Every finding on record at Pruitthealth - Rome

Based on observations, staff and family interviews, record reviews, and review of the facility policy titled Care Plan, the facility failed to develop and implement the care plan for three of 24 sampled residents (R113, R85, and R53) related to (1) developing a care plan for verbalization/refusal of Activities of Daily Living (ADL) care for R113; (2) developing a care plan for Range of Motion (ROM) and implementing a care plan related to nail care and oral care for R85; and (3) implementing a care plan related to nail care for R53. Actual harm was identified to have occurred on 1/13/2026, when Certified Nursing Assistant (CNA) EE failed to implement interventions for R113 during Activities of Daily Living (ADL) care, resulting in R113 sliding from the wheelchair onto the floor and sustaining a right femur fracture.Findings included:1. A review of the electronic medical record (EMR) revealed that R113 was admitted to the facility on [DATE], with diagnoses including, but not limited to, Alzheimer's disease, major depressive disorder, generalized anxiety disorder, schizoaffective disorder, osteoarthritis, and abnormalities of gait/mobility. A review of the quarterly Minimum Data Set (MDS) assessment for R113, dated 1/6/2026, documented a Brief Interview for Mental Status (BIMS) score of 99, indicating severe cognitive impairment with the inability to complete the interview.A review of the care plan for R113 revealed no care plan in place for intermittent verbalization/refusal of ADL care. During a telephone interview on 2/17/2026 at 4:55 pm, CNA EE revealed that when she entered R113's room on 1/13/2026, she could tell that she was already agitated. She stated that in her attempt to assist R113 with ADL care, R113 slid from the wheelchair onto the floor on her left side.A review of the progress notes dated 1/13/2026 documented that at 7:51 am, R113 had a witnessed fall by staff while being adjusted on her wheelchair and sustained a supracondylar fracture to the right femur.2. During an observation on 2/17/2026 at 10:24 am, 2/17/2026 at 3:59 pm, and 2/19/2026 at 9:31 am, R85 was observed lying on his back with both hands tightly closed in a fist. There were no splints or rolls in the resident's hands.During an observation on 2/19/2026 at 9:37 am, CNA II was observed providing am care for R85. R85's hands were not washed; no mouth or foot care was provided. Upon completion of R85's bath, CNA II removed R85's socks, which showed the great toe was thickened with a buildup of debris beneath the toenail. The nails appeared to have a yellowish discoloration. CNA II stated they don't do anything for R85's hands. No skin or foot care was provided during this observation. CNA II stated the CNA's do not trim toenails. A review of the EMR revealed that R85 was admitted to the facility on [DATE] with diagnoses including, but not limited to, aphasia (difficulty speaking) following cerebral infarction, quadriplegia (unable to move arms and legs) related to a cerebral vascular accident (CVA), contracture, unspecified hand, contracture of muscle, multiple sites (a contracture is tightening or shortening of muscles/joints that causes them to be unable to be moved), and diabetes type 2.A review of the quarterly MDS assessment dated [DATE] documented that R85 was severely impaired - never/rarely made decisions, and was dependent on staff for personal hygiene, including combing hair, shaving, washing/drying face, hands, and nail care.A review of the care plan dated 1/28/2026 revealed R85 was dependent on staff for dressing, oral hygiene, personal hygiene, and bathing. The care plan specified checking nails for cleanliness and ensuring they are clean. There were no care plan interventions related to upper extremity contractures or range of motion.During an interview on 2/19/2026 at 10:50 am, Licensed Practical Nurse (LPN) JJ stated that R85 did not have any resident-specific interventions for nail care and confirmed that there was no care plan for contractures. The care plan only specified turning and repositioning on rounds. LPN JJ verified there was no documentation that showed the resident refused care or that care planned interventions were tried.3. During an observation on 2/17/2026 at 10:33 am, R53's fingernails were observed to be long and jagged. R53 stated he had asked for them to be cut a while ago, and added his toenails were really long. R53 removed his shoes and socks, which revealed that his toenails were overgrown on both feet, curling into the skin. The toenails were cloudy/tan colored and were curled up on the side of the nails, pulling away from the nailbed.A record review of the EMR revealed that R53 was admitted to the facility on [DATE], with diagnoses including, but not limited to, vascular dementia, emphysema, and chronic obstructive pulmonary disease.A review of the admission MDS assessment dated [DATE] revealed a BIMS score of nine, indicating that R53 had moderate cognitive impairment. A record review of the admission MDS assessment dated [DATE], revealed that R53 required staff assistance for set up/cleanup for personal hygiene.A review of the care plan for R53, with a start date of 9/3/2025, revealed R53 experienced an ADL self-care decline related to recent hospitalization, and an approach included, but was not limited to, checking nails and ensuring they are clean.A review of the care plan revealed that R53 required staff assistance for ADL care. R53's care plan specified that staff should check nails and ensure they are clean. During an interview on 2/18/2026 at 1:05 pm, CNA KK stated that all CNAs can trim fingernails. Podiatry comes every two months. CNA KK stated that usually she does nailcare during the shower. She stated she does not do toenails.During an interview on 2/19/2026 at 10:40 am, CNA MM stated she trimmed R53's nails. CNA MM stated the shower aid should be doing nail care. The shower aid can trim nails as long as they are not diabetic. CNA MM stated she trimmed R53's nails and said it was painful, but felt better when it was done. CNA MM stated she did not know who normally trimmed R53's nails. During an interview on 2/19/2026 at 11:27 am, the Director of Health Services (DHS) stated she talked to the NP, and she confirmed that R53's toenails were long. The DHS stated that a resident-specific care plan would identify the needs of each resident and that care plans are supposed to be resident-specific.During an interview on 2/19/2026 at 10:50 am, LPN JJ stated R53 did not have resident-specific interventions for nail care. LPN JJ verified there was no documentation that the resident refused care or had care planned interventions tried or documented.A review of the facility's policy titled Comprehensive Care Plans, implemented in March 2025, revealed that the care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. All services provided or arranged by the facility, as outlined by the comprehensive care plan, must meet professional standards of quality and incorporate culturally competent and trauma-informed care as indicated. The comprehensive care plan will be prepared by an interdisciplinary team that includes, but is not limited to, the resident and the resident's representative, to the extent practicable, and other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. A review of the policy titled Care Plan, revised 10/21/2025, documented that the care plan approach serves as instructions for the patient/resident's care and provides continuity of care by all partners. When approaches that involve the CNA have been added to the care plan, those approaches should also be included on the CNA Care Record or Resident Profile/Care Plan. Updates to the care plans should be made with any changes in condition at the time the change in condition occurred. Care plans will be updated by nurses, Case Mix Directors (CMD), or any other interdisciplinary team member so that the care plan will reflect the patient/resident's needs at any given moment.

Based on observations, staff interviews, record reviews, and review of the facility policies titled Occurrences and Dementia Care Policy, the facility failed to ensure the safety of one of three residents (R) (R113) reviewed for falls. Actual harm was identified to have occurred on 1/13/2026, when Certified Nursing Assistant (CNA) EE failed to implement interventions for R113 during Activities of Daily Living (ADL) care, resulting in R113 sliding from the wheelchair onto the floor and sustaining a right femur fracture.Findings included:A review of the progress notes dated 1/13/2026 documented at 7:51 am revealed that R113 had a witnessed fall by staff while being adjusted on her wheelchair, that R113 slid off the wheelchair onto a sitting position with no apparent injury, that she denied pain at the time, and was assisted back in the wheelchair. Further review of the 1/13/2026 progress notes revealed that at 11:33 am, R113 complained of pain in her right leg, was given Tylenol (a pain reducer), was seen by the Nurse Practitioner, and a new order was received for a right lower extremity x-ray. At 8:27 pm, an x-ray confirmed a supracondylar fracture to the right femur. A review of the progress note dated 1/21/2026 at 9:10 am by the Director of Health Services (DHS) documented an Interdisciplinary Team (IDT) Fall note that R113 returned to the facility after a fall on 1/13/2026 while an aide was dressing the resident and that R113 slid from the edge of the wheelchair with no immediate signs of injury but later R113 complained of right leg pain. Nurse Practitioner in the facility visited R113 and ordered a mobile x-ray that showed a right femur fracture. R113 was sent to the local emergency room for evaluation and treatment.A review of the electronic medical record revealed that R113 was admitted to the facility on [DATE], with diagnoses including but not limited to Alzheimer's disease, major depressive disorder, generalized anxiety disorder, schizoaffective disorder, osteoarthritis, and abnormalities of gait/mobility. A review of the quarterly Minimum Data Set (MDS) assessment for R113, dated 1/6/2026, documented a Brief Interview for Mental Status (BIMS) score of 99, indicating severe cognitive impairment with inability to complete the interview, severely impaired daily decision making, and inattention with disorganized thinking was continuously present, and is dependent with upper and lower body dressing.A review of a facility's in-service sign-in sheet dated 8/18/2025 revealed a topic of Care of Combative Resident that stated, If a resident becomes combative or agitated during care, stop care, redirect/diffuse if possible, and obtain resident safety and dignity, then go for help. If you are unable to leave the resident, yell for assistance and use the call light. Stop actions causing behaviors. It was observed that CNA EE signed the sheet as being in attendance for the training.A review of a facility's in-service sign-in sheet dated 10/7/2025 revealed a topic that stated, If a resident becomes combative/agitated during care, STOP, Reassess Situation, ensure resident safety and dignity, and get help. If unable to leave, use the call light and yell for help if needed. It was observed that CNA EE signed the sheet as being in attendance for the training.During a telephone interview on 2/17/2026 at 4:55 pm, CNA EE revealed that when she entered R113's room on 1/13/2026, she could tell that she was already agitated. She stated that she was assisting R113 to put on a shirt that had to be pulled over the top of her head and that R113 was pushing against her to get the shirt off. She stated that she was pushing the shirt down when the resident slid from the wheelchair onto the floor on her left side. CNA EE stated she called for the nurse, the nurse came into the room to assess R113 and found no injury. She stated that R113 was not complaining of pain at that time, so assisted R113 from the floor back into the wheelchair. She stated that she and CNA DD assisted R113 onto the edge of the bed, and it was then that she started complaining of pain in her right leg. She said she notified the nurse. CNA EE stated that she redirects a resident who has negative behaviors and would not necessarily call for assistance. She stated that there are times when a resident has negative behaviors that she will walk away and give them a while before returning and trying again, but she did not feel she needed to do that with R113 because she can just redirect her. CNA EE stated that she received education related to how to deal with residents with behaviors.During a telephone interview on 2/18/2026 at 11:00 am, a family member of R113 revealed that on the day of the fall, a CNA was attempting to assist R113 with putting on her top while she was agitated and resisting. The family member stated that R113 usually had 2 to 3 people assist her and cannot understand why the CNA did not stop when R113 was agitated and she slipped out of the wheelchair and sustained a fracture.During an interview on 2/18/2026 at 2:54 pm, the Education Coordinator revealed that in a situation where a resident becomes physically resistant to care and agitated during changing their clothes, she would expect staff to ensure the resident was decent and then get help, but not to leave the resident until assuring the safety of the resident. Education Coordinator stated for the situation with R113 when she slid from her chair with the CNA present on 1/13/2026, she would hope that the CNA would have stopped when R113 began trying to pull off the shirt while the CNA was trying to put it on her, especially if she knew she was already agitated and if necessary, yell out for help but not leave the resident to ensure her safety.During an interview on 2/19/2026 at 12:21 pm, the DHS revealed that for residents with behaviors that could result in potential injury to self or staff, the staff receive regular education related to how to care for residents with dementia and behaviors. She stated that specific education related to challenging behaviors is provided regularly through in-house staff, providing education as well as online. The DHS stated it was her expectation that staff would stop what they are doing and retrieve additional help when a resident is agitated, resistant to care, and unable to be redirected.A review of the facility policy titled Occurrences, revised 1/11/2024, documented Policy Statement: The healthcare center recognizes that due to the frailty of the patients/residents served, there is an increased risk of occurrences that may result in injury to the patient/resident and/or others. To prevent occurrences, each patient/resident will be observed and assessed for risks. Appropriate, realistic interventions will be implemented in accordance with their care plan.A review of the facility policy titled Dementia Care Policy, revised 10/19/2021, documented Policy Statement: [Name of the facility] recognizes that no single strategy is sufficient and some residents with dementia will need a combination of approaches that might include prescribing of appropriate medications and specialized psychological interventions. Procedure: 2. [Name of the facility] partners are encouraged to see residents with dementia as a whole person and accept their reality. 3. [Name of facility] partners are required to treat residents with dementia with respect and dignity. 4. Approaches to providing care for residents with dementia include: a. Communication 2. Be mindful of non-verbal communication. 7. Don't argue or contradict. 9. Slow down (slower is faster). Be patient and give the resident time to respond without feeling rushed.

Based on observation, staff interviews, and review of facility policies titled Labeling, Dating, and Storage, the facility failed to ensure food items, stored in two of the two kitchen refrigerators and one of one freezer were properly dated and labeled; that one of three male kitchen staff wore facial hair restraints during food preparation; two of two fans were dirty and blowing on clear dishes and food preparation area. These failures have the potential to compromise food safety, impair sanitation practices, and increase the risk of foodborne illness for 87 of 89 residents who receive meals prepared in the facility's kitchen.Findings included:During the initial tour of the kitchen on 2/17/2026 at 9:30 am, observation revealed dirty fans in the dishwashing area over the dirty area, but was blowing toward the clean area. One fan was observed in the corner near the three-compartment sink, blowing towards the food preparation area.During an observation of the walk-in refrigerator on 2/18/2026 at 9:36 am, two pitchers of a yellowish liquid were observed with no label or date; one box of opened juice carton was observed with no open date; and a jar of grape jelly was observed with no date when opened.During an observation on 2/18/2026 at 1:22 pm, in the main refrigerator, condiments (barbecue sauce and pickles) were observed open and without an open date. On the bottom rack, cooked bacon was observed in a bag on top of raw bacon. In the freezer, there were two plastic bags not in the original container and with no label or date. The Food Service Director (FSD) confirmed the findings.During an interview on 2/18/2026 at 1:29 pm, the FSD revealed that staff are supposed to label food products once opened with the date. She stated that she educates monthly, and the last in-service was in February 2026 on infection control and cross-contamination. The last in-service on labeling was conducted in October 2025 or November 2025.During an interview on 2/18/2026 at 1:44 pm, the Maintenance Director and Maintenance Assistant confirmed the fans in the kitchen were dirty. The Maintenance Director stated that he had not been informed that this was their responsibility.During an observation on 2/19/2026 at 1:57 pm, the evening dietary cook was in the middle of the preparation area with no facial covering over his beard.During an interview on 2/19/2026 at 1:59 pm, the evening dietary cook revealed he has been working at the facility for 10 years. He stated he was aware of the process of wearing a hair and beard net in the kitchen.During an interview on 2/20/2026 at 1:47 pm, the Administrator revealed her expectation in the kitchen is to be sanitary and that quality food is important. She stated that hair nets are at the door and are to be worn at all times in the kitchen. Anyone who enters the kitchen must have head restraints, such as a head covering and beard covering. She further revealed that the dietary staff is expected to date and label all food.A review of the facility's policy titled Labeling, Dating, and Storage, revised on 11/11/2022 revealed that food and beverage items will have identifying label as well as received date and open date, as applicable; for items prepared onsite, a use by date will also be indicated and that food will be stored in their original or approved container and, if opened, shall be wrapped tightly with film, foil, etc.No policy provided for head restraints while working and preparing food in the kitchen.No policy provided for maintaining and cleaning the fans in the kitchen.

Based on observations, staff and resident interviews, record review, and review of the facility policy titled Specialty Services: Dental Services, Vision Services, Podiatry, the facility failed to ensure Activities of Daily Living (ADL) care was provided for two of two sampled residents (R) (R53 and R85) related to toenail care.Findings included:1. During an observation on 2/17/2026 at 10:33 am, R53's fingernails were observed to be long and jagged. R53 stated he had asked for them to be cut a while ago, and added his toenails were really long. R53 removed his shoes and socks, which revealed that his toenails were overgrown on both feet, curling into the skin. The toenails were cloudy/tan colored and were curled up on the side of the nails, pulling away from the nailbed.A review of the electronic medical record (EMR) revealed that R53 was admitted to the facility on [DATE], with diagnoses including, but not limited to, vascular dementia, emphysema, and chronic obstructive pulmonary disease.A review of the physician order dated 3/11/2025 revealed that R53 may have podiatry as needed.A review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed that R53 required staff assistance for set up/clean up for personal hygiene.A review of the care plan revealed that R53 required staff assistance for ADL care and specified that staff should check nails and ensure they are clean.During an interview on 2/18/2026 at 1:58 pm, the Social Worker stated that there is no documentation of R53 refusing any nail care.2. During an observation on 2/19/2026 at 9:37 am, CNA II was observed providing morning care for R85. R85's hands were not washed; no mouth or foot care was provided. Upon completion of R85's bath, CNA II removed R85's socks, which showed the great toe was thickened with a buildup of debris beneath the toenail. The nails appeared to have a yellowish discoloration. CNA II stated they don't do anything for his hands. No skin or foot care was provided. CNA II stated the CNA's do not trim toenails.A review of R85's EMR revealed that R85 was admitted to the facility on [DATE] with diagnoses included, but not limited to, aphasia (difficulty speaking) following cerebral infarction, quadriplegia (unable to move arms and legs) related to a cerebral vascular accident (CVA), contracture, unspecified hand, contracture of muscle, multiple sites (a contracture is tightening or shortening of muscles/joints that causes them to be unable to be moved), and diabetes type 2.A review of the quarterly MDS assessment dated [DATE] documented that R85 was severely impaired - never/rarely made decisions. R85 was dependent on staff for personal hygiene, including combing hair, shaving, washing/drying face and hands. R85 was dependent on staff for nail care.A review of the care plan dated 1/28/2026 revealed R85 was dependent on staff for dressing, oral hygiene, personal hygiene, baths, shave as needed. The care plan specified checking nails for cleanliness and ensuring they are clean. During an interview on 2/18/2026 at 1:05 pm, CNA KK stated that all CNAs can do fingernails. Podiatry comes every two months. CNA KK stated that usually she does nailcare during the shower. She stated she does not do toenails.During an interview on 2/18/2026 at 1:58 pm, the Social Worker stated there is a podiatrist who comes to the facility every five to six weeks and documents a resident-specific note on each resident seen at the facility. The Social Worker verified there was no documentation of podiatry care for R53 or R85 since their admission to the facility.During an interview on 2/19/2026 at 9:58 am, the Assistant Director of Health Services (ADHS) confirmed R85's toenails were too long and said that he didn't know when they were last trimmed. The ADHS measured the toenails for each foot. He said the right foot's great toe measured one-fourth of an inch over the great toe tip. The third toe measured one-fourth of an inch over the tip of the toe, and the fourth toe measured one-fourth of an inch over the tip of the toe. The fifth toe was not measurable. The ADHS stated the CNAs don't clip toenails. The ADHS proceeded to measure the left foot and stated the second toe measured one-fourth of an inch over the tip of the toe, the third toe measured one-eighth of an inch over the tip of the toe, and the fourth toe measured one-eighth of an inch over the tip of the toe. The fifth toe was not measurable. The ADHS stated he would have the Nurse Practitioner (NP) look at them. During an interview on 2/19/2026 at 10:13 am, the NP verified R53's toenails looked like there could be a fungal infection, and the nail bed was lifting on the sides. She stated R85's great toe could be fungal, but the other nail beds were just long.During an interview on 2/19/2026 at 10:30 am, Licensed Practical Nurse (LPN) LL stated that we have a podiatrist who comes about every three to five months. The aides can trim nails if they are not thick. LPN LL stated she could trim R53's toenails, but stated that since there was redness around the nail bed, it looked like he may have some circulatory issues. During an interview on 2/19/2026 at 11:27 am, the Director of Health Services (DHS) stated that the CNAs can cut toenails if the resident is not diabetic and that the Social Worker signs residents up for podiatry care.During an interview on 2/20/2026 at 2:03 pm, the DHS and RN OO stated that the CNAs perform ADL care, including bathing of the total body, including face, hands, oral care, and nail careA review of the facility policy titled Specialty Services: Dental Services, Vision Services, Podiatry, with an effective date of 11/28/2016 and last revised date of 12/6/2022, documented that it shall be the responsibility of the healthcare center to obtain regular and emergency specialty services for each patient/resident to ensure the highest well-being of the residents.

Based on observations, staff interviews, record review, and review of the facility policy titled Restorative Nursing Policy and Procedure, the facility failed to ensure that one of three sampled residents (R) (R85) received restorative services to prevent contractures and/or to prevent a decrease in range of motion (ROM) mobility.Findings included: During an observation on 2/17/2026 at 10:24 am, 3:59 pm, and on 2/19/2026 at 9:31 am, R85 was observed lying on his back with both hands tightly closed in a fist. He had no splints or hand rolls in his hands, and none were visible in the room. During an observation on 2/19/2026 at 9:37 am, Certified Nursing Assistant (CNA) II was observed providing morning Activities of Daily Living (ADL) care for R85. During this observation, the CNA did not open or wash the resident's hands, and no range of motion or lotion was provided to the resident's hands. During an interview with CNA II at this time, she stated they don't do anything for R85's hands.A review of the electronic medical record (EMR) revealed that R85 was admitted to the facility on [DATE] with diagnosis of, but not limited to, aphasia (difficulty speaking) following cerebral infarction, quadriplegia (unable to move arms and legs) related to a cerebral vascular accident (CVA), contracture, unspecified hand, contracture of muscle, multiple sites (a contracture is tightening or shortening of muscles/joints that causes them to be unable to be moved), and diabetes type 2.A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that R85 presented with a Brief Interview for Mental Status (BIMS) score of 99, indicating that R85 had severely cognitive impairment; that R85 never or rarely made decisions; that R85 was dependent on staff for personal hygiene, including combing hair, shaving, washing/drying face and hands; and that R85 had impairment on both upper extremities.A review of the care plan dated 1/28/2026 revealed R85 was dependent on staff for dressing, oral hygiene, personal hygiene, baths, shave as needed. There were no care plan interventions related to upper extremity contractures or range of motion.During an interview on 2/19/2026 at 10:50 am, Licensed Practical Nurse (LPN) JJ stated that R85 did not have resident-specific interventions, and there was no care plan for contractures. LPN JJ verified there was no documentation related to contracture management.During an interview on 2/19/2026 at 12:13 pm, the Rehabilitation Director (RD) stated R85 had an occupational therapy evaluation in October 2025, and no interventions were implemented at that time. The RD stated that R85 would certainly benefit from having either rolls or something in his hands to prevent them from continuing to contract. During an interview on 2/19/2026 at 10:50 am, LPN JJ (also the MDS Coordinator) stated there was no care plan for contractures. During an interview on 2/19/2026 at 3:19 pm, Registered Nurse (RN) PP verified that she was able to open R85's hands with passive range of motion.During an interview on 2/19/2026 at 4:23 pm, the RD stated a rehabilitation evaluation had not been completed as ordered on 1/28/2026. The RD verified there were no progress notes or orders that stated to hold therapy. She stated therapy evaluations are typically done within 48-72 hours after being ordered. She stated she had not seen the physician's order dated 1/28/2026 for rescreen.During an interview on 2/20/2026 at 12:45 pm, the RD verified that R85 was referred to receive restorative services on 5/9/2025. The RD stated that once a resident has been referred to the restorative program, they are no longer followed by the therapy department.During an interview on 2/20/2026 at 12:52 pm, RN NN (the restorative RN) stated she was unable to find documentation or any restorative notes for R85 from May 2025 to current. RN NN stated that R85 was in and out of the hospital and was never seen for any restorative services. A review of the facility policy titled Restorative Nursing Policy and Procedure, effective 2/1/2006 and revised 11/4/2021, revealed that the facility will provide restorative nursing, which actively focuses on achieving and maintaining optimal physical, mental, and psychological functions and well-being of the resident. The restorative nursing program refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. A nurse will complete the restorative nursing screening tool observation, determine appropriate restorative services based on the screening, and develop a care plan for each restorative service with measurable goals.

36190 18947 Based on observation, interview, record review, Centers for Disease Control and Prevention (CDC) guidance, and policy review, the facility failed to follow the COVID policies regarding how to contain the COVID virus and prevent the spread, in that the policies indicated 1; the door to the COVID positive residents' rooms were to be kept closed and that staff were to wear Personal Protective Equipment (PPE) of a gown, mask, face shield and gloves when upon entering resident's room to provide care to residents positive for COVID; 2. to ensure transported dishes from COVID positive residents were covered and dishes were washed at 120 degrees Fahrenheit (F) temperature to sanitize, and 3. infection control measures during medication pass were to be followed for one resident (R52). The facility failed to ensure room doors remained closed for the residents who had tested positive for COVID-19 nine of 16 residents in the long (male) 100 hallway (Resident (R)81, R20, R35, R58, R43, R33, R65, R31, and R50) and the short (female) 100 hallway failed to ensure doors were closed for five of 15 residents (R19, R36, R47, R2, and R1). Staff failed to apply proper PPE when in a COVID-positive resident's room (R35, R58, R43, and R33). The facility failed to ensure dishes removed from COVID-positive resident rooms were covered for transport to the kitchen and cleaning was done at the manufacturer's recommended temperatures. On 1/7/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 1/7/2025, at 10:20 am. The noncompliance related to the IJ was identified to have existed on 12/28/2024. An Acceptable Removal Plan was received on 1/9/2025. Based on observation, record review, a review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice were removed on 1/9/2025. The facility remained out of compliance while the facility continued management-level staff oversight as well as continuing to develop and implement a Plan of Correction (POC). This oversight process includes an analysis of the facility staff's conformance with the facility's policies and procedures governing infection control. Findings included: 1. An observation on 1/6/2025 at 10:46 am, on the long (male) 100 hallway revealed doors were open for five rooms housing R81, R20, R35, R58, R43, R33, R65, R31, and R50 and the doors had signs stating the doors were to be closed due to special droplet precautions being in place. a. A review of R81's Face Sheet, located in the electronic medical record (EMR) under the Face Sheet tab, revealed an admitted [DATE] and readmission on 1/2/2025, with medical diagnoses that included sepsis and 2019-nCoV acute respiratory disease. A review of the EMR CCD-Continuity of Care Document revealed that R81 tested positive for COVID-19 on 1/4/2025. b. A review of R20's Face Sheet located in the EMR under Face Sheet revealed an admitted d 3/2/2022 and readmission on 12/31/2024 with medical diagnoses that included contact with and (suspected) exposure to other viral communicable diseases, wheezing, and 2019-nCoV acute respiratory disease. A review of the EMR CCD-Continuity of Care Document revealed that R20 tested positive for COVID-19 on 1/4/2025. c. Review of R35's Face Sheet located in the EMR under Face Sheet revealed an admitted d 1/2/2017 and readmission on 1/2/2025 with a medical diagnosis that included pneumonia. A review of the EMR CCD-Continuity of Care Document revealed that R35 tested positive for COVID on 1/4/2025. d. A review of R58's Face Sheet located in the EMR under Face Sheet revealed an admitted d 8/30/2023 and readmission on 1/2/2025 with medical diagnoses that included diabetes Type II, and 2019-nCoV acute respiratory disease. A review of the EMR CCD-Continuity of Care Document revealed that R58 tested positive for COVID-19 on 1/4/2025. e. A review of R43's Face Sheet located in the EMR under Face Sheet revealed an admitted d 7/17/2024 and readmission on 12/19/2024 with a medical diagnosis that included unspecified dementia. A review of the EMR CCD-Continuity of Care Document revealed that R43 tested positive for COVID-19 on 1/4/2025. f. A review of R33's Face Sheet located in the EMR under Face Sheet revealed an admitted d 8/22/2018 and readmission on 11/23/2024 with medical diagnoses that included pneumonia, acute respiratory failure, and 2019-nCoV acute respiratory disease. A review of the EMR CCD-Continuity of Care Document revealed that R33 tested positive for COVID-19 on 1/4/2025. g. A review of R65's Face Sheet located in the EMR under Face Sheet revealed an admitted d 02/11/23 and readmission on 4/23/2024 with medical diagnoses that included diabetes Type II, and 2019-nCoV acute respiratory disease. A review of the EMR CCD-Continuity of Care Document revealed that R65 tested positive for COVID-19 on 1/1/2025. h. A review of R31's Face Sheet located in the EMR under Face Sheet revealed an admitted d 3/25/2015 and readmission on 9/8/2024 with medical diagnoses that included pneumonia, and 2019-NCoV acute respiratory disease. A review of the EMR CCD-Continuity of Care Document revealed that R31 tested positive for COVID-19 on 1/1/2025. i. A review of R50's Face Sheet located in the EMR under Face Sheet revealed an admitted d 8/10/2023 and readmission on 1/7/2025 with medical diagnoses that included chronic obstructive pulmonary disease (COPD), chronic respiratory failure, and 2019-CoV acute respiratory disease. A review of the EMR CCD-Continuity of Care Document revealed that R50 tested positive for COVID-19 on 1/1/2025. An observation on 1/6/2025 at 10:48 am of the short (female) 100 hallway, revealed doors were open for three rooms housing R19, R36, R47, R2, and R1 and the doors had signs stating the doors were to be closed due to special droplet precautions being in place. j. A review of R19's Face Sheet located in the EMR under Face Sheet revealed an admitted d 10/16/2024 and readmission on 12/3/2024 with medical diagnoses that included chronic obstructive pulmonary disease (COPD), chronic respiratory failure, and 2019-CoV acute respiratory disease. A review of the EMR CCD-Continuity of Care Document revealed that R19 tested positive for COVID-19 on 12/28/2024. k. A review of R36's Face Sheet located in the EMR under Face Sheet revealed an admitted d 7/1/2020 and readmission on 2/5/2023 with medical diagnoses that included chronic obstructive pulmonary disease (COPD), and 2019-CoV acute respiratory disease. A review of the EMR CCD-Continuity of Care Document revealed that R36 tested positive for COVID-19 on 12/28/2024. l. Review of R47's Face Sheet located in the EMR under Face Sheet revealed an admitted d 01/27/23 and readmission on 10/5/2024 with medical diagnoses that included wheezing and 2019-CoV acute respiratory disease. A review of the EMR CCD-Continuity of Care Document revealed that R47 tested positive for COVID-19 on 12/30/2024. m. A review of R2's Face Sheet located in the EMR under Face Sheet revealed an admitted d 11/21/2022 with medical diagnoses that included pneumonia, and 2019-CoV acute respiratory disease. A review of the EMR CCD-Continuity of Care Document revealed that R2 tested positive for COVID-19 on 12/28/2024. n. Review of R1's Face Sheet located in the EMR Face Sheet revealed an admitted d 12/24/2011 and readmission on 5/7/2024 with medical diagnoses that included spastic quadriplegic cerebral palsy, and 2019-CoV acute respiratory disease. A review of the EMR CCD-Continuity of Care Document revealed that R1 tested positive for COVID-19 on 12/28/2024. An observation on 1/6/2025 at 11:37 am revealed a Certified Nursing Assistant (CNA)3 was inside the room for R35 who was on special droplet precautions providing care by taking the resident's vital signs. CNA3 was using PPE by wearing an N95 mask and gloves only. During an interview on 1/6/2025 at 11:44 am, when questioned about wearing PPE for the care provided to R35, CNA3 said had not read the signs posted on the door that read All personnel to follow the directions below: prior to entering the room, wash hands, wear a gown and remove before exiting the room, wear an N95 mask, protective eyewear, and gloves to remove before exiting the room. An observation on 1/6/2025 at 11:30 am revealed that housekeeper (HK) 1 was cleaning the room for R43 and R33 who were on special droplet precautions. The housekeeper was using PPE by wearing an N95 mask and gloves only. During an interview on 1/6/2025 at 11:30 am, HK1 explained being told the room for R43 and R33 was not an isolation room and therefore did not wear proper PPE and did not read the signs posted on the outside of the door. During an interview on 1/6/2025 at 11:53 am, Licensed Practical Nurse (LPN)1 confirmed staff entering resident rooms who were positive for COVID were to wear proper PPE including N95 mask, gloves, gown, and eye protection. During an interview on 1/9/2025 at 12:38 pm, the Infection Control Preventionist confirmed when staff entered the resident room who was on special droplet precautions PPE to wear was an N95 mask, gloves, gown, and eye protection. A review of the facility policy titled COVID-19 Isolation and Cohorting Process, revised 11/13/2023 revealed, Ideally, residents suspected or confirmed to have COVID-19 infection should be placed in single-person room on Transmission-Based Precautions but if limited single rooms are available or numerous residents are simultaneously identified, residents should remain in their current room on Transmission-Based Precautions. The door should remain closed and ideally, they should have a dedicated bathroom. At the entrance to the resident room door, there must be Proper Signage on the door indicating Transmission-Based Precautions. STOP and only enter if Necessary and in Proper PPE. PPE will be used in each Transmission-Based Precautions room. A review of the CDC guidance titled Infection Control Guidance: SARS-CoV-2, dated 6/24/2024, found on the website: https://www.cdc.gov/covid/hcp/infection-control/index.html, revealed, Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). Ideally, the patient should have a dedicated bathroom. Health Care Personnel (HCP) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). 2. During an interview on 1/6/2025 at 10:06 am, the Dietary Manager (DM) was asked about COVID-19 procedures in the kitchen. The DM stated they used normal delivery, but the consumed meal trays were bagged at pickup and brought back to the kitchen. On 1/6/2025 at 1:34 pm, the lunch cart containing consumed trays was observed coming off the 100 COVID hall and pushed to the kitchen. None of the trays were bagged. Certified Nurse Assistant (CNA)1 was asked if trays were to be bagged and CNA1 stated, No. During a follow-up interview on 1/6/2025 at 1:38 pm, the DM was asked if the COVID-positive trays on the 100 COVID hall cart should be bagged. The DM confirmed the trays were not bagged and thought they should be. A review of the facility policy titled Dishwashing, revised 8/3/2017, provided by the facility revealed, Temperature Guide: Adhere to the Manufacturer's guidelines for appropriate temperature ranges. On 1/6/2025 at 10:07 am, the dish machine was observed with the Dietary Manager (DM) while in use. The wash cycle measured 104 degrees Fahrenheit (F), and the rinse cycle measured 110 degrees F. Dietary Aide (DA)2 was asked if the temperatures of the dish machine should be higher. DA2 stated maintenance checked the machine at the beginning of use and the temperatures were good. DA2 went on to say, As the machine is used, temperatures drop. A review of the January 2025 dish machine log, for dates 1/1/2025 through 1/6/2025 located on the wall revealed the wash cycle temperature ranged from 120 degrees F to 125 degrees F and the rinse cycle temperature ranged from 123 degrees F to 124 degrees F. On 1/6/2025 at 3:35 pm, the dish machine was observed with the DM at the end of washing the lunch dishes. The dish machine's wash cycle measured 105 degrees F, and the rinse cycle measured 118 degrees F. The dish machine's manufacturer's requirements posted on the machine were reviewed with the DM. The posted plaque revealed 120 degrees F for the wash cycle and 130 degrees F for the rinse cycle. The DM stated the dish machine company checked the dish machine last month. The DM was asked if the hot water supply was lasting long enough to get through all the dishes. The DM stated she did not know but would ask maintenance. On 1/7/2025 at 3:41 pm, the dish machine was observed in progress. The wash cycle measured 118 degrees F, and the rinse cycle measured 122 degrees F. The DM was asked again about the temperatures. The DM stated the dish machine company would be at the facility on 1/7/2025 to check it. A review of the facility policy titled COVID-19 Infection Prevention and Control Practices, revised 6/25/2024 revealed, Dishware will be sanitized following chemical or temperature guidelines. Used dishware from positive or presumptive units will be transported in covered or closed carts. 3. IC procedures not followed for one of five residents (R52) observed during medication administration: A review of R52's Face Sheet, dated 1/9/2025, and found in the electronic medical record (EMR) under the Face Sheet tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included a history of stroke, type 2 diabetes, hemiplegia, and hemiparesis following stroke affecting the right dominant side. A review of R52's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 12/2/2024 and found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (which indicated the resident was cognitively intact). A review of R52's Active Orders Report, dated 1/9/2025 and found in the EMR under the Orders tab, revealed orders for the resident to receive Lyrica, with an original order date of 6/10/2021, 75 milligrams (MG) by mouth every 12 hours related to control pain, Lantus (insulin), with an original order date of 12/13/2024, 15 units subcutaneously every twelve hours to control blood sugar and blood sugar checks, with an original order date of 10/29/2024, routinely every twelve hours to monitor blood sugar. LPN 4 was observed administering R52's medication on 1/8/2025 at 9:41 am. LPN 4 was observed to have long false nails (approximately half inch in length) applied to most of her fingertips. During the pouring of the resident's medication, LPN4, who was not observed to apply gloves or sanitize her hands prior to pouring the medication, was observed to drop the resident's Lyrica onto the top of the medication cart and then obtain the medication off the medication cart with her bare fingers and put the Lyrica into the resident's medication cup for administration. The medication was administered to R52. In addition, LPN4 did not place a clean barrier on the resident's bedside table prior to placing R52's insulin pen and blood sugar monitor on the table. After administration of the resident's blood sugar check, LPN4 was observed placing the monitor in her pocket to transport it to the medication cart before putting the monitor and the insulin pen back onto the top of the medication cart. During an interview with LPN 4 on 1/8/2025 at 10:01 am, she stated she was attempting to remove her long false fingernails but had only been able to remove a couple of the nails so far. She stated she was aware she was not supposed to be wearing long false nails while providing resident care due to potential infection control and safety concerns. LPN4 stated she was aware she was supposed to place a clean barrier on surfaces in residents' rooms prior to placing any equipment to be returned to the medication cart on the surface. LPN4 additionally stated she was aware she was supposed to perform adequate hand hygiene, such as sanitizing her hands and wearing gloves when touching medication directly, and was aware medications should not be administered after coming into direct contact with the top of the medication cart. During an interview with the Director of Nursing (DON) on 1/9/2025 at 10:28 am, she confirmed her expectation was false nails not be worn while providing direct care/medication administration to residents, hand hygiene was expected to be performed during medication pass/prior to administering and pouring medication, a clean barrier was expected to be placed on any room surface before placing equipment/medications to be returned to the medication cart, and medications were to be discarded and repoured if dropped on the medication cart rather than administered. The facility's Medication Administration: Hand Hygiene Policy dated most recently revised on 10/14/2024, read, in pertinent part, It is the policy of Pruitthealth Pharmacy Services that partners will use appropriate hand hygiene during medication administration. Appropriate hand hygiene reduces the spread of germs and decreases the spread of infections. Additional policies related to infection control procedures with medication administration were requested by the survey team on 1/9/2025 at 12:30 pm, however, these policies were not provided by the facility prior to the survey exit on 1/9/2025.

Based on policy review, observation, interview, and record review, the facility failed to ensure the dish machine operated at the correct temperature and that equipment and surfaces were kept clean and in good repair. This had the potential to affect 82 of 82 residents who received meals prepared in the facility's kitchen. Findings included: A review of the facility policy titled Cleaning Procedures: Kitchen Area, revised 8/3/2017, provided by the facility, revealed Monthly: l. Take out removable drawers and wash them with a detergent and warm water. 2. Rinse shelves and drawers with a clean sponge or cloth. 3. Sanitize using appropriate strength solution. Check walls, ceilings, floors, and vents for chipped and/or peeling paint, and keep in good repair. Control lighting, ventilation, and humidity to prevent moisture condensation and the growth of molds and mildew. Monthly: wash the walls, ceilings, doors, and vents with hot water and detergent. Heavily soiled surfaces need to be cleaned more often. The type of surface determines the type of detergent needed and the cleaning method to use. A review of the facility policy titled Dishwashing, revised 8/3/2017, provided by the facility revealed, Temperature Guide: Adhere to the Manufacturer's guidelines for appropriate temperature ranges. A review of the kitchen's working copy of the Cleaning Assignments Form - Daily, provided by the facility revealed Walls: Clean behind shelves and work areas daily, Work Tables: Tops/shelves/legs clean, and Range: Clean Surface Areas, Clean Drip Pans were marked as completed on 1/7/2025 and 1/8/2025. No working copies for weekly or monthly cleaning schedules were provided. 1. On 1/6/2025 at 10:07 am, the dish machine was observed with the Dietary Manager (DM) while in use. The wash cycle measured 104 degrees Fahrenheit (F), and the rinse cycle measured 110 degrees F. Dietary Aide (DA)2 was asked if the temperatures of the dish machine should be higher. DA2 stated maintenance checked the machine at the beginning of use and the temperatures were good. DA2 went on to say, As the machine is used, temperatures drop. A review of the January 2025 dish machine log, for dates 1/1/2025 through 1/6/2025, located on the wall revealed the wash cycle temperature ranged from 120 degrees F to 125 degrees F and the rinse cycle temperature ranged from 123 degrees F to 124 degrees F. On 1/6/2025 at 3:35 pm, the dish machine was observed with the DM at the end of washing the lunch dishes. The dish machine's wash cycle measured 105 degrees F, and the rinse cycle measured 118 degrees F. The dish machine's manufacturer's requirements posted on the machine were reviewed with the DM. The posted plaque revealed 120 degrees F for the wash cycle and 130 degrees F for the rinse cycle. The DM stated the dish machine company checked the dish machine in December 2024. The DM was asked if the hot water supply was lasting long enough to get through all the dishes. The DM stated she did not know but would ask maintenance. On 1/7/2025 at 3:41 pm, the dish machine was observed in progress. The wash cycle measured 118 degrees F and the rinse cycle measured 122 degrees F. The DM was asked again about the temperatures. The DM stated the dish machine company would be at the facility on 1/7/2025 to check it. 2. On 1/7/2025 at 3:01 pm, DA1 was observed loading soiled trays on the rack and then handling clean glasses without washing his hands. The DM was asked to observe DA1 on the dish machine while he was working the dish machine and asked if DA1 should have washed his hands before touching clean dishes. The DM observed DA1 and stated, Yes, then instructed DA1 to wash his hands between soiled and clean dishes. 3. On 1/6/2025 at 10:06 am, 1/7/2025 at 3:02 pm, and 1/9/2025 at 11:21 am, the kitchen observations were conducted with the DM present: The two drawers in the production table storing serving utensils were noted to be soiled with hardened food particles. The outside of the range/ovens and fryer contained an accumulation of grease and food particles. The wall above the three-compartment sink contained a build-up of dark mold-like substance. The baseboard was missing from the column in the dish room and the painted surfaces were broken. On 1/6/2025 at 10:06 am, the DM stated they had discussed repairing the surfaces and the baseboard. The DM stated that the last time the kitchen was updated was in 2013. During a telephone interview on 1/9/2025 at 12:41 pm, the Registered Dietitian (RD) was asked about kitchen sanitation. The RD was asked about the wall above the three-compartment sink, the grease and food build-up on the range and fryer exterior and drawers, the broken baseboard in the dish room, the dish machine temperatures not per manufacturer requirements and DA1 not washing his hands before touching clean dishes. The RD stated the kitchen staff were to be constantly aware of the risk of cross-contamination, use two people to wash dishes, if possible, ensure the cleaning schedule was being used and followed to identify sources of a breach, keep equipment clean, etc.

Based on policy review, interview, and record review, the facility failed to ensure residents and/or their representatives participated in care planning conferences for four of five residents (R) (R26, R7, R51, and R29) reviewed for care conferences. The deficient practice of not inviting residents and/or family members to care planning conferences potentially could decrease resident/family satisfaction with care. Findings included: A review of the facility policy titled Care Plans, revised 7/27/2023, provided by the facility, revealed Document IDT [interdisciplinary team] attendance using Care Conference notes . Complete Care Conference Acknowledgement form with signature from patient/resident and/or resident representative, Care plan meetings should be documented in [electronic charting system]/LTC [long term care] using the Multidisciplinary Care Conference User Defined Assessment (UDA) as evidence that the care conference has taken place and occurred with the multidisciplinary team, the patient/resident and patient/resident representative, and Care plan meetings including IDT, patient/resident, and/or patient/resident representative attendance should be documented in Care Conference notes. A facility policy was requested addressing the residents and/or their representative's right to participate in care planning. None was provided. 1. A review of R26's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) date of 12/16/2024 revealed an admitted [DATE]. R26 had a Brief Interview for Mental Status (BIMS) score of five out of 15, indicating that R26's cognition was severely impaired, and had diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, Cerebral infarction, unspecified, and hemiplegia or hemiparesis. A review of R26's Care Plan revised on 12/21/2024 revealed Problem: R26 plans to stay in the facility long term. An approach included Encourage RP [resident representative] to participate in care plan conferences. A review of R26's Care Conference forms revealed only two care conferences, dated 1/8/2020 and 10/15/2024. The latter did not list the resident representative in attendance. A review of R26's care conference letters dated 1/30/2024, 4/29/2024, 7/22/2024, and 10/15/2024, provided by the facility, revealed no acknowledgment from the resident representative that the letters were delivered to the resident representative. During an interview on 1/7/2025 at 1:26 pm, Family Member (F) 4 was asked if she attends care conferences. F4 stated she had not received an invitation or notice of a care conference for the five years R26 had resided at the facility until recently. F4 stated she received a letter for a care conference on 12/24/2024 but requested to reschedule as 12/24/2024 was Christmas Eve. F4 stated she had not heard back yet about a new date and time for the care planning conference. During an interview on 1/8/2025 at 10:38 am, the MDS Coordinator (MDSC) was asked about the documentation of care conferences for R26. The MDSC stated she has been having the care plan conferences. The MDSC was asked why there were only dates 10/15/2024 and 1/8/2020 in the electronic medical record (EMR). The MDSC stated that R26's representative was at the facility all the time and they kept her informed. The MDSC was asked about formal conferences with all the discipline's input. During a follow-up interview on 1/8/2025 at 12:50 pm, the MDSC provided additional letters for care plan conference invitations but acknowledged there was no evidence the conferences occurred, or the invitations were sent to R26's representative. The letters were dated 1/30/2024, 4/29/2024, 7/22/2024, and 10/15/2024. The MDSC confirmed these dates were not documented in the EMR and there was no evidence of who attended and what was discussed. During an interview on 1/9/2025 at 10:45 am, the Director of Nursing (DON) and the Administrator were asked about care plan participation for R26. The DON stated, I understand it's not documented, and it should be. During a follow-up interview on 1/9/2025 at 12:38 pm, F4 was shown the scanned copies of the letters dated 1/30/2024, 4/29/2024, 7/22/2024, and 10/15/2024 and asked if she received them. F4 stated, No, she did not receive these letters. F4 stated the first care conference letter she received was dated 12/24/2024. 2. A review of R7's Resident Face Sheet indicated the resident was admitted to the facility on [DATE] with a diagnosis of heart failure. A review of R7's Care Plan dated 1/3/2024 indicated the resident had cognitive loss. A review of R7's significant change MDS assessment with an ARD of 10/13/2024 indicated the resident had a BIMS score of six out of 15 which revealed the resident was severely cognitively impaired. A review of untitled documents provided by the facility, referring to the care plan meeting invitation, indicated F1 was invited to R7's care plan meetings on 3/26/2024, 6/18/2024, 9/24/2024, and 10/22/2024. There was no documentation on each of the invitations of whether the resident and/or her representative received the invitations to the care conferences. A review of R7's EMR failed to contain evidence that the resident and/or her representative were invited to participate in the resident's care conferences. During an interview on 1/7/2025 at 11:23 am, R7's F1 stated she was invited to the care plan meetings when the resident was first admitted to the facility and has not been invited recently by the facility. 3. A review of R51's Resident Face Sheet indicated the resident was admitted to the facility on [DATE] with a diagnosis of stroke with aphasia. A review of R51's Care Plan dated 11/15/2024 indicated the staff could not determine a BIMS score, indicating that the assessment could not be completed due to cognitive impairment. A review of R51's View Care Conference documentation dated 11/19/2024 indicated the facility held a care conference but there was no evidence the resident and/or her representative were invited to participate in her care conferences. A review of untitled documents provided by the facility, but referred to as the care plan meeting invitation, indicated R51's representative was invited to the resident's care plan meetings on 3/12/2024, 6/4/2024, 8/27/2024, and 11/19/2024. There was no documented evidence on each of the invitations of whether the resident and/or her representative received the invitation to the care conferences. During an interview on 1/7/2024 at 11:53 am, R51 responded to yes/no questions and stated she did not get invited to her care conferences. 4. A review of R29's Resident Face Sheet indicated the resident was admitted to the facility on [DATE] with a diagnosis of amyotrophic lateral sclerosis (ALS). A review of R29's Care Plan dated 5/17/2019 indicated the resident had a history of refusal of care. A review of R29's annual MDS assessment with an ARD of 10/31/2024 indicated the resident had a BIMS score of 15 out of 15, indicating no cognitive impairment. An interview with R29 was attempted but not completed due to R29's advanced ALS and difficulty speaking. A review of R29's Care Conferences documentation indicated the facility held care conferences on 1/23/2024 and 8/13/2024 and there was no evidence that the resident was invited to participate in her care conferences. A review of untitled documents provided by the facility referred to as the care plan meeting invitation, indicated R29 was invited to her care conferences on 2/20/2024, 5/21/2024, 8/13/2024, and 11/5/2024. There was no documented evidence on each of the invitations of whether the resident received the invitations to the care conferences. During an interview on 1/8/2025 at 2:17 pm, the Director of Social Services (DSS) stated that residents and/or their representatives were to be invited to the care conferences. During an interview on 1/9/2025 at 10:18 am, the DON and the Administrator were present. The DON was asked about the blank resident invitations, and how verification could be made when a resident and/or representative states they were not invited. The DON and the Administrator provided no response. During this interview, a request was made for a facility policy on the invitation of the resident and/or representative to the care conferences and DON stated she would look for another policy. No additional policy was provided by the end of the survey. 12679

12679 39540 18947 Based on policy review, interview, and record review, the facility failed to ensure residents and/or their representatives were informed of the risks of psychotropic medications for five of five residents (R) (R83, R29, R37, R33, and F58) reviewed for psychotropic medications. The deficient practice could potentially cause residents and/or their representatives to make uninformed decisions about their treatment, increasing the risk of adverse reactions. Findings included: A review of the facility policy titled Unnecessary Medications Use and Monitoring, reviewed 12/5/2024, provided by the facility, revealed no mention of the discussion of the risks versus the benefits. 1. A review of R83's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) date of 11/21/2024, in the electronic medical record (EMR), revealed an admitted [DATE]. R83 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating R83's cognition was moderately impaired, was taking antianxiety and antidepressant medications, and had diagnoses of anxiety and depression. A review of R83's Orders revealed buspirone tablet; 5 mg [milligrams]; amt [amount]: 1 tab; oral At Bedtime 9:00 pm, dated 11/15/2024 and Lexapro (escitalopram oxalate) tablet; 10 mg; amt: 1 tab; oral Once A Day 9:00 am, dated 12/4/2024. A review of R83's Care Plan revised 11/18/2024, located in the EMR revealed Problem: R83 has an order for Psychotropic Drug Use. Dx [diagnosis]. Depression and Anxiety. A review of R83's Consent, dated 1/8/2025, located in the EMR under the Resident Document tab, revealed Verbal Consent from [name] - Family Member (F)2 for Buspar- Anxiolytics, Sedatives and Hypnotics and Lexapro- Psychotherapeutic Agents Antidepressants. There was no evidence that the risks versus benefits were discussed. During an interview on 1/8/2025 at 1:19 pm, the Social Service Director (SSD) was asked if risks and benefits were discussed with R83 and/or a representative for the two antidepressant medications when consent was obtained on 1/8/2025. The SSD stated she was not aware of the requirement to discuss risks vs benefits for all psychotropic medications. During an interview on 1/9/2025 at 9:54 am, F3 was asked if risk versus benefits were discussed when consent was obtained for R83's two antidepressants. F3 stated she was with F2 when the facility called on 1/8/2025 to obtain permission to administer psychotropic medications and only permission was requested. F3 stated the risks versus benefits were not discussed. 2. A review of R29's Resident Face Sheet indicated the resident was admitted to the facility on [DATE] with a diagnosis of amyotrophic lateral sclerosis (ALS). A review of R29's Care Plan dated 3/15/2021 indicated the resident used psychotropic medications for diagnoses of anxiety and depression. A review of R29's physician orders dated 12/20/2022 indicated the resident was ordered alprazolam (an antianxiety) 0.5 mg to be administered orally one time a day for a diagnosis of anxiety. A review of R29's EMR titled physician orders located dated 2/26/2024 indicated the resident was ordered citalopram (an antidepressant) 10 mg to be administered orally one time a day for a diagnosis of depression. A review of R29's annual MDS with an ARD of 10/30/2024 indicated the resident had a BIMS score of 15 out of 15 which revealed the resident was cognitively intact. The assessment indicated the resident was administered an antianxiety and an antidepressant during the assessment period. A review of R29's EMR failed to contain evidence that the resident and/or her representative were provided risks versus benefits for the use of antianxiety and antidepressant medication. 3. A review of R37's Resident Face Sheet indicated the resident was admitted to the facility on [DATE] with a diagnosis of post-stroke. A review of R37's Care Plan dated 9/11/2024 indicated the resident used psychotropic medications for depression. The care indicated the resident used an antipsychotic medication for dementia behaviors. A review of R37's physician orders dated 9/20/2024 indicated the resident was ordered citalopram 40 mg to be administered orally one time a day for depression. A review of R37's physician orders dated 9/20/2024 indicated the resident was ordered quetiapine 12.5 mg to be administered at bedtime for behavioral symptoms related to dementia. A review of R37's quarterly MDS with an ARD of 12/13/2024 indicated the staff could not determine the resident's BIMS score but revealed the resident had short and long-term memory problems. The assessment indicated the resident was administered an antipsychotic and an antidepressant during the assessment period. A review of R37's EMR failed to contain evidence that the resident and/or her representative were provided risks versus benefits for the use of an antianxiety and an antipsychotic. During an interview on 1/8/2025 at 1:11 pm, the Director of Social Services (DSS) confirmed there were no risks versus benefits in the clinical records for R29 and R37. 4. A review of R33's Face Sheet revealed an admitted d 8/22/2018 and readmission on 11/23/2024 with medical diagnoses that included unspecified dementia, psychotic disturbance, mood disturbance, major depressive disorder, anxiety disorder, acute respiratory failure, and 2019-nCoV acute respiratory disease. A review of R33's annual MDS with an ARD of 9/17/2024, revealed a BIMS score of five out of 15, indicating R5 was severely cognitively impaired. A review of the physician orders documented on 1/27/2023 physician orders for buspirone tablet 5 mg every 12 hours for anxiety, 1/27/2023 mirtazapine tablet 7.5 mg at bedtime for depression, and 8/22/2023 trazodone table 150 mg at bedtime for depression for R33. A review of the Care Plan for R33 revealed R33 was at risk for adverse side effects related to (r/t) Psychotropic medication used for Depression and Anxiety with interventions for Behavior/mood monitoring as ordered and monitor for side effects. A review of the progress notes for R33 lacked documentation on the risks and benefits of the antianxiety and antidepression medications were provided to R33's representative. A review of the Observations tab in the EMR for R33 lacked the document titled Consent for Use of Psychotropic Medications, which included the risks and benefits of the antianxiety and antidepression medications. 5. A review of R58's Face Sheet dated 1/9/2025 revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included type 2 diabetes and depression. A review of R58's quarterly MDS assessment, with an ARD of 11/8/2024 indicated a BIMS score of 15 out of 15 (which indicated the resident was cognitively intact). The assessment indicated R58 was receiving routine antidepressant medication and indicated the resident did not exhibit any signs or symptoms of depression during the assessment reference period. A review of R58's Order Summary Report dated 1/9/2025 revealed an order, with an original order date of 12/11/2023, for Duloxetine (an antidepressant medication) 60 mg by mouth every twelve hours for depression. A review of R58's Psychotropic Medication Care Plan dated 11/24/2024 revealed the resident was receiving antidepressant medication for his depression. Interventions included providing antidepressant medications as needed and notifying the physician and resident/resident representative (of medication activity) as needed. A review of R58's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated 12/1/2024 through 1/9/2025 and found in the EMR revealed the resident's Duloxetine was being administered as ordered. A review of R58's comprehensive record revealed nothing to show risks and benefits were discussed for the administration of R58's psychotropic (antidepressant) medication. During an interview on 1/9/2025 at 10:18 am, the Director of Nursing (DON) and Administrator were present. The DON stated there was a form in the EMR that addressed risks versus benefits and confirmed there was no documented evidence that this was in place for R83, R29, R37, R33, and 58.

Based on a review of facility policy, record review, observations, and interviews, the facility failed to ensure one of 22 sampled residents (R) (R52) reviewed for self-administration of medication was capable of storing and administering her own medication. This failure created the potential for the resident to experience a medication error related to her inability to properly self-administer the medication. Findings included: The facility's Self-Administration of Medications by Patients/Residents Policy dated most recently reviewed 1/6/2025 read, in pertinent part, Each patient who desires to self-administer medication is permitted to do so if the healthcare center's Licensed Nurse and physician have determined that the practice would be safe for the patient/resident and other patients/residents of the healthcare center; and The opportunity to self-administer medications is reviewed during the routine assessment by the healthcare centers interdisciplinary team utilizing the Electronic Health Record Observation Tool, Medication Self-Administration Observation; and If the patient/resident or family member desires to self-administer medications, an assessment is conducted by the Licensed Nurse to assess the individual's cognitive, physical, and visual ability to carry out this responsibility; and If the Licensed Nurse determines the patient/resident or family member to be capable of self-administration of medications, the attending physician must write an order to that effect that includes the specific medications based off of the Self-Administration Medication Observation. A review of R52's Face Sheet dated 1/9/2025 revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included a history of stroke, hemiplegia, and hemiparesis following the stroke affecting the right dominant side. A review of R52's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 12/2/2024 indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. A review of R52's Active Orders Report dated 1/9/2025 revealed an order, with an original order date of 7/22/2023, for the resident to receive Biofreeze Gel 4.0 % (a topical gel applied to the skin to control pain) apply a dime-sized amount to her right shoulder every 12 hours. The report did not indicate orders for the resident to self-administer her own medication. A review of R52's comprehensive care plan revealed no documentation to address the self-administration of the resident's medications. A comprehensive review of R52's record revealed no assessment to determine whether the resident was able to self-administer her own medication. Licensed Practical Nurse (LPN) 4 was observed administering R52's medication on 1/8/2025 at 9:41 am. LPN 4 provided a medication cup with a dime-sized amount of Biofreeze Gel to the resident and left the medication with R52, stating the resident would apply the medication herself to her shoulder at a later time. During an interview with LPN 4 on 1/8/2025 at 10:01 am, she stated she was unaware she was not to leave medication unattended with R52 since she had not been assessed to be safe to self-administer her own medication. During an interview with R52 on 1/9/2025 at 10:17 am, she confirmed she had not been assessed to administer her own medication prior to the previous day (1/8/2025). She stated she had been assessed to self-administer her medication the previous day, but that the Biofreeze gel was going to be kept in the nurses' medication cart for safe storage moving forward. During an interview with the Director of Nursing (DON) on 1/9/2025 at 10:28 am, she confirmed R52 had not been appropriately assessed for self-administration of her Biofreeze and no care plan or physician's orders were in place for the resident's self-administration of medication. She stated the Biofreeze should not have been left in R52's room by LPN 4.

Based on a review of facility policy, record review, and interviews, the facility failed to ensure one of five residents (R) (R58) reviewed for abuse was free from misappropriation of his personal funds when Certified Nursing Assistant (CNA4) wrote checks and cashed checks for herself from R58's personal checking account. This failure created the potential for this and other residents to experience further staff-to-resident misappropriation and created the potential for R58 to suffer negative financial consequences related to the misappropriation. Findings included: The facility's Abuse Prevention and Reporting Policy dated most recently revised on 8/18/2023 read, in pertinent part, Exploitation: Unjust or improper use of another person's or his/her property through undue influence, coercion, harassment, duress, deception, false representation, false pretense, or other similar means for one's own profit or advantage; and This (facility) will not tolerate abuse, neglect or exploitation of its residents by anyone. Such incidents will be reported to all appropriate authorities, agencies, and registries, and a written copy as such reports maintained in a central file and the resident's file. A review of R58's Face Sheet dated 1/9/2025 revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included type 2 diabetes and depression. A review of R58's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 11/8/2024 indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (which indicated the resident was cognitively intact). A review of R58's comprehensive progress notes dated 1/1/2025 through 1/9/2025 revealed nothing to indicate the misappropriation of the resident's property/money. A review of the facility's documentation from 1/1/2025 through 1/9/2025 revealed an incident dated 1/3/2025 when a staff member misappropriated personal money belonging to R58. A review of the facility's investigation of the misappropriation of R58's funds dated 1/9/2025 revealed a thorough investigation into the incident and revealed the investigation was conducted with input and coordination with the local police department and the resident's bank. The investigation revealed the facility was able to substantiate that CNA4 misappropriated an undetermined amount of money from the resident's personal bank account by obtaining the resident's checkbook, writing checks to herself, and then cashing the checks. CNA4 was placed on leave immediately after the misappropriation was reported and then terminated based on the investigation findings. During an interview with R58 on 1/7/2025 at 12:12 pm, he confirmed the money had been misappropriated from his personal bank account and he had reported the missing funds to facility administration on 1/3/2025. The resident stated that CNA4 had access to the personal checkbook he kept in his room since he had previously requested she assist him with writing checks out for him. He stated he would then sign the checks himself. R58 stated, She (CNA4) wrote herself checks and completely wiped me out. R58 indicated he was upset and disappointed because he had previously had a good relationship with CNA4 and had never had any other issues with her. He stated, (CNA4) has been good to me. I am very surprised about this. R58 denied he had ever been abused by anyone at the facility before the incident. He stated the Director of Nursing (DON) and Administrator were investigating the situation, along with his bank and the police, and stated they were keeping him updated on the progress of the investigation. During an interview with the DON and Administrator on 1/9/2025 at 10:36 am, both confirmed the allegation that money had been misappropriated from R58 by CNA4 and confirmed CNA4 had been terminated related to the incident. Both stated their expectation was residents were to be free from abuse, including misappropriation of funds. The DON stated, Money should not be taken from any resident by any staff member in the facility.

Based on policy review, observations, record review, and staff interviews, the facility failed to ensure one of three residents (R) (R3) reviewed for accidents was appropriate for the use of side rails on her bed. This failure created the potential for the resident to be injured related to potentially unnecessary side rails installed and in use on her bed. Findings included: The facility's Bed Rails Policy dated most recently revised on 8/8/2024, read, in pertinent part, It is the policy of Pruitthealth and its affiliated healthcare centers (collectively, the Organization) that healthcare center patients (including those referred for rails, except when the use of bed rails has been appropriately determined to be medically necessary in accordance with this policy or in instances where the use of bed rails has been specifically requested by the patient or the patient's representative. A review of R3's Face Sheet dated 1/9/2025 indicated the resident was admitted to the facility on [DATE]. The document indicated the resident's diagnoses included severe dementia and adult failure to thrive. The document indicated that R3 was receiving hospice services. A review of R3's quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 12/14/2024 revealed a Brief Interview for Mental Status (BIMS) score of five out of 15, which indicated the resident was severely cognitively impaired. The assessment indicated R3 was completely dependent upon staff (staff did all the work) to move about in her bed and to transfer in and out of her bed and was receiving hospice services. The assessment did not indicate side rails were in use for R3. A review of R3's Active Orders Report dated 1/9/2025 indicated orders with an original order date of 9/13/2024 for the resident's use of quarter side rails on her bed for turning and repositioning. A review of R3's Activities of Daily Living (ADL) Care Plan most recently dated 12/27/2024 indicated the resident was no longer safely able to be transferred in and out of her bed due to her fragile condition and indicated the resident was completely dependent upon staff to turn and reposition in her bed. The care plan indicated an intervention dated 9/14/2024, which directed Padded (quarter) side rail for turning and repositioning (in bed). A review of R3's Side Rail assessment dated [DATE] indicated the use of quarter side rails on both sides of her bed as an enabler to promote resident mobility, positioning, and independence. The document revealed nothing to indicate the rails were in use per the request of the resident or her representative. R3 was observed lying in her bed with quarter side rails in the raised position at the head of her bed on 1/7/2025 at 11:54 am, 1:19 pm, 2:49 pm, and 4:44 pm, on 1/8/2025 at 9:25 am, 11:18 am, 12:45 pm, 1:55 pm, and 3:43 pm. R3 was observed to be unresponsive or minimally responsive during each of the observations. R3 was not able to be interviewed due to her poor cognition. R3 was observed along with Licensed Practical Nurse (LPN) 5 on 1/8/2025 at 3:43 pm. R3 was lying in her bed and was minimally responsive. LPN 5 confirmed that both residents' bed rails were raised at the head of her bed. LPN 5 confirmed that R3 was not able to roll from left to right or move about independently in her bed and was no longer able to be transferred in or out of her bed due to the decline in her health condition. LPN 5 indicated the resident's bed rails might be in use to prevent the resident from falling out of her bed and stated the resident would not be able to use the rails to assist staff or herself in moving about in bed. R3 was observed along with the Director of Nursing (DON) on 1/8/2025 at 3:57 pm. The DON confirmed the resident's rails in raised on both sides of her bed and stated the resident no longer needed the rails since she was not able to use the rails for bed mobility any longer. During an interview with the DON and the Administrator on 1/9/2025 at 10:25 am, both confirmed R3's rails were not necessary and confirmed the rails had been discontinued earlier that morning. The DON stated her expectation was bed rails were not to be utilized for residents who don't need them. R3's Hospice Provider was contacted by phone on 1/9/2025 at 12:56 pm. The survey team was not able to reach the provider for an interview related to the resident's use of bed rails.

Based on observation, interview, and document review, the facility failed to ensure a Certified Nursing Assistant (CNA3) provided care as educated through training and in-services for residents in isolation positive for 2019-nCoV, by not applying the appropriate Personal Protective Equipment (PPE) while providing care for two of nine residents (R) (R35 and R58) on special droplet isolation on the long 100 hallway. As a result of this deficient practice, the residents had the potential for harm by spreading the 2019-nCoV to residents who previously tested negative. Findings included: A review of the employee record for CNA3 revealed a hire date of 9/3/2024. Documentation in the record revealed an orientation checklist. A review of the Position Description Acknowledgement in the employee file for CNA3 documented I understand that as a result of my employment, I may be exposed to blood, body fluids, infectious diseases, air contaminants, and hazardous chemicals and that the healthcare center should provide to me instructions on how to prevent and control such exposures. The form was signed by CNA3 and dated 9/3/2024. A review of a document from an online training system revealed a Certificate of Completion (2019-nCoV) Long Term Care Requirements on 9/3/2024 for CNA3. A review of the in-service sign-in sheet titled Isolation PPE with content including Before entering a (2019-nCoV ) POSITIVE room, put on ALL NEW PPE, including gown, gloves, face shield, and N95 masks. DO NOT walk away from the room with PPE on. Before leaving the room, remove all PPE and place it in the trashcan in the room. Sanitize hands. After leaving the room, change the N95 mask DO NOT wear gloves in the hallways. CNA3's signature was dated 11/7/2024, documenting that the training was done. A review of the in-service sign-in sheet for the CNA Annual Skills Fair course description Annual Skills Fair competency checklist for HCC CNA partners revealed The listed subjects have been reviewed with me during orientation and upon the Annual Skills fair. I understand, that during my assignment, I will observe the requirements of the policies. I am aware provider policies and procedures are subject to change based on the changes of [NAME] Health policies and procedures and I am aware of how to review policies for updates. The content included donning (putting on) and doffing (taking off) of PPE, and hand hygiene, CNA3 signature was dated 11/24/2024, documenting the skills review training was completed. A review of the in-service sign-in sheet titled Proper use of PPE for COVID (2019-nCoV) and Flu (Influenza), dated 12/30/2024 was conducted by the Clinical Competency Coordinator (CCC) and the Infection Control Preventionist. CNA3 signature, was on the sign-in sheet, documenting the training was received. A review of R35's Face Sheet revealed an admitted d 1/2/2017 and readmission on 1/2/2025 with a medical diagnosis that included pneumonia. A review of the EMR CCD (Continuity of Care Document) revealed that R35 tested positive for 2019-nCoV on 1/4/2025. A review of R58's Face Sheet revealed an admitted d 8/30/2023 and readmission on 1/2/2025 with medical diagnoses that included diabetes Type II, and 2019-nCoV acute respiratory disease. A review of the EMR CCD (Continuity of Care Document) revealed that R58 tested positive for 2019-nCoV on 1/4/2025. An observation on 1/6/2025 at 11:37 am revealed Certified Nursing Assistant (CNA)3 was inside the room for R35 who was on special droplet precautions providing care by taking the resident's vital signs. CNA3 was using PPE by wearing an N95 mask and gloves only. During an interview on 1/6/2025 at 11:44 am, when questioned about wearing PPE for the care provided to R35, CNA3 said she had not read the signs posted on the door that read All personnel to follow the directions below: before entering the room, wash hands, wear a gown and remove before exiting the room, wear an N95 mask, protective eyewear, and gloves to remove before exiting the room. An observation on 1/6/2025 at 1:38 pm revealed that CNA3 entered the room for R35 and R58. Both residents were on special droplet isolation due to positive 2019-nCoV, to address a loud argument between the residents about food on the lunch trays. CNA3 entered the room to de-escalate the argument. CNA3 was wearing PPE that included an N95 mask and gloves only. During an interview on 1/9/2025 at 10:35 am, the Director of Nursing (DON) confirmed that CNA3 had been educated about the use of PPE and should have applied the knowledge to resident care. The DON checked the camera in the hallway for the long 100 hallway and confirmed that CNA3 had not worn proper PPE when entering rooms for residents on special droplet precautions and should have worn PPE when entering the room.

Based on observation, interview, record review, and facility policy review, the facility failed to provide resident-specific activities as interventions for wandering into other resident rooms for one of 22 sampled residents (R) (R77). Findings included: A review of the facility policy titled Procedure: Care of the Wandering Resident, dated 2019, provided by the facility revealed 2. Continuously reorient the resident to his or her room and belongings 3. Encourage group activities and attempt to keep the resident occupied 8. Ask the resident to fold towels and washcloths, or sort other harmless items . 13. Tag team with other staff so someone is responsible and available to visually monitor the resident at all times. A review of R77's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 10/6/2024 revealed an admitted [DATE]. R77 had a Brief Interview for Mental Status (BIMS) score of 99 out of 15 indicating R77's cognition was severely impaired, had behaviors of wandering, wandering placed the resident at significant risk of getting to a potentially dangerous place, and wandering did not significantly intrude on the privacy of activities of others, and had diagnoses severe intellectual disabilities, schizophrenia, unspecified, and Alzheimer's disease. This MDS documented that R77 liked books/magazines, music, and religious services as her activities. A review of R77's Care Plan revised on 1/8/2025 revealed: Problem: [R77] is noted with Presence of Behavioral Symptoms such as going into other resident's rooms taking their personal belongings and (going) into other resident's rooms to sit. Approaches included Redirect resident. Assist with diverting attention such as recommending an activity such as getting coffee and Intervene as needed to protect the rights and safety of others; approach in a calm manner, divert attention, remove from the situation, and take to another location as needed. This Care Plan did not include R77's identified activities of choice as an intervention for her wandering. On 1/6/2025 at 4:51 pm, R77 was observed wandering into room [ROOM NUMBER]. On 1/7/2025 at 11:24 am, Family Member (F)4 stated R26's stuffed Koala bear was missing. R77 was observed wandering into R26's roommate's side of the room and sitting on the bed. At 11:29 AM Licensed Practical Nurse (LPN)1 walked into R26's room. LPN1 was asked about R26's missing bear. LPN1 stated R77 most likely picked it up and there was no way keeping R77 from walking in and out of other resident rooms and picking up their things. LPN1 stated she understands it's resident's right to have personal items without others picking them up. LPN1 was asked what was in place to prevent R77 from wandering in other resident rooms and picking up other residents' property. LPN1 stated, Just keep an eye on her and bring back the items. At this time R77 was observed entering R26's side of her room during LPN1's interview. LPN1 and F4 attempted to redirect R77 three times out of the room when R77 finally exited the room. LPN1 stated they constantly intervene for R77. On 1/8/2025 at 10:14 am, R77 was observed walking into room [ROOM NUMBER] and sitting on bed A. The nurse redirected her out of the room. R77 then walked into room [ROOM NUMBER]. During an interview on 1/8/2025 at 10:29 am, Certified Nurse Aid (CNA)1 was asked about R77's wandering into other resident rooms. CNA1 stated, (R77) wanders in and out of resident rooms and picks up other resident's things. CNA1 stated the only intervention in place was to redirect the resident. On 1/8/2025 at 1:40 pm, R77 was observed wandering into room [ROOM NUMBER] which was under Enhanced Barrier Precautions (EBP). Housekeeper (HK)1 was in the hallway and was asked what she did when R77 wandered into another resident's room. HK1 stated, R77 is redirected. During an interview on 1/8/2025 at 3:23 pm, the Director of Nursing (DON) was asked about R77's wandering in other resident rooms and what was in place to prevent her wandering. DON stated, Just redirecting her, involving (R77) in activities, placing (R77) one-on-one with staff, medication adjustment, and (R77) was referred to mental health services. The DON stated, That's all that can be done and no one has complained of missing items. The DON was informed that R77 had taken personal items from other resident rooms. During a follow-up interview on 1/9/2025 at 10:36 am, the DON stated that her expectation was for staff to work with R77 with more activities and for one-on-one staff monitoring.

Based on medical record review, staff interviews, observations, and review of the facility's COVID-19 and Glucometer Cleaning Policies, the facility failed to ensure infection control procedures were consistently followed for two of 9 residents (Resident (R) #7 and R#8) sampled during the survey. Specifically, Licensed Practical Nurse (LPN BB) failed to follow standard facility procedures regarding the sanitization of blood glucose monitors for R#7 and R#8 and failed to follow facility policy regarding the use of Personal Protective Equipment (PPE) while working in the facility's COVID-19 Isolation Unit. Findings include: 1. Failure to adequately sanitize facility glucose monitors. The facility's Glucometer Cleaning and Disinfecting Policy, revised on 1/29/2020, read, . Policy Statement: A blood glucose monitor measures the concentration of glucose in a person's blood. The Centers for Disease Control and Prevention recommends refraining from sharing blood glucose monitors among residents whenever possible. If one device must be used to monitor several residents, it must be cleaned and disinfected after every use following the manufacturer's instructions to prevent carryover of blood and infecting agents; and Procedure: For (Brand) glucometers: Use Clorox Healthcare Bleach Germicidal and Disinfectant Wipes to wipe the outside of the glucometer and allow the surface to remain visibly wet for 3 minutes. Let air dry. LPN BB was observed cleaning one of two blood glucose monitors available on the COVID-19 Isolation Unit on 12/8/2020 at 3:35 p.m. LPN BB removed the blood glucose monitor from her medication cart at the request of the surveyor and showed the surveyor how she routinely cleaned and sanitized the monitor by using an alcohol wipe to clean all exterior surfaces of the machine. LPN BB stated that when she was finished wiping the glucose monitor down with the alcohol wipe, she let the monitor dry for about 30 seconds to one minute before using the monitor on the next resident or putting it away in the medication cart. When asked if she ever used any other cleaning solution to sanitize the glucose monitor, she stated, No. I always use the alcohol wipes. When asked which residents on the unit she was administering blood glucose checks to routinely, she indicated she used the blood glucose monitor on her medication cart to check blood glucose levels for R#7 and R#8. During an interview on 12/8/2020 at approximately 3:45 p.m. LPN BB was asked to explain the procedure for cleaning and sanitizing multi-use equipment, such as the facility glucose monitors. She stated that the facility glucometers, located on each medication cart and used for multiple residents in each facility area, were to be cleaned and sanitized by wiping the exterior of the monitor down thoroughly with an alcohol wipe. Review of the medical record revealed R#7 was admitted to the facility with [DIAGNOSES REDACTED]. The resident also had a recent [DIAGNOSES REDACTED]. Review of R#7's Diabetes Care Plan, dated 11/26/2020, read . (Resident) has the [DIAGNOSES REDACTED]. Review of R#7's current Physician Orders, dated 12/2020, indicated an order for [REDACTED]. Review of R#7's Medication Administration Record [REDACTED]. Review of the medical record revealed R#8 was admitted with [DIAGNOSES REDACTED]. The resident also had a recent [DIAGNOSES REDACTED]. Review of R#8'sDiabetes Care Plan, dated 10/17/2020, read . (Resident) at risk for hyper/[DIAGNOSES REDACTED] related to diabetes mellitus; and Monitor for s/s (signs and symptoms) of [MEDICAL CONDITION] and Monitor blood glucose as ordered. Review of R8's current Physician Orders, dated 12/2020, indicated an order for [REDACTED]. Review of R#8's MAR, dated 12/1/10 through 12/8/2020, indicated LPN BB administered the resident's blood sugar test a total of eight times during that period of time. During an interview with the Director of Nursing (DON) and the Administrator on 12/7/2020 at 4:30 p.m., the DON stated it was her expectation that the blood glucose monitors be cleaned and sanitized per facility policy in order to prevent the spread of infection between residents. 2. Failure to consistently follow PPE Guidelines in the COVID-19 Isolation Unit. The facility's Covid-19 Pandemic Isolation and Cohorting Process for Healthcare Centers Policy, revised on 11/11/2020 read . PPE (on the Level 1 Unit) will include: Gloves, Gowns, N95 Mask in conventional capacity, KN95 Mask in contingent or crisis capacity, Eye Protection (face shields, goggles, etc.), Surgical mask can be worn over the N95/KN95 for extended use in contingent and crisis capacity (only if face shield is not available), Shoe covers (where available). LPN BB was observed working behind the nurse's station on the COVID-19 Isolation Unit on 12/7/2020 at approximately 3:30 p.m. revealed that she was not observed to be wearing her face shield at that time. LPN BB obtained her face shied and put it on after the Housekeeping Supervisor, who was conducting the tour of the COVID-19 Isolation Unit with the surveyor, reminded her to do so. LPN BB stated she had recently returned to the unit from a break and had not put her shield back on yet. During an interview with LPN BB on 12/7/2020 at approximately 3:45 p.m., she stated she understood facility procedure was to put all PPE, including her face shield, on prior to entering the COVID-19 Isolation Unit and that her N-95 mask and shield were to remain in place at all times while on the unit. She stated she had come onto the facility through the outside door per procedure, and that she had to go to the other end of the unit to obtain a new face shield when she returned from a break. During an interview with the DON and Administrator on 12/7/2020 at 4:30 p.m., the DON stated all PPE was to be donned prior to entering the COVID-19 Isolation Unit and that each staff members N-95 mask and face shield were to be worn continuously while on the unit.

Based on observation, resident and staff interview, and record review, the facility failed to provide sufficient nursing staff, in sufficient numbers, to care for the assessed needs of the residents. The sample size was 35. Findings include; During the initial tour an interview on 9/24/18 at 10:50 a.m. R#19 stated has not been getting showers on a regular basis. There was a time when ten days went by without a shower and another time when 11 days went by without a shower. During interview on 9/25/18 at 10:27 a.m. R#19 stated he has not yet received his bath today. Review of #19 Minimum Data Set (MDS)assessment dated [DATE] revealed R#19 has a Brief Interview of Mental Status( BIMS) of 15. A BIMS score of 13-15 indicates resident is cognitively intact. Further review of the same MDS, Section G , in support regarding bathing, R#19 was assessed for needing set up only. Per the MDS dated [DATE] it identified the that the bathing activity did not occur activity did not occur during the entire look back period. During an interview on 9/25/18 at 4:05 p.m. with R#19 revealed he was not offered opportunity for showers today, Tuesday. When asked when was the last time he had a shower, he stated Friday. When asked if he refused his shower today he stated no. When asked if he had a conversation with anyone about his shower concerns he stated no but that he believed the ADON (Assistant Director of Nursing). During a record review on 9/26/18 at 1:20 p.m., of the grievance book R#19, on 6/15/18 complained that he hasn't received his showers for over a week because there is no staff. Review of the response of reflected an implementation of hiring staff and advertising for more employees. Unable to identify any interventions directed toward resident's specific concern. During an interview on 9/26/18 at 1:40 p.m. with the Nurse Navigator revealed when asked what was done to specifically address R#19's concern; she stated R#19 was immediately given a shower that day; but it wasn't in writing. When asked what has been done to address similar concerns of all residents stated the DHS (Director of Healthcare Services) ADON can answer that question. Further review of the grievance book revealed R#19, on 8/16/18, complained of being awaken at 2:30 a.m. to receive a bath. Intervention stated staff reminded some resident's do not want to get up in the night to take a bath. When further asked if staff typically wake him up at that time to take a bath R#19 stated no. During an observation/interview on 9/25/18 at 11:33 a.m. R#69 was not able to express herself. Could not answer screening questions. Nods and shakes head when questions asked. Call light noted in place and resident cleaned and groomed. Review of #69's MDS (Minimum data set) revealed R#69 has a BIMS of 0. A BIMS of 00-07 indicates severe cognitive impairment. [DIAGNOSES REDACTED]. Further review of R#69's MDS assesses R#69 requires extensive assistance in most areas of ADLS (Activities of Daily Living) along with two person assist. Care plan states Resident requires total assistance with ADLs ( Assistance of Daily Living). Resident is at risk for psychosocial isolation and CNAs are to provide care interventions. During an observation on 9/24/18 at 3:00 p.m. noted R#69's call light on during afternoon rounds. Observed resident lying in bed. Was safe in bed and alert. Looked at surveyor while in doorway. Surveyor walked to nurses station where there were five employees standing and seated at the nurse's station. Employees include CNA CC, CNA FF, CNA GG, LPN (Licensed Practical Nurse) DD, and LPN EE. Surveyor stood nearby the nurses station while R#69's call light sounded and in view for more than 20 minutes. During an interview on 9/24/18 at 3:40 p.m. with LPN EE revealed that call lights were to be answered within a minute of them being heard. Nurse EE was in attendance. When asked if they could hear the call bell alert, both stated yes. Both were told the light had been sounding for more than 20 minutes. Nurse DD looked at the call board. Announced who should be providing care to the resident. There were no CNAs at the desk at this time and no one had yet gone to answer R#69's. When asked if nurses can answer call bells both nurse stated yes however; no one made a move to answer the call bell for approximately 30- 45 seconds. Finally Nurse DD arose and went to answer the bell. During an attempted interview on 9/25/18 at 11:18 a.m. with R#69 was asked if she often has to wait for someone to answer her call light for more than 15-12 minutes, she nodded yes. During an interview with CNA HH she stated R#69 is able to understand questions posed to her. Resident has just started using her call light over the last two - three weeks. Previously staff would try to meet R#69's needs. Stated when resident's ring their light we try to answer them as soon as possible. At least within five minutes. We the light is ringing because when can hear it at the desk and we can see it in the hall. When asked if there is enough staff provided to assist residents with their needs. CNA HH stated no. Staff often work short and other CNAs that have duties in other departments have to work the floor because there isn't enough staff. When asked if management is aware of the shortage of staff CNA HH stated management is aware. Nurses do not answer lights and pull their weight. Management states everyone should answer the call lights. During an interview on 9/26/18 at 1:50 PM with CNA, also Medical Records Coordinator, stated she was assigned to the floor. When asked if this happens often stated yes. During an interview on 9/26/18 at 2:00 p.m. with the DHS stated that the unit manager and treatment nurse are supposed to let us know when bath sheets are submitted blank. There has not been an established/set way for how this is done. Further interview with the DHS revealed that there has been difficulty maintaining staff and minimizing CNA (Certified Nursing Assistant) turnover. She has had to utilize CNAs from other departments in order to meet staffing requirements. On 9/27/18 at 1:00 p.m. request for staffing policy offer no results. Also several requests for daily staffing posted time for the months of (MONTH) and (MONTH) (YEAR), offered no results. During an interview on 9/26/18 at 2:15 p.m. with members of the resident council, it was revealed that some of the members had experienced difficulties/delays in receiving care that they believed (based on responses they received from staff), were related to insufficient staffing numbers. R B said that staff tells the residents there are not enough aides when they ask for a bath. Sometimes, it's bath day and I don't get a bath because they say they have too many people to give a bath to and not enough aides, so they do the people who need more help. R C recounted similar experiences. I've been told that they don't have enough people, or they're not doing baths that day. I got a bath yesterday, but it had been a long time since I got a bath. My hair was stinky. They just didn't have enough people to give baths. During an interview on 9/26/18 at 1:25 pm with Certified Nursing Assistant (CNA) AA she stated that she is actually a restorative aid but has been on the floor for a little over a month because they have been so short staffed. She stated there is a bath team, and usually there are 2 bath aids, but one quit leaving only one aid. Continued interview with CNA AA revealed that there are times that the residents don't get their showers but she tries to give bed baths. She stated that today, for instance, the shower aid was pulled to the floor because of being short staffed so in this case the baths are split between 1st and 2nd shift and that baths are normally given on day shift if there is enough staff. During an interview on 9/26/18 at 1:30 p.m. with CNA BB she stated that today there is only one shower aid, and that is her. She stated that today she was pulled to the floor because they were short staffed. Stated that being pulled from her job doesn't happen all of the time, but about 50% of the time. Continued interview with CNA BB revealed when gets pulled to the floor it is those days that the showers are split between 1st and 2nd shift and stated when she ask for help the nurses help her with whatever she needs.

Based on observation, review of policy, and staff interview, the facility failed to ensure that the temperature of the snack/nourishment refrigerator on one of two halls was maintained at or below 41 degrees Fahrenheit for 24 consecutive days. The facility census was 93 residents. Findings include: Review of the policy titled Refrigerator/Freezer Temperatures last revised 4/11/16 revealed that all dietary refrigerator/freezer equipment must be maintained with safe temperatures to prevent spoilage and the growth of bacteria during food storage. Refrigeration temperatures are to be maintained at or below 41 degrees. If the refrigeration or freezer temperature is outside of the appropriate range, staff are to notify the manager and the maintenance department. During observation of the nourishment refrigerator on the North hall on 9/25/18 at 11:44 a.m., it was revealed that the thermometer reflected a temperatures of 45 degrees Fahrenheit (F). During this observation, it was also noted that the temperature log posted on the door for the month of (MONTH) (YEAR) documented that between 9/1/18 and 9/24/18, the temperature of the refrigerator had consistently read 45 degrees F on each of those 24 days. The temperature log also directed that the appropriate temperature ranges for the refrigerator should be between 33 degrees and 41 degrees F. Observation of the contents of the refrigerator revealed several unopened containers of thickened water. During an observation of the North hall refrigerator on 9/25/18 at 4:31 p.m., it was revealed that the thermometer still reflected a temperature of 45 degrees F. An interview with Licensed Practical Nurse (LPN) KK at the time of this observation revealed that the evening staff is responsible for checking and documenting the temperature of the refrigerator each day. LPN KK verified that the temperature in the resident's nourishment refrigerator on that hall was showing 45 degrees F at the time of this interview and that the temperature log for that refrigerator documented that the refrigerator temperature was 45 degrees F for the entire month of September. This nurse said that the staff usually adjusts the temperature gauge if the refrigerator is observed to be outside of the recommended range of 33 degrees F to 41 degrees F. She proceeded to adjust the thermostat inside the refrigerator, saying that the temperature should be within the recommended range within the next hour or so. Observation on 9/26/18 at 8:24 a.m. of the residents' nourishment refrigerator on the North hall again revealed the thermometer reflected a temperature of45 degrees F. A Review of the POS [REDACTED]. Further observation revealed that, in addition to the thickened water, the refrigerator also now contained three cartons of chocolate milk (one opened), and a covered plate containing a meal belonging to one of the residents on the unit. During an interview on 9/26/18 at 8:51 a.m. with the Registered Nurse unit manager for the North hall, it was revealed that the temperature logs for the residents' refrigerators are used to ensure that the items in the refrigerator are kept at temperatures appropriate to retard the growth of bacteria that could cause food spoilage. If the staff responsible for daily documentation of the refrigerator temps notices that the refrigerator/freezer temperatures are consistently outside of the required range, they are to report this to the unit manager who will, in turn, report the problem to maintenance. The staff who become aware of the problem can also directly report it to maintenance themselves. The unit manager said she planned to re-educate staff about reporting temperature ranges for the refrigerators that are outside the acceptable parameters and that she would immediately discard all the food items in that refrigerator. Observation on 9/26/18 12:57 p.m. of the refrigerator in the North wing nourishment room revealed the food items had been removed. Observation on 9/27/18 at 12:00 p.m. revealed that the nourishment refrigerator on the North wing had been replaced with another refrigerator and the thermometer on the inside read 39 degrees F.

Based on observation, resident interview, staff interview, and record review facility failed to provide scheduled showers for one Resident (R#19). Resident sample size was 35. Findings include; Review of #19 's annual Minimum Data Set (MDS) assessment dated [DATE] Section C revealed R#19 has a Brief Interview of Mental Status (BIMS) of 15. A BIMS score of 13-15 indicates resident is cognitively intact. Further review of the same MDS, Section G regarding bathing, R#19 was assessed as needing set up only. Per the MDS dated [DATE] it identified the that the bathing activity did not occur during the entire look back period. Which is seven days before the assessment is completed. R#19 [DIAGNOSES REDACTED]. During an interview on 9/24/18 at 10:50 a.m. with R#19 stated he has not gotten showers on a regular basis. There have been times when where ten days went by without a shower and another time, 11 days went by without getting showers. R#19 was unable to recall when this occurred .R#19 states it's because they don't have enough staff. During an further interview and follow up with R#19 on 9/25/18 at 10:27 a.m. R#19 stated he has not yet received his bath today (Tuesday). Per facility's bath schedule. R#19 was to receive his bath on Tuesday Thursdays and Saturdays. Further interview with R#19 at 3:30 p.m. R#19 still had not receive his bath. During an interview on 9/25/18 at 4:05 p.m. further interview with R#19 revealed he was not offered an opportunity for showers today (Tuesday). When asked when was the last time he had a shower, he stated Friday( 9/21/18). When asked if he refused his shower today ( Tuesday) he stated no. When asked if he had a conversation with anyone about his shower concerns he stated no but that he believed the ADON (Assistant Director of Nursing) knew. During an interview on 9/25/18 at 3:02 p.m. Licensed Practical Nurse (LPN) Charge Nurse DD stated that Certified Nursing Assistants (CNA) use the Kiosk to document when Assistance in Daily Living (ADL) care, including showers, are provided to the resident. If the resident refuses, the CNA lets the nurse know and then the nurse documents in the nurses notes. When asked how are the showers monitored to determine if a resident refuses bath, Nurse DD stated, a shower sheet is complete and the nurse signs off on it. During an interview on 9/25/18 at 3:32 p.m. with LPN Staff Development Coordinator (SDC) was asked to demonstrate the use of Kiosk to surveyor. SDC was able to explain how CNAs document however the Kiosk did not have the days of when a resident is assigned to shower. When asked if the Kiosk alerts the charge nurse to days when a resident went without a shower, SDC stated that was a supervisory mode function. When asked if it could be determined when the resident was to be provided showers she stated. R#19 days for showers were Tuesday (Tues), Thursday (Thurs), and Saturday (Sat). During an interview on 9/25/18 at 3:46 p.m. with LPN KK stated that bath sheets are completed daily. If the resident refuses their shower it is documented on the bath sheet. The CNA notifies the Nurse. The nurse attempts to encourage the resident to take the bath. If the resident continues to refuse after several attempts it is documented in the resident record. Should the resident desire to bathe the next day. We try to work them in. When asked how does the nurse know that this is a behavior that has been occurring throughout the week, Nurse KK stated that the ADON, is given the bath sheets daily and he is the one that monitors the overall bath times. During an interview on 9/25/18 at 4:43 p.m. with ADON, revealed that he collects the sheets on a daily basis then gives them to the treatment nurse. After the sheets have been reviewed they are kept for about three months. When asked the if the treatment nurse provides a compilation of reviewed data which would indicate which residents are receiving their baths and who are not, ADON stated that would be the expectation. When asked is there a process by which the Interdisplinany team (IDT)reviews the constant refusal of baths from residents ADON stated no. During an interview with MDS Coordinator, on 9/26/18 at 9:45 p.m. was asked to review R#19 MDS dated [DATE]. When asked how she obtained her information to complete the MDS. Stated she reviews the nurse's notes and the CNA information in the kiosk. When asked if she alerted anyone to the fact that R#19 had not received any baths during the look back period she stated no. Further interview with MDS Coordinator revealed the look back period is seven days. When it was noted the R#19 did not receive a bath the Social Worker (SW) and the DHS (Director of Health Care Service) would have/ should have been notified. When asked if the process is set up in such way that the IDT should have known that R#19 did not receive his bath she stated yes. Review of resident nurse's notes revealed there was no documentation. Review R#19 care plan revealed CNAs to provide showers. Record review of grievances on 9/26/18 at 1:00 p.m. noted R#19 lodged concerns of not receiving a bath on 6/15/18. Facility's written response to the concern stated Staffing Coordinator is staffing all available employees. Corporate is advertising for more employees. During an interview on 9/26/18 at 1:43 p.m. with the Nurse Navigator when asked what was specifically done to address R#19 concern of 6/15/18 regarding not receiving a bath, she stated resident immediately received a shower, that day, but I guess I didn't document that. When asked what process has been put in place to address all residents receiving their baths, she stated the ADON and AHS would be able to answer that. During an interview with DHS on 9/26/18 at 2:00 p.m. stated that Unit Managers and the treatment nurse are supposed let us know if the bath sheets are blank. Stated that there is no set way of how this is done. When asked if she and the IDT should have known that R#19 had not received his bath she stated yes. On 9/25/18 at 1:00 p.m. a request for the policy on showers was made. Facility unable to provide one. A policy on Documentation on Charting Activities of Daily Living date 11/7/17 provided.

Based on staff interview and review of the Minimum Data Set, the facility failed to transmit the MDS Assessment for 2 Residents (R) (R#1 and R#2) within the 14 day time period. During an interview on 9/27/18 at 1:09 p.m. with the Minimum Data Set (MDS) Coordinator revealed that R#1's assessment was completed on 7/10/18 but was not transmitted until today when it was brought to her attention. Continued interview with the MDS Coordinator revealed that R#2's assessment was complete on 9/4/18 but was not transmitted until today when it was brought to her attention. MDS Coordinator stated she can't explain why she missed those transmissions. Review of the MDS for R#1 and R#2 revealed that the Assistant Director of Health Services (ADHS) signed off that the MDS assessments were completed. During an interview on 9/27/18 at 1:18 p.m. with the ADHS he stated that he signs off that the MDS assessments are completed but doesn't ensure that the transmissions are done. During an interview on 9/27/18 at 1:29 p.m. with the Consultant Nurse she stated that they receive a report in regards to the MDS transmissions and that R#1 and R#2's should have been caught on that report.

Based on record review, including review of the policy titled Discharge Planning, and staff interview, the facility failed to complete a discharge summary that included a recapitulation of the resident's stay, a post discharge plan of care, or a final summary of the resident's status for one resident (#91) from a sample of 35 residents. Findings include: Review of policy titled, Discharge Planning last revised 10/5/17 revealed that, prior to or on the date of discharge, each member of the interdisciplinary team should complete a final summary of the resident's status on a Post Discharge Plan of Care form. In addition, a completed recapitulation of the resident's stay, signed by the physician, should be given to the resident at the time of discharge. A review of the clinical records revealed Resident (R) #91 was admitted on [DATE] and discharged on [DATE]. A review of the Minimum Data Set (MDS) records for R #91 revealed an admission MDS of 7/22/18 which documented that the resident and family participated in the assessment, and there was an active discharge plan in place for the resident to return to the community. A review of a physician's telephone order dated 7/31/18 revealed the resident was to discharge home with home health care, social services, physical therapy, occupational therapy, and nursing. A review of a nurses' note of 8/1/18 revealed the resident was discharged from the facility on that day with all belongings and medications. A Review of the POS [REDACTED]. No other information related to the resident's stay, status, or discharge was provided. Review of the Interdisciplinary Discharge Summary for R#91 revealed it was initiated on 8/1/18 and completed on 8/23/18. Under the section titled Recapitulation of Resident's Stay, staff had documented only that the resident was admitted on [DATE] and discharged on [DATE] and that the resident was discharged home with home health. There was no reason given for admission, no details of the treatment provided during the stay, or any progress/complications experienced. Interview on 9/27/18 at 10:48 a.m. with Registered Nurse (RN) JJ revealed that, when a resident is discharged , a post discharge plan of care and a discharge summary which recapitulates the resident's stay is to be completed for that resident. When R#91 was discharged , the post discharge plan of care and the discharge summary were not completed in their entirety and there was no recapitulation of the resident's stay completed on the discharge summary. RN JJ said she planned to provide education to the staff immediately regarding the proper completion of required discharge paperwork upon a resident's discharge from the facility.