Every finding on record at Ansley Park Health and Rehabilitation

Based on observations, staff interviews, record review, and the document titled, Logbook Documentation, the facility failed to ensure the dryer lint trap and the vent located in the ceiling that circulates hot air from the dryer were not clean. This deficient practice has the potential to cause adverse consequences, including fire, for all residents residing in the facility. The census was 65. Findings include: Review of the Logbook Documentation dated 1/30/2024, 2/14/2024, and 3/7/2024 indicated the vent in the Laundry Room passed review. There was not a review for April 2024. The Maintenance Supervisor stated the review was done each month and the specific day of the month was determined by the last day of the review from the previous month. During a tour of the Laundry on 4/10/2024 at 1:30 pm with the Director of Nursing (DON) and Housekeeping BB revealed there were two dryers in the clean room; lint traps were not clean in these dryers. Housekeeping BB stated she cleaned the lint out of the bottom of the dryers every hour. The vent in the clean room that faces the dryer was there to circulate hot air from the dryer. There was dust located on the vent. There was one blanket and cloth lift slings lying directly below the vent. They were not covered. The Laundry staff stated Maintenance is responsible for cleaning the vent. Interview on 4/10/2024 at 2:00 pm with the Maintenance Supervisor, she stated Housekeeping cleaned the vent in the laundry dryer every hour. During observation of the large vent in the ceiling after being cleaned by the Maintenance Supervisor, there was an accumulation of dust seen on the vent. The Maintenance Supervisor confirmed there was still dust on the vent. She stated she will clean it again. Observation of the dryer indicated the lint trap had not been cleaned; there was still an accumulation of lint in the dryer.

Based on observations, staff interviews, and record review, the facility failed to ensure oxygen (O2) administered by nasal cannula (NC) was set at the prescribed rate for one of 19 residents (R) (R49) receiving O2 therapy. The deficient practice has the potential to cause respiratory distress for R49. Findings include: Review of the electronic medical record (EMR) for R49 in the Minimum Data Set (MDS) under Section C-Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Under the MDS Section J-Health Conditions revealed R49 has a condition or chronic disease that may result in a life expectancy of less than 6 months. The medical diagnoses include malignant neoplasm of body of pancreas, anemia, unspecified, personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, essential (primary) hypertension, other seizures, pneumonia, unspecified organism. Review of a Physician Order with a start date of 4/7/2024 revealed Oxygen: Nasal Cannula (Oxygen: Nasal Cannula) 2 lt liter per Minute (LPM) nasally every 8 hours As Needed OTHER (document in order notes) 2Lt [sic] per minute via nasal cannula as needed for shortness of breath and/or o2 [sic] saturation below 90 for comfort. The care plan revealed Resident at risk for adjustment difficulty, limited mobility, self-care deficit, needs assistance participating in activities due to terminal diagnosis / end-of-life, and respiratory difficulties/ risk for further decline. Observation and interview on 4/9/2024 at 1:43 pm with R49, she was lying in bed, answering verbal questions with one word, talking softly. Her sister was at her bedside. O2 was on at 3 LPM via NC with no distress noted. Observation of wound care on 4/11/2024 at 10:10 am, R49 was on O2 at 3 LPM. The Resident was sleeping during the treatment with no distress noted. Interview on 4/11/2024 at 11:00 am with Licensed Practical Nurse (LPN) AA revealed R49 received morphine this morning that could be contributing to R49's lethargic state. LPN AA confirmed O2 at 3 LPM via NC was on R49, but the physician order states 2 LPM via NC. LPN AA turned the O2 down to 2 LPM. Interview on 4/11/2024 at 11:20 am with the Director of Nursing (DON) revealed they do not have a respiratory therapist; the nurses manage respiratory care. She expects the nurses to follow the physician's orders. Interview on 4/11/2024 at 5:22 pm with the Administrator revealed her expectations include getting the order right and providing the correct amount of O2 for the resident.

Based on observation, interview. and record review, the facility failed to have all personal protective equipment (PPE) readily available for staff use for one of one resident (Resident (R) 137) reviewed for transmission-based precautions. Additionally, PPE that was readily available was stored for use in the patient room where it could become contaminated. R137 was in quarantine due to being a new admission and unvaccinated for coronavirus disease 2019 (COVID-19). This failure had the potential to allow spread of infections, including COVID-19, to 22 residents on the first floor who were cared for by the same staff as R137. Findings include: During an observation on 04/25/22 at 10:30 AM, one resident (R137) was located in the COVID-19 quarantine unit. The quarantine unit was located on the first floor at the end of the hallway. The quarantine unit was blocked off from the other residents by a plastic wall with a doorway. There were three signs placed on R137's door stating, STOP Droplet Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry or Remove face protections before room exit; STOP Contact Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person .; COVID-19 Personal Protective Equipment (PPE) for Healthcare Personnel Preferred - Use N95 of Higher Respirator Face shield or goggles, N95 or higher respirator, Isolation gown, one pair of clean non-sterile gloves . There was not any PPE or hand sanitizer located immediately outside of R137's room or in the hallway. The door to R137's room was open and on a table inside the room were several gowns. Surveyor looked in the adjacent two rooms and there was no PPE readily available for use. One of the rooms was being used as a storage room and had numerous boxes in it, but the surveyor was unable to determine what was in the boxes. Surveyor left the quarantine area to locate a staff member to discuss the lack of PPE in the quarantine unit. During an interview on 04/25/22 at 10:38 AM, with Licensed Practical Nurse (LPN) 2, when asked about the PPE on the quarantine unit, LPN2 noted there were some gowns in R137's room and stated additional PPE must be the adjacent room. LPN2 went into the adjacent room and looked around but could not locate PPE that was readily available for use. LPN2 acknowledged the PPE should be available to don prior to entering R137's room. LPN2 left the quarantine unit and returned carrying a PPE door hanging unit with filled with PPE but stated she did not have access to the stickers to enable her to hang the holder on R137's door. LPN2 left the unit and returned with a rolling bedside table and laid the door hanger on the table. Surveyor questioned how staff were to sanitize their hands prior to donning gloves (there was no sanitizer located in the hallway) and LPN 2 stated she would obtain the hand sanitizer. Surveyor questioned LPN2 who was responsible for placing the required PPE for a resident who was under quarantine, and she said replied, Anybody. During an interview on 04/25/22 at 10:45 AM, on the quarantine unit, the Director of Nursing (DON) said she was surprised the PPE had not been available for staff to don prior to entering R137's room. The DON stated there was a red cart stocked with PPE that should have been placed outside of R137's room and she did not know why the staff did not utilize the cart. The DON stated she was responsible to ensure that PPE was in place for use with a resident on the quarantine unit. Review of R137's EMR under the Face Sheet tab indicated R137 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R137's EMR under the Orders tab indicated an order 04/24/22 droplet precautions 9 days, Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R137's EMR under the Test Results tab revealed R137 received COVID-19 tests on 04/22/22 and 04/24/22 and both test results were negative. Review of the facility's policy titled, Admission and Placement of Patients dated 02/22 stated, Purpose To provide guidance to centers regarding admission and readmission of patients during COVID-19 pandemic . Managing New Admission and Re-Admission Patient Placement . 2. New admissions . whose COVID-19 status is unknown or not up to date on all recommended COVID_19 vaccine doses should be placed in the observation unit. 3. New admissions regardless of vaccination status should have a series of two [CONDITION(S)] test for [CONDITION(S)]-Cov-2 infection; immediately . Review of the facility's policy titled Transmission-Based Precautions (Contact, Enhanced Barrier Precautions, Droplet, Airborne) dated 2020 stated, Intent It is the policy of this facility to use transmission-based precautions for patients who have infectious or communicable diseases that may necessitate the use of barriers in addition to those used for Standard Precautions . Contact Precautions This facility uses Contact Precautions . for patients with known or suspected infection . with highly transmissible . pathogens for which additional precautions are needed to prevent transmission . Use of PPE Gloves . Gowns . Droplet Precautions This facility uses Droplet Precautions as recommended . for patients with known or suspected to be infected with pathogens transmitted by respiratory droplets . Use of PPE . For patients with suspected or proven . pandemic influenza refer to the following websites for the most current recommendations at the time (https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.Html . Review of the Centers for Disease Control and Prevention, above mentioned, website revealed COVID-19. Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 Pandemic updated 02/02/22 indicated, . Personal Protective Equipment HCP who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face).

Based on observation, interview, and facility policy review, the facility failed to ensure one of three medication carts were locked when not under the direct control of a licensed nurse. The failure could have led to residents or unauthorized staff having access to medications stored in the medication cart. Findings include: Observation of the 100-hall on 04/28/22 at 8:43 AM revealed an unlocked medication cart pushed against the wall with the drawers facing the hallway. The cart was against the wall to the right of Resident (R) 36's room with no nurse or medication aide in the area. Licensed Practical Nurse (LPN) 1 was observed down the hall entering R138's room with medications. LPN1 was away from the cart for four minutes, during which the cart was not under the direct supervision or sight of an employee with the qualifications to supervise a medication cart. At 8:47 AM on 04/28/22, LPN1 returned to her medication cart, she locked the cart as this surveyor approached her to conduct an interview. During the interview at 8:48 AM on the same day, LPN1 stated the cart should have been locked before she walked away from it. When asked why the cart had not been locked, she replied, I forgot to double check myself. LPN1 confirmed the cart should have been locked before she walked away to administer R138's medications or when she was not physically in the presence of the medication cart. During an interview on 04/28/22 at 9:32 AM, the Director of Nursing (DON) stated her expectation was that the medication cart should have been locked before LPN1 walked away to administer medications. The DON confirmed medication carts were to be locked when unattended or not under the direct supervision of the nurse or medication aide assigned to the medication cart. Review of the facility policy titled, Pharmacy Services Medication Administration-General with a copyright date of 2019 stated, . During routine administration of medications, the medication cart is kept locked or under direct observation of licensed staff .

Based on observation, staff interview, and policy review the facility failed to properly store clean dishware; failed to hold cold food items at/or below 41 degrees Fahrenheit as well as hot foods above 135 degrees Fahrenheit on the steam table; and dietary staff failed to properly wash hands after touching soiled dishware before touching clean dishware. This deficient practice had the potential to effect 51 residents receiving an oral diet. Findings include: Observation on 7/21/18 at 12:20 p.m. of Dietary Aide AA revealed she exited the dish room with a cart that had clean dishware on the top shelf and was taking the items to their appropriate areas. Continued observation revealed Dietary Aide AA took a green colored cloth and dried the inside of measuring cup before placing on the storage rack. Observation on 7/21/18 at 12:28 p.m. revealed Dietary Aide BB exiting the dish room wiping a metal spatula dry with a green colored cloth and placing it in a wire metal basket hanging from the wall. Further observation revealed a box labeled Foodservice Counter Towel on a shelf under a food preparation table which contained the green colored clothes Dietary Aide AA and Dietary Aide BB were using to dry the dishware. Steam table temperatures were attained on 7/21/18 at 12:30 p.m. using the facility's calibrated thermometer and the Dietary Manager (DM) assisted with obtaining and verifying the food temperatures. The following food items were not held at the proper temperatures: - Chopped Smoked Sausage was 107 degrees Fahrenheit. - Puree Cauliflower was 127 degrees Fahrenheit. - Glass of Skim Milk was 49 degrees Fahrenheit. Continued observation of the steam table revealed that the chopped smoked sausage was in a small pan, resting on the back ledge on the steam table, the pan was not directly inside the steam table. Observation of the pureed cauliflower revealed it was in a small pan and that pan was placed inside another pan that was in the steam table. Further observation revealed an open cart the multiple shelfs, and one shelf had a bin that contained beverages poured into glasses. There was ice in the bin that covered the bottom one inch of the glasses, the top 4 inches of the beverage glasses were not covered with ice. Interview on 7/21/18 at 12:30 p.m. with the Dietary Manager revealed that the chopped smoked sausage, pureed cauliflower, and milk were not at the correct temperatures. Continued interview with the Dietary Manager revealed that one more resident was to receive the chopped smoked sausage and one more resident was to receive the pureed cauliflower. Continued interview with the DM stated that the dietary aides get the cold food prep cart ready for lunch. Observation on 7/21/18 at 12: 40 p.m. of Dietary Aide BB revealed she exited the dish room wiping 2 metal ice cream type scoops dry with a green colored cloth. Observation on 7/21/18 at 12:50 p.m. of Dietary Aide AA revealed she took a soiled plate from the window ledge in the dish room placed it in the wash sink, then took the water hose and sprayed sink. Continued observation revealed Dietary Aide AA exited the dish room and touch a stack of 4 resident meal trays sitting on the food preparation table. Dietary Aide AA was observed placing the 4 meal trays on top of a larger stack of trays next to the steam table which the cook was using to serve the resident lunch meal. Dietary Aide AA did not wash her hands after touching the soiled plate before touching the clean resident trays. Interview on 7/21/18 at 1:00 p.m. with Dietary Aide BB revealed she confirmed that she dried the metal spatula and scoops with the green cloth. She stated that the scoops were needed by the cook, so she wiped them dry for the cook to use. When asked why she wiped the metal spatula dry earlier and placed it in the storage basket she was not able to provide an answer. Interview on 7/21/18 at 1:05 p.m. with Dietary Aide AA revealed she confirmed that she did not wash her hands after touching the dirty plate and before touching the clean trays. Further interview with Dietary Aide AA she stated that she usually washes her hands between touching dirty to clean but forgot. Interview on 7/21/18 at 2:25 p.m. with the DM revealed that the documents she provided for review were the policies the dietary department follows. Continued interview revealed that the DM expects dietary staff to wash hands between handling dirty dishes and before touching clean dishes. The DM expects dietary staff to allow washed dish items to air dry before storing and not to wipe dry. Review of the document titled Ready 365 Best Practice Standard of the Week: Hand Washing revealed when to wash hands: after touching anything else that may contaminate hands, such as dirty equipment, work surfaces, or cloths. Review of the document titled Ready 365 Best Practice Standard of the Week: Monitoring temperatures during meal service revealed Food that is being held for service (either hot or cold) is at risk for time-temperature throughout meal service and maintain proper safe food handling practices to minimize risks. Proper holding temperatures, hot food is 135 degrees or higher, cold food is 41 degrees or lower. Continued review of the document revealed that cold items should be kept in the refrigerator for as long as possible; keeping the items in smaller batches and utilizing ice baths will help maintain proper temperatures. Further review of the document revealed all hot items should be appropriately inside a steam table well. Placing items above the steam table will not hold food at proper temperatures. Review of the document titled Ready 365 Best Practice Standard of the Week: Three compartment sink revealed to air dry items on a clean and sanitized surface (place the items upside down so they will drain, Never use a towel to dry items as it could contaminate them). Review of the document titled Ready 365 Best Practice Standard of the Week: High Temperature Dish Machine stated that dishes must be air-dried prior to storing them. Review of the document titled Resident Diets revealed that 4 residents receive a chopped diet and 2 residents receive a pureed diet. Review of the Food and Nutrition Competency Checklist for Dietary Aide BB revealed the dietary competency were completed however there was no dated documentation. Dish Machine topic was discussed with her and air drying was indicated, discussed infection control with dirty verses clean areas. Review of the Competencies for Food and Nutrition Services Employees revealed that Dietary Aide AA completed competencies on 5/10/18. The competency checklist indicated that the Dietary Aide has knowledge regarding stores dishware in a clean, dry location, not exposed to splash, dust, or other contamination and covered or inverted. Competencies included, understands infection control precautions, maintains appropriate practice for handling clean and sanitized equipment and utensils to protect them from contamination. Also, competencies in, properly washes hands with soap and water to prevent cross-contamination. Review of the in-service dated 2/6/18 revealed that the dietary staff were in-service regarding Measuring temp of food and the education provided included reheating food, measuring temps, cleaning food thermometer, monitoring controls on thermometer and adjusting. Review of the in-service regarding the Three compartment sink conducted on 8/14/18, revealed that neither Dietary Aide AA or BB had attended. Review of the in-service titled Hand washing conducted on 8/4/18 revealed that neither Dietary Aide AA or BB had attended. Review of the in-service titled High Temperature Dish Machine conducted on 10/3/17 revealed that neither Dietary Aide AA or BB had attended.

Based on record review, staff interview, and policy review, the facility failed to develop a plan of care related to the use of [MEDICAL CONDITION] medications for three residents (#4, #11, and #26) from a sample of 21 residents. Findings include: 1. Review of the clinical records for resident (R) #11 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the current physician's orders [REDACTED]. A review of the Minimum Data Set (MDS) assessment records for the resident revealed a Quarterly MDS assessment of 5/20/18 which documented [DIAGNOSES REDACTED].#11 on 12/1/17 and this assessment documented that the resident was being administered an antidepressant medication daily. Under the Care Area Assessment Summary (CAAS) of that annual assessment, [MEDICAL CONDITION] drug use triggered, and the decision was made to create a plan of care for that area. A review of the care plan records for R#11 revealed there was no plan of care related to the use of a [MEDICAL CONDITION] medication (an antidepressant). 2. A review of the clinical records for R#26 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the current physician's orders [REDACTED]. A review of the most recent comprehensive assessment for R#26 - a Significant change MDS dated [DATE] revealed the resident was assessed as having active [DIAGNOSES REDACTED]. The assessment also documented that the resident was receiving antidepressant and antianxiety medications daily. Under the Care Area Assessment Summary, [MEDICAL CONDITION] drug use triggered and a decision was made to complete a plan of care for that area. A review of the care plan records for R#26 revealed there was not a plan of care related to the resident's use of [MEDICAL CONDITION] medications (anxiolytic and antidepressant). 3. A review of the clinical records for R#4 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the current physician's orders [REDACTED]. A review of the Annual MDS assessment dated [DATE] revealed the resident was assessed as having an active [DIAGNOSES REDACTED]. Under the Care Area Assessment Summary, cognitive loss/dementia, behavioral symptoms, and [MEDICAL CONDITION] drug use triggered and the decision was made to complete a plan of care for those areas. A review of the care plan records for R#4 revealed there was not a plan of care related to the resident's use of [MEDICAL CONDITION] medications (antipsychotic and antidepressant). Review of the policy titled Patient's Plan of Care last reviewed and updated (MONTH) (YEAR) revealed that the care plan is developed from the patient assessment (MDS) and incorporates identified problem areas. During an interview on 7/21/18 at 4:06 p.m. with MDS Coordinator CC revealed that care plans for R#11, R#26, and R#4 related to the use of a [MEDICAL CONDITION] medication was not completed as planned and this was an oversight. She confirmed that the residents were receiving [MEDICAL CONDITION] medications.

Based on record review, staff interview, and policy review, the facility failed to ensure that a Baseline Care Plan was created related to the use of Intravenous(IV) medications for one Resident (R)#52 of one residents reviewed for hospitalization out of a sample of 21 residents. The census was 52. Findings included: A review of the clinical records for R#52 revealed he was admitted to the facility on [DATE] with the relevant [DIAGNOSES REDACTED]. Review of the Admission Physician order [REDACTED]. A review of the Electronic Medication Administration Record [REDACTED]. A review of the clinical record revealed that there was no documentation of a Baseline Care Plan for R#52 related to the use of a IV medication. A comprehensive care plan was documented as being created on 5/16/18 related to use of [MEDICATION NAME] evidenced by the [DIAGNOSES REDACTED]. An interview was conducted with the Minimum Data Set (MDS) Coordinator EE on 7/22/18 at 12:44 p.m. She has been employed at the facility since (YEAR). She stated that R#52 was admitted on [DATE] with an order for [REDACTED]. She stated that Baseline Care Plan was created on 5/16/18 and that the MDS department was educated two weeks ago related to completing the Baseline Care Plan within 48 hours. She was asked if she was aware of the recent changes to the regulations related to baseline care plans and she stated, I don't believe that rule was in place when he was here. When asked why the care plan related to the [MEDICATION NAME] IV medication use was created after the completion date of the medication, she could not provide an answer. During an interview with the Asistant Director of Nursing (ADON) on 7/22/2018 at 1:04 p.m. she stated that she has been at the facility for one year and that she was not sure of the facility policy or process related to the Baseline Care Plans. During an interview with the Director of Nursing (DON) on 7/22/2018 at 1:10 p.m. she stated that the facility has twenty-one days to complete the Baseline Care Plan. She was asked if she was aware the regulation changes related to creating a Baseline Care Plan within 48 hours of a resident's admission. She stated that she was aware. She stated that the comprehensive care plan is the Baseline Care Plan and that the reason that the dates don't reflect that it was created within the 48 hours is because the MDS staff changed the dates. She stated that there was no way to retrieve the original dates that the care plan was created. She was asked why the care plan had been changed by the MDS department to reflect the use of the [MEDICATION NAME] when he was no longer receiving the [MEDICATION NAME] IV treatment and she stated that she could not answer that question. During an interview via telephone with the Director of Clinical Assessments on 7/22/18 at 2:04 p.m. she stated that the policy is the regulation related to creating a Baseline Care Plan. She stated that she will send over the training and the process at which they train the staff. A review of the Process documentation provided by the Director of Clinical Assessments and the Nursing Home Administrator on 7/22/18 revealed that the admission nurse begins the process of developing the patients Baseline Care Plan as this is formed from the Admissions Nursing Assessment. The admitting Nurses are to review the care plan for each patient, after completing the admission assessment . must be individualized and specific to the patient. Review the problem, goal, and interventions . to update and revise to meet the needs of the patient.

Based on observations, record review, review of the facility's menu guide, and staff interviews, the facility failed to ensure mechanical soft - chopped meats were prepared properly for one resident (R) (#2) out of seven sampled residents. Findings include: Observation on 7/2/18 at 1:15 p.m. revealed R#2 in the dining room. Resident received meat cut into four large pieces without gravy and whole pieces of broccoli. Speech Therapist (ST) AA was observed cutting up the meat and broccoli. ST AA obtained gravy from the kitchen and poured over the meat. Interview with ST AA at this time revealed that the meat did not come out chopped as ordered. The meat came out in large cup up pieces. Observation on 7/2/18 at 6:15 p.m. during supper meal revealed R#2 received turkey pot pie which contained large chunks of turkey. Resident was unassisted for the entire meal and attempted to cut the turkey with a fork unsuccessfully. Resident did not eat any turkey pot pie. Review of the lunch and supper meal tickets for R#2 dated 7/2/18 indicated mechical soft: chopped. Review of the Minimum Data Set (MDS) Admission assessment dated [DATE] revealed R#2 with a Brief Interview of Mental Status (BIMS) score of 12, indicating cognition intact and an active [DIAGNOSES REDACTED]. Review of the physician order [REDACTED].#2 on a mechanical soft - chopped meat diet. Speech/Language Pathology Daily Notes for R#2 documented Skilled Services Provided: treatment of [REDACTED]. On 6/11/18, resident seen in the dining room for the noon meal. Resident given a trial of a whole piece of chicken. Resident does not cut meat and bites a big bite off the bone. Resident is unable to cut meat into small pieces. Resident will be left on mechanical soft chopped. On 6/21/18, resident seen in dining room. Resident did not receive the correct diet. Resident received a whole piece of chicken. On 6/29/18, resident seen in dining room. Resident did not receive the correct diet and received a whole filet of fish. Speech/ Language Pathologist cut up fish in very small pieces and put tartar sauce on it. Review of the Carolina Nutrition Menu Guide with no revision dated revealed the mechanical soft, chopped meat diet may be used for residents who have difficulty chewing and/or swallowing regular textured foods. Guidelines for this diet follow the Dysphagia Advanced Level 3 diet (foods should be moist and in bite-sized pieces that are about the size of your thumb nail). Meats that are difficult to chew are chopped and moistened with broth or gravy. Further interview with ST AA on 7/2/18 at 2:15 p.m. revealed that the meats often come out of the kitchen without being properly chopped. She stated that the kitchen staff have been educated on the proper consistency of the different diets. Interview with Dietary Manager on 7/2/18 at 4:31 p.m. revealed that chopped meats should be chopped with a knife into thumbnail size pieces. Review of the Nursing and Dietary Inservice dated 9/6/17 revealed education provided on diet consistencies: mechanically altered - meats will be specified chopped (cut into bite size pieces) or ground, and meats should always contain a moistener. Inservice/ Training Report dated 10/4/17 revealed education provided related to consistencies of liquids and solids, safety risks for patients and liability risks. Telephone interview with the Director of Dining Services on 7/3/18 at 1:19 p.m. revealed that she expects chopped meats to be round and pea size. She expects staff to have a close relationship with the residents and to follow appropriate guidelines per ST.

Based on observation, staff interview, and documentation review the facility failed to label, date, and cover opened food items in one of one walk-refrigerators; failed to discard food items past the use by date; and failed to ensure storage racks in the dry storage area were free from food debris to prevent pests/rodents. This deficient practice has the potential to effect 54 residents receiving an oral diet from a census of 55 residents. Findings include: Observation on 8/18/17 at 8:00 a.m. during the initial kitchen tour revealed the following in the walk-in refrigerator: 1) A five pound container of sour cream with a use by date of 7/21/17. 2) A one gallon container of Italian salad dressing opened with no lid. 3) A five pound bag of shredded cheddar cheese opened with no date. 4) A five pound bag of grated parmesan cheese opened with no date. 5) A square clear plastic container with sliced American cheese with no label or date. 6) A one gallon container of Home Style Ranch salad dressing opened with no date. 7) A square clear plastic container with a white liquid food item with no label or date. Observation on 8/18/17 at 8:20 a.m. and 8/19/17 at 3:50 p.m. of the dry storage area revealed a white granular substance on the storage rack that was present on three shelves, top, middle, and bottom. Interview on 8/18/17 at 8:25 a.m. with the Food Service Director (FSD) revealed she confirmed that the Italian dressing was opened with no lid, the ranch dressing opened with no label or date, the shredded cheddar cheese, parmesan cheese and sliced American cheese were all opened with no date. Continued interview with the FSD revealed she confirmed that the container of sour cream had a use by date of 7/21/17 and should have been discarded. She confirmed that the container with the white liquid food item was not labeled or dated. The FSD stated that staff are to label and date any opened food item, excepts staff to cover opened food items and to discard items past the use by date. Observation on 8/18/17 8:30 a.m. outside the door near the walk-in refrigerator revealed an undated sign title Discard Date Guidance which stated the manufacturer's expiration date, when available, is the use by date for unopened items. Interview on 8/18/17 at 3:50 p.m. with the FSD revealed she confirmed the white food substance on the storage rack in the dry storage room. The FSD revealed that the dry storage area is on the weekly cleaning schedule and excepts staff to clean the shelves. Review of the Serv Safe document dated 2008 title How to Store Food Properly: Best Practices for Storing Food revealed label and date all stored food and also keep storage areas dry and clean. Review of the Nutritional Services Procedural Guidelines revised May 2017 of Food Preparation, Storage and Serving revealed it is the intent of this center to serve safe food and practice basic safe food handling principles. Procedure Guidelines: 1) Food service associates will follow best practice standards from ServSafe, GA Dept. of Health, FDA, and CMS Regulations.

Based on observations and interviews, the facility failed to ensure that one (1) of four (4) ice machines were free from brown buildup on the dispensing lid and failed to ensure that foods were stored in a safe and sanitary manner in one (1) of one (1) cafe refrigerator and in two (2) of two (2) food pantries. Findings include: Observation and interview on 04/20/16 at 9:01 a.m. with the Food Service Manager revealed that the dining room Cafe refrigerator had two (2) forty-six ounce (oz) containers of thickened water dated 4/12/16 to be used by 4/18/16, that were expired. Interview with the Food Service Manager at this time confirmed that the items were out of date. Observation on 04/20/16 at 9:22 a.m. of the first floor food pantry revealed two (2) bowls of cereal were covered but not labeled or dated. Observation on 04.20/16 at 9:36 a.m. of the second floor food pantry revealed four (4) yogurt containers two (2) yogurt containers with a sell by date of 4/11/16 and two (2) yogurt containers with a sell by date of 4/13/16. Observation on 04/20/16 at 9:38 a.m. revealed the Ice Machine dispensing lid had a buildup that was brownish in color. Observation on 04/20/16 9:40 a.m. revealed one (1) Taco Bell rice bowl located in the cabinet of the second floor food pantry was not labeled with the residents name that had an expiration date of February 17, 2016. Interview on 04/20/16 at 9:44 a.m. with the Resident Care Coordinator (RCC) Coordinator/Unit Manager for the second floor confirmed the brownish build up on the ice machine dispensing lid and reported that maintenance is responsible for the cleaning and servicing of the ice machine. The RCC Coordinator/Unit Manager for the second floor confirmed that the expired yogurt and rice bowl would be discarded. Interview on 04/20/16 date at 10:36 a.m. with the RCC Coordinator/Unit Manager for the first floor at confirmed that the cereal in the food pantry cabinet should have been labeled and dated prior to being placed in the cabinet.

Based on record review and staff interviews, the facility failed to follow physician's order regarding physician notification for one (1) resident (#279) from a sample of twenty-five (25) residents. Findings Include: Record review for resident #279 revealed [DIAGNOSES REDACTED]. A physician's order dated 2/27/15 indicated the resident was to have daily weights and to notify physician of a gain of two (2) to three (3) pounds in 24 hours or five (5) pounds in a week Review of Medication Administration Records (MARs) for February and March 2015 reveal a weight gain of ten pounds from 2/28/2015 until 3/2/2015. Further review of these MARs revealed a weight of 190.4 pounds on 2/28/15 but no other weights unit 3/2/15, when the resident's weight was 200 pounds. The resident was not weighed again until 3/5/15, and his weight was 204 pounds. There was no evidence that the facility notified the physician of the weight gain. Interview with Licensed Practical Nurse (LPN) "AA" on 3/11/2015 at 11:35 AM revealed she was not aware of the physician's order for daily weights for resident (#279). After record review she determined that the physician was not notified of the ten (10) pound weight gain discovered on 3/2/2015. Interview with the Director of Nurses (DON) conducted 3/11/2015 at 12:53 PM revealed she had reviewed this resident's chart and the was no evidence the physician was notified of the resident's weight gain.

Based on record review and staff interview the facility failed to follow a physician's order for daily weights for one (1) resident (#279) from a sample of twenty-five (25)residents. Findings Include: Record review for resident #279 revealed [DIAGNOSES REDACTED]. A physician's order dated 2/27/2015 indicated the resident was to have daily weights and to notify physician of a gain of two (2) to three (3) pounds in 24 hours or five (5) pounds in a week. Review of Medication Administration Records (MARs) for February and March 2015 reveal a weight gain of ten pounds from 2/28/2015 until 3/2/2015. Further review of these MARs revealed a weight of 190.4 pounds on 2/28/15 but no other weights unit 3/2/15, when the resident's weight was 200 pounds. The resident was not weighed again until 3/5/15, and his weight was 204 pounds. There was no evidence that the resident was weighed daily according to the physician order. Interview with Licensed Practical Nurse (LPN) "AA" on 3/11/2015 at 11:35 AM revealed she was not aware of the physician's order for daily weights for resident (#279). Record review with " AA " indicated weights were taken three times since his admission. After record review, she determined that the resident had a ten (10) pound weight gain as of 3/2/2015. Interview with LPN "BB" on 3/11/2015 at 11:40 AM revealed daily weights were not done on this resident and she was not aware of the physician's order. Interview with the Director of Nurses (DON) conducted 3/11/2015 at 12:53 PM revealed she had reviewed this resident's chart and the physician's ordered for daily weights and daily weights had not been done.

Based on record review and staff interviews the facility failed to follow a the plan of care for weight and physician notification for one (1) resident (#279) from a sample of twenty-five (25) residents. Findings Include: Record review for resident #279 revealed [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of the resident's plan of care dated 3/10/15 revealed a care plan for nutrition. The goal was for the resident not to have a significant weight change. An intervention was to observe weights and notify the physician of significant weight changes. Interview with Licensed Practical Nurse (LPN) "AA" on 3/11/2015 at 11:35 AM revealed she was not aware of the physician's orders [REDACTED].#279). After record review she determined that the physician was not notified of the ten (10) pound weight gain discovered on 3/2/2015. Interview with the Director of Nurses (DON) conducted 3/11/2015 at 12:53 PM revealed she had reviewed this resident's chart and the was no evidence the physician was notified of the resident's weight gain. Cross Refer to F157.

Based on observations, staff interviews, and review of the USDA "Cold Storage Chart", the facility failed to discard potentially hazardous foods timely. Findings include: On 5/27/14 at 10:40am during the initial tour of the kitchen, observation of one (1) reach-in cooler revealed various expired condiments as follows: One (1) squeeze bottle of BBQ sauce with a prepared date of 10/11/13, One (1) squeeze bottle of Thousand Island dressing with a use by date of 3/25/14, One (1) squeeze bottle of Honey Mustard dressing with a use by date of 3/25/14, One (1) squeeze bottle of French dressing with a use by date of 3/25/14, One (1) squeeze bottle of Creamy Italian dressing with a use by date of 3/25/14, One (1) squeeze bottle of Mustard with a prepared date of 4/3/14, The kitchen manager was present during this observation and acknowledged all should have been discarded. She removed all the squeeze bottles of condiments at this time and placed them in the sink area to be emptied and cleaned. Observation of the dry storage area at 10:50am revealed one (1) bag of cake mix dated 5/2/14 that was not covered and the top was loosely folded over. Interview with the Kitchen manager at this time confirmed the cake mix should have been stored in a closed zip lock baggie. Continued observations conducted at 11:00 am of the walk-in cooler revealed : One (1) smoked ham loaf, approximately half, used wrapped in saran wrap with no open date on the clear wrapping. Raw hamburger meat in an uncovered plastic bin, wrapped in clear saran wrap, but had a prep date of 5/14/14. One (1) large covered plastic storage container of roast beef and gravy with a preparation date of 5/22/14. An uncovered plastic container with eleven (11) hard boiled eggs submerged in water. The egg shells were shattered, cracked and broken. There were pieces of egg yolk, egg whites and egg shells in the water. The water was discolored with odor. The container was labeled with the date of 5/24/14. One (1) covered plastic container with nine (9) large bratwurst links. The skins were dry and splitting open. The label on the container indicated vegetable soup with a preparation date of 5/18/14. Five (5) quart size cartons of Heavy Cream with an expiration date on each of them of 5/22/14. Interview on 5/27/14 at 11:25am with the Administrator revealed Ethica, as a corporation, does not have specific written polices for food storage and labeling. They follow State guidelines for food storage and she could get me a copy of the guidelines they use. She said the staff is oriented on food storage during the initial orientation process. She provided a "Cold Storage Chart" by the USDA. which indicated the following: Mayonnaise/Dressings/Condiments are to be refrigerated after opening for one (1) month. Raw hamburger is to be refrigerated for two (2) days. Meat leftovers consisting of cooked meat and meat dishes are to be refrigerated for three (3) to four (4) days. Meat leftovers consisting of gravy and meat broth are to be refrigerated for one (1) to two (2) days.

Based on observations, review of the medical records, physician and staff interviews, the facility failed to ensure physician's orders were followed for two (2) residents (# 84 and #143) from a sample of twenty-two (22) residents. Findings include: 1. Review of the physician's orders for resident # 143 revealed an order dated 5/5/14 for house supplement one hundred and twenty (120) milliliters (ml) three times per day (tid). Further review of the May 2014 Medication Administration Record [REDACTED]. Interview with the Licensed Practical Nurse (LPN) "GG" on 5/27/14 at 2:40pm revealed the supplement was not on the MAR. She was not aware of the resident being on a house supplement, and she had not administered a supplement to this resident. 2. Observation conducted on 5/29/14 at 9:25am revealed resident #84 was up in wheelchair with an immobilizer on the Right arm. The resident was moaning with pain and a Licensed Practical Nurse (LPN) was assisting her with her medications. Observation conducted on 5/29/14 at 4:08pm revealed the resident in her wheelchair in the hallway crying out in pain and holding her right shoulder. A staff member assisted her back to her room. Review of the medical record revealed an admission date of [DATE] and on 5/20/14 she was [DIAGNOSES REDACTED]. Review of the physician's orders revealed an order dated 5/20/14 for [MEDICATION NAME] 5/325mg by mouth (po) every (q) six (6) hours as needed (PRN) for mod-severe pain; cold compress to (R) shoulder PRN fifteen (15) to twenty (20) minutes on and Biofreeze to (R) shoulder q 4 hours PRN. Further review revealed an order dated 5/21/14 to discontinue (DC) [MEDICATION NAME] and give [MEDICATION NAME] 75mg po twice a day (BID) for pain. D/C [MEDICATION NAME] when [MEDICATION NAME] arrives. Change Tylenol to 650mg po q 8 hours scheduled for pain. Review of the May 2014 MAR indicated [REDACTED]. Interview with the physician for resident #84 conducted on 5/29/14 at 4:00pm revealed that due to allergies [REDACTED]. The physician further revealed that Tylenol 650mg every 8 hours, [MEDICATION NAME] 75mg BID, cold compresses to right shoulder as needed (PRN) for 15-20 minutes and Biofeeze to the right shoulder every 4 hours PRN were ordered to manage the resident's pain. Review of the May 2014 Medication Administration Record [REDACTED]. Interview conducted on 5/29/14 at 4:10pm with Registered Nurse (RN) "JJ" revealed that he signed off the order for Biofreeze and faxed it to the pharmacy. "JJ" then gave the orders to the medication nurse and they are supposed to add the new orders to the MAR. "JJ" further revealed that he did not check to make sure it had been done.

Based on review of the Care Plan Conference Sheet, resident, and staff interviews, the facility failed to ensure one (1) resident "R" had participated in planning care and treatment from a sample of twenty-two (22) residents. Findings include: Review of the Care Plan Conference Sheet dated 8/30/13 revealed a care plan meeting was conducted with the attendance of one (1) Registered Nurse and the Activities Coordinator who also functioned as the Social Service Director at that time. There was no evidence that the resident had been invited or attended this meeting. There was no other documentation related to any care plan conferences having been conducted until 5/16/2014. Interview conducted on 05/27/14 at 2:00pm with resident "R" revealed she was not involved with decisions about her care. During this interview she indicated she had concerns with Activities. She felt there were not enough and some were boring. She would like activities related to going outdoors, using the spa, snacks more than once a day, and more exercise such as walking. The resident revealed she was invited to a care plan conference once a long time ago but it was canceled. Interview conducted on 05/29/14 at 10:45am with the Social Service Director revealed care plan conferences with invitations to resident and family members should take place with each quarterly review. She further revealed that she had no knowledge of why this residents' care plan meeting was canceled in August and does not know why the resident had not been invited to the meeting. She does not know why the meeting were not held in November and February for the quarterly assessments. Interview conducted on 5/29/14 at 11:10am with the Activities Director revealed she does not know why the resident and her family were not invited to the meeting that did take place in August or why there were no further care plan meetings. She revealed that care plan meetings should include the dietary manager, social service director, activity director, therapist, and charge nurses.

Based on review of the physician's orders, Medication Administration Record [REDACTED]#33) from a sample of twenty two (22) residents. Findings include: Review of the physician's orders for Resident # 33 revealed an order dated 7/12/13 to obtain H & H every other Tuesday, give [MEDICATION NAME] 20,000 units (u) subcutaneous (SQ) every two weeks on Wednesdays, hold if the Hemoglobin (Hgb) was greater than ten (10). Review of the Laboratory (lab) reports revealed there was no evidence of an H&H obtained on 4/8/14, 5/6/14 or 5/20/14. A new order was transcribed on 5/21/14 for H&H every two (2) weeks on Monday. Give [MEDICATION NAME] 10,000u every two (2) weeks on Thursday. Do not give [MEDICATION NAME] if Hgb is greater than ten (10). Draw H&H in morning (am). Further review of the lab report revealed this H&H was not obtained until 5/26/14. Interview with the Licensed Practical Nurse (LPN) charge nurse "AA" on 5/29/14 at 2:30pm revealed lab request were placed in the lab book under the date the lab was due, and the lab sheet was also placed in the lab book. When the lab technician came to draw blood, she looked at the lab book for the day and obtained what was listed. The lab tech initialed all labs drawn. Return lab results were placed in the physicians' book for their review and signature. The LPN was not sure why the labs were not done as ordered. Interview with the Director of Nurses (DON) on 5/29/14 at 4:05pm revealed that during the two (2) months of missed H&Hs there were agency nurses working the medication cart on A-hall. The process was in place of hiring a new LPN to work that hall. The Resident Care Coordinator (RCC) responsible for oversite of labs due, resigned 5/1/14. Audits given to the DON were not correct. Delinquent labs were discovered by the interim RCC, during her audits. The Physician was informed and wrote a new order dated 5/21/14 to obtain H&H every two (2) weeks on Mondays.