Every finding on record at Pruitthealth - Southwood

Based on interviews and record reviews, the facility failed to assure accuracy of billing, by charging a resident's account for services covered by insurance after winning an appeal, for 1 out 3 records reviewed. (Resident #2) The findings include:A review of Resident #2's medical record revealed the resident was admitted on [DATE] to the facility under skilled nursing care after hospitalization. Resident #2's record had a Notice of Medicare Non-Coverage (NOMNC) dated [DATE], ending services on [DATE]. A review of Resident #2's medical record revealed an Expedited Appeal Documentation Request dated [DATE]. The request was reviewed and required the facility to upload the necessary documentation to the Quality Improvement Organization (QIO) (beneficiary and family centered care quality improvement organization authorized by the Medicare program to review inpatient services provided to Medicare patients) website by close of business. Resident #2's record revealed an appeal decision from the QIO dated [DATE]. The decision stated that ending services was not appropriate due to the facility's failure to provide sufficient medical records or other required documentation within the mandated timeframe. Resident #2's record revealed a completed financial responsibility statement for post skilled services dated [DATE], indicating the last covered date as [DATE]. Documentation showed that, effective [DATE], Resident #2 will transition to Private Pay/Medicaid Pending status. The noted private pay rate was $399 a day. A review of an email correspondence dated [DATE] at 3:38 PM between the Business Office Manager and the corporate Care Management Team revealed Resident #2 had active insurance coverage as supported by email documentation. However, the system deleted the email confirming this coverage. A review of an email correspondence dated [DATE] at 4:28 PM between the insurance company's Lead Clinical Review Nurse and the corporate Care Management team revealed that the resident's authorization listed [DATE] as the last covered day. Resident #2 remained in the facility under long term care status beginning [DATE]. A communication note was documented indicating that a member of the corporate Care Management team sent a secure email conveying this information. Resident #2's billing record revealed an account balance of $19,215.18 as of [DATE]. On [DATE] at approximately 9:50 AM, a phone interview was conducted with the representative for Resident #2. She stated that the facility informed her on [DATE] that, as of [DATE], the resident was not approved, therefore covered under his insurance. However, she was under the impression that her appeal was approved. She recalled receiving a phone call from the facility's Business Office Manager at 7:30 PM, informing her that she needed to come immediately to remove the resident due to an outstanding bill. She stated she was told that, because his insurance had not approved of his stay, the balance had increased to around $10,000 at a rate of $399 per day. On [DATE] at approximately 10:00 AM, an interview was conducted with the facility's Business Office Manager. She explained that she had discussed with the resident and family that Resident #2 had the option to apply for long-term care (LTC) Medicaid, which they declined. However, the resident remained on private pay Medicaid pending status, and his outstanding balance upon discharge was $19,215.18. She stated that the billing error was the result of corporate oversight. She clarified that as of [DATE], the payer was changed to Medicaid private pending, and this is when the resident began being billed in error. She recognized the lack of communication, as the resident was authorized for stay and services the whole time under his insurance. On [DATE] at approximately 3:00 PM, a phone interview was conducted with the Consultant Regional Business Office. After reviewing the Notice of Medicare Non-Coverage (NOMNC) and the appeal documents, she confirmed that the resident won the appeal and should not have been removed from services. She explained that, because the insurance coverage was not active as of [DATE] due to the facility failure to submit required documentation timely, a second NOMNC should have been issued for technical denial. As of [DATE], the Resident status should have been classified as technical overturn (that refers to the successful appeal and reversal of a claim denial that was initially rejected due to a procedural or administrative error) instead of Private Pay-Medicaid pending, which was incorrect. The resident should have remained covered without authorization lapse. She reported that the change of payer source was not communicated to the corporate Care Manager Team and reiterated that the failure was on the facility, not the resident. She added that staff did not read properly the QIO documentation. On [DATE] at 9:58 AM, a phone interview was conducted with the Care Management Manager Supervisor. She explained that after the appeal was won with the resident, due to the facility failure to submit paperwork in a timely matter, a second NOMNC should have been issued. This resulted in the resident being billed in error. She explained that communication and follow up about the Resident #2's account between the facility and corporate should have occurred. A patient financial responsibility statement post skilled services included in the admission package was reviewed. It states that residents are responsible for any charges if the resident's health plan determines that the services they received are not medically necessary and/or not covered by their insurance plan; their health plan coverage has lapsed or expired at the time they receive services.

Based on record review, interviews and facility policy, the facility failed to communicate the need for dialysis to the receiving provider, resulting in the resident missing dialysis treatment, for 1 of 3 residents reviewed. (Resident #3)The findings include:Record reviews revealed Resident #3 was admitted on [DATE] with a diagnosis of Dependence of Renal Dialysis related to End Stage Renal Disease. The resident's medication orders revealed dialysis treatment on Tuesday and Saturday with next treatment after discharge being 11/1/25. However, this appointment was missed because there was no communication to the dialysis center that Resident #3 was discharged from the nursing home on [DATE]On 12/9/25 at approximately 2:55 PM, an interview was conducted with Director of Health Services (DHS). The DHS indicated that the residents' dialysis centers are responsible for coordinating change of facilities for dialysis treatments.On 12/10/25 at approximately 11:15 AM, an interview was conducted with the Social Service Director. The Social Service Director revealed the resident's family is responsible for notifying the need to change dialysis centers when the resident is discharged from the nursing home.On 12/10/25 at approximately 1:30 PM, an interview was conducted with Director of Nursing (DON). The DON indicated the residents discharge plan done by social services should have a continuous care plan for dialysis.On 12/10/25 at approximately 2:00 PM a telephone interview was conducted with previous dialysis center staff. The staff member from this facility stated, the nursing home is responsible of notifying the current dialysis center of the resident discharge date and plan to ensure the resident is transferred to the dialysis center needed close to where the resident will be residing.On 12/10/25 at approximately 3:30 PM an interview was conducted with Case Mix Director. The Case Mix Director stated, if the resident has a planned discharge, then we would notify the dialysis center of the discharge and the need to transfer services, however this resident advised social services on 10/29/25 that she planned to discharge on [DATE] therefore was not a 3-day planned discharge, and dialysis was not notified. The Case Mix Director reviewed the facility discharge policy that revealed the discharge planning will begin with each patient/resident and patient/resident's representative upon admission. The process is coordinated by Social Services/Senior Care Partner or designee. The patient/resident, patient/resident representative and Interdisciplinary Team (IDT) are involved in the planning process. The post-discharge plan of care is developed with the participation of the patient/resident and/or the patient/resident's representative with the patent/resident's consent. The discharge plan will be monitored and revised as necessary. The discharge summary is initiated by the Social Service Director, Senior Care Partner, or Administrator Designee upon admission. The Discharge Planning policy also included Social Services, or the designee will contact community resource providers to schedule care and services that will be needed at the time of the discharge. Case Mix Director indicated the nursing home should have notified the dialysis center of the discharge on [DATE].On 12/11/25 at approximately 11:30 AM a telephone interview was conducted with a representative from the resident's current outpatient dialysis center and they stated, resident #3 resumed dialysis on 11/3/25 and missed scheduled dialysis on 11/1/25.

Based on record review, staff interview, and policy review, the facility failed to provide specialized rehabilitative services as indicated in the comprehensive plan of care and physician orders for 2 of 3 sampled residents reviewed for specialized rehabilitative services. (Resident #8 and #10) The findings include: Resident #8A review of Resident #8's medical record revealed a physician order dated 6/16/25 for physical therapy (PT) to be provided daily 6 times per week for 6 weeks for cerebral infarction due to embolism of the left posterior cerebral artery and muscle weakness. Treatment includes therapeutic exercise, therapeutic activities, neuromuscular reeducation, gait training to increase strength, balance and endurance in order to improve bed mobility, transfers and gait. The mode of treatment is via individual, group, and/or cotreat. A review of Resident #8's comprehensive plan of care dated 6/15/25 revealed a care plan for Activities of Daily Living (ADL) decline related to cerebrovascular accident, recurrent urinary tract infection, dizziness, mood disorder, depression, and generalized anxiety disorder with an intervention dated 6/15/25 for physical therapy/occupational therapy to evaluate and treat. A review of Resident #8's PT evaluation and plan of treatment for certification period dated 6/16/25-6/17/25 indicated the resident was to receive physical therapy 6 times a week daily times 6 weeks. Review of the treatment notes revealed a missed physical therapy visit on 6/23/25 due to a staffing shortage, a missed physical therapy visit on 7/1/25 due to a staffing shortage, a missed physical therapy visit on 7/10/25 due to the resident eating dinner at 5:50 PM, and a missed physical therapy visit on 7/11/25 due to a staffing shortage. Resident #10A review of Resident #10's medical record revealed a physician order dated 8/5/25 for occupational therapy (OT) to be provided daily 6 times per week, for 8 weeks for medical conditions and treatment diagnosis. Treatment includes ADL retraining, therapeutic exercise, therapeutic activities, neuromuscular reeducation, and wheelchair management. The mode of delivery is via individual, group, and/or cotreat therapy. The medical record also revealed a physician order dated 8/4/25 for speech therapy (ST) to be provided daily, 5 times per week, for 6 weeks for treatment of receptive/expressive speech/language deficits due to aphasia. Skilled treatments include therapeutic tasks, compensatory strategy training, patient/caregiver education, graded speech/language tasks, and development/implementation of carryover activities. The mode of delivery includes individual, concurrent, cotreatment, and group therapy. A review of the comprehensive plan of care for activities of daily living decline related to recent hospitalization with left cerebrovascular accident dated 8/1/25 revealed an intervention dated 8/1/25 for PT and OT to evaluate and treat and a comprehensive plan of care for nutrition risk dated 8/1/25 with an intervention dated 8/1/25 for ST to evaluate and treat. Review of the OT evaluation and plan of treatment for certification period 8/4/25 -9/2/25 revealed the resident was to receive OT daily, 6 times a week for 8 weeks. Review of the ST evaluation and plan of treatment for certification period 8/4/25- 9/14/25 revealed the resident was to receive ST daily, 5 times a week for 6 weeks. Review of the occupational therapy visit documentation revealed a missed visit on 8/23/25 due to staffing. Review of the ST visit documentation revealed missed visits on 8/28/25 and 8/29/25 due to staffing issues. An interview was conducted with Employee A (Physical Therapist) on 9/16/25 at 11:05 AM. Employee A stated they were having a staffing shortage and using as needed (prn) therapists. The prn therapists would usually come in the evening around 4-6 PM and at times the residents would be eating. An interview was conducted with the Administrator on 9/16/25 at 4:16 PM. The Administrator stated he was not aware of therapy missing visits due to staffing issues. He was aware therapy had hired some more staff. Review of the facility policy for Therapy Evaluations (revised 5/13/2020 version 6) revealed, It is the policy of Pruitthealth Therapy Services that all physician's orders for therapy evaluations be addressed in a timely manner by Physical, Occupational and/or Speech Therapy as designated by the physician. The evaluation will include discipline-specific findings related to the patient/resident's functional status and underlying impairments and prior functional level.

Based on staff interviews, record review, and policy review, the facility failed to immediately identify and report allegations of abuse to the state survey agency for 1 of 1 sampled residents. (Resident #9)The findings include:On 7/22/25, a review of the facility's federal report incident on 9/2/24 concerning the allegation of assault made by Resident #9's representative on 9/2/24 was conducted. A summary of the facility's interview with the participants states bruising was noted on the day shift (7:00 am-3:00 pm). The bruising was noticed by the assigned Certified Nursing Assistant (CNA) K and documented by the day shift assigned Nurse J on 8/31/24.On 7/22/25 a review of the nurse's notes was conducted. No nurses' notes were documented on 8/31/24. However, a late entry note was entered on 9/2/24 at 11:01 am stating, Upon entering on 8/31/24 at 8:15 am during medication administration, noticed black and blue bruise under the right eye. Unknown cause, resident unable to verbally express the cause. Order to monitor area daily until healed. Will continue to monitor.On 7/23/25 at approximately 5:00 PM, an interview was conducted with the Risk Manager (RM). She confirmed the expectation is for all alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are to be reported immediately but not later than two hours, and the results of all investigations of alleged violations should be reported within five working days of the incident.On 7/24/25 at approximately 11:30 am, an interview was conducted with the Director of Nursing (DON). The DON stated the nurse did not submit a federal report because she did not view it as abuse since she called the doctor and his order was to monitor until healed. The DON confirmed an injury of an unknown source is required to be reported within two hours. She further stated she was notified on 9/1/24. The Federal report was filed on 9/2/25 when Resident #9's representative observed bruise and contacted law enforcement.The facility's policy titled Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property (dated 12/02/2001, revised 11/15/2024) revealed, It is the policy of PruittHealth to actively preserve each patient's right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, exploitation, mistreatment, and misappropriation of patient property, (referred to collectively in this policy as abuse, neglect, mistreatment, and exploitation). The Organization and its partners should assure that best efforts are made to prevent any occurrences of any form of abuse, neglect, and exploitation.The facility's policy titled Occurrences (dated 7/1/2012, revised 1/11/2024), revealed Occurrence hazards are physical features in the healthcare center environment which may pose a risk to a residentts safety, including but not limited to: Unexplained injury to a patient/resident where no specific or actual incident was observed; yet the patient/resident exhibits evidence of an injury, such as a bruise or skin tear. Reporting Occurrences: 1. Occurrences are to be reported to the Charge Nurse immediately, no matter how minor they may appear. 2. Patient/resident care software incident entry must be completed on the shift the occurrence took place. 3. If occurrence is noted without direct staff observation, the incident entry must be completed in the software system on the shift the occurrence was reported. 4. Partners witnessing an occurrence involving a patient/resident must report details of occurrence to his/her Charge Nurse as soon as possible. Do not leave an occurrence victim unattended unless it is necessary to summon assistance. Occurrence Documentation: I. The licensed nurse will be responsible for completing the following occurrence documentation requirements prior to the end of the shift when the occurrence took place. This documentation will be noted in the patient/resident's clinical record and in the occurrence reporting software program. The Administrator or designee will complete the supervisor investigation on all occurrences, and report to the appropriate state agency and/or other external agencies according to law. This documentation is to be typed on the patient/resident care software occurrence report follow up section. The Administrator's findings will include, but not limited to: Interview findings, Was abuse ruled out, if abuse was noted list in detail type of abuse and who was involved, date of when report was completed, date external agencies were notified, etc. Was abuse ruled out, if abuse was noted list in detail type of abuse and who was involved, date of when report was completed, date external agencies were notified, etc. When the physician and responsible party was notified. List any education and/or corrective action related to the occurrence.

Based on observations, interviews and record reviews, the facility failed to implement the baseline care plan for 1 of 2 individuals reviewed for care plans. (Resident #35) The findings include:On 07/22/25 at approximately 9:50 AM during a visit with Resident #35, the resident was observed lying in bed wearing only a shirt and a brief. The Director of Nursing (DON) and Staff B from Physical Therapy (PT) entered the room to respond to the resident's complaint earlier that day. The resident was upset and tearful. She verbally expressed frustration regarding her perceived lack of progress in therapy and a decline in her ability to perform functional tasks independently. She specifically voiced a desire to regain the ability to use the bathroom independently and shared concerns that she is not receiving sufficient therapy. She reported that she had been waiting in bed for someone to assist her with getting up, using the bathroom, and performing hand hygiene. The resident stated that she is at the facility to improve and return to her independent living situation and expressed concerns over the current level of support. On 07/22/25 at approximately 9:55 AM, an interview was conducted with Resident #35. She expressed feelings of frustration regarding a perceived delay in her physical progress and continued dependence on staff for mobility and personal care. She reported that she is still in bed at the time of the interview and has not yet had assistance to get up or attend therapy, which she believes should have already begun. She feels strongly about going back to her independent living and being able to walk to the bathroom independently. She further explained that she was continent but currently wears a brief, explaining that this is due to her inability to independently access the bathroom.On 07/22/25 at approximately 3:25 PM, an interview was conducted with Staff C, Certified Nursing Assistant (CNA). She is the sole caregiver assigned to the 100 and 200 halls, which currently house a total of 11 residents. When asked about bladder training, she stated that nursing restorative provides that service. Regarding incontinence care, she acknowledges that the facility's expectation is to conduct rounds every two hours, or more frequently if needed, to meet the residents' needs.On 07/23/25 at approximately 9:49 AM, an interview was conducted with the DON. She confirmed that the goal is to return Resident #35 to her highest level of functioning and agreed that the resident, though not currently on a toileting program, would benefit from one. The DON also acknowledged Resident #35's strong motivation to participate in therapy and her goal of returning home to her prior level of functioning. She confirms that it is the facility's expectation to provide the necessary services to support the residents in achieving these goals.On 07/23/25 at approximately 4:02 PM, an interview was conducted with the Physical Therapy Outcome Coordinator. According to their documentation, Resident #35 ambulated distances of 80 feet, 90 feet and 150 feet with supervision or touching assistance. Transfers from sit to stand were performed with partial/moderate assistance, requiring approximately 50% assistance. Resident #35 is a one person assist for mobility and transfers.On 07/23/25 at approximately 5:00 PM, an interview was conducted with Staff E (CNA). When asked about the level of assistance she provides Resident #35 for toileting needs, she explained that she has not yet assisted with toileting since the resident's readmission on [DATE], despite having worked five shifts with her, stating that the resident is incontinent. Additionally, she mentioned that therapy staff take Resident #35 to the bathroom, but that she only provides incontinent care and does not offer her toileting. She added that the resident is a limited transfer when she assists her to bed.On 07/23/25 at approximately 5:15 PM, an interview was conducted with the DON. She describes the facility's expectations to check and assist residents with toileting and incontinence care every 2 hours. She reviewed Resident #35's care plan dated 07/14/25, which stated: ADL needs will be met and independence potential maximized and Improve ADL function to maintain independence through next review. She recognized that since the documentation of the resident being continent on 06/27/25, toileting the resident should be an intervention to meet the goal of the care plan and optimize the potential for the resident to regain bladder control and her prior level of independence. A recent Physical Therapy (PT) note dated 07/22/25 was reviewed that indicates Resident #35 was ambulating in therapy with touch assistance. A review of progress notes from 06/25/2025, 06/27/2025, 06/28/2025 indicated the resident is alert and oriented and able to communicate needs, continent of bowel and bladder and requires one person assist with all transfers. A review of a progress note from 07/18/2025 indicated the resident requires one person assist for Activities of Daily Living. A review of the discharge plan dated 07/23/2025 reveals resident plan to return to Independent Living.On 07/23/25, the Minimum Data Set, dated [DATE] was reviewed. It stated that the resident is using a wheelchair and walker for mobility device, accomplishes toileting with partial/moderate assistance, and performs bed to chair transfer with Substantial assistance. It was also revealed that a trial of a toileting program (schedules toileting, prompted voiding, bladder training) was not attempted. A physical therapy note dated 07/22/25 states, Toilet transfer = Partial/moderate assistanceThe Care Conference dated 06/23/25 noted that the Resident lives at an independent living. She has a rollator, walker and bedside commode. The goal is to be able to walk again.On 07/24/25 at approximately 9:27 AM, a policy titled: Care Plans effective 12/31/1996 and revised 07/23/23 was reviewed. Person Centered Care-Focus is on the resident as the center of control. Supports each resident in making his or her own choices. Includes making an effort to understand what each resident is communicating, verbally or non-verbally, to identify what is important to each resident with regard to daily routines and preferred activities and having and understanding of the resident's life before coming to reside in the health center. Baseline Care-Plan must include the minimum healthcare information necessary to properly care for each resident immediately after admission, which would address 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. The comprehensive person-centered care plan is developed to include measurable goals and timeframes to meet a resident's medical, nursing and psychosocial needs, the services that are to be furnished to attain the resident's highest practicable physical, mental and psychosocial needs that are identified in the comprehensive assessment. The type of goals may include discharge goals, improvement goals, prevention goals and/or maintenance goals.On 07/24/25 at approximately 9:47 AM, a policy titled Resident Rights effective 10/01/2029 and revised 12/01/2023 was reviewed. It is the policy of this healthcare center to promote and protect the rights of the residents residing in the center. The Center will make any effort to assist the resident in understanding and exercising her rights to assure the resident is always treated with respect, kindness, and dignity. Each resident shall be accorded privacy and freedom to use the bathrooms at all hours.

Based on observations, record review, interviews and facility policy review, the facility failed to develop a care plan for 2 of 2 residents sampled for Gerichair use (Residents #42 and #45) and 1 of 1 resident sampled for Hoyer lift use (Resident #4).The findings include:Resident #4 On 07/21/2025 at 4:34 PM, Resident #4 was observed inside his room in a wheelchair waiting to be assisted to bed. A few minutes later, Staff A, a Certified Nurse Assistant (CNA), was observed assisting the resident from the wheelchair to the bed via Hoyer Lift. There was no other staff assisting during this transfer. On 07/21/2025 at 4:47 PM, an interview was conducted with Staff A, CNA. She stated she knew there were supposed to be two staff members assisting with the Hoyer lift. She further stated the reason she was doing it alone was because the resident had used the call light three times, and she could not find anyone to help her. A medical record review of Resident #4 was conducted. Resident #4 was admitted on [DATE] with diagnoses including metabolic encephalopathy, sepsis, rhabdomyolysis, encounter for change or removal of surgical wound dressing, local infection of the skin and subcutaneous tissue, open wound left hip, chronic systolic heart failure, unsteadiness on feet, atrial fibrillation, cognitive communication deficit, hypertension, type 2 diabetes mellitus, cerebral palsy, and adult failure to thrive. The plan of care included risk for falls and impaired mobility with requiring assistance with transfers. The plan of care did not include use of Hoyer lift. On 7/22/25 at 12:37 PM, an interview was conducted with Director of Nursing (DON). She was made aware that the CNA was using the Hoyer lift alone. She stated it was facility policy to have two staff members using the Hoyer lift. She confirmed Resident #4 had been using a Hoyer lift since admission because he was unable to stand safely. She was asked how the staff would know the resident would need to be transferred via Hoyer lift and she stated the resident would be care planned for it. She reviewed the plan of care for Resident #4 and verified that the Hoyer lift was not included as intervention, but it should had been included. She further stated she would add it immediately. Resident #42: On 7/21/25 at approximately 1:58 PM, an observation was made of resident #42 in her room sitting up in a Geri-chair (a chair that reclines) with a Hoyer lift sling noted underneath the resident (a device used to transfer the resident from bed to chair). A review of Resident #42’s medical record revealed there was no physical or occupational therapy evaluation for the use of a Geri-chair. Further review of the resident’s medical record revealed that there was no physician order for the Geri-chair, nor a care plan for the use of the Geri-chair in the record. On 7/22/25 at approximately 1:00 PM an interview was conducted with Staff Member F, a Certified Nursing Assistant, (CNA) who indicated that she had been getting the resident up in a Geri-chair as long as the resident had been in the facility and further indicated that she was not sure who made the decision that the Geri-chair is appropriate for the residents. CNA F further indicated that she was instructed to get the resident up today in a regular wheelchair. On 7/22/25 at approximately 1:15 PM an interview was conducted with Nurse G, Registered Nurse Unit manager, and Nurse H, Licensed Practical Nurse. Both Nurse G and H confirmed that there was no care plan, physician order, or therapy evaluation for the use of the Geri-Chair for resident #42. On 7/22/25 at approximately 2:40 PM an interview was conducted with the Physical Therapist B, who indicated that she did do an evaluation of resident #42 for wheelchair versus Geri-chair for positioning today, and recommended that resident #42 was appropriate for wheelchair. The Physical therapist B further indicated that she did not have resident #42 when she was on therapy case load, so she was not aware of why the resident was in the Geri-chair, however she does tend to lean forward and to the side when the resident is tired, so I did recommend that the resident be laid down for a rest period in bed when tired. Resident #45: On 7/22/25 at approximately 1:00 PM an observation was made of Resident #45 sitting in a Geri-chair in the dayroom area of the 600 hall. Resident #45 stated “I wish they would let my legs down; I do not like sitting like this.” On 7/22/25 at approximately 1:10 PM an interview was conducted with CNA I, who indicated that Resident #45 was in the Geri-chair because he keeps trying to get up and falls, and he messes with the other residents, that the Geri-chair was for his safety. On 7/22/25 at approximately 1:15 PM an interview was conducted with Nurse G, Registered Nurse Unit manager, and Nurse H, Licensed Practical Nurse. Both Nurse G and H confirmed that there was no Care plan, physician order, or therapy evaluation for the use of the Geri-Chair for Resident #45. Nurse H indicated that the resident had been in the Geri-chair for the 3 weeks that Nurse H had been working at the facility. On 7/22/25 at approximately 2:15 PM, an observation was made of the resident being evaluated by the Physical Therapist for a high back wheelchair. Resident #45 was observed to be able to propel himself about the dayroom during the observation. On 7/22/25 at approximately 2:40 PM an interview was conducted with the Physical Therapist, who indicated that she did the evaluation of Resident #45. She recommended that the resident was appropriate for the high back wheelchair instead of the Geri-chair and further indicated that the resident was able to propel himself 10 feet during the evaluation. The Physical Therapist indicated that she was not sure why the resident was in a Geri-chair. On 7/22/25 at approximately 2:45 PM an interview was conducted with the Risk Manager (RM) and Director of Nursing (DON) concerning the use of Geri-chairs for resident #42 and #45. Both the RM and DON indicated that neither of them was aware that Geri-chairs could be considered a physical restraint. The RM stated after contacting the regional nurse for the facility and confirming that the Geri-chair could be considered a physical restraint, the residents were referred to therapy for an evaluation for positioning. The DON indicated that it was her understanding that Resident #45 used the Geri-chair for comfort due to being on hospice, but confirmed no documentation was available to indicate the reasoning for the Geri-chair. The DON further indicated that they have started a performance improvement plan on the use of Geri-chairs and that they make sure the staff are trained and that the residents receive evaluations for appropriate positioning.

Based on observation, resident interview, staff interview, record review and policy review, the facility failed to ensure the interdisciplinary team assessed and determined if a resident was capable of self-administration of medications prior to allowing the practice for 1 of 20 sampled residents. (Resident #66) The findings include: An observation of Resident #66's room was conducted on 4/8/24 at 2:06 PM, 4/9/24 1:52 PM, and 4/9/24 at 3:26 PM. A bottle of multivitamins was observed to be sitting on the bedside table. An observation of Resident #66's room was conducted on 4/10/24 at 9:20 AM. During all of these observations, Resident #66 was in her room and the bottle of multivitamins remained at her bedside. She stated she takes one of the multivitamins every day and the staff are aware. A review of Resident #66's electronic medical record revealed no physician's order for the multivitamins. The quarterly minimum data set, with an assessment reference date of 2/11/24, revealed she has a brief interview of mental status (BIMS) score of 15, indicating she is cognitively intact. The quarterly self-administration of medications observation dated 2/14/24 revealed the resident is not appropriate to self-administer medications. A further observation of Resident #66's room was conducted on 4/10/24 at 9:49 AM in the presence of the Director of Nursing (DON). The DON observed the multivitamins at the bedside and stated the resident's sister likely brought them in the facility. The DON stated the resident was not to self-administer medications. A review of the facility policy for Self-Administration of Medications by Residents (2014 Pruitthealth) revealed each resident 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 resident and other residents of the healthcare center.

Based on record review and staff interview, the facility failed to complete and submit the discharge minimum data set for 4 of 5 sampled discharged residents. (Resident #27, #50, #53, and #67) The findings include: A review of Resident #27's electronic medical record revealed the resident was admitted to the facility on [DATE]. The resident was discharged on [DATE] to a hospital emergency room . The record revealed the discharge minimum data set was not completed and submitted. A review of Resident #50's electronic medical record revealed the resident was admitted to the facility on [DATE]. The resident was discharged home on 12/29/23. The record revealed the discharge minimum data set was in progress but not complete or submitted. A review of Resident #53's electronic medical record revealed the resident was admitted to the facility on [DATE]. The resident was discharged home on 11/27/23. The record revealed the discharge minimum data set was not completed or submitted. A review of Resident #67's electronic medical record revealed the resident was admitted to the facility on [DATE]. The resident was discharged home on 11/24/23. The record revealed the discharge minimum data set was not completed and submitted. An interview was conducted with employee C (Registered Nurse Case Mix Director) on 4/11/24 at 10:16 AM. Employee C confirmed the discharge minimum data set was not completed or submitted for these residents. She stated the records system did not alert the facility staff or corporate staff that the assessments were not complete.

Based on observations, record review, staff interview, and policy review, the facility failed to provide appropriate quality care and treatment for 1 of 1 residents with a skin tear (Resident #14) and 1 of 1 residents reviewed for edema (Resident #18). The findings include: Resident #14: Observations of Resident #14 were conducted on 4/8/24 at 2:21 PM and 4/9/24 at 3:13 PM. During these observations, the resident was in bed and had an undated dressing on her left middle forearm. On 4/8/24 at 2:21 PM, her husband was at her side and stated he was not sure what happened to her arm. A review of the electronic medical record revealed no current physician's orders for the dressing on the left arm or documentation of a skin issue to the left arm. A skin observation note dated 4/9/24, completed by Employee A (licensed practical nurse (LPN)), indicated the resident had no skin impairments. A telephone interview was conducted with Employee A on 4/10/24 at 9:38 AM. She stated she completed a skin observation on Resident #14 on 4/9/24. She stated the resident had a skin tear under the pink dressing on her left arm. She thought the wound care nurse placed the dressing on the resident's arm, but she did not ask the wound care nurse to confirm this. She stated she forgot to document the dressing on the skin observation on 4/9/24. On 4/10/24 at 9:45 AM, Resident #14 was observed in the presence of the Director of Nursing (DON). The DON observed the pink dressing on the resident's left arm and confirmed it was not dated. The DON removed the dressing and stated the area under the dressing was a scabbed skin tear. She stated there should have been an order for the dressing in the electronic medical record. An interview was conducted with Employee B (licensed practical nurse, wound care) on 4/10/24 at 10:33 AM. She stated she had no knowledge of the pink dressing or a skin tear on Resident #14's arm. A review of the facility policy for Documentation of Skin and Wound Care (PruittHealth 2014) 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 the 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. 48580 Resident #18: On 04/09/24 at 02:45 PM, Resident #18 was observed to be semi reclined in bed with bilateral (both) lower extremities (BLE) elevated on pillows and wearing non-skid socks. The skin of the lower extremities was noted to be red and scaley with swelling present on both lower extremities. Resident #18 was observed on 04/10/2024 on three separate occasions (11:25am, 12:51pm and 1:50pm) while in his room and in the dining area. For all observations, Resident #18 had no Thrombo-embolic deterrent (TED) hose applied to his lower extremities. A review of the electronic medical record revealed the medical diagnosis of lymphedema, Non-pressure chronic ulcer of right ankle, Localized edema and Muscle wasting and atrophy, multiple sites. There was an order dated 3/29/2024 at 03:45 pm to Apply TED hose on BLE for 12 hours, start time 09:00 AM, remove at 09:00 PM daily per Verbal Order (VO). On 04/10/24 at 02:12 PM, an interview with Staff E, a Certified Nursing Assistant, was performed. She stated that she had nothing in her tasks that indicated that Resident #18 was to have TED hose, but that the nurse would be responsible for applying and removing any TED hose. During an interview with Nurse G, a LPN, it was reported that this resident had refused TED application on several occasions. She stated she had located some TED hose in the facility that were size Large and had attempted to apply them on her shift but they were very tight and she had had to remove them, that's probably why he refused them. When asked who would be responsible to measure patient for appropriate size she responded that's a good question, I don't know. Probably the nurse manager but [Nurse K] must know because she is the only one that documented that resident needed a size 2XL on the Medication Administration Record (MAR). On 04/10/2024 at approximately 3:00 PM, an interview was conducted with Nurse H, a Registered Nurse, and Nurse F, a LPN, who reviewed residents record and confirmed the orders for Compression stockings. After reviewing the record, Nurse F stated that, following Resident #18's appointment with the Dermatologist, they had recommended that the patient be referred to the lymphedema clinic. Nurse H stated that the clinic had declined to see the resident due to the amount of skin lesions and Resident #18's physical limitations. Per Nurse F, the lymphedema service recommended that the facility apply TED hose on BLE for 12 hours on and off for 12 hours then they will see if the resident will tolerate any form of compression. Nurse H informed Resident #18's attending physician of the recommendation and was given a verbal order for TED hose to BLE for 12 hours per day per the recommendation. When asked who and how they determine what size compression hose are needed, they could not provide an answer. Observation of the facility's stock of knee-high TED hose revealed two boxes of TED hose. One box revealed measurement instructions on the box and in one box measurement instructions were on each individual pack. (Photographic evidence obtained.) Nurse F agreed that the order had not been implemented in a timely manner and confirmed that Resident #18 had not been appropriately measured.

Based on record review and interviews, the facility failed to accurately document the administration of pain medications for 2 of 3 sampled residents for medication administration. (Resident #4 and Resident #5) The findings include: Resident #4 A review of Resident #4's medical record was conducted. Resident #4 was admitted on [DATE] with a physician's order of Oxycodone 5 mg-Acetaminophen 325 mg, every 4 hours, as needed, for pain. The Medication Administration Record (MAR) was reviewed and revealed this medication was not documented as administered on 12/20/23. The Oxycodone controlled drug record sheet was reviewed and revealed the Oxycodone was withdrawn on 12/20/23 at 6:00 am, 11:00 am, 4:00 pm, and 9:00 pm. On 1/18/24 at 2:47 PM, an interview was conducted with Resident #4 via telephone. He confirmed he received his 4 doses of oxycodone for pain on 12/20/23. Resident #5 A review of Resident #5's medical record was conducted. Resident #5 was admitted on [DATE] with a physician's order of Oxycodone 10 mg every 4 hours, as needed, for pain. The Medication Administration Record (MAR) was reviewed and revealed Oxycodone was not documented as given on 1/18/24. The Oxycodone controlled drug record sheet was reviewed and revealed Oxycodone was withdrawn on 1/18/23 at 6:30 am, 11:20 am, 3:00 pm, and 8:00 pm. On 1/19/24 at 9:20 AM, an interview was conducted with Resident #5. She confirmed she received four doses of Oxycodone on 1/18/24. On 1/19/24 at 10:35 AM, an interview was conducted with the Director of Nursing (DON). She verified the MARs for Resident #4 and #5 were not documented appropriately.

Based on staff interviews, the facility failed to employ a qualified staff member to serve as the director of food and nutrition services. The findings include: On 12/28/22 at 9:31 AM, an interview was conducted with the Dietary Manager. She confirmed she was not a certified dietary manager, a certified food service manager, and had not had similar national certification for food service management and safety from a national certifying body. She further verified that she did not have an associate's or higher degree in food service management or in hospitality, or 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and had not completed a course of study in food and safety and management. The Dietary Manager further stated that the facility's dietitian worked part time. On 12/28/22 at 9:54 AM, an interview was conducted via phone with the facility's dietitian. The dietitian confirmed she worked part time at the facility. On 12/28/22 at 11:05 AM, an interview was conducted with the facility's Administrator. She confirmed the facility did not have a Certified Dietary Manager or a qualified Director of Food and Nutrition Services.

Based on observation, interview, and record review the facility failed to ensure staff followed the facility's policy for dressing changes of peripherally inserted central catheters (PICC) for 1 of 1 residents sampled for PICC lines. (resident #51) The findings include: On 9/27/21 at approximately 11:00 AM, a Registered Nurse (RN), Staff Member C, was observed changing the right antecubital PICC line dressing for resident #51. The RN put on gloves, removed the soiled PICC line dressing and discarded the soiled dressing and gloves on the floor next to the resident's bed. The RN then proceeded to put on sterile gloves without washing or sanitizing her hands. On 9/29/21 at approximately 9:00 AM, an interview was conducted with Staff Member C. She was asked about discarding soiled dressing and gloves on the floor and not sanitizing hands. She indicated she dropped the dressing on the floor because that is what she normally does in the hospital and did not have a trash can nearby. She indicated she did not sanitize her hands because the sanitizer was on the other side of the room. A review of the facility's policy for Central Infusion Access Devices (revised 4/19/19), revealed staff were to sanitize hands prior to putting on sterile gloves.

Based on observations, interviews and record review, the facility failed to develop and implement care plan interventions to monitor a resident with a known high risk for elopement, which resulted in the resident leaving the building unsupervised, putting the resident at risk for serious injury or death for 1 of 2 sampled resident at risk for wandering/elopement (#1). The findings include: A review of the elopement risk assessment form, (the facilities internal elopement assessment tool), dated 7/9/21 revealed resident #1 scored 15, a high risk for elopement. The scoring scale at the bottom revealed the following: 0-4 Low Risk, 5-10 Moderate Risk, 11 or Greater - High Risk. A score of 15 indicated the resident was a high risk for elopement. The elopement risk assessment tool interventions for High Risk included, but not limited to 3-day monitoring, Weekly Behavioral Management, and Wander guard Program. A review of resident #1 Care Plan revealed a care plan for Behavioral Symptoms: Resident exhibits wandering and exit seeking behavior with a problem start date of 7/13/2021, the date the resident eloped from the facility. An interview was conducted with the Director of Nurses on 7/27/21 at approximately 1:18 PM, who confirmed the nursing staff should complete an elopement risk assessment when the resident is admitted and should monitor, and initiate interventions as needed, and confirmed the wander guard and placing the resident in the elopement book occurred after the elopement. A review of the Elopement Risk Observation Form, effective 4/1/12, last revised 1/28/15 under policy guidelines revealed: All residents will be assessed on admission, re-admission, significant change in condition and at least quarterly. For residents who score 11 or more, interventions should be promptly put in place. Under Score 11 or greater High Risk the document revealed interventions include but not limited to: 3 day monitoring, weekly behavioral management, wander guard program.

Based on observation, record review, and interview the facility failed to ensure activity of daily living (ADL) care was performed on residents who were unable to perform ADL care independently for 1 of 3 sampled residents (Resident # 2). The findings include: On 7/26/2021 at approximately 3:20 PM, an observation of Resident #2 was noted. She had multiple facial hairs on her chin. The hairs were approximately ¼ of an inch long. On 7/27/2021 at approximately 8:39AM, an observation of Resident #2 was made. She had received assistance with activities of daily living (ADL) care already that day. She continued to have multiple hairs on her chin. In an interview the resident expressed that she would like to have the hair removed. Resident #2 struggled to reach her chin with the back of her left hand to feel the hairs. As she touched her chin, her eyes filled with tears. Due to [CONDITION(S)] on the left-side she had limited fine and gross motor control of her left hand. Her right hand was contracted and of in a brace. (photographic evidence was obtained after the resident provided verbal permission). A record review of resident #2's medical record showed pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set Assessment (MDS) dated [DATE] section G revealed that the resident was assessed as needing extensive assistance with personal hygiene (combing hair, brushing teeth, shaving, washing and drying hair). Section G0120 of the MDS assessment from 7/2/2021 listed Resident #2 as being totally dependent for assistance with bathing. The resident's care plan dated 6/29/2021 indicated that the resident was at risk had impaired mobility and required assistance with mobility and care. A review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 had orders to turn and reposition every two hours due to bed mobility issues. On 7/27/2020 at approximately 11:00 AM in interview with Staff Member B, Certified Nursing Assistant (CNA) was conducted. She was shown the image of the hair on Resident #2's chin. She was notified that the resident expressed that she would like the hair removed. Staff Member B, CNA explained that the hair should have already been removed this morning when ADL care was provided earlier in the day. The surveyor notified Staff Member B, CNA that the hair was present yesterday afternoon as well. Staff Member B, CNA explained that she did not care for the resident yesterday, but whomever took care of Resident #2 should have addressed the hair on her chin. She stated: I will take care of this right now. She then proceeded to gather supplies to remove the hair. On 7/27/2020 at approximately 11:00 AM, an interview was conducted with the Director of Nursing (DON). She was shown the image of the hair on Resident #2's chin. The surveyor explained to the DON that Resident #2 expressed that she wished to have the hair removed and that Resident #2's eyes filled up with tears during the interview. The DON was asked if the hair should have been removed. The DON explained that the hair should have been removed during ADL care. The DON was asked if there was documentation regarding hair removal during ADL care. After looking in the electronic record the DON was unable to find documentation. A copy of the policy for provision of ADL care to residents was requested.

Based on observation, staff interview, and record review, the facility failed to ensure 1 of 1 resident at risk for elopement (#1) was not able to exit the building unsupervised. Resident #1 eloped from the facility on 7/13/2021. The findings include: A review of resident #1 Admission Minimum Data Set (MDS) revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 - moderate impairment. The BIMS score is used to assess the cognitive status of a resident. The resident discharge goal was noted to return home. A review of the elopement risk assessment form, (the facilities internal elopement assessment tool), dated 7/9/21 revealed resident #1 scored 15, a high risk for elopement. The scoring scale at the bottom revealed the following: 0-4 Low Risk, 5-10 Moderate Risk, 11 or Greater - High Risk. A score of 15 indicated the resident was a high risk for elopement. The elopement risk assessment tool interventions for High Risk included, but not limited to 3-day monitoring, Weekly Behavioral Management, and Wander guard Program. A review of resident #1 Care Plan revealed a care plan for Behavioral Symptoms: Resident exhibits wandering and exit seeking behavior with a problem start date of 7/13/2021, the date the resident eloped from the facility. The goal stated as, Resident will not injure/harm self-secondary to wandering. A review of the nursing progress notes failed to reveal nursing assessment for elopement for the 3-day monitoring requirement on the elopement assessment. On 7/27/2021 at approximately 1:18 PM, an interview was conducted with the Director on Nurses (DON) who confirmed the nurses should monitor a high risk for elopement resident and initiate interventions as needed. The DON confirmed the elopement assessments should be completed on admission and quarterly, or more frequently if needed. The DON confirmed the nursing staff should complete progress notes daily for a new admission resident who is receiving therapy. The DON stated the Elopement Risk Assessments are not always accurate and stated Resident #2, who is not mobile was also scored a High Risk on the Elopement Risk Assessment. A review of Resident #2 Elopement Risk Assessment was completed. The resident scored 16 which is high risk for elopement. The scoring scale at the bottom revealed the following: 0-4 Low Risk, 5-10 Moderate Risk, 11 or Greater - High Risk. A score of 16 indicated the resident was a high risk for elopement. The elopement risk assessment tool interventions for High Risk included, but not limited to 3-day monitoring, Weekly Behavioral Management, and Wander guard Program. A review of resident #2 MDS Admission assessment dated [DATE] revealed the resident requires extensive assistance for bed mobility and walking in the room or corridor did not occur during the look back period. The MDS Assessment revealed Resident #2 with impairment on upper and lower extremity on one side. An interview was conducted with Staff G, on 7/27/2021 at approximately 3:50 PM. Staff G confirmed resident #1 eloped from the facility on 7/13/21 at approximately 7:50 PM. Staff G stated the resident was well dressed, and looked like a visitor, and the resident stated she, had a visit and was waiting on her ride and further stated she let the resident out because she believed the resident was a visitor. Staff G stated the resident provided an alternate name and stated she checked the elopement book for the photos in the elopement book as well as the census for the name the resident gave her. Staff G confirmed the resident was not listed in the elopement risk book. Staff G stated the resident walked down the sidewalk, very slowly toward the parking lot. She stated she watched her for a while but went back to get the elopement book to re-check the book. Staff G stated Staff D, a Licensed Practical Nurse, (LPN) was outside and escorted resident #1 back into the building. The receptionist confirmed she had no training related to elopement prior to the event. A review of the facility 7/14/21 Adhoc Quality Assessment Performance Improvement, (QAPI) Meeting revealed issues discovered related to the elopement included: Resident #1 information was not placed in the Elopement Binder at the front desk or nursing stations; wander guard was not applied and the visitor policy was not adhered to allowing resident to walk out the front door, the resident did not have an ID badge. A review of the visitation during COVID-19 pandemic process, (no date) document revealed the exit process for visitors included: the visitor must return the badge and scan the code into the visitor management kiosk, the receptionist will unlock the door for the visitor to exit. Only one visitor/partner/vendor will exit the door at a time; once the visitor/partner/vendor has exited the center, the receptionist will release the door lock allowing the next person to exit. Prior to allowing the visitor/vendor to exit verification will be needed on the identification of the person exiting; if the visitor/vendor does not have the badge and cannot provide proof of identification, the receptionist will notify the administrator/manager on duty supervisor to assist A review of the facility elopement drills revealed the last elopement drill was conducted on 7/30/2020. The facility has had resident elopements on 5/1/2021, 5/2/2021 and 6/27/2021. An interview was conducted with the Senior Nurse Consultant who confirmed no additional elopement drills were conducted and confirmed they will be added to the safety team calendar. A review of elopement training was conducted which revealed 3 out of 8 staff members reviewed had no elopement training documented. The staff with no training include: Staff E, receptionist; Staff G, receptionist and staff J, an LPN. Four of 8 records reviewed revealed elopement training on 7/14/21, no training was found prior to 7/14/21. The staff include Staff F, Certified Nursing Assistant (CNA); Staff H, CNA; Staff I, housekeeper; Staff K, CNA. The review revealed staff K, CNA did not have evidence of abuse, neglect and exploitation training. An interview was conducted with the Senior Nurse Consultant on 7/27/2021 at approximately 3:40 PM, who confirmed the training documents given to the surveyors were all the training documents that were available.

Based on record review and interview, the facility failed to ensure abuse, neglect, and exploitation training was completed for 1 of 8 staff records reviewed for training, (Staff K). The findings include: A review of Abuse, Neglect and elopement training was conducted which revealed staff K, a certified nursing assistance, (CNA), did not have evidence of abuse, neglect and exploitation training. An interview was conducted with the Senior Nurse Consultant on 7/27/2021 at approximately 3:40 PM, who confirmed the CNA did not have the required Abuse, Neglect, Exploitation training, and confirmed the CNA will not work until the training is completed.

Based on record review and staff interview, the facility failed to develop and implement a policy and procedure to ensure that residents and staff were offered the COVID vaccine, educated on the risk and benefits of the vaccine, informed regarding additional dose requirements and given the opportunity to refuse the COVID-19 vaccine which currently affects 95 staff members and 55 residents. The findings include: On 06/15/2021 the facility's policies and procedures regarding infection control, COVID-19 and vaccinations were requested for review. The facility did not have a policy and procedure regarding the offering; education; and refusal of the COVID-19 vaccine for staff and residents. On 06/15/2021 at 10:30AM an interview was conducted with the Infection Control Nurse regarding COVID-19 vaccinations for staff and residents. She stated that when residents are admitted they are asked about their COVID-19 vaccine status and this information is uploaded into Preventative Healthcare. She said that when the vaccine first became available, some of the residents received the vaccine at that time. But currently we don't have a way to offer residents the COVID-19 vaccine. We just ask them if they have had it (COVID-19 vaccine), when they get admitted . She said that staff members, if they want the vaccine, will go and get the vaccine on their own. She does keep a log of residents/staff that have received the COVID-19 vaccine, which revealed - 15 of 55 residents currently in the facility have received the COVID-19 vaccine, and 33 of 95 employees have received the COVID-19 vaccine. She says she verbally encourages staff to get the vaccine.

Based on record review, staff interview, and policy review the facility failed to implement their policy regarding staff training of abuse and neglect for 1 of 5 sampled employees. (Employee A) The findings include: Review of employee A's (certified nursing assistant) personnel file revealed a hire date of 4/20/21. The file revealed no abuse and neglect training. The file contained only a memorandum dated 6/21/16, and signed by employee A on 4/20/21, stating call the Administrator when any abuse allegations have been made and call the director of health services when a resident states they have been abused. An interview was conducted with the Administrator on 5/25/21 at 3:21 PM. The Administrator stated the facility has no other abuse training for employee A. Review of the facility policy for In-services and Continuing Education dated November 2012 revealed each partner is required to attend abuse and neglect recognition and reporting training prior to patient contact and annually.