Every finding on record at A.G. Rhodes Home Wesley Woods

Based on observations, staff interviews, record review, and review of the facility policy titled, Oxygen Therapy, the facility failed to administer oxygen (O2) at the correct ordered setting for one of 21 residents (R) (R3) receiving O2 therapy. This deficient practice had the potential to place R3 at risk for hypoxia (low O2 levels) which could have led to adverse clinical outcomes.Findings include:Review of facility's policy titled Oxygen Therapy revised May 2024 indicated the following: Policy Explanation and Compliance Guidelines: Oxygen is administered under the orders of a physician, except in cases of an emergency. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: The type of oxygen delivery system, When to administer, such as continuous or intermittent and/or when to discontinue, Equipment setting for the prescribed flow rates, Monitoring of SpO2 (oxygen saturation) levels and/or vital signs as ordered, Monitoring for complications associated with the use of oxygen. Review of the electronic medical record (EMR) for R3 revealed diagnoses including but not limited to chronic diastolic congestive heart failure, Alzheimer's Disease, and hypertensive heart disease.Review of R3's Physician orders revealed an order on 1/9/2025 for Oxygen at two liters (LPM-liters per minute) for increased work of breathing as needed. Document Oxygen saturations on room air, Respiratory Rate, Assess and Document Breath Sounds, every shift. Review of the quarterly Minimum Data Set (MDS) dated [DATE] documented R3 had a Brief Interview for Mental Status (BIMS) score of 4, indicating the resident had severe cognitive impairment. Section O (Special Procedures, Treatments, and Programs) revealed no O2 use.Review of the care plan dated 8/14/2025 revealed that O2 therapy is not addressed.Observation on 9/9/2025 at 11:43 am revealed that R3 was lying in bed facing the door, resting with their eyes closed. The O2 concentrator (machine that produces oxygen) was running at the setting of 4.5 LPM (liters per minute).Additional observations were made on 9/10/2025 at 11:19 am and 9/11/2025 at 10:04 am which revealed the O2 concentrator running at the setting of 4.5 LPM on both occasions. Interview with observation on 9/11/2025 at 10:06 am with Licensed Practical Nurse (LPN) EE revealed during review of the physician's order for O2 confirmed that the order was for 2 LPM. LPN EE confirmed, while in the room of R3, that the setting on the concentrator was 4.5 LPM. She then adjusted the O2 setting to 2 LPM. Further interview with LPN EE confirmed that O2 should be given at the setting ordered by the physician and confirmed that the O2 settings should be monitored per shift.Interview on 9/11/2025 at 10:13 am with the Director of Nursing (DON) revealed the O2 concentrator settings should match the physician order. The expectation was that oxygen saturations checks were completed according to physician orders. The DON confirmed there was no process in place to check concentrator settings against the physician orders. She also confirmed that O2 use should be care planned. Interview on 9/11/2025 at 12:05 pm with the Administrator revealed her expectation was that O2 use should have been administered as ordered by the physician and should be care planned.

Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Accident and Supervision, the facility failed to ensure the residents' environment remained free of potential accident hazards for three of 44 sampled residents (R) (R131, R122 and R48). Findings include: Review of the facility policy titled Accidents and Supervision revised on 6/26/2023 states under intent: The elder environment will remain free of accident hazards as is possible. Each elder will receive adequate supervision and assistive devices to reduce the risks of accidents. This includes identifying hazard(s) and risk(s), evaluating and analyzing hazard(s) and risks, implementing interventions to reduce hazard(s) and risk(s), and monitoring for effectiveness and modifying interventions when necessary. The policy explanation and guideline states: The community shall establish and utilize a systematic approach to address elder risk and environmental hazards to minimize the likelihood of accidents. 1. Identification of Hazards and Risks-the process through which the community becomes aware of potential hazards in the elder environment and the risk of an elder having an avoidable accident. All staff (e.g., professional, administrative, maintenance, etc.) are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident. The community should make a reasonable effort to identify the hazards and risk factors for each resident. 1. Review of the electronic medical record for R131 revealed diagnoses that include but not limited to other specified peripheral vascular disease (primary diagnosis), Alzheimer's disease with early onset, hereditary and idiopathic neuropathy, muscle weakness, spinal stenosis (lumbar region without neurogenic claudication), hyperlipidemia, generalized anxiety disorder, anemia, primary osteoarthritis (left shoulder), unspecified dementia, pain right hip, spondylolisthesis (lumbar region), type 2 diabetes, chronic kidney disease, stage 3. Review of the quarterly Minimum Data Set (MDS) dated [DATE] for R131 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicates R131 is cognitively intact. Observation and interview on 9/9/2025 at 11:55 am, R131 was observed sitting up in wheelchair watching television. A can of name of disinfectant spray and name of disinfectant spray were on a stand beside the television. R131 stated, I am glad to be here. I have been to a lot of places, and I love it here. Observation on 9/10/2025 at 11:34 am, R131 was sitting up in a wheelchair in her room watching television. The two cans of disinfectant spray were on a stand beside the television. Observation on 9/11/2025 at 9:46 am, R131 was sitting up in a wheelchair eating breakfast. Two cans of disinfectant spray remained on a stand beside the television. Interview on 9/11/2025 at 10:13 am with the Director of Nursing (DON) revealed that there should be no chemicals at a resident's bedside. If staff observed chemicals in the resident's room, they should remove the item and notify the resident and family that the resident cannot have these items at bedside. Facility chemicals should be locked up when not in use 2. Review of the quarterly MDS for R122 revealed a BIMS score of 7, indicating R122 was severely cognitively impaired. Observation on 9/9/2025 at 8:30 am during a walk-through of the facility revealed that resident R122 had a spray bottle of alcohol sitting on the bedside table, and resident R48 had two aerosol cans of 'brand name' disinfectant. Interview on 9/10/2025 at 10:00 am with R122 revealed that she uses alcohol to clean her ears, and her daughter bought it for her. Interview on 9/11/2025 at 10:45 am with the DON, she stated that currently there were no residents residing in the facility who had been assessed and deemed appropriate to use rubbing alcohol and 'brand name disinfectant' for disinfection. She confirmed that R122 and R48 should not have chemicals in their rooms as this poses a potential accident hazard.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, Medication Administration Policy, the facility failed to assess for the ability to self-administer medications prior to leaving medications at the bedside for one of 44 sampled residents (R) (R50). The deficient practice had the potential to allow access to medications otherwise not prescribed by a physician to other residents. Findings include: Review of the facility's policy titled Medication Administration policy revised December 2023 indicated the following: Policy: Medications are administered by licensed nurses, or other care partner who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Review of the medical record for R50 revealed diagnoses including but not limited to encephalopathy, unspecified, transient cerebral ischemic attack, unspecified, difficulty in walking, not elsewhere classified, muscle weakness (generalized), unilateral primary osteoarthritis, right knee, benign prostatic hyperplasia with lower urinary tract symptoms, type 2 diabetes mellitus with unspecified complications, repeated falls, other specified disorders of bone density and structure, unspecified site, wedge compression fracture of first lumbar vertebra, subsequent encounter for fracture with routine healing. Review of R50's Physician orders revealed an order on 9/9/2025 for Biofreeze roll-on external gel 4% (menthol (topical analgesic)) apply to right knee topically every 24 hours as needed for right knee pain. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE] documented R50 had a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident had moderate cognition. Review of the clinical record revealed there was no assessment for medication self-administration. Initial screening observation on 9/9/2025 at 2:03 pm revealed Biofreeze roll-on pain relief bottle and arthritis pain reliever ointment tube resting on top of a dresser cabinet near doorway entrance. Observation on 9/9/2025 at 2:35 pm revealed R50 sitting in his wheelchair. He mentioned he had been downstairs for several hours waiting on his son to drop off a personal package. He stated he uses Biofreeze roll-on pain relief bottle and arthritis pain reliever ointment almost every day. He stated he had all the items on top of his dresser cabinet since he was admitted and was never questioned about having them from the nurse. Interview on 9/9/2025 at 2:45 pm with Licensed Practical Nurse (LPN) BB indicated that no resident from her knowledge has a physician's order to self-administer any medications. She confirmed R50 had Biofreeze roll-on pain relief bottle, and arthritis pain reliever ointment tube resting on top of a dresser cabinet near doorway entrance. She further removed all items and explained to resident it was a safety precaution, and she would speak with his doctor about receiving an order to use the items. R50 mentioned to LPN that the medications had been on top his dresser cabinet since he was admitted . R50 further stated to LPN that he uses the Biofreeze roll-on pain medicine every day for his right knee area due to discomfort and pain. Interview on 9/11/2025 at 10:45 am with the Director of Nursing (DON), she stated that currently there was not a resident residing in the facility who had been assessed and deemed appropriate to self-administer medications. The DON confirmed R50 did not have a physician order for the medications that were located on the resident's dresser cabinet. She stated the residents must be assessed and approved for self-administration of medication. She stated if a resident is approved then medications should be locked on nurse's cart, care planned, and residents assessed on a quarterly basis. The DON further stated that there should not be any medications left at the resident's bedside, and she expected the nurse to administer the residents' medications.

Based on observations, staff interviews, and review of the facility policy titled, Preventive Maintenance, the facility failed to ensure the residents' living area was safe, clean, comfortable, and homelike in three rooms (room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) on two of four halls (300 Hall and 400 Hall). Specifically, residents' rooms contained damaged sheetrock walls with holes, scuffed/chipped paint, and a dirty personal fan that had the potential to affect patient comfort and safety. Findings Include: Review of the facility's undated policy titled Safe and Homelike Environment revised 7/20/2024 revealed under Intent Preventive Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Observation on 9/9/2025 at 8:30 am in rooms [ROOM NUMBERS] revealed, scuffed/ chipped paint and a hole in the wall. Observation on 9/9/2025 at 8:10 am in room [ROOM NUMBER] revealed a small black oscillating fan blowing on bed B near the window with fuzzy grayish substance on its fan vents. Interview with concurrent observation rounds on 9/11/2025 at 10:24 am with the Facility Manager Director (FMD) CC and Environmental Services Director (ESD) DD confirmed, dirty personal fan, damaged sheetrock walls with holes, scuffed/ chipped paint and a hole in the wall in rooms 304, 410 and 419. The FMD CC stated that the cleaning of personal fans was not part of the housekeepers' original responsibilities, however it will be added. The FMD CC and ESD DD stated that their staff will immediately correct and address the damaged areas and dirty items in each room.

Based on record review, staff interviews, and review of the facility policy titled, Comprehensive Care Plans, the facility failed to complete/update care plans for two of 44 sampled residents (R) (R40 and R3). Specifically, R3 had orders for oxygen therapy and oxygen was not on the care plan. Also, the facility failed to complete a care plan for R40 related to hearing loss and communication interventions. The deficient practice had the potential to lead to negative health outcomes and unmet care needs.Findings include: Review of facility policy titled, Comprehensive Care Plan revised on 6/26/2023 states under Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident consistent with resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The policy explanation and compliance guidelines revealed: The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally-competent and trauma-informed. 1. An interview on 9/11/2025 at 10:30 am with Licensed Practical Nurse (LPN) BB confirmed that R40's care plan did not address hearing loss, or how to address communication concerns. She explained at present they raised their voices to speak with R40 and relied on her daughter to assist with communication. An interview with MDS Director on 9/11/2025 at 11:05 am confirmed that a care plan was not in place to address hearing loss for R40. She revealed the hearing loss should have been addressed in the care plan. The MDS Director was making the correction today and would make sure the correction was added to tasks, and reviewed and communicated the change of the care plan to the Administrator. An interview on 9/11/2025 at 11:50 am with the Director of Nursing (DON) confirmed that hearing loss should be addressed in the care plan. Care plans were reviewed by the Inter disciplinary Team (IDT team). The lack of care planning for R40 hearing loss was an oversight that has been corrected. The DON expectation was that the care plan would include hearing loss. An interview on 9/11/2025 at 12:05 pm with the Administrator revealed her expectation was that the care plan would include hearing loss. 2. An interview on 9/11/2025 at 10:13 am with the DON revealed for R3, the oxygen settings should match the oxygen order. She also confirmed that oxygen orders should be care planned and meet the expectations of the resident as determined by the physician. An interview on 9/11/2025 at 12:05 pm with the Administrator revealed her expectations was that oxygen orders should have been administered as ordered and should be care planned.

Based on record review, interviews, and review of the policy titled Safe Elder Handling-Transfers, the facility failed to ensure that one of 25 residents (R) (R100) was safely transferred using a mechanical lift. Actual harm occurred on 1/20/2024, when R100 fell from a mechanical lift during transfer from bed to chair and sustained one left rib fracture and two right rib fractures. There were 25 residents that required transfer assistance with a mechanical lift. Findings included: Review of the facility policy titled Safe Elder Handling-Transfer, revised 8/28/2023 documented the policy is to ensure elders are handled and transferred safely to prevent risk for injury and provide a safe, secure, and comfortable environment. Policy Explanation: All elders require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. Compliance Guidelines: Number 3. Mechanical lifting equipment or other approved transferring aids will be used based on the elders' needs to prevent manual lifting except in medical emergencies. Review of the clinical record revealed R100 was admitted to the facility on [DATE]. Diagnoses included cerebral vascular accident (CVA) with left hemiplegia, aphasia, diabetes, dementia, obesity, and depression. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating no cognitive impairment. Section GG revealed R100 had impairment in bother upper and lower extremities and was dependent on staff for all transfers. Review of the Progress Note dated 1/20/2024 at12:29 pm documented Nurse at Nurses Station was alerted that resident was lying on floor in bedroom beside the mechanical lift. The nurse went into residents' room and observed resident lying on floor with a complaint of pain to right side of the head, neck, and hip areas. Review of the Progress Note dated 1/20/2024 at 1:06 pm documented the Nurse at the desk was alerted that resident was on floor post mechanical transfer with two CNA's. Resident complained of back and right hip pain. Review of the Progress Note dated 1/20/2024 at 1:57 pm revealed resident was transferred to a local hospital related to post fall observation and treatment. The facility staff updated the responsible party. Review of the hospital medical records dated 1/20/2024 revealed multiple radiologic studies were completed status post polytrauma, blunt trauma from fall; Computerized Tomography (CT) of left elbow, CT of the chest/abdomen/pelvis; CT of the brain and spine; and two views (internal and external) x-ray of right shoulder. All testing revealed no injuries. Review of the Progress Note dated 1/25/2024 at 3:51 pm documented a new order from the Physician for right lateral rib series due to pain to rule out fracture. Review of the Progress Note dated 1/25/2024 at 5:56 pm documented that an x-ray was ordered for R100, and the results revealed that R100 was positive for a fracture to the eighth and nineth rib. It was further documented that the Physician Assistant (PA) and spouse were notified. Review of the Radiology Results Report dated 1/25/2024 revealed a test of the right ribs noted acute fractures of the eighth and nineth lateral ribs. Review of the Radiology Results Report dated 1/26/2024 revealed a test of the left ribs noted non-displaced fracture of the 11th rib. Interview on 4/5/2024 at 9:22 am, R100 stated that two staff members were helping him transfer to a chair using a mechanical lift, and he fell out of the sling and landed on the floor. He stated he immediately felt pain after the fall and was transferred to a local emergency room (ER), where he had several tests to see if he had any injuries. He stated the ER doctor told him he had not sustained any fractures or injuries. Further interview revealed over the next few days post fall, R100 experienced abdominal pain, and additional testing was ordered. He stated the results revealed he had some fractured ribs. Interview on 4/5/2024 at 10:38 am, the Director of Nursing (DON) confirmed that R100 had a fall on 1/20/2024, while being transferred with the mechanical lift. She stated that the mechanical lift had silver hooks to which the mechanical sling connects. Upon investigation, it was determined that Certified Nursing Assistant (CNA) CNA BB did not properly attach the sling to the mechanical lift, causing R100 to fall from the sling, when lifted. She stated the resident was sent to ER for evaluation and all tests were negative for fractures. During further interview, the DON stated on 1/25/2024, R100 complained of pain in the abdomen, and additional diagnostic testing was completed. The results from the 1/25/2024 tests revealed R100 had fractured the eighth and nineth right ribs and the 11th left rib. The DON revealed that CNA BB resigned without notice on 1/22/2024. Interview on 4/6/2024 at 9:07 am, CNA AA stated she had received training on the use of mechanical lifts as part of her annual training in-services throughout the year. CNA AA confirmed she work on 1/20/2024 and stated R100 required assistance transferring from the bed to a chair for his lunch meal. She stated she asked CNA BB to help her, as two staff were required for all mechanical lifts. She stated she secured the mechanical sling on her side, and CNA BB secured her side of the sling to the hooks on the lift. CNA AA stated she lifted R100 up with the lift and began the transfer. She stated as resident was lifted from the bed and moving towards the chair, the sling became disconnected from the hook on the side of the lift CNA BB was on, causing the resident to fall to the floor. She stated the incident happened so fast that she could not break the residents fall. During further interview, she stated she stayed with R100, while CNA BB went to get the nurse. Resident was transferred to the ER for evaluation. After the incident, the mechanical lift and the sling were inspected, and there were no indications the mechanical lift malfunctioned.

Based on observations, staff interviews, and review of the facility policies, the facility failed to document receive dates on food items in the dry storage area; failed to ensure dietary staff washed hands after entering the kitchen and between touching dirty/clean dishes; failed to discard food items past the best by date; and failed to ensure dietary staff properly sanitized dishware to prevent cross contamination. There were 134 residents consuming an oral diet. Findings include: 1. Review of the policy titled Production, Purchasing, Storage - Food and Supply Storage revised 1/2024, revealed foods past the use by, sell by, best by, best by, or enjoy by date should be discarded. Date and rotate items; first in, first out and discard food past the use by or expiration date. Observation on 4/5/2024 at 9:15 am, the dry storage area revealed a shelf containing four, 32-ounce containers of Dijon mustard, two one-gallon containers of mayonnaise, one gallon container of balsamic dressing, one gallon container of BBQ sauce, and an eight-pound container of salsa all with no receive date. Continued observation revealed approximately 30 cans in the can rack all with no receive date. Interview on 4/5/2024 at 9:15 am, the Dietary Manager (DM) stated that they do not put receive dates on the dry storage food items when received. The DM stated that she did not realize that a receive date was needed and stated the dietary staff have been using the expiration date or use by date indicated on the food items. 2. Review of the policy titled Safety & Sanitation - Hand Washing revised 9/2013, revealed one of the methods to prevent food borne illness is ensuring that all team members practice good personal hygiene by washing their hands throughout the course of their workday, after using a restroom, smoking, and after handling dirty equipment or raw food products. Observation on 4/6/2024 at 8:55 am, Dietary Aide EE entered the kitchen wearing an outdoor coat. The dietary aide placed his coat in the Dietary Managers office then walked over to the dish room and started unloading clean dishes from dish rack. Dietary Aide EE did not wash his hands after entering the kitchen and before touching clean dishes. Continued observation revealed he was loading dirty dishware in dish racks, placed in the dish machine, then unloading the clean dishware, no hand washing was performed from touching dirty dishware to touching clean dishware. Interview on 4/6/2024 at 9:15 am, Dietary Aide EE confirmed that he did not wash his hands after entering the kitchen and before going into the dish room to unload clean dishes. Dietary Aide EE stated that he often works in healthcare facilities and knows that he should wash his hands after entering the kitchen. Dietary Aide EE confirmed that he touched dirty dishware and did not wash his hands before touching the clean dishes. He stated that he wanted to get started washing the dishes and overlooked washing his hands. Interview on 4/6/2024 at 9:15 am, the DM stated that she expects dietary staff to wash their hands upon entering the kitchen and before starting any task. She revealed that she expects dietary staff to wash hands after touching dirty dishes and before unloading clean dishes. 3. Review of the policy titled Emergency and Disaster Procedures revised March 2016, documented to rotate emergency foods into the menu every six months. Review of the facility policy titled Production, Purchasing, Storage - Food and Supply Storage revised January 2024, revealed foods past the use by, sell by, best by, or enjoy by date should be discarded. The policy stated to date and rotate items; first in, first out. Discard food past the use by or expiration date. Observation on 4/6/2024 at 9:20 am, of the emergency food supplies revealed a case containing six large cans of Chili Con Carne, each can state a best by date of 4/2021. Continued observation revealed on the outside cardboard case of Chili Con Carne was the date 3/19/2020. Interview on 4/6/2024 at 9:20 am, the DM revealed that the emergency food supplies are rotated by the expiration date on the actual food products. The DM confirmed that the date on the outside case of the Chili Con Carne case stated 3/19/2020 and confirmed the best by date stated 4/2021 on the cans. The DM revealed that she overlooked this case of emergency food, and it should have been discarded and new case ordered to replace. 4. Review of the facility policy titled Sanitation and Infection Prevention/Control - Cleaning of Food and Non-Food Contact Surfaces revised 1/2024 - Food Contact Surfaces indicated to prevent cross-contamination, kitchenware and food contact surfaces of equipment shall be washed, rinsed, and sanitized after each use and following any interruption of operations during which time contamination may have occurred. Equipment and utensils are used for the preparation of potentially hazardous foods on a continuous or production line basis, utensils and the food contact surfaces of equipment shall be washed, rinsed, and sanitized before and after each use with potentially hazardous food at any time contamination is suspected. Observation on 4/6/2024 at 11:42 am, Dietary Cook FF after pureeing the BBQ chicken, washed the blender bowl, blade, and lid, he rinsed the items in the food prep sink and then took the items to the three-compartment sink and rinsed the items again with water using the spray hose. Dietary Cook FF then placed the blender bowl on the blender machine base and began to prepare additional puree food items. Dietary Cook FF did not sanitize the blender bowl, blade, or lid after preparing a food item and before preparing the next item. Interview on 4/6/2024 at 11:50 am, Dietary Cook FF confirmed that he rinsed the blender bowl, blade, and lid with water only, and did not sanitize the items. He revealed that he usually washes the dishware items in the three-compartment sink and did not do so because he was in a rush. Interview on 4/6/2024 at 11:50 am, the DM revealed that she expects dietary staff to properly wash the blender bowl, blade, and lid between food preparation usage, so the items are probably sanitized. The DM requested the dietary cook to discard the puree rice and properly wash the blender bowl and items.

Based on observations, review of facility recipes, and staff interviews, the facility failed to ensure that dietary staff followed recipes for preparing puree food items to avoid compromising the nutritive value and flavor. This affected 14 residents receiving a pureed diet. Findings include: Review of the undated recipe titled P. Chicken BBQ Quarter revealed the ingredients listed included with amount for serving of 20: Chicken BBQ Quarter 5 pounds, Chicken Broth 2 1/8 cup, and thickener 1 1/3 cup. Review of the undated recipe titled P. Rice [NAME] revealed the ingredients listed included amount for 48 servings: prepared white rice, vegetable broth, and thickener. During the preparation of puree food items on 4/6/2024 at 11:35 am, Dietary Cook FF was observed preparing puree BBQ chicken. He placed an unmeasured amount of steamed diced chicken into a standard blender bowl, then added an unmeasured amount of chicken broth and began to puree. Dietary Cook FF stopped the blender and added an unmeasured amount of BBQ sauce, two different times, and continued the puree process. Dietary cook FF then added an unmeasured scoop of food thickener and continued to puree. Once the puree BBQ chicken was at desired consistency, Dietary Cook FF placed it in a steam table pan and put it into the oven. During the preparation of puree rice on 4/6/2024 at 11:40 am, Dietary Cook FF was observed placing 10 heaping spoonsful of cooked rice into a standard blender bowl. He then added an unmeasured amount of hot water, the hot water added filled the blender bowl to the top. Dietary Cook FF then added an unmeasured amount of melted butter and then began to puree the rice. Once the proper consistency was achieved, he placed the rice into a steam table pan. Interview on 4/6/2024 at 11:45 am, Dietary Cook FF confirmed that he did not measure any of the food items in order to prepare the BBQ chicken or rice. Dietary Cook FF revealed that he knew how much of the ingredients to add from his experience. The cook stated that recipes for puree food items are printed with the days production sheets and available for review. The dietary cook reviewed the recipe for BBQ chicken and confirmed the ingredient amounts listed were not followed. Interview on 4/6/2024 at 11:45 am, the Dietary Manager (DM) revealed the expectation of the dietary cooks is to follow recipes for pureed food items and expects the cooks to measure the ingredients added.

Based on record review, staff interviews, and review of the policy titled PASRR Program Policy, the facility failed to submit an application for Level II Preadmission Screening and Resident Review (PASRR) for evaluation and determination of specialized services for two of three residents (R) R65, and R116 reviewed for PASRR. R65 was admitted to the facility with diagnoses of post-traumatic stress disorder (PTSD), psychotic disturbance, mood disturbance, anxiety, and major depressive disorder. R116 was admitted with diagnoses of PTSD, schizophrenia, depression, and anxiety disorder. Findings include: Review of the policy titled PASRR Program Policy revised 6/8/2023, revealed the policy states the facility coordinates assessments with the preadmission screening and resident review (PASRR) program to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: Number 1. b. PASRR Level 2 - a comprehensive evaluation by the appropriate state-designated authority that determines whether the individual has MD, ID, or related conditions, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs. Number 6. The Social Services Director shall be responsible for keeping track of each resident's PASRR screening status and referring to the appropriate authority. 1. Review of the clinical record revealed R65 was admitted to the facility on [DATE] with diagnoses including psychotic disorder, mood disturbance, anxiety, somatization disorder, major depressive disorder with psychotic features, and post-traumatic stress disorder. Review of R65's DMA-6 (Physician's Recommendation Concerning Nursing Facility Care or Intermediate Care for Mentally Retarded) form dated 10/21/2020 with diagnosis not checked, however admission diagnosis of Post-Traumatic Stress Disorder. Review of the PASARR Level One Application Resident Identification Screening Instrument, dated 4/18/2011 for R65, revealed the resident had no primary diagnosis of dementia, serious mental illness, or mental disorder. Further review of the screening instrument revealed If the nursing facility admits the applicant and discovers information that was not disclosed to the PASRR screeners, the nursing facility is required to contact the [screening authority] immediately. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed R65 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition, active diagnoses include depression and post-traumatic stress disorder, and received antidepressant medication seven days of the look back period. Review of the Physician Order's (PO) revealed R65 was currently receiving Zoloft (a medication to treat depression, PTSD, obsessive compulsive disorder (OCD) and anxiety) 100 milligrams (mg) by mouth one time a day. 2. Review of the clinical record revealed R116 was admitted to the facility on [DATE]with diagnoses including schizophrenia, depression, anxiety, and PTSD. Review of R116's DMA-6 form dated 7/24/2023 revealed no diagnoses were checked, however admission diagnosis of post-traumatic stress disorder and schizophrenia. Review of the PASARR Level One Application Resident Identification Screening Instrument, dated 7/24/2023 for R116, revealed the resident had no primary diagnosis of dementia, serious mental illness, or mental disorder. Further review of the screening instrument revealed If the nursing facility admits the applicant and discovers information that was not disclosed to the PASRR screeners, the nursing facility is required to contact the [screening authority] immediately. Review of the Quarterly MDS assessment dated [DATE] for R116 revealed a BIMS score of 15, indicating intact cognition, active diagnoses include anxiety, depression (other than bipolar), schizophrenia, and post-traumatic stress disorder (PTSD), and received antidepressant medication seven days of the look back period. Review of the PO revealed R116 was currently receiving Zoloft (a medication to treat depression, PTSD, and anxiety)150 mg by mouth one time a day. Interview on 4/5/2024 at 10:06 am, the Director of Nursing (DON) confirmed R65 does not have a level II PASRR. The DON stated that she checked with the front office staff, where PASRRs are kept, and verified R65 does not have a [NAME] II. During continued interview with the DON, revealed she is not sure about the PASRR level II process and would get the Social Service Director (SSD) to come speak with the surveyor. Interview on 4/6/2024 at 11:04 am, the Social Service Director (SSD) CC revealed there are no residents in the facility with a level II PASRR. She stated the process for a level II PASRR is that the resident must have something that's mental or an intellectual disability. She stated that residents with diagnoses of PTSD are seen by psych services every four to six weeks unless there is a change in medications or a change in behaviors. During further interview, SSD CC stated R65 does not have any behaviors. Interview on 4/6/2024 at 11:47 am, the SSD DD revealed her responsibilities include care plan scheduling, working with hospice referrals, referrals for psychiatrist, and shopping for the residents. She stated that the Admissions Director (AD) or the admissions nurse reviews the PASRR level I's on admission. She stated she submits records for PASRR level II evaluations within a year based on the admission diagnoses. She stated that residents with a diagnosis of PTSD are provided psych services, and stated the psychiatrist comes in twice monthly. Interview on 4/6/2024 at 2:50 pm, the Administrator revealed there are currently no residents in the facility with a level II PASRR. She stated that she would have the SSD talk to the surveyor about the level II PASRR. The Administrator stated that R65 and R116 should have a level II PASRR completed.

Based on observations, staff interviews, and review of facility policies, the facility failed to maintain an effective Infection Control Program (ICP) to prevent the spread of infections by not disinfecting a multi-use blood glucometer (a device used to test blood sugar levels) between residents for one of two nurses observed; also failed to ensure nursing staff performed hand hygiene during medication pass for one of four nurses observed. Findings Include: 1. Review of the facility policy titled Glucometer Policy Glucometer Cleaning and Disinfecting, revised 4/28/21 policy statement revealed if one device must be used to monitor several residents, it must be cleaned and disinfected after every use following the manufactures' instructions to prevent carryover of blood and infectious agents. Procedure 1. Clean and disinfect glucose meter before and after each patient use. 4. Clean and disinfect meter by using approved Germicidal and Disinfectant Wipes. Observation on 5/18/22 at 8:13 a.m. with Licensed Practical Nurse (LPN) AA, was observed to remove a glucometer from the medication cart. LPN AA placed the glucometer, alcohol pad, lancet, and a bottle of glucose test strips on a metal tray and proceeded to R#29's room. After asking permission to perform finger stick blood sugar (FSBS) check, LPN AA donned gloves, without washing his hands. He cleansed R#29's left index finger with alcohol pad and proceeded to prick her finger. Nurse wiped for blood sample away and proceeded to apply second sample on test strip. Nurse went back to medication cart, placed the metal tray on medication cart, removed contents, cleaned the inside of the metal tray with an alcohol wipe, removed gloves he used to perform test, loaded the metal tray with blood sugar supplies to include the same glucometer (without being disinfected/cleaned), applied gloves and proceeded to check R# 100's room to perform FSBS. Surveyor intervened just as nurse was about to stick resident's finger. Interview on 5/18/22 at 8:13 a.m. with LPN AA, he was asked if he was aware that he is required to wash/sanitize his hands after he removes his gloves and if he was aware that the glucometer should be cleaned/disinfected between resident use. LPN AA stated that he is aware that he should perform hand hygiene after removing gloves and that the glucometer should be cleaned between resident use. He further stated that he was just trying to get through the day because he has medications to administer, the breakfast trays were coming on the hall, and he needed to get the blood sugars completed. He stated, I forgot. During further interview, LPN AA confirmed that he had checked blood sugars on four other residents before surveyor arrived to observe. He acknowledged that he did not clean the glucometer between the residents. LPN AA confirmed with surveyor that there was only one glucometer on the medication cart. 2. Review of facility policy titled Medication Administration: Hand Hygiene revised 12/13/21, revealed the policy is that partners will use appropriate hand hygiene during medication administration. Appropriate hand hygiene reduces the spread of germs and decreases the spread of infections. Hand hygiene is defined as cleansing of hands by using the organization-approved, alcohol-based hand sanitizer or by washing hands with soap and water. Procedure 4. Wear gloves during medication administration while opening capsules during medication preparation and before donning or doffing gloves. During a medication observation on 5/18/22 at 9:04 a.m. with LPN CC, revealed that nurse had preset medications for R#105 prior to administering. LPN CC was asked to count the number of medications in the cup to compare the number of pills in the cup to the number of scheduled 9 a.m. medications. Nurse poured the medications in the cup on a paper towel and began to count them with her bare hands and placing each one back into the cup. LPN CC did not wash or sanitize hands or don gloves prior to touching the medications. LPN CC, then pulled another plastic medication cup from medication cart containing preset pills for R#88. LPC CC again poured the medications onto a paper towel and used her bare hands to count the medications in the cup. She did not perform hand hygiene or wear gloves while handling these medications. Interview on 5/18/22 at 9:04 a.m. with LPN CC, regarding performing hand hygiene prior to handling medications and during medication administration, and LPN CC did not provide a response to surveyor's questions. Interview 5/18/22 at 2:29 p.m. with Director of Nursing (DON) revealed that it is her expectation that nurses use proper hand hygiene when handling medications, adhere to all infection control guidelines to ensure the safety of the residents, and follow the 5 rights of medication administration when administering medications.

Based on observations, record review, and staff interview, the facility failed to ensure the medication error rate was less than five percent (5%). A total number of 26 medication opportunities were observed. There were three errors for one of five residents (R), R#12, by one of three nurses observed during medication pass, for a medication error rate of 11.54%. Findings include: Observation of medication administration on 5/18/22 at 9:04 a.m., with Licensed Practical Nurse (LPN) CC revealed she pulled a clear medicine cup containing multiple medications from the medication cart for R#12. LPN CC stated that she pre-set the medications earlier on her shift, to save time. Surveyor asked LPN CC to count the number of pills in the cup and she confirmed that was all the medications resident was to receive at that time. She then placed all the medications from the clear plastic cup in the pill crush sleeve and crushed the medications together and opened the three capsules. She combined all the crushed medications in a plastic cup with applesauce. She then prepared the liquid medications for administration. Nurse CC entered resident's room and administered the medications. During reconciliation review of the May 2022 electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of medical record reveled resident did not have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Interview on 5/18/22 at 9:12 a.m. with LPN CC, she stated that she prepared R#12's morning medications at the beginning of the shift, to save time. She stated that all the medications that she prepared earlier were all the medications that R#12 received for that time of day. She verified that the potassium chloride and [MEDICATION(S)] orders were extended-release medications and should not be opened or crushed. Review of the May 2022 electronic medication record revealed that R#12 was to receive the [MEDICATION(S)] Extended Release (ER) 24 Hour 100 mg and the potassium chloride ER 10 MEQ capsule as follows: 2 capsules by mouth one time a day for [CONDITION(S)]. Review of record also revealed that resident did not have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on record review, policy review, interviews, and Rule 410-10-.02 Standards of Practice for Licensed Practical Nurses, the facility failed to maintain professional nursing standards of quality as evidenced by one of four Licensed Practical Nurse's (LPN) observed during facility medication administration task by presetting medications; also failed to practice infection control guidelines during medication administration and during point of care testing for two of two nurses observed. Findings include: 1. Review of the facility policy titled, Medication Administration: General Guidelines, revised 4/10/19, revealed policy statement as medications are administered as prescribed, in accordance with the good nursing principles and practices. Procedure 4. Medications are administered at the time they are prepared. Medications are not pre-poured/pre-set/pre-crushed. 10. Medications are administered within 60 minutes before or after scheduled time, except for medications ordered to be taken with food and before or after meals, which are administered precisely as ordered. Unless otherwise specified by the physician, routine medications are administered according to the established medication administration schedule for the healthcare center. 23. If breaking tablets is necessary to administer the proper dose, hands are washed with soap and water or alcohol gel prior to handling tablets (preferable gloves should be worn). Review of facility policy titled Medication Administration: Hand Hygiene revised 12/13/21, revealed the policy is that partners will use appropriate hand hygiene during medication administration. Appropriate hand hygiene reduces the spread of germs and decreases the spread of infections. Hand hygiene is defined as cleansing of hands by using the organization-approved, alcohol-based hand sanitizer or by washing hands with soap and water. Procedure 4. Wear gloves during medication administration while opening capsules during medication preparation and before donning or doffing gloves. Review of the Georgia Rule 410-10-.02 - Standards of Practice for Licensed Practical Nurses revealed that: The practice of licensed practical nursing means the provision of care for compensation, under the supervision of a physician practicing medicine, a dentist practicing dentistry, a podiatrist practicing podiatry, or a registered nurse practicing nursing in accordance with applicable provisions of law. Such care shall relate to the promotion of health, the prevention of illness and injury, and the restoration and maintenance of physical and mental health through acts authorized by the board, which shall include, but not be limited to the following: (a) Participating in patient assessment activities and the planning, implementation, and evaluation of the delivery of health care services and other specialized tasks when appropriately educated and consistent with board rules and regulations. (b) Providing direct personal patient observation, care, and assistance in hospitals, clinics, nursing homes, or emergency treatment facilities, or other health care facilities in areas of practice including, but not limited to coronary care, intensive care, emergency treatment, surgical care and recovery, obstetrics, pediatrics, outpatient services, [CONDITION(S)], specialty labs, home health care, or other such areas of practice. (c) Performing comfort and safety measures. (d) Administering treatments and medications by various routes. Observation on 5/18/22 at 9:04 a.m. during medication administration with LPN CC revealed she opened the medication cart and pulled out a clear plastic medication cup already preset with medications. Surveyor questioned the nurse about the preset medications in the cup and she stated the medicine was for R#105. There was no name or room number on the cup. LPN CC was asked to count the number of medications in the prefilled cup and compare it to the EMAR. She counted 21 medications preset in the cup. Surveyor and LPN CC reviewed the EMAR together at medications scheduled for R#105 during the 9:00 a.m. medication pass. There were 19 medications scheduled to be administered at 9:00 a.m. LPN CC stated I don't know what the other two are because I did not put anything else in the cup. She further stated, I will deal with that later. Continued observation on 5/18/22 medication pass with LPN CC revealed she pulled another clear plastic cup of medications from the medication cart that were preset. LPN CC stated these preset medications were for R#88. There was no name or room number on the cup. She was asked to count the preset medications in the cup. LPN CC counted nine medications in the cup. She stated that she preset R#88's 1:00 p.m. Tylenol and [MEDICATION(S)] to give with the 9:00 a.m. medications because R#88 reported that her stomach was hurting. Review of the EMAR revealed that there were four medications scheduled for 9 a.m. LPN CC reiterated that she was giving the two Tylenol and one [MEDICATION(S)] that was scheduled for 1:00 p.m. at this time. Surveyor asked LPN CC if she was aware that resident had received two Tylenol with the 6:00 a.m. medication pass and had a scheduled dose of [MEDICATION(S)] for 9:00 a.m., LPN CC responded Yes. Surveyor asked LPN CC about the other two medications in the cup, and LPN CC stated she did not know what the other two medications were. She stated that she presets the medication according to the EMAR. After the observations of the preset medications for R#105 and R#88, LPN CC was asked to open each drawer of the medication cart. There were four additional clear plastic cups of preset medications in the medication cart, that had not been given yet. There was no name or room number on any of the cups. LPN CC stated that the other medications were preset earlier, but she had already administered them. Interview on 5/18/22 at 9:04 a.m. with LPN CC stated, I pull all my residents' medications every morning and place the cup in the drawers before I go down the hall to administer the medications to my residents because it is more efficient for me to do it that way. When asked about the five rights of medication administration process indicated in the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 5/18/22 at 2:03 p.m. with LPN DD revealed that she pulls her medications and places them in the medication cup for administration at the time she is going to administer the medication and that presetting medications is not allowed. Interview on 5/18/22 at 2:31 p.m. with LPN II, revealed that nurses are not allowed to preset medications at the facility. That is not a practice the facility uses. During further interview, she stated the facility utilizes the five rights of medication administration when administering medications. Interview on 5/18/22 at 2:57 p.m. with the Director of Nursing (DON) revealed that all nurses should administer medication using the five rights of medication administration. The DON stated that she incorporated the five rights of medication administration on the electronic medication administration for the nurses to review while administering medications. During further interview, the DON stated that it is not standard practice or the facility's policy to preset medications. Interview on 5/19/22 at 10:28 a.m. with facility's Physician revealed that the medications should be administered as ordered by the physician. He stated that R#88 is being followed by Gastroenterologist due to the colon/[CONDITION(S)]. He further stated that the [MEDICATION(S)] should not have a negative impact if the dose was doubled and administered short term. He stated that long term use of double dosing could potentially restrict the absorption of vitamin B12 or cause [CONDITION(S)] (C-diff). 2. Review of the facility policy titled Glucometer Cleaning and Disinfecting, revised 4/28/21, policy statement revealed if one device must be used to monitor several residents, it must be cleaned and disinfected after every use following the manufactures' instructions to prevent carryover of blood and infectious agents. Procedure 1. Clean and disinfect glucose meter before and after each patient use. 4. Clean and disinfect meter by using approved Germicidal and Disinfectant Wipes. Observation on 5/18/22 at 8:13 a.m. during medication administration, LPN AA was observed to remove a glucometer (a device used to test blood sugar levels) from the medication cart. LPN AA placed the glucometer and testing supplies on a metal tray and proceeded to R#29's room. After asking permission to perform finger stick blood sugar (FSBS) check, LPN AA donned gloves, without washing his hands. He cleansed R#29's left index finger with alcohol pad and proceeded to prick her finger. After the test was completed, LPN AA went back to medication cart, placed the metal tray on medication cart, removed contents, cleaned the inside of the metal tray with an alcohol wipe, then removed the same pair of gloves used to during the testing. He loaded the metal tray with additional blood sugar supplies to include the same glucometer (without cleaning or disinfecting it), applied gloves (without washing his hands or using hand sanitizer) and proceeded to R#100's room to obtain FSBS. Just as LPN AA was about to stick resident's finger, surveyor intervened. Interview on 5/18/22 at 8:13 a.m. with LPN AA, he was asked if he was aware that the glucometer should be cleaned and disinfected between each resident use and that hand washing/sanitizing of hands after he dons and after he removes his gloves is required? LPN AA stated that he was aware that he should perform hand hygiene after removing gloves and that the glucometer should be cleaned between each resident use. During further interview, he stated he was just trying to get through the day because he had medications to administer, breakfast trays were coming to the hall, and he needed to get the blood sugars completed. He stated, I forgot. LPN AA confirmed to the surveyor that he had already checked FSBS on four other residents before surveyor arrived to observe. He acknowledged that he did not clean the glucometer between any of the residents. LPN AA confirmed with surveyor that that there was only one glucometer on the medication cart. Review of LPN AA's personnel file revealed that he had received training and successfully completed a Blood Glucose Monitoring Written Competency Test on 2/14/22 and a Blood Glucose Monitoring Observation Competency on 2/16/22.

Based on observation, record review, interviews, and policy review titled, Medication Administration: General Guidelines, the facility failed to assess two residents (R) R#35 and R#79 for the ability to safely self-administer medications, before leaving mediations at bedside for residents to self-administer. Findings include: Review of the facility policy titled, Medication Administration: General Guidelines, revised 4/10/19 revealed procedure 3. Patients/residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. Procedure 4. Medications are administered at the time they are prepared. Medications are not pre-poured/pre-set/pre-crushed. Only one patient/resident's medications are prepared and administered at a time. 1. Observation on 5/17/22 at 10:36 a.m. during initial tour/screening with R#35, surveyor observed a bottle of saline nasal spray on R#35's bedside table. R#35 informed surveyor that the nurse left it there for her to use this morning. A review of the clinical record for R#35 revealed resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 13, which indicated no cognitive impairment. Review of R#35's record revealed there is no evidence that an assessment for self-administration of medication was completed. Review of the resident's current care plan revealed there was no evidence that resident had a care plan to self-administer medications or keep medications at bedside. Review of the May 2022 Medication Summary Report for R#35 revealed there was not an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Observation on 5/17/22 at 10:49 a.m. during initial tour/screening with R#79, surveyor observed a green liquid in a clear medication cup on R#79's bedside table. R#79 stated the green liquid was [MEDICATION(S)] and her nurse left it there. She further stated she did not take it because today is Tuesday, and she does not take [MEDICATION(S)] on Tuesday's. A review of the clinical record for R#79 revealed resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's quarterly MDS, dated [DATE], revealed a BIMS was coded as 13, which indicated no cognitive impairment. Review of R#79's record revealed there is no evidence that an assessment for self-administration of medication was completed. Review of the resident's current care plan revealed there was no evidence that resident had a care plan to self-administer medications or keep medications at bedside. Review of record revealed that resident has a medication order for [MEDICATION(S)] Solution 10 GM/15 ml. Give 30 ml by mouth one time a day every Monday, Wednesday, Friday. There was no order for resident to have medications at bedside for self-administration. Interview on 5/18/22 at 2:03 p.m. with LPN DD, revealed she is never to leave medications at a resident's bedside to self-administer. She stated that as a nurse it is her responsibility to make sure that the resident has swallowed the medications before she leaves the room. Interview on 5/18/22 at 2:31 p.m. with LPN II, stated medications are never supposed to be left at the resident's bedside. Interview on 5/18/22 at 2:57 p.m. with DON stated that R#79 and R# 35 are not able to self-administer their own medications. DON stated that it is not standard practice or the facility's policy to leave medications at a resident's bedside.

Based on observation, interview and record review, the facility failed to ensure two of six housekeeper/environmental service (EVS) staff working on 12/28/20 were knowledgeable about and allowed the necessary contact time required for cleaning chemicals to be effective against bacteria [MEDICAL CONDITION] such as COVID-19. Findings include: A review of the housekeeping/EVS schedule noted that EVS DD was assigned Lobby/Sanitize on 12/28/20. In an interview on 12/28/20 at 1:40 PM, EVS DD was asked about the products used to clean and disinfect various surfaces. EVS DD stated that a product called GenEon Cleaner and Disinfectant was used on high-touch surfaces such as handrails, while a product called Microkill was used on computers, doorknobs, phones and switches. When asked the contact time (the length of time the surface should be wet prior to removal), EVS DD indicated he did not know the specific contact times for each cleaning product, stating Make sure - not too long, guess I'm not sure. As for leaving it wet, I don't keep track of that. A review of the product labels with EVS DD revealed the Microkill had a contact time of 30 seconds - three minutes, depending on the organism, while GenEon had a contact time of 10 minutes. In an interview on 12/28/20 at 2:03 PM, Housekeeper (Hskpr) KK was asked about the products used to clean and disinfect high touch areas. Hskpr KK was observed to go to the housekeeper cart and pulled out GenEon Cleaner and Disinfectant. When asked about the contact (wet) time for the GenEon product, Hskpr KK was unaware that the product should wet the surface for 10 minutes, stating, I think five minutes. I spray and wipe, then (use) a dry cloth. Hskpr KK also pulled out a trigger spray bottle with the label Sir SaniHand and responded that this product also had a five-minute contact time. The last cleaning product Hskpr KK produced from the cleaning cart was Clorox Cleanup Disinfectant with Bleach and stated We spray then use a dry towel after five minutes. Review of manufacturer information for Sir SaniHand received from the facility Administrator on 12/29/20 via email showed American Formula Sir SaniHand Liquid Hand Sanitizer - 32 oz Spray Bottle. The Administrator's email stated, The Sani Hand is a 70% alcohol hand sanitizer that our distributor sent to us by accident and rather than send it back, they told us to keep it. After speaking to the Environmental Department Director, a few of the housekeepers kept a bottle on their carts for themselves to clean their hands and it is not used as a surface cleaner or any other type of cleaning. Review of the facility in-service education records showed an EVS in-service held on 12/18/20 with the Topic: Covid 19 Disinfectant and Sanitizer was attended by EVS DD. EVS DD also attended an EVS in-service held on 10/28/20 with the Topic: All Department Sanitizing, High Low surface. Review of the in-service records revealed no evidence that Hskpr KK attended either of these trainings on sanitizing/disinfecting surfaces. During an interview on 12/28/20 at 4:45 PM, the Administrator reviewed these in-service records and confirmed that KK was not on them.

Based on observations, interviews, record reviews and review of the facility policy titled, Care Planning - Interdisciplinary Team the facility failed to follow the care plan for one resident (R), #49. Actual harm was identified when R#49 suffered a midline laceration to the forehead and a [MEDICAL CONDITION] (Cervical) vertebral body requiring the use of a C-spine collar when she fell from her bed after being left unattended during a bed bath on 12/15/18. Additionally, the facility failed to develop a care plan for one Resident (R#94) for the use of a travel pillow for neck positioning. The sample size was 26 residents. Findings include: Review of the facility's policy titled Care Planning - Interdisciplinary Team reviewed on 3/1/18 noted: 1. A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS (Minimum Date Set)); 2. The care plan is based on the resident's comprehensive assessment and is developed by a care planning/interdisciplinary team. The policy did not include additional information regarding the development and implementation of resident care plans. 1. Review of the clinical record for R#49 revealed that the resident had the following [DIAGNOSES REDACTED]., [MEDICAL CONDITION] (left eye) and depression. Review of the Annual MDS, for R#49, dated 9/5/18 and review of the Quarterly MDS dated [DATE] revealed that the resident was assessed to be severely cognitively impaired, had physical and verbal behaviors directed towards others for one to three days during the assessment period. Review of Section G of this MDS documented that during this assessment period the resident was assessed to be dependent on staff for bathing requiring two plus person assist for bathing. R#49 had no impairment of the upper or lower extremities. Continued review revealed during this assessment period the resident had no falls and did not utilize any restraints or alarms. Review of the Fall care plan for R#49 last reviewed on 1/24/19 revealed the resident was a fall risk and required extensive to total assistance for Activities of Daily Living (ADLs). Pertinent interventions in place at the time of the resident's fall on 12/15/18 included the following: to assist with all ADLs, total transfer assist with Hoyer lift, floor mat at bedside, assist rails x 2; Broda chair when out of bed for comfort and positioning; and to keep bed in low position. Review of the Behavior care plan for R#49 last reviewed on 1/24/19 revealed that R#49 had behaviors - at risk for complications/side effects r/t (related to) use of antipsychotic and other mood stabilizing medication use. The interventions documented that if resistive/combative behavior was noted, leave R#49 alone and return when safe to do so/provide additional assist as needed. Review of a handwritten statement dated 12/21/18 written by CNA FF documented the following: On 12/15/18 at 10:45 a.m., I (CNA FF) entered room [ROOM NUMBER]. I began washing R#49's upper body and during the process she was fighting. She was yanking on the face towel and shirt. She punch at me and hit the right bedrail. I let her head down and lifted the right bedrail up and begin peri care. I turned her (R#49) to her left side to clean her bottom. She continue swinging her right arm backward towards me and pushing back. I felt that I could not clean her well, so I place her on her back. I went to pull right bedrail back down (meaning put the siderail in place) and R#49 grabbed it and begin shaking and punching it. I left it up (meaning that the siderail was not in place) and walked to the doorway and called for help. While I was standing in the doorway I heard a bang and when I turned around R#49 was laying on her back on the floor. I went towards her and yelled for the nurse. Signed by CNA FF. (sic) During an interview at the nurses' station on 1/30/19 at 11:55 a.m. with Registered Nurse Charge Nurse AA on 12/15/18, revealed that CNA FF told Registered Nurse AA that R#49 was combative so she (CNA FF) went to the resident's door to ask for help and when she turned back around the resident was on the floor. CN AA said that even if CNA FF felt like she had to go get someone, she should have made sure the bed was lowered as indicated in R#49's plan of care. During an interview at the nurses' station on 1/30/19 at 3:20 p.m. with CNA EE, CNA EE revealed that it usually required two staff to care for R#49. When asked about steps to take when the resident became combative during care, CNA EE said staff were supposed to wait until she calms down and then try to give care later. Telephone interview on 1/30/19 at 4:43 p.m. with CNA FF revealed on 12/15/18 the CNA FF was providing care to R#49 when the resident became aggressive. CNA FF said the resident and she played tug of war with the face towel while CNA FF washed the resident's upper extremities. According CNA FF, R#49 was striking out at the CNA FF and also punched the side rail with her right fist. Continued interview with CNA FF revealed that she did not re-approach the resident as indicated in her care plan and did not use the call light to seek help from other staff. During a follow-up interview at the nurses' station on 1/31/19 at 9:58 a.m. with Registered Nurse Charge Nurse AA revealed that the she thinks the resident's care plan called for one person for receiving care in bed and two people if resident is combative. Cross Reference F689 2. Review of the clinical record for R#94 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment for R#94 dated 1/8/19 revealed R#94 was severely cognitively impaired and required extensive to total assistance of one to two staff persons for all activities of daily living (ADLs). During this assessment period, R#94 received occupational therapy (OT), passive range of motion (PROM), and splint/brace assistance. Review of the Task tab printed from the electronic record for R#94 on 1/31/19 revealed Restorative staff was to provide R#94 with Passive Range of Motion (PROM) to the left hand six times per week for 15 minutes for each treatment and was to apply a splint/brace to her left hand for up to six hours - six times per week. The Task tab did not list the use of a travel neck pillow to be used for proper head positioning. Review of the comprehensive care plans for R#94 last reviewed on 1/12/19 revealed that there was not a plan of care developed to address proper neck/head positioning. Review of the Occupational Therapy (OT) Discharge Summary for R#94 dated 1/11/19 revealed one of the discharge recommendations was to continue to use cervical travel pillow when in bed and in Broda chair. Review of an Interdisciplinary Communication Memo for R#94 dated 1/11/19 completed by OT BB documented the following: Continue to use cervical travel pillow when in bed and Broda chair to maintain appropriate head positioning. Observation of R#94 in her room on 1/28/19 at 10:55 a.m. revealed that R#94 was lying in her bed with the head of the bed (HOB) elevated approximately 30 degrees. R#94 had a travel neck pillow around the back of her neck and the resident's head was bent forward and to the right near her shoulder with the resident's chin touching her chest as she slept. Interview at the nurses' station on 1/30/19 at 12:06 p.m. with Registered Nurse Charge Nurse AA revealed that R#94 used the travel neck pillow for positioning and for comfort. Interview on 1/30/19 at 3:50 p.m. with the Director of Nursing (DON) and Minimum Data Set (MDS) Coordinator revealed that R#94 had used the travel neck pillow for quite some time (over a year) at the daughter's request because she felt her mother was comfortable with its use. The MDS Coordinator confirmed that a care plan should have been developed to address the use of the resident's travel neck pillow. Cross Reference F688

Based on observations, interviews, record reviews and review of the facility policy titled, Fall Policy the facility failed to provide supervision during a bed bath to prevent an avoidable fall for one Resident (R), #49. Actual harm was identified when R#49 suffered a midline laceration to the forehead and a [MEDICAL CONDITION] (Cervical) vertebral body requiring the use of a C-spine collar when she fell from her bed after being left unattended during a bed bath on 12/15/18. The sample size was 26 residents. Findings include: Review of the facility's policy titled, Fall Policy reviewed 3/1/18 revealed The facility will identify each resident who is at risk for falls and will plan appropriate care and implement interventions to assist in fall prevention. The facility will attempt to decrease falls with injury by providing an environment that is free from potential hazards. Review of the clinical record for R#49 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. and depression. Review of the Annual Minimum Data Set (MDS), for R#49, dated 9/5/18 and review of the Quarterly MDS dated [DATE] revealed that the resident was assessed to be severely cognitively impaired, had physical and verbal behaviors directed towards others for one to three days during the assessment period. Review of Section G of this MDS documented that during this assessment period the resident was assessed to be dependent on staff for bathing and required two plus person assist for bathing. R#49 had no impairment of the upper or lower extremities. Continued review revealed during this assessment period the resident had no falls and did not utilize any restraints or alarms. Review of a handwritten statement dated 12/21/18 written by Certified Nursing Assistant (CNA) FF documented the following: On 12/15/18 at 10:45 a.m., I (CNA FF) entered room [ROOM NUMBER]. I began washing R#49's upper body and during the process she was fighting. She was yanking on the face towel and shirt. She punch at me and hit the right bedrail. I let her head down and lifted the right bedrail up and begin peri care. I turned her (R#49) to her left side to clean her bottom. She continue swinging her right arm backward towards me and pushing back. I felt that I could not clean her well, so I place her on her back. I went to pull right bedrail back down (meaning put the siderail in place) and R#49 grabbed it and begin shaking and punching it. I left it up (meaning that the siderail was not in place) and walked to the doorway and called for help. While I was standing in the doorway I heard a bang and when I turned around R#49 was laying on her back on the floor. I went towards her and yelled for the nurse. Signed by CNA FF. (sic) Review of a Fall Report dated 12/15/18 completed by Registered Nurse Charge Nurse (CN) AA documented the following: CN AA (Registered Nurse Charge Nurse AA) was summoned to R#49's room and that the resident was noted lying on the floor on the right side of her bed .range of motion done, patient assessed and placed back on the bed. According to the report, the fall resulted in a laceration to the top of the resident's scalp. There were no other injuries noted. Predisposing Physiological Factors affecting the fall were noted as confused, drowsy, incontinent, recent change in condition, impaired memory and recent change in medications/New. Review of the section titled Witnesses revealed there were No Witnesses found. According to the report, the resident's Physician and family were notified of the fall. There was no other information included in the report. Record review of the Health Status Notes for R#49 dated 12/15/18 documented by Registered Nurse Charge Nurse AA revealed the following documentation in pertinent part: summoned to resident's room by caregiver, resident noted lying on the floor with a laceration to forehead extending to top of head with a small amount of bleeding. Patient assessed, and range of motion done and placed back to bed. Vital signs stable. Small amount of bleeding noted, able to control the bleeding. Neuro checks completed and intact .spoke to Nurse Practitioner who gave orders to send to ER (emergency room ). Spoke with patient's son and niece who agreed for her (R#49) to be sent out. Review of a History and Physical (H&P) Hospital Final Report from the acute care hospital dated 12/15/18 documented that R#49 was a [AGE] year old female with severe dementia, who presents from nursing home after ground level fall (do not know many details of how fall happened, attempting to contact nursing home and family) .Non-contrast head CT (computed tomography) scan revealed left parietal and occipital hemorrhage which appeared to be hemorrhagic conversion of ischemic stroke given fairly localized to PCA territory (neurosurgery in agreement). Patient also found to have a C1 fracture for which she was placed in a C-spine collar. Further review of this H&P revealed that the Assessment/Plan documents . found to have a left parietal and occipital ICH ([MEDICAL CONDITION]) which appears to stay fairly confined to the left PCA territory, suggesting hemorrhagic conversion of an ischemic stroke rather than traumatic ICH. She (R#49) was also found to have a C1 fracture which will require stabilization. On exam, she moves all extremities equally and spontaneously. Review of R#49's Task List Report (a list of tasks to be completed by the Certified Nursing Assistants (CNAs) printed on 1/31/19 revealed the tasks of completing personal hygiene, bathing, and bed mobility were initiated on 1/13/17 (the resident's date of admission). According to the report, R#49 required the total assistance of one-two persons for personal hygiene; she required the extensive assistance of one person for bathing; and she required the extensive assistance of one person for bed mobility. According to the Task Report, the resident's level of assistance during ADLs had not changed since the tasks were initiated on 1/13/17. Observation in the resident's room on 1/30/19 at 11:09 a.m. revealed the resident was in her bed sleeping and the head of bed (HOB) was elevated approximately 30-45 degrees. The bed was in a low position. R#49 wore a neck collar, and the floor mat was on the floor to the left side of the bed. Continued observations revealed a healed vertical scar down the middle of the resident's forehead spanning from the middle of her forehead and into her hairline. During an interview at the nurses' station on 1/30/19 at 11:55 a.m. with Registered Nurse CN AA revealed that on 12/15/18, when the nurse entered the resident's room after the fall, R#49 was on the floor and had a laceration to her forehead that was deep. R#49 was sent out to the emergency room for the laceration and once at the hospital, it was found that her injuries were more than that. Registered Nurse CN AA said she remembered CNA FF was in the resident's room providing care. CNA FF told Registered Nurse CN AA that R#49 was combative, so she came to the door to ask for help and when she turned back around the resident was on the floor. Registered Nurse CN AA said staff were trained to use the call light if a resident became combative. The nurse said staff should get help to come to the room because at that point they (residents) can't be left unsupervised. Registered Nurse CN AA continued that even if (CNA FF) felt like she had to go get someone, she should have made sure the bed was lowered. Interview at the nurses' station on 1/30/19 at 3:20 p.m. with CNA EE revealed that CNA EE did not usually work with R#49, but that she had assisted other CNA's who had were assigned to assist the resident. CNA EE said it usually required two staff to care for the resident because, she (R#49) fights. Continued interview with CNA EE revealed that when residents become combative staff were supposed to wait until she (the resident) calms down and then try to give care later. Go in with two people once she calms down. Telephone interview on 1/30/19 at 4:43 p.m. with CNA FF revealed on the day of the resident's fall, she entered the resident's room to provide care (bed bath). The resident was sitting in bed with the head of the bed (HOB) elevated approximately 60 degrees. CNA FF said she raised the bed in order to provide care and left the resident with the HOB elevated and in a sitting position in order to wash the resident's face and upper extremities. CNA FF said the bilateral side rails were lowered (meaning that they were in place). When CNA FF began to wash the resident's face, the resident became combative and was grabbing at the towel. CNA FF said they were playing tug of war with the towel. CNA FF said she was able to complete washing the resident's upper extremities and then began to put on the resident's shirt. At this point, CNA FF said the resident began to swing at her which prevented the CNA FF from being able to put the resident's arms in her shirt. CNA FF stated that at one point in an attempt to hit CNA FF, that R#49 punched the side rail. Once CNA FF completed the resident's upper body, she lowered the HOB and lifted the side rail towards the HOB (meaning that the side rails were not in place), so she could complete peri care for the resident. CNA FF stated she raised the side rail to complete peri care because it was easier to reach the resident with the side rail raised (meaning that the side rail was not in place). CNA FF turned the resident over on her left side while the resident was still being combative, and the resident was using her right hand to swing back at CNA FF and grabbing the towel. CNA FF said she continued to take the towel out of the resident's hand. Once on her left side, CNA FF realized that the resident had been incontinent of bowel. The resident continued to be combative and striking and CNA FF realized she needed help to complete the resident's care. At this point, CNA FF said she attempted to put the side rail back in place and attempted to lower the bed. Due to the resident's physical aggression, she was unable to do so, but CNA FF stated she believed the bed did lower some. CNA FF then went to the doorway of the resident's room to call for assistance from another staff member. CNA FF said she called for help three times and then heard a loud thump and turned around and saw the resident's feet on the floor. CNA FF went to the resident's side of the room and found the resident on the floor on her back with her head near the dividing wall between the resident's and her roommate's beds. R#49's legs were near the foot of her bed. CNA FF said she screamed out for help. Continued interview with CNA FF revealed that sometimes it required one and two staff members to provide care for R#49. When asked about methods of caring for residents who are exhibiting combative/resistive behaviors, CNA FF said options were: 1) re-approaching, 2) pushing call light, and 3) calling for help. CNA FF said she did not re-approach the resident and did not use the call light to seek help from other staff. CNA FF said the resident required a Hoyer lift for transfers and required staff assistance for bed mobility. According to CNA FF, R#49's level of assistance in bed mobility sometimes varied. Interview on 1/31/19 at 9:33 a.m. with CNA GG revealed R#49 usually required two person assist, but sometimes, it depends. CNA GG worked on 12/15/18, the day the resident fell from bed. CNA GG said she was on the other hall when the fall occurred but was told by CNA FF that the resident fell out of bed. CNA FF told CNA GG that she went to the resident's doorway to call her for assistance because the resident was being combative and fighting and while at the door CNA FF heard a thump and turned around and realized the resident fell out of bed. CNA GG said that when caring for combative residents, it was the staff's responsibility to make sure they (the residents) are safe before leaving their side to get help, or that staff should push call light to get assistance. During a follow-up interview on 1/31/19 at 9:58 a.m. with Registered Nurse CN AA, the nurse was asked what she saw when she walked into the resident's room. Registered Nurse CN AA said R#49 was face down on the floor and she could see a little blood on the floor. At that time, she turned the resident over and saw the laceration in the middle of her forehead. Registered Nurse CN AA said she thinks the bed was still in a high position and the side rail was up towards the HOB. Registered Nurse CN AA continued by stating she thinks that the resident's care plan called for one person for receiving care in bed and two people if resident is combative. Interview on 1/31/19 at 10:18 a.m. with Licensed Practical Nurse (LPN) HH revealed she was present along with Registered Nurse CN AA in R#49's room on 12/15/18, immediately after the fall. LPN HH said R#49's bed was in a high position and that the side rail was up towards the head of the bed (meaning the side rail was not in place). LPN HH revealed that she did not work on R#49's hall so she was not familiar with the kind of assistance the resident required; however, LPN HH said that when providing care for a combative resident that sometimes you need to get someone else or re-approach. Make sure the resident is safe and then ring call bell for assistance. An interview on 1/31/19 at 10:20 a.m. with the facility's Associate Medical Director (AMD) and the facility's Director of Nursing (DON) confirmed R#49's fall resulted in a C1 fracture. The AMD acknowledged that he was aware of the resident's combative behaviors and said the resident was very strong. During the interview, the DON said that when dealing with combative residents there should be two staff, and if a CNA realizes more assistance is needed, then they should get more help. The DON said it would have been a better choice for CNA FF to use the call light to ask for assistance, or to have lowered the bed and then seek help. She said that for R#49, one-two staff were required for care while in bed, it was at the CNA's discretion depending on the resident's behavior. Post survey telephone interview on 2/14/19 at 5:15 p.m., with the Administrator and Director of Nursing (DON) revealed that the Task List is a mini care plan that lists out Activities of Daily Living for CNA's for care planned individualized approaches. The DON revealed that if a resident has been assessed (such as for MDS) to require two plus person assist for baths then a two plus person assist bath should be provided. Further interview, at this same time, with the DON and Administrator revealed that during the facility's investigation of the fall they determined that CNA FF had left the bed in a high position and that the side rail was in the up position (meaning that the side rail was not in place at the time the resident fell out of bed). Continued interview with the DON revealed that what should have happened that did not happen was that CNA FF should have gotten additional assistance by using the call light or by yelling out, the CNA should have lowered the bed before leaving the resident, and that CNA FF should have ensured the safety of the resident. Post survey telephone interview on 2/14/19 at 6:25 p.m., with CNA FF clarified that that she was familiar with working with R#49, and that R#49 had exhibited behaviors like this before when she had provided care previously. CNA FF stated that previously she had been able to talk to the resident and redirect her but on 12/15/19 she was not able to re-direct the resident. CNA FF further revealed that she should have let the side rail down (put the side rail in place), and that she should have used the call button to call for help or even used her cell phone to call for help and that she should not have walked away from the resident.

Based on observations, interviews, record reviews and review of the facility policy titled, Resident Mobility and Range of Motion the facility failed to assess and provide treatment for one Resident (R), (R#94) for neck positioning. The sample size was 26 residents. Findings include: Review of the facility's policy titled Resident Mobility and Range of Motion reviewed on 2/1/18 revealed 3. Residents with limited range of motion will receive treatment and services to increase and/or prevent further decrease in range of motion; 4. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable .5. Therapy will evaluate/reevaluate the resident's mobility on a routine basis to determine the need for range of motion exercises. Review of the clinical record for R#94 revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] with documented [DIAGNOSES REDACTED]. Continued review of the MDS revealed R#94 was severely cognitively impaired and exhibited no behaviors during the assessment period. The resident required extensive to total assistance of one to two staff persons for all Activities of Daily Living (ADLs). During this assessment period, R#94 received Occupational Therapy (OT), passive range of motion (ROM), and splint/brace assistance. Review of the Task tab for R#94 printed from the electronic record on 1/31/19 revealed the resident required total assistance for eating; required two-person total dependence for bathing, bed mobility, and dressing. These tasks were to be completed by the Certified Nursing Assistants (CNAs). Further review revealed Restorative staff was to provide the resident with passive ROM to the left hand six times per week for 15 minutes for each treatment and was to apply a splint/brace to her left hand for up to six hours - six times per week. The Task tab did not list the use of a travel neck pillow to be used for proper head positioning. Review of the comprehensive care plans for R#94 last reviewed on 1/12/19 revealed the plan did not list appropriate head positioning as a focus area requiring interventions. Review of Therapy Screening Forms for R#94 dated 4/26/18, 7/31/18, 9/25/18 and 12/17/18 revealed a section with instructions to Indicate all areas reflecting a change in condition or an area with a deficit that may warrant therapy. For each screening form, the items in this section were left blank and unaddressed. Some of the items included in this section were: Poor positioning/body alignment, swallowing difficulties, choking/coughing with meals/meds. The 12/17/18 screening form recommended an OT evaluation. Review of the OT Discharge Summary for R#94 dated 1/11/19 revealed R#94 received OT services from 12/18/18 through 1/11/19. R#94 received OT services for the following reasons: 1) increase trunk strength; 2) increase sitting balance during ADLs; 3) to achieve normal anatomical alignment of the right hand for three hours using a hand roll; 4) to exhibit a decrease in pain at rest in the left hand to improve functional use of upper extremities during ADLs; and 5) to safely wear finger extension splint on left fingers for up to five hours. R#94 was discharged from OT services on 1/11/19 due to achieving the highest practical level of functioning. One of the discharge recommendations was to continue to use cervical travel pillow when in bed and in Broda chair. Review of an Interdisciplinary Communication Memo for R#94 dated 1/11/19 completed by OT BB documented the following: to Continue to use cervical travel pillow when in bed and Broda chair to maintain appropriate head positioning. Observation in the resident's room on 1/28/19 at 10:55 a.m. revealed R#94 was lying in her bed with the head of the bed (HOB) elevated approximately 30 degrees. R#94 had a travel neck pillow around the back of her neck and the resident's head was bent forward and to the right near her shoulder with the resident's chin touching her chest as she slept. Observation in the resident's room on 1/30/19 at 11:35 a.m. revealed R#94 was lying in her bed and positioned slightly on her right side. The resident had the travel neck pillow around her neck, and her chin rested on her chest near her right shoulder. Interview at the nurses' station on 1/30/19 at 12:06 p.m. with Registered Nurse Charge Nurse (CN) AA revealed that R#94 used the travel neck pillow for positioning and for comfort. Registered Nurse CN AA confirmed, at this time, that the resident's head alignment was chin-to-chest, and stated that it had been that way for at least several months. Observation in the day room of the secured unit on 1/30/19 at 2:35 p.m. with OT BB present revealed R#94 was sitting in a padded Broda chair with her travel neck pillow behind her neck. The resident's chin was resting on her chest and leaning towards her right shoulder. During an interview at this time with OT BB in the day room of the secured unit, the therapist confirmed R#94 did not have appropriate neck positioning. OT BB revealed the travel neck pillow was something the family wanted the resident to have to address the resident's right lateral lean of her head towards her right shoulder that began over a year ago. OT BB stated that it was possible the travel neck pillow was contributing to the resident's chin sitting on her chest and therefore, OT BB felt she needed to screen the resident regarding neck flexion and the possible use of a neck collar. Interview on 1/30/19 at 3:50 p.m. with the Director of Nursing (DON) and MDS Coordinator revealed R#94's daughter encouraged and provided the use of the travel neck pillow. The DON said the pillow was brought in by the daughter over a year ago because the daughter felt her mother was comfortable with its use. Observation of R#94 in the day room of the secured unit with the DON present on 1/30/19 at 4:10 p.m. revealed the resident had the travel neck pillow around her neck and the resident's chin was resting on her chest. During an interview at this time in the day room of the secured unit with the DON, the DON stated she had not seen the resident's head/neck in that position before and felt that it (chin-to-chest position) was something that had recently happened. Interview on 1/31/19 at 8:55 a.m. with the DON revealed the DON had spoken with OT BB and that the therapist informed her that the intended purpose was for the travel neck pillow to be used as a preventative intervention for hyper-extension of the resident's neck (going backwards) but after looking again, the OT BB felt the travel neck pillow may be causing flexion of the neck muscle (going forward). Interview on 1/31/19 at 10:38 a.m. with the DON revealed OT BB assessed R#94 (on the morning of 1/31/19), and OT BB was going to call the residents daughter to discuss discontinuing the use of the travel neck pillow. Follow-up interview with the DON on 1/31/19 at 11:46 a.m. revealed that the DON spoke with the resident's daughter and that the daughter explained that the initial reason for getting the travel neck pillow was to keep the resident's head from leaning to the right side. She said the daughter realized that the resident's head was now moving forward in the chin-to-chest position and the daughter agreed with discontinuing the use of the travel neck pillow. Interview on 1/31/19 at 12:46 p.m. with OT BB revealed the therapist completed the resident's screening and the resident was going to be picked up for therapy to do some neck exercises and stretching and to determine if a soft collar should be utilized. OT BB said the daughter was in agreement of discontinuing the use of the travel neck pillow. Follow-up interview on 1/31/19 at 2:05 p.m. with OT BB revealed when asked about the resident's quarterly therapy screens not addressing the resident's neck posture, OT BB said that when she evaluated the resident earlier in (MONTH) 2019, she looked at her mostly for her hand splint. OT BB said she didn't realize until today (1/31/19) how thick and heavy the travel neck pillow was and said, gravity and the pillow are causing it (the resident's neck) to move forward and thrust her chin against her chest. The therapist stated the travel neck pillow needs to be discontinued.

Based on observation, interviews and review of facility policy titled, Handwashing/Hand Hygiene the facility failed to ensure food was served in a sanitary manner for six of 41 residents (R), R#63 and five unsampled resident) residing on the secured unit. Findings include: Review of the facility's document entitled Handwashing/Hand Hygiene policy (undated) noted the following: 6. Wash hands with soap and water for the following situations: a. When hands are visibly soiled; b. After contact with a resident with infectious diarrhea .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: a. Before and after coming on duty; b. Before and after direct contact with residents; .i. After contact with a resident's intact skin; .l. After contact with objects in the immediate vicinity of the resident; .o. Before and after eating or handling food; p. Before and after assisting a resident with meals. Review of the clinical record for R#63 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Quarterly MDS dated [DATE] revealed the resident required the limited assistance of one staff person for eating and required the extensive assistance of one staff person for personal hygiene. During the lunch meal observation in the north dining room of the facility's secured unit on 1/28/19 at 1:07 p.m. an unsampled resident was seated at a dining table waiting to be served her lunch meal. The resident's left shoe was off of her foot and the resident was having difficulty putting her shoe back on. At this time, the Activity Director (AD) was passing out utensils wrapped in cloth napkins to all of the resident in the dining room and when the AD approached this unsampled resident, the AD set the tray of utensils down on the table and then assisted the resident by putting her shoe on for her. After the resident's shoe was on, the AD picked up the tray and passed out the remaining two cloth wrapped utensils that were on the tray. The AD did not perform hand hygiene before passing the utensils to the two other unsampled residents. Upon completion of passing out the utensils, still having performed no hand hygiene, the AD then served and provided meal set-up for three other unsampled residents. Continued observation of this meal service at 1:15 p.m., revealed the AD left the dining room area and went to R#63's room to escort the resident to the dining room for lunch. The AD was observed to brush R#63's hair as the resident was sitting on her bed. After brushing the resident's hair, the AD prompted the resident to stand up and then escorted R#63 to the dining room by using side by side assistance while holding the resident's hand. Once in the dining room, the AD assisted the resident in sitting down at the table. Without performing any hand hygiene, the AD served the resident her meal tray and then provided meal set-up. Interview with the AD in the north hallway of the secured unit on 1/28/19 at 1:25 p.m. revealed when the AD was asked what she should have done after assisting the unsampled resident with her shoe, the AD paused and then said, My hands! The AD continued and said that because she was multi-tasking, she over-looked the step of washing her hands or using hand sanitizer after assisting the resident with her shoe and after brushing R#63's hair. The AD said she missed that step. Interview at 1:30 p.m. at the nurses' station with Registered Nurse Charge Nurse (CN) AA revealed that the AD was also a CNA (Certified Nursing Assistant) and that she assisted the other CNA's with meal service on the unit at least once or twice each week. Registered Nurse CN AA confirmed that the AD should have performed hand hygiene after assisting the residents with their dressing and hygiene tasks. In addition, Registered Nurse CN AA said hand hygiene should be conducted between each resident's meal set-up.

Based on observation, staff interview, anonymous interviews, review of dish washer temperature log, and review of the Dish Machine Temperatures policy, revised 1/2016, and the Uniform Dress Code policy dated 1/2016, the facility failed to ensure the high temperature dishwasher wash temperature was maintained at 160 degrees Fahrenheit (F) and final rinse temperature was maintained at 180 degrees (F), or higher, The facility failed to have test strips for the dishwasher and attach the test strips to the dishwasher log as required by facility policy, and failed to ensure that staff wore hair and beard restraints while in the kitchen. This failure had the potential to effect 128 residents that received food from the kitchen. Findings include: Observation on 3/21/17 at 10:37 a.m. of the electronic dishwasher monitor screen revealed that it was red and had a tringle with an exclamation point (!) in it. In an interview at this time Dietary Aide DD stated that the dishwasher monitor screen was red and had an exclamation point in the triangle, because the water temperature in the dishwasher was too low. Dietary Aide DD stated that the dishwasher was a hot water dishwasher, the wash water temperature is supposed to be 160 degrees F and the rinse is supposed to be 180 F, but the water temperature has been fluctuating. Continued observation on 3/21/17 from 10:37a.m. to 10:45 a.m. revealed that the Dietary Aide DD continued to wash the dishes and the monitor continued to be red with an exclamation point inside a triangle. The wash water temperatures on the electronic monitor fluctuated from 132 to 157 degrees F and the rinse temperature fluctuated from 177 degrees F to 192 degrees F. Further observation revealed Dietary Aide DD never verified the water temperature fluctuation with a test strip attached to a dish. In an interview at this time the Dietary Aide stated that he had washed about 10 racks of dishes and the other staff member put them on the storage rack. In further interview, Dietary Aide DD stated that his supervisor instructed him to continue to wash dishes, the repair person had been called and was on his way. In an interview on 3/21/17 at 11:05 AM the Dietary Manager CC stated that she had the staff re- wash all the dishes that were ran through the dishwasher using the three compartment sink and she in-serviced the staff on not using the dishwasher when the water temperatures were not correct. Duringan interview on 3/21/17 at 3:09 PM the Dishwasher repair person stated that the wash water temperature in the dishwasher was only getting up to 140 F degrees for wash temperature and the rinse water temperature was at 160 degrees F, but the wash should be at 160 degrees F, the rinse should be at 180 degree F, he would run his test strips through the dishwasher once he gets the water temperature corrected. In continued interview the Dishwasher repairman stated that the dishwasher booster heater was tripped by the cold water that had been sitting in the pipes and he would email this surveyor the invoice once the work was completed. Surveyor received an email from the dishwasher repair person on 3/21/17 at 4:07 p.m., requesting a call back. When called the repair person stated ESR booster heater not working, Temp was low on rinse and wash tank, reset booster heater, now reading 195 on the rinse, 160 on the wash. During an interview on 3/22/17 at 10:48 AM the Dietary Manager stated that the dishwasher's electric monitor was not working, she called the repair person to replace it and she did not have test strips to check the water temperature of the dishwasher. Review of the facility's Dish Machine Temperatures policy dated revised 1/16 revealed: Single-tank, conveyor, dual temperature machine: Wash temperature 160 degrees F, Final rinse temperature 180 F -194 F. High Temperature Dish machine- Record on Dish machine record form wash and final rinse temperatures during each period of use. Once a day, run a test strip through the dish machine to verify the surface temperature of a dish. Attach the used test strip to the temperature log. The test strip must verify that the surface temperature of the plate reached 160 degrees F. If documentation of the temperatures and test strips has been assigned to a Food and Nutrition Associate confirms that it is completed at each meal period. Director determines if reading is due to malfunctioning gauge or inappropriate temperature .If due to inappropriate water temperature (high temperature machine) or inappropriate concentration of sanitizer solution (low temperature), implements disposable service ware, contacts sources of repairs, documents action taken on back of form. Review of the facility's dishwasher log for the month of March 2017 revealed that there were no test strips attached to the dishwasher log verify the surface temperature of a dish. Beard and hair restraints In a confidential interview on 3/20/17 at 1:33 p.m. an employee stated that the staff are only wearing hair nets because surveyors were in the building. Observation on 3/21/17 at 12:05 p.m. revealed that Dietary Aide EE had facial hair and was in the kitchen without a beard restraint. In an interview at this time Dietary Aide EE stated that he is supposed to have on a beard restraint when he is in the kitchen. Observation 3/21/17 at 12:05 p.m. revealed that Licensed Practical Nurse (LPN) FF was in the main kitchen in the food prep area without a hair net. In an interview on 3/21/17 at 12:01 p.m. the Dietary Manager stated that staff are not supposed to be in the kitchen without hair nets or beard restraints. Review of the facility's Uniform Dress Code policy dated 1/16 revealed . Wear the approved hair restraint when on duty. The only exception is to remove hair restraints when delivering trays to patients/residents . Facial hair must be effectively restrained as per local and state regulations .

Based on interview with facility staff, review of the electronic records, and review of the policy titled Room Change/Roommate Assignment, revised December 2006, the facility failed to ensure that written notification of room change was provided before moving a resident from the third floor to the fourth floor for one of 32 sampled residents (R) (R#194). Findings include: Review of a Social service assessment dated [DATE]; the resident is coded as independent for decision making skills and understanding the need for placement and participated in the placement decision. Review of the Room Change/Roommate assignment policy, revised in December 2006 includes in part; Prior to changing a room or roommate assignment all parties involved in the change assignment (e.g.) Residents and their representatives (sponsors) will be given a 2-day advanced notice of such change. The notice of a change in room or roommate assignment may be oral or in writing, or both, and will include the reason(s) for such change. On 3/20/2017 at 1:00 p.m., R#194 was interviewed and he reported that he was very upset at the time that he was moved to this room from the third floor. He stated this happened about three months ago and no one prepared him for a room change. The resident said, they came to me after I finished my breakfast and moved me the same day. The resident stated, They told me I had to be moved because I no longer needed therapy and I became long term care. If they do it again I will speak up for myself because that really upset me. Review of the Shift Charting Notes dated 1/16/2017 at 9:49 a.m., the resident was transferred to (a room on the fourth floor) per staff. Medications and personally belongings transferred, report given as well. Review of a General Social Services Note dated 1/12/2017 at 3:18 p.m, documents the resident is to remain for long term care. MSW left a message on voice mail of his daughter to discuss room change to the 4th floor- traditional long term care unit. Advised bed is available a telephone service would need to be established if they desire a land line, needs a dresser and TV. Requested a return call to discuss this further. Planning for change to a fourth floor room, if agreeable. On 3/22/2017 at 11:03 a.m., during interview with the Social Service Associate he confirmed that he did not receive a return call from R#194's daughter and he did not call her back, nor did he document any conversation with the resident regarding any room changes. He stated that he was off for the weekend holiday and returned on 1/17/2017 and was then notified the resident had been moved from the fourth floor on 1/16/2016. He provided the surveyor with a room change notification form dated 1/17/2017 at 9:11 a.m., the form included new room number on the fourth floor and the residents' daughters' name as being notified a day after the move occurred.

Based on record review, review of policy and procedure and interview, the facility failed to ensure that one of three sampled residents (R) (R#1) was free from abuse. Specifically, actual harm was identified on 12/26/16 when R#1, a resident with advanced dementia and [MEDICAL CONDITION], was mistreated in the form of physical abuse, mental abuse, intimidation and corporal punishment when a Certified Nursing Assistant (CNA) FF pulled the resident backward in his wheelchair from the back of his collar and back of his shirt. R#1 would not respond to interview questions however, a telephone interview with the Family on 1/25/17 at 3:55 p.m. revealed she recalled one evening that a nurse called to report she was having problems giving R#1 his medication and reported he seemed more agitated than usual. The Family stated she talked to R#1 on this occasion on the telephone and he told her someone is pushing me around and being mean to me. A post survey interview during the Quality Assurance (QA) process, with the DON on 1/30/17 at 2:15 p.m. revealed a review of the facility video surveillance confirmed the abuse and she could actually see the shirt pressing against the resident's neck as he was being pulled backward in his wheelchair. This incident was entity reported to the State Agency on 1/12/17 (GA 510). Findings include: Review of the facility's undated policy titled Abuse Prevention Policy and Procedures documented: It is the intent of this facility to actively preserve each resident's right to be free from mistreatment, neglect, abuse, exploitation or misappropriation of resident property. We believe each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. This policy applies to anyone subjecting a resident to abuse including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends, or other individuals. Definitions: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish. Physical Abuse includes hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. Mistreatment is the inappropriate treatment or exploitation of a resident. Review of the facility's follow up letter to the State Agency- Long Term Care Section- Compliant Unit dated 1/18/17 documented: During the course of a facility investigation conducted on 1/12/17 (into an unrelated, unsubstantiated complaint involving Certified Nursing Assistant (CNA) FF reported on 1/10/17), CNA AA reported there had been an inappropriate incident that she witnessed on 12/26/16 involving CNA FF and R#1. CNA AA reported that on 12/26/16, around dinner time, she observed that R#1 was very restless and agitated that evening and kept trying to get out of his wheelchair and staff were redirecting him because they were afraid he would stand up and fall. Toward the end of the meal, CNA FF took R#1 by the back of the shirt and snatched him back into his wheelchair. The motion caused him to fall back into the chair and then she pulled him backwards in his wheelchair by the collar/back of his shirt toward the direction of his room. The Director of Nursing (DON) was able to review camera footage of the incident which occurred in the 2S dayroom area and was time stamped on 12/26/16 at 5:40 p.m. Details of incident indicated R#1 is seen seated in his wheelchair with CNA GG seated behind him. He appears restless and persists in trying to stand from the chair. CNA GG is seen redirecting him by patting his shoulders in a reassuring manner. CNA FF is then seen clearing the table of dishes, placing them in a tray rack, then turns and walks toward R#1 who is seated in his wheelchair. CNA GG walks away down the hall, then CNA FF is seen grabbing and pulling R#1 by the back of his shirt collar and begins to roll him backwards in his wheelchair by pulling on his shirt. She then changes her hand position to grab the middle of his shirt and continues pulling him backward to his room. The facility does substantiate CNA wrongdoing and suspicion of resident mistreatment in this incident. CNA FF was terminated on 1/13/17 related to this incident with R#1 for suspected mistreatment of [REDACTED]. The facility immediately followed up this incident by conducting all-staff-in-services on abuse policy and procedure and reporting protocols. R#1 was assessed for any physical injury, none noted. The Family of R#1 was notified of this incident and facility follow-up to protect residents from future occurrences. The Family stated that she recalled one evening recently that a nurse called to report that she was having problems giving R#1's medication and reported that he seemed more agitated than usual. The Family stated she talked to her husband on this occasion and he told her someone is pushing me around and being mean to me. The Family could not remember the nurse's name or the date of this conversation with the nurse and her husband but believes it may correspond with the timing of the incident. Record review for R#1 indicates this is a [AGE] year old male, admitted to the facility dementia unit on 10/26/16 with primary [DIAGNOSES REDACTED]. The resident has a history of falls with left [MEDICAL CONDITION] July 2016. He is alert with confusion, has limited speech and impulsive behaviors with no safety awareness. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) summary score of 99, indicating the resident was unable to complete the interview. The resident's cognitive skills for daily decision making is moderately impaired. The resident has disorganized thinking that fluctuates, comes and goes and changes in severity. The resident did not exhibit behaviors. The resident required extensive assistance with all Activities of Daily Living (ADL) except with eating. An interview on 1/25/17 at 2:21 p.m. with CNA AA revealed the day of the incident, was the day after Christmas and it was me, CNA FF and another employee (CNA GG) in the dining area with R#1. The other employee (CNA GG) no longer works here so I'm the only witness. That day R#1 was real agitated because he hadn't seen his wife and he wanted to go see his wife that day. R#1 was walked from the north side dining room to the south side dining which is next to his room. He was agitated and CNA FF had him (sic) and it was time for his shower. CNA FF went to put the resident in the wheelchair and he got back up. CNA FF pulled R#1 by his shirt back into the chair. He wasn't injured but he was already upset and this aggravated him more. R#1 is a sweet guy. He only really wants to get in his bed. He doesn't want to get up until it's time to go to the dining room, then he wants to go back to the bed and to watch CNN. An interview with R#1 was attempted on 1/25/17 at 3:13 p.m. R#1 did not respond to any questions or engage in conversation. A telephone interview on 01/25/2017 at 3:55 p.m. with the Family of R#1 revealed that on the evening of the incident, R#1 called to tell her that a girl had pushed him around. The Family told R#1 they love you and wouldn't hurt you and they are going to put you to bed. She added, the facility called her at a later date that she could not exactly remember, and told her that the girl (CNA FF) grabbed him and jerked him around by the shirt. The Family of R#1 recalled one evening that a nurse called to report she was having problems giving R#1 his medication and reported he seemed more agitated than usual. The Family stated she talked to R#1 on this occasion on the telephone and he told her someone is pushing me around and being mean to me. A post survey interview, during the Quality Assurance (QA) process, with the DON on 1/30/17 at 2:15 p.m. revealed that during an investigation for a different situation that involved CNA FF (that was not substantiated), CNA AA told her about the incident that occurred on 12/26/16 in the dining room. She said the CNA AA told her that CNA FF snatched the back of the resident's shirt causing him to fall back into his wheelchair. The DON reviewed the facility surveillance video and stated that she could see R#1 seated in his wheelchair but could not see from that view if CNA FF pulled him into his wheelchair. The DON Stated that she could see on the video that CNA FF grabbed the back of the resident's shirt collar and began pulling him backward in his wheelchair. She said she could actually see the shirt pressing against the resident's neck as he was being pulled backward in his wheelchair. CNA FF then switched her hand position and grabbed the middle back of the resident's shirt and continued to pull him backward in his wheelchair towards the direction of resident's room. The DON stated that she called the Resident's Family member to notify her of the incident. The DON stated that the Family member remembered receiving a call from the nurse telling her he was much more agitated than usual and that R#1 wanted to talk to her. The Family stated that when she spoke to the resident on the phone that evening and he told her someone was pushing him around and being mean to him, at first she thought he was probably confused so she did not report it to the facility. The Family felt bad that she did not believe him. Review of a written statement signed by CNA FF and dated 1/13/17 documented: After dinner the resident (R#1) was very upset because he wanted to talk to his wife at the time I didn't know that he can walk so I grab him by the pants to sit him down so he won't fall and I pull him hack. So to his room so we can come him down and we took him to the shower and I played like I was his wife and he come down. Yes he was come and went to sleep. So I left out and went back and started to feed in the dinner. (sic) Review of a written statement signed by CNA GG and dated 1/18/17 documented: I did not see CNA FF grab R#1 by his shirt. I hand him over to her and walked away to get his stuff together for the shower. So once my back was turn I didn't see anything happen after that. This incident happen 12/26/16. (sic) Review of an undated written statement signed by CNA AA documented: R#1 was very restless and agitated and he kept trying to get up out of his wheelchair. The staff was trying to redirect him because they were afraid he would stand up and fall. Toward the end of the dinner meal at around 5:30 p.m., I observed the following: CNA FF took R#1 by the back of the shirt and snatched him back into his wheelchair. This caused him to fall back into his wheelchair and then she pulled him backwards in his wheelchair toward the direction of his room. Review of a facility Employee Conference form dated 1/13/17 revealed CNA FF was given a final warning. Action taken was termination based upon mistreatment of [REDACTED].#1 on 12/26/16 at 5:40 p.m.-incident reported to the State office). Review of a facility employee conference form dated 1/18/17 revealed CNA AA was given a warning for poor work performance: Failure to report suspicion of resident mistreatment timely. Action taken: Immediate improvement needed or further disciplinary action will result up to and including termination. Goal: Understanding and follow-through to timely reporting of any pertinent observations related to resident treatment and care. Approach: Monthly in-services on abuse policies and procedures for three months. Review of documents titled In-Service Training Report revealed the following: On 11/21/16 the Topic of in-service was Abuse P&P (Policy and Procedure) which included a sign in sheet on the back of the document with a signature of attendance by CNA FF. On 12/28/16 the Topic of the in-service was Abuse P&P- How to report abuse which included a sign in sheet on the back of the document with signatures of attendance by CNA FF and CNA AA. On 1/11/17 the Topic of the in-service was Abuse P&P, employees present: CNA's, Nurses. Included sign-in sheet revealed 61 employee signatures in attendance. CNA AA's signature was included on this sig-in sheet. On 1/18/17 the Topic of the in-service was Abuse P&P- Reporting Guidelines which included a sign in sheet with one signature of attendance, CNA AA. Review of the Georgia Criminal History Name and Identifier Search dated 5/25/16 for CNA FF indicated no criminal records found.