Every finding on record at Pruitthealth - Greenville

Based on observations and staff interviews, the facility failed to maintain the kitchen in a clean and sanitary condition. This deficient practice had the potential to place residents receiving meals and hydration from the kitchen at risk of food-borne illness. The census was 85 residents. Findings include: The facility did not provide a policy for kitchen procedures.Observation of the kitchen on 8/6/2025, beginning at 10:00 am, revealed the following: 1. 26 of 26 storage crates in the kitchen were soiled with light and dark gray substances throughout the openings of the crates and the outside surfaces.2. The wall behind a storage rack for clean pots and pans was soiled. 3. A soiled return heating and air ventilation cover.In a concurrent observation of the kitchen and interview on 8/7/2025 beginning at 9:35 am, with the Certified Dietary Manager (CDM), she observed and confirmed that 26 of 26 storage crates were soiled with light and dark gray substances throughout the openings of the crates and the outside surfaces, the wall behind storage rack was stained, and the return heating and air ventilation was soiled. The CDM stated she started working at the facility in May 2025, and the storage crates had not been washed since she started. She further stated that the wall behind the clean pots and pans should be cleaned, and she had not addressed the other concerns related to maintenance. She stated she was not sure what duties the housekeeping and maintenance staff were responsible for in the kitchen. In a concurrent observation and interview with the Maintenance Director, on 8/7/2025 at 4:20 pm, he observed and confirmed the observations related to the soiled return heating and air ventilation cover. He stated he worked alone and, in addition to his routine duties, he expected staff to inform him of other needs throughout the facility, including the kitchen.

Based on observations, staff interviews, record review, and review of the facility-provided document titled [Brand name] Blood Glucose Monitoring System Healthcare Professional Operator's Manual, the facility failed to place open dates on the vials of glucometer strips in two of four medication carts. This deficient practice had the potential to cause inaccurate blood sugar readings and worsening of medical conditions for the residents.Findings include:Review of the facility-provided document titled [Brand name] Blood Glucose Monitoring System Healthcare Professional Operator's Manual, revealed page 8 included, Important: . For vial test strips, record the date on the bottle when you open a new bottle of test strips.Observation on 8/6/2025 at 2:15 pm, during review of the B Hall medication cart, revealed one open vial of glucometer strips with no open date.In an interview on 8/6/2025 at 2:15 pm, Licensed Practical Nurse (LPN) BB confirmed there was one open vial of glucometer strips with no open date on the B Hall medication cart. He stated there should be an open date on it, and if it was used on the residents, there could be abnormal blood sugar readings.Observation on 8/6/2025 at 3:20 pm, during review of the medication cart on the Memory Care Unit, revealed one open container of glucometer strips with no open date.In an interview on 8/6/2025 at 3:20 pm, LPN CC confirmed there was one open vial of glucometer strips with no open date on the Memory Care Unit. She stated there should be an open date on glucometer strips when the vials were first opened, and if the strips were used on the residents, there could be skewed blood sugar readings.In an interview, the Director of Health Services (DHS) confirmed there was no open date on the vial of glucometer strips on the B hall medication cart. He stated his expectations were for the nurses to place open dates on the glucometer strip vials when they were opened. He stated it was the manufacturer's requirement for the strips' vials to have open dates when they were first opened. The DHS further stated that a negative outcome if the strips were used on the residents could be that they could have altered blood sugar readings.In an interview on 8/7/2025 at 10:45 am, LPN AA stated there should be open dates on the glucometer strips vials when they were first opened. She stated the nurses were responsible for placing open dates on the glucometer strip vials when they first opened them. She further stated that if the strips were used on residents, it could cause false blood sugar readings, and the resident could be given the wrong treatment.

Number of residents sampled: Number of residents cited: Based on observations, staff interviews, and review of the facility-provided document titled Position Description, Housekeeper, the facility failed to maintain seven of 24 resident bathrooms on the Memory First-A (MFA) unit in a clean, safe, and sanitary manner. Specifically, there were dusty bathroom air vent covers and a cracked toilet tank cover.Findings include:Review of the facility-provided document titled Position Description, Housekeeping, modified 10/2016, revealed the Job Purpose section stated, Provides cleaning services to provide a safe, sanitary, comfortable, and homelike environment for residents, staff, and the public. Housekeeping services provided are in accordance with facility policies and procedures and consistent with state and federal laws and regulations to maintain an environment that enhances the quality of life for residents. The Key Responsibilities section included, . 4. Cleans bathroom sinks, fixtures, and toilets, following center procedures. 11. Dust/damp cleans surfaces in patient/resident rooms (furniture, bed frames, windowsills, etc.) following center procedure.Observation of resident rooms on the MFA unit on 8/5/2025 revealed the following:8/5/2025 at 10:16 am, MFA 8-2: a dusty bathroom air vent cover.8/5/2025 at 11:07 am, MFA 17-2: a dusty bathroom air vent cover.8/5/2025 at 11:20 am, MFA 16: a dusty bathroom air vent cover.8/5/2025 at 3:49 pm, MFA 6: a dusty bathroom air vent cover.8/5/2025 at 3:58 pm, MFA 4: a dusty bathroom air vent cover. Observation of the same resident rooms beginning on 8/7/2025 at 10:30 am revealed that the aforementioned observations persisted.In an observation and interview with Housekeeping Aide JJ, on 8/7/2025 at 10:40 am, she stated her routine duties included dusting, sweeping, and mopping of resident rooms and bathrooms. She observed and confirmed the dust on the bathroom air vents in rooms MFA 8, 17, 16, 6, and 4, and stated it was the responsibility of the Maintenance Department to keep the bathroom air vent covers clean. In an observation and interview with the Housekeeping Supervisor, on 8/7/2025 at 3:40 pm, she observed and confirmed the presence of thick dust on the air vents in the identified bathrooms on the MFA unit. She stated it was the responsibility of the housekeeping staff to remove the surface dust from the air vents daily. She stated she had no actual policies, but scheduled duties were stored and accessed through the electronic housekeeping and maintenance tracker. She stated she would add the task of dusting the bathroom air vents to the list of daily duties for her staff. In an observation and interview with the Maintenance Director, on 8/7/2025, beginning at 4:00 pm, he stated he had only been working at the facility for a few months. He stated he performed annual cleaning of the insides of the bathroom air vents, but had no maintenance logs to speak of. He stated he cleaned approximately six to seven bathroom air vents per month. However, dusting the air vent covers was the responsibility of the housekeeping staff. He observed and confirmed the presence of a break in the toilet tank cover, which had been glued back together, but still had a large, sharp chip on the outer edge. He stated he would replace it as soon as possible. He stated staff usually reported maintenance concerns to him in person or by phone.

Based on observation, staff interviews, record review, and review of the facility's polices titled Infection Prevention and Control Plan and Medication Administration: Oral Medications, the facility failed to implement infection control practices for one of five residents (R) (R77) during medication administration observation. This deficient practice had the potential to place R77 at an increased risk of infection due to cross-contamination. Findings include:Review of the facility's policy titled Infection Prevention and Control Plan, reviewed 10/11/2022, revealed the Policy Statement section included, . The goals of the program are to decrease morbidity/mortality attributable to infections in residents; prevent and control outbreaks of infection in residents; prevent acquisition of infection by staff members .Review of the facility's policy titled Medication Administration: Oral Medications, reviewed 10/23/2024, revealed the Procedure and Key Points section included, . 6. Place medication into a souffle cup. Never touch any of the medication with fingers.Review of the Physician's Orders for R77, dated 5/25/2025, revealed medication orders including, but not limited to, adult low-dose aspirin over the counter (OTC) tablet, delayed release (DR); 81 milligrams (mg); amount (amt): 1 tablet; oral once a day, 9:00 am, potassium chloride capsule, extended release; 10 milliequivalent (mEq); amt: 2 capsules (caps); oral once a day 9:00 am, torsemide tablet; 5 mg; amt: 1 tablet; oral once a day 9:00 am.Observation on 8/6/2025 at 9:15 am, during medication administration with Licensed Practical Nurse (LPN) BB, revealed he was preparing medications for R77, and when he placed the aspirin 81 mg tablet, potassium chloride 10 mEq 2 tablets and torsemide 5 mg tablet in a medication cup, the cup tilted, and the medications fell on the medication cart. LPN BB used his bare hands, picked up the medications from the cart, and placed them back in the cup.In an interview on 8/6/2025 at 9:16 am, LPN BB confirmed he used his bare hands to pick up the medications from the medication cart. He stated he should not have used his bare hands to pick up the medications because it was an infection control issue, and the resident could get an infection.In an interview on 8/7/2025 at 10:34 am, the Director of Health Services (DHS) stated his expectations were for the nurses not to use bare hands to pick up tablets or medications. He stated the nurses were to use gloved hands when handling medications. The DHS further stated that there could be contamination of the medication, which the resident could receive.In an interview on 8/7/2025 at 10:37 am, the Infection Preventionist (IP) DD stated that during medication administration, the nurses were not to use bare hands to touch medications because it would be an infection control issue. She stated the nurse should use gloved hands to pick up medications if they spill. The IP further stated that the residents could be exposed to pathogens and could get infections.In an interview on 8/7/2025 at 10:45 am, LPN AA stated that if medications spill, the nurse should grab gloves and scoop them up with a spoon. She stated that bare hands should not be used to pick up or handle medications. LPN AA further stated that this would put the residents at risk of contracting infections.

Based on observation, staff interview and a review of the facility policy titled Cleaning Procedure-Kitchen area the facility failed to ensure a clean sanitary environment in the kitchen. The census was 66 of 67 residents will be affected. Findings include: A review of the facility policy titled It is policy of [NAME] Health to maintain a clean and sanitary environment to prepare patient/resident meals revealed that the policy applies to all dietary staff, housekeeping , and maintenance partners scheduled to assist in cleaning/sanitizing procedures, All soiled, dirty, dusty, surfaces and /or areas within the kitchen should be cleaned and /or sanitized (as needed ) immediately upon identification. During initial walk thru of the kitchen on 10/27/2023 at 08:00 am the surveyor observed the ceiling had dust mites hanging out from the ceiling. Observation of greasy burnt food debris inside the oven and the burner. During a follow up visit of the kitchen on 10/28/2023 at 8:35 am with the Dietary Manager (DM) , The surveyor observed confirmed the dust mites and greasy burnt food debris inside the oven and the burner with the DM. The DM stated that the Maintenance Director is responsible for keeping the kitchen ceiling free of dust mites. The DM further revealed that the staff has schedule for cleaning kitchen equipment. During a follow up visit of the kitchen on 10/29/2023 at 8:39 am observation of the dust mites were still hanging on the ceiling. During an interview on 10/29/2023 at 8:26 am with the facility Administrator regarding her expectation of dietary staff and she revealed that she expects the DM to make sure the dietary staff complete daily and monthly cleaning of the kitchen . During an interview on 10/29/2023 at 8:40 am with the DM regarding his expectation of the dietary staff he revealed that he expects the dietary staff to keep the kitchen clean . During an interview on 10/29/2023 at 10:17 am with the Administrator, she confirmed that she saw the dust mites in the kitchen ceiling and stated that after meal the diet staff will clean it During a follow up visit in the kitchen on 10/29/2023 at 11:42 am with facility consultant, Administrator and DM, confirmed that the oven and the burner were not clean.

Based on record review, staff interviews, and review of the policies titled Infection Prevention Control Plan and Infection Prevention and Control Program Surveillance Reporting the facility failed to provide evidence that infection control surveillance data was collected ten out of fifteen months reviewed (July 2022 through September 2023). Findings include: Review of the policy titled Infection Prevention and Control Program Surveillance Reporting review date 1/24/2023 indicated: Policy Statement-It is the policy of this facility to establish and maintain an Infection Control Program that includes detection, prevention, and control of the transmission of disease and infection among patients/residents and partners. The Administrator of the Healthcare Center is responsible for the Infection Control Program. All infection prevention and control practices reflect current Centers for Disease Control (CDC) guidelines. Procedure: 1. Patient/resident infection cases are monitored and documented by the IP. The IP reviews cases of infections, including tracking and analysis of the findings and develops an action plan to resolve identified concerns. 2. A report of resident infections, Epidemiology Report and monthly Tuberculosis (TB) reports are submitted monthly to the Administrator and Director of Health Services (DHS). Review of the policy titled Infection Prevention Control Plan review date 6/23/2023 indicated Policy Statement- This Infection Prevention and Control Plan outlines the framework by which all ___ facilities will assess, implement, and evaluate an active, effective, comprehensive facility-wide Infection Prevention and Control program. The Medical Director and Director of Health Services are responsible for the identification of appropriate resources and/or resource allocation that supports the Infection Prevention and Control Program. The goals of the program are to decrease morbidity/mortality attributable to infections in residents; prevent and control outbreaks of infection in residents; prevent acquisition of infection by staff members; maintain resident functional status; maintain optimal social environment for residents; and limit costs of care attributable to infections. The Infection Prevention and Control Program will incorporate risk assessments, surveillance activities, evidence-based prevention practices, communication to mitigate risks and decrease adverse outcomes related to Infection Prevention and Control. Review of the infection control binder provided by the Infection Preventionist (IP) on 10/28/2023 at 9:30 a.m. revealed no data was obtained for July 2022, August 2022, September 2022, October 2022, November 2022, December 2022, February 2023, March 2023, April 2023, and July2023. An interview on 10/28/2023 at 9:44 a.m. with the Director of Health Services (DHS) and the IP stated the infection control binder that contains the required information that includes the Monthly Healthcare Associated Infection Summary Report, line listing, mapping, Epidemiology Report Form, and Monthly Surveillance for Tuberculosis Form for 7/2022-12/2022 could not be located. An interview on 10/28/2023 at 12:10 p.m. with the Director of Health Services confirmed that there were no data collection February 2023, March 2023, April 2023, and July 2023. The DHS stated it is her responsibility to make sure that the data is collected to complete the Monthly Healthcare Associated Infection Summary Report, Line Listing, Mapping, Epidemiology Report Form, and Monthly Surveillance for Tuberculosis Form.

Based on record review, staff interviews, and review of the policy titled Antibiotic Stewardship Program, the facility failed to provide evidence of a monitoring system to track and trend antibiotic use for ten out of fifteen months of the infection control data reviewed (July 2022 through September 2023). Findings include: Review of the policy titled Antibiotic Stewardship Program review date 2/8/2023 indicated: Policy Statement-As part of the Infection Prevention and Control Program, ____ will implement and maintain an Antibiotic Stewardship Program (ASP). Under the direction of the Medical Director and Director of Health Services (DHS) the ASP is designed to promote appropriate use of antibiotics and improve patient health outcomes. The goal of ASP is to promote appropriate use of antibiotics to treat infections and reduce possible adverse events associated with antibiotic use. Each month the Antibiotic Stewardship Pharmacist will monitor, document, and provide each facility the following antibiotic use information on the Monthly Healthcare Associated Infection Summary Report: Percent of residents receiving antibiotics, Percent of new admissions receiving antibiotics, New Antibiotics Starts, Rate of Antibiotic Days of Therapy, New Antibiotics Starts, Rate of Antibiotic Days of Therapy (DOT), and Antibiotic Utilization Ratio. Review of the infection control binder provided by the Infection Preventionist (IP) on 10/28/2023 at 9:30 a.m. revealed no evidence of antibiotic surveillance data, analysis, documentation of follow up in response to the data or monthly antibiotic reporting for ten months. The ten months included July 2022, August 2022, September 2022, October 2022, November 2022, December 2022, February 2023, March 2023, April 2023, and July2023. An interview on 10/28/2023 at 12:10 p.m. the Director of Health Services (DHS) stated the facility has had problems with keeping an infection preventionist. She stated since May 2023 the facility has had three different people in the infection preventionist role. The facility hired a Registered Nurse on 10/2/2023 that will be fulfilling the IP role. An interview on 10/29/2023 at 10:15 a.m. with the Administrator and DHS. The Administrator stated the previous IP was not providing her with the monthly Healthcare Associated Infection Summary Report She stated her expectation is that the facility's policy and procedure are followed. She stated the infection control surveillance will be placed Performance Improvement Project and discuss in Quality Assurance and Performance Improvement (QAPI). The Administrator stated she will ensure all staff involved are doing their work. The DHS stated she has been reporting to the Physician based on the lab results and culture sensitivities and the physician will order the appropriate antibiotics based on the information given. She stated the pharmacy consultant has not provided the facility with the Antibiotic Stewardship Report. An interview on 10/29/2023 at 10:52 a.m. with the Senior Nurse Consultant stated the newly hired IP will be in-service on the infection control policy and procedure. She stated herself and the corporate IP will work closely with her to ensure that the HAI and ASP are completed monthly per policy and CMS guidelines. Post exit telephone interview on 10/30/2023 at 10:30 a.m. with the facility's Consultant Pharmacist BB stated he visits the facility monthly. During the visit to the facility, he will review the residents that have an order for antibiotics and look for a start date, stop date, and diagnosis. In the event he encounters a problem it is addressed with the Director of Health Services. The Pharmacy Consultant stated he is not responsible for generating the Antibiotic Stewardship Report for the facility. He is not part of the ASP but does participate in the quarterly QAPI meetings. Post exit telephone interview on 10/30/2023 at 1:59 p.m. with the facility's Pharmacist CC stated the Antibiotic Stewardship Report for the facility is auto generated every month between the third-sixth of the month. She uploads the report to Teams to each facility. The facility is responsible for accessing the folder and reviewing the antibiotics that are used for the month. She stated no one from the facility has ever communicated to her that the facility was unable to access the report. She stated her responsibility is to review the report before uploading it to Teams and the report is reviewed by herself. The Pharmacist stated she looks for anything that doesn't have a stop date, antibiotic that doesn't have a diagnosis, any antibiotic that stands out that is not normally used. She stated anything that is concerning she will reach out to the facility. She stated the pharmacy will also look to make sure the required information is in the order before sending the antibiotic to the facility. The pharmacist provided the surveyor with a copy of the facility's report from last month for review.

Based on observation, staff interview, and record review, the facility failed to ensure that one of four exit doors was properly secured, resulting in one resident (R) (#27) eloping from the facility. The sample was 44 residents. Findings include: Review of facility's policy titled Elopement Prevention revised 06/02/17 reads, Residents of the center with cognitive deficits which place them at risk for elopement or engaging in unsafe wandering, will be referred for residency in the Memory Support Unit, where applicable, or for transfer/discharge to an environment secure enough to accommodate their needs. Review of record revealed that resident has a diagnosis of dementia with behavioral disturbances and has a history of wandering and exit seeking while in the facility. The care plan with a problem as behaviors lists a behavior of resident leaving out of the facility on 6/7/21. Review of record revealed that on 6/07/21 at 4:54 p.m. R#27 was observed outside the facility, in the front near the road, staff assisted him back in and resident was put on every 15-minute checks until ordered to stop, skin check revealed no skin issues, educated resident on safety and he stated understanding, R#27 was noted about 15 minutes prior to him being found outside. R#27 showed staff which door he went out of and stated that he wanted to go play in the woods like he use to do with his cousin. R#27 has history of wandering within the facility. Review of record revealed that on 3/18/21 at 1:50 p.m. R#27 was observed in the hallway of Memory Support Unit (MSU) appeared agitated, stating he's going home, and soon as he gets out those doors he's gone. R#27 has his bags packed. Redirection attempted, unsuccessful. Interview on 6/02/22 at 8:15 a.m. with Certified Nursing Assistant (CNA) AA revealed that she has worked at the facility for 8 years. CNA AA stated that she was the one who spotted R#27 outside the facility. (CNA) AA stated that the R#27 exited the building through the side exit door leading to the smoke porch and walked around the building and was up by the facility's driveway exit when he was retrieved. She stated that the door leading to the smoke porch did not close completely which allowed R#27 access out of the facility. She stated that the R#27 told her that he was headed to his house in [NAME] Ga. Interview on 6/02/22 at 8:57 a.m. with Maintenance Director revealed that he checks all the exit doors daily in the morning when he gets to the facility. He stated that the door checks are documented electronically in a Building Engines Program. He further stated that the front door is the only exit door that is equipped with the wander guard system. The other doors have the keypad to go in and out the facility. He also stated that he checked the smoke porch exit door the next day (6/08/21) after learning R #27 was found outside the facility the day before. The Maintenance Director stated that the facility has 4 exit doors, and each exit door is checked daily and loaded into the building engines program. Interview on 6/02/22 at 1:31 p.m. with the Maintenance Director revealed that he was on vacation on 6/5/21, 6/6/21 and 6/7/21. He stated that the Housekeeping Supervisor verbally told him that she checked the doors on those days and that the doors were working properly so he cleared the Door Checks Tasks the Building Engine program for those days when he returned from vacation on 6/08/21. The Maintenance Director further stated that the doors were working properly when he returned and checked them on 6/08/21. Interview on 6/02/22 at 1:52 p.m. with Housekeeping Supervisor revealed that she does check the doors when the Maintenance Director is not in the facility, but she did not check the doors on 6/05/21 or 6/06/21 because she did not work that weekend according to her work calendar. Housekeeping Supervisor: work schedule was verified with HR Director, and she did not work on the days in question. She further stated that she documents the door checks that she completes in a Manager Notebook, which was kept at the nurse's station. She further stated that the notebook is now missing.

Based on interviews, record reviews, and policy review, the facility failed to protect two cognitively impaired residents (R) (A and #2) from having sexual contact from a total sample of eight residents. Findings include: The facility had a Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property policy. The policy included a definition of sexual abuse as non-consensual sexual contact of any type with a patient. The facility's Abuse Prevention and Reporting policy defined sexual abuse as including but not limited to sexual harassment, sexual coercion, and sexual assault. RA was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of the 9/8/19 Quarterly Minimum Data Set (MDS) assessment revealed that RA was assessed as having severe cognitive impairment and impaired memory. A review of the clinical record revealed that RA was ambulatory and wandered. R#2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of the 10/3/19 MDS assessment revealed that R#2 was assessed as being ambulatory and having a Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicating some memory and cognitive impairment. A review of the clinical record revealed no history of sexually inappropriate behaviors prior to nursing home placement or during his nursing home stay until 11/19/19. A review of facility reported incidents revealed a Facility Incident Report Form, dated 11/19/19, that documented an allegation of resident to resident sexual abuse. The form included that the allegation involved RA as the alleged victim and R#2 as the alleged perpetrator. A further review of the form revealed the date and time of the incident as occurring on 11/19/19 at 7:00 a.m. Resident #2 was observed in RA's room and engaged in a possible oral sexual assault. The residents were separated, and the physician, police and responsible parties were notified. The witness to the incident was listed as Certified Nursing Assistant (CNA) CC. Resident #2 was placed on one to one supervision by staff. A further review of the Facility Incident Report Form and accompanying investigation, that included resident interviews, staff written statements, police report, and emergency room report, revealed that the allegation of sexual abuse was substantiated by the facility. R#2 was discharged from the facility with law enforcement on 11/19/19. RA was transferred to the emergency room for treatment. A review of the hospital documentation from 11/19/19 revealed that petechiae were found in the roof of the mouth on exam, but otherwise a normal physical exam, and that a rape kit was performed. RA received a dose of [MEDICATION NAME] (an antianxiety medication) while in the emergency room and was returned to the facility on [DATE] with no new physician's orders [REDACTED]. During an interview on 11/21/19 at 4:28 p.m., Certified Nursing Assistant (CNA) CC confirmed that she witnessed the oral sexual assault of RA by R#2 on 11/19/19 while making morning rounds around 6:30 a.m. She stated that she told R#2 to stop and he left the room and she immediately reported the incident to the nurses. CNA CC stated RA kept saying that she did not know what to do. During an interview on 11/21/19 at 3:05 p.m., Licensed Practical Nurse (LPN) DD confirmed that CNA CC reported the alleged assault to her and that R#2 was immediately placed on one to one supervision with staff, with the Administrator and Director of Nursing (DON) being notified. During an interview on 11/25/19 at 1:05 p.m., the DON confirmed that RA is not capable of giving (sexual) consent. In addition to immediately placing R#2 on one to one supervision, the facility implemented additional interventions. R#2 was discharged from the facility on 11/19/19 with law enforcement personnel. After an initial investigation by law enforcement, R#2 was placed under arrest. Interviews were attempted on all possible residents with no additional residents indicating abuse. Education on abuse was initiated for staff on 11/20/19.

Based on observation and staff interview the facility failed to assure resident notification of care plan meetings. This deficient practice affected three residents (Resident (R) #34, #50, and #85) of 38 sampled residents. Findings included: 1. Review of medical record for R#34 revealed care plan assessment dates that included 4/18/18, 7/5/18, and 9/23/18. There was only documentation of notice for a care plan meeting for (MONTH) (YEAR). Review of care plan sign in sheet from 4/12/18 and 9/27/18 did not indicate that resident was present for the meeting. Review of the Quarterly Minimum Date Set ((MDS) dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 12 (indicating the resident was cognitively intact and able to make her needs known). Interview conducted on 11/27/18 at 9:12 a.m. with R# 34 who reported that she has only been invited to one care plan meeting since being admitted . 2. Review of medical record for R#50 revealed care plan assessments dated for 7/16/18 and 10/12/18. There was no documentation to suggest that resident or family member was present for the care plan meetings. There was one letter of notification for 10/18/18 but no documentation to confirm the notification made for any previous care plan meetings. Review of the Quarterly MDS dated [DATE] revealed the resident the resident had a BIMS of 15 (indicating the resident was cognitively intact and able to make her needs known). During an interview on 11/26/18 at 3:41 p.m. with R# 50 it was reported that in the past she has received invitations to and has attended care plan meetings. However, it is reported that she has not attended or received notifications to attend meetings during the past eight months. Interview on 11/28/18 at 3:13 p.m. with R#50 who denied that the letter was received about the care plan meeting in (MONTH) (YEAR). The resident further reported that she wants to receive a copy of the care plan notice letter even if a copy is sent to a family member. 3. Review of medical record for R#85 did not reveal documentation of attendance to care plan meetings or notification of the meetings. Review of medical record revealed care plan assessments dated for 6/21/18, 8/14/18, and 11/12/18. There was a letter of notification for 11/12/18 but no documentation to confirm the other dates. Review of the Quarterly MDS dated [DATE] revealed that the resident had a BIMS of 13 (indicating the resident was cognitively intact and able to make her needs known). 11/26/18 02:59 PM Resident # 85 reported that she has not been invited to care plan meetings. Interview on 11/27/18 at 4:00 p.m. with the Social Services Director (SSD) who reported that she sends letters out to both residents and family members related to care plan meetings. SSD agreed to provide notification letters for R#34, R#50, and R#85. Interview on 11/28/18 at 10:26 a.m. with SSD who reported that she began in (MONTH) but did not send any care plan meeting letters as she was informed that they had already been sent off. She further reported that there are no copies of letters being sent prior to her starting in this position. Interview on 11/28/18 at 11:57 a.m. with R#85 who reported that she had spoken with family member who denied receiving care plan notifications. Interview on 11/28/18 at 3:02 p.m. with family member of R#85 who reported receiving only two care plan meeting letters since family member has been in the facility the past three years. Family member denied receiving any letters inviting them to the care plan meetings this year. Care plan policy requested regarding care plan notifications, however, the policy did not identify the timeframe's or expectations for notifying residents or family members about care plan meetings.

Based on observation, staff interview, and review of policy Patient/Resident Council the facility failed to assure that policy was followed related to resident complaints voiced during resident council meetings. The facility census was 90 residents. Findings include: Review of council minutes indicated resident complaints each month but there was no documentation to confirm that the resident complaints were followed up on. Interview conducted on 11/28/18 at 11:15 a.m. with the Activities Director and Social Services Director. The Activities Director reported that whenever a complaint is brought up in the resident council meeting she verbally tells the appropriate department about the concern but acknowledged that there is no follow up with the department once they have been verbally notified. She then reported that at the next council meeting she asks residents if the issue has been resolved. The Resident Council Policy that was attached to the front of the Resident Council binder was reviewed with the Activities Director and the Social Services Director although both denied knowledge of this policy related to documenting complaints of residents expressed during the Resident Council meetings. Patient/Resident Council Policy Review revealed: 10. Issues, concerns, ideas or complaints of the Council will be transferred to the Patient/Resident Council/Family Council Department response form by the staff liaison person and given to the Administrator for distribution and response by the appropriate department. The response/action will be documented on this form, returned to the Administrator for review and signature and returned to the Council staff liaison for communication back to the Council Presiding Officer and presentation at the next council meeting. The department response form will be attached to the minutes of the meeting in which the issue was brought up.

Based on interview, record review and review of the facility policy titled Change of Status, Identifying and Communicating, Long Term Care, the facility failed to notify the responsible party of significant weight loss for one resident (R) (A) out of 38 sampled residents. Findings include: During an interview on 11/26/18 at 5:28 p.m., the family of R A revealed that she has not been notified of anything involving the resident. Family of R A stated that she was unaware that the resident had experienced weight loss. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] documented R A was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Resident experienced weight loss of 5% or more in last month or 10% or more in last six months; and resident is not on a Physician prescribed weight loss program. Review of the Yearly Weight Record Form for (YEAR) revealed the following: 8/10/18 - 178 pounds (lbs) 8/17/18 - 176 lbs 8/24/18 - 173 lbs 9/1/18 - 174 lbs 9/4/18 - 174 lbs 10/1/18 - 149 lbs 11/3/18 - 153 lbs Review of the Nurses Notes from 8/21/18 through 11/28/18 revealed no documentation indicating that the responsible party was notified regarding weight loss for R A. Interview with the Director of Nursing (DON) on 11/29/18 at 11:52 a.m. revealed that when a resident has weight loss, they are added to the weight program, put on weekly weights, and then staff notify the family, Physician, and Registered Dietician of the weight loss. The DON stated that she is responsible for notifying the family but that she has not yet notified the family of R A of the weight loss. Review of the policy titled Change of Status, Identifying and Communicating, Long Term Care revised 5/18/18 revealed - Implementation: Notify the resident's representative about the change in the resident's condition and the subsequent treatment plan.

Based on observations and interviews the facility failed to ensure the upkeep of resident wheelchairs related to dirt and build up. This affected six residents (R#11, R#15, R#38, R#46, R#61, R#88, and R#89) of 38 sampled residents. Findings include: Observation on 11/26/18 at 11:30 a.m. revealed for R#61 a buildup on undercarriage of wheelchair and for R#38 having hair, dirt, and dust build up on spokes and undercarriage of the wheelchair. Observation on 11/26/18 at 12:52 p.m. revealed dust and dirt buildup on the wheelchair for R# 89. On 11/27/18 at 1:18 p.m. R#38 was observed in room sitting in wheelchair that was noted to have buildup of dust and debris. Observation on 11/27/18 at 1:35 p.m. of R#46 and R#88, who were on B hall, revealed dust and dirt build up on their wheelchairs. Observation of buildup of dirt and debris on resident wheelchairs on 11/28/18 at 5:05 p.m. on the B hall for R#11, R#46, R#15, and R#88. Interview on 11/29/18 at 10:05 a.m. with the Housekeeping Supervisor who reported that housekeeping staff are responsible for cleaning resident wheelchairs. The Housekeeping Supervisor reported that wheelchairs are cleaned monthly and on an as needed basis. A tour was done of facility and the Housekeeping Supervisor confirmed the dirt, dust, and buildup on resident wheelchairs. Interview conducted on 11/29/18 at 12:09 p.m. with the Housekeeping Supervisor, Floor Tech/Housekeeper (HH), and Floor Tech/Housekeeper II. It was reported that some of the residents' wheelchairs had not been cleaned due to the residents always being in the wheelchair during the day. Floor Tech/Housekeeper HH denies that nursing was ever notified that residents chairs needed cleaning to see if alternate wheelchairs would be available during the cleaning times. It was further reported that not all wheelchairs are cleaned each month. Floor Tech/Housekeeper HH reported that wheelchairs were identified on yesterday and there were plans of cleaning the wheelchairs today. Floor Tech/Housekeeper II reported that sometimes wheelchairs have to be cleaned when residents are in the shower. HSK Supervisor reported that there are wheelchairs on back porch but she was unsure if they are workable. Housekeeping supervisor also reported that in the past Certified Nursing Assistants (CNA) have cleaned the wheel chairs. The facility did not provided a policy for cleaning of wheelchairs. Review of the documents of the wheelchair cleaning reveal R#11 wheelchair being cleaned on 8/3/18, 9/17/18, and 10/25/18; R#38 wheelchair cleaned on 10/7/18, and R#89 wheelchair being cleaned on 11/7/18. There was no evidence that wheelchairs for R#15, R#46, R#61, and R#88 had been cleaned.

Based on record review and staff interview, the facility failed to complete a significant change assessment for one resident (R#40) for hospice care. The sample size was 38 residents. The findings are: A review of R#40's medical record revealed that on 11/5/18 the resident was admitted to a Hospice service due to a [DIAGNOSES REDACTED]. Further review of the resident's medical record indicated there were no significant change assessments completed for R#40 as of 11/27/18. An interview on 11/28/18 at 10:18 a.m.with MDS Coordinator FF revealed that the facility has twenty-one days from the dated of admission to complete a comprehensive plan of care for any resident being admitted into hospice. She also stated that MDS has fourteen days to complete their significant change assessment after a resident is being admitted into hospice. Additionally, she confirmed that R#40 had no comprehensive plan of care for hospice nor that a significant change assessment had been completed at this time.

Based on staff interview and observation the facility failed to assure that the baseline care plan was completed timely for one Resident (R) #394 of 38 sampled residents. Findings included: Record review for R#394 revealed the resident was admitted to the facility on [DATE]. Further review of the medical record revealed a base lime care plan that was completed on 11/27/18. During an interview on 11/29/18 at 9:15 a.m. with the Director of Nursing (DON) a copy of the baseline care plan for R#394 was provided by the DON was reviewed. The DON reported that R#394 admitted on [DATE] but when she checked for the baseline care plan on 11/26/18 she noticed that it was not done. As a result of this the DON reported that she and the wound care nurse completed the baseline care plan. The DON acknowledged that the base line should have been completed within 48 hours. She further confirmed that the nursing staff have a template to follow for completing the base line care plan but it was not done. Care Plan Policy 2014 Procedure: 1.Upon a new admission, a baseline care plan will be developed by the admitting nurse/nurses in conjunction with other IDT, the patient/resident and/or patient/resident representative. The baseline care plan should be initiated in 24 hours and will be completed and implemented within 48 hours of admission.

Based on observations, record review and staff interviews, the facility failed to follow the Physician order [REDACTED].#24 of 38 sampled residents, to for the administration of [MEDICATION NAME] Regular (R) Insulin, 180 units before and after meals, and [MEDICATION NAME] R 100 units at 5:00 p.m. Resulting in missing three doses on 11/24/18, 11/25/18, 11/26/18 although there was no adverse reaction documented. Findings include: A review of the clinical record for R#24 revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) coded as 15. Section N revealed that the resident received insulin for high blood sugar. Review of the Physician order [REDACTED].>Review of Medication Administration Record [REDACTED]. An interview on 11/26/18 at 11:00 a.m. with R#24 revealed that I didn't have my [MEDICATION NAME] Regular (R) insulin for two days; when I asked the nurses, they replied it's finished, and no one has reordered it. I am a brittle diabetes with high blood sugar. An interview on 11/26/18 at 11:05 a.m. with Licensed Practical Nurse (LPN) AA revealed that she came on duty at 7:00 a.m. and revealed that the night nurse hadn't reported that R#24's insulin was empty and not available. She only became aware of it between 9:00 a.m. and 10:00 a.m. when she wanted to administer the medication and it was unavailable. The LPN AA revealed that she had notified Unit Manager immediately. An interview on 11/26/18 at 11:10 a.m. with Licensed Practical (LPN) GG revealed that she was not aware that R#24 [MEDICATION NAME] Regular (R) insulin has finished until LPN AA told her that morning. LPN GG revealed that she called the Physician and Pharmacy to obtain the insulin. LPN GG further revealed that the Physician gave an order to cover the resident by sliding scale until the normal Insulin arrived then resume the previous orders. An interview on 11/26/18 at 12:30 p.m. with Director of Nursing, Administrator and Nurse Consultant revealed that they were not notified that resident R#24 insulin has finished and has not been administered for two days. An interview on 11/26/18 at 12:40 p.m. with the Pharmacist (PH) DD via telephone revealed that she had not received notification from facility during the weekend. However, she received a telephone call one hour ago that the resident's [MEDICATION NAME] Regular (R) insulin needed to be refilled. She confirmed the insulin amount was verified with Physician. An interview on 11/27/18 at 9:00 a.m. with the DON, who provided a written statement from Licensed Practical Nurse (LPN) BB, stating that she was not aware that R#24 [MEDICATION NAME] Regular (R) insulin has finished and had not been ordered. However, when she became aware, she ordered it on a blue sheet and faxed it to pharmacy. However, she didn't follow up with a call to pharmacy or the medical director (MD); she only documented on the computer that insulin was not administered because fresh supplies had not been ordered. An interview on 11/28/18 at 11:02 a.m. with Licensed Practical Nurse (LPN) CC via telephone revealed that she worked on weekend but was so busy she forgot to call Pharmacy, Physician, or notify oncoming night shift nurse. LPN CC stated she documented in the electronic record that insulin was not given because it was unavailable. Review of the policy titled Medication Administration dated (MONTH) 1, 2012 and revised (MONTH) 1, (YEAR) documented: To ensure that refills of ordered medications shall be ordered timely so there is no interruption of the medication. If the pharmacy does not have the needed medication the physician shall be notified, and directions requested.

Based on observation, interview, and resident record review, it was determined the facility failed to ensure one Resident (R) #65 with a physical restraint was free from any physical restraint not required to treat the resident's medical symptoms and/or was evaluated to determine the least restrictive alternative for the resident of 23 sampled residents. Findings include: On 1/8/18 at 10:30 a.m., R#65 was observed to have a mitten restraint on his right hand. At 1:30 p.m. on 1/8/18 the mitten restrain was observed to remain in place on R#65's right hand. A third observation of the mitten restraint to R#65's right hand was made on 1/9/18 at 11:30 a.m. Review of the Minimum Data Set (MDS) section A1900 in the medical record of R#65 revealed an admission date of [DATE] Further review of the medical record for R#65 revealed there was no physician's order, no care plan and no documentation in the progress notes regarding the mitten restraint worn by R#65. There was no evaluation to determine if this mitten restraint was the least restrictive method which would be effective for R#65 or if an alternative method would be more effective. There was no documentation for the ongoing use and re-evaluation of the need for the mitten restraint. On 1/9/18 an interview with Registered Nurse (RN) BB (the MDS coordinator) at 2:30 p.m. in her office revealed she was unaware of the restraint on R#65. She stated she had not assessed him for restraints because she was unaware the resident was wearing one. RN BB confirmed by not assessing the resident for the least restrictive use of restraints, a plan of care for the use of a restraint had not been developed. During an interview with the RN AA on 1/9/18 at 3:00 p.m., she stated the day shift was blaming the night shift for putting the restraint on R#65 last night. When she was informed the restraint was observed on R#65 on 1/8/18 she stated she would check into it and find out how long R#65 had been wearing the mitten restraint. At 4:10 p.m., RN AA reported R#65 was admitted to the facility wearing mitten restraints to both hands. She stated the hospital put them on him to prevent him from pulling on his feeding tube. When questioned regarding the assessment and evaluation of the use of the restraint, RN AA confirmed an assessment should have been completed and a plan of care should have been developed to ensure the least restrictive method of restraint which was effective could have been put in place for R#65. RN AA confirmed an assessment and plan of care for use of a mitten restraint had not been completed on R#65. She also confirmed there was no physician's order for the use of [REDACTED] The facility failed to appropriately assess and evaluate the placement of a mitten restraint on R#65's right hand.

Based on record review, observation, and staff interview, it was determined the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for one resident (R) #65 for the use of a mitten restraint of 23 sampled residents. Findings include: On 1/8/18 at 10:30 a.m., Resident (R)#65 was observed to have a mitten restraint on his right hand. At 1:30 p.m. on 1/8/18 the mitten restrain was observed to remain in place on R#65's right hand. A third observation of the mitten restraint to R#65's right hand was made on 1/9/18 at 11:30 a.m. Review of the admission Minimum Data Set (MDS )section A1900 in the medical record of R#65 revealed an admission date of [DATE] Review of Section P0100 of the MDS assessment dated [DATE] reveals no coding for restraints. The coding all contain 0 indicating restraints are not used for this resident. There has not been another MDS assessment completed since the initial one on 11/30/17. Additional review of the resident's medical records revealed there was no physician's order, no care plan and no documentation in the progress notes regarding the mitten restraint worn by R#65. On 1/9/18 an interview with Registered Nurse (RN) BB at 2:30 p.m. in the MDS office, revealed she was unaware of the restraint on R#65. She stated she had not assessed him for restraints because she was unaware the resident was wearing one. RN BB reported she should have coded the restraint in Section P when she completed the admission MDS. During an interview with the RN AA in the conference room on 1/9/18 at 3:00 p.m., she stated day shift was blaming night shift for putting the restraint on R#65 last night. When she was informed the restraint was observed on R#65 on 1/8/18 she stated she would check into it and find out how long R#65 had been wearing the mitten restraint. At 4:10 p.m., the RN AA reported R#65 was admitted to the facility wearing mitten restraints to both hands. She stated the hospital put them on him to prevent him from pulling on his feeding tube. When questioned regarding the assessment and evaluation of the use of the restraint, she confirmed an assessment should have been completed and a plan of care should have been developed to ensure the least restrictive method of restraint which was effective could have been put in place for R#65. She confirmed an assessment and plan of care for use of a mitten restraint had not been completed on R#65. She also confirmed there was no Physician's order for the use of [REDACTED] The facility failed to ensure the accuracy of the MDS assessment for R#65's use of mitten restraints (Cross reference to F604)

Based on record review, observation and staff interview, it was determined the facility failed to ensure a bed bound resident received activities for one Resident (R) #58 of 23 sampled residents. Findings include: Review of R#58's admission Minimum Data Set (MDS) documented the resident had been admitted to the facility on [DATE]. The Brief Interview for Mental Status assessment of 15, indicating the resident as being cognitively intact. Review of facility's document titled Activity Assessment form, dated 11/17/17, documented, Resident has impaired mobility and propels around in W/C (wheelchair). Resident stays in the bed all the time. In the area of the form for one on one visits, he receives snacks/hydration. The form also documented the resident, is meeting activity goals and approaches, will continue to update as needed. On 1/8/18 at 8:53 a.m., the resident was observed lying in his bed. A motorized W/C was observed sitting across from the resident's bed. In an interview during this observation the resident reported he wanted to get up in his W/C but was waiting on clearance to get back in motorized W/C. The resident was observed watching TV (television) at the time of interview. The resident was asked how long it had been since he had been out of the bed. The resident reported he had not been out of the bed in over a month. On 1/8/18 at 10:00 a.m., the Director of Nursing (DON) reported the resident refuses frequently to get out of bed, but plan to get up today. On 1/8/18 at 9:25 a.m., the resident was observed lying in his bed. The resident was alert and talkative. The resident was talking about football and his children. On 1/11/18 at 8:24 am the AD (Activity Director) was interviewed, in the activity room after all the residents had left the room . The AD was asked what activities R#58 received. She reported he did not get out of the bed. She was asked if she did one on one, or in room activities for the resident. The AD reported she did not have any documentation on one on one activities and that she did not do them. She stated, I am one person and I don't have time to do those, memory care and all the other activities. She also reported on the weekends and occasionally during the week a housekeeper helps her a little. The facility failed to provide an activities program residents that are bed bound.

Based on observation, resident record review and facility staff interview, the facility failed to ensure that a medication error rate was less than five percent. 33 opportunities were observed for three residents with five errors noted resulting in an error rate of 15.15 percent. Findings include: 1. On 1/11/18 at 8:36 a.m. on the B wing a medication administration was observed with the Director of Nursing (DON) administering medications to the residents. The DON administered multiple medications to Resident (R)#23. The following observations were made: Two Vitamin C (a dietary supplement) 500 milligrams (mg) tablets were administered. [MEDICATION NAME] a medication given to lower gastric secretions) 40 mg capsule was administered. [MEDICATION NAME] (a medication given to lower blood pressure) 25 mg tablet was administered [MEDICATION NAME] ( medication given for hypoactive [MEDICAL CONDITION]) 100 microgram (mcg) was administered. Review of the January 2018 monthly Physician's orders in the medical record of R#23 revealed the following orders: Vitamin C 1000 mg tablets give 2000 mg every morning; [MEDICATION NAME] 40mg capsule give daily at 7:30 a.m. [MEDICATION NAME] 100 mcg give daily at 6:30 a.m. An updated order dated 1/3/18 for [MEDICATION NAME] 12.5 mg was also noted. Review of the Medication Administration Record [REDACTED]. [MEDICATION NAME] is to be administered on an empty stomach and with no other medications and [MEDICATION NAME] is to be administered before eating a meal per manufacturers recommendations Interview with the DON on B wing hallways, on 1/11/18 at 10:10 a.m. confirmed she had administered the incorrect dose of Vitamin C, and incorrect dose of [MEDICATION NAME]. She stated she did not notice the dosage on the medication container of Vitamin C was different from the dosage ordered by the physician. She also stated she did not notice the dosage for [MEDICATION NAME] on the MAR indicated [REDACTED]. The DON confirmed both medications were administered after R#23 had eaten his breakfast and with other medications. She also confirmed there was no Physician's order to change administration times from 6:30 a.m. to 9:00 a.m. for the [MEDICATION NAME] nor was there a Physician's order to change administration time of [MEDICATION NAME] from 7:30 a.m. to 9:00 a.m. to be given with the other 9:00 a.m. morning medications. 2. The DON was observed to administer multiple medications to R#61 at 9:10 a.m. on 1/11/18. During this time, she was observed to administer [MEDICATION NAME] 25 mcg along with other medications. Review of the monthly Physician's orders for January 2018 for R#61, revealed an order for [REDACTED].>Interview with the DON on 1/11/18 at 10:10 a.m. confirmed she had administered the [MEDICATION NAME] with Resident #61's 9:00 a.m. medications. She also confirmed there was no Physician's order to administer the [MEDICATION NAME] ordered for 7:30 a.m. with the routine 9:00 a.m. medications. [MEDICATION NAME] is to be administered on an empty stomach and with no other medications. The DON also confirmed that the levothyroxin was administered to R#23 after the resident had eaten breakfast and with other morning medications. The DON stated, I guess I'll have to write myself up for making all these med errors.