Every finding on record at Heart of Georgia Nursing Home

Based on observations, interviews, and review of facility policies titled Ingredient Bins, Food Storage-Refrigerators & Freezers, Food Storage Dry Goods, and Frozen Food Storage, the facility failed to ensure food items were labeled, dated, and used by the expiration date. In addition, the facility failed to maintain sanitary conditions when utilizing a three-compartment sink. These deficient practices had the potential to affect 85 of 89 residents receiving oral diets.Findings include: Review of facility Policies and Procedures revealed: Ingredient Bins revised 4/5/2024 1.Tracking sheets are to be used on ingredient bins. It is taped on the cover. 2. One tracking sheet can be used for four refills of the ingredient Bin. 3.Each employee is responsible for completing the information. 4.Definition are as follows: c.Filled: Date that the ingredient bin was filled. d. Use by: Date that the ingredient should be used by. This is typically 3 months from the fill date. Food Storage-Refrigerators & Freezers revised 4/5/2024 2. Label and Cover Food following our label policy. ii.All foods delivered by an approved vendor must be properly labeled and dated. iv.Date by which it should be consumed or discarded (use by date). Food Storage Dry Goods revised date 4/5/2024 3. All food items must be dated, labeled, and sealed. Frozen Food Storage (not dated) 3. Label, Date, and Cover all food items that are stored in the freezer in accordance with our Label Policy. Observation and review of sanitizer signage over three compartment sink revealed: Directions for use: Expose all surfaces of equipment, ware or utensils to sanitizing solution for a period of not less than one minute. Air dry. The initial kitchen tour began on 1/9/2026 at 7:56 AM with observations revealing the following: 1.There were three plastic pitchers with beverages that were not labeled or dated. 2.In the dry storage area there was a plastic container containing thickener that was not dated to indicate an open date or a use by date. 3.There was a plastic container on a shelf labeled cornmeal and ketchup, but it had bags of brown sugar in it. One of the bags had been opened but did not have an open date. 4.In the dry storage area there were four large plastic bins labeled flour, cornmeal, sugar, and rice. 5.In the dry storage area there was a plastic container containing pasta that did not have an open date or use by date. 6.In the dry storage area there was a plastic container with saltine crackers that did not have a use by date. 7.In the walk-in cooler there was a box of garlic Texas toast without an open date or use by date. 8.In the walk-in cooler there was a box of individual orange juice containers that did not have a use by date. 9.In the walk-in cooler there were at least four bags of salad mix that had a best by date of 12/25/2025. The lettuce was noted to be turning brown with a watery mix in the bottom of the bag. 10.In the walk-in cooler there were two bags of slaw mix that did not have an in date or a use by date. 11. In the reach-in freezer and standard freezer in the dining room there were bags of vegetables that did not have an in date or use by date. During an interview on 1/9/2026 at 8:31 AM with the Certified Food Manager (CFM) during the initial kitchen tour she confirmed the items in the dry food storage area were not reflecting a use by/expiration date. The lettuce was confirmed to be beyond its use by date, and the bags of slaw were confirmed to not have an in date or use by date. She also confirmed that the pitchers in the refrigerator did not have any dates but reported that staff had probably just sat the items in the refrigerator but would come back later to label them. The items in the reach in freezer were confirmed to not have labels or expiration dates, and it was reported that the labels would not stick on the items in the freezer. During a secondary kitchen visit on 1/10/2026 at 11:05 AM, observation of the puree process revealed the following: 1.Observation of Dietary [NAME] CC on 1/10/2026 at 11:12 AM washing the puree blender bowl, puree blender top, and blade revealed, the items were washed in compartment one, rinsed in compartment two and submerged and removed from the sanitized water in compartment three. Specifically, the bowl was dipped in the sanitation sink and removed. The top was submerged and then removed. The blade was in the water for less than one minute. 2. Observation of Dietary [NAME] CC on 1/10/2026 at 11:17 AM again washed the puree blender top, puree blender bowl, and blade and then rinsed. The items were then submerged and immediately removed from the sanitized water. The items were in sanitized water for less than one minute. 3. Observation of Dietary [NAME] CC on 1/10/2026 at 11:22 AM a third time washing the puree blender bowl, puree blender top, and blade. The items were then rinsed. The puree blender bowl, puree blender top, and blade were dipped in the sanitation sink and removed. The items were in the sink for less than one minute. Interview with Dietary [NAME] CC on 1/10/2026 at 1:35 PM revealed she initially stated that the items should be in the sanitation sink for at least 10 seconds. Review of the poster above the sanitation sink revealed that items should be in the sanitation sink for no less than one minute. [NAME] CC reported that she typically does it the correct way but was trying to hurry because a surveyor was watching the process. Tour of the resident's food pantry on 1/11/2026 at 9:21 AM revealed the following: 1.In the refrigerator there were two containers of orange juice and two containers of cranberry juice that were thawed but did not have a use by/expiration date. 2.There were two bottles of probiotics with [DATE] listed. 3.There was a jar with pickles that did not have a use by/expiration date. 4.There were two strawberry rice treats that were not in their original container and did not have an expiration date. 5. In the freezer there was a bag in the freezer with hamburgers that were not labeled or dated. Observation and interview on 1/11/2026 at 9:20 AM with RN Supervisor revealed night shift is responsible for checking refrigerator temperatures and the refrigerator for expired foods. The RN Supervisor confirmed the bag of burgers was unlabeled without dates and the cranberry juice, orange juice, two juice barrels and two strawberry rice treats were stored without an expiration date and left available for resident consumption.

Based on observations, interviews, and review of medical records, the facility failed to ensure a stop date was provided on as needed (PRN) psychotropic medications for one resident (R) (R6) of five residents reviewed for unnecessary medications. The deficient practice created the potential for residents to receive unnecessary medications. Findings include:Review of the electronic medical record (EMR) for R6 revealed diagnoses that included but were not limited to vascular dementia, severe with agitation.Further review of the EMR revealed an order for Ativan oral tablet 0.5 milligrams (mg) with a start date of 12/22/2025. There was also an order for Haloperidol Lactate oral concentrate 2 mg/milliliter (ml) to be given every 6 hours as needed for agitation/nausea/vomiting with a start date of 12/22/2025.Review of Consultant Pharmacist Communication to Physician dated 8/11/2025 revealed the pharmacist notified the physician that PRN antipsychotics are limited to a hard 14 day stop unless the physician makes a physical assessment and rewrites the order. The physician responded on 8/22/2025 agreeing with the recommendation by the pharmacist and continued the order for Haldol for 14 days.During an interview on 1/11/2026 at 11:25 AM with Minimum Data Set (MDS) Coordinator EE who confirmed the Haldol PRN order dated 12/22/2025 had no end date. She reported that the hospice provider sends a list of medications that hospice residents will take and the facility writes the order as received from hospice.During an interview on 1/11/2026 at 12:00 PM with the Director of Nursing (DON) who reported that she pulled the report from pharmacy yesterday when she arrived to review for a recommendation to add stop dates for the PRN medications. She confirmed that Haldol requires a 14-day automatic stop date and nursing staff have been educated about the stop dates for PRN psychotropic medications. During an interview and observation on 1/11/2026 at 12:10 PM with Licensed Practical Nurse (LPN) DD, she reviewed the order for Haldol and confirmed there was no end date. LPN DD stated that she was unsure if the order for the medication required an end date.During an interview and observation 1/11/2026 at 12:55 PM with MDS Coordinator, Registered Nurse (RN), she reviewed and confirmed the order for Ativan had no end date. It was further stated that Ativan, Morphine, and Haldol are part of a comfort pack of medications provided to hospice residents.During an interview on 1/11/2026 at 1:00 PM with R6's Physician, he stated it was his understanding that pharmacy sends an automatic stop date for PRN psychotropic medications.

Based on observations, interviews, and review of medical records, the facility failed to ensure the accuracy of assessments for one resident (R)(R6) of 38 sampled residents. The deficient practice had the potential for inaccurate and/or omitted care planning. Findings include:Review of the electronic medical record (EMR) for R6 revealed diagnoses that included but were not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, unspecified sequelae of cerebral infarction, other lack of coordination, and unsteadiness on feet. Review of the Minimum Data Set (MDS) 5-day assessment dated [DATE], Section J: Health Conditions indicated no falls during the assessment reference period.Review of the care plan that was initiated on 7/21/2025 and revised on 8/20/2025 indicated falls on 7/26/2025 and 8/20/2025.Interview on 1/11/2026 at 11:25 AM with MDS Coordinator EE confirmed that R6 had fallen on 7/26/2025 and 8/20/2025. Review of the MDS 5-day assessment dated [DATE] section J: Health Conditions with the MDS Coordinator EE confirmed that the falls were not coded but occurred in the assessment reference period and should have been captured.

Based on observations, interviews, and record reviews, the facility failed to ensure the care plan for fall prevention was followed for one resident (R)(R6) of 38 sampled residents. The deficient practice had the potential to place R6 at risk of injury and diminished quality of life. Findings include:Review of the electronic medical record (EMR) for R6 revealed diagnoses that included but were not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, unspecified sequelae of cerebral infarction, other lack of coordination, and unsteadiness on feet.Review of the Minimum Data Set (MDS) dated [DATE] Section J: Health Conditions, documented no falls for R6.Review of the care plan for R6 that was initiated on 7/21/2025 and revised on 8/20/2025 indicated falls on 7/26/2025 when R6 was found lying on fall mat beside bed with lower lip bleeding and on 8/20/2025 when R6 was found lying beside bed on fall mat. The care plan also noted that R6 frequently attempted to roll out of bed during the night. One of the interventions initiated on 7/25/2025 was fall mat placed by bed.Observations on 1/10/2026 at 8:58 AM, 1/10/2026 at 2:37 PM, 1/11/2026 at 8:51 AM of R6 in low bed with fall mat at head of bed between bed and the wall.During an observation and interview on 1/11/2026 at 8:52 AM with Housekeeper GG, she confirmed fall mat was not at the bedside but between the head of the bed and the wall.Observation and interview on 1/11/2026 at 8:55 AM with Certified Nursing Assistant (CNA) FF who stated that she is not aware of any falls for R6, but she could review his care plan to know what resident's needs are. CNA FF reported that the bed is kept lowered but she is not aware of a fall mat being used for R6. It was further reported that if a fall mat was required it would be kept on the floor beside the bed. When in the room with R6 CNA FF confirmed the fall mat was between head of the bed and the wall.During an interview on 1/11/2026 at 11:25 AM with Minimum Data Set Coordinator, Licensed Practical Nurse (LPN) EE who confirmed R6 had falls on 7/26/2025 and 8/20/2025. She stated that CNAs can access the Kardex to determine resident's needs. Review of the Kardex revealed the fall mat was not listed as an intervention. LPN EE stated the nurse for the hall should verbally remind CNAs of resident needs.

Based on record review, staff interview, and review of facility policy titled Administering Medications, the facility failed to ensure a medication for hypotension was given as ordered and not held without a physician's order or physician ordered parameters for two residents (R) (R72 and R9) of 38 sampled residents. The deficient practice increased the potential risk of adverse clinical outcomes.Findings include:1.Record review revealed R72 was admitted to the facility 11/5/2024. R72 had a diagnosis of orthostatic hypotension since 2/6/2025. Review of the Physician's Order dated 10/25/2025 documented midodrine HCl (hydrochloride) (Medication used to increase blood pressure) give 1 tablet by mouth three times a day for hypotension. The order did not specify a blood pressure parameter for holding the medication.Interview on 1/11/2026 at 10:41 AM with Licensed Practical Nurse (LPN) AA revealed there are no ordered blood pressure parameters for the midodrine. LPN AA stated they hold the medication if the blood pressure is elevated. LPN AA could not verbalize a specific number that she would hold for just an elevated blood pressure. Review of the Medication Administration Record (MAR) for October 2025 through January 2026 revealed midodrine 5 mg was held on 11/5/2025, 11/14/2025 - 11/16/2025, 11/28/2025, 11/29/2025, 12/3/2025, 12/4/2025, 12/9/2025, 12/13/2025, 12/14/2025, 12/17/2025, 12/18/2025, 12/22/2025, 12/23/2025, 12/26/2025, 12/27/2025, 12/28/2025, 12/31/2025, 1/1/2026, 1/5/2026, 1/6/2026, 1/8/2026, 1/9/2026, and 1/10/2026 for a total of 49 times. There was no physician order to hold the medication. Further interview with LPN AA on 1/11/2026 at 11:17 AM revealed she does not contact the physician when holding R72's midodrine.2. Record review revealed R9 was admitted to the facility on [DATE]. Review of Physician's Order dated 9/23/2025 revealed midodrine HCl Oral Tablet 5 MG (milligrams), give 1 tablet by mouth three times a day for hypotension. The order did not specify a blood pressure parameter for holding the medication.Observation and interview with LPN BB on 1/10/2026 at 2:26 PM revealed the midodrine was given due to the blood pressure being within the parameters. She pulled up the supplemental documentation on the MAR, and it showed to hold the medication if blood pressure greater than 110. Director of Nursing (DON) provided a printout of the supplemental documentation.Review of the MAR from November 2025 through January 2026 revealed the midodrine 5 MG was administered when systolic blood pressure was greater than 110 on 11/1/2025, 11/3/2025, 11/4/2025, 11/6/2025 - 11/14/2025, 11/17/2025 - 11/21/2025, 11/25/2025 - 12/12/2025, 12/15/2025, 12/16/2025,12/19/2025 - 12/25/2025, 12/27/2025, 12/29/2025, 12/30/2025, 1/2/2026, 1/3/2026, 1/6/2026 - 1/9/2026 for a total of 106 times. Interview with the DON on 1/11/2026 at 11:00 AM revealed she is unsure how the parameter of hold for Systolic Blood Pressure (SBP) greater than 110 was implemented for R9. The DON stated It appears that it was put in the supplemental documentation and not in the original order. It is not on the original order or the original note documented for this medication. The DON stated it is her expectation that staff give medications as ordered and notify the Physician if there was a need to hold the medication. Review of post survey Physician Documentation provided on 1/12/2026 revealed the resident was originally prescribed midodrine by the nephrologist who did provide the parameters to hold the medication if the systolic blood pressure was greater than 110.The facility policy titled Administering Medications revised April 2019 documented medications are administered in accordance with prescriber orders.

Based on observations, record reviews, staff interviews, and review of the facility's policy titled Nursing Standards of Practice: Respiratory Equipment, Care & Handling, the facility failed to maintain the cleanliness of respiratory equipment for three of 17 Residents (R) (R64, R7, and R92) receiving respiratory treatments. Specifically, the facility failed to ensure R64 and R7 Continuous Positive Airway Pressure (CPAP) masks and R92 nebulizer masks were covered and placed in a plastic bag when not in use. This deficient practice had the potential to place the residents at risk for respiratory complications and a diminished quality of life.Findings include:Review of the facility's undated policy titled Nursing Standards of Practice: Respiratory Equipment, Care & Handling under the section titled Policy documented, Respiratory equipment will be available for immediate use and in clean working condition. Under Procedure documented, 2. Maintain cleanliness when opening and handling equipment.10. Empty the nebulizers after each use and rinse with water and place on a clean paper towel to air dry. Place in plastic bag after cleaning.1. Review of the Electronic Health Record (EHR) for R64 revealed diagnoses that included but not limited to, chronic obstructive pulmonary disease (COPD), cardiomegaly, interstitial pulmonary disease, influenza due to identified novel influenza a virus with pneumonia.Review of R64's physician order revealed, CPAP Apply at bedtime and remove in morning related to (R/T) obstructive sleep apnea (OSA) dated 11/25/2025.Review of R64 Quarterly Minimum Data Set (MDS) dated [DATE] for Section C (Cognitive Patterns) revealed, Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognitive impairment; Section GG (Functional Abilities and Goals) revealed, impairment to one side to the lower extremities, required set up assistance with bed/chair, sit/stand, uses walker or wheelchair and required supervision/touching with mobility. Section O (Special Treatments, Procedures, and Programs) revealed that R64 received non-invasive mechanical ventilator while a resident.Observation on 1/9/2026 at 10:05 AM revealed, R64's CPAP machine not in use with the C-PAP mask lying on bedside table uncovered and not bagged. Observation on 1/10/2026 at 8:38 AM revealed, R64's CPAP machine not in use with the CPAP mask lying in bed next to the resident and uncovered. Licensed Practical Nurse (LPN) AA was observed going into the room to speak with R64 and then exited the room leaving the CPAP mask uncovered and not bagged.During an observation and interview with LPN AA on 1/10/2026 at 1:25 PM, LPN AA confirmed that R64's CPAP mask was lying on the bedside table unbagged and not covered. LPN AA stated she was responsible for making sure respiratory masks were covered with a labeled and dated bag. LPN AA confirmed that the mask should have been covered when not in use and that she forgot to make sure it was done.2. Review of the EHR for R7 revealed diagnoses that included but not limited to, COPD, chronic diastolic (congestive) heart failure, dependence on supplemental oxygen, chronic atrial fibrillation, and obstructive sleep apnea.Review of R7's physician orders revealed, CPAP at bedtime related to obstructive sleep apnea dated 3/28/2023; oxygen: PRN (as needed) for SOB (shortness of breath) Oxygen (O2) at 2 liter per minute (LPM) nasal cannula as needed for shortness of breath dated 3/29/2023.Review of R7's Quarterly MDS dated [DATE] for Section C (Cognitive Patterns) revealed, BIMS score of 99 which indicated severe cognitive impairment; Section GG (Functional Abilities and Goals) revealed impairment to upper and lower extremities on both sides, dependent on staff for mobility; Section O (Special Treatments, Procedures, and Programs) revealed, the resident received oxygen therapy, non-invasive mechanical ventilator, and CPAP while a resident.Observation on 1/9/2026 at 10:10 AM revealed, R7's CPAP machine is not in use with the CPAP mask lying on bedside table uncovered and not bagged.Observation on 1/10/2026 at 8:44 AM revealed, R7's CPAP machine not in use with the CPAP mask lying on bedside table uncovered and not bagged.During an observation and interview with LPN AA on 1/10/2026 at 1:28 PM, LPN AA confirmed that R7's CPAP mask was lying on the bedside table unbagged and not covered. LPN AA revealed that she was responsible for making sure respiratory masks were covered with a labeled and dated bag. She acknowledged that it should have been covered when not in use and that she forgot to make sure it was done.3. Review of the EHR for R92 revealed diagnoses that included but not limited to, acute respiratory failure with hypoxia and chronic obstructive pulmonary disease with (acute) exacerbation.Review of R92's physician orders revealed, O2 at 2 LPM via nasal cannula dated 1/5/2026, ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg (milligram)/3ml (milliliter) one vial per nebulizer four times daily for COPD exacerbation dated 1/9/2026, Trelegy Ellipta 100-62.5-25 mcg (microgram)/act aerosol powder, breath activated inhale one puff by mouth every morning for COPD** rinse with water (H2O) & spit after each dose dated 1/3/2026.Review of R92's admission MDS dated [DATE] revealed, the assessment had not been completed with a status of In Progress.Observation on 1/9/2026 at 11:01 am revealed, R92's nebulizer machine was not in use with the nebulizer mask lying on bedside table uncovered and not bagged.During an observation and interview on 1/10/2026 at 1:35 PM, the Director of Nursing (DON) was shown pictures of R92's nebulizer mask, R7's and R64's CPAP masks uncovered. The DON revealed her expectations was that the nurses make sure respiratory masks were properly stored and covered when not in use. She revealed leaving respiratory masks uncovered could potentially lead to infection control issues and respiratory complications.During an observation and interview on 1/11/2026 at 10:00 AM, the Infection Control Preventionist (ICP) nurse was shown pictures of R92's nebulizer mask, R7's and R64's CPAP masks uncovered. The ICP nurse revealed her expectations was that the nurses make sure respiratory masks were cleaned after each use and bagged when not in use.

Based on resident and staff interviews, record review, and review of the facility policy titled Dental, the facility failed to ensure one of 31 sampled residents (R) (R66) received annual oral screenings and timely dental care to treat tooth pain. This failure caused R66 to have untreated oral pain. Findings include: Review of the facility's undated policy titled Dental, revealed the Policy was Dental care shall be offered to all residents. The Policy Interpretation and Implementation section included . 2. The contracted provider or personal dentist will be notified of resident's need for dental treatment or consultation as appropriate . Review of R66's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/24/2024, located in the electronic medical record (EMR) under the MDS tab, revealed R66 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated R66 was moderately cognitively impaired. The MDS indicated no mouth or facial pain or discomfort or difficulty with chewing. Review of R66's Medication Administration Record (MAR) dated 4/2024, located in the EMR under the Orders tab, revealed R66 received Amoxicillin (an antibiotic) 500mg (milligrams) three times a day for tooth infection for seven days, with a start date of 4/23/2024 through 5/1/2024. Review of R66's Progress Note, dated 4/23/2024, located in the EMR under the Progress Notes tab, revealed new order for Amoxicillin r/t [related to] tooth infection. An additional note for R66 dated 4/23/2024 revealed, needs referral to oral surgeon. R66's Progress Notes, dated 4/24/2024 through 5/1/2024, revealed that R66 continued to take the antibiotic for oral pain. A Progress Note dated 4/26/2024 revealed, Resident continues antibiotic therapy .Oral surgeon appt (appointment) in progress .Will continue current POC (Plan of Care) and notify provider as needed. There were no further progress notes mentioning tooth pain. Review of R66's comprehensive Care Plan, updated 7/4/2024, provided by the facility, documented R66 had oral/dental problems and, as of 4/23/2024, an oral abscess related to impaired dentition. The goal was for R66 to be free of infection, pain, or bleeding in the oral cavity by the review date. Interventions included consulting with an oral surgeon as ordered, coordinating arrangements for dental care transportation as needed, diet as ordered, monitor/document any signs or symptoms of oral/dental problems needing attention including pain and abscess. Review of the Physician's Orders under the Orders tab in the EMR, revealed R66 was given Amoxicillin 500mg twice daily for seven days, with a start date of 9/12/2024. Review of the Admission Record revealed the Payer Information documented the Primary Payer was Medicaid (GA) [Georgia] and there was no other payer source documented. During an interview on 9/10/2024 at 2:04 pm, R66 said he had three lower back teeth that needed to be pulled. He said he had told staff, and they had not done anything. He said his pain was a 10 of 10, with a 10 being extreme pain. During an interview on 9/12/2024 at 11:15 am, the Social Services Director (SSD) and the Business Office Manager (BOM) said they had scheduled R66 for a dental appointment in January 2025, and that was the quickest appointment she could get. She said R66 received Medicaid and did not have a dentist. The SSD said she had called every dentist in the area to see who would accept residents who received Medicaid and was unsuccessful. The SSD said she did not document her attempts to locate a dentist in R66's EMR. The SSD said in April, she remembered the dentist looking at R66's teeth and told the nurse that R66 should be seen by an oral surgeon and should receive an antibiotic. The SSD said the Medical Director ordered the antibiotic. The SSD and the BOM said they did not have a formal system to ensure all Medicaid residents received an annual screening and were unaware this was their responsibility. The BOM said there were 70 residents in the facility who received Medicaid benefits and had not had their annual oral screening. During an interview on 9/12/2024 at 3:02 pm, the Administrator and the Director of Nursing (DON), the Administrator said she would expect any resident who resided in the facility to receive dental care as soon as possible when they expressed tooth pain. The DON agreed that a resident who expressed oral pain should be treated as quickly as possible. The DON said she remembered when R66 had expressed pain before, and he was given an antibiotic. She said it should have been addressed at that time. She said this week was the first time she heard R66 had tooth pain again.

Based on staff interviews, record review, and review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, the facility failed to protect one resident (R), (R1) from physical abuse by a staff member from a sample of three residents. Findings include: Facility policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program, last revised April 2021 revealed Policy Statement: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Facility Incident Form dated 11/29/2023 revealed staff to resident abuse in which Housekeeper AA punched R1 in the left eye, causing R1 to fall to the floor and hit his head. The local law enforcement, physician, and responsible party were immediately notified. Housekeeper AA left the facility. Review of Annual Minimum Data Set, dated dated dated [DATE] revealed a Brief Interview for Mental Status score of 99, indicating severe cognitive decline with short and long-term memory problems. Interview on 12/4/2023 at 10:15 am with the Director of Nursing (DON) revealed the incident between R1 and Housekeeper AA was not witnessed by anyone. Stated several staff members heard resident hit the floor and came out into the corridor to see what happened. R1 was found lying on the floor with Housekeeper AA standing over him. Housekeeper AA immediately left the premises, and the facility notified the local law enforcement. The DON stated staff education was immediately started. Interview on 12/4/2023 at 10:49 am with Registered Nurse (RN) BB revealed upon looking down the hall she could see R1 sitting on the floor holding the back of his head. RN BB stated that Housekeeper AA stated, he hit me first. RN BB stated she called 911 for law enforcement assistance while a nurse and Certified Nursing Assistant assisted the resident. Interview on 12/4/2023 at 12:52 pm with Licensed Practical Nurse (LPN) CC revealed she was standing at the nurse's station when she heard a sound like a hit. Upon turning around, R1 was seen on the floor and Housekeeper AA was walking away. LPN CC stated she asked Housekeeper AA 'did you hit him?' and Housekeeper AA stated, he hit me twice, so I hit him back. LPN CC revealed she told Housekeeper AA to leave, and she assisted R1 after notifying RN BB.

Based on record review, staff interviews, and review of the policy titled Care Plans, Comprehensive Person-Centered, the facility failed to develop a person-centered care plan for one resident (R) (R#251) for pneumonia. The sample size was 40 residents. Findings include: A review of the facility policy, Care Plans, Comprehensive Person-Centered, revised 3/2022, revealed each resident would have a person-centered care plan that reflected any problem areas and conditions. Additionally, the assessment of the residents would be ongoing, and the care plan would be revised as information about the residents' conditions changed. A review of R#251's Minimum Data Set (MDS) OBRA Annual Assessment, dated 7/15/22, Section - I/Active Diagnoses, revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of R#251's care plan for June 2022 and August 2022 revealed that R#656 was not care planned for pneumonia or respiratory issues. A review of the Medical Doctor (MD) orders revealed that R#251 was administered [MEDICATION(S)] 875-125 mg via G-tube twice a day for five days for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the Licensed Practical Nurse (LPN) AA on 10/29/22 at 9:57 a.m., LPN AA stated that R#251 was not verbal, but he grunted when he needed something. She stated when a resident had an infection and was on antibiotics, and she monitored for signs and symptoms of side effects to the medication as well as improvement or decline related to the infection. LPN AA added that if a resident had pneumonia, she would follow the care plan for interventions specific to the resident. She stated she would ensure the head of the bed was elevated, monitor oxygen saturation, and monitor for fever and signs and symptoms of shortness of breath or increased difficulty breathing. She would immediately contact the MD and family if she noted any issues. During an interview with the Infection Control Preventionist (ICP) on 10/29/22 at 1:46 p.m., she stated that she expected residents with infections had a person-centered care plan specific to that infection. She indicated it would be the responsibility of the MDS Coordinator to ensure the care plan was developed. During an interview with the MDS Coordinator on 10/29/22 at 2:13 p.m., she stated that she developed a person-centered care plan for any resident with an infection. She added she checked her box each morning to see if there were any new orders for a resident which required an update to the resident's care plan. The MDS Coordinator acknowledged that R#251 had no care plan for pneumonia. However, she stated it was an oversight and that a care plan should have been developed.

Based on record review, resident and staff interview, and policy review, the facility failed to enter an order in the record for one resident (R) (R#95) requiring suprapubic catheter care. The sample size was 40. Finding include: Record review revealed that R#95 was admitted to the facility on [DATE] with a diagnosis [CONDITION(S)], Overactive Bladder, and [CONDITION(S)] Bladder. Review of Admission Summary Note dated 8/15/22 revealed R#95 had a 20 French supra pubic catheter in place with 10 cubic centimeter (cc) bulb filled with normal saline. Review of the Minimum Data Set (MDS) Admission assessment dated [DATE] revealed in Section C R#95 Brief Interview for Mental Status (BIMS) score was 7 and Section H he had an Indwelling Catheter. review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan for R#95 revealed he had a suprapubic catheter due to [CONDITION(S)] and would remain free from catheter related trauma. Care plan indicated signs/symptoms would be monitored and recorded for discomfort or Urinary Tract Infection ([CONDITION(S)]), and Findings reported to Medical Director (MD). No catheter care was included in care plan. During an interview on 10/29/22 at 1:11 p.m. with R#95 revealed he admitted to the facility with his suprapubic catheter and goes to the Urologist every six weeks for catheter changes. He reported dressing changes are done by the facility staff. An observation was conducted during this time revealed R#95 had a dry dressing to suprapubic catheter site. Interview on 10/29/22 at 2:17 p.m. with Wound Nurse revealed resident did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 10/29/22 at 2:25 p.m. with the Director of Nursing (DON) confirmed R#95 did not have active orders for suprapubic catheter care. She revealed the facility does not use any form of ADL sheets and document ADL care including catheter care in the electronic medical record. She reported R#95 suprapubic catheter care was completed during routine care but could not provide documentation it was given. Her expectation that residents with catheter's have physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the policy titled Nursing Standards of Practice: Suprapubic Catheter Care date unknown, Policy revealed: Suprapubic catheter care will be provided to alleviate risk of irritation and Infection. Procedure: 1. Wash hands and don gloves. 2. Cleanse the skin around the catheter and catheter with soap and water. 3. Remove all exudates while cleaning. 4. Rinse and dry the area. 5. Apply a dressing if ordered or if drainage is present that would soil clothing. 6. Secure the catheter tubing with a strap, if desired. 7. Remove gloves and wash hands. 8. Document the procedure in the medical record. Note: If drainage is minimal, do not use a dressing. Leaving the area open to air will assist in alleviating drainage.

Based on observation, staff interviews, and facility policy, Handwashing/Hand Hygiene, the facility failed to ensure staff performed hand hygiene during one lunch dining service of two dining services observed. Findings Include: A review of the facility policy, Handwashing/Hand Hygiene, revised 8/2019, revealed that all personnel would follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. A further review revealed that an alcohol-based hand rub, or alternately, soap and water, would be utilized before and after direct contact with residents, after contact with objects in the immediate vicinity of the resident, and before and after assisting residents with meals. During an observation of the lunch dining service on 10/29/22 at 12:01 p.m., the Registered Nurse (RN) BB assisted the residents with their lunch service. At 12:06 p.m., RN BB placed both hands in her hair, touched the back of R#36's chair, and then assisted R#52 with the lid on her glass of tea. RN BB did not wash her hands or use the hand sanitizer. At 12:08 p.m., RN BB was observed assisting R#59 with fluids and opening his straw. At 12:10 p.m., RN BB touched the left side of her face and then assisted R#252 at 12:12 p.m. by opening and placing straws in his tea and water. At 12:15 p.m., RN BB touched her eyeglasses and face and helped R#25 with her cutlery and straw. Finally, RN BB touched the back of R#36's chair, moved an empty dining room chair, and began feeding R#5 at 12:18 p.m. RN BB never used hand sanitizer or washed her hands during the observation from 12:01 p.m. through 12:49 p.m. During an interview with RN BB on 10/29/22 at 12:49 p.m., she explained that she began working at the facility on 10/10/22. She acknowledged she did not use the hand sanitizer or wash her hands before assisting the residents with dining or feeding R#5. RN BB stated that she usually hand-sanitized before assisting residents during their meals. She could not explain why she did not hand-sanitize or wash her hands during the lunch services. RN BB stated that using hand sanitizer or washing hands during meals and between resident contact was standard infection control practice. During an interview with the Infection Control Preventionist (ICP) on 10/29/22 at 1:43 p.m., she stated it was her expectation for staff to hand wash or hand sanitize between passing out resident trays before and after assisting a resident with dining or meals. In addition, she expected staff to wash their hands or hand sanitize after touching objects or their face. The ICP indicated that all new staff members are given education on handwashing before working with the residents. She added that quarterly education and in-services were provided to all staff.

Based on observation, review of the facility policy titled Dating and Labeling Policy, and staff interviews, the facility failed to assure that items were labeled/dated and used before the expiration date in the kitchen, emergency food storage, and in one food pantry. The facility failed to assure that equipment in the kitchen was clean, hairnets were worn to cover all hair, and items in the dry food storage area were without dents and rust. This deficient practice affected 88 of 91 residents receiving an oral diet. Findings include: A brief kitchen tour began on [DATE] at 10:35 a.m. and revealed the following: The following was observed unlabeled and undated in the reach in cooler: 1. There was a one-gallon bag with sausage meat that was not labeled or dated. 2. There was a bag of scrambled eggs with seven boiled eggs that was not labeled or dated. 3. There was a peanut butter and jelly sandwich that was not labeled or dated. 4. There was a one-gallon sized bag of cornbread that was not labeled or dated. 5. There was a bag with sliced cheese with an open date of [DATE] but there was no expiration date. 6. There were 4 trays of glasses with water in them that were not dated. 7. There was a bag of shredded cheese with an open date of [DATE] but there was no expiration date. 8. There were individualized cups of apple juice that did not have an open date or an expiration date. The following was observed expired in the walk-in cooler: 1. There were nine packs of 12 count hamburger buns with best by dates of [DATE], [DATE], [DATE], [DATE], and [DATE]. The following was observed unlabeled and undated in the reach in freezer #1: 1. There was a box of tater rounds with an in date of ,[DATE] but no expiration date. 2. There were two boxes of chopped collards with no in date or expiration date. DM reported delivered on last week. 3. There was a partially used box of pollock sticks that did not have an expiration date. The following was observed unlabeled and undated in the reach in freezer #2: 1. There was a bag of carrots with an in date of [DATE] but no use by date. 2. There were three bags of red skinned potato wedges that did not have an expiration date. 3. There was a bag of onion rings that did not have an expiration. During an interview with the Dietary Manager (DM) on [DATE] at 11:00 a.m., it was reported that the bread in the refrigerator is checked daily and if it looks fine, they will continue to use the bread beyond the best by date. The DM further reported that items in the refrigerator should be labeled/dated and confirmed that items in the refrigerator were not labeled or dated. She further reported that canned goods are kept no longer than six months before they are thrown away. The resident pantry tour began on [DATE] at 2:51 p.m. and revealed the following: Freezer 1. There was one package of pizza rolls with a best by date of [DATE]. 2. There was one popsicle that was not labeled and did not have an expiration date. Refrigerator 1. There was one cup not dated. 2. There were three eight fluid ounce (fl. oz) chocolate Boost with an expiration date of [DATE]. 3. There were two staff members observed getting ice and water from ice/water machine in pantry that is noted to have a white buildup. 4. There was one 20 oz Coke Zero with an expiration date of [DATE]. 5. There were nine four fl. oz apple juices with no expiration date. During an interview and observation on [DATE] at 3:12 p.m. with the Licensed Practical Nurse (LPN) Supervisor AA it was reported that the night shift nurses are responsible for cleaning the refrigerator in the resident pantry as well as checking for expired items in the refrigerator. LPN Supervisor AA confirmed the expired juices, Coke, pizza rolls, and unlabeled cup in the freezer and refrigerator of the resident pantry. It was further reported that housekeeping staff are responsible for the cleaning of the ice/water machine in the resident pantry. During interview with the Housekeeping Supervisor on [DATE] at 3:23 p.m. it was reported that housekeeping staff cleans the ice machine/water machine daily. When the Housekeeping Supervisor used a white paper on the water dispenser a pinkish brown substance was noted on the paper after wiping. He also reported that the white buildup noted on the machine was from calcium buildup. The Housekeeping Supervisor further reported that there is no policy for cleaning the machine because the machine is wiped down daily. During an interview with the Maintenance Director on [DATE] at 7:42 a.m. it was reported that the ice/water machine in the pantry is a leased machine. Further reporting that if there are issues the company is called and someone comes out to resolve the issue. A follow up kitchen tour began on [DATE] at 12:33 p.m. and revealed the following: 1. There was an expired 5.44 pound can of mashed potatoes with an expiration date of [DATE] with an in date [DATE] in the emergency food supply. 2. The can opener in the kitchen has black buildup on the base. 3. There was one kitchen staff noted serving on the tray line with hair not fully covered by hairnet. 4. There were dented and rusted cans in the emergency food storage area. During an interview on [DATE] at 12:48 p.m. the DM reported that the can opener blade is washed daily, and Maintenance will have to remove the base to be washed. DM reported that this last took place a few months ago. DM also reported that some of the cans may be dented due to the rack falling on yesterday. She acknowledged that staff in the kitchen did not have hair fully covered by the hairnet but should have and reported that a larger hairnet is needed. DM reported that apple juice typically does not stay in the resident refrigerator in the pantry for residents. It was confirmed that the directions on the box for the apple juice said to use within 10 days of thawing. She confirmed that she is not able to determine when the apple juice was sent to the pantry and going forward apple juice will not be sent unless it is specifically asked for. During an interview with the ice machine Tech DD on [DATE] at 1:03 p.m. it was reported that he was called in today to clean the machine. He explained that he is contracted to clean and service the machine every six months. The servicing of the machine includes removing the cover and removable parts, emptying the ice bin, and cleaning of the ice shooter. He stated that routinely the machine can be maintained by using hot water to clean it. When Tech DD removed the ice shooter there was a black and white buildup noted at the mouth of the shoot in which the ice traveled. When touched by Tech DD some of the buildup moved from the shoot. He reported that most of what was being seen was calcium buildup. He also reported that the calcium buildup is on the outside and not on the inside of the tube from which the water comes. An observation on [DATE] at 1:07 p.m. of the resident refrigerator in the pantry revealed three bottles of Boost with an expiration date of (MONTH) 2019. Review of the facility policy titled Dating and Labeling Policy revised [DATE] revealed: kitchen will assure food safety by maintaining proper dates and labels to all goods and ready to eat food products. Procedure: 4. Ready to eat foods must be dated with a 72 hour use by date and discarded when expired. 5. Foods marked with manufactures use by date may be used and stored until expiration date. 10. Discard all foods that expire immediately.

Based on record review and resident/staff interviews, the facility failed to provide the resident/family with a written explanation of reason for a transfer to an acute care hospital for two residents (#33 and #69) reviewed of 85 residents transferred to the hospital since 7/23/18. Findings include: 1. Review of the electronic medical record (EMR) for R#69 revealed an Admission Minimum Data Set ((MDS) dated [DATE] with section C indicating a Brief Interview Mental Status score of 15. This indicates intact cognition for R#69. Further review of the EMR revealed hospitalized from [DATE] until 11/1/19 and 11/9/19 until 11/25/19. The EMR did not indicate that a transfer notice was provided to the resident. During an interview on 12/12/19 at 4:28 p.m. R#69 denied being provided any documentation when being transferred to the hospital detailing the reason for the need to go to the hospital. 2. Review of the Resident Census History for R#33 revealed a hospitalized from [DATE] through 10/7/19. Review of the medical record revealed there was no evidence that written notice of transfer was given to R#33 or the resident's responsible party when he was discharged to the hospital. During an interview with the Assistant Director of Nursing (ADON) on 12/12/19 at 9:46 a.m. it was reported that a transfer form is given to emergency personnel when the resident is sent to the hospital, but no written documentation is provided to residents regarding the transfer to the hospital. It was also reported that the resident's family is notified via telephone of transfers to the hospital. The facility provided a policy titled Transfer or Discharge, Emergency revised (MONTH) (YEAR). The policy indicated to notify the representative or other family member of an emergency transfer. The facility had no other policies related to notification of transfer.

Based on record review, resident and staff interviews, and review of the facility policy titled Bed Holds and Returns Policy, the facility failed to ensure that two residents (R) (#33 and #69) were made aware of the facility's bed hold and reserve bed payment policy upon transfer of 85 residents transferred to the hospital since 7/23/18. Findings include: Review of the Bed Holds and Returns Policy revised (MONTH) (YEAR) revealed prior to transfer, written information will be given to residents and the representative that explains in detail: the rights and limitations of the resident regarding bed-holds, the facility per diem rate required to hold a bed for non-Medicaid residents or to hold a bed beyond the state bed-hold period for Medicaid residents. 1. Review of the electronic medical record (EMR) for R#69 revealed an Admission Minimum Data Set ((MDS) dated [DATE] with section C indicating a Brief Interview Mental Status score of 15. This indicates intact cognition for R#69. Further review of the EMR revealed hospitalized from [DATE] until 11/1/19 and 11/9/19 until 11/25/19. The EMR did not indicate that any type of bed hold notification was provided to R#62 who is a Medicare resident. Interview on 12/11/19 at 2:37 p.m. with Licensed Practical Nurse (LPN) Supervisor AA who reported that nursing does not provide any documentation to residents when going to the hospital. It was further reported that the Business Office Manager (BOM) would likely be responsible for notifying residents of bed hold procedures. During an interview with the BOM on 12/11/19 at 4:22 p.m. it was reported that R#69 was a Medicare resident and a bed hold notice was not provided. During interview with BOM on 12/12/19 at 8:23 a.m. it was reported that she has not been providing written documentation to non-Medicaid residents regarding bed hold policy or room rates as stated in the facility policy. During further interview with the BOM on 12/12/19 at 8:47 a.m. it was reported that whenever room rates change residents are notified via a letter and residents are verbally notified of room rates on Admission. It was further disclosed that bed rates are not currently posted anywhere in the facility. BOM confirmed that there is no current process for notifying residents in writing whenever they are discharged to the hospital of bed rates or of the bed hold policy. During an interview on 12/12/19 at 4:28 p.m. with R# 69 it was confirmed that no documentation had been provided detailing rates for holding her bed when she went out to the hospital. 2. Review of the Resident Census History for R#33 revealed a hospitalized from [DATE] through 10/7/19. Review of the medical record revealed no evidence that written notice of bed hold policy was given to R#33 or the resident's responsible party when he was discharged to the hospital. The resident had Medicare and Medicaid. An interview conducted on 12/12/19 at 1:14 p.m. with the BOM revealed that the facility did not issue written notification of bed hold policy to the resident or resident representative.

Based on observation, record review, review of the facility policy titled Oxygen Administration, and staff interviews, the facility failed to obtain a Physician's Order for one resident (R) (#69) reviewed of 21 residents receiving oxygen. Findings include: Review of the Electronic Medical Record (EMR) for R#69 revealed [DIAGNOSES REDACTED]. Observations on 12/10/19 at 8:55 a.m., 12/11/19 at 9:01 a.m., and 12/12/19 at 8:18 a.m. revealed R#69 receiving oxygen therapy per nasal cannula ranging from 3 to 4/LPM (liters per minute). During an interview and observation on 12/12/19 at 8:28 a.m., Licensed Practical Nurse (LPN) BB confirmed that R#69 was currently receiving oxygen. However, LPN BB was unable to find a physician's order for oxygen therapy. During an interview with LPN Supervisor AA on 12/12/19 at 8:35 a.m. it was reported that when R#69 returned from the hospital and there was no order for oxygen the admitting nurse should have contacted the Physician to request an order to resume oxygen. LPN BB confirmed, at this time, that she was the admitting nurse and must not have written the order for oxygen. Review of the facility policy titled Oxygen Administration dated 2010 revealed the following procedure: 1. Verify that there is a Physician's Order for this procedure. Review the Physician's Orders or facility protocol for oxygen administration.

Based on staff and family interviews and record review the facility failed to ensure one of four Residents (R#2) received treatment and care in accordance with professional standards of practice. Findings include: Review of the undated face sheet in the Electronic Health Record (EHR) revealed R#2 was admitted to the facility on [DATE] and discharged on [DATE]. Review of the [DIAGNOSES REDACTED]. Review of her 6/9/19 Discharge Return Anticipated Minimum Data Set (MDS) revealed R#2's cognition was not assessed due to unplanned discharge. Review of section C of the MDS revealed a memory problem. Review of section G revealed R#2 required extensive assistance or was totally dependent on caregivers for all Activities of Daily Living (ADLs). Further review revealed ambulation did not occur during the review period. Review of section H revealed R#2 was always incontinent of bowel and bladder. R#2 Progress Note Review revealed the following: 1. On 5/31/19 at 6:30 p.m. R#2 was admitted to the facility after a Left Total Hip Replacement (THR) done on 5/26/19. Further review revealed no pain or other signs of distress. 2. On 5/31/2019 at 10:45 p.m. R#2 was found lying on right hip on the fall mat next to the bed. Further review revealed no apparent injuries were noted. 3. On 6/1/2019 at 12:30 a.m. R#2 was found on fall mat next to bed and denied pain. Further review revealed R#2 denied pain and was assessed for injuries, with no apparent injury noted. 4. On 6/8/2019 at 4:42 a.m. R#2 experienced pain during care consisting of brief change and turning. Further review revealed R#2 did not want her left leg moved and she wanted to remain on her right side. 5. On 6/8/2019 at 10:41 a.m. R#2 was experienced pain when changed or turned. 6. On 6/9/2019 at 10:53 a.m. R#2 experienced pain needed (PRN) pain medication. 7. On 6/9/2019 at 10:55 p.m. R#2 was transported to the hospital after her RP called and asked for the resident to be sent to the emergency room (ER). Review of the 6/10/19 at 1:33 a.m. Radiology Report revealed a computerized tomography (CT) scan of R#2 showed a dislocation of her left total hip replacement hardware, with soft tissue swelling and a hematoma (bruise) about the left hip. Review of an undated written statement in the FRI, signed by Licensed Practical Nurse (LPN) CC revealed she cared for R#2 on the night of 6/8/19 through 6/9/19, a Saturday. Further review revealed the written statement documented that R#2 would stiffen up and did not want to be changed or touched. Further review revealed LPN CC documented that R#2's daughter called and requested R#2 be sent to hospital for evaluation. Further review revealed LPN CC documented that she called the physician and transferred R#2 to the hospital. On 7/17/19 at 10:40 a.m. the Family of R#2 was interviewed in the surveyor's work room. She stated she recalled the Physical Therapist (PT) told her on 6/8/19 or 6/9/19 that she thought R#2's hip was dislocated. Family of R#2 stated she was not sure, but she did not think the PT reported this to the nurse or anyone else in the facility. Family of R#2 stated that she did not report the possibility that R#2's hip was dislocated to anyone in the facility either. Family of R#2 stated R#2 cried out a lot and this was part of her baseline. Family of R#2 stated looking back on it, she should have reported this to the nursing staff because this was a significant concern. A telephone interview with PT DD on 7/17/19 at 11:05 a.m. revealed she stated she worked at the facility for four months. PT DD stated she was filling in for another PT and that she only saw R#2 one time. She stated she was told by the rehab staff that R#2 cried out whenever anyone worked with her so crying out was R#2's baseline. PT DD stated she was suspicious that the resident's left hip might be dislocated after working with her. PT DD stated she provided education on hip precautions to R#2's daughter at the bedside. PT DD stated this was late in the day, after hours, on the Friday before R#2 went to the hospital. She stated she shared her suspicion with the Family of R#2. PT DD stated she did not report her suspicion to the nursing staff. PT DD stated looking back on it she wished she ordered an x-ray and reported her suspicion to the nursing staff. Interview on 7/17/19 at 12:05 p.m. with the Administrator in her office, the Administrator stated if the PT was suspicious the hip was dislocated on 6/7/19, two days before R#2 was sent to the hospital, the PT should have reported her concern to the facility. The Administrator stated the Family of R#2 should have reported this concern to nursing or to her. On 7/17/19 at 12:30 p.m. R#2's Medical Doctor (MD) was interviewed on the telephone. The MD stated he had been the facility Medical Director for three years. The MD stated he could not recall if he had been called about R#2 during any part of her stay. The MD stated his expectations were any suspicion of any injury or change of condition should be reported to him immediately. He stated the PT should have reported her suspicion of R#2's hip being dislocated.

Based on staff interview and record review, the facility failed to accurately assess three residents (#1, #2, and #3) for falls on the Minimum Data Set (MDS) assessments, from a total sample of three residents. Findings include: 1. A review of Resident (R) #1's clinical record revealed that the resident sustained [REDACTED]. However, the fall was not coded, in section J, on the 5 day Prospective Payment System (PPS) MDS assessment, with an Assessment Reference Date (ARD) of 3/11/18. 2. A review of R#2's clinical record revealed that the resident sustained [REDACTED]. However, the fall was no coded, in section J, on the 30 day PPS MDS assessment, with an ARD of 5/12/18. 3. A review of R#3's clinical record revealed that the resident sustained [REDACTED]. The resident also sustained a fall on 3/31/18, while out of the facility on a leave of absence. However, the falls were not coded, in section J, on the Significant Change MDS assessment, with an ARD of 4/11/18. Further review of R#3's clinical record revealed that she sustained a fall on 4/29/18. However, the fall was not coded, in section J, on the 30 day PPS MDS assessment, with an ARD of 5/2/18. During an interview on 5/25/18 at 3:08 p.m., the Director of Nursing (DON) stated that the MDS coordinator completed the falls section of the MDS assessments and had missed coding the falls for R#1, R#2, and R#3.

Based on observations, resident interview and record review, the facility failed to develop a care plan for range of motion for one (1) resident ("A") from a sample of thirty eight (38) residents. Findings include: Observation on 10/10/12 at 8:19 a.m., on 10/11/12 at 9:30 a.m. and 11:30 a.m. and on 10/12/12 at 8:40 a.m. revealed the resident sitting up in a geri-chair, leaning to the left. The resident's left arm had dropped down between his/her body and the arm of the geri-chair. The resident's left hand was curled. Continued observation revealed there was no positioning device in place to prevent the resident from leaning to the left or to prevent the left arm from dropping down. Review of the clinical record for resident "A" revealed that the resident was admitted with a [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was assessed with [REDACTED]. Review of the resident care plan revealed no evidence that a care plan had been developed for limited range of motion to the left upper and lower extremities. Interview with resident "A" on 10/11/12 at 9:30 a.m., revealed that he/she could not move the left arm without using the right arm to lift it, but because the arm was heavy, he/she was unable to move it very far. Continued interview revealed that the resident was unable to open his/her left hand completely and that he/she had never had a splint to wear on the left hand.

Based on record review, review of the Georgia Practical Nurses Act and staff interview, the facility failed to follow the standards of practice related to sliding scale Insulin administration for two (2) residents (#25 and #83) from a sample of thirty eight (38) residents. Findings include: 1. Review of the clinical record for resident #25 revealed that the resident was admitted to the facility in September, 2012 with [DIAGNOSES REDACTED]. Review of the physician progress notes [REDACTED]. Review of the physician's orders [REDACTED]. (BS-100/30= #u [MEDICATION NAME] Insulin.) Review of Medication Administration Records for resident #25 from September 10, 2012 through September 30, 2012 and October 1, 2012 through October 10, 2012 revealed twenty-six (26) times that the [MEDICATION NAME] Insulin was not administered as ordered. Interview with the Director of Nursing (DON) and Administrator on 10/10/2012 at 3:33 p.m. revealed that the physician's orders [REDACTED]. Continued interview revealed that the physician orders [REDACTED]. 2. Review of the clinical record for resident #86 revealed that the resident was was admitted to the facility in July 2012 with a [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the Medication Administration Records from July 5, 2012 through October 7, 2012 revealed forty five (45) times that the [MEDICATION NAME] R Insulin was not administered as ordered. Interview with the Administrator and Director of Nursing (DON) on 10/11/12 at 10:55 a.m., confirmed the above concerns. continued interview revealed that in front of each Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the Georgia Practical Nurses Practice Act revealed that the practice of licensed practical nursing means the provision of care for compensation related to the maintenance of health and prevention of illness which shall include: -2.3.2-Section J #3-Administers medications accurately Section E-Seeks clarification of orders when needed Cross to F309

Based on record review, and staff interview, the facility failed to follow physician orders [REDACTED].#68) from a sample of thirty-eight (38) residents. Findings include: 1. Resident #86 was admitted to the facility in July 2012 with a [DIAGNOSES REDACTED]. Review of Physician order [REDACTED].=# of units. Review of the July 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] 1. 7/4: Accucheck at 6:30 a.m. was 270, Insulin given was five (5), should have received six (6) units. 2. 7/13: Accucheck at 4:30 p.m. was 216, Insulin given was three (3) units, should have received four (4) units. 3. 7/18: Accucheck at 4:30 p.m. was 295, Insulin given was six (6) units, should have received seven (7) units. 4. 7/23: Accucheck at 4:30 p.m. was 344, Insulin given was eleven (11) units, should have received eight (8) units. 5. 7/25: Accucheck at 4:30 p.m. was 208, Insulin given was three (3) units, should have received four (4) units. 6. 7/30: Accucheck at 4:30 p.m. was 328, Insulin given was seven (7) units, should have received eight (8) units. Review of the August 2012 Medication Record revealed the following concerns: 1.) 8/2: Accucheck at 4:30 p.m. was 261; however, no coverage was given. 2.) 8/3: Accucheck at 11:30 a.m. was 309, Insulin given was nine (9) units, should have received seven (7) units. 3.) 8/4: Accucheck at 4:30 p.m. was 338, Insulin given was seven (7) units, should have received eight (8) units. 4.) 8/8: Accucheck at 4:30 p.m. was 291, Insulin given was seven (7) units, should have received six (6) units. 5.) 8/9: Accucheck at 4:30 p.m. was 261, Insulin given was seven (7) units, should have received five (5) units. 6.) 8/16: Accucheck at 4:30 p.m. was 360, Insulin given was eight (8) units, should have received nine (9) units, 6:30 a.m. was 297 with no documentation of Insulin given. 7.) 8/18: Accucheck at 4:30 p.m. was 300, Insulin given was six (6) units, should have received seven (7) units. 8.) 8/20: Accucheck at 4:30 p.m. was 215; however, no evidence of coverage being given. 9.) 8/21: Accucheck at 4:30 p.m. was 343, Insulin given was six (6) units, should have received eight (8) units. 10.) 8/27: Accucheck at 6:30 a.m., was 228 without any coverage. 11.) 8/29: Accucheck at 6:30 a.m., was 219 without any coverage. 12.) 8/30: Accucheck at 4:30 p.m. was 331, Insulin given was seven (7) units, should have received eight (8) units. 13.) 8/31: Accucheck at 4:30 p.m. was 406, Insulin given was nine (9) units, should have received ten (10) units. Review of the September 2012 Medication Record revealed the following concerns: 1.) 9/1: Accucheck at 4:30 p.m. was 512, Insulin given was eighteen (18) units, should have received fourteen (14) units. 2.) 9/3: Accucheck at 6:30 a.m. was 281, Insulin given was three (3) units, should have received six (6) units. Also, at 4:30 p.m., Accucheck was 313, received six (6) units, but should have received seven (7) units of Insulin. 3.) 9/4: Accucheck at 4:30 p.m. was 370, Insulin given was eight (8) units, should have received nine (9) units. 4.) 9/5: Accucheck at 6:30 a.m., was 340, Insulin given was five (5) units, should have received eight (8) units. 5.) 9/6: Accucheck at 6:30 a.m. was 246, Insulin given was two (2) units, should have received five (5) units, 4:30 p.m. was 337 Insulin given was seven (7), should have received eight (8). 6.) 9/7: Accucheck at 6:30 a.m., was 227 but no coverage was given. 7.) 9/10: Accucheck at 6:30 a.m. was 330, Insulin given was four (4) units, should have been eight (8) units. 8.) 9/11: Accucheck at 6:30 a.m. was 308, Insulin given was four (4) units, should have been seven (7) units. And at 4:30 p.m. the Accucheck was 390, Insulin given was nine (9) units, should have been ten (10) units. 9.) 9/12: Accucheck at 6:30 a.m. was 329, Insulin given was four (4) units, should have been given eight (8) units. Also, at 4:30 p.m. Accucheck was 416, given ten (10) units and should have been eleven (11) units. 10.) 9/13: Accucheck at 6:30 a.m., was 261, Insulin given was two (2) units, should have been given five (5) units. 11.) 9/15: No evidence of Accucheck taken at 4:30 p.m. 12.) 9/16: Accucheck at 4:30 p.m., was 333, Insulin given was seven (7) units, should have been eight (8) units. 13.) 9/17: Accucheck at 6:30 a.m., was 341, Insulin given was five (5) units, should have been eight (8) units. 14.) 9/18: Accucheck at 6:30 a.m., was 219 without any evidence of coverage. 15.) 9/19: Accucheck at 6:30 a.m. was 317, Insulin given was four (4), should have received seven (7) units. 16.) 9/23: Accucheck at 6:30 a.m. was 223, Insulin given was five (5) units, should have received four (4) units. Also, at 4:30 p.m., Accucheck was 407, received nine (9) units and should have received ten (10) units. 17.) 9/24: Accucheck at 6:30 a.m. was 299, Insulin given three (3) units, should have received seven (7) units. 18.) 9/25: Accucheck at 11:30 a.m. was 372, Insulin given was eight (8) units, should have received nine (9) units. 19.) 9/26: Accucheck at 4:30 p.m. was 216 without any coverage. 20.) 9/27: No Accucheck was taken at 4:30 p.m. Review of the October 2012 Medication Record revealed the following concerns: 1.) 10/2: Accucheck at 11:30 a.m. was 369, Insulin given was five (5) units, should have received nine (9) units. Also, at 4:30 p.m., Accucheck was 248, given twelve (12) units and should have been given five (5) units. 2.) 10/4: Accucheck at 4:30 p.m. was 269, Insulin given was five (5) units, should have received six (6) units. 3.) 10/5: Accucheck at 4:30 p.m. was 405, Insulin given was nine (9) units, should have received ten (10) units. 4.) 10/6: Accucheck at 4:30 p.m. was 296, Insulin given was six (6) units, should have received seven (7) units. 5.) 10/7: Accucheck at 4:30 p.m. was 341, Insulin given was seven (7) units, should have received eight (8) units. Interview with the Administrator and Director of Nursing (DON) on 10/11/12 at 10:55 a.m., confirmed the above concerns; however, the Administrator indicated that in front of each Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. 2. Clinical record review revealed that Resident #25 was admitted into the facility in September of 2012 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. The formula was blood sugar minus one hundred divided by thirty equals the number of units of [MEDICATION NAME] insulin. (BS-100/30= #u [MEDICATION NAME] Insulin.) Review of the Medication/ Treatment Administration Record for 09/10/2012- 09/30/2012 and 10/01/2012 - 10/10/2012 indicated the following concerns: September 10, 2012 4:30 p.m. BS 199 No coverage given should have been 3 u [MEDICATION NAME] September 11, 2012 6:30 a.m. BS 176 No coverage given should have been 3 u [MEDICATION NAME] September 11, 2012 4:30 p.m. BS 198 No coverage given should have been 3 u [MEDICATION NAME] September 13, 2012 4:30 p.m. BS 168 No coverage given should have been 2 u [MEDICATION NAME] September 15, 2012 6:30 a.m. BS 143 No coverage given should have been 1 u [MEDICATION NAME] September 18, 2012 6:30 a.m. BS 189 No coverage given should have been 3 u [MEDICATION NAME] September 19, 2012 6:30 a.m. BS 132 No coverage given should have been 1 u [MEDICATION NAME] September 20, 2012 6:30 a.m. BS 191 No coverage given should have been 3 u [MEDICATION NAME] September 21, 2012 6:30 a.m. BS 176 No coverage given should have been 2 u [MEDICATION NAME] September 24, 2012 6:30 a.m. BS 195 No coverage given should have been 3 u [MEDICATION NAME] September 25, 2012 6:30 a.m. BS 148 No coverage given should have been 1 u [MEDICATION NAME] September 25, 2012 4:30 p.m. BS 315 No coverage given should have been 7 u [MEDICATION NAME] September 26, 2012 6:30 a.m. BS 157 No coverage given should have been 2 u [MEDICATION NAME] September 27, 2012 6:30 a.m. BS 199 No coverage given should have been 3 u [MEDICATION NAME] September 29, 2012 6:30 a.m. BS 131 No coverage given should have been 1 u [MEDICATION NAME] October 1, 2012 6:30 a.m. BS 136 No coverage given should have been 1 u [MEDICATION NAME] October 1, 2012 4:30 p.m. BS 200 No coverage given should have been 3 u [MEDICATION NAME] October 2, 2012 6:30 a.m. BS 160 No coverage given should have been 2 u [MEDICATION NAME] October 3, 2012 4:30 p.m. BS 221 No coverage given should have been 4 u [MEDICATION NAME] October 5, 2012 11:30 a.m. BS 167 No coverage given should have been 2 u [MEDICATION NAME] October 6, 2012 11:30 a.m. BS 148 No coverage given should have been 1 u [MEDICATION NAME] October 6, 2012 4:30 p.m. BS 182 No coverage given should have been 3 u [MEDICATION NAME] October 8, 2012 11:30 a.m. BS 155 No coverage given should have been 2 u [MEDICATION NAME] October 9, 2012 6:30 a.m. BS 136 No coverage given should have been 1 u [MEDICATION NAME] October 9, 2012 11:30 a.m. BS 194 No coverage given should have been 3 u [MEDICATION NAME] October 10, 2010 11:30 a.m. BS 184 No coverage given should have been 3 u [MEDICATION NAME]. Interview with the Director of Nursing (DON) and Administrator on 10/10/2012 at 3:33 p.m. revealed that the physician's orders [REDACTED]. The DON and Administrator acknowledged that the physician orders [REDACTED].