Every finding on record at Pruitthealth - Swainsboro

Based on resident and staff interviews, record review, and review of the facility policy titled Freedom from Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, Mission Statement, the facility failed to ensure that one of 26 sampled residents (R) (R22) was free from involuntary seclusion when staff placed R22 in a locked shower room, unattended, for 30 minutes to one hour, without the ability to exit. As a result, R22 experienced psychosocial harm on April 11, 2026, as evidenced by expressing anger about the incident. Findings include: Review of the facility policy titled Freedom from Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, Mission Statement, revised 11/21/2016, included, . The Organization recognizes that every patient has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish. Involuntary Seclusion is defined as a separation of a resident from other residents or from his or her room or confinement to his or her room (with or without roommates) against the resident's will, or the will of the resident's legal representative.Review of the Facility Reported Incident Form, dated 04/11/2026, revealed the facility reported an incident of staff-to-resident abuse to the State Survey Agency. The report revealed that the incident occurred on 04/10/2026. The details of the reported incident included that a Certified Nurse Aide (CNA) put a resident who was hollering in the shower, turned on the hot water, and left him unattended. Nurse stated the resident did not ask to be put in the shower. The form documented that no injury was noted, and the physician, the responsible party, and the police were notified. Review of the Sheriff's Office Incident Report dated 4/11/2026 at 8:30 am revealed that a deputy was dispatched to the facility in reference to a report of elder abuse. The report documented that the complainant stated the offender left the victim in the shower for approximately one hour due to the victim hollering. Review of the facility-provided Separation Notice for CNA KK documented the period of employment as 09/05/2023 through 04/10/2026. The documented circumstance of the separation was Terminated due to serious rules violations.Review of the Face Sheet for R22 revealed the resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, generalized anxiety disorder, bipolar disorder, and major depressive disorder.Review of the quarterly Minimum Data Set (MDS) assessment, for R22, with an Assessment Reference Date (ARD) of 02/12/2026, revealed that Section C (Cognitive Patterns) documented a Brief Interview Mental Status Score (BIMS) of 12, which indicates cognitive awareness with little to no periods of confusion. Section E (Behaviors) documented that behaviors were not exhibited. Section GG (Functional Abilities and Goals) documented R22 was non-ambulatory, and required substantial assistance to was dependent for Activities of Daily Living (ADLs).Review of the progress note, for R22, revealed an entry by Licensed Practical Nurse (LPN) DD and dated 04/11/2026, of Resident has been brought back to room and assisted back in bed. breath and lung sounds are clear and unlabored. skin assessed. no injuries observed. resident denies pain. will continue to monitor. {sic}Review of a facility-provided handwritten statement, signed by LPN DD and dated 04/11/2026, documented that R22 . was removed from his room by CNA KK, placed in the shower room, and left unattended. The resident had been inside for approximately 30 minutes to an hour. The resident reported he was having trouble breathing. I subsequently questioned the CNA who had placed the resident in the shower room and asked whether a shower had been provided. He (CNA KK) responded, No. I just put him in there so that he would hush. I informed [name of] CNA KK that his action was inappropriate and constitutes a form of abuse. {sic}In a telephone interview on 04/24/2026 at 11:01 AM, CNA KK confirmed that he placed R22 in the shower room and left him unattended because the resident was yelling out. CNA KK stated that his intention was to allow the R22 to quieten down and prevent him from disturbing his roommate and other residents with his yelling out. CNA KK reported that the estimated time the resident remained in the shower room was almost an hour. In an interview on 04/22/2026 at 12:01 PM, R22 confirmed that CNA KK locked him in the shower room. R22 identified CNA KK by his first name. He stated, I did not want to be in the shower room. I told him that I did not want to go in there, but he still did it. He left me in there against my will. I was in there for a long time. Don't know how long. When asked if he was having any stress or concerns that were affecting him. R22 reported being angry that night when the incident first happened. R22 denied any physical abuse from CNA KK. In an interview on 04/22/2026 at 3:10 PM, LPN DD confirmed that on 04/11/2026 at a few minutes past 1:00 AM, she observed CNA KK push R22, seated in a geriatric chair, into the shower room, and stated R22 was yelling. She further stated that she went to check on the resident a few minutes before 2:00 PM and found R22 alone in the shower room, locked in. LPN DD stated R22's face was pink in color, and he was having difficulty breathing. She continued to state that she returned the resident to his room and assessed him. She stated that CNA KK confirmed to her that he had placed R22 unattended in the shower room. In an interview on 04/23/2026 at 9:11 AM, CNA BB reported that on 04/11/2026, she entered the shower room with LPN DD and observed R22 in the shower room stating, Please get me out of here and Thank you. She stated R22 was in a geriatric chair in the reclined position. In an interview on 04/22/2026 at 12:03 PM, the Social Services Director (SSD) stated she provided services to R22 on 04/13/2026. The SSD stated that R22 stated he was angry about CNA KK placing him in the shower room and leaving him alone. He stated he told CNA KK that he didn't want to be left in the shower room. The SSD stated the psychiatric therapist was at the building on 04/13/2026 to see other residents, and the therapist stated another therapist would see the resident as soon as possible. She further stated she visited R22 on 04/13/2026, 04/14/2026, and 04/15/2026.In an interview on 04/22/2026 at 10:25 AM, the Administrator reported being made aware of the incident on 04/11/2026 by Unit Manager CC around 7:30 AM. She confirmed that staff reported R22 was locked in the shower room for 30 minutes to an hour. The Administrator stated that CNA KK was terminated on the same date as the incident. The Administrator stated that yelling out was normal behavior for R22, that staff should check on him to assess his needs, and that he should not have been locked alone in the shower room. The Administrator further stated she considered being locked in the shower room to be seclusion and abuse. R22 was seen by psychiatric services on 4/23/2026. The facility implemented the following:1. On 4/11/2026, the facility submitted an incident report to the State Survey Agency (SSA) and reported to the State CNA Registry. 2. On 4/11/2026, a police report was completed at 9:05 AM. Case number: 2026-04-00053.3. On 04/11/2026, CNA KK was terminated from employment. 4. On 04/11/2026, a skin assessment was completed for R22. 5. From 04/11/2026 through 04/14/2026, the facility completed skin assessments on the residents who were assigned to CNA KK. The results revealed no abuse concerns.6. On 04/11/2026, the facility conducted an Abuse Questionnaire with residents who were assigned to CNA KK. The results revealed no abuse concerns.7. On 4/13/2026, 4/14/2026, and 4/15/2026, Social Services provided services to R22.8. On 04/13/2026, Social Services offered a hospital emergency room visit or immediate psychiatric services to R22, and he declined. 9. On 04/13/2026, an education titled Abuse: Identifying, Reporting, Types, Seclusion, was conducted with all staff. Review of the sign-in sheet revealed 94 unique names. 10. On 04/13/2026, the facility conducted a Quality Assurance and Performance Improvement (QAPI) meeting to address the incident. The attendees included the Medical Director, Administrator, and DON.

Based on observations, resident representative and staff interviews, record review, and review of the facility policy titled Enteral Nutrition (Tube Feeding), the facility failed to follow the prescribed enteral feeding order for one of five residents (R) (R84) with prescribed enteral feedings. This deficient practice had the potential to place R84 at risk of enteral feeding complications. Findings include:Review of facility policy titled Enteral Nutrition (Tube Feeding), reviewed 10/21/2025, revealed the Procedure section included, . 2. The physician will write orders prescribing the formula rate, route of administration, and flush orders for the individual patient/resident.Review of the Face Sheet for R84 revealed the resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, pneumonitis due to inhalation of food and vomit, dysphagia following cerebral infarction, and gastrostomy status. Review of the annual Minimal Data Set (MDS) assessment for R84, dated 01/28/2026, revealed that section K (Swallowing/Nutritional Status) documented the resident had a feeding tube and received 51 percent or more of total calories and 501 cubic centimeters (cc) through the feeding tube. Review of the physician orders for R84 revealed an order dated 01/28/2026 for Jevity 1.5 feeding at a rate of 60 milliliters (ml) per hour from 10:00 PM through 6:00 AM, with a water flush at 50 ml per hour from 10:00 PM through 6:00 AM.Observation on 04/21/2026 at 10:56 AM revealed that Jevity 1.5 was infusing through a feeding pump at 60 ml per hour. Observation on 04/21/2026 at 3:03 PM revealed that Jevity 1.5 was infusing through a feeding pump at 60 ml per hour. In an interview on 04/23/2026 at 10:07 AM, Licensed Practical Nurse (LPN) EE confirmed that the feeding pump should be turned off at 6:00 AM and not infused during the day. He confirmed that the physician's order was to turn off the feeding pump at 6:00 AM.In an interview on 04/23/2026 at 10:36 AM, LPN/Unit Manager GG confirmed that the formula was infusing and the physician's order was to turn off the feeding pump at 6:00 AM. In an interview on 04/23/2026 at 1:07 PM, the Director of Health Services (DHS) revealed that the nurse should follow the physician's order for administering the feeding tube formula. The DHS stated that the night-shift nurse was responsible for turning off the feeding at the time ordered to end it. The DHS further stated that if the night shift nurse did not stop the infusion, the day shift nurse was responsible for following the orders.

Based on observations, staff interviews, record review, and review of the facility's policy titled Care Plans, the facility failed to develop or implement a comprehensive person-centered care plan for one of 26 sampled residents (R) (R84). This deficient practice had the potential to place R84 at risk of unmet needs, medical complications, and diminished quality of life.Findings include:Review of the facility's policy titled Care Plans, revised 10/21/2025, revealed the admission Comprehensive Care Plan of Care section included, . 3. The comprehensive person-centered care plan is developed to include measurable goals and time frames to meet a patient/resident's medical, nursing, and psychosocial 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.Review of the Face Sheet for R84 revealed the resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, pneumonitis due to inhalation of food and vomit, dysphagia following cerebral infarction, and gastrostomy status. Review of the annual Minimum Data Set (MDS) assessment for R84, dated 01/28/2026, revealed that section K (Swallowing/Nutritional Status) documented the resident had a feeding tube and received 51 percent or more of total calories and 501 cubic centimeters (cc) through the feeding tube. Review of the care plan for R84, dated 04/8/2026, revealed that R84 had a feeding tube and was at risk of aspiration. The goal was for R84 to maintain nutritional stability through the next 90 days. Interventions included tube feeding as ordered, flushing as ordered, notifying the MD (Medical Doctor) of any problems, and elevating the head of the bed per protocol.Review of the physician orders for R84 revealed an order dated 01/28/2026 for Jevity 1.5 feeding at a rate of 60 milliliters (ml) per hour from 10:00 PM through 6:00 AM, with a water flush at 50 ml per hour from 10:00 PM through 6:00 AM.Observations on 04/21/2026 at 10:56 AM and 3:03 PM revealed that Jevity 1.5 was infusing via a feeding pump at 60 ml per hour. In an interview on 04/23/2026 at 10:07 AM, Licensed Practical Nurse (LPN) EE confirmed that the feeding pump should be turned off at 6:00 AM and not infused during the day. He confirmed that the physician's order was to turn off the feeding pump at 6:00 AM.In an interview on 04/23/2026 at 12:39 PM, Case Mix Director HH confirmed the care plan interventions for R84 included administering the tube feeding as ordered. She further stated that the care plan should always be followed.

Based on observation, record reviews, staff interviews, and review of the facility's policies titled Expired Medication and Medication Storage in the Healthcare Centers, the facility failed to ensure expired medications were not stored in one of two medication storage rooms. This deficient practice had the potential to place the residents at risk of receiving medications with altered effectiveness. The facility's census was 72. Findings include: Review of the facility's policy titled Expired Medication, reviewed 6/18/2024, revealed the Policy Statement included . Expired medication must be removed from the active medication storage area and disposed of according to Assisted Living Community (ALC) policy. Review of the facility's policy titled Medication Storage in the Healthcare Centers, revised 11/1/2024, revealed the Procedure section included, . 3. Nurses are required to check all medications for deterioration and expiration before administration Observation on 3/5/2025 at 11:00 am of the medication room located at the Back Nurses' Station revealed two vials of naloxone HCL (hydrochloride) injection (a medication used to rapidly reverse an opioid overdose) 0.4 milligram (mg)/ milliliters (ml) with an expiration date of March 1, 2024, on each vial. In a concurrent interview and observation of the medication storage room on 3/5/2025 at 11:05 am, Unit Manager (UM) AA confirmed that the two vials of naloxone injection in the medication room were expired. She stated the expired medications should not be in the medication room and should have been removed before they expired. UM AA stated that if a resident received the expired medication, the medication could be less effective and might not work. In an interview on 3/5/2025 at 12:05 pm, Registered Nurse (RN) BB stated that expired medications should not be in the medication room because the use of expired medications could have adverse effects if administered to a resident. RN BB further stated that expired medications could be less potent and less effective. In an interview on 3/5/2025 at 12:22 pm, the Director of Health Services (DHS) stated her expectation was that expired medications should not be in the medication room. She stated that medications should be removed from the medication room before they expire by the nurse or UM. She further stated that naloxone was administered to counteract a narcotic overdose and that if the medication was expired, it could have a decreased desired effect.

Based on observations, staff interviews, record reviews, and record reviews, the facility failed to ensure one of 37 sampled residents (R) (R72) call light was within reach. This deficient practice had the potential to place R72 at risk of unmet needs and increased risk of injury. Findings include: Review of R72's medical record revealed diagnoses including, but not limited to, cognitive communication deficit and impaired mobility. Review of R72's Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 13 (indicating little to no cognitive impairment), and Section GG (Functional Abilities and Goals) documented R72 required partial to moderate assistance with mobility. Review of R72's care plan, dated 2/10/2025, revealed the resident was at risk for falls related to impaired mobility, received psychotropic medication, and had weakness. Interventions included placing the call light within reach. Observations on 3/4/2025 at 9:49 am and 12:03 pm and 3/5/2025 at 12:57 pm revealed R72 seated in a wheelchair in her room behind a privacy curtain with no call light within reach. In an interview on 3/5/2025 at 1:35 pm, R72 revealed that she was unable to reach her call light on multiple occasions. She stated that staff would sometimes leave it on the bed or in other places out of her reach, leaving her unable to call for help when needed. In an interview on 3/5/2025 at 1:50 pm, Certified Nursing Assistant (CNA) DD confirmed that the resident's call light was not within her reach and should be within reach at all times. She further stated that R72 would have no way to call for help with the light being out of her reach.

Based on observations, staff and resident interviews, record review, and review of the facility's policy titled Self-Administration of Medications by Patients/Residents, the facility failed to assess one of 37 sampled residents (R) (R35) for the ability to safely self-administer medications prior to leaving medications at the bedside. This deficient practice had the potential to place R35 at risk of unsafe medication use. Findings include: Review of the facility's policy titled Self-Administration of Medications by Patients/Residents, reviewed 1/6/2025, revealed the Policy Statement stated, Each patient/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 patient/resident and other patients/residents of the healthcare center. Medication self-administration also applies to family members who wish to administer medication. Review of R35's Face Sheet revealed diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure with hypercapnia, and hypertension. Review of R35's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Section C (Cognitive Pattern) documented a Brief Interview for Mental Status (BIMS) score of 6 (indicating severe cognitive impairment). Review of R35's care plan, dated 2/12/2025, revealed no care area or interventions for medication self-administration. Review of R35's Physician Orders revealed an order dated 8/13/2024 for ipratropium-albuterol solution (a medication used to treat lung diseases) for nebulization (the administration of a solution in the form of a fine mist directly into the lungs), 0.5 milligrams (mg)-3 mg/ 3 milliliters (ml) three times a day. Further review of the orders revealed no order for self-administration of medication. Review of the Medication Administration Record (MAR) from 2/4/2025 to 3/4/2025 revealed documentation that staff administered the ipratropium-albuterol solution as ordered. Review of the clinical record revealed R35 did not have a self-administration of medication assessment to indicate the resident was capable of medication self-administration. Observation on 3/4/2025 at 10:06 am of R35's nightstand revealed a cup sitting on the nightstand containing nine albuterol solution ampules. In an interview, R35 stated that she self-administered albuterol nebulizer treatments three times daily in the morning, after lunch, and after dinner and would take additional doses as needed when experiencing excessive coughing. Observation on 3/4/2025 at 12:06 pm revealed the albuterol solution ampules remained at the bedside. During a concurrent observation and interview on 3/4/2025 at 3:01 pm, Registered Nurse (RN) CC revealed that R35 was not permitted to self-administer breathing treatments or keep albuterol medication in her room. RN CC confirmed the cup containing albuterol ampules on R35's bedside table.

Based on record review, family and staff interview, the facility failed to provide evidence that quarterly statements from two of two resident (R) (R#11 and R#43) trust fund accounts reviewed were being sent to the responsible parties (RP). The facility handled a total of 56 resident accounts. Findings include: 1. During interview with R#11's RP on 8/28/18 at 9:01 a.m., revealed that the RP did not receive quarterly statements from the resident's trust fund account. He added during continued interview that he got these statements in the past, but did not get them now. Review of the facility's Trial Balance report dated 8/28/18, revealed that R#11 currently had a trust fund account being managed by the facility. During interview with the Financial Manager on 8/29/18 at 8:50 a.m., she stated that she sent out quarterly statements for the residents and RPs that wanted them, and that she pretty much just knew who these people were. She stated during further interview that she did mail quarterly statements to R#11's RP. Review of R#11's Resident Fund Management Service Statement for the Period 12/30/17 through 3/30/18 revealed that the resident's name and the address of the facility were on the statement, and it did not contain the RP's name and/or mailing address. During interview with the Financial Manager at this time, she stated that she had to look up RPs' addresses in the computer, and then handwrite the name and address on the outside of the envelope for all of the quarterly statements mailed to RPs. She stated during continued interview that she had no proof that the quarterly statements were being mailed to R#11's RP. During continued interview, the Financial Manager stated that she had never received any quarterly statements for the period of 4/1/18 through 6/30/18 from corporate, who managed the accounts, and stated that she mailed a Resident Statement Landscape report to the RPs, but could not provide evidence that this was done. 2. Review of the Trial Balance report revealed that the facility managed R#43's trust fund account. During interview with the Financial Manager on 8/30/18 at 11:56 a.m., she verified that R#43 had a trust fund account, and that her social security check went to the RP and not the facility. She stated during further interview that because of this, she did not provide a quarterly statement to the RP, and that the RP called her all the time to see if she needed to deposit more money in R#43's account. Review of facility policy entitled 'Resident Trust Policy' issued September, 2009, revealed: The resident shall have reasonable access, upon request, to a record of all transactions made to his/her account. Quarterly statements will be provided in writing to the resident or the resident's responsible representative within 30 days after the end of the quarter.

Based on record review, staff interviews, and review of the Lippincott procedures - [MEDICAL TREATMENT] care - pre and post [MEDICAL TREATMENT] the facility failed to obtain pre and post [MEDICAL TREATMENT] blood pressures for one resident (R) #15. The sample size was 28 residents. Findings include: Record review revealed that R#15 was admitted to the facility on [DATE]. Review of the resident's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 14 indicating that the resident was cognitively intact. Review of section O, Special Treatment and Programs, revealed the resident receives [MEDICAL TREATMENT]. physician's orders [REDACTED].>B/P & Pulse monitor and record before and after [MEDICAL TREATMENT]. Review of Lippincott procedures - [MEDICAL TREATMENT] care - pre and post [MEDICAL TREATMENT] revealed 1.Pre [MEDICAL TREATMENT] - take and record patient/resident blood pressure and pulse, and observe shunt access (AV shunt or Permacath) prior to patient/resident transport to [MEDICAL TREATMENT]. 2. Post [MEDICAL TREATMENT] - Upon return from [MEDICAL TREATMENT], take and record patient/resident blood pressure, pulse and observations of the dressing at the access site. Review of the Medication Administration Record [REDACTED]. The Medication Administration Record [REDACTED]. The MAR for August 2017 showed documented blood pressure on 7am to 7pm shift on August 7 and 16 and on the 7pm to 7am shift on August 7 thru August 15. Interview on 8/16/17 at 2:39 p.m. with Registered Nurse (RN) CC who reported that R#15 should have vitals taken prior to going to [MEDICAL TREATMENT]. MAR for July reflected that vital signs are not being documented consistently before or after [MEDICAL TREATMENT]. Interview on 8/17/17 at 8:36 a.m. with Senior Care Partner GG reported that blood pressure is taken at the [MEDICAL TREATMENT] center and should be transcribed onto the MAR. Interview on 8/17/17 at 8:40 a.m. with the Unit Manager who reported that the facility is to obtain vitals for the resident prior to going to [MEDICAL TREATMENT] but the information that is listed on the [MEDICAL TREATMENT] communication form should be placed on the MAR. Interview on 8/17/17 at 12:33 p.m. with the Administrator who reported that the Lippincott Procedures for [MEDICAL TREATMENT] care should be followed and the expectation is that blood pressures will be taken at the facility both before and after a resident returns from [MEDICAL TREATMENT].

Based on staff interview and record review the facility failed to revise the care plan to address treatment for [REDACTED].#60. The sample size was 28. Findings include: Review of the resident's care plan revealed there had been no revision of R#60 plan of care to indicate the resident had interventions to reflect any treatment for [REDACTED]. The Braden Scale assessment revealed that the resident was at high risk for impaired skin integrity. Further review for resident R#60's plan of care dated 3/31/17 title Alteration to skin integrity revealed an update added on 4/6/17 for a pressure ulcer to the left heel. Further review of the care plan did not reveal any interventions to address preventive measures for the heel area.Review of the wound assessment notes and physician order revealed that R#60 was receiving treatment for [REDACTED]. Interview with the Treatment Nurse on 8/16/17 at 1:58 p.m. revealed that she was unaware that R#60's care plan was missing interventions to address the pressure ulcer now categorized as a friction area on the left heel area. She reported that area to left heel is a friction area with an intact crust. She stated a crust means a scab and not considered a pressure sore to the left heel. She reported the heel has never been open and is presently being assessed as a friction area. She described the heel as having a crust with no drainage with a harden discoloration, and crust is about a pea size. She stated the friction area is being treated with skin prep. She further stated that she was not the treatment nurse at the time the heel area was identified as a pressure ulcer. She stated that the Director of Nurses was the former treatment nurse prior to she taking the position in latter part of June 2017 . Interview with the Assistant Director of Nurses on 8/16/17 at 2:36 p.m. confirmed that the resident has a friction area to the left heel and not a pressure ulcer to the left heel. She verified that the care plan had not been revised to include interventions related to the friction area. She further stated that R#60 was admitted on [DATE] with a Stage 3 pressure sore to sacral and a Stage 2 pressure sore to left heel. The left heel healed on 4/27/17 and the sacral is presently ongoing. On 6/5/17 the pressure ulcer to left heel was re-assesed as a friction area to left heel. She stated that the left heel now is enclosed with a scab over it and no longer an open area. Review of the facility policy title, Facility Pressure Injury Prevention -Long Term Care Policy revealed pressure ulcers should be completed by a licensed nurse under the assignment of a register nurse with perodic validation by an register nurse Braden Scales should be completed on admission, readmission , and weekly for 4 weeks after admission or readmission, quarterly, and with any significatnt changes. Care plan, supportive device, and treament was noted in the policy

Based on staff and resident interview, and review of facility documents, the facility failed to assure that one resident (R#125) was provided showers according to resident's choice and shower schedule. The resident sample was 28. Findings: R#125 was admitted to the facility on [DATE]. Review of the medical record revealed [DIAGNOSES REDACTED].>[MEDICAL CONDITION], Primary Hypertension, [MEDICAL CONDITION], Asthma, [MEDICAL CONDITION], and [MEDICAL CONDITION]. Review of the most recent quarterly Minimal Data Set (MDS) (a standardize screening and assessment tool used for long term care residents), dated 7/28/17, revealed under Section C - Cognitive Patterns that R#125 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. Section G - Functional Status documented that R#125 required limited assistance with one person physical assist for transfers, walking, locomotion, toilet use, dressing, and personal hygiene, and R#125 is depended on staff for bathing with one person physical assistance needed. Review of the comprehensive care plan for R#125 revealed a care plan for self-care deficit activities of daily living (ADL) related to physical status. Resident requires assistance with ADL's. Approaches for R#125 included bath/shower as scheduled, incontinent care after each episode, and assure adequate rest periods. Interview on 8/15/17 at 9:08 a.m., with R#125 who reported that a shower was offered to her at 10:00 p.m., on 8/14/17 but she did not get it as she wants morning showers. R#125 then reported that she was informed that Tuesday is the men's day for showers. Interview on 8/15/17 at 3:30 p.m. with R#125 who reported that she requested a shower this morning but was told that today is showers for men only. Resident is unsure of who she spoke with but she stated she requested a shower tomorrow morning at 10:00 a.m. Interview on 8/16/17 at 10:38 a.m., with FF Certified Nursing Assistant (CNA) who reported that following shower schedule: Women shower on Monday, Wednesday, and Friday and men shower Tuesday, Thursday, and Saturday. It was further reported that baths/showers are documented in the kiosk and the shift for the shower is randomly assigned. Interview on 8/16/17 at 10:51 a.m., with R#125 who reported that she has spoken to her CNA about showers and she has agreed to give her a shower today. R#125 reported that she has received 5 showers since being admitted to the facility and she denies that anyone has ever spoken with her regarding shower preferences. Interview on 8/16/17 at 12:30 p.m., with R#125 who reported that she is supposed to get a shower after lunch. R#125 reported that she has expressed multiple times to staff that she wanted to get her shower today. Interview on 8/16/17 at 1:10 p.m. with HH CNA who reported that she assists resident's with showers and R#125's shower days are Monday, Wednesdays, and Fridays. It is reported that the resident will be taken down for a shower after lunch today. It was further reported that if R#125 reported that she wanted a shower on a Tuesday, Thursday, or Saturday the shower would be provided. HH CNA denies that the resident ever refused care. Interview on 8/16/17 at 2:48 p.m., with CC Registered Nurse (RN), who reported that R#125's shower is determined by the list that tells when residents get their showers. It was reported that residents who are alert are asked if they received showers when questioned, that is how the charge nurse assures that residents are receiving showers. CC RN reviewed the Bath (CNA Role) and confirmed that per the printout R#125 is not receiving three showers per week per the schedule. Interview on 8/16/17 at 3:05 pm with II CNA, Restorative, who reported that she did work with R#125 on Monday 8/14/17 but denies giving her a shower. II CNA further reported that if residents ask for a shower on a non-shower day she will give the shower if resident requests it. Interview on 8/18/17 at 8 a.m. with EE Unit Manager, who reported that residents can have showers anytime but specific days for men and women. It was reported that at admission the nurse should be asking preference regarding showers and bath times. EE Unit Manager further reported that best practice is to document when resident refuses and plans to begin assessing ADL care at least weekly. Review of Bath (CNA Role) EE Unit Manager confirmed that showers are documented for R#125 on 7/24/17, 7/28/17, 8/4/17, and 8/14/17 which is only 4 times since admission.

Based on record review and interview, the facility failed to take measures to prevent a fecal impaction and follow physician standing order for one (1) resident (#115) from a sample of twenty-three (23) residents. Findings Include: Review of the Minimum Data Set (MDS) Admission assessment dated [DATE] revealed Section G Functional Status for Toilet Uses that resident #115 was independently toileting and need set up only. Section C Cognitive Patterns Summary Score noted 03 indicating significant impairment. Section E Behavior revealed no resistance of care. Section I listed [DIAGNOSES REDACTED]. Review of Nurse's Note and the Nursing Home to Hospital Transfer Form dated 08/24/15 revealed resident #115 was found on the floor and was sent to Meadows Regional Medical Center with an admitting [DIAGNOSES REDACTED].#115 returned to the facility on [DATE]. The Minimum Data Set (MDS) 5 day assessment dated [DATE] revealed Section I Active Diagnosis, of a [MEDICAL CONDITIONS], Hypertension and [MEDICAL CONDITION]. Section G Functional Status for Toilet Uses was extensive assistance. Section E Behavior revealed no resistance of care. Review of the Nurse's Note and a Nursing Home to Hospital Transfer Form dated 09/14/15 revealed that resident #115 was noted to have rectal bleeding was sent the Hospital Emergency Department for evaluation. admitting [DIAGNOSES REDACTED]. The Nurse's notes dated 08/30/15 through 09/14/15 revealed that the resident was assessed as incontinent of bowel and bladder and total dependent on staff for toileting. There were four (4) documented Nurse's Note entries that the resident were administered narcotics to ease the pain of his/her [MEDICAL CONDITION]. The Certified Nursing Assistant (CNA) Care Interventions Record Signature Sheet Form dated August 2015 revealed during the month of August 28-31, 2015 there was no documented bowel movement and was there was missing data. September 2-4, 2015 there were no document of a bowel movement and there was missing data. September 5-13, 2015 noted small to no bowel movement and missing data. There were no documentation or indication that the Certified Nurse Assistant (CNA) had informed the Charge Nurse that resident #115 had two episodes of a three day period without having a bowel movement. Further record review revealed that resident #115's physician's orders [REDACTED]. Nurse's Notes and the Medication Administration Record [REDACTED]. An interview on 10/15/15 at 5:43 p.m. with the Director of Nursing (DON) revealed that Certified Nursing Assistants (CNA) are to report to their Charge Nurse any resident that had not had a bowel movement within three days, and that the Charge Nurses are expected to follow up with appropriate interventions.

Base on record review and interview, the facility failed to resolved a grievance related to one (1) resident B on a sample of twenty-three (23) residents. Findings Include: During an interview on 10/14/15 at 3:02 p.m. the family member of resident B stated that resident B was admitted to the facility on the 200 hall, and that initially resident B was unable to shower due to a recent stroke. After receiving therapy services, resident B was beginning to go to the shower. Shortly afterwards, stated resident B did not want to go to the shower anymore. The family member of resident B continued to state that he/she came to the facility to speak with the Social Worker (SW) to find out why resident B was refusing showers and to request a room change. During an interview on 10/15/15 at 8:00 a.m. the Social Worker (SW), they acknowledged that the family member of resident B came to the facility with concerns about resident B not wanting to take showers and requesting a room change. SW stated that the family member of resident B informed him/her last week of these issues. When asked to explain the process for family/resident concerns or complaints, SW stated that a concern or complaint is written on a grievance form. The Social worker stated a grievance form was not completed for the family member of resident B because the SW had told another staff but could not recall whom. Review of the Grievance Log entries from 03/15 through 10/14/15 revealed there were no documented entries in the Grievance Log for resident B. Review of the facility policy entitled Grievances: Healthcare Center Section Procedure: (4.) The Social Services Partner will be responsible for following up with the patient/resident, authorized individual or other representative to make sure that the grievance has been resolved or that they understand what actions have been take. And number (5.) The Grievance/Complaint should be completed within three business days.

Based on record review and staff interview, it was determined that the facility failed to provide continuing mental health services for one (1) (#97) of one (1) sampled residents for Pre-Admission Screening/Resident Review (PASRR) from a total sample of twenty-three (23) residents. Findings include: Review of the the medical record for resident #97 revealed the following [DIAGNOSES REDACTED]. Review of the 07/28/14 Level II Pre-Admission Screening/Resident Review (PASRR) revealed that the resident was eligible to receive additional specialized specialized services and/or supports according to an individualized plan of care to treat the resident's serious mental illness. Review of the 06/29/15 Quarterly Minimum Data Set (MDS), and the 08/07/15 Annual MDS revealed the resident had not displayed any behaviors and had not received Psychological therapy in the past seven days. During interviews with the Director of Nursing, the Administrator and the Nurse Consultant on 10/15/15 at 3:50 p.m., they stated there was not a staff person who was responsible for reviewing the Level II PASRR reviews, that it was a team approach. However, the facility could not provide any documentation of where the team had reviewed this resident's Level II PASRR or discussed his/her recommended ongoing psychiatric care. They further stated the resident had not had any behaviors until August 2015 when the resident started throwing him/herself from bed or the chair. After the resident was found on the floor on 09/01/15, the resident's physician gave an order to send the resident to the emergency room for psychiatric evaluation. The resident was admitted for inpatient psychiatric treatment and returned to the facility on [DATE]. When they were asked who was responsible for determining if this resident would receive the recommended services they all stated the physician. They then confirmed that the resident's primary care physician was not a psychiatrist. They stated if any resident needed continued psychiatric care that the resident would be sent to the local hospital for psychiatric service to be conducted through Telemed services. During an interview with the staff at that time, they refused to answer the surveyor's question of whether this resident had received the Telemed psychiatric service. As of 10/15/15 at 6:30 P.M., the facility could not provide any documentation of where resident #97 had received the recommended diagnostic/ongoing psychiatric care as recommended by Georgia PASRR evaluation since his/her admission to the facility.

Based on observation and staff interview the facility failed to ensure that staff sanitized hands between serving resident's meal trays on five (5) of five (5) halls during three (3) dining observations. Findings include: 1. During dining observation on 12/7/14 at 5:45 p.m. a Certified Nursing Assistant (CNA) delivered a meal tray to a resident in room [ROOM NUMBER]. She applied a clothing protector to resident in B bed and touched the resident's neck and back of the head. She then exited that room and carried a meal tray to resident in room [ROOM NUMBER] without washing or sanitizing her hands. 2. During dining observation on 12/10/14 at 7:50 a.m. a CNA coughed into her hand, then picked up a tray and delivered it to 402 B without sanitizing her hands. She then repositioned the resident in bed, then held the resident's bread in her bare hand while applying jelly to the bread. She then put a pair of gloves on and washed the resident's face, then removed the gloves . She did not wash or sanitize her hands. She then delivered a meal tray to room [ROOM NUMBER]. 3. During dining observation on 12/7/14 at 5:20 p.m. a CNA delivered a meal tray to resident in room [ROOM NUMBER] A and placed it on the bedside table. The CNA the moved the bedside commode, repositioned the resident in bed and then took a meal tray to room [ROOM NUMBER] B without washing or sanitizing her hands in between resident contact. The CNA then delivered a tray to room [ROOM NUMBER] and placed it on the bedside table. The CNA then left the room without sanitization or washing her hands and delivered a tray to 210. The CNA then returned to room [ROOM NUMBER]. The CNA did not sanitize or wash her hands in between resident contact. 4. During observation on 12/10/14 at 7:30 a.m. a CNA delivered a meal tray to resident in room [ROOM NUMBER] and then 207. The CNA moved a bedside commode in room [ROOM NUMBER], then she provided set up and placed a clothing protector on the resident. She did not wash or sanitize her hands in between residents. She then carried a meal tray to room [ROOM NUMBER] and set up tray. The CNA fail to wash or sanitize her hands in between residents. 5. Observation on 12/10/14 at 7:55 a.m. of Certified Nursing Assistant (CNA) "GG" passing meal tray to the resident in 403 B where she moved the tray table and the newspaper. She then setup the resident's tray then moved the resident's bed and turned on the light. She then returned to the hall for the resident in 403 A meal tray. She moved the newspaper from the tray table, placed the tray table down, moved the bed, adjusted the resident with another staff and readjusted the bed again. She then handed the resident in 403 B his denture cup and glasses then went back to setting up 403 A food. She then went to room [ROOM NUMBER] and assisted the resident with eating and never washed or sanitized her hands. An interview on 12/10/14 at 10:20 a.m. with the Director of Nursing (DON) in regards to hand hygiene with staff. She revealed that staff are suppose to wash / sanitize hands after patient contact and after soiling of hands. Review of the facility's Policy on Handwashing Techniques dated August 2008, revised 8/2011 reveals the Purpose: To thoroughly cleanse hands before and after patient/resident contact and/or contact with the patient/resident environment to reduce microbial count and prevent the spread of infection. Procedure: 1. Hands should be washed before and after patient/resident contact and as necessary during patient/resident care.

Based on record review and staff interview, the facility failed to develop a comprehensive care plan which addressed a significant change in the range of motion status of one (1) resident ("C") on a survey sample of thirty-three (33) residents. Findings include: Please cross refer to F318 for more information regarding Resident "C". Record review for Resident "C" revealed a Minimum Data Set (MDS) assessment, dated 5/03/11 which indicated, in Section G, Functional Status - Functional Limitation in Range of Motion, that the resident had no impairment in either the upper or lower extremities. An 8/04/11 Significant Change MDS indicated, in Section G, Functional Status - Functional Limitation in Range of Motion, that by that time, the resident had impairment on both sides of the upper and lower extremities. However, review of the resident's current Care Plan revealed that even though the Care Plan had been reviewed on 8/25/11, there was no identification of the resident's range of motion being limited and having declined, nor were approaches identified to address this problem. Further record review revealed the resident had received Skilled Occupational Therapy (OT) beginning on 7/22/11, and a Restorative Therapy Referral form documented that the Skilled Occupational Therapy had been discontinued on 9/09/11. The resident had also received Skilled Physical Therapy (PT) beginning on 7/26/11, and a Restorative Therapy Referral form documented that the Skilled Physical Therapy had been discontinued on 9/08/11. Further review of the resident's Care Plan revealed that under the problem of the resident having a self care deficit of activities of daily living (ADL) function and requiring assistance per staff for ADL function, one approach was for OT and PT as ordered. During an interview conducted on 10/27/11 at 12:05 p.m., when asked about the lack of a reference on the care plan of the resident's decline in range of motion from May through August of 2011 or a plan to address that decline, Care Plan Coordinator "BB" stated that upon the review of the Care Plan, it had been felt that the general reference to OT and PT as ordered under the Activities of Daily Living problem was sufficient to address the resident's range of motion decline.

Based on observation, record review, and staff interview, the facility failed to provide services in accordance with the Care Plan of one (1) resident (#82), regarding fall-prevention, and one (1) resident ("C"), regarding nail care, on the survey sample of thirty-three (33) residents. Findings include: 1. Cross refer to F323 for more information regarding Resident # 82. Record review for Resident #82 revealed that the resident's Care Plan referenced an entry of 3/29/2011 which identified that the resident had a history of [REDACTED]. However, during observations conducted on 10/26/11 at 12:22 p.m. and 10/27/11 at 8:02 a.m., no mat was observed to be in place by toilet. During an interview with Licensed Practical Nurse (LPN) "HH" conducted on 10/27/11 at 8:46 a.m., she stated she checked the resident's Care Plan and agreed that the mat was a current intervention. 2. Cross reference to F312 for more information regarding Resident "C". Record review for Resident "C" revealed a Minimum Data Set assessment of 08/04/11 which indicated that the resident was totally dependent on staff for Activities of Daily Living (ADL) care, including grooming. The resident's Care Plan also indicated that the resident required extensive to total assistance for ADL care, and included an Approach to provide nail care as needed. However, during observations conducted on 10/24/11 at 5:10 p.m., 10/25/11 at 8:08 a.m., 10/25/11 at 11:20 a.m., 10/26/11 at 9:50 a.m., 10/26/11 at 11:00 a.m., 10/26/11 at 3:00 p.m., and 10/27/11 at 8:05 a.m., the resident was noted to have fingernails that were one-quarter inch or greater in length.

Based on record review and staff interview, the facility failed to ensure that one (1) resident ("C") who had a limited range of motion, on the survey sample of thirty-three (33) residents, received the appropriate treatment, related to the Restorative Nursing Program, as indicated by the Occupational Therapist. Findings include: Record review for Resident "C" revealed an 8/04/11 Significant Change MDS which indicated, in Section G, Functional Status - Functional Limitation in Range of Motion, that the resident had impairment on both sides of the upper and lower extremities. Record review revealed that the resident had received Skilled Physical Therapy (PT) beginning on 7/26/11, and a Restorative Therapy Referral form documented that the Skilled Physical Therapy had been discontinued on 9/08/11. This Restorative Therapy Referral form, signed by the Physical Therapist on 9/08/11, also referred the resident to the Restorative Program, with Approaches/Recommendations being to provide transfers 3 to 5 times per week, and active/passive range of motion 5 times weekly to bilateral lower extremities (the hip, knee, and ankles) for 3 to 10 repetitions. Record review revealed that the resident also received Skilled Occupational Therapy (OT) beginning on 7/22/11, and a Restorative Therapy Referral form documented that the Skilled Occupational Therapy had been discontinued on 9/09/11. This Restorative Therapy Referral form, which was signed by the Certified Occupational Therapy Assistant (COTA) on 9/13/11, also referred the resident to the Restorative Program, with Approaches/Recommendations being to perform passive range of motion to both upper extremities (elbows, wrists, and all 10 digits) for 10 repetitions in all planes. During interview with Restorative Certified Nursing Assistant (CNA) "CC" on 10/27/11 at 8:25 a.m., this CNA stated that she had been performing bilateral restorative exercises to the resident's lower extremities, consisting of three sets of ten, with the resident lifting his legs, bending his knees, and moving his legs side-to-side. However, this CNA stated that she had been performing no restorative exercises to the resident's upper extremities, as recommended by Occupational Therapy. During an interview with Administrative Nurse "EE" 10/27/11 at 9:15 a.m., this nurse reviewed the resident's medical record and acknowledged the recommendation by OT to do range of motion exercises to the resident's upper extremities on the September 2011 referral. During an interview with Nurse "DD", the Director of the Restorative Nursing Program, conducted on 10/27/11 at 8:20 a.m., Nurse "DD" stated that the resident was getting active and passive range of motion exercises to the bilateral lower extremities, including the hip, knee and ankle, 3 sets of 10 repetitions, 5 times per week. During additional interview on 10/27/11 at 8:50 a.m., Nurse "DD" provided a copy of the Restorative Nursing Flow Records for September and October of 2011 which documented these lower extremity exercises had been done. However, no evidence was provided to indicate any upper extremity exercises had been done as recommended as approaches by the OT, or any rationale why these approaches had not been implemented. During an interview with Certified Occupational Therapy Assistant "FF" on 10/27/11 at 10:18 a.m., she stated that when OT recommendations are made, OT staff met with the restorative team and instructed them as to what care to provide, per OT recommendations. She stated that the expectation would be that restorative nursing care would be provided per the OT recommendations, and if a resident could not perform the tasks, further consultation with OT would be done. However, further record review revealed no evidence of any follow-up which would indicate that Resident "C" could not perform the OT recommendations made on the 9/13/11 Restorative Therapy Referral form referenced above, or that the resident had refused. During an interview with the Director of Nursing (DON) conducted on 10/27/11 at 10:41 a.m., the DON stated that she had contacted the physician about the OT referral, and he had ordered that OT do a reexamination to determine the resident's current status. She further stated that she was unsure why the September 2011 OT recommendation had not been implemented or followed-up on, further stating that if the recommendations were not acceptable to the resident, staff should have gone back to the therapist and ask about a reevaluation.

Based on observation, record review, and staff interview, the facility failed to ensure that one (1) resident (#82) who had a history of [REDACTED]. Findings include: Record review for Resident #82 revealed that the resident's Care Plan referenced an entry of 3/29/11 which identified that the resident had a history of [REDACTED]. The above referenced Care Plan identified that in addition to the fall of 01/06/11, the resident had also experienced falls on 7/30/11, 8/04/11, 8/15/11, and 8/17/11. This Care Plan specifically documented that on the fall of 7/30/11, the resident had slipped and fallen after losing his balance while trying to get on the toilet, and on the fall of 8/04/11, the resident was observed lying on his back on the floor of the bathroom between the wheelchair and the wall. The Incident Report which referenced the 8/04/11 the resident's fall of that date also documented that the floor mat was in place at that time. However, during observations conducted on 10/26/11 at 12:22 p.m. and 10/27/11 at 8:02 a.m., no mat was observed to be in place by toilet. During an interview with Licensed Practical Nurse (LPN) "HH" conducted on 10/27/11 at 8:34 a.m., when asked about the mat that was to be beside the commode, she stated that she was unsure. During further interview with this nurse conducted on 10/27/11 at 8:46 a.m., she stated she had checked the resident's Care Plan and agreed that the mat was a current intervention. She further stated that staff were replacing the mat at that time, and that she was unsure why it was missing. During an observation conducted on 10/27/11 at 8:57 a.m., the mat was now observed in place on the floor by the commode.

Based on observation and staff interview the facility failed to provide personal privacy during the medication pass resulting in exposure of body parts of two residents (#39, #86) on a sample of thirty three (33) residents. Findings include: Observation on 10/24/11 at 4:24 p.m. during the medication pass revealed Licensed Practical Nurse (LPN) "AA" administered insulin to the abdomen of resident #86. The nurse failed to pull the curtain or close the resident's door, leaving him exposed to hall traffic where one (1) resident rolled by the resident's doorway during the resident's abdomen being exposed. The resident's roommate was also in the room sitting less than 10 feet from the resident during the insulin administration. The nurse failed to pull the curtain between the residents while administering the insulin injection to resident #86. Interview with this LPN "AA" on 10/27/11 on 7:50 a.m. confirmed that she did not close the door or pull the curtain between this resident and his roommate when she administered this resident's medication which exposed the resident to his roommate and to a resident passing by in the hallway. Observation on 10//25/11 at 9:45 am revealed LPN "AA" to apply a [MEDICATION NAME] to the back of resident #39 while leaving the door open in full view of residents and staff in the hallway. During this time one (1) resident and two (2) staff members were seen passing by the room during the time the resident's back was exposed. Interview with the LPN "AA" on 10/27/11 at 7:50 a.m. confirmed that she did not close the door when she administered this residents medication which exposed the resident's back to people passing by in the hallway.

Based on observation, record review, staff interview, and resident interview, the facility failed to provide the necessary services, related to fingernail care, to one (1) resident ("C"), who required staff assistance with Activities of Daily Living care, on the survey sample of thirty-three (33) residents. Findings include: Record review for Resident "C" revealed a Minimum Data Set assessment of 8/04/11 which indicated that the resident was totally dependent on staff for Activities of Daily Living care, including grooming. During observations conducted on 10/24/11 at 5:10 p.m., 10/25/11 at 8:08 a.m., 10/25/11 at 11:20 a.m., 10/26/11 at 9:50 a.m., 10/26/11 at 11:00 a.m., 10/26/11 at 3:00 p.m., and 10/27/11 at 8:05 a.m., the resident was noted to have fingernails that were one-quarter inch or greater in length. During interview with Resident "C" conducted on 10/27/11 at 10:59 a.m., the resident stated that he wanted his fingernails trimmed, and would prefer that they be trimmed soon. Observation conducted at the time of this interview revealed that the resident's fingernails were still long. During an interview with Treatment Nurse "GG" conducted on 10/27/11 at 10:15 a.m., she stated that it was the responsibility of the treatment nurse, and at times the certified nursing assistants, to trim resident fingernails.

Based on record review, staff interview, and review of a Resident Incident Report, the facility failed to ensure that one (1) resident (#1), on the survey sample of six (6) residents, was transferred with a lift, as specified in the ADL Care Plan. This resulted in the resident sustaining a right knee dislocation. Findings include: Review of the clinical record for Resident #1 revealed a Daily Skilled Nurses Notes entry of 03/14/2011 at 2:45 p.m. which documented that the resident was admitted on that date having [DIAGNOSES REDACTED]. Both the resident's Admission Care Plan of 03/14/2011 and Comprehensive Care Plan of 03/31/2011 identified the resident to be at risk for injury related to having the potential for falls. During an interview conducted on 06/15/2011 at 2:15 p.m., Nurse "AA" stated that the resident's ADL Care Plan specified that staff were to utilize a sit-to-stand lift for transfers. Review of the Nurse's Notes of 04/21/2011 at 11:40 a.m. revealed the resident had a swollen right knee which was warm to the touch, and that both the physician and hospice staff were notified. Orders were received for administration of Decadron 8 milligrams and Lasix 80 milligrams intramuscularly and an X-ray of the leg. A Nurse's Notes entry of 04/21/2011 at 6:00 p.m. documented that the results of the X-ray were an anterior dislocation of the femur in relation to the tibia, which was posteriorly displaced, superimposed on osteopenia and severe degenerative changes involving all three joint space compartments, with no obvious displaced fracture fragment. This Note documented that the physician and hospice staff were notified, and an order to immobilize the right knee was given. A Nurse's Notes entry of 04/22/2011 at 9:15 a.m. documented that the hospice nurse assessed the resident and an order was given to transport the resident to the emergency room for evaluation and treatment. Review of the Resident Incident Report referencing Resident #1 revealed that the initial report of the resident's leg being swollen and warm to the touch was made on 04/21/2011 at 11:40 a.m. by a certified nursing assistant (CNA). This Report described the resident's injury as a right knee dislocation, and documented that the facility initiated an investigation into this injury. In an Incident Witness Statement of 04/21/2011 at 1:00 p.m. which documented statements from CNA "CC" and CNA "DD", CNA "CC" stated that she and CNA "DD" had gotten the resident up the previous night (04/20/2011) upon the request of the hospice chaplain and the family. CNA "CC" stated that she and CNA "DD" stood the resident up, turned her, and put her in the chair. CNA "CC" stated that later, she and CNA "DD" had put the resident back to bed. CNA "CC" further stated that she had noted the resident's right leg to be a little contracted and unable to straighten for a couple of days, but the leg did not look that way on the night of the transfer. Records of Partner Counseling Forms dated 04/22/2011 documented that both CNA "CC" and CNA "DD" had been counseled due to their failure to follow company policy related to lifts and patient transfers, due to the failure to use a sit-to-stand lift to transfer Resident #1, as directed on the ADL Care Plan. These Counseling Forms documented that each CNA was re-educated regarding the use of lifts and transfers. During the 06/15/2011, 2:15 p.m. interview with Nurse "AA" referenced above, Nurse "AA" acknowledged that the two (2) CNAs did not use the sit-to-stand lift when transferring the resident, but rather pivoted the resident from the bed to the chair and back to the bed.