Every finding on record at Hart Care Center

Based on observations, staff interviews, and review of the facility's policy documented Labeling and Dating the facility failed to appropriately discard expired food items and did not properly store, label, or date them. In addition, the facility did not maintain sanitary practices related to food handling and hand hygiene. These deficiencies created a potential risk for 57 out of 59 residents who received an oral diet from the kitchen, increasing their risk of foodborne illnesses.Findings Include:Review of facility's policy titled, Labeling and Dating dated 04/2024, documented.All items that are not in their original containers must be labeled. If any item is not labeled and dated appropriately, we are putting our patients at risk or putting another associate at risk of using a product that is out of date or could be mistaken for another (for example: chemicals mistaken for sugar, baking powder, or flour). Section Upon receipt documented all items should be inspected and marked with the date it was received into your facility and the date it should be discarded or expired. Section After opening documented any item, the date it was opened must be clearly labeled on the front of the package and a new use by date should also be noted.All items will have: Receive date Expiration date Open date Use by dateFor items not in their original containers, or leftovers kept, food labels should include: the common name of the food; the date the item was prepped, or placed in the cooler for storage; the date the item should be discarded or the use-by date (generally, 3 days from the time of preparation, unless the product has a label that clearly states a discard date)During the initial kitchen tour on 06/16/2026 at 8:42 AM, with the Dietary Manager (DM) revealed inside the kitchen a three-door stand-alone reach-in freezer. During the inspection, five packs of 10-count pork chops were found, two were voided of labeling and dating, while two had expiration dates of 05/21/2026 and 04/08/2026, one had a single date of 04/29/2026. Additionally, it was observed three-gallon bags were missing proper labeling and dating, with one single date being visible; the DM recognized one bag as containing vegetable medley and identified two bags with egg rolls, one 5-lb (pound) bag of okra that was both unlabeled and undated, and one 5-lb bag of chicken strips, which was verified by the CDM.The inspection of the stand-alone reach-in refrigerator revealed five flat pans of meat, confirmed by DM as bacon used for the following day without proper labeling; dated 06/16/2026. Additionally, there was one 8 oz. (ounce) butter, one 5 lb. tuna salad, one 4 qt.(quart) with fruit, and one 4 qt. with jelly, one sandwich bag with two slices of tomatoes, nine peanut butter and jelly sandwiches, two banana sandwiches, and three tomatoes sandwiches dated 06/16/2026, and one 32 oz. ham that had an expiration date of 06/10/2026.On 6/16/2026, at 9:09 AM, an interview was conducted with Dietary Aid (DA) CC, who confirmed that she prepared all the sandwiches observed during initial tour of the kitchen. She mentioned that she only documented the preparation date on all items used and prepared.On 6/16/2026, at 9:13 AM, an interview was conducted with [NAME] BB. She confirmed her responsibility for verifying labeling and dating; [NAME] BB stated she simply marked today's date on the prepared items not thinking.The follow-up of the kitchen tour conducted on 06/17/2026, between 9:47 AM and 11:21 AM, revealed three kitchen staff not practice hand hygiene; one entered the kitchen without washing their hands, another staff touched the top of the dumpster during tasks, and another licked their fingers while preparing meal ticket placements. An interview with the Registered Dietitian (RD), indicated that one dietary aide (DA) unidentified entered the kitchen without washing her hands but asserted that she did not perform any tasks in the kitchen and instructed her to wash hands. The second kitchen staff member, known as [NAME] BB, prepared the lunch menu line and touched plastic dumpster lid without washing between tasks, it was noted that [NAME] BB was immediately corrected by RD. Furthermore, during the observation, DA CC was observed and corrected for licking her fingers while assembling the resident's meal tickets on tray.An additional interview with the RD was conducted on 06/17/2026 at 11:45 AM, revealed that last month she completed a kitchen inspection and conducted training to review the delivery date, open date, and used by date of items.

Based on observations, staff interviews, record review, and review of the facility's policy titled Oxygen Administration, the facility failed to ensure one of 18 residents (R) R16 was administered oxygen therapy as per the physician's orders. The deficient practice had the potential to place R16 at increased risk of respiratory complications.Findings include:Review of the facility policy titled Oxygen Administration revision dated 10/2010, revealed in section Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration. Review of the clinical record for R16 revealed diagnoses including but not limited to chronic obstructive pulmonary disease (COPD), chronic diastolic (congestive) heart failure, and paroxysmal atrial fibrillation.Review of the most recent Minimum Data Set (MDS) for R16, dated 06/03/2026, revealed that section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 05, indicating severe cognitive impairment. Section GG (Functional Abilities and Goals) documented that R16 was dependent for sit-to-lying, lying-to-sitting on the side of the bed, sit-to-stand, and chair/bed-to-chair transfer. Section O (Special Treatments, Procedures, and Programs) documented that R16 received oxygen therapy.Review of the physician's orders for R16 revealed an order dated 04/22/2026 for oxygen at 2 LPM (liters per minute) via (by way of) a nasal cannula (NC) as needed for shortness of breath.Review of the care plan for R16 revealed a Care Area/Problem of Breathing: Resident has potential for difficulty breathing related to COPD. Interventions included administering oxygen as ordered.Observation on 06/16/2026, at 11:37 AM, revealed R16 was seated in a reclining chair, with one pillow positioned behind her head and another under her legs, while a blanket was draped over her body. The chair was situated in front of an oxygen concentrator delivering oxygen at a flow rate of 3.5 LPM via a NC.Observation on 06/16/2026 at 01:48 PM revealed R16 seated in a reclining chair positioned in front of an oxygen concentrator and receiving oxygen via a NC at 3.5 LPM.In a concurrent observation and interview on 06/16/2026 at 4:29 PM, Licensed Practical Nurse (LPN) DD confirmed that R16 was receiving oxygen at 3.5 LPM and the prescribed rate was 2 LPM. She noted that R16 would adjust her oxygen, but based on R16's position in the chair and the oxygen concentrator positioned behind her chair, she confirmed this incident did not occur at that time.In an observation via phone on 06/16/2026 at 4:39 PM, the Director of Nursing (DON) confirmed the oxygen flow rate for R16 was set at 3.5 LPM via a NC. The DON also verified the residents' diagnoses of chronic obstructive pulmonary disease (COPD) and heart failure.In an interview on 06/18/2026 at 2:40 PM, LPN AA confirmed that the nurses were responsible for checking the oxygen flow rates. LPN AA stated that R16 would not be able to adjust her oxygen by turning the dial, as she uses her knuckles due to her contractures.

Based on observation, interview, record review, and policy review, the facility failed to ensure the staff trained through the Paid Feeding Assistants (PFA) program did not provide assistance to residents with swallowing disorders or were at risk for aspiration for one of three sample residents (Resident (R) 115) reviewed for swallowing disorders out of a total sample of 23 residents . Failure to ensure the Interdisciplinary Team (IDT) identified residents who could be assisted with meals by the PFA, increased the risk R115 could experience aspiration pneumonia and/or choking. Findings include: The policy Paid Feeding Assistants dated ,d+[DATE], included the following directives: 1. Paid feeding assistants provide assistance only for resident [sic] with no complicated feeding problems include difficulty swallowing, recurrent lung aspirations and tube or parenteral IV feedings. 2. Resident are assessed for the appropriateness for the feeding assistant program by the interdisciplinary team, taking into account the most recent assessment and plan of care. 3. Only residents who have been selected by the interdisciplinary team are eligible for feeding assistance by a paid feeding assistant. R115's Admission Record tab in the Electronic Medical Record (EMR) identified an admitted d of [DATE], with hospice services in place. The admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of [DATE], revealed the full assessment had not yet been completed. Review of the EMR Orders tab revealed physician orders for a pureed no added salt diet with nectar think liquids. The MDS assessment indicated R115 was dependent on staff for eating. Review of a Nursing Note dated [DATE], documented by an Licensed Practical Nurse (LPN) under the tab for nursing notes, , identified concerns about the resident swallowing abilities. The entry stated, After lunch today the resident continued to cough and spit out clear frothy mucus the entry went on to note lungs clear . puree diet and ordered palliative set up suction at bedside if needed The entry went on to explain that a crushed medication was administered with thicken liquids to help manage the oral secretions observed. On [DATE], at 12:30 PM, the residents in the dining room were seated at three tables. Each table had staff seated next to them assisting with feeding. Each table had one and/or two staff members seated next to residents who were assisting with feeding. On [DATE] at 12:30 PM, R115 was seated in the dining room, next to her was the Activities Director (AD) who was assisting by feeding her a pureed diet and nectar thick liquids. Two other residents sitting at the table were eating with verbal prompts and encouragement. On [DATE], at 12:45 PM, LPN 2 who was supervising the dining session was interviewed. LPN 2 explained the second seating in the dining room was for residents who were dependent on the staff for eating. When asked about the staff observed assisting the residents, she identified four of the five staff observed were Certified Nursing Assistants (CNA's), except the AD who was assisting R115. When asked about the AD specifically, she explained the AD was also a CNA. On [DATE] at 2:00 PM, the Minimum Data Set Coordinator (MDSC) 2, was interviewed and identified she coordinated the PFA program. She provided the training curriculum. MDSC2 then provided the names of the staff who had completed the program, which included AD. When asked which residents were eligible to receive assistance from the PFA, she stated the IDT had not reviewed or identified residents who were eligible to receive services from staff who completed the PFA training. On [DATE] at 12:00 PM the AD was interviewed, when asked if she was a CNA, she stated her CNA license expired. The AD explained she had last worked as a CNA in 2023 and had recently returned to work at the facility taking the position as the AD and added she had completed the PFA training. On [DATE] at 2:15 PM, during a follow up interview when asked who directed her to assist R115 with the meal, the AD stated, she could not recall.

Based on observation, interviews, record review, and policy review, the facility failed to ensure staff followed infection control policies related to transmission-based precautions for three of five residents (Resident (R)#1, R#3, and R#4) observed for infection control practices. Certified Nursing Assistant (CNA) AA, CNA BB, and Licensed Practical Nurse (LPN) AA cared for residents positive for COVID-19 without wearing a face shield. Findings include: Review of the facility's policy titled Pandemic Response Plan, revised on 4/23/20, directed that when COVID-19 is Suspected or Confirmed in Your Center .Ensure signs are displayed for patients on droplet and contact precautions . assign goggles to direct care staff . Interview with the Director of Nursing (DON) on 8/27/20 at 4:45 PM revealed that in July 2020 the facility adopted the following CDC guidance as the facility policy. Review of the CDC Guidance on Cohorting COVID or Suspected COVID Individual in Nursing Homes dated 7/20/20 directed for the Care of Residents with COVID-19 .HCP (Health Care Personnel) should wear an N95 or higher -level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or disposable face shield that covers the front and sides of the face) , gloves, and gown when caring for these residents universal use of all recommended PPE (Personal Protective Equipment) for the care of all the residents on the affected unit (or facility-wide depending on the situation) is recommended when even a single case among residents or HCP is newly identified in the facility; this could also be considered when there is sustained transmission .Place signage at the entrance of the COVID-19 care unit that instructs HCP they must wear eye protection and an N95 mask .at all times while on the unit. Gowns and gloves should be added when entering resident rooms. During an interview on 8/27/20 at 9:15 AM, the DON stated that she is the designated Infection Control Preventionist (ICP) in the facility. The DON stated that the facility currently has four residents positive for COVID-19 on transmission-based precautions on a COVID Unit, Hall 100, with the remainder of the unit housing COVID recovered residents (residents who previously had COVID and no longer require precautions). The facility is keeping the COVID positive residents on transmission-based precautions for 20 days. During an interview on 8/27/20 at 9:40 AM, the Minimum Data Set (MDS) Registered Nurse (RN) identified R#1, R#2, R#3, and R#4 as active COVID positive cases who required transmission-based precautions, specifically, contact and airborne precautions. The remainder of the COVID Unit houses COVID recovered residents who remain on Droplet Precautions. Review of the 8/27/20 Resident Room List revealed that 32 residents resided on Hall 100 and denoted the four residents who were on active COVID-19 precautions resided in rooms [ROOM NUMBER]. Review of R#1's Clinical Laboratory Services Result, located in the Electronic Health Record (EHR) under the scan docs tab, dated 8/21/20, documented that on 8/18/20 the lab received a sample taken on 8/17/20 for Coronavirus [DIAGNOSES REDACTED] CoV-2 (COVID-19) and the result was positive. Review of R#2's EHR under the scan docs tab, dated 8/5/20, documented that on 8/3/20 the lab received a sample taken on 8/3/20 for Coronavirus [DIAGNOSES REDACTED] CoV-2 (COVID-19) and the result was positive. Review of R#3's Clinical Laboratory Services Result, located in the EHR under the scan docs tab, dated 8/21/20 documented that on 8/18/20 the lab received a sample taken on 8/17/20 for Coronavirus [DIAGNOSES REDACTED] CoV-2 (COVID-19) and the result was positive. Review of R#4's hospital discharge medical records provided by the Medical Record Department documented the resident was hosptalized on [DATE] for Urinary Tract Infection [MEDICAL CONDITIONS] and COVID-19. At the time of the survey, R#4 was still on transmission-based precautions per the facility's 20-day isolation policy. During an observation on 8/27/20 at 10:00 AM, CNA AA exited R#3's room wearing a blue isolation gown, N95 mask, and gloves with a plastic bag in her right hand and walked across the hall to two large plastic bins; she was not wearing goggles or a face shield. During an interview on 8/27/20 at 10:30 AM, the DON stated that the facility does not have a problem with the supply of face shields. During an observation on 8/27/20 at 12:20 PM, LPN AA administered medications to R#4. Prior to entering the room LPN AA donned (put on) a blue isolation gown and gloves; however, no goggles or face shield was worn. During an interview on 8/27/20 at 4:30 PM, LPN AA stated she did not wear a face shield when she administered medications to R#4 because it's not posted on the signage. During an observation on 8/27/20 at 12:30 PM, CNA BB was noted in the room at R# 1's bedside feeding the resident. CNA BB was wearing a long-sleeved isolation gown, gloves, and an N95 mask; however, she was not wearing goggles or a face shield. During an interview on 8/27/20 at 4:35 PM, CNA BB stated she did not wear a face shield when she fed R#1 because a face shield was not posted on the signage on the resident's door and the resident does not spray when she eats.

Based on observation, record review, and staff interview, the facility failed to ensure privacy curtains on two out of three halls in two resident rooms affecting four residents (R)(R#87, R#7, R#45, R#32) on the 300 hall who were not provided full visual privacy. In addition, the facility failed to provide privacy during medication administration for one resident (R#76) out of 6 resident observed for medication administration, when administering R#76 an insulin injection in the abdomen. The sample size was 45 residents. Findings include: 1. During observation on 4/1/19 at 11:55 a.m., there was an approximate three-foot gap between the end of the privacy curtain and the wall at the head of the beds when the privacy curtain was pulled between the A- and B-beds in room [ROOM NUMBER]. During interview with R#7 at this time (who resided in the B-bed), she stated this gap did not bother her, as she was independent and able to perform her own care, so that staff did not need to pull the privacy curtain for her. R#7 further stated that the staff pulled the curtain for her roommate (R#87 in the A-bed) when they did care, so that resident couldn't be seen from the hallway. During an observation of wound care done by the Wound Care Coordinator and assisted by Licensed Practical Nurse (LPN) BB on 4/2/19 at 10:10 a.m., R#87 was observed to have a Stage III pressure ulcer to her left hip, and Stage IV pressure ulcer to her right hip. The privacy curtain had been pulled between R#87 and R#7's beds before the treatment was started, and there was an approximate one-foot gap on the wall at the head of the bed between these two beds. Further observation revealed that the second privacy curtain that had been pulled from the hallway wall and door and around the foot of R#87's bed was not long enough to reach the first curtain between the A- and B-beds, leaving a gap of approximately one-foot at the foot of R#87's bed. Further observation revealed that R#7 was not in the room at the start of the treatment, but opened the hallway door and ambulated herself past the foot of R#87's bed (A-bed) on the way to her bed (B-bed) at 10:15 a.m. R#87's bed covers were observed pulled down to her legs, and the right hip dressing had been removed and the wound potentially visible by R#7 through the gap in the privacy curtain as she walked past the foot of the bed. Continued observation revealed that at 10:32 a.m., R#7 left her bed, ambulated past R#87's bed on her way out the hallway door, and at this time R#87's left hip wound was uncovered and potentially visible by R#7 as she walked past the gap in the privacy curtain at the foot of R#87's bed. On 4/3/19 at 10:26 a.m., an additional observation revealed that the privacy curtain for R#87's bed could not be pulled all the way across the foot of the bed because there were 13 unused hooks in the curtain track at the end of the track, as well as an Easter decoration hanging from one of these hooks. During interview with LPN CC at this time, she verified the gap created by not being able to pull the privacy curtain all the way to the end of the track. During interview with the Director of Nursing (DON) on 4/4/19 at 9:58 a.m., she stated that her expectations were for staff to pull the privacy curtain all the way around the bed when doing a treatment. She verified that there was a gap of a little over 12 inches, as measured with the surveyor's tape measure, between the A- and B-beds at the foot of the A-bed in room [ROOM NUMBER], and that the curtain could not be fully closed due to the holiday decoration and empty hooks on the curtain track in front of the A-bed. During interview with the Wound Care Coordinator on 4/4/19 at 11:38 a.m., she verified that there had been an opening between the privacy curtains at the end of R#87's bed when she performed the wound care on 4/2/19, but that R#7 was not in the room at the time she started the treatment and could not ask R#7 to leave when she wanted to come into her room. She stated during continued interview that if she was aware of a privacy curtain not being long enough, that she would tell the Housekeeping Supervisor, but did not remember doing this after the treatment for [REDACTED]. During interview with the Environmental Services Supervisor on 4/4/19 at 1:06 p.m., she stated that a housekeeper will take a privacy curtain down to wash if they noted it was soiled, but that the housekeeping staff did not check to see if the privacy curtains were long enough. Review of the facility's policy on Wound Care Guidelines, reviewed (MONTH) (YEAR), revealed: Provide privacy for the patient: Close the door and pull the curtain. 2. During observation on 4/2/19 at 10:04 a.m., there was an approximate three- to four-foot gap between the A-bed (R#32) and B-bed (R#45) in room [ROOM NUMBER] along the wall at the heads of their beds, when the privacy curtain was pulled between R#45 in the B-bed all the way across to the C-bed at the foot of his bed. During interview with the DON on 4/4/19 at 10:05 a.m., she verified that there was a 21-inch gap, as measured with the surveyor's tape measure, between the B- and C-beds at the foot of the beds, if the privacy curtain was flush against the wall at the head of the beds between the A- and B-beds. Review of a copy the facility's Resident Rights revealed: The right to privacy concerning accommodations and medical treatment. Review of the facility's Georgia Admission Packet, Resident Rights Under Federal Law, revealed: Privacy. Each resident has the right to privacy with regard to accommodations, treatment, communications, personal care, visits and meetings of family and resident groups. 3. During an observation on 4/3/19 at 10:50 a.m. of medication administration done by Licensed Practical Nurse (LPN) AA, R#76 was observed sitting up in wheelchair in her room with her shirt pulled up exposing her abdomen. LPN AA entered room to administer insulin injection. This room occupies 3 residents and R#76 occupies the bed by the window and roommate was sitting up in chair at the side of the middle bed. LPN AA explained procedure to R# 76 and proceeded to perform insulin injection to upper abdomen area and did not provide privacy by pulling the curtains or closing the door to ensure privacy. During an interview on 4/3/19 at 11 a. m. with LPN AA and she stated she should have close the door and pulled the curtain before administering insulin to R#76 to ensure privacy. During an interview on 4/4/2019 at 10:25 a.m. with Director of Nursing (DON), she stated her expectations is for nurses and staff to always ensure privacy for residents and privacy is to be maintained for all care provided including administering insulin injections.

Based on observations, record review and staff interviews, the facility failed to submit application for Level II PASRR (Preadmission Screening and Resident Review) for evaluation and determination of specialized services for one resident (R) #2 that had a positive Level I PASRR for mental illness and [DIAGNOSES REDACTED]. The sample was 24 residents. Findings include: Record review for R#2 revealed a DMA-6 (Physician's Recommendation Concerning Nursing Facility Care or Intermediate Care for Mentally Retarded) form dated 2/16/10 that indicated an admitting [DIAGNOSES REDACTED]. Review of the PASRR Level I Application record dated 2/16/10 indicated the resident had a mental illness, mental [MEDICAL CONDITION], development disability or related condition. Review of the DMA-6 form dated 2/6/17 identified R#2 had a [DIAGNOSES REDACTED]. Further record review for R#2 revealed current [DIAGNOSES REDACTED]. Review of the Physician Order's revealed the resident was currently receiving [MEDICATION NAME] ([MEDICATION NAME]) 0.5 MG at bedtime for anxiety, [MEDICATION NAME] ([MEDICATION NAME]) 75 MG BID (two times a day) for depression, [MEDICATION NAME] ([MEDICATION NAME]) 30 MG QD for depression and [MEDICATION NAME] ([MEDICATION NAME]) 1 MG at bedtime for [MEDICAL CONDITION]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) summary score of six, indicating R#2 had severe cognitive impairment. Section D- Mood assessed that R#2 exhibited moods of feeling down, depressed or hopeless and trouble falling asleep or staying asleep or sleeping too much and feeling tired or having little energy. R#2 did not exhibit behaviors. Section I- Active [DIAGNOSES REDACTED]. Section N- Medications coded that R#2 received antianxiety, antidepressant and antipsychotic medications all seven days of the assessment look back period. During observations of R#2 on 2/20/18 at 3:45 p.m., 2/21/18 at 8:00 a.m. and 2/22/18 at 10:00 a.m., no negative behaviors were noted. The resident was alert but had a flat affect. R#2 appeared leery and would not engage in conversation or interview. Interview on 2/21/18 at 8:45 a.m. the Certified Nursing Assistant (CNA) EE revealed R#2 does talk with the staff but most likely is not engaging in conversation with surveyor due to unfamiliarity. CNA EE stated that the resident does not exhibit negative behaviors but she does have occasional crying, particularly if her son had not visited. CNA EE further stated she had seen R#2 have a delusion once when she thought her son was her husband. Interview on 2/22/18 at 10:50 a.m. the Registered Nurse (RN) Admissions Coordinator revealed she is responsible for resident admissions and she ensures that there is a DMA-6 form and an approved Level 1 PASRR prior to admission to the facility. She stated that she reviews the DMA-6, Level 1 PASRR and resident records for any [DIAGNOSES REDACTED]. The Admissions Coordinator stated she will then forward that information verbally to the Social Service Director (SSD) who is responsible for submitting an application for PASRR Level II evaluation. The Admissions Coordinator stated that the SSD is out of the facility this week due to an illness and was not available for interview. She further stated she is not sure why an application for a Level II PASRR had not been submitted to the state designated authority for evaluation and determination of specialized services. Interview on 2/22/18 at 11:15 a.m. with the Medical Records (MR) staff DD revealed she is responsible for filling out the annual DMA-6 form for residents in the facility. She stated she fills out the forms and places them in the Physician's folder to be signed. MR staff DD stated that once the DMA-6 is signed by the Physician, she gives it to the SSD for her review. The SSD then returns it to her to file on the resident's chart. Interview on 2/22/18 at 11:30 a.m. with the MDS Coordinator CC revealed the facility does not have a policy and procedure related to submitting an application of Level II PASRR. She stated she looked everywhere and they do not have one.