Every finding on record at Greene Point Health and Rehabilitation

Based on observations, staff interviews, and a review of the facility policy titled Medication Storages in the Care Center the facility failed to properly lock and secure two of five medication carts (medication cart A-hall and medication cart C-hall). Review of the policy titled, Medication Storage in the Care Center with a review date of 12/21/2025 documented under the section Intent: to facilitate safe, secure and proper storage of medication and biologicals following manufacturer's recommendations or those of the supplied . Under the section Guideline: medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. The Director of Nursing (DON) is responsible for controlling access to medication carts. The DON is accountable for overseeing the security of medication carts at the center. 1.During an observation and interview on 03/27/2026 at 7:32 AM with the DON revealed medication cart C-hall was unlocked and unattended. She stated the staff responsible for that cart worked on C-hall. During an interview on 03/28/2026 at 4:14 PM with the DON stated her expectations are for all carts to be locked and the nurse should take the medication keys with them. 2.Observation on 03/28/2026 at 8:38 AM revealed Certified Medication Aide (CMA) AA unlocked the A hall medication (med) cart and stated she was going to start her med pass, but she had to see if the resident was in her room because she needed to check her blood pressure before she gave the blood pressure pill. CMA AA walked away from the unlocked med cart and walked down A hall. CMA AA returned to the unlocked med cart at 8:39 AM. CMA AA stated that the resident was not in her room. CMA AA looked at the unlocked med cart and stated to the surveyor that she apologizes for not locking the cart before she walked away.

Based on record review, staff and family interviews, and review of the facility policy titled, Abuse Prohibition, the facility failed to protect the resident's right to be free from physical abuse by another resident (R) (R2) for one of three residents (R) (R1) reviewed for abuse. Findings include: A review of the facility policy titled, Abuse Prohibitions dated 4/7/2025 documented under Intent: It is the intent of this center to actively preserve each patient's right to be free from mistreatment, neglect, abuse, misappropriation of patient property. We believe each patient has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. 1. Review of the electronic medical record (EMR) revealed R1 was admitted to the facility with pertinent diagnoses including but was not limited to fracture of unspecified part of the neck of right femur, subsequent encounter for closed fracture with routine healing, unspecified dementia, unspecified severity with other behavioral disturbances, Alzheimer's disease with early onset, and anxiety disorder. Review of R1 quarterly and annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 0, which indicates R1 has severe cognitive impairment. Section GG, functional status, revealed R1 requires moderate assistance for activities of daily living (ADLs) with one person assistance. R1 benefits from the use wheelchair toileting, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene requires moderate assistance. Review of R1's care plan dated 9/18/2024 indicated a problem of cognitive impairment. Goals included but not limited to patient needs will be maintained during review period and patient safety will be maintained during review period. Interventions included but not limited to administer medication as ordered, allow patient ample time to absorb and respond to information, provide consistent routine, and SATFF (sic) NOT TO ALLOW RESIDENT TO PUSH HER W/C (wheelchair). Continued review of R1's care plan dated 9/18/2024 indicated a problem of anxiety. Goals included but not limited to patients will demonstrate reduction in symptoms of anxiety episodes through the review period. Interventions included but not limited to Administer medication as ordered, analyze key times, places, circumstances, triggers, and what de-escalates anxiety, psychiatric/psychological evaluation as indicated. 2. Review of the EMR revealed R2 was admitted to the facility with pertinent diagnoses including but was not limited to Alzheimer's disease, altered mental status, unspecified, dementia in other diseases classified elsewhere, severe, with agitation. Review of R2 quarterly and annual MDS assessment dated [DATE] revealed a BIMS score of 99, which indicates R2 has severe cognitive impairment. Section GG, functional status, revealed R2 required/was assistance for activities of daily living (ADLs) with one person assistance. Walks without assistance, toileting, setup or clean-up assistance, shower/bathe self- partial/moderate assistance, upper body dressing, lower body dressing, putting on/taking off footwear- independent, and personal hygiene- supervision or touching assistance. Review of R2 care plan dated 10/1/2024 indicated a problem of behaviors. Goals included but not limited to patient's needs will be met and safety maintained during review period and patient will demonstrate improvements during the review period. Interventions included but not limited to administer medications for a clearly defined goal aimed at a specific target behavior for which the drug is effective, analyze key times, places, circumstances, triggers, and what de-escalates behavior, assess for the need of pain medication adjustment, and assess patterns of behavior with behavior monitoring. Review of the progress note in the HER that documented, CNA (certified nursing assistant) BB reported that R1 was grabbed around the neck by another resident by the name of R2. R2 was trying to snatch another resident's belongings, and the resident snatched her belongings back and R2 got upset and grabbed another resident, R1 around the neck. The CAN BB stated that she had to pull R2's hand from around R1's neck. No apparent injury of R1, made aware by Registered Nurse (RN) AA 8/31/2025. Review of the past 12 months of the facility's state reportable incidents (FRI's) revealed no incidents for August 2025 which included R1 and R2's incident of physical abuse. Review of the past 12 months of the facility's FRI's revealed a reportable from November 2024 in which R2 threw coffee on R1. Phone Interview with Registered Nurse (RN) AA on 10/29/2025 at 3:09 pm confirmed CNA BB was working and reported to her the choking incident between R1 and R2. She further revealed CNA BB stated she took R2's hands from around R1's neck. RN AA revealed when she reported the incident to the Director of Nursing (DON), she was instructed to put R2 on 1:1 (one to one) observations. RN AA revealed in order to keep the residents safe in the facility, they will do a 1:1 with R2 if enough staff was present. She revealed R2 was mostly in the hallways but would venture into another resident's room. They always try to keep eyes on R2 as best as they could, but she seemed to target R1. Interview on 10/29/2025 at 2:05 pm with the Scheduling Coordinator revealed R2 would go into other resident rooms and would walk up and down the hallway until she got tired. R2 would have restless nights and would sometimes push other residents. The Scheduling Coordinator revealed R2 would lash out at other residents and staff. The Scheduling Coordinator revealed RN AA was the RN on shift that day. She reported if she saw a resident have behaviors, then she would report it to the nurse. An interview with CNA BB on 10/30/2025 at 1:07 pm confirmed she did report to RN AA the choking incident between R1 and R2. She further stated she was in the front of the building near the nurse station when she saw R2 with her hands around R1's neck. CNA AA revealed she was not able to verbally prompt R2 to let go of R1 but had to use hand over hand physical assistance to remove R2's hand from around R1's neck. She then stated at that time she reported the incident to the weekend manager (RN AA). Interview on 10/29/2025 at 4:49 pm with the Director of Nursing (DON) revealed she was aware of the reported choking incident. The DON revealed she did question CNA BB about the incident on the same day that it occurred, since she reported it. She spoke with the Nurse Practitioner (NP) because she wanted R2 to be 1013'd (involuntary treatment) to the psychiatric hospital. The NP said she would monitor her and review medications in house. From there the DON stated staff observed 1:1 ration with R2 on that Sunday when the incident happened and told the nurse on duty to get the 1:1 sheet off copier and start for two days. When the DON returned to work on the following Tuesday and R2 was reassessed by the NP (who comes three times per week). The 1:1 for R2 was discontinued on 9/2/2025 when the DON returned to work. Interview with the Administrator on 10/29/2025 at 5:09 pm revealed the Administrator had received complaints regarding R2 because she wandered into resident rooms and was touchy, but staff would redirect her. The Administrator further revealed she was not aware of the reported choking incident. Cross refer to F609 and F610

Based on staff interviews, record review, and review of the facility policies titled, Abuse Prohibition - Reporting and Investigating and Abuse Prohibition, the facility failed to report an incident of physical abuse within two hours of identifying to the State Agency (SA) for two of three residents (R) (R1 and R2).Findings include: A review of the facility policy titled, Abuse Prohibition – Reporting and Investigating dated 12/27/2024 documented under Intent: It is the intent of this center to establish standards of practice for investigation and reporting of abuse, neglect, mistreatment, exploitation, and misappropriation of property. Guidelines: Reporting- All allegations of abuse or allegations involving serious bodily injury must be reported immediately but no later than 2 hours. A review of the facility policy titled, Abuse Prohibition dated 4/7/2025 documented under Identification of possible abuse, neglect, or exploitation: Identification and coverage: Any person observing abuse, neglect, or exploitation as previously defined, should immediately report it to the Administrator or the direct supervisor (i.e. Charge Nurse, Director of Nursing, Departmental Leaders) present at the time of the incident. Any person hearing or receiving an allegation or complaint of abuse, neglect, or exploitation should immediately report to the Administrator or the direct supervisor (i.e. Charge Nurse, Director of Nursing, Departmental Leaders) present at the time of the incident. 1. Review of the electronic medical record (EMR) revealed R1 was admitted to the facility with diagnoses including but was not limited to fracture of unspecified part of the neck of right femur, subsequent encounter for closed fracture with routine healing, unspecified dementia, unspecified severity with other behavioral disturbances, Alzheimer's disease with early onset, and anxiety disorder. Review of R1 quarterly and annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 0, which indicates R1 has severe cognitive impairment. Section GG, functional status, revealed R1 requires moderate assistance for activities of daily living (ADLs) with one person assistance. R1 benefits from the use wheelchair toileting, shower/bathe self, upper body dressing, lower body dressing, putting on/ taking off footwear, personal hygiene requires moderate assistance. Review of R1 care plan dated 9/18/2024 indicated a problem of cognitive impairment. Goals included but not limited to patient needs will be maintained during review period and patient safety will be maintained during review period. Interventions included but not limited to administer medication as ordered, allow patient ample time to absorb and respond to information, provide consistent routine, and SATFF (sic) NOT TO ALLOW RESIDENT TO PUSH HER W/C. Review of R1 care plan dated 9/18/2024 indicated a problem of anxiety. Goals included but not limited to patients will demonstrate reduction in symptoms of anxiety episodes through the review period. Interventions included but not limited to Administer medication as ordered, analyze key times, places, circumstances, triggers, and what de-escalates anxiety, psychiatric/psychological evaluation as indicated. 2. Review of the EMR revealed resident R2 was admitted to the facility with diagnoses including but was not limited to Alzheimer's disease, Altered mental status, unspecified, dementia in other diseases classified elsewhere, severe, with agitation. Review of R2 quarterly and annual MDS assessment dated [DATE] revealed a BIMS of 99, which indicates R2 has severe cognitive impairment. Section GG, functional status, revealed R2 required/was assistance for activities of daily living (ADLs) with one person assistance. Walks without assistance, toileting, setup or clean-up assistance, shower/bathe self- partial/moderate assistance, upper body dressing, lower body dressing, putting on/taking off footwear- independent, and personal hygiene- supervision or touching assistance. Review of R2 care plan dated 10/1/2024 indicated a problem of behaviors. Goals included but not limited to patient's needs will be met and safety maintained during review period and patient will demonstrate improvements during the review period. Interventions included but not limited to administer medications for a clearly defined goal aimed at a specific target behavior for which the drug is effective, analyze key times, places, circumstances, triggers, and what de-escalates behavior, assess for the need of pain medication adjustment, and assess patterns of behavior with behavior monitoring. Record review of the requested facility state reportable incidents from the last 12 months revealed no reported incident of R1 and R2 which involved choking. Interview on 10/29/2025 with Registered Nurse (RN) AA at 3:09 pm revealed she did complete an incident report regarding the choking incident between R1 and R2 and was told by the administrative team to start 1:1 (one to one) with R2. She further revealed the protocol was to report to the Director of Nursing (DON), Administrator, and family members along with ensuring resident safety first. Joint Interview on 10/29/2025 with the DON and the Administrator at 5:09 pm revealed the Administrator was not aware of choking incident between R1 and R2. The DON revealed she was aware, but she didn't report to state agency. The DON stated she cannot remember if she reported the incident to the Administrator. The DON further revealed she spoke to the facility Nurse Practitioner about the choking incident. Cross refer to F600 and F610

Based on staff interview, record review, and review of the facility policies titled, Abuse Prohibition, Abuse Prohibition - Reporting and Investigating, and Falls, the facility failed to complete a thorough investigation of witnessed physical abuse for two of two residents (R) (R1 and R2). Findings include: A review of the facility policy titled, Abuse Prohibition – Reporting and Investigating dated 12/27/2024 documented, All investigative information will be kept on file in a secured location. All information gathered is confidential information. A review of the facility policy titled, Abuse Prohibition dated 4/7/2025 documented, Identification of patients whose behavior is abusive to other patients. If a patient is identified in one of the following categories, a thorough assessment will be completed to include any identified situations or factors that trigger abusive behavior. Appropriate interventions should be implemented in an effort to protect patients and associates. A review of the facility policy titled, Fall Management dated 12/27/2024 documented, Defining a Fall: Current CMS guidelines regarding falls states that a fall is defined as an unintentional change in position that results in someone landing on the floor, ground, or lower surface including whether the event was witnessed/un-witnessed. Fall Event: When a fall occurs: The patient should receive a head-to-toe assessment to identify injuries or changes in condition. The patient should be observed and interviewed, along with any witnesses, to determine possible cause of the fall. The patient should have interventions implemented to prevent recurrence and maintain safety. The licensed nurse should complete the Initial Event in the EHR to capture the investigation of the fall and assessment of the patient. 1. Review of the electronic medical record (EMR) revealed R1 was admitted to the facility with pertinent diagnoses including but was not limited to fracture of unspecified part of the neck of right femur, subsequent encounter for closed fracture with routine healing, unspecified dementia, unspecified severity with other behavioral disturbances, Alzheimer's disease with early onset, and anxiety disorder. Review of R1 quarterly and annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 0, which indicates R1 has severe cognitive impairment. Section GG, functional status, revealed R1 requires moderate assistance for activities of daily living (ADLs) with one person assistance. R1 benefits from the use wheelchair toileting, shower/bathe self, upper body dressing, lower body dressing, putting on/ taking off footwear, personal hygiene requires moderate assistance. Review of R1 care plan dated 9/18/2024 indicated a problem of cognitive impairment. Goals included but not limited to patient needs will be maintained during review period and patient safety will be maintained during review period. Interventions included but not limited to administer medication as ordered, allow patient ample time to absorb and respond to information, provide consistent routine, and SATFF (sic) NOT TO ALLOW RESIDENT TO PUSH HER W/C. Review of R1 care plan dated 9/18/2024 indicated a problem of anxiety. Goals included but not limited to patients will demonstrate reduction in symptoms of anxiety episodes through the review period. Interventions included but not limited to Administer medication as ordered, analyze key times, places, circumstances, triggers, and what de-escalates anxiety, psychiatric/psychological evaluation as indicated. 2. Review of the EMR revealed resident R2 was admitted to the facility with pertinent diagnoses including but was not limited to Alzheimer's disease, Altered mental status, unspecified, dementia in other diseases classified elsewhere, severe, with agitation. Review of R2 quarterly and annual MDS assessment dated [DATE] revealed a BIMS of 99, which indicates R2 has severe cognitive impairment. Section GG, functional status, revealed R2 required/was assistance for activities of daily living (ADLs) with one person assistance. Walks without assistance, toileting, setup or clean-up assistance, shower/bathe self- partial/moderate assistance, upper body dressing, lower body dressing, putting on/taking off footwear- independent, and personal hygiene- supervision or touching assistance. Review of R2 care plan dated 10/1/2024 indicated a problem of behaviors. Goals included but not limited to patient's needs will be met and safety maintained during review period and patient will demonstrate improvements during the review period. Interventions included but not limited to administer medications for a clearly defined goal aimed at a specific target behavior for which the drug is effective, analyze key times, places, circumstances, triggers, and what de-escalates behavior, assess for the need of pain medication adjustment, and assess patterns of behavior with behavior monitoring. Review of the facility state reportable incidents (FRIs) of the last 12 months failed to document a complete investigation of the incident between R1 and R2 on 8/31/2025. Cross refer F600 and F609

Based on observations, staff interviews, and review of facility policies titled Storage Areas and Food Preparation and Distribution, the facility failed to discard milk by the use by date; failed to remove dented cans from the dry storage area; and failed to properly thaw ground beef to prevent bacteria growth and food borne illness. The facility had a census of 44 out of 48 residents that consumed an oral diet from the kitchen. Findings include: Review of the facility's policy titled Storage Areas dated 12/29/2023 under the section titled Guideline revealed, Dry Storage: Dented cans should be stored separately in a clearly labeled area. Review of the facility's policy titled Food Preparation and Distribution dated 12/29/2023 under the section titled Guideline revealed, Thawing methods: Submerged under running water at a temperature no greater than 70 F. 1. Observation on 12/6/2024 at 8:35 am of the two-door reach-in refrigerator near the steam table revealed an open case of 18, eight-ounce cartons of 2% (two percent) milk with a use by date [DATE]. During an interview on 12/6/2024 at 8:35 am, the Dietary Manager (DM) confirmed that the cartons of 2% milk had a use by date of [DATE]. The DM revealed that dietary staff should have discarded the milk. 2. Observation on 12/6/2024 at 8:45 am of the canned food storage rack revealed a can of black beans with a large dent towards the bottom. During an interview on 12/6/2024 at 8:45 am, the DM confirmed that the can of black beans was in the food storage rack and had a large dent. The DM revealed that dietary staff should have not placed the can in the rack and should have placed the dented can in her office which was the location for damaged cans. 3. Observation on 12/7/2024 at 8:50 am of the food preparation sink labeled Meat revealed a large tube of ground beef. The ground beef was on the bottom of the sink with cool water from the faucet running over the top. The ground beef was not covered or submerged in water. During an interview on 12/7/2024 at 8:50 am, the DM confirmed that the tube of ground beef was in the process of being thawed to use for lunch meal. The DM did not want to confirm if the ground beef was being properly thawed using the sink and running water. The DM did confirm that food items thawed in a sink should be submerged in water. The DM revealed that the ground beef should have been taken out of the freezer a few days earlier and placed in the refrigerator to be thawed.

Based on observations, staff interviews, record review, and review of facility's policy titled Tube Feeding Syringes, the facility failed to clean and store a tube feeding syringe after use for one of four residents (R) (R44) who received nutrition through a gastrotomy tube. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs, increased risk for infection, and a diminished quality of life. Findings include: Review of the facility's policy titled Tube Feeding Syringes dated 12/29/2023 under the section titled Intent revealed, It is the intent of this center to help prevent nosocomial infections (infection that develops during medical treatment) associated with enteral feeding equipment. Under the section titled Guidelines revealed, The following Procedural guidelines should be followed when storing a piston syringe: Tube Feeding and Medication Administration: wash the syringe; separate the piston from the barrel; Store the syringe separated on a clean surface to air dry, or place separated in a bag mounted to the feeding pump pole (the bag should not be airtight). Review of the Electronic Medical Record (EMR) revealed, R44 was admitted to the facility with diagnoses that included but was not limited to aphasia (inability to swallow), dysphasia (difficulty swallowing foods or liquids) following a cerebral infarction (stroke), and gastrostomy (surgical opening to the stomach for introduction of food) status. Review of R44's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 11/8/2024 revealed Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) of five, which indicated R44 had severe cognitive impairment; Section K (Swallowing/Nutritional status) revealed, R44 received 25% or less calories through parenteral or tube feeding and an average fluid intake per day by tube feeding of 1500 millimeters/day or less as a resident. Review of R44's EMR revealed physician's orders that included but was not limited to: Peg-tube flush, 150 milliliter every four hours per feeding tube dated 6/6/2024 and Peptamen 1.5 calories, one carton per feeding tube at bedtime; may be held for activities of daily living care, therapy, and medication administration dated 10/10/2024. Observations on 12/7/2024 at 7:48 am of R44's room revealed, a catheter tipped syringe on the nightstand uncovered with a white colored liquid in the tip of the syringe. There was a clear bag observed next to the uncovered syringe dated 12/6/2024. Observations and interview on 12/7/2024 at 2:55 pm with Licensed Practical Nurse (LPN) Wound Care Nurse AA revealed, a catheter tipped syringe with a white colored liquid in the tip of the syringe. LPN Wound Care Nure AA confirmed the observation and stated the catheter tipped syringe should not be stored on the nightstand. She stated the syringe should be cleaned after use, allowed to air dry, and then placed into a protective covering. Observation and interview on 12/7/2024 at 3:01 pm with the Assistant Director of Nursing/ Infection Preventionist revealed an observation of a catheter tipped syringe with a white colored liquid in the tip of the syringe lying on R44's nightstand uncovered. She confirmed the observation and revealed the syringe should not be left on the nightstand uncovered. She stated the nurse should clean and rinse the syringe thoroughly with water, allow to air dry, then place the syringe in a protective covering after each use. She stated the possible outcome of this practice would be the resident could develop a possible infection. Interview on 12/8/2024 at 12:19 pm with the Director of Nursing revealed that her expectation was that the nurse rinse the syringe out after use, allow the syringe to air dry, and then place the syringe in a protective covering. She stated the possible outcome of this practice would be the resident could possibly develop an infection.

Based on observations, staff interview, and review of the facility policy titled, Skilled Nursing Services - Storage Areas, the facility failed to ensure that opened food items were labeled and dated. The deficient practice had the potential to affect 41 residents receiving an oral diet. Findings include: Review of the facility policy titled, Skilled Nursing Services - Storage Areas, reviewed 12/30/2022 revealed food items should be covered, sealed, labeled, and dated appropriately. Observation on 7/28/2023 at 8:11 a.m. of the stand-alone refrigerator number four revealed a plastic bag containing mozzarella cheese slices that had not been labeled with an open date. Observation on 7/28/2023 at 8:18 a.m. of the stand-alone freezer number one revealed a large bag of frozen rolls that did not have a label with an open date. Further observation revealed an unknown meat wrapped in tin foil that did not have a label to identify the meat or an open date. Observation on 7/28/2023 at 8:16 a.m. of the stand-alone freezer number two revealed a large bag of chicken breasts that had been opened but did not have a label or an open date. Observation on 7/28/2023 at 8:20 a.m. of the stand-alone freezer number six revealed a bag of tater tots, cookies, French fries, and a 31-ounce bag of chopped green peppers, all unlabeled with no open date. Observation on 7/28/2023 at 8:23 a.m. of the stand-alone refrigerator in the kitchen (no number) revealed a 48-ounce jar of apple sauce and a 24-ounce plastic container of cottage cheese. Both items were unlabeled with no open date. Observation on 7/28/2023 at 8:25 a.m. of the stand-alone refrigerator located near the dry storage area (no number) revealed a bag with an unknown brown pudding type substance and a 16-ounce plastic container of frosting, which were unlabeled and did not have an open date. Further observation revealed a large stainless-steel bowl of chicken salad covered with tin foil, with an ice-cream scoop sitting on top of the chicken salad. The container was not labeled or dated. Observation on 7/28/2023 at 8:31 a.m. of the dry storage area revealed a 42-ounce container of quick oats, a 15-ounce box of sweetened corn cereal, a bag of devil's food cake mix (no weight), and a large bin of spiral pasta (no weight). All items were unlabeled with no open date. Observation on 7/28/2023 at 8:37 a.m. of the stand-alone freezer in the dining room revealed a large bag of frozen peas that were not labeled with the open date. Interview on 7/28/2023 at 8:42 a.m. with the Dietary Manager (DM) she acknowledged that the dry storage area, refrigerators, and freezers contained items that were not labeled and dated after they were opened. The DM explained she expected staff to label and date items after opening. She added that she also expected staff not to leave serving utensils inside any food containers.

Based on observation, staff interview and review of the Georgia Food Code: US Food Code: Nation Restaurants Association/Serv Safe Guidelines and the undated facility policy titled, Food and Nutrition Services, the Dietary Manger (DM) failed to wash or sanitize her hands, or to wear gloves, prior to checking steam table temperatures during lunch service. This deficient practice had the potential to affect 40 residents receiving an oral diet. Findings Include: Review of the undated facility document titled Georgia food code: US Food Code: Nation Restaurants Association/Serv Safe Guidelines, revealed proper food safety handling practices should be implemented to minimize the risk of food borne illness. Guidelines of Cross Contamination revealed good hand washing techniques should be practiced, no bare hand contact with food items, and gloves should be changed between tasks. Review of the undated document titled Food and nutrition services: personal food items 4 (a) 1. revealed that that the proper hand washing protocol must be done as outlined in the procedure under DPH rule 511- 6-1-03 (5) to protect the cooked meal by contamination with bare hands. Observation and Interview on 3/29/22 at 12:34 p.m. with the DM, revealed that she performed the task of checking temperatures on the buffet during lunch and did not wash or sanitize her hands prior to task and she did not wear gloves during task. During this time an interview was conducted with the DM, and she revealed because she did not actually touch the food itself, she did not need to wear gloves for this task. An observation was made at this time of staff using utensils to place food onto plates and were wearing gloves. Observation on 3/29/22 at 12:34 p.m. with DM, revealed she did not wash her hands, use any hand sanitizer, or wear any gloves during obtaining steam table temperatures. Interview on 3/29/22 at 1:00 p.m. with the DM, confirmed she did not wear gloves when performing the task of checking food temperatures on the tray line and stated she doesn't recall if she washed or sanitized her hands prior to performing task. Interview on 3/29/22 at 3:00 p.m. with the Registered Dietitian (RD) for the facility, revealed she expects the kitchen staff to always follow kitchen food handling policies and procedures and proper infection control practices. Interview on 3/30/22 at 11:15 a.m. with Corporate Nurse Consultant, revealed that they don't have any infection control policy in the kitchen, but they do follow Food and Nutrition Guidelines from Georgia food code. Interview on 3/31/22 at 1:30 p.m. with Cook BB, confirmed that she has observed DM fail to follow the procedure for safe food handling before taking the temperature of the foods.

Based on record review and staff interviews, the facility failed to ensure the Administrator held a current license from the State of Georgia during the timeframe of [DATE] through [DATE]. Findings include: Upon request for employee records on [DATE], the Administrator was unable to provide a current copy his Administrator's license. Review of the Administrator's license at: http://verify.sos.ga.gov/verification/ revealed the license expired on [DATE]. During an interview with the Administrator on [DATE] at 5:54 p.m., he stated that he knew his license was due to expire on [DATE] and he renewed it timely but was unaware it had not processed until it was requested by the Survey Team. He stated he would not return on [DATE] and the corporate office would be sending the Regional Vice President (RVP) to replace him. He confirmed the facility was without a licensed Administrator from [DATE] through [DATE]. Interview with the RVP on [DATE] at 9:00 a.m., revealed that the Administrator was suspended on [DATE] pending the outcome of the investigation by the corporate office. He stated the Administrator was suspended until the license was renewed and an Interim Administrator was installed as of [DATE]. In addition, the RVP stated the corporate office performed an audit of all licensed personnel to confirm all licenses and certifications were current. On [DATE] at 9:00 a.m., The RVP brought in interim Administrator to run the facility until further notice.

Based on observations, staff interviews, record review, and review of the undated facility policy titled, Direct Supply TELS, the facility failed to maintain safe hot water temperatures for 17 rooms on two of three units, 100 Hall and 300 Hall, plus one Shower Room. Findings include: Review of the undated facility policy titled, Direct Supply TELS documented the following regarding the monitoring of water temperatures: 1. Ensure patient room water temperatures are between 105° and 115° Fahrenheit (or as specified by state requirements) .Georgia - shall not exceed 110 degrees Fahrenheit (F). Observation of resident rooms on 3/29/22 beginning at 10:00 a.m. on the 100 Hall and 300 Hall revealed hot water was extremely hot to touch in the following resident bathrooms: 101/103, 102/104, 105/107, 106/108, 109/111, 110/112, 301, 302, 303/304 and 305. On 3/29/22, beginning at 11:05 a.m., observation and testing of water temperatures in the resident's bathrooms with the Maintenance Director (MD) confirmed the following: 101-103=121.6 °F 102-104=130.6 °F 105-107=123.7 °F 106-108=129.1 °F 109-111=124.3 °F 110-112=127.5 °F 301-P=129.7 °F 302-P=125.0 °F 303-304=123.5 °F Bath=127.3 °F 305=122.5 °F During observation and interview with MD on 3/29/22 at 11:25 a.m., he observed the hot water heater on the 300 Hall which revealed the mixer was turned up to 130°F. He stated he sets the mixer at 110°F but staff have been known to adjust it when he's not in the building. He stated staff should notify him of needed repairs by entering a maintenance request into the electronic maintenance system called TELS. He stated that staff mostly just tell him what they need when they see him. Observation on 3/29/22 at 11:27 a.m. of the hot water heater located on the 200 Hall revealed it had a mixing valve but no gauge to set the temperature, so the MD measures the water temperature after making an adjustment. Interview with the Administrator on 3/29/22 at 11:30 a.m., surveyor informed him of the hot water readings on the 100 and 300 halls. He stated he was not aware of staff adjusting the mixing valves and had no resident complaints of [CONDITION(S)] to skin or water being too hot. He stated he would address the matter as soon as possible with the staff and contact a plumber for an assessment today. He stated he expected the staff to refrain from adjusting the hot water heaters and contact the MD with any problems. Observation Rounds on 3/29/22 5:10 p.m., with the MD after plumbing service revealed the following: 101-103=91.9°F 102-104=100.1°F 105-107=93.2°F 106-108=98.7°F 109-111=95.6°F 110-112=97.4°F 305=94.4°F 303-304=93.9°F 301-302=95.1°F Follow-up temperatures documented by the MD on 3/30/22 at 8:16 a.m. revealed the following: 102-104=103.4°F 101-103=98.6°F 106-108=103.2°F 110-112=99.3°F 111-109=101.6°F 107-105=103.7°F 305=102.8°F 304-303=103.6°F 302=99.4°F 301=102.8°F On 3/30/22 at 5:15 p.m., the MD documented the resident bathroom temperatures on the two resident units between 97.7°F and 101.6°F.

Based on observation, interviews, and review of policy titled Food and Nutrition Services: Meal Service the facility failed to ensure that staff used proper hand sanitation methods during meal service for two of two meal observations. The facility census was 47 residents. Findings include: Observation on 8/3/18 at 12:47 p.m. during service of the lunch meal revealed Certified Nursing Assistant (CNA) AA serving a lunch tray to the resident in room [ROOM NUMBER]-1. The CNA removed the resident's roll from a wax packet with her bare hand and placed it on the resident's plate. Observation on 8/3/18 at 12:49 p.m. during service of the lunch meal revealed CNA AA serving a lunch tray to the resident in room [ROOM NUMBER]-1. The CNA removed the resident's roll from a wax packet with her bare hand and placed it on the resident's plate. Observation on 8/4/18 at 12:15 p.m. during service of the lunch meal revealed CNA AA serving a lunch tray to the resident in room [ROOM NUMBER]-2. The CNA removed the resident's roll from a wax packet with her bare hand and placed it on the resident's plate. Observation on 8/4/18 at 12:18 p.m. during service of the lunch meal revealed CNA AA serving a lunch tray to the resident in room [ROOM NUMBER]-1. The CNA removed the resident's roll from a wax packet with her bare hand and placed it on the resident's plate. Observation on 8/4/18 at 12:21 p.m. during service of the lunch meal revealed CNA AA serving a lunch tray to the resident in room [ROOM NUMBER]-1. The CNA removed the resident's roll from a wax packet with her bare hand and placed it on the resident's plate. Interview on 8/4/18 at 2:27 p.m. with CNA AA who reported that hands should be washed prior to passing meal trays and food should not be touched with bare hands when assisting residents with meals. CNA AA acknowledged that she touched rolls with bare hands during meal service but was not supposed to do this. Interview on 8/4/18 at 2:27 p.m. with CNA DD who reported that she has been taught to not touch resident's food with bare hands and to sanitize before and after each tray delivery. Interview on 8/4/18 at 2:47 p.m. with CNA CC who reported that hands are to be washed and sanitized whenever in resident's room and food is not to be touched with the bare hand. CNA CC further reported that when bread is in the wax bag she opens the bag and allows the bread to slide out without touching with her hand. Interview on 8/4/18 at 4:33 p.m. with Licensed Practical Nurse (LPN) BB who reported that staff should not be touching resident's food with their bare hands. Interview with the Administrator on 8/5/18 at 4:57 p.m. who reported that skills training was provided for staff on 6/26/18 and a checkoff of skills for meal delivery was completed at that time. The Administrator provided documentation of training/education of CNAs. Review of inservices revealed that CNA EE was present for training on 6/26/18 but here was no evidence that CNA AA attended the training. The Administrator also provided documentation of hand washing training on 5/31/18 and hand hygiene training on 7/12/18. The sign in sheet for 5/31/18 does not reflect that CNA AA or CNA DD attended this training. CNA AA and CNA DD both signed in for the training on 7/12/18. Food and Nutrition Services: Meal Service Intent: It is the intent of the center to provide an enjoyable meal service in a safe, sanitary, and comfortable environment while focusing on patient centered care. Procedural Guidelines 1. Meals will be served under sanitary conditions. 2. Associates will follow safe food handling techniques. Revised: 11/28/2017 Observation on 8/3/18 at 12:33 p.m. during service of the lunch meal revealed Certified Nursing Assistant (CNA) EE serving a lunch tray to the resident in room [ROOM NUMBER]-1. The CNA removed the resident's roll from a wax packet with her bare hand and placed it on the resident's plate. Observation on 8/3/18 at 12:36 p.m. revealed CNA EE served a lunch tray to the resident in room [ROOM NUMBER]-1. The CNA removed the resident's roll from a wax packet with her bare hand and placed it on the resident's plat.; Observation on 8/3/18 at 12:49 p.m. revealed CNA EE served a lunch tray to the resident in room [ROOM NUMBER]-1. The CNA removed the resident's roll from a wax packet with her bare hand and placed it on the resident's plate. During an interview on 8/05/18 at 12:35 p.m. with CNA FF, it was revealed she has worked at the facility for several months and she is aware that the staff are not to touch resident's food with bare hands. During an interview on 8/5/18 at 4:02 p.m. with the administrator the Regional Nurse revealed that the CNAs received training related to dining and infection control as needed and during and annual skills fairs last completed in (MONTH) (YEAR). A checklist is used to ensure that pertinent areas are covered, and hand-washing and hand hygiene during dining is included in this training. Had hygiene during dining includes areas such as not touching food with bare hands and the proper way to hold glasses and flatware. It is not acceptable for CNAs to touch residents' food with bare hands. This training is also part of the orientation education the staff receives upon hire. Review of the sign-in sheet for the skills check-off dated 6/28/18 revealed CNA EE signed as having received the training.

Based on resident and staff interviews and record reviews, the facility failed to accurately assess the functional status of Resident (R) #12 and the dental status of R #15 in the Minimum Data Set (MDS) assessments of 33 sampled residents. Findings include: 1. Clinical record review for R #12 revealed a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Further clinical record review for R #12 revealed an Annual MDS assessment dated [DATE] documented his cognitive status in Section C-Cognitive Patterns with a Brief Interview for Mental Status (BIMS) score of 15 (a score of 13-15 indicates the person is cognitively intact). His functional status was documented in Section G-Functional Status, Subsection G0110 Activities of Daily Living (ADLs) as follows: item C. Walk in Room: 1. Self-Performance-(8) Activity did not occur-activity (or any part of the ADL) was performed by the resident or staff at all over the seven-day (observation) period; 2. Support: ADL activity itself did not occur during the entire (observation) period. Subsection G0300 Balance During Transitions and Walking documented: [NAME] Moving from seated to standing position; B. Walking with assistive device if used; C. Turning around and facing the opposite direction while walking; D. Moving on and off toilet and E. Surface-to-surface transfer as: 1. Self-Performance-(8) Activity did not occur; 2. Support-Activity itself did not occur during the entire period. Subsection G0400 Functional Limitation in Range of Motion, item [NAME] Upper extremity (shoulder, elbow, wrist, hand) -no impairment; B. Lower extremity (hip, knee, ankle, foot) -impairment on both sides. Continued review of the MDS for R #12 revealed a Quarterly MDS assessment dated [DATE] documented his cognitive status in Section C-Cognitive Patterns with a BIMS score of 13. Section G-Functional Status, Subsection G0110 ADLs, item C. Walk in Room as: 1. Self-Performance--(8) Activity did not occur during the seven-day (observation) period; 2. Support-Activity did not occur. Subsection G0300 Balance During Transitions and Walking documented items A through [NAME] as: Steady at all times. Subsection G0400 Functional Limitation in Range of Motion, item [NAME] Upper extremity (shoulder, elbow, wrist, hand) -no impairment; B. Lower extremity (hip, knee, ankle, foot) -no impairment. The care plan for R #12, updated 6/23/18, revealed he was at high-risk for falls as evidenced by problem with balance and non-weight-bearing status; limited range of motion, at risk for/actual contractures as evidenced by a history of joint pain; at risk for pain related to lumbar disc disease. In an interview with R #12 on 8/4/18 at 6:39 p.m., when asked if could walk, he stated he had not been able to walk in the last two years. 2. Review of the clinical record for R #15 revealed a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Observation and an attempt to interview R #15 on 8/3/18 at 3:02 p.m. revealed his mouth revealed missing teeth and eroded teeth throughout his mouth. R #15 was unavailable for further observation due to transfer to a local hospital on [DATE] due to acute shortness of breath. Review of the Annual MDS assessment for R #15, dated 8/10/17 documented his cognitive status in Section C-Cognitive Patterns with a BIMS score of 3 (0-7 indicates severe cognitive impairment). Section L-Oral/Dental Status, L0200 Dental documented R #15's oral/dental status from the following selections: [NAME] Broken or loosely fitting full or partial denture (chipped, cracked, uncleanable or loose); B. No natural teeth ot tooth fragment(s) (edentulous); C. Abnormal mouth tissue (ulcer, masses, oral [MEDICAL CONDITION], including under denture or partial if one is worn); D. Obvious or likely cavity or broken natural teeth; E. Inflamed or bleeding gums or loose natural teeth; F. Mouth or facial pain, discomfort or difficulty with chewing; G. Unable to examine; Z. None of the above. The assessment was coded: Z. none of the above. Review of the Quarterly MDS assessment for R #15, dated 2/16/18 revealed the BIMS score was not calculated and the oral/dental status was not addressed. Review of the Annual MDS assessment for R #15 dated 5/9/18 documented in Section C-Cognitive Patterns a BIMS score of 99, which indicated a BIMS score could not be calculated or assessed. Section L-Oral/Dental Status, L0200 Dental documented his oral/dental status as: Z. none of the above. In an interview with Licensed Practical Nurse (LPN) JJ on 8/5/18 at 9:20 a.m. regarding R #15's oral/dental status, he confirmed R #15 was missing most of his natural teeth, eating a pureed diet with thickened liquids and received crushed medications. In an interview on 8/5/18 at 6:06 p.m. with LPN GG regarding MDS assessments, she confirmed the discrepancies in the MDS assessments for R#12 related to functional status and for R#15 related to dental status. The MDS Director was unavailable for this survey. In an interview 8/5/18 at 6:30 p.m. with the Administrator regarding the MDS discrepancies for R #12 and R #15, she stated she was unaware of the assessment inaccuracies in the MDS assessments for both R#12 related to functional status and R#15 related to dental status. She stated she expected accuracy and timeliness from her MDS contributors without exception. In an interview with the Regional Nurse Consultant on 8/5/18 at 6:39 p.m., she stated she was unaware of the MDS discrepancies in the assessments for R #12 related to functional status and R #15 related to oral/dental status. She stated her expectation is MDS assessments should be accurate and submitted in a timely manner. She was unable to locate a facility or corporate policy related to MDS assessments.

Based on a review of the records and staff interview, the facility failed to follow the plan of care related to [MEDICAL CONDITION] medications, specifically not monitoring targeted behaviors for one resident (R#1) from a sample of 33 residents. Findings include: Review of the clinical records for resident (R)#1 revealed she was admitted on [DATE] and has [DIAGNOSES REDACTED]. Review of the current orders for the resident revealed she is to receive memantine 10 mg daily, and [MEDICATION NAME] (an antipsychotic) 5 mg twice a day for dementia with behavioral disturbance. Review of the Annual Minimum Data Set (MDS) assessment of 8/16/17 documented the resident had active [DIAGNOSES REDACTED]. Under the Care Areas Assessment Summary (CAAS) [MEDICAL CONDITION] drug use triggered with the intent to complete a plan of care for that area. A review of the plan of care for R#1 last updated 7/2/18 for [MEDICAL CONDITION] drug use revealed interventions which included documenting refusal of care and monitoring for behaviors. Review of behavior monitoring records revealed R#1 was being monitored for repetitive behaviors every shift beginning in (MONTH) (YEAR). The records document that these behaviors were monitored in (MONTH) (YEAR) and (MONTH) (YEAR). However, no behavior monitoring logs were located for the resident related to repetitive behaviors (or any behaviors) for the months of (MONTH) (YEAR) and (MONTH) (YEAR). Interview with Admissions Coordinator/Licensed Practical Nurse (LPN) GG on 8/05/18 at 10:25 a.m. revealed that behavior monitoring was not completed for R#1 for the months of (MONTH) and (MONTH) (YEAR) because the facility was switching from a paper system to an electronic health record system at that time and some of the behavior monitoring information were not transferred. After an audit completed in (MONTH) (YEAR), it was discovered that behavior monitoring for R#1 was missing and this was added to the new system. Behavior monitoring for the resident related to repetitive behaviors was resumed in (MONTH) (YEAR). Cross-refer to F758

Based on observations, record review, review of the policy titled Blood Glucose, PT/INR Coagulation, and ISTAT Testing Quality Control Program and staff interviews, the facility failed to follow physician orders [REDACTED].#24) that received anticoagulant therapy ([MEDICATION NAME]). The sample was 33 residents. Findings include: Review of the policy titled Blood Glucose, PT/INR Coagulation, and ISTAT Testing Quality Control Program dated (MONTH) (YEAR) revealed protocols for Quality Control of the device. The policy did not include procedures for documenting results of Fingerstick INR results. R#24 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) summary score of 14, indicating no cognitive impairment. The resident was not assessed with [REDACTED]. The resident received anticoagulant medication all seven days of the look back period. Record review for R#24 revealed a physician's orders [REDACTED]. Review of the PT/INR (unit of measure that's used to determine how quickly blood is clotting) lab results dated 3/1/18 revealed PT- 24.2 and INR- 2.4. A note on the lab results documented the Physician was notified and orders received to continue [MEDICATION NAME] ([MEDICATION NAME]) 3 mg daily and repeat on 4/2/18. An order was entered in the electronic medical record (EMR) on 4/2/18 for PT/INR Diagnostic Test Stick, one time only 1 day. There was no evidence in the paper or electronic clinical record that the PT/INR was done on 4/2/18. Further record review for R#24 revealed a Physician order [REDACTED]. There was no evidence in the paper or EMR that the INR stick was collected or resulted. A Physician order [REDACTED]. There was no evidence INR fingersticks or results in the paper or EMR for May, June, (MONTH) or (MONTH) (YEAR). Observation on 8/4/18 at 8:15 a.m. revealed R#24 in his room in wheel chair ambulating to his bathroom. Further observation at 8:30 a.m. the resident had propelled himself to the nurse's station. No bruising, bleeding or skin tears were observed. Interview on 8/4/18 at 12:20 p.m. with R#24 revealed he was doing well and denied complications from anticoagulant therapy. Interview on 8/5/18 at 1:34 p.m. with the Administrator revealed the Director of Nursing (DON) was on Military Active Duty this weekend. The Administrator stated that in (MONTH) (YEAR), the facility had switched from paper charting to (brand) EMR. She stated that prior to the EMR, INR fingerstick results were documented on the INR Control Sheet. The Administrator stated they stopped using the INR Control Sheet when they switched to the (brand) EMR. She stated they are identifying problems as they go and forwarding concerns to Corporate. The Administrator was not aware that Fingerstick INR results was an area of concern in the EMR until now. She stated that the INR fingersticks for R#24 read to be done monthly but she is not sure how the order forwards each month. She confirmed the start date and the end date for the monthly order om 5/7/18 was the same and perhaps that was the problem. The Administrator stated the nurse did not transcribe the order for June, (MONTH) or (MONTH) and they checked a fingerstick for R#24 yesterday on 8/4/18 on the house machine to check the residents INR and stated it was 2.3 and within normal limits. She stated they have a new EMR system and they are working through the processes. The Administrator stated the INR machine does store the results but she did not think it stored the resident's identification just the results. Further interview with the Administrator and the Licensed Practical Nurse (LPN) JJ revealed prior to the implementation of the (brand) EMR system, they were documenting the results of the fingerstick INR on the INR tracking log. LPN JJ stated he went to training for the EMR system but could not recall specifics about where to document the fingerstick INR results. He stated he documented the fingerstick INR results from yesterday (8/4/18) in the nurse's notes. LPN JJ stated the Medication Administration Record [REDACTED]. He stated that the reason the start date and the stop date is the same on the monthly Fingerstick INR order is because the results are called to the Physician and he may want the next INR in a week or two weeks depending on the result and/or medication changes. He stated if the Physician does not order a Fingerstick INR sooner, the nurse would have to enter the order for the next month's Fingerstick INR. LPN JJ stated he did not enter the orders in for (MONTH) or (MONTH) but the nurses who did the INR should have entered the results and document that the MD was notified. LPN JJ and the Administrator stated there have been no other residents that have used the COAG Check device and there were monthly results in the device that had to the Fingerstick INR results for R#24. He stated that the device was never set up with the correct date but even though the dates are wrong, the results have to be R#24's. LPN JJ confirmed there was no evidence in the EMR nurse's notes, for results of the Fingerstick INR in April, May, (MONTH) or (MONTH) (YEAR). Observation of the COAG CHECK XS revealed it did not have the accurate date. The INR results checked yesterday on 8/4/18 was dated in the device 8/30/18. There was no resident identification or name in the device, therefore, unable to identify who the results in the device belong to. Review of the INR Control Sheet revealed the last documented INR results for R#24 was on 3/1/18. INR- 2.4 (External Lab). Next test date: 4/2/18. Interview on 8/5/18 at 3:20 p.m. with the Medical Director revealed he typically checks INR once a month unless there is an abnormal result, he may repeat in a week or two weeks until stable. He stated if a resident is stable, the INR can be checked every three months. He stated specifically for R#24, he is on monthly Fingerstick INR checks in the facility and if he needs a PT/INR that is drawn through the outside lab. The Medical Director stated that the nurses are pretty good about calling him to report the Fingerstick INR results but stated he could not say for absolute sure they did because he gets calls for lab and INR results all day from different places. He stated that he does see the residents every month and documents the INR results in his progress notes sometimes or his Nurse Practitioner (NP) does. The Medical Director stated he was not aware that the Fingerstick INR results for R#24 had not been documented since 3/1/18. He stated that they have switched to the new computer system and it accounts for some of the problems but that is not an excuse. When asked how did you know what the Fingerstick INR results for R#24 were if it was not documented in the clinical record, the Medical Director stated That's a good question, I would not and we need to fix that. He stated he assumes the nurses most likely called him with results but there are too many assumptions and they need to address the process. He stated the nurse should at least be documenting in the nurse's notes. The Medical Director stated that LPN JJ checked the R#24's Fingerstick INR yesterday and reported the results to him which were within range for him. He stated he ordered to continue with monthly Fingerstick INR. The Medical Director stated that he visits R#24 every month and the resident has been stable with no complications. He stated at the beginning of the year R#24 had pneumonia and he had to check his INR and PT/INR more often but he has since stabilized. Interview on 8/5/18 at 4:45 p.m. with the Nurse Practitioner (NP) revealed R#24 gets a FIngerstick INR every month. The NP stated she knows that a Fingerstick INR was done on 5/7/18 because she ordered it and was at bedside when it was done. She stated the staff is pretty good about calling her Fingerstick INR results but she gets calls on 270 people so she cannot say for sure that any of the other INRs were conducted and reported to her. She stated they have recently switched to the computer system and she has just learning how to use it herself.

Based on record review, staff interview and review of policy, [MEDICAL CONDITION] Medications, the facility failed to consistently monitor behaviors for two residents (#1 and #16) receiving [MEDICAL CONDITION] medications from a sample of 33 residents. Findings include: Review of policy title [MEDICAL CONDITION] Medications last updated (MONTH) (YEAR) revealed that residents who receive any type of medication prescribed to modify behavior are to be evaluated to determine the effectiveness of the medication for the identified problems. When [MEDICAL CONDITION] therapy is initiated, the resident is monitored quantitatively and qualitatively to determine the effectiveness of the medication and the presence of side effects. 1. Review of the clinical records for resident (R)#1 revealed she was admitted on [DATE] and has [DIAGNOSES REDACTED]. Review of the current orders for the resident revealed she is to receive memantine 10 milligrams (mg) daily, and [MEDICATION NAME] (an antipsychotic) 5 mg twice a day for dementia with behavioral disturbance. Review of behavior monitoring records revealed R#1 was being monitored for repetitive behaviors every shift beginning in (MONTH) (YEAR). The records document that these behaviors were monitored in (MONTH) (YEAR) and (MONTH) (YEAR). However, no behavior monitoring logs were located for the resident related to repetitive behaviors (or any behaviors) for the months of (MONTH) (YEAR) and (MONTH) (YEAR). Interview on 8/4/18 at 1:42 p.m. with Certified Nursing Assistant (CNA) KK revealed she has provided care for R#1 four about 4 years. The only behavior she is currently aware of for the resident is that the resident always asks staff where she needs to be - dining room, etc. CNAs learn what behaviors to observe for each resident from the plans of care. Interview with Admissions Coordinator/Licensed Practical Nurse (LPN) GG on 8/05/18 at 10:25 a.m. revealed that behavior monitoring was not completed for R#1 for the months of (MONTH) and (MONTH) (YEAR) because the facility was switching from a paper system to an electronic health record system at that time and some of the behavior monitoring were not transferred. After an audit completed in (MONTH) (YEAR), it was discovered that behavior monitoring for R#1 was missing and this was added to the new system. Behavior monitoring for the resident related to repetitive behaviors was resumed in (MONTH) (YEAR). Interview on 8/5/18 at 1:21 p.m. with LPN HH revealed that the nurses check under Monitoring during each shift to see which residents need monitoring for certain behaviors and then charts for those behaviors. Only the residents listed under Monitoring are required to be charted for behaviors. If the resident is not listed under this tab, staff does not monitor this resident for behaviors. Instructions for monitoring a resident's targeted behaviors are not listed on the MAR. During an interview on 8/5/18 at 6:08 p.m. with the Administrator, it was revealed that the staff are expected to check the behavior tab on the electronic medical record (EMR) during their shift to determine which residents need to have behavior monitoring documentation completed on their behalf. 2. Review of the clinical records for R#16 revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the current orders revealed the resident is to receive [MEDICATION NAME] 10 mg daily for depression (beginning 3/26/18), ziprasidone 20 mg twice a day for dementia with behavioral disturbance (3/26/18). A review of the annual Minimum Data Set (MDS) assessment completed for R#16 on 5/21/18 revealed active [DIAGNOSES REDACTED]. A review of the behavior monitoring logs for R#16 revealed the resident should be monitored for resisting care and depression every shift. A review of the (MONTH) (YEAR) behavior monitoring log for R#16 revealed that targeted behaviors of depression and resisting care were not documented as being monitored 7 times on the day and 20 times on evening shifts. A review of the (MONTH) (YEAR) behavior monitoring log for R#16 revealed that targeted behaviors were not documented as being monitored 10 times on the day and 6 times on the evening shifts. A review of the (MONTH) (YEAR) behavior monitoring log for R#16 revealed the resident was not monitored for targeted behaviors 8 times on the day and 3x on the evening shifts. Interview on 8/5/18 at 10:36 a.m. with Admissions Coordinator LPN GG revealed she acts as a backup for the Director of Nursing (DON) to ensure that monitoring is being done for the residents with behaviors. She is aware that some instances of behavior monitoring were missed for this resident.

Based on record review and staff interview, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to the resident or responsible party upon discharge from Medicare Part A services to indicate that they understood the contents of the form for two of three residents (R) reviewed (#40 and #42) of three residents reviewed. Findings include: Review of a Beneficiary Notice-Residents discharged Within the Last Six Months form, provided by the facility, revealed that R #40 was discharged off Medicare Part A skilled services on 7/2/18 and remained in the facility afterwards with benefit days remaining. There is no evidence that a copy of the SNFABN was provided to resident or family member. Further review of this form revealed that R #42 was discharged off skilled services on 4/9/18, and remained in the facility with benefit days remaining. There is no evidence that a copy of the SNFABN was provided to resident or family member. Interview on 8/5/18 at 12:39 p.m. with Social Services Director (SSD) who reported that SNFABN forms were mailed to family for R #40 and R #42. SSD reported that she did not notice that the form she used for documenting her telephone contacts did not address the SNFABN.

Based on observation and interview the facility failed to label two (2) multi-use medication vials with the open dates. Findings include: Observation on 09/17/15 at 9:33 a.m. with Licensed Practical Nurse (LPN), AA revealed that in medication room [ROOM NUMBER]Tuberculin Purified Protein Derivative (Mantoux) Tubersol. 5 TU/0.1mL 4 mL vial and Influenza Vaccine 5 ml vial opened without an open date. Interview with LPN AA on 9/17/15 at 9:33 a.m. confirmed that both medications were not labeled or dated.

Based on observations and staff interview the facility failed to properly distribute the resident's meals in a sanitary manner on three (3) of ( 3) halls for two (2) of (2) dining observations. Findings include: Observation on 12/17/14 at 7:55 a.m. of the B Hall revealed that nursing staff received the food cart from the dietary staff with a clear plastic bag covering all the resident trays. Continued observation revealed that once nursing staff received the food cart they removed the clear plastic bag exposing the resident trays while pushing the cart from room to room for distribution. Observation of the residents' breakfast trays revealed that each tray contained an uncovered beverage and uncovered dishes of fruit. Observation of the A Hall on 12/18/14 at 12:35 p.m. revealed a Certified Nursing Assistant (CNA) receiving the food cart from the dietary staff. The food cart was covered with a clear plastic bag which was removed by the CNA. Continued observation revealed that the resident's lunch trays had several food items which were not individually wrapped such as the beverages, the banana pudding, and the dinner rolls. The CNA pushed the food cart down the hall for distribution without covering the cart while it was in motion. Continued observation revealed a Licensed Practical Nurse (LPN) who removed a resident's lunch tray from the uncovered cart and carried it to a resident on the C Hall. Interview on 12/18/14 at 12:35 p.m. with the Dietary Manger (DM) revealed that she expects all food items on the resident's meal tray to be covered when staff delivers it to their rooms. The DM confirmed that nursing staff were removing the clear plastic bag completely from the food cart. She further confirmed that nursing staff were pushing the food cart down the hall while food items were uncovered on the trays. The DM confirmed the observation of the LPN delivering the resident's uncovered lunch tray to the C Hall. She acknowledged that all food items should be covered on the meal tray if walked down the hallway.

Based on observations, record review, resident and staff interviews, it was determined that the facility failed to provide timely bowel incontinence care for one resident ("Z") from a sample of twenty-five (25) residents. Findings include: Resident "Z" was admitted on [DATE] with the following diagnoses; [MEDICAL CONDITION] [MEDICAL CONDITION], Depression, [MEDICAL CONDITION] (CAD) and status [REDACTED]. Review of the fourteen (14) day Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was assessed as having a Brief Interview for Mental Status (BIMS) score of eight (8) indicating that she was alert and oriented most of the time,she was non-ambulatory, having limitations in range of motion of her extremities on one side, frequently incontinent of bowel and bladder and as being totally dependent on staff for toileting. Review of the resident's care plan dated 12/4/14 revealed that staff was suppose to assist the resident with activities of daily living (ADLS) as needed. Interview with resident "Z" on 12/15/2014 at 2:18 p.m., revealed that she had waited up to one (1) hour for staff to provide incontinence care. On 12/16/14 at 8:35 a.m., the resident was observed lying in her bed. Interview with resident "Z" at that time revealed that she had just used the call light to request assistance from staff to provide bowel incontinence care. Observation of the light above the resident's door at that time revealed that it was not blinking to indicate to staff in the hall that the resident needed assistance. Continued observation at 8:45 a.m., revealed a Certified Nursing Assistant (CNA)who removed breakfast trays from residents' rooms, placed the trays on the cart in the hall and then returned the cart to the kitchen. At 8:55 a.m., the same CNA was observed to return to the hall carrying clean linens into another resident's room and close the door. Continued observation at 9:14 a.m., the light above resident "Z"s door was turned on and answered by a Registered Nurse (RN) staff at the nurses' station. The resident was overheard to tell the RN that she needed someone to change her "dirty, dirty" brief. The RN told the resident "Yes" and the light over the door stopped blinking. An odor of feces emanated from the resident's room and into the hall at that time. Continued observation at 9:21 a.m., a CNA was observed to return a resident to her room from the dining room and then return to the dining room for another resident. At that same time, a Licensed Practical Nurse (LPN) was observed in the hall administering medications to residents and another CNA was observed to walk down the hall, past the resident's room and out the exit door at the end of the hall. At 9:24 a.m., a CNA went into resident "Z"s room and provided bowel incontinence care at that time. Interview with resident "Z" on 12/17/14 at 9:35 a.m. revealed that she was uncomfortable lying in the soiled brief, but that she realized staff may have been busy with other residents. Staff had failed to provide timely bowel incontinence care for resident "Z" who laid in a soiled brief for 49 minutes. Interview with the Director of Nursing (DON) on 12/18/14 at 2:55 p.m., revealed that she would expect staff to provide incontinence care for a resident within ten (10) minutes of the resident's request for assistance, even during meal time. Continued interview revealed that forty-nine (49) minutes was too long for a resident to have a soiled brief and that if the CNA's were busy providing care for other residents then the nurses were responsible for providing incontinence care. Further interview with the DON at that time revealed that the call lights over the resident room doors should remain on until staff entered the resident's room, manually reset the call light at the resident's bedside and provided requested assistance at that time. Observation on 12/18/14 at 3:10 p.m., of a random resident call light on the hall when pressed it lighted above the door; however, when the DON answered the call light at the nurses' station, the light above the door went out. The DON revealed that the lights above the resident's rooms should remain on, so that any staff in the hall would know that the resident needed assistance.

Based on observation, review of the Weekly Water Temps/Equipment Log, and staff interviews the facility failed to ensure that hot water for resident use was at a safe temperature for one (1) shared bathroom on one (1) of three (3) halls. Findings include: Observation on 12/15/14 at 10:45 a.m., of random resident bathrooms during initial tour revealed that the hot water in the bathroom sink for the adjoining rooms 214 and 216, shared by four (4) residents was uncomfortably hot to the touch. The hot water temperature was taken with a thermometer and was noted to be one hundred and twenty (120) degrees Fahrenheit (F). Interview with the Director of Nursing (DON) and the Maintenance Director on 12/15/14 at 11:00 a.m. to notify them of the unsafe water temperature, the DON revealed that none of the residents had sustained burns from hot water temperatures. On 12/15/2014 at 11:15 a.m. the hot water temperature was verified at one hundred and twenty degrees (120F) with the Maintenance Director using the facility's thermometer. The hot water was adjusted by the Maintenance Director and the temperature was rechecked and verified to be one hundred degrees (100F) . Interview with the Maintenance Director on 12/15/2014 at 12:00 p.m., revealed that the four rooms at the end of the (200) hallway are on a different hot water heater. He further revealed that he was able to lower the hot water by adjusting the valve. Continued interview revealed that if a resident or staff identifies hot water being very hot, staff notify him right away and staff completes a work order, and places it in the Maintance book which he checks every day. The Maintenance Director revealed that he checks the hot water temperatures randomly in the resident bathrooms. Review of the Weekly Water Temps and Equipment Log revealed that there was no evidence that the hot water temperatures were checked in the adjoining bathrooms for rooms 214 and 216 in the months of August, September, October, November or December 2014. Interview with the Administrator on 12/18/14 at 2:55 p.m. revealed that she was not aware that the hot water temperatures in the bathroom adjoining rooms 214 and 216 were one hundred and twenty degrees (120F). She revealed that she expected the hot water temperatures to be checked and maintained at a safe temperature.