Every finding on record at Green Acres Care Center LLC

Based on observations, staff interviews, and a review of the facility's records, and facility's policies titled Date Marking for Food Safety, and Sanitation Inspection, the facility failed to discard expired food items and failed to properly label and date. Additionally, the facility failed to maintain sanitary practice with ice machine. The deficient practices had the potential to place 101 of 102 residents who received an oral diet from the kitchen at risk of contracting a foodborne illness. Findings Include:Review of facility's policy titled, Date Marking for Food Safety review dated 01/08/2026, documented in Policy Explanation and Compliance Guideline for Staffing 3.The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. 4. The marking system shall consist of a color-coded label, the day/date of opening, and the day/date the item must be consumed or discarded. Review of facility's policy titled, Sanitation Inspection dated 01/08/2026, documented in Policy Explanation and Compliance Guideline for Staffing 1. All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects. Review of facility records Work History Report on category Ice Machine documented Tasked Description Ice Machines: check filters (if present), clean coils, sanitize interior, delime as necessary. Task Completion Marked done on-time by Maintenance JJ on 03/30/2026. During the initial tour 04/24/2026 at 7:40 AM with Assistant Dietary Manager (ADM) revealed in the dry storage two 5-lb. boxes of vanilla creme icing with an expiration date of 11/28/2025, and five 5lb.boxes of butterflakes biscuit mix with an expiration date of 04/23/2026. Several open items without open dates; one 32 oz. seasoning sauce, (one) 1-gallon teriyaki marinade and sauce, one 10-lb bag spaghetti noodles, one 10-lb. bag tri-color rotini pasts, one 5-lb bag egg noodles. The double reach-in refrigerator revealed one 1/8 pan labeled pudding with expiration date 04/21/2026 and one 5-lb. heavy sour cream with expiration date 03/16/2026. Several open items without open dates; (one) 1-gallon Italian dressing, (one) 1-gallon dill pickle relish, (one) 1-gallon sweet and sour sauce, (one) 1-gallon ranch dressing. The walk-in refrigerator revealed (one) 48 lb. box of chicken with an expiration date of 04/16/2026. The Assistant Dietary Manager observed and confirmed all food items. The walk-in cooler/refrigerator was inspected and revealed (36) 8 fl oz. fat free milks; eighteen in each box with expiration date 02/21/2026 and (50) 8 fl oz. chocolate 1% low fat milk with expiration date 04/22/2026. 50 red tomatoes and 24 yellow onions in facility containers without labeling nor dating; confirmed by Dietary Manager.Further inspection indicated that at the far end of the meat and vegetable countertop/sink, there were approximately 70 pieces of raw fish in a large serving bowl, thawing under a parachute paper cover, which was submerged in shallow standing water. Inspection of the ice machine situated at the exterior door of the kitchen uncovered a black-like substance inside, near the ice on the bolt and screw, as well as at the top interior of the ice machine. An interview held on 04/24/2026, at 8:17 AM with the Assistant Dietary Manager (ADM) verified that fish was placed on the countertop/sink covered; it was noted that the fish was thawing for lunch. The ADM shared that Dietary Aid LL was tasked with cleaning the ice machine to the best of his knowledge, but he is uncertain whether LL received training on how to clean the ice machine. The ADM confirmed the presence of all expired, unlabeled, and undated items.On 04/25/2026, from 12:23 PM, [NAME] KK explained that the thawing procedure involves placing the food item in a pan and then submerging it, without using running water, as it typically transitions from the freezer to the cooler. [NAME] KK confirmed that she has never cooked food that is taken directly from the freezer to serve, thus she is uncertain about the thawing method. [NAME] KK shared that seafood should be placed in cold water, while other meats, such as chicken and beef, should be placed in warm water. Additionally, [NAME] KK mentioned that we label items for three days ahead without considering the manufacturer's date, and she has never observed maintenance cleaning the ice machine, although she is aware that Dietary Aid (DA) LL performed the last cleaning.On 04/25/2026, at 12:31 PM, an interview with Maintenance JJ shared that his department is responsible for cleaning the ice machine and confirmed that he cleaned the ice machine on 04/24/2026 after being told of black-like substance. Maintenance JJ confirmed the black-like substance was from dirt in the air and sulfur sweating and sitting there. Interview on 04/25/2026 at 2:40 PM, with DA LL discussed he place the dates for receipt and expiration during the delivery truck days, as well as the sporadic checks for labeling, dating, and expired food items. However, he recently returned from vacation but confirmed he conducted a check last Friday, but neither the freezer nor the refrigerator was inspected. DA LL also noted that ADM had requested he clean the ice machine on Thursday, but he was not trained. Upon examining the ice machine, DA LL observed a black-like substance.An interview conducted on 04/26/2026, at 11:14 AM with DM revealed that DA LL was not provided with an in-service from her leadership regarding the cleaning of the ice machine. All staff members were and expected to focus on ensuring that the received date, open date, and discard date for food items are accurately recorded, adhering to the standard three-day timeframe. DM clarified that all food thawing must occur either under running water or in a pan placed in the cooler.

Based on observations, resident and staff interviews, and review of the facility policy titled, Promoting/Maintaining Resident Dignity the facility failed to protect and value one resident (R88) of 39 sampled resident private space. Specifically, staff failing to ensure knocking on R88 bedroom door before entering. Findings include: Review of facility policy titled, Promoting/Maintaining Resident Dignity with a revision date of 01/08/2026 stated under the Policy section, it is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of like by recognizing each resident's individually. Under the section Compliance Guidance (1) all staff members are involved in providing care to residents to promote and maintain resident dignity and respect residents' rights and (12) maintain resident privacy. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that R88 had a Brief Minimum Data Set (BIMS) score of 11, indicating moderate cognitive impairment. During an observation and interview on 04/24/2026 at 8:40 AM with R88 stated there is a lack of acknowledgement from staff knocking on his door before entering. While in the resident room it was observed Certified Nurse Assistant (CNA) FF entered his room without knocking. Continued with the observation in R88 room CNA GG entered behind CNA FF without knocking on the door before entering. During an interview on 04/24/2026 at 9:09 AM with CNA FF confirmed she did not knock before entering R88 room and she is aware she is supposed to knock. During an observation on 04/25/2026 at 8:56 AM revealed CNA HH walked into room [ROOM NUMBER] without knocking to retrieve a meal tray. During an observation on 04/25/2026 at 8:58 AM revealed CNA MM walked into room [ROOM NUMBER] without knocking to retrieve a meal tray. During an interview on 04/25/2026 at 9:01 AM with CNA HH confirmed she did not knock on room [ROOM NUMBER] door prior to entering and stated she forgets to knock if the room door is open. During an interview 04/25/2026 at 9:36 AM with CNA MM revealed she did not knock on room [ROOM NUMBER] door and stated she is supposed to announce herself prior to entering a resident room. During an interview on 04/25/2026 at 10:41 AM with the Director of Nursing (DON) stated this is the resident home and staff are expected to knock prior to entering a residents room.

Based on observations, resident and staff interviews, record review and review of the facility's policy titled Resident Self-Administration of Medication, the facility failed to remove medications from the bedside of one of 39 sampled residents (R35) for self-administration of medications. This deficient practice had the potential to cause medication overdose and worsening of R35's medical condition.Findings include:Review of the facility's policy titled Resident Self-Administration of Medication reviewed 01/08/2026 documented Policy: It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. Policy Explanation and Compliance Guidelines: 7. Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the other resident's rooms or to confused roommates of the resident who self-administers medication. The following conditions are met for bedside storage to occur: The manner of storage prevents access by other residents. Lockable drawers or cabinets are required only if locked storage is ineffective. The medications provided to the resident for bedside storage are kept in the containers dispensed by the provider pharmacy. 11. When the interdisciplinary team determines that bedside or in-room storage of medications would be safety risk to other residents, the medications of residents permitted to self-administer are stored in th medication cart or medication room. Review of the facility's Electronic Medical Records (EMR) revealed resident (R)35 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis included but not limited to cirrhosis of the liver.Review of the Medicare 5 day Minimum Data Set (MDS) dated [DATE] Section C (Cognition) Brief Interview for Mental Status (BIMS) score of 15 which indicated R35 had intact cognition, Section I (Active Diagnosis) cirrhosis of the liver.Review of care plan revealed there was no care plan for self-administration of medication for R35. Review of Physician's Orders revealed there was no order for self-administration of medication for R35.Hydrocortisone External Cream 1 % (Hydrocortisone (Topical)) Apply to upper extremities/ back topically two times a day for itching for 30 DaysObservation on 04/24/2026 at 9:35 AM revealed one bottle of Tylenol 500 milligram (mg) tablets, one tube of first aid antibiotic ointment, one bottle 175 mg herbal supplement tablets, one medication cup with white creamy substance (unlabeled) were on R35's overbed table beside her bed.Record review of the facility's Self Administration of Medication assessment dated [DATE] documented R35 was not approved to self-administer medications.Interview on 04/24/2026 at 09:44 AM with R35 revealed she stated her son brought the Tylenol tablets and the antibiotic ointment to her four days ago because she stated to him that she had a headache. R35 stated if she had any headache she would have taken two of the Tylenol tablets three times per day. R35 further stated she had been at the facility for four weeks and she had been taking the herbal supplement tablets since she was admitted to the facility. R35 stated the Tylenol, the antibiotic ointment, and the herbal supplement tablets 175 mg, have all been on her overbed table and the nurses were aware they were there on the overbed table. R35 further stated she was given an ointment for her skin the night before by the night nurse and it was placed in a medication cup and left on the overbed table for R35 to use whenever she needed it.Interview on 04/24/2026 at 09:50 AM with Registered Nurse (RN)/Unit Manager (UM) AA revealed she confirmed there were one bottle of Tylenol 500 mg tablets, 1 bottle of herbal supplement 175 mg tablets, one tube of antibiotic ointment, and one unlabeled medication cup of white substance were on R35's overbed table. She stated the medications should not be in R35'sroom and she further stated that R35 should not have been taking the medications on her own because she was not ordered to self-administer medications. Interview on 04/25/2026 at 09:57 AM with RN/UM BB revealed she stated the facility did not allow medications at the resident's bedside. She stated that if a resident was to self-administer medications, the nurse had to witness the resident taking the medication at the right time and log the administration into the system which was not done with R35. RN/UM BB stated there was no resident on the unit who self-administered medication. RN/UM BB confirmed there was no doctor's order and no care plan for R35 to self-administer medications. Interview on 04/25/2026 at 3:07 PM with the Director of Nursing (DON) revealed she stated her expectations were for the nurses not to leave medications at the residents' bedside. She confirmed there was no physician's order and no care plan for R35 to self-administer medication. The DON further stated that her expectations were for the nurses not to leave medications at the residents' bedside and unattended.

Based on observations, resident and staff interviews, record review and review of the facility's policy titled Preventative Maintenance Program, the facility failed to ensure call device was within reach of one of 39 residents (R) R53 and failed to ensure proper accommodation of wheelchair device for R70. This deficient practice had the potential to cause delayed care and injury to the residents.Findings include: Review of R70 clinical record revealed that he was admitted to the facility on [DATE], with diagnoses included but not limited to cervical disc dsorder with dadiculopathy. The R70s most recent Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicated no cognitive impairment. Review of the Care Plan date 02/26/2024 revealed in Focus the resident has had a fall. Goals the resident will not sustain serious injury through the review date. Intervention Therapy to evaluate resident for a new wheelchair. Date Initiated: 01/26/2025 Review of the Occupational Therapy (OT) Screen dated 01/27/2025 and signed dated 01/29/2025 documented in section Recommendation Nursing requested OT screen to ensure fitting of new (wheelchair) w/c assigned (due to) d/t fall on 01/26 & 01/19. On 04/13/2026 Date of Service: 04/14/2026 Visit Type: Acute Transition of Care: No transition occurred. Details: This is a copy of a signed encounter note documented in (Geriatric Electronic Health Record (EHR) and Medical Management) GEHRIMED. who is being seen for pain. Patient is examined in wheelchair and is in no acute distress. Reports to nursing pain level 10, reports immediate pain level. On 04/11/2026 section N Adv – Fall Risk Evaluation Fall Risk revealed History of falls . Balance problem while walking. Gait / balance: Requires use of assistive devices (i.e. cane, wheelchair, walker, furniture). During interview and observation on 04/24/2026, at 9:47 AM R70 indicated that the cushion on the left armrest was absent and been like that for a while at least two months. The resident was observed resting his left arm on the bare metal. During an interview and observation on 04/25/2026, at 12:52 PM, with the Regional Therapy Manager noted that she is not present at the facility every day and that there is no formal process in place to audit resident equipment, as there are no logs or records maintained. Instead, the process is informal, relying on staff to inform maintenance or rehabilitation personnel. The Regional Therapy Manager observed the chair used by R70 and confirmed that R70 will receive a new chair immediately, attributing this was an oversight. An interview and observation with Maintenance JJ conducted on 04/25/2026, at 1:14 PM, disclosed that he has been assigned the responsibility of maintaining and repairing wheelchairs and walkers. Maintenance JJ mentioned that he inspected all residents' wheelchairs last month and did not find any issues or missing components on the R70 chair. However, Maintenance JJ observed R70 chair and confirmed he will proceed with the necessary repairs. During an interview with the Administrator on 04/26/2026, at 9:17 AM, wheelchair invoices dated before the Occupational Therapy assessment on 01/27/2026, were displayed. She expressed uncertainty regarding the reason the resident had not received a new wheelchair. During an interview with the Director of Nursing (DON) on 04/26/2026, at 10:53 AM, the DON revealed that R70 is using a standard adult wheelchair measuring 18 inches. The DON noted that she frequently observed R70 sitting outside and has never seen the armrest missing. 1.Findings include: Requests were made for the facility's policy regarding call device however, none was provided. Review of the facility's Electronic Medical Records (EMR) revealed R53 was admitted to the facility on [DATE] with diagnosis included but not limited to dementia, muscle weakness, unsteadiness on feet, abnormalities of gait and mobility, lack of coordination, symptoms and signs involving cognitive functions and awareness. Review of the admission Minimum Data Set (MDS) dated [DATE] documented Section C (Cognition) Brief Interview for Mental Status (BIMS) score of 03, which indicated R53 had severely impaired cognition, Section GG (Functional Abilities and Goals) R53 required substantial/maximal assistance for toileting and partial/moderate assistance for personal hygiene. Review of care plan dated 01/27/2026 documented R53 is at risk for falls with goal that R53 will have no injury related to falls and interventions to anticipate and meet his needs and ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Review of Physician's Orders dated 03/22/2026 documented included but not limited to observe closely for side effects of antipsychotic medication including. blurred vision, disorientation or confusion, . lethargy, .disturbed gait. Observations on 04/24/2026 from 9:13 AM to 09:55AM revealed R53's call light was on the floor, under his bed, and inaccessible to him. Observation on 04/24/2026 at 12:57 PM revealed R53's call light was on the floor, under his bed and inaccessible to him. Observation on 04/24/2026 at 2:57 PM revealed R53's call light was on the floor, under his bed and inaccessible to him. Observation on 04/25/2026 at 08:44 AM revealed R53's call light was on the floor, under his bed and inaccessible to him. Observation on 04/25/2026 at 09:51 AM revealed R53's call light was on the floor, under his bed and inaccessible to him. Observation and interview on 04/25/2026 at 09:52 AM revealed Certified Nursing Assistant (CNA) CC walked into R53's room then left R53's room within a less than 10 seconds. CNA CC and the Surveyor walked into R53's room. CNA CC looked for R53'S call light and did not find it on R53's bed nor was it visible near R53. CNA CC confirmed R53's call light was not visible, and his call light was not accessible to R53. CNA CC held the section of the call light cord which was attached to the wall above R53's bed and pulled it from under the bed. CNA CC confirmed the call light was pulled from under R53 's bed and it was not accessible to R53. Interview on 04/24/2026 at 09:14 AM with R53 revealed he stated he did not know where his call light was. R53 reached for his call light and did not find the call light. Interview on 04/25/2026 at 08:45 AM with R53 revealed he stated he would use the call light to ask the staff for assistance and he was unable to find his call light during the interview. He stated he did not know where his call light was because it should be on his bed or wherever he could reach it and it was not. Interview on 04/25/2026 at 9:55 AM with Registered Nurse (RN) Unit Manager (UM) BB revealed she stated R53's call light should be within his reach at all times. Interview on 04/25/2026 at 3:10 PM with the Director of Nursing (DON) revealed she stated her expectations were for call lights to always be within reach of the residents. She stated that whenever the staff did rounds, they should always ensure that the call lights were within the residents' reach.

Based on staff interview, record review, and review of the facility policy titled, Comprehensive Care Plan the facility failed to ensure one of 39 sampled residents (R) (R52) care plan was revised in a timely manner related to her code status. Findings include: Review of the facility policy title, Comprehensive Care Plan with a revision date of 01/08/2026 stated it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Under the section Policy Explanation and Compliance Guidelines (5) the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. Review of R54 profile tab in the electronic medical record (EMR) revealed R54 is documented as a do not resuscitate (DNR). Review of the Physicians Orders revealed R54 is a DNR. Review of the Physicians Order for Life-Sustaining Treatment (POLST) revealed R54 to allow natural death (and) do not attempt resuscitation. Review of the care plan revealed R54 is a code status as full code with interventions to in the event of cardiac/respiratory arrest initiate cardiopulmonary resuscitation (CRP) and contact emergency services and notify the Nurse Practitioner (NP) or the Medical Director (MD) and family of changes in resident's status. During an interview on 04/25/2026 at 4:50 PM with Minimum Data Set (MDS) Coordinator confirmed R52 full code status was discontinued on 02/09/2026 and DRN order was initiated 02/09/2026. The MDS Coordinator stated there should be more efficient communication processes when code statuses are switched.During an interview on 04/25/2026 at 4:54 PM with the Director of Nursing (DON) revealed when the code status is updated or changed it is communicated in morning meetings and the care plan are expected to be update in real time as possible.

Based on record review, observations, interviews, and review of the facility's policy titled, Oxygen Administration the facility failed to obtain a physician's orders for oxygen therapy for one resident (R) (R103) of 13 residents receiving oxygen therapy.Review of the facility's policy titled, Oxygen Administration with a revision date of 01/08/2026 documented in the section Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician, except in the case of an emergency. R103 was admitted to the facility on [DATE] with diagnoses not limited to chronic respiratory failure with hypoxia.Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed R104 had a Brief Interview of Mental Status (BIMS) score of 15 indicating cognition was intact. Further review of the MDS in section (O) documented resident is receiving oxygen therapy. Review of the care plan documented R103 required oxygen therapy and to give medications as ordered by physician. Review of the Physician's orders revealed no order for oxygen therapy.Observations on 04/24/2026 at 9:03 AM and 04/26/2026 at 8:45 AM revealed R103 receiving oxygen therapy at rate of 2 liters per minute (LPM)An interview on 04/25/2026 at 9:45 AM with Licensed Practical Nurse (LPN) DD confirmed R103 did not have a physician order for oxygen therapy. LPN DD looked in the Electronic Health Record (EHR) and verified there was no physician order. An interview on 04/25/2026 at 10:00 AM with the Director of Nursing (DON) confirmed R103 did not have a physician order for oxygen therapy. The DON looked in the Electronic Health Record (EHR) and verified there was no physician order and stated she was going to obtain an order and enter it into the EHR immediately.

Based on observations, resident and staff interviews and record review, the facility failed to remove one pair of scissors from the bedside of one of 39 sampled residents (R) (R35). This deficient practice had the potential to cause injury to residents.Based on observations, resident and staff interviews and record review, the facility failed to remove one pair of scissors from the bedside of one of 39 sampled residents (R35). This deficient practice had the potential to cause injury to residents.Findings include:Requests were made for the facility's policy regarding accident hazards however, none was provided. Review of the facility's Electronic Medical Records (EMR) revealed R35 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis included but not limited to cirrhosis of the liver.Review of the Medicare 05-day Minimum Data Set (MDS) dated [DATE] Section C (Cognition) Brief Interview for Mental Status (BIMS) score of 15, which indicated R35 had intact cognition, Section I (Active Diagnosis) cirrhosis of the liver.Review of care plan dated 04/02/2026 documented included but not limited to R35 had activities of daily living (ADL) self-care performance deficit related to (r/t) activity intolerance with intervention to assist R35 with ADLs as needed. Review of Physician's Orders dated 04/20/2026 documented included but not limited to behavioral monitoring behaviors: 0) none 1) hitting 2) delusions 3) kicking 4)pinching 5) scratching 6) biting 7) paranoia 8) spitting 9) side effects:0) none 1) tardive dyskinesia 2) postural (orthostatic) hypotension 3) new onset confusion 4) akathisia 5) parkinsonism 6) sedation 7) constipation 8) confusion. Every shift for behavior monitoring.Observation on 04/25/2026 at 09:01 AM revealed one pair of scissors were on the overbed table beside R35's bed.Observation on 04/25/2026 at 1:50 PM revealed one pair of scissors were on the overbed table beside R35's bed.Observation on 04/26/2026 at 09:20 AM revealed one pair of scissors were on the overbed table beside R35's bed.Observation on 04/26/2026 at 09:30 AM revealed one pair of scissors were on the overbed table beside R35's bed.Observation on 04/26/2026 at 09:34 AM revealed one pair of scissors were on the overbed table beside R35's bed.Interview on 04/25/2026 at 09:02 AM with R35 revealed she confirmed the pair of scissors belonged to her and it was kept on the overbed table beside her bed. She stated she used the pair of scissors to cut packets of ketchup and condiments for her meals.Interview on 04/26/2026 at 09:35 AM with R35 revealed she confirmed the pair of scissors was always kept on her overbed table for her to use whenever she wanted to cut the condiments.R35 stated no nurse or no one had removed the scissors since she had it in her room, the scissors were always on her overbed table.Interview on 04/26/2026 at 09:40 AM with Registered Nurse (RN) EE revealed she confirmed there was a pair of scissors on the overbed table beside R35's bed and she was not aware that R35 had the pair of scissors in her room. She stated she did not know if residents were supposed to have scissors in their rooms. LPN EE stated she was not aware of the process regarding residents having scissors in their rooms. Interviews on 04/26/2026 at 9:43 AM with Registered Nurse/Unit Manager (UM) BB and Assistant Director of Nursing (ADON) revealed LPN BB confirmed there was a pair of scissors in R35's room and she was not aware R35 had the scissors in her room. She stated that residents were not allowed to have scissors in their rooms. LPN BB informed the ADON that R35 had a pair of scissors in her room. LPN BB stated she was not aware of the process if residents had scissors in their rooms. The ADON stated residents were not allowed to have scissors in their rooms, the nurses should keep the scissors in the medication carts and the resident could ask for the scissors when they needed it. LPN BB then stated that she would remove the scissors from R35'S room and place it on the medication cart. Interview on 04/26/2026 at 09:47 AM with the Director of Nursing (DON) revealed she stated her expectations were she preferred not to have scissors in the residents' rooms. She stated scissors should be kept in the medication carts with the residents' names. She stated the residents may request the scissors from the nurse whenever they needed it.

Based on observations, staff interviews, and review of facility policy titled, Medication Storage, the facility failed to ensure medications were secured on one (cart 3) of four medication carts reviewed and failed to ensure two of four medication (medication cart 1 and 2) carts were locked and secure.Review of the facility policy titled Medication Storage with a revised date of 01/08/2026 stated under Policy, it is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, lights, ventilation, moisture control, segregation, and security. Under Policy Explanation and Compliance Guidelines (1) General Guidelines (a) all drugs and biologicals will be stored in locked compartments (i.e, medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature control. During an observation and interview on 04/24/2026 at 09:10 AM with the Assistant Director of Nursing (ADON) and Registered Nurse (RN) BB revealed in the South Wing Unit in the mall area medication cart 1 was unlocked and unattended while it was observed residents were wandering in mall area and RN BB was attending to medication cart 2. Continued with the observation and interview at 09:19 AM the ADON walked into the South Wing and approached medication cart 1 and confirmed the cart was unlocked and unattended. Further, while at medication cart 1 RN BB approached medication cart 1 and confirmed she was the last nurse on the cart to count the medication with the night shift nurse, and the cart was unlocked since 7:00 AM that morning. During an observation and interview on 04/24/2026 at 01:22 PM with RN BB revealed medication cart 2 on South Wing Unit was unlocked and unattended. RN BB approached the medication cart 2 and confirmed the medication cart was unlocked while she stepped away. She continued to state she thought she locked the cart and she is aware the cart is to be locked while not in use. During an interview on 04/25/2026 at 10:41 AM with the Director of Nursing (DON) stated she expects the nurses to lock the medication carts. Findings include: A review of the facility policy, Medical Storage, revised 1/08/2026, revealed that during medication pass, medications must be under the direct supervision of the person administering medications or locked in the medication storage area/cart. During an observation of the medication pass in the South area on 4/25/2026, at 8:36 AM, RN EE had the medication cart positioned in the open Mall area. Residents were seen eating breakfast and sitting in the Mall, while staff members were walking around assisting them. RN EE removed the following medications from the cart to administer to Resident 58 (R58): Amlodipine besylate oral tablet 5 mg Coreg oral tablet 12.5 mg (Carvedilol) Donepezil HCl oral tablet 10 mg (Donepezil Hydrochloride) Apixaban oral tablet 2.5 mg (Apixaban) Escitalopram oxalate oral tablet 10 mg (Escitalopram Oxalate) Memantine HCl oral tablet 10 mg (Memantine HCl) The RN then placed the medications on top of the cart, locked the cart, and walked to the center of the Mall area to take R58's blood pressure while she was eating breakfast. The medications remained unsecured on top of the cart, with the RN facing away from it. Staff and residents were observed passing by the cart. During an interview with the RN on 4/25/2026 at 8:42 AM, she acknowledged that she had left R58's medications unsecured on top of the cart. The RN stated that she should have locked the medications in the cart before taking the resident's blood pressure. During an interview with the Director of Nursing on 4/25/2026 at 9:05 AM, she stated that she expects all nursing staff to secure any medications if they need to leave them unattended or plan to administer them later.

Based on observation, staff and resident interviews, and review of the facility policy titled, Promoting/Maintaining Resident Dignity the facility failed to ensure a privacy curtain for one of 4 residents (R) (R49) in room [ROOM NUMBER] bed-A. Findings include: Review of facility policy titled, Promoting/Maintaining Resident Dignity with a revision date of 01/08/2026 stated under the Policy section, it is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of like by recognizing each resident's individually. Under the section Compliance Guidance (1) all staff members are involved in providing care to residents to promote and maintain resident dignity and respect residents' rights. A review of the annual Minimum Data Set (MDS) assessment dated [DATE] documented that R49 had a Brief Minimum Data Set (BIMS) score of 3, indicating severe cognitive impairment. During an observation and interview on 04/24/2026 at 10:53 AM with R49 stated he has not had a privacy curtain for a while. R49 further stated a staff member came into the room to clean the curtains however, his curtain was not put back up. During an observation on 04/24/2026 at 1:21 PM and 04/25/2026 at 8:40 AM revealed in room [ROOM NUMBER] bed-A does not have a privacy curtain. During observation and interview on 04/25/2026 at 10:47 AM with the Housekeeping Supervisor (HKS) confirmed in room [ROOM NUMBER], bed-A did not have a private curtain. She continued to state privacy curtains are taken down when they deep clean. However, bed-A privacy curtain was missed and there is round that should be conducted to identify missing privacy curtains.

Based on observation, staff interview, record review, and review of the facility's policy titled Fall Prevention Program, the facility failed to provide an environment free from accident hazards for one of three Residents (R) (R1) reviewed for accidents. On 11/18/2025, actual harm occurred when R1 attempted to use her bathroom, which was under renovation, and her sock became stuck to the glue on the bathroom floor, resulting in an unwitnessed fall. R1 sustained a right humerus shaft fracture, right open distal femur fracture, and a hematoma over the right inferior frontal scalp. R1 was hospitalized on [DATE] and underwent an operative fixation (a surgical repair for broken bones) on 11/20/2025 as a result of the fall.Findings include:Review of a facility's policy titled, Fall Prevention Program, with an implemented date of 1/8/2025 revealed, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Policy Explanation and Compliance Guidelines: 5. Low/Moderate Risk Protocols: a. Implement universal environmental interventions that decrease the risk of resident falling including, but not limited to: i. A clear pathway to the bathroom and bedroom doors. b. Implement routine rounding schedule.Review of the facility's five-day report revealed on 11/18/2025, R1 fell in the restroom, and stated her arm hurt and that she could not move. R1 was sent to the Emergency Room. R1 received Cat Scans (CT) and x-rays, indicating an acute comminuted displaced fracture of the distal diaphysis of the right femur and a comminuted displaced fracture of the mid diaphysis of the right humerus with displacement measuring greater than one shaft length. R1 had surgical repair and is doing well. This incident of an unwitnessed fall with major injury is substantiated as R1 has sustained two fractures.Review of the Emergency Medical Service (EMS) report dated 11/18/2025 for R1 revealed employees stated she went into the bathroom where her socks got stuck on glue that was spread on floor and came out of them falling on arm. Patient complaint was right arm pain and right leg pain. The right upper arm had obvious deformity. Right leg was noted to be shorter then her left leg with noted pulse. Patient stated it was in position of comfort and didn't want us to move it. The patient also had a hematoma above the right eye.Review of hospital records dated 11/18/2025 revealed R1 arrived at the hospital after a fall. Her foot got stuck in glue, she fell face-first, and it was an unwitnessed fall. R1 had x-rays completed and a diagnosis of displaced fracture of shaft of humerus, closed fracture of right femur, contusion of knee, and facial swelling. R1 was transferred on 11/18/2025 to a hospital for higher level of care.Review of hospital Discharge summary dated [DATE] revealed R1 was transferred and admitted after a fall resulting in a right humeral shaft fracture and a right open distal femur fracture confirmed through radiograph on 11/18/2025. R1 underwent operative fixation on 11/20/2025 for both fractures, and postoperative imaging confirmed improved alignment and intact hardware. R1 was discharged on hospital day 14 to a subacute rehabilitation facility.Review of the Electronic Medical Record (EMR) revealed that R1 was admitted with diagnoses that included but not limited to Alzheimer's disease, other symptoms and signs involving cognitive functions and awareness, dementia in other diseases classified elsewhere, severe, with anxiety, parkinsonism, and unspecified osteoarthritis. Review of the most recent Quarterly Minimum Data Set (MDS) for R1, dated 9/17/2025, revealed a Brief Interview for Mental Status (BIMS) score of eight out of 15, indicating moderately cognitively impaired. R1 was independent for toileting and did not use a wheelchair or walker.An interview on 12/1/2025 at 2:34 pm with Licensed Practical Nurse (LPN) LPN AA stated that on 11/18/2025, she was sitting at the nursing station when a Certified Nursing Assistant (CNA) DD jumped up, and she did as well and went behind CNA DD to R1's room. LPN AA saw R1 lying on the floor on her back, to her right. She stated that she completed an assessment and neuro-check as well. LPN AA stated that R1 complained of pain in her arm and leg and stated she couldn't move her arm. She stated that she called 911, notified the Nurse Practitioner (NP), and either the Director of Nursing (DON) or the Assistant Director of Nursing (ADON). She stated that she could not remember what the floor looked like because she was focused on the resident. R1 revealed that she hit her head and nose. LPN AA stated that R1 was wearing one sock when they found her after the fall.An interview on 12/1/2025 at 1:05 pm with the DON revealed that she was informed by the nurse and the unit manager that R1 had a fall in the bathroom. The DON stated that the nurse revealed that R1 went to use the bathroom, which was her normal routine. She stated that remodeling was underway at the facility. The DON stated that they were putting new floors in the bathroom and remodeling the patient rooms, including the floor. The DON stated that rooms [ROOM NUMBERS] (R1 room) share a bathroom and couldn't say whether the bathroom floor was completed at the time of R1's fall, but the bathroom and room [ROOM NUMBER] were complete by the end of the day.An interview on 12/1/2025 at 1:43 pm with the Director of Maintenance (DOM) revealed that the contractors were remodeling R1's room and the adjoining bathroom floors. He revealed that R1's bathroom floor was not completed prior to the fall. He stated that R1's room and bathroom floor was completed a couple of hours after R1 fell. The DOM stated there was still glue on part of the bathroom floor prior to R1 falling. He stated that after the fall, furniture was used as a barrier, and caution tape was placed before the furniture. The DOM revealed that he is familiar with R1 and that she wears socks. He stated that R1's socks got stuck to the bathroom floor glue. An interview on 12/2/2025 at 11:02 am with CNA DD revealed that she was at the nurses' station and saw someone (one of the contractors remodeling the residents' floor and bathroom floors) waving at her. CNA DD stated that she approached the contractor, who pointed at room [ROOM NUMBER]'s bathroom door shared by room [ROOM NUMBER] (R1's room). She stated that she went into room [ROOM NUMBER], and the contractor pointed at the bathroom shared by rooms [ROOM NUMBERS]. She stated that the bathroom door was half open, and the resident was lying on the floor on her side. She stated that the bathroom floor was under construction and was not completed when she saw the resident on the floor. CNA DD stated that R1 was ambulatory and did not use a wheelchair or walker prior to the fall. An interview on 12/2/2025 at 11:20 am with Registered Nurse (RN) CC, and the Unit Manager on duty revealed that LPN AA called her to report a fall. RN CC stated that she went into the bathroom with a male nurse, LPN BB, where R1 was on the floor. She stated that she asked R1 what happened, and R1 stated that she was toileting. She stated that R1 was lying on her left side, guarding her right arm. She stated that R1 stated that she hit her head when asked. RN CC stated R1 had a skin tear on her right thigh and was complaining of right leg pain. RN CC stated that the bathroom floor was under construction and not completed prior to R1 falling. She stated that R1 had a goose egg on her forehead. She stated that R1 was not at risk for falls and was ambulatory. She stated that R1 has not had a fall in over two years. RN CC revealed that R1 does not require assistance with toileting; the most they do is place her clothes on the bed. An interview on 12/2/2025 at 11:45 am with LPN BB revealed that he was on break when the floor nurse called for assistance with R1. He stated that R1 was on the bathroom floor when he arrived. He stated that R1 said she had fallen, and they were more concerned about her head. LPN BB revealed they completed an assessment and vital signs, and made R1 comfortable, while the other nurses called the ambulance and completed paperwork. He stated that the contractors were still working on the bathroom floor, and it was not completed prior to R1's fall. LPN BB stated that R1 was ambulatory.An interview on 12/8/2025 at 11: 39 am with the DON revealed residents were not reassigned rooms during the remodeling of their rooms and bathrooms. She stated that staff assisted residents who needed to use the restroom during rounds. The DON revealed that R1 was not assisted to the restroom because she was independent and cognitively fit and did not require assistance. The DON stated that, moving forward, the facility will have a better-planned approach to ensure resident safety and education for both residents and staff, and will take into account residents' cognitive levels.

Based on observations, staff interviews, and review of the facility policies titled Food Storage Areas and Food from Family Members, the facility failed to ensure food items were labeled, dated, and securely wrapped in the kitchen storage areas and in two of two resident pantries. In addition, the facility failed to ensure that staff food items were stored separately from resident food items. These failures had the potential to place the 89 residents who consumed food from the kitchen at risk of foodborne illness. Findings include: Review of the facility's policy titled, Food Storage Areas, dated 4/20/2024, indicated, It is the intent of this center to store food in a manner that maintains quality and safety. First in, first out should be followed with Refrigerator Food codes, and internal tools may be used as a reference for proper dating. Review of the facility's policy titled, Food from Family Members, dated 3/20/2024, indicated, It is the intent of this center to store food in a manner that maintains quality and safety. First in, first out should be followed with Refrigerator Food codes, and internal tools may be used as a reference for proper dating. Storage food from family members will be placed in one of the two units' refrigerators. After resident food is dated, there will be a three-day period to be used. After three days, residents' food will be thrown out. Observations on 5/5/2025 from 10:30 am to 11:15 am, during the initial kitchen inspection with the Dietary Manager (DM), revealed that the main refrigerator contained hamburger patties in an open plastic bag inside a cardboard box, exposed and undated. Hot dogs were observed in an open plastic bag inside a cardboard box, exposed and undated. Breaded chicken tenders were observed inside an open cardboard box, exposed and undated. Observation in the kitchen pantry storage room revealed rice stored in a large open bag with no date, white rice in a large paper bag that was open with no date, and extra-long rice in a large, open paper bag with no date. [NAME] sugar was observed in a large plastic bag that was open, with no date. Observations on 5/5/2025 from 1:30 pm to 2:15 pm, during the inspection of the nutrition pantry on the Unit North, with the DM, revealed that the resident refrigerator contained bean dip in a plastic container inside a shopping bag. Inside the shopping bag was a receipt dated 1/31/2025. Further observation revealed three insulated food bags, which the DM stated belong to staff, pineapple chunks in a plastic container dated 3/31/2025, green grapes in a plastic container with a resident's name and no date, and watermelon in a plastic container with no resident name or date. Observations on 5/5/2025 from 1:30 pm to 2:15 pm, during the inspection of the nutrition pantry on the Unit South, with the DM, revealed the resident refrigerator contained slices of deli meat in a plastic bag with no date or resident name, two insulated food bags, which the DM thought belonged to staff, and iced tea in a plastic container with no resident name or date. During an interview on 5/5/2025 at 2:20 pm, the DM confirmed all identified concerns and stated that food products should be in a closed package and dated by staff when taken out of the main refrigerator. The DM confirmed that the rice products should be in closed containers and dated by staff after being opened. The DM stated that food had not been checked for expiration dates. The DM confirmed that the staff members were using the residents' refrigerators, and that resident food was not being dated or labeled with the residents' names.

Based on resident and staff interviews, record review, review of facility documents, and review of the facility policy titled, Management of Residents' Personal Funds, the facility failed to provide written quarterly statements within 30 days of the end of the quarter to one of 43 residents (R) (R78) and/or the resident representative to inform them of the residents' balance in their personal funds account. This failure had the potential to cause R78 and/or the resident representative to be uninformed of the balance in their account. Findings include: Review of the facility's undated policy titled, Management of Residents' Personal Funds, revealed, Policy Statement: Our facility manages the personal funds of residents who request the facility do so. Policy Interpretation and Implementation: . 3. Should the facility manage the resident's funds, the facility acts as a fiduciary of the resident funds and holds, safeguards, manages and accounts for the personal funds of the resident . 4. Should our facility be appointed the resident's representative payee, and directly receive monthly benefits to which the resident is entitled, such funds are managed in accordance with established policies and federal/state requirements . Further review of the facility's policy revealed that the policy failed to address the requirement to provide a written quarterly statement to the resident and/or resident representative within 30 days of the end of the quarter. Review of the Trail Balance report dated 3/1/2025 revealed 43 resident names as having active accounts. Review of R78's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/13/2025, located in the EMR under the MDS tab, revealed R78 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Review of a facility-provided document titled Resident Statement Landscape documented that R78 had a resident account through the facility, with entries dated 2/26/2025 through 5/6/2025. During an interview on 5/6/2025 at 10:29 am, R78 stated he had not received any statements about his account. During an interview on 5/6/2025 at 3:12 pm, the Business Office Manager (BOM) verified that R78 had an active resident funds account. During an interview on 5/6/2025 at 3:40 pm, the BOM stated no quarterly statements had been sent out since the end of December 2024 due to the transition between resident fund management providers. The BOM further stated that the March 2025 statements should have been provided in April 2025.

Based on staff interviews, record review, and review of the facility policy titled, Admission, Transfer, and Discharge, the facility failed to provide a written notification of transfer to the hospital to the resident and resident representative for one resident (R) (R26) reviewed for hospital transfer. This deficient practice had the potential to affect the resident and their representative by not having the knowledge of where and why a resident was transferred and/or how to appeal the transfer, if desired. Findings include: Review of the facility's undated policy titled Admission, Transfer, and Discharge revealed that the policy did not provide guidance related to providing the written notification of transfer to the resident and the resident representative. Review of R26's Electronic Medical Record (EMR) revealed a Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/30/2025, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R26 was cognitively intact. Review of R26's EMR located under the Census tab revealed that R26 was discharged to the hospital on 3/20/2025 and returned to the facility on 3/25/2025. There was no record in the EMR of the facility providing a written notice of transfer to the resident or the resident representative. During an interview on 5/8/2025 at 11:53 am, the Director of Nurses (DON) stated the facility called the family and noted in the chart when a resident was transferred. The DON stated the facility did not provide a written transfer notice to the resident or resident representatives. During an interview on 5/8/2025 at 11:55 am, the Social Services Director (SSD) stated that she was unsure about written transfer notices being sent to the family. During an interview on 5/8/2025 at 1:28 pm, the Assistant Director of Nurses (ADON) stated that the facility called the resident's representative and documented in the nurse notes in the EMR for transfers.

Based on observation, staff interview, and review of the facility policy Food Preparation Safety and Service, the facility failed to ensure expired foods were properly discarded and opened food items were properly dated and labeled in the walk-in cooler, the walk-in freezer, and the dry food pantry. In addition, the facility failed to ensure the oven and food carts were clean. This deficient practice had the potential to affect 83 of 85 residents receiving an oral diet. Findings Include: Review of the facility policy Food Preparation Safety, and Service dated ,d+[DATE] revealed all food sources not in their original packages are covered, dated, and labeled. Further information on this policy includes Part C. Equipment - which indicates all kitchenware and food contact surfaces used to prepare and service food and drink are cleaned and sanitized before use and cleaned after each meal preparation time. Observation of the kitchen on [DATE] at 11:00 a.m. with the Dietary Manager revealed there was expired food in the pantry: Cream of Mushroom Soup dated 2019, Golden Cream Style Corn best by date 2021, and Spice Ground Cinnamon dated [DATE]. The Dietary Manager discarded the food items after the surveyor noted the expiration dates. Observation on [DATE] starting at 10:30 a.m. of the walk-in cooler and freezer with the Dietary Manager revealed the following foods with improper labeling: Vanilla wafers open -no date on bag, sliced tomatoes open and in plastic dietary container with no date on bag, bacon open with no date, smoked sausage open with no date, tater tots (x2) open with no date on bags. During an observation and interview on [DATE] at 10:40 a.m., Dietary Manager confirmed the stove and carts had debris on them. The Dietary Manager also stated it is the responsibility of the person prepping the food to label and date the item.

Based on observation and staff interviews, the facility failed to store resident personal care items in a sanitary manner in two bathrooms shared by a total of eight residents on one of two halls. Findings include: Observation on 3/15/22 at 9:15 a.m. revealed that there were four wash basins nested inside of each other, unlabeled and unbagged, on the shelf in the bathroom shared by four residents in rooms 12 and 13. Observation on 3/15/22 at 9:45 a.m. revealed that there were three wash basins nested inside of each other, unlabeled and unbagged, on the shelf in the bathroom shared by four residents in rooms 16 and 17. Observation on 3/16/22 at 10:00 a.m. revealed that there were four wash basins nested inside of each other, unlabeled and unbagged, on the shelf in the bathroom shared by four residents in rooms 12 and 13. Observation on 3/16/22 at 10:15 a.m. revealed that there were three wash basins nested inside of each other, unlabeled and unbagged, on the shelf in the bathroom shared by four residents in rooms 16 and 17. Observation on 3/17/22 at 9:00 a.m. revealed the same concerns with the unlabeled and unbagged wash basins in the bathroom for rooms 12 and 13, and rooms 16 and 17. Observation in the bathroom shared by rooms 12 and 13, and rooms 16 and 17 revealed that the wash basins remained unlabeled and unbagged. During observation rounds made on 3/17/22 at 8:00 a.m. for rooms 12-13, and rooms 16-17 with Registered Nurse (RN) BB verified the improper storage of resident wash basins. She agreed the wash basins should be labeled with a resident's name and placed in a bag. Interview with RN BB on 3/17/22 at 8:00 a.m. revealed wash basins should be labeled and bagged. She stated the Certified Nursing Assistants (CNAs) are responsible for making sure the wash basins are bagged after each use. RN BB stated the residents receive one shower weekly because of COVID. She stated there is currently no COVID in the building. RN BB also stated residents receives six bed baths and one shower weekly. She stated residents are given baths with the wash basins in the bathroom. RN BB further stated there is no way to know who the wash basins belong to if the basins are not labeled. She stated the CNAs should change the wash basins when they get old and dirty looking. She stated she could not give an exact time frame, but they should change it when it looks dirty probably after a couple of weeks. RN BB stated those wash basins should have been thrown away. RN BB verified the concerns with the sanitary storage of the above wash basins and stated that the wash basins should have been bagged and labeled with the resident's name. Interview with CNA DD on 3/17/22 at 10:30 a.m. revealed there is no set time to change the wash basins. She stated she randomly changes them in a couple of weeks after use. CNA DD stated whoever get the wash basin is responsible for labeling and bagging it. Interview with CNA NN on 3/17/22 at 10:40 a.m. revealed anyone can change out wash basins. She stated if a resident is a new admit whoever admits them can label and bag their wash basin. CNA NN stated if the wash basins are not bagged or labeled it should be thrown away an get new ones. She also stated if the wash basins are not labeled there is no way to tell who it belongs to. Policy on storage of residents' personal care items requested. Interview on 3/17/22 at 11:20 a.m. with Administrator KK revealed there is not a policy on storage of residents' personal care items.

Based on observation, interview, review of training documentation, and review of facility policies, the facility failed to ensure housekeeping staff were aware of proper disinfection techniques in accordance with appropriate standard and transmission-based precautions to prevent the spread of Coronavirus (Covid)-19, on one of two facility wings, the South Wing. There were five residents who tested positive for Covid-19 residing on the South Wing. In addition, one mislabeled spray bottle of disinfectant was identified on the cleaning cart on the North Wing. Findings include: Review of a facility policy entitled, Transmission Based Precautions - Covid-19 (Published 4/10/2020) revealed a policy statement It is WellStar Health System's policy to follow Centers for Disease Control (CDC) on transmission-based precautions for Covid-19. The stated purpose was to define and update a process to control the spread of Covid-19 among patients, staff, visitors, and volunteers. Further review of policy revealed an Environmental policy and procedure change occurred (dated 2/26/2020 -3/10/2020) related to infection prevention regarding patient care equipment cleaning and low-level disinfectants. The policy contained a checklist for terminal cleaning of patient rooms and common areas. The checklist specified staff should use Oxycide (disinfectant) presoaked microfiber cleaning cloths. When using the disinfectant staff should ensure the surface was left sufficiently wet, to stay wet for the dwell time recommended by the manufacturer. A tour of the North Wing of the facility was conducted on 7/14/2020 at 10:45 a.m. There were no residents on the unit identified to be positive for Covid-19. Two residents in separate rooms were identified to be under contact precautions and personal protection equipment (PPE) was noted to be available outside of each resident room. There was one resident observed to be in the common area who was wearing a surgical mask. No other residents were observed to be out of their rooms. A cleaning cart was noted to be stationed in the hallway and a housekeeper GG was observed to be mopping a resident's room. Interview was conducted in a hallway of the North Wing on 7/14/2020 at 10:55 a.m. with Housekeeper GG. Housekeeper GG stated she was assigned to clean all residents' rooms and common areas on the North Wing. Housekeeper GG removed two spray bottles from the cleaning cart, indicating these were the disinfectants used. Observation of the two spray bottles revealed both were labeled as being Virex II 256; however, the liquids contained in each bottle were noted to be different colors. Housekeeper GG stated although each bottle was labeled the same, only one bottle contained Virex II 256 disinfectant. According to Housekeeper GG the second bottle contained a disinfectant called Oxycide. Housekeeper GG indicated the Oxycide disinfectant was stored in a large machine in the housekeeping closet and had to be poured out into a spray bottle. The facility did not have labels available to allow the Oxycide disinfectant to be properly identified and so she had used the mislabeled spray bottle. A tour of the South Wing was conducted on 7/14/2020 at 11:05 a.m. There were no residents observed to be in common areas or in the hallways of the South Wing. Interview conducted in the common area of the South Wing at 11:12 a.m. with a Licensed Practical Nurse (LPN) KK revealed there were five residents on the wing who were positive for Covid-19. According to LPN KK, the residents were confined to one end of the wing and there were empty rooms separating the positive Covid-19 residents from other residents who were negative for Covid-19. Observation revealed the positive Covid-19 residents were under droplet precautions and the appropriate PPE was being utilized by staff providing care for the residents. Interview was conducted on 7/14/2020 at 11:55 a.m. in the conference room with the Housekeeping Supervisor. The Housekeeping Supervisor stated she was responsible for cleaning the South Wing today. The Housekeeping Supervisor stated she used Oxycide disinfectant to clean resident rooms and the disinfectant was stored in a machine in the janitor's closet. The Housekeeping Supervisor confirmed there were no labels to properly identify the disinfectant when it was poured into a spray bottle for use. According to the Housekeeping Supervisor the labels had been ordered but had not arrived at the facility. The Housekeeping Supervisor stated she placed cleaning clothes into a green bucket and poured the Oxycide disinfectant onto the cleaning clothes, allowing them to soak up the disinfectant. She then used the Oxycide disinfectant soaked clothes to wipe off surfaces, followed immediately by using a dry cloth to wipe the disinfectant off the surfaces. Interview was conducted on 7/14/2020 at 2:52 p.m., via telephone, with the Housekeeping Director. The Housekeeping Director stated the disinfectants being used were qualified EPA-registered disinfectants for use against Covid-19. The Housekeeping Director indicated Oxycide came in a large dispensing container and labels for individual bottles come automatically with it. According to the Housekeeping Director, housekeeping staff had been trained in the proper use of Oxycide disinfectant, which was to use the provided green buckets and microfiber clothes. The microfiber clothes should be placed into the green bucket, and the Oxycide disinfectant poured in the bucket to saturate the microfiber clothes. Staff should then use the saturated microfiber clothes to wipe off all surfaces in the room/area being cleaned. It should then be allowed to air dry and should not be wiped off the surface. The Housekeeping Director stated he had conducted huddle training sessions with all housekeeping staff since the Covid-19 pandemic, but the biggest focus was on ensuring the proper use of PPE. Since the facility's cleaning/disinfecting process had not changed, the Housekeeping Director thought housekeeping staff were continuing to implement the proper procedure. The Housekeeping Director stated the facility had a monitoring system in place to determine all surfaces were being cleaned/disinfected. However, the Housekeeping Director stated he had not identified that housekeeping staff were not following facility procedures for proper use of the EPA-approved disinfectants. Interview was conducted on 7/15/2020 at 10:20 a.m. in the conference room with the Administrator. The Administrator stated the housekeeping services were monitored and housekeeping staff supervised by the Housekeeping Director. The Administrator stated the Housekeeping Director served as part of the Infection Control Committee and reported to the committee at each quarterly meeting. The Administrator stated the Housekeeping Director was also responsible for providing all housekeeping staff with in-service training pertinent to assigned job duties and responsibilities. Review of in-service training records revealed Housekeeper GG and the Housekeeping Supervisor both participated in facility provided training on 3/19/2020 and 4/30/2020 regarding Coronavirus and special pathogens and Personal Protection Equipment (PPE). Review of a facility manual titled Environmental Service Department, Housekeeping Safety Data Sheets (revised 9/4/2019) revealed a safety data sheet for Oxycide Daily Disinfectant Cleaner. The safety data sheet contained precautionary statements that included Take any precaution to avoid mixing with combustibles. Keep only in original container. Review of information obtained from the Environmental Protection Agency (EPA) government website (www.epa.gov) revealed when using disinfectants, the most important factor is the products' dwell time or contact time. The disinfectant needs time to breakdown all membranes that surround bacteria [MEDICAL CONDITION]. The EPA defines dwell time as the amount of time a sanitizer or disinfectant must be in contact with the surface and remain wet, in order to achieve the product's advertised kill rate. The contact time for Oxycide is three minutes. The facility's failure to ensure staff utilized EPA-registered disinfectant properly when cleaning surface areas of the facility increased the risk of the spread of infections to all residents, including the spread of Covid-19.

Based on observation, interview, and review of facility policy titled Medication Storage in the Facility, the facility failed to ensure that expired medications and biologicals were not available for resident use in one of two medication storage rooms and on two of four medication carts; and failed to ensure medications were dated appropriately when opened to determine the discard date. In addition, the facility failed to ensure that three of four medication carts remained locked. Findings include: An observation was conducted on 11/18/19 at 6:30 p.m. where the medication cart for South II was found unlocked. There were no wandering residents observed at this time. Interview with Licensed Practical Nurse (LPN) EE on 11/18/19 at 6:35 p.m. revealed that she belonged to the cart and confirmed that it had been unlocked for about 10 minutes. An observation was conducted on 11/18/19 at 7:32 p.m. when a medication cart for the North Wing was observed unlocked for approximately three minutes. Licensed Practical Nurse FF indicated that she knows the medication cart is to be locked at all times. An observation was conducted on 11/21/19 at 10:10 a.m. of the South I medication cart, the observation revealed it was unlocked. The cart was located along the long wall in the South I common area where several residents were seated. LPN AA assigned to the cart was observed sitting at the nurse's station for 10 minutes before she was notified that the cart was unlocked. No resident approached the cart. During the survey process of checking medications on 11/20/19 at 10:25 a.m. of the South II medication cart with LPN BB, the LPN walked away from the medication cart to the nurse's station to look for the narcotic book, leaving the cart unlocked for a few minutes. The South II medication cart was located along the long wall in the South II common area where residents were seated at tables. She then returned to continue checking narcotics. No resident approached the cart. During a brief interview with the Director of Nursing (DON) on 11/21/19 at 2:00 p.m. she confirmed the South Wing has seven residents that have behaviors of wandering, and the North Wing has seven residents that have behaviors of wandering. On 11/20/19 from 10:10 a.m. to 11:30 a.m. observations and medication storage checks were conducted of the facility's four medication carts and two medication storage rooms as follows: At 10:15 a.m. an observation of medications was conducted on the South II medication cart with LPN BB. 1. One [MEDICATION NAME] (insulin) 100 units/ milliliter (ml) flex touch injection pen found contained an expiration sticker, with an expiration date of 11/13/19. 2. One box of 12 [MEDICATION NAME] HCL (antiemetic) 25 milligram (mg) suppositories found with an expiration date of 7/20/19. 3. One [MEDICATION NAME] (antifungal oral solution) 100,00 units/ml, a 340 ml multi-use bottle found opened, with an expiration date of 10/30/20- however, no resident's name was attached, and no date/label found documenting when it was opened, that would determine the discard date. 4. One [MEDICATION NAME] (insulin) Flex Pen 3ml/100 u/ml found contained an expiration date sticker with an expiration date of 11/18/19. At 10:30 a.m. an observation of medications was conducted on the South I medication cart with LPN A[NAME] The LPN confirmed she was unable to determine which resident these following medications belonged to: 1. One container of Taradox/[MEDICATION NAME] (a [MEDICATION NAME] antibiotic) 50 mg/tabs/5 tabs/per container; five tablets were found in the opened container with an expiration date of 9/20. However, no resident's name was attached, and no date/label was found documenting when it was opened that would determine the discard date. 2. One container of Taradox/[MEDICATION NAME] (a [MEDICATION NAME] antibiotic) 50 mg/tab/5 tabs/per container; one tablet was found left in the opened container with an expiration date of 9/20. However, no resident's name was attached, and no date/label was found documenting when it was opened that would determine the discard date. 3. One generic brand Cherry Sore Throat Spray (oral anesthetic/[MEDICATION NAME]) [MEDICATION NAME] 1.4% 6 fluid oz. multi-use bottle was found. No resident's name was attached, and no date/label was found documenting when it was opened that would determine the discard date. At 11:05 a.m. an observation of stored medications was conducted of the North Wing medication storage room with LPN LL. 1. One vial of [MEDICATION NAME] Purified Protein (PPD) ([DIAGNOSES REDACTED]. Unable to determine the number of missing doses. Manufacture's recommendation is to discard product after 30 days from when opened. During an interview on 11/20/19 at 1:00 p.m., the DON that multiple facility staff were responsible for stocking and checking medications. On 11/20/19 at 2:30 p.m. during an interview with Registered Nurse (RN) DD, she confirmed they have an agreement with a local pharmacy, explaining that a Pharmacy Tech comes out monthly to check medications, and can deliver new medications daily. In addition, she stated the nursing staff was responsible for discarding expired medications and placing an open date on multi-use containers and expiration labels on medications with firm expiration dates. Review of the undated facility policy titled Medication Storage in the Facility documented that medication and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications. In Section B. under Procedures, documentation reflects only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. In Section [NAME] under Procedures, documentation reflects refrigerated medications are kept in closed and labeled containers, with internal and external medications separated. In Section K. under Procedures, documentation reflects that outdated, contaminated or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedure for medication disposal and reordered from the dispensing pharmacy, if a current order exists.

Based on record review and staff interviews, the Certified Nursing Assistant (CNA) failed to use two person assist as care planned for one resident (R) (#24) of 39 sampled residents. Findings include: Review of the Minimum Data Set (MDS) Admission assessment dated [DATE] revealed R#24 with a Brief Interview for Mental Status (BIMS) score of 12, indicating cognition intact. Section G Functional Status indicated resident requires extensive assistance two plus person physical assist for bed mobility and transfer. The resident had [DIAGNOSES REDACTED]. Review of the resident's Baseline Care Plan, effective date 8/5/19 at 8:10 a.m. documented: the resident has initial nursing goals at Section No. 2 Safety- resident as risk for falls-no history of falls; Section No. 3 Activities of Daily Living (ADL)- for an assist of 2 for transfers; Section No. 4 documents- checkmarks for wheelchair and mechanical lift for equipment used. Review of the Admission Care Plan effective 8/5/19 to 11/7/19 documents: The resident requires extensive assistance by two staff to move between surfaces as necessary, resident is totally dependent on two staff to provide bath/shower on scheduled bath days and as necessary. A review of the nursing note dated 8/19/19 at 10:20 a.m. documented: Fall Notification. Bath aide had difficulty transferring patient back to wheelchair, lowered to floor in seated position. During an interview on 11/20/19 at 2:50 p.m., CNA JJ explained that she and another CNA had transferred the resident from the bed to the wheelchair because he could only pivot, due to one side of him is weak. She confirmed that she was alone during the shower, had transferred him to the shower chair, had just about finished dressing him when he became un-steady and lost his balance when about to sit back in his wheelchair. Stating she tried to help him but assisted him to slide to the floor. The CNA confirmed she had training and had read the later note that was posted in their electronic software system titled, All Staff Please Note that staff was to use the sit to stand lift or two people to transfer the resident. A brief interview was conducted with the Director of Nurses on 11/21/10 at 12:15 p.m. where she confirmed the facility did not have a Care Plan policy, stating the facility follows the MDS requirements. She also confirmed they do not have a transfer procedure/protocol for residents transferring from bed to wheelchair or wheelchair to shower chair. Cross Refer to F689.

Based on record review and staff interviews, the facility failed to revise the care plan to include updated fall interventions for one resident (R) (#12) of 39 sampled residents. Findings include: A review of the Annual Minimum Data Sets (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 07, indicating severely impaired cognition. The MDS documents active [DIAGNOSES REDACTED]. It also documents one fall without injury and one fall with major injury. A review of incident log revealed that R#12 had falls on 12/5/18, 3/19/19, 4/1/19, 4/5/19, 4/15/19, 5/16/19, 6/6/19, 7/19/19, and 9/13/19. A review of the care plan revealed that the resident was at risk for falls and the interventions had been updated to reflect that resident should have on non-skid footwear and reminded to use rolling walker on 7/9/19. An interview on 11/21/19 at 8:13 a.m. with the Director of Nursing (DON) revealed that all falls were discussed during the Fall Team Meeting that meets weekly. A review of the SAFER report for R#12 revealed that both staff and the resident were educated multiple times about wearing non-skid footwear and keeping the resident's walker within the resident's visual field. No other new interventions were added. An interview on 11/21/19 at 11:25 a.m. with Licensed Practical Nurse/MDS nurse KK confirmed that no new interventions have been added to the care plan except for having non-skid soles and walker within vision even though the resident has had 9 falls in the last year. She stated that she doesn't know why no new interventions have been added. She stated that MDS participated in the weekly fall meetings. She also stated that during the fall meetings they try to figure out what happened and what they can do to intervene. Interview and review of SAFER reports on 11/21/19 at 12:02 p.m. with RN, QM/Infection Control Nurse DD confirmed that the only new interventions added in the last year were to have non-skid socks on at night and have her walker where she can see it. An interview on 11/21/19 at 1:48 p.m. with RN, Nurse Practitioner MM revealed that she remembered the resident falling and breaking her left hand. She stated that at that time the resident was in a four-bed ward room and had since been moved to a semi-private room with a decreased walking distance to the bathroom and the resident has had no further falls since she had been moved to the new room. An interview on 11/21/19 at 2:07 p.m. with the DON and the RN, MDS Coordinator HH revealed that they were able after reviewing incident notes and fall meeting notes to find interventions that had been put in place for the falls but they confirmed that the interventions were not added to the care plan and that they have no way to show that the interventions were being evaluated for reducing the resident's falls. The RN, MDS Coordinator stated that she was unsure why these interventions had not been added to the care plan. The interview also revealed that they do not have a policy for care plans but use the Resident Assessment Instrument (RAI) guidelines.

Based on record review, review of the facility's Safety Policy #8201-200-21 and staff interviews, the facility failed to use two person assist which resulted in a fall for one resident (R) (#24) of three residents reviewed for falls. Findings include: A record review was conducted that documented R#24 was admitted [DATE] from an acute hospital with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Admission assessment dated [DATE] revealed R#24 with a Brief Interview for Mental Status (BIMS) score of 12, indicating cognition intact. Section G Functional Status indicated resident requires extensive assistance two plus person physical assist for bed mobility and transfer. A review was conducted of the 8/3/19 at 7:22 a.m. Fall Risk Admission Assessment form documenting that R#24 has a history of a gait disorder/lower extremity weakness, is non-ambulatory, and requires physical assistance of one or two. Review of the resident's initial Physical Therapy evaluation, dated 8/5/19, in section titled Functional Characteristics and Analysis-Functional Mobility, documented poor unsupported and supported sitting balance. Pelvis is posteriorly tilted causing him to slide forward into wheelchair. Sit to standing using walker at bedside required max of two. Stand-pivot transfer bed to wheelchair with max of two. Review of the resident's Baseline Care Plan, effective date 8/5/19 at 8:10 a.m. documented: the resident has initial nursing goals at Section No. 2 Safety- resident as risk for falls-no history of falls; Section No. 3 Activities of Daily Living (ADL)- for an assist of 2 for transfers. Review of the Admission Care Plan effective 8/5/19 to 11/7/19 revealed: The resident requires extensive assistance by two staff to move between surfaces as necessary, resident is totally dependent on two staff to provide bath/shower on scheduled bath days and as necessary. Record review of the nursing note dated 8/19/19 at 10:20 a.m. documentation reflects a Fall Notification. Bath aide had difficulty transferring patient back to wheelchair, lowered to floor in seated position. Certified Nursing Assistant (CNA) and Licensed Practical Nurse (LPN) called to assist. Vitals taken, B/P 115/62, HR 95, Temp 97.5, O2 saturation 97%. Wife notified via in person and notified Nurse Practitioner (NP) via email. Injuries noted: None. Treatments initiated: N/[NAME] Interventions: Non-Skid Socks. Neuro-checks initiated? Yes. Name and time of family notified: wife notified at 10:30 a.m. Physician name and time notified: NP 10:30 via email. A review conducted of the facility form (event log) provided titled, All Events for period 7/16/18 to 11/19/19 documented R#24 sustained a fall on 8/19/19 while transferring, no harm- an event occurred that reached the patient but did not cause patient harm. During an interview on 11/20/19 at 2:50 p.m., CNA JJ explained that she was filling in for a shower CNA the day of the incident. She stated that she and another CNA had transferred R#24 from the bed to the wheelchair because he could only pivot, due to one side of him is weak. She confirmed that she was alone during the shower, had transferred him to the shower chair, had just about finished dressing him when he became un-steady and lost his balance when about to sit back in his wheelchair. Stating she tried to help him but assisted him to slide to the floor. She confirmed she called for help, the floor nurse and another CNA came and helped her to get him up into his wheelchair. She confirmed the resident did not complain of any pain or have an injury. The CNA confirmed she had training and had read the later note that was posted in their electronic software system titled, All Staff Please Note that staff was to use the sit to stand lift or two people to transfer the resident. A brief interview was conducted with the Director of Nurses (DON) on 11/21/10 at 12:15 p.m. where she confirmed the facility does not have a transfer procedure for residents transferring from bed to wheelchair or wheelchair to shower chair. A review was conducted of the provided facility policy titled Safety Policy #8201-200-21 reviewed last on 7/2019. Policy revealed the Skilled Nursing Facility ensures that the resident's environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents. The multidisciplinary care plan team will evaluate all interventions to ensure the appropriate procedures have been implemented to prevent further accidents.