Every finding on record at Cartersville Center for Nursing and Healing

Based on observations, staff interviews, and review of the facilities policies titled, Food Preparation and Service, Food Brought by Family/Visitors, and Sanitization, the facility failed to ensure food was labeled, stored and prepared under sanitary conditions. In addition, the facility failed to ensure cleanliness of the kitchen and that equipment was working properly. The deficient practices created an unsanitary environment that increased the potential for cross contamination and food borne illness for the 109 of 112 residents receiving meals prepared in the kitchen.Findings include:Review of the undated policy titled Food Preparation and Service documented Food service employees shall prepare and serve food in a manner that complies with safe food handling practices. Review of the policy titled Food Brought by Family/Visitors undated, documented Liberalized diets will be permitted as much as possible. Staff must be aware of, and approve, food(s) brought to a resident by family members. Section titled Guidelines number 6. documented Perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator. Containers will be labeled with the resident's name, the item and received date. Review of the policy titled Sanitization undated, documented The food service area shall be maintained in a clean and sanitary manner. The section titled Policy Interpretation and Implementation number 2. documented . Seals, hinges and fasteners will be kept in good repair. The food storage policy was requested but was not provided by the facility. During the initial observation tour of the kitchen, dry storage, walk-in freezer on 12/16/2025 beginning at 9:04 am with the Administrator, the following concerns were identified and confirmed:- Four pans on the steam table were covered in plastic wrap. Each pan was labeled (1) Item: Soup prepared 12/15; (2) Item: Beef Pot Roast Prepared Date 12/15/2025; (3) Item Ham prepared 12/15; and (4) Pureed Meat Prepared 12/16. -25-pound box of Powered Sugar was observed to be open and not sealed or labeled. During the tour, Administrator confirmed and verified all identified concerns and revealed he was unaware of why the four pans were on the steam table and confirmed the staff should have sealed the box of sugar and labeled it with date and time of opening. During observation and interview with the Registered Dietician (RD) on 12/16/2025 at 9:28 am in the walk-in refrigerator, a 32-ounce carton of Liquid Whole Eggs with Citric Acid was observed unlabeled without an open date. The RD confirmed the observation. During observation and interview with the RD on 12/16/2025 at 9:32 am, the walk-in freezer had ice build-up on the step and threshold strip and the horizontal air curtains. Inside the freezer a large package of meat wrapped in plastic wrap was unlabeled or dated. The RD confirmed the observation. Observation and interview with the Certified Dietary Manager (CDM) on 12/16/2025 at 9:32 am revealed the door handle to the walk-in freezer did not latch securely. CDM confirmed the observation of ice buildup on the step, threshold strip, and horizonal air curtains. Observation and interview with the CDM on 12/17/2025 at 12:10 pm revealed a tray of white and burgundy colored coffee cups turned face down. The CDM described the cups as clean and ready for use. After his assessment of the coffee cups on the tray with a gloved hand it was revealed the burgundy coffee cups had an unidentified, orange-colored film in ten of ten cups. He stated these cups should not have any film or residue inside. Observation and interview with the CDM on 12/17/2025 at 2:39 pm revealed a ceiling fan centrally located above the dishwasher and clean and soiled dish location. The ceiling fan blades had a buildup and accumulation of fuzzy grey matter. The CDM confirmed and verified the blades were covered with grey and fuzzy matter. Observation and interview with Certified Nursing Assistant (CNA) EE on 12/17/2025 at 5:05 pm on the 200 Hall Pantry revealed a box of take-out chicken on the top shelf of the refrigerator with a hand-written notation room [ROOM NUMBER] on the top of the box. CNA EE confirmed there was no date or name on the box. The CNA stated all resident food brought in from family/friends should be labeled with the resident's name and the date it was placed in the refrigerator. CNA EE further revealed items three days old or greater should be discarded. Review of Maintenance Work Reports for the Walk-In Freezer reveals there were no work orders created for the walk-in freezer, since a repair was made in February 2025. There was no record of Maintenance being notified of equipment repair needs for the walk-in freezer from February 2025 to December 2025 when the loose latch was identified during the Kitchen Tour. During Interview with Administrator, CDM and RD on 12/18/2025 at 1:18 pm the CDM revealed the [NAME] pulled [items] from the cooler on Tuesday 12/16/2025 and placed them on the steam table for the lunch meal. CDM stated it is not normal to pull food that early. He stated the soup, ham and roast beef were on the lunch menu for Wednesday, 12/17/2025. He further added, the [NAME] should have returned the food items to the oven to hold the temperature. The CDM verified and confirmed there was ice buildup on the threshold step and horizontal curtains of the walk-in freezer because the latch did not always secure when the door was closed. He also verified and confirmed coffee cups were found ready for use but had an orange-colored film/substance inside ten of ten coffee cups. The CDM verified and confirmed that the ceiling fan located in the dishwasher area was covered with a grey fuzzy substance. The CDM stated his expectation of food brought in from family to be stored in the Pantry refrigerators to be labeled with the resident's name and the date brought into the facility. The RD verified and confirmed a 32 ounce of Liquid Eggs located in the walk-in refrigerator was found to be open and unlabeled, and verified and confirmed frozen meat in the walk-in freezer was open and unlabeled. The CDM, RD and Administrator all agreed their expectations were food should not be left on a steam table turned off. All open items should be labeled and dated whether frozen, dry or refrigerated.The Administrator stated his expectation for the freezer latch was for it to be repaired as soon as possible, and the ceiling fans should be cleaned on a routine basis or removed from the area. He further revealed he expects preventative maintenance will be completed on major equipment in the Kitchen at least every 30 days. The Administrator expects Dietary and other departments to submit work order requests for repairs timely. Maintenance staff are to acknowledge receipt of TELS reports within 24 hours and regularly communicate repair dispositions.

Based on observations, staff and resident interviews, record review, and review of the facility's policies titled, Medication Administration, the facility failed to maintain a medication error rate below 5% (percent). The observed medication administration error rate was 17.24% with 5 errors of 29 opportunities for four residents (R) (R50, R15, R23, and R82) during medication administration. This deficient practice had the potential to cause health complications for residents on B hall.Findings include:Review of the facility's policy titled Medication Administration, revised 4/2/2025, section 10. revealed Ensure that the six rights of medication administration are followed. Right time Section 12b Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by the physician.Review of the facility's policy titled Pharmacy Services, revised June 2023, section 8. f. states Strive to assure that medications are requested, received, and administered promptly as ordered by the authorized prescriber (in accordance with state requirements), including physicians, advanced practice nurses, pharmacists, and physician assistants.Observation on 12/17/2025 at 8:49 am of a medication pass with Licensed Practical Nurse (LPN) JJ revealed one omitted medication for R50, polyethylene glycol 3350 17000MG (milligrams) powder for oral solution, one packet daily mixed with 8 ounces of water or juice. Observation made on 12/17/2025 at 9:02 am of medication administration with LPN JJ revealed LPN JJ did not assist or instruct R15 to rinse his mouth after the use of fluticasone propionate and salmeterol inhaler 100 mcg/50mcg daily.Observation made on 12/17/2025, started at 9:19 am, of a medication administration with LPN OO revealed that LPN OO omitted R23's Nepro supplement that was scheduled at 7:30 am due to unavailability.An observation made on 12/17/2025, starting at 9:53 am and ending at 10:56 am with LPN OO revealed that at 10:08 am, while preparing medications for R82, she realized that R82's Blood Pressure was 101/57 and heart rate of 66. R82 had no visible signs of hypotension, and there were no parameters set for R82's lisinopril. She held the medication and continued to prepare the rest of R82's medications. At 10:15 am, OOLPN discovered that R82 was out of apixaban, and she left the medication cart to pull apixaban from emergency stock. At 10:43 am, OOLPN returned to the medication cart and stated that apixaban was not in the emergency stock, and she spoke with the provider, and who ordered to hold the lisinopril for low blood pressure and hold the apixaban and the Spiriva for one day due to unavailability of the medication. At 10:49 am, LPN OO had finished preparing R82's medication, but the resident had left and gone to therapy. LPN OO then labeled the cup of medications and locked them up in the top drawer of the medication cart and went to find R82. At 10:52 am, OOLPN returned to the medication cart with R82 in his wheelchair and proceeded to give the resident his medication in the hall and rubbed Naprosyn cream on his knees. LPN OO omitted the nystatin external powder 100000 units/GM (units per gram).An interview with LPN OO on 12/17/2025 at 10:47 am revealed that she usually gets through her 9:00 am medication pass at 10:30 am. She confirmed that she has more than half of the residents on B hall left to give 9:00 am medications too, and that she is more than an hour late with those medications. LPN OO confirmed that in the case of twice a day, three times a day, and every 8 and 12-hour timed medications, the residents could have complications due to these medications being given too close together or a drop in blood levels when too far apart. An interview with LPN KK on 12/18/2025 at 8:10 am revealed that LPN KK was working on the 200 hall today. She looked to see if R82 had his apixaban and Spiriva on the 200-hall medication cart, and R82 did have a full card of apixaban that came in last night, and his bedtime dose was administered. R82's Spiriva was not on the cart.An interview via telephone with the pharmacy provider on 12/18/2025 at 8:37 am, and spoke with Pharmacist MM who revealed that Apixaban was ordered 12/14/20205 and was delivered last night, and the resident did get his bedtime dose. The Spiriva was ordered according to Pharmacist MM, 12/14/20205, and has not been filled yet, and the resident did not have any available. He stated that there was no drug shortage associated with apixaban or Spiriva.An interview on 12/18/2025 at 10:12 am with Registered Nurse (RN) GG, Unit Manager, revealed his expectations for appropriate time limits on medication passes were an hour before and an hour after the ordered time. He also expected that the residents get their medications on time and the correct medications. He also revealed that there were about 20-25 residents on each cart and that the 9:00 am med pass was the heaviest medication administration pass. An interview with LPN NN Unit Manager on 12/18/2025 at 10:29 am revealed that she expected medications to be given within an hour before and an hour after the rule. She also had about 25 residents per cart.An interview with the Director of Nursing (DON) on 12/18/2025 at 10:40 am revealed that her expectation was for the medication passes should be completed an hour before and an hour after the time the medication was ordered. Her expectation for pharmacy delivery from ordering to delivery should be 24 hours. The nursing staff were to order the medications one week before running out of the medication.

Based on observations, record review, staff interviews, and review of the facility policy titled, Catheter Care, the facility failed to ensure residents were provided with privacy bags for the urinary drainage bag on the Foley catheter for two of eight Residents (R) (R119 and R128) with catheters. The deficient practice had the potential for infection for R119 and R128.Findings include:Review of Policy titled Catheter Care dated October 2025 revealed that the catheter should have a Privacy bag available and catheter drainage bags will be covered at all times while in use. Privacy bags will be changed out when soiled, with a catheter change or as needed.Review of the clinical record for R119 revealed a [AGE] year-old male admitted with diagnosis included but not limited to: urinary retention, chronic kidney failure, congestive heart failure.Review of the care plan dated 12/16/2025 revealed that R119 has an indwelling catheter related to urinary retention.Observation on 12/16/2025 at revealed R119 up in his wheelchair in the therapy room for rehab with his Foley catheter attached to the lower part of the wheelchair without a privacy bag.Observation on 12/17/2025 revealed R119 in activities in the dining room without a privacy cover to his drainage bag.Observation on 12/18/2025 when surveyor passed room of R128 and observed resident in bed with a Foley catheter to the bedside without a privacy cover.Interview on 12/18/2025 at 11:15 am with Licensed Practical Nurse (LPN) JJ revealed that all catheters should have a privacy bag, and this should be checked by the nurses and the Certified Nursing Assistants (CNA) working on the hall.Interview on 12/18/2025 at 11:25 am with LPN LL revealed that all residents who have a catheter are expected to have a privacy bag and should be checked by the nurse.Interview on 12/18/2025 with Director of Nursing revealed that she expected all nursing staff to perform correct catheter care and follow the policy on privacy bags. She revealed that privacy bags should be put in place on admission to the facility if they were admitted without one.

Based on record review, staff interviews, and review of the facility policy titled, MDS 3.0 Completion, the facility failed to properly code a resident for discharge furthermore there was no correction transmittal sent to Center for Medicaid Services (CMS) for one of two residents (R) (R116) reviewed for discharge. Findings include:A review of the facility policy titled, MDS 3.0 Completion dated October 2025 documented, Definitions: ARD, or Assessment Reference Date, refers to the specific endpoint in the MDS (Minimum Data Set) assessment process ( last day of MDS observation period). 2. Type of OBRA (Omnibus Budget Reconciliation Act) Assessments: f. Discharge Assessment - completed using the discharge date as the ARD. Must be completed within 14 days of the discharge date /ARD. 5. Correction of Errors on the Assessment: . d. i. An inactivation request is used when a record has been accepted into IQIES (CMS on line system) but the corresponding event did not occur. ii. An inactivation must be completed when specific items on the MDS are inaccurate.Review of the electronic medical record (EMR) revealed R116 was admitted to the facility with pertinent diagnoses including but was not limited to chronic obstructive pulmonary disease with (acute) exacerbation, atherosclerotic heart disease of native coronary artery with unspecified angina pectoris, other specified arthritis, unspecified site, gastro-esophageal reflux disease without esophagitis, chronic kidney disease, unspecified, hypertensive heart disease with heart failure, transient cerebral ischemic attack, unspecified. Review of the EMR in the section labeled Progress Notes documented a note dated 10/6/2025 by the Occupational Therapist stating R116 scheduled for ST (speech therapy) and OT (occupational therapy) evaluations today but requested discharge from facility. No therapy evaluations completed due to DC from facility. Review of the EMR in the section labeled Progress Notes/nurse note dated 10/6/2025 documented R116 and granddaughter packed all of resident's personal belongings and removed them from the facility. All medications and paperwork were explained to both resident and granddaughter, both verbalized understanding. Resident left facility at 1503 (3:03 pm).Review of the EMR in the section labeled MDS - Section A documented Discharge MDS dated [DATE] Section A: unplanned discharge - return anticipated; discharge status short term general hospital (acute hospital, IPPS).R112 did not have a baseline care plan in the system. R116 had a base line care plan in the system, was able to find when the Director of Nursing (DON) explained the process of the assessment and showed how the baseline was in the system.Interview on 12/17/2025 at 4:13 pm with the Minimum Data Set (MDS) Coordinator revealed she completed section A of the MDS and she would get her information from the morning meetings and would run reports when she checked her dashboard. If there was a discharge from the facility, she would typically know. For those residents who were unplanned, she would search her dashboard then it would be discussed in the morning meeting. For those who were discharged to the hospital, it depended on insurance as to when she would code them as a discharge. If there was a mistake, she would ask for assistance to correct the code. As far as R116, she was unsure of what happened with her discharge and why it was coded as hospitalization when she discharged home. Interview on 12/17/2025 at 4:49 pm with the Remote MDS Coordinator revealed R116 should have been coded as discharge return not anticipated and not sure as to why it was not. She further stated it was unplanned and should have done a correction and she could do that right now, this was purely an oversight.Interview on 12/17/2025 at 4:58 pm with the DON revealed if anything was coded wrong she expected for MDS to check and triple check the process to make sure the correct transmittals are sent to CMS.

Based on observations, staff and resident interviews, record review, and review of the facility's policy titled, Pharmacy Services, the facility failed to provide routine and emergency drugs and biologicals to the facility residents for one of four halls sampled, and specifically for resident (R) (R82). This deficient practice had the potential to cause serious complications with resident health.Findings include:Review of the facility's policy titled Pharmacy Services revised June 2023, revealed under Compliance Guidelines: 1.The facility will provide pharmaceutical services to include procedures that assure the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice. Section 8 subsection f. states Strive to assure that medications are requested, received, and administered on time as ordered by the authorized prescriber.Review of the electronic medical record (EMR) revealed resident R82 was admitted to the facility with pertinent diagnoses, including but not limited to chronic kidney disease, chronic obstructive pulmonary disease, diabetes mellitus with diabetic neuropathy, obstructive sleep apnea, paroxysmal atrial fibrillation, pain in right foot, syncope and collapse, bradycardia, chronic diastolic heart failure, sick sinus syndrome, cardiac pacemaker, malignant neoplasm of skin on face, atherosclerosis of native arteries of extremities with rest pain.Review of R82's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated R82 was cognitively intact. Section GG, functional status, revealed R82 required minimum assistance with meals and oral hygiene, dependent on staff for toileting hygiene and personal hygiene, was independent for dressing upper and lower body, and independent for footwear. R82 was independent for transfer from bed to wheelchair. Review of the Physician's Orders for R82 included, but was not limited to:Order dated 5/30/2025 Spiriva HandiHaler Inhalation Capsule 18 MCG (Tiotropium Bromide Monohydrate)Order dated 12/14/2025 Eliquis Oral Tablet 5 MG (Apixaban)Observation on 12/17/2025 at 9:53 am revealed on the medication pass on 200 hall with Licensed Practical Nurse (LPN) OO observing medication pass for R82. Two medications were missing: apixaban 5mg oral tablet, nine am dose, and Spiriva inhaler 18mcg capsule for inhalation. At 10:15 am LPN OO went to pull the apixaban from the emergency stock. 10:30 am LPN OO was still trying to find apixaban, and a Certified Nursing Assistant (CNA) came to the medication cart to report that another resident needed pain medication. At 10:43 am, LPN OO came back to the medication cart after calling the Nurse Practitioner (NP) and receiving orders to hold the apixaban, Spiriva, due to drugs being unavailable. At 10:49 am, LPN OO went to find R82 to give him his 9:00 am medication, but he had left his room and was in therapy. At 10:52 am, LPN OO came back to the medication cart with R82 and administered his 9:00 am medication that was available.An interview with LPN KK on 12/18/2025 at 8:10 am revealed that on the 200-hall medication cart, R82's apixaban did come in the night before, and he did receive his nine pm dose of apixaban last night, but the Spiriva did not come in, and the resident will not get it today at the 9:00 am medication pass.An Interview with Pharmacist MM from the providing pharmacy on 12/18/2025 at 8:37 am revealed that R82's apixaban was ordered on 12/14/2025 and was delivered last night on 12/17/2025. R82's Spiriva was ordered according to Pharmacist MM, on 12/14/2025, and for reasons that he could not explain, it had not been filled yet, and the resident did not have any available. Pharmacist MM also stated that they had been short-staffed but that in a perfect world, the medication turnaround was 24 hours from ordering to delivery.An interview with LPN KK on 12/18/2025 at 11:30 am revealed that the pharmacy called her and said that R82's insurance denied the Spiriva claim, and they were working on it.An interview with an unnamed pharmacist from the pharmacy provider on 12/18/2025 at 12:24 pm after multiple attempts to contact the pharmacy concerning the insurance denial for R82's Spiriva. She revealed that she was not going to give me her name because she didn't know anything, she was a PRN (as needed) pharmacist, and that I should call the insurance specialist, and she would be in at 1:00 pm.An interview on 12/18/2025 at 1:17 pm call conducted with the providing pharmacy, and a message was left on the insurance specialist's voicemail concerning the insurance denial on R82's Spiriva. An interview with LPN NN Unit Manager on 12/18/2025 at 10:29 am revealed that she expected the reordering of medications should be done a week before they are out. If medication was not available, they called the pharmacy, and if we couldn't get it, we would call the MD (Doctor of Medicine) and put the medication on hold until it was available. An interview with the Director of Nursing (DON) on 12/18/2025 at 10:40 am revealed that her expectation for pharmacy delivery from ordering to delivery should be 24 hours. We must keep following up and calling until the pharmacy sends the medication.

Based on resident and staff interviews, record review, and facility policy review, the facility failed to provide written notice of a room change prior to changing residents' rooms within the facility, which affected 4 (Residents #1, #7, #11, and #12) of 4 residents reviewed for multiple room changes. Findings include: A facility policy titled, Change of Room or Roommate, revised 07/2023, revealed, It is the policy of this facility to conduct changes to room and/or roommate assignments when considered necessary and/or when requested by the resident or resident representative. The policy also revealed, 4. Prior to making a room change or roommate assignment, all persons involved in the change/assignment, such as residents and their representatives, will be given advance notice of such a change as is possible. 5.The notice of a change in room or roommate will be provided in writing, in a language and manner the resident and representative understands and will include the reason(s) why the move or change is required. 1. According Resident #1's admission Record, the resident had a medical history that included diagnoses of end stage renal disease with dependence on renal dialysis, congestive heart failure, atrial fibrillation, diabetes mellitus, chronic pain syndrome, and traumatic subarachnoid hemorrhage (bleeding in the space below one of the thin layers that cover and protect the brain) without the loss of consciousness. The admission Record revealed the facility discharged the resident on 09/11/2024. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/17/2024, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Review of Resident #1's Census report revealed the resident changed rooms on the following dates since their admission on [DATE]: 04/15/2024; 06/03/2024; and 07/05/2024. Review of Resident #1's Progress Notes revealed no documentation of written notification of a room change being provided to the resident or their responsible party on or prior to 04/15/2024. Review of Resident #1's Progress Notes revealed a note, dated 06/03/2024 at 11:22 AM and electronically signed by the Social Services Director (SSD), that revealed the SSD left a voicemail to update Resident #1's responsible party on a room change. The Progress Notes revealed no documentation of prior written notice being provided to the resident, or of a return call or conversation with the resident's responsible party. Review of Resident #1's Progress Notes revealed no documentation that a written notification of a room change was provided to the resident or their responsible party on or prior to 06/03/2024 or 07/05/2024. 2. Review of Resident #7's admission Record indicated the facility originally admitted the resident on 06/28/2021 and most recently readmitted the resident on 01/24/2024. According to the admission Record, the resident had a medical history that included diagnoses of congestive heart failure, schizophrenia, sick sinus syndrome, and paroxysmal atrial fibrillation. Review of an annual MDS with an ARD of 04/10/2025, revealed Resident #7 had a BIMS score of 8, which indicated the resident had moderate cognitive impairment. Review of Resident #7's Census List report revealed the following dates the resident changed rooms following their readmission on [DATE]: 02/06/2024 (two different room changes on the same day); 02/07/2024; 02/08/2024; 09/06/2024; 09/11/2024; 09/12/2024; 09/17/2024; and 12/10/2024. Review of Resident #7's Progress Notes, for the timeframe from 2/01/2024 through 2/10/2024, revealed no documentation of written notifications of room changes being provided to the resident or their responsible party. Review of Resident #7's Progress Notes, for the timeframe from 09/01/2024 through 09/11/2024, revealed no evidence that prior written notification of transfer was provided to the resident or responsible party prior to or on 09/06/2024 or 09/11/2024. Review of Resident #7's Progress Notes revealed a Social Service note, dated 09/12/2024 at 4:24 PM and electronically signed by the Social Services Director (SSD), that revealed a telephone call was made to Resident #7's responsible party to notify them the resident had been moved to another room, however, the Census List report revealed a different room number than that in the note. Resident #7's Progress Notes, revealed no evidence that a written notification of a room change was provided to the resident or their responsible party prior to or on 09/17/2024. Review of Resident #7's Progress Notes revealed a Social Service note, dated 12/10/2024 at 2:38 PM and electronically signed by the SSD, which revealed a telephone call was placed to Resident #7's family member; however, there was no answer and no voicemail was left. The notes revealed no evidence the resident or responsible party was provided written notification of a room change prior to or on 12/10/2024. During an interview on 04/24/2025 at 10:40 am, Resident #7 stated the facility staff had moved them from room to room so many times I cannot remember them all. The resident stated the facility staff did not always give them the choice or tell the resident beforehand. Resident #7 stated the staff come in here and say they have talked to my family about it [the move] and that I am moving. The resident stated that they had never received written notice of a room change. 3. Review of Resident #11's admission Record indicated the facility admitted the resident on 12/16/2023. According to the admission Record, the resident had a medical history that included diagnoses of schizophrenia, diabetes mellitus, and chronic obstructive pulmonary disease (COPD). Review of a quarterly MDS with an ARD of 03/19/2025, revealed Resident #11 had a BIMS score of 14, which indicated the resident had intact cognition. Review of Resident #11's Census List report revealed the following dates the resident changed rooms since their admission on [DATE]: 01/01/2024; 01/11/2024; 02/28/2024; 02/29/2024; and 08/15/2024. The Census List indicated the resident was transferred to a hospital on [DATE] and readmitted to the facility on [DATE] (nine days later), then changed rooms on 10/24/2024. Review of Resident #11's Progress Notes revealed no documentation on or prior to each of the room changes that the resident or their responsible party was notified in writing of a room change. During an interview on 04/24/2025 at 10:20 am, Resident #11 stated they had been moved several times within the facility and had never been given written notice of the move. The resident also stated that they were often not given any notice of the intent to move from room to room and that staff would just show up and get you and your belongings and don't really give you time to say goodbye. 4. Review of Resident #12's admission Record indicated the facility admitted the resident on 03/10/2023. According to the admission Record, the resident had a medical history that included diagnoses of congestive heart failure, diabetes mellitus, and atrial fibrillation. Review of a quarterly MDS with an ARD of 04/15/2025, revealed Resident #12 had a BIMS score of 15, which indicated the resident had intact cognition. Review of Resident #12's Census List report revealed the following dates the resident changed rooms since January 2024: 01/05/2024 and 01/07/2024. Review of Resident #12's Progress Notes revealed no documentation on or prior to 01/05/2024 or 01/07/2024 that the resident or their responsible party was notified in writing of a room change. During an interview on 04/24/2025 at 10:24 am, Resident #12 stated they had been moved several times from room to room in the facility and had never received a written notice of the room change at any point, either before or after the move. The resident stated, I have never even been given advanced notice of a move or the option to give my opinion about the moves. The staff show up and I am basically told I need to move to a new room because of new admissions or something, and it has never been presented as optional to me. Resident #12 stated there had been times when they (Resident #12) did not want to leave their roommate at the time and would have preferred to stay where they were instead of being moved. During an interview on 04/24/2025 at 10:16 am, Certified Nurse Aide (CNA) #5 stated that during a room-to-room transfer, she helped Resident #12 pack up their belongings and helped get them to the new room. She stated she had never seen a resident get any kind of written notification of a room change. During an interview on 04/24/2025 at 10:23 am, CNA #6 stated when there was a room transfer in the facility, she helped the resident pack their belongings and take them to the new room. She stated she had never seen a resident get any kind of written notification of the room change. noted she had completed many room changes. During an interview on 04/24/2025 at 9:51 AM, Licensed Practical Nurse (LPN) #1 stated that when a resident was being transferred from room to room in the facility, they notified the family and the resident and helped to move their belongings from room to room. She stated there was not any paperwork completed that she was aware of, noting the room number was just changed in the electronic health record (EHR). During an interview on 04/24/2025 at 10:05 am, LPN #3 stated that during an in-house room transfer, she notified the nurses' station associated with the new room, ensured medications were transferred over to the new unit, and contacted the unit manager and the family to let them know. She stated she had never seen any paperwork filled out for a room transfer or written notification of the change given to a resident. She stated the staff just changed the room number in the EHR. During an interview on 04/24/2025 at 10:09 am, Registered Nurse (RN) #4, a unit manager, stated that for a room-to-room transfer, she ensured a CNA knew to assist the resident with the move and that the family was notified of the new room number. She stated she changed the room number in the EHR, took the resident's medications and treatments to the new nurses' station, and gave report to the new nurse. RN #4 stated there was no paperwork involved in a room-to-room transfer, and she had not seen any written notification of the change given to a resident. During an interview on 04/23/2025 at 3:16 pm, the Social Services Director (SSD) stated she was the process owner for room transfers. She stated if a room transfer were to occur, she notified the family of residents whose BIMS scores were low and talked to the residents and asked if they were ready to move that day. She stated they resident was given an option of when the room change would take place. She stated there was not a written notice given to the residents or the family regarding room transfers, noting she was not aware that doing so was a federal regulation. During an interview on 04/24/2025 at 12:17 pm, the Director of Nursing (DON) stated her expectation for a room-to-room transfer was for staff to consider the personalities of the residents prior to the move. She stated that staff were to ask the resident their opinion of a transfer and if a resident was unable to make a decision, staff were to notify the resident's family. The DON stated the SSD documented room changes in the EHR, but there was not currently any paperwork that was filled out or handed out. During an interview on 04/24/2025 at 12:37 pm, the Administrator stated that for room-to-room transfers, they notified the resident and the family verbally and staff made the move as accommodating as possible. He stated he was not aware of a written notice of transfer given to the residents. He stated that EHR documentation was all that the facility had ever completed for room transfers.

Based on resident attorney, medical records company representative, and staff interviews, record review, and facility policy review, the facility failed to provide a written copy of the residents' medical records within two working days of the initial written request for three (Residents #2, #9, and #10) of three residents reviewed for timely access to their medical records. Findings include: An undated facility policy titled, Release of Medical Records indicated, Medical records will be released with a valid request and in accordance with state and federal laws. The policy indicated, 2. Requests for records should be referred to the Director of Nursing or Administrator, or Medical Records Designee, previously designated by [the corporation's name]. The policy revealed, 5. Records Requests/Compliance should be notified of the request for records through the records request email. Records should not be released prior to discussion with a records request/compliance team member, to further validate authenticity of the request. 6. Upon receipt of the authorization request form for medical records, [the corporation's name] should notify the requesting party of the cost for obtaining records [sic] Copies should not be released prior to the receipt of payment for associated charges. 7. Fees for copying medical records are determined according to state regulations. The policy revealed, 8. Once a request for records is received, all records for that resident should be gathered and secured in a place inaccessible to anyone except the records request/compliance team, Administrator, Director of Nursing, or designee. The policy further indicated, Access Rights to Medical Information are as Follows 1. The resident (current resident) - the resident's record is accessible to him/her within 24 hours (excluding weekends and holidays) notice, following an oral or written request. The policy revealed, The resident or his/her legal representative may receive a copy of his/her record within 2 working days after the request has been made. If we need more time to process your request, we can take another 30 days if we notify you that additional time is needed. The policy revealed, 12. Attorneys - the resident or his/her legal representative's authorization must be obtained prior to release of information to attorneys. 1. Review of Resident #2's admission Record indicated the facility admitted the resident on 03/07/2018. According to the admission Record, the resident had a medical history that included diagnoses of Alzheimer's disease, vascular dementia, and diabetes mellitus. The admission Record indicated the facility discharged the resident on 07/13/2023. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/19/2023, revealed Resident #2 had severe impairment in cognitive skills for daily decision-making and had short-term and long-term member problems per a staff assessment of mental status (SAMS). Review of Resident #2's Care Plan Report included a focus area, initiated 09/16/2019, that indicated the resident had impaired cognitive function and impaired thought processes related to diagnoses of vascular dementia with behaviors and Alzheimer's disease. Interventions directed staff to use the resident's preferred name, identify themselves during each interaction, face the resident when speaking, and to make eye contact (initiated on 04/30/2020); administer medications as ordered (initiated 09/16/2019); and to anticipate and meet resident's needs (initiated 08/22/2022). During a phone interview on 04/22/2025 at 4:46 pm, Attorney #7 stated their law firm had sent a Letter of Representation to the facility at the beginning of September 2024 and had given them 30 days to produce the requested medical records. Attorney #7 stated that after 30 days had past, a paralegal attempted to reach out to the facility a couple of times without being able obtain Resident #2's medical record for the timeframe from 08/20/2019 through their discharge date . Review of a letter from a law firm to the facility, dated 09/09/2024, indicated they were representing Resident #2 and requested the resident's medical records be sent to them within 30 days. The letter indicated it was sent via first class mail and certified mail and listed the return receipt tracking number. Review of a United States Postal Service request for proof of delivery, dated 09/26/2024 and matching the tracking number listed on the request for Resident #2's medical record, indicated the request was delivered to the facility and signed for by a front desk/receptionist on 09/12/2024 at 12:46 pm. Review of an email dated 10/10/2024 at 10:37 am and sent from the Senior Compliance Officer (SCO) of the facility's hired compliance office to the former facility owners, who owned the facility through 08/19/2024, revealed the SCO shared with them a medical record request and requested confirmation that they received the email and asked if the former owners would like to produce Resident #2's records for the timeframe the facility was under their operations. Review of an email dated 10/10/2024 at 4:39 pm from Medical Records (MR) #12 at the facility to the facility's Records Request email with an attached scanned document revealed the scanned document included the letter from the law firm sent to the facility requesting Resident #2's record. The scanned document also included a HIPAA [Health Insurance Portability and Accountability Act] Compliant Medical Authorization Form, signed by Resident #2's legal representative and dated 08/01/2024, and a signed Affidavit of Kinship signed by Resident #2's family member and dated 08/01/2024. Review of an email dated 10/10/2024 at 4:50 pm from the SCO to MR #12 revealed she informed MR #12 a legal request was signed by Resident #2's next of kin and asked her to ensure all hard copy records had been scanned into the electronic health record (EHR). The email indicated the SCO asked MR #12 to clarify when the request was received at the facility, because the request was dated 09/09/2024, which brought the facility to the 30-day legal response period. Review of an email dated 10/18/2024 at 12:49 pm indicated that the former facility owners forwarded the email from the SCO that was sent on 10/10/2024 to their own Quality Assurance Director in response to Resident #2's record request. Review of an email dated 10/21/2024 at 8:35 am from the SCO to MR #12 indicated that Resident #2's medical records from the current owners had been prepared as requested for the law firm, and the requested certification would need to be notarized prior to the release of the records. The email indicated that an invoice was also attached, and that once the facility received payment, the records and notarized certification could be released to the law firm. Review of an email dated 10/21/2024 at 8:35 am from the previous facility owners to Paralegal #8 indicated that they received the letter of request for records on Friday, 10/18/2024, and had gathered all of Resident #2's electronic records through 08/19/2024. The email requested a response from Paralegal #8 and indicated that they would then provide a link and password to access the requested records. Review of an email dated 10/21/2024 at 3:09 pm from the former owners to Paralegal #8 included the link and password to access Resident #2's medical record for one week to download or print as needed. The entire process took 39 calendar days to obtain Resident #2's medical record. 2.Review of Resident #9's admission Record indicated the facility admitted the resident on 12/03/2024. According to the admission Record, the resident had a medical history that included diagnoses of atrial fibrillation and chronic obstructive pulmonary disease (COPD). Review of an admission MDS with an ARD of 12/09/2024, revealed Resident #9 had a BIMS score of 15, which indicated the resident had intact cognition. Review of Resident #9's Care Plan Report included a focus area, initiated 12/03/2024, that indicated the resident had an activity of daily living (ADL) self-care performance deficit related to weakness and debility. Interventions indicated the resident required one to two staff for bed mobility (initiated 12/03/2024), set up assistance for eating (initiated 12/03/2024), and required one to two staff for transfers (initiated 12/03/2024). Review of the form, Release of Information, dated 02/04/2025, revealed a law firm representing Resident #9 had faxed a medical records request to the facility and included a HIPAA [Health Insurance Portability and Accountability Act] Release Form. The HIPPA Release Form was signed by Resident #9 and dated 01/24/2025. A Facsimile (fax) coversheet indicated the request for Resident #9's records was sent on 02/04/2025 at 6:30 am. Review of an email, dated 02/14/2025 at 7:41 am and sent from Medical Records (MR) #12 to Records Request, indicated that they had received a request for records. An email within the same email chain, dated 02/17/2025 at 8:18 AM, from the SCO of a third party company used by the current facility owners to prepare medical records requests to MR #12 indicated the facility had received a legal request for records for Resident #9 and requested that she ensured all hard copy records had been scanned into the EHR. Review of an email from the same email chain, dated 03/11/2025 at 3:09 am, from the SCO to MR #12 indicated that Resident #9's medical record had been prepared as requested by the law firm. The email indicated that a link was provided for the law firm to access the EHR, and an invoice was attached to the email. The email provided instructions that revealed, Once the facility has received payment, you may release the records. The entire process from the initial request for Resident #9's medical record took 35 calendar days for the requester to have the ability to access the records. 3. Review of Resident #10's admission Record indicated the facility admitted the resident on 12/01/2023. According to the admission Record, the resident had a medical history that included diagnoses of diabetes mellitus, obesity, and hyperlipidemia (high cholesterol). Review of the quarterly MDS with an ARD of 04/15/2024, revealed Resident #10 had a BIMS score of 4, which indicated the resident had severe cognitive impairment. Review of Resident #10's Care Plan Report included a focus area, initiated 12/07/2023, that indicated the resident had an activity of daily living (ADL) self-care performance deficit related to urinary tract infections, diabetes, kidney failure, obesity, arthritis, and neuropathy. Interventions indicated the resident required assistance from one to two staff for bed mobility (initiated 12/07/2023), set up assistance with eating (initiated 12/07/2023), and assistance from one to two staff for toileting (initiated 12/07/2023). Interventions also indicated the resident required the use of a mechanical lift for transfers (initiated 12/07/2023). Review of a letter to the facility dated 08/09/2024 from Resident #10's next of kin (NOK) indicated the NOK requested Resident #10's medical records. The letter indicated it was sent via certified mail. Review of a second letter from a law office representing Resident #10 and their NOK, dated 11/21/2024, provided proof of representation and listed multiple attempts by the law office to contact someone from the facility to assist in obtaining the medical records for Resident #10. The letter indicated the attempts to contact the facility that were unsuccessful were as follows: 09/25/2024, 09/26/2024, 09/30/2024, 10/03/2024, 10/18/2024, 10/22/2024, 10/30/2024 (facility receptionist said they would take the message to medical records staff, but no return call was received), 11/04/2024, and 11/14/2024. Review of an email dated 12/02/2024 at 1:19 pm from Medical Records (MR) #12 to the facility's Records Requests email indicated that she had just received a medical records request for Resident #10 that day. Review of an email dated 12/02/2024 at 1:32 pm from the SCO of a third party company used by the current facility owners to prepare medical records requests to MR #12 indicated that they had received the record request for Resident #10 that was sent in August of 2024. The email indicated that the notice referenced multiple attempts to make contact with the facility regarding the status of the request. The email indicated that the compliance office would get the record together as soon as possible to avoid a complaint and potential fine from the Office of Civil Rights. The email indicated that the facility had only 30 days to process a valid request. The email indicated that if there were still hard copy records, they needed to be sent to the SCO by the end of the business day that day (12/02/2024). Review of an email dated 12/03/2024 at 9:32 AM from the SCO to MR #12 indicated Resident #10's medical record was ready as requested by the law firm and included an attachment of the record. The email requested MR #12 send the invoice for payment that day [12/03/2024], as they were already past the 30-day regulated response time. The email indicated that once payment was received from the law firm, the facility could release the record. From the initial request for Resident #10's medical record to when the record was available for the law firm to access took a total of 116 calendar days. During an interview on 04/24/2025 at 10:16 am, the SCO, who stated she represented the compliance company hired by the facility to compile medical record requests, especially legal chart requests, stated the compliance company attempted to meet the 30-day response time given to them by an attorney's office. She stated that if there were circumstances in which they were busy and not able to meet those deadlines, the company tried to reach out to the lawyer's office to give an explanation for the delay. The SCO stated that when a medical records request was made, the facility received the initial request, then the medical records staff at the facility contacted the compliance company and forwarded the request. The SCO stated that she then contacted the facility's medical records staff and made sure all the hard copy records, if there were any, had been scanned into the electronic health record (EHR) prior to her gaining access to it. She stated the compliance company had remote access to the facility medical records system and was able to pull the information needed, once the EHR was completed from the facility's end. She stated that once the chart was verified as complete by the medical records staff at the facility, the turnaround time for processing a legal medical records request on the compliance end was between 15 and 21 days; however, there had been instances when it took longer. The SCO stated that not only was the compliance office compiling the record into a timeline format, but they were also scanning the documents for areas of liability, informing the company that owned the facility of any potential issues, and verifying the validity of the requestor of the record. She stated verifying was to ensure, for residents with a low BIMS score, that an unauthorized person was not seeking access to the resident's record without the proper permissions. After discussing the federal regulation for providing a resident's medical record to them in full within 48 business hours, the SCO stated it was her company's understanding, after having a conversation with a representative of the Office of Civil Rights (OCR) of Georgia, that the 48 hours regulation only applied to residents who were still actively residing in the facility. She stated that if a resident had been discharged from the facility and requested records afterwards, a 30-day rule applied to provide them with access to the record, like the timeframe provided by most lawyers' offices. She stated the compliance company had never met the 48-hour rule for outside requests for this facility, and often did not even get the initial medical record request from the facility within the 48-hour mark. During an interview on 04/24/2025 at 12:17 pm, the Director of Nursing (DON) stated she knew that when a medical record request was made, the corporate office was notified, who reviewed the record. She stated a resident had to fill out a form to request the record, and she was unsure how long the process usually took. During an interview on 04/24/2025 at 12:37 pm, the Administrator stated residents completed a form for a record request, the form was sent to medical records staff at the facility, and then the request was sent to a third-party company to process. He stated that once the record was compiled for the resident and sent back to the facility, the facility collected the charges for copying the file and then released it to the resident or representative.

Based on observations, staff interviews, and review of the facility's policies titled, Sanitation, Refrigeration and Freezer, Food Receiving and Storage, and Food Preparation and Service, the facility failed to discard dry and frozen food by expiration dates, ensure proper food labeling, storage and dates, follow puree recipe, perform proper thawing procedure, and maintain proper sanitary conditions of two of two ice machines. The deficient practice had the potential to affect 108 residents who receive an oral diet from the kitchen. The facility census was 110 residents. Findings Include: Review of the facility policy titled Sanitation dated [DATE] revealed under 12. Ice machines and ice storage containers will be drained, cleaned, and sanitized per manufacturer's instructions and facility policy.16. The Nutrition Service Manager will be responsible for scheduling staff for regular cleaning of the kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. Review of the facility policy titled Refrigeration and Freezer dated [DATE] revealed under 7. All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and on individual items removed from cases storage. Use by dates will be utilized on all prepared food in refrigerators. Expiration dates on unopened food will be observed and adhered to. Use by or open dates will be labeled on food items once opened. 8. Supervisors will be responsible for ensuring food items in pantries, refrigerators, and freezers are not expired or past perish dates. Supervisors should contact vendors or manufacturers when expiration dates are in question or to decipher codes. Review of the facility policy titled Food Preparation and Service dated [DATE] revealed the following under Thawing Frozen Food b. Submerging the item in the cold running water (70 F (Farenheit) or below). Review of the facility policy titled Food Receiving and Storage dated [DATE] revealed under 6. Dry foods that are stored in bins will be removed from original packaging, labeled, and dated. Such foods will be rotated using a first in first out system. Observations during the kitchen tour on [DATE] at 9:05 am with the Dietary Manager (DM) revealed in the walk-in refrigerator nine bowels of peaches, 32 prepared liquid gelatins in bowls, 30 prepared gelatins with fruit in bowls, four yellow like puddings in drinking cups, and three red like liquids in cups without correct wrapping storage, labeling, and dates. The freezer revealed two medium sized bags; one clear bag and one blue bag with unidentified frozen meat, one white like cream substance, and one clear wrapped french fries pack without proper labeling and dates. Observation of dry storage foods revealed 30 single packs of thickened coffee, eight 24 ounce gelatin bags, and two 32 ounce honey cartons with expired dates. The DM confirmed expired items, immediately discarded, and mentioned all three morning kitchen staff including himself were responsible for checking labeling, storage, and dates. The DM and Dietitian confirmed food was ordered and rotated out when food trucks deliver. Observation of black like substance on ice machines and confirmed substance by DM from white paper towel. The DM revealed dietary staff were responsible to clean the ice machines monthly, but no log was presented, and maintenance deep cleaned the ice machines quarterly. Maintenance provided cleaning log from the electronic maintenance work order system. Cleaning log revealed the last deep cleaning was [DATE]. Observation on [DATE] at 11:27 am revealed three five-pound ground beef meats in a large sink thawing under steaming hot running water. Observation on [DATE] at 11:27 am with [NAME] DD revealed morning cook not following the recipe puree process for eight residents who received pureed food. [NAME] DD confirmed she put beef base on 12 uncooked boneless pork ribs meat for baking process in place of pouring into the Robot Coupe (robotic arm) during the puree process. [NAME] DD mentioned it was her little trick to prevent meat from being dry. Observed [NAME] DD pour two cups of hot water into the puree. [NAME] DD confirmed she doesn't usually do that. Observation on [DATE] at 12:37 pm revealed seven 60 fluid ounces of apple juice in emergency preparedness with expiration date of [DATE]. Interview on [DATE] at 3:46 pm, the Dietitian confirmed she noticed the high temperature running water on frozen meat. She informed cook to make immediate correction.

Based on resident family and staff interviews, and record reviews, the facility failed to notify the responsible party (RP) of new medication orders for one of 63 sampled residents (R) (R315). The facility census was 110. Findings include: A phone interview was conducted on 8/22/2024 at 11:30 am with the daughter of R315. She stated that she was concerned about the lack of concern that the facility had for her mother. She stated that her mother was a holiness (high religious dignitary) and did not believe in taking medications. She then stated that the only thing that she was supposed to be taking was a blood pressure medication. Review of electronic medical record (EMR) revealed that the only conversations between staff and the RP for R315 was on 3/8/2024 and 4/19/2024, not about medication. Review of the medication orders for R315 revealed that the resident was receiving the following medications, but was not limited to Topamax 50 milligrams (mg) by mouth, prescribed on 4/12/2024, Depakote 250 mg by mouth, prescribed on 2/6/2024, Ivermectin 12 mg by mouth, prescribed on 2/6/2024, and Lexapro 10 mg by mouth, prescribed on 12/22/2024. An interview with Registered Nurse KK on 8/22/2024 at 2:15 pm revealed that if she received any new medication orders, she would call the pharmacy, and then follow up until the medication was delivered. She was asked if there was anyone else that should be called and she stated no, except making sure the primary physician knows. An interview on 8/22/2024 at 5:00 pm with the [NAME] Director of Clinical Services revealed that it was his expectation that family and responsible parties were notified of any changes.

Based on observations, resident and staff interviews, record review, and review of facility's policy titled, Minimum Data Set, the facility failed to ensure accurate assessment for two of 63 sampled residents (R) (R413 and R68). The deficient practice had the potential to reflect an inaccurate status of the resident's current condition and progress. Findings include: Review of the facility's policy titled Minimum Data Set, dated dated dated [DATE] revealed a Policy Statement: This facility makes a comprehensive assessment of each resident's needs, strengths, goals, life history and preferences using the resident assessment instrument, (RAI) specified by Centers for Medicare and Medicaid Services (CMS). Item three states, The assessment process will include direct observation and communication with the resident as well as communication with licensed and non-licensed direct care staff members on all shifts. 1. During an observation and interview on 8/19/2024 at 10:30 am, R413 was noted to be alert, oriented, and pleasant. R413 stated he needed some assistance but could get up in the wheelchair, bath himself, use a urinal, and used the restroom for bowel movements. A review of R413's admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section H (bowel and bladder) documents presence of Foley catheter. Documentation on R413's medication administration record (MAR) revealed nursing removed the Foley catheter on 8/1/2024. 2. R68 was admitted [DATE] with diagnoses including but limited to neuropathy (numbness that can cause pain and numbness and worsen over time) and back pain. Review of R68 quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, which indicates intact cognition. Section GG (functional status) revealed R68 was independent for activities of daily living (ADLs). Section M (skin assessment status) revealed R68 has one stage two pressure ulcer (open wound where deeper layers of skin are damaged). Section J (health conditions) revealed R68 had no pain issues. Care plan dated 7/11/2024 revealed the resident has potential for pain related to neuropathy, wounds, lumbar disc degeneration, history of urinary retention and complaints of lower back pain. Interventions to administer pain medication. The resident has right hip pressure ulcer with intervention assess/ record/monitor wound healing, measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress and treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort. The resident has pressure ulcer development left hip. The resident has pressure ulcer development related to sacral area interventions for all three pressure ulcers same. Review of the Physician's orders dated 6/19/2024 revealed an order for oxycodone/acetaminophen tablet 5-325 milligrams (mg). Give one tablet by mouth every six hours as needed for chronic pain. An observation and interview on 8/20/2024 at 3:24 pm with R68 during medication administration, he stated he was in pain. R68 described pain in both feet which he stated he has had for a long time and took medicine when he needed to. Interview on 8/21/2024 at 1:00 pm with Registered Nurse (RN) LL revealed an expectation of pain assessment was done to include the location of pain, describe the pain, follow the nursing process. He then revealed intervention should be decided based on assessment, orders, and care plan.

Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Activities of Daily Living (ADLs), the facility failed to provide scheduled showers/baths for two residents (R) (R10 and R45) dependent on staff for ADLs. The facility census was 110 residents. Findings include: Review of the undated facility policy titled Activities of Daily Living revealed under Purpose: To attain or maintain the patient's highest practicable, physical, mental, and psychosocial wellbeing. The policy revealed under Practice Standards: 1. The Center must ensure that: 1.1 A patient is given the appropriate treatment and services to maintain or improve his/her ability to carry out ADLs; and 1.2 A patient who is unable to carry out ADLs receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 1. Review of the electronic medical record (EMR) revealed R10 was admitted with diagnoses of but not limited to chronic obstructive pulmonary disease (COPD), hypertensive chronic kidney disease, and unspecified osteoarthritis. Review of the quarterly Minimum Data Set (MDS) assessment from 7/12/2024 revealed that R10 had a Brief Interview for Mental Status (BIMS) score of 15, which suggests that cognition is intact. Review of a care plan completed for R10 on 4/14/2020 revealed R10 has an activities of daily living self-care deficit related to neuropathy, osteoarthritis, muscle weakness and lack of coordination. During an interview on 8/19/2024 at 3:15 pm, R10 stated that she received showers only once a week due to not enough staff members, but she wanted to receive showers two times per week. Review of the Activities of Daily Living task list from 7/25/2024 to 8/22/2024 revealed that R10 was scheduled for bathing on Tuesdays, Thursdays, Saturdays, and as needed (PRN). The task was marked only one time as complete, on 8/6/2024. 2. Review of the EMR revealed R45 was with diagnoses of but not limited to Parkinsonism, neurocognitive disorder with Lewy bodies, left ankle contracture, right hip contracture, right knee contracture, and right ankle contracture. Review of the significant change MDS assessment from 7/23/2024 revealed that the resident had a BIMS score of 15, which suggests that cognition is intact. Review of a care plan initiated for R45 on 6/3/2022 revealed R45 has a self-care deficit related to Parkinsonism, dementia with Lewy body, contractures, and muscle weakness. Review of Activities of Daily Living task list from 7/25/2024 to 8/22/2024 revealed that R45 was scheduled for bathing on Tuesdays, Thursdays, Saturdays, and as needed. The task was marked complete six out of 13 scheduled times. Interview on 8/22/2024 at 12:50 pm with Certified Nursing Assistant (CNA) AA revealed that CNAs were responsible for entering shower/bath tasks into the EMR. She stated that she started to work in this facility about one month ago and does not know the electronic system very good. CNA AA was not able to pull shower records for the entire month of August. Interview on 8/22/2024 at 1:20 pm with the Regional Director of Clinical Operations and Administrator revealed that the facility had sufficient staffing to provide showers as scheduled, but sometimes residents refused showers. When asked to provide refusal documentation, it was not available. Interview on 8/22/2024 at 3:10 pm, the Administrator confirmed that they did not have any additional documentation showing that R10 and R45 were receiving showers as scheduled.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, Activities, the facility failed to develop and introduce an activities program for one of 63 sampled residents (R) (R 413). The deficient practice had the potential to place the resident at risk for a diminished quality of life. Findings include: A review of facility's policy titled Activities dated January 2024 revealed a Policy Statement: It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designated to meet the interests of each resident, as well as support their physical, mental and psychosocial well-being. An interview and observation on 8/19/2024 at 10:30 am of R413 revealed he was awake and alert, lying in bed. He voiced concern around being moved into this room on 8/15/2024, that there was no television and that was his only entertainment. He was unaware of activities as no one had spoken to him about any activities. R413 further stated that he had asked about a television for several days as he needs something to do. He also stated he did ask the Administrator about getting him a television. A review of facility documentation titled Activities - Initial Review dated 7/26/2024 revealed he liked church services, read the bible, wanted to participate in activities and group activities, additionally indicated he would like to have some independent activities like reading, puzzles, etc. Activities Note also stated assistance should be provided to get resident to activity. An observation on 8/19/2024 at 1:22 pm, R413 had no television for him to watch in his room and had no visit from Activities. An observation on 8/20/2024 at 8:33 am of R413 revealed no television for him to watch in his room or visits from Activities. An observation on 8/20/2024 at 2:22 pm of R413 revealed no television for him to watch in his room. R413 revealed he does not know anything about activities, and no one has spoken with him about activities. He would like to know how to schedule activities. An observation on 8/20/2024 at 2:45 pm, R413 was in a wheelchair leaving his room to go to physical therapy. There was no television for him in his room. An interview on 8/19/2024 at 1:55 pm with the Administrator confirmed he was aware of the need for a television, and it was being worked on. An interview on 8/21/2024 at 4:46 pm with Activities Director (AD) revealed she started each day with smoke break and television in the dining room. The AD revealed the process was that initial assessments were done when admitted and follow up was done in one week. She was not familiar with R413, but will check the records. An interview on 8/22/2024 at 9:00 am AD confirmed there was no additional documentation for activities for R413. An interview on 8/22/2024 at 9:37 am with Administrator revealed an overview of the Activities Department right now was Activities had staffing issues. He further revealed the expected process was the AD would do the initial assessment, follow up, and include residents on relevant activities including one to one (1:1). The Administrator also stated he expected all newly admitted residents would have an activities assessment within 48 hours, then ideally a comprehensive assessment within 21 days. He also revealed the AD was responsible to evaluate and make changes within the care plan and Minimum Data Set (MDS) as needed. The Administrator also confirmed the facility does supply televisions for residents.

Based on observations, staff and resident interviews, and record review, the facility failed to follow the physician's orders for ointment and compression stockings for one of 63 sampled residents (R) (R413). The deficient practice had the potential to place the resident at risk for medical complications, and a diminished quality of life. Findings included: A review of the electronic medical record (EMR) revealed R413 was admitted with diagnoses including, but not limited to, cellulitis of the right lower limb, lymphedema, venous insufficiency chronic, and heart failure. A review of R413's admission Minimum Data Set (MDS) assessment dated [DATE] revealed section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 15 (indicating little to no cognitive impairment). A review of R413's Physician Orders dated August 2024 revealed an order dated 8/2/2024 for skin assessment to be done on day shift every Friday. Further review revealed an order dated 8/15/2024 for wound care to bilateral lower extremities and to apply Dermaphor ointment (a moisturizing ointment) to bilateral lower extremities two times a day for dry skin with a start date of 8/15/2024. Continued review revealed an order dated 8/15/2024 for compression stockings every morning, remove at bedtime for bilateral lower leg edema, congestive heart failure with start date of 8/17/2024. An observation and interview on 8/19/2024 at 10:30 am of R413 revealed he did not have compression stockings on, his legs had a reddish-purple discoloration below the knees, and he had extremely dry, scaly skin with very thick areas on his feet building up thicker on the toes. His toes on bilateral feet were edematous and had discolored reddish-blue areas. Further observation revealed a large amount of flaked skin covering the lower area of the bed. During an interview, R431 stated a nurse had removed his compression stockings several days ago, and no one had put them back on. He further stated no one had washed his legs or applied ointment to his legs. Observations on 8/19/2024 at 1:22 pm and 8/20/2024 at 2:45 pm revealed R413's compression stockings were not on. An observation on 8/20/2024 at 4:58 pm revealed R413 sitting in a wheelchair in the dining area. Observation revealed both legs were dark in color, and increased swelling was noted. There were no compression stockings on his legs. An observation of R413 on 8/21/2024 at 11:18 am revealed compression stockings on both legs. In an interview on 8/20/2024 at 4:20 pm, Licensed Practical Nurse (LPN) II stated she was unaware of a physician's order for compression stockings for R413. She reviewed R413's physician's orders and confirmed the order for compression stockings to be put on at 6:00 am and stated the order had not shown on the Medication Administration Record (MAR) for her to place them. LPN II confirmed the order for Dermaphor ointment and stated the wound nurse would complete that. In an interview on 8/20/2024 at 4:30 pm, LPN JJ confirmed the physician's orders for applying compression stockings and applying Dermaphor ointment to R413's legs were on the MAR. In an interview on 8/21/2024 at 1:07 pm, Treatment Nurse LPN FF stated topical treatments for skin were administered by the nurses on the unit. In an interview on 8/21/2024 at 1:20 pm, Registered Nurse (RN) LL stated the Treatment Nurse managed wounds and would look at the skin when needed.

Based on observations, staff interviews, and review of the facility policy titled, Oxygen (O2) Safety the facility failed to ensure O2 tanks were securely stored in a designated location to prevent accidents and hazards for one of eight residents (R) (R163) who use O2. Findings include: A review of the facility policy titled Oxygen Safety detailed 1. Safety is the responsibility of all staff, residents, visitors, and the general public. 4. Oxygen Storage- a. Oxygen storage location shall be in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors or gates that can be secured against unauthorized entry. 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. Observation on 8/19/2024 at 11:30 am revealed R163 sitting in a wheelchair in her room. Two O2 tanks (e-cylinder) were in the corner of R163's room between the bedside table and the bed. Both O2 tanks were in an upright position and one of the tanks had no regulator attached and there was a plastic cover on the tank where the regulator should have been. One of the O2 tanks was not in an O2 tank holder. There was an O2 concentrator (machine that makes O2 from room air) on the opposite side of R163's bed with O2tubing and face mask (undated) attached to the concentrator. There was no distilled fluid in the humidifier bottle attached to the concentrator. No O2 in use signage was posted on R163's room door. Review of the record for R163 showed no physician orders for O2 usage. Interview on 8/19/2024 at 11:50 am with registered nurse (RN) Unit Manager (KK), she revealed the O2 tanks were not supposed to be in R163's room. She verified and confirmed one of the O2 tanks was not in a holder. She revealed the O2 tanks have the potential to be dangerous and could cause damage, hurt, or harm to the resident if it fell and it was not secured in an O2 tank holder. The Unit Manager took the O2 tanks from the room and took them to storage area outside the facility. She placed the O2 cylinder with a plastic cover on the tank where the regulator should have been into the empty storage area in direct sunlight. Interview on 8/19/2024 at 12:30 pm with the Administrator, he revealed the O2 tanks should be kept in tank holders, and they should be stored in the storage area outside the facility when they are not in use. The Administrator further revealed the staff should take the O2 tanks out of the residents' rooms and place them in the storage area. He further revealed the maintenance staff would check the O2 tanks on Mondays each week before the tanks were picked up from the facility on Tuesdays. The Administrator revealed the staff received education on the usage and storage of O2 tanks. Interview on 8/19/2024 at 12:41 pm with the Respiratory Therapist (RT) NN confirmed the plastic cover on the O2 tank meant the tank was full. She revealed the full tanks go in the full side of the storage area and empty tanks go in the empty side of the storage area. The RT confirmed the staff would know the O2 tank was full if the plastic cover was on the tank. The RT revealed it was the staff's responsibility to remove the tanks from the residents' rooms and education on O2 tank usage and storage were provided to the staff. She revealed the O2 tanks had the potential to cause injury or harm to the resident if it fell and it could become a torpedo if it was not secured in an O2 tank holder.

Based on observations, staff and resident interviews, record review, and review of the facility's policies titled, Medication Administration, and Pain Management, the facility failed to ensure pain management was provided for one of two residents (R) (R68) reviewed for pain management. The deficient practice had the potential of unmet needs and a diminished quality of life. Findings include: A review of the facility's policy titled Medication Administration dated January 2023 revealed a Policy Statement as follows: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent infection or contamination. A review of the facility's policy titled Pain Management dated August 2023 revealed a Policy Statement as follows: The facility must ensure that pain medication is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Further review under Policy Explanation and Compliance Guidelines, revealed: The facility will use a systemic approach for recognition, assessment, treatment, and monitoring of pain. Under the section titled Recognition, item one stated: To help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain the facility will: item c. stated: Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. A review of the electronic medical record (EMR) revealed R68 was admitted to the facility with pertinent diagnoses including but was not limited to pain in right leg, pain in left leg, low back pain, other intervertebral disc degeneration, lumbar region, hereditary and idiopathic neuropathy. A review of R68's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicates R68 was cognitively intact. Section GG, functional status, revealed R68 was dependent for activities of daily living (ADLs). Section M, skin assessment status, revealed R68 has three stage one pressure ulcer. Section J, health conditions, revealed R68 was not in pain. Review of R68's care plan updated 7/11/2024 indicated resident has potential for pain related to neuropathy, wounds, lumbar disc degeneration. Monitor/document for side effects of pain medication. Interventions are to administer pain medication as ordered, attempt non-pharmacological interventions for pain; i.e. re-positioning, relaxation therapy/music, bathing, heat and cold application, muscle stimulation, ultra-sound. A review of Physicians Order 7/19/2024: oxycodone acetaminophen oral tablet 5-325 mg (milligrams) (oxycodone with acetaminophen) give one tablet by mouth every six hours as needed for chronic pain. Observation on 8/20/2024 at 9:05 am during medication administration, R68 complained of pain in both feet at level seven out of 10. Licensed Practical Nurse (LPN) II checked medication orders, opened the narcotic box and found R68 had none of the prescribed medication in stock. LPN II asked Unit Manager (UM) LPN JJ to check the emergency management back up medication dispensing system to see if the prescribed medication for chronic pain was available, and she agreed. During an interview on 8/20/2024 at 9:27 am LPN JJ returned and stated there was no oxycodone acetaminophen available in the emergency management back up medication dispensing system and stated it was requested from physician yesterday, she further instructed LPN II to administer Tylenol. LPN JJ stated she will resend the request for the oxycodone to physician. During an interview and observation on 8/20/2024 at 3:40 pm with R68, found he was lying in darkened room, head covered with blanket, easily aroused when knocked on door, R68 revealed he is still in pain; however, he stated pain has increased from seven to eight out of 10. He revealed he has gotten no relief from the medication given earlier, and further stated no one has been back to check on his pain. An interview on 8/20/2024 at 3:48 pm with LPN II revealed the oxycodone acetaminophen oral Tablet 5-325 mg has not come in yet and she did not followed up with resident's pain level. Interview on 8/20/2024 at 3:50 pm, with LPN JJ revealed there had been a new order signed just after 9:30 am this morning and she will go get it out of the emergency management back up medication dispensing system. LPN JJ revealed the process for pain management is nurse would check his pain in one to two hours after, assess and if needed reach out to the provider. LPN JJ confirmed it has now been around six hours and this is not the normal process the staff should be following. LPN JJ states she can obtain medication after getting code from pharmacy. LPN JJ confirmed once the order was signed by the physician the medication could have been retrieved from the emergency management back up medication dispensing system for administration. An interview on 8/21/2024 at 1:00 pm with the RN LL revealed his expectation of pain management consists of an assessment being done with location of pain, description of the pain, and following the nursing process. He confirmed pain should be re-assessed in one to two hours depending on intervention and it is unacceptable for a resident to be left in pain especially for more than six hours. a review of Nurses Note dated 8/20/2024 at 4:09 pm, revealed LPN II administered oxycodone-acetaminophen medication for chronic pain. A review of Nurses Note dated 8/20/2024 at 5:33 pm, revealed LPN II, documented follow up and pain was now a zero.

Based on observations, staff interview, and review of the facility's policy titled, Medication Storage, the facility failed to lock the medication cart for one of two medication carts; and found expired, used and new items co-mingled in bags, sink, and storage box in one of two medication storage rooms. The deficient practice had the potential for residents, unauthorized staff, and visitors to have access to medications and biologicals stored on the medication cart and staff to use contaminated items. The facility census was 110 residents. Findings include: A review of the facility's policy titled Medication Storage dated [DATE] revealed under General Guidelines: a. all drugs and biologicals will be stored in locked compartments under proper temperature controls. b. During a mediation pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. 8. Unused medications: the pharmacy and all medication rooms are routinely inspected by the consult pharmacist for discontinued, outdated, defective, or deteriorated, medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our destruction of unused drugs policy. An observation on [DATE] at 8:45 am revealed Licensed Practical Nurse (LPN) II walked away from a medication cart and entered a resident room leaving the medication cart unattended. An interview on [DATE] at 8:48 am with LPN II, she confirmed the cart was not locked, and stated she forgot to lock the cart. On [DATE] at 10:20 am a tour of the medication storage room at the end of the 100 hall near the nursing station, escorted by LPN MM revealed the medication storage room had one side with a countertop and sink, directly across were some shelves hanging shoulder level with plastic storage containers with drawers, on the floor under those shelves were boxes, a brown bag, a laundry hamper full of medication in patient medication cards, and more brown bags full of various pharmacy items. The top shelf drawer contained a Foley Catheter with first layer of plastic wrapping open, inner layer closed, and an expiration date of [DATE]. The laundry basket with a lid unable to be fully closed, full of resident medication cards, was awaiting disposal. The sink was filled with various items including three, one-liter bags of intravenous (IV) fluids, one with a half torn patient label, several IV tubing sets, one with thick, white liquid in the drip chamber and tubing, one intravenous start kit, and an oxygen nasal cannula. An interview and review of item on [DATE] at 10:25 am with LPN MM revealed she would not have used it since it's open and before using she checked packaging and expiration date. LPN MM confirmed process for used tubing was to discard in the closest trash can and remove the bag from the resident room. An interview on [DATE] at 10:30 am with RN KK confirmed as Unit Manager she was responsible, and she organized the medication storage room yesterday, [DATE]. Upon viewing the sink and tubing with white fluid she stated, why would they do this? several times. She confirmed the used items should have been discarded and not returned to the medication storage room. She added the IV fluid bags should be sent back to the pharmacy with the other items, and they were not reused. LPN KK further confirmed brown bags full of items were not marked Do Not Use, although they should not be used, and the nurses know this, adding the pharmacy was supposed to have picked all of them up yesterday. LPN KK further revealed staff would not use them because they were aware they were to be returned, and confirmed there was no indication on the bags not to use the items. An IV box was observed on the counter underneath the brown bags with a content list on the box, with no expiration dates. The box was locked with a white plastic, break away lock.

Based on observations, staff and resident interviews, record review, and review of the facility policy titled, Documentation in Medical Record, the facility failed to maintain accurate documentation of care and services provided for one of 63 sampled residents (R) (R413). Findings include: A review of the facility policy titled, Documentation in Medical Record, dated November 2023, revealed the Policy Statement stated, Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the residents' progress through complete, accurate, and timely documentation. The section titled Principles of Documentation section three included a. Documentation shall be factual, objective, and resident centered. False information shall not be documented. A review of the clinical record revealed R413 was admitted on [DATE] with diagnoses including, but not limited to, cellulitis of the right lower limb, lymphedema, venous insufficiency chronic, and heart failure. A review of R413's admission Minimum Data Set (MDS) assessment dated [DATE] revealed section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating little to no cognitive impairment. A review of the Physician Orders revealed orders dated 8/2/2024 for a skin assessment to be done on the day shift, open skin check form, and complete from user-defined assessment every day shift every Fri for Skin surveillance with a start date of 8/2/2024. Further review revealed an order dated 8/15/2024 for wound care to bilateral lower extremity. Apply Dermaphor ointment to bilateral lower extremities two times a day for dry skin, start date, 8/15/2024. Continued review revealed an order dated 8/15/2024 for compression stockings every morning and remove at bedtime, for bilateral lower leg edema and congestive heart failure with the start date of 8/17/2024. A review of the medication administration record (MAR) dated August 2024 revealed the wound care order was documented as performed on 8/16/2024 at 9:00 am and 6:00 pm, 8/17/2024 at 9:00 am and 6:00 pm, 8/18/2024 at 9:00 am and 6:00 pm, and 8/19/2024 at 9:00 am. Further review of the MAR revealed the compression sock placement at 6:00 am and removal at evening/bedtime was documented as performed on 8/17/2024, 8/18/2024, and 8/19/2024. A continued review of the MAR revealed documentation that revealed the removal of an indwelling urinary catheter on 8/1/2024. Assessment of the catheter was documented as completed on 8/3/2024 in the pm, and twice daily from 8/4/2024 through 8/18/2024. Indwelling urinary catheter care was documented as performed on 8/3/2024 in the pm and twice daily from 8/4/2024 through 8/18/2024. Observations on 8/19/2024 at 10:30 am and 1:22 pm revealed that R413 did not have compression stockings on. In an interview on 8/19/2024 at 10:30 am, R413 stated no one had applied ointment to his legs. In an interview on 8/20/2024 at 4:30 pm, Licensed Practical Nurse (LPN) JJ confirmed both the physician's order for compression stockings and application of Dermaphor ointment to R413's legs were on the MAR and were documented as provided. She stated both needed to be addressed and walked away. In an interview on 8/21/2024 at 1:20 pm, Registered Nurse (RN) LL confirmed the documentation of the compression stockings and application of the Dermaphor ointment. He further confirmed the documentation of the urinary catheter assessment and care, which was documented after the removal of the catheter. He stated his expectations were for staff to document what they do and not falsify documentation.

Based on observations, record review, staff interviews, and review of the facility's policies titled, Catheterization of a Male, Infection Prevention and Control Program, and Transmission-Based Precautions, the facility failed to maintain infection control protocol during indwelling urinary catheter insertion for one of seven residents (R) (R15) with an indwelling catheter, to perform hand hygiene during medication administration for one resident (R53), and to keep doors closed for contact isolation in two of four residents (R23 and R25) on contact isolation. The deficient practice had the potential to cause infection and adverse health outcomes. Findings include: Review of facility's policy titled Catheterization of a Male revised August 2024 revealed under Policy: Urinary catheterizations will be performed in accordance with current standards of practice to minimize risk for bacterial contamination or urethral trauma. Review of the facility's policy titled Infection Prevention and Control Program with a revision date of May 2023 revealed that when a resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by the current Centers for Disease Control (CDC) guidelines. Residents will be placed on the least restrictive transmission-based precautions for the shortest duration possible under the circumstances. Review of the facility's policy titled Transmission-Based Precautions with a revision date of 9/12/2022 revealed that any resident with a diagnosis of scabies, should be placed in contact precautions until twenty-four (24) hours after initiation of treatment. 1. R15 was admitted with diagnosis included but not limited to muscle weakness (generalized), cerebrovascular disease and benign prostatic hyperplasia (BPH). Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed in Section C (Cognition) a Brief Interview of Mental Status (BIMS) score of 15, which indicates intact cognition, Section GG (Functional Abilities) R15 was independent for eating and personal hygiene and dependent on staff for toileting. Review of care plan dated 8/2/2024 included but not limited to: The resident has Foley catheter related to neurogenic bladder size 18 French (FR)/10 cubic centimeters (cc). The resident will remain free from catheter-related trauma through review date. Catheter: Change per MD orders. Review of Physician ' s orders dated 8/19/2024 revealed orders included but not limited to: Foley catheter 18FR with 10cc balloon to bedside straight drainage for diagnosis/history of BPH benign prostatic hyperplasia). May change when Foley catheter is occluded, leaking or obtaining a new specimen as needed for BPH and every shift. May change Foley catheter when occluded, leaking, or to obtain urine specimen as needed for catheter care. Review of Physician ' s orders dated 8/31/2024 revealed orders included but not limited to: Change Foley Catheter monthly per MD (medical doctor) order as needed for catheter care every night shift starting on the last day of month, Change per night shift. Observation on 8/21/2024 at 2:31 pm revealed R15 in his room with Licensed Practical Nurse (LPN) FF preparing to change his indwelling catheter. R15 was on Transmission Based Precautions, signage on door. R15 complained of pain and unit Licensed Practical Nurse (LPN) EE gave him pain medication. LPN FF wore PPE (personal protective equipment) and provided privacy around R15's bed. LPN GG, Regional Skin Specialist was in attendance. LPN FF explained the procedure to R15 and assessed if he had pain. R15 stated he was not in pain and gave consent for her to start the procedure. LPN FF performed hand hygiene, donned (put on) gloves and cleaned R15's perineal (groin) area. She positioned R15, provided privacy and provided drapes to protect bed clothing. She began the procedure utilizing personal cleaning wipes, she performed perineal care and cleaned the insertion site of the indwelling catheter. LPN FF then removed gloves, performed hand hygiene with soap and water, and donned clean gloves. She withdrew 20 milliliters (ml) of clear fluid from the indwelling catheter bulb, then she slowly removed the indwelling catheter. She disposed of the indwelling catheter and drainage bag system in the receptacle beside the bed. She then removed gloves, performed hand hygiene with soap and water, and donned clean gloves. She then cleaned R15's penis starting at the tip working in a circular motion around where the urinary meatus (opening) should be, using a betadine swab down the shaft of the penis to the surgically created urinary meatus, cleaning the entire area with three swabs. She then placed a drape under the penis and placed the head of the penis on the drape. She disposed of her gloves, performed hand hygiene with soap and water, donned sterile gloves, opened supplies and attached the drainage bag to the bed frame. LPN GG suggested she change her gloves since she touched non-sterile packaging with her sterile gloves. LPN FF removed the gloves and disposed of them in the receptacle beside the bed. She did not perform hand hygiene, donned sterile glove on her right hand then picked up the other glove, fanned it in the air to open and donned glove on her left hand touching the inside of the glove with the other sterile glove. She used the sterile gloves to pick up the unsterile packet with the catheter and removed the outer packaging with the sterile gloves then removed all of the inner sterile packaging. She gathered all the catheter tubing in her hand, placed lubricant on the tip of the catheter and was about to insert the catheter when the surveyor stopped her. Review of education provided on Personal Protective Equipment (PPE) Competency Validation revealed LPN FF in attendance on 9/12/2023. Review of education provided on Hand Washing Competency Validation revealed LPN FF in attendance on 9/12/2023. Review of Validation Checklist Catheterization (Male) revealed LPN FF completed competency check on 9/12/2023. Interview on 8/21/2024 at 2:48 pm with LPN FF and LPN GG revealed: LPN FF acknowledged, confirmed and verified she did not maintain infection control protocol by not sanitizing her hands when she changed her sterile gloves. She confirmed and verified she did not maintain sterile procedure when she fanned the gloves in the air to open them which touched her wrist. She confirmed and verified she did not maintain infection control protocol when she coiled the catheter in her hand without its sterile packaging. She stated she should have sanitized her hands between sterile gloves change and she should have maintained sterile technique throughout the procedure and after donning sterile gloves. Interview on 8/21/2024 at 2:55 pm with LPN GG, she confirmed LPN FF did not maintain infection control protocol when she did not sanitize her hands between sterile gloves change, when she fanned the gloves in the air to open them which touched her wrist and when she coiled the catheter in her hand without its sterile packaging. LPN GG stated LPN FF should have maintained sterile technique throughout the procedure and after donning sterile gloves. She stated her expectations were for LPN GG to maintain sterile technique during catheter insertion and the highest possible outcome was infection to R15. Interview on 8/22/2024 at 12:55 pm with the Regional Director of Clinical Services revealed staff competencies were reviewed at orientation or during onboarding, and education was provided on certain topics periodically whenever the need arose. He revealed handwashing and use of PPE education were provided to the staff annually and as needed. He further stated that LPN GG also conducted education and competency checks to the staff annually and periodically. He further stated that his expectations were for the staff to always maintain the highest standard of practice when providing care and in the event of staff not maintaining sterile technique during catheter insertion, the highest possible outcome of not maintaining sterile technique was the possible development of an infection. 50526 2. An observation on 8/20/2024 at 8:45 am revealed LPN II began to prepare resident medications and had to go to the medication storage room to retrieve multivitamins at which time she did not perform hand hygiene when returning to medication preparation. An interview on 8/20/2024 at 8:48 am with LPN II confirmed she did perform hand hygiene when she left resident before room but confirmed she did not after leaving the medication cart to go to the medication room and returning to complete medication preparation. 46579 3. Review of the EMR for R23 revealed that he was admitted to the facility with diagnoses that included but were not limited to tremor, depression, anxiety, dementia, delusional disorder, schizoaffective disorder, and traumatic subdural hemorrhage. Review of the Dermatology note dated 8/15/2024 revealed that skin scaping results for R23 came back positive for Methicillin Resistant S. aureus (MRSA) and scabies. The review also revealed that resident was to be isolated and that the plan was to re-scrape at follow up visit and for staff to continue to monitor the resident. An observation occurred on 8/22/2024 at 10:34 am. The door to R23 room had a contract precautions door signage. On that sign revealed that the door was to remain closed. Resident was noted in the room, dressed, walking around. An observation occurred on 8/22/2024 at 5:10pm. The room door for R23 was noted to be open. Review of the EMR for R25 revealed that he was admitted to the facility with diagnoses that included but were not limited to legal blindness, vitamin deficiency, hypertension, unilateral inguinal hernia and history of COVID-19. Review of the progress note for the Dermatologist for R25 dated 8/15/2024 revealed that the resident had scabies throughout his trunk and contact dermatitis located on the left leg and trunk. An observation on 8/21/2024 at 4:40 pm of the R25 revealed the resident was in his room, walking around, pushing his wheelchair throughout the room. It was noted that there was a Contact Precautions sign on his door, and the door was noted to be open. An observation of the room of R25 occurred on 8/22/2024 at 10:45 am. The resident was noted sitting in his wheelchair, dressed. The door to his room was open and Contact Precautions signage was visible on his door. An interview on 8/22/2024 at 4:50 pm with the Infection Preventionist revealed that it was her expectation that the doors to the transmission-based precaution rooms be closed. She then stated that she expects staff to use proper PPE in transmission-based precaution rooms, because keeping the doors closed and the use of PPE are ways to prevent the spread of infection.

Based on observations, staff interviews, record review, and review of the facility policy titled, Handwashing and Hand Hygiene, the facility failed to follow proper infection control practices to prevent the spread of disease for one of seven sampled Residents (R) (R1). Specifically, staff entered R1's room, who was on contact isolation, without washing their hands or wearing gloves and a gown. Findings include: Review of the undated facility policy titled Handwashing and Hand Hygiene revealed under Policy Interpretation and Implementation 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents. and visitors. 1. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: a. Before and after coming on duty. b. Before and after direct contact with residents. c. Before preparing or handling medications. i. After contact with a resident's intact skin. m. After removing gloves. n. Before and after entering isolation precaution settings. p. Before and after assisting a resident with meals. 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. Review of the electronic medical record (EMR) for R1 revealed the resident was admitted with diagnoses including, but not limited to acute renal failure, diarrhea, and possible clostridium difficile, and Urinary Tract Infection Methicillin Resistant Staphylococcus Aureus Infection (MRSA) meaning contagious bacteria resistant to antibiotics treatment. Review of R1's care plan dated 1/4/2024 revealed R1 had MRSA and was on contact isolation. The care plan directed staff to wear gowns and masks when in contact with R1. Observation on 6/11/2024 at 10:30 am revealed a red sign on R1's door which read Contact Precautions and instructed staff to sanitize hands before and after contact with R1. The sign also instructed staff to wear gloves before contact with R1. Observation on 6/11/2024 at 10:40 am showed Licensed Practical Nurse (LPN) AA in the hallway, behind a medication cart preparing medications. LPN AA did not wash or sanitize her hands before she entered R1's room, without a gown or gloves, and gave R1 his medication. LPN AA left the room and did not wash or sanitize her hands. LPN AA was observed touching the resident's empty water cup and proceeded to the medication cart when R1 asked LPN AA for a missing pain pill dose. LPN AA returned to R1's room, did not don (put on) a gown or gloves, and informed R1 that his pain medication was due later. LPN AA proceeded to her medication cart and did not wash or sanitize her hands and proceeded preparing medication for another resident. During an Interview with LPN AA on 6/11/2024 at 11:05 am, LPN AA revealed she forgot R1 was on contact isolation and did not read the sign on R1's door. LPN AA stated she should have washed her hands and donned gloves before and after contact with R1, as per facility policy. During an interview with the Infection Control Preventionist (CP) CC on 6/11/2024 at 2:20 pm. Confirmed R1 was on contact isolation precautions. CP CC stated she expected all staff to wear gowns and gloves before staff entered R1's room. CP CC revealed she expected staff to wash their hands before and after contact with R1. CP CC stated staff were instructed to wash their hands before entering R1's room, don gloves, wear a gown, and wash their hands after contact with R1. CP CC confirmed that LPN AA did not follow proper facility infection control procedures. During an interview with the Director of Nursing (DON) on 6/11/2024 at 2:30 pm, the DON stated that the facility placed a sign and Personal Protective Equipment (PPE) on R1's door as a reminder to staff and visitors to follow infection procedures when entering R1's room.

Based on resident's family and staff interviews, and record review, the facility failed to provide written notification to the resident, the resident representative (RP), or the family, with an explanation of why the move to a new room was required for one of one Resident (R) (R#20). Findings include: Review of the Electronic Medical Records (EMR) for R#20 revealed on the census tab R#20 was moved from a private room to a semiprivate room on 12/30/2022. Review of the EMR for R#20 revealed there were no written notices related to moving R#20 from a private room to a semi-private room. Interview on 6/20/2023 at 9:06 p.m. with family member of R#20. They stated R#20 was moved from a private room to a semi-private room on a covid unit while he was at dialysis. They stated he found out about the move after he returned. They reiterated that no one asked him if he wanted to move or if he minded moving, they revealed it was a shock to him to return from dialysis and be taken to a new room. She stated the staff moved his belonging while he was out of the building without his permission. She stated the family was not notified of this move. They discovered the move when they came to visit him. Interview on 6/22/2023 at 4:00 p.m. with the Social Service Director revealed reasons residents are moved to new rooms are by request of the resident, need for a gender specific room, and sometimes because families request the move. She stated in every instance the resident is involved in the move. She stated they will ask the resident prior to moving if it is ok and they will show the resident the new room prior to moving. She stated she did not remember R#20. Interview on 6/23/2023 at 9:00 a.m. with the Director of Nursing (DON) revealed she expected the staff to speak with the resident and gain permission from them to move prior to moving. During the move the resident should be present to help direct placement of their personal items.