Every finding on record at Cottages at Rockmart, The

Based on observations, staff interviews, and review of the facility policy titled, Date and Label, the facility failed to ensure opened food item in the kitchen's dry storage area, emergency preparedness supply, and refrigerator were properly labeled and dated. The deficient practice had the potential to affect 98 out of 99 facility residents who received an oral diet.Findings include: Review of the facility's policy titled Date and Label, dated March 2024, under the section titled Dry Storage revealed, 1. Date each box, package, can, spice container, pasta bag, flour bag, bulk container, etc. upon delivery 2. When food is removed from the original box or when placed in a generic container, the individual food or generic container must be labeled with the name of the item inside and original delivery date. 6. Discard food that has expired or passed the used by date. Under the section titled Refrigerated Foods revealed,1. Food that is defined as Ready-To-Eat (RTE) or a Prepared foods or a food that is a high risk for food poisoning (Time/Temp Controlled Food), and BULK containers MUST be dated with the following: a. Date the food was prepared or opened. 7. Discard food that does not have an open or prepared date or a discard indicated on the food.During a kitchen tour conducted on 1/10/2026 at 7:40 am, alongside the Certified Dietary Manager (CDM), several expired canned products were identified in the Emergency Food supply: 24 cans of 12 fl oz (fluid ounce) ( Company name Evaporated Milk, which expired on 12/5/2025; six cans of 48 oz Pulled Chicken in Broth, with an expiration date of 3/8/2025; seven cans of 106 fl oz beef stew, expiring on 12/1/2024; 12 cans of 15 fl oz sweet corn puree, which expire on 1/9/2025; 12 cans of 15 fl oz beef stew puree, also expiring on 1/9/ 2025; 12 cans of 15 fl oz carrots and peas, with an expiration date of 1/9/2025; 48 cans of 15 fl oz seasoned green beans pureed, expiring on 1/9/2025; 12 cans of 15 fl oz pureed beef, which expires on 1/9/2025; and six cans of 104 oz peeled apricot halves, with an expiration date of 1/23/2024. The CDM has acknowledged her duty to oversee the monitoring of food expiration dates.The inspection of the walk-in freezer's continuation revealed that several food items were either open or repackaged and labeled with the received date, but they did not have an expiration date label. An examination of the food items identified 60 pancakes, 25 loaves of garlic bread, 46 portions of cookie dough, 12 waffles, 30 pork chops, 14 beef pepper steaks, 32 beef fritters, and 31 pieces of fish.An interview on 1/10/2026 at 9:30 am, with the Dietary Manager Assistant disclosed that she was accountable for labeling and dating food items, as well as conducting rounds in each cottage. The Dietary Manager Assistant indicated that upon receiving food deliveries, she recorded the received date and, if the item was opened, she assigned a 'used by' date that was calculated from three days thereafter. The Dietary Manager Assistant affirmed that there was a risk of residents becoming ill.An interview on 1/10/2026 at 9:37 am with the CDM confirmed her responsibility for verifying emergency preparedness food items. She believed that she only needed to label the open/prepared dates on frozen items; however, she acknowledged that the canned goods observed were overlooked because they were stored on a higher rack, out of direct sight, and she should have been more attentive.

Based on observations, staff interviews, record review, and review of the facility policies titled, Catheter Management Care, Anchoring and Changing, and Handwashing/Hand Hygiene, the facility failed to maintain infection control practices related to hand washing during catheter care for one of five residents (R) (R76) with an indwelling urinary catheter. This failure had the potential to cause R76 to have increased urinary tract infections (UTI). Findings include:Review of the facility policy titled Catheter Management Care, Anchoring and Changing revised January 2025 revealed each resident who is incontinent of bladder and has an indwelling catheter receives appropriate treatment of services to prevent urinary tract infections and to restore as much bladder functions as possible. Review of the Procedure for providing catheter care revealed . 5. Wash hands, assemble equipment. 10. For the male resident, use a gloved hand and a washcloth with peri-wash to cleanse the meatus outward, utilizing only one pass of the washcloth per cleaning stroke. 12. After cleansing area, place soiled washcloth into a plastic bag or place on under pad. 13. Use second washcloth to rinse area in the sequence as before. Place into plastic bag or on under pad. 14. Pat dry with dry cloth from front to back and remove gloves. Pull drape over resident, wash hands, and return to bedside. 15. Remove soiled linen and trash when leaving room, wipe table with paper towel. Review of the facility policy titled Handwashing/Hand Hygiene reviewed January 2025 revealed under Policy: This facility considers hand hygiene the primary means to prevent the spread of infection. 7. h. Before moving from a contaminated body site to a clean body site during resident care.R76 was admitted to the facility with a diagnosis that included but not limited to retention of urine.Review of the 12/26/2025 Quarterly Minimum Data Set (MDS) assessment for R76 revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment, dependent for all Activities of Daily Living (ADLs), and has an indwelling urinary catheter. Review of the care plan for R76 revised 11/28/2025 revealed a focus of The resident has Indwelling Foley catheter with a goal that the resident will show no signs or symptoms of urinary infection through review date. Interventions include the resident has an 18 French (size of catheter) Foley. Position the catheter bag and tubing below the level of the bladder and away from the entrance room door, monitor and document intake and output as per facility policy, monitor for pain/discomfort due to catheter, monitor for signs and symptoms of discomfort on urination and frequency, and monitor/report to Medical Doctor (MD) for signs and symptoms of Urinary Tract Infection (UTI): pain burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns.Review of the Physician orders for R76 revealed orders dated 11/17/2025 of resident admitted with 18F/10cc catheter attached to bedside drainage bag and change 18F/5cc indwelling catheter as needed. Observation on 1/9/2025 at 11:28 am of R76 revealed he was resting in bed in his room. An indwelling urinary catheter bag was hanging on the right side of the bed.Observation on 1/10/2026 at 10:09 am of Certified Nursing Assistant (CNA) BB assisting CNA AA perform catheter care for R76 revealed both CNA AA and CNA BB placed on Enhanced Barrier Precaution personal protective equipment (PPE). CNA AA obtained a pan of water and a pan of soap water and sat them on the bedside table of R76 and placed clean washcloths on the table next to the pan with water. CNA AA took a clean washcloth and placed it in the soapy water, squeezed out the excess water, and began providing care. CNA AA used the clean, unused parts of the washcloth when cleaning around the meatus (urinary opening of the penis) and the catheter tubing. When she finished, she placed the used cloth back into the soapy water, rinsed it, and began cleaning around the resident's genital area. During this time CNA BB asked CNA AA to hand her a clean, wet, cloth. CNA AA reached and got a clean washcloth from the stack and placed it into the soapy water that she had just rinsed a soiled cloth in, then handed it to CNA BB who began using it to assist in cleaning the genital area of R76. CNA AA placed both used clothes into the soapy water. CNA BB and CNA AA turned R76 on his right side and CNA AA took a clean cloth, placed it into the soap water with the soiled cloths, squeezed out the excess water and proceeded to clean the buttocks of R76. When she finished, she tossed the soiled cloth into the soapy water, took a clean cloth, placed it in the clean water and rinsed R76 buttocks then tossed the soiled cloth into the soapy water. CNA AA took a paper towel and dried the buttock of R76, applied barrier cream, and after placing a new brief under him she sprinkled powder onto the scrotum, then sealed the brief. CNA AA then changed her gloves and after making R76 comfortable, she discarded the used water and cloths. At no time during catheter care did CNA AA or CNA BB change their gloves, wash, or sanitize their hands. During an interview on 1/10/2026 at 10:30 am with CNA BB and CNA AA, they confirmed they failed to wash or sanitize their hands during catheter care for R76. CNA AA stated she should change her gloves and wash her hands when going from dirty to clean. Both confirmed that not following proper infection control practices has the potential to cause or spread infections. Interview on 1/10/2026 at 11:30 am with the Assistant Director of Nursing (ADON) with the Administrator present revealed that it was her expectation that staff changed their gloves and washed or sanitized their hands when going from dirty to clean when providing care to residents so as not to spread infection.

Based on record review, staff interviews, facility document review, and review of the facility policy titled Abuse Policy, the facility failed to protect residents from sexual abuse by another resident by not completing a thorough investigation of an allegation of resident-to-resident sexual abuse for one of three incidents of abuse reviewed. Specifically, following an incident of alleged sexual abuse involving two residents (R) (R1and R2), the facility did not interview other residents or assess residents who were cognitively impaired to ensure they had not experienced abuse.Findings included:Review of the facility policy titled Abuse Policy, reviewed 1/2025, revealed, It is our goal to achieve and maintain an abuse-free environment. The Administrator is designated as the Abuse Coordinator for the facility. The Administrator assumes the responsibility for the overall coordination and implementation of our facility's abuse prevention program policies and procedures. The policy revealed V. Investigation, which included 6. Should an incident or suspected incident of resident abuse, neglect or injury of unknown source be reported, the administrator or his/her designee, will appoint a member of management to investigate the alleged incident. 7. The individual conducting the investigation will, as a minimum: a. Review the completed ‘Electronic Incident Entry; [sic] b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident (as medically appropriate); f. Interview staff members (on all shifts) who have had contact with the resident during the periodof the alleged incident; g. Interview the resident's roommate, family members, and visitors; h. Interview other residents to whom the accused employee provides care or services; and i. Review all events leading up to the alleged incident.1. Review of the admission Record for R1 revealed an admission date of 5/30/2025. According to the admission Record, diagnoses included, but were not limited to, metabolic encephalopathy, severe vascular dementia with other behavioral disturbances, cognitive communication deficit, other sexual disorders with onset 7/10/2025, other symptoms and signs involving appearance and behavior, and depression.Review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/6/2025, for R1 revealed severe impairment in cognitive skills for daily decision-making and had short- and long-term memory problems per a Staff Assessment of Mental Status (SAMS). The MDS indicated that the resident exhibited physical and verbal behavioral symptoms directed towards others, as well as other behavioral symptoms not directed towards others, during the assessment timeframe. The MDS indicated the behaviors put the resident at risk for significant physical illness or injury and significantly interfered with the resident's care. The MDS indicated the resident was independent with indoor mobility but required some help with functional cognition. The MDS indicated the resident did not have any upper or lower extremity impairments and used a walker or a wheelchair for ambulation. The MDS indicated that the resident received antipsychotic medications. Review of the Care Plan Report for R1 revealed a focus area initiated 6/10/2025, which indicated the resident was verbally and physically aggressive with staff. Interventions initiated 6/10/2025 directed staff to monitor the resident daily and document observed behaviors and attempted interventions; and analyze key times, places, circumstances, triggers, and what de-escalated behaviors and document. 2. Review of the admission Record for R2 revealed an admission date of 12/3/2021. According to the admission Record, diagnoses included, but were not limited to, senile degeneration of the brain; cognitive communication deficit; major depressive disorder; other symbolic dysfunctions; moderate dementia in other diseases classified elsewhere, with other behavioral disturbance; bipolar disorder; adjustment disorder with mixed anxiety and depressed mood; Alzheimer's disease with late onset; and anxiety.Review of the Significant Change MDS, with an ARD of 7/11/2025, for R2 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. Review of the Care Plan Report for R2 revealed a focus area, initiated 10/7/2022 and revised on 7/24/2025, that indicated the resident had impaired cognitive function and indicated the resident had diagnoses of Alzheimer's disease and dementia that were progressing. Review of a Facility Incident Report Form, dated 7/10/2025, revealed that the facility reported an incident of resident-to-resident abuse to the state survey agency. The document indicated that on 7/10/2025 at 11:25 am, R1 inappropriately touched R2. The report was completed by the Director of Nursing (DON).Review of a letter from the facility to the State Survey Agency, dated 7/10/2025, indicated that on 7/10/2025, a hospice Registered Nurse (RN) (RN 8) reported that R1 approached R2, who was sitting in a wheelchair in the dining room. The letter indicated that she noticed R2's hand went down in R1's lap. Per the letter, RN8 walked up beside R2 and observed R1 tickling R2 on the legs and R2's genital area. The letter indicated that RN8 told R1 to stop touching R2, and R1 immediately began tickling R2's stomach and went across R2's breasts. The letter indicated that RN8 stopped R1, separated the two, and notified the Social Service Director (SSD), who was the Cottage Guide. Review of the facility's investigation revealed no evidence that other residents had been interviewed or assessed to ensure they had not experienced any abuse. During an interview on 8/22/2025 at 10:33 am, RN8 stated she worked for a contracted hospice provider. She stated she witnessed an incident between R1 and R2. She stated that she was seeing another resident, and as she left the room and walked down the hall, she saw R2 talking with R1. She stated that they were friends who talked all the time and hung out together since the facility admitted R2. RN8 stated that as she walked towards them, she could see that R1's hand was down on R2's lap, in the groin area. She stated that when she walked up beside R2, she said, Let's keep our hands off each other, and then R1 started tickling R2. She stated that R1's hands went up R2's body and across their breasts. She stated that she moved R2 away from R1 and immediately reported it to the SSD. During an interview on 8/22/2025 at 12:24 pm, the SSD stated that there was one incident where R1 touched R2 inappropriately. She stated that she did not see it, but a hospice nurse came and told her that R1 was touching R2. She stated that she took R2 to a different area to separate them and reported the incident to the Administrator after the residents were separated. She stated that she did not interview any of the other residents who were of the same gender as R2 in the unit and did not know if anyone else did. She stated that most of the other residents would have told staff if something like that happened to them. During an interview on 8/22/2025 at 2:35 pm, the Director of Nursing (DON) stated she did not conduct interviews with any of the alert and oriented residents who resided in the cottage where R1 resided, following the incident. She stated that there were only a couple of residents who had a BIMS score high enough to be interviewed, and they both pretty much stayed in their rooms at the time. She said the rest of the residents there all had low BIMS scores and would not have been able to answer questions. When asked how she ensured those residents were safe, the DON stated, That is a good question.During an interview on 8/22/2025 at 4:24 pm, the Administrator stated that she was the Abuse Coordinator. The Administrator stated that as part of their investigation process, staff were supposed to conduct interviews with other residents to make sure they had not had any incidents with R1. She stated that most of the residents in the building where R1 resided were unable to be interviewed. She stated that to ensure their safety, staff were instructed to monitor those residents with routine checks. She stated that they conducted weekly skin checks for all residents and ensured there were no visible signs of abuse. She stated she did not think anyone had reported anything, and the residents were told to report if they had any incidents of abuse. She stated she did not have concerns about the other residents. Regarding residents who were not cognitively intact, the Administrator stated that it may upset them if they attempted a full skin check.

Based on observations, staff interviews, and review of facility policy titled, Oxygen (O2) Concentrator, the facility failed to ensure respiratory equipment was maintained in a sanitary manner for one of 21 residents (R) (R34) who receive oxygen therapy. The deficient practice had the potential to place R34 at an increased risk of respiratory complications and infection. Findings include: Review of the facility policy titled Oxygen Concentrator revealed under Care of the Concentrator: Follow manufacturer recommendations for the frequency of cleaning filters and servicing the device, external filters will be cleaned weekly. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed in section O (Special Treatments, Procedures, and Programs) that R34 was receiving oxygen therapy while in the facility. Review of the physician orders for R34 revealed clean oxygen concentrator filter weekly - every day shift every Friday when oxygen is in use. Observation on 11/22/2024 at 10:10 am and 11/23/2024 at 1:20 pm of R34 O2 concentrator revealed the filter was covered with a heavy layer of lint. During an interview on 11/23/2024 at 1:35 pm, Certified Nursing Assistant (CNA) EE revealed that they were the Cottage Guide for Cottage E. Cottage Guides oversee the day-to-day operations of the Cottage where residents reside. The CNA EE verified that R34's O2 filter was full of lint. The CNA stated that the treatment nurse was responsible for cleaning the filters to all residents' O2 concentrators when the O2 tubing [NAME] replaced. The CNA revealed that staff should have cleaned the filter. During an interview on 11/23/2024 at 1:45 pm with the Director of Nursing (DON) revealed that the Treatment Nurse was responsible for cleaning the O2 filters on resident's O2 concentrator machines. During an interview on 11/23/2024 at 2:45 pm, Licensed Practical Nurse (LPN) DD, Treatment Nurse, confirmed that she was responsible for cleaning the O2 filters on all O2 concentrator machines and completed the task when she changed the resident's O2 tubing. LPN DD stated that the cleaning of the O2 filters was completed weekly on Fridays. LPN DD revealed that she had asked another staff member to assist her with the task this week and the filter to R34's O2 concentrator was overlooked. LPN DD revealed that she should have gone back to ensure the other staff member completed the task.

Based on record review, staff interviews, and review of the facility policy titled, Medication Orders, the facility failed to ensure a stop date was implemented, not to exceed 14 days for psychotropic medications for one of six residents (R) (R12) reviewed for unnecessary medications. Findings include: A review of the facility policy titled Medication Orders, effective 11/28/2017 revealed that as needed (PRN) orders for psychotropic medications are limited to 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she would document their rationale in the resident's medical record and indication the duration of the PRN order. A review of R12's physician (MD) orders dated 9/23/2024 revealed an order for 0.5 mg (milligrams) of lorazepam by mouth (PO) every four hours PRN for anxiety. The stop date was documented as indefinite. A review of the Medication Administration Record (MAR) revealed R12 was administered lorazepam 0.5 mg PO on 9/27/2024 at 9:36 am. During an interview with the Director of Nursing (DON) on 11/23/2024 at 11:40 am, she stated that all PRN psychotropic medications were supposed to have a 14-day stop date. If the MD determined a clinical rationale to extend the medication beyond 14 days, the MD would write a progress note noting the clinical indication, and the note would be added to the chart. She added that she would also call the MD at times to get an order if a psychotropic medication was getting close to the 14-day stop date. Per the DON, she received all new orders on the system's dashboard and reviewed all medications for stop dates. She acknowledged the lorazepam did not have a stop date, and she said she must have missed it on review.

Based on observations, staff interviews, facility document review, review of the Center for Disease (CDC) guideline titled, Handle With Care: Protect Your Vaccine, Protect Your Patients, and review of the facility's policy titled, Medication Storage in the Facility, the facility failed to store vaccines under proper temperature controls with twice daily monitoring in two of six refrigerators used to store medications and biologicals. The deficient practice created the potential for residents to receive vaccinations with altered effectiveness. The facility census was 78 residents. Findings include: A review of the facility's policy titled Medication Storage in the Facility dated June 1, 2018 revealed the Temperature section included F. The facility should check the refrigerator or freezer in which vaccines are stored, at least two times a day, per CDC [Center for Disease Control] guidelines. A review of the CDC guideline titled Handle With Care: Protect Your Vaccine, Protect Your Patients, dated 3/19/2024, included Check and record storage unit min/max (minimum/maximum) temperatures at the start of each workday. If your device does not display min/max temperatures, then check and record current temperature a minimum of 2 (two) times (at start and end of workday). A concurrent observation and interview on 11/23/2024 at 10:00 am with Licensed Practical Nurse (LPN) AA revealed one refrigerator located on a countertop in the Nurse's Office in Cottage D. Observation revealed a Refrigerator Temperature Log Location: D dated November 2024, secured to the refrigerator with documentation of once daily temperature checks. Observation of the refrigerator contents revealed a stand-alone refrigerator thermometer displaying the current temperature and one box containing ten pre-filled syringes of single-dose influenza vaccine Afluria (a vaccine given to protect residents from influenza). LPN AA confirmed the vaccine was stored in the refrigerator, and the temperature of the refrigerator was documented as checked once daily. She stated the night shift nurse checked the temperature, and the day shift nurse was not required to document the refrigerator temperatures. A concurrent observation and interview on 11/23/2024 at 10:55 am with LPN (CC) revealed one refrigerator located on a countertop in the Nurses' Office in Cottage B. Observation revealed a Refrigerator Temperature Log Location: B dated November 2024, secured to the refrigerator with documentation of once daily temperature checks. Observation of the refrigerator contents revealed a stand-alone refrigerator thermometer displaying the current temperature, one Previnar20 (a vaccine given to protect residents from pneumonia) single dose 0.5 milliliter (ml), and one Arexvy (a vaccine given to protect residents from respiratory syncytial virus [RSV]) 120 milligram (mg)/0.5 ml single dose stored in the refrigerator. LPN CC confirmed the vaccine was stored in the refrigerator, and the temperature of the refrigerator was documented as checked once daily. She stated the night shift nurse checked the temperature, and the day shift nurse was not required to document the refrigerator temperatures. A review of the facility-provided documents titled Refrigerator Temperature Log Location: D and Refrigerator Temperature Log Location: B, dated September 2024 and October 2024, revealed the refrigerator temperatures were documented once daily. In an interview on 11/23/2024 at 3:55 pm with the Infection Preventionist (IP) and Director of Nursing (DON), the DON stated the Nurse's Office medication refrigerator temperatures in each Cottage were checked once daily, generally by the night shift nurses. The IP confirmed vaccines were currently stored in Cottages B and D refrigerators. The DON stated a pharmacy nurse consultant conducted compliance checks every three months, and the facility had not been provided with education on monitoring medication refrigerator temperatures. The DON and the IP stated they were unaware that the refrigerators where vaccines were stored should have temperatures checked and documented twice daily. The DON stated if vaccinations were not stored according to CDC guidelines, the vaccine may have decreased effectiveness.

Based on observations, staff interviews, and review of the facility's policies titled, Glucometer Disinfection, Laundry, and the User And Care Guide Manual, the facility failed to ensure the infection control process was followed by one Licensed Practical Nurse (LPN) on cleaning and disinfecting a glucometer (a device used to measure blood glucose) after using it on one of two residents (R) (R31) with a physician order for a glucometer reading. In addition, the facility failed by not using a barrier before placing the glucometer on any surface. The facility also failed to clean the dryer lint screens from two of twelve dryers. Findings include: Review of the facility policy titled Glucometer Disinfection dated January 2024 revealed under Policy: The purpose of this procedure is to provide guidelines for the disinfection of capillary-blood glucose sampling devices to prevent transmission of blood borne diseases to residents and employees. Under Policy Explanation and Compliance Guidelines: . 2. The facility will ensure multi-use blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. Review of the facility policy titled Laundry dated 7/29/2021 revealed on the bottom of page 2 ***Clean lint screen and dispose of lint in trash after each load***. Review of Use and Care Guide manual indicated on page 13: Cleaning The Lint Screen: Every-load cleaning. The lint screen is located in the door opening of the dryer. Clean the lint screen before each load. A screen blocked. To clean: 1. Pull the lint screen straight up. Roll lint off the screen with your fingers. An observation and interview on 11/24/2024 at 8:30 am of Licensed Practical Nurse (LPN) FF performing a glucometer reading on R31 revealed LPN FF removed the glucometer from a small, dark colored, flexible container and placed the glucometer on top of the medication cart without a barrier. LPN FF gathered additional supplies and carried the supplies to the resident's room. LPN FF placed the supplies on the resident's overbed table without a barrier. After obtaining the residents' blood sugar, the LPN exited the room and placed the glucometer back into a small, dark colored, flexible container. The LPN stated the resident did not have her own personal glucometer machine. LPN FF was asked if the glucometer machines were cleaned after use. LPN FF then removed the glucometer machine from the black bag, wiped the test strip slot, and placed the glucometer back into the small, dark colored, flexible container. An observation on 11/23/2024 at 8:50 am of the six laundry areas for the facility revealed that the Cottage B laundry area has two home size dryers. When standing facing the dryers: dryer one was to the left: an observation of the lint screen revealed a moderate amount of lint. The area where the lint screen was held also had a moderate amount of lint. Dryer two, to the right: an observation of the lint screen revealed a copious amount of lint. The area where the lint screen was held also had a moderate amount of lint. An observation on 11/23/2024 at 8:55 am of the laundry area in Cottage C revealed two home size dryers. When standing facing the dryers: dryer one, to the left was in use. Dryer two, to the right: an observation of the lint screen revealed a copious amount of lint. The area where the lint screen was held also had a moderate amount of lint. An interview on 11/23/2024 at 9:23 am with Laundry Supervisor GG confirmed the lint was not removed from the screen in the dryers in Cottage B and C. The Supervisor stated the lint should be removed from the screens and the area where the screen was held. The Laundry Supervisor stated the staff would be educated to remove the lint from the dryer screens and where the screen was held. She also stated that she would be responsible for ensuring that all the dryers were being cared for properly. An interview on 11/24/2024 at 10:38 am with the Director of Nursing (DON) revealed the glucometer should be cleaned before and after use with a disinfectant wipe. She stated staff education would be started immediately to ensure that the glucometers were cleaned before and after use. She stated she was aware of the lint screens not being cleaned after dryer use. The DON stated the Laundry Supervisor has started education with the staff on cleaning the lint screens after the dryer was used.

Based on record review, interview, and policy review, the facility failed to ensure three of 21 sampled residents (R) (R14, R20, and R36) and/or their representatives were provided with written transfer/discharge notice that stated the reason for transfer, the place of transfer, and other information regarding the transfer or appeal information. Findings include: Review of the facility policy titled Transfer or Discharge, Emergency, revised December 2016, showed: Policy Statement Emergency transfers or discharges may be necessary to protect the health and/or well-being of the resident(s). Policy Interpretation and Implementation .4. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: a. Notify the resident's Attending Physician; b. Notify the receiving facility that the transfer is being made; c. Prepare the resident for transfer; d. Prepare a transfer form to send with the resident; e. Notify the representative (sponsor) or other family member; f. Assist in obtaining transportation; and g. Others as appropriate or necessary 1. Review of R14's Transfer/Discharge Report (a report with demographic and limited medical information) from the electronic medical record (EMR) Profile tab, showed an admitted [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R14's EMR Prog Note [Progress Notes] tab showed: 8/13/22 at [4:02 AM] Nurse's Note: At approximately 1 am, this resident yelled out that seemed he was in pain. CNA [certified nurse aide] and writer ran to his room to find this resident in bed and his body was jerking uncontrollably and repeatedly. CNA and writer turned resident to his left side, kept his head on his pillow, and guarded him from falling off the bed. Staff talked to resident to let him know we were with him. The [CONDITION(S)] activity lasted about 3-5 minutes and resident was unconscious. Staff stayed at resident's bedside for approximately 10 minutes. Resident was diaphoretic and would not respond to a chest sternal rub. Writer contacted [name] NP [Nurse Practitioner] and she ordered to obtain a Kepra [sic] level and CBC [complete blood count]. Give [MEDICATION(S)] 0.50mg IM [intramuscular] stat [immediately]. Obtain VS [vital signs] every hour x 4 hours then, obtain VS every 4 hours x 24 hours. 8/13/22 at [7:35 AM] eINTERACT SBAR Summary for Providers Situation: The Change In Condition/s reported on this CIC Evaluation are/were: Altered mental status [CONDITION(S)] Talks/Communicates Less .Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Send to ER [emergency room ] . 8/13/22 at [7:45 AM] Nurse's Note Note Text: Resident was taken via ambulance to [name] Medical Center with copies of resident information. Further review of R14's EMR Prog (Progress) Note and Misc (Miscellaneous) tabs did not show any documentation the resident and/or RR were provided a written notice of transfer/discharge. During a telephone interview on 8/23/22 at 3:34 PM, R14's RR1 was asked about recent hospitalization s and stated, Yes, less than two weeks ago for seizures, was admitted and has returned. When asked if R14's RR had received a written transfer/discharge notice regarding where R14 was transferred to and why, the RR responded No, they called and told me. 2. Review of R20's Transfer/Discharge Report, from the EMR Profile tab showed an admitted [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R20's EMR Progress Notes showed: 3/6/22 at [7:37 AM] Nurse's Note: Resident refused to get up this morning stating that she did not feel well. CNA informed this nurse and nurse went in to evaluate. Resident c/o [complained of] dizziness upon standing, nausea, and pain all over. This nurse called Dr [name] and was ordered to send resident to ER. [name], daughter, notified and she understood and agreed. EMS arrived at 0713 and transferred her to [name] ER . This nurse notified weekend supervisor 5/30/22 at [8:20 AM] Nurse's Note : Resident noted leaning on left side, unable to stand without assistance, drooling and left side facial /drooping and swelling 911 called. Resident leaving facility via stretcher to [medical center name]. Daughter, [name] called via telephone . 6/10/22 at [2:43 AM] Nurse's Note Note Text: Resident noted be cold and clammy to touch, she was also noted to have increased respirations of 30, and [oxygenation] was noted to be 89. Dr. [name] was called and notified of resident's change in condition and ordered to send resident to the emergency room for eval [evaluation]/treatment. Resident is her own responsible party and requested to go to [medical center]. Resident was sent by ems to [medical center initials]. Emergency contact [name] was called with no answer, voicemail was left to call back. 6/10/22 at [7:35 AM] Nurse's Note Note Text: This nurse called [medical center] to check on resident, and they stated that resident was admitted to the 4th floor with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R20's EMR Misc tab did not show any documentation of written transfer/discharge notices. Further review of R20's EMR Prog Note tab showed no documentation of written transfer/discharge notices. 3. Review of R36's Transfer/Discharge Report from the EMR Profile tab showed a facility admitted [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 8/22/22 at 3:19 PM, R36 responded to a question about recent hospital admissions or emergency room visits stating, The last time was about the first week of August. When asked if she had received a written transfer/discharge notice with why and where she was being transferred, R36 responded, No. Review of R36's Prog Note EMR tab showed: 8/5/22 at [4:27 PM] eINTERACT CIC [change in condition] Evaluation are/were: Abnormal vital signs (low/high BP, heart rate, respiratory rate, weight change) . Nursing observations, evaluation, and recommendations are: Resident was shaking and trembling stating she was cold. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Send resident out to the ER to be eval mainly because her HR is 130 . On 8/24/22 at 9:10 AM the Director of Nursing (DON) provided the E-Interact Transfer Discharge form and confirmed that form goes to hospital. In an interview on 8/24/22 at 10:45 AM, the Administrator stated, All we have is the nurse's note regarding the family being notified and the Interact that goes to the hospital that says why. The Administrator verified that the Interact form does not include the ombudsman information. In an interview on 8/25/22 at 1:07 PM regarding what paperwork a nurse completed for an emergent transfer, Licensed Practical Nurse (LPN) 3 stated, A transfer/discharge report [clarified, a face sheet of demographics and diagnoses], Bed Hold notice, Interact Change in Condition form. We give that to EMS [emergency medical services] to give to the hospital. When asked if anything in writing was provided the resident regarding why and where they were going, LPN3 stated, No, we just verbalize it to them [resident]. When asked if there was anything in writing sent to the Resident Representative, LPN3 stated, We let the resident representative know by phone where they are going and why. Nothing written. During an interview on 8/25/22 at 1:22 PM, the DON confirmed residents being emergently transferred and the RR should have received a written notice of transfer/discharge.

Based on observation, interview, and policy review, the facility failed to ensure foods were stored and/or labeled in the snack and kitchen areas in two of four cottages. This deficient practice had the potential to affect 30 of 58 residents who received meals and/ or snacks prepared in the facility's four snack areas and four cottage kitchens. Findings include: Review of the facility policy for Dating and Labeling, titled Georgia Nutrition Consulting, Inc., Dating and Labeling, (Rev. [DATE]): Policy: The elderly, young children and those with a poor immune system are very susceptible to becoming sick from foods that are not handled in a proper and safe manor. The government has mandated with this statement that labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its us-by-date or frozen (when applicable) or discarded. All foods, whether frozen, fresh, or cooked have specific guidelines for discarding. Some foods follow an expiration date listed on the container. Other foods, however, must be discarded within a safe time frame after preparation and usage to ensure bacterial growth is limited and the food remains safe. Dry Storage 1. Products removed from their original container or box should be placed in a closed container with a label and date. A large plastic baggie is a great container to store many food items. 2. Always look at the Expiration date or Best if Used by. Discard and do not use if past these dates. During an observation of snack refrigerator and dry snack storage for rooms ,d+[DATE] in the E Cottage on [DATE] at 9:57 AM, this surveyor observed six individual snack Cheez-it baked snack crackers not dated with expiration dates, one large package of Fieldstone Oatmeal Creme Pies which contained ,d+[DATE].34 oz. (38g) individually wrapped Sandwich cookies not dated with expiration date; two large packages of Fieldstone Bakery Fudge Rounds which contained 24 1.19 oz. (34g) individually wrapped sandwich cookies not dated with expiration date; one individually wrapped oatmeal creme snack (1.34 oz.) not dated with expiration date, one Fieldstone Bakery Fudge Round individually wrapped not dated with expiration date (1.19 oz.), nine Fieldstone Bakery Fudge Brownies (2.15 oz.), individually wrapped not dated with expiration date, and eight [NAME] Snacking Squares Lemon, not dated with expiration date. During an observation of snack refrigerator and dry snack storage for room 1 through 8 in the E Cottage on [DATE] at 10:30 AM, this surveyor observed ten individual snack Cheez-it snack crackers not dated with expiration dates, 20 Fieldstone Bakery Fudge Rounds individually wrapped cookies (1.19 oz.) with no expiration date, and 22 Fieldstone Bakery Oatmeal Cookies, individually wrapped, (1.34 oz) with no expiration date. During the initial tour of the F Cottage on [DATE] at 11:05 AM, one open plastic bag dated [DATE] containing four egg patties was observed in the pantry. During the initial tour of the F Cottage on [DATE] at 11:10 AM, one open five-pound plastic bag of grits, dated [DATE] was observed in the pantry. During the initial tour of the snack refrigerator for rooms one through eight in the F Cottage on [DATE] at 11:10 AM, one frozen coke bottle, half filled with no name was observed in the snack refrigerator. During the initial tour of the snack refrigerator for rooms one through eight in the F Cottage on [DATE] at 11:22 AM, eight individually wrapped cheese sticks, not dated, were observed in the snack refrigerator. Interviews with Certified Nursing Assistant (CNA) 6 and Licensed Practical Nurse (LPN) 2 on [DATE] at 10:45 AM revealed they were not able to identify expiration dates on the above Fieldstone and Cheez-it snack packages. During an interview with the Certified Food Manager (CFM) and the Registered Dietitian (RD) on [DATE] at 11:22 AM, both the CFM and RD reviewed the food snack items and verified there was not a meaningful expiration date on the packages and did not know if the packages of food were expired or not. The CFM and RD removed the food from the shelves and stated they would review their process and ensure the individual snacks of the residents had meaningful dates of expiration on the packages. Interview on [DATE] at 1:58 PM with the Certified Dietary Manager (CDM) about the unlabeled dietary snacks observed in the E cottage and opened plastic bags in the pantry and unlabeled food in the snack refrigerator observed in the F cottage, revealed her expectation was that all the resident's food be appropriately labeled, stored, and have an expiration date on the food and snacks. [DATE] 01:30 PM Interview with the Administrator on [DATE] at 1:30 PM about the observations of expired snacks, opened food plastic bags and un-labeled food items in resident areas of the E and F Cottages revealed, It is my expectation that all of the food for the resident's be stored appropriately according to the recommended guidelines to ensure the safety of the food for the residents. All the food should be appropriately labeled and have an expiration date on the package.

Based on interview, record review, and policy review, the facility failed to ensure one of 21 sampled residents (R) (R29) was accurately assessed for insulin use and the completion of a level two preadmission screening and resident review (PASARR). This failure could affect the care planning for the resident to receive all required services. Findings include: Review of the facility policy titled Conducting an Accurate Resident Assessment, revised July 2017, showed: Policy: The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas. Definition: Accuracy of assessment means that the appropriate, qualified health professionals correctly document the resident's medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the appropriate Resident Assessment Instrument (RAI) (i.e., comprehensive, quarterly, significant change in status). Policy Explanation and Compliance Guidelines: 1. The Administrator will ensure that all participants in the assessment process have the requisite knowledge to complete an accurate assessment. 2. Qualified staff who are knowledgeable about the resident will conduct an accurate assessment addressing each resident's status, needs, strengths, and areas of decline. The assessment will be documented in the medical record. 3. The appropriate, qualified health professional will correctly document the resident's medical, functional, and psychosocial problems and identifies resident strengths to maintain or improve medical status, functional abilities, and psychosocial status Review of R29's Transfer/Discharge Report (a sheet of demographic and limited medical information), from the electronic medical record (EMR) Profile tab showed an admitted [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R29's Order Summary from the EMR Orders tab showed: [MEDICATION(S)] Solution Pen-injector 1.5 mg [milligrams]/0.5ml [milliliters] ([MEDICATION(S)]) [generic name] Inject 0.5 milliliter subcutaneously one time a day every Wed [Wednesday] related to Type II diabetes mellitus . Order date 09/14/21 Start Date 10/15/21 Review of R29's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/7/22; quarterly MDS with an ARD of 4/26/22; and quarterly MDS with an ARD of 6/21/22 all showed coding for receiving insulin one time in the seven day look back period for each assessment. A review of the [MEDICATION(S)] website (https://www.[MEDICATION(S)].com > how-to-use) revealed [MEDICATION(S)] is a non-insulin option that helps your body release the insulin it's already making. In studies, [MEDICATION(S)] has been proven to lower blood sugar levels. People taking [MEDICATION(S)] may notice better blood sugar numbers before eating in the morning (fasting blood sugar). During an interview on 8/23/22 at 1:34 PM regarding the MDS coding for insulin, MDS Coordinator (MDSC) 1 reviewed the assessments and stated, All three were coded for insulin. When asked what insulin R29 was receiving, MDSC1 stated, Her [MEDICATION(S)]. When queried if [MEDICATION(S)] was an insulin, MDSC1 responded, As far as I know. MDSC1 reviewed and confirmed it was the [MEDICATION(S)] coded as insulin on all three of the assessments and did not have a reference that showed [MEDICATION(S)] was an insulin. Upon looking up [MEDICATION(S)] on the internet, MDSC1 stated, No, [MEDICATION(S)] is not an insulin. The MDSs are coded in error. Review of the October 2019 Resident Assessment Instrument [RAI] Manual showed on page N-3: Steps for Assessment 1. Review the resident's medication administration records for the 7-day look-back period (or since admission/entry or reentry if less than 7 days). 2. Determine if the resident received insulin injections during the look-back period. 3. Determine if the physician (or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) changed the resident's insulin orders during the look-back period. 4. Count the number of days insulin injections were received and/or insulin orders changed Review of R29's hard (paper) chart showed a Level II PASARR assessment was completed on 10/28/04. Review of R29's annual MDS with an ARD of 2/7/22 showed coding for depression, psychotic disorder, and [CONDITION(S)] disorder, but not that there had been a Level II PASARR completed. During an interview on 8/25/22 at 1:15 PM, MDSC1 confirmed PASARRs are only coded on comprehensive assessments (admission, annual, and significant change assessment). MDSC1 reviewed R29's annual assessment in February, and stated, Well, it sure is coded that way. (Clarified, as no Level II PASARR had been completed.) MDSC1 continued She's had a PASARR II since 2004, but it's not been included on that last two annual assessments. Review of the October 2019 Resident Assessment Instrument [RAI] Manual showed on page A-21 to A-23 showed: A1500: Preadmission Screening and Resident Review (PASRR) Code 0, no: and skip to A1550, Conditions Related to ID/DD Status, if any of the following apply: PASRR Level I screening did not result in a referral for Level II screening, or Level II screening determined that the resident does not have a serious MI and/or ID/DD or related conditions, or PASRR screening is not required because the resident was admitted from a hospital after requiring acute inpatient care, is receiving services for the condition for which he or she received care in the hospital, and the attending physician has certified before admission that the resident is likely to require less than 30 days of nursing home care. Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions.

Based on interview and record review, the facility failed to ensure two of three residents (R) (R14 and R20) with new mental health diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the undated facility policy titled Resident Assessment - Coordination with PASARR Program showed: Policy: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: .9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include: a. A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder (where dementia is not the primary diagnosis). b. A resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR. c. A resident transferred, admitted , or readmitted to the facility following an inpatient psychiatric stay or equally intensive treatment. Review of the American Psychological Association website, created 08/27/19 showed: (https://www.apa.org/topics/mental-health/support-serious-mental-illness) Serious mental illnesses include a variety of diseases including [CONDITION(S)], [CONDITION(S)] disorder, panic disorder, obsessive-compulsive disorder and major depressive disorder 1. Review of R14's Transfer/Discharge Report (a report with demographic and limited medical information) from the facility's electronic medical record (EMR) Profile tab, showed an admitted [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R14's Level 1 PASARR (Preadmission Screening And Resident Review) from the hard (paper) chart showed it was completed on 1/11/19 and did not include a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R14's EMR Med Diag (Medical Diagnosis) tab showed R14 received a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the EMR and hard chart did not reveal a resubmission of a Level I screening with the new diagnoses. During an interview on 8/25/22 at 8:29 AM, the facility Psychiatrist stated he last saw R14 in 2020 and if a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Review of R20's Transfer/Discharge Report, from the EMR Profile tab showed an admitted [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R20's hard (paper) chart showed a Level I PASARR dated 11/10/15 noting no mental illness and not referred for a Level II screening. Review of R20's EMR Med Diag tab showed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Dementia was diagnosed on [DATE]. During an interview on 8/25/22 at 8:42 AM, the Psychiatrist confirmed delusional disorder should have triggered a new Level I screening. In an interview on 8/24/22 at 9:10 AM, the Director of Nursing (DON) reviewed the dates of the PASARR screens and the dates of the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a follow up interview on 8/25/22 at 1:22 PM, the DON confirmed no rescreen had been completed stating, Yes, we have missed sending some [PASARR updates] with new diagnosis. In an interview on 8/25/22 at 1:33 PM, the Social Service Director (SSD) stated, Yes, I would be responsible for updated PASARRs. When asked how she was advised of new diagnoses, the SSD stated, They [clarified - nursing staff] would need to tell me about the diagnosis. The SSD stated she was aware of the need of updated screens if there is a new diagnosis.

Based on observations, interviews, record review, and policy review, the facility failed to provide range of motion (ROM) services for one of 21 sampled residents (R) (R48). Findings include: Review of the policy titled Resident Mobility and Range of Motion, revised July 2017, indicated Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts. Review of R48's electronic medical record (EMR) Face Sheet under the Profile tab revealed R48 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Contractures are the fixed shortening of a muscle or tendon resulting in joint deformity. Review of the annual Minimum Data Set (MDS) found under the MDS tab with an Assessment Reference Date (ARD) of 7/27/22, revealed R48's cognition was not intact with an undocumented Brief Interview for Mental Status (BIMS). This MDS revealed R48 required extensive staff assistance with activities of daily living (ADLs) such as bed mobility, transfers, and dressing. R48 had not walked during the assessment period with ROM limitations on both sides of upper and lower extremities (arms, hands, legs, and feet). R48 was incontinent of bowel and bladder. Review of the Care Plan, dated 10/25/21 and located in the EMR under the Care Plan tab, indicated ROM to all extremities was to be completed every shift 15 minutes for 5 minutes each shift. R48 required restorative nursing for Passive range of motion related to multiple contractures. Perform passive ROM with slow stretches to all extremities for a total of at least 15 minutes daily. Restorative passive range of motion to all extremities would be dome 15 minutes a day for 5 minutes each shift. On 8/23/22 at 4:50 PM during an observation and interview, Certified Nursing Assistant (CNA) 2 attempted to open R48's hands, both clenched tightly. CNA2 could not open the resident's hands. CNA2 said she did not know R48 required ROM and had not been providing ROM for R48. During an interview on 8/23/22 at 5:00 PM related to ROM every shift, CNA5 stated she had not done any ROM on the resident's hands. During an interview on 8/23/22 at 5:10 PM, Licensed Practical Nurse (LPN) 1 stated said that he did not monitor to ensure the staff were completing ROM for R48 and did not know she required ROM five minutes every shift. On 8/24/22 at 10:45 AM, CNA1 said when she changes the resident she stretches and massages her hands, she said the resident used to have washcloths or something like hand rolls but not sure why she does not have them now. CNA1 said she did not know about R48's ankles and feet requiring ROM. On 8/24/22 at 12:19 PM, R48 was in her room in bed with arm pillows under arms, hands both clenched together, she had no hand rolls in either hand. On 8/24/22 at 12:45 PM during an observation R48's feet were noted to be turned in and on a pillow. On 8/25/22 at 11:AM during an interview and observation, MDS Coordinator (MDSC) 2 observed the hands of R48 and stated noticed staff were putting N/A on the passive ROM mostly at night. MDSC2 was able to open R48's hands very little and was able to stretch R48's arms a few inches from her chest. MDSC2 stated there was no reason the night shift could not do ROM as the resident was incontinent and the staff had to provide care. The ADL sheet provided by MDSC2 was reviewed and indicated R48 did not receive ROM on the night shift on 8/14/22, 8/15/22, 8/16/22, 8/17/22, and 8/29/22. The Task to be completed under Restorative: Passive ROM to BUE (bilateral upper extremities) and bilateral hips 15 minutes daily (5 minutes each shift) wash hands and place hand rolls after each Passive ROM is completed. On 8/25/22 at 3:53 PM during an interview, the Director of Nursing (DON) stated her expectations were that residents requiring ROM received the care and services to prevent further decline in ROM. On 8/25/22 at 3:58 PM during an interview, the Administrator stated her expectations were staff completed ROM for R48.

Based on observation, interview, and record review, the facility failed to ensure one of two residents (R) (R14) reviewed for accident hazards was informed of the risks and benefits of assist or enabler bar use while in bed. Findings include: Review of the undated facility policy titled Positioning / Enabling Devices showed: Policy: When determined necessary, positioning/enabling devices will be used to attain and maintain the highest possible level of wellbeing/functioning for each resident. Procedure: If a positioning/enabling device is determined necessary, the following steps will be taken: 1. The Restraint / Enabler Decision Tree will be completed. 2. The Therapy Department screen/evaluate [sic] resident to assist in determining appropriate device to meet resident's needs. 3. Resident and or responsible party will be educated regarding the use of the device. 4. A consent form will be signed by requesting resident if alert and oriented, or by the responsible party. 5. The enabler quarterly update will be utilized to decide continued use. 6. Orders will include a medical reason and state if the device is an enabling and/or positioning device. 7. The positioning/enabling device will be Care Planned Review of R14's Transfer/Discharge Report (a report with demographic and limited medical information) from the facility's electronic medical record (EMR) Profile tab, showed an admitted [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of R14 on 8/22/22 at 11:14 AM and 1:27 PM showed him in bed with bilateral upper quarter rails. Observation of R14 on 8/23/22 at 10:15 AM showed him in bed with bilateral upper quarter rails. Review of R14's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/26/22 showed R14 required extensive assistance of two plus staff members for bed mobility. Review of R14's care plan for bed mobility and transfers, revised on 6/1/22 and located under the Care Plan tab in the EMR, showed: BED MOBILITY: (1) staff to assist bed mobility, turning, and repositioning in bed. Staff may provide more assistance as needed. TRANSFER: 2 staff and transfer device to assist with transfer. Staff may provide more assistance as needed. During a telephone interview on 8/23/22 at 3:36 PM, R14's Resident Representative (RR)1 stated he was unaware if risks and benefits of side rails had been reviewed. In an interview on 8/24/22 at 9:10 AM, the Director of Nursing (DON) stated because the new beds had the enabler bars attached and they were used to hold the bed control they did not believe an assessment or informed consent needed to be done. During a follow up interview on 8/25/22 at 1:22 PM, the DON confirmed No, we didn't have risk benefit or [informed] consent for [R14's name].

Based on observation, record review staff interview, and policy review, the facility failed to ensure nursing staff received education and were competent on the proper use and care for multi-use blood glucose meters (glucometers), thereby adhering to infection control standards. As a result, one nurse was observed to obtain finger stick blood sugar (FSBS) level checks for two residents (#119, and #31) without cleaning/sanitizing the glucometer between uses and the facility also failed to practice infection control guidelines for [MEDICAL CONDITION] care on one R #A. The facility's census was 67. Findings include: 1. Review of the policy titled, Blood Sampling - Capillary (Finger Sticks) last revised (MONTH) 2014, revealed that staff are to always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident use. Review of the records for Resident (R) #119 revealed a [DIAGNOSES REDACTED]. During observation of morning medication pass on the A-hall on 5/9/18 at 8:20 a.m. LPN AA was seen to remove the blood glucometer from a small black pouch on the medication cart and, without cleaning the glucometer, she completed the FSBS check for R#119. After obtaining the sample, she replaced the glucometer in the black pouch on her cart without cleaning/sanitizing it. Review of the records for R#31 revealed a [DIAGNOSES REDACTED]. During observation of a blood glucose monitoring procedure on the A-hall on 5/9/18 at 11:30 a.m., LPN AA was seen to remove the glucometer from a small black pouch on the medication cart and without cleaning it, she proceeded to obtain the FSBS level from R#31. After obtaining the sample, she replaced the meter in the black pouch on her cart without cleaning/sanitizing it. During interview with LPN AA at the time of this observation, she said it was her understanding that the blood glucose meters are only cleaned once a week by the night shift. During an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 9/5/18 at 5:45 p.m., it was revealed that LPN AA was employed with the facility since 5/14/16 and had received education on the proper cleaning/use of the glucometer during orientation. The DON also said that education on the cleaning of blood glucose meters is given to the nurses during orientation, but at no other time. The nurse had reported her failure to clean the glucometer between uses to the DON and the facility had immediately initiated Glucometer Cleaning education directed at their nursing staff. Eight out of a total of 18 nursing staff were educated on 5/9/18; this included staff on the day and night shifts (the facility has two shifts for nursing staff). The facility was in the process of providing education to the remaining 10 nurses via phone and this would be completed when each returned to work. During an interview on 5/9/18 at 7:03 p.m. with LPN BB, the nurse on the night shift, it was revealed that she was aware of the correct procedures for cleaning/disinfecting the multi-use blood glucose meters. LPN BB also stated that she had just received the re-education the facility provided on the cleaning/disinfecting of the glucose meters earlier that evening. She had received this education only once before during her orientation as a new employee two years before. During an interview with the DON on 5/10/18 at 10:40 a.m., it was revealed that the facility had no formal system of education for their licensed staff related to the proper cleaning of glucometers. The education provided in this area, to date, was informal and had not included return demonstration. The nurse consultant to the facility had discussed initiating a skills check-off program for the nursing staff but, but this had not yet been implemented. 2. Review of the clinical record for R A revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's procedure titled [MEDICAL CONDITION]/[MEDICAL CONDITION] Care revised (MONTH) 2010 documented the purpose is to provide guidelines that will aid in preventing exposure of the resident's skin to fecal matter. Director of Nursing stated she could not locate a policy for [MEDICAL CONDITION] care. She was only able to locate a procedure for performing [MEDICAL CONDITION] care. Interview on 5/10/18 at 3:02 p.m., with Wound Care Nurse FF, stated that she rinsed out residents [MEDICAL CONDITION] bag and reused it, because that is what she was told to do when he is out of supplies. She further stated that in her professional opinion, the bags should not be washed and reused. Interview on 5/10/18 at 3:11 p.m., with Infection Control Nurse, stated that she would not recommend rinsing and re-using the [MEDICAL CONDITION] bags. She further stated that she was not aware this practice was being done. Interview on 5/10/18 at 6:09 p.m., with Director of Nursing (DON), stated that it was her expectation that the nurses performing [MEDICAL CONDITION] Care following the infection control guidelines. She further stated she was not aware that staff were rinsing out the [MEDICAL CONDITION] bags and reusing them.

Based on observation, record review, staff and resident interviews the facility failed to provide effective infection control practices related to improper [MEDICAL CONDITION] care process for one resident (R) A, one unlabeled bedpan for one resident and two unlabeled urinals for two residents and improper cleaning and disinfecting of glucometers for one of three nurses. The facility census was 67. Findings include: 1. During initial tour on 5/7/18 at 10:26 a.m., observation in room [ROOM NUMBER] bathroom, revealed two urine measuring canisters sitting on top of toilet tank. There was no name on either canister and canisters were not in a plastic bag. Observation in room [ROOM NUMBER] bathroom, revealed an unlabeled and un-bagged bedpan leaning against the wall. Interview on 5/10/18 at 12:50 p.m,., with Director of Nursing (DON) confirmed on walking rounds the two urine measuring canisters in room [ROOM NUMBER] sitting on top of the toilet tank and the unlabeled and un-bagged bedpan leaning against wall in room [ROOM NUMBER] bathroom. She stated it is her expectation that staff label and bag all residents personal care equipment. She further stated there is not a policy on this topic, but the staff are educated on how to store personal care equipment, by labeling and bagging them. 2. Observation on 5/9/18 at 8:20 a.m., with Licensed Practical Nurse (LPN) AA performing Finger Stick Blood Sugar (FSBS) for R#119 in his room. LPN AA did not clean or disinfect the multi-use blood glucose monitoring machine prior to or after obtaining R#31 blood sample. LPN AA also obtained FSBS for R#31 on 5/9/18 at 11:20 a.m., without cleaning or disinfecting the blood glucose monitoring machine. Review of the policy titled Blood sampling-capillary (Finger Sticks) revised on (MONTH) 2014, indicated to always ensure that blood glucose meters intended for re-use are cleaned and disinfected between resident uses. Interview on 5/9/18 at 11:30 a.m. with LPN AA stated she thought the blood glucose machines were cleaned by the night shift nurses, and she believed it to be done once per week. Interview on 5/9/18 at 5:45 p.m., with DON, revealed it was her expectation that all the nurses know what the policy is and she expects them to follow the policy. She further stated that LPN AA had already spoken to her about not cleaning the blood glucose machine before and after use. 3. Observation on 5/9/18 at 9:47 a.m., with wound care LPN FF revealed that she performed [MEDICAL CONDITION] care for R#A. She removed the [MEDICAL CONDITION] bag, placed it in a garbage bag and carried it out of the resident's room down the hall to the soiled utility room. She rinsed the bag out, and brought it back to the residents room and re-applied the bag to the wafer on right lower abdomen. Interview on 5/10/18 at 3:02 p.m., with wound care LPN FF, stated she rinsed out residents [MEDICAL CONDITION] bag and reused it, because that is what she was told to do when he is out of supplies. She further stated that in her professional opinion, the bags should not be washed and reused. Interview on 5/10/18 at 3:11 p.m., with infection control nurse revealed that she would not recommend rinsing and reusing the [MEDICAL CONDITION] bags. She further stated that she was not aware of this happening. Interview on 5/10/18 at 6:09 p.m., DON stated it was her expectation that the nurses performing [MEDICAL CONDITION] Care following the infection control guidelines and she expected staff to follow the directions for changing [MEDICAL CONDITION] bags as written in the plan of care. She further stated she was not aware that staff were rinsing out the [MEDICAL CONDITION] bags and reusing them.

Based on observation and interviews, the facility failed to ensure that it was maintained in a safe, clean and comfortable home-like environment including stained and damaged ceiling tiles in two resident bathrooms, broken and missing towel bar in one resident bathroom and one damaged bathroom door in one resident room on two of three halls; also one unsecured shelving in one of two community shower rooms. The sample size was 19. Findings include: 1. During observation on 5/7/18 at 10:26 a.m., revealed room [ROOM NUMBER] A had two ceiling tiles in resident bathroom with tanish-brown stain spots, approximately two inches round, on each tile. 2. During observation on 5/7/18 at 11:50 a.m., revealed room [ROOM NUMBER] B had two ceiling tiles in resident bathroom with tanish-brown stains on them, approximately two inches by two inches. Another ceiling tile over the residents bed had approximately one inch stain on it. 3. During observation on 5/10/18 at 11:00 a.m., revealed room [ROOM NUMBER] bathroom had loose towel bar brackets and missing towel bar. 4. During observation on 5/10/18 at 11:00 a.m., revealed room [ROOM NUMBER] bathroom door does not close to provide full visual privacy. 5. During observation on 5/10/18 at 11:00 a.m., revealed that the North Shower community shower had unsecured shelving and loose soap holder. During walking tour and interview on 5/10/18 at 3:36 p.m., with Maintenance Supervisor, who verified environmental concerns: room [ROOM NUMBER] A had two ceiling tiles with tanish/brown stains; room [ROOM NUMBER] B had three separate ceiling tiles with tanish/brown stains on them; room [ROOM NUMBER] bathroom towel bar was missing and the brackets were loose; bathroom door in room [ROOM NUMBER] would not close and the shelving in the North Shower room was unsecured and shower stall soap holder was loose. Further interview, at this time, with Maintenance Supervisor, revealed that there is not a process for inspection or maintenance schedule. He has plans for creating a weekly schedule for inspecting, but currently he goes room to room, inspecting various items. He stated that staff fill out a Maintenance work order for repair requests. He further stated that he keeps a paper tracking system for inspections/repairs that he has completed. He further stated there was not a policy for Maintenance/Environmental inspections.

Based on observation and interview, the facility failed to provide full privacy for residents in their rooms as evidenced by privacy curtains which were not wide enough to extend the length of the ceiling curtain tracks, missing curtain panels or missing the complete curtain in eight of 40 rooms sampled on two of three halls. Findings include: Observation during initial tour on 5/7/18 at 10:58 a.m., revealed that the privacy curtain in room [ROOM NUMBER] B was approximately four feet too short and did not providing full visual privacy for resident. Observation during initial tour on 5/7/18 at 11:10 a.m., revealed that the privacy curtain in room [ROOM NUMBER] B was approximately two feet too short and did not providing full visual privacy for resident. Tour and observation of Hall C on 5/9/18 from 4:00 p.m. to 6:00 p.m. revealed privacy curtains which were too short, missing curtain panels or missing in the following rooms: room [ROOM NUMBER]-A: missing complete curtain room [ROOM NUMBER]-B: missing the middle curtain panel room [ROOM NUMBER]-A: 12 inches short room [ROOM NUMBER]-B: 3 feet short room [ROOM NUMBER]-A: missing curtain panel room [ROOM NUMBER]-A: 2 feet short room [ROOM NUMBER]-B: missing curtain panel room [ROOM NUMBER]-B: 2 feet short room [ROOM NUMBER]-C: missing curtain panel room [ROOM NUMBER]-B: 3 feet short Observation during initial tour on 5/8/18 at 9:00 a.m. revealed that the privacy curtain in room [ROOM NUMBER] B had a large tanish-brown stain in center of curtain. Observation during initial tour on 5/8/18 at 9:27 a.m. revealed that the privacy curtain in room [ROOM NUMBER] A, had a sticky, gummy substance stuck to bottom of privacy curtain. Interview on 5/10/18 at 12:58 p.m., with the Housekeeping Assistant Supervisor, confirmed the identified concerns with privacy curtains. She stated that there is no specific policy on inspecting the privacy curtains, or how often to wash them. She further stated that she was not aware that the curtains had to go all the way around the bed, to provide full visual coverage. She stated that when the curtains are taken down and laundered, they do not have any extras to hang while the originals are washing/drying.

Based on observation, record review and staff interview the facility failed to follow the care plan for one resident (R) A related to not changing [MEDICAL CONDITION] wafer/bag daily as ordered. The facility census size was 67. Findings include: Review of the clinical record for R A revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 15, indicating that resident had no cognitive impairment. Review of the care plan initiated on 10/9/16 and revised on 4/4/18, revealed that resident has alteration in gastro-intestinal status, has [MEDICAL CONDITION] due to long history of pressure ulcer that affected colon/rectum and required irreversible [MEDICAL CONDITION]. Approaches to care include to provide daily [MEDICAL CONDITION] care and wafer changes as ordered and as needed (PRN). Observation on 5/7/18 at 10:58 a.m., revealed [MEDICAL CONDITION] intact to right lower abdomen. Bag was distended with stool. Observation on 5/8/18 at 8:08 a.m., revealed [MEDICAL CONDITION] bag to right lower abdomen. No stool present in bag, but large stoma filling most of the bag space. Observation on 5/9/18 at 9:47 a.m., with Wound Care Licensed Practical Nurse (LPN) FF performed [MEDICAL CONDITION] care for R A. She removed the current [MEDICAL CONDITION] bag and after cleaning stoma, exited the room carrying [MEDICAL CONDITION] bag in a garbage bag down the hall to the soiled utility room, where she rinsed the bag out with water. She returned to R A room and reapplied the bag to the [MEDICAL CONDITION] wafer attached to right lower abdomen. Review of the facility's procedure titled [MEDICAL CONDITION]/[MEDICAL CONDITION] Care revised (MONTH) 2010 documented the purpose is to provide guidelines that will aid in preventing exposure of the resident's skin to fecal matter. During interview with R A on 5/7/18 at 10:58 a.m., revealed that he can't get enough [MEDICAL CONDITION] bags to last him the whole month. He stated that he only gets 20 bags per month, and that the staff wash out the bag and re-use it to make them last the whole month. He further stated that he does not like re-using the bags because its dirty and can cause infections. During interview with R A on 5/8/18 at 8:08 a.m., revealed the night shift nurse rinsed out his [MEDICAL CONDITION] bag and re-applied it this morning, because he is out of bags. Interview on 5/9/18 at 2:17 p.m., with Central Supply Certified Nursing Assistant (CNA) GG, stated that Medicare part B insurance pays for 20 [MEDICAL CONDITION] bags per month for R A. She stated that resident usually gets a shipment of bags on the 6th day of each month, but this month they didn't come on the 6th. She stated that the facility keeps extra supplies for R A, so he has some back up supplies, if he runs out. She stated that she ordered back-up supplies on Tuesday and that she was not aware that he was out of bags, until that day. Interview on 5/10/18 at 3:02 p.m., with Wound Care Nurse FF, stated that she rinsed out residents [MEDICAL CONDITION] bag and reused it, because that is what she was told to do when he is out of supplies. She is not certain how long he has been out of supplies, but did state she has rinsed it out and reused it before. Interview on 5/10/18 at 6:09 p.m., with Director of Nursing (DON), revealed that it was her expectation that the nurses performing [MEDICAL CONDITION] Care follow the infection control guidelines. She further stated she expected staff to follow the directions for changing [MEDICAL CONDITION] bags as written in the plan of care. She further stated she was not aware that staff were rinsing out the [MEDICAL CONDITION] bags and reusing them. She is not sure why there were not extra supplies on hand as back-up when his supplies ran out. Director of Nursing revealed that she could not locate a policy for [MEDICAL CONDITION] care although was able to locate a procedure for performing [MEDICAL CONDITION] care. Cross refer F691

Based on observation, record review, resident and staff interviews, the facility failed to provide daily [MEDICAL CONDITION] care consistent with professional standards of practice in a manner to prevent possible infection control for one resident (R) R A with a [MEDICAL CONDITION]. The facility census was 67. Findings include: Review of the clinical record for R A revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 15, indicating that resident had no cognitive impairment. Review of the care plan initiated on 10/9/16 and revised on 4/4/18, revealed that resident alteration in gastro-intestinal status, has [MEDICAL CONDITION] due to long history of pressure ulcer that affected colon/rectum and required irreversible [MEDICAL CONDITION]. Approaches to care include provide daily [MEDICAL CONDITION] care and wafer changes as ordered and as needed (PRN). Review of the facility's procedure titled [MEDICAL CONDITION]/[MEDICAL CONDITION] Care revised (MONTH) 2010 documented the purpose is to provide guidelines that will aid in preventing exposure of the resident's skin to fecal matter. Director of Nursing stated she could not locate a policy for [MEDICAL CONDITION] care. She was only able to locate a procedure for performing [MEDICAL CONDITION] care. During interview with R A on 5/7/18 at 10:58 a.m., revealed that he can't get enough [MEDICAL CONDITION] bags to last him the whole month. He stated that he only gets 20 bags per month, and that the staff wash out the bag and re-use it to make them last the whole month. He further stated that he does not like re-using the bags because its dirty and can cause infections. During interview with R A on 5/8/18 at 8:08 a.m., revealed the night shift nurse rinsed out his [MEDICAL CONDITION] bag and re-applied it this morning, because he is out of bags. Observation on 5/9/18 at 9:47 a.m., Wound Care Nurse, Licensed Practical Nurse (LPN) FF, performed [MEDICAL CONDITION] care. She had prepared ahead supplies of 4 X 4 gauze pads soaked with saline on a tray with plastic bag covering. She had a small red Biohazard bag for dirty supplies. She put on gloves and removed [MEDICAL CONDITION] bag from zip wafer secured to right side of abdomen. Stoma was noted to be extremely large in size, approximately six inches long and three inches in diameter. The stoma almost filled the bag with its size. The stoma was bright pink in color. There was a small amount of soft formed stool in the bag. [MEDICAL CONDITION] bag was placed in the red Biohazard bag, while she cleaned the ostomy stoma. Saline soaked 4 x 4 gauze pads were used to wipe the stool from the stoma. She then placed 4 x 4 soaked gauze pads over the stoma, placed the stoma sitting in the biohazard bag and covered with the residents gown. She then exited the residents room with the [MEDICAL CONDITION] bag with stool placed in a garbage bag and proceeded to the soled utility room to clean the bag, for re-use, because resident did not have any bags to replace it with. She returned to residents room approximately 5 minutes later and re-applied the [MEDICAL CONDITION] bag to the wafer that was secured to right abdomen. Resident had voiced to surveyor that he did not like staff having to rinse out the [MEDICAL CONDITION] bag and re-use them. He feels like it is a huge risk for infection to re-use the bags more than one day. Interview on 5/9/18 at 2:17 p.m., with Central Supply Certified Nursing Assistant GG, stated that Medicare part B insurance pays for 20 [MEDICAL CONDITION] bags per month for R A. She stated that resident usually gets a shipment of bags on the 6th day of each month, but this month they didn't come on the 6th. She called the supplier, and was told that they changed software ordering program and it caused a delay in delivering to the facility. She stated that the facility keeps extra supplies for him that the facility pays for, so that if he does run out, he has some back up supplies. She stated that she ordered him back-up supplies on Tuesday and that she was not aware that he was out of bags. She further stated she was not aware that staff were washing the bags out in the sink and re-using them. She further stated that the facility accepts residents with the understanding that they can provide for the care the residents require, and that this resident has been in this facility for many years. Interview on 5/10/18 at 1:20 p.m., with CNA HH stated she does not tend to resident's [MEDICAL CONDITION] bag. If he should ask her to tend to it, she notifies treatment nurse that he needs assistance with it. Interview on 5/10/18 at 3:02 p.m., with Wound Care Nurse FF, stated that she rinsed out residents [MEDICAL CONDITION] bag and reused it, because that is what she was told to do when he is out of supplies. She is not certain how long he has been out of supplies, but did state she has rinsed it out and reused it before. She further stated that in her professional opinion, the bags should not be washed and reused. Interview on 5/10/18 at 3:11 p.m., with Infection Control Nurse, stated that she would not have recommended rinsing and re-using the [MEDICAL CONDITION] bags. She further stated that she was not aware this practice was being done. Interview on 5/10/18 at 6:09 p.m., with Director of Nursing (DON), stated that it was her expectation that the nurses performing [MEDICAL CONDITION] Care following the infection control guidelines and she expected staff to follow the directions for changing [MEDICAL CONDITION] bags as written in the plan of care. She further stated she was not aware that staff were rinsing out the [MEDICAL CONDITION] bags and reusing them. She is not sure why there were not extra supplies on hand as back-up when his supplies ran out. Cross refer F880 DONE

Based on observation, interview and policy review, the facility failed to ensure medications were dated appropriately when opened to determine the discard date, in one of one medication rooms and one of three medication carts. Also, the facility failed to discard expired biological's and medical supplies prior to expiration date. The sample size was 19. Findings include: 1. Observation on [DATE] at 4:12 p.m., North Wing medication storage room, revealed one opened and used multi-dose vial of [MEDICATION NAME] with open date, but no use by date; one opened and used multi-dose vial of [MEDICATION NAME] with no open or use by date; and one opened and used multi-dose Influenza vial with no open or use by date. 2. Observation on [DATE] at 4:40 p.m., C Hall Medication cart revealed one opened and used bottle of Brimondine ophthalmic drops with no open or use by date on the bottle; one opened and used multi-dose vial of [MEDICATION NAME], with no open of use by date; and one [MEDICATION NAME] inhaler with no open or use by date on it. Review of the policy titled Medication Storage in the Facility with effective date of (MONTH) 1, (YEAR), indicated that medications and biological's are to be stored safely, securely, and properly, following manufacturer's recommendations or those of the partner. In the section of the policy titled Expiration Dating (Beyond-use-dating) revealed certain medications or package types, such as IV solutions, multiple dose injectable vials, ophthalmic, [MEDICATION NAME] tablets, blood sugar testing solutions and strips, once opened, require and expiration date shorter than the manufacture's expiration date to insure medication purity and potency. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or regulation/guidelines require different dating. Interview on [DATE] at 4:18 p.m., Licensed Practical Nurse (LPN) II stated she believed the expiration date for all opened vials was 30 days after opening. She stated the med storage room is kept neat and organized by all the med nurses. No particular shift is responsible for cleaning the refrigerator or restocking the med carts. She confirmed the open vials in the refrigerator and sated she does not know why the vials are not marked with an open date. The medications unlabeled on the C Hall cart were verified by LPN II. She stated that she always puts open and discard dates on the medications that she opens on her medication carts.

Based on record review, hospital document review, and staff interview, the facility failed to provide food prepared in a form to meet the individual needs of one (1) resident (#1), of a total of five (5) residents on the survey sample who had been assessed to need, and ordered to receive, pureed food, on the total survey sample of twelve (12) residents. A total of fifteen (15) residents (including Residents #1, #3, #8, #9 and #10 on the survey sample) required pureed diets. This resulted in serious harm to Resident #1, who was subsequently diagnosed with [REDACTED]. It was therefore determined that an immediate and serious threat to resident health and safety existed from May 17, 2009 through June 3, 2009, at which time the facility took action to abate the immediate jeopardy. Findings include: Record review for Resident #1 revealed a speech therapy Progress Note of 06/06/2008 which indicated that the resident had been receiving skilled speech therapy and could safely swallow a pureed diet. A 05/09/2008 Telephone Order specified that the resident receive a thin puree diet. Further record review revealed a May 2009 physician's orders [REDACTED]. A Nurse's Note of 05/17/2009 at 9:20 a.m. documented that a certified nursing assistant (CNA) had summoned Nurse "AA" to the South Wing where this nurse observed Resident #1 lying on the floor, and observed another nurse administering the [MEDICATION NAME] Maneuver and a CNA doing mouth sweeps. Nurse "AA" documented that she noted the resident's breathing to be shallow and went to get a Rescue Bag. Nurse "AA" documented that upon returning, she took over administering the [MEDICATION NAME] Maneuver and the other nurse took over doing mouth sweeps. This Note documented that Emergency Medical Technicians then arrived and took over the resident's care, and that the physician was notified. A Nurse's Note of 05/17/2009 at 12:00 p.m. documented that the resident had been transferred to the hospital. A 05/17/2009 Physician Clinical Report from the hospital emergency department documented that the chief complaint was that the resident had been eating a peanut butter sandwich and had been found unresponsive. The hospital Chest X-ray report included in the Findings Section that aspiration was not excluded. During an interview conducted on 06/01/2009 at 12:30 p.m., the Administrator acknowledged that on the date of the incident referenced above, CNA "BB" had given Resident #1, who was to receive a pureed diet, a peanut butter sandwich and the resident had choked. During an interview conducted on 06/03/2009 at 2:45 p.m., CNA "BB" stated that at the time of the incident referenced above, Resident #1, who was in the hallway, told the CNA that he/she was hungry. The CNA stated that she then proceeded to the dietary department, asked Dietary Staff "CC" to provide a sandwich for Resident #1, and was told to get a sandwich from the cooler. The CNA stated that she obtained an unlabeled peanut butter sandwich, returned to the unit, and gave the sandwich to the resident. The CNA stated that she then went to the Break Room, and then heard someone saying that "she's choking." The CNA stated that she called for the nurse and went to call Emergency Medical Services (EMS) 911. The CNA further stated that as nursing staff were doing the [MEDICATION NAME] Maneuver on Resident #1, she observed part of the sandwich coming out of the resident's mouth. A Nurse's Note of 05/17/2009 at 12:30 p.m. documented that the resident had returned to the facility from the hospital. A Nurse's Note of 05/18/2009 at 3:30 a.m. documented that the resident had become lethargic, had cold and clammy skin, pale and ashy color, an oxygen saturation level of only 68, and shallow respirations. A Nurse's Note of 05/18/2009 at 3:45 a.m. documented that EMS 911 had been called to transport the resident to a second hospital, and a Nurse's Note of 3.55 a.m. documented that EMS staff had arrived to transport the resident to the second hospital. The 05/18/2009 History and Physical from the second hospital documented the resident's chief complaint as unresponsiveness and decreased oxygenation at the nursing facility. This History and Physical documented that the resident was admitted to the hospital for the possibility of aspiration pneumonia. The hospital Discharge Summary of 05/22/2009 documented a Discharge [DIAGNOSES REDACTED]. During the 06/01/2009, 12:30 p.m. interview referenced above, the Administrator acknowledged that Resident #1 had a physician's orders [REDACTED]. However, the Administrator acknowledged that on 05/17/2009, the CNA had given the resident an un-pureed peanut butter sandwich. The Administrator further acknowledged that prior to this choking incident involving Resident #1, the facility did not have a functional system which ensured that staff were always aware of residents who had orders for, and were to receive, pureed diets. Administrative staff provided a list of residents which documented that as of 05/18/2009, a total of fifteen (15) residents required pureed diets. Based on the above, it was determined that an immediate and serious threat to resident health and safety existed from May 17, 2009 through June 3, 2009, at which time the facility had completed the following actions to abate the jeopardy situation: 1. Only nurses will obtain and give out snacks to ensure that residents receive food of the proper consistency. All snacks will be locked up and out of residents' reach to ensure that only charge nurses obtain and give out snacks. 2. A list was created listing all residents with orders for pureed diets and was posted in the front of the Activities of Daily Living books, the Medication Administration Records, and the Dietary Intake Book. Copies were provided to the Dietary Department and the Activities Department. This list is to be updated when changes in resident diet orders occur, and will be monitored by charge nurses. 3. A list of all resident diets was placed in front of the Activities of Daily Living books, Medication Administration Records, and Dietary Intake Book. This list is to be updated by the Dietary Manager when diet orders are changed, and the Assistant Director of Nursing will update the referenced books. 4. A pink sticker was placed on the name plate outside each resident's room who had an order for [REDACTED]. 5. A Diet Consistency Ladder was created which listed appropriate foods to be provided to residents who were to receive foods of modified consistency. 6. The facility established a checklist to verify compliance with all above interventions. Charge nurses will verify and sign each shift and the Assistant Director of Nursing will review daily. The Registered Nurse Weekend supervisor will review on the weekends. 7. Staff were inserviced on all the new procedures and changes referenced above. 8. The above interventions will be monitored and tracked through the facility's monthly quality assurance program meetings, and follow-up will be performed by the facility's Director of Nursing. Although the facility had implemented interventions to abate the immediate jeopardy, to ensure that these actions remain in effect and effective, the noncompliance continues, but the scope and severity is reduced to the "E" level.