Every finding on record at Hartwell Health and Rehabilitation

Based on observations, staff interviews, and review of facility policy titled, Food Preparation and Distribution, the facility failed to ensure dietary staff properly washed hands in the dish room to prevent cross contamination. The facility census was 85 and all residents were receiving an oral diet. The deficient practice had the potential to affect all facility residents.Findings include:Review of the facility policy titled Food Preparation and Distribution revealed Cross contamination - hand washing should occur before putting on gloves and after removing gloves. Gloves should be changed between tasks, such as between handling raw meats or ready-to-eat foods and between handling soiled and clean dishes.Observation on 02/07/2026 at 12:35 PM of Dietary Aide EE revealed she was in the dish room washing soiled dishes and was wearing blue colored plastic gloves. Continued observation revealed the dietary aide placing soiled meal trays in a dish rack and pushed them through the conveyer belt style dish machine. Dietary Aide EE then placed six soiled small plastic gray bowls on a dish rack and sent them through the dish machine. Dietary Aide EE was observed handling the six now clean small gray colored bowls from the dish rack while still wearing the same blue colored plastic gloves used to rack the soiled dishes. The dietary aide took these six small gray colored bowls and placed them on a large tray with other clean bowls. The dietary aide began to arrange and organize the entire tray of bowls while wearing the soiled blue plastic gloves. Dietary aide EE did not remove the plastic gloves and did not wash her hands after handling soiled dishes before handling clean dishes.Interview on 02/07/2026 at 12:35 PM with Dietary Aide EE confirmed that she did not remove her plastic gloves and did not wash her hands after touching the soiled dishes and before touching the clean dishes. Dietary aide EE was not able to answer any additional questions when asked about hand washing in the kitchen.Interview on 02/07/2026 at 12:35 PM with the Food Service Manager (FSM) revealed they typically had two dietary staff members in the dish room, one staff at the dirty side of the dish machine loading soiled dishes on racks and another staff on the clean side of the dish machine. The FSM stated that Dietary Aide EE was assigned to the dirty side of the dish machine and there should have been another dietary staff with her, but all other staff were assisting with the lunch meal service. The FSM revealed that Dietary Aide EE has been reminded to remove plastic gloves and wash hands when going from dirty dishes to clean dishes. The FSM stated that she expected staff to remove plastic gloves and wash hands if going between dirty to clean dishes.

Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Foot Care, the facility failed to adequately provide Activities of Daily Living (ADL) care pertaining to foot treatment for one of 36 sampled residents (R) (R11). The deficient practice had the potential to place R11 at risk for unmet needs and a diminished quality of life.Findings include:Review of the facility policy titled Foot Care review dated 12/27/2024 revealed under Intent: To provide foot care in accordance with professional standards of practice as part of routine care to assist in identifying skin concerns, maintain mobility and sustain good foot health.Review of the electronic medical record (EMR) for R11 revealed she was admitted to the facility with diagnoses including but not limited to chronic obstructive pulmonary disease, age-related physical debility, morbid (severe) obesity due to excess calories, lymphedema, repeated falls, iron deficiency anemia, diastolic (congestive) heart failure, chronic kidney disease, stage 3b.Review of an annual Minimum Data Set (MDS) assessment for R11 dated 12/31/2025 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Section GG (Functional Abilities) revealed lower extremity impairment on both sides. Dependent with Toileting hygiene, shower/bathe self, upper body dressing, put on/take off footwear, roll left and right, tub/shower.Review of the care plan initiated on 01/14/2025 and revised on 01/14/2026 confirmed limited mobility related to R11 needs assistance with functional ADLs. Goal revealed patient will continue to assist with ADLs on a daily basis through the review period. Intervention assist with ADLs as needed and provide appropriate level of assistance to promote safety of residents.Review of podiatry record revealed on 12/30/2025, unable to file nails, (nail polish)Review of podiatry resident visit list revealed R11 was listed and seen on 12/30/2025, on 01/15/2026 not listed nor seen. During the initial screening interview on 02/06/2026 at 10:17 AM, R11 conveyed her wish to have her toenails trimmed. She shared that the podiatrist declined to carry out the procedure during her previous visit because of the nail polish on her toes. R11 noted that she had the polish removed, yet no one had come back to perform the trimming.Interview on 2/8/2026 at 09:08 AM, with Licensed Practice Nurse (LPN) MM/ Wound Care Nurse indicated that she was responsible for foot care. However, she was uncertain about the schedule of podiatry visits or the specific patients they attend to, although she believed these visits occurred on a monthly basis. LPN MM shared she did not have a copy of the podiatry provider agreement. She was unable to explain the cause for refusal of care by the provider. LPN MM clarified that if the nursing staff had any concerns, she would reach out via email to the podiatry provider. LPN MM confirmed that she did not send an email concerning R11.Observation and interview on 02/08/2026 at 09:20 AM with CNA JJ and LPN MM confirmed the removal of nail polish from R11's feet and the growth of toenails. CNA JJ indicated that R11's toenails were hard and jagged, while LPN MM verified R11's toenails were long and hard. LPN MM expressed to the resident, I wish you would have told me.Interview on 02/08/2026 at 11:50 AM with LPN MM and the Staffing Director disclosed that this oversight should have been identified by CNA JJ and she had undergone in-service training and had been thoroughly educated to recognize and report issues concerning residents.

Based on record review, staff interviews, and review of the facility policy titled, Abuse Prohibition-Screening, Hiring, And Training Practices, the facility failed to complete and receive satisfactory background check screenings for one of 11 nursing staff reviewed. The deficient practice had the potential for staff with criminal backgrounds to care for vulnerable residents.Findings include:Review of the facility policy titled Abuse Prohibition-Screening, Hiring, And Training Practices reviewed date 12/04/2021 revealed it is the intent of this center to establish standards of practice for screening, hiring and training of associates. Guideline:Prospective Associate Screening and Hiring Practices: A background and criminal records history investigation is conducted for prospective associates that will include:Background and Criminal History Investigation. Non-licensed associates are completed through the Georgia Criminal History Check System (GCHECXS) and may include fingerprinting. The center will not employ individuals who have an unsatisfactory determination from the criminal records check or who have had a finding entered into the State Nurse Aide Registry or licensing authority, concerning abuse, neglect, mistreatment of patients and misappropriation of property. Review of the facility employee files revealed the following:Certified Nursing Assistant (CNA) II was hired on 12/22/2025 with an unsatisfactory background check status. CNA II clock events from 12/21/2025 to 01/03/2026, indicated seven days of active check-ins and check-outs. The facility noted from 12/21/2025, to 12/27/2025, CNA II was engaged in orientation and in-service training and started providing care to residents on the floor on 12/29/2025.Review of the Georgia Criminal History Check System (GCHECXS) report dated 01/15/2026 revealed: CNA II determined to be unsatisfactory; details of arrest and/or conviction offense possession of methamphetamine. Georgia Criminal History Check System (GCHECXS) person summary revealed application 892072 closed on 1/16/2026. Reason: Not hired due to criminal history check. Application closed on date was recorded on 1/16/2026. Application 905640, application Status: Closed -Hired, application Status Date 1/16/2026. Interview on 02/07/2026 at 10:00 AM with the Human Resources (HR) Director revealed CNA II was hired on 12/22/2025 and officially began working on the floor on 12/27/2025. However, she confirmed that CNA II's GCHEX was not satisfactory until 01/16/2026, as she had to repeatedly submit documents for review. During follow-up with the HR Director at 12:30 PM, she provided the timeline for the background check concerning CNA II, indicating that there was a charge for drug possession on the CNA's record. The HR Director verified that the CNA was employed, but she was undergoing orientation after hire and did not go on the floor until a week afterwards.

Based on staff and resident interviews and record review, the facility failed to follow physician orders and to contact the physician for a change in condition for one of 16 residents (R) (R13) sampled with physician orders for daily weights. The deficient practice had the potential to place R13 at risk for medical complications, unmet needs, and a diminished quality of life.Findings include:Review of R13's electronic medical record (EMR) revealed R13 was admitted to the facility with pertinent diagnoses including but was not limited to acute and chronic respiratory failure with hypoxia, hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, stage 3 chronic kidney disease, chronic diastolic (congestive) heart failure, paroxysmal atrial fibrillation, need for assistance with personal care, Parkinson's disease, dementia, and wheezing.Review of R13's 5-Day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10, which indicates R13 had moderate cognitive impairment. Review of R13's care plan initiated [DATE] indicated a focus of respiratory difficulties and a risk for further decline related to acute and chronic respiratory failure with hypoxia as evidenced by diminished breath sounds, shortness of breath at rest, and wheezing. Interventions included to monitor vital signs, notify physician of changes, and administer medications and treatment as ordered.Review of R13's care plan initiated [DATE] indicated a focus of cardiovascular disease related to heart failure. Interventions included to monitor vital signs and monitor weight.Review of R13's physician's orders included an order dated [DATE] for daily weights before breakfast for weight check and weight change check related to his diagnosis of chronic systolic (congestive) heart failure.Further review revealed an order dated [DATE] for a chest x-ray portable exam stat (immediately) due to shortness of breath.Further review revealed an order dated [DATE] for chest x-ray portable exam due to cough.Further review revealed an order dated [DATE] for furosemide (diuretic) 20 mg (milligram) tablet with instructions to take 1 tablet by mouth 1 time per day for three days related to a diagnosis of chronic diagnostic (congestive) heart failure.Review of R13's Medication Administration Record (MAR) revealed the following weights: 155 pounds on [DATE], no weights entered from [DATE]-[DATE], 155 pounds on [DATE], no weights entered from [DATE]-[DATE], 155 pounds on [DATE], 155 pounds on [DATE], no weight entered from [DATE], 155 pounds on [DATE], no weights entered from [DATE]-[DATE], no weight entered on [DATE] due to being held, 155 pounds on [DATE], no weight entered on [DATE], 155 pounds on [DATE], 156 pounds on [DATE], 157 pounds on [DATE], 161 pounds on [DATE], no weight entered on [DATE], 161 pounds on [DATE], 157 pounds on [DATE], 149 pounds on [DATE], no weights entered from [DATE] to [DATE], 150 pounds on [DATE], 150 pounds on [DATE], no weight entered on [DATE], 152 pounds on [DATE], no weight entered on [DATE], 154 pounds on [DATE], no weights entered on [DATE] to [DATE], 155 pounds on [DATE], 165 pounds on [DATE], no weight entered on [DATE], 168 pounds on [DATE], 164 pounds on [DATE], no weights entered from [DATE] to [DATE], 164 pounds on [DATE], and no weight entered on [DATE].Review of R13's EMR under the Weights tab revealed the same documented weights as the MAR.Review of R13's EMR revealed a History and Physical assessment by Nurse Practitioner (NP) HH dated [DATE] that documented, under the assessment for chronic diastolic heart failure diagnosis, Euvolemic (normal or balanced volume of body fluids) at present. Continue beta-blocker and monitor for any signs of fluid volume excess. Will add diuretic as indicated.Review of R13's EMR revealed a History and Physical assessment by NP HH dated [DATE] that documented, under the assessment for the chronic diastolic heart failure diagnosis, Stable. Continue metoprolol. Will monitor for fluid volume excess and diuretic as indicated.Review of R13's EMR revealed a History and Physical assessment by NP HH dated [DATE] documented under the assessment for the chronic diastolic heart failure diagnosis, Stable and euvolemic. Continue beta-blocker. Monitor blood pressure and monitor for edema and Shortness of breathReview of R13's EMR revealed a Nurses Note dated [DATE] that revealed Daily Weight not documented by sched (scheduled) nurse on [DATE] (2025) at 0600 (6:00 AM).Review of R13's EMR revealed a Nurses Note dated [DATE] that revealed Resident CBC (complete blood count) 14.9 which has increased since 12/17 (2025) where CBC was 11.7. NP [HH] notified and new orders received TORB (telephone order read back) for U/A (urinalysis) with C&S (culture and sensitivity), chest x-ray. Daughter notified. Therapy also stated that resident has had increased confusion and is not following directions well. He did vomit x 1 yesterday while working with ST (speech therapy). No cough or SHOB (shortness of breath) noted. Lungs diminished bilaterally with auscultation (listening with stethoscope). No N/V (nausea/vomiting) noted today. Review of R13's EMR revealed a chest x-ray with date of service [DATE] that documented a reason for SOB [shortness of breath]. Under Findings documented pulmonary interstitial edema.Review of R13's EMR revealed a Nurses note dated [DATE] that revealed The patient demonstrated decreased participation in therapy this morning. He has a moderate amount of clear nasal drainage and watery eyes. The patient does not report any pain or discomfort, and vital signs are within normal limits. No cough was observed, and lung sounds are clear. The patient expressed feeling unwell and tired. Both flu and COVID tests came back negative. N/O (new order) was received from NP [HH] for daily Claritin and Flonase, and Tussin DM if the patient develops a cough. The patient's daughter has been notified. We will continue to monitor for any changes.Review of R13's EMR revealed a Nurses note dated [DATE] that revealed The patient has continued not feeling well and has continued to decrease his participation in therapy. His runny nose and watery eyes have improved with the use of Flonase and Claritin. However, he has developed a congested cough. NP [HH] was notified, and it was recommended to follow the original plan if a cough developed. An order for Tussin DM, 10 ml (milliliters) three times a day for seven days, has been placed. Additionally, a CXR (chest X-ray) has been ordered since the patient is prone to pneumonia.Review of R13's EMR revealed a chest x-ray with date of service [DATE] for the reason of cough. Under Findings documented central pulmonary vascular congestion with perihilar interstitial densities. Under Impressions documented mild cardiogenic pulmonary edema.Review of R13's EMR revealed a Nurses note dated [DATE] that revealed X-Ray report received. Results showed mild cardiogenic pulmonary edema. Results called to NP [HH]; New orders for Lasix 20MG daily x3days and Potassium ER (extended release) 10mEQ (milliequivalent) daily 3days. Medication to be pulled from ebox (emergency medication).Review of R13's EMR revealed a Nurses note dated [DATE] that revealed, Physician order [DATE] [DATE] [Expired] furosemide 20 mg tablet (FUROSEMIDE) 1 tablet by mouth 1 time per day 3 Days Dx (diagnosis) : Chronic diastolic (congestive) heart failure.Review of R13's EMR revealed a Nurses note dated [DATE] that revealed The patient continues to experience nasal drainage and a lingering cough. Throughout the shift, the patient has tolerated medications and diet well. He consumed approximately 75% (percent) of his supper, maintaining a consistent intake of 75%-100% of most meals. The patient is receiving PEG (percutaneous endoscopic gastrostomy tube) tube feeding for 12 hours daily and nutritional supplements three times a day. The most recent chest x-ray showed some pulmonary edema, and the patient is being treated with Lasix (diuretic). The patient has no complaints of abdominal pain, and bowel sounds are intact in all four quadrants; the abdomen is soft and non-tender.Review of R13's EMR revealed a Nurses note dated [DATE] that revealed, Resident weighed on the wheelchair scale with a weight of 161# (pounds). He is ordered Lasix daily that started yesterday.Observation on [DATE] at0 8:29 AM revealed R13 eating breakfast in his room. When asked if he has been feeling well lately, he stated no and he thinks that is why he is in the hospital. When asked what his symptoms were, he stated he had a dry cough, he stated it is also hard to breathe, even right now.Interview on [DATE] at 11:37 AM with Licensed Practical Nurse (LPN) FF revealed that daily weights were done before breakfast usually by the Certified Nursing Assistants (CNAs) and Certified Medication Aides (CMAs). LPN FF confirmed R13 had an order for daily weights and sometimes he refused, but sometimes they tried to weigh him at a different time. LPN FF further stated that usually in the event of a weight gain of five pounds in a week or three pounds weight gain in 24 hours, she would contact the NP to consider diuretics. LPN FF stated that this morning R13 refused his weight check according to the third shift. While reviewing the MAR with LPN FF, she stated that X usually means refused and sometimes there may be a nurse note associated with it. She stated that if there was a pattern of refusals, nurses would notify the physician to possibly change the time of weight check. She further confirmed a pattern of refusals and stated that she did not see any documentation about the physician being contacted regarding refusals of weights. When asked about R13's documented 10 pound weight gain between [DATE] and [DATE], she stated that must be a discrepancy. She further confirmed the weight gain she had documented and she confirmed that weight gain in a nurse note dated [DATE]. LPN FF further confirmed R13 experienced pulmonary edema and congestive cough on [DATE] and had an order for Lasix and potassium for three days as treatment. LPN FF stated that R13 seemed better since the Lasix and potassium treatment. LPN FF stated that the importance of monitoring daily weights for a resident with congestive heart failure was to avoid fluid overload and exacerbation of the heart failure.Interview on [DATE] at 11:40 AM with CMA GG revealed her responsibilities as CMA included medication administration, vital signs, daily weights, and weekly weights. An interview on [DATE] at 12:31 PM with the Director of Nurses (DON) revealed was familiar with R13. The DON stated that daily weights were done in the mornings and sometimes R13 did not like to be bothered by it. She confirmed several X's and patterns of R13's weights not taken on the MAR, sometimes three days in a row. With refusals, she would expect to let the doctor know about a pattern of refusals. The DON stated she was not sure if the physician had been contacted. She confirmed R13's daily weights were done due to his diagnosis of congestive heart failure and the importance of monitoring the daily weights was to avoid fluid overload. When asked about R13's documented 10-pound weight gain between [DATE] and [DATE], she stated she would have to talk to other staff but she thought it was likely an incorrect weight, and she would have to confirm. The DON confirmed R13 had a chest X ray done and found pulmonary edema on [DATE] and was treated with 3 days of Lasix and potassium. The DON stated she expects physician orders to be followed, and the importance was for care being delivered as ordered and care being maintained. The DON further stated that she was not aware that R13 was refusing weights that frequently.A phone interview on [DATE] at 4:18 PM with NP HH revealed she visited this facility twice a week at minimum and expected physician orders to be followed. She expected to know about refusals, and the importance of knowing about consistent refusals was to adjust the plan of care. She further stated that she wanted to know why a resident refused and then find out what the reason was to help them to better review the medications and treatment. She further stated she would want to consider if they were refusing because they were confused or the timing of the medication or treatment. NP HH further stated that the EMR did not prompt her of refusals so she depended on staff to notify her. When asked about R13, she stated she believed he had an order for daily weights due to tube feedings. She stated that the facility staff had told her that R13 refused things from time to time. She was made aware of his refusals of weights maybe last week on Thursday. NP HH stated she did not necessarily monitor his weights and instead looked at a whole picture of edema and shortness of breath. When asked about R13's documented 10-pound weight gain between [DATE] and [DATE], she stated that she would have questioned the accuracy of it. She did not confirm or deny, based on technical issues. She further confirmed R13 experienced pulmonary edema within the last 10 days and had been prescribed Lasix and potassium to treat for about three days. When asked about the importance of monitoring daily weights for a resident with congestive heart failure, she provided no response.

Based on observations, record review, staff interviews, and review of the facility's policy titled, Patient Smoking Guidelines, the facility failed to keep facility free of accident hazards for one of three sampled residents (R) (R22) who smoked. Specifically, smoking materials were not kept away from R22's bedside. This deficient practice had the potential to result in choking, aspiration, oral injury, and other avoidable harm to facility residents.Findings include:A review of the facility policy titled Patient Smoking Guidelines reviewed on 12/27/2024 revealed in section General Smoking Guidelines: No patient will be allowed to be in possession of smoking paraphernalia (i.e., cigarettes, lighters, e-cigarettes, matches, etc.) on their person, in their rooms or any other place in the Center or Center grounds other than the Center has identified location to keep patient smoking materials. All patient smoking materials will be kept in a designated location in the Center and dispensed at the time of the smoke break.Review of the electronic medical record (EMR) revealed R22 was admitted with diagnoses including, but not limited to, unspecified sequelae of cerebral infarction, hemiplegia affecting the right dominant side, dementia, dysphagia, chronic kidney disease stage 4, contractures of the bilateral hands, anxiety disorder, and poor dentition.Review of R22's Annual Minimum Data Set (MDS) assessment dated [DATE] documented in Section C (Cognitive Patterns) with a score of 6, indicating R22 was severely cognitively impaired. Section GG (Functional Abilities and Goals) documented R22 required dependent assistance for oral hygiene, toileting, bathing, dressing, and personal hygiene. Section K (Swallowing/Nutritional Status) documented a swallowing disorder including holding food in the mouth or cheeks and coughing or choking. Section L (Oral/Dental Status) documented broken or decayed natural teeth.Review of R22's care plan, reviewed on 2/5/2026, revealed problem areas for cognitive impairment, behavioral symptoms, tobacco use, resident preferences, and risk for altered nutrition status. The cognitive impairment care plan documented memory deficits and the need for cues and redirection. The behavioral symptoms care plan documented R22 had episodes of delusions and verbal aggression. The risk for altered nutrition status care plan documented poor dentition and a mechanically altered diet with monitoring for swallowing concerns. The tobacco uses care plan identified the R22 as a chewing tobacco user; however, interventions focused on hygiene reminders and monitoring for oral complications. The resident preferences care plan allowed the R22 to keep chewing tobacco and a dip spit cup on the bedside table.Observation on 02/06/2026 at 8:32 AM in R22's room revealed two packages of loose-leaf chewing tobacco at the bedside, one opened and one closed.Observation on 02/07/2026 at 8:53 AM in R22's room revealed one bag of loose-leaf chewing tobacco accessible on the bedside table.Observation on 02/07/2026 at 11:15 AM in R22's room revealed one bag of loose-leaf chewing tobacco accessible on the bedside table.Interview on 02/07/2026 at 11:17 AM with Certified Medication Aide/Certified Nursing Assistant (CMA/CNA) AA revealed she stated the resident in room [ROOM NUMBER]-A (R22) used tobacco products. She stated she had been told to make sure residents do not choke and to ensure their head was up when using tobacco. She stated that since she had worked at the facility, R22 had always used tobacco products. She stated, to her knowledge, R22 always had tobacco products on his bedside table.Interview on 02/07/2026 at 12:09 PM with Licensed Practical Nurse (LPN) BB revealed the facility had approximately three residents who used tobacco products on one hall. She stated residents were assessed based on their BIMS scores to determine whether tobacco products could be kept in the room or must be locked at the nurses' station. She stated residents were assessed upon admission, and stated R22 had been grandfathered in. She stated the resident had used tobacco products for as long as she had worked at the facility.Interview on 02/07/2026 at 5:34 PM with the Regional Nurse Consultant (RNC) stated tobacco products should be kept at the nurses' station. She identified potential negative outcomes as the risk of choking and stated if residents were not properly educated on the risk's tobacco posed, there was also a risk of other residents accessing the tobacco products.Interview on 02/08/2026 at 8:38 AM with the Director of Nursing (DON) revealed that tobacco products were not to be kept at the bedside and were to be locked at the nurses' station or in the medication room. She identified potential negative outcomes as other residents accessing tobacco products and stated the residents could experience swallowing issues, even though the product was not meant to be swallowed since it remained in the mouth.Interview on 02/08/2026 at 8:38 AM with the Administrator revealed the facility wanted to support residents' rights as much as possible and stated they had never had any issues related to tobacco use. He stated he did not picture an issue and stated he did not have an answer. He stated he wanted residents' rights to be honored. He stated perhaps a better approach would be to keep tobacco products in a drawer. He stated there was a fine line between what was safe and residents' rights. When asked if assessments should be completed to mitigate the risk for residents, he stated the facility wished to operate according to its policies. He further stated, hypothetically, there were a number of potential risks when residents had tobacco products at the bedside table.

Based on observations, record review, staff interviews and review of the facility policies titled, Infection Prevention Plan and Transmission-Based Precautions, the facility failed to maintain effective infection control practices concerning contact precautions standards for one of 39 sampled residents (R) (R78). Additionally, the facility failed to prevent the risk of cross-contamination for one of 39 sampled residents (R) (R16). The deficient practices had the potential for cross-contamination of pathogens to other residents and staff.Findings include:Review of the facility's policy titled, Infection Prevention Plan last reviewed date 12/27/2024, revealed under Intent: The Infection Prevention Plan provides an overview of the infection prevention practices of the center that is charged with the promotion of a healthy and safe environment to reduce the risk of infections in patients, staff, visitors, and others in health care environment. Under Goals: . Maintain a sanitary environment for personnel and patients. Under Scope: . Hand hygiene shall be monitored by each facilities infection preventionist or designee.Review of the facility's policy titled, Transmission-Based Precautions (Contact, Enhanced Barrier Precautions, Droplet, Airborne) last reviewed date 12/27/2024, revealed under Purpose: In addition to standard precautions, this facility uses Transmission-Based precautions for residents with documented or suspected infection or colonization with highly transmissible or epidemiologically important pathogens for which additional precautions are needed to prevent transmission. Under Contact Precautions: Use of Personal Protective Equipment, Gown and Gloves: For all interactions that may involve contact with the patient or the patient's environment. Donning (putting on) PPE upon room entry and properly discarding before exiting the patient room is done to pathogens.Review of R78's electronic medical record (EMR) revealed admission to facility with diagnoses including but not limited to encounter for orthopedic aftercare following surgical amputation, Type 2 diabetes mellitus with hyperglycemia, Type 2 diabetes mellitus with diabetic chronic kidney disease, peripheral vascular disease, acquired absence of left leg below knee, hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R78 with a Brief Interview for Mental Status (BIMS) score of 13, indicating R78 is cognitively intact.Review of the Care Plans for R78 revealed a care plan dated 01/16/2026 revealed care area Post op surgical wound infection. Goal Patient will not require hospitalization as a result of infection Evidence Purulent drainage from open area at surgical site. Wound culture = MRSA (methicillin resistant staphylococcus aureus) heavy growth. Intervention Administer medication and / or treatment as ordered Diagnostics as orderedReview of R78's physician's order dated 01/20/2026 revealed: Contact Isolation Dx: Encounter for orthopedic aftercare following surgical amputation. D/C (discontinue) on 02/7/2026.Review of R78 nurse notes dated 01/17/2026 revealed: Stump protector held due to currently MRSA treatment and dressing change. Will continue to observe.Observation on 02/6/2026 at 10:23 AM revealed that the door to R78's room exhibited signage indicating contact precautions.Observation and interview on 02/06/2026 at 10:25 AM with R78 revealed that Certified Nursing Assistant (CNA) KK entered the resident's room without using any PPE. CNA KK proceeded to check the vital signs of the resident. Additionally, CNA KK checked the vital signs of the resident's roommate before exiting the room. CNA KK confirmed that he assessed the vital signs of both residents. CNA KK further explained that R78 had a wound/MRSA and that he should have worn gloves.Review of R16's EMR revealed admission to the facility with diagnoses including but not limited to unspecified sequelae of cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dysphagia following cerebral infarction, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance mood disturbance, and anxiety, slow transit constipation, iron deficiency anemia, unspecified.Review of the quarterly Minimum Data Set (MDS) dated [DATE] documented R16 with a Brief Interview of Mental Status (BIMS) score of 5, indicating severe cognitive impairment.Review of the Care Plans for R16 revealed care plan dated 01/30/2024 revealed Risk for altered nutrition status. Related Dysphagia / swallowing difficulty. Evidence Will tolerate current diet consistency with no s/s (signs and symptoms) of aspiration thru the review period. Interventions Allow eating at own pace, Allow extra time during meals, and Honor food and dining preferences.Review of R16's physician's order dated 06/10/2024 revealed diet: Regular Easy Chew 7 GR (ground) Meat 5.Observation on 02/06/2026 at 8:30 AM revealed that CNA JJ was using their bare hands to tear apart the breakfast meal of R16, which was identified as pancakes. There was no evidence of hand hygiene being practiced.Interview on 02/07/2026 at 4:22 PM with Nurse Supervisor (NS) LL, revealed that the facility census indicated R16 was no longer under contact precautions and was not receiving any treatment. The NS confirmed that this signified the resident was not deemed to have an active infection. She elaborated that she worked part-time and functions as the Infection Preventionist, noting that signs may remain on doors until she verified that treatment had been completed and that precautions could be altered or removed. NS LL indicated that as of today, the resident was not undergoing any treatment. Upon reviewing the documentation, she observed that there was no evidence suggesting that treatment was either continued or declined, leading her to conclude that the last day of transmission-based precautions was 01/25/2026. She mentioned that she had been instructing a class, and upon her return, the sign was still affixed to the door despite all PPE having been removed. She expressed uncertainty as to why the staff had not taken down the sign. NS LL emphasized that even if a sign remained posted, she expected CNAs and nurses to communicate and clarify the resident's status. She could not verify whether this communication had taken place. She noted that the staff believed the resident did not have an active infection, which contributed to their confidence in providing care without adhering to the posted sign. Concerning enhanced barrier precautions, NS stated that when staff were delivering direct, close care, they should don gloves and a gown, particularly when working near the resident's operative site. She expressed her belief that the organism was not present elsewhere on the resident.Interview on 02/07/2026 at 4:28 PM with the Director of Nursing (DON) disclosed that residents under enhanced barrier precautions required staff to don gowns and gloves when delivering direct contact care. She specified that this requirement did not extend to medication administration or the preparation of meal trays. Furthermore, she elaborated that procedures such as wound care, complete clothing changes, transferring patients, changing linens, assisting with personal hygiene, aiding with toileting, and caring for devices necessitate the use of gowns and gloves due to the close physical interaction involved. She also mentioned that the resident did not have any open skin areas that would necessitate wound dressings. The DON emphasized that if staff members encountered a sign or a precaution noted in the system, they should seek clarification from the nurse. Should the nurse be unable to provide clarification, staff were advised to consult the system, where she had previously updated the resident's status to enhanced barrier precautions earlier that same morning.Interview on 02/07/2026 at 4:33 PM with the Clinical Standard Quality Nurse revealed when the surveyor raised concerns regarding inconsistent documentation pertaining to the residents' MRSA treatment dates, the NC expressed that her expectations were for the staff to seek clarification when documentation was ambiguous, to ensure that necessary signs were displayed, and to adhere to PPE guidelines, which included the use of gowns and gloves when enhanced barrier precautions were in effect.

Based on observations, record review, staff interviews, and review of the facility's policy titled Medication Beyond-Use and Expiration Dates, the facility failed to remove expired insulin pens from two of three medication carts observed. This failure had the potential for residents to be administered expired medications. Findings include: Review of the undated facility's policy titled Medication Beyond-Use and Expiration Dates, under the section titled Guidelines revealed, An expiration date indicates the last date at which the manufacturer guarantees a drug's full potency and safety Medication should not be stored, transported, or administered after beyond-use or expiration date. Observation on 10/24/2024 at 9:38 am of Licensed Practical Nurse (LPN) DD while working on Medication Hall Three cart, revealed one Humalog insulin pen with a sticker that indicated a discard date of 10/21/2024. There was no identifiable open date on the pen. Interview on 10/24/2024 at 9:44 am with LPN DD, while working on Hall Three medication cart, confirmed the Humalog insulin pen had a sticker with discard date of 10/21/2024. She removed the Humalog insulin pen from Hall Three cart and placed it in the medication storage room, in a destruction bin. Observation on 10/24/2024 at 9:50 am of RN FF while working on Medication Hall Two cart, revealed one Novolog insulin pen with a sticker that indicated an open date of 9/23/2024 and a discard date of 10/21/2024. Interview on 10/24/2024 at 9:54 am with RN FF confirmed the Novolog insulin pen had a sticker with an open date of 9/23/2024 and a discard date of 10/21/2024. He removed the Novolog insulin pen from Hall Two cart and placed it in the medication storage room, in a destruction bin. He further stated he will report this to the Director of Nursing (DON). Interview on 10/24/2024 at 10:27 am, with the DON stated that all insulins should be stored per protocol and procedural standards. She stated that all expired medications should be removed and discarded according to manufacturer's instruction or facility policy.

Based on observation, staff interviews, record reviews, and review of the facility's policies titled, Elopement, Anti-Wandering Equipment, and Bedside Storage of Medications, the facility failed to ensure two residents (R) (R54 and R68) with wander guards, were properly assessed for an elopement risk, and that their skin under the wander guard was properly assessed for breakdown. In addition, the facility failed to adequately assess R32 for self-administration of medication. This failure had the potential to place the residents at risk for adverse consequences. The sample size was 30 residents. Findings include: Review of the facility policy titled Elopement with a review date of 12/29/2023, revealed that the intent is to promote person-centered care for patients at risk for elopement. The policy also revealed that elopement is defined when a patient leaves the premises or a safe area without authorization and/or necessary supervision. The assessment section of the procedure states that the center will take a proactive approach for new residents and assess new admissions for elopement risk. It then continues by stating that the licensed nurse will re-assess resident at least quarterly, annually, with any significant change, and upon readmission to the center. Review of the undated policy titled Anti-Wandering Equipment Policy revealed that the facility uses anti-wandering equipment inside the facility to alert staff when a resident that is at risk for elopement is close to the front entrance. It also stated that residents that have exhibited one or more of the following behaviors meet the criteria of placement of wander guard transmitter: aimless wandering and/or has exit seeking behaviors, resident states or has stated that they will leave the facility, and the resident ambulates with or without assistive devices and has impaired cognition. Review of the undated facility policy titled, Bedside Storage of Medications revealed, under section titled, Intent To support self-administration of medication by appropriate patients within the nursing center while facilitating medication security. Under section titled Guideline, it documented, The Pharmacy supports bedside medication storage for patients who are able to self-administer medications upon the written order of the prescriber and when it is deemed appropriate in the judgment of the nursing center's interdisciplinary patient assessment team. Furthermore, under section titled Procedure revealed, A medication-specific order is required from the prescriber for bedside medication storage (e.g., add May keep at bedside to each applicable medication order). Bedside medications may be labeled May keep at bedside by the provider pharmacy upon request. An assessment for self-administration of medications is completed and kept in patient's care plan in the medical records. The manner of storage must prevent access by other patients. Lockable drawers or cabinets are REQUIRED. Patients who self-administer medications are asked during each med pass if he/she has taken any meds. Each dose self-administered at bedside is documented on the Medication Administration Record (MAR). The patient informs nursing staff when as needed (PRN) doses have been taken. Nurses and aides report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage and give unauthorized medications to the charge nurse for return to the family or responsible party. Families or responsible parties are reminded of this procedure and related policy when necessary. 1. Review of the Electronic Medical Record (EMR) revealed that R54 was admitted to the facility on [DATE] with diagnoses that included but are not limited to Alzheimer's disease, adjustment disorder with mixed anxiety, depressed mood, and dementia. Review of the physician orders revealed that there were no orders for behavior monitoring, a wander guard, or skin checks for the area under the wander guard bracelet. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed for Section C (Cognitive Patterns) R54 had a Brief Interview for Mental Status (BIMS) score of 11, that indicated moderately impaired cognition; Section E (Behaviors) revealed no behaviors at the time of the assessment; Section GG (Functional Abilities and Goals) revealed the resident was ambulatory with no assistive devices used. Review of the care plan revealed R54 was at risk for elopement related to exist seeking behavior as evidenced by a history of aimless wandering, exit seeking behavior, and the resident left the property twice on 8/1/2024. Interventions included staff were to provide one on one supervision while outside, provide activities of interest, redirect as needed, and use of a wander guard on resident's wrist. Review of the assessments revealed R54 had an elopement risk assessment dated [DATE] with an elopement risk score of 14 indicating moderate risk. The risk assessment was signed on 10/24/2024 by Social Services. Social Services also completed a behavioral assessment on 8/2/2024, after the resident had left the building twice the prior day on 8/1/2024. 2. Review of the EMR revealed R68 was admitted to the facility on [DATE] with diagnoses that included but were not limited to metabolic encephalopathy, cognitive communication deficient, dementia and delirium. Review of physician orders revealed there were no orders for behavior monitoring, a wander guard, or skin monitoring under and around the wander guard. Review of the Admission/5-day MDS assessment dated [DATE] revealed for Section C (Cognitive Patterns) R68 had a BIMS score of seven, that indicated moderately impaired cognition; Section E (Behaviors) revealed delusions and behavioral symptoms occurred daily that were not directed towards others and Section GG (Functional Abilities and Goals) revealed R68 was ambulatory and did not require any assistive devices for mobility. Review of the care plan revealed that on 9/5/2024, R68 was at risk for wandering and elopement, related to a diagnosis of dementia. That risk was evidenced by the resident being a new admission, highly confused, frequent request to go home, and ambulated independently with or without assistive devices. Interventions included, distract resident from wandering, redirect to appropriate places, and a wander guard placed on resident. Review of assessment's that were completed after R68's admission by social services included but not limited to the following: 1. A behavioral assessment dated and signed on 8/9/2024. 2. A wander guard was not an intervention added for the resident at that time. 3. A comprehensive nursing assessment dated of 8/6/2024. 4. An elopement risk assessment dated [DATE] revealed R68 had an elopement risk score of 20, which meant there was a moderate risk. However, the assessment was not signed until 10/24/2024. Review of an additional Elopement Risk Assessment for R68 dated 10/24/2024 revealed that there was no elopement risk. Observation on 10/22/2024 at 1:54 pm revealed R68 ambulating in the hallway. An observation inside R68's room revealed five black bags full and tied up, and a stack of books on the over-the-bed table. R68 entered the room and revealed that she was going home, and that the recliner was given to her by a friend. R68 further revealed she did not know how she was going to get the recliner home but that all her other belongings were bagged, and the stack of books was ready to go with her. R68 was dressed, and a wander guard bracelet was on her right wrist. Observation on 10/23/2024 at 9:45 am revealed R68 ambulating in the hallway, headed to her room. Inside her room it was noted that black bags were still tied and was laying throughout the room. The stack of books was stacked on her bed. R68 was pleasant and revealed that she was still waiting to go home. The wander guard was still on her right wrist. Interview on 10/24/2024 at 4:00 pm, the Social Services Director revealed she had been here for 15 to [AGE] years, and use of a wonder guard depended on cognitive status. If they exhibited exit seeking behavior, staff discussed it in morning meeting and then they would place it on them. She revealed they do not need an order. The SSD did not know about assessments the nurses did. Interview on 10/24/2024 at 4:47 pm, the Director of Nursing (DON) revealed the elopement and wander guard process. The elopement risk assessment is included in the comprehensive assessment at admission. It is also completed when MDS assessments are completed, quarterly and annually. She revealed a wander guard is used when residents demonstrate certain behaviors, and they start by doing an elopement risk assessment. She revealed that they did not need an order, the physician knows about it, and it should be care planned. She revealed the nurse should document in the chart that the wander guard is in place and that skin is intact, and she thought it was on the electronic Medication Administration Record (eMAR). 50272 3. Review of the EMR for R32 revealed she was admitted to the facility on [DATE]. R40 had diagnoses that included but not limited to, unspecified dementia (moderate) with other behavioral disturbance, personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, unspecified sequelae of cerebral infarction, other lack of coordination, pain (unspecified). Review of R32's quarterly Minimum Data Set (MDS) dated [DATE] documented in Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) of 13, which indicated the resident was cognitively intact. Review of the care plan revised on 8/12/2024, revealed R32 was care planned for cognitive impairment related to dementia and history of cerebrovascular accident (CVA), as evidence by memory problem, poor decision making/needs cues, on dementia medications, memory problem short term, and impaired decision making in new situation. Review of the care plan revised on 8/12/2024, revealed R32 was care planned for risk for communication difficulties related to dementia and history of CVA as evidence by ability limited to making concrete requests and hearing mildly impaired. Further review of the care plan revealed R32 had not been cared planned for any kind of self-administration of medication. Review of consolidated physician orders for R32 with print date of 10/24/2024 revealed no orders were found for Mentholatum Original Ointment (Topical Analgesic Rub). Review of the EMR for R32 revealed on 10/23/2024 the facility had conducted an Assessment Self-Administration of Medications, documenting the medications under consideration was [Name] vapor rub. The assessment documented that R32 was unable to correctly state the name of the medication and what it was used for, and that the resident could read the print on the prescription label but requires assistance. R32 was unable to correctly state the common side effects of each medication. R32 was unable to correctly state what time the medications are to be taken. R32 is unable to correctly state the proper dosage for each medication. R32 was unable to demonstrate proper handwashing techniques prior to and following medication administration. R32 was able to correctly measure the appropriate amount of medication from the container, but only with assistance. R32 was unable to correctly document self-administration of medications. R32 was unable to demonstrate secure storage for medications kept in their room. R32 was able to correctly state situations warranting the administration of PRN medications but requires assistance. R32 was unable to correctly document the administration of PRN medications. R32 was able to correctly request medications stored at the nurses' station but needs assistance. R32 was able to open and close medication containers but requires assistance. Approval for self-administration has not been granted. Additionally, there was no physician's order for self-administration of the specific medication under consideration. Review of the EMR for R32 revealed on 10/23/2024 the facility had conducted an Patient Education V2, and an explanation of non-ordered items by the physician was covered, specifically noting that menthol ointment was not recommended for use on the lips. R32 representative notified of this education. Furthermore, R32 was able to voice understanding in response to the education provided. Observation and interview on 10/22/2024 at 10:18 am with R32 revealed that a container of Mentholatum Original Ointment (Topical Analgesic Rub) was observed on her bedside table. R32 stated that she uses it on her lips when they get dry and mentioned that she has been using it for a long time. R32 also noted that the staff is aware of the ointment's presence but do not address it. Observation and interview on 10/23/2024 at 11:48 am revealed that the same container of Mentholatum Original Ointment (Topical Analgesic Rub) 28 G was again observed on her bedside table. R32 stated that she used the ointment on her lips earlier that day. Observation and interview on 10/23/2024 at 11:53 am in R32's room with Licensed Practical Nurse (LPN) DD revealed, that she had not seen the Mentholatum Original Ointment (Topical Analgesic Rub) on R32's bedside table. LPN DD further mentioned that R32 was not allowed to have the topical analgesic rub because there was no order for it. LPN DD immediately took the Mentholatum Original Ointment (Topical Analgesic Rub) from R32's bedside table. LPN DD indicated that she checks residents' rooms multiple times a day and was not in the facility on 10/22/2024. LPN DD noted that Certified Nursing Assistants (CNAs) have received in-service education regarding bedside medication, but she did not recall when this training was conducted. LPN DD expressed concerns about negative outcomes from having unprescribed medication at the bedside, stating that R32 could have a reaction, take the medication incorrectly, become ill and require hospitalization , or that a roommate could access it. Interview on 10/24/2024 at 10:27 am with the Director of Nursing (DON) revealed that residents with bedside medication are supposed to have orders, and there is a process that must be followed. The DON indicated that the family was informed of this process and that assessments must be conducted before any medication can be used. The DON stated that an assessment was done on R32, who does not qualify to have medication on her bedside table. When asked to clarify why [Name] Vapor Rub was mentioned, she explained that it was the brand name of the rub. The DON further emphasized that trained staff and nurses are aware of the process and policies, and they consistently check for bedside medications, following the established procedures diligently. Interview on 10/24/2024 at 10:32 am with the Administrator revealed that the process for having bedside medication involves obtaining an order, proper documentation, and making residents aware of the policy. The Administrator indicated that a lockbox should be used for these medications and that administration and documentation are essential. The Administrator stated her expectations are that residents who are cognitively able will follow the process and procedures. The Administrator expressed concerns about negative outcomes from not documenting medications, stating that it could harm the patient and lead to adverse consequences. Administrator emphasized the importance of staff being observant during their rounds and reporting any issues to the DON or charge nurse, as well as involving families in these matters. Furthermore, the Administrator noted that as part of the admission process, there was a list of prohibited items that families are made aware of.

Based on observations, staff interviews, record review, review of facility's policy titled, , Housekeeping, review of the documents titled, Patient Room Cleaning Standard and 10 Step Patient Room Cleaning, the facility failed to maintain clean exhaust fans for six shared bathrooms out of 35 bathrooms. This had the potential to compromise the hygiene and safety of the shared bathroom environments, increasing the risk of infection and negatively impacting the health and well-being of residents. The facility census was 84. Findings Include: A review of the facility's policy titled Housekeeping, dated 12/29/2023, under the section titled Intent revealed, It is the intent of this center to maintain a clean and sanitary center that is free from odor and other environmental factors that may affect the quality of life of our patients. Under the section titled Guidelines revealed, This center should be cleaned in a manner that is consistent with protocols and recommendations from the manufacturer of the chemicals and supplies used. A review of the facility standards document titled, Patient Room Cleaning Standard, revealed Dust: Always dust starting with high level surfaces (top to bottom/high to low). 1. Using the microfiber dusting tool begin at the entranceway and working around the room in a circle. 2. Never dust above a patient. 3. Dust the patient room first, the bathroom last. 4. Remove dusting tool head and place in dirty receptacle. A review of the facility's manufacturer protocol/recommendations titled 10 Step Patient Room Cleaning, revealed on the 3rd step to high dust and on the 8th step room inspection. An observation on 10/22/2024 at 10:07 am revealed that the exhaust fans in the shared bathroom of room [ROOM NUMBER] and room [ROOM NUMBER] were covered with a thick layer of white, fuzzy substance, indicating a significant buildup of dust and possible mold. An observation on 10/22/2024 at 10:45 am revealed that the exhaust fan in the shared bathroom of room [ROOM NUMBER] and room [ROOM NUMBER] was covered with a thick layer of white, fuzzy substance, indicating a significant buildup of dust and possible mold. An observation on 10/22/2024 at 11:04 am revealed that the exhaust fans in the shared bathroom of room [ROOM NUMBER] and room [ROOM NUMBER] were covered with a thick layer of white, fuzzy substance, indicating a significant buildup of dust and possible mold. Observation and interview on 10/23/2024 at 1:49 pm with the Maintenance Supervisor (MS) revealed that the exhaust fans in resident rooms should be cleaned daily. MS revealed it was brought to his attention that the fans in certain resident rooms were dusty. MS communicated this concern to the Administrator, who then informed the Housekeeping Supervisor (HS). MS revealed that the housekeeping aides were instructed to clean the exhaust fans in all resident rooms. Additionally, the MS revealed that he conducted an internal test once a month on all exhaust fans located in resident bathrooms to ensure they were clean, he inspected the exhaust fans on the roof of the facility, and he maintained inspection logs for these activities. Interview on 10/24/2024 at 9:48 am with Environmental Service Aide (ESA) AA, who oversaw Hall 1 revealed that she dusted the exhaust fans every two weeks and checked them daily. Although ESA AA mentioned that the HS had instructed her to check the exhaust fans daily, she dusted them every two weeks and as needed. ESA AA confirmed that she had in-service training regarding infection control. Interview on 10/24/2024 at 9:57 am with ESA BB revealed that she was responsible for Hall 3. ESA BB stated that she checked the exhaust fans at least twice a week but was not aware of any specific policies or protocols regarding how often they should be cleaned. ESA BB noted that she was informed about the dirty exhaust fans in residents' rooms on 10/22/2024. Interview on 10/24/2024 at 9:56 am with Environmental Service Supervisor (ESS) revealed that ESAs were encouraged to inspect the exhaust fans in residents' rooms daily. ESS verified that the ESA's should be cleaning the exhaust fans approximately three times a week. ESS confirmed that on Hall 3, there were two to three rooms where the exhaust fans had more debris than in others. ESS expectation was that the environmental aides check the exhaust fans daily. ESS revealed that ESA BB on Hall 3 was relatively new and required frequent reminders about various tasks. In an interview on 10/24/2024 at 10:43 am with the Administrator revealed that the expectations for cleaning included thoroughly sanitizing the entire room from top to bottom, which specifically encompasses ensuring that the exhaust fans are free of dust.

Based on observations, resident and staff interviews, record reviews, and review of the facility's policy titled, Skilled Nursing Services Use of Oxygen Therapy, the facility failed to ensure one of 11 residents (R) (R33) receiving oxygen therapy, was administered oxygen in accordance with the physician order. Specifically, R33 did not receive oxygen at the accurate flow rate prescribed by the physician. The deficient practice had the potential to cause respiratory complications for R33. Findings include: Review of the facility's policy titled Skilled Nursing Services Use of Oxygen Therapy, dated 7/1/2024 revealed, Intent: To ensure that patients maintain optimal oxygenation via the proper device and concentration when appropriate and medically indicated. Guideline: . oxygen with liter flow as ordered . Review of the Electronic Health Records (EHR) revealed R33 was admitted on [DATE] with diagnoses that included but not limited to paroxysmal atrial fibrillation, hypertensive heart disease with heart failure and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Section C (Cognition): Brief Interview for Mental Status (BIMS) score of 2 (two) which indicated severe cognitively impaired; Section I (Diagnoses): anemia, coronary artery disease (CAD), heart failure, hypertension and peripheral vascular disease (PVD); and Section O (Special Treatments): oxygen therapy Review of care plan reviewed 8/27/2024 revealed, Focus: Breathing patterns, altered. Evidenced by: As needed (PRN) oxygen. Goal: Patient will demonstrate an effective respiratory rate, depth, and pattern during the review period. Intervention: Oxygen (O2) at two liters (L) nasal canula (NC) PRN. Review of Physician's orders dated 9/2/2024 included but not limited to: Oxygen (O2) via nasal cannula 2 Liter per Minute (LPM) nasally as needed (prn), other (document in order notes) bedtime and prn to maintain sats >90% (oxygen) saturation above 90 percent). Diagnosis (Dx): chronic diastolic (congestive) heart failure, and vital signs every Sunday on night shift, that included but not limited to, O2 Saturation check. Dx: Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of facility's document dated 9/24/2024 from Registered Respiratory Therapist (RRT) EE documented orders not reflecting the liter flow the resident is receiving. A resident had an order for 2LNC prn but was on 4L. If the resident needs 4 L then I recommend center changing the order. I also recommend center completes self-audit to ensure that orders reflect patient usage. Review of facility's Education In-Service Attendance Record revealed no documentation of staff in-service education or self-audit done after recommendations from RRT EE and prior to survey. Observation on 10/22/2024 at 11:14 am revealed R33 sitting in chair beside bed in her room with oxygen cannula in place in her nostrils for oxygen therapy with the oxygen concentrator flow rate set at 2.5 LPM. Observation on 10/23/24 10:30 am, and at 3:53 pm revealed R33 sitting in chair beside bed in her room with oxygen cannula in place in her nostrils for oxygen therapy with the oxygen concentrator flow rate set at 1.75 LPM. Interview on 10/23/2024 at 3:53 pm with Licensed Practical Nurse (LPN) DD confirmed the oxygen liter flow rate was not set on two liters per medical doctor (MD)'s order. She stated she did not check the oxygen flow liter this shift. She also stated she was supposed to check R33's flow liter and monitor her oxygen saturation but she did not get a chance to do it. Interview on 10/23/2024 at 4:00 pm with Director of Nursing (DON) revealed she was aware that residents on oxygen were not getting the accurate liter flow as ordered at times and it was commonly not correct. She revealed it was noted the day before that R33's oxygen flow liter was more than what was ordered, this had been happening for a while and had been discussed in meetings. The DON further revealed the corporate RRT EE visited the facility routinely, and in September 2024, RRT EE noticed that a few residents on oxygen were not getting the correct amount as ordered by the MD. The DON confirmed RRT EE recommended the facility contact the MD to change the order and complete self-audit to ensure that orders reflect patient usage. She stated the orders for the liter flow are on the Medication Administration Record (MAR) and she expected the nurses to follow the orders. She further stated her expectations were for staff to check the residents' liter flow rate each time they enter the residents' rooms and at least twice per shift. The DON stated if R33 did not receive the correct amount of oxygen liter flow as ordered, the outcome for R33 would be respiratory compromise.

Based on observations, record review, staff interview, and review of the facility's policy titled Oral Inhalation and Nebulizer Administration, the facility failed to properly administer an oral steroid inhaler for one of nine residents (R) R6 observed during medication administration. This failure had the potential to reduce the efficacy of the medication. Findings include: Review facility's policy titled Oral Inhalation and Nebulizer Administration, dated 2022 revealed, that if a steroid inhaler is used, have patient thoroughly rinse mouth with water and spit out after use to minimize risk of oral pharyngeal candidiasis (thrush). Review of clinical records revealed R6 was admitted on [DATE] with chronic obstruction pulmonary disease (COPD), atrial fibrillation (AF), and peripheral vascular disease (PVD). Review of the quarterly Minimum Data Set (MDS) assessment dated revealed, R6 had a Brief Interview for Mental Status (BIMS) of eight; thus, the resident had mildly impaired cognition. She has no behaviors or psychosis to be noted. Record review further revealed that R6 needs minimal assistance with activities of daily living due to lower body weakness. Review of physician orders for R6 revealed an order dated 4/8/2024 for fluticasone furoate/vilanterol trifenatate 100 mcg (microgram)-25 mcg/dose powder for inhalation, one puff two times per day for Dx (diagnosis) of persistent atrial fibrillation. Observation on 10/23/2024 at 8:14 am during medication administration revealed, Licensed Practical Nurse (LPN) JJ administered the fluticasone furoate/vilanterol trifenatate 100 mcg-25 mcg/dose powder to R6 with one puff by inhalation. However, during the administration, the nurse did not instruct nor educate the resident about rinsing her mouth after medication administration of the inhaler. During an interview on 10/23/2024 at 8:22 am, LPN JJ confirmed and verified that she did not rinse R6's mouth after inhaler administration. During an interview on 10/23/2024 at 11:31 am, Director of Nursing revealed, that inhalers should be administered per physician's orders and as policy dictates.

Based on observation, record review, resident and staff interviews, and review of facilities policies titled, Fall Management and Documentation in the Medical Record revealed, the facility failed to maintain accurately documented resident record in accordance with accepted professional standards and practices regarding falls for one Resident (R) R32 out of 29 sampled residents. The facility census was 84. Findings Include: A review of the policy titled, Fall Management dated 12/29/2023 under the section titled Overview revealed, Each patient is assisted in attaining/maintaining his or her highest practicable level of function by providing the patient adequate supervision, assistive devices and/or functional programs as appropriate to minimize the risk for falls. Each patient's risk for falls is evaluated by the interdisciplinary team (IDT). A plan of care is developed and implemented based on this evaluation with ongoing review. If a fall occurs, the interdisciplinary team conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls. The Director of Nursing/Designee is responsible for coordination of an interdisciplinary approach to managing the processes for prediction, risk assessment, treatment, evaluation, monitoring, and calculation of patient falls. Each center will take a proactive approach for new patients admitted and will consider all patients to be at risk for falls until reviewed by the IDT. Under the section titled, Falls Defined: revealed, Current CMS guidelines regarding falls states that a fall is defined as anytime a patient is on the floor including whether the event was witnessed/un-witnessed. Under section titled Fall Management Practice Guidelines revealed, Fall Event: Complete the Initial Event in the EHR to capture the investigation of the fall and assessment of the patient; Assess the patient at least every shift for 72 hours or until the patient is stable. Document the assessment findings in the medical record; Review falls with the IDT in the morning meeting to facilitate appropriate actions taken and documentation is accurate and complete (including Initial Event in EHR); Review the event and patient status at the next scheduled PAR and/or UR meeting as indicated. A review of the policy titled, Documentation in the Medical Record dated 12/29/2023 under section titled Intent revealed, It is the intent of this center that services provided to the patient or changes in the patient's condition is recorded in the patient's medical record. Under the section titled Guideline revealed, Pertinent observations, medications given, services performed, etc., should be recorded in the patient's medical record; Incidents, accidents or changes, in the patients' condition should be recorded; Information recorded in the patient's medical record is confidential and may not be released to unauthorized persons. Refer requests for information to the Charge Nurse, Health Information Technician, or to the Director of Nursing. A review of Electronic Health Record (EHR) for R32 revealed she was admitted to the facility on [DATE]with diagnoses that included but not limited to, displaced fracture of medial malleolus of left tibia, unsteadiness on feet , other lack of coordination , muscle weakness (generalized) , abnormal posture, initial encounter for closed fracture unspecified dementia (moderate) with other behavioral disturbance, personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, unspecified sequelae of cerebral infarction, paroxysmal atrial fibrillation, other idiopathic peripheral autonomic neuropathy, spondylolysis ( lumbar region), encounter for prophylactic measures (unspecified ), and pain (unspecified). A review of R32's quarterly Minimum Data Set (MDS) dated [DATE] documented in Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) of 13, which indicated the resident was cognitively intact; Section J (Health Conditions) revealed one fall with major injury since admission or prior assessment, whichever is more recent. A review of the care plan revised on 8/12/2024, revealed R32 was care planned for fall risk related to fracture related to fall. A review of the facility provided Matrix for Providers dated 10/21/2024 indicated R32 had a fall with major injury (FMI) however, a review of the facility provided incident report fall list, for the last twelve (months) revealed R32 had a fall on 8/2/2024 in resident room-bed with the type of injury documented as no apparent injury. A review of nurse's notes for R32 located the EHR, dated 8/2/2024 at 5:50 am revealed, patient (pt) noted lying beside bed on the floor, pt stated that she got up to cook breakfast, pt assessed and passive range of motion (ROM) performed. small bruise noted on left side of arm. Moves all extremities freely, no bumps or bruises noted to head. Neuro-checks initiated. Pt assisted into bed with two (x 2) person assist and repositioned in bed for comfort. At 7:08 am representative (RP) called and notified of pt fall, and small bruise noted to left wrist. RP voiced understanding A review of nurse's notes for R32 located the EHR dated 8/2/2024 revealed, Resident complains (c/o) of left ankle pain, bruising noted with some swelling. Now ordered (N/O) x-ray left ankle. Son aware of new orders. A review of nurse's notes for R32 located in the EHR, dated on 8/2/2024 documented, x-ray report of left ankle received and noted osteopenia and probable fracture of the medial malleolus. Medical Director (MD) notified and gave new orders for ankle brace and ortho consultation. I informed MD it would likely be Monday before we were able to get either and he stated that was fine, it was non-emergent, but resident is to remain non-weight bearing to left ankle. RP notified and voiced understanding. A record review on 10/23/2024 of nurse's notes, located in the EHR, dated on 8/5/2024 documented, resident returned to facility wearing an orthopedic boot to left foot. Follow-up (F/U) with Physician Assistant-Certified (PA-C) at clinic 8/28/2024 at 10:10 am. A record review on 10/23/2024 of nurse's notes, located in the EHR, dated on 8/11/2024 documented, 1300: Boot removed from left lower extremity (LLE) Comprehensive Nursing Assessment: bruising noted, pedal pulses =, no significant pain, ankle rotated inward, no heel discoloration, skin intact. A record review on 10/23/2024 of patient report X-ray findings for R32 dated 8/2/2024 revealed, a technologist was called into the facility regarding pain and arrived at 18:10 pm (6:10 pm) and left at 18:20 pm (6:20 pm). R32 report findings revealed, four views of the left ankle obtained. There is no comparison study available. Images obtained show a fracture lucency which extends through the cortex of the of the medial malleolus. There is near anatomic alignment of the fracture fragments. No additional fractures or dislocations are seen. There is diffuse osteopenia. Impressions: Osteopenia and probable fracture of the medial malleolus. Recommend clinical correlation. A record review on 10/23/2024 of document titled Event Follow-Up V2.0, dated 8/3/2024 revealed under section titled Physical Status, resident with recent fall. Resident with fractured right (R) ankle. New orders for ortho consults. As needed (PRN) Tylenol given by day shift with good effects. No complaints of pain currently. Resident resting quietly in bed with eyes closed and respirations even and regular. After reviewing the document titled Event Follow-Up V2.0, dated 8/3/2024 it was noted that the facility incorrectly recorded a fracture on R32's right ankle, when in fact, R32 had a fracture of the left ankle. A record review on 10/23/2024 of document titled, Event Follow-Up V2.0, dated 8/4/2024 revealed under Physical Status, patient had recent fall resulting in fracture (FX) of right ankle, patient able to planter and dorsi flex right foot without pan, pedal pulses =, no swelling. After reviewing the document titled Event Follow-Up V2.0, dated 8/4/2024 it was noted that the facility incorrectly recorded a fracture on R32's right ankle, when in fact, R32 had a fracture of the left ankle. A record review on 10/23/2024 of document titled Therapy Referral dated 9/5/2024 revealed under section titled Nursing to Therapy, prior level of function and/or comments: post fracture right ankle from fall. Furthermore, under section titled Therapy Screen R32 dx included displaced fracture of medial malleolus of left tibia. After reviewing the document titled Therapy Referral, dated 9/5/2024 it was noted that the facility incorrectly recorded a fracture on R32's right ankle, when in fact, R32 had a fracture of the left ankle as evidence by her dx of displaced fracture of medial malleolus of left tibia. Record review on 10/23/2024 of Physician Orders dated 9/17/2024 revealed, weight bearing as tolerated (WBAT) LLE. Dx: Displaced fracture of medial malleolus of left tibia, initial encounter for closed fracture Record review on 10/23/2024 of Physician Orders dated 9/17/2024 revealed, custom order follow-up Orthopedic appointment for 11/19/2024 at 10:20 am. Dx: Displaced fracture of medial malleolus of left tibia, initial encounter for closed fracture. Interview and observation on 10/22/2024 at 10:18 am revealed R32 was observed in her room sitting in her sofa chair with a boot on her left ankle, dressed and groomed, watching television. R32 stated she had a fall while getting up from bed and has a swollen ankle, she stated she had not had any other falls since the last fall. Interview on 10/24/2024 at 10:16 am with the Director of Nursing (DON) stated charting should have been changed to fall with major injury. DON stated the facility has a clinical meeting every morning and they do their meetings regarding falls on the Interdisciplinary Team (IDT) morning meeting. DON stated it was overseen and that the status should have been changed to fall with major injury. DON further revealed the first nurse that notes the fall with injury is responsible of the status change. DON stated it was her expectations that all staff follow the process and the policy, and expects that the change of status to be recorded on the EHR, and that it was the facilities duty to report any findings to corporate. Interview on 10/24/2024 at 10:38 am with the Administrator revealed that it was the clinical team's responsibility to update the status of falls, with the nurse manager overseeing this information and facilitating team discussions. The Administrator emphasized her expectation that the staff continues to meet regularly as a cohesive clinical team. Administrator further stated that all documentation should be consistent and comprehensive, ensuring that the status of falls was accurately recorded.

Based on observations, staff interviews and review of the facility's policy titled, Guidelines for Eyewash Stations and Emergency Showers, the facility failed to maintain one of one eyewash station observed in a safe, functional manner by ensuring proper drainage. Specifically, water flowed from an open pipe below the eyewash station onto the floor and onto the feet of staff using the sink. This deficiency had the potential to cause falls and injury to staff utilizing the eye wash station. Findings include: Review of facility's policy titled Guidelines for Eyewash Stations and Emergency Showers (undated) documented Location: Adequate drainage; Provide a drain for the large amounts of water used in flushing or ensure a plan exists to manage and remove the water if a drain does not exist. Inspection: Ensure proper drainage or collect run-off water under the device. Observation on 10/23/2024 at 12:03 pm during tour of the laundry department revealed water flowing from an open pipe below the eye wash station when the eye wash station was in use. Water was observed flowing from under the eye wash station and onto the feet of the surveyor and Laundry Aide (LA) GG's feet. LA GG used a towel and placed it on the floor to cover the water which continued to flow until the eye wash station was turned off. Observation on 10/24/2024 at10:13 am revealed the Maintenance Director (MD) turned on the eye wash station and the water from the open pipe under the eye wash station flowed on the floor. The MD placed a bucket under the pipe to collect the water to prevent it from flowing on the floor until he turned off the eye wash station. Interview on 10/23/2024 at 12:03 pm with LA GG confirmed the pipe under the eye wash station was always open and whenever the eye wash station was in use, the water flowed from the open pipe to the floor where the person was standing who used the eye wash station. She stated no one had used it in a long time. Interview on 10/24/2024 at 10:13 am with the Maintenance Director revealed the open pipe below the eye wash station was there before he came to the facility five years ago. He revealed he checked the eye wash station each month and he placed a bucket under the open pipe to catch the water from flowing on the floor when the eye wash station pipe was turned on. He stated in an emergency, as long as the eye wash station was working, that was the important thing. He further stated that no one will slip and fall on the floor because it was concrete. Interview on 10/24/2024 at 10:49 am with the Administrator revealed her expectations would be for the water not to spill on the floor under the eyewash station and the water should drain in place. She also stated the outcome could cause a slip and fall because of the water flowing on the floor was a hazard.

Based on record review and interviews, the facility failed to ensure a level two Pre-Admission Screening and Resident Review (PASRR) was completed after a change in mental health status for one resident (R) (R#29) reviewed for Pre-Admission Screening and Resident Review (PASRR). The sample size was 21. Findings include: Review of clinical record for R#29 revealed she was admitted to the facility on ,d+[DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Georgia Department of Medical Assistance, PASRR Level I Application, Resident Identification Screening Instrument, dated 7/10/19, revealed R#29 had no serious mental disorder. Review of R#29's medical record revealed no other PASRR screenings. The resident's most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was coded as 4, which indicated severe cognitive impairment. Section N revealed the resident received antipsychotic medications seven of seven days during the assessment period. The PASRR section of the MDS (Item A 1500) was not coded to indicate whether or not the resident was considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or related condition. Review of pharmacy note to attending physician, dated 1/27/21, revealed the indication for the use of antipsychotic medication is depression with psychotic features. Review of Behavioral assessment dated [DATE], revealed assessment for new behaviors of agitation, anxiety and disruptive sounds and inappropriate vocalizations. The assessment revealed the residents behaviors fluctuate throughout the day and night. During further review of the Behavior Assessment revealed in notes/comments section that Social Services is in the process of completing a new level 1 due to the previous level 1 not having the mental diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Nurse's Note dated 7/7/21, written by Licensed Practical Nurse (LPN) AA, revealed resident continues to have frequent episodes of crying, yelling and delusions. MD notified. New order received for [MEDICATION(S)] 5 mg tab-1 tab po daily. Update MD of behaviors in two weeks. Review of Psychoactive Medication Consent Form dated 1/11/22, revealed condition to be treated as psychotic mood disorders and antipsychotics to be used on continuo basis. Review of Nurse's Note dated 7/20/22, written by LPN AA, revealed resident is yelling ongoing daily. MD notified and new orders received for [MEDICATION(S)] 25 milligrams (mg) tablet - 0.5 tablet by mouth one time per day at 9:00 a.m. Review of untitled/undated document provided by the facility, revealed a list of residents who reside in the facility, that have a level 2 PASRR completed. Interview on 7/23/22 at 8:40 a.m. with LPN BB, stated that R#29 yells out frequently, but she is unable to tell staff why she is yelling out. Interview on 7/23/22 at 1:28 p.m. with Certified Nursing Assistant (CNA) CC, stated that R#29 has frequent outbursts and crying episodes. She stated that she reports the episodes to the charge nurse. Interview on 7/23/22 at 1:05 p.m. with Social Services Coordinator, stated that she runs a medicaid case mix report each month, that identifies changes in condition and captures new mental health diagnoses. She stated that residents with new mental health diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that she overlooked R#29 change in mental status and submitted a evaluation for a level 2 PASRR yesterday, 7/22/22. She stated that resident was not currently receiving any psych services.

Based on record review and staff interview, the facility failed to develop a comprehensive, person centered care plan that integrated with the Hospice Services plan of care for one resident (R#61) and failed to follow care plan interventions related to Activities of Daily Living (ADL), specifically, nail care for one resident (R#36) that required extensive staff assistance with ADLS. The resident sample was 26 residents. Cross Reference F684 Findings include: 1. Record review for R#61 revealed a Minimum Data Set (MDS) assessment dated [DATE] which documented a Brief Interview for Mental Status (BIMS) summary score of 13, indicating no cognitive impairment. The resident had difficulty communicating some words or finishing thoughts and missed some part/intent of message. The resident required extensive to total staff assistance with Activities of Daily Living (ADL) with the exception of eating independently. The resident was always incontinent of bladder and bowel. The resident was assessed as having a condition or chronic disease that may result in a life expectancy of less than 6 months. The resident received scheduled and PRN (as needed) pain medication. R#61 was assessed as being at high risk for pressure ulcers but did not currently have pressure related or non-pressure related skin conditions. The resident received antidepressant, antibiotic and opioid medications all seven days of the look back period. R#61 received Hospice Services while not a resident and while a resident in the facility. The Care Area Assessment (CAA) triggered Communication, ADL Function/Rehabilitation Potential, Urinary Incontinence, Falls, Dental Care, Pressure Ulcers and [MEDICAL CONDITION] Drug Use with the decision to be care planned. Nutrition and Pain did not trigger but was decided to be addressed in care plan. Further review of the clinical record for R#61 revealed the resident was admitted to the facility on [DATE] under the care of Hospice Services. There was no evidence of comprehensive care plans in the resident's clinical record. Interview on 5/10/18 at 1:15 pm with the MDS Director confirmed that no care plans had been developed for R#61 and should have. She stated she usually keeps a note to herself what care plans are due to be completed and she was not sure how the care plans for R#61 had been missed. She stated she would work on them today. 2. R#36 had a care plan that stated that he required extensive assistance with activities of daily living (ADLs) with an intervention, dated 2/10/16, and reviewed on 3/23/18, for nursing to assist resident with ADLs. Observation on 5/08/18 at 11:26 a.m., revealed R#36 with long, jagged, dirty finger nails on both hands with a dark substance observed under the nails and around the cuticles. R#36 was observed on 5/09/18 at 9:12 a.m. at 11:01 a.m., and at 2:03 p.m. His nails remained long, jagged, and dirty with a dark substance underneath the nails and around the cuticles. An interview on 5/10/18 at 12:15 p.m. with the Licensed Practical Nurse BB Charge Nurse revealed that the facility policy was for Certified Nursing Assistants (CNAs) to perform nail care when they give the resident a bath. The nurse stated that since R#36 was diabetic, the wound care nurse was responsible for nail care as needed. She confirmed that the resident's nails were long & needed to be cleaned and trimmed. An interview with the Wound Nurse CC on 5/10/18 at 12:29 p.m. revealed that in the facility, all licensed nurses could trim diabetic resident's nails. She stated that usually the CNAs let her or the charge nurses know that a diabetic resident's nails needed to be trimmed. The wound nurse verified that R# 36's fingernails had a dark substance under the nails & that the fingernails needed to be trimmed. Cross refer to F677

Based on record review and staff interview, the facility failed to reconcile all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter) for one resident (R # 85). Findings include: A review of the clinical record revealed that R#85 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident also had [DIAGNOSES REDACTED]. Review of Physician order [REDACTED]. [MEDICATION NAME] 2.5 milligram (mg), take one by mouth twice daily [MEDICATION NAME] 40 mg, take one capsule by mouth twice daily [MEDICATION NAME] 50 mg, take 1/2 tablet by mouth at bedtime [MEDICATION NAME] 325 mg tablet, take two tablets by mouth twice daily prn for pain (650mg) [MEDICATION NAME] 24 mg capsules, take one capsule by mouth twice daily for constipation Cipro 250 mg tablets, take two tablets by mouth every 12 hours for [MEDICAL CONDITION] X 7 days [MEDICATION NAME] Regular Insulin per sliding scale (SS), Blood sugar (BS) <150-0units, 151-200= 2 units, 2012-250= 4 units, 251-300=6 units, 301-350= 8 units, 351-400=10 units [MEDICATION NAME] five units Sub Cutaneous (SQ) at bedtime [MEDICATION NAME] 25 mg 1/2 tablet by mouth twice daily for hypertension (HTN) and senna plus take two tablets by mouth daily for constipation Physician order [REDACTED]. Review of the Discharge Plan and Instructions sheet revealed that R#85 required extensive assistance of two people for walking, transfer, toileting, dressing, bathing, and grooming. Included was the nursing summary, instructions for activity, and a follow-up Physician appointment scheduled for 2/15/18 at 1:30 p.m. Under the section labelled discharge medications, written in was a note that read see Medication Teaching Tool. Review of the clinical record did not reveal the completed facility Medication Teaching Tool. An interview with the Resident Care Coordinator (RCC) on 05/10/18 at 11:06 a.m., revealed that the Medication Teaching Tool was not in the clinical record. The RCC verified that this document was not in the chart. She stated that there was no evidence that the medications had been reconciled for R#85 at discharge.

Based on observations, record review, and staff interviews, the facility failed to ensure that Activities of Daily Living (ADL) care was provided related to finger nail care for one dependent Resident (R) #36. The sample size was 26. Findings include: Record review revealed that R#36 has [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that R# 36's Brief Interview for Mental Status (BIMS) score was 10. He was assessed as requiring extensive assistance from one to two staff members for most of his ADL care. Documentation specified that R#36 required extensive one-person physical assistance with his personal hygiene. Review of one of R#36's care plans related to activities of daily living (ADLs) dated 2/10/16 stated that the resident required extensive assistance with ADLs. The goal for the resident was that he would have his needs met and dignity maintained by the nursing staff assisting him with his ADL care. Observation on 5/08/18 at 11:26 a.m., revealed R#36 with long, jagged, dirty finger nails on both hands with a dark substance observed under the nails and around the cuticles. R#36 was observed on 5/09/18 at 9:12 a.m., 11:01 a.m., and at 2:03 p.m. His nails remained long, jagged, and dirty with a dark substance underneath and around the cuticles. An interview on 5/10/18 at 12:15 p.m. the Licensed Practical Nurse ( LPN) BB Charge Nurse stated that the facility policy is for Certified Nursing Assistants (CNAs) should perform nail care when they give the resident a bath and that this was part of ADL care. The nurse stated that since R#36 has diabetes, the wound care nurse was responsible for nail care as needed. She confirmed that the resident's nails were long & needed to be cleaned and trimmed. An interview with the Wound Nurse (WN) CC on 5/10/18 at 12:29 p.m. revealed that in the facility, all licensed nurses can trim diabetic resident's nails. She stated that usually the CNAs let her or the charge nurses know that a diabetic resident nails need to be trimmed. She verified that Resident # 36 fingernails had dark substances under them & that the nails needed to be cleaned and trimmed. CC verified that R#36's fingernails needed to be cleaned and trimmed.

Based on observation, record review, review of the Hospice and Respite Services Agreement and staff interviews, the facility failed to ensure there was a collaboration of care with Hospice Services related to communication and plan of care for one of 26 sampled residents (R) (R#61). Findings include: Review of the Hospice and Respite Services Agreement with an effective date of 3/26/18 documented in General Allocation of Duties section 2.4- Supervision/Coordination of Care Hospice shall develop and maintain a system of communication and integration, in accordance with Hospice's own policies and procedures, to: (5) provide for an ongoing sharing of information with other non-hospice healthcare providers furnishing services unrelated to terminal illness and related conditions. Hospice shall be responsible for the professional management of the Hospice Plan of Care. Hospice shall provide case management/supervisory services, which shall include, but not limited to, the following: a regular and ongoing review and comparison of the Nursing Center Services and Hospice Plan of Care, an ongoing dialogue with Nursing Center staff, patient and his or her family, and a review performed at least weekly, of the care actually provided to a patient. Hospice and Nursing Center shall communicate with one another regularly and as needed for each Hospice patient. Each party is responsible for documenting such communication in its respective clinical records to ensure the needs of Hospice Patients are addressed and met 24 hours a day. Record review for R#61 revealed an Admission Minimum Data Set (MDS) assessment dated [DATE] assessed that the resident received Hospice Services while not a resident in the facility and while a resident in the facility. Observation of R#61 on 5/7/18 at 9:30 a.m. revealed a Hospice Aide assisting the resident in brushing her teeth. Interview with the Hospice Aide at the time of the observation revealed she provides Activity of Daily Living (ADL) care during her visits. She stated that she reports to the facility nurse if there are any changes in the resident. The Hospice Aide stated she documents her visits on a Hospice form. Further record review for R#61 revealed no evidence of Hospice records including but not limited to; authorization for admission to Hospice, Hospice Plan of Care, communication notes or Hospice Nursing visits. On 5/10/18, the facility called (name) Hospice to have all Hospice records faxed to the facility. Review of the (name) Hospice Authorization for Admission/Informed Consent form indicated R#61 was admitted to Hospice Services on 9/21/17, prior to admission to the nursing facility on 3/30/18. Review of the Visit Schedule indicated that Skilled Nursing visits were one - two times per week and PRN (as needed), Nurse Practitioner visits for certification/recertification and PRN for symptom management, Physician visits for certification/recertification and PRN for symptom management, Social Service visits were one - three time a month and PRN, Hospice Aide visits were five times per week, Chaplain and Volunteer visits were declined. Interview on 5/10/18 at 1:40 p.m. with the Certified Nursing Assistant (CNA) EE in care of R#61 revealed she did not know when the Hospice Aide comes to see the resident or what care the Hospice Aide provides. CNA EE stated she provides ADL care for R#61 everyday regardless if the Hospice Aide visited the resident or not. She stated the Hospice CNA does not report to her when she visits. CNA EE stated she knows when the Hospice Aide had visited when she sees her in the hall. CNA EE then stated sometimes the Hospice Aide will speak with her before she leaves the facility. Interview with the Resident Care Coordinator DD revealed there is no communication log kept in the facility. She further stated the Hospice Nurses or Aides do not sign in or report to anyone when they visit. She stated their main Hospice Service does communicate with the staff and the facility nurses sign off on their tablet prior to leaving the facility. Interview on 5/10/18 at 1:44 p.m. with Licensed Practical Nurse (LPN) FF revealed she did not know when the Hospice Nurse visits with R#61, she just knows she is here when she sees her in the hall. LPN FF stated she does not talk to the nurse prior to her visit or when she leaves. She stated the other Hospice uses electronic tablets and they sign off on the Hospice nursing visits. LPN FF stated she is not aware of a communication form or log to communicate with Hospice Nurses or Aides but if there was something wrong the resident, the Hospice Nurse would tell them. LPN FF stated the Hospice Aides do not report or speak to the nurses, they would communicate with the facility CNAs. Interview on 5/10/18 at 1:35 p.m. with the Administrator revealed R#61 is the first resident they have had services with (name) Hospice. He stated they usually use another Hospice and he was not aware of a lack of collaboration and communication but he would look into it right away. Interview on 5/10/18 at 2:14 p.m. with the Hospice Registered Nurse (RN) revealed R#61 was under (name) Hospice Services at her home, prior to admission to the nursing facility. She stated the facility agreed as a onetime agreement to have R#61 admitted to the facility under the continued care of (name) Hospice. The Hospice RN stated their company has communication forms but the nursing facility would not let them use them or keep them in the facility. She stated she wanted to bring R#61's records to the facility and the facility would not let them. The Hospice RN stated the facility told her there will be no hospice folders in the facility. The Hospice RN stated she had expressed her concerns to the facility about the lack of communication/coordination of care and that communication with the facility has mostly just been verbal. She stated the facility eventually told her she could print their hospice visits weekly and they would place a Hospice tab in the resident's chart and that would be good enough. The Hospice RN stated she asked about the Hospice Aides form and the facility told her to just hold on to them until the end of the week. She stated she was going to bring all the records for R#61 this Friday.

Based on observation and staff interview, the facility failed to ensure that privacy curtains in two rooms shared by two residents (R) (room 136 and room 148), and in one room shared by four residents (room 119) on two of three halls (B- and C-halls) were long enough to provide full visual privacy when closed. The sample size was 25 residents. Findings include: During an observation on 5/30/17 at 2:27 p.m., there was an approximate 8-foot section where the privacy curtains did not encircle one whole side of the D-bed in room 119. During observation on 5/31/17 at 10:04 a.m., there was an approximate 24-inch gap when the two privacy curtains were pulled around the A-bed in room 136. Observation on 5/31/17 at 9:59 a.m. revealed that there was an approximate 12-inch gap around the A-bed in room 148 when the two privacy curtains were pulled together. The above observations were verified with the Environmental/Laundry Supervisor and Maintenance Supervisor on 6/2/17 at 8:37 a.m. During an interview with the Maintenance Director at this time, he stated that the curtain track in room 148-A was too short on one side to enable the privacy curtains to totally enclose the bed, and that for room 119-D he could either order a longer curtain, or attach another curtain to the existing one. On 6/2/17 at 8:53 a.m., Certified Nursing Assistant (CNA) CC was observed setting up to do activity of daily living care for R #16 in room 119-D, and when she pulled the privacy curtains one whole section across the foot of the resident's bed was entirely uncovered. During an interview with CNA CC at this time, she verified that the privacy curtain was too short, and that she had to position R#16 in the middle of the curtain so that the resident could not be visualized by the other residents in the room.

Based on observation, record review, and staff interviews, the facility failed to dispose of used lancets properly for two of two residents (R) observed (#42 and #105), and failed to store an ice scoop in a sanitary manner on one of three halls. The sample size was 25 residents. Findings include: 1. On 5/31/17 at 3:20 p.m., Registered Nurse (RN) AA was observed performing fingerstick blood sugars (FSBS), and during interview stated she was obtaining all of the blood sugars ordered for that time of day. RN AA was observed to do a FSBS first for R#42, using a lancet to prick the resident's finger. After the FSBS procedure was completed, the nurse was observed to wrap up the used supplies, and removed them from the resident's room. Further observation revealed that the nurse was observed to dispose of the items in a trash bag tied to the cart that held her FSBS supplies, and no sharps container was seen on the cart for disposal of the used lancets. During an observation of RN AA performing a FSBS for R#105 immediately after the observation for R#42, the used supplies were again noted to be disposed of in the trash bag tied to the cart. During an interview with RN AA at this time, she stated that she had thrown away the used lancets for both residents in the trash. During further interview, she stated that she would retrieve the lancets from the trash, and that used lancets should be disposed of in a sharps container on the medicine cart. During an interview with the Assistant Director of Nursing (ADON) on 6/2/17 at 9:16 a.m., she stated that they did yearly competency checkoffs that included fingerstick blood sugars. Review of a Nursing Blood Glucose Monitoring System performance checkoff form provided by the ADON at this time revealed a task to Dispose of Lancet Properly. During an interview at this time, the ADON stated that although their guidelines were vague on how to dispose of lancets, they preferred that they be disposed of in a sharps container after use. The ADON further stated that the cart that had been used by RN AA to do the FSBSs on 5/31/17 usually had a sharps container on it, but it must have been removed off the cart for some reason and not replaced. Review of the facility's Syringe and Needle Disposal policy reviewed and updated July 2012 noted: Immediately after use, syringes and needles are placed into puncture resistant, one-way container specifically designed for that purpose. 2. On 5/30/17 at 11:55 a.m. and 12:45 p.m., and on 6/1/17 at 2:50 p.m., a mesh pouch was observed attached to a cart holding an ice chest for distribution of ice to the residents on Hall 3. Further observation revealed that inside this pouch was the scoop to remove the ice from the ice chest, as well as a 30-milliliter plastic medicine cup that had a small amount of a white substance smeared on the inside of the cup. Continued observation revealed that this medicine cup was touching the surface of the ice scoop. During an environmental walk-through with the Environmental/Laundry Supervisor on 6/2/17 at 8:37 a.m., he verified that there was a plastic medicine cup with a white substance on the inner surface inside the pouch holding the scoop for the Hall 3 ice chest. During an interview at this time, he stated that it was the joint responsibility of nursing and housekeeping to clean the ice chest and ice scoop, and that this should be done daily. During an interview on 6/2/17 at 10:22 a.m., the Environmental/Laundry Supervisor stated that there was no log or other documentation of when the ice scoop was cleaned. During an interview with the Environmental/Laundry Supervisor on 6/2/17 at 10:35 a.m., he stated that the kitchen staff was responsible for cleaning the ice chest and ice scoop, and he provided the facility's Ice Chests and Ice Machines policy with a reviewed and updated date of November 2015 that noted: The following policy should be followed to reduce the likelihood of contamination of ice chests (ice-storage compartments) and ice machines. Ice scoops used should be smooth and impervious and should be kept on an uncovered stainless steel, impervious plastic or fiberglass tray on top of the chest or in a mounted holder when not in use. The tray and the scoop should be run through a dishwasher daily. During an interview with kitchen staff BB on 6/2/17 at 12:01 p.m, she stated that the facility's procedure was for whoever was assigned to run the dish machine in the kitchen, was responsible for washing ice scoops and the pouch that held the ice scoop daily. During an interview with the Dietary Manager on 6/2/17 at 12:08 p.m., she stated that the ice chests and scoop holders were cleaned weekly, and that these items on Hall 3 were washed on Mondays. She further stated that the ice scoops were run through the dish machine daily. During interview with the Dietary Manager on 6/2/17 at 12:38 p.m., she stated that there was no specific documentation for the cleaning of the ice scoop pouch. Review of a May 2017 Log for Ice Machine and Scoops that she provided at this time revealed daily documentation of the ice scoops being washed, but no documentation of the cleaning of the ice scoop pouch.