Every finding on record at Eastman Trails of Journey LLC

Based on observations, staff interviews, record review, and review of facility policy titled Food Safety Requirements Policy, the facility failed to ensure food was stored, sealed, and labeled correctly. This deficient practice had the potential to cause food contamination and foodborne illness among 63 residents consuming facility-prepared food.Findings include:A review of the Food Safety Requirements Policy, revised 2025, documented the facility adheres to a date marketing system to ensure the safety of ready-to-eat, time/temperature control for safety food.Observation and walk through 02/15/2026 at 10:20 AM with [NAME] AA revealed the following concerns:1.In the walk-in freezer a bag of pepperonis was observed sealed but not dated.2. In the walk-in freezer a bag of filet fish was observed undated and unlabeled.3. In the walk-in freezer a bag of chicken fingers was observed opened, not sealed, and undated.Interview on 02/16/2026 at 3:42 PM with the Dietary Manager (DM) confirmed the concerns and stated that moving forward he and the kitchen staff will routinely monitor the dates and labels of all foods stored in the walk-in freezer.

Based on record review and staff interview, the facility failed to notify the resident and/or resident's responsible party when their personal funds were within $200 of the Social Security Income (SSI) limit and when accounts had exceeded the limit for four of 63 Residents (R) (R3, R27, R31, R38) with accounts reviewed for personal funds. The deficient practice placed residents at risk related to resource limits of qualifying for Medicaid during the renewal period.Findings include:Review of the Resident Fund Management Service (RFMS) Resident Statement Landscape and RFMS Trial Balance report dated 01/30/2026 revealed the following resident trust fund accounts exceeded the SSI limit of $2000.There was no documented evidence that the resident or responsible party were notified of the amounts exceeding the SSI limit.1. Record review of R27's account revealed a current balance of $3,639.77.2. Record review of R31's account revealed a current balance of $2,050.38. 3. Record review of R38's account revealed a current balance of $2,297.15. 4. Record review of R3's account revealed a current balance of $2,714.10. Interview and review of the residents' personal fund accounts with the Business Office Manager (BOM)/Financial Coordinator on 02/16/2026 at 2:00 PM revealed the SSI limit for the State of Georgia was $2000. The BOM/Financial Coordinator confirmed the facility had not notified the resident and/or the resident's responsible party of the excess in the account as of 02/16/2026. The BOM/Financial Coordinator stated that she was informed to keep resident fund accounts under $2000 to qualify for Medicaid. She confirmed that the Patient Liability for resident's accounts had already been pulled out for the month of February 2026 and that the remaining balance showing was the actual balance left in the cited resident accounts.

Based on observation, interviews and review of the facility's policy Resident Environmental Quality, the facility failed to provide a safe, clean, comfortable, and homelike environment for two of five hallways (200 Hall and 400 Hall) and four of 41 occupied rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER].) Specifically, the hallways had flooring that was missing, creating an uneven walking surface and the rooms exhibited dirty fans, missing floor tiles and one dirty bathroom. The deficient practice had the potential to affect residents' comfort and safety. Findings Include: Review of the facility policy titled Resident Environmental Quality, not dated, documented The facility will be designed, constructed, equipped and maintained to provide safe, functional sanitary, and comfortable environment for residents, staff, and the public. Under General Guidelines, the facility personnel are responsible for reporting, broken, defective, or malfunctioning equipment or furnishings immediately upon identification of the issue. 1. Observation on 02/15/2026 at 1:17 PM revealed that dust and grime had accumulated on a portable fan in room [ROOM NUMBER]. Observation on 02/15/2026 at 5:32 PM revealed that dust and grime had accumulated on the portable fan in room [ROOM NUMBER] and was still present. Observation on 02/16/2026 at 8:45 AM revealed that dust and grime accumulation was still present on the portable fan in room [ROOM NUMBER]. An observation and concurrent interview with the Administrator, Director of Nursing and Maintenance on 02/16/2026 at 4:45 PM confirmed the dust and grime accumulation was on the portable fan in use in room [ROOM NUMBER]. 2. Review of the Quarterly Minimum Data Set (MDS) for R47 dated 11/14/2025, revealed that Section C (Cognitive Patterns) documented that R47 had a Brief Interview for Mental Status (BIMS) score of 15 indicating little to no cognitive impairment. Section I (Active Diagnosis) documented diagnoses of, but not all inclusive, hypertension, paranoid schizophrenia, myocardial infarction, morbid obesity with alveolar hypoventilation. Review of the care plan dated 11/18/2025, revealed that R47 is often asked by staff to shower/bathe due to pungent odor around her and in her room. An observation and concurrent interview with R47 in room [ROOM NUMBER] on 2/15/2026 at 12:42 PM revealed a smell of sewage in bathroom, duct tape on toilet seat, and black substance in the bottom of the toilet. R47 states that the toilet was backing up into the shower and that five to six months ago someone ran a device down the toilet. She states the toilet has not been used for four months. An observation on 02/15/2026 at 5:29 PM revealed that the bathroom continues to smell of sewage, duct tape on the toilet seat, and black substance in the bottom of the toilet. An observation on 02/16/2026 at 11:53 AM revealed that restroom continues to smell of sewage, duct tape over the seat, and dark black substance at bottom. An observation and concurrent interview with Maintenance Director on 02/16/2026 at 4:45 PM confirmed a smell of sewage, duct tape on toilet seat, and dark substance on the bottom of the toilet. He confirmed he was not aware of the duct tape, smell of sewage, and dark substance in the toilet. He states the water was turned off to the toilet, which leads to the smell from the p-trap. He stated he does not conduct observations on rooms unless the nurses place a maintenance request into maintenance system or notify him of a repair need. An observation and concurrent interview with the Administrator on 02/16/2026 at 4:45 PM confirmed a smell of sewage, duct tape on toilet seat, and dark substance on the bottom of the toilet bowl. The Administrator confirmed she was not aware of the smell, duct tape, or dark substance in the toilet. She stated that leadership completes angel rounds every morning and nursing staff should notify housekeeping and maintenance of the need for repair and cleaning. 3. A daily environment tour of the facility hallways (Hall 100, Hall 200, Hall 300, and Hall 400) was conducted on 02/15/2026 at 1:30 PM, 02/16/2026 at 9:00 AM, 02/17/2026 at 10:00AM, and 02/18/2026 at 9:07 PM which revealed a damaged, uneven floor tile with dark thick brown substances in the flooring groove exposing the cement floor underneath on the 400 Hall and the 200 Hall. Observation of the flooring in the hallway of room [ROOM NUMBER] exit on 02/15/2026 at 2:00 PM, 02/16/2026 at 10:01 AM and 3:01 PM 02/17/26 at 10:01 AM, revealed missing floor tiles causing an uneven floor in the doorway. Observation of room [ROOM NUMBER] on 02/15/2026 at 2:00 PM, 02/16/2026 at 10:01 AM and 3:01 PM 02/17/26 at 10:01 AM, revealed a fan with blades coated in dark greyish thick substance and small particles of black speckle substance. Interview with the Administrator and Maintenance Supervisor on 02/17/2026 at 5:01 PM, revealed the floor was caused by water infiltration and poor installation. Both staff confirmed that the damage was an accidental tripping hazard for ambulatory residents who are either walking or using a walker. The Administrator stated that the uneven floor directly in front of some of the room entrances was due to missing tiles which cause the floor to be uneven and is a hazard for most residents who do not pick up their feet and walk with a shuffle. The Administrator stated a company will be coming out within the next two weeks to install new tiles. Both staff confirmed the dirty fan in the resident room and stated it is the responsibility of the maintenance director to clean the fan. The Maintenance Director stated that he was not familiar with the condition of the fan. The Administrator confirmed not being aware of the condition of the fan. She stated that all staff are responsible for reporting any issues with cleanliness in the building.

Based on resident and staff interviews, record reviews, and review of the facility policy titled Bed Hold and Returns Policy, the facility failed to ensure two of two residents (R) (R67 and R5) reviewed for hospitalizations were provided with a written bed hold notice upon transfer. This failure had the potential to place the resident and/or resident representative at risk of being uninformed about their rights related to their return to the facility. Findings include: Review of the facility policy titled Bed Hold and Returns Policy, dated [DATE], revealed the Procedure section documented, . 3. Prior to a transfer, written information will be given to the residents and the residents' representatives that explains in detail: a. The rights and limitations of the resident regarding bed holds. b. the reserve bed payment policy as indicated by the state plan c. the facility per diem rate required to hold a bed or to hold a bed beyond the stated bed hold period. 1.Review of R67's Quarterly Minimum Data Set (MDS), dated [DATE], revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 07 indicating moderate cognitive impairment. Review of R67's Clinical Resident Profile (face sheet) revealed the resident was his own responsible party. Review of R67's Clinical Census and progress note dated [DATE] revealed R67 was transferred to the hospital from the facility on [DATE]. R67's hospital stay was from 01/12 /2026 through [DATE]. Review of R67's clinical record (progress notes) revealed no evidence of the provision of a notice of bed hold was provided to R67 on [DATE] through [DATE]. In an interview on [DATE] at 1:00 PM, the Director of Nursing (DON) stated the facility did not provide a written bed hold notice on [DATE] or prior to [DATE]. She stated that the resident expired at the hospital on [DATE]. In an interview on [DATE] at 11:26 AM, the Administrator stated that residents were to be given a bed hold notice when they transferred from the facility by the nurse. The next step is for the Business Office Manager or Social Worker to follow up. The Administrator confirmed there was no record of R67 being given a bed hold notice on [DATE]. She stated her expectations are for the staff to follow up and ensure the resident is given notification of the date the bed hold would expire. 2. Review of R5's Quarterly Minimum Data Set (MDS), dated [DATE], revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. Review of R5's Clinical Resident Profile (face sheet) revealed the resident's sister was documented as Emergency Contact #1 Next of Kin. Review of R5's progress notes documented the resident was transferred to the hospital on [DATE]. Documentation lacked confirmation that the bed-hold notice was reviewed with or signed by R5 or the sister who was listed as the resident representative on the day of transfer. During an interview with the DON and Administrator on [DATE] at 2:32 PM, both confirmed there was no documentation that the bed-hold policy was reviewed with or provided to the resident or the resident's representative at the time of transfer.

Based on observations, staff interviews, record review, and review of the facility's policy titled Oxygen Administration, the facility failed to ensure that one of 13 residents (R) (R1) receiving oxygen was administered oxygen therapy in accordance with the physician orders. This deficient practice had the potential to place R1 at risk for respiratory complications and a diminished quality of life.Findings include:Review of the electronic health record (EHR) for R1 revealed diagnoses including but not limited to acute respiratory failure with hypoxia.Review of R1's admission Minimum Data Set (MDS) dated [DATE] revealed for Section O (Special Treatment Procedures, Program) R1 was receiving continuous oxygen therapy. Section C (Cognitive Patterns) revealed a Brief Interview Mental Status (BIMS) score of 08, which indicated moderate cognitive impairment.Review of the physician orders for R1 dated 12/17/2025, documented O2 at 2LPM via NC continuously (oxygen at two liters per minute by nasal cannula continuously) every shift for SOB (Shortness of Breath). Observation on 02/15/2026 at 1:30 PM and 5:24 PM, revealed R1 in the room receiving oxygen from an oxygen concentrator by nasal cannula at a flowrate of 1.5 LPM instead of the physician ordered 2 LPM.Observation on 02/16/2026 at 9:01 AM, revealed R1 in the room receiving oxygen from an oxygen concentrator by nasal cannula at a flowrate of 1.5 LPM instead of the physician ordered 2 LPM.During an interview and observation on 02/16/2026 at 2:05 PM with the Director of Nursing (DON), it confirmed that the oxygen was set on a flowrate of 1.5 LPM instead of 2.0 LPM as ordered by the physician. The DON stated that R1 was not known to have a history of changing the oxygen setting on the concentrator. She stated her expectations are for nursing staff to monitor the resident oxygen flow rate during each resident room visit.

Based on observations, staff interviews, and review of the facility policies titled Food Receiving and Storage and Refrigerators and Freezers, the facility failed to label and date food items with a use-by date in the walk-in cooler and walk-in freezer. In addition, the facility failed to ensure a sanitary environment in the kitchen and failed to ensure dietary staff properly used the three-compartment sink for sanitation to prevent cross-contamination. The deficient practices had the potential to place residents who received an oral diet from the kitchen at risk of contracting a foodborne illness. The facility census was 78. Findings include: Review of the facility policy titled Food Receiving and Storage, revised July 2014, revealed the Policy Statement stated, Foods shall be received and stored in a manner that complies with safe food handling policies. The Policy Interpretation and Implementation section included, 1. Food Services, or other designated staff, will maintain clean food storage areas at all times. 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Review of the facility policy titled Refrigerators and Freezers, revised December 2014, revealed the Policy Statement stated, This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. The Policy Interpretation and Implementation section included 7. All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened foods will be observed, and use by dates will be indicated once the food is opened. During the initial kitchen tour on 11/22/2024 at 7:46 am with the Dietary Manager (DM), the following was identified: 1. Observation of a cart revealed bread consisting of hot dog buns, hamburger buns, loaves with no expiration dates, one box of unlabeled and undated crescent rolls, and two cell phones. 2. Observation of the walk-in freezer revealed three bags of unlabeled and undated frozen meat. 3. Observation of the walk-in cooler revealed a tray of unlabeled and undated sandwiches, three unlabeled and undated open cheese packages, an unlabeled and undated wrapped cucumber, and unlabeled and undated wrapped meat. Further observation of the walk-in cooler revealed peas in a container with a prepared date of 11/21, green beans in a container with a prepared date of 11/20, succotash with a prepared date of 11/19, and [NAME] slaw in a container with a prepared date of 11/21. None of the food items had a use-by date. 4. Observations near the dry food storage area revealed a white door with black build-up on it and an air conditioner with black dust in the vents. Further observation revealed a brown door leading to the dry food storage area, which had dust build-up on the vents of the door. During an interview on 11/22/2024 at 7:55 am, the DM confirmed the identified items in the walk-in freezer and walk-in cooler were not labeled or dated and stated all items should be dated. The DM stated bread typically comes thawed, and they use it frequently. She reported that she was unaware that bread needed any dates on it. Observation on 11/22/2024 at 2:17 pm of the three-compartment sink and a sanitation bucket revealed the DM used Hydrion Quat Check strips to check the three-compartment sink and sanitizing bucket. The label stated the measurement should be 0 to 1000 parts per million. The DM tried multiple times to obtain a reading on the quaternary strips and had to leave the strips in the water for an extended period, to obtain a reading. Review of a poster on the wall in the kitchen for sanitation range testing indicated the use of Hydrion Papers QT-40 strips with a range of 0 to 500 parts per million. In an interview on 11/24/2024 at 11:20 am, the DM confirmed she was unable to determine if the three-compartment sink sanitizing water was the correct strength due to having the wrong test strips and stated she would order the correct ones. She further confirmed the buildup on the white door, brown door, and air conditioner.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled Resident Self-Administration of Medication, the facility failed to ensure two of 37 sampled residents (R) (R48 and R11) did not have unauthorized and unsecured medicated treatment products at the bedside. This deficient practice had the potential to cause adverse effects for R48 and R11 and allow unsecured medicated treatment accessible to other residents and visitors. Findings include: Review of the facility's undated policy titled Resident Self-Administration of Medication revealed the section titled Policy stated, It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. The Policy Explanation and Compliance Guidelines section included 7. Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the other residents' rooms or to confused roommates of the resident who self-administers medication. The following conditions are met for bedside storage to occur: (a) The manner of storage prevents access by other residents. Lockable drawers or cabinets are required only if locked storage is effective. (b) The medications provided to the resident for bedside storage are kept in the containers dispensed by the provider pharmacy. 1. A review of R48's Electronic Health Records (EHR) revealed diagnoses included, but were not limited to, muscle weakness, type 2 diabetes mellitus without complications, and chronic pain syndrome. Review of R48's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Section C (Cognitive Pattern) documented a Brief Interview for Mental Status (BIMS) score of 11 (indicating moderate cognitive impairment), Section GG (Functional Abilities and Goals) documented R48 was dependent for personal hygiene, toileting, and bathing, Section M (Skin Conditions) documented no ulcers, wounds, or skin problems, and documented R48 had moisture associated skin damage (MASD) and received applications of ointments/medications other than to feet. A review of R48's Physician's Orders revealed an order dated 10/11/2024 and discontinued on 11/22/2204 for triamcinolone acetonide external cream 0.1 percent applied to bilateral buttocks topically every dayshift for MASD buttocks. There was no order for medication self-administration. Review of R48's EHR revealed a Self-Administration Assessment Form had not been completed to determine the resident's capability with medication self-administration. During a concurrent observation and interview on 11/22/2024 at 8:35 am, observation revealed two medicine cups of cream and one bottle of antiseptic spray on top of R48's bedside table. In an interview, R48 stated, The staff mixed up those creams and left it there so that they could put it on my backside. During a concurrent observation and interview on 11/22/2024 at 9:00 am, Licensed Practical Nurse (LPN) Wound Nurse DD verified the two medicine cups of creams and a bottle of antiseptic spray on top of R48's bedside table. LPN Wound Nurse DD was unable to identify what kind of creams were in the cup and confirmed that the creams and antiseptic spray should not be left at the bedside. Observation on 11/23/2024 at 8:30 am revealed two bottles of antiseptic spray on the top of R48's bedside table. Observation on 11/23/2024 at 9:50 am revealed R48 was sitting in a wheelchair within reach of her bedside table with two bottles of antiseptic spray on the top of her bedside table. 2. Review of R11's EHR revealed diagnoses included, but were not limited to, restless legs syndrome, vascular dementia, adjustment disorder with anxiety, and insomnia. Review of R11's Annual MDS assessment dated [DATE] revealed a BIMS of 01 (indicating severe cognitive impairment), and Section GG (Functional Abilities and Goals) documented R11 was dependent for personal hygiene, toileting, and bathing. Review of R11's EHR revealed a Self-Administration Assessment Form had not been completed to determine the resident's capability with medication self-administration. Observation on 11/22/2024 at 8:40 am revealed one jar of a moisture barrier cream on top of R11's bedside table. During a concurrent observation and interview on 11/22/2024 at 9:00 am, LPN Wound Nurse DD confirmed the jar of moisture barrier cream at R11's bedside. She reported that she was unsure if they still used this kind of cream anymore but had used it in the past. However, they had always kept it at the bedside. Observation on 11/23/2024 at 8:35 am revealed one bottle of perineal cleanser on top of R1's bedside table. During a concurrent observation and interview on 11/23/2024 at 10:01 am, the Director of Nursing (DON) verified two bottles of antiseptic spray on top of R48's bedside table and one bottle of perineal cleanser on top of R11's bedside table. During this time, pictures of the unidentified creams in the two medicine cups were observed. The DON revealed she was not able to say for certain what creams were in the cup. She reported her expectations of staff were to make sure to remove any medicated creams from residents' rooms after using them. The DON further revealed that R11 and R48 were not capable of self-administering medications, creams, or barrier creams and that a medication self-assessment had not been completed for R11 or R18.

Based on staff interviews, record review, and review of the facility policy titled Resident's Rights Regarding Treatment and Advanced Directives, the facility failed to ensure that an Advance Directive Acknowledgement form was completed or all components of the document were thoroughly completed for five of eight residents (R) (R22, R46, R25, R31, and R51) reviewed for Advance Directives. This deficient practice had the potential to affect R22, R46, R25, R31, and R51's ability to make informed decisions about their care. Findings include: Review of the facility's undated policy titled Resident's Rights Regarding Treatment and Advanced Directives revealed the Policy section stated, It is the policy of the facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advanced directive. 1. Review of R22's medical record revealed an admitted [DATE]. Further review of the medical record revealed no completed Advance Directives Acknowledgement form. 2. Review of R46's medical record revealed an admitted [DATE]. Further review of the medical record revealed an Advance Directive Acknowledgement form was signed, but there was no indication of an Advanced Directive being executed. During an interview on 11/24/2024 at 9:13 am, the Business Office Manager (BOM) confirmed she was unable to locate an Advance Directive Acknowledgement form for R22. She further confirmed R46's Advance Directive Acknowledgement was signed. However, there was no indication on the form if he did or did not execute an Advanced Directive. 41914 3. Review of R25's medical record revealed an admitted [DATE]. Further review of the medical record revealed R25's Advance Directives Acknowledgement form was signed, but there was no indication of an Advanced Directive being executed. 4. Review of R31's medical record revealed an admitted [DATE]. Further review of the medical record revealed R31's Advance Directives Acknowledgement form was signed, but there was no indication of an Advanced Directive being executed. 5. Review of R51's medical record revealed an admitted [DATE]. Further review of the medical record revealed R51's Advance Directives Acknowledgement form was signed, but there was no indication of an Advanced Directive being executed. In an interview on 11/23/2024 at 9:15 am, the Social Services Director (SSD) confirmed R25, R31, and R51's Advanced Directives Acknowledgement forms did not indicate if the advanced directive had been executed and acknowledged the forms should be completed to indicate if an advance directive had been executed. In an interview on 11/23/2024 at 9:30 am, the Director of Nursing revealed the Advanced Directive Acknowledgement form was completed upon admission by the Admissions Director. Further interview revealed the nursing department did not review the form for accuracy once it was completed.

Based on observations, staff interviews, and review of the facility's policy titled Safe and Homelike Environment, the facility failed to ensure a clean and comfortable environment for six resident rooms (Rooms 105,107, 501, 503, 502, 504) with shared bathrooms and one shower room (300 Hall), failed to replace the door cover for one resident room (room [ROOM NUMBER]), and failed to ensure one shower room (500 Hall) was functional on three of five units. These deficient practices had the potential to place residents at risk of living in an unsanitary and unsafe living environment and a potential for diminished quality of life. The census was 78 residents. Findings include: Review of the facility's undated policy titled Safe and Homelike Environment revealed the Policy section stated, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. The Policy Explanation and Compliance Guidelines section included 3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment. Observations on 11/22/2024 at 8:10 am, 11/23/2024 at 7:40 am, and 11/24/2024 at 7:50 am in the shared bathroom for rooms [ROOM NUMBERS] revealed a stained toilet bowl. Observations on 11/22/2024 at 8:15 am, 11/23/2024 at 7:40 am, 11/24/2024 at 7:55 am, and throughout the survey in the shared bathroom for rooms [ROOM NUMBERS] revealed a stained toilet bowl and a soiled, wet discolored towel on the floor in front of the toilet. Observations further revealed the water in the toilet ran continuously and was audible outside the room. Observation on 11/22/2024 at 7:58 am on the 500 Hall revealed a sign on the outside of the shower room door that read Out of order, closed for construction, Do Not Enter. Observations on 11/22/2024 at 8:58 am of the 300 Hall shower room revealed an unbagged, unlabeled basin on top of a plastic cabinet, a cardboard box, a blue bed liner, an electric wheelchair, a plastic container with several heel protectors, a cardboard box with a black plastic trash bag and heel protector on top of it, a cart with a basin on top with shampoo, shaving cream and other items inside, a blue brief on top of the cart, several items on the shelves of the cart to include gloves, a shower bed with several trash bags and clothing on top of it, a nebulizer machine, and an air mattress stored in the shower room. In an interview on 11/22/2024 at 9:00 am, Certified Nursing Assistant (CNA) BB stated the 500 Hall shower room had been out of order for at least two months. She further stated the 300 Hall shower room was used for storage to store extra items and equipment. During concurrent environmental rounds and interviews on 11/23/2024, the Administrator and the Maintenance Director revealed they were unaware of the stained toilets or the toilet running in the shared bathroom for rooms [ROOM NUMBERS]. The Administrator stated she did not know how long the 500 Hall Shower Room had not worked and was inaccessible to residents. The Maintenance Director stated the shower room had not worked for about a month. He stated that they were remodeling it, but he had no help. The Administrator and Maintenance Director verified the stained toilets in the shared bathroom for rooms [ROOM NUMBERS]. 42463 Observation on 11/22/2024 at 8:01 am revealed the cover was missing from room [ROOM NUMBER]'s door. Further observation revealed the shared bathroom for rooms [ROOM NUMBERS] was unkept, not clean and smelled like urine. Observation revealed the shared bathroom had two dirty gowns lying underneath the bathroom's sink, the trash can was overflowing with soiled briefs, and dirty wash clothes were noted in the sink. Observation on 11/22/2024 at 8:30 am revealed the shared bathroom for rooms [ROOM NUMBERS] remained unkept, not clean, and smelled like urine. The shared bathroom had two dirty gowns lying underneath the bathroom's sink, the trash can was overflowing with soiled briefs, and dirty wash clothes were noted in the sink. During concurrent observations and interviews on 11/23/2024 at 8:50 am, the Maintenance Director and Administrator confirmed the missing door cover for room [ROOM NUMBER]. The Maintenance Director stated he was aware and working to fix it. During the interview with the Administrator, she observed photos of the shared bathroom for rooms [ROOM NUMBERS]. She stated the condition of the bathroom was not acceptable and that staff should check residents' rooms during their rounds. She further stated the CNAs and Housekeeping staff were responsible for keeping residents' rooms clean. In an interview on 11/23/2024 at 10:01 am, the Director of Nursing revealed CNAs were responsible for ensuring residents' rooms were cleaned, and if staff observed the rooms dirty, they should clean them up.

Based on observations, staff interviews, and record review, the facility failed to ensure that dietary orders were followed for one of 37 sampled residents (R) (R2). Specifically, the facility failed to ensure that a non-spill cup (sippy cup) was provided with meals for R2. The deficient practice had the potential to prevent the maintenance of adequate nutritional (or hydration) status to the extent possible for R2. Findings include: Review of R2's Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section GG (Functional Abilities and Goals) documented R2 required set-up assistance with meals. Review of R2's medical record revealed diagnoses including, but not limited to, dysphagia - oropharyngeal phase, and severe protein-calorie malnutrition. Review of R2's Order Summary Report revealed a dietary order dated 9/11/2024 for regular large portions diet, mechanical soft texture, and regular consistency, a divided plate, and a non-spill cup. During meal observation on 11/23/2024 at 12:50 pm, Certified Medication Aide (CMA) NN was observed assisting R2 with lunch. A review of R2's meal ticket indicated Mech, Soft, CHOPPED with beverages/equipment that consisted of iced tea, water, divided plate, and weighted utensils. Preferences consisted of a sippy cup. CMA NN confirmed that there was no sippy cup on R2's lunch tray. During meal observation on 11/24/2024 at 8:14 am, Certified Nursing Aide (CNA) OO assisted R2 with breakfast by assisting with feeding. After breakfast was completed, CNA OO confirmed there was no sippy cup on the breakfast tray. During an interview on 11/24/2024 at 9:43 am, the Dietary Manager (DM) reviewed R2's breakfast meal ticket and stated the nurses and CNAs have the sippy cups and she does not send them on the meal tray unless nursing staff sends them to the kitchen to be washed and used. During an interview on 11/24/2024 at 9:57 am, Licensed Practical Nurse (LPN) MM, the Director of Nursing (DON), and the Assistant Director of Nursing (ADON) reported the dietary order for R2 was changed in September and weighted utensils were no longer needed. The DON reported that the non-spill cup comes from the dietary department. LPN MM also reported that the Dietary Communication Form is utilized to inform dietary of changes. The ADON and DON both confirmed that whatever is listed on the dietary order should be on residents' meal trays.

Based on observations, staff interviews, and facility-provided documents, the facility failed to ensure that dietary staff followed recipes and measured ingredients when preparing puree food to prevent compromising the nutritional value and flavor for five residents who received a puree consistency diet. This deficient practice had the potential to cause the residents who received a puree diet to have a decreased nutritional intake and the potential for weight loss. Findings include: Review of facility-provided puree recipes for green beans, chicken thighs, mixed vegetables, and hot turkey sandwiches indicated a food thickener should be used to thicken puree foods. During an observation on 11/23/2024 at 4:00 pm of puree preparation, [NAME] LL stated no recipes were used to prepare the puree meal. Observation of puree of the mixed vegetables revealed the vegetables initially could not be pureed to a smooth consistency, so an alternate vegetable was used. Observation of the puree of the turkey sandwich revealed that an unmeasured amount of chicken broth was used as the liquid for the turkey sandwich. Observation on 11/24/2024 at 11:08 am of puree preparation with [NAME] LL revealed [NAME] LL preparing pureed green beans and pureed chicken tenders. A 4-ounce (oz) spoon was used to measure the green beans and three chicken tenders were used for protein. [NAME] LL stated that three chicken tenders equaled one serving. Five 4-oz scoops of green beans were used, and butter was poured into the green beans without measuring. One cup of chicken broth was added to the 15 chicken tenders. Once the puree was complete, the green beans and chicken tenders were placed into the oven. [NAME] LL reported that the food would thicken while in the oven, so no thickener was used. She reported that recipes have not historically been used when preparing the puree items. During a telephone interview on 11/24/2024 at 11:37 am, the Registered Dietitian stated that ideally, the dietary staff should follow a recipe, but there was no strict protocol for following the recipe.

Based on observation, staff interview, record review, and review of the facility policies titled Enhanced Barrier Precautions (EBP) and Clean Dressing Change, the facility failed to put on (don) Personal Protective Equipment (PPE) and failed to wash/sanitize hands and change gloves during wound treatment for one of 37 sampled residents (R) (R65). The deficient practices had the potential to increase R65's risk of infection due to cross-contamination and the potential to increase the risk of spread of infection to other residents. Findings include: Review of the facility's undated policy titled Enhanced Barrier Precautions revealed the Policy section stated, It is the policy of this facility to implement enhanced barrier precautions for the preventions of transmission of multidrug-resistant organisms. The Policy Explanation and Guidelines section included, 4. High-contact resident care activities include: h. wound care: any skin opening requiring a dressing. Review of the facility's undated policy titled Clean Dressing Change revealed the Policy section stated, It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. The Policy Explanation and Guidelines section included, 9. Loosen the tape and remove the existing dressing. 10. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. 11. Wash hands and put on clean gloves. 12. Cleanse the wound as ordered, taking care to not contaminate other skin surfaces or other surfaces of the wound. Pat dry with a gauze. 13. Measure wound using disposable measuring guide. 14. Wash hands and put on clean gloves. 15. Apply topical ointments or creams and dress the wound as ordered. Protect surrounding skin as indicated with skin protectant. 16. Secure dressing. Review of R65's Physician Orders dated 11/22/2024 revealed to cleanse the right dorsal foot with wound cleanser, Medihoney, and wrap with kerlix daily and secure with tape daily and as needed. R65 was also receiving Keflex 500 milligrams (mg) (an antibiotic used to treat infection) two times a day for the right dorsal foot infection for 14 days. On 11/7/2024, an order was initiated for EBP related to an arterial wound. Observation of wound care for R65 on 11/23/2024 at 8:55 am revealed Registered Nurse (RN) EE entered the resident's room and started the treatment without donning PPE according to the sign on the resident's door for EBP. RN EE washed her hands, put on gloves, and removed the old dressing. RN EE cleaned the wound to the right dorsal foot with wound cleanser and gauze, applied Medihoney, and covered it with dry dressing and kerlix wrap. RN EE did not wash or sanitize hands or change gloves after cleaning the wound and before applying the medication. During an interview on 11/23/2024 at 9:49 am, RN EE confirmed that she did not put on the PPE for EBP and asked if there was a sign on the door. She stated that she had never changed her gloves after cleaning a wound and before applying the ordered medication. In an interview on 11/24/2024 at 9:40 am, the Director of Nursing (DON) revealed she expected the nurse to change gloves according to policy. She stated she should have worn the PPE indicated for EBP as indicated on the door.

Based on staff interviews, and record review the facility failed to ensure that one of 24 residents (R) (#67) was assessed for level two Pre-Admission Screening/Resident Review (PASRR) and coordinate services, if warranted. Findings include: Record review of the electronic medical record (EMR) for R#67 revealed a diagnosis including but not limited to major depressive disorder, schizoaffective disorder, and bipolar. Record review of the care plan for R#67 revised date 10/25/2022 indicated resident is at risk for adverse reactions related to daily use of antidepressants for diagnosis of depression and anti-psychotic use for diagnosis of schizoaffective disorder. Record review of the Preadmission Screening/Resident Review (PASRR) Level 1 Assessment for R#67 dated 8/11/2020, revealed that level 1 documentation was negative for Mental Illness. There was no evidence that a Level 2 PASRR assessment was completed and in his medical record for reference. Record review of the Admission Record Diagnosis Information for R#67 dated 5/7/2023, indicated diagnoses of schizoaffective disorder, bipolar type with an onset date of 11/09/2020, and major depressive disorder with an onset date of 08/12/2020. Review of Order Summary Report for R#67 dated 5/7/2023 revealed active orders dated 1/31/2023 for Duloxetine 60 milligram (mg) one capsule by mouth one time a day and Seroquel tablet 300 mg 0.5 mg tablet by mouth two times a day related to Schizoaffective disorder, Bipolar type. Interview on 5/7/2023 at 8:43 a.m. with Social Services Director (SSD), confirmed R#67 did not have a Level II PASRR. She reported that R#67 was diagnosed with a Serious Mental Illness (SMI) of schizoaffective disorder, bipolar type after admission. The SSD further stated that a PASRR Level 1 application should have been re-submitted. Interview on 5/07/23 at 10:52 a.m. with Registered Nurse, Minimum Data Set (RN MDS) Coordinator AA revealed that she reviews admission paperwork and puts diagnoses in the EMR. She stated that if she notices an issue with Level 1 and diagnosis, she will alert the SSD. The MDS RN Coordinator AA reported that the SSD would review the diagnosis and submit PASRR screening if needed. Interview on 5/07/2023 at 11:05 a.m. with the Director of Nursing (DON) stated the expectations of staff is to make sure there were no discrepancies with the diagnosis and Level 1 screening. The DON reported that should a resident receive a qualifying diagnosis after admission, Level 1 should be re-submitted.

Based on record review and staff interviews, the facility failed to apply for Level II PASRR (Preadmission Screening and Resident Review) for evaluation and determination of specialized services for four of five residents (R) (#7, #8, #69, and #75) that had a positive Level I PASRR for mental illness. Findings include: 1. Review of R#8 diagnoses revealed the following diagnoses: major depressive disorder, schizophrenia, brief psychotic disorder, delusional disorders, anxiety disorder, and unspecified psychosis. Interview on 5/6/2023 at 8:43 a.m. with Social Service Director (SSD) revealed she did not do a level II on R#8. The SSD stated that R#8 was at the facility before she started working at the facility. The SSD further revealed that the process for applying for a Level II PASRR is if a resident is admitted to the facility with no behaviors and develops behaviors during their stay, they are referred for a behavioral evaluation. The SSD stated R#8 does have behavior, and refuses showers, appointments, medications, and care at times. The SSD again stated that a Level II should have been submitted, but she just did not do it. A further interview on 5/7/2023 at 9:40 a.m. with SSD revealed R#8 should have been submitted for a level II related to diagnoses and behaviors. 42464 2. R#7 was admitted to the facility with diagnoses including but not limited to bipolar disorder, schizophrenia, and anxiety. Further review revealed additional diagnoses of post-traumatic stress disorder added 7/10/2015, schizoaffective disorder, bipolar type added 12/17/2019, obsessive-compulsive disorder added 10/21/2021, and psychotic disorder with hallucinations added 1/17/2022. Review of the PASRR form dated 10/3/2008 revealed check marks next to depressive disorder, bipolar disorder, and anxiety. There is no evidence in the electronic medical record (EMR) that a new PASRR was submitted after each new diagnosis resident received. 3. R#69 was admitted to the facility with diagnoses including but not limited to schizophrenia, bipolar disorder, and psychotic disorder. Review of the PASRR form dated 11/13/2020 revealed '4. Does the individual have a primary diagnosis of serious mental illness or mental disorder?' the box indicating 'No' has an X. 4. R#75 was admitted to the facility with diagnoses including but not limited to major depressive disorder and schizotypal disorder. Review of the PASRR form dated 3/15/2021 revealed '4. Does the individual have a primary diagnosis of serious mental illness or mental disorder?' the box indicating 'No' has an X. Interview on 5/7/2023 at 9:40 a.m. with SSD revealed R#7, R#69, and R#75 should have had a PASSR resubmitted related to diagnoses and behaviors after admission. Interview on 5/7/2023 at 11:05 a.m. with the Director of Nursing (DON) revealed her expectations of staff is that they ensure there no discrepancies with the diagnosis and PASSR Level 1 screening. The DON further stated, should a resident receive a qualifying diagnosis after admission, the PASSR Level 1 should be re-submitted.

Based on staff interviews, record review, and a review of the facility's policy titled Care Plans, Comprehensive Person-Centered, the facility failed to develop a comprehensive person-centered care plan for one resident (R) (#71) related to Preadmission Screening and Record Review (PASRR) Level II out of six residents reviewed for PASRR. Findings include: Review of facility policy titled Care Plans, Comprehensive Person-Centered last revised 12/2016 revealed 8. The comprehensive, person-centered care plan will: d. Describe any specialized services to be provided as a result of the PASSR recommendations. Record review of the electronic medical record (EMR) for R#71 revealed a PASRR level II screening dated 12/8/2020 with services to end 12/31/2299. Record review of the care plan for R#71 revealed that PASRR level II was not addressed. Interview on 5/7/2023 at 8:35 a.m. Registered Nurse Minimum Data Set (RN MDS) Coordinator AA revealed that R#71's PASRR level II status should have been addressed on the care plan. The RN MDS Coordinator AA Confirmed R#71 did not have a care plan to address PASRR level II. Interview on 5/7/2023 at 11:05 a.m. with Director of Nursing (DON) revealed her expectations of staff are to ensure appropriate care plans are in place.

Based on observation, review of facility policy titled Maintaining a Sanitary Tray Line, and staff interviews, the facility failed to ensure that dietary staff prepared food in a sanitary manner as evidence by two staff members not wearing hair nets appropriately in the food preparation area. There were 90 of 91 residents who received an oral diet. Findings include: During an initial tour of the kitchen on 1/4/22 at 9:40 a.m., Dietary Staff II was observed with blond hair braids long in length several inches below her waist. She was observed at the kitchen sink washing a large pot and was not wearing a hair net. The Dietary Manager (DM) identified Dietary Staff II as the cook. During a follow-up visit to the kitchen on 1/6/22 at 8:00 a.m., the Business Office Manager (BOM) stated she was covering for the DM because she was out. Dietary Staff MM and NN were observed with hair nets not providing full coverage. BOM stated she would tell Dietary Staff NN to cover her hair. Dietary Staff MM was observed standing at the steam table with a hair net covering the front portion of her hair. The back of hair exposed an uncovered ponytail. Further observation revealed Dietary Staff NN standing next to the steam table wearing a hair net covering the top of her hair with the sides and back of her hair sticking out from under the hair net. Interview with the DM on 1/4/22 at 2:44 p.m. revealed that her expectations are that all dietary staff wear hair nets to completely cover the hair. Review of the undated policy titled Maintaining a Sanitary Tray Line revealed: 3. During tray assembly, staff shall: g. Wear hair restraints (bonnets, caps, nets to cover hair) when preparing or handling food.

Based on record review and staff interview, the facility failed to notify the resident and/or residents' responsible party when their personal funds were within $200 of the Social Security Income (SSI) limit and when accounts had exceeded the amount for 10 of 75 accounts reviewed (Resident #'s 69, 78, 44, 32 ,66, 47, 17, 54, 80, and 35). Findings include: Review of the Trial Balance report dated 1/6/22 revealed the following resident trust fund accounts exceeded the SSI limit of $2000: 1) Resident #69 - $2591.72 2) Resident #78 -$2057.14 3) Resident #44 - $2990.69 4) Resident #32 - $2211.91 5) Resident #66 - $2008.03. 6) Resident #47 - $2670.06 7) Resident #17 - $2152.90. 8) Resident #54 - $2861.47 9) Resident #80 - $12,514.00 10). Resident #35 - $2214.15 There was no documented evidence that the resident or responsible party were notified of the amounts exceeding the SSI limit. During an interview on 1/6/22 at 2:50 p.m., the Business Office Manager (BOM)/Financial Coordinator reviewed the residents' personal funds. The BOM/Financial Coordinator stated the SSI limit for the State of Georgia was $2000. The BOM/Financial Coordinator confirmed the facility had not notified the resident and/or the resident's responsible party of the excess in their accounts. The BOM/Financial Coordinator reported that she was informed to keep resident fund accounts under $2000 to qualify for Medicaid. She confirmed that the Patient Liability for all the residents accounts had already been pulled out for the month of January 2022 and that the remaining balance showing is the actual balance left in the resident accounts.

Based on observations, review of facility policies titled Preventive Maintenance Program and Environmental Services Inspection, and staff interviews, the facility failed to maintain a safe and homelike environment related to dirt buildup and disrepair of resident rooms and bathrooms including ceilings, floors, walls, and vents in 9 of 48 rooms (107, 209, 214, 501, 503, 505, 506, 507, and 508), two shower rooms (300 Hall and 500 Hall), and the front entrance to the building. Findings include: 1. Observation of room 505 on 1/04/22 at 10:11 a.m. revealed there was a bulging ceiling tile covered in a black substance, there was also a black substance noted on the ceiling tile over the A bed in the corner of the room near the door. Outside of the room in the hall there was tile missing in the ceiling with exposed wood planks covered in a black and gray substance. To the right of the missing tile in the hallway was a small tile that was covered in gray and black substance. 2. Observation of room 506 on 1/04/22 at 10:15 a.m. revealed there were four floor tiles that were not adhered to the floor and freely moving around at the foot of bed B. Interview with resident (R) R#85 on 1/04/22 at 10:17 a.m. (Brief Interview of Mental Status (BIMS) score 13, indicating cognitively intact) revealed that the tile had been like that for the past two weeks and that he did report the issue to the facility staff for repair. 3. Observation of room 501 bathroom on 1/04/22 at 10:21 a.m. revealed there were three tiles missing in the doorway entering the bathroom. 4. Observation of room 503, 507, and 508 on 1/04/22 starting at 10:24 a.m. revealed that each room had vents that were covered in dust. Dust was also noted on the ceiling beside the vents. Continued observation of 500 hall revealed the vent located in the hall beside the nurse's station had a thick layer of dust covering the vent grates. 5. Observation of room 214 on 1/04/22 at 10:29 a.m. revealed there was a large brown spot on the ceiling by the window. Continued observation of room 209 revealed there was a large whole in the wall entering the room at the head of resident's bed. 6. Observation on 1/4/22 at 10:36 a.m. of the front of the building revealed cigarettes butts lying on the ground on the grass near the front entrance and in the parking lot. During an interview on 1/6/22 at 12:08 p.m. the Administrator reported that her expectation is that staff smoke in the designated smoke area and put their cigarettes in the red fireproof can. 7. Observation on 1/4/22 at 1:41 a.m. revealed a large hole in wall and on the side of the wall near A Bed in room 107. Environmental rounds were conducted with the Administrator and Maintenance Director on 1/05/22 at 8:45 a.m. which confirmed all above observations that were observed during initial facility tour. Interview with Maintenance Director on 1/05/22 at 9:15 a.m. revealed that the staff let him know if there are issues that need to be addressed by verbally telling him and there is a maintenance book that is kept at each nurse's station to put work orders in. If there is an issue that needs to be addressed right away, the staff would notify him by phone. Further interview revealed that he became aware of the issue with the tile in room 505 on Tuesday (1/4/22) but was unable to find a replacement for it until today. Maintenance Director stated that there was a leak in the roof, and it had rained over weekend causing the tile to bulge and have the black stains on it which was debris from out of the ceiling. The Maintenance Director was not aware of the missing tiles that were observed in room 501 in the bathroom or in room 506 at the foot of the resident's bed. The Maintenance Director was not aware of the whole in wall at the head of the bed in room 209. Continued interview revealed that housekeeping was responsible for ensuring that the vents in the resident's rooms and in the hallways were cleaned and he would paint them if indicated. Interview with the Administrator on 1/05/22 at 10:45 a.m. revealed that there was not a House Keeping Supervisor employed at the facility at this time, but it is the responsibility of the house keepers to ensure that the vents in the residents' rooms are clean and free of dust. Further interview also revealed that for any maintenance issues that the staff are to put those issues in the maintenance book that is located at each nurse's station. 8. Shower rooms (Hall 300 and Hall 500) revealed the following: Observation with the Administrator on 1/6/22 at 1:00 p.m. of the 500 Hall shower room revealed the following: one vent cover with dark grayish substance with speckles of debris, shower chairs were covered with dark substances, a fluorescent light fixture with no cover, and privacy curtains were stained with brown substances. There were boxes stacked to the ceiling on the floor in an open area. Observation with the Administrator on 1/6/22 at 1:20 p.m. of the 300 Hall shower room revealed the following: one vent covered with dark grayish speckled substances and a black substance circling the ceiling tiles, dark black speckled substances on the baseboard of the shower area, water puddles on the floor, and shower head was constantly running with water. During an interview on 1/6/22 at 1:45 p.m., the Maintenance Director reported being aware of the condition of the shower room. He was last in the shower room last week and a few weeks ago. He described the dark substances as brown dirt. Review of facility policy titled Preventative Maintenance Program revised 6/12/21 revealed under Policy Explanation and Compliance Guidelines: 1. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. Review of an undated facility Deep Cleaning instructional sheet revealed that during the deep cleaning process each housekeeper must deep clean one room and bathroom a day. Everything in the room is disinfected including cleaning vents, sprinklers, and ceiling. Review of facility policy titled Environmental Services Inspection dated 7/10/21 revealed under policy: it is the policy of this facility to regularly monitor environmental services to ensure the facility is maintained in a safe and sanitary manner and assessed on a regular basis.

Based on observations, staff interviews, and record review, the facility failed to ensure a urinary catheter bag was covered to protect the dignity of one of two residents (R) (R#29) with indwelling urinary catheters. Findings include: Review of the clinical record revealed R#29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed R#29 had a Brief Interview of Mental (BIMS) score of 15, indicating cognition intact and the resident had an indwelling catheter. Observation on 1/4/22 at 12:30 p.m. revealed R#29 in the B-Bed with her catheter bag uncovered (no dignity bag), exposing dark urine in the catheter bag. A closer observation revealed the resident in the A-Bed was sitting directly across the room eating lunch facing R#29's catheter bag. During an interview and observation on 1/4/22 at 2:25 p.m. with Certified Nursing Assistant (CNA) RR, R#29 was observed lying in B-Bed (in a three-bed unit room) with her catheter bag uncovered (no dignity bag) facing directly in front of the roommate in A-Bed sitting on the side of her bed. A closer observation of R#29's catheter bag revealed dark color urine in the bag. CNA RR confirmed that the catheter bag was uncovered and reported receiving no verbal or written instructions to provide a dignity bag for any resident with a catheter. During an interview on 1/6/22 at 10:39 a.m., the Administrator was unaware that nursing staff were not using a dignity bag for urinary catheter bags. She reported that all residents should have a dignity bag covering the urinary catheter bag. During an interview on 1/6/22 at 11:43 a.m., R#29 revealed that she prefers the bag to be covered because this is her business.

Based on observation, record review and staff interview, the facility failed to follow the care plan for administering enteral feedings as ordered for one resident (R) (#33) of 38 sampled residents. Findings include: Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed R#33 was unable to complete a Brief Interview of Mental Status (BIMS) score and had a feeding tube. The resident has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the care plan last revised on 11/5/21 revealed R#33 has a g-tube (gastrostomy tube) due to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included feedings and flushes as ordered. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 1/5/22 at 10:16 a.m. R#33 was observed in bed with tube feeding running at 55 ml/hr. During an observation and interview on 1/6/22 at 9:50 a.m., Licensed Practical Nurses (LPN) EE confirmed the feeding pump was set at 55 ml/hr. Cross refer to F693.

Based on observations and interviews, the facility failed to ensure that the resident bathrooms were maintained in working condition on four (4) halls (100, 200, 300, and 500) of five (5) halls, in rooms 111/109, 210/208, 214/212, 217, 305/307, 501/503, 504/502, 505/507 and 508/506 including toilets that did not flush properly, sinks that would not drain, and leaking water from the base of the toilets and sinks. The census was ninety-four (94). It was determined that the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to residents. The Director of Nursing (DON) and the owner were informed of the Immediate Jeopardy (IJ) on 02/26/2016 at 4:05 p.m. which was identified to have existed on 02/26/2016, the date the plumbing problems was identified to exist. Findings include: Observation on 2/26/16 with the Maintenance Director and the owners, revealed the following: Observation on 2/26/16 at 9:50 a. m. in the bathroom of room 111/109 the toilet was leaking water from around the toilet base onto the floor. Observation on 2/26/16 at 10:15 a.m. in the bathroom of room 210/208 the sink was filled with clear water that would not drain. Interview on 2/26/2016 at 10:15 a.m. with the resident in room 501/503 revealed that the toilet was always stopped up and the staff had to work on it all the time. Observation on 2/26/16 at 10:25 a.m. in the bathroom of room 214/212 the toilet was leaking around the base. Observation on 2/26/16 at 10:30 a.m. in the bathroom of room 217 wet sheets were wrapped around the toilet base, the toilet flushed slowly with water coming to the top of the rim of the base, then drained slowly and continued leak around the base. Observation on 2/26/16 at 10:45 a.m. in the bathroom of room 305/307 the toilet is leaking around the base, with wet sheets around the base of the toilet to absorb the water. Observation on 2/26/16 at 10:50 a.m. revealed in the bathroom of room 501/503 the toilet was leaking around the base and would not flush. Interview with the Maintenance Director and DON on 2/26/16 at 4:25 p.m. confirmed the plumbing backup began on Wednesday, 2/24/16. The Maintenance Director stated he had tried to correct the problem using a snake (a plumbing tool with a wire like cord that is placed into a drain to remove blockage) but was unsuccessful. The Maintenance Director stated the plumbing issues began on 2/24/16. Review of the plumbers invoice dated 2/25/16 revealed that the plumber ran a cable line through the pipes to access and to clean out stoppage, then provided a Hydro-Scrub and Bio Choice treatment. Interview on 2/27/16 at 10:30 a.m. with the DON revealed that the plumber had worked until 2:00 a.m. to correct the plumbing problems. The DON stated that during her rounds this morning she observed a sink that was not draining thus the plumber is returning to correct the problem with the sink. Observation on 2/27/16 at 11:23 a.m. through 11:29 a.m. revealed in room 505/507, the toilet was slow to drain when flushing; in room 508/506, the sink was slow to drain; in room, 504/502 and 503/501, the toilets were slow to flush, and the water went to the over flow line before it drained slowly. Interview on 2/27/16 at 11:30 a.m. with the resident in room 505/507 revealed that the toilet stays backed up all the time. However, interview on 4/15/16 at 1:30 p.m. via telephone with the Administrator and DON revealed that this resident has an Obsessive Compulsive Disorder (OCD), uses four (4) squares of toilet tissue at a time, and completes this cycle for thirty (30) times. Interview on 2/27/16 at 1:30 p.m. the DON stated the plumber had arrived earlier and all toilets and sinks were functioning. Observation on 2/27/16 at 1:45 p.m. validated that all the plumbing including toilets that flushed properly without spillage and water rising to the overflow rim, sinks that drained freely after three (3) minutes of running water through the drain, there was no evidence of leaking water around the base of the toilets or sinks and all the linens used to absorb the water was removed in rooms 111/109, 210/208, 214/212, 217, 305/307, 501/503, 504/502, 505/507 and 508/506. Review of the plumbers invoice notations dated 2/27/16 revealed there was a couple of sewer lines causing the problems with flushing of toilets. The plumber indicated on the report he took a machine down the floor flange on the 500 wing and got the main line unclogged, this is the line where the 300, 400, and 500 wings restrooms join together to flow through the main sewer line. Continued review of the invoice notations revealed there was a sewer line going across the 200 hall that was full of water and backing up. They (the plumber) took a cable machine down that line on 200 hall and got the water to drain. Then they (the plumber) used the camera and placed it into the drain pipes of 300-500 halls and everything is flowing freely. The State Survey Agency validated the Immediate Jeopardy was removed on 2/28/16 prior to the exit on 2/28/16. The scope and severity (S/S) was lowered to a D at 483.15(h) (2) - F253 (K) Housekeeping & Maintenance Services, and at 483.25(h) - F323 (K) Free of Accident/Hazards/supervision/devices on 2/28/16 while the facility implements, monitors the Plan of Correction for the effectiveness of systemic changes, and continues to implement the process of monitoring water temperatures and plumbing issues. 1. The department managers were stationed on hall 300, to assure that residents were safe, other bathrooms/shower rooms, bed baths were available for resident use until water temperatures were 120 degrees or below and the plumbing was repaired. 2. The maintenance department adjusted the hot water heater temperature settings. 3. An in-service was provided to eight (8) management staff members on acceptable water temperatures on 2/26/16. 4. The maintenance department will monitor the hot water temperatures every (q) two (2) hours (hrs.) until the water temperatures reach 110 degrees and for twenty-four (24) hours, and; Review of the water temperature log dated 2/26/16 and 2/27/16 verified compliance with the every 2 hour monitoring of the water temperature. 5. Then, monitor the water temperatures q twelve (12) hours for 24 hrs. To assure continued compliance the maintenance department will monitor twenty (20) rooms, for five (5) days a week for ninety (90) days and report findings to the QaPI Committee. Review of the temperature monitoring conducted on 2/26/16 at 12:47 p.m. revealed the following; in room 301-303 the water temperature was 105; in room 302 -304 the water temperature was 102, and; in room 305- 307 the temperature was 102. Review of the temperature monitoring on 2/27/16 at 1:00 a.m. revealed in room 306 the water temperature was 104.2; in room 307 the water temperature was 104.2, and; in room 309 the temperature was 103.8. Review of the temperature monitoring on 2/27/16 at 3:00 a.m. revealed in room 306 the water temperature was 104.2; in room 307 the water temperature was 104.2, and; in room 309 the temperature was 103.8. Review of the temperature monitoring on 2/27/16 at 5:00 a.m. revealed in room 306 the water temperature was 103.6; in room 307 the water temperature was 103.6, and; in room 309 the temperature was 104. Review of the temperature monitoring on 2/27/16 at 7:00 a.m. revealed in room 306 the water temperature was 96; in room 307 the water temperature was 96, and; in room 309 the temperature was 100. In addition, review of the water temperatures monitored in all rooms revealed no evidence of a temperature greater than 110. 6. The facility developed interventions including continuous monitoring of residents by department managers until the plumbing issues were resolved, including offering bed baths and use of showers in the other shower areas. 7. The maintenance department will monitor the shower areas, identified resident rooms and other areas as needed twice a day for the next thirty (30) days, then daily for 30 days, and then weekly for ninety (90) days. Water was removed via mopping, using a wet/vacuum and/or linen was used to absorb the water until the areas were repaired. Observation on 2/27/16 at 9:30 a.m. revealed the 200 hall shower room was repaired and fully functional. Observation on 2/28/16 at 8:35 a.m. through 11:15 a.m. revealed that the toilets were flushing without leaking around the base, without filling to the top of the overflow rim. After running water in the sinks for three (3) minutes they drained freely in rooms 114/112, 111/109, 108, 107/105, 204/206, 210/208, 214/212, 209, 302/304, 306/308, 309,305/307, 311/313, 404/402, 405/403, 407/409, 408/406, 501/503, 505/507, 508/506 and 504/502. The rooms were clean, orderly and without odors. Observation on 2/28/16 at 8:50 a.m. of the 500 hall shower room revealed the toilet was in place and flushing freely, the shower drain was clean and draining freely. The room was clean, orderly and without odors. Observation on 2/28/16 at 9:30 a.m. of the 200 hall shower room revealed the toilet was flushing freely, the shower drain was clean and draining freely. The room was clean, orderly and without odors. Interview on 4/15/16 at 1:30 p.m. via telephone with the Administrator and DON stated that the 300 hall shower room had been closed since June of 2015, she said it needed remodeling and they had been using it for storage. She said that since the plumbing issue began, it has been cleaned out, cleaned and is in full operation effective on 3/3/16. Continued interview on with the DON revealed during the plumbing crisis there was never raw sewage running out in the floors, she said during the blockage some of the toilet began leaking clear liquid fluid from the base, however it did not smell and was clear not sewage. She said to prevent water from running out in the floors they used sheets to absorb the water, and they were disposed of after they were removed from the base of the toilets. She verified she was mopping the floor however it was clear without odor. She said the toilet was removed because that is where maintenance was using the snake to try and clean out the blockage. 8. Monitoring will be reported to the QaPI Committee. Interview on 4/15/16 at 1:30 p.m. via telephone with the Administrator and DON stated that on 2/26/16 the Medical Director was on site during the survey. She stated they had an emergency QaPI Meeting with the Department Managers, Corporate Representatives, Medical Director and they established a plan of action to assure the safety of the residents, to assure that residents received their daily care, and honored the preferences of the residents. The DON stated that the Medical Director was very active with the facility and he came to the facility every week. During his visit to the facility weekly, they met and discussed any areas that needed immediate attention. In addition, he attended the monthly QaPI meeting. The DON stated that maintenance issues were discussed in the monthly QaPI meeting, however they plumbing had not been an issue of this depth until now. The DON stated a QaPI meeting was conducted on 3/3/16 and plumbing issue was discussed in detail at that time. 9. Any issues that arise will be repaired by the maintenance department and/or other service providers. Interview on 4/15/16 at 1:30 p.m. via telephone with the Administrator and DON revealed the Maintenance Director could usually unstop or clear the plumbing problems. When he could not the plumber would be called. The Administrator stated that there is a maintenance request book at each nursing station. The Administrator stated that daily the maintenance Director goes to each station and obtains the needed repair request and they are reviewed in the morning meetings. If at the end of the day the repairs were not completed, or supplies are needed, the maintenance director meets with him. If there is something that needs to be purchased above certain limits, the Administrator calls the corporate office and purchase is granted.

Based on observations, record review and staff interviews, the facility failed to ensure that the resident environment was free of accident hazards including unsafe hot water temperatures in rooms 306/308, 305/307 and 309), failed to ensure toliets flushed, sinks, showers drained freely, without leakage around the toliet base, without leaking sinks, showers and drained freely pipes in rooms 109, 209, 210/208,214/212, 217, 307, 404/402, 405/403 501/503, 504/502, 505, 507/509, and 508/506 and central shower area on the 200 and 500 on five (5) of five (5) halls. The census is ninety four (94). It was determined that the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to residents. The Director of Nursing (DON) and the owner were informed of the Immediate Jeopardy (IJ) on 02/26/16 at 4:05 p.m. which was identified to have existed on 02/26/16, the date the plumbing problems was identified to exist at 483.15(h) (2) - F253 (K) Housekeeping & Maintenance Services, and at 483.25(h) - F323 (K) Free of Accident/Hazards/supervision/devices. Findings Include: Observations on 2/26/16 with the Maintenance Director who validated the findings during the observation revealed the following: Observation on 2/26/16 at 9:50 a.m. in the bathroom of 109 it was noted the toilet was leaking water from around the toilet base. Observation on 2/26/16 at 10:15 a.m. during an observation in the bathroom of 210 the sink was filled with clear water that would not drain. Observation on 2/26/16 at 10:25 a.m. in the bathroom of 214 the toilet was leaking around the base. Observation on 2/26/16 at 10:30 a.m. in the bathroom of 217 wet sheets were wrapped around the toilet base, the toilet was leaking around the base, and it flushed sluggishly. Observation on 2/26/16 at 10:45 a.m. in the bathroom of 305/307 the toilet is leaking around the base, and had wet sheets around the base of the toilet. Observation on 2/26/16 at 10:50 a.m. in the bathroom of 503 the toilet was leaking around the base and would not flush. Observation on 02/26/16 at 10:55 a.m. the Director of Nursing (DON) was mopping the five hundred (500) hall floor, and the floor in the five hundred (500) hall central bath, the shower drain had brown colored particles on the outer aspects circling the drain, clear liquid was gushing out of the shower drain flooding the room and the hall. The DON flushed the toilet in the central bath, and fluid came out of the shower drain. The toilet had been removed and placed to the right side of the bath. The toilet drain was exposed, not capped and allowing fumes to escape. The shower room drain was flooded with clear fluid backup that covered approximately three fourths of the shower area. Observation on 02/26/16 at 11:00 a.m. with the Maintenance Director using the facility thermometer revealed the water temperature in room 306/308 to be 122 degrees Fahrenheit, in room 305/307 the sink water temperature was 121 degrees Fahrenheit, and in room 309 the sink water temperature was 123 degrees Fahrenheit above the acceptable 120 degree Fahrenheit range to prevent burns to residents. Observation on 2/27/16 at 11:15 a.m. revealed the toilets was slow to drain water after flushing in rooms 404/402, 405/403 and 409/407. Observation on 2/27/16 at 11:23 a.m. revealed the toilet and the sink drained very slowly in rooms 507/505 and 508/506. Observation of rooms 504/502 and 503/501 revealed that the toilet flushed, however water filled to the over flow line and the sinks drained water slowly. On 2/27/16 at 12:15 p.m. the above list of concerns was given to the DON who stated she would give the list to the Maintenance Director. Interview on 2/27/16 at 1:30 p.m. with the owner revealed that the plumber had arrived earlier and all plumbing was working at this time. Interview on 2/28/16 at 8:35 a.m. upon arrival with the DON revealed that the plumber was in the facility until 2:00 a.m. at which time all the plumbing issues had been resolved. The DON stated that during her rounds this morning she observed a sink that was not draining, so she called the plumber and he was on his way to the facility. Review of a plumbing services invoice dated November 2015 (could not identify day) revealed that the HydroScrub Method pipe was placed in the line in an attempt to clear blockage, then two (2) hours later a camera was placed in the drainage pipes, revealing that all pipes were clear of blockage and draining freely. (HydroScrub uses water pressure and water volume to clear pipes of clogs and debris. HydroScrub consists of a large tank of water, special high pressure hose and high strength nozzle, and machine that pressurizes water and controls flow. Beginning at the downstream end of your plumbing system, the HydroScrub nozzle is inserted into the cleanout, an opening in your plumbing offering access for the removal of debris. The pressure created by the nozzle causes it to pull itself through the pipe during the drain & sewer cleaning. Propelled forward by water pressure up to 3500 psi and emitting water at an incredible volume of 18 gallons per minute, HydroScrub works its way upstream, clearing the path for debris to easily flow into the sewer. There are many sizes of HydroScrub nozzles in use today, for pipes from 1.25 to 36 wide) Review of a plumbing services invoice dated 12/10/15 revealed that the plumber used a tool named RotoRooter, which goes into the drain pipes and cleaned out the lines. Review of a plumbing services invoice dated 12/11/15 revealed that the plumber used a tool named RotoRooter, which goes into the drain pipes and cleaned out the lines. Review of a plumbing services invoice dated 2/2/16 revealed that the plumber replaced hose bin, installed a 4 inch clean out pipe, repaired a leak on 1 inch galvanized pipe, and connected water line from meter to gate valve (a valve in a pipe that has a sliding plate that controls the flow) Review of a plumbing services invoice dated 2/13/16 revealed that a toilet and shower were clogged and the plumber serviced the area and indicated that all was draining. The invoice did not identify the location, the problem nor the type of service that was provided. Interview with the DON and Administrator on 4/4/16 at 1:00 p.m. revealed this was related to the 500 hall shower room. Review of a plumbing services invoice dated 2/16/16 revealed a toilet was stopped up with paper towels, the toilet was pulled flange and seal at the base of the toilet, then a cable line was placed down the pipe to clear the blockage. The invoice did not identify the location. I Interview with the DON and Administrator on 4/4/16 at 1:00 p.m. revealed this was related to the 500 hall shower room. Continued review of a plumbing services invoice dated 2/26/16 revealed that on the hall where the rehab center was stopped up. Review of the facility floor plan identified this to be on the 400 hall. Continued review of the invoice revealed that the plumber ran a cabled line to down the pipe then used HydroScrub the line to clean ones. Cleaned the line, rinsed out the dirt in it, checked toilets and showers all drains were clear. Review of a plumbing services invoice dated 2/27/16 revealed a couple of sewer lines backing up and causing problems with flushing toilets. Cable machined down a floor flange on 500 hall, for the main line unclogged where the 300, 400 and 500 halls flow through. Once the lines were unclogged, the plumber used a camera with video to visualize and inspect the lines, all lines were clear. The clean out plug (a clean out is a access point into a drain line that allows you to clean a drain that is clogged or, for just a routine maintenance cleaning, cleanouts are usually a tee or, an extension off a tee in the line with a removable plug to provide access for the plumber to insert a snake and cable the line or, high pressure water jetting hose to clean the clog away) outside of 300 hall was empty with water flowing. A sewer line going across 200 hall hat was full of water causing a backup, the plumber then the cable machine, placing it down the line also and got water flowing. The State Survey Agency validated the Immediate Jeopardy was removed on 2/28/16 prior to the exit on 2/28/16. The scope and severity (S/S) was lowered to a D at 483.15(h) (2) - F253 (K) Housekeeping & Maintenance Services, and at 483.25(h) - F323 (K) Free of Accident/Hazards/supervision/devices on 2/28/16 while the facility implements, monitors the Plan of Correction for the effectiveness of systemic changes, and continues to implement the process of monitoring water temperatures and plumbing issues. 1. The department managers were stationed on hall 300, to assure that residents were safe, other bathrooms/shower rooms, bed baths were available for resident use until water temperatures were 120 degrees or below and the plumbing was repaired. 2. The maintenance department adjusted the hot water heater temperature settings. 3. An in-service was provided to eight (8) management staff members on acceptable water temperatures on 2/26/16. 4. The maintenance department will monitor the hot water temperatures every (q) two (2) hours (hrs.) until the water temperatures reach 110 degrees and for twenty-four (24) hours, and; Review of the water temperature log dated 2/26/16 and 2/27/16 verified compliance with the every 2 hour monitoring of the water temperature. 5. Then, monitor the water temperatures q twelve (12) hours for 24 hrs. To assure continued compliance the maintenance department will monitor twenty (20) rooms, for five (5) days a week for ninety (90) days and report findings to the QaPI Committee. Review of the temperature monitoring conducted on 2/26/16 at 12:47 p.m. revealed the following; in room 301-303 the water temperature was 105; in room 302 -304 the water temperature was 102, and; in room 305- 307 the temperature was 102. Review of the temperature monitoring on 2/27/16 at 1:00 a.m. revealed in room 306 the water temperature was 104.2; in room 307 the water temperature was 104.2, and; in room 309 the temperature was 103.8. Review of the temperature monitoring on 2/27/16 at 3:00 a.m. revealed in room 306 the water temperature was 104.2; in room 307 the water temperature was 104.2, and; in room 309 the temperature was 103.8. Review of the temperature monitoring on 2/27/16 at 5:00 a.m. revealed in room 306 the water temperature was 103.6; in room 307 the water temperature was 103.6, and; in room 309 the temperature was 104. Review of the temperature monitoring on 2/27/2016 at 7:00 a.m. revealed in room 306 the water temperature was 96; in room 307 the water temperature was 96, and; in room 309 the temperature was 100. In addition, review of the water temperatures monitored in all rooms revealed no evidence of a temperature greater than 110. 6. The facility developed interventions including continuous monitoring of residents by department managers until the plumbing issues were resolved, including offering bed baths and use of showers in the other shower areas. 7. The maintenance department will monitor the shower areas, identified resident rooms and other areas as needed twice a day for the next thirty (30) days, then daily for 30 days, and then weekly for ninety (90) days. Water was removed via mopping, using a wet/vacuum and/or linen was used to absorb the water until the areas were repaired. Observation on 2/27/16 at 9:30 a.m. revealed the 200 hall shower room was repaired and fully functional. Observation on 2/27/16 at 1: 45 p.m. of rooms 507/505, 508/506, 504/502, 503/501, 409/407, 404/402, and 405/403 revealed the sinks and toilets flushing and drained freely. Interview on 4/15/16 at 1:30 p.m. via telephone the DON stated 500 hall has a total of 16 residents with nine (9) residents being independent with toileting, and seven (7) residents requiring assistance and/or having total incontinence as follows: room 501, 502, 503 each have two (2) residents and one (1) resident in 504 need assistance with toileting. Rooms 505, 506 and 507 have two (2) residents and room 504 has one (1) residents that are independent for toileting. Observation on 2/28/16 at 8:35 a.m. through 11:15 a.m. revealed that the toilets were flushing without leaking around the base, without filling to the top of the overflow rim. After running water in the sinks for three (3) minutes they drained freely in rooms 114/112, 111/109, 108, 107/105, 204/206, 210/208, 214/212, 209, 302/304, 306/308, 309,305/307, 311/313, 404/402, 405/403, 407/409, 408/406, 501/503, 505/507, 508/506 and 504/502. The rooms were clean, orderly and without odors. Observation on 2/28/16 at 8:50 a.m. of the 500 hall shower room revealed the toilet was in place and flushing freely, the shower drain was clean and draining freely. The room was clean, orderly and without odors. Observation on 2/28/16 at 9:30 a.m. of the 200 hall shower room revealed the toilet was flushing freely, the shower drain was clean and draining freely. The room was clean, orderly and without odors. Interview on 4/15/16 at 1:30 p.m. via telephone with the Administrator and DON stated that the 300 hall shower room had been closed since June of 2015, she said it needed remodeling and they had been using it for storage. She said that since the plumbing issue began, it has been cleaned out, cleaned and is in full operation effective on 3/3/16. Continued interview on with the DON revealed during the plumbing crisis there was never raw sewage running out in the floors, she said during the blockage some of the toilet began leaking clear liquid fluid from the base, however it did not smell and was clear not sewage. She said to prevent water from running out in the floors they used sheets to absorb the water, and they were disposed of after they were removed from the base of the toilets. She verified she was mopping the floor however she stated she was mopping clear water without odor. She said the toilet was removed because that is where maintenance was using the snake to try and clean out the blockage. 8. Monitoring will be reported to the QaPI Committee. Interview on 4/15/16 at 1:30 p.m. via telephone with the Administrator and DON stated that on 2/26/16 the Medical Director was on site during the survey. She stated they had an emergency QaPI Meeting with the Department Managers, Corporate Representatives, Medical Director and they established a plan of action to assure the safety of the residents, to assure that residents received their daily care, and honored the preferences of the residents. The DON stated that the Medical Director was very active with the facility and he came to the facility every week. During his visit to the facility weekly, they met and discussed any areas that needed immediate attention. In addition, he attended the monthly QaPI meeting. The DON stated that maintenance issues were discussed in the monthly QaPI meeting, however they plumbing had not been an issue of this depth until now. The DON stated a QaPI meeting was conducted on 3/3/16 and plumbing issue was discussed in detail at that time. 9. Any issues that arise will be repaired by the maintenance department and/or other service providers. Interview on 4/15/16 at 1:30 p.m. via telephone with the Administrator and DON revealed the Maintenance Director could usually unstop or clear the plumbing problems. When he could not the plumber would be called. The Administrator stated that there is a maintenance request book at each nursing station. The Administrator stated that daily the maintenance Director goes to each station and obtains the needed repair request and they are reviewed in the morning meetings. If at the end of the day the repairs were not completed, or supplies are needed, the maintenance director meets with him. If there is something that needs to be purchased above certain limits, the Administrator calls the corporate office and purchase is granted. Review of the grievance log beginning on 2/27/15 through 3/22/16 revealed no evidence of complaints related to water temperatures and/or plumbing concerns.