Every finding on record at Pruitthealth - Savannah

Based on staff interviews, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to complete a Discharge Minimum Data Set (MDS) assessment for one of 36 residents (R) (R2) reviewed for MDS completions. The facility census was 132. Findings include:Review of the RAI Manual, dated October 2025, indicated, There are three types of discharges: two are OBRA [Omnibus Budget Reconciliation Act] required-return anticipated and return not anticipated; the third is Medicare required-Part A PPS [Prospective Payment System] Discharge. A Discharge assessment is required with all three types of discharges . Any of the following situations warrant a Discharge assessment . Resident is discharged from the facility to a private residence . Discharge Assessment - return not anticipated. Discharge assessments must be completed within 14 days of discharge. Record review for R2 revealed that the resident was admitted to the facility on [DATE] and was discharged from the facility on 12/1/2025. Review of the MDS assessments for R2 revealed a discharge MDS was not completed within the 14-day requirement. Review of the list of current MDS assessments provided by the facility revealed 36 MDS assessments were not completed within the required time frames.An interview on 12/17/2025 at 10:15 am with Registered Nurse (RN) MDS Coordinator FF revealed the resident was discharged on 12/1/2025. RN FF reviewed the discharge MDS for R2 and indicated it was in progress and not yet completed. She indicated the due date was 12/15/2025. She stated they were behind in getting them completed, even using remote employees. RN FF stated it was her expectation that assessments would be completed on time and follow the RAI Manual instructions as policy. An interview on 12/17/2025 at 11:37 am with RN MDS Coordinator GG confirmed they have 36 MDS assessments currently in progress that are late. She stated there are three MDS Coordinators that share the duties equally and a person completing parts of the MDS assessments remotely. She confirmed they follow the RAI manual as policy. MDS Coordinator GG also confirmed the MDS department is responsible for completing the MDS Assessments in a timely manner.

Based on observations, staff interviews, and review of the facility's policies titled Medication Administration - Insulin Injections and Medication Administration - General Guidelines, the facility failed to ensure insulin injection pens were used as recommended by the manufacturer and medications were administered according to physician's orders, resulting in a medication administration error rate of 13.64 percent with six errors for four residents (R) (R121, R43, R64, and R31) out of a possible 44 opportunities for error. This failure had the potential to affect the accurate dosing of insulin administered or the potential blood bioavailability of multi-dose medications administered per day to the residents. Findings include: Review of the facility policy titled Medication Administration - Insulin Injections, revised 7/18/2024, revealed: For Insulin Pens: 1. Remove the cover from the pen and swab with an alcohol swab. Screw on a new needle and remove cap. 2. Prime pen by dialing up 2 units on the pen and pressing the button on the end of the pen. Repeat priming procedure until insulin secretes from the needle. 3. Tum the knob on the end of the pen (or dial) to the number of units. 4. Insert the needle under the skin at a 90 degree angle. 5. Press the button on the end of the pen. 6. Count to 10 and remove the pen. Review of the facility policy titled Medication Administration - General Guidelines, reviewed 7/22/2024, revealed: 8. If the facility receives its medications packed with the AdvantageRx system: -The authorized personnel will compare the AdvantageRx bag to the MAR. -The authorized personnel will check off in ink on the bag the medications as they correspond to the MAR. -The authorized personnel will tum the bag over and make a final check to make sure that the actual tablet or capsule in the AdvantageRx bag corresponds to the MAR. 10. Medications are administered within 60 minutes before or after scheduled time, except for medications ordered to be taken with food and before or after meals, which are administered precisely as ordered. Unless otherwise specified by the physician, routine medications are administered according to the established medication administration schedule for the healthcare center. 1. During the observation of medication administration on 6/19/2025 at 8:10 am, Licensed Practical Nurse (LPN) 5 removed an over-the-counter bottle of calcium with vitamin D3 500 milligrams (mg)/ 5 micrograms (mcg) and administered that along with R121's other medications. Review of R121's physician orders from the facility Resident - Orders tab showed Citrical D3 Plus Mg [magnesium] - D3 - Zn [zinc] - cop [copper] - man [manganese - [NAME] [[NAME]] tablet 250-40-125mg - mg-unit; amt [amount] 1 tabl [tablet] qd [daily] at 9a [9:00 am]. In an interview on 6/19/2025 at 9:20 am regarding the two different calcium supplements and if they were interchangeable, an Advanced Practice Registered Nurse (APRN) reviewed the two and responded, Not from my knowledge. In a follow up interview on 6/19/2025 at 9:32 am, LPN5 reviewed the bottle and confirmed 500 mg + D3, then read the back of the bottle, stating, it's 25mcg or 200 iu [international units] and 500 calcium, then read aloud the order from the medication administration record 250-40-125 and stated, It doesn't match to me. 2. During the medication administration observation on 6/19/2025 at 11:05 am, LPN3 removed the Humulin R insulin pen from the medication cart; performed a blood glucose check; dialed 40 units on the pen, applied the needle, cleaned R43's skin, placed the pen, pushed the plunger and held the pen against the skin for two seconds. During a follow-up interview on 6/19/2025 at 11:22 am regarding when a pen should be primed, LPN3 stated, Every time you use it. When asked why it was not primed (dialing two units to ensure insulin is exiting through the needle), LPN3 stated that she had forgotten. 3. During the medication administration observation on 6/19/2025 at 11:30 am, LPN6 prepared R3's medications that included Eliquis (an anticoagulant medication) 2.5mg and Nystatin 100,000/milliliters (ml), pouring out 5ml into a medication cup and administering them to R3. Review of R3's EMR Residents - Orders tab showed the Eliquis was to be given at 9:00 am and 9:00 pm, and the Nystatin was to be administered at 9:00 am, 3:00 pm, and 9:00 pm. 4. Continuing the medication administration observation with LPN6 on 6/19/2025 at 11:50 AM, LPN6 administered Eliquis 5mg to R64. Review of R64's EMR Resident - Orders tab revealed that the medication was to be administered at 9:00 am and 9:00 pm. In a follow-up interview on 6/20/2025 at 12:55 pm, regarding the late medication administration times, LPN6 stated, I had someone that was not doing well and they kept calling me into her room because she was not looking good, I did end up sending her out yesterday. LPN6 confirmed the meds were administered late, stating, I just got behind. 5. During medication administration observation on 6/20/2025 at 8:22 am, LPN7 was observed to check medications against a prepackaged medication pouch, placing a dot by each medication, take a bottle of cetirizine 10 mg, and pour one tablet into the medication cup. LPN7 then opened a prepackaged medication pouch that contained (as printed on the pouch) valsartan, mirabegron, metoprolol, and loratadine; then administered the medications to R31. Review of R31's Active Orders revealed an order dated 4/28/2025 for Claritin (loratadine) [OTC] tablet; 10 mg; [NAME] [amount]:1 tab [tablet]; oral once a day at 9:00 am. Further review revealed no order for cetirizine 10 mg. In a follow-up interview with LPN7 on 6/20/2025 at 10:55 am, LPN7 sorted through the opened preprinted pouches in her cart drawer to find the one for R31. LPN7 noted she did not place a dot by the loratadine but verified with the medication packet in the drawer for 6/21/2025 for R31. The LPN stated the loratadine was included in the medication in the pouch, and it would have been contained in her medication pass. LPN7 then stated, When it states OTC [on the MAR, over the counter], we always give this [showed the cetirizine bottle]. LPN7 confirmed it is a different medication than loratadine and stated, There is no OTC loratadine. LPN7 verbally confirmed R31 would have received two allergy medications and stated she would contact the APRN about it. During an interview on 6/20/2025 at 11:15 am, the Director of Health Services (DHS) stated, They need to do a pharmacy interchange for the medication, and it will be switched to the cetirizine. At 3:53 pm, the DHS stated an expectation that insulin pens would be primed before each use and that medication would be administered within one hour before or after the scheduled time.

Based on resident and staff interviews, record review, and review of the facility's policy titled Involuntary Transfer and Discharges, the facility failed to ensure written bed hold policy and transfers notices were provided to the resident or resident representative (RR) for seven of seven residents (R) (R7, R66, R76, R43, R26, R57 and R45) reviewed for emergent hospital transfer out of a total sample of 28 residents. This failure had the potential to affect the resident and/or their RR by not having the knowledge of where and why a resident was transferred and/or how to appeal the transfer, if desired, and had the potential to contribute to the possible denial of re-admission and loss of the resident's home following a hospitalization for residents transferred to the hospital. This had the potential to affect all residents who resided at the facility in the event that they were transferred out of the facility. Findings include: Review of the facility's policy titled Involuntary Transfer and Discharges, dated 3/30/2023 included the following: (5) For Emergency Transfer or Discharges follow the Acute Care Transfer Reduction Plan - document in the medical record, including patient/resident's understanding of transfer or discharge and Administrator/Social Worker provide a Notice of Involuntary Transfer and Discharge form to the patient/resident, guardian or representative, and the patient/resident's physician as soon as practicable. Facility must keep a copy of the notice in the medical record. 1. Review of R7's undated admission Record located under the Resident tab in the electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE]. Review of R7's Progress Note dated 1/21/2025 at 11:03 pm, located in the EMR under the Resident tab, revealed R7 was slumped over sitting on the side of his bed with his head down nurse/ writer asked resident if he was SOB [short of breath] due to symptoms of SOB increased respiratory rate at 23 and labored breathing. [The] resident stated 'I don't feel good. I'm short of breath.' [The] nurse/ writer asked [the] resident when did this start, [and] he stated after dinner. When [the] oxygen was checked he was at 82% room air. [The] resident was given oxygen at 4 liters and oxygen came up to 93%. He [was] noted to have crackles upon auscultation of lung fields. 2. Review of R66's admission Record, located in the resident's EMR under the Resident tab, revealed R66 was admitted on [DATE] and readmitted on [DATE]. Review of R66's Progress Note, dated 11/16/2024 at 5:05 pm, located under the Resident tab of the EMR revealed Staff found [the] resident lying on the floor on her left side from an unwitnessed fall. Staff informed NP [nurse practitioner], DHS [Director of Health Services], Family #4 (others couldn't be reached) and Facility Administrator. This writer was informed that [the resident] res [resident] could not move her left leg. [The] Res [resident] left [the] facility via stretcher with EMS [emergency medical services]. 3. Review of R76's admission Record, located under the Resident tab in the EMR, revealed R76 admitted on [DATE]. Review of R76's Progress Notes dated 6/2/2025, located under the Resident tab of the EMR, revealed R76 was observed on the floor lying on her back, in the bathroom. Moderate amount of blood noted on floor surrounding right leg, skin tear even wound edges and skin flap attached measuring 10 x 4 cm [centimeters] noted on right lateral leg. Resident states she was attempting to ambulate to restroom when she lost her balance and fell on her right side .unable to assess ROM [range of motion]to right hip d/t [due to] severe pain. R76 was transferred to the hospital. 4. During an interview on 6/17/2025 at 12:10 pm, R43 stated, I went [to the hospital] a few weeks back for breathing/lungs .they say a little pneumonia. When asked if he had received anything in writing regarding his hospital transfer (where he was going, why he was being sent, information regarding an appeal of the transfer if he desired), R43 did not remember receiving anything in writing. Review of R43's annual Minimum Data Set (MDS), with an assessment reference date (ARD) of 5/16/2025 and located in the resident's EMR under the Resident tab, showed R43 had a Brief Interview for Mental Status (BIMS) of 14 out of a possible 15, indicative of intact cognition. Review of R43's EMR Resident - Progress Notes tab revealed: 5/8/2025 7:19 pm Resident c/o [complained of] difficulty breathing /SOB [shortness of breath]. Neb [nebulizer] treatment given, also rescue inhaler given, and resident continued to complain. NP [Nurse Practitioner] call to room to assess. NP give [sic] orders to send resident to ER [emergency room] for evaluation and treatment. Review of R43's Resident - Census, located in the resident's EMR under the Census tab, showed a hospital leave on 5/8/2025. In response to a request for evidence of the provision of a written transfer notice to R43 and his responsible party on 6/18/2025 at 5:05 pm, a written bed hold notice was provided. 5. Review of R26's Census tab in the EMR revealed R26 was originally admitted to the facility on [DATE]. Review of R26's Progress Note, dated 8/16/2024 and located under the Prog Note [Progress Note] tab in the EMR, revealed R26 was observed to be unresponsive with oxygen levels at 77% and below .R26 transported to local hospital. Review of R26's EMR revealed no documented evidence of a written notice of transfer, nor was a bed hold notice issued to the resident and his representative upon his emergent transfer to the hospital. 6. Review of R57's admission Record, located in the resident's EMR under the Resident tab, revealed the resident was admitted to the facility on [DATE]. Review of R57's Progress Note, dated 4/19/2025 and located in the resident's EMR under the Resident tab, revealed R57 was found lying on the floor in front of the bathroom asking, mama to come help her off the floor. The note also revealed that R57 was assessed and found to have a laceration to her forehead that was bleeding. The resident's physician was contacted, and orders were received to send the resident to the emergency department (ED). Review of the EMR did not reveal a written notification of the transfer. 7. Review of R45's admission Record located in the resident's EMR under the Resident tab revealed the resident was admitted to the facility on [DATE]. Review of R45's Progress Note, dated 4/7/2025 and found in the resident's EMR under the Resident tab, revealed R45 was found on the floor, and per the resident's representative (RR), the resident slipped off her bed and hit her head on her trash bin. R45 indicated pain in her right temple/jaw that radiated down her neck and shoulder, which she reported to be a 9/10 on the pain scale. The RR requested that the resident be transferred to the ED. A review of R45's Census, located in the resident's EMR under the Resident tab, revealed the resident was sent to the ED and returned the same day. The census also revealed the resident was transferred to the ED on 4/12/2025 and returned on 4/14/2025. A progress note dated 4/12/2025, labeled a FALL NOTE, revealed the resident was found on the floor, sitting in urine. The resident confirmed to staff that she slipped in her urine but had no injuries. The note continued, advising that the resident's physician was notified and sent orders to send the resident to the ED. Review of the EMR did not reveal any documentation confirming that the resident and the RR were notified in writing of the transfer to the ED. During an interview on 6/18/2025 at 1:30 pm, Licensed Practical Nurse (LPN) 1 stated she had never filled out a transfer/discharge notice and was not aware one needed to be filled out and provided to the residents and their representatives. During an interview on 6/19/2025 at 2:41 pm, the Administrator stated the facility had not been providing the residents and/or their representative with a written transfer and discharge notice. He stated he was aware the facility's policy indicated the Administrator or Social Worker would provide the notice to residents and their representatives. During an interview on 6/19/2025 at 2:51 pm, the Social Worker stated she had not been providing residents or their representatives with a written transfer/discharge notice. She stated she was not aware they needed one until today, when she was shown the policy on transfer/discharge notices. During an interview on 6/19/2025 at 3:04 pm, the Interim Director of Health Services (IDHS) confirmed there were no transfer forms, stating, The only form they have is for the 30-day discharge, and that has not been being used for hospital transfers.

Based on staff interview, record review, and review of the facility's policy titled Care Plans, the facility failed to review and revise residents' care plans for one of 28 sampled residents (R) (R27). The facility did not ensure care conferences occurred at least quarterly, where R27's care plan would be reviewed and/or revised. This failure placed the resident at risk for unmet care needs. Findings include: Review of the facility's policy titled Care Plans, reviewed on 7/27/2023, revealed It is the policy of the health care center for each patient/resident to have a person-centered baseline care plan followed by a comprehensive care plan developed following completion of the Minimum Data Set (MDS) and Care Area Assessment (CAA) portions of the comprehensive assessment according to the Resident Assessment Instrument (RAI) Manual and the patient/resident choice. Review of R27's admission Record, located in the resident's electronic medical record (EMR) under the Resident tab, revealed the resident was admitted to the facility on [DATE] with multiple diagnoses that included history of urinary tract infections (UTI), acute kidney failure, and generalized muscle weakness. Review of R27's Quarterly MDS with an assessment reference date (ARD) of 4/18/2025 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated the resident was moderately cognitively impaired. Review of R27's Care Plan, located in the residents' EMR under the Care Plan tab, revealed that the last care conference was held on 6/25/2024. During an interview on 6/20/2025 at 9:30 am, the Director of Health Services (DHS) stated he was advised that there was no documentation that R27 had a care plan conference since 6/25/2024. During an interview on 6/20/2025 at 10:20 am, the Minimum Data Set Coordinator (MDSC) confirmed that the last care conference for R27 was held on 6/25/2024. The MDSC also stated that the facility had experienced some turnover in its MDS and RAI (Resident Assessment Instrument) teams, leading to delays in completing care plan conferences.

Based on observations, staff interviews, and review of the facility policy titled Infection Control - Linen and Laundry, the facility failed to ensure one Laundry Aide (LA)1 donned (put on) proper personal protective equipment (PPE) while sorting soiled resident clothing and bed linens. This deficient practice had the potential to affect the staff and/or all residents which could potentially lead to the development of infectious diseases. Findings include: Review of a policy provided by the facility titled Infection Control - Linen and Laundry, dated 10/30/2023 indicated .Soiled laundry will be handled as contaminated, and all partners will practice standard precautions when handling or exposed to soiled laundry. Standard precautions involve wearing the appropriate PPE when handling or exposed to soiled laundry.Personal protective equipment (e.g. gown, gloves, and mask) will be readily available for use and must be worn, as indicated, to protect employees from exposures.Laundry partners should wear protective gloves, procedure mask, rubber/plastic apron and eye protection while handling soiled linen in the laundry area to prevent unnecessary exposure to pathogens. During an observation on 1/18/2024 at 2:21 pm, LA1 was observed on the clean linen side of the laundry room. LA1 stated she did not don PPE when she sorted the soiled laundry which included resident clothing and bed linens. LA 1 stated she did not know where the gowns were and confirmed she had exposed her uniform to the soiled clothing she sorted. LA 1 was observed with a face mask on and hanging under her chin. The Director of Health Services (DHS) was present during this observation and interview. The DHS stated all staff and especially the laundry staff have been in-serviced on proper donning of PPE while sorting soiled laundry. The DHS stated there were plenty of gowns available for staff to use. During an interview on 1/18/2024 at 2:34 pm, the Housekeeping Supervisor stated her expectation for laundry staff was to don a gown and gloves to protect the laundry staff and prevent the spread of contaminants to clean laundry and to the rest of the facility.

Based on observation, staff interviews, documentation review, review of the facility documents titled Hot Water Sanitizing Upright Door Dish Machine, and Installation and Operating Manual for ECOLAB Models: ES-2000HT INTL, and review of the facility policy titled Dishwashing, the facility failed to ensure the dishwasher rinse temperature was at the proper temperature to sanitize the dishes. The facility further failed to ensure staff performed hand hygiene between handling the soiled dishes and handling the clean dishes. This had the potential to affect 120 of 126 residents in the facility who consumed food from the kitchen. The facility identified six residents who consumed nothing by mouth (NPO). Findings include: Review of the Instruction Manual for the dish machine titled Hot Water Sanitizing Upright Door Dish machine, and Installation and Operating Manual for ECOLAB Models: ES-2000HT INTL dated July 10, 2006, page 8 under operating instructions revealed the operator should verify the temperature of the rinse water is between 180- and 195-degrees Fahrenheit for the entire rinse sequence. Under the specifications section of the manual, it revealed the wash temperature should be a minimum of 150 and the rinse temperature should be a minimum of 180 degrees F. Review of the facility policy titled, Dishwashing, with a revised date of 3/23/2016 revealed, Wash and sanitize hands properly before pulling racks from the clean side of the dish machine or handling clean items. The policy further revealed to run the dish machine until proper temperature is reached and to adhere to the manufacture's guidelines for appropriate temperature guidelines. Under the section titled Temperature Log Policy the policy revealed, The Dish machine temperature log form must be completed by staff directly involved in the dishwashing process. This enables the wash and rinse temperatures to be properly monitored and controlled. The policy revealed to post the log in the immediate vicinity of the dishwashing area and to report temperatures that are out of range to the Dietary Manager immediately. During an observation on 1/15/2024 at 9:15 am the dishwasher rinse cycle's temperature was registering 108 degrees Fahrenheit (F) on the thermometer. When the dish machine was run, the temperature on the thermometer remained at 108 degrees F. Dietary Aide (DA)1 placed dirty trays, plates, and plate covers on the dish machine racks and was running them through the dishwasher. After three racks of soiled dishes had been run through the dishwasher, she took her gloves off and without washing her hands she obtained a clean pair of gloves from a box located across from the dishwasher. She was observed to be touching the outside of the clean gloves and then put them on her unwashed hands. She then took the clean dishes off of the rack and put them away in the kitchen with the other clean dishes. During an interview on 1/15/2024 at 9:23 am, DA1 verified the wash temperature was 108 degrees F and verified she was not washing her hands between glove changes between going from the soiled end of the dishwasher to the clean end. She stated that since she was dipping her gloved hands into a container of water to rinse the dishes off prior to placing them on the racks she did not feel as if she needed to wash her hands. When asked about the rinse temperature, she stated they were supposed to write the temperature down each day. She stated the rinse water temperature was supposed to be 180 degrees F. When asked what she was supposed to do if it was not 180 degrees F, she stated she did not know. She continued running the dishwasher after she verified the wash temperature was 108 degrees F and she continued to change her gloves without washing her hands between the clean and soiled sides of the dishwasher. She also continued taking the dishes off the racks at the clean end of the dishwasher and putting them away in the kitchen. Review of the Dish machine Temperature Log Form, with a revised date of 4/06/2015 revealed there were no temperatures documented for 1/12/2023, 1/13/2023, and 1/14/2023. DA1 verified the temperature had not been recorded for those dates. After she verified the thermometer on the dishwasher was 108 degrees F, she continued running the soiled dishes through the dishwasher. During an interview on 1/18/2024 at 9:40 am the Dietary Manager stated the employee should not have continued washing the dishes and putting them away when the rinse thermometer read 108 degrees F. The DM also revealed the employee should have had one employee on the soiled end of the dishwasher and one employee on the clean end of the dishwasher. She further confirmed the employee should have washed her hands between changing her gloves and going from the soiled end of the dishwasher and the clean end of the dishwasher.

Based on staff interviews, record review, and review of the facility's policy titled Care Plans, the facility failed to ensure a baseline care plan was provided for one of nine sampled residents (Resident (R) 329). Specifically, the facility failed to develop a baseline care plan for pressure ulcers. This failure had the potential to cause staff to not receive the necessary instructions needed to provide effective care and meet the needs of residents. Findings include: Review of the facility's policy titled, Care Plans, revised on 7/27/2023, revealed . It is the policy of the health care center for each patient/resident to have a person-centered baseline care plan followed by a comprehensive care plan . Baseline Care Plan- Must include the minimum healthcare information necessary to properly care for each patient/resident immediately upon their admission, which would address patient/resident specific health and safety concerns to prevent decline or injury, and would identify needs for supervision, behavioral interventions, and assistance with activities of daily living, as necessary . Upon a new admission, a baseline care plan will be developed by the admitting nurse/nurses in conjunction with other IDT [Interdisciplinary Team], the patient/resident and/or patient/resident representative. The baseline care plan should be initiated in 24 hours and will be completed and implemented within 48 hours of admission . Review of R329's Face Sheet, located in the electronic medical record (EMR) under the Resident tab, revealed R329 was admitted to the facility on [DATE] with diagnoses that included a sacral unstageable pressure ulcer. Review of R329's Observation Detail List Report, dated 1/05/2024 and located in the EMR under the Progress Note tab, revealed R329 had a sacrum/coccyx ulcer. Review of R329's Wound Management Detail Report, dated 1/05/2024 and located in the EMR under the Wound Documentation tab, revealed R329 had a 5.0 centimeter (cm) by 6.0 cm by 0.2 cm unstageable sacral pressure ulcer with slough and eschar in the wound base and a 3.0 cm by 3.0 cm stage 1 pressure ulcer on the right hip. Review of R329's Baseline Care Plan, dated 1/09/2024 and located in the EMR under the RAI (Resident Assessment Instrument) tab, revealed, . Feeding tube -resident will maintain nutritional stability . The baseline care plan failed to include the presence of pressure ulcers and interventions to implement for care. During an interview on 1/18/2024 at 1:30 pm, the Director of Health Services (DHS) stated the admission nurse was responsible for initiating the baseline care plan for a resident, and the baseline care plan should include pertinent areas of concern including pressure ulcers and treatment so staff could provide the necessary care. The DHS confirmed R329's baseline care plan did not include the pressure ulcers identified on admission. Review of the facility's policy titled, Documentation of Skin and Wound Care, revised on 3/18/2021, revealed, . Admission Documentation should occur on: Baseline admission care plan related to risk for skin breakdown as well as for actual breakdown .

Based on resident and staff interviews, record review, and review of a policy provided by the facility titled Care Plan, the facility failed to ensure four residents (Residents (R) R280, R60, R52, R51) and/or their representative was invited to participate in their quarterly care plan meetings out of a total sample of 40 residents. This failure had the potential to affect the residents' care needs. Findings include: Review of a policy provided by the facility titled Care Plan, dated 7/27/2023 indicated . The patient/resident and or the patient/resident's representative will participate to the extent practicable in the care planning process. An explanation must be included in a patient/resident's medical record if the participation of the patient/resident and their patient/resident representative is determined not practicable for the development of the patient/resident's care plan. Comprehensive care plans should be reviewed not less than quarterly according to OBRA [Omnibus Reconciliation Act] MDS [Minimum Data Set] schedule, following the completion of the assessment. Care plan updates/reviews will be performed within 7 days of each quarterly assessment, each acute change in condition, and as needed following each hospital stay. 1.Review of R280's electronic medical record (EMR) titled Resident Face Sheet located under the Resident tab indicated the resident was admitted to the facility on [DATE]. Review of R280's EMR titled comprehensive MDS with an Assessment Reference Date (ARD) of 10/19/2023 indicated the staff could not determine the resident's Brief Interview for Mental Status [BIMS] score and determined the resident had short-and-long-term memory problems. Review of R280's EMR titled Care Plan located under the Resident Assessment Instrument [RAI] tab indicated the resident's last care conference was on 8/10/2023 and the next scheduled care conference was on 11/08/2023. Review of R280's EMR titled Progress Notes located under the Resident tab failed to indicate the resident and/or her representative were invited to participate in the care planning process. During an interview on 1/15/2024 at 9:13 am, R280 stated she did not get invited to her care conferences on a consistent basis. 2.Review of R60's EMR titled Resident Face Sheet located under the Resident tab indicated the resident was admitted to the facility on [DATE]. Review of R60's EMR titled quarterly MDS with an ARD of 11/07/2023 indicated the resident had a BIMS score of 11 out of 15 which revealed the resident was moderately cognitively impaired. Review of R60's EMR titled Progress Notes located under the Resident tab failed to indicate the resident and/or his representative were invited to participate in the care planning process. Review of R60's EMR titled Care Plan located under the RAI tab indicated the resident's last care conference was on 7/24/2023 and the next scheduled care conference was on 10/23/2023. During an interview on 1/16/2024 at 1:19 pm, Social Service Director (SSD) 2 stated the MDS Coordinator (MDSC) 1 and MDSC 3 were the staff who set up the care conferences on a quarterly basis. During an interview on 1/16/2024 at 1:32 pm, MDSC 1 stated she does send out quarterly care plan meeting invitations. MDSC 1 confirmed R280 missed the quarterly care conference scheduled on 11/08/2023 and stated she missed the quarterly meeting for the resident. MDSC 1 stated there were staffing issues and she was unable to complete the quarterly meetings and the care conferences. During an interview on 1/18/2024 at 8:27 am, the Corporate Nurse confirmed R280 and R60 had no care plan meetings, nor did they or their representatives receive invitations to the quarterly care conferences. 09262 3.Review of R52's EMR titled Resident Face Sheet located under the Resident tab indicated the resident was admitted to the facility on [DATE]. Review of R52's EMR admission MDS with an ARD of 11/03/2023 indicated the resident had a BIMS score of 15 out of 15 which revealed the resident was cognitively intact. Review of R52's EMR titled Progress Notes located under the Resident tab failed to indicate the resident and/or his representative were invited to participate in the care planning process. Interview on 1/15/2024 at 1:13 pm, R52 stated that she has not been invited or attended a care plan meeting. 4. Review of R51's EMR titled Resident Face Sheet located under the Resident tab indicated the resident was admitted to the facility on [DATE]. Review of R51's EMR admission MDS with an ARD of 9/02/2023; R51's significant change MDS with an ARD of 9/21/2023; and R51's quarterly MDS with ARD of 12/14/2023 indicated the resident had a BIMS score of 11 out of 15 which revealed the resident cognition was moderately impaired. Review of R51's EMR titled Progress Notes located under the Resident tab failed to indicate the resident and/or his representative were invited to participate in the care planning process. Interview on 1/15/2024 at 2:29 pm, R51 stated that she doesn't recall being invited or attending a care plan meeting. Interview on 1/18/2024 at 9:29 am, the MDS Coordinator (MDSC)1 stated that when R51's MDSs were completed, no care plan meetings were being conducted. Interview on 1/18/2024 at 09:09 am, the Corporate Nurse revealed that residents admitted in September, October, November, and December 2023 did not have timely care plan meetings. Interview on 1/18/2024 at 11:56 am, the Administrator said that she was not aware that the MDSCs were not conducting care plan meetings.

Based on staff interviews, record reviews, review of facility policy titled MDS Assessment Accuracy, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure one resident (R) (R89) of 40 sampled residents, had an accurate Minimum Data Set (MDS) assessment related to anticoagulant use. Failure to code the MDS correctly could potentially lead to inaccurate federal reimbursements and inaccurate assessment and care planning of the resident. Findings include: Review of the facility's policy titled MDS Assessment Accuracy, dated 12/06/2022 revealed: It is the policy of this healthcare center that each Minimum Data Set (MDS) reflects the acuity and the medical status of each resident .6. All MDS Assessments must be completed following the guidance set forth in the RAI manual as directed by the Centers for Medicare and Medicaid Services (CMS). Review of the RAI Manual, dated 10/01/2019, indicated, It is important to note here that information obtained should cover the same observation period as specified by the Minimum Data Set (MDS) items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [interdisciplinary team] completing the assessment. Review of R89's Physician's Orders dated 9/19/2023 located in the electronic medical record (EMR) under the Orders tab, revealed R89 had an order for aspirin 325 milligrams (mg) (a nonsteroidal anti-inflammatory medication) one time per day. The physician's orders did not indicate that R89 received an anticoagulant medication. Review of the electronic medical record (EMR) section RAI revealed the quarterly MDS with an Assessment Reference Date (ARD) of 10/13/2023 indicated that R89 received an anticoagulant medication during the last seven days of the assessment period. During an interview on 1/16/2024 at 11:12 am, MDS Coordinator (MDSC) 3 reviewed R89's quarterly MDS dated [DATE] and R89's Physician Orders and confirmed that the MDS was coded inaccurately since R89 only received aspirin. 09262

Based on staff interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to follow the RAI's transmittal requirements, which indicates that within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the Center for Medicare & Medicaid Services (CMS) System for one resident (R) (R94) of 40 sampled residents reviewed. Specifically, it has been over 120 days since the quarterly MDS was completed and the MDS had not been transmitted to the CMS System. Finding include: Review of the RAI 3.0 Manual section 5.2 Timeliness Criteria indicated, .Transmitting Data: Submission files are transmitted to the Quality Improvement and Enhancement System (QIES) Assessment Submission and Processing (ASAP) system using the CMS wide area network. Providers must transmit all sections of the MDS 3.0 .Transmission requirements apply to all MDS 3.0 records used to meet both federal .requirements Assessment Transmission: .All other MDS assessments must be submitted within 14 days of the MDS Completion Date . Review of a document titled MDS [Minimum Data Set] 3.0 Resident Assessment, provided by MDS Coordinator (MDSC) 3, indicated that R94's 10/16/2023 quarterly MDS status was finalized. During an interview on 1/16/2024 at 11:12 am, MDSC 3 showed, on her computer, that R94's quarterly MDS with an Assessment Reference Date (ARD) of 10/16/2023 was completed but had not been transmitted. During the interview, MDSC 3 stated that after the MDS was completed, it was batched to be transmitted. MDSC 3 stated that she could see on the computer screen that R94's quarterly MDS's status was finalized should read production accepted, which would indicate the MDS has been transmitted.

Based on staff interviews, record review, and review of the facility policy titled Bed Holds and Room Reserves, the facility failed to ensure two residents (R) (R59 and R110), and/or their responsible party (RP), of four residents reviewed were given a written bed hold policy at the time the residents were transferred/discharged to the hospital. Findings include: Review of the facility's policy titled Bed Holds and Room Reserves, with a revised date of 11/22/2016 revealed it is the facility's policy to provide written information regarding the bed hold policy and allowed duration to the resident or the responsible representative prior to the resident transfer. The policy stated upon initiation of transfer, the charge nurse on duty is responsible to offer the patient the bed hold option. The bed hold acknowledgment form will be presented to the resident or resident representative and the written notice will be included in the transfer packet. If the resident representative is not present, a copy of the bed holds acknowledgment form will be sent by mail to the responsible representative within one business day. 1. Review of R59's Face Sheet in the Face Sheet tab of the electronic medical record (EMR) revealed diagnoses of vascular dementia and late-onset Alzheimer's. Review of the quarterly (Minimum Data Set (MDS) dated [DATE] revealed she had a Brief Interview for Mental Status (BIMS) score of two out of 15, indicating she was severely cognitively impaired. Review of R59's Progress Notes under the Progress Notes tab dated 7/08/2023 of the EMR revealed the resident's left hip was noted to be swollen and red. The Nurse Practitioner (NP) was called and instructed the staff to send her to the emergency room (ER). Review of a Progress Note located in the Progress Note tab dated 7/13/2023 of the EMR revealed R59 returned to the facility. The EMR revealed no evidence that R59 or her responsible party (RP) was given a written bed hold notice. During an interview on 1/15/2023 at 2:11 pm R59's RP revealed he did not remember if he received any written notices, however, they held the bed for her. During an interview on 1/17/2024 at 1:10 pm the Corporate Nurse confirmed a written bed hold notice was not given to R59 or her RP. 21382 2. Review of R110's quarterly MDS, with an ARD of 11/22/2023 and located under the RAI tab of the EMR, revealed R110 had a BIMS score of 14 out of 15, indicating R110 was cognitively intact. Review of R110's Progress Note, dated 10/23/2023 at 2:24 am and located in the EMR under the Progress Notes tab, revealed R110 was sent to the ER for complaints of shortness of breath and pain radiating down her left arm. The Progress Note read, . NP and son were notified . There was no evidence the resident or the RP was given a bed hold policy. Review of R110's Progress Note, dated 11/08/23 at 6:11 PM and located in the EMR under the Progress Notes tab, revealed R110 had complaints of shortness of breath and requested to go to the ER. The NP was called and gave an order to send R110 to the ER. The Progress Note read, . aware of bed hold policy . There was no evidence a written bed hold notice was given to the resident or RP. During an interview on 1/16/2024 at 2:30 pm, the Director of Health Services (DHS) confirmed there was no bed hold policy given to R110 or the resident's RP.

Based on staff interviews, record review, and review of the facility policy titled Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to ensure that thorough investigations of resident-to-resident incidents that involved residents (R) (R279, R60, and R1) were completed. There was no evidence the facility interviewed other current residents or staff regarding the allegations of a physical resident-to-resident altercation with R279 and R60. There was no evidence the facility interviewed other current residents or staff regarding the physical resident-to-resident altercation with R279 and R1. The facility's investigation failed to include the names of the residents who were the victims. This lack of investigation had the potential to place other dependent residents at risk for abuse/neglect. Findings include: Review of a policy provided by the facility titled Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, dated 10/09/2020 indicated .Documentation of the investigation should include, but not be limited to, the following.Date and time of alleged occurrence .Patient's full name and room number.Names of accused and any witnesses.Names of [NAME] Health partners staff who investigated the allegation.Any physical evidence and description of emotional state of patient(s).Details of the alleged incident and injury.Signed statements from pertinent parties.Cognitive staff of victim(s).who are witnesses.Information gathered from the investigation.Interviews should be conducted of all individuals who have relevant information.Written signed statements from any involved parties should be obtained.Statements should be gathered from the following individuals.the suspect.reliable patients who may have witnessed the incident; and any other persons who may have information.All investigative information should be kept on file.A written report of the investigation and follow-up should be submitted to the appropriate agency within five working days of the occurrence, unless otherwise if indicated. 1. Review of R279 electronic medical record (EMR) titled Resident Face Sheet located under the Resident tab indicated the resident was admitted to the facility on [DATE]. 2. Review of R60's EMR titled Resident Face Sheet located under the Resident tab indicated the resident was admitted to the facility on [DATE]. 3. Review of R1's EMR titled Resident Face Sheet located under the Resident tab indicated the resident was admitted to the facility on [DATE]. Review of a file, which contained a letter dated 1/02/2024 and referred to the resident-to-resident altercation which involved R279 and R60, failed to contain evidence of interviews with witnesses and possible residents who may have witnessed the incident. The file failed to contain copies of R279's and R60's clinical records which contained evidence of the resident-to-resident incident. Review of a file, which contained a letter dated 1/05/2024 and referred to the resident-to-resident altercation which involved R279 and R1, failed to contain evidence of interviews with witnesses and possible residents who may have witnessed the incident. The file failed to contain copies of R279's and R1's clinical records which contained evidence of the resident-to-resident incident. During an interview on 1/16/2024 at 11:14 am, the Administrator confirmed she did not collect written witness statements since the staff were the witnesses and documented the events in the clinical records. During an interview on 1/18/2024 at 11:56 am, the Administrator confirmed she did not gather statements from staff or other residents for each of the resident-to-resident incidents. The Corporate Nurse was present during this interview.

Based on staff interview, record review, and review of the facility policy titled Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to ensure that an allegation of abuse was reported to the State Survey Agency (SSA) in a timely manner for one of eight residents (R) (R60) reviewed for abuse. This failure had the potential for other allegations of abuse to not be reported in a timely manner. Findings include: Review of the facility policy titled Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, dated 10/09/2020 indicated .Federal regulations applicable to skilled nursing facilities.do not require that every bruise or scratch incurred by patients in the course of everyday activities be reported to the State. The regulations require that occurrences of abuse and mistreatment be reported, including injuries of unknown origin, in accordance with established State procedures. Review of R60's EMR titled Resident Face Sheet located under the Resident tab in the electronic medical record (EMR) indicated the resident was admitted to the facility on [DATE] with a diagnosis of unsteadiness on feet. Review of a document provided by the facility for R60 titled Quarterly Minimum Data Set (MDS) with an ARD of 11/07/2023 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated the resident was moderately cognitively impaired. Review of R60's EMR titled nursing Progress Notes located under the Resident tab dated 12/26/2023 revealed R279 punched R60 in the chest. Review of a document provided by the facility titled Facility Incident Report Form dated 1/16/2024 indicated the facility reported the resident-to-resident incident which involved R279 to R60 to the State Agency on 1/16/2024. During an interview on 1/16/2024 at 12:03 pm, the Administrator confirmed she was late with the submission of the initial allegation of resident-to-resident which involved R279 and R60. The Administrator stated she typically reports to the State Agency immediately and then begins an investigation of the incident.

Based on staff interviews, record review, and review of the facility policy titled Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to ensure two residents (R) (R1 and R60) of eight residents reviewed for abuse, were free from resident-to-resident abuse for two separate incidents. Findings include: Review of the facility policy titled Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, dated 10/09/2020 indicated .It is the mission of [NAME] Health and its affiliated providers (collectively, the Organization) actively to preserve each patient's right to be free from abuse, neglect, exploitation, mistreatment, and misappropriation of patient property. The Organization recognizes that every patient has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The purpose of our abuse prohibition procedures is to assure that our partners are doing all that is within our control to create a standard of intolerance and to prevent any occurrences of any form of patient abuse, neglect, exploitation, mistreatment, and misappropriation of property. Our policies and procedures establish standards of practice for screening and training partners, protecting patients, and the prevention, identification, investigation and responding/reporting of abuse, neglect, exploitation, mistreatment, and misappropriation of property. 1.Review of R279 electronic medical record (EMR) revealed a Resident Face Sheet located under the Resident tab indicated the resident was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, unspecified severity, without behavioral disturbance and psychotic disturbance. Review of a document provided by the facility for R279 titled quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/26/2023 indicated the resident had a Brief Interview for Mental Status (BIMS) score of three out of 15 which indicated the resident was severely cognitively impaired. The assessment indicated the resident had behavioral and verbal incidents directed towards others. Review of R279's EMR revealed a Progress Notes located under the Resident tab dated 12/26/2023 indicated the resident was observed to hit another resident (R60). The resident responsible party and the physician were notified. The physician ordered R279 to be transported to the local hospital. The resident returned later that same day. Review of R60's EMR titled Resident Face Sheet located under the Resident tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of unsteadiness on feet. Review of a document provided by the facility for R60 titled quarterly MDS with an ARD of 11/07/2023 indicated the resident had a BIMS score of 11 out of 15 which indicated the resident was moderately cognitively impaired. The assessment indicated the resident had no behavioral and verbal incidents directed towards others. Review of R60's EMR titled Care Plan located under the RAI tab dated 8/03/2022 indicated the resident had impaired decision-making and some memory problems. Review of R60's EMR titled nursing Progress Notes located under the Resident tab dated 12/26/2023 indicated the resident was punched in the chest by a resident (R279). The progress notes revealed R60 did not sustain any injury and voiced he was fine. Review of a document provided by the facility untitled, referred to as the facility's Investigation, dated 1/02/2024 indicated on 12/26/2023 R279 became increasingly agitated and began to wander in and out of other resident rooms. R279 then came to R60 and struck him in the chest. R60 sustained no injury. R279 was sent out to the local emergency room for evaluation and treatment and the goal was to find a more appropriate placement for R279. 2. Review of R279's EMR revealed a Progress Notes located under the Resident tab dated 12/29/2023 indicated the resident hit a resident (R1). The progress notes revealed the resident was difficult to redirect and agitated. The physician was notified and ordered to administer Haldol (antipsychotic) 2 milligrams (mg) intramuscular and to repeat in two hours if indicated. A referral was made to a geri-psychiatric unit. Review of R1's EMR titled Resident Face Sheet located under the Resident tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of unspecified dementia. Review of a document provided by the facility for R1 titled annual MDS with an ARD of 11/09/2023 indicated the staff could not determine a BIMS score and indicated the resident had short and long-term memory problems. Review of R1's EMR titled nursing Progress Notes located under the Resident tab dated 12/29/2023 indicated the resident was struck in the face by a resident (R279). R1 sustained no injuries but was tearful after the incident. Review of a document provided by the facility untitled, referred to as a facility Investigation, dated 1/05/2024 indicated R1 was struck by R279. The document revealed R1 sustained no injuries. The investigation indicated R279 was sent to a geri-psychiatric facility and the medical center staff was assisting with locating placement elsewhere. Review of R279's EMR titled Nursing Progress Notes located under the Resident tab dated 1/02/2024 indicated the resident was eventually transferred from the facility to the geri-psychiatric unit and admitted . During an interview on 1/16/2024 at 12:27 pm, Certified Nursing Assistant (CNA) 1 stated she saw R279 hit R60 in the chest. CNA 1 stated she immediately separated the two residents and redirected R279. During an interview on 1/16/2024 at 12:34 pm, CNA 2 stated she observed R279 slap R1. CNA 2 stated she reported the incident to the nurse immediately after the incident happened. During an interview on 1/16/2024 at 12:49 pm, Licensed Practical Nurse (LPN) 2 stated she witnessed when R279 slapped R1. During an interview on 1/16/2024 at 12:58 pm, CNA 3 stated she observed R279 slap R1 and stated R1 was hit on the head by R279. CNA 3 stated R1 started to cry after the incident, and he/she reported the incident immediately to the nurse and he/she considered the incident resident to resident abuse. An attempt was made to interview R60 and R1 and neither were interviewable. During an interview on 1/17/2024 at 9:04 am, LPN 1 stated she was the supervisor the day R279 hit R60 and was asked to assess R60 after the resident-to-resident incident. LPN1 stated R60 sustained no injuries. LPN 1 stated she reported the incident to the residents' physician and their responsible parties. LPN 1 stated the incident between R279 and R60 was abuse. During an interview on 1/17/2024 at 9:19 am, LPN 3 stated she witnessed the incident when R279 hit R60 across the chest. LPN 3 also stated R1 came to her after being slapped by R279 and was crying and upset after the incident. During an interview on 1/17/2024 at 7:23 pm, the Administrator confirmed the incidents between R279 and R60 and R279 and R1 were abuse. Cross Reference F609 and F610.

Based on staff interviews, record review, and review of the facility policy titled Advance Beneficiary Notices (ABNs),, the facility failed to issue a Notice of Medicare Non-Coverage Notices (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN) to Medicare A recipients when therapy or skilled nursing services were ending for three of three sampled residents (R) (R112, R179, and R379) reviewed for NOMNC and SNFABN. This failure had the potential for residents and/or their representatives not being informed of potential available services and fees for those services or the advisement of the ability to appeal the Resident's discharge from Medicare Part A benefits. Findings include: Review of the facility policy titled, Advance Beneficiary Notices (ABNs), last revised 7/19/2016, revealed, . The company recognizes the patients/residents have the right to be informed in writing (in a readable and comprehensive manner) in a timely fashion, about their liability for payment of services prior to the provision of those services if Medicare is expected not to pay . The purpose of an Advanced Beneficiary Notice (ABN) is to inform the patient/resident that Medicare will probably not pay for a certain item or service in a specific situation, even if Medicare might pay for the item or service under different circumstances. This allows the patient/resident to make an informed decision about whether or not to receive to item or service for which he/she may have to pay out of pocket or through other insurance . 1. Review of R112's Progress Notes tab of the electronic medical record (EMR) revealed R112 was admitted to the facility on [DATE] for therapy. He later transitioned to long-term care. There was no evidence R112 received a NOMNC and SNFABN when his therapy ended. 2. Review of R179's Progress Notes tab of the EMR revealed R179 was admitted to the facility on [DATE] for therapy. Her therapy ended on 1/16/2024 and she was discharged from the facility on 1/17/2024. There was no evidence R112 received a NOMNC prior to her Medicare A stay ending and her discharge home. 3. Review of R379's Progress Notes tab of the EMR revealed R379 was admitted on [DATE] and discharged home on 8/01/2023. There was no evidence R379 received a NOMNC prior to her Medicare A services ending and her discharge home. During an interview with the Minimum Data Set Coordinator (MDSC) 3 on 1/16/2024 at 12:19 pm, she stated she had not issued any NOMNCs or SNF (Skilled Nursing Facility) ABNs. She stated the facility only issued NOMNC/SNFABNs to managed care residents. She stated in her orientation nothing was said about issuing the notices to Medicare A residents. In an interview with the Corporate Nurse on 1/16/2024 at 3:30 pm, she stated the policy for NOMNCs provided was the only policy that the facility had. The Administrator was present for that interview and stated at the morning meetings she asked about NOMNCs and just assumed it included Medicare A residents. During a further interview with the Corporate Nurse and MDSC 3 on 1/17/2024 at 1:33 pm, they confirmed the facility did not have a policy for issuing NOMNCs to Medicare A residents. The MSDC 3 stated she reached out to a sister building and asked if they had a policy or issued NOMNCs to Medicare A residents and was told no.

Based on staff interviews, record review, and review of the facility policy titled Physician Notification, the facility failed to ensure the physician was notified of a change of skin condition for one of 40 sampled residents (R) (R103). Specifically, the facility failed to notify the physician of a fungal rash that required treatment. This failure had the potential for R103 to not receive the necessary treatment needed to promote the healing of a skin condition. Findings include: Review of the facility's policy titled Physician Notification, revised on 9/15/2023, revealed, . the physician will be notified when the resident has a change in condition . Review of R103's Face Sheet, located in the electronic medical record (EMR) under the Resident tab, revealed R103 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, rash and other skin eruption. Review of R103's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/13/2023 and located under the RAI (Resident Assessment Instrument) tab of the EMR, revealed R103 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition; was frequently incontinent of urine, and had a rash and other skin condition. During an observation and interview on 1/17/2024 at 5:20 am, Certified Nursing Assistant (CNA) 5 provided incontinent care for R103. When R103's brief was removed, red excoriation and open areas were noted on both buttocks. R103's bilateral inner thighs and genital area were noted with large areas of bumpy red rash and excoriation. CNA5 stated she worked on the unit and had cared for the resident for a while and the areas had been there for at least a week. CNA5 stated she applied intensive skin cream to the resident's inner thighs and buttocks. Review of the Physician Orders, located in the EMR under the Orders tab, revealed no treatment for skin excoriation or other skin conditions. During an interview on 1/17/2024 at 8:15 am, the Director of Health Services (DHS) reviewed the resident's EMR with the surveyor and was unable to locate physician orders for treatment of the excoriated areas and rash on the inner thighs, genital area, and buttocks until 1/17/2024 at 3:58 pm. The DHS confirmed her expectation was for the physician to be notified of any new skin impairment. During an interview on 1/17/2024 at 8:40 am, CNA6 stated she worked on the unit regularly and was assigned to provide care to R103. CNA6 stated R103 had excoriated areas on the inner thighs and buttocks for at least a week and she applied intensive skin cream to the inner thighs and buttocks. CNA6 stated she thought the nurses were aware of R103's skin condition. During an interview on 1/17/2024 at 9:00 am, Licensed Practical Nurse (LPN) 7 stated when she worked on the unit, she did not do the treatments because the facility had a treatment nurse. LPN7 stated she was unaware of the excoriated rash. During an interview on 1/17/2024 at 9:40 am, facility Wound Nurse (WN) 1 stated the resident had a fungal rash on and off since admission. WN1 stated she was not aware the fungal rash had returned and R103 was not being treated for the fungal rash. During an interview on 1/17/2024 at 10:20 am, the consultant Wound Nurse Practitioner (WNP) stated she evaluated R103's inner thighs and buttock areas on this day at the request of the facility. The WNP stated R103's entire peri-genital area and buttocks had a fungal (candida) mild excoriation. The WNP stated an anti-fungal medication was ordered to be applied to the peri-genital and buttock areas twice a day. During an interview on 1/17/2024 at 10:30 am, Private Duty Certified Nursing Aide (PDCNA) stated R103 had the areas on the buttocks and inner thighs on and off since admission to the facility. PDCNA stated the areas were visible for at least a week and she thought the nurses knew. Review of the Physician Orders located in the EMR under the Orders tab, revealed an order dated 1/17/2024 at 3:58 pm for Lotrimin (anti-fungal medication) AF aerosol powder 2% topical to the pelvic folds and buttocks twice a day. Review of the nursing Wound Note, dated 1/17/2024 at 4:40 pm and located in the EMR under the Progress Note tab, revealed, . The resident was seen by the [name] wound care provider. He [resident] is noted to have a yeast rash. He was educated that when he is in bed, it's best to leave the brief open to reduce moisture. The resident verbalized his understanding. Fungal powder was applied to help with the discomfort. He verbalized having some comfort after the powder was applied .

Based on record review, staff interviews, and review of the facility policy titled Advanced Directives: Georgia, the facility failed to ensure one resident (R) (R44) of 36 residents reviewed for code status was accurately documented in the medical record to ensure her and/or her responsible party (RP) wishes were honored. Findings include: Review of the facility policy titled Advanced Directives: Georgia, with a revised date of [DATE], revealed that the resident had the right to change the code status and the change should be documented in the medical record. Review of R44's Face Sheet located in the Face Sheet tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with an order for a Full Code status. In addition, the Face Sheet of the EMR revealed Full Code in a red block. Review of her Plan of Care located under the Care Plan tab of the EMR with a problem start date of [DATE] revealed her Care Plan revealed attempt resuscitation under the area of advanced directives. Review of a Hospice Order Form located in the Documents tab of the EMR dated [DATE] revealed the resident had an order for Do Not Resuscitate (DNR). During an interview on [DATE] at 3:50 pm the code status and the Hospice Order Form were reviewed with the Administrator. She verified the Hospice Order Form with an order for DNR contradicted the code status (Full code/resuscitate) written in the physician's orders, Care Plan and the Face Sheet of the EMR. Review of the document titled POLST [physician order for life-sustaining treatment] Georgia Physician orders for Life-Sustaining treatment provided by the Director of Health Services (DHS) revealed the physician order POLST document was signed by R44's RP and dated [DATE]. Two physicians also signed it. R44's RP dated his signature [DATE]. One physician dated his signature [DATE], and the second physician dated his signature [DATE]. The POLST stated to allow natural death, do not resuscitate, comfort measures, no intravenous fluids, and no artificial nutrition by tube. During an interview, the DHS stated hospice obtained the POLST with the change in code status to a DNR. However, the facility never received it, therefore the POLST, physician's order for full code, and Care Plan for full code were never updated to reflect the new code status to a DNR. She confirmed if the resident had coded, the staff would have performed cardiac pulmonary resuscitation (CPR) on the resident up until [DATE] when the error was discovered, and the status was corrected in the medical record.

Based on observation, staff interviews, record review, and review of the facility policy titled Medication Storage in the Healthcare Centers, the facility failed to assess one of 12 sampled residents (R) (R109) reviewed for self-administration of medications. This failure had the potential for the resident not to self-administer the medication properly and for staff not to be aware if they were administered. Findings include: Review of the facility's policy titled Medication Storage in the Healthcare Centers, last reviewed on 7/28/2023, revealed Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication . is accessible only to licensed nursing personnel . Review of R109's quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 12/13/2023 and located under the RAI (Resident Assessment Instrument) tab of the electronic medical record (EMR), revealed R109 was admitted to the facility on [DATE] and scored 12 out of 15 on the Brief Interview for Mental Status (BIMS), indicating R109 was moderately cognitively impaired. Review of R109's Orders tab of the EMR revealed R109 did not have an order for self-administration of medication. Observation on 1/15/2024 at 10:22 am revealed R109 was in bed with his eyes closed. A medication cup containing three pills was observed on his overbed table. Interview with Licensed Practical Nurse (LPN) 8 at 10:27 am on 1/15/2024 confirmed there were prescription medications of aspirin, iron, and Lopressor (a medication for high blood pressure) in the cup. She removed the pills and stated he usually takes them right away. An interview with the Director of Health Services (DHS) on 1/18/2024 at 3:13 pm revealed she expected that nurses shouldn't leave medications at the bedside.

Based on staff interviews, record review, and review of the facility's policy titled Care Plans, the facility failed to ensure one of one (Resident (R)52) who went to dialysis three times per week, had care plan interventions including to monitor R52's left upper extremity fistula for bleeding or bruising, monitoring of blood pressure, and venipuncture to the left arm. The Care Plan further failed to include R52's liberalized renal diet with Complex Carbohydrates, High Fiber, and Optimal Protein (CCHO) and double portions of protein and whether to provide a to-go breakfast before R52 left the facility for dialysis. Findings include: Review of the facility's policy titled Care Plans dated 7/27/2023 revealed, .3. The comprehensive person-centered care plan is developed to include .a .resident's medical, nursing .needs, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial needs that are identified in the comprehensive assessment. 4 . The care plan approach services as instructions for the .resident's care and provides continuity of care by all partners . Review of R52's Physician Orders dated 10/24/2023 through 1/17/2024 under the Resident tab of the electronic medical record (EMR) revealed R52 was admitted to the facility on [DATE] with a diagnosis of End Stage Renal Disease (ESRD). R52's Physician Orders indicated dialysis three times per week at 6:00 am; dialysis access site-fistula location: left upper arm (LUA); no venipuncture or blood pressure to left arm; and liberalized renal/CCHO with double protein on trays. During an interview and review of R52's Care Plan with the Minimum Data Set Coordinator (MDSC) 3 on 1/17/2024 at 11:52 am, the MDSC confirmed that R52's Care Plan did not include R52's diet, to monitor the fistula on the LUA, no blood pressure or venipuncture to the left arm. In addition, the MDSC confirmed that the Care Plan did not address that R52 left the facility at 5:00 am on dialysis days and if the facility was to provide a breakfast meal for R52 prior to her leaving the facility.

Based on observations, staff interviews, record review, and review of the facility's policies titled, Care Plans, Documentation of Skin and Wound Care, and Physician Orders, the facility failed to ensure pressure ulcer care was provided according to professional standards for one of four sampled residents (Resident (R) 329) out of a total sample of 40 residents. Specifically, the facility failed to transcribe physician treatment orders in the electronic medical record (EMR), conduct pressure ulcer assessments per the facility policy, develop a baseline care plan for pressure ulcers, and document treatments administered in the EMR. This failure had the potential to cause the resident not to receive the necessary care needed to promote healing of pressure ulcers. Findings include: Review of the facility's policy titled, Care Plans, revised on 7/27/2023, revealed . It is the policy of the health care center for each patient/resident to have a person-centered baseline care plan followed by a comprehensive care plan . Baseline Care Plan- Must include the minimum healthcare information necessary to properly care for each patient/resident immediately upon their admission, which would address patient/resident specific health and safety concerns to prevent decline or injury, and would identify needs for supervision, behavioral interventions, and assistance with activities of daily living, as necessary . Upon a new admission, a baseline care plan will be developed by the admitting nurse/nurses in conjunction with other IDT, the patient/resident and/or patient/resident representative. The baseline care plan should be initiated in 24 hours and will be completed and implemented within 48 hours of admission . Review of the facility's policy titled, Documentation of Skin and Wound Care, revised on 3/18/2021, revealed, . It is the policy of the healthcare center to complete documentation that reflects the current resident status as related to skin/wound care. Documentation will provide current and timely documentation on resident's condition related to skin/wound care, accurate information on resident's status as it pertains to skin/wound care, record care rendered and interventions in place and provide a detailed history of the wound assessments that have occurred in the healthcare center . Documentation regarding wound observations and care should be completed: On pressure ulcers, venous insufficiency/stasis ulcers, arterial ischemic ulcers, diabetic wounds and any other chronic or complex wounds (weekly). Wound measurements are completed when there is significant change in wound status and weekly . At least every 7 days a comprehensive nursing assessment is completed . that includes a review of the current plan of care, current wound status (based on assessment and review of all documentation), and the patient/residents' response to the treatment plan . Admission Documentation should occur on: Baseline admission care plan related to risk for skin breakdown as well as for actual breakdown . Review of the facility's policy titled, Physician Orders, revised on 9/15/2017 revealed, . Verbal and Telephone Orders: All verbal and telephone orders will be immediately transcribed in the medical record by the licensed professional taking the order . The licensed professional will verify the verbal or telephone order by reading the order back to the practitioner issuing the order . Review of R329's Face Sheet, located in the electronic medical record (EMR) under the Resident tab, revealed R329 was admitted to the facility on [DATE] with diagnoses that included a sacral unstageable pressure ulcer. Review of R329's Observation Detail List Report, dated 1/05/2024 and located in the EMR under the Progress Note tab, revealed R329 had a sacrum/coccyx ulcer. Review of R329's Wound Management Detail Report, dated 1/05/2024 and located in the EMR under the Wound Documentation tab, revealed R329 had a 5.0 centimeter (cm) by 6.0 cm by 0.2 cm unstageable sacral pressure ulcer with serous drainage, slough and eschar in the wound base and a 3.0 cm by 3.0 cm stage 1 pressure ulcer on the right hip. Review of R329's Baseline Care Plan, dated 1/09/2024 located in the EMR under the RAI (Resident Assessment Instrument) tab, revealed, . Feeding tube -resident will maintain nutritional stability . R329's baseline care plan failed to include the presence of pressure ulcers and interventions to implement for care. Review of R329's entire EMR revealed no documentation of an assessment of the unstageable pressure ulcer to the sacrum or the stage 1 pressure ulcer on the right hip after 1/05/2024. Review of R329's entire EMR revealed no physician order for the treatment of the unstageable sacral pressure ulcer or the stage 1 pressure ulcer on the right hip. Observation of R329's sacral pressure ulcer on 1/16/2024 at 2:20 pm with the facility Wound Nurse (WN)1 revealed an open sacral wound that was butterfly in shape. The wound bed was noted with areas of eschar and slough. Observation of the right hip revealed a stage I pressure ulcer. Review of WN1's Employee Timecard, provided by the Administrator, revealed WN1 worked as the wound nurse on 1/05/2024, 1/07/2024, 1/08/2024, 1/09/2024, 1/10/2024, 1/11/2024, 1/12/2024, 1/15/2024, 1/16/2024, and 1/17/2024. WN1 did not work on 1/06/2024, 1/13/2024, and 1/14/2024. During an interview on 1/16/2024 at 2:40 pm, WN1 stated she did not conduct the weekly assessment of the unstageable sacral pressure ulcer or the stage 1 pressure ulcer on the right hip after 1/05/2024 because the consultant Wound Nurse Practitioner (WNP) was coming to evaluate the areas on 1/17/2024. During an interview on 1/17/2024 at 8:15 am, the Director of Health Services (DHS) reviewed R329's EMR and confirmed she was unable to locate any assessments of the sacral and right hip pressure ulcers after 1/05/2024. The DHS stated it was the facility's policy and standard of care to conduct weekly wound assessments of any pressure ulcers and the facility wound nurse was responsible to ensure the weekly assessments were completed. During an interview on 1/17/2024 at 10:00 am, the consultant WNP stated she evaluated R329's sacral pressure ulcer and determined it was a result of skin failure and was a Kennedy ulcer. The WNP stated a new treatment was ordered to cleanse the pressure ulcer with normal saline, use gauze soaked with Dakin's one-half strength to the wound bed, and cover with a protective dressing once a day. During an interview on 1/18/2024 at 9:50 am, WN1 stated she called the consultant WNP on 1/05/2024 when R329 was admitted , to obtain treatment orders for the pressure ulcers because the hospital discharge orders did not include a treatment. WN1 stated the WNP gave a telephone order to cleanse the pressure ulcer with normal saline, apply Alginate (material used to absorb wound fluid) to the wound bed, cover with a protective dressing every day and apply skin prep to the right hip. WN1 stated she forgot to transcribe the treatment orders into the EMR. WN1 stated she did the wound treatments every day she worked but she did not document the treatments provided to R329 in the EMR. WN1 was unable to provide documentation R329's treatments were performed on 1/06/2024, 1/13/2024, and 1/14/2024, the days when she was not on duty. During an interview on 1/18/2024 at 12:21 pm, the Corporate Nurse was asked what her expectation was for when a nurse took a telephone order. The Corporate Nurse stated, My expectation is that the nurse would write the order in the MD [physician] order section of the EMR before the end of their shift. During an interview on 1/18/2024 at 1:30 pm, the DHS stated the admission nurse was responsible for initiating the baseline care plan for a resident and that the baseline care plan should include pertinent areas of concern including pressure ulcers and treatment so staff could provide the necessary care. The DHS confirmed R329's baseline care plan did not include the pressure ulcers identified on admission. The DHS stated when a nurse receives a verbal or telephone order from a physician, the order should be written by the end of their shift in the residents' EMR.