Every finding on record at Emanuel County Nursing Home

Based on observations, staff interview, record review, and review of the facility policies titled, Labeling, Dating, Storage and Dietary Staff Dress Code/Personal Hygiene, the facility failed to ensure food items were discarded and properly labeled and dated. In addition, the facility failed to ensure dietary staff's hair was completely contained in a hair net. This deficiency practice had the potential for food-borne illness for all residents receiving food items from the kitchen.Findings include:1. Review of the facility policy titled, Labeling, Dating, Storage, dated 02/01/2026, documented in reference to Policy Statement: It is the policy of [NAME] Medical Center for all partners who assist in handling , preparing, serving , and storing food and beverage items to follow the proper procedures for labeling, dating, and storage to ensure food safety. 1. Food and/or beverage items will be properly labeled with the name of the item, the date the item was received and use by date.During an initial tour of the facility kitchen on 07/10/2026, beginning at 8:03 AM, and ending at 8:33 AM, revealed the following food items not properly discarded due to expiration date and not properly labeled/dated in the walk-in cooler and pantry:Fruit parfait cups dated 07/06/2026 (prepared with fresh ingredients) with a discard date 07/10/2026, which exceeded the three-day time limit.Pudding pan in a water pan, missing a preparation date and expiration date.Flour in bin with an expiration date of 06/08/2026 and a use by date of 07/08/2026. The DM reported that her dietary staff had just placed the flour in the bin yesterday and forgot to put a new label on it.Observation of the kitchen pantry revealed the following at 8:33 AM:One bag of brand name creamy potatoes, opened and sealed with plastic wrap, missing an open date.One bag of cake mix, opened and sealed with plastic wrap, missing an open date.2. Review of the facility policy titled, Dietary Staff Dress Code/Personal Hygiene, dated 02/01/2026, documented under Policy, The purpose of this policy is to ensure that Dietary Staff present a clean, professional, and safe appearance while performing their duties. Proper attire promotes hygiene, safety, and a positive image for guests and colleagues.5. Personal Appearance & Grooming. Hair should be clean. Hair restraints that cover all the hair must always be worn when on duty. Men should wear [NAME] or, if hair is long, they also must wear hair restraints.Observation on 07/10/2026 at 8:46 AM, Dietary Aide (DA) DA3 was observed preparing a mixture of baked beans at the preparation table. A closer observation of DA3's face revealed a thick mustache and beard with bristly hair, uncovered with a beard guard. During an interview with DA3 at the time of observation, DA3 reported being unaware of the regulation that male staff 's facial hair should be covered.Interview with the Dietary Manager (DM) on 07/10/2026 at 8:41AM, the DM confirmed the deficient finding with food not being discarded within three days, food not properly dated, and dietary staff failing to ensure all hair was completely covered in a beard guard. She reported that her expectations were that staff follow all policies relating to food items.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, Medications-Administration and Preparation, the facility failed to ensure two of 24 sampled residents (R) (R25 and R30) did not have unauthorized and unsecured medications at the bedside. This deficient practice had the potential to cause adverse effects for R25 and R30 and allowed unsecured medications to be accessible to other residents and visitors.Findings include:Review of the facility's policy titled, Medications-Administration and Preparation, dated 6/30/2026, under the section titled, Procedure revealed, .8. Prepare medication for one patient at a time. Do not prepare medications ahead of time for groups of patients. Do not carry medications for several patients on top of the cart or on a tray at one time.13. Do not use the medication a patient brings with him; send them home or place with valuables to be returned when he is discharged . (Possible exception, with doctor's order.) 14. Do not leave medication at bedside unless specifically ordered by physician.1. Review of R25's electronic health records (EHR) revealed diagnoses that included, but were not limited to, disorder of the skin and subcutaneous tissue and dry eye syndrome of bilateral lacrimal glands.Review of R25's physician's orders revealed orders dated 06/11/2024 for [Name of over the counter (OTC) medication] (vit c, e-zinc-copper-lutein-zeaxan) one capsule; 250-90-40-1 (one) mg (milligram); twice a day. There were no orders for medication self-administration or to keep OTC medications at bedside.Review of R25's Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Section C (Cognitive Pattern) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition; and Section GG (Functional Abilities and Goals) documented R25 required setup or clean up assistance for toileting, supervision or touching assistance for personal hygiene, and bathing. Review of R25's EHR revealed a Self-Administration Assessment Form had not been completed to determine the resident's capability with medication self-administration.Observation and interview on 07/10/2026 at 9:24 AM revealed R25 sitting in her room in a recliner chair near a dresser. The dresser's drawer, which was within arm's reach of R25, was slightly open and one bottle of [Name of OTC medication] was observed lying in the dresser's drawer. R25 revealed that a family member brought it into her and that she was going to keep it in her room and give it to the nurses when they ran out of it on the medication cart. R25 revealed that she did not self-administer her own medications and that the nurses prepared and administered them to her. Interview on 07/10/2026 at 9:53 AM with Registered Nurse (RN) AA and RN BB, both revealed that they did not have any residents who had been assessed for medication self-administration and that there were no residents that had been authorized to keep medications at bedside.During an observation and interview on 07/10/2026 at 9:54 AM with RN AA in R25's room, she confirmed the [Name of OTC medication] in R25's dresser drawer. RN AA revealed that she was not aware that the family had brought in the medication and acknowledged that they should have given it to the nurse instead of leaving it in the resident's room. RN AA stated that they would provide education to the family and then proceeded to remove the OTC medication before exiting the room.2. Review of R30's EMR revealed diagnoses that included, but not limited to, vascular dementia and allergic rhinitis. Review of R30's Quarterly MDS assessment dated [DATE] for Sections C (Cognitive Patterns) documented a BIMS score of 13, indicating intact cognition; Section O (Special Treatments, Procedures, and Programs) documented the resident received respiratory therapy while a resident.Review of R30's physician orders dated 05/20/2025 revealed, ipratropium-albuterol solution (medication for breathing treatment) for nebulization; 0.5 milligram (mg)-3 mg (2.5 mg base)/3 milliliter (mL); one vial; inhalation twice a day dated 08/27/2025.Observation and interview on 07/10/2026 at 9:31 AM revealed R30 sitting in the room in a wheelchair. Further observation revealed a nebulizer mouthpiece sitting on bedside table, uncovered. R30 revealed that he had just completed his breathing treatment this morning, before breakfast. During the observation and interview, RN AA entered the room and discarded the nebulizer mouthpiece sitting on the bedside table and replaced it with a new one. She then opened a vial of nebulizer solution, placed it in the cannister and exited the room. After RN AA exited the room, one vial of nebulizer solution was observed on the dresser near the nebulizer machine. Interview with R30 revealed that the nurses pre-set the nebulizer treatments up for him to use when it's time for it again.During an observation and interview on 07/10/2026 at 9:58 AM in R30's room with RN AA, she confirmed she had left the nebulizer medication unattended and removed the nebulizer medication and mouthpiece. She confirmed that R30 had not been assessed to self-administer medications.During an observation and interview on 07/11/2026 at 1:00 PM with the Director of Nursing (DON), he confirmed that unauthorized medications should not be left at bedside unattended. He confirmed that the facility did not have any residents who had been assessed to self-administer their own medications and treatments.

Based on observations, staff interviews, and review of the policy titled, Resident's Federal and State Rights, the facility failed to protect the privacy and confidentiality of two of 24 sampled residents (R) (R14 and R16) personal and medical records. This failure placed R14 and R16 at risk for unauthorized disclosure of sensitive information.Findings include:Review of the policy titled, Resident's Federal and State Rights, documented under Privacy & Confidentiality-1. You have a right to personal privacy and confidentiality of your personal privacy which includes privacy in accommodations, medical treatment, written and telephone communications, personal care, visits and meetings of family and residents groups, but this does not require the facility to provide a private room. The administrator of the facility must make available at least one private place for visits during normal visitation hours, which shall be open for at least 12 continuous hours per day.5. You have a right to respect and privacy in your medical, personal, and bodily care program. Your case discussion, consultation, examination, treatment, and care shall be confidential and shall be conducted in privacy. Those persons not directly involved in your care must have your permission to be present.1. Review of the electronic medical record (EMR) revealed that R14 was admitted to the facility on [DATE] with pertinent diagnoses including, but not limited to, chronic obstructive pulmonary disease, unspecified and chronic diastolic (congestive) heart failure.Review of R14's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating that R14 was cognitively intact.Review of the Physician's Orders for R14 revealed active medication orders, including, but not limited to an order dated 08/31/2025 included Bumetanide 1 mg (milligram), to take one tablet by mouth on Monday, Wednesday, and Friday for hypertensive heart disease with heart failure and an additional orders reviewed included Clonazepam 1 mg at bedtime for anxiety disorder, unspecified; Donepezil 10 mg daily; and Eliquis (apixaban) 2.5 mg as prescribed.2. Review of the EMR revealed that R16 was admitted to the facility on [DATE] with pertinent diagnoses including, but not limited to, hypertensive heart and chronic kidney disease with heart failure and stage 1-4 chronic kidney disease, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.Review of R16's quarterly MDS assessment dated [DATE] revealed a BIMS score of 12, indicating moderate cognitive impairment.Review of the Physician's Orders for R16 revealed active medication orders including Clonazepam 1 mg (milligram, a unit of measurement indicating the amount of medication administered) to be taken at bedtime for anxiety disorder, unspecified; Donepezil 10 mg (ten milligrams) to be taken every day; and Eliquis (apixaban) 2.5 mg (two and a half milligrams*) as prescribed for anticoagulation management.Observations on 07/10/2026 at 7:35 AM noted that no staff member was present at the medication cart, where two computer screens were open and unlocked, displaying R14's and R16's personal and medical information. Continued monitoring showed Registered Nurse (RN) BB returning to the cart while both screens remained unlocked and visible, after which RN BB again walked away, leaving the confidential information exposed.Interview and observation on 07/10/2026 at 7:55 AM, with RN BB, confirmed that the computer screens were unlocked and that residents' medical information was visible to the public. RN BB acknowledged that resident medical information must be protected at all times and agreed that computer screens should be locked prior to walking away.Interview on 07/12/2026 at 11:30 AM with the Director of Nursing (DON), in the presence of the Administrator, revealed that all computer screens must be locked and must not display residents' personal or medical information when unattended. The DON stated that it is his expectation that staff lock the screen before leaving it unattended. The Administrator concurred.

Based on staff interviews, record review, and review of the facility policy titled, Pre-admission Screening and Resident Review (PASRR) Policy Level I and Level II, the facility failed to ensure one of two residents (R) (R6) reviewed with a serious mental disorder was referred for a Level II PASARR assessment on admission or within 30 days of a new diagnosis. This deficient practice had the potential to affect the appropriate level of care and services provided for R6.Findings include:Review of the facility policy titled, Pre-admission Screening and Resident Review (PASRR) Policy Level I and Level II, with origination date July 11, 2026, documented under Policy Level I and Policy Level II-Policy: It is the policy of [NAME] Nursing Home to comply with all federal and Georgia requirements regarding Pre-admission Screening and Resident Review (PASRR). All individuals seeking admission to the facility will receive the appropriate [NAME] screening prior to admission to determine whether the individual may have a serious mental illness (SMI), intellectual disability (ID), or related condition and whether further evaluation is required. The facility will screen before admission an individual requiring a [NAME] Level II evaluation until the appropriate evaluation and determination have been completed, except when admission is permitted under an applicable federal or state exemption or categorical determination. PURPOSE: To ensure that all applicants and residents are appropriately screened and evaluated to determine: 1. Whether the individual has or is suspected of having a serious mental illness, intellectual disability, or related condition; 2. Whether nursing facility services are appropriate for the individual; and 3. Whether specialized services or additional supports are required.1. Review of the electronic medical record (EMR) revealed R6 was admitted to the facility on [DATE] with pertinent diagnoses, including, but not limited to, depression, unspecified; other bipolar disorder; and anxiety disorder, unspecified.Review of R6's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating R6 had moderate cognitive impairment.Review of R6's physician orders revealed the following medications: Chlordiazepoxide 15 mg (milligrams) (QD (once daily)-& 10 mg HS (at bedtime), Depakote ER (extended release) 250mg BID (twice daily) for bipolar, and Olanzapine 5 mg QD and 7.5 mg HS.Review of R6's care plan dated 08/11/2025 indicated the following:Problem: Resident has the potential to grieve and/or become depressed or withdrawn due to loss of outside independence. The resident's well being and activity participation level has the potential to be affected secondary to history of TBI (traumatic brain injury), need for assistance with activities and ADLs (activities of daily living)/mobility, and poor short term memory. Residents participate in facility activities without concern at this time.Goals included but were not limited to: Resident will participate in activities of choice during the review period.Interventions/Approaches included but were not limited to: Encourage family visits. Offer outside enjoyment as accepted by the resident when weather permits. Provide assistance as needed. Post calendar of events for resident/family viewing; give verbal reminders and encourage participation. Provide in room [ROOM NUMBER]:1 (one to one) activities as needed. Encourage resident to come out of the room as tolerated for interaction and socialization. Observe for changes in the resident's desire to participate in activities or socialization.Problem: Resident has verbal behavioral symptoms directed toward others (e.g., yelling/cursing). Resident has been noted to aggressively yell and curse at staff at times.Goal: Resident will not threaten, scream at, or curse at other residents, visitors, and/or staff.Approaches/Interventions: When the resident becomes verbally abusive, move them to a quiet, calm environment. Administer medications as ordered; monitor and record effectiveness. Report any adverse side effects. Avoid over stimulation (e.g., noise, crowding, presence of other physically aggressive residents). Maintain a calm environment and use a calm approach when interacting with the resident.Interview on 07/11/2026 at 12:45 PM with the Admissions Coordinator confirmed that R6 should have had a PASRR Level II completed due to his diagnosis. She confirmed that she should have looked more closely at the diagnoses when entering the resident into the facility system. The Admissions Coordinator stated that she would complete a PASRR Level II for R6.Interview on 07/02/2026 at 11:25 AM with the Director of Nursing (DON), in the presence of the Administrator, confirmed that a PASRR Level II should have been submitted for R6. The DON stated that the facility should not have relied solely on the hospital's PASRR Level I and that a follow up review should have been completed to ensure the resident did not qualify for a PASRR Level II, and the Administrator concurred.

Based on observations, record review, staff interviews, and review of the facility's policy titled, Resident Nursing Care Plans, the facility failed to follow the care plan related to providing oxygen as ordered for one of 24 sampled residents (R) (R43) reviewed for oxygen administration. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs and a diminished quality of life.Findings include: A review of facility policy titled, Resident Nursing Care Plans, dated 3/1/2026 under the section titled, Policy revealed, A resident's Care Plan identifies problems and/or needs that are evidenced through an interdisciplinary team as well as the resident and/or family member (s). With proper representation from all members, the goals are identified, and time limits are set so that goals are measurable and realistic. Specific approaches are given for each individual goal including the care and services that must be provided to reach the limits set. Review of R43's electronic medical record (EMR) revealed diagnoses that included, but not limited to, chronic obstructive pulmonary disease (COPD) and paroxysmal atrial fibrillation. Review of R43's Quarterly Minimum Data Set (MDS) assessment dated [DATE], for Sections C (Cognitive Patterns) documented a Brief Interview of Mental Status (BIMS) score of 10, indicating moderate impaired cognition; Section J (Health Conditions) documented, shortness of breath (SOB) or trouble breathing when lying flat; and Section O (Special Treatments, Procedures, and Programs) documented R43 received oxygen therapy while a resident. Review of R43's physician orders dated 2/17/2026 for humidified oxygen (O2) at 2 liters per minute (L/M) via nasal cannula (N/C) continuous every shift. Review of R43's care plan, dated 03/02/2026, revealed R46 requires oxygen therapy R/T (related to) COPD with interventions that included administer oxygen as ordered. Observation on 07/10/2026 at 9:16 AM revealed R43 receiving O2 at 3 L/M via N/C from the O2 concentrator. Observation on 07/10/2026 at 11:50 AM revealed R43 was receiving O2 at 3L/M via N/C from the O2 concentrator. Interview on 07/11/2026 at 12:00 PM with Registered Nurse (RN), MDS Coordinator, revealed she was responsible for ensuring residents had care plans. She confirmed that R43 had a care plan to administer oxygen as ordered. She reported that her expectations of staff was to follow care plans as directed. Cross Reference F695

Based on observations, staff interviews, record review, and review of the facility's policy titled, Respiratory Devices Nebulizer Treatments, the facility failed to follow the physician's order for the administration of oxygen (O2) for one Resident (R) (R43) and failed to prevent the spread of infections by not cleaning the O2 concentrators for three of 12 residents (R36, R40, and R43) receiving O2 therapy. The deficient practice had the potential to place the residents at risk for medical complications, unmet needs, and a diminished quality of life.Findings include: Review of the facility's policy titled, Respiratory Devices Nebulizer treatments, dated 5/1/2026 revealed, the following are measures used to prevent respiratory tract infections: under the section titled, 1. General Measures revealed, a. Thoroughly clean all equipment before sterilizing or disinfecting the equipment weekly and PRN. 2. Small-Volume Medication Nebulizers: In-Line and Hand-Held Nebulizers revealed, a. Disinfect, rinse and air dry small-volume medication nebulizers, between treatments on the same patient. 1. Review of R43's Electronic Medical Record (EMR) revealed diagnoses that included, but not limited to, chronic obstructive pulmonary disease (COPD) and paroxysmal atrial fibrillation. Review of R43's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed, Sections C (Cognitive Patterns), a Brief Interview of Mental Status (BIMS) score of 10, indicating moderate impaired cognition; Section J (Health Conditions) documented, shortness of breath (SOB) or trouble breathing when lying flat; Section O (Special Treatments, Procedures, and Programs) documented, received oxygen therapy while a resident.Review of R43's physician orders dated 02/17/2026 revealed, for humidified oxygen (O2) at 2 liters per minute (L/M) via N/C continuous every shift.Observation on 07/10/2026 at 9:16 AM revealed R43 receiving O2 at 3L/M via N/C from the dirty O2 concentrator covered with dust (white and grayish debris). Observation on 07/10/2026 at 11:50 AM revealed R43 receiving O2 at 3L/M via N/C from the dirty O2 concentrator covered with dust (white and grayish debris). 2. Review of R36's EMR revealed diagnoses that included, but not limited to, acute on chronic diastolic (congestive) heart failure and chronic obstructive pulmonary disease, unspecified.Review of R36's Annual MDS assessment dated [DATE] revealed in Sections C, a BIMS score of 10, indicating moderately impaired cognition; Section J documented shortness of breath (SOB) or trouble breathing when lying flat; Section O documented oxygen therapy was received while a resident.Review of R36's physician orders dated 7/22/2025 revealed humidified O2 at 3 L/M via N/C continuous dated 1/13/2025.Observation on 07/10/2026 at 9:03 AM revealed R36 receiving O2 at 3L/M via N/C from the dirty O2 concentrator covered with dust (white and grayish debris). Observation on 07/11/2026 at 9:31 AM revealed R36 receiving O2 at 3L/M via N/C from the dirty O2 concentrator covered with dust (white and grayish debris). Observation on 07/11/2026 at 9:45 AM revealed Registered Nurse (RN) AA entered R36's room to change the humidifier bottle and O2 tubing. She removed and replaced the humidifier bottle and tubing attached to the dirty O2 concentrator and exited the room.3. Review of R40's EMR revealed diagnoses that included, but not limited to, allergic rhinitis due to pollen. Review of R40's Quarterly MDS assessment dated [DATE] revealed Section C documented a BIMS score of 12, indicating moderately impaired cognition; Section O documented respiratory therapy was received while a resident.Review of R40's physician orders dated 1/15/2026 revealed an order for O2 at 2 L/M via N/C every shift.Observation on 07/10/2026 at 1:54 PM revealed R40 receiving O2 at 2 L/M via N/C from the dirty O2 concentrator covered with dust (white and grayish debris). Observation on 07/11/2026 at 9:34 AM revealed R40 receiving O2 at 2 L/M via N/C from the dirty O2 concentrator covered with dust (white and grayish debris). Observation and interview on 07/11/2026 at 11:30 AM with the Director of Nursing (DON) confirmed R36, R40, and R43's oxygen concentrators were dirty, in addition to R43's oxygen setting set at 2.5 L/M. The DON confirmed R43's oxygen was set at 3 L/M and that the oxygen concentrator was dirty. The DON revealed that R43's oxygen should have been set at 2L/M as ordered. He further revealed the nurses were responsible for making sure oxygen was administered as ordered and cleaning the oxygen concentrators weekly and as needed.During an observation and interview on 07/11/2026 at 11:38 AM with RN AA, R43's oxygen orders were reviewed and RN AA verified that R43 was ordered humidified O2 at 2 L/M via N/C, as needed (PRN) for SOB. She revealed that R43 was physically not able to adjust the oxygen settings herself nor did she have a history of changing it. She confirmed R36, R40, and R43's O2 concentrators were dirty and that R43's oxygen was set at 2.5 L/M. RN AA also confirmed R36, R40, and R43's concentrators were dirty. Cross Reference F656

Based on observation, staff interviews, record review, review of the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHREA) and Centers for Disease Control and Prevention (CDC) guidelines, and review of the facility document titled, Water Management Program for [NAME] County Nursing Home, the facility failed to have an adequate water management program. The facility's water management program was incomplete and was not consistent with the current ASHRAE Guideline, which specifically called for design and maintenance procedures for the potential exposure of Legionnaires' disease (a serious pneumonia infection) within a healthcare facility. This failure created the potential for the facility residents to be infected by Legionella. Findings include: Review of a website for ASHRAE titled Successfully Managing the Risk of Legionellosis dated 4/7/2021 indicated . Legionellae the biological classification name for a [NAME] of bacteria.is the plural, referring to more than one Legionella bacterium.Legionellosis: any illness (disease) caused by the exposure to Legionella. Legionnaires' disease (LD) and Pontiac fever (PF) are the two known types of legionellosis.Potentially fatal, multisystem respiratory illness, accompanied by pneumonia.Symptoms.high fever, chills, muscle pain, headache, dry cough, diarrhea, vomiting, confusion, and delirium common.Immune suppressed.transplant patients, cancer, cardiac, diabetes, steroid/drug therapy.Sick/in poor health. Elderly/infirm.Heavy smokers, lung/COPD diseases.Describe the building water systems using flow diagrams & a written description: Include details such as where the building connects to the (municipal) water supply, how water is distributed and used (processed), where hot tubs, water heaters, cooling towers, etc. are located. Review of the CDC website titled Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings, dated 6/24/2021, indicated . Describe the building water systems using text and flow diagrams. Identify areas where Legionella could grow and spread. Review of a facility document titled Water Management Program for [NAME] County Nursing Home, dated 5/28/2024, indicated . Identified Risks: Water shortages due to drought or municipal supply issues. Contamination risks from plumbing systems. Inefficient fixtures leading to water wastage. Increased costs due to water leaks or infrastructure issues. The document failed to address the facility's water system in text and a diagram which would then identify the areas of the facility's water system which were potential locations for the development of Legionella and other water pathogens. The document failed to address what control measures would be implemented and failed to identify how the facility would then monitor the control measures. Finally, the document did not indicate how the facility would document their efforts to maintain an effective water management plan/program. During an interview on 4/3/2025 at 9:31 am, the Maintenance Director stated the facility tested for Legionella and conducted a risk assessment. When asked if the facility had a water management plan, the Maintenance Director stated he tests all resident rooms for temperatures, and this was done on a weekly basis. The Maintenance Director stated there have been no Legionella outbreaks. During an interview on 4/3/2025 at 10:00 am, the Director of Nursing (DON) stated the facility did not have a water management plan, and his expectation was to follow CDC guidance.

Based on staff interviews, record review, and review of the facility policy titled, Reference 8: Behavior Monitoring Procedure, the facility failed to ensure that three of five residents (R) (R17, R21, and R40) sampled for unnecessary medications were monitored for behaviors, side effects and efficacy of antipsychotic medications. This failure to monitor for adverse effects and efficacy had the potential to place R17, R21, and R40 at risk of medical complications and unmet needs. Findings Include: Review of the facility's undated policy titled, Reference 8: Behavior Monitoring Procedure, revealed 1. Each MAR (Medication Administration Record) will have three major lines (one for each shift), with four subdividing minor lines within each major line. 2. Inside the frequency column of each minor line will have directions. a. Line 1-will indicate the shift. This is where the nurse will enter her initials. b. Lines 2-4 will state Behaviors =__. In the blank, a number is to be entered, that corresponds to a behavior listed to side the side .Each shift will have room for 3 different behaviors to monitor, if needed. If an occasion arises when more than 3 behaviors need to be monitored, please use the next available blank space on the MAR .Side Effect Monitoring: 1. The nurse will indicate Y for yes and N for no, beside the appropriate shift and under the appropriate day, to indicate if a side effect is observed. 2. If a Y is entered beside that nurse's shift, then a corresponding number to describe the side effect is entered on the minor line that states 'S. E.' Review of a Food and Drug Administration (FDA) website titled https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/020592s052,021086s031,021253s037lbl.pdf, indicated . Elderly Patients with Dementia-Related Psychosis: Increased risk of death and increased incidence of cerebrovascular adverse events (e.g., stroke, transient ischemic attack).close supervision of high-risk patients should drug therapy. Hyperglycemia: In some cases, extreme and associated with ketoacidosis or hyperosmolar coma or death, has been reported in patients taking olanzapine (Zyprexa). Patients taking olanzapine should be monitored for symptoms of hyperglycemia and undergo fasting blood glucose testing at the beginning of, and periodically during, treatment. Hyperlipidemia: Undesirable alterations in lipids have been observed. Appropriate clinical monitoring is recommended, including fasting blood lipid testing at the beginning of, and periodically during, treatment. Weight Gain: Potential consequences of weight gain should be considered. Patients should receive regular monitoring of weight. 1. Review of R17's electronic medical record (EMR) titled Resident Face Sheet located under the Resident tab indicated the resident was admitted to the facility on [DATE]. Review of R17's EMR quarterly Minimum Data Set (MDS) located under the RAI (Resident Assessment Instrument) tab with an Assessment Reference Date (ARD) of 3/11/2025 indicated the resident's Brief Interview for Mental Status (BIMS) score of three out of 15 which revealed the resident was severely cognitively impaired. The assessment indicated the resident had no behaviors. Review of R17's Care Plan located under the RAI tab, dated 1/22/2024, indicated the resident was on an antipsychotic, and it was used for dementia with behavioral disturbances. The care plan indicated there was a potential for the resident to experience intolerance and/or adverse side effects and had no identified problems at this time. The approach was to administer the resident's medications as prescribed, to observe the effectiveness of the treatment, and to monitor adverse side effects. Review of R17's EMR titled Orders located under the Resident tab, dated 8/7/2024, indicated that the physician ordered Zyprexa one tablet, 10 milligrams (mg), to be administered twice a day at 9:00 am and 5:00 pm. Review of R17's EMR titled Medications Administration History, located under the Resident tab, dated 2/1/2025 through 4/2/2055 indicated the resident was administered Zyprexa for depression. Review of R17's EMR titled General Administration History, located under the Resident tab, dated 2/1/2025 through 4/2/2025, indicated the facility was monitoring the following behaviors: yelling, biting, scratching, refusal of care, spitting, cursing, and other abnormal behaviors. There were no specific targeted behaviors identified with R17's diagnosis of depression and the associated use of Zyprexa. In addition, there was no evidence the facility was monitoring the side effects from the use of an antipsychotic. During an interview on 4/2/2025 at 1:34 pm, the Director of Nursing (DON) stated that the behaviors of residents who were on psychotropic medication were to be documented at the end of the shift, and the behavior was to be documented whether it was observed or not. He said that the effectiveness was to be documented, as well as any side effects. 2. Review of R21's undated Face Sheet located in the EMR under the Face Sheet tab indicated the resident was initially admitted to the facility on [DATE], with a readmission on 2/24/2025. The resident had diagnoses of Parkinson's disease, Asperger's syndrome, schizophrenia, bipolar disease, and anxiety. Review of R21's quarterly MDS, with an (ARD) of 3/20/2025, located in the EMR under the MDS tab, revealed the resident had a BIMS score of 15 out of 15, which indicated the resident is cognitively intact. R21 did not exhibit any behavior during the seven-day look-back period. Review of R21's Orders located in the EMR under the Orders tab revealed the following orders: duloxetine (selective serotonin reuptake inhibitors (SSRIs) for anxiety disorder, start date10/1/2021; Geodon (antipsychotic) for schizophrenia, start date 9/1/2022; hydroxyzine pamoate (antihistamine, sedative) for anxiety disorder, start date 12/30/2021, and Target Behavior: Monitor for yelling, biting, scratching, refusal of care, spitting, cursing and other abnormal behaviors, start date 10/1/2021, this order was not for specific medications. There was no order for the monitoring of adverse reactions for specific medications. Review of R21's Medications Administration History for January 2025, February 2025, and March 2025, located in the EMR under the Reports tab, indicated that although the facility is monitoring for behaviors. These behaviors were not specific to each medication ordered for different psychiatric behaviors. Additionally, there was no monitoring of the medication's adverse effects and efficacy. 3. Review of R40's undated Face Sheet located in the EMR under the Face Sheet tab indicated the resident was admitted to the facility on [DATE], with diagnoses including dementia, with severe agitation, and depression. Review of R40's quarterly MDS with an ARD of 3/25/2025, located in the EMR under the MDS tab, revealed the resident had a BIMS score of three out of 15, which indicated the resident was severely cognitively impaired. R40 was assessed as exhibiting delusions (misconceptions or beliefs that are firmly held, contrary to reality) but did not exhibit any other behaviors during the seven-day look-back period. Review of R40's Orders located in the EMR under the Orders tab, revealed the following orders: mirtazapine (anti-depressant) for depression, start date 9/7/2024; sertraline (anti-depressant) for depression, start date 9/7/2024; trazodone (anti-depressant) for insomnia, start date 12/13/2024; and Target Behavior: Monitor for yelling, biting, scratching, refusal of care, spitting, cursing and other abnormal behaviors, start date: 10/1/2021. This order was not for specific medications. There was no order for the monitoring of adverse reactions for specific medications. Review of R40's Medications Administration History for January 2025, February 2025, and March 2025, located in the EMR under the Reports tab, indicated that although the facility was monitoring for behaviors. These behaviors were not specific to each medication ordered for different psychiatric behaviors. Additionally, there was no monitoring of the medication's adverse effects and efficacy. During an interview on 4/2/2025 at 3:13 pm, the Director of Nursing (DON) confirmed the General Order, under Order Description, revealed Target Behavior: Biting, pinching, hitting, disruptive behaviors, or refusal of care. At the end of each shift mark Frequency-how often behavior occurred & intensity-how resident responded to redirection. Intensity Code: 0=Did not occur; 1=Easily altered; 2=Difficult to redirect was a blanket order for monitoring behaviors for all psychiatric medications. The DON also confirmed there was no monitoring for adverse side effects or efficacy of medications. During an interview with the Pharmacist on 4/3/2025 at 9:16 am, the Pharmacist was asked what his expectations were related to psychiatric medications and the monitoring of the resident's behaviors, adverse reactions, and efficacy for each medication. The Pharmacist responded that monitoring needs to be precise on what behaviors that are particular to the residents, adverse effects, and efficacy specific to the medications ordered. The Pharmacist added that in the past, there have been behaviors with associated numbers to indicate what behavior was being exhibited. Additionally, there should be a list of side effects for anti-psychotics and psychotropic medications. The Pharmacist was asked if he was aware of the facility not documenting the monitoring. The Pharmacist responded that he assumed they were monitoring for the behaviors, side effects/adverse reactions, and efficacy. During an interview on 4/3/2025 at 9:20 am, during medication pass, Registered Nurse (RN) 1 was asked if she had a resident on an antipsychotic that had a behavior or side effect where this would be documented. RN1 responded that she was unsure but would always document it in the nurse's notes. RN1 was asked how she knew the resident needed this medication (antipsychotic) and how she knew if it was effective. RN1 stated that she documented behavior daily. When asked if it was specific to the class of medications, RN1 stated it was just a general observation with a blanket list.

Based on observations, staff interviews, record review, and review of the facility policies titled, titled, Medications - Administration and Preparation and Policy and Procedure for Expired Drugs, the facility failed to ensure one of six residents (R) (R7) observed during medication pass medications were not expired. This deficient practice increased R7's risk of infection and exacerbation of R7's compromised respiratory status related to chronic obstructive pulmonary disease. Findings include: Review of facility-provided policy, revised 04/22/2024, titled, Medications - Administration and Preparation revealed . 15. check all medications .for expiration dates. Review of a facility-provided policy, reviewed and approved dated 04/22/2024, titled, Policy and Procedure for Expired Drugs, revealed, .During each medication pass, it is the nurse's responsibility to check medication labels for expiration dates, before dispensing drug.3. Any expired drugs will be removed from medication chart and be re-ordered . Review of R7's undated Admission Record found in the electronic medical record (EMR) under the Profile Tab revealed an admitted [DATE], with diagnoses including unspecified systolic (congestive) heart failure and chronic obstructive pulmonary disease (COPD). Review of R7's Physician's Orders under Orders tab located in the EMR revealed an order for fluticasone propionate [over the counter (OTC)] spray suspension 50 microgram (mcg) /actuation; (amount) one spray each nostril; nasal special instructions: Instill one spray each nostril daily for allergies. Once a day at 9:00 am. The order was written on 8/15/2024 and dispensed to the facility on [DATE]. Further review revealed an order for Refresh Tears (carboxymethylcellulose sodium) [OTC] drops; 0.5 %; amt: 1 drop each eye; ophthalmic (eye). Special Instructions: Apply one drop into each eye PRN [as needed] dry eye syndrome as needed. During an observation of the medication pass on 4/3/2025 at 9:58 am with Registered Nurse (RN) 1, for R7, two medications were identified as expired. 1) Fluticasone propionate OTC spray suspension was identified as dispensed and began use on 11/15/2024 without an open date and without an expiration date. 2) Refresh Tears was identified as dispensed on 2/10/2025 and expired on 3/24/2025. RN 1 verified the dates on the medications. In an interview on 4/3/2025 at 12:25 pm, the Director of Nursing (DON) stated the expectation was for no expired medications ot be on the medication carts. The DON stated that expired nasal and ophthalmic drops could increase the risk of infections.

Based on staff interview, record review, review of the facility policy titled Immunizations, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer one of five residents (R) (R28) reviewed for flu and pneumonia vaccinations and/or their representatives the opportunity for the residents to be vaccinated in accordance with nationally recognized standards of 44 sample residents. In addition, the facility failed to update their immunization to reflect current CDC recommendations. These deficient practices had the potential to place R28 at risk of contracting pneumonia and other residents at risk of not being offered immunizations based on current CDC guidelines. Findings include: Review of the facility policy titled Immunizations, dated 5/22/2024, indicated .To provide guideline for administering Pneumococcal Vaccine - PCP13 (Previnar) [sic] pr PPSV23 (Pneumovacc) [sic]. Review of the CDC website titled, https://www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/index.html, dated 10/26/2024, indicated .Based on shared clinical decision-making, adults [AGE] years or older have the option to get Prevnar 20 (PCV20) or PCV21, or to not get additional pneumococcal vaccines. They can get PCV20 or PCV21 if they have received both . PCV13 (but not PCV15, PCV20, or PCV21) at any age and .PPSV23 at or after the age of [AGE] years old. Review of R28's electronic medical record (EMR) titled Resident Face Sheet, located under the Resident tab, indicated the resident was admitted to the facility on [DATE]. The resident was over the age of 65 at the time of her admission. Review of R28's EMR titled Vaccination, located under the Resident tab, failed to indicate if the resident received any pneumococcal vaccination(s). There was no evidence that R28 had been offered the opportunity to be vaccinated with one dose of PCV20 or PCV21 after the final pneumococcal vaccination. Review of a document provided by the facility titled Georgia Registry of Immunization Transactions and Services indicated R28 received the Pneumovax 23 on 7/15/2010 and received the PCP13 on 12/8/2015. During an interview on 4/2/2024 at 8:30 am, the Director of Nursing (DON) stated the state had an online system that informed him that R28's pneumococcal vaccines were complete. The DON stated that the state online system did not have updated CDC guidance for the current recommendations. The DON stated it was important to follow CDC recommendations for the pneumococcal vaccines. During an interview on 4/3/2025 at 10:38 am, the Administrator stated the facility missed identifying current CDC recommendations and applying the recommendations to the current facility policy.

Based on observations, interviews, and policy review, the facility failed to ensure that opened food items were labeled and dated in two walk-in refrigerators, the walk-in freezer, and the dry storage area. The facility census was 46, with 44 residents receiving an oral diet. Findings include: A review of facility policy, Labeling, Dating, and Storage, revised 1/8/21, revealed food items, once opened, would be stored in their original packaging or wrapped tightly with film and/or foil and clearly labeled with the name of the item and the date opened. A further review revealed that opened refrigerated items would be labeled and dated. An observation on 3/17/23 at 8:10 a.m. of the walk-in refrigerator #1 revealed a plastic container with approximately five pickles. The container was unlabeled and undated. An observation on 3/17/23 at 8:18 a.m. of the walk-in refrigerator #2 revealed a box of breakfast sausage. Inside the box was an opened bag of breakfast sausage that had not been labeled or dated with an opened date. Additionally, the breakfast sausage was in an unsealed bag, and the breakfast sausage was exposed to the open air. An observation on 3/17/23 at 8:21 a.m. of the walk-in freezer revealed an opened bag of breaded okra, onion rings, and French fries that were unlabeled and undated. A further inspection revealed a box of (name) Steak Patties. Inside the box was an opened bag of steak patties that were unlabeled and undated. The bag was unsealed, and the steak patties were exposed to the open air. A box of (name) Beef Patties revealed an opened bag of beef patties, which was unlabeled and undated. The beef patties were unsealed and exposed to the open air. A box of (name) Skinless Boneless Breasts revealed a bag of boneless breasts that was opened, unlabeled, and undated. The breasts were unsealed and exposed to the open air. An observation on 3/17/23 at 8:23 a.m. of the dry storage area revealed an opened 32-ounce bag of (name) Brownie Mix and an opened 2-pound bag of (name) enriched noodles, which were not labeled or dated. During an interview with Dietary Manager (DM), on 3/17/23 at 8:02 a.m., she acknowledged that the dry storage, refrigerators, and walk-in freezer items were not labeled and dated after they were opened. The DM explained she expected staff to label and date things after opening. She added that she also expected staff to seal opened items, so they were not exposed to the open air.

Based on staff interviews, record review, and review of policy titled Bed Holds During Hospital Stays and Therapeutic Leaves, the facility failed to provide written documentation of bed hold to resident/family upon discharge to hospital for one of eight residents (R# 2) who was transferred to the hospital. Policy on Bed Holds During Hospital Stays and Therapeutic Leaves last revised 1/20/23: 1. Hospital stays: Medicaid will provide payment to hold the Resident's bed for a period of seven days while the Resident is hospitalized . List of transfers December 2022 through March 2023 indicated eight residents had been transferred during the identified time period. Electronic record review for R#2 revealed hospital leaves on 12/22/22 and 3/14/23. Review of the electronic medical record and the hard chart record did not reveal any evidence of the resident/family being notified in writing of the bed hold policy. During interviews on 3/17/23 at 10:55 a.m. with Licensed Practical Nurse (LPN) AA, LPN BB, and LPN CC who all reported that when a resident has to go out to the hospital there are specific documents that must be completed and sent to the hospital with the resident which included a face sheet, labs, and Health and Physical. LPN BB reported that if a bed hold is needed the Director of Nursing (DON) or Assistant Director of Nursing (ADON) will provide the document to the resident before exiting the facility to the hospital (even on night shift). LPN CC reported that the Office Manager probably would handle bed hold notification because that is not something that she would do but is aware that there is a seven day bed hold. Interview was conducted with the Office Manager on 3/18/23 at 12:55 p.m. who provided a blank copy Notice of Transfer or Discharge. She reported that nursing should be providing this document to the residents at the time of transfer. During a subsequent interview with LPN AA on 3/18/23 at 1:00 p.m. she acknowledged that she was the nurse on duty at the time that R#2 was discharged to the hospital on 3/14/23. LPN AA denied being educated to use the Notice of Transfer or Discharge document. LPN BB and LPN CC also denied being educated to use the Notice of Transfer or Discharge form that included bed hold information. During an interview on 3/19/23 at 11:58 a.m. with the Administrator, DON, and Administrator in Training, bed hold notification was discussed. The Administrator reported that bed hold is discussed during the admissions process at the facility and the Education nurse will provide education to the nursing staff moving forward. The DON reported that family members are typically notified via telephone call if a resident is admitted to the hospital. However, she acknowledged that the Admin Team (which consists of the Office Manager, Social Worker, and the Clinical Manager) was responsible for training nursing staff about the bed hold policy requirements.

Based on record review and staff interviews, the facility failed to ensure that the staff designated as Dietary Manager (DM) was a Certified Dietary or Food Service Manager or had a similar food service management certification or degree. This had the potential to affect 37 residents receiving an oral diet. Findings include: Review of the job description in the employee file of the DM documented Food Service Manager (FSM) and did not indicate the requirement of a certification. During a tour of the kitchen and interview on 8/31/21 at 11:21 a.m., the DM revealed his present food certification status as ServSafe certified and not certification as a Certified Dietary Manager. He stated that he is enrolled in a CDM course but could not provide a start date or a target date for completion of the CDM certification course. Review of the employee file for the DM revealed a hire date of March 2021. Record review of the DM's resume revealed no certification or education degree in culinary art or any other food service management degree. During an interview on 9/2/21 at 12:10 p.m., the Administrator verified that the current DM was not certified. The Administrator reported she figured the (contracted agency) had ensured certification of the DM prior to the hire date. Telephone interview on 9/2/21 at 10:58 p.m. with the consulting Registered Dietician revealed she is a consultant for the hospital and the nursing home. She is not full-time and only works 8 to 10 hours weekly for the nursing home.

Based on observations and staff interviews, the facility failed to maintain the cleanliness of one ice machine, label and date food items, discard expired food, prepare food in a sanitary manner, store food to prevent food borne illness, maintain a pest free environment, and ensure staff wear hair nets appropriately while in the kitchen. This had the potential to effect 37 residents that received an oral diet. Findings include: During the initial walk-through of the kitchen with the Dietary Manager (DM) on [DATE] at 9:29 a.m. through 10:33 a.m., the following concerns /issues were observed: 1. Observation of the ice machine revealed sticky dark watery brown substances on the inside panels of the ice machine. At the time of the observation, (the DM wiped the inside panel with a white cloth), the DM identified the substances as mildew. The DM could not provide a log date for the cleaning schedule for the ice machine. Record review showed the ice machine was cleaned on [DATE]. 2. Observation of Refrigerator #1 revealed five ham sandwiches contained in a Ziploc bag, with no open date and no expiration date. 3. Observation of preparation counter located at the rear of the kitchen revealed a block of butter in a small plastic container exposed with no lid or covering. Further observation revealed a fly swarming around kitchen area near the butter. 4. Observation of food preparation counter attached to the vegetable and meat sink, revealed Dietary Aide (DA) BB making salad trays for lunch. Closer observation revealed a pan of lettuce uncovered on the counter, and a fly swarming around the pan. An open garbage can (with no lid) filled with trash was also positioned next to the preparation counter. 5. Observation of the flour bin revealed a scoop covered with dried clumpy flour laying on top of the lid of the bin. Further observation revealed a fly swarming around the bin and the scoop. 6. Observation of the walk-in-cooler revealed the following food items outside of the expiration dates: a large pan of macaroni salad expiration date [DATE] and a large pan of chicken salad expiration date [DATE]. 7. Observation of the dry food pantry revealed the following: a large plastic gallon container of rice sitting on a shelf with no covering for the lid. Further observation revealed no label to show open date and expiration date. A roach was also observed crawling on the floor in the pantry. 8 Observation revealed DA BB and DA CC at the food counter prepping food. A closer observation revealed both DA BB and DA CC wearing hair nets that cover only the middle section of their head leaving the back of their hair exposed and hanging. During an interview on [DATE] at 9:55 a.m., the DM reported that all food items should be labeled and dated within a four days' time frame. DM reported that his expectations are for food to be discarded based on expiration dates. Food items should be sealed and closed. DM reported that it is the responsibility of dietary staff to check and monitor the refrigerator to ensure all food is properly stored and labeled. DM further confirmed and verified that two of his dietary aides' hair were not contained in the hair net. During an interview on [DATE] at 10:01 a.m., DA BB reported being knowledgeable of the hair net policy. DA BB failed to recheck the placement of her hair net to ensure that all her hair was contained in the hair net. DA BB verified receiving training on food labeling, dating, and storage. She reported that all expired food should be discarded after four days. During an interview on [DATE] at 9:59 a.m., DA CC reported that she was aware her hair was not contained in her hair net. She was aware of the policy and verified receiving training on discarding of expired food after five days, food labeling, dating, and storage.

Based on observation, record review, staff interviews, and review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Plan, the facility failed to implement corrective action plans that effectively addressed kitchen concerns including discarding expired food items and appropriately wearing hairnets in food preparation areas. The census was 37 residents. Findings include: Review of the facility policy titled QAPI Plan revised [DATE] revealed: Purpose - all staff will participate in ongoing QAPI efforts which support our mission to enhance quality of life. Performance Improvement Projects - the QAPI team will review sources of information to determine if gaps or patterns exist in our systems that could potentially result in quality-of-care issues or if there are opportunities for improvement. QAPI Goals - the nursing home supports performance improvement by encouraging each staff member to be accountable for their own professional performance and practice. Observations of the kitchen on [DATE] at 9:45 a.m. through 10:30 a.m. revealed expired food items in the cook's cooler and dietary staff inappropriately wearing hair nets. Review of facility daily audit tool titled Audit of Expired foods and Dry storage revealed audits were completed for the months of September, October, and the beginning of [DATE]. There was no indication on any of the audits reviewed that any food items were expired or that any food item had been removed from the storage areas. Review of facility QAPI Sign- Sheet dated [DATE] revealed no indication of results of monitoring that was conducted by the dietary staff. Further review revealed no evidence that any member from the dietary department participated in the QAPI meeting. Interview on [DATE] at 12:00 p.m. with the Chief Executive Officer (CEO) revealed that currently they do not have a CDM (Certified Dietary Manager) on staff full time, but there is one candidate that is already certified that they are hoping to employ. Currently there are two Registered Dieticians that are in the facility at least 32 hours a week for consultation. Further interview revealed that it was his expectation that the dietary department participate in the QAPI process monthly and to make the changes that are needed to be in compliance. Interview on [DATE] at 1:24 p.m. with Cook AA revealed the daily audits are conducted twice a day in the morning at the beginning of the shift and in the evening at the end of the shift. During the audit all food items are checked for expiration dates and if there are any foods that are expired, they are discarded at that time. Further interview revealed that an audit was completed on [DATE] and the noted expired food items were not seen during the audit that was completed on that day. Continued interview also revealed that there was not an audit completed on [DATE] at the beginning of the shift. Interview on [DATE] at 1:52 p.m. with the Kitchen Supervisor revealed that the cook on duty for the day is responsible for checking the food in the cook's cooler for expiration dates at the beginning of their shift and are to document if there are any food items that are expired and remove them from the storage area. She stated she had not attended a QAPI meeting and had no knowledge of whether the Dietary Manager attended the meeting. Interview on [DATE] at 2:24 p.m. with the Administrator revealed that there was no documentation that indicated that the dietary department participated in the QAPI process. Further interview also revealed that the issues with dietary were discussed but there was no written documentation that indicates the discussion was a part of the QAPI process. The Administrator revealed that dietary is supposed to be a part of QAPI but rarely to never participates. They only send in their reports, but there have not been any reports received at this time. Interview on [DATE] at 3:00 p.m. with the Certified Dietary Manager (CDM) revealed that she started at the facility on [DATE] and had not been participating in the QAPI process but intends to attend the next scheduled meeting. The daily audits should be conducted by the supervisor or the CDM daily. During the audits if there is any food item that is noted to be expired it should be removed immediately and indicated on the audit tool. Further interview revealed that the next step in correcting the issues of expired food items is to walk around with the staff members and show them the correct way to label food and educate on when to dispose of food items.

Based on observation, record review, staff interviews, and review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Plan, the facility failed to implement corrective action plans that effectively addressed kitchen concerns including discarding expired food items and appropriately wearing hairnets in food preparation areas. The census was 37 residents. Findings include: Review of the facility policy titled QAPI Plan revised 4/7/2020 revealed: Purpose - all staff will participate in ongoing QAPI efforts which support our mission to enhance quality of life. Performance Improvement Projects - the QAPI team will review sources of information to determine if gaps or patterns exist in our systems that could potentially result in quality-of-care issues or if there are opportunities for improvement. QAPI Goals - the nursing home supports performance improvement by encouraging each staff member to be accountable for their own professional performance and practice. Observations of the kitchen on 11/8/2021 at 9:45 a.m. through 10:30 a.m. revealed expired food items in the cook's cooler and dietary staff inappropriately wearing hair nets. Review of facility daily audit tool titled Audit of Expired foods and Dry storage revealed audits were completed for the months of September, October, and the beginning of November 2021. There was no indication on any of the audits reviewed that any food items were expired or that any food item had been removed from the storage areas. Review of facility QAPI Sign- Sheet dated 10/28/2021 revealed no indication of results of monitoring that was conducted by the dietary staff. Further review revealed no evidence that any member from the dietary department participated in the QAPI meeting. Interview on 11/8/2021 at 12:00 p.m. with the Chief Executive Officer (CEO) revealed that currently they do not have a CDM (Certified Dietary Manager) on staff full time, but there is one candidate that is already certified that they are hoping to employ. Currently there are two Registered Dieticians that are in the facility at least 32 hours a week for consultation. Further interview revealed that it was his expectation that the dietary department participate in the QAPI process monthly and to make the changes that are needed to be in compliance. Interview on 11/8/2021 at 1:24 p.m. with [NAME] AA revealed the daily audits are conducted twice a day in the morning at the beginning of the shift and in the evening at the end of the shift. During the audit all food items are checked for expiration dates and if there are any foods that are expired, they are discarded at that time. Further interview revealed that an audit was completed on 11/7/2021 and the noted expired food items were not seen during the audit that was completed on that day. Continued interview also revealed that there was not an audit completed on 11/8/2021 at the beginning of the shift. Interview on 11/8/2021 at 1:52 p.m. with the Kitchen Supervisor revealed that the cook on duty for the day is responsible for checking the food in the cook's cooler for expiration dates at the beginning of their shift and are to document if there are any food items that are expired and remove them from the storage area. She stated she had not attended a QAPI meeting and had no knowledge of whether the Dietary Manager attended the meeting. Interview on 11/8/2021 at 2:24 p.m. with the Administrator revealed that there was no documentation that indicated that the dietary department participated in the QAPI process. Further interview also revealed that the issues with dietary were discussed but there was no written documentation that indicates the discussion was a part of the QAPI process. The Administrator revealed that dietary is supposed to be a part of QAPI but rarely to never participates. They only send in their reports, but there have not been any reports received at this time. Interview on 11/8/2021 at 3:00 p.m. with the Certified Dietary Manager (CDM) revealed that she started at the facility on 9/14/21 and had not been participating in the QAPI process but intends to attend the next scheduled meeting. The daily audits should be conducted by the supervisor or the CDM daily. During the audits if there is any food item that is noted to be expired it should be removed immediately and indicated on the audit tool. Further interview revealed that the next step in correcting the issues of expired food items is to walk around with the staff members and show them the correct way to label food and educate on when to dispose of food items.

Based on record review and staff interviews, the facility failed to obtain a concurring Physician's signature for a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the document titled Guidance for Completing the POLST Form revealed the following: 5. If the patient lacks decision making capacity, the POLST form may be signed by an authorized person which includes, in the order of priority: a. the agent named on the patient's durable power of attorney for health care, or a health care agent named on the patient's advance directive for health care. b. spouse c. a court-appointed guardian d. son or daughter (age 18 or older) e. parent f. brother or sister (age 18 or older) When a POLST is signed by an authorized person and attending Physician: if section A indicated allow natural death - do not attempt resuscitation . a concurring Physician signature is required. Review of the medical record for R A revealed an admitted [DATE]. R A had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Brief Interview of Mental Status (BIMS) score at time of Admission (Minimum Data Set -MDS dated [DATE]) indicated 0 unable to assess-severely cognitively impaired (cognition score range of 0 to 15). Review of the Physician's Do Not Resuscitate Order document dated 6/23/17 for R A listed and documented the signature of family of A as the designate authorized person. There was only one Physician signature on the document (signed and dated 6/26/17). The DNR form further stated This patient/resident does not have the ability to understand and appreciate the nature and consequence of an order not to resuscitate including the benefits and disadvantage of such an order and to reach an informal decision regarding the order. Review of the admission face sheet listed family of A as a contact person only. Further review revealed no documents to provide evidence that family of A had legal documentation as a Durable Power of Attorney for Health Care or Guardianship. Interview on 9/2/21 at 10:36 a.m. with the Business Office Manager/Admission Staff (BOM) revealed that she was knowledgeable of the policy about DNR required documentations. The policy is to review all DNR at the time of admission for appropriate documents. BOM confirmed that she had failed to review the DNR documentation for R A to ensure two Physician signatures if the resident did not have a Durable Power of Attorney for Health Care or Guardianship. She reported that R A was admitted to the facility from the hospital. BOM reported that prior to his hospital admission, the resident was at another local nursing home facility and his DNR code status was completed at the former nursing facility.

Based on observation and staff interview, the facility failed to label and date open food items, as well as discarding expired food items in the dried foods storage area and produce cooler. The deficient practice had the potential to effect 45 out of 45 total residents receiving an oral diet. Findings Include: During initial tour of the kitchen on [DATE] at 9:46 a.m., the following food items were expired in the dried foods storage area: red velvet cake mix 32 ounces expired [DATE], orange dessert mix 16 ounces expired [DATE], and corn chips 10 ounces expired [DATE]. All food items were confirmed to be expired by the Assistant Food Service Director (AFSD) at time of observation. Continued observation on [DATE] at 10:15 a.m. of produce cooler located in the main kitchen revealed the following food items were expired or unlabeled: opened five pound bag of shredded Mozzarella cheese not dated, three pound tub of pimento cheese spread with expiration date of [DATE], 32 ounce container of pico-de Gallo with expiration date of [DATE], opened 16 ounces bag with frosting tip of whipped topping with no expiration date or open date, creamy French salad dressing one-gallon container with no open date or expiration date. Interview at this time with the AFSD confirmed that items were not labeled and noted food items were expired. Continued interview with the AFSD on [DATE] at 10:30 a.m. revealed the expectation for proper labeling and discarding of expired foods was that all food items are to be labeled and dated when opened and all expired foods are to be discarded immediately. Interview with Dietary General Manager on [DATE] at 10:16 a.m. in reference to process of labeling and dating food items revealed that food is to be dated and labeled when it is received. After a food item is opened, an open date and expiration date should be put on the item. There is a rotation of food items when supply is received. The older items are brought forward for use and newer items are stored behind them. Food storage policy was not provided by facility for review.

Based on record review, resident and staff interview, the facility failed to have residents' funds available for withdrawal afterhours and on weekends for two of 24 residents (R) (#5 and #38) with trust fund accounts. Findings Include: 1. Interview with R#5 on 11/18/19 at 10:29 a.m. revealed money is not available on weekends and after 5:00 p.m. R#5 stated she must let the business office manager (BOM) know a couple of days in advance for funds that are needed. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed R#5 with a Brief Interview of Mental Status (BIMS) score of 15 indicating resident is cognitively intact. 2. Interview with R#38 on 11/18/19 at 11:04 a.m. revealed funds are not available on weekends or after 5:00 p.m. because everybody goes home. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed R#38 with a Brief Interview of Mental Status (BIMS) score of 15 indicating resident is cognitively intact. Interview on 11/19/19 at 1:59 p.m. with BOM in reference to resident fund distribution revealed if residents want money after five or on the weekends there is no program in place at this time that makes residents money available to them. Observation of posted business hours located on business office door revealed hours posted are from 9:00 a.m. to 5:00 p.m. Monday through Thursday and 9:00 a.m. until 2:00 p.m. on Friday. Interview with BOM on 11/19/19 at 2:24 p.m. revealed that as of 11/19/19, there will be a system set up for residents to receive funds after posted business hours by giving the petty cash to the charge nurse and have them sign off on how much money is distributed to residents. This system according to BOM will allow residents access to their funds on the weekends and after hours. Interview with Director of Nursing (DON) on 11/20/19 at 8:17 a.m. revealed residents that were able to go out for the weekend, the staff would go to the residents and ask if they needed money for the weekend and distribute it to them at that time. The DON confirmed that there is no current system in place for residents to receive funds after hours and on the weekend.

Based on observation, interviews and review of the facility records and policy, it was determined the facility failed to have an effective monitoring system to ensure safe hot water temperatures were maintained less than 120 degrees farhenheit for nine resident rooms on three halls (room [ROOM NUMBER], 304, 309, 310, 314, 315, 320, 321, 323). The facility census was 48 residents. Findings include: On 7/16/18 during the initial tour and resident screening, hot water from the sink, in all resident rooms on Hall two and Hall three, were observed to be extremely hot to the touch. The surveyor could not leave her hand or wrist under the running water for more than two to three seconds. Interview on 7/16/18 at 12:55 p.m. with the Director of Nursing (DON) revealed she was not aware of the hot water temperatures (temps). Interview on 7/16/17 at 1:00 p.m. with the Maintenance Supervisor revealed he was not aware of unsafe hot water temps and no unsafe hot water temps had been reported to him prior to today. On 7/16/18 from 1:05 p.m. through 1:30 p.m. hot water temps were confirmed in eleven rooms on three halls, with Maintenance Worker AA, using the facility's digital thermometer. After the first confirmation, Maintenance Worker AA revealed his surprise in the temps and said they were way to hot, and the Maintenance Supervisor immediately left to check the hot water heater/boiler. The following temps were confirmed on Hall One (1)/East Wing: room [ROOM NUMBER] - 136.2 degrees Fahrenheit (F) room [ROOM NUMBER] - 133.6 degrees (F) room [ROOM NUMBER] - 133.8 degrees (F) room [ROOM NUMBER] - 134.5 degrees (F) The following temps were confirmed on Hall Two (2)/North Wing: room [ROOM NUMBER] - 137.8 degrees (F) room [ROOM NUMBER] - 135.0 degrees (F) room [ROOM NUMBER] - 136.0 degrees (F) room [ROOM NUMBER] - 135.6 degrees (F) The following temps were confirmed on Hall Three (3)/West Wing: room [ROOM NUMBER] - 134.0 degrees (F) Interview on 7/16/18 at 1:30 p.m. with the Maintenance Supervisor revealed he had turned the water heater/boiler off at 1:15 p.m. and had found a busted diaphragm on the pneumatic controller on the boiler. The rubber diaphragm had a hole in it and was not regulating the water temperature. He further revealed temps are checked weekly by his department, had been checked last week and revealed an inspection form titled Utility Management Program dated 7/5/18 with results of water temp checks, no action or follow up was documented on form. room [ROOM NUMBER] - 110.4 room [ROOM NUMBER] - 119.6 room [ROOM NUMBER] - 110.6 Further interview revealed the shower room & whirlpool/bath room were on separate boilers from the sink boiler, had their own controls and would not be affected. He had checked the boilers and revealed the shower temp was 94 degrees (F), and the whirl-pool/bath temp was 104 degrees (F). Interview on 7/16/18 at 1:20 p. m. with CNA BB revealed she had worked the day before, on Sunday (MONTH) 15th, she had not noticed a change in water temps and was not aware of any report of resident burns. Further interview revealed when she used hot water she adjusted the hot & cold to a comfortable temperature for washing hands or bathing residents, she didn't use just the hot water. Interview on 7/16/18 at 1:35 p.m. with Charge Nurse CC revealed today was the only time water seemed to be warmer. She revealed when she washed her hands she used hot & cold, adjusted it to a comfortable temp and had not reported water temp to anyone because it was not too hot. Interview on 7/16/18 at 2:05 p.m. with the DON revealed she worked the prior weekend, was not aware of hotter water temps, or any resident or staff being burned. Her expectations were, no injuries from hot water burns, staff would report immediately water that was very hot, or hotter than normal. Interview on 7/16/18 at 2:24 p.m. with the Administrator revealed this had never happened before, no resident had been burned, they had revised their policy, will monitor temps for the next 24 hours, and are looking into an automatic cut off valve for the boiler and/or ways to get alerted if something tears up on boiler. Interview on 7/16/18 at 4:47 p.m. with DON & Maintenance Supervisor revealed the new part had been installed and confirmation of temps after installation revealed the boiler tank temp was 108.6 degrees (F). The Maintenance department will check temps until 11:00 p.m. and then the nursing department will check temps. All temps will be logged and copy will be given to state. The Maintenance Supervisor revealed the following water temp checks were performed and logged for the past three months: 4/5/18 East wing (no Rm #) 127 degrees (F) 4/12/18 Rm 326 112.5 F 4/19/18 Rm 319 112.8 F 5/24/18 Rm 312 113.2 F 5/24/18 Rm 322 117.6 F 6/7/18 Rm 319 115.9 F 6/21/18 Rm 301 115.8 F 6/28/18 Rm 323 117.7 F 6/28/18 Rm 314 116.9 F 6/28/18 Rm 301 114.3 F Interview on 7/19/18 at 9:40 a. m. with the Maintenance Supervisor revealed his department monitored temps weekly, he did not do the temp check, a maintenance worker/aide from his department did. He revealed his staff were knowledgeable, competent & allowed to turn the boiler off if the temps were to high, and to follow up. They didn't always notify him unless it was something major or something they could not fix on their own. He further revealed he was not aware of any temps that exceeded 112 degrees (F) after retest, after maintenance staff turned off the boiler. Further he denied knowledge of State guidelines that water temperatures should not be greater than 110 degrees and Federal guidelines that water temperatures should not exceed 120 degrees. Interview on 7/19/18 at 10:00 a.m. with DON revealed she had not been aware of the State & Federal temp of 110 degrees and 120 degrees. The facility policy titled Engineering Policy Water Temperature, stated water temperature in the nursing home will be set at 112 degrees in the boiler room to give the patients rooms a temp of 110-112 degrees throughout the nursing home.

Based upon observation, record review, family and staff interviews the facility failed to ensure that two (2) residents where supervised to prevent accidents during whirlpool and bed baths ("C" and #62); one (1) resident was assessed for self-medication administration and the medications were stored safely (#51); one (1) resident had a properly fitting mattress (#15) and that chemicals were not left, unattended, on one (1) housekeeping cart with fifteen (15) cognitively impaired, independently mobile residents. Harm occurred to residents "C" and #62. The sample was twenty-six (26) and the census was forty seven=47. Findings include: 1. Record Review of the most recent Minimum Data Set (MDS) assessment for resident "C", dated 8/29/11, revealed the resident was totally dependent upon staff for all care and had impaired range of motion for both upper and lower extremities with severe cognitive impairment. Record review of the Nurses Notes and Incident Report for 9/28/11 revealed the resident received a whirlpool bath at 5:30 a.m. by two (2) Certified Nursing Assistants (CNA), "AA and BB". While the resident was still on the stretcher lift (bath trolley), in a flat position, the safety belt had been released to apply the resident's brief and not reapplied. When CNA "BB" left the side of the stretcher lift to retrieve the resident's socks, the resident fell from the stretcher lift, head first. The resident's head hit the bottom of the lift stabilizer legs resulting in a laceration of the resident's right ear. Review of the Incident Report and Investigation revealed statements from CNA "AA and BB" that the safety belt was not in place when the incident occurred. The resident was sent to the emergency room for care and received twelve (12) stitches to the right ear laceration. A family interview on 10/03/11 at 3:00 p.m. and on 10/04/11 at 2:45 p.m. revealed when they visited resident "C" on 9/30/11, the resident had been grimacing when the leg was moved and the resident's left leg was swollen. The family member brought this to the attention of the physician during rounds and the facility on 9/30/11 at which time an X-ray was done confirming a displaced fracture of the left femur. Observation and interview with CNA "BB" in the Hall II whirlpool room on 10/04/11 at 10:00 a.m. revealed that she had been trained in May 2011 when the facility received a new lift (same type) for use in the Hall III whirlpool room. She indicated that the safety belt should have been in place at all times. Interview with CNA "AA" on 10/05/11 at 7:55 a.m. revealed it was not usual practice to leave the safety belt off while providing a bath. CNA "AA" had attended an inservice on the lift last year and again after resident "C" fell . Review of the manufacture's instruction for use of the stretcher lift revealed that two (2) safety straps should be used (waist and feet) and should be in place at all times. The instructions also revealed the safety straps are positioned over the resident, not under the stretcher lift and over. Observation on 10/5/11 at 7:15 a.m. of a random resident, who is cognitively intact and gave permission for the surveyor to observed the resident's bath using the stretcher lift by CNA's "AA" and "BB", revealed that only one (1) safety strap was utilized for this resident which was applied by putting the safety strap under the stretcher from the vertical lift bar then across the resident's waist attached to the vertical lift bar. The stretcher lift was never placed into the locked position during the entire bath. An interview with the Director of Nursing (DON) on 10/05/11 at 11:30 a.m. revealed she had attended an inservice provided by a manufacture's representative. She understood that two (2) safety straps should be used and agreed that only one (1) strap was currently on the stretcher lift. She stated the lift was to be in the locked position except during transport. The DON supplied a copy of a sign in sheet for an inservice on 6/22/11 on how to use the tub and lift safely. CNAs "AA" and "BB" attended this inservice. 2. Review of the resident most recent MDS (annual) assessment revealed resident #62 was severely cognitively impaired and was totally dependent upon staff for transfers, dressing and bathing. The bath assessment was for a two (2) person assist. Record review for resident # 62 revealed had fallen 7/11/10 from the bed, during a bed bath, resulting in a laceration to the forehead. CNA "CC" was giving the resident a bed bath then she stepped away from the resident to get clean clothes. Resident #62 rolled off the bed onto the floor, resulting in a laceration to the forehead. The laceration was treated in the emergency room . Record review of the facility Incident Report revealed the resident had not been secured before CNA "CC" left the side of the bed. An interview with CNA "CC" on 10/06/11 at 8:18 a.m. revealed the mistake she made was going to the closet to get the resident's clothes and not making sure the resident was secure before walking away from the bedside. 3. Review of the facility's Incident/Accident Log revealed that resident #15 had four falls in 2011 that involved attempts to ambulate without staff assistance. Review of the Significant Change Minimum Data Set ((MDS) dated [DATE] revealed that the resident had short-and long-term memory problems, and severely impaired decision-making skills. [DIAGNOSES REDACTED]. On 10/04/11 at 12:08 p.m., a 5-1/2 inch gap between the end of the mattress and the footboard was noted. This was verified by the Assistant Director of Nursing (ADON), who said there was a gatch on the bed to prevent this. However, when she raised it, it increased the space to 6-1/2 inches. She stated they could put some pillows between the mattress and footboard to fill this space. On 10/05/11 at 7:05 a.m., the resident was noted in bed. The gap at the end of the bed was still present. At 9:20 a.m., the ADON was again notified. Review of the Guidance to Industry and Food and Drug Administration (FDA) Staff: Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment issued on 3/10/06 noted that the space between the inside surface of the head board or foot board and the end of the mattress may present a risk of head entrapment when taking into account the mattress compressibility, any shift of the mattress, and degree of play from loosened head or foot boards. 4. On 10/04/11 at 9:10 a.m., Housekeeper "MM" was noted to go into room 313 to clean, and closed the door behind her. The Housekeeping cart was left outside the room, and on top of the cart there was a caddy containing multiple bottles of various chemicals. There were no unattended independently mobile residents in the area at the time. Approximately two (2) minutes later the housekeeper came out of the room. At 9:40 a.m., Housekeeper "MM" verified that she had left her cart unattended in the hall, and added she did have the ability to lock the chemicals up in the cart. The chemicals were in spray bottles and included All-purpose cleaner; furniture polish; Best Bet liquid cream cleaner (in a squirt bottle); pH7Q ultra disinfect; and Oxy Fect disinfectant. On 10/06/11 at 10:05 a.m., the Assistant Housekeeping Supervisor stated that he would expect that any chemicals would be in eyesight of the housekeeper at all times. At 10:30 a.m. he provided the Material Safety Data Sheets for the chemicals listed above, and potential hazards included: mouth, throat, gastrointestinal, eye and skin irritation or corrosion; central nervous system depression; and respiratory irritation. On 10/06/11 at 10:25 a.m., the ADON provided a list of residents who were cognitively impaired and independently mobile, and fifteen residents met this criteria. 5. On 10/06/11 at 10:47 a.m., the following medication bottles were noted on top of the bedside table of resident #51: Vitamin D 1000 I.U. Senior Multivitamins with Minerals Avocado/Soy Extract The resident's medical record was reviewed, and no assessment was found for safety of self-administration, no care plan was noted for self-administration of meds, and no physician order to take these medications. On 10/06/11 at 10:49 a.m., the ADON verified this observation, and stated the facility did not do assessments for self-administration of medications.