Every finding on record at Gordon Health and Rehabilitation

Based on observations, staff interviews, and review of the facility's policy titled Standard Precaution/ Use of Personal Protective Equipment (PPE), the facility failed to ensure medications were prepared and administered using appropriate infection control practices and safe medication handling techniques to prevent contamination for two residents (R) (R20 and R21) of three residents observed during a medication pass. This deficient practice increased the risk of cross contamination and spread of infection to residents and staff.Findings include:Review of the facility's policy titled Standard Precautions/Use of PPE, last reviewed 12/27/2025, documented the following guideline for hand hygiene: During the delivery of healthcare, avoid unnecessary touching of surfaces near the patient to prevent contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surfaces.Review of the facility's policies titled Hand Hygiene, and Pharmacy Services: Medication Administration - General, revealed no documented protocol or procedure that addressed handling medications with bare hands or dropped medications. On 03/31/2026 at 8:47 AM, Certified Medical Aide (CMA) BB was observed during the 8:00 AM medication pass for R21. CMA BB opened the floor stock container of medications and placed the pills into her palm before transferring them into a medication cup, including vitamin C tablet, aspirin tablet, vitamin D3 capsule, and a multivitamin tablet. During this process, CMA BB dropped the vitamin C tablet onto the medication cart surface, picked up the tablet with her bare fingers, placed it into the medication cup, and administered the tablets to R21. On 03/31/2026 at 8:52 AM, CMA BB was observed during the 8:00 AM medication pass for R20. Second observation revealed that CMA BB prepared vitamin B12, Mucinex ER, senna plus, and vitamin D3 for administration. She placed the medications from the containers into the container lid and then used her bare fingers to transfer the medicine into the medication cup and administered it to R20. In an interview immediately following the medication pass, CMA BB confirmed she touched the medications with her hands and stated she should have transferred them to the lid and then to the medication cup. CMA BB stated that if a tablet falls, it should be discarded and replaced.In an interview conducted on 03/31/2026 at 12:00 PM, the Director of Nursing (DON) stated she provides training and competencies for CMAs and that they are taught not to touch medications with bare hands and to discard any dropped medication; however, she acknowledged this is not specific on the competency checklist. The DON added that this practice is emphasized on the CMA exam, including a question addressing proper handling of dropped medications. In an interview conducted on 03/31/2026 at 4:00 PM, the Infection Preventionist (IP), who is also the Assistant Director of Nursing (ADON) and a Registered Nurse (RN), stated that staff are expected not to touch medications with bare hands and to discard any dropped medication. She explained that replacement doses should be obtained either from floor stock, the emergency (E) box, or the pharmacy.Review of a grievance filed on 09/29/2025 documented an allegation that a nurse dropped a medication on the floor, picked it up, and administered it to a resident. The grievance documented the facility investigated and confirmed the allegation.In an interview conducted on 03/31/2026 at 4:10 PM with the Social Services Director who conducted the investigation, she stated she did not notify the Infection Preventionist or the DON and did not re-educate staff following the incident, acknowledging that additional action should have been taken to prevent recurrence.In an interview conducted on 03/31/2026 at 4:15 PM, the DON stated she was not aware of the incident and reiterated her expectation that staff do not touch medications with bare hands and that any dropped medication must be discarded.

Based on observations, staff interviews, record review, and policy review, the facility failed to ensure a medication error rate of less than five percent during medication administration review. Four errors were identified from 33 opportunities, resulting in a 12 percent (%) medication error rate. The deficient practice placed residents at risk for inaccurate dosing and adverse clinical outcomes.Findings include:Review of the facility's policy titled Insulin Administration, dated 12/31/2025, documented the following guidelines for insulin pen administration: .10. Inject the insulin by quickly inserting the needle straight in at a 90-degree angle per manufacturer instruction.11. Use your thumb to press down on the dose knob until it stops.12. Needle should remain in subcutaneous tissue for 10 seconds to allow all of the medication to be administered properly.Review of the facility's policy titled Medication Administration-General, reviewed 04/15/2025, documented the following guidelines for medication administration: .Prior to medication administration, the Nurse or Certified Medication Aide (CMA) identifies the patient and verifies the patient, reads the administration directions on the MAR {medication administration record}, and verifies the correct medication, dose, and directions for use. Following medication administration, immediately thereafter, the medication should be documented as given on the patient's MAR/TAR {treatment administration record} by the person who administered the medication. At the end of each medication pass, the person administering the medications reviews the MAR to ascertain that necessary doses were administered and that administered doses were documented. The individual who administered the medications should complete documentation of administration of medications prior to going off duty.On 03/31/2026 at 8:20 AM, Certified Medication Aide (CMA) AA was observed conducting the 8:00 AM medication pass for resident (R) R51. CMA AA stated she needed to administer two different insulins: 10 units of Humalog and 45 units of insulin Lantus. She further stated that a licensed nurse must double-check insulin administration to prevent errors. The CMA AA called Licensed Practical Nurse (LPN) HH, to observe the administration.The CMA AA prepared the insulins without concern and administered 10 units of Humalog subcutaneously into the abdomen, then immediately withdrew the needle. Insulin leakage was observed at the injection site. CMA AA then administered 45 units of Lantus and again immediately withdrew the needle without waiting for the manufacturer's recommended 10 seconds, resulting in additional leakage. LPN HH did not voice any concerns at that time.At the conclusion of the observation, LPN HH was interviewed regarding what, if anything, had been performed incorrectly during the insulin administration. LPN HH stated that nothing had been done incorrectly. CMA AA was also unable to identify any areas for improvement. When asked whether the insulin pen should have been held in place against the skin to prevent leakage, LPN HH then acknowledged that this should have been done. CMA AA confirmed that she forgot to hold the pen in place and withdrew it immediately.On 03/31/2026 at 8:52 AM, CMA BB was observed conducting the 8:00 AM medication pass for R20. The resident had a lidocaine patch in place on the left shoulder. CMA BB removed the existing patch and applied a new one. During interview, CMA BB stated the patch should have been removed the previous night and that removal had been documented on the MAR as completed, but it was not removed.Further review of the MAR revealed potassium chloride 10 mEq {milliequivalents} was documented as administered on 03/31/2026, however, it was not given. CMA BB stated she documented it as administered despite not giving it because the pharmacy packaged the medication in the strip for the following day (4/1/2026 at 8:00 AM) and indicated the next shift would administer it without documentation.In an interview conducted on 03/31/2026 at 12:00 PM, the Director of Nursing (DON) stated staff are expected to follow physician orders, document medication administration accurately and timely, and report discrepancies immediately. She acknowledged these practices were not consistent with facility expectations. The DON further stated lidocaine patches are to be removed at bedtime and documented at the time of removal, and that failure to remove the patch as ordered may cause increased medication absorption and skin irritation. Regarding insulin pen use, the DON stated staff are expected to hold the pen in place for 5-10 seconds to ensure an accurate dose is delivered.

Based on observations, staff interviews, record review, and review of the facility's policy titled Medication Administration-General, and Insulin Administration Policy, the facility failed to maintain professional standards of practice for three medication observations from a total of 33 medications observed. Specifically, the facility failed by signing that medication was administered but not due until the following day and failed to accurately administer insulin from a pen device. This deficient practice increased the risk of adverse clinical outcomes. Findings include: Review of the facility's policy titled Insulin Administration, dated 12/31/2025, documented the following guidelines for insulin pen administration: .10. Inject the insulin by quickly inserting the needle straight in at a 90-degree angle per manufacturer instruction.11. Use your thumb to press down on the dose knob until it stops.12. Needle should remain in subcutaneous tissue for 10 seconds to allow all of the medication to be administered properly.Review of the facility's policy titled Medication Administration-General, reviewed 04/15/2025, documented the following guidelines for medication administration: .Prior to medication administration, the Nurse or Certified Medication Aide (CMA) identifies the patient and verifies the patient, reads the administration directions on the MAR {medication administration record}, and verifies the correct medication, dose, and directions for use. Following medication administration, immediately thereafter, the medication should be documented as given on the patient's MAR/TAR {treatment administration record} by the person who administered the medication. At the end of each medication pass, the person administering the medications reviews the MAR to ascertain that necessary doses were administered and that administered doses were documented. The individual who administered the medications should complete documentation of administration of medications prior to going off duty.1. On 03/31/2026 at 8:20 AM, Certified Medication Aide (CMA) AA was observed conducting the 8:00 AM medication pass for resident (R) R51. CMA AA stated she needed to administer two different insulins: 10 units of Humalog and 45 units of insulin Lantus. She further stated that a licensed nurse must double-check insulin administration to prevent errors. The CMA AA called Licensed Practical Nurse (LPN) HH, to observe the administration.The CMA AA prepared the insulins without concern and administered 10 units of Humalog subcutaneously into the abdomen, then immediately withdrew the needle. Insulin leakage was observed at the injection site. CMA AA then administered 45 units of Lantus and again immediately withdrew the needle without waiting for the recommended 10 seconds, resulting in additional leakage. LPN HH did not voice any concerns at that time.At the conclusion of the observation, upon review LPN HH stated nothing was done incorrectly. CMA AA was also unable to identify any areas for improvement. When asked whether the insulin pen should have been held in place against the skin to prevent leakage, LPN HH acknowledged this should have been done. CMA AA confirmed that she forgot to hold the pen in place and withdrew it immediately.2. Review of the MAR for R20 revealed an order for potassium chloride 10 mEq (milliequivalents) to be administered every 48 hours and was scheduled for the 8:00 AM medication pass on 03/31/2026. CMA BB documented the potassium as administered on the MAR, but it was not given during the observation.In an interview conducted on 03/31/2026 at 11:55 AM, CMA BB confirmed that the medication was not administered but was documented on the MAR as administered. CMA BB stated she did not handle this correctly, as the correct process is to administer medications and document them immediately following administration. She explained that the medication strip package was dated by the pharmacy for the following day, which was 04/01/2026 and did not match the MAR. CMA BB confirmed she marked the medication as administered on the MAR without giving it and that the next shift would administer the medication without documenting it since the package and MAR do not match.In an interview conducted on 03/31/2026 at 12:00 PM, the Director of Nursing (DON) stated that medical records should accurately reflect the care provided and that medication administration should be documented immediately and accurately. She further stated that any discrepancies should be reported promptly to the pharmacy and licensed nursing staff. Regarding insulin pen use, the DON stated staff are expected to hold the pen in place for 5-10 seconds to ensure an accurate dose is delivered. The DON acknowledged that the CMA's actions were not consistent with facility expectations.

Based on observations, staff interviews, record review, and review of the facility's policies titled, Transmission-Based Precautions (Contact, Enhanced Barrier, Droplet, Airborne) and Hand Hygiene, the facility failed to ensure infection control processes were followed during a dressing change for one of 13 residents (R) (R12) on enhanced barrier precautions (EBP). This deficient practice created the potential for the spread of infections in the facility. Findings include: Review of the facility's policy titled, Transmission-Based Precautions (Contact, Enhanced Barrier, Droplet, Airborne), dated 12/27/2024, revealed the Enhanced Barrier Precautions (EBP), section included, Enhanced Barrier Precautions are indicated for patients with any of the following: . Wounds and indwelling medical devices even if the patient is not known to be infected or colonized with a MDRO [multi drug resistant organism]. Enhanced Barrier Precautions expand the use of PPE [personal protective equipment] and refer to the use of gown and gloves during high contact activities that promote opportunities for transfer of MDROs to staff hands and clothing, . Examples of high contact patient care activities requiring gown and glove use for Enhanced Barrier Precautions include . Device care or use: .feeding tube . Review of the facility's policy titled, Hand Hygiene, dated 12/27/2024, revealed the Purpose section stated, Hand hygiene is the single most important means of preventing the spread of infections. The use of gloves does not replace hand washing. The Guideline section included, .Associates should use alcohol based hand rub or wash hands with soap and water for the following indications: . Immediately after glove removal. Gloves should not be used as a substitute for hand hygiene. Perform hand hygiene immediately after removing gloves. Review of R12's quarterly Minimum Data Set (MDS) assessment, dated 3/5/2025, revealed Section K (Swallowing Disorders) documented R12 had a feeding tube. Review of R12's care plan dated 3/14/2025 revealed a care area of skin breakdown risk due to a gastrostomy tube (G-tube) [a tube inserted through the abdominal wall directly into the stomach] site dressing with intervention to change the dressing as ordered. Review of R12's physician's orders revealed an order dated 11/8/2024 to clean the G-tube site once per day and apply a drain sponge (a type of dressing). Observation of G-tube site dressing change on 4/12/2025 at 10:00 am revealed Licensed Practical Nurse (LPN) AA entered R12's room to perform the procedure with the supplies in her hands. After providing privacy, she washed her hands, donned (put on) gloves, removed the G-tube site dressing, discarded the dressing in a trash can, cleaned the site per the physician's order, discarded the cleaning material, doffed (took off) her gloves, donned clean gloves, placed the dressing on the site, doffed gloves, and performed hand hygiene. She did not wear a gown or perform hand hygiene between glove changes during the procedure. Observation of R12's room revealed EBP signage on the wall above the head of the bed instructing staff to wear a gown and gloves when providing high-contact care to the resident. Further observation revealed gloves and an alcohol-based hand rub (ABHR) dispenser on the wall inside the room. In an interview on 4/12/2025 at 10:15 am, LPN AA confirmed she did not wear a gown for the procedure or perform hand hygiene between glove changes. She stated she was aware R12 was on EBP due to the G-tube and should have worn a gown for the procedure. She further stated she should have performed hand hygiene when changing gloves, and she was nervous and forgot to wear the gown and perform hand hygiene between glove changes. She stated that PPE was available on the supply carts in the hallways. In an interview on 4/12/2025 at 2:00 pm, the Director of Nursing (DON) stated the nurses should wear gloves and a gown when providing G-tube site dressing changes, and hand hygiene should be performed between glove changes and when going from dirty to clean steps during dressing changes. She further stated that the infection control process should be followed to prevent the spread of infections.

Based on staff interviews, record review, and review of the facility policy titled, Mental Wellness Services, the facility failed to perform a Level II PASRR (Preadmission Screening and Resident Review) for evaluation and determination of specialized services for one of 41 sampled residents (R) (R108) reviewed. This failure had the potential for residents with mental disorders not to receive identified specialized services. Findings include: A review of the facility policy titled Mental Wellness Community last reviewed 12/27/2024 revealed under Guideline: Patients living on the community should have appropriate level 1's completed as required to determine whether a new level 2 is needed. For those patients whose level 2 evaluation has determined that they have a serious mental illness or mental retardation, the level 2 recommendations are followed. A review of the Minimum Data Set (MDS) Admission assessment dated [DATE] Section A (Identification Information) revealed R108 had not been evaluated for level II PASRR. A further review revealed R108 had a Brief Interview for Mental Status (BIMS) from Section C (Cognitive Patterns) score of 14, indicating little or no cognitive deficit, and a diagnosis from Section I (Active Diagnoses) of Manic Depression (bipolar disease). A review of the electronic medical record (EMR) revealed that R108 had diagnoses that included but not limited to bipolar disorder. Further review revealed R108's level I PASRR dated 11/25/2024 reflected that R108 did not have bipolar disorder. A review of R108's physician's (MD) orders revealed an order for oxcarbazepine 300 mg milligrams) two tablets, dated 11/28/2024, to be administered by mouth twice per day for the treatment of bipolar disorder, Seroquel 300 mg 0.5 tablet, ordered 12/12/2024, to be administered by mouth at bedtime every day for bipolar disorder, and venlafaxine ER (extended release) 150 mg, dated 11/27/2024, to be administered by mouth every day for bipolar disorder. During an interview with the Director of Nursing (DON) on 4/13/2024 at 9:20 am, she stated that the Social Worker (SW) was responsible for auditing the PASARRs in the facility, but the SW overlooked R108's level II PASRR. The DON acknowledged that R108 did have bipolar disorder and should have been evaluated based on her diagnosis. The DON added that the SW was not in the facility and was unavailable for an interview.

Based on interview and record review, the facility failed to develop and implement a process for the notification of the Ombudsman when a resident is transferred to the hospital for two of two residents (R) (R#72 and R#73) reviewed for hospital transfer. The deficient practice had the potential to affect any resident that was transferred or discharged from the facility. Finding include: 1. Review of the Electronic Medical Record (EMR) for R#72 under the Census tab revealed diagnoses including a fracture, respiratory issues, and arthritis. On 1/31/2023, R#72 was transferred to the hospital due to a change in condition and returned from the hospital on 2/05/2023. Review of the EMR revealed no evidence that the facility notified the Ombudsman when the resident was transferred to the hospital. 2. Review of the EMR for R#73 under the Census tab revealed diagnoses including respiratory failure. On 2/10/2023, R#73 was transferred to the hospital due to a change in condition and returned to the facility on [DATE]. Review of the EMR revealed no evidence that the facility notified the Ombudsman when the resident was transferred to the hospital. Interview on 3/02/2023 at 10:00 a.m. with the Administrator and the Social Services Coordinator confirmed the facility failed to notify the Ombudsman when the R#72 and R#73 were transferred and admitted to the hospital. They stated that the facility did not have a policy or procedure to ensure the Ombudsman was notified each a time a resident was transferred to the hospital.

Based on observation, interview, and record review, the facility failed to maintain a clean and comfortable environment as evidenced by stained ceilings, damaged walls and baseboards in six resident rooms and in a communal area on two of four halls. The sampled rooms housed twelve residents out of a census of 108. Findings Include: 1. During continuous observations between the times 2:10 p.m. and 3:00 p.m. the following concerns were noted: Peachtree Hall In room 35 small dime-sized holes were observed in the drop ceiling above the B bed. A large brown stain was observed in the drop ceiling around the fire sprinkler. There was a large peeling paint area with white drywall showing behind and next to the B bed. There was another area of peeling paint on the outer wall of the room near the window. There were two (2) silver dollar-sized areas of peeling paint in the bathroom. In room 30 there was a large area of peeling paint, with white drywall showing behind recliner chair. In room 23 there was a several foot-long cable TV-type cord dangling from television which dangled just off the floor. In room 27 the baseboard near the Heating, Ventilation, and Air Conditioning (HVAC) unit below the window was peeling. There were small holes in the walls above the bathroom light switch. Apple Trail Hall In room 118 there were large areas of peeling paint with white drywall showing behind both bed A and B beds. There was peeling paint with white drywall showing in the bathroom. In room 112 there was a large area of peeling paint with bare drywall showing behind the A bed. Worn baseboards were observed in the halls outside rooms 102, 115, 117, 118, 119, and in the day room. The ceiling vent in day room was rusty, dirty, and had peeling paint. There was peeling baseboard around HVAC in the day room. The day room is also used as a restorative dining area. There was a large brown stain in drop ceiling next to fire sprinkler in front of Cherry Hill Nurses' Station. On 11/02/17, between 8:10 a.m. and 8:40 a.m., a tour was made of the above areas of concern with the Maintenance Director (MD). The MD said that painting was to be done this year, but was deferred because of other company priorities. He said painters are assigned by the corporate owners. He said he did not know when any painting will be done. The MD toured, observed, and affirmed all areas of concern noted on 10/31/2017, in the presence of the surveyor. He said most of the drywall damage was due to reclining chairs and beds hitting the walls. The MD said the building was in need of much restorative work such as painting, HVAC, and electrical. 3 On 11/02/17 at 8:50 a.m. an interview was held with the Administrator. He said the building was in need of painting and other major maintenance although the Administrator revealed there were currently no plans for implementation of painting or other maintenance. He showed a multi-page document dated 9/2015 that detailed a proposal for major renovations, including paint, electrical, and HVAC. He said corporate did not move forward with these plans and there were no implementation date for these renovations. He said these renovations was part of the lease agreement. The new ten-year lease was signed over a year ago. The Administrator said I will not lie to you there are no start dates for renovations. During observations in resident rooms and bathrooms on the Peachtree and Apple Trail halls, the following environmental concerns were noted: Peachtree Hall: Room 22 on 10/30/17 at 1:11 p.m.: Observation in the bathroom revealed that one corner of a ceiling tile over the sink was stained brown. Room 24 on 10/31/17 at 10:22 a.m.: Observation in the residents' room revealed that the wall behind the A-bed nightstand had numerous scrapes approximately six inches above the nightstand. Observations in the bathroom revealed two brown-stained ceiling tiles, and under one of these tiles were two vertical brown streaks from the ceiling to the light over the sink. Room 25 on 10/30/17 at 1:56 p.m.: Patched but unpainted walls were observed in the bathroom to the right of the soap dispenser, near the floor by the grab bar, and under the sink. Horizontal scrapes and two small holes were observed on the wall across from the commode. Observation behind the A-bed revealed that the wall for the entire width of the bed had numerous scrapes as well as holes, exposing the inner part of the wall. Room 27 on 10/31/17 at 9:13 a.m.: Observation at the corner of the bedroom wall where the closet wall met the bathroom wall revealed the plaster had been knocked off the wall in several places. Apple Trail Hall: Room 116 on 10/31/17 at 8:50 a.m.: A circular hole was observed in the wall across from toilet in bathroom. Observations in the resident's room revealed the corner where the closet wall met the bathroom wall near the baseboard had an area approximately eight inches long where the plaster has been knocked off the wall, exposing a metal plate underneath. Room 117 on 10/31/17 at 10:01 a.m.: Observations in the bathroom revealed that there was a sewer-type odor. Observations in the resident's room revealed that the baseboards were chipped on three of the four walls. Room 118 on 10/31/17 at 10:13 a.m.: Long, horizontal scrapes were observed on the wall across from the commode, and the baseboard on this wall had several chipped pieces.

Based on observation, staff interview, and record review , the facility failed to ensure bulk food items, removed from original packaging, were properly labeled, dated, and closed securely for one (1) bag of frozen vegetables used for resident consumption. The facility failed to store food in accordance with professional standards for food service safety. This deficient practice had the potential to effect one hundred ten (110) residents receiving an oral diet. The facility census was one hundred twelve (112). Findings Include: Observation on 12/5/2016 at 11:30 a.m. of the walk-in freezer revealed one (1) package of frozen rutabagas opened from it's original packaging, not labeled, dated, or closed securely. Interview with the Dietary Manager (DM) at 2:00 p.m. on 12/12/2016 reveals the Dietary Assistants/Dietary Aides are responsible for labeling, dating, and securing closure of food products designated for resident consumption after staff has opened the product from its original packaging. Interview reveals the DM acknowledges that open food products designated for resident consumption must be labeled, dated, and securely closed by the Dietary Assistants/Dietary Aides after opening food items from their original packaging. Interview reveals the opened, non-labeled, non dated vegetables (rutabagas) were not stored in accordance with sanitation guidelines due to the Dietary Assistants not having a chance to properly label, date, and safely seal after the weekend shift was completed, and putting up new food deliveries. Interview on 12/12/2016 at 3:15 p.m. with the DM and the Registered Dietician (RD) reveals the dietary department is expected to follow the company policies which is to follow the ServSafe Sanitation 050 guidelines and the Georgia Guidelines for food sanitation. The DM and RD revealed the dietary staff are also expected to follow the State Guidelines for food Sanitation. A copy of the ServSafe Holding Food Safely guidelines was requested for review. Record Review of the State Operations Manual (SOM) reference page 477, reveals labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable) or discarded. Review of Sanitation 050-ServSafe Study Guide reveals It is important to Label and date all foods.

Based on staff interview and record review the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) for one (1) Resident (#23) of three (3) residents reviewed who were discharged from Medicare Part A services. The facility also failed to provide a copy of the Skilled Nursing Facility Advanced Beneficiary Notice to the resident (#23) who continued to reside in the facility under Part B services. The sample was twenty-six (26). Findings include: Review of the records for Resident (R#23) revealed the resident was admitted to the facility for skilled services on 10/24/16. Review of the skilled services review note dated 11/22/16 revealed R#23 was discharged from physical therapy (PT) and occupational therapy (OT) services with effect from 11/22/16. Review of the physician ' s progress note dated 11/22/16 revealed the physician documented the resident's last day of therapy would be 11/22/16 and that the resident would transition to LTC effective from 11/23/16. Further review of the records for R#23 revealed that it did not contain a copy of the Notice of Medicare Non-Coverage (NOMNC), nor a copy of the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN). Interview on 12/12/16 at 1:15 p.m. with the Financial Comptroller (FC), revealed that the facility expected R#23 to be discharged from skilled services after 11/22/16 based on a recommendation from therapy, and also expected the resident to remain in the facility on custodial care with effect from 11/23/16. The resident resumed skilled services, effective from 12/1/16, after a cast was removed from her arm. The financial comptroller confirmed that neither a copy of the Notice of Medicare Non-Coverage (NOMNC), nor a copy of a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) was on file to indicate it was provided to the resident or family at the time of discharge from services on 11/22/16, and that she did not know why this was not done, except that it might have been an oversight. The FC further stated she had checked with the MDS coordinator who is responsible for completing the forms and forwarding them to the FC to be placed in the residents' records and the MDS coordinator had not completed any such forms for R#23. Interview on 12/12/16 at 1:35 p.m. with the facility Administrator revealed that the resident was admitted with a cast on her arm and therapy felt they had done all they could do until the cast was removed. Therefore, the resident was discharged from therapy services on 11/22/16. The resident had an appointment to have the cast removed later in the month, and the facility thought they would stop therapy services on 11/22/16 and resume once the cast came off in about a week. He said the resident and family were aware of this plan and was in agreement. The administrator said it may have been an error on the part of the facility not to provide any liability notices, but they did not think that they needed to under the circumstances. Interview on 12/14/16 at 1:30 p.m. with the MDS coordinator revealed that she usually provides residents receiving Medicare Part A services with a NOMNC when their skilled services come to an end or when they have exhausted their one hundred (100) days of covered services. If the resident is to continue in the facility under Part B services, she also provides the SNF ABN to the resident in addition to the NOMNC. The MDS coordinator said she had not provided either form (the NOMNC or the SNFABN) to R#23 or the resident ' s family because the plan was for the resident to resume skilled services at a later date and the resident ' s family/representative was aware of and in agreement with that plan. The skilled services did end on 11/22/16 and resumed on 12/1/16.

Based on record review and staff interviews, the facility failed to ensure that staff provided care according to the fall interventions in the plan of care for one (1) resident (#117) from a sample of twenty-one (21) residents. Findings include: Interview conducted with Registered Nurse "AA" on 9/16/13 at 11:30 a.m. revealed that resident #117 had an incident on 8/19/13 in the shower room and had to be lowered to the floor. Record review revealed resident #117 had [DIAGNOSES REDACTED]. A Comprehensive Falls Assessment form dated 8/21/13 revealed that the resident was standing in the shower, holding on to the grab bar, he lost strength in his legs and was lowered to the floor. A new intervention initiated on 8/19/13 was to use the Stand Up Lift for transfers. The Falls Intervention Care Plan was updated to reflect the use of the Stand Up Lift for the resident during transfers. Interview conducted on 9/18/13 at 11:30 a.m. with Registered Nurse "AA" revealed that the Certified Nursing Assistant (CNA's) should be using the Stand Up Lift for transfers with this resident. Interviews conducted on 9/18/13 at 8:45 a.m. and 9:10 a.m. with CNA "BB" revealed that she currently uses a gait belt and lets the resident hold onto the grab bar. "BB" further revealed that she does not remember being told that the Stand-up lift should be used for transfers. "BB" indicated that this resident is able to stand and ambulate with assistance.