Deficiency Text Not Available

Based on observation, staff interview, and Review of the facility's policies titled, Pot/Pan Washing and Sanitation and Dishwashing, the facility failed to ensure kitchen staff thoroughly cleaned and air-dried plates and pans prior to storage. This failure had the potential to increase the risk of foodborne illness and had the potential to affect 61 of 66 residents who received dietary services. Findings include: Review of the facility's policy titled, Pot/Pan Washing and Sanitation, dated 11/16/2020 revealed, Policy Statement: It is the policy if PruittHealth that equipment and utensils are cleaned and sanitized appropriately after use to maintain a clean and sanitary environment for food preparation. Scope: This applies to all dietary partners employed by PruittHealth. Procedure: . Air dry pots and pans on the drain board. Never use a dish towel. Inspect for cleanliness and store pots and pans inverted in a clean, dry, protected area . Review of the facility's policy titled, Dishwashing dated 8/3/2017, revealed, Policy Statement: It is the policy of PruittHealth that all utensils, dishes, glassware and trays will be cleaned and sanitized. Scope: This policy applies to all dietary partners employed by PruittHealth. Procedure: . 8. Allow all items to thoroughly air dry before unloading racks or storing items. During an observation and interview on 6/23/2025 at 10:15 am, the Food Service Manager (FSM) confirmed five six-inch plates were found to have been stacked for use and were still wet and had not properly been allowed to air-dry. Interview with the FSM at this time, stated, the dishes should be dry before being stacked. During an observation and interview on 6/23/2025 at 10:2025 am, the FSM confirmed two pans, 6 inches by 12 inches by 3 inches deep, two pans 12 inches by 18 inches by 3 inches deep, and three pans 12 inches by 18 inches by 6 inches deep that had been cleaned and stacked for use and were still wet when they were stacked. The pans were found to have been stacked wet and not allowed to air dry. Interview with the FSM at this time, stated, they should be dry before being put away, they weren't allowed to properly dry.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and a review of the policy titled, Abuse Identification the facility failed to maintain an environment that was free from sexual abuse by another resident for one of three residents (R1) sampled for abuse. Findings include: Review of the policy titled Abuse Identification, last reviewed on 1/11/2024 revealed the following: Policy Statement 3. Patients/residents in a Health Care Center should not be subjected to abuse or neglect by anyone (including but not limited to: staff, other patients/residents, consultants, volunteers, staff of other agencies serving the individual, family members or legal guardians, friends, or other individuals). Review of the medical record for R1 revealed diagnosis that included but was not limited to unspecified dementia, unspecified severity, with psychotic disturbance, cerebral infarction. Review of the admission Minimum Data Set (MDS) dated [DATE] with a Brief Interview for Mental Status (BIMS) score that was not indicated Review of Progress Notes dated 4/11/2024 revealed R53 was sexually inappropriate towards a female resident. He was rubbing her in inappropriate places. Review of Progress Notes dated 4/13/2024 indicated inappropriate sexual behavior was noted towards another resident by R53. Review of Progress Notes dated 4/21/2024 indicated, male resident entered R1's room and was seen by staff inappropriately touching her breast. Facility administrator and DON notified. During an interview on 4/25/2024 at 3:15 pm with Registered Nurse (RN) AA it was revealed R1 was admitted to the facility with only the clothes she had on and clothing had to be utilized from the Lost and Found items. It is reported that R1 pulled up her shirt exposing her breast. R53 is reported as seeing R1 exposing herself and he began to follow her. RN AA further reported that R1 has not exposed herself since that initial incident because her family brought her clothing in the next day. RN AA also reported there was an incident in which R53 was observed rubbing on R1's legs when they were sitting outside. R53 was told not to touch R1. During an interview on 4/25/2024 at 3:15 pm with Licensed Practical Nurse (LPN) BB it was revealed, R1 frequently walked and R53 would follow her. LPN BB further reported that staff would monitor R53's behavior by making sure he was not near R1. During an interview on 4/25/2024 at 4:15 pm with Certified Nursing Assistant (CNA) CC it was revealed R53 was in R1's room sitting on the side of the bed touching her breast. CNA CC reported that she told R53 to stop touching R1 and to get out of the room. R53 then walked out of the room and went to stand near the back door. During an interview on 4/25/2024 at 3:40 pm with RN DD, it was revealed R53 exhibited inappropriate behavior towards R1. It was explained that R53 reached for R1 and pulled her to his chest, her shoulder was touching his chest. RN DD reported that she separated the two residents and R53 went outside. During an interview on 4/25/2024 at 4:45 pm with the Social Service Director (SSD), it was revealed that R53 was sent out to a psychiatric facility because of his inappropriate sexual behavior toward R1 on 4/21/2024. During an interview on 4/25/2024 at 5:00 pm with LPN EE it was revealed on 4/21/2024 she was called to the room of R1 and the staff in the room told her R53 was observed touching R1's breast. When LPN EE got to the room, R53 was no longer touching R1 but remained in the room. During an interview on 4/25/2024 at 5:15 pm with the Administrator she revealed she was notified on 4/21/2024 of inappropriate sexual behavior exhibited by R53 towards R1. She reported that she instructed staff to provide 15-minute checks of R53 until he could be transferred out of the facility the next day.

Based on observations, interviews, record reviews, and review of the policy titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property the facility failed to timely report an allegation of sexual abuse to the State Agency (SA) for one resident of three residents (R1) sampled for abuse. Findings include: Review of the policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, last reviewed 1/11/2024, under the Policy Statement: It is the policy of (named facility) and its affiliated entities (collectively, the Organization) to comply with all applicable federal and state requirements regarding the reporting of patient abuse, neglect, exploitation, mistreatment, and misappropriation of property. Under the Procedures section: Any allegation, suspicion, or identified occurrence is identified involving, patient abuse, neglect, exploitation, mistreatment, and misappropriation of property, including injuries of an unknown source, should be immediately reported to the Administrator of the provider entity. In accordance with applicable laws and regulations, the Administrator or his or her designee should notify the appropriate state agency (or agencies), the patient's attending physician, and the patient's designated representative of any allegation or incident described above and of the pending investigation. Review of the medical record for R1 revealed, a Brief Interview for Mental Status (BIMS) score was not indicated. R1 diagnosis included unspecified dementia, unspecified severity, with psychotic disturbance, and cerebral infarction. Review of Progress Notes dated 4/11/2024 revealed R53 was sexually inappropriate towards a female resident. He was rubbing her in inappropriate places. Review of Progress Notes dated 4/13/2024 indicated inappropriate sexual behavior, by R53, was noted towards another resident. Review of Progress Notes dated 4/21/2024 indicated, R53 resident entered R1's room and was seen by staff inappropriately touching her breast. Facility administrator and DON notified. There was no evidence to support that the incidents on 4/11/2024 and 4/13/2024 were reported to the SA. During an interview on 4/25/2024 at 4:45 pm with the Social Service Director (SSD), it was revealed that R53 was sent out to a psychiatric facility because of his inappropriate sexual behavior toward R1 on 4/21/2024. She did not know about any allegation of sexual abuse documented by the staff on 4/11/2024. During an interview on 4/25/2024 at 5:15 pm with the Administrator she revealed she was notified on 4/21/2024 of inappropriate sexual behavior exhibited by R53 towards R1. She stated that staff were then instructed to provide 15-minute checks of R53 until he could be transferred out of the facility the next day. During a post survey interview on 5/9/2024 at 9:29 am, the Administrator reported that she was not aware of any incidents between R53 and R1 before 4/21/2024. The Administrator further stated that the supervisor should have reported any incidents to her, and the staff who witnessed any incidents should have reported them to their supervisor.

2.Findings include. Review of the facility policy titled, Coronavirus (COVID-19) Infection Prevention and Control Practices revision date of 1/25/2024, revealed under section VI (Isolation) During the care of any HCC or ALF patient/resident with known or suspected COVID-19, healthcare personnel should do the following: Wear a N95 mask and appropriate PPE upon entering the exposed or confirmed positive patient/resident's room or when working within three feet of the patient/resident. Remove the mask when leaving the patient/resident's room and dispose of the mask in a waste container outside the patient/resident room. If appropriate, don a procedure mask after exiting the resident room. Wear goggles or face shield, waterproof gowns and gloves with Contact and Droplet isolation of these patients/residents. Review of the policy titled, COVID-19 Isolation and Cohorting Process revised date 11/13/2023; under section III, number 9. (Entering or Exiting Confirmed Positive or suspected of COVI-19 Infection room) 2. PPE will be used in each Transmission Based Precautions Room and changed accordingly. a) N95 mask (N95 mask that the staff was fitted for). b) Eye protection must be wiped clean with a disinfectant wipe or changed before entering a positive or suspected resident room. During an observation and interview on 2/21/2024 at 11:55 am, Registered Nurse (RN) AA gathered supplies to administer insulin to R12 who was on droplet precautions for COVID-19. The nurse had on a surgical mask and gloves only. The nurse was asked what the appropriate PPE was to use for a resident who was COVID positive; she went to the cart outside of the room and opened each drawer and stated the supplies in the drawer included the N95 mask, gowns, and gloves. The nurse was asked why she only wore a surgical mask and gloves to enter the room and she stated she had been working with the resident and just wanted to get in the room and give her the medicine. The nurse admitted she should have worn the N95 mask and gown. The nurse states the appropriate PPE to wear in a COVID positive room is a gown, mask, and face shield. Staff should wear an N95 mask. The nurse stated there have been in-services on the type of PPE to wear when providing care for a COVID-19 positive resident, but she had not attended any of the classes. Review of the facility in-service education provided to the staff revealed the following classes: on 6/2/2023 Infection Prevention; Topic: Personal Protective Equipment (PPE) - there were 22 attendees including RN AA; 2/22/2024 - PPE for COVID Positive Residents - 4 attendees. Interview on 2/22/2024 at 10:00 am, with the Infection Control Nurse (ICP) it was revealed staff are to wear N95 mask, eye protection, gloves, and gown when going into a room to care for a resident who is COVID positive; the contents of the PPE supply cart in front of the resident's room was reviewed with the ICP nurse which included N95 mask, face shields, gloves, gown, shoe covers that were available for staff use. Interview on 2/22/2024 at 10:15 am with the DON revealed; staff should wear gown, mask (N95), gloves, and shoe covers (optional) when entering a room that has a COVID positive resident. Based on observations, staff interviews, record review, and review of the facility's policies titled Coronavirus (COVID-19) Infection Prevention and Control Practices Policy and COVID-19 Isolation and Cohorting Process, the facility failed to ensure notification of the facility's current active COVID-19 status was posted on the front exterior doors of the facility as recommended by the Centers for Disease Control (CDC). In addition, the facility failed to follow infection control procedures of applying and removing Personal Protective Equipment (PPE) during treatment services for one of 17 Residents (R) (R12). Findings include: Observations on 2/20/2024 at 8:35 AM, 2/21/2024 at 8:30 AM, and 2/22/2024 at 8:40AM revealed there were no COVID -19 status signs on the front entrance doors of the facility to provide notification of active COVID-19 in the building. Interview on 2/22/2024 at 10:35 AM with the Administrator and the Infection Control Preventionist (ICP) regarding the lack of notification of the facility's current COVID -19 status on the front entrance doors of the facility revealed that both parties confirmed that the notification signs were not posted. During the interview with the ICP she confirmed that the facility had one active case of Covid-19 in the building. The ICP also reported being aware of the policy regarding notification of Covid-19 in the building but was unaware of the missing notification signs that should have been posted on the facility's front entrance doors. The Administrator reported that this was an error by the facility and all facility staff should have ensured the Covid-19 signs were posted. The Administrator reported that the importance of having the sign notification was to make sure that everyone including family members, staff, and the residents were protected and aware. A policy was requested by the survey team regarding Covid-19 notification signage posting and the facility failed to provide a policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to maintain bookkeeping techniques for one of four private pay residents (R) (R1) reflecting discrepancies with the daily rates and billing. The facility census was 62 residents. Findings include: Review of the record revealed that Resident 1(R1) was admitted to the facility as a private pay resident. The admission agreement contract revealed a rate of $288 per day or $8,805 per month. Review of the Resident Account Detail dated [DATE] through [DATE] revealed that R1 was initially charged a daily rate of $284.03 for the month of [DATE]. The responsible party paid the facility a cashier check dated [DATE] for $8,500. R1 had a carryover credit of $831.19 from daily rate calculation. In [DATE], the responsible party submitted a cashier check dated [DATE] in the amount of $8,257.90 for [DATE] through [DATE] at a calculated daily rate of $284.03. R1 had a carryover credit of $568.19. In [DATE], the responsible party submitted a cashier check dated in the amount of $9,243.00 for [DATE] through [DATE]. The July month had two sets of calculations of daily rate which was not reflected on the statement. [DATE] through [DATE] revealed a daily rate of $284.03. However, the rate for [DATE] through [DATE] reflected a rate of $302.645. R1 had a carryover credit of $722.23 (rate at $284.03) or $349.86 (rate at $302.645). In [DATE], the responsible party submitted a cashier check dated [DATE] in the amount of $2,920.00. R1 daily rate of $302.645 was calculated for [DATE] through [DATE] reflected a balance of $605.29. R1 was discharged to a behavior facility on [DATE]. She was readmitted to the facility on [DATE] through [DATE] at a daily rate of $249.23 to reflect a room charge of $2,741.53. R1 had carryover credit of $332.64 (rate at $249.23) or a negative balance of $76.96 (rate at $302.645). In [DATE], the responsible party submitted a cashier check dated [DATE] in the amount of $4,000 dollars. R1 daily rate of $249.23 for [DATE] through [DATE] total to $7,476.90. Therefore, the responsible party was $3,144.26 or $3,553.84 in the arrear and with or without the carryover credit consecutive order. In [DATE], R1 daily rate was $245.86 for [DATE] through [DATE]. She expired on [DATE] with arrears of $737.58 . R1 arrears total to $3881.82 or $4,291.42 . The pharmacy bill was included in the calculations. Review of the Resident Statement dated [DATE] revealed a billing for [DATE] through [DATE] for charges dated /credit dated [DATE] through [DATE]. The bill dated [DATE] revealed [DATE] through [DATE] did not list the daily rate for charges. Review of the Progress Notes dated [DATE] through [DATE] revealed that R1 had multiple behaviors directed toward other residents that R1 was moved to a private room. Review of the Notice of Decision (Medicaid) dated [DATE] revealed R1 was denied medical assistance for refused or failed to verify required information. An interview on [DATE] at 10:30 am, with the Financial Office Manager AA revealed that she does not process any checks received. And that all checks are processed by corporate. An interview on [DATE] at 11:00 am, with Corporate Financial CC revealed that if a resident overpays, they get the overpayment as credit. The $4,706.55 she explained that the resident was a private pay pending Medicaid approval for room and board estimated liability. R1 was paying her estimated liability. A subsequent interview at 4:03 pm, to clarify the room rate before a Medicaid application is approved. She stated that R1 rate on admission was 293.50 dollars through [DATE]. When she returned on [DATE] through [DATE], her rate was $249.23 dollars per day. The rate for [DATE] through [DATE] was $249.23. And for [DATE] through [DATE] her rate was $245.86. However, she could not explain the discrepancy for the actual daily rate charged.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews the facility failed to ensure that it was maintained in a safe clean and comfortable environment. Specifically, the facility failed to ensure residents rooms were in good repair on two of seven halls 200 Hall and 300 Hall that were occupied by residents. These areas contained a loose appendage on the floor, jagged edges at bathroom threshold, cracks in floor tile, rust on doorframe, missing baseboard, and dirt buildup on floor. The facility census was 69. Findings include: 1. An observation on 5/3/22 at 10:40 a.m. of resident room [ROOM NUMBER] revealed bathroom thresh hold is jagged with missing pieces. An observation on 5/4/22 at 11:03 a.m. of 200 Hall revealed there was a silver metal stripping in the hallway that was secured with black electrical tape that was coming lose from the floor. On 5/5/22 at 9:07 a.m. Environmental rounds were conducted with Administrator, Maintenance Director, and Housekeeping Supervisor who confirmed the repairs needed for 200 Hall and room [ROOM NUMBER] bathroom thresh hold that was observed during the three-day survey process. On 5/5/22 at 9:27 a.m. Interview with Maintenance Director revealed the staff reports any maintenance issues to the department by logging the concern in electronic program that can be accessed from any computer in the facility. The Maintenance Director revealed that he was already aware of confirmed observations on 200 Hall but did not have a time frame of when repairs would be completed. On 5/5/22 at 9:47 a.m. Interview with Administrator revealed the expectation is for the facility to be always in good repair. Further interview also revealed there are no policy or procedures pertaining to maintenance. There is a quarterly maintenance process that is followed by maintenance that alerts them to what areas to check for repairs. 2. During observations of the environment on the 300-hall on 5/3/22, beginning at 9:00 a.m. and concluding at 9:50 a.m., the following concerns were noted: In room [ROOM NUMBER] there were several visible cracks in the floor tile, and the floor near the air conditioner had dirt buildup. In the shared bathroom for rooms [ROOM NUMBERS] (shared by four residents): the door frame was noted with rust. In room [ROOM NUMBER] the floor near the air conditioner unit had dirt buildup and missing a piece of the baseboard. In room [ROOM NUMBER] and 309 there were several visible cracks in the floor tile. In room [ROOM NUMBER] there were several visible cracks in the floor tile and the floor near the air conditioner had dirt buildup. An Environmental round was initiated on 5/5/22 beginning at 9:07 a.m. with the Administrator, Maintenance Director, and Housekeeping Supervisor. The Administrator, Maintenance Director, and the Housekeeping Supervisor confirmed the room concerns related to cracked floor tile, rust on doorframe, dirt buildup on floor by air conditioning units, missing baseboard, and rusty doorframe. During an interview with the Maintenance Director on 5/5/22 at 9:30 a.m. revealed that maintenance concerns are reviewed in the facility's online maintenance reporting program daily. He further stated daily room rounds are also conducted. Maintenance Director expressed that there are monthly maintenance tasks that must be completed that is generated by the online maintenance program that he follows. He stated he prioritizes and works on what is most severe first.