Every finding on record at Brown's Health and Rehabilitation

Based on observations, staff interviews, record review, and review of the facility's policy titled Resident Self-Administration of Medication, the facility failed to ensure unauthorized medications were not stored at the bedside for one of 27 sampled residents (R) (R25). This deficient practice had the potential to place R25 at increased risk for the use of unauthorized medications. Findings include:Review of the facility's policy titled Resident Self-Administration of Medication, dated 8/3/2025, revealed the Policy section stated It is the policy of this facility to support each resident's right to self -administer medications. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. The Policy Explanation and Compliance Guidelines section included, . 8. All nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage. Unauthorized medications are given to the charge nurse for return to the family or responsible party.Review of the electronic health record (EHR) for R25 revealed diagnoses including, but not limited to, osteomyelitis, atrial fibrillation, cardiac arrhythmia, hypertension, and gastroesophageal reflux (GERD).Review of the admission Minimum Data Set (MDS) for R25, dated 10/15/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview Mental Status Score (BIMS) of 15, which indicated little to no cognitive impairment.Review of the care plan for R25 revealed no care plan for medication self-administration.Review of the active physician orders for R25, dated1/9/2026, revealed active orders for Omega-3 oral capsule 1000 milligram (mg), and Nasonex nasal suspension 50 microgram (mcg)/actuation (ACT). Further review revealed no orders for medication self-administration. Review of the EHR for R25 revealed there was no self-administration assessment/evaluation. Observation and interview with R25 in the resident's room, on 1/9/2026 at 10:23 am, revealed a bottle of OTC (over-the-counter) nasal spray and a prescription bottle of mometasone fumarate (nasal spray) sitting on the resident's bedside rolling table, within view of other residents and/or visitors entering the room. Further observation revealed one bottle of Omega Acid Ethyl [NAME] pills and a prescription bottle of potassium pills on the dresser stand. R25 stated that the medications were being used without staff supervision.During an observation and interview on 1/9/2025 at 2:55 pm, the Assistant Director of Nursing Unit Nurse (ADON) confirmed the medications were in the resident room. She reported being unaware of the medications in the room. She confirmed the R25 was at risk of receiving additional doses of the same medications because all the medications found in the resident's room were also on the nurse's medication cart and were being administered daily to the resident. The ADON instructed Registered Nurse (RN) AA to remove the medications from the resident room.During an interview on 1/9/2027 at 2:39 pm, RN AA confirmed that all medications were removed from R25's room today. In addition, she reported that R25 and the resident's family have a previous history of bringing in unauthorized medications and received education about the risk of self-administering medications without nurse supervision. She reported recently removing medications from the R25's room a few weeks ago.

Based on observation, staff interviews, record review, and review of the facility's policy titled Oxygen Safety (Use and Storage), the facility failed to ensure an environment free from potential accident hazard by failing to ensure an oxygen cylinder was secure in a cylinder holder for one of seven residents (R) (R50) receiving oxygen therapy. This deficient practice had the potential to place R50 at increased risk of avoidable accidents. Findings include:Review of the facility's policy titled Oxygen Safety (Use and Storage) dated 12/1/2024, revealed the Policy section stated It is the policy of this facility to provide a safe environment for resident, staff, and the public. This policy addresses the use and storage of oxygen and oxygen equipment. The Policy Explanation and Compliance Guidelines section included, . 4. Oxygen Storage - c. Cylinders will be properly chained or supported in racks or other fastenings (i.e. sturdy portable carts approved stands) to secure all cylinders from falling, whether connected, unconnected, full, or empty.Review of the electronic health record (EHR) for R50 revealed diagnoses including, but not limited to, senile degeneration of the brain and Parkinson's disease.Review of the Quarterly Minimum Data Set (MDS) for R50, dated 10/14/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview Mental Status (BIMS) score of seven, indicating severe cognitive impairments. Section O (Special Treatments, Procedures, and Programs) documented that the resident did not receive oxygen therapy. Review of the active physician orders for R50, dated 1/9/2026, revealed an active documented order dated 10/10/2025 of: Check oxygen saturation every shift for SOB (shortness of breath) apply oxygen 2 LPM via NC (two liters per minute by nasal cannula) for O2 sats less than 90% (percent). Record review of the Hospice care plan for R50 revealed a focus area for advanced care planning interventions. Interventions included Comfort measures: . Use oxygen, suction, and manual treatment of airway obstruction as needed for comfort.Observation on 1/9/2026 at 11:41 am in R50's room revealed an unsecured cylinder tank sitting on the floor between the resident's bed and a dresser. Further observation revealed R50 lying in bed, and the oxygen cylinder was within the resident's reach. In an interview on 1/9/2026 at 11:49 am, Licensed Practical Nurse (LPN) CC and Registered Nurse (RN) AA both reported being unaware of the oxygen cylinder tank in R50 room. RN AA removed the cylinder tank from the room and reported that, most likely, the Hospice staff left it in the room. LPN CC and RN AA reported that the facility policy required the oxygen cylinder to be secured in a holder to prevent tipping and explosions.In an interview on 1/9/2026 at 11:50 am, Certified Nursing Assistant (CNA) BB reported providing Activities of Daily Living Care (ADL) to R50 earlier that morning and stated she did not observe the unsecured cylinder tank in the room. She reported receiving in-services on monitoring unsecured oxygen cylinder tanks and the danger of not using a cylinder holder, which can cause the tank to tip over and explode.In an interview on 12/12/2026 at 10:11 am, the Assistant Director of Nursing (ADON) stated she was unaware of the unsecured oxygen cylinder in R50's room. She stated that her expectations were that all staff, including non-nursing staff, were responsible for monitoring for safety issues related to oxygen cylinders. She reported that her plans were to provide education on free-standing oxygen to facility staff and Hospice Staff.

Based on resident and staff interviews, record reviews, review of the facility's policy titled Advance Directive, and review of the facility's Admission Packet, the facility failed to provide residents or resident representatives written information regarding the right to accept or refuse medical or surgical treatment for four of 19 sampled residents (R) (R19, R28, R29, and R7). This deficient practice had the potential to affect R19, R28, R29, and R7's ability to make informed decisions about their care. Findings included: Review of the facility's policy titled Advance Directive, revised 10/2023, revealed the Purpose section stated, The facility must inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and formulate an advance directive. The Process section included, Upon admission/readmission, the facility Social Services Director will inform and educate the resident, or POA [Power of Attorney] in writing about the right to refuse medical and surgical treatment and their right to an advance directive. Review of the facility-provided document titled Admission Packet revealed it did not contain language that pertained to the facility's provision of written information about the resident/representative's right to accept or refuse medical or surgical treatment. 1. Record review revealed R19 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that include, but not limited to, multiple sclerosis, bipolar disorder current episode depressed severe with psychotic features, major depressive disorder, recurrent, moderate, and cerebral palsy unspecified. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed R19's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 15. Review of R19's medical records revealed no signed acknowledgment or evidence the resident or the resident's representative was provided written information about the right to accept or refuse medical or surgical treatment. In an interview on 11/6/2024 at 9:18 am, R19 revealed no one from the facility had discussed anything about her right to accept or refuse treatment. She stated the facility did not provide her any written information about these rights, and that she did not sign anything regarding these rights. 2. Record review revealed R28 was admitted to the facility on [DATE] with diagnoses that include, but not limited to, paroxysmal atrial fibrillation chronic respiratory failure with hypoxia, generalized anxiety disorder, major depressive disorder, recurrent, mild. Review of R28's Annual MDS dated [DATE] revealed R28's cognition was intact with a BIMS score of 15. In an interview on 11/6/2024 at 12:32 pm, R28 revealed no one from the facility had discussed anything about her right to accept or refuse treatment. She stated the facility did not provide her any written information about these rights, and that she did not sign anything regarding these rights. 3. Record review revealed R29 was admitted to the facility on [DATE] with diagnoses that include but are not limited to multiple sclerosis and muscle weakness. Review of the Annual MDS dated [DATE] revealed R29's cognition was intact with a BIMS score of 15. In an interview on 11/6/2024 at 12:54 pm, R29 revealed no one from the facility had discussed anything about her right to accept or refuse treatment. She stated the facility did not provide her any written information about these rights, and revealed she did not sign anything regarding these rights. 39786 4. Record review revealed R7 was admitted to the facility on [DATE], with the most recent readmit after hospitalization on [DATE]. Active diagnoses included but were not limited to acute kidney failure, hemorrhage of anus and rectum, acute respiratory failure with hypoxia, acute pulmonary edema, essential primary hypertension, muscle weakness. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Review of the clinical record revealed a Physician Order for Life-Sustaining Treatment (POLST) form. Review of R7's Admission Packet revealed it did not contain an advance directive checklist or written information, and the POLST did not contain certain language informing the resident or their representative or responsible party of the right to accept or refuse an advanced directive, medical or surgical treatment. In an interview on 11/6/2024 at 10:43 am, R7 revealed she did not recall anyone at the facility speaking with her about medical or surgical treatment options or refusing care. In an interview on 11/6/2024 at 3:30 pm, the Social Services Director revealed the facility did not provide residents or resident representatives information about the resident or resident representative's right to accept or refuse medical or surgical treatment. She provided a newly developed document and stated they planned to implement providing the information. In an interview on 11/7/2024 at 11:23 am, the [NAME] President of Regulatory Compliance confirmed no evidence was found to support R19, R28, R29, R7 or their resident representatives had been advised of or were provided written information related to their right to accept or refuse medical or surgical treatment, on or after admission to the facility.

Based on resident and staff interviews and record reviews, the facility failed to provide a written notice of transfer to residents or their representatives for one of one resident (R) (R19) reviewed for hospitalization . This failure created the potential for R19 to be uninformed about their rights related to the hospital transfer. The sample size was 19 residents. Findings include: A policy was requested and the [NAME] President of Regulatory Compliance stated the facility did not have one. R19 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that include but are not limited to, multiple sclerosis, bipolar disorder current episode depressed severe with psychotic features, major depressive disorder, recurrent, moderate, and cerebral palsy unspecified. Review of R19's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 (indicating little to no cognitive impairment). Review of R19's medical records revealed R19 was transferred from the facility to the hospital on 8/9/2024 and readmitted to the facility on [DATE]. Further review revealed no evidence of a transfer/discharge notice provided to R19. In an interview on 11/6/2024 at 9:18 am, R19 revealed she did not receive anything in writing from the facility regarding the transfer to the hospital before or after the transfer. In an interview on 11/7/2024 at 9:04 am, Licensed Practical Nurse (LPN) DD revealed nurses complete a transfer form in the electronic medical record (EMR) and it goes to the physician for his review. LPN DD stated no written information was given to the residents about transfers. In an interview on 11/7/2024 at 9:08 am, Registered Nurse (RN) BB revealed the notice of transfer was sent to the hospital via fax or with Emergency Medical Services and was not provided to the resident. RN BB stated the information on the transfer document included medications, code status, and insurance information, and did not state the reason for transfer. She stated most residents were demented and had low BIMS scores, so they did not give residents notices of transfer. In an interview on 11/7/2024 at 11:27 am, the [NAME] President of Regulatory Compliance revealed nothing in writing was given to the residents upon transfer from the facility. She stated the staff completed a transfer form in the EMR and it was printed and sent to the hospital. The [NAME] President of Regulatory Compliance further stated the residents should be verbally informed of the reason they were transferred to the hospital.

Based on resident and staff interviews, record review, and review of the facility's policy titled Bed Hold, the facility failed to provide notice of bed hold, in writing, at the time of transfer or within 24 hours, for one of one resident (R) (R19) reviewed for hospitalization . This failure had the potential to contribute to possible denial of re-admission and loss of the resident's room following hospitalization for residents transferred to the hospital. The sample size was 19 residents. Findings include: Review of the facility policy titled Bed Hold, dated 3/3/2020, revealed Policy: All residents are given the option of reserving their bed when leaving the facility with the intent to return. This temporary absence may be for hospitalization or therapeutic leave. All residents or their Responsible party are informed in writing about the facility's bed hold policy at the time of admission. A copy of the bed hold agreement is also provided to the Resident or Responsible party prior to a resident's transfer to a hospital or start of a therapeutic leave. The bed hold policy provides written information detailing bed hold regulations for specific payers including Medicare regulations, the duration of the bed hold policy under the specific State's Medicaid plan, if any, and private bed hold rules. Review of the medical record revealed R19 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that include but are not limited to multiple sclerosis, bipolar disorder current episode depressed severe with psychotic features, major depressive disorder, recurrent, moderate, and cerebral palsy unspecified. Review of R19's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 (indicating little to no cognitive impairment). Review of medical records revealed R19 was transferred from the facility to the hospital on 8/9/2024 and readmitted to the facility on [DATE]. Further review revealed no evidence a bed hold notification was provided to R19. In an interview on 11/6/2024 at 9:18 am, R19 revealed she did not receive a notice of the facility's bed hold policy when she was transferred to the hospital on 8/9/2024. In an interview on 11/7/2024 at 9:13 am, Medical Records Clerk CC revealed she was responsible for uploading notifications of bed holds into the medical record after they were given to the resident or resident's representative. She stated if the bed hold notification was not located in the electronic medical record (EMR), the notice was not completed and not given to the resident or the resident's representative. Medical Record Clerk CC confirmed there was no bed hold notice provided to R19 when she was transferred to the hospital on 8/9/2024. In an interview on 11/7/2024 at 9:52 am, the Director of Nursing (DON) and Registered Nurse (RN) Unit Manager AA revealed that when residents were transferred to the hospital, they were given a notice of the bed hold policy. RN AA confirmed no bed hold policy was provided or given to R19 upon her transfer to the hospital on 8/9/2024. In an interview on 11/7/2024 at 11:27 am, the [NAME] President of Regulatory Compliance confirmed the facility did not provide a notice of the facility's bed hold policy to R19 or the resident's representative upon the resident's transfer to the hospital on 8/9/2024.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled RAI [Resident Assessment Instrument]/Care Planning Management, the facility failed to develop and implement a care plan for smoking one of four residents (R) (R24) who smoked. This failure increased the potential for R24 to not receive treatment and/or care according to their needs. Findings included: Review of the policy titled RAI/Care Planning Management, revised August 2017, revealed the The Care Plan section included, The Comprehensive Care Plan is completed within seven days after the MDS [Minimum Data Set] is completed (at no time will this time frame exceed 21 days) and reviewed quarterly thereafter. If modifications, deletions, additions are necessary, changes should be made at the time of occurrence. Record review revealed R24 was admitted on [DATE], with diagnoses that included but were not limited to chronic obstructive pulmonary disease (COPD), depression, type 2 diabetes mellitus without complications, unspecified dementia, unspecified severity with anxiety, and other behavioral disturbance. Review of R24's Physician Orders included an order dated 4/11/2204 of May smoke supervised. Review of the Quarterly MDS assessment dated [DATE] revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 7 (indicating moderate cognitive impairment), Section GG (Functional Abilities and Goals) documented R24 required assistance for activities of daily living (ADLs), Section J (Health Conditions) documented the Current Tobacco Use section was unmarked. Review of R24's care plan revealed no care plan area or interventions for smoking. Review of R24's Assessments revealed smoking assessments were completed on 4/5/2024 and 4/11/2024 that documented the resident used tobacco and had poor vision. The smoking assessment dated [DATE] documented the resident used tobacco, had poor vision, and was a supervised smoker. Review of a List of Smokers provided by the facility revealed R24 was included on the list. Observation on 11/6/2024 at 11:00 am revealed R24 being escorted to the smoking area by Certified Nursing Assistant (CNA) GG. In an interview on 11/6/2024 at 11:06 am, CNA GG confirmed R24 usually went out to smoke at the residents' smoke breaks. In an interview on 11/7/2024 at 11:28 am, the Administrator and the Regional [NAME] President of Regulatory Compliance confirmed R24 smoked. They further confirmed R24's care plan did not contain a care area for smoking and stated smoking should be included in the care plan.

Based on observations, staff interviews, record review, and review of the facility's policy titled Medication Administration Guidelines, the facility failed to ensure that two residents (R) (R1 and R2) were protected from not following physician orders. Actual harm occurred when pain medication with sedative effects was administered to R1 and R2, which caused them to become lethargic and hard to arouse on 3/6/2024, resulting in both residents being transferred to the emergency room (ER) and treatment with Narcan (reverses an opioid overdose). R1 was admitted with a diagnosis of somnolence (drowsiness), and R2 returned to the facility, declining admission to the hospital. Findings include: A review of the Medication Administration Guidelines, dated January 2018, Purpose: The purpose of these guidelines is to promote the health and safety of the residents we serve by ensuring the safe assistance and administration of medications and treatments. Monitoring: Assessing and evaluating the resident's responses to medication therapy and monitoring residents for adverse drug reactions. A. General procedures completed before administering medication by any route: a. The resident's Medication Administration Record (MAR) is reviewed to determine what medications are to be administered, and then staff removes those medications from the medication cart. c. Staff will compare the MAR with the label of each medication for the following: i. Right Person, ii. Right Medication, iii. Right Date, iv. Right Time, v. Right Route, vi. Right Dose, vii. Expiration Date. 1. Record review of the most recent Medicare -5 Day Minimum Data Set (MDS) for R1, dated 3/5/2024, revealed a Brief Interview for Mental Status (BIMS) score of 7 (a BIMS score between 0 and 7 indicated severe cognitive impairment). Record review revealed R1 had a physician order with a start date of 3/4/2024 for oxycodone (treats moderate to severe pain) hydrochloride (HCl) 5 (milligrams) mg to be administered by mouth every six hours as needed (PRN) for severe pain. Record review of the Medication Administration Record (MAR) for R1 dated 3/5/2024, documented the following: oxycodone 5 mg was administered at 4:05 pm. A review of R1's Controlled Substance Proof of Use Form revealed the following documentation: oxycodone HCL 5 mg was signed out and administered on 3/5/2024 at 4:00 pm by the 6 am-6 pm nurse. And then signed out by Licensed Practical Nurse (LPN) AA, the 6 pm-6 am nurse, at 6:00 pm. The 6 pm dose was administered two hours after the 4:00 pm dose was administered. A review of R1's Progress Notes dated 3/6/2024 at 9:28 am revealed the resident received multiple doses of oxycodone 5 mg for pain to left hip. Medical Director (MD) was notified. A new order is to administer Narcan 4 mg nasal spray; after 5 minutes, if not effective, administer 2nd dose and send to hospital for evaluation. 1st dose administered at 9:30 am, and a 2nd dose administered at 9:37 am; R1 was sent to the hospital. 2. Record review of the most recent Medicare - 5 Day MDS for R2 dated 3/8/2024 revealed a BIMS score of 14 (a BIMS score between 13 and 15 indicated cognition is intact). Record review revealed R2 had a physician order with a start date of 3/4/2024 for oxycodone HCL 10 mg to be administered by mouth every six hours as needed for pain. A review of the MAR for R2 dated 3/5/2024 documented the following: oxycodone 10 mg was administered at 3:08 pm. A review of R2's Controlled Substance Proof of Use Form revealed the following documentation: oxycodone HCL 10 mg was signed out and administered on 3/5/2024 at 3:00 pm by the 6 am-6 pm nurse. And then signed out by LPN AA, the 6 pm-6 am nurse, at 6:00 pm. The 6 pm dose was administered three hours after the 3:00 pm dose was administered. A review of R2's Progress Notes dated 3/6/2024 at 9:29 am revealed the resident received multiple doses of oxycodone 10 mg for generalized body pain. MD was notified, and a new order was to administer Narcan Nasal Spray 4 mg. The first dose of Narcan at 9:29 am in the left nostril. A review of R2's Progress Notes dated 3/6/2024 at 10:55 am revealed the resident had a fall, the MD was notified, and the resident was sent to the hospital for evaluation. Interview on 3/12/2024 at 8:30 am with the Director of Nursing (DON) revealed that on the morning of 3/6/2024 a Registered Nurse (RN) was making rounds on A Hall and noted that two residents were more lethargic than usual. She then reported what she had observed to the DON and the Unit Managers, they proceeded to assess the two residents in question (R1 and R2) by completing vital signs and assessing pupil reaction, which was sluggish for both residents. When the DON reviewed the narcotic sheets for the residents, it was noted that both residents had been given oxycodone within two-three hours of their last dose and then two more times during LPN AA's 6 pm - 6 am shift. The resident's physician was notified and orders to administer Narcan to the residents were received. R1 was given one dose and was aroused and R2 received two doses two hours apart. R1 was sent to the hospital, where she was admitted for somnolence (drowsiness) and did not return to the facility. R2 had a fall later that morning after the two doses of Narcan, was sent to the ER, and returned to the facility. Further interview with the DON revealed that LPN AA was suspended pending an investigation, and a report to the State Agency was completed. LPN AA was terminated and did not return any phone calls to the DON regarding this incident. Interview on 4/8/2024 at 12:57 pm with the DON revealed that LPN AA was the only nurse signing off on PRN pain medication and stated that she educated LPN AA regarding medication administration. The DON stated that pain assessments are done every shift. The DON revealed that the LPN AA was not documenting effectiveness from pain medication. She stated that she wasn't consistently signing off on the MAR, but she did sign out on the narcotic sheet. During the continued interview, the DON revealed that after the in-service, LPN AA continued to be inconsistent signing out narcotics on the MAR. The DON stated that she did not specifically meet with her again and re-educate her. The DON stated that LPN AA, who worked the night shift went home and refused to talk over the phone and refused to come in and discuss the incident.

Based on observations, staff interviews, record review, and review of the facility's policy titled Medication Administration Guidelines, the facility failed to ensure that two residents (R) (R1 and R2) were free of a significant medication error. Actual harm occurred when pain medication with sedative effects was administered to R1 and R2, which caused them to become lethargic and hard to arouse on 3/6/2024, resulting in both residents being transferred to the emergency room (ER) and treatment with Narcan (reverses an opioid overdose). R1 was admitted with a diagnosis of somnolence (drowsiness), and R2 returned to the facility, declining admission to the hospital. Findings include: A review of the Medication Administration Guidelines, dated January 2018, revealed the Purpose: The purpose of these guidelines is to promote the health and safety of the residents we serve by ensuring the safe assistance and administration of medications and treatments. Definitions: Transcribing: Ensuring accurate transcription and documentation of medications from physician telephone orders, faxed orders, etc. Dispensing: Communicating with pharmacy to ensure accurate and timely delivery of medications. Administering: safe administration of large volumes of medications within time constraints. Monitoring: Assessing and evaluating the resident's responses to medications therapy and monitoring residents for adverse drug reactions. The resident's Medication Administration Record (MAR) is reviewed to determine what medications are to be administered, and then staff removes those medications from the medication cart. c. Staff will compare the MAR with the label of each medication for the following: i. Right Person, ii. Right Medication, iii. Right Date, iv. Right Time, v. Right Route, vi. Right Dose, vii. Expiration Date. 1. Record review of the Electronic Medical Record (EMR) revealed R1 was admitted to the facility on [DATE] with diagnoses of cellulitis of the groin, urinary tract infections, pain unspecified. Record review revealed R1 had a physician order with a start date of 3/4/2024 for oxycodone (treats moderate to severe pain) hydrochloride (HCl) 5 (milligrams) mg to be administered by mouth every six hours as needed (PRN) for severe pain. A review of R1's Controlled Substance Proof of Use Form revealed the following documentation: oxycodone HCL 5 mg was signed out and administered on 3/5/2024 at 4:00 pm by the 6 am-6 pm nurse. And then signed out and administered by Licensed Practical Nurse (LPN) AA, the 6 pm-6 am nurse, at 6:00 pm. The 6 pm dose was administered two hours after the 4:00 pm dose was administered. Record review of Progress Notes dated 3/6/2024 at 9:28 am for R1 revealed resident noted with decreased responsiveness. VS (vital signs) 118/60, 89, 97.1, 24, 92% on O2 (oxygen) @ 2LPM (liters per minute) via NC (nasal cannula). Pupils constricted with decreased responsiveness. The resident received multiple doses of oxycodone 5mg for the pain in the left hip. MD (Medical Director) notified. New order to administer Narcan 4mg nasal spray, after 5 minutes if not effective administer 2nd dose and send to ER (emergency room ) for evaluation. 1st dose administered at 9:30 am, resident aroused for a few minutes but was still noted to be drowsy. 2nd dose administered at 9:37 am, and EMS (Emergency Medical System) called. 2. Record review of the EMR revealed R2 was admitted to the facility on [DATE] with diagnosis of fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing. Record review revealed R2 had a physician order with a start date of 3/4/2024 for oxycodone HCL 10 mg to be administered by mouth every six hours as needed for pain. A review of R2's Controlled Substance Proof of Use Form revealed the following documentation: oxycodone HCL 10 mg was signed out and administered on 3/5/2024 at 3:00 pm by the 6 am-6 pm nurse. And then signed out by LPN AA, the 6 pm-6 am nurse, at 6:00 pm. The 6 pm dose was administered three hours after the 3:00 pm dose was administered. Record review of Progress Notes dated 3/6/2024 at 9:29 am revealed R2 observed to have decreased responsiveness and increased drowsiness. VS 123/48, 99.0, 85, 92% RA, 14. Tremors noted to bilateral upper extremities. The resident received multiple doses of oxycodone 10 mg for generalized body pain. MD notified and new order to administer Narcan Nasal Spray 4 mg. If non-effective after 5 minutes, administer second dose. Send to ER if ineffective. Administered first dose of Narcan at 9:29 am in left nostril. Resident observed with increased responsiveness. Able to tell nurse what her name is and where she is located. Remains with increased drowsiness but is able to answer questions when asked. MD notified and states to monitor resident for decrease in responsiveness. VS 104/53, 96% RA, 85, 98.7. Record review of Progress Notes dated 3/6/2024 at 10:55 am for R2 revealed Certified Nursing Assistant (CNA) reported the resident rolled out of bed. Upon entering the room, Resident was observed laying on the floor on her L side, back up against the ptac [sic] unit. CNA reported the resident attempted three times to get up and she was able to prevent but this time she was unable to get to her before she rolled off the bed. Resident is currently on a low air loss mattress due to wounds. Head to toe assessment completed, new area to the R lower calf, blister previously documented open with top layer of skin gone. Redness noted to [sic] the back of the neck. MD notified, new order to send to ER for evaluation. Staff assisted Resident up to sitting position and with EMS help lifted her onto stretcher. Resident sent to ER for evaluation. Director of Nursing (DON) notified. Record review of Progress Notes dated 3/6/2024 at 10:55 am R2 returned to the facility from the hospital via EMS. Hospital paperwork sent back with patient with discharge diagnoses sepsis and rhabdomyolysis. ER MD noted that she needed to be hospitalized but resident declined hospitalization at this time. Interview on 3/12/2024 at 8:30 am with the DON revealed an incident with Licensed Practical Nurse (LPN) AA administering pain medications for two residents (R1 and R2) without reviewing the Medication Administration Record (MAR) before giving medication to see if the residents were previously medicated. As a result, one of the residents was sent immediately to the hospital. Further interview also revealed that LPN AA had worked the night shift at the facility full time since November or December of 2023. During this time, two other disciplinary actions were conducted for LPN AA, which included not completing wound care for assigned residents and administering (PRN) pain medication to residents routinely without a pain assessment. It was also determined that the DON did report to the State Agency and reported LPN AA to the Nursing Board, and confirmation verified. Interview on 4/8/2024 at 12:57 pm with DON revealed LPN AA was not a new nurse but new to the facility. She stated that LPN AA stated that if residents had prn pain medications or complained of pain, she just gave them pain medications. She stated LPN AA works 6 pm-6 am shift. The DON revealed LPN AA clocked in at 6:15 pm and signed the narcotic sheet for 6 pm on 3/5/2024. The DON stated that she was not doing a documented narcotic audit. The DON revealed since the March 5, 2024 incident; she has been doing daily narcotic audits of the PRN meds with no discrepancies. DON also stated that R2's Narcan was effective, and later that morning, she had a fall, was sent to the ER, and returned. She stated that R1 was still drowsy after she received Narcan, and she was sent to the hospital for evaluation. She did not return to the facility per family choice after admission to the hospital. The DON further revealed that the nursing staff had been educated on medication administration.

Based on observations, interviews, and review of facility document titled Plant Operation Manager the facility failed to ensure that the facility was in good repair as evidence by chipped/peeling paint on handrails on two of four halls (100 hall and 200 hall). The facility also failed to ensure three residents' rooms of nine reviewed (room 2, 3, and 9), were in good repair, specifically all three rooms had chipped/peeling paint on the walls. Findings include: Initial observation on 7/15/22 at 8:59 a.m., room nine revealed air vent loose from wall, paint on wall by vent chipped with sheet rock showing, paint peeling and bulging on the wall above bed A. Initial observations on 7/15/22 at 9:28 a.m. revealed side rail all along the 100-hall had chipped/peeling paint all the way down the hall starting from room 17 through 22 on both sides of the hallway. Initial observation on 7/15/22 at 9:41 a.m. revealed side rail by station 2 had noted chipped/peeling paint on both sides of the hall starting from area by the Director of Nursing office to room 27 through 29. Initial observation on 7/15/22 at 11:18 a.m. revealed room 3 had paint missing on board behind head of the bed with wood splinters noted protruding out of board, sheet rock showing on the wall by the fourth drawer coming out of the residents' room on both sides between the drawers, paint spots missing on wall between the closet and bathroom. There was also a large area on the wall by the window that had paint that had peeled off down to the sheet rock. In bathroom of room 3 there was a large area to the right of the paper towel holder with missing paint down to the paper porting of the sheet rock on the wall. Initial observation on 7/15/22 at 11:27 a.m. room 2 had paint peeling behind head of residents' bed, blinds missing slats at the top and middle of the blind to the outside window, bathroom has a two by four with the tissue holder attached that was detaching from the wall with nails protruding out of the wall. Chipped paint on the wall going out of door by dresser next to the fourth drawer. Observation on 7/16/22 at 10:50 a.m., handrails at the corner of 100 Hall and 200 hall had chipped paint as well as a hole in wall by the base board of 200 - Hall. On 7/16/22 at 2:21 p.m., environmental rounds were conducted with Administrator. All observations were confirmed during rounding. Interview with the Administrator regarding observed concerns revealed that the Maintenance Director is out. There is one other director that comes and assists from another facility as needed. Further interview also revealed that when there are any maintenance issues the staff can address them by filling out an maintenance request form and placing it in the maintenance book and one in his box located on his door. During interview it was also disclosed that the building should always be in good repair. Review of undated facility job description for Maintenance Director titled Plant Operations Manager revealed under Facility Maintenance Functions : Paint walls, ceilings, doors, window and door frames, closets, tables, chairs, shelves, racks and parking space stripes.

Based on interviews and record review, the facility failed to evaluate and revise the care plan interventions and/or determine the need to identify additional interventions for fall prevention for one resident (R) (#17) who had been assessed to be at risk for falls and who sustained additional falls. The sample size was 31 residents. Findings include: Review of the facility policy titled RAI /Care Planning Management with a revision date of 08/21 reads: The Care Plan: If modifications, deletions, additions are necessary, changes should be made at the time of occurrence. A review of the clinical record for R#17 revealed resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's most recent Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicated cognitively intact. Section G revealed resident requires extensive assistance with transfers. Review of the care plan revised 5/13/22 revealed that R#17 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R# 17 has had several actual falls since admission to the facility. Interventions include ambulates via wheelchair, call light within reach and therapy to evaluated and treat as needed. Further review revealed that there was not any evidence that new interventions were put in place to prevent any future falls after R#17 experienced falls and there was not any evidence that previously implemented interventions were evaluated for effectiveness. Interview on 7/17/22 at 8:41a.m. with LPN MDS Coordinator. She stated that she is responsible for updating residents care plans with appropriate interventions to reduce the risk of a fall reoccurring. She looked at the interventions listed on R#17's fall care plan for the falls on 1/10/22 and 7/03/22. She verified that the interventions on the care plan would not likely reduce the risk of R#17 falling again. MDS Coordinator also verified that the intervention care planned for the fall on 7/03/22 regarding physical therapy continued use with the leg brace is not new intervention as R#17 had been working on this prior to the fall. She reviewed the record and verified that the nurses on duty at the time of the falls did not put an immediate intervention in post fall. Interview with DON and Administrator on 7/17/22 at 9:02 a.m., DON stated that it her expectation that the nurses who are caring for the resident at the time of the fall put in an immediate intervention to reduce the risk of anther fall at the time of the fall. Cross refer to F689.

Based on record review, interviews, and review of the facility policy, the facility failed to implement appropriate new measures to prevent additional falls for one resident (R) (#17) reviewed for falls. The sampled size was 31 residents. Findings include: Review of the facility policy titled Fall Standard with a revision date of 08/22 reads: Standard of Practice: The facility strives to reduce the risks for falls and injuries by promoting the implementation of the Risk Reduction: Falls and Injuries Program. The interdisciplinary teams work with the residents and family to identify and implement appropriate interventions to reduce the risk of fall or injuries while maximizing dignity and independence. A review of the clinical record for R#17 revealed resident was admitted to the facility on [DATE] with diagnoses of but not limited to cerebral infarction with right side [CONDITION(S)], history of falling, weakness, unsteadiness on feet, difficulty in walking, other lack of coordination, and acquired absence of right great toe. The resident's most recent Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicated cognitively intact. Section G revealed resident requires extensive assistance with transfers. Review of the care plan revised 5/13/22 revealed that R#17 had a history of falls prior to admission and remains at risk for falls due to right side weakness due to history of [CONDITION(S)] ([CONDITION(S)] disease). R# 17 has had several actual falls since admission to the facility. Interventions include ambulates via wheelchair, call light within reach, therapy to evaluated and treat as needed. Review of Nurses Note dated 1/10/22 at 5:10 a.m. revealed writer was down the hall, with another resident and heard R#17 calling out. Upon entering room, R#17 was noted lying on the floor at the bathroom door entrance. R#17 stated he slipped in urine and fell . R#17 was going to the bathroom but urinated on himself before he made it to the toilet and slipped in his urine. Small laceration noted to the top right area of his head. Bleeding easily controlled; dry dressing applied. Physician notified of fall with laceration. New order given to send resident to the ER (emergency room ) for evaluation. Interventions put in place during the morning meeting: Resident sent to the ER for evaluation, resident tested positive for COVID in ER. Upon reentry into facility: Move resident to COVID Unit, Medications as ordered, treatment to laceration on head as ordered. Therapy to evaluate on 1/29/22. The clinical record did not reflect a new intervention added at the time of the fall or an appropriate new intervention to reduce the risk of a repeated fall. The Interact SBAR (Situation Background Assessment Recommendation) form for the fall in the electronic record did not list an intervention for the fall. The new intervention section is left blank. Review of Nurses Note dated 7/03/22 at 2:30 p.m. revealed R#17 was coming back from being on a leave of absence with family. R#17 fell in doorway. The fall was witnessed by housekeeping. The family member stated R#17 attempted to sit down in wheelchair, the wheels were unlocked, and the wheelchair rolled from under him. Interventions put in place during the morning meeting: Physical Therapy to continue working with brace to left leg, neuro-checks as indicated, observe and report as needed x 72 hours to physician for signs and symptoms: pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. The clinical record did not reflect a new intervention added at the time of the fall or an appropriate new intervention to reduce the risk of a repeated fall. The Interact SBAR form for the fall in the electronic record did not list an intervention for the fall. The new intervention section is left blank. Interview on 7/17/2022 at 8:19 a.m. with Licensed Practical Nurse (LPN) AA revealed that after a fall, the nurses are required to complete an Interact SBAR Change in Condition Form and a Fall Risk Assessment/ Risk Management Assessment. LPN AA stated that nurses are required to implement a new intervention on the care plan and in the Risk Management assessment for the fall. Interview on 7/17/22 at 8:31 a.m. with the Unit Manager LPN DD revealed that she is responsible for tracking the falls in the facility. She stated that the nurse should assess the resident and vital signs are obtained. If the fall is unwitnessed, neuro checks are initiated. If the resident hit their head, it is the policy that the resident is sent to the ER for a CT scan. The family and physician are informed of the fall. The nurse is responsible to document all falls in the electronic record on the Risk Management Report, on an Interact SBAR Change in Condition Form, on a Fall Assessment Post Fall Assessment and in the progress note. The Unit Manager further stated that the nurse is responsible for initiating an immediate intervention after the fall. She also stated that the nursing administration team discusses all falls the next day in the morning meeting. Interview with DON and Administrator on 7/17/22 at 9:02 a.m. DON stated that it her expectation that the nurses who are caring for the resident at the time of the fall put in an immediate intervention to reduce the risk of anther fall at the time of the fall.

Based on observations, record review, staff interviews, and review of the policy titled Respiratory System Management, the facility failed to provide respiratory care consistent with professional standards of practice for two of five residents (R) (R# 8 and R#49) receiving oxygen therapy related to ensuring oxygen filters were cleaned and oxygen nasal cannula are stored in plastic bag when not in use. Findings include: 1. A review of the clinical record for R#8 revealed she was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a Minimum Data Set (MDS) assessment dated [DATE], revealed R#8 had a Brief Interview for Mental Status (BIMS) of 15, which indicated no cognitive impairment. Observation on 07/15/22 at 8:59 a.m. during initial screening, resident observed lying in bed oxygen tubing and nasal cannula is lying on the floor. The oxygen concentrator is on with the settings at 4 liters. The filter on the oxygen concentrator has a white fuzzy substance over the entire filter. Interview with R#8 on 7/15/22 at 11:01 a.m. R#8 stated that she does not wear her oxygen during the day, she only wears it at night. Observation 7/16/22 at 8:44 a.m. revealed resident lying in bed. Resident is not wearing her oxygen; the oxygen nasal cannula is lying on the oxygen concentrator not bagged. The oxygen filter on the back of the concentrator continues to be completely covered with a white/ light grey fuzzy substance. Surveyor observed staff member enter residents' room at 8:49 a.m. and exit the room at 8:56 a.m. Surveyor re-entered resident's room to find the nasal cannula still lying across the concentrator not bagged. Observation on 7/16/22 at 12:08 p.m. revealed the oxygen nasal cannula lying on the concentrator, oxygen filter continues to have a white/light grey fuzzy substance on the entire filter. Concentrator is on while not in use. 2. A review of the clinical record for R#49 revealed she was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of an Admission Minimum Data Set (MDS) assessment dated [DATE], revealed R#49 had a BIMS of 0, which indicated severe cognitive impairment. Observation on 7/16/22 at 10:24 a.m. and 1:15 p.m. revealed R#49 lying in bed with oxygen via nasal cannula intact. Observation of the oxygen filter has an accumulation of a white/light grey fuzzy substance on the filter. During interview with LPN CC on 7/16/22 at 1:56 p.m., she confirmed that R#8's oxygen nasal cannula was not in use, off, and was not properly bagged. LPN CC also confirmed that the filter on the concentrator was dirty and was completely covered with a white/light grey substance. Interview with the DON on 7/16/2022 at 2:08 p.m. revealed that R#8 tends to remove her oxygen and is care planned for self-removing oxygen. DON stated that she expects the staff to turn off the concentrator and properly store/bag the oxygen nasal cannula when it is not in use. DON also stated that the oxygen concentrators filters are to be cleaned weekly every Tuesday night and the Wound Nurse is responsible for checking the oxygen filters to ensure that the filters have been cleaned. When looking at the substance build up on the concentrator's filter, DON acknowledged that the oxygen concentrator filters are not being cleaned weekly. DON removed the cover of R#49 oxygen concentrator, the filter is completely covered with a large amount of white/light grey fuzzy substance. DON verified that the filter was dirty, and she stated that the filter had not been cleaned as required. Review of facility's policy titled Respiratory System Management Standard dated August 2021, page 10, #15 reads; Attach a clean, dated plastic bag to the oxygen source to be used to store the equipment when not in use. Plastic bags are replaced weekly and as needed. Administrator told surveyor that the facility does not have a policy regarding cleaning of the oxygen concentrator's filter, but the filters should be cleaned per the manufactures recommendations. The Administrator provide surveyor with the oxygen concentrators cleaning recommendations that reads: 7.3 Cleaning the Cabinet.1. Remove the filter and clean as needed. Environmental conditions that may require more frequent inspection and cleaning of the filter include, but are not limited to high dust, air pollutants, etc. 2. Clean the cabinet filter with a vacuum cleaner or wash with a mild liquid detergent (such as Dawn) and water. Rinse thoroughly.

Based on observation and staff interviews, the facility failed to wash/sanitize hands and change gloves during wound treatment for one resident (R) (#48) and failed to practice acceptable infection control practices to prevent possible cross-contamination, by one of one licensed nurse observed, as evidenced by not cleaning/sanitizing a glucometer during a routine fasting blood sugar check on one resident (R) (#24). The sample size was 31 residents. Findings include: 1. Review of the Infection Control Manual Policy with an original date of 2/2016 revealed the following - 7. For glucometer and (name) machines, clean the outside of the machines with virucidal/antifungal approved disinfectant wipe. Follow virucidal/antifungal wipe recommendations for wait time (typically 2-5 minutes) before reuse of the machine. Do not clean the battery compartment, code chip port or test strip port unless contamination occurs noting that excessive fluid in the wipe used on these critical areas may cause the machine to malfunction. During an observation on 7/16/22 at 7:45 a.m., Licensed Practical Nurse (LPN) AA, on the100 hall, performed a fasting blood sugar check for R#24. LPN AA removed the glucometer from the top drawer of her medication (med) cart and placed it on top of the med cart without cleaning or sanitizing the med cart or placing a barrier between the med cart and the glucometer. LPN AA entered R#24's room and placed the glucometer on his bedside table without cleaning or sanitizing it or placing a barrier between the bedside table and the glucometer. LPN AA performed a blood sugar check, picked up the glucometer exited the room and place the glucometer on top of her med cart and then placed the glucometer in the top drawer of the med cart without cleaning or sanitizing it. During an interview with LPN AA on 7/16/22 at 7:45 a.m., LPN AA stated this is her third week and she did receive education on glucometer cleaning when she started. LPN AA stated she should have put a barrier down and disinfect the glucometer after using it, and before she put it back in the cart. Further interview with LPN AA on revealed that she usually cleans and sanitizes the glucometer before and after use. LPN AA stated she was nervous. Interview with the Director of Nursing (DON) on 7/16/22 at 10:36 a.m. revealed the treatment nurse is on vacation. She stated that she and the treatment nurse are in the process of doing individual training with each nurse. DON stated that LPN AA has been in-serviced on infection control related to glucometers. DON stated LPN AA has not had the individual training. She stated she has regular in-services on infection control and competencies are done on hire and annually. DON stated her expectation is for nurses to sanitize and clean glucometers before and after each use and between residents. 2. Observation of wound care for R#48 on 7/16/22 at 10:30 a.m. revealed Licensed Practical Nurse (LPN) BB placed a red biohazard bag on R#48's bed. LPN BB washed her hands, donned gloves, and turned R#48 over to her left side. LPN BB removed gloves and donned gloves without sanitizing or washing hands. LPN BB removed the old dressing from sacrum. She cleaned the wound with a normal saline soaked gauze and patted dry with a clean gauze. She then applied calcium alginate to wound base and covered with a dry dressing. LPN BB did not wash/sanitize hands or change gloves after removing the dressing, cleaning the wound or before applying the calcium alginate. LPN BB then removed the red biohazard bag from off R#48's bed and placed the bag in the trash can on the treatment cart located outside of R#48's room door. LPN BB then removed her gloves at the treatment cart. LPN BB returned to R#48's bathroom and washed her hands. During an interview on 7/16/22 at 10:30 a.m., LPN BB stated she has been in-serviced on hand hygiene and infection control. LPN BB stated she guesses she just forgot to sanitize her hands. LPN BB stated she is in RN (Registered Nurses) school, and she will graduate next month. LPN BB further stated her professor would not be happy with her forgetting to sanitize her hands. Interview with the DON on 7/16/22 at 10:36 a.m. revealed the treatment nurse is on vacation. She stated that she and the treatment nurse are in the process of doing individual training with each nurse. DON stated that LPN BB has been in-serviced on infection control related to wound care. DON stated LPN BB have not had the individual training. She stated she has regular in-services on infection control and competencies are done on hire and annually. Further interview with the DON revealed that she expects the nurses to sanitize/wash hands and apply clean gloves after removing the dressing and after cleaning the wound.

Based on observation, record review, review of the facility policy COVID-19 Protocol: Phase IV Re-Opening of Facility Updated Healthcare Infection Prevention and Control Recommendations in Response to COVID-19 Vaccinations, review of the Centers for Medicare and Medicaid Services (CMS) QSO-20-39-NH Nursing Home Visitation-COVID 19, family interview and staff interview, the facility failed to ensure that residents were allowed to receive visitors on the weekends for two residents (R) (R A and R B) of three residents reviewed. Findings include: Review of the CMS QSO-20-39-NH Nursing Home Visitation-COVID 19 (dated 9/17/20 and revised 4/27/21) revealed that Facilities should allow indoor visitation at all times and for all residents regardless of vaccination status except for the following: Unvaccinated residents, if the nursing home's COVID-19 county positivity rate is >10% and <70% of residents in the facility are fully vaccinated; residents with confirmed COVID-19 infection whether vaccinated or unvaccinated until they have met the criteria to discontinue Transmission-Based Precautions; and residents in quarantine, whether vaccinated or unvaccinated, until they have met criteria for release from quarantine .Compassionate care visits should be permitted at all times. Interview with the Administrator on 6/28/21 at 9:20 a.m. revealed that the facility did not have any residents who were positive for COVID-19. Continued interview revealed that the facility did not allow visitation on the weekends due to less staff working on the weekends. She stated that office staff were available during the weekdays to assist with visitors. 1. Observation of R A on 6/28/21 at 1:10 p.m. revealed that he was clean, neat and without odors. He was watching television in his room and did not appear to be in emotional distress. Interview with family of R A on 6/29/21 at 11:26 a.m. revealed that she had requested visitation with R A for Sunday, 6/20/21, which was Father's Day. She stated that R A's son who lived out of town wanted to visit the resident that day. However, she was informed by the Administrator that the facility did not allow Sunday visits. Continued interview revealed that she was allowed to visit R A on the weekdays only. 2. Observation of R B on 6/28/21 at 3:02 p.m. revealed that he was sitting in his recliner in his room watching television. He was clean, neat and without odors. He did not appear to be in emotional distress. Telephone interview with family of R B on 6/28/21 at 1:53 p.m. revealed that about 3 to 4 weeks ago, she was informed by staff in the front office that she could only visit R B on weekdays. She stated that she worked Monday through Friday and recently took a workday off in order to visit R B. Continued interview revealed that she preferred to visit R B on the weekend. Interview with the Administrator on 6/29/21 at 11:37 a.m. revealed that 46 of the 60 current residents (76.66%) had been vaccinated for COVID-19. Continued interview revealed that there were only three residents in the facility who were on isolation because they were recently admitted and had not been vaccinated for COVID-19. Review of the Department of Public Health website (dph.georgia.gov) revealed that the indicator report for [NAME] County dated 6/28/21 showed a 1.4% COVID-19 positivity rate from 6/19/21 to 6/25/21. The 1.4% county positivity rate indicated that [NAME] County had a low level of community transmission. Review of the facility policy COVID-19 Protocol: Phase IV Re-Opening of Facility Updated Healthcare Infection Prevention and Control Recommendations in Response to COVID-19 Vaccinations (effective date 4/27/21) revealed that the facility had followed the Centers for Disease Control (CDC) recommendations which did not address that indoor visitations should be allowed at all times and for all residents except in instances for unvaccinated residents, if the county positivity rate was >10% and <70% of residents were vaccinated; residents with confirmed COVID-19 infection until they met the criteria to discontinue Transmission-based Precautions; and residents in quarantine until they have met the criteria for release from quarantine.

Based on observations, review of the facility's policy titled Medication Administration Guidelines: (MONTH) (YEAR) Safe Medication Administration, and interviews, the facility failed to discard expired biologicals prior to the expiration dates in two out of two medication storage rooms. The facility census was 59 residents. Finding include: An observation made of the Unit Two's medication room with Licensed Pracital Nurse (LPN) FF on 5/07/19 at 9:10 a.m. revealed an opened vial of [MEDICATION NAME] solution with an opened date of 2/28/19 written on the vial. According to the package insert the solution expires 30 days after opening (3/30/19). Two [MEDICATION NAME] flush syringes had an expiration date of 4/30/19 for resident R#54. The resident was on intravenous antibiotics with a scheduled [MEDICATION NAME] flush. An observation made of the Unit One's medication room with LPN BB on 5/07/19 at 3:00 p.m. revealed a bottle of Thera Vital multivitamins that had an expiration date of 4/2019 and a bottle of calcium+vitamin D 600 milligram (mg) that had an expiration date of 4/2019. Review of the facility policy titled Medication Administration Guidelines: (MONTH) (YEAR) Safe Medication Administration revealed medications are to be stored appropriately as per manufacturer instructions. All expired non-controlled medications or medications to be destroyed are to be taken off the medication cart and properly destroyed per the Environmental Protection Agency guidelines. Controlled medications stay secured on double locked medication cart. An interview with LPN FF on 5/07/19 at 9:10 a.m. verified the expired medications in the Unit Two medication room. She revealed when a medication is expired it should be removed and put in the destruction box located in the medication room. An interview made with LPN BB on 5/07/19 at 3:00 p.m. verified the expired medications in the Unit One medication room. She revealed when a medication is expired it is removed from stock and put in the box for destruction. An interview held on 5/08/19 at 11:48 a.m. with the Director of Nursing (DON) revealed her expectations are to have the medications rooms checked daily on the night shift. She expects the nurses to remove medications on or before the expiration date.

Based on observation, staff interview, and facility policies titled Refrigerator /Freezer Temperature Log and Food Labeling Reference Guide, the facility failed to store, labeled, and discard of expired food items for one of two reach in refrigerator and one of two freezers, and monitor the daily temperature for one milk floor chest cooler. This had the potential to affect a total of 59 orally fed residents. Findings include: Reviewed document dated ,[DATE] titled Refrigerator /Freezer Temperature Log stated purpose to record temperatures of all refrigerator/freezer units located in the kitchen area.1. Record month and year walk in refrigerator, walk in freezer, cooks reach in refrigerator, serving table refrigerator, serving table refrigerator, and milk cooler. 2. Mark in column heading which unit is to be recorded 3. record temperature in the A.M column when unit first opened for the day. 4. Record temperature in the P.M. column prior to closing for the day. Reviewed document dated ,[DATE] titled Food Labeling Reference Guide stated frozen foods stored in the freezer : used by date of 6 months, open date and 7 day use by date Meats, eggs, and other frozen food items that are placed in the refrigerator to thaw-manufacture's expiration date for use by date, open date and 7 days used by date. Observation on [DATE] at 10:40 a.m. of Refrigerator #2 revealed the following: 1. leftover macaroni & beef pasta storage in a tupperware labeled with a cook date [DATE] and no used by date 2. leftover pasta noodles stored in a plastic bag labeled with a cook date [DATE] and no used by date 3. leftover lemon icing wrapped in a plastic wrap labeled with preparation date [DATE] and no used by date 4. slice cheese wrapped in plastic wrap which was not labeled 5. tortilla wraps wrapped in plastic wrap which was not labeled 6. cheese sauce with an open date of [DATE] stored in a plastic tupperware container and no expiration date Observation on [DATE] at 10:43 a.m. of freezer #1 revealed the following: 1. leftover cooked Texas Toast stored in a large freezer zipper bag labeled with a preparation date [DATE] and no used by date 2. leftover cooked corn bread squares stored in a large freezer zipper bag labeled with a preparation date [DATE] and no expiration date 3. cooked garlic bread which was not labeled and stored in large freezer zipper bag 4. ,[DATE] bag of tater tots which was not labeled 5. turkey meat dated [DATE], with no expiration date 6. bag of cooked dinner rolls dated [DATE] with no expiration date 7. open bag of chicken tenders which was not label Observation on [DATE] at 10:01 a.m. revealed a large floor milk chest cooler with several crates of milk stored inside with a temperature log titled Temperature /Cleaning Log for Milk Cooler/Refrigerator Unit dated ,[DATE] taped to the outside of the chest. Further observation of the temperature log revealed missing temperature loggings for several days during the month of April. Out of a total of 30 days for the month of (MONTH) the dietary staff only documented temperature logs for only 10 days. (The following entries were made for only the days listed on the (MONTH) (YEAR) log : ,[DATE], ,[DATE], ,[DATE] ,,[DATE], ,[DATE], ,[DATE], ,[DATE], and ,[DATE], ,[DATE]/ and ,[DATE]). During an interview on [DATE] at 1:44 p.m., the Register Dietician (RD) stated her expectations are for all food items to be stored and labeled properly. During an interview on [DATE] at 2:00 p.m., the Food Service Manager (FSM), revealed that her expectations are for the staff to label and store all food items based on the received date, expiration date, used by date and remove all expired food items from the refrigerator and freezer. Interview with Administrator on [DATE] at 2:55pm revealed that his expectations are anything food items that is received or open should have an expiration date and used by date.

Based on observation, review of the Facility's Infection Control Manual, Infection Prevention: Handwashing, review of the Centers for Disease Control (CDC) Hand Hygiene Guidelines: Standard Precautions and staff interview, it was determined that the facility failed to ensure that nursing staff washed/sanitized hands between resident contact during one (1) of two (2) meal services on one (1) of three (3) halls (A Hall). The census was 59 residents. Findings include: Review of the facility's Infection Contol Manual, Infection Prevention: Handwashing revealed that handwashing is the single most important procedure for preventing nosocomial infections. Handwashing is mandated between resident contact and hands must be washed after contact with contaminated items or surfaces. Review of the CDC Hand Hygiene Guidelines: Standard Precautions provided by the facility revealed that use of alcohol hand sanitizer is the preferred method of hand hygiene in health care settings. On 5/8/17 at 12:36 p.m., during observation of the lunch meal on A Hall, Certified Nursing Assistant (CNA) AA obtained a meal tray from the meal cart and placed it on the overbed table for the resident in room [ROOM NUMBER]. The CNA moved the overbed table closer to the resident in the bed and used the remote to raise the head of the bed. Without washing/sanitizing her hands CNA AA obtained another meal tray from the meal cart and placed it on the overbed table for the resident in room [ROOM NUMBER]. CNA AA then repositioned the resident's legs in the bed, placed a clothing protector around the resident's neck, moved the overbed table closer to the resident in the bed, adjusted the resident's bed linens and raised the head of the bed. CNA AA unwrapped the utensils from the napkin and placed the fork in the resident's food on the plate. Without washing/sanitizing her hands CNA AA then left the room to obtain another meal tray from the cart for the resident in room [ROOM NUMBER]. While walking to the room, CNA AA touched her hair. CNA AA placed the meal tray on the overbed table, used the remote to lower the foot rest of the recliner that the resident was sitting in, placed shoes on the resident's feet, moved the overbed table closer to the resident, removed the top from the resident's tea glass, held the top of the tea glass while stirring sweetener into the tea, unwrapped the utensils from the napkin and placed the fork in the food on the plate. CNA AA then reached under the resident's arm to assist her to sit up straighter in the recliner. Without washing/sanitizing her hands, CNA AA obtained a meal tray from the cart for the resident in room [ROOM NUMBER], turned on the ceiling light, placed the tray on the overbed table, unwrapped the utensils from the napkin and placed the fork in the food on the plate. Without washing/sanitizing her hands, CNA AA then obtained a meal tray from the cart for the resident in room [ROOM NUMBER], placed the tray on the overbed table, unwrapped the utensils from the napkin and placed them next to the plate for the resident to use. Review of the facility In-service dated 1/9/17 revealed that eleven (11) staff including CNA AA attended the in-service on the CDC Hand Hygiene Guidelines: Standard Precautions. Interview with the Director of Nursing (DON) on 5/12/17 at 12:05 p.m. revealed that she expected staff to use sanitizer between resident contact during meal service. Continued interview revealed that during the survey, she had observed staff failing to sanitize their hands during the meal service and in-serviced them this week on appropriate hand hygiene. She provided a copy of the inservice dated 5/10/17 which was two days after observation of the lunch meal on 5/8/17 when staff failed to wash/sanitize between residents.

Based on observation, interview, and record review, the facility failed to provide oral care for one resident (R) #42 out of 33 sampled residents. Findings include: During an interview on 5/9/17 at 2:52 p.m. R#42's family member revealed that when he visits, the resident's teeth are dirty. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] documented the resident to be rarely/ never understood and requires one person total assistance with personal hygiene. Resident data collection form dated 2/14/14 documented that resident has own teeth. Review of the care plan revised 3/1/17 documented R#42 to have a self-care deficit related to needing assistance with bathing, grooming, and personal hygiene. Residents needs total assistance by staff as indicated. Interventions included oral care daily and as needed. Observation on 05/10/17 at 11:00 a.m. revealed resident in bed resting. Mouth noted with dried skin and/or debris on lips and in the corner of right side of mouth. Teeth noted with thick white film. Observation on 05/10/17 at 4:15 p.m. revealed R#42's mouth noted with dry skin; thick white film on teeth and foul odor from mouth when resident speaks. Observation on 05/11/17 at 10:45 a.m. revealed R#42 with thick white film on teeth. Interview on 5/12/17 at 11:00 a.m., Certified Nursing Assistant (CNA) AA stated that oral care for R#42 is usually provided after each feeding. Observation on 05/12/17 at 11:31 a.m. revealed CNA AA performed oral care for R#42 with mouth swabs and mouth rinse. The resident had stringy white particles in mouth. Resident did clench teeth down some during cleaning. Lips were washed with a wash cloth and Chap Stick applied. Interview with the Director of Nursing (DON) on 05/12/17 at 12:17 p.m. revealed that her expectation is for staff to assist R#42 with oral care every day and more than once a day. Review of the Nursing Procedure Manual: Oral Care dated January 2013 documented: Purpose- to remove soft plaque deposits and calculus from teeth, to clean and massage the gums, and reduce mouth odor. Procedure- provide/ assist with oral care in the morning and before bed and more often as indicated.

Based on observation, interview, and record review, the facility failed to follow the care plan related to oral care for one resident (R) #42 out of 33 sampled residents. Findings include: Review of the care plan revised 3/1/17 documented R#42 to have a self-care deficit related to needing assistance with bathing, grooming, and personal hygiene. Residents needs total assistance by staff as indicated. Interventions included oral care daily and as needed. Observation on 05/10/17 at 11:00 a.m. revealed resident in bed resting. Mouth noted with dried skin and/or debris on lips and in the corner of right side of mouth. Teeth noted with thick white film. Observation on 05/10/17 at 4:15 p.m. revealed R#42's mouth noted with dry skin; thick white film on teeth and foul odor from mouth when resident speaks. Observation on 05/11/17 at 10:45 a.m. revealed R#42 with thick white film on teeth. Interview on 5/12/17 at 11:00 a.m., Certified Nursing Assistant (CNA) AA stated that oral care for R#42 is usually provided after each feeding. Interview with the Director of Nursing (DON) on 05/12/17 at 12:17 p.m. revealed that her expectation is for staff to follow the care plan and to assist R#42 with oral care every day and more than once a day. Cross Reference F312

Based on Observation, interviews, and record review the facility failed to maintain foods at safe temperatures, at or below forty-one degrees in one (1) of one (1) Refrigerators. On 07/27/15 at 1:19 p.m. during the initial tour it was noted that the temperature in Refrigerator/Cooler #1 was sixty-four degrees Fahrenheit per the external thermometer and sixty degrees Fahrenheit per the internal thermometer. On 07/27/15 at 6:20 p.m. a re-check of Refrigerator/Cooler #1's temperature revealed the internal temperature remained elevated at fifty-two degrees Fahrenheit. A review of the Temperature log sheets for June and July revealed the following temperatures for the month of June 2015: June 4 -- 48.9 degrees June 6 -- 45.9 degrees June 7 -- 44.2 degrees June 11 - 48.9 degrees June 13 - 47.0 degrees June 15 - 48.7 degrees June 16 - 43.4 degrees June 18 - 64.9 degrees June 19 - 43.4 degrees June 21 - 49.6 degrees June 24 - 48.7 degrees June 25 - 48.7 degrees June 27 - 42.4 degrees June 30 - 42.4 degrees 07/27/15 at 6:39 PM - Recheck of temperatures revealed two internal thermometers one thermometer registered fifty degrees Fahrenheit, the second thermometer registered forty-eight degrees Fahrenheit. External thermometer registered 48.6 degrees Fahrenheit. Observation at this time revealed the contents of Refrigerator/Cooler #1 to include: One Bowl of cooked hotdog's One bowl of Pea Salad Several cooked Rolls Bowl of Cooked Shrimp Bowl of Stewed Tomatoes Fresh Tomatoes Bowl of Cooked Broccoli Cooked ham Cooked Chicken Noodle Soup Cooked Baked Sweet Potatoes Several pieces of cooked Cornbread Fresh Vegetables including: box of Cauliflower, box of carrots, box of bell pepper, box of tomatoes. 15 dozen eggs Institutional size Mayonnaise 3/4 full Institutional size Mustard, ketchup, salsa, ketchup The following Dairy Products: Yogurt 1 case + 10 individual cartons Approximately 20 slices of cheese Sour Cream - 24 ounce container Butter Packs - 12 packs House Shakes - 7 individual containers Thousand Island Salad Dressing 15 individual packs and Chicken - 4 bags of thawing chicken approximately 90% thawed (confirmed by the dietary manager) Temperatures were confirmed with the dietary manager. The Dietary Manager stated that foods were used from this refrigerator for breakfast, lunch and dinner. During this same interview the dietary manager stated refrigerator temperatures are checked each day by staff. If the temperature is out of normal range, then the staff are to report the temperature to her. The Dietary Manager states she reviews the temperature logs daily. The Dietary Manager states she contacts the maintenance man and the Administrator if there are temperature problems. On 07/27/15 at 6:22 p.m. during an interview with the Dietary Manager it was revealed that her expectations were for the temperatures in the refrigerator to be forty-one degrees Fahrenheit or lower. On 07/27/15 at 7:25 p.m. an interview with the Administrator revealed that her expectations of staff were that staff members would notify the dietary manager when temperatures are elevated above forty-one degrees Fahrenheit.