.m. and 4:40 p.m., the Director of Health Services (DHS) stated that the facility required all nurses to be CPR certified. She further stated that the Clinical Care Coordinator (CCC) was responsible for maintaining a notebook with CPR certifications. However, CCC ZZ had been out on leave for three to four months and they were unable to locate all certificates. A review of CPR certifications and Basic Life Support courses listing, taught by the previous CCC AAA on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE], revealed that there was no evidence that six of the 15 nurses employed at the facility had a current CPR certification.

Based on observations, interviews and record review, it was determined that 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 69 residents in the facility. Findings include: Review of the Resident Census and Conditions of Residents form revealed the facility census was 69 residents and of those 69 residents 35 residents were dependent for bathing, 13 residents were dependent for dressing, 31 residents were dependent for transferring, and 23 residents were dependent for toilet use. It also revealed that 31 residents required the assistance of one or two staff for bathing, 54 residents required assistance for dressing, 27 residents required assistance for transferring and 37 residents required assistance for toilet use. Review of the[NAME]Health[NAME]Daily Nursing Assignment Form revealed the following assignments: 6/3/19- one CNA to cover the North Hall which had 34 beds on the 7 p.m.-7 a.m. shift. 6/4/19- one CNA to cover the North Hall which had 34 beds on the 7 p.m.-7 a.m. shift. 6/6/19- one CNA to cover the North Hall which had 34 beds on the 7 p.m.-7 a.m. shift. 6/8/19- one CNA to cover the West/Southwest Halls which had a total of 43 beds on the 7 a.m.- 7 p.m. shift and the 7 p.m.-7 a.m. shift. 6/9/19- one CNA to cover the West/Southwest Halls which had a total of 43 beds on the 7 p.m.-7 a.m. shift. 6/12/19- one CNA to cover the West/Southwest Halls which had a total of 43 beds on the 7 p.m.-7 a.m. shift. 6/13/19- one CNA to cover the West/Southwest Halls which had a total of 43 beds on the 7 a.m.- 7 p.m. shift 6/18/19- one CNA to cover the West/Southwest Halls which had a total of 43 beds on the 7 p.m.-7 a.m. shift. 6/18/19- one CNA to cover the West/Southwest Halls which had a total of 43 beds on the 7 p.m.-7 a.m. shift and one CNA to cover the North Hall which had 34 beds on the 7 p.m.-7 a.m. shift. 1. Record review revealed that Resident #1 had a care plan since 4/17/18 for self-care deficit activities of daily living related to impaired cognition and physical condition. There was an approach for nursing staff to provide a bath of choice as scheduled. A review of the Quarterly Minimum data Set ((MDS) dated [DATE] revealed the resident was totally dependent on staff for hygiene and bathing. Review of the bath schedule revealed the resident was scheduled to receive a bath on Tuesdays, Thursdays, and Saturdays. Review of the computerized Bath Form revealed there was not any documentation that the resident consistently received a bath from 5/2/19 until 5/7/19, 5/10/19 until 5/16/19, 5/22 until 6/1/19, 6/1/19 until 6/18/19 and from 6/20/19 until 6/26/19. In addition, record review revealed R#1 had a care plan since 4/13/18 for alteration in elimination: incontinent of bowel and bladder with an intervention for nursing staff to change soiled or wet clothing promptly. A review of the Quarterly MDS dated [DATE] revealed the resident was totally dependent on staff for hygiene and bathing. During an observation of the resident on 6/12/19 at 11:35 a.m., the resident's incontinence brief was heavily saturated with urine. During an interview with CNA KK on 6/12/19 at 12:00 p.m., she stated that she had not changed the resident's brief on her shift (7 a.m.-7 p.m.) until 11:35 a.m. She stated the resident was probably last changed around 5:30 a.m. or 6:00 a.m. She stated the facility had been short of staff for the past couple of months. She stated she was able to get most things finished except she was not able to bathe her residents or get them out of bed. 2. During observations on 6/12/19 at 10:30 a.m. and 6/13/19 at 10:00 a.m., the Director of Health Services (DHS) was observed working on the medication cart on the North Hall. During an interview with the DHS on 7/3/19 at 10:00 a.m., she stated she was working the medication cart today on the North Hall. The DHS stated she started working at the facility in (MONTH) 2019 and staffing was a concern at that time. The DHS stated she has worked on the medication cart on 6/12/19, 6/13/19, 6/24/19 and 7/3/19 due to the facility being short staffed. She stated the staff were tired and that she tries to assist with baths and feedings as well. During an interview with the Administrator on 6/13/19 at 2:40 p.m., he stated that currently he has openings for three LPN's on night shift and three on day shift. He also has openings for five-day shift CNAs and four-night shift CNAs. He recently had two Licensed Practical Nurses (LPN's) quit and the DHS was pulled to work the medication cart this week. He stated that corporate does not allow the facility to use agency staff. Corporate HR had recently been in the building and had identified concerns with staffing. During an interview LPN DDD on 6/12/19 at 2:25 p.m., she stated that she finds R#1 saturated with urine often. LPN DDD also stated that the residents were not getting showers like they should. Continued interview with LPN DDD revealed that she also finds other residents soiled and they have been short of staff for the past couple of months. During an interview with the Medical Director on 6/13/19 at 4:00 p.m., revealed that the facility had been short staffed for the past six months. He has had staff and family report to him that residents were not being turned and repositioned. The Medical Director stated he has had several meetings with corporate regarding these concerns and nothing has been done. During an interview with LPN BB on 6/18/19 at 4:08 p.m. she stated that they usually had two nurses and two CNA's on the Southwest and West Halls on the day and night shifts and that the work was overwhelming. She stated she was not able to get everything completed such as the Weekly Observation Forms. LPN BB stated she finds residents wet and she tries to help out when she can. LPN BB stated she has to do her own treatments in addition to her own assignments when the treatment nurse was not in the facility. LPN BB stated she has complained to everybody and they say that they are working on it. During an interview with LPN SS on 6/19/19 at 11:05 a.m., she stated that the facility routinely only has two CNAs. On the days they have five CNAs, three of them leave work at 3:00 p.m. leaving them with only two CNA's until 7:00 p.m. LPN SS stated she has to do her work and help change residents, pass meal trays and help feed residents. She stated they get it done but they have to stay late to get it all done. During an interview with the Treatment Nurse on 6/12/19 at 2:25 p.m., she stated she was pulled to work the medication cart at least one to three times a week and she also had to do all of the treatments as well. She stated it had been going for the past couple of months. 4. Resident (R) B had care plans, dated 2/15/19, for having a self-care deficit in Activities of Daily Living (ADL's) and being at risk for falls with an intervention to assist the resident with transfers and encourage her to get out of bed. A review of the quarterly Minimum Data Set (MDS) assessment, dated 5/18/19, revealed that the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. The MDS assessment also documented that the resident needed extensive assistance from staff for transfers. During an interview and observation on 6/24/19 at 10:24 a.m., RB was observed lying in bed. R B stated that she would like to get out of bed daily, but she only gets up maybe once a week because the certified nursing assistant (CNA) staff did not have enough help and time to get her up. During a subsequent interview and observation on 6/26/19 at 3:20 p.m. RB was observed lying in bed. R B stated that she had not been out of bed that day but wanted to get up. However, the CNA had not had time to get her up yet because she had a couple of other residents to take care of. R B stated that she wanted to sit up in her wheelchair to work on her crafts. During an interview on 6/26/19 at 3:25 p.m., CNA YY, who was assigned to assist RB on the 7:00 a.m. to 7:00 p.m. shift, stated that she was aware that RB wanted to get out of bed, but that she had not had time to get her up. She stated the resident liked to get out of bed after lunch. CNA YY stated she needed additional staff assistance to get the resident out of bed. She further stated that when she needed help, she had to go to another hall to find another CNA to help her, and she had not had time to do that. CNA YY stated that RB could stand and transfer with a walker to the wheelchair with staff assistance. During a subsequent interview on 7/2/19 at 2:35 p.m., CNA YY stated that she was able to get the resident out of bed that day (7/2/19) because she had another CNA helping her on the hall. However, the resident wanted to get out of bed on 6/29/19, but she was unable to get her up at all because she did not have enough help on the hall.

Based on observation, interview and record review, the facility failed to consistently provide a bathing schedule for three of five residents (R#1, R#3, and R#12) reviewed for Activities of Daily Living (ADL's) and failed to provide timely incontinence care for one of three residents (R#1) reviewed for incontinence care. Findings include: 1. Resident (R) #12 resided at the facility from 1/8/19 through 3/30/19 and had [DIAGNOSES REDACTED]. There was a care plan in place, dated 1/8/19 for a self-care deficit of Activities of Daily Living (ADL's) related to limited mobility, fracture and muscle weakness, with an intervention for nursing staff to provide a bath and/or shower as scheduled. A review of the 14-day Minimum Data Set (MDS) assessment, dated 3/18/19, revealed that the resident had impaired cognition with a Brief Interview for Mental Status (BIMS) score of eight. The MDS assessment also documented that R#12 was dependent on nursing staff for personal hygiene and bathing. During interviews on 7/2/19 at 9:30 a.m. and 7/3/19 at 10:30 a.m., and review of R#12's bathing documentation with the Director of Health Services (DHS), she stated that the Certified Nursing Assistants (CNA's) are supposed to document the ADL care provided every shift. The current bathing schedule, implemented on 6/20/19, was set up for residents to receive a bath three times weekly, with adjustments made for individual preferences. Any refusals of care are to be documented on a new refusal form and given to the nurse. However, that was not in place during R#12's stay at the facility. The DHS stated that she did not know what the previous bathing schedule was for R#12. A review of the clinical record revealed that R#12 was not documented as being provided with a bath on a consistent basis. The computerized ADL Dressing and Personal Hygiene and Bath forms from 1/8/19 through 3/30/19 documented that the resident received a sponge bath or bed bath for six days in (MONTH) (1/12, 1/15, 1/19, 1/28, 1/29, and 1/31/19), two days in (MONTH) (2/5/19 and 2/11/19) and two days in (MONTH) (3/8/19 and 3/11/19). Additional bathing tasks were documented in the Occupational Therapy notes during therapy sessions on 1/14/19 and 3/6/19. There was no further evidence in the clinical record of the resident being provided with a bath. 2. R#1 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. The resident had a care plan since 4/17/18 for self-care deficit activities of daily living related to impaired cognition and physical condition. There was an approach for nursing staff to provide a bath of choice as scheduled. A review of the Quarterly MDS dated [DATE] revealed the resident was totally dependent on staff for hygiene and bathing. Review of the bath schedule revealed the resident was scheduled to receive a bath on Tuesdays, Thursdays, and Saturdays. Review of the computerized Bath Form revealed there was no documentation that R#1 consistently received a bath from 5/2/19 until 5/7/19, 5/10/19 until 5/16/19, 5/22 until 6/1/19, 6/1/19 until 6/18/19 and from 6/20/19 until 6/26/19. In addition, R#1 had a care plan since 4/13/18 for alteration in elimination: incontinent of bowel and bladder with an intervention for nursing staff to change soiled or wet clothing promptly. A review of the Quarterly MDS dated [DATE] revealed the resident was totally dependent on staff for hygiene and bathing. During an observation of the resident on 6/12/19 at 11:35 a.m., the resident's incontinence brief was heavily saturated with urine. During an interview with CNA KK on 6/12/19 at 12:00 p.m., she stated that she had not changed the resident's brief on her shift (7 a.m.-7 p.m.) until 11:35 a.m. She stated the resident was probably last changed around 5:30 a.m. or 6:00 a.m. She stated the facility had been short of staff for the past couple of months. She stated she was able to get most things finished except she was not able to bathe her residents or get them out of bed. 3. R#3 resided in the facility from [DATE] until 5/28/19. She had a care plan since 4/12/19 for self-care deficit with activities of daily living and required extensive assistance with activities of daily living. There was an approach for bed bath daily and as needed. Review of the 5/3/19 Significant Change MDS revealed the resident required extensive assistance with hygiene and was totally dependent on staff for bathing. Review of the electronic Bath Report revealed there was no documentation that R#3 received a bath from 5/5/19 until 5/27/19. During an interview with the DHS on 7/3/19 at 9:45 a.m., she stated the CNA's are expected to offer the residents a bath three times a week and fill out a refusal form if the resident refused a bath.

Based on observation, record review, staff interviews, and review of the Lippincott Procedure titled Wound Assessment, the facility failed provide heel boots to the left foot and a pillow between the resident's legs, failed to follow physician's orders for pressure sore treatment and failed to obtain an order for [REDACTED]. Findings include: R#1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed R#1 had a care plan dated 6/3/19 for having an unstageable pressure ulcer to the left ischium, sacrum, and right medial foot and a stage 1 pressure ulcer to the right medial ball of the foot with the following approaches: resident needs wound care as ordered by physician, soft heel boots to bilateral feet and pillow between legs to cushion between knees and heels. Observation on 6/11/19 at 3:45 p.m., revealed that the resident had a heel boot to the right foot only. Additional observation at that time revealed that there was not a pillow in place between the resident's legs. An interview with the treatment nurse, at that time, revealed the resident should have a heel boot to the left foot. Record review revealed that R#1 had a 5/28/19 order from the wound care physician for wound care to the right inner, medial foot ulcers times three to wash daily with mild soap and water, cushion with gauze/foam. Review of the Treatment Records for (MONTH) 2019 and (MONTH) 2019 revealed that there was no documentation that the wound care had been provided as ordered by the wound care physician. During an interview with the treatment nurse on 7/2/19 at 2:50 p.m., revealed that the Treatment Nurse did not provide the wound care as ordered by the wound care physician because the areas were scabs and were basically healed. She further stated she did not call the wound care physician or the primary care physician to clarify if it was okay to discontinue wound care. Record review revealed that R#1 had a 4/30/19 physician's order for treatment to the left lateral hip to clean with normal saline, apply 3M barrier spray and cover with [MEDICATION NAME] every other day and as needed. Review of the (MONTH) 2019 and (MONTH) 2019 Treatment Records revealed there was no documentation that wound care treatment had been completed as ordered from 6/1/19 through 6/3/19. Further review of the 5/1/19 treatment record revealed the resident's sacrum and left lateral hip were being treated with normal saline, hydrogel to the wound bed and cover with [MEDICATION NAME] every other day and as needed starting on 5/29/19. However, review of the clinical record revealed there was no physician's order to treat the sacrum and left lateral hip. Review of the (MONTH) 2019 treatment record revealed the left lateral hip was being treated with 3-M barrier spray on 6/1/19, 6/2/19 and 6/3/19. Further review revealed there was no descriptive documentation regarding the sacrum on 5/29/19. Continued record review revealed that on the Wound Observation and Assessment Form, staff documented on 6/3/19 the sacrum was an unknown stage pressure sore measuring 1.8 centimeters (cm) x 1.5 cm x 0 cm with eschar to the wound bed. The physician was notified, and new orders were obtained. Review of the Lippincott Procedure provided by the facility titled Wound Assessment revised on (MONTH) 11, (YEAR) noted the following under the section titled Introduction: A thorough wound assessment should consist of objective criteria and measurements that promote accurate, consistent comparisons to determine the extent of the wound and the effectiveness of wound healing. You should complete a comprehensive wound assessment during every dressing change and compare the results to previous assessments so that you can monitor, communicate, treat, and document wound healing progression or complications. During an interview with the Treatment Nurse (TN) on 6/12/19 at 2:25 p.m., she stated that on 5/28/19 the resident had a Stage II to the sacrum which was reported to her by the Certified Nursing Assistant (CNA). TN stated she called the physician and received the order for the hydrogel, but she failed to actually write the verbal order. She also stated on 6/4/19 she noticed that the wound to the left hip was starting to decline so she called the physician to obtain an order for [REDACTED]. wet to moist gauze and cover with dry dressing daily and as needed without a physician's order. During an observation of wound care on 6/11/19 at 3:45 p.m., there was an undated bandage that appeared to be border dressing to the resident's left lateral foot. When the treatment nurse removed the bandage, the skin was intact with no wounds present. She stated nobody made her aware of the bandage and she did not know why it was there. Review of the clinical record revealed there was no physician's order for the dressing and there was no documentation regarding the left foot or why a dressing was placed on the foot. During an interview with the treatment nurse on 7/2/19 at 2:50 p.m., she stated the left hip and the sacrum should have been treated with the hydrogel.

Based on interviews and record review, the facility failed to ensure that restorative nursing services were consistently provided for one of four residents (B) reviewed for restorative nursing. Findings include: The facility had a Lippincott Procedure for a Restorative Nursing Program. The procedure noted that it was the policy of the facility to provide restorative nursing which focuses on achieving and maintaining optimal physical, mental and psychosocial functioning of the resident. The restorative nursing program is under the supervision of a licensed nurse and provided by restorative nursing assistants or certified nursing assistants or any other qualified staff. The procedure also documented if it is determined that the resident would benefit from a Restorative Nursing Program, the nurse should arrange for such a minimum of six days a week, unless otherwise noted. During an interview on 6/24/19 at 12:35 p.m., the Assistant Director of Health Services (ADHS) stated that she oversaw the restorative program and restorative certified nursing assistant (CNA) BBB provided the restorative nursing services. The ADHS also stated that restorative services are usually set up to be provided three to five times per week or as tolerated. She added that currently restorative CNA BBB had been out of the facility, since last week, on leave, and that a list of all residents who received restorative nursing services would be given to the CNA's assigned to the residents that day (6/24/19). Resident (R) B had [DIAGNOSES REDACTED]. She received skilled physical therapy services from 2/19/19 through 4/30/19 and was discharged to a Restorative Nursing Program on 5/1/19. Care plan problems were developed on 4/30/19 for requiring restorative assistance to maintain goals and for being at an increased risk for falls with interventions to complete passive range of motion (PROM) exercises and ambulate as able with a bariatric walker for 15 to 80 feet, with staff to follow close behind with a wheelchair. A review of the quarterly Minimum Data Set (MDS) assessment, dated 5/18/19, revealed that the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. The MDS assessment also documented that the resident was provided with extensive assistance from staff for transfers and supervision and set up assistance for ambulation. The Restorative Therapy Referral form, with an effective date of 5/1/19, included the approaches of 15 to 30 repetitions of therapeutic exercises to the bilateral lower extremities and ambulation with a bariatric walker for 15 to 80 feet as able. The goal of the program was to maintain range of motion and strength to the bilateral lower extremities and maintain ambulation. A review of the Restorative Log, Restorative I CNA Role, Restorative II CNA Role, and Restorative Nursing Flow Record forms from 5/1/19 through 7/1/19 revealed that range of motion services were provided 21 times in May, only six times in (MONTH) and once in July. Restorative ambulation services were provided 21 times in (MONTH) and only four times in June. There was no additional evidence that restorative services were consistently provided, as care planned after (MONTH) 2019. Although restorative documentation indicated that restorative services were being provided, during an interview on 6/24/19 at 10:24 a.m. and 6/26/19 at 3:20 p.m., RB stated that she had only been assisted by nursing staff to walk one time, since being discharged from physical therapy (4/30/19) and being placed on restorative nursing services. She further stated that she performed range of motion exercises herself, like physical therapist (PT) CCC showed her. During an interview on 6/24/19 at 12:20 p.m., PT CCC indicated that she did not think RB was receiving restorative nursing services. She had observed the resident ambulating with restorative only once, maybe twice. She stated that she did not feel like it was being provided based on what she was told by RB, who would ask her repeatedly, where restorative nursing staff was, and when restorative nursing staff was coming to ambulate with her. PT CCC did state that she, herself, was not at the facility all the time because she went to other buildings also. However, she thought that if restorative nursing services were being provided, RB would not have repeatedly asked her about it. PT CCC added that she used to go by the resident's room almost daily, going down her hall, and RB would call out to her, but she had not been down that hall and talked to her as much in the past month. PT CCC stated that she could not remember the last time that the resident complained to her about not getting walked with restorative. PT CCC stated that she had brought up her concerns to management in the past, and they had attempted to resolve the issue several times. PT CCC stated that RB was safe to ambulate but needed supervision to follow her with a wheelchair, obtain her walker for her, and manage her oxygen. During an interview on 7/3/19 at 10:30 a.m., the Director of Health Services (DHS) stated that she had not received any complaints regarding RB not being provided with restorative services and had observed her ambulating with three to four staff members once the previous week or two.

Based on observation, record review, and staff interviews, the facility failed to properly secure the Hoyer lift sling during transfer for one resident, R#3, on 3/7/17. Actual harm was identified when R#3 fell during a transfer with a Hoyer lift, on 3/7/17, which resulted in a fracture to the resident's spine and hip. The sample size was six (6) residents. Findings include: 1. Review of a document titled, Admission Form dated 1/2/17 revealed that R#3 was admitted to the facility on [DATE] with a readmission date of [DATE], and that R#3 had the following diagnoses, that included, but not limited to muscle weakness and unspecified lack of coordination. Review of the annual MDS assessment dated [DATE], Section C - Cognition revealed that R#3 had a Brief Mental Interview Status (BIMS) score of 15 indicating that the resident was cognitively intact. Continued review of the MDS assessment revealed the resident was total dependent of two plus persons for transfers. An interview on 5/30/17 at 2:47 p.m. with R#3 revealed that two Certified Nursing Assistants (CNA) II and JJ were transferring her with a Hoyer lift. The resident revealed that one CNA was in front and one CNA was behind her. They (CNAs) were taking her out of her wheelchair and the strap broke and she fell on the legs of the Hoyer lift. R#3 continued to state that she screamed out in pain and the ambulance took her to the hospital. The resident stated that one CNA was on a cell phone. Review of a Physician's Interim Orders dated 3/7/17 revealed R#3 was sent to a local emergency room for evaluation. Review of the medical record for R#3, revealed that R#3 complained of lower back pain and left hip pain and that she fell two feet from a Hoyer lift and she was sent to a local emergency room . Review of a Computed Axial Tomography (CAT) scan without contrast dated 3/7/17, for R#3, revealed that the residents thoracic spine showed left side transverse process fractures of the lumber spine. The lumber spine indicated acute fractures of the left spine from L2 through L4. The pelvis indicated acute minimally displaced left femoral neck fracture, subcapital location. Further review revealed, the differential Diagnosis: [REDACTED]. R#3 is not ambulatory and it does not make it optimal to do surgery. Recommendation was made to follow-up with the orthopedic physician tomorrow (3/8/17). Review of the Orthopedic physician progress notes [REDACTED].#3 complained of lower back pain and left hip pain that began after she fell on [DATE]. The Orthopedic physician indicated no surgery at this point and to return in six weeks for a follow-up. Review of the Skilled Daily Nurses Note revealed a note dated 3/18/17 which indicated that R#3 was being transferred from the wheelchair to the bed by two staff members using a Hoyer lift. The left strap that was holding the residents lower left body slid off the metal hook causing the resident to be placed on the floor. An interview on 5/30/17 at 3:27 p.m. CNA JJ revealed that she and CNA II were getting ready to put R#3 in the bed when the left bottom Hoyer lift strap came off the hook. CNA JJ stated that she had hooked the Hoyer lift straps on the right side and that CNA II had hooked the Hoyer lift strap on the left side. CNA JJ stated that during the transfer, R#3 fell from the sling and that CNA II could not break the residents fall because CNA II was pregnant. Further interview revealed that R#3's body hit the legs of the Hoyer lift and that her bottom hit the floor. CNA JJ said that she and CNA II then placed pillows on the floor, and lay the resident's head onto the pillow, and that R#3 was not moved from the floor because the resident was complaining of pain on the left side. CNA JJ revealed that LPN KK was feeding the resident's roommate in the B bed and had her back turned. CNA JJ revealed that LPN KK assessed the resident and that the ambulance attendant removed the resident off the floor. An interview on 5/30/17 at 3:30 p.m. with LPN KK revealed that she was feeding the resident in bed B. She glanced up at CNA II and CNA JJ for brief moment and saw that they had taken R#3 out of her wheelchair using the Hoyer lift. She turned her head to continue to feed the resident in bed B when she heard a boom and she turned to see that R#3 was on the floor. Continued interview with LPN KK revealed that she immediately left the bedside of the resident in the B bed and told the two CNAs not to move R#3 from the floor. LPN KK revealed that she used her cell phone to call the emergency room (ER) nurse to give report. She said that later she received a report from the local emergency room nurse that R#3 had sustained fractures. An interview on 5/31/17 at 2:49 p.m. with CNA II revealed that the bottom left sling pad on the Hoyer lift came off the hook during the transfer of R#3. She stated that she had checked the left straps to make sure they were seated, but when they were getting R#3 out of the wheelchair that the strap came loose and that R#3 fell to the floor. Continued interview with CNA II revealed that R#3's body landed on the legs of the Hoyer lift and that they got pillows to lay her head down on the floor. They (CNA II, CNA JJ, and LPN KK) did not move R#3 from the floor. When the Emergency Medical Service (EMS) arrived they got the R#3 off of the floor. An interview on 6/15/17 at 4:20 p.m. with CNA HH revealed that two people are to transfer a resident with a Hoyer lift. CNA HH revealed that in regards to selecting the sling size, she would just hold up the sling to determine if the size was small, medium or large. CNA HH admitted that she was unsure of the sling sizes because they are not marked. An interview on 6/15/17 at 2:10 p.m. with the Director of Health Service (DHS) indicated that the last in-service for Hoyer lift training was 3/13/17. The DHS revealed that new hires receive skills check proficiency. Additionally the DHS revealed that in regards to the slings not being marked for size, the DHS stated this would be corrected.

Based on record review, staff interview and resident interview, the facility failed to ensure that prudent care and safety precautions were used by staff to prevent injury to resident during use of Hoyer mechanical lift resulting in actual harm and serious injury to Resident (R) #3. The resident experienced a fall from the mechanical lift while suspended and sustained a fracture to her hip and spine. The sample size was 6 residents. Findings include: Review of R#3's medical record revealed that when she was admitted to the facility she was totally dependent on staff for all activities and was not ambulatory. She was cognitively intact, alert and oriented with a Brief Interview for Mental Status score of 15. A lift Evaluation Form was completed 3/1/17 and again on 6/1/17 by a nurse and the need for a mechanical lift was identified for the resident. Care plan review revealed the mechanical lift care plan was in place with interventions. Further review of chart revealed an extra-large sling was identified for use. Observation of sling in resident's room revealed that the sling had her name on it, but there was no size noted. Interview on 7/5/17 at 11:30 a.m. with Licensed Practical Nurse (LPN) NN revealed that when a resident is admitted or needs assistance getting out of bed or in and out of a chair, an evaluation is completed on a Lift Evaluation Form to determine if a mechanical lift is needed or sit to stand lift is needed. Once the determination is made that a mechanical lift is needed, the sling size is determined. When asked how she determined the size sling needed she stated that she looks at previous sling size. She stated that these evaluations are done on admission and quarterly and with any significant change and if she has any doubts about the size of the sling she gets a second opinion from another nurse or Physical Therapy. Interview on 7/5/17 at 11:45 a.m. with Certified Nursing Assistant (CNA) JJ revealed that she uses a mechanical lift on three of her residents and the slings are ordered for each resident individually. When asked about the loops and the different colors she accurately explained what the loops were for. Interview on 7/5/17 at 12:30 p.m. with the Maintenance Director revealed the Invacare lifts they have in the facility all have a weight limit of 450 pounds and all canvas slings ordered have a weight limit of 450 pounds. Review of maintenance logs revealed that the mechanical lifts are inspected and serviced quarterly. He also stated that when slings go to the laundry for washing, they are inspected before washing and any fraying of fabric, loops or stitching on edges noticed are brought to his attention and he ensures that another sling is ordered. Review of operating manual for mechanical lift revealed a warning that when a resident is in the sling and the sling is a few inches off the surface and before moving the resident, check again to make sure that the sling is properly connected to the hooks of the swivel bar. If any attachments are not properly in place, lower the resident back onto the stationary surface and correct the problem, otherwise, injury or damage may occur. Observation completed on 7/5/17 at 1:15 p.m. of the mechanical lift being used by CNAs JJ and RR for transfer of R#4. The observation of R#4 revealed she was moved from the wheelchair to the bed with no issue noted in use of lift or in transfer. Review of personnel files for all seven CNAs working 7/5/17 from 7:00 a.m. to 7:00 p.m. revealed that all had mechanical lift skills assessed during orientation. Also, review of in-services with topics of Hoyer lifts or mechanical lifts revealed all participated in the in-services of 9/30/16, 10/13/16, 3/07/17 and 3/13/17. Observation completed on 7/5/17 at 4:15 p.m. of a R#5 being transfer from bed to chair using a mechanical lift. This was being completed by CNAs II and SS. No issues with use of lift or transfer. All safety precautions followed. Interview on 7/5/17 at 4:30 p.m. with CNA RR revealed that the facility has numerous in-services that are mandatory to complete. When asked about in-services for the mechanical lift she stated they have several a year and they had one recently. Interview on 7/5/17 at 4:50 p.m. with CNA II revealed that they have in-services on the mechanical lift several times a year. When asked if she had known of a resident that had fallen from a lift she stated yes that she was helping in the room when resident fell out of the sling. She stated that they were moving resident from chair to bed and they attached the loops for reclining and started to lift her and one of the loops just jumped off the hook and the resident slid out and hit the legs of the lift. When asked where she was positioned during the lift she stated she was behind the resident working the controls. The CNA revealed she is seven months pregnant and tries not to strain with lifting residents. She stated the other CNA was at the bottom of the lift so she could move the resident to the bed. When asked if the other CNA was distracted doing something else while transferring resident, she stated no. When asked who the other CNA was she stated CNA JJ. Re-interview on 7/5/17 at 5:00 p.m. with CNA JJ revealed that she was in the room when the resident fell out of the sling of the mechanical lift. She stated that the loop just jumped off the hook and she tried to catch the resident and she eased her to the floor so she wouldn't hit her head. When asked if she checked the loops before the lift was activated she stated yes. When asked if she was distracted by something else during this process she stated no. Interview on 7/5/17 at 5:25 p.m. with R#3 revealed that she is always moved and positioned with the mechanical lift. She stated that the day of the incident, the CNAs were moving her from the chair to the bed, they hooked up the straps to the sling and started to lift her. The resident stated that she felt a release and a snap on the bottom corner and she started sliding out of the lift and landed on the legs of the lift. She stated that CNA JJ was at the bottom of lift when she was sliding, was talking on her cell phone and she feels she was not paying attention to what she was doing. When asked again what the CNAs name was she identified CNA JJ. Interview on 7/5/17 at 6:00 p.m. with Director of Health Services (DHS) revealed the facility immediately had a mandatory in-service on 3/7/17, the day the resident fell . The DHS revealed that a skills competency in-service was completed on 3/13/17, however she stated that there was no staff sign in sheet. She revealed that they had an employee roster that they highlighted when the employees came in, but did not keep it after the in-service was completed.