Every finding on record at PruittHealth - Lithonia, LLC

Based on observations, staff interviews, and review of the facility policy titled, Waste Disposal: Dietary Services, the facility failed to ensure the outdoor garbage and refuse area was free of litter by being maintained in a sanitary manner. Findings include:Review of the facility policy titled Waste Disposal: Dietary Services reviewed dated 10/20/2025 revealed under Procedure: 6. Dumpster lids, doors, and plugs should be kept closed at all times. 7. Dumpster and surrounding areas should be kept clean and free of debris. During the initial observation of the dumpster on 03/18/2026 at 11:58 AM the Dietary Manager (DM)PP confirmed the presence of two dumpsters. The dumpster adjacent to the brick wall; left door was observed to be completely open, overflowing with clear trash bags protruding from the left door. Observation indicated the presence of one compressed empty box, purple gloves, remnants of straws, and several white surgical face masks surrounding the two dumpsters. Interview on 03/18/2026, at 11:59 AM was conducted with the DM PP, who acknowledged the presence of trash and debris around the dumpster. The dumpster located near the brick wall door left open. DM PP confirmed the responsibility for the dumpster was with the kitchen. DM PP confirmed that the dumpster was open.Observation on 03/18/2026, at 3:00 PM revealed two dumpsters and the dumpster adjacent to the brick wall left door was observed mid-open, overflowing with clear trash bags and purples gloves protruding on to the ground. Observation indicated the presence of one compressed empty box, purple gloves, remnants of straws, and several white surgical face masks surrounding the two dumpsters. Interview on 03/19/2026 at 9:53 AM with Register Dietitian OO confirmed she was uncertain regarding who was responsible for maintaining the dumpster. However, she confirmed that any individuals who place trash in the dumpster should ensure that it is free of debris and that the doors are closed.Interview on 03/19/2026 at 11:38 AM with Maintenance Director confirmed that his department is tasked with the upkeep of the dumpsters. He noted that the facility operates continuously, 24 hours a day, and that the night shift had been notified of their responsibilities.

Based on observation, staff interview, record review and review of the facility's policies titled, Foodborne Illness and Labeling, Dating, and Storage facility failed to adequately uphold food safety practices, which could lead to potential foodborne illnesses. Opened food products in the walk-in refrigerator were not appropriately labeled, dated, and discarded. The deficient practices had the potential to place 135 residents who received an oral diet from the kitchen at risk of contracting a foodborne illness. Findings Include:Review of facility's policy titled, Foodborne Illnesses reviewed dated 01/8/2021, revealed in Procedure 2. Foods will be used before the expiration date, use by date, and sell by date, indicated on the food item. Foods not used prior to the expiration date, use by date, best by date, or sell by date must be discarded. 3. It is the responsibility of the Dietary Manager to see that dietary employees practice safe and sanitary methods when preparing foods to prevent cross contamination and the spread of bacteria. 7. Meats will be thawed and cooked to appropriate internal temperature to prevent foodborne illnesses. Thaw meat under refrigeration at or below 41 degrees Fahrenheit in a drip proof container or submerged in a solid bottom pan under cold running water.Review of facility's policy titled, Labeling, Dating, and Storage review dated 11/12025, in Procedure section 1. Food and Beverage items will have an identifying label as well as a received date and opened date, as applicable, for items prepared onsite, a use by date will also be indicated.During the initial tour on 03/17/2026 at 8:49 am, revealed in the kitchen walk-in cooler/refrigerator (19) 1 oz. single packs of sour cream, which have an expiration date of 01/12/2026. Additionally, there were (10) half-pint cartons of milk with an expiration date of 03/15/2026. Ongoing observation of the kitchen indicated that in the separate double sink designated solely for washing and preparing vegetables/produce, as well as thawing meat, there was a large silver bowl containing meat, which the cook SS identified as pork chops, submerged in water.Observation and Interview on 03/17/2026, at 9:13 AM, conducted during the breakfast meal tray pass and the distribution of carts to the floor revealed expired milk present on both the prepared tray and the cart. Dietary Aid (DA) RR confirmed that she was tasked with ensuring the accuracy of the meal trays. Dietary Aid RR stated that she had not received any training regarding storage, labeling, and dating.Observation on 03/17/2026, at 9:19 AM, revealed the presence of one half pint of expired milk, with the expiration date 03/15/2026, on breakfast tray for resident(R)91.The record review for R91 revealed a comprehensive Minimum Data Set (MDS) dated [DATE] and a Brief Interview for Mental Status (BIMS) score of 14, indicating no cognitive impairment. A review of R91of the care plan initiated on 02/21/2026 revealed problem: At risk for altered nutritional status. Approach: Observe intake. Provide diet as prescribed/ordered.Observation on 03/17/2026, at 9:22 AM, revealed that breakfast meal tray for R139 contained one half pint of milk that had expiration date 03/15/2026.The record review for R139 revealed a quarterly Minimum Data Set (MDS) dated [DATE] and a Brief Interview for Mental Status (BIMS) score of 12, indicating no cognitive impairment. A review of R139 of the care plan initiated on 02/5/2026 revealed problem: Resident requires a therapeutic diet. Approach: Diet: as ordered.Follow up tour of the kitchen revealed for the three-compartment sink used for dishwashing revealed and checked by DM on 03/18/2026 at 1:36 PM, sanitizing solution strips with expiration date 10/1/2027, with no results. Retest completed on 03/19/2026, at 8:50 AM, revealed no solution disbursing from sanitizer, no results.Interview on 03/19/2026 at 8:53 AM, with cook MM disclosed that he had washed the morning dishes and discovered that the sanitizer machine was not working. [NAME] MM explained he manually poured the sanitizer solution into the water. [NAME] MM acknowledged that he did not test the sanitizer concentration nor did he measure the volume of the solution. Interview on0 3/19/2026 at 9:03 AM, with Dietary Aid NN revealed that on the morning of 03/17/ 2026, the kitchen was in disarray because the previous night, all meal tickets had not been printed, and there was no key available to access the kitchen that morning due to the cook who possessed the key calling off. DA NN explained that she had to stop with working on the meal tray line, to print tickets and then provide assistance in the dining room; so, she had DA RR to check the tickets.

Based on observations, record review, staff interviews, and review of the facility's policy titled Oxygen Administration, the facility failed to ensure respiratory equipment was maintained in a clean and sanitary manner by not cleaning the oxygen concentrator filter for one resident (R) (R69) out of 12 residents on respiratory care. This deficient practice had the potential to cause ineffective oxygen delivery, respiratory complications, and increased risk of infection.Findings include:Record review of facility's policy titled Oxygen Administration, reviewed on 11/17/2025, revealed the Policy Statement included, It is the policy of [NAME] Health Hospice and Healthcare Centers/Veterans Homes to provide oxygen safely and accurately to appropriate patients/residents. The policy further revealed The large external, black filter should be washed with soap and water once each week and PRN [as needed]. Dry with towel and reinsert. Clean exterior of concentrators weekly and between each patient/resident use with bactericidal surface cleaner.Record review of the electronic health record (EHR) revealed R69 was admitted on [DATE] with diagnoses including but not limited to chronic respiratory failure with hypoxia, dementia, shortness of breath, and dependence on supplemental oxygen.Record review of the Annual Minimum Data Set (MDS) for R69, dated 09/22/2025, revealed that Section C (Cognitive Patterns) documented that the Brief Interview for Mental Status (BIMS) was not performed. The MDS further revealed R69 was dependent on staff for all activities of daily living and received oxygen therapy and hospice services.Record review of physician orders for R69, dated 12/16/2025, revealed an active order for oxygen at 3 liters per minute via nasal cannula continuously, with additional orders to change respiratory circuit/supplies weekly and monitor pulse oximetry as needed.Record review of the care plan, last revised on 12/18/2025, for R69 revealed an active problem for oxygen use with interventions to administer oxygen as ordered, monitor oxygen saturation, position for optimal breathing, and observe for signs of hypoxia.Observations conducted on 03/17/2026 at 12:02 PM, 03/18/2026 at 9:11 AM, and 03/18/2026 at 12:57 PM revealed the oxygen concentrator filter had grey, fuzzy debris present.Interview conducted on 03/19/2026 at 9:10 AM with Licensed Practical Nurse (LPN) BB stated that the Maintenance Director was responsible for cleaning the concentrator filter. LPN BB observed the concentrator filter and stated she saw visible dust on the filter.Interview conducted on 03/19/2026 at 9:21 AM with the Maintenance Director revealed Certified Nursing Assistants (CNAs) were expected to notify the Maintenance Department when the oxygen concentrator filters were dirty, and then he would proceed to clean them. The Maintenance Director observed the concentrator filter and stated he saw visible debris.Interview conducted on 03/19/2026 at 9:22 AM with the Director of Nursing (DON) revealed that she was not aware of who was responsible for cleaning the filters and was not aware of the process. The DON observed the concentrator filter and stated she saw visible dust. The DON stated that expectations were to follow policy in maintaining filters.Interview conducted on 03/19/2026 at 12:52 PM with the Administrator revealed she was unsure how often the filters were cleaned and stated an outside company serviced the equipment monthly. The Administrator stated that staff were expected to report concerns.

Based on observations, staff interviews, and review of the facility's policy titled Medication Storage in Healthcare Centers, the facility failed to ensure that medications and biologicals were stored securely on one of eight hallways. This deficient practice had the potential to place the residents and staff at risk of having unauthorized access to medications. Findings include:A review of the facility's policy titled Medication Storage in Health Care Centers, revised March 12, 2026, revealed that medications and biologicals are stored safely, securely, and properly following the manufacturer's recommendation or those of the supplier. The medication supply is accessible only to licensed nursing personnel, certified medication aides, and pharmacy personnel. Observation on 03/18/2026 at 6:10 AM revealed that a medication cart on the G Hall Corridor was unlocked, unattended, and out of direct sight of a nurse. Observation revealed the cart remained unlocked and unattended for three to five minutes. In an interview on 03/18/2026 at 6:15 AM, Registered Nurse (RN) DD confirmed the medication cart was unlocked and unattended, and stated the cart should be locked. RN DD further stated a consequence of leaving the medication storage cart unlocked was that a resident or unauthorized staff could gain access to medications. In an interview on 03/18/2026 at 6:18 AM, Certified Medical Assistant (CMA) EE revealed that she stepped away from the medication cart for a moment to get ice.

Based on observation, interview, and review of the policy titled Food Temperatures the facility failed to ensure that the temperature for cold food (orange juice) was maintained at a temperature of 41 degrees ( ) Fahrenheit (F) or less; This deficient practice had the potential to promote the growth of pathogens that cause foodborne illness. This had the potential to effect 134 of the 141 residents receiving an oral diet.Findings include: Review of the policy titled Food Temperatures revised date of 10/21/2025. Policy: It is the policy of __ that the Dietary Manager or designee be responsible for ensuring that all food has reached and continues to maintain proper temperature prior to tray assembly. Procedure: 2. All potentially hazardous cold foods must be held at 41 degrees or less. 12. Potentially hazardous cold food should be held on the line in an ice bath at 41 degrees or below. Cold foods should not be set up on meal trays longer than 15 minutes prior to meal service and must be kept on ice or chilled during tray line/meal service. An observation on 03/5/2026 at 7:29 am of temperatures taken at breakfast by cook AA using the facility's thermometer, three four-ounce plastic container of orange juice did not register below 51 F. The [NAME] stated the orange juice temperature should be 41 F or below. The Interim Dietary Manager had the staff remove the orange juice from the residents' breakfast trays. An interview on 03/6/2026 at 1:05 pm with the Registered Dietician BB stated cold items should be kept on ice during the tray line service. The Registered Dietician stated she spoke with the dietary staff on 03/5/2026 regarding keeping cold items on ice during meal service.

Based on observation, staff interview, and review of the facility's policies titled, Skilled Nursing Services Storage Areas and Skilled Nursing Services Cleaning and Sanitizing, the facility failed to ensure opened food items in the dry storage and the walk-in refrigerator area were securely wrapped, labeled, dated, and discarded by the expiration date. In addition, the facility failed to maintain sanitary cleanliness of the ice maker and prevent wet nesting by ensuring clean pots, pans and baking trays were properly stacked and stored to dry. The facility census was 147 residents. Findings Include: Review of facility's policy titled, Skilled Nursing Services Storage Areas dated [DATE] under the section titled Guidelines revealed, items should be covered, sealed, labeled, and dated appropriately. Under the subsection titled, Ice machines, revealed, ice chest should be cleaned on a routine basis and as needed. Review of facility's policy titled Skilled Nursing Services Cleaning and Sanitizing, dated [DATE] under the section titled Guidelines revealed, All small ware equipment should be stored in self-draining position that allows it to air dry. Observation on [DATE] at 10:00 am with the Dietary Manager (DM) revealed in the dry food storage pantry one 46 fluid (fl) ounces (oz) thickened orange juice dated [DATE], four vanilla 32 fl oz nutritional drink dated [DATE], and 1 pound (lb) traditional stuffing mix dated [DATE] were all expired. The DM confirmed it was everyone responsibility to check for expiration dates, past use and/or out of date foods. The DM discarded expired items and revealed he had new staff and was still conducting in-services on storage, labeling, and dates. The DM revealed, he moved the older items to the front. Further observation revealed, the walk-in refrigerator had four boxes of 100 count 1 oz single serve packets of sour cream with expiration date of [DATE], one 5 lb. cottage cheese with expiration date of [DATE], two 16 lb cream cheese icing with expiration date of [DATE], one cabbage and carrot mix with expiration date of [DATE]. One clear wrapped head of lettuce was observed with no label or date. The DM revealed they use open food items only for three days then discard. The DM confirmed all dietary staff clean the ice machine daily, weekly, as needed, and the maintenance contact provider would deep clean the ice machine quarterly or as needed. Review of the work order revealed the last service date the ice machine was deep cleaned was on [DATE]. The DM confirmed the observation of the reddish- black substance on the inner/outer side of the white casing and on the white paper towel. Observation on [DATE] at 10:05 am with the DM confirmed the sanitizing process was being performed by rewashing dishes through the low temperature dishwasher. During this time, wet nesting was observed. Interview on [DATE] at 3:00 pm with the Registered Dietitian (RD) revealed, the kitchen audit consists of equipment base, label/dating, and cleanliness once a month. The RD confirmed she did not physically label, and date food items and that she conducted observation and generate monthly reports. The RD emphasized when the truck come on Tuesday or Friday, she informs the staff to label and date food items. The RD revealed she review opened, received, and used by dates and if she found anything expired, she would pull the items and notify staff. The RD revealed that she would emphasize the three day rule for open foods to staff if its passed the date to be thrown out. The RD revealed she put on last month report for the ice machine to be cleaned. The RD confirmed staff was responsible for spot cleaning ice machine daily. Interview and Observation on [DATE] at 3:10 pm confirmed wet nesting with DM and RD. The DM revealed he would complete an in-service today and ongoing for new staff. The DM shared he would ensure the dietary aid spread pots out to dry and rearrange another drying rack to open more space. The DM revealed he was working with maintenance in utilizing limited space and racks.

Based on observations, resident and staff interviews, and review of the facility's policy titled, Bedside Storage of Medications, the facility failed to assess one of eight residents (R) (R88) for self-administration of medication and failed to maintain medication in a secure location for one of three residents (R43). The deficient practice had the potential to allow unauthorized access to unsecured medications to residents and visitors at the facility. Findings Include: 1. A review of the undated facility policy titled, Bedside Storage of Medications revealed under section titled Intent, To support self-administration of medication by appropriate patients within the nursing center while facilitating medication security. Under section titled GUIDELINE revealed, The Pharmacy supports bedside medication storage for patients who are able to self-administer medications upon the written order of the prescriber and when it is deemed appropriate in the judgment of the nursing center's interdisciplinary patient assessment team. Under section titled PROCEDURE, revealed, A medication-specific order is required from the prescriber for bedside medication storage (e.g., add May keep at bedside to each applicable medication order). Bedside medications may be labeled May keep at bedside by the provider pharmacy upon request. An assessment for self-administration of medications is completed and kept in patients care plan in the medical records.The manner of storage must prevent access by other patients. Lockable drawers or cabinets are REQUIRED. A review of clinical record for R88 revealed diagnoses including, but not limited to, Alzheimer's disease with early onset and Dementia. A review of the Annual Minimum Data Set (MDS) dated [DATE] revealed section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 09, indicating moderate cognitive impairment. A review of the care plan for R88 dated 7/1/2024 revealed a focus area of risk for communication difficulties related to diagnosis of dementia and Alzheimer's. Further review of care plan revealed a focus area of risk for cognitive deficit related to dementia and Alzheimer's. Observation on 9/3/2024 at 1:41 pm revealed R88 bed side table contained the following medications: Tiger Balm; Pain Relieving Ointment 0.63 ounces (oz.) and Asper creme Lidocaine (2 in 1 pain relief + moisturization) 4 oz. An interview on 9/3/2024 at 1:41 pm with R88 revealed resident stated he has a bad knee, and he puts pain reliving ointment for the pain and that the facility was aware he had the pain-relieving ointment. An interview on 9/4/2024 at 10:55 am with Certified Nursing Assistant (CNA) EE revealed she was familiar with R88 care, but she was not aware if R88 is supposed to be self-administering pain relieving ointment. An interview on 9/4/2024 at 11:03 am with Licensed Practical Nurse (LPN) BB revealed that if residents are self-administering medications they are supposed to be care planned and will need a physicians' order. LPN BB was not aware that R88 was self-administering pain-relieving ointment, and states she checks in on residents as frequent as she can, but never realized he had ointments on his bedside table. LPN BB stated the possible outcome of residents self-administering medication without physicians' orders or proper care planning is that residents can over medicate. An interview on 9/4/2024 at 11:16 am with Assistant Director of Nursing (ADON) revealed that residents who self-administer medications are given an assessment and residents must demonstrate that they are able to self-administer medication on their own. ADON further stated the Nurse Practitioner will then write an order and fill out an inform care consent form. She further states depending on the medication it is kept in medication cart and sometimes it is kept in the resident's room, locked away in a safe box. ADON revealed she visits residents every day and was not aware that R88 had pain relieving ointment on his bedside table. ADON further revealed it is her expectations that all CNA's should be aware of residents who self-administer medication and if they see medication in a resident room, they should inform a nurse. ADON revealed that a possible negative outcome would be medication interactions. 50524 2. Review of the Electronic Medical Records (EMR) revealed R43 was admitted to the facility with diagnosis including but not limited to obesity, lower abdominal dermatitis, vaginitis and diabetes mellitus. Review of the Annual MDS dated [DATE] documented in Section C R43 has a BIMS score of 15 which indicated intact cognition. Review of care plan dated 6/21/2024 revealed no focus area for medications to be left at R43's bedside. Review of the Physician Orders revealed there was no order for R43 to have medications left at bedside. Observation and interview on 9/03/2024 at 12:04 pm with R43 in her room revealed there were three medication cups on the bedside table. One cup had a powdery substance, one cup had a white gel substance, and the other cup had a clear gel substance. The resident stated one ointment was for her face, another was for her abdominal fold and the third was for the bottom of her feet since she has diabetic neuropathy, and her feet has tingling sensation. She stated the nurse leaves the ointments on the table for the CNAs to put them on after she has her bath. Interview on 9/4/2024 at 1:18 pm with CNA CC revealed, the nurse gives the ointments to the CNAs to apply on the resident. Interview on 9/4/2024 at 2:01pm with Registered Nurse Supervisor (RNS) DD stated medications of any sort should not be left unattended in the residents' rooms. She stated the nurses should not be leaving ointments or powders in the resident's room for the CNA to administer. She stated her expectations were for the nurses to administer the resident's medications themselves and not leave medications at the resident's bedside unattended. Interview on 9/4/2024 at 2:23 pm with CNA EE, she stated she was on duty on 9/3/2024 and was assigned to R43. She stated she saw the three medication cups on the table beside the resident's bed. She stated medications are left at R43's bedside sometimes at least twice per week and with different nurses. She stated the nurses usually give the ointments to the CNAs to apply on the resident or they leave it at the R43's bedside. Interview on 9/4/2024 at 2:28 pm with DON, she stated that medications should not be left at the resident's bedside. She stated her expectations were for nurses not to leave medications at the resident's bedside and if they cannot administer the medications themselves, they should keep them instead of leaving the medications at the resident's bedside.

Based on staff and resident interviews, record reviews, and review of the facility's policy titled, Best Practice for PASRR, the facility failed to screen one of five residents (R) R43 for Pre-Admission Screening and Record Review (PASRR) level two. The deficient practice had the potential to cause R43 not to receive care and services in the most integrated setting appropriate to her needs. Findings include: Review of the facility's undated policy titled, Best Practice for PASRR documented There are two areas a person can be a PASRR patient: Significant Mental Illness (SMI) or Intellectual Disability/Developmental Disability (ID/DD) To be included in the PASARR population, a patient must have a SMI, or an ID/DD as determined on their level two assessment. Review of the Electronic Medical Record (EMR) revealed R43 was admitted to the facility with diagnosis that included but not limited to paranoid schizophrenia. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] documented in Section C (Cognitive Patterns) R43 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated little to no cognitive impairment, and Section N (Medication) reported, takes anti-psychotropic and anti-depressant medications. Review of care plan dated 6/21/2024 revealed no focus area for R43 screening for PASARR level two. The care plan included but not limited to, Focus: Paranoid schizophrenia, Trazodone (3/29/2024) Intervention: CARENOW services, labs as ordered, monitor closely for worsening of depression and/or suicidal behavior or thinking, especially during initiation of therapy and during any change in dosage. Focus: Resident requires psychotropic medication for dx of paranoid Schizophrenia (6/21/2024) Has period of anxiety, with risk for adverse reactions relating to medication Lithium. Intervention: Administer medication as ordered. Focus: Behavior easily annoyed/angered (6/18/2023). Patient will demonstrate effective coping skills through the review period. Intervention: Encourage patient to verbalize feelings and provide reassurance as needed. Review of Physician Orders dated 8/18/2023 revealed orders which included, Lithium carbonate 300 mg (milligram) capsule (Lithium Carbonate) for diagnosis (Dx): bipolar disorder. Interview on 9/4/2024 at 1:04 pm revealed R43 was diagnosed with bipolar [AGE] years ago. She revealed being previously diagnosed with manic depressive disorder, but her diagnosis was changed to bipolar. R43 revealed she takes Lithium medication for the bipolar disorder. Interview on 9/4/2024 at 2:01 pm with the Registered Nurse (RN) Supervisor RN DD revealed residents are screened prior to admission for psychiatric conditions and the Social Workers refer the residents to CARENOW for further evaluation. She revealed if a resident had behaviors the Nurse Practitioner (NP) or Medical Doctor (MD) is informed, and they will assess the resident and make the referral for further assessment. She revealed R43 had no behaviors, and the NP was not informed of any behavior for her to make a referral. Interview on 9/4/2024 at 2:28 pm the Director of Nursing (DON) revealed residents are admitted to the facility with a PASRR level one and if they have a major mental disorder they are referred for PASRR level two. If the resident is triggered for further evaluation, the Social Services Director (SSD) or his assistant will send referral information to GAMMIS which is the government service that determines the PASRR level services. Interview on 9/4/2024 at 5:22 pm with the SSD revealed residents come to the facility at PASRR level one but if they have a psychiatric disorder, they are PASARR level two and are referred for specialized services. He stated referrals are sent to GAMMIS by the Social Services Assistant. The SSD confirmed R43 was not referred for PASRR two. The SSD revealed that whatever length of time the resident is in the facility, if there were no behaviors, there was no need for PASRR level two screening.

Based on observations, staff interviews, and review of the policy titled, Cleaning of Shared Equipment, the facility failed to clean and disinfect a shared blood pressure cuff before and after use between residents. The deficient practice had the potential to increase the probability of cross transmission of bacteria that could cause infections for residents that the equipment was utilized for. Findings: Review of the facility policy titled, Cleaning of Shared Equipment with a review date of 12/29/2023, revealed that the purpose was to decrease the risk of cross transmission of bacteria that could colonize or infected patients. It was revealed that medical equipment which is shared between patients shall be cleaned with soap and water or other appropriate cleaner and then disinfected prior to and again after its use on another patient. Sharded equipment include but are not limited to blood pressure cuffs and pulse oximeters. An observation on 9/4/2024 at 9:20 am revealed that Certified Nurses Aid (CNA) JJ, removed an electronic blood pressure cuff out of a room and went across the room, into another room. In the room, she took the vital signs, which include blood pressure, heart rate and pulse oximetry, of one of the residents in the room. While in that room, she was observed, going to the roommate and taking the vital signs of the other resident in the room. Observation of CNA JJ, on 9/4/2024 at 9:26 am, revealed CNA left the room with the electronic blood pressure machine and cuff. At that time, she was asked by this surveyor, when does the cuff get cleaned, and she stated, they are supposed to be cleaned in between residents. She then stated that she did clean it. She was then asked where the cleaning and disinfected wipes were that are used, and she stated that they are found and kept at the nurse's station. She then stated that she had completed all her vitals and was going to clean it now and headed to the nurse's station. At the nurse's station, she was observed looking for the disinfecting wipes, and then asked someone where they were kept, so that she could clean and disinfect them. She then was observed going to a medication cart, to remove a purple topped disinfecting wipe. An interview on 9/4/2024 at 11:25am with the Assistant Director of Nurses (ADON) revealed that blood pressure cuffs and other shared equipment is to be cleaned before and after use and in between each resident. CNA JJ, revealed at 9/5/2024 at 2:55 pm, that she was nervous, and should not have told me that she had cleaned and disinfected the blood pressure cuff in between use, as observed the shift prior.

Based on interviews, record review and review of the facility's policies Skilled Nursing Services Grievance/Concern Guidelines for Patients and Missing Items, the facility failed to appropriately resolve grievances and provide a reasonable expected time frame for completing the review of the grievances related to lost personal items for three of 13 sampled residents (R) (R1, R2, and R8). Findings include: Review of facility's policy titled, Skilled Nursing Services Grievance/Concern Guidelines for Patients dated 12/29/2023, under the Policy Statement revealed, It is also the intent of the center to support each patient's right to voice concerns and to assure that after receiving a concern/grievance, we will actively seek a resolution and keep the patient (or representative) apprised of our progress toward resolution . Under the section titled, Guidelines revealed, Patients will be provided with reasonable expected time frames for completion. lf the concern is not resolved within three business days, the administrator /designee should give a written response to the complainant. Review of the facility's policy titled, Missing Items dated 12/29/2023 under the section Guideline revealed, A complaint of missing items will be investigated through an established procedure. Under the section titled, Additional Instructions revealed, Department staff should actively search for the missing item as soon as it is identified as missing .Within 24 hours or the next business day, if the item is not located the Social/Patient Services Director (or designee) will meet or talk with the person making the complaint to get any further applicable information. The Social/Patient Services Director should be responsible for adding items that have been lost or reported stolen to the tracking system. Results of the investigation should be documented in the investigation portion of the tracking system. 1. Review of facilities grievance logs one year from March 2023 to March 2024 revealed only one grievance form from R1's family, who had multiple complaints and allegations. Interview on 3/21/2024 at 2:33 pm with R1's family revealed that resident had multiple clothing items that went missing and were never found, or reimbursed back in April 2023 when the facility did her laundry. Interview on 3/25/2024 at 6:00 pm with Social Service Specialist HH regarding grievances revealed she was not sure why only one grievance dated 12/19/2023 was documented for R1 (which was not related to lost items) that the family reported back in April 2023. Interview on 4/2/2024 at 4:00 pm with R1 family revealed that the family had bought more clothes for the resident and that the family would try to lock them up in her room because they did not trust that the facility would keep them safe. 2. Review of a grievance dated 2/7/2024 filed by R2 for missing dresses, jogging outfits, t-shirt, and a black jacket revealed there was no evidence that a follow up was completed by the social service department until 3/25/2024 during the survey investigation. 3. Review of facility grievance logs revealed a grievance dated 9/28/2022 filed by R8 for missing a large amount of her clothes including half of all her dresses. There was no resolution of these missing items was documented as being resolved. Interview on 3/25/2024 at 12:45 pm with Administrator revealed they did not have a policy or guidelines for laundry services for the residents. She also revealed that the laundry supervisor's last day was March 2024 and that she was actively looking for a new supervisor. She acknowledged that their lost and found process needed improvement. She stated that they needed to work on it and put a better process in place based on timeliness. Interview 3/25/2024 at 1:00 pm with Laundry Staff LLL revealed there was a backup of linen and towels for residents on all halls. She also revealed resident laundry was picked up two times in the mornings and two times in the evening. She reported that when morning laundry was completed, they would return the laundry that afternoon and the evening laundry would be returned the next day. She reported if an item was lost or did not have a label on it, it would be placed on the lost and found rack if no one claimed them. She stated the unclaimed lost and found was kept for an unknown period in a container in the conference room, however she was not sure what happened to them after that. Interview on 3/25/2024 at 1:50 pm with the Administrator revealed that grievances are reported to the social service department and within two to three business days the expectations were to get back with the family for residents who had lost items such as clothing. The Administrator reported the labeling should be done by the family. She reported if the items were not labeled and got lost, they would put them in the lost and found. Interview on 3/25/2024 at 2:40 pm with Social Service Specialist HH revealed that the process for grievances was once a grievance is filed, it would be sent to the proper department about the lost items to investigate the grievance. Social Service Specialist HH stated after the investigation, a follow-up should be done within 14 days.

Based on observation, record review, resident and staff interviews, the facility failed to offer one of 13 sampled residents (R) (R2) the choice for showers and to facilitate scheduled shower times that would accommodate the needs of the resident. This failure had the potential to affect the resident's comfort, body image and increase the risk for infections. Findings include: Review of R2's face sheet revealed she admitted with the following diagnoses that included bilateral amputee, end stage renal disease on hemodialysis. Review R2's Admission Minimum Data Set (MDS) dated [DATE] revealed Section C-Cognitive Pattern, a Brief Interview of Mental Status (BIMS) score of 13 which indicated she was cognitively intact; Section F-Preferences for Customary Routine and Activities indicated it was somewhat important to her to choose what clothes to wear and choose between a tub bath, shower, bed bath or sponge bath. Section GG-Functional Abilities and Goals revealed she was dependent on ADL care needs; Section H-Bladder and Bowel indicated no toileting program, frequent urinary and bowel incontinence. Review of the facility's shower sheets revealed that R2's shower days were scheduled for Mondays and Thursdays. Further review of the facility provided shower sheets dated 3/25/2024 revealed she received a bed bath; on 3/28/2024 she refused shower, and on 4/1/2024 refused shower times three and a bed bath was given; R2 stated she was tired after being dialyzed. No other shower sheets were provided. Interview on 3/25/2024 at 3:36 pm with Dialysis Social Worker (DSW) NNN revealed R2 was scheduled dialysis on Monday, Wednesday, and Saturdays. DSW NNN revealed that she was at the clinic once a week and in January and it was reported to her that the resident arrived for treatment in the same clothing, she had on from the previous Friday to the following Monday session. DSW NNN reported, R2 smelled like feces and her hair appeared matted and greasy at that visit. DSW NNN reported that the resident told her she had only one shower since she had been admitted to the facility. Observation and Interview on 3/25/2024 at 4:35vpm revealed R2 returned from dialysis and staff was providing her a bed bath. R2 revealed it was her shower day, but staff did not offer her a shower and she was unsure why. She verified that she only had one shower since she had been admitted in November 2023 and had been given bed/sponge baths instead. Interview on 3/25/2024 at 4:35pm with CNA AAA, who was providing R2 a bed bath revealed that she was not sure if the resident should be getting a shower instead of bed bath. CNA AAA reported she did not offer R2 a shower and had not ever given her a shower. R2 revealed that she was not aware that she could have a shower but would like to have a shower. R2 reported she was never offered a shower since she had been at the facility. CNA AAA who was at R2's bedside then proceeded to offer the resident a shower. Interview on 3/26/2024 at 12:02 pm with CNA AAA revealed that R2 had never been given a shower and did not recall offering her shower until yesterday although resident had been on the shower schedule for Monday and Wednesday. CNA AAA reported she had not offered her a shower and gave her sponge baths because she thought the resident would not like showers because of her foot and legs not being there. CNA AAA revealed she agreed that the resident should still be offered a shower. Interview on 3/26/2024 at 12:15 pm with CNA ZZ, revealed that she had been assigned to R2 often but had not offered R2 a shower. Interview on 4/2/2024 at 2:40 pm with R2 revealed that she finally got a shower recently and stated that it felt so good to have the water running on me. She revealed that she wasn't aware that she could have a shower. Interview on 4/2/2024 at 5:45 pm with the Director of Nursing (DON) revealed that R2 was care planned for showers on Wednesday and Saturday evenings. DON confirmed that R2 was not on the Daily Showers list although care planned for showers twice per week. DON was not sure why the resident had not been given a shower and confirmed there was no documentation of refusals or that resident had been given a shower. She further revealed that the resident shower days were on her dialysis days which did not accommodate the residents' needs. Cross Reference F656

Based on staff and resident interviews, record review and review of the facility's policy titled, Activity of Daily living (ADL) Plan of Care, the facility failed to develop a person-centered care plan for one of 13 sampled residents (R) (R2) related to bath/shower preferences. Findings Include: Review of facility policy for ADL Plan of Care dated 12/29/2023 Intent statement revealed, Develop and communicate patient needs for assistance with an ADLs. Record review of R2's face sheet revealed diagnoses that included bilateral amputee, end stage renal disease on hemodialysis. Review of the Admission Minimum Data Set (MDS) for R2's dated 12/4/2023 revealed Section C-Cognitive Pattern, a Brief Interview of Mental Status (BIMS) score of 13 which indicated she was cognitively intact; Section F-Preferences for Customary Routine and Activities indicated it was somewhat important to her to choose what clothes to wear and choose between a tub bath, shower, bed bath or sponge bath. Section GG-Functional Abilities and Goals revealed she was dependent on ADL care needs. Review of facility's ADL Care Plans revealed that the CNA documented the resident's needs on the ADL care plan; however, the ADL care failed to include R2's shower and bathing preferences. Review of R2's care plans dated 3/13/2024 revealed there were no care area/problem, goals or interventions related to showers and bathing preferences. Observation and Interview on 3/25/2024 at 4:35pm revealed R2 returned from dialysis and staff was providing her a bed bath. R2 revealed it was her shower day, but staff did not offer her a shower and she was unsure why. She verified that she only had one shower since she had been admitted in November 2023 and had been given bed/sponge baths instead. Interview on 3/25/2024 at 11:16 pm with the Director of Nursing (DON) revealed that ADL care needs are documented on the resident's ADL care plans. Interview on 3/25/2024 at 4:35 pm with CNA AAA, who was providing R2 a bed bath revealed that she was not sure if the resident should be getting a shower instead of bed bath. CNA AAA reported she did not offer R2 a shower and had not ever given her a shower. R2 revealed that she was not aware that she could have a shower but would like to have a shower. R2 reported she was never offered a shower since she had been at the facility. Interview on 4/2/2024 at 5:45 pm with the DON revealed that R2 was care planned for showers on Wednesday and Saturday evenings. DON confirmed that R2 was not on the Daily Showers list although care planned for showers twice per week. Cross Reference F561

Based on observations, interviews, and record review, the facility failed to have operating mechanical lifts readily available for use to provide care for one of 13 sampled residents (R) (R13) reviewed. Findings include: Review of R13's Annual Minimum Data Set, dated dated dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of nine which indicated moderate cognitive impairment, and dependent for all Activities of Daily Living (ADL) needs with use of a mechanical lift; diagnoses included but not limited to arthritis, Alzheimer's Disease, Cerebrovascular Accident, dementia and hemiplegia or hemiparesis. Observation on 3/20/2024 at 9:40 am revealed multiple items on both sides of hallways on all five halls consisting of mechanical lifts not in use at that time with most of them not plugged into the power socket to keep them charged and readily available for use. Observation and Interview on 3/27/2024 at 12:30 pm on hallway B revealed one mechanical lift near R13's room, who was sitting in his wheelchair in his room and called out to the surveyor asking to be put back in his bed. Interview with R13 revealed his butt was hurting him, and he needed to lay down. He stated he had been waiting long enough to watch a show. This surveyor informed Certified Nurse Assistant CNA (BBB) that R13 needed help. CNA BBB responded that the resident would need a mechanical lift and the one near his room was not charged for use and therefore resident would need to wait. She also revealed that there were 13 working mechanical lifts. Interview on 3/27/2024 at 3:45 pm with the Director of Nursing (DON) revealed that there was an issue with the mechanical lifts, but the issue should be resolved because the facility bought new mechanical lifts and they had approval to purchase two more mechanical lifts. She further revealed that an in service was completed and that if a resident needed use of a mechanical lift, staff should get another working lift to assist the resident. DON further revealed that all mechanical lifts should always be charged for immediate use.

Based on record review, observations, and interviews, the facility failed to ensure that the call light was kept within reach for one resident (R) (R #114), of 23 sampled residents. Findings include: A policy related to call light use was requested from the facility, but the facility did not have a policy. A review of R#114's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 3 out of 15, which indicated the resident had severe cognitive impairment. The resident required extensive assistance by two staff for bed mobility. The resident was totally dependent on two staff for transfers, dressing, and toilet use. The resident required extensive assistance by one staff member for personal hygiene. The care plan dated 5/25/22, revealed the resident was at risk for falls related to a history of falls, and impaired mobility. The interventions included to keep the call light and most frequently used personal items within reach and to remind the patient to call when needing assistance. Observation on 6/7/22 at 12:25 p.m., the call light in R#114's room was observed to be pinned to the bedsheet on the right side of the bed. R#114 was unable to reach the call light because he could not use his right hand. He attempted to reach the call light with his left hand but was unable to reach it. Observation on 6/8/22 at 3:34 p.m., R#114 was in the room, sitting up in bed watching television. The call light was clipped to the sheet on the right side of the bed. R#114 was not able to reach the call light when he attempted. Observation and concurrent interview on 6/9/22 at 8:52 a.m., R#114 was in his room, sitting in bed, and finishing up breakfast. The call light was clipped to the sheet on the upper right side of the bed. He said he could not see or reach the call light. Interview on 6/9/22 at 8:53 a.m., Certified Nurse Aide (CNA) NN stated the call light should be in reach of the residents so they could let staff know if they needed something. She explained if a resident was paralyzed on the left side, then the call light should be on the right side or if the resident was paralyzed on the right side the call light should be on the left side. CNA NN said R#114 was paralyzed on the right side and the call light should be on left side of the resident. CNA NN confirmed the call light was clipped to the sheet on the upper right side of the bed. R#114 told the CNA he could not see the call light or reach it. CNA NN repositioned the resident and placed the call light on the bedside table on the left side of the bed within reach of the resident. Interview on 6/9/22 at 9:06 a.m., Licensed Practical Nurse (LPN) OO said the call lights should be within reach of all residents to access easily. She said the call light was the way for residents to communicate their needs. LPN OO said if residents were weak on one side, then the call light needed to be on the side the resident could use. She said most residents had the call light clipped on the bedsheet or near their hand. LPN OO explained because R#114 had a stroke with right-side weakness, the call light should be on the left side, near the residents' hand. She said the resident could not use the call light if it was on the right side. LPN OO said it was important for the call light to be near the resident in case they needed something and added the resident had to be able to reach it. She stated the resident could be hurt or something and would not be able to get her attention without it in reach. Interview on 6/10/22 at 1:09 p.m., with the Director of Nursing (DON) and Administrator, the DON stated the call lights should be accessible to the residents. She stated if they were in bed then the call light needed to be on the bed, and if the residents were in the wheelchair the call light needed to be within reach. The DON stated it was important to have the call lights within reach in case the residents needed anything, and the call light was used to alert the staff. The DON stated a possible negative outcome could be in the event of an emergency the resident would not have access to a call light. The Administrator stated the call light must be within reach as well as knowing the residents' barriers and strengths. She also stated if the call light was not in reach, it could affect the resident's quality of life and care, and not having the call light within reach could be detrimental to the resident's wellbeing.

Based on observation, interview, record review and review of the facility's policy, the facility failed to develop a comprehensive care plan for transfers for one of one resident reviewed for falls (Resident (R) #4). Staff were to use a Hoyer lift for transferring R#4; this was not care planned and the resident sustained [REDACTED]. Findings include: Review of R#4's clinical record revealed an admission date of [DATE]; [DIAGNOSES REDACTED]. Review of R#4's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS revealed the resident required extensive assistance of two people for bed mobility and toileting, did not ambulate and required total assistance of two people with transfers. The activity of moving from a seated to standing position, walking, turning around and facing the opposite direction while walking and moving on and off the toilet did not occur. The resident was not steady and only able to stabilize with staff assistance with surface-to-surface transfers. The MDS documented R#4 did not have any falls since the previous assessment. Review of the comprehensive care plan dated 1/3/2020 addressing falls listed the following interventions: activity referral; assess contributing factors related to fall history; assess medications for contributing factors; assist resident with activities of daily living (ADLs) and mobility as needed; bed in low position; keep call light and most frequently used personal items within reach; keep personal items within reach; mat at bedside; pharmacy consultant referral; redirect; remind resident to call when needing assistance; social services referral; therapy referral; toileting. Encourage resident to call for assistance; walker; wheelchair. The care plan did not address the resident's need for the Hoyer lift (sling lift) for transfers. The care plan lacked any guidance regarding how many staff and which equipment was needed for transferring R#4. Review of R#4's Certified Nurse Aide (CNA) care plan, dated 2/8/2020, revealed the resident required the use of the Hoyer lift (sling lift) with an extra-large size lift pad and two staff for transfers. The CNA care plan was kept on the computer system used by the CNA to document care on and not part of the comprehensive care plan. Review of the Nurse's Note dated 2/8/2020 at 2:41 p.m. revealed, at approximately 12:30 p.m. R #4 was in the process of being transferred by two CNAs with the Hoyer lift when she began to slide down. At that time, the staff lowered the resident to the floor and placed her in a supine position and notified the nurse. Review of R#4's right femur x-ray dated 2/8/2020, revealed a comminuted oblique fracture (an oblique fracture has an angled line across the shaft and a comminuted fracture is broken into three or more pieces) of the distal femur. Interview with CNA NN on 11/20/2020 at 2:03 p.m. revealed she and another CNA were helping the resident get from the bed to the bathroom. CNA NN stated one of the resident's feet came off the platform and she put it back on and then the other foot came off the platform, and the CNAs gradually sat her on the floor. CNA NN identified the lift they were using as the Stand-Up lift and not the Hoyer lift that was identified in the CNA care plan. Observation and interview with ADON HH on 11/20/2020 at 1:00 p.m. revealed she identified the Stand- Up Lift as the lift utilized for the transfer of R#4 when she was assisted to the floor and not the Hoyer Lift. Interview with the DON and Administrator on 11/12/2020 at 1:00 p.m. revealed the Hoyer lift would not fit in the resident's bathroom. The Sit to Stand Lift was the only lift that would fit in the bathrooms. Review of the Inferior Health Sit to Stand Lift Criteria revealed the resident must be able to sit forward in a chair or sit unsupported on the edge of the bed; be able to hold onto both handles on the lift; be able to keep both feet flat on the footplate of the lift throughout the transfer; be able to actively straighten their hips with the lift. Review of the policy, ADL Plan of Care (activities of daily living) dated February 2020 revealed the comprehensive plan of care would determine if the resident has an identified need for assistance with ADL care and the resident's ADL care plan would communicate the level of assistance required for the resident. The facility failed to develop a comprehensive care plan, which included use of the correct mechanical lift; the resident fell and sustained a fracture to the right femur.

Based on observation, interview, and record review, the facility failed to ensure one of three residents reviewed for abuse (Resident (R) #15) was free from abuse. The facility failed to prevent staff to resident physical abuse with resulting injury to R#15. Findings include: Review of R#15's Face Sheet dated 11/9/2020 reflected that R#15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R#15's Quarterly Minimum Data Set ((MDS) dated [DATE] reflected a Basic Interview for Mental Status (BIMS) score of four indicating severe cognitive deficit, no moods, no behaviors, the requirement for extensive support and two (2) person assistance with mobility, total support and two person assistance with dressing, transfers, toileting, personal hygiene, and bathing, and total support with one person assistance for eating. R#15 had an indwelling urinary catheter in place and was always incontinent of bowel. R#15 was administered scheduled pain medications, daily insulin injections, antianxiety and antidepressant medications, and had no skin breakdown with preventative skin protective measures in place. R#15 received restorative therapy two of seven days of the reporting period. Review of R#15's care plan updated 11/3/2020 reflected that R#15 was care planned for: -Depression with interventions including administer medication, monitor labs as ordered, and monitor resident closely; -Social isolation with interventions including assign buddy and gradually increase participation in group activities; -Cognitive impairment with interventions including allow patient ample time to absorb information and explain all procedures; -Communication with interventions including anticipate needs and ask patient to repeat words as needed; -Vision impairment with interventions including assist with meals as needed and ensure glasses are clean; -Self-care deficit with interventions including assist bars to bed and assist patient with meals; -Pain with interventions including administer medications as ordered and encourage socialization. An observation of R#15 on 11/10/2020 at 9:45 a.m. revealed R#15 resting on her back in bed, lying slightly to her left side, with her eyes closed. Her bed was against the wall next to the window. R#15 was noted to be clean and without odor. R#15 had an indwelling urinary catheter in place with a privacy bag, and a pressure reducing mattress was in place and in operation. R#15 did not respond to the surveyor. There was no roommate present in the room. No bruising or skin discolorations were observed on R#15. Review of Nursing Notes dated 1/14/2020 reflected that Registered Nurse (RN) HH had been notified of bruising the morning of 1/14/2020 by another staff member and had immediately assessed R#15. RN HH documented the incident including notifications to management, the Nurse Practitioner (NP), who was on site at the time of the assessment, and the responsible party, who had come into the facility shortly after the assessment. The notes reflected that R#15 did not complain of pain and that an X-ray was ordered and ice applied to the bruised area. The wound care nurse, Licensed Practical Nurse (LPN) FF also assessed R#15's left palm on 1/14/2020 and documented that there was bruising around digits four (4) and five (5) (ring finger and little finger, respectively). Review of the facility's investigation of the allegation of abuse dated 1/14/2020 related to the bruising on R#15's left hand reflected Certified Nursing Assistant (CNA) PP, who had provided care on the morning of 1/14/2020, was immediately suspended and subsequently terminated for cause. The investigation reflected that notifications to the Physician, Responsible Party (RP), and regulatory authorities were made on 1/14/2020. X-rays were performed in the facility on 1/14/2020 and revealed an impression of proximal [MEDICAL CONDITION] phalanx (the little finger at the base near the palm) and R#15 was transported to the emergency room immediately for care. Further radiological studies at the hospital reflected the fracture was of indeterminate origin due to osteoporotic changes (reduced bone density) and the hospital records reflected that the injury was a contusion (deep bruise). Hospital records reflected that R#15 did not require further treatment and R#15 was returned to the facility with orders for Tylenol for pain as needed and ice to the affected area. Further review of nursing notes reflected that R#15 did not complain of pain to the left hand after returning from the hospital. Undated records supplied by the facility reflected that the incident investigation was reported to the State Survey Agency (SSA). The investigation was thorough and reflected multiple interviews with the resident and statements from staff members. The injury was not witnessed by another staff member and R#15's roommate was not in the facility at the time; however, consistent statements by R#15 that described the incident that resulted in injury, along with statements by staff members about observations of R#15 before the discovery of the injury, caused the facility to determine that the injury had been caused by CNA PP during the provision of care on the morning of 1/14/2020. CNA PP did not admit to being rough with R#15 or causing the injury, and her statement indicated that she did not know anything about R#15's hand discoloration. CNA PP was not available for interview and her phone had been disconnected. R#15 stated to the RP on the date of the incident and to the Administrator during the facility investigation that CNA PP was the staff member who hurt her but R#15 was not interviewable during the investigation. During an interview on 11/14/2020 at 4:10 p.m., R#15's RP stated she had come into the facility to visit R#15 on 1/14/2020 at approximately 11:00 a.m. She stated R#15 told her that her left hand hurt and told her that a CNA had pushed her hand against the bedframe with force when R#15 resisted bathing/hygiene care. R#15's RP stated that R#15 was consistently able to describe the incident and identified CNA PP as the staff member who had hurt her. R#15's RP stated that she was very concerned about this report and immediately took pictures of R#15's left hand and went to speak to RN HH. R#15's RP stated that she subsequently accompanied R#15 during treatment and then to the hospital. R#15's RP stated that she thought the facility management had appropriately handled the situation but that she was upset that it happened. During an interview with Registered Nurse (RN) HH on 11/9/2020 at 10:26 a.m. revealed that she did not remember the specifics of the injury, but that she recalled reporting the incident at the time. She stated she always immediately reported and documented any situations that she thought could possibly be mistreatment or abuse and referred the surveyor to the records for further questions. During an interview with Licensed Practical Nurse (LPN) DD on 11/10/2020 at 9:50 a.m. revealed that she was familiar with R#15, but that she did not care for R#15 often. She stated that R#15 became upset during care at times but she had had no concerns about caring for R#15 and was unaware of any previous injury to R#15. During an interview with the Administrator on 11/9/2020 at 2:40 p.m. revealed that she was the abuse coordinator for the facility and that she had conducted the investigation of R#15's incident of 1/14/2020. The Administrator provided a copy of the investigation of the incident and stated that the CNA PP had been suspended from duties immediately upon discovery of the injury to R#15, and that CNA PP had been terminated due to the statements of R#15. She stated that the facility held upon on-hire and ongoing abuse and neglect training for all staff including additional in-services after the incident. During an interview with the Social Services Director on 11/10/2020 at 11:40 a.m. revealed that she always documented and reported any concerns or complaints about potential abuse. The Social Services Director did not recall the incident with R#15 but stated she had spoken to R#15's family members and she did not recall any specific concerns that they had reported to her. She stated the facility held ongoing in-services for staff about abuse and neglect including reporting of suspicious injuries. Review of facility policy titled, Abuse Prohibition updated 2/2020 reflected that each patient has the right to be free from .physical .abuse .and the purpose of these procedures is . to prevent any occurrences of any form of .abuse .of any patient. Patients in our center will not be subjected to abuse by anyone (including but not limited to: center staff .). Abuse is defined as the willful inaction of injury .with resulting physical harm, pain, or mental anguish. WILLFUL .means the individual must have acted deliberately, not the individual must have intended to inflict injury or harm. The policy further reflected that the center will identify .situations in which abuse .is more likely to occur. This will include an analysis of .the supervision of staff to identify inappropriate behaviors, such as .rough handling .and the assessment, care planning, and monitoring of patients with needs and behaviors which might lead to conflict .such as patients with communication disorders, those that require heavy nursing care and/or are totally dependent on staff.

Based on observation, interview, record review and facility policy review, the facility failed to transfer one of one residents reviewed for falls (Resident (R) #4) with the appropriate lift and in accordance with the Certified Nurse Aide (CNA) care plan. This failure resulted in acutal harm due to a [MEDICAL CONDITION]'s right femur (thigh bone) when she was lowered to the floor. Findings include: Review of R#4's closed clinical record revealed an admission date of [DATE] and the [DIAGNOSES REDACTED]. Review of the clinical record revealed R#4 was discharged from the facility on 2/15/2020. Review of the current Fall Risk assessment dated [DATE] revealed a score of 12, with a score of seven (7) to 18 placing the resident at a high risk for falls. Review of R#4's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident displayed verbal behaviors one (1) to three (3) days of the seven (7) day observation period. The MDS revealed the resident required extensive assistance of two (2) people for bed mobility and toileting, did not ambulate and required total assistance of two (2) people with transfers. The activity of moving from a seated to standing position, walking, turning around and facing the opposite direction while walking and moving on and off the toilet did not occur. The resident was not steady and only able to stabilize with staff assistance with surface-to-surface transfers. The MDS documented R#4 did not have any falls since the previous assessment. Review of the fall care plan reviewed on 1/3/2020 listed the interventions: activity referral; assess contributing factors related to fall history; assess medications for contributing factors; assist resident with activities of daily living (ADLs) and mobility as needed; bed in low position; keep call light and most frequently used personal items within reach; keep personal items within reach; mat at bedside; pharmacy consultant referral; redirect; remind resident to call when needing assistance; social services referral; therapy referral; toileting. Encourage resident to call for assistance; walker; wheelchair. The care plan did not address the resident's need for the Hoyer lift (sling lift). Review of R#4's Certified Nurse Aide (CNA) care plan, identified on 2/8/2020 the resident required the use of the Hoyer lift with an extra-large size lift pad and two (2) staff for transfers. Review of the Nurse's Note dated 2/8/2020 at 2:41 p.m. revealed, at approximately 12:30 p.m., R#4 was in the process of being transferred by two CNAs with the Hoyer lift when she began to slide down. At that time, the staff lowered the resident to the floor and placed her in a supine position (lying horizontally with the face and torso facing up) and notified the nurse. According to the Nurse's Note, the resident did not fall or hit her head and there were no visible injuries at this time. Range of motion (ROM) was checked and was within normal limits. Review of R#4's Nurse's Note dated 2/8/2020 at 4:17 p.m. revealed the resident complained of pain in the right lower extremity. An order was received for x-rays of the right lower extremity. Review of R#4's right femur x-ray dated 2/8/2020, revealed a comminuted oblique fracture (an oblique fracture has an angled line across the shaft and a comminuted fracture is broken into three or more pieces) of the distal femur. Review of the Nurse's Note dated 2/9/2020 at 7:54 a.m. revealed R#4 was transferred to the hospital for the fractured femur, never returned to the facility and was officially discharged on [DATE]. Review of the facility's investigation revealed: Accident/Incident - Initial Note, revealed on 2/8/2020 the resident was in process of being transferred by a lift and when she began to slide down to the floor, two (2) CNAs assisted the resident to the floor. The resident was placed in bed. The noted indicated the resident was being transferred from the Hoyer lift with two (2)person assist. The statement from CNA OO dated 2/9/2020 revealed, while taking her to the bathroom her left leg slipped off {and} then tried to put the foot back to the original position. Then the other one (1) slipped off having her to a kneeling position. {CNA} and I tried to put her back to bed but she was lower than the bed so we gently help lower her to the floor. The statement from CNA NN dated 2/19/2020 revealed, We strapped the {slings} accordingly and started rolling the lift towards the bathroom door. As we got close to the entrance, {resident's} left foot slipped out of the lift platform. {CNA OO} tried to put the foot back to its original position, the next foot slipped out keeping her in a kneeling position. We immediately tried to return her back to the bed but she was lower than the height of the bed for the lift to fit in. At that point {resident} pulled herself out of the strap of the sling. {CNA} and I now assisted her to the floor. The Inservice Sign-In Form dated 2/10/2020 revealed Assistant Director of Nursing (ADON) HH provided training on how to use the lift and to make sure two (2) staff were used each time. The training did not specify which lift the training was referring to. Observation and interview with ADON HH on 11/20/2020 at 1:00 p.m. revealed she identified the Stand-Up Lift as the lift utilized for the transfer of R#4 when she was assisted to the floor. ADON HH also stated she utilized the term Hoyer Lift for either the Hoyer Lift or the Stand-up Lift. Interview with the DON on 11/10/2020 at 1:14 p.m. revealed R#4 fell on a Saturday and when she returned to the facility on Monday, R#4 was already in the hospital. The DON stated staff were transferring R#4 to the bathroom and R#4 slid to the floor. The DON also stated the facility did not interview R#4 regarding the fall. The DON stated the nurse working on 2/8/2020 was an agency nurse and CNA OO was no longer working at the facility. Interview with CNA NN on 11/20/2020 at 2:03 p.m. revealed she and another CNA were helping the resident get from the bed to the bathroom. CNA NN stated one (1) of the resident's feet came off the platform and she put it back on and then the other foot came off the platform, and they gradually sat her on the floor. CNA NN identified the lift they were using as the Stand-Up lift and not the Hoyer lift as directed in the CNA care plan. Interview with the DON and Administrator on 11/12/2020 at 1:00 p.m. revealed the Hoyer lift would not fit in the resident's bathroom. The Sit to Stand Lift was the only lift that would fit in the bathrooms. The DON confirmed therapy had not been involved in the assessment of the use of the lifts. Review of the policy, Using a Portable Lifting Machine dated 2/2020 revealed the resident's plan of care or nurse's clinical judgment should direct if a lift should be used, which type of lift was appropriate, and the amount of support required. Mechanical lifts should be used, as appropriate when transferring residents to promote resident safety and comfort as well as to promote workplace safety for associate. Review of the policy, Fall Management dated 2/2020 revealed, when a fall occurs the facility should interview the resident to determine possible cause of the fall. Review of the (Brand) Sit to Stand Lift Criteria revealed the resident must be able to sit forward in a chair or sit unsupported on the edge of the bed; be able to hold onto both handles on the lift; be able to keep both feet flat on the footplate of the lift throughout the transfer; be able to actively straighten their hips with the lift. The facility failed to complete a thorough investigation of the fall to determine how the staff were transferring the resident prior to the fall and failed to transfer the resident as care planned with a Hoyer lift resulting in R#4 and sustaining a fracture to the right femur during a transfer by staff.

Based on interview, record review and facility policy review, the facility failed to initiate discharge planning and provide discharge instructions for one (1) of three (3) residents reviewed for discharge planning. (Resident (R) #2). Findings include: Review of R#2's clinical record revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. R#2 resided on the locked memory care unit. Review of R#2's Five Day Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of four (4), indicating severe cognitive impairment. The resident displayed other type of behavior one (1) to three (3) days during the seven (7) day observation period. The resident required extensive with bed mobility, dressing, toilet use, personal hygiene and bathing. The MDS revealed the R#2 received occupational and physical therapy services and expected to be discharged to the community. Review of R#2's care plan revealed the care area for Discharge Plan was initiated on 3/16/2020. The interventions included: assess resident's overall expectations concerning discharge, discuss discharge planning goals with resident and representatives, and invite resident and family to discharge planning conferences to educate about resident's progress toward rehabilitation goals as well as discuss discharge expectations. Review of the clinical record lacked evidence these interventions were completed. Review of R#2's 4/7/2020 MDS revealed Part A (skilled services) were discontinued. Review of the Involuntary Discharge Letter dated 4/8/2020 revealed R#2 would be discharged on [DATE] for a past due balance. The Certified Signature Receipt revealed the Responsible Party (RP) received the letter on 4/11/2020. Review of the Nurse Note's dated 4/10/2020 at 1:15 p.m. revealed R#2 was discharged to home. The resident was picked up by transportation around 12:24 p.m. and left in stable condition. Routine medications were taken along with his personal belongings. As needed (prn) [MEDICATION NAME] was left behind mistakenly. Review of R#2's, undated, Discharge Instructions For Care revealed the Follow-Up Physician Care, Home Health referral and Durable Medical equipment delivery were left blank. Eight medications (8), including [MEDICATION NAME] (used to help with sleep), [MEDICATION NAME] (anti-depressant), [MEDICATION NAME] sprinkles (used as a mood enhancer), and [MEDICATION NAME] (used to treat anxiety) were listed. Further review of the medication section included an area for Quantity Sent with the Resident, Prescription sent with the Resident, and Prescription sent to the Pharmacy. The facility did not document in any of these sections. Further review of the Discharge Instructions For Care revealed the section, I understand and accept responsibility of this medication regimen and have taken possession of applicable medications. The signature section for the resident/responsible party and the signature of the releasing nurse were left blank along with the date of discharge. Interview with Licensed Practical Nurse (LPN) JJ on 11/11/2020 at 10:05 a.m. revealed on the Discharge Instructions form, the nurse should document how many days of each medication was sent with the resident. If 10 days or less of medications were sent, then a prescription was also sent with the resident. Interview with Assistant Director of Nursing (ADON) HH on 11/11/2020 at 10:16 a.m. revealed on discharge the nurse should count each medication with the resident or RP and document the count on the discharge sheet. The facility should send one week of medications with the resident. Interview with the Director of Nursing (DON) on 11/11/2020 at 12:43 p.m. revealed Social Services started the discharge planning. Social Services would contact a Home Health agency to see if the resident would benefit from their services. The nurses started the discharge instructions. The DON also stated if the resident was cognitively impaired, the facility would have the family come in and receive the discharge instructions and sign the form. Interview with the Social Worker (SW) on 11/11/2020 at 12:53 p.m. revealed on admission, they asked the resident and/or RP if the goal was to discharge. If the goal was to discharge, they would start a care plan for discharge. When discharge was approaching, they would talk with the resident and/or RP about Home Health and equipment available to assist with the care of the resident. The SW was unable to find documentation in the clinical record that this occurred for R#2. Attempted to reach the family member who R#2 was discharged to on 11/10/2020 at 12:17 p.m. was unsuccessful. A message was left for the family member to call surveyor back. No return call was received. Review of the policy, discharged Patient's Medications and Orders updated 12/2019 revealed, discharge medications are counted and documented in the permanent medical record. Both the nurse releasing the medication and the resident or RP receiving the medication must sign the record acknowledging transmission and receipt of this information. The facility failed to provide discharge planning for R#2 and failed to provide complete Discharge Instructions for Care.

Based on observation, record review, resident and staff interview, the facility failed to implement the care plan related to performing weekly skin assessments for one resident (R) (R#147), who developed a facility-acquired pressure ulcer. In addition, the facility failed to implement the care plan related to two-person assist for activities of daily living for one ventilator-dependent resident (R#65). The sample size was 56 residents. Findings include: 1. Review of R#147's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that she had one unstageable pressure ulcer, and one venous or arterial ulcer. Review of R#147's high-risk for pressure ulcer development care plan reviewed on 8/2/19 revealed an intervention dated 7/1/18 for weekly skin inspections. Review of R#147's Skin Data assessments revealed: 11/2/18, 11/9/18, 11/16/18, 11/23/18, 11/30/18, 12/28/18: No wound. No heel discoloration. 11/27/18: Wound-yes. Right anterior thigh blister. No heel discoloration. Continued review of the Skin Data assessments revealed no evidence that a skin assessment was performed for R#147 between 11/30/19 and 12/28/18. Review of R#147's Wound Report revealed that a facility-acquired SDTI (suspected deep tissue injury) was identified to the right heel on 1/4/19, measuring 6.0 centimeters (cm) long by 6.0 cm wide. Further review of this Wound Report revealed that R#147 also had facility-acquired arterial ischemic ulcers identified on 1/4/19 to the left heel; right great toe; all five toes of the left foot; and left medial ankle. Observation of R#147's wound care performed by Licensed Practical Nurse (LPN) Treatment Nurse AA on 8/13/19 at 10:07 a.m. revealed that there was an circular-shaped open area over the right medial heel, measured by the nurse as 2.3 centimeters (cm) long by 2.0 cm wide. Further observation revealed the upper and lower edges of the wound contained tannish-colored slough, and the treatment nurse stated because of this she would not measure the depth of the pressure ulcer, and would consider the wound to be unstageable. During interview with LPN Treatment Nurse AA on 8/15/19 at 10:01 a.m., she stated that starting around (MONTH) of this year, skin assessments were done by one of the three treatment nurses for all residents once a month, and that the charge nurses did skin assessments on all residents weekly on the weeks not done by a treatment nurse. She further stated that before this there was only one treatment nurse, so the charge nurses had to do all of the weekly skin assessments. She verified that there was no evidence that a skin assessment was done for R#147 between 11/30/18 and 12/28/18, and did not know why. During interview with the Director of Nursing on 8/15/19 at 3:33 p.m., she stated that skin assessments were done by a combination of the treatment nurses and charge nurses weekly. During interview with LPN Treatment Nurse BB at this time, she stated that the management team did skin sweeps of all the residents in the facility to obtain a baseline of any skin issues around (MONTH) and (MONTH) of (YEAR), because there was only one treatment nurse at that time, and they determined that the charge nurses were not doing the weekly skin assessments consistently. Review of the facility's wound Prevention Measures policy updated (MONTH) 2019 revealed: 4. A skin assessment should be performed weekly for four weeks with admissions and readmissions. Ongoing weekly skin assessments should be performed on patients identified at high risk for pressure ulcers. Cross-refer to F 686. 2. Resident (R)#65 was a [AGE] year-old [MEDICAL CONDITION]/ventilator-dependent (trach/vent) male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The advanced directives documented full code status. The Annual Minimum Data Set assessment dated [DATE] documented the Brief Interview for Mental Status (BIMS) score as 13, indicating he was cognitively intact. The functional status was documented as total dependent/two-person assist for bed mobility, dressing, toilet use, personal hygiene, and bathing. The Activities of Daily Living (ADL) plan of care documented R#65's self-performance as Total Dependence requiring the support of two people for bed mobility, dressing, toilet use, personal hygiene, and bathing. During an interview with R#65 in his room on 8/12/19 at 2:34 p.m., he stated in the last month or so, only one Certified Nursing Assistant (CNA) has assisted him with his routine ADLs, particularly on the night shift (11 p.m.-7:00 p.m.) but he feels it is faster and safer to use two caregivers consistently due to his [MEDICAL CONDITION] and his inability to assist his caregivers. He stated he gets very anxious when there's only one caregiver. He stated the one-person assist was not the care he was used to and would like to go back to routinely using two caregivers to support him. Review of the clinical record for ADLs from 6/1/19 through 8/11/19 documented ADL tasks completed by one CNA for identified tasks assessed for two-person assist on the following dates: 1. Bed Mobility: 6/9/19 (2:46 a.m.), 6/14/19 (1:51 a.m.), 6/23/19 (3:24 a.m.), 6/25/19 (6:32 a.m.), 6/28/19 (1:47 a.m.), 7/6/19 (1:13 a.m.), 7/18/19 (6:26 a.m.), 7/22/19 (9:55 p.m.), 7/28/19 (12:38 p.m.), 7/31/19 (6:36 a.m.), 8/2/19 (3:15 a.m.), 8/3/19 (1:04 a.m.), 8/4/19 (3:28 a.m.), 8/5/19 (3:34 a.m.), 8/7/19 (7:00 a.m.), 8/8/19 (4:10 a.m.), 8/9/19 (1:59 a.m.) 2. Dressing: 6/8/19 (4:37 a.m.), 6/26/19 (8:13 p.m.), 7/22/19 (9:56 p.m.), 7/28/19 (12:38 p.m.) 3. Personal Hygiene: 6/4/19 (8:40 p.m.), 6/8/19 (4:37 p.m.), 6/9/19 (2:46 p.m.), 6/10/19 (1:26 p.m.), 6/14/19 (1:51 a.m.), 6/15/19 (8:56 p.m.), 6/16/19 (7:42 p.m.), 6/17/19 (12:22 a.m.), 6/18/19 (12:15 p.m., 7:26 p.m.), 6/19/19 (12:47 p.m.), 6/20/19 (12:16 p.m.), 6/23/19 (3:24 a.m.), 6/25/19 (6:34 a.m.), 6/26/19 (8:13 p.m.), 7/1/19 (5:43 p.m.), 7/1/19 (1:39 p.m.), 7/5/19 (2:47 p.m.), 7/6/19 (1:13 a.m.), 7/18/19 (6:26 a.m.), 7/22/19 (9:59 p.m.), 7/28/19 (12:38 p.m.), 7/31/19 (6:36 a.m.), 8/2/19 (3:15 a.m.), 8/3/19 (1:03 a.m.), 8/4/19 (3:28 a.m.), 8/5/19 (3:34 a.m.), 8/7/19 (11:40 p.m.), 8/8/19 (4:10 a.m.), 8/9/19 (1:57 a.m.), 8/10/19 (11:09 p.m.) 4. Toilet-bladder: 6/3/19 (5:27 a.m.), 6/8/19 (4:37 a.m.), 6/9/19 (2:46 a.m.), 6/14/19 (1:51 a.m.), 6/17/19 (12:22 p.m.), 6/22/19 (1:07 a.m.), 6/23/19 (3:24 a.m.), 6/25/19 (6:30 a.m.), 6/26/19 (5:17 a.m., 8:12 p.m.), 6/28/19 (1:47 a.m.), 7/1/19 (5:42 a.m.), 7/6/19 (1:13 a.m.), 7/7/19 (4:02 a.m.), 7/18/19 (6:25 a.m.) 5. Toilet-bowel: 6/1/19 (6:46 a.m.), 7/14/19 (11:40 a.m.) During an interview with the Ventilator Unit Manager on 8/15/19 at 3:15 p.m., she stated she educates and inservices respiratory therapists (RT), nurses and CNAs on hire, quarterly, and as needed to always use two-person assist when moving a trach/vent resident to prevent accidental dislodging of [MEDICAL CONDITION]. She stated she has observed staff nurses assisting and supporting CNAs in the vent unit for resident safety and customer service. She stated two-person assist for trach/vent residents was clinical standard as well as the facility's and the ventilator contractor's policy for trach/vent residents. During an interview on 8/15/19 at 3:28 p.m. with CNA CC, she stated had no problem getting help to assist her with a trach/vent resident. She stated she was trained to use two-person assist for ADLs with a trach/vent resident. She could offer no explanation for why she only documented one-person assist on some of the shifts she worked with R#65 except she probably couldn't get anyone to assist her at those times. She stated the vent unit usually schedules two CNAs to cover unless someone calls out or the vent unit census is low. She stated she did her best to keep R#65 safe in the process but, in the future, she would be sure to wait for another CNA or nurse to assist with ADLs for the trach/vent residents. During an interview on 8/15/19 at 3:40 p.m. with CNA DD, she stated she was trained to use two-person assist for all total-dependent, trach/vent residents. She stated she understood the danger of [MEDICAL CONDITION] dislodging and was careful to get help when moving R#65. She stated usually there is enough staff on the night shift to easily get help when she needs it. During an interview with Licensed Practical Nurse (LPN) EE on 8/15/19 at 3:50 p.m., she stated she was trained to follow the ADL care plan which calls for two-person assist for all ADLs for R#65. She stated staffing was adequate on night shift to provide appropriate care for the vent unit. During an interview with LPN FF on 8/15/19 at 4:05 p.m., she stated she always gets help when she needs to move a trach/vent resident. She stated there are enough CNAs on night shift to get help when they need it to care for and protect her residents. She stated she was educated about care for trach/vent residents when hired but inservices go on all the time. In an interview with the Staff Development Coordinator on 8/15/19 at 4:15 p.m., she stated she does not specifically educate staff for the vent unit but does provide support training after the RT manager does the orientation and ongoing training. In an interview with the Director of Nurses (DON) on 8/15/19 at 4:30 p.m., she stated she was not aware of individual CNAs performing ADL care on R#65 or any other trach/vent resident with only one-person assist. She stated she expected all clinical staff to follow the ADL Plan of Care at all times, which is available on electronic tablets that CNAs document in. In an interview with the Corporate Nurse Consultant on 8/15/19 at 4:40 p.m., she stated she expected the facility staff to follow the ADL P[NAME] for all residents and understood the significance of keeping R#65 and other residents safe and free from anxiety about their safety. She stated she would begin staff education immediately.

Based on observation, record review, resident, Nurse Practitioner and staff interview, the facility failed to consistently perform weekly skin assessments and/or perform accurate skin assessments, and failed to provide evidence that weekly wound measurements and descriptions were done for one resident(R) (R#147), who had a facility-acquired pressure ulcer. A total of four residents were reviewed for pressure ulcers. Findings include: Review of R#147's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of R#147's Pressure Ulcer Risk assessment dated [DATE] revealed she was assessed as moderate risk for pressure ulcer development. Review of R#147's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 15 (a BIMS score between 13 and 15 indicates that a resident has no cognitive deficits), that she needed extensive assistance for bed mobility, had one unstageable pressure ulcer, and one venous or arterial ulcer. Review of R#147's high-risk for pressure ulcer development care plan reviewed on 8/2/19 revealed an intervention dated 7/1/18 for weekly skin inspections. Review of an at risk for/actual skin breakdown care plan reviewed on 8/2/19 revealed that R#147 had a pressure ulcer and arterial disease, as evidenced by a DTI (deep tissue injury) to the right heel. Review of an In House Acquired Pressure Ulcers Report revealed that R#147 had a [DIAGNOSES REDACTED]. Review of the Plan of Care for Prevention of Pressure Wounds attached to this wound report revealed one of the interventions was for weekly skin checks. Review of an Initial C[NAME] (Change of Condition) Report to MD (Medical Doctor) for R#147 dated 1/3/19 revealed: Resident observed during a.m. (morning) care with swelling of right leg, +2 [MEDICAL CONDITION], +3 of foot. A dime size open blister to back of lower leg, bruising/discoloration to tips of toes and large area of blister/discoloration to inner right heel. Drainage to top of 4th toe around nail bed. Also +1 swelling to left leg with +2 of foot. A dime size irregular shaped blister to outer ankle area. Partial nail evulsion of 4th toe nail with some bleeding around bed of nail. Also discoloration to tips of toes. Review of R#147's Skin Data assessments revealed: 11/2/18, 11/9/18, 11/16/18, 11/23/18, 11/30/18, 12/28/18: No wound. No heel discoloration. 11/27/18: Wound-yes. Right anterior thigh blister. No heel discoloration. Continued review of the Skin Data assessments revealed no evidence that a skin assessment was performed for R#147 between 11/30/19 and 12/28/18. Further review of the Skin Data assessments revealed that the staff nurse documented that R#147 had no wounds and no heel discoloration on 1/11/19 and 1/18/19 (see above C[NAME] report dated 1/3/19 listing multiple skin issues). Review of R#147's Physician's Telephone Order dated 1/10/19 revealed an order to clean the right heel with normal saline, and apply [MEDICATION NAME] iodine daily. During interview with R#147 on 8/13/19 at 9:48 a.m., she stated that earlier in the year both of her heels were hurting badly, and a test was done which revealed that she had vascular disease. R#147 further stated that she had no problems with her left heel now, but that she had a hole in her right heel which the nurse told her would take a month to heal. Observation of R#147's wound care performed by Licensed Practical Nurse (LPN) Treatment Nurse AA on 8/13/19 at 10:07 a.m. revealed that there was an circular-shaped open area over the right medial heel, measured by the nurse as 2.3 centimeters (cm) long by 2.0 cm wide. Further observation revealed the upper and lower edges of the wound contained tannish-colored slough, and the treatment nurse stated because of this she would not measure the depth of the pressure ulcer, and would consider the wound to be unstageable. Interview with LPN AA at this time revealed the right heel pressure ulcer started as a blister, and due possibly from the resident rubbing her heels on the mattress or chair. LPN AA further stated that multipodus boots were obtained for the resident to wear after the heel wound had developed. Review of R#147's Wound Report for the right heel revealed: 1/6/19: Facility acquired DTI to right heel, 6.0 cm x 6.0 cm x 0 cm. Wound base maroon/purple. Arterial doppler shows significant stenosis, vascular consult was ordered. (There were no right heel wound descriptions or measurements on this report between 1/6/19 and 3/5/19). 3/5/19: 6.0 cm x 6.0 cm x 0 cm, DTI, wound base maroon/purple. 3/12/19: 6.0 cm x 6.0 cm x 0 cm, DTI, wound base maroon/purple. Comments: eschar hard. (There were no right heel wound descriptions or measurements on this report between 3/12/19 and 4/18/19). 4/18/19: 8.4 cm x 6.0 cm x 0 cm, DTI, wound base maroon/purple. Eschar hard, 2.4 (cm) x 3.4 (cm). Medial portion of heel has white serous exudate, no odor, pain, or swelling noted, will monitor for changes. 4/26/19: 4.0 cm x 7.2 cm x 0 cm, DTI, wound base maroon/purple. Hard black eschar. 5/2/19: 4.0 cm x 7.2 cm x 0 cm, hard black eschar. 6/6/19: 4.8 cm x 3.6 cm x 0 cm, unstageable with eschar. (A left heel pressure ulcer was documented as resolved on this date). 7/4/19: 3.6 cm x 3.6 cm x 0 cm, with eschar. 8/1/19: 3.0 cm x 2.2 cm x 0.2 cm. During interview with LPN Treatment Nurse AA on 8/15/19 at 10:01 a.m., she stated that starting around (MONTH) of this year, skin assessments were done by one of the three treatment nurses for all residents once a month, and that the charge nurses did skin assessments on all residents weekly on the weeks not done by a treatment nurse. She further stated that before this there was only one treatment nurse, so the charge nurses had to do all of the weekly skin assessments. She verified that there was no evidence that a skin assessment was done for R#147 between 11/30/18 and 12/28/18, and did not know why. LPN AA stated that wound measurements and descriptions were done by the treatment nurses weekly, and verified that there were no wound notes with measurements or descriptions done in February, none done between 3/12/19 and 4/18/19, and did not know how they were missed. She verified during continued interview that the right heel wound was larger when the wound assessment was done on 4/18/19 from the last assessment done on 3/12/19, but that the treatment was not changed as the wound still contained intact eschar. During interview with R#147's Nurse Practitioner on 8/15/19 at 1:32 p.m., she stated that once the facility went from having one to having three treatment nurses, that communication about resident wounds had gotten much better. She further stated that she could not recall if the treatment nurse had notified her that the right heel pressure ulcer had gotten larger and now had white serous exudate in (MONTH) (on 4/18/19). During interview with LPN Treatment Nurse AA on 8/15/19 at 2:29 p.m., she stated that she was unable to find any documentation of measurements or description of R#147's right heel wound in February, or from 3/12/19 to 4/18/19. She further stated that she did not report to the physician or Nurse Practitioner when the wound was larger on 4/18/19, because the wound was not infected and felt the [MEDICATION NAME] ([MEDICATION NAME] iodine) treatment was still the appropriate treatment. During interview with the facility's Corporate Registered Nurse Consultant on 8/15/19 at 2:40 p.m., she stated that she would expect staff to use their clinical discretion on whether to notify the physician if a pressure ulcer had become larger. During interview with the Director of Nursing on 8/15/19 at 3:33 p.m., she stated that there was a PRN (as needed) treatment nurse that was called and remembered doing at least one of R#147's wound reports on paper instead of in the computer. The DON stated during continued interview that skin assessments were done by a combination of the treatment nurses and charge nurses weekly, and measurements of wounds were done by the treatment nurses weekly and recorded on the wound report in the computer. The DON further stated that the physician should have been notified when the wound assessment that was done on 4/18/19 revealed that R#147's right heel wound was larger than the previous measurement on 3/5/19. During interview with LPN Treatment Nurse BB at this time, she stated that the Wound Reports were printed weekly and given to the DON, Assistant DON, and Administrator, but that if a resident's wound was missing off that report for some reason, they would not know it. During further interview with LPN BB, she stated that the management team did skin sweeps of all the residents in the facility to obtain a baseline of any skin issues around (MONTH) and (MONTH) of (YEAR), because there was only one treatment nurse at that time, and they determined that the charge nurses were not doing the weekly skin assessments consistently. Review of the facility's Wound Measurements procedure updated (MONTH) (YEAR) revealed: Measure (the wound) on admission/readmission, weekly and with any major change. Review of the facility's wound Prevention Measures policy updated (MONTH) 2019 revealed: 3. At risk is defined according to the Pressure Ulcer Risk for predicting pressure ulcer risk (numerical rating of 18 and below), completion of the comprehensive MDS with the CAA (Care Area Assessment), presence of recent history of pressure ulcer or by clinical assessment and judgment. Consider advancing to the next level of risk if a comprehensive review of the patient warrants. 4. A skin assessment should be performed weekly for four weeks with admissions and readmissions. Ongoing weekly skin assessments should be performed on patients identified at high risk for pressure ulcers. Review of the facility's treatment of [REDACTED]. Intent: It is the intent of this center using a multidisciplinary approach to provide a comprehensive treatment plan designated to meet the individual patient's goal, as well as, provide necessary medical treatment to patients with pressure ulcers that prevents infection, deterioration of the ulcers and/or prevents the development of additional pressure ulcers in keeping with the patient's medical condition.

Based on review of facility records, policies, incident reports , staff interviews and an interview with the hospital physician, it was determined the facility failed to provide adequate bed mobility assistance to prevent an avoidable accident, specifically, a fall for Resident (R) #1, resulting in harm to one (1) of five (5) residents reviewed for falls, of a total sample of eleven (11) residents. Findings include: Resident #1 was re-admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Interview on 12/4/17 at 12:54 p.m. with Certified Nursing Assistant (CNA) AA revealed that when the fall occurred, she was changing R#1 in bed and had to turn him to get to his ostomy. CNA AA further revealed she did know that she needed to get another person to help move him and added, she used a pillow to roll him over but should not have done it alone. When asked about R#1's care planned interventions she revealed, she knew the care plan said two people were required for assistance with bed mobility for resident and added, the incident was a mistake. Interview on 12/4/17 at 12:06 p.m. with Licensed Practical Nurse (LPN)/Unit Manager DD revealed, the CNA Care Plan Worksheet shows that R#1 was totally dependent for assistance from two people for bed mobility and CNAs get a copy of the baseline care plan from the Activities of Daily Living (ADL) book. Interview on 12/4/17 at 2:10 p.m., with the facility Director of Nursing (DON) revealed, the ADL services provided by CNAs are guided by the CNA Care Plan Worksheet. The DON agreed that the baseline care plan, effective 11/3/17, indicated the resident required the assistance of two people for bed mobility. Interview on 12/4/17 at 2:38 p.m. with the facility Registered Nurse /Assistant Director of Nursing (RN/ADON), revealed, CNA AA made a mistake with moving R#1 by herself and there needs to be two people for his bed mobility. The RN/ADON further revealed, the staff do huddles before each shift and the nurse describes what is going on, they also ask questions of other CNAs, and CNAs need to clarify with the nurse whether residents require a two person assist. The RN/ADON added, he personally assessed R#1 for mobility on 11/3/17 and is aware R#1 required two person assistance for bed mobility at that time. He further added that he put the requirements on R#1's baseline care plan form on 11/3/17 but, the facility had not had time to share it with the CNAs yet. Interview on 12/5/17 at 6:36 p.m. with the facility's Administrator revealed she believes the mobility on the CNA care plan worksheet covers bed mobility and that is what the CNAs have been trained on and should understand. Phone interview on 12/12/17 at 3:40 p.m. with hospital physician GG revealed R#1 was admitted to the intensive care unit of the hospital on [DATE] with a head wound that required sutures and had a [MEDICAL CONDITION] vertebral body as a result of the fall. Physician GG further revealed the fall, in combination with R#1's [DIAGNOSES REDACTED]. Review of a facility policy titled, Grievances and dated 2004-2017 indicated: The center will identify, correct and intervene in situations in which abuse or neglect is more likely to occur. This will include analysis of: The deployment of staff on each shift in sufficient numbers to meet the needs of the patients, and assure that the staff assigned has knowledge of each individual patient's care needs. Review of the facility Incident Report Form faxed to the State Survey Agency (SSA) dated 11/15/17 indicated the date and time of incident was on 11/15/17 during the 11:00 p.m. to 7:00 a.m. shift. Details of the incident indicated that R#1 was observed on the floor, on his back, bleeding from the forehead. Assessment revealed a laceration to the forehead and Steri-strips and pressure was applied to his head. Resident complained of pain in the forehead and both shoulders. Review of the facility Notice of Transfer or Discharge form indicated R#1 was transported to the emergency roiagnom on [DATE] due to the fall with injury. Review of CNA AA written statement dated 11/15/17 regarding slip/fall with injury, indicated that at 6:00 a.m., she was rolling R#1 to wash/clean him up for the day, he rolled/slipped off the bed onto the floor. Review of a facility Corrective Action Improvement Plan for CNA AA dated 11/15/17 indicated CNA AA was suspended 11/15/17 through 11/19/17 for a performance issue because R#1 rolled out of bed while CNA AA was providing care. Goals for improvement of behavior/performance included: Will inform charge nurse of all changes in condition if resident requires more assistance, will inform charge nurse. Review of the facility Baseline Care Plan dated 11/3/17 and signed by the Assistant Director of Nursing (RN/ADON) indicated R#1 is a bilateral above the knee [MEDICAL CONDITION] and is totally dependent on staff for bed mobility and requires a mechanical lift for transfers with two person assistance. Review of the undated CNA Care Plan Worksheet for R#1 indicated he is two person assistance for mobility with a mechanical lift for transfers. Devices listed for assistance with his mobility included: wheelchair and [MEDICAL CONDITION] sling. Further record review revealed fall risk evaluations dated 9/4/17 and 11/4/17, and a comprehensive falls assessment dated [DATE] for R#1 that indicated he was at high risk for falls. Review of the facility Situation, Background, Assessment, Recommendation (SBAR) Communication Form dated 5/26/17 indicated, the date and time of a fall incident on 5/26/17 at 2:45 p.m. Details of incident indicated R#1 reported to staff that he was dropped on the floor after a staff member attempted to pick him up and transfer him from the chair to the bed on the previous day. Change in conditions, symptoms listed included, swelling/pain to the right arm. Review of progress notes dated 5/26/17 revealed the responsible party (RP) was contacted via telephone for notification of occurrence. The RP informed staff that the resident had swelling in his right arm due to multiple IV therapies during recent hospitalization and he also had a Doppler study just to make sure no blood clots were present. Employee was suspended pending outcome of the investigation and did not work again with resident. Review the facility Corrective Action Improvement Plan for CNA EE dated 5/30/17 indicated a Tier 1 Verbal Warning based on a safe patient handling guidelines violation related to incident on 5/25/17 during the 3:00 p.m. to 11:00 p.m. shift, in R#1's room. The employee stated he observed R#1 in an unsafe position and he transferred him without a lift. Goals for improvement of behavior/performance included; CNA EE will adhere to the guidelines of safe patient handling.

Based on record review of facility records and staff interview the facility failed to revise the comprehensive care plan related to bed mobility assistance requirements for one (1) of five (5) sampled residents, of a total sample of eleven (11) residents. Findings include: Review of Resident (R#1)'s Minimum Data Set ((MDS) dated [DATE], Section G- Functional Status revealed R#1 required two-person, full staff, physical assistance for bed mobility and transfers. Review of the comprehensive care plans for R#1 dated 5/23/17, 7/24/17 and 11/21/17 indicated Resident (R) #1 requires extensive assistance with all Activities of Daily Living (ADLs) but did not indicate that resident requires two-person assistance with mobility or bed mobility. Review of the facility Baseline Care Plan dated 11/3/17 and signed by the Registered Nurse/Assistant Director of Nursing (RN/ADON) indicated R#1 is a bilateral above the knee [MEDICAL CONDITION] and is totally dependent on staff for bed mobility and requires a mechanical lift for transfers with two-person assistance. Review of undated Certified Nursing Assistant Care Plan Worksheet for R#1 indicated he is two-person assistance for mobility with a mechanical lift for transfers. Devices listed for assistance with his mobility included: wheelchair and [MEDICAL CONDITION] sling. Further record review revealed fall risk evaluations dated 9/4/17 and 11/4/17, and a comprehensive falls assessment dated [DATE] for R#1 that indicated he was at high risk for falls. Interview on 12/4/17 at 11:57 a.m. with RN/Minimum Data Set Coordinator FF revealed, she completed an assessment on R#1 after he was already in the hospital after the fall. She based that assessment on the Activities of Daily Living (ADL) flow sheet and talking to the staff indicating he was a total assist. Interview on 12/4/17 at 2:10 p.m., with the facility Director of Nursing (DON) revealed, the ADL services provided by CNAs are guided by the CNA Care Plan Worksheet. When asked did she understand that per the baseline care plan, effective 11/3/17, the resident required two people for bed mobility, the DON replied yes, I do understand that. The DON further added, the facility has created new baseline care plans that have not been shared with the CNAs yet, and she planned to have CNAs trained on the new baseline care plans by 12/7/17. Interview on 12/5/17 at 6:36 p.m. with the facility Administrator revealed she believes the mobility on the CNA care plan worksheet covers bed mobility and that is what the CNAs have been trained on and should understand.