Every finding on record at Heritage Inn of Sandersville Health and Rehab

Based on observations, staff interviews, and review of the facility's policy titled, Storage Areas, the facility failed to store food in a safe and sanitary manner by failing to: ensure food items were properly labeled and dated; ensure expired food items were discarded; and ensure kitchen equipment was stored off the floor and away from cleaning chemicals and supplies. This deficient practice had the potential to affect all 58 residents who receive food orally by placing them at increased risk for foodborne illness and contamination.Findings include:Review of the facility's policy titled, Storage Areas, revealed the policy, review date 12/27/2025, to read in part: Items should be covered, sealed, labeled, and dated appropriately. The policy further reads, First in first out (FIFO) should be followed. Regarding equipment storage, the policy reads, Items should be stored off the floor and clear of ceiling sprinklers.An initial brief kitchen tour was conducted on 07/18/2026 at 7:47 AM with Dietary Aide (DA) AA and the following concerns were identified:Observation of the cooler conducted on 07/18/2026 at 7:47 AM, revealed a bag of parmesan cheese with an opened date of 07/02/2026 and no expiration date; a bag of uncooked chocolate chip cookies with no opened date or expiration date; a bag of uncooked peanut butter cookies with an opened date of 05/06/2026 and an expiration date of 07/06/2026, making the item expired at the time of observation; a bag of broccoli bits with an opened date of 07/02/2026 and no expiration date; a bag of French toast with no opened date or expiration date; and a bag of piping whipped cream with an opened date of 06/03/2026 and a use-by date of 06/30/2026, making the item expired at the time of observation.Observation of the bread cart was conducted on 07/18/2026 at 7:47 AM with DA AA, revealed three bags of white bread with no expiration date; two bags of hamburger buns with no expiration date; a bottle of lemon extract with a use-by date of 04/02/2026, making the item expired at the time of observation; and a seasoned salt container with no label.Observation of the kitchen storage corridor conducted on 07/18/2026 at 7:47 AM with DA AA, further revealed two pots stored directly on the floor in a small storage corridor located at the back of the kitchen leading to the bathroom. Both pots were observed surrounded by miscellaneous cleaning equipment, including a mop, dustpan, hose, and vacuum.Interview conducted on 07/19/2026 at 8:51 AM with the Dietary Kitchen Manager (DKM), revealed all staff are responsible for dating and labeling food items, and items should be labeled when deliveries arrive. She stated her expectation is that staff check the coolers, freezer, and pantry for expired items and items nearing expiration, and stated the facility also conducts a weekly cleaning during which all food items are reviewed and any expired items are discarded. She stated a checklist is used to document that staff have checked for expired items. She stated all items are required to be labeled and dated, and any expired items must be discarded. She stated pots, pans, and similar items should not be placed on the floor near chemicals or brooms. She stated a potential negative outcome of items not being labeled could be an infection control concern or foodborne illness, as staff would not know when an item arrived or was opened and therefore could not determine whether it was still safe for use; labeling and dating are important to prevent contamination or foodborne illness. Interview conducted on 07/19/2026 at 9:02 AM with the Administrator, revealed that all items in the kitchen should be labeled accordingly, and any expired items should be discarded, and pots should not be stored on the floor; she stated this reflects her expectations for the kitchen.

Based on observation, record review, and staff interview, the facility failed to ensure that the thermometer on the interior of the walk-in cooler was accurate to be able to determine if the temperature in this cooler was at an acceptable range to prevent the potential for foodborne illness. In addition, the facility failed to provide documentation that the temperatures in the coolers were re-checked after the recorded temperatures were above the acceptable range of 41 degrees Fahrenheit (F). In addition, the facility failed to ensure that condensation dripping from a ceiling vent, and dust-like debris on the ceiling surface and fluorescent lights in the kitchen over food prep areas, did not have the potential for contaminating food and kitchen equipment underneath it. There were 56 residents that consumed an oral diet. Findings include: 1. Observation during the initial tour of the kitchen on 7/10/17 beginning at 10:19 a.m. revealed that the thermometer located outside of the walk-in cooler indicated that the temperature inside the cooler was 44 degrees F., and the thermometer on the inside of this cooler was observed to indicate a temperature of 25 degrees F. This was verified during interview with the Clinical Dietary Manager (CDM) at this time, who stated that whenever staff opened the walk-in freezer door (which was located inside the walk-in cooler), that it made the temperature in the cooler go down, and that was why the thermometer on the inside of the cooler registered a temperature of 25 degrees. On 7/11/17 at 3:55 p.m., the outside thermometer for the walk-in cooler was observed to indicate a temperature of 45 degrees F., and the thermometer on the inside of this cooler was observed to be 26 degrees F. On 7/12/17 at 1:55 p.m., the outside thermometer for the walk-in cooler was observed to register a temperature of 44 degrees F., and the thermometer on the inside of this cooler was observed to read 25 degrees F. This was verified during interview with the CDM at this time, who stated that they went by the reading on the thermometer on the inside of the cooler when checking the cooler temperatures. The CDM was observed to place two new, previously unopened thermometers in the walk-in cooler at this time. During observation on 7/12/17 at 3:04 p.m., the outside thermometer on the walk-in cooler was observed to register a temperature of 42 degrees F., and the old, original thermometer on the inside of the cooler was observed to indicate a temperature of 25 degrees F. Further observation at this time revealed that the temperatures on the two new thermometers that had been placed next to the original thermometer on the inside of the walk-in cooler both indicated that the temperature was 42 degrees F. (the same temperature as the thermometer on the outside). This was verified during interview with the CDM at this time, who again stated that staff went by the temperature reading on the interior thermometer, but that they also looked at the outside thermometer, too. During further interview with the CDM, she stated that the appropriate temperature in the coolers should be 41 degrees F. or less. During interview with kitchen employee BB at this time, she stated that she used the inside thermometer to check the walk-in cooler temperature. Review of the June Walk in Cooler Temperature Record revealed that the recorded AM (morning) and PM (afternoon) temperatures ranged from a low of 27 degrees F. on 6/1/17 and 6/25/17, to a high of 48 degrees F. on 6/14/17. Further review of this form revealed that there were 27 temperatures recorded as less than 32 degrees F., and no indication that the temperatures were rechecked. Review of the July Walk in Cooler Temperature Record through 6/12/17 revealed that the temperatures ranged from a low of 28 degrees on 7/1/17, to a high of 45 degrees on 7/2/17. Further review of this form revealed that there were two temperatures recorded as less than 32 degrees F., and no indication that the temperatures were rechecked. 2. Review of the Temperature Record forms revealed that there were columns available to include the AM (morning) and PM (afternoon) temperatures, columns for staff to initial as they recorded the temperatures, and a column for the DM (Dietary Manager) to initial that she reviewed the readings. Review of the Unit #1 reach-in cooler Temperature Record revealed that through July 12th, there was one AM (morning) temperature not recorded (on 7/1/17), and four AM temperatures that exceeded the acceptable temperature of 41 degrees F. as follows: 7/5/17: 48 degrees 7/7/17: 45 degrees 7/10/17: 45 degrees 7/12/17: 45 degrees Review of the June Temperature Record for Unit #1 reach-in cooler revealed that there was one AM temperature not recorded on 6/23/17, and 12 temperatures that exceeded 41 degrees F. as follows: 6/3/17: 48 degrees 6/4/17: 46 degrees 6/6/17: 47 degrees 6/8/17: 46 degrees 6/9/17: 45 degrees 6/13/17: 47 degrees 6/14/17: 42 degrees 6/15/17: 50 degrees 6/18/17: 48 degrees 6/20/17: 48 degrees 6/26/17: 50 degrees 6/28/17: 44 degrees Review of the Temperature Record for Unit #2 reach-in cooler through July 12th revealed that there was one PM temperature not recorded on 7/5/17, and five AM temperatures that exceeded 41 degrees F. as follows: 7/1/17: 48 degrees 7/2/17: 46 degrees 7/5/17: 47 degrees 7/7/17: 42 degrees 7/12/17: 44 degrees Review of the June Temperature Record for Unit #2 reach-in cooler revealed that there was one AM temperature not recorded on 6/23/17, and 15 temperatures that exceeded 41 degrees F as follows: 6/3/17: 46 degrees 6/4/17: 45 degrees 6/6/17: 45 degrees 6/8/17: 42 degrees 6/9/17: 42 degrees 6/13/17: 49 degrees 6/14/17: 47 degrees 6/17/17: 46 degrees 6/18/17: 44 degrees 6/21/17: 48 degrees 6/26/17: 45 degrees 6/27/17: 49 degrees 6/28/17: 47 degrees 6/29/17: 45 degrees 6/30/17: 44 degrees Review of the Temperature Record for the Walk in Cooler through July 12th revealed that there were four AM temperatures that exceeded 41 degrees F. as follows: 7/1/17: 44 degrees 7/2/17: 45 degrees 7/5/17: 44 degrees 7/7/17: 42 degrees Review of the June Temperature Record for the Walk in Cooler revealed that there was one AM temperature not recorded on 6/23/17, and 14 temperatures that exceeded 41 degrees F. as follows: 6/3/17: 47 degrees 6/4/17: 47 degrees 6/6/17: 46 degrees 6/9/17: 44 degrees 6/13/17: 46 degrees 6/14/17: 48 degrees 6/17/17: 44 degrees 6/18/17: 42 degrees 6/20/17: 45 degrees 6/21/17: 45 degrees 6/22/17: 44 degrees 6/26/17: 43 degrees 6/28/17: 42 degrees 6/29/17: 44 degrees Review of all of these Temperature Records revealed that the Dietary Manager initialed as having reviewed them. Further review of the Records revealed that there was no notation that the temperatures were rechecked if they were above 41 degrees. During interview with the CDM on 7/12/17 at 1:55 p.m., she verified the multiple entries on the Temperature Records that the temperatures exceeded 41 degrees, and that there was no documentation that the temperatures were rechecked. 3. During an observation of pureed food preparation on 7/11/17 beginning at 3:55 p.m., drops of condensation from a ceiling vent were noted on the food prep table directly below this vent, as well as a small puddle on the floor below the vent. Also observed under this ceiling vent were pots, colanders, and serving utensils hanging from a suspended rack. During further observation, a plastic pitcher without a lid that was used to prepare a slurry for the pureed food was noted on the prep table, and there were several drops of the ceiling vent condensation on the prep table approximately one inch away from this open pitcher. Further observation revealed that there were five upside-down steam table pans on the shelf below the prep table that extended several inches over the edge of the shelf, making them subject to possibly coming into contact with the drops of condensation. On 7/12/17 at 1:55 p.m., brown dust-like particles were observed on the ceiling extending away approximately 24-inches on all four sides of the ceiling vent over the prep table. Further observation revealed that the two fluorescent ceiling lights close to the end of the prep table where the food processor was located also contained a coating of the brown dust-like material. Further observation revealed that condensation continued to drop from the ceiling vent near the edge of the prep table. Continued observation revealed that partially under this ceiling vent on a suspended rack were 16 colanders, pots, pans and various utensils. Observed on the shelf under the prep table was a plastic bin that contained 13 or more lids, four upside-down steam table pans, and an unopened bag of potato chips. During interview with the CDM at this time, she stated that they have had a heating and air conditioning company come to the facility in the past to try and fix the condensation from the ceiling vents, but were told there was nothing that could be done. She further stated that they did all food prep on the side of the prep table closest to the ovens, which would not subject them to possible contamination from the ceiling vent drops. Observation of an upside-down steam table pan on the shelf under the prep table and under the ceiling vent at this time revealed that there was a small amount of moisture on the rim of the pan. During interview with the CDM at this time, she stated that although the pots and pans hanging from the ceiling and located on the prep table shelf were washed prior to storing them there, they rewashed these items before they actually used them to prepare food. During interview with kitchen employee AA on 7/12/17 at 2:08 p.m., she stated that the pots and pans under the prep table and hanging from the ceiling had already been washed, and she did not wash them again prior to use. Observation of the CDM at this time revealed that she wiped the brown dust-like material on the ceiling over the prep table with her fingers, and this material was noted to coat her fingers afterwards. During interview with the CDM at this time, she stated that she did not know how long it had been since the ceiling was cleaned, but that it had been painted about a month to a month-and-a-half ago. Review of the facility's Food Preparation, Storage and Serving procedure with an updated date of May 2017 revealed: It is the intent of this center to serve safe food and practice basic safe food handling principles. Food service associates will follow best practice standards from ServSafe, Georgia Department of Health, FDA (Food and Drug Administration), and CMS (Centers for Medicare and Medicaid Services) Regulations. Food storage standards will be in place to ensure food is stored under correct conditions and used timely for best quality value of products. Review of the Georgia Department of Public Health Rules and Regulations Food Service revealed: Food products requiring temperature control for safety shall be immediately stored within approved temperature control storage equipment verified by the food service establishment management that is capable of maintaining food product temperatures of 41 degrees F. or less, if held cold. Cleaned equipment and utensils, laundered linens, and single-service and single-use articles shall be stored In a clean, dry location; where they are not exposed to splash, dust, or other contamination. Ambient air temperature, water pressure, and water temperature measuring devices shall be maintained in good repair and be accurate within the intended range of use. DONE

Based on observations, record review of Maintenance work history report and staff interviews facility failed to ensure the facility was in good repair on three of the three halls (Hall 1, Hall 2, and hall 3) with findings of holes in bathroom doors, holes in walls some partially patched and not painted, loose and/or missing baseboards, peeling paint, scuffed and peeled away areas of drywall at base of walls, ceilings with areas of plaster missing and stained areas on ceilings. Sample of 22 rooms out of 32 rooms. With 17 rooms of the 22 rooms found to have concerns. Findings include: Observation on 7/10/2017 beginning at 3:40 p.m. revealed the following: Room 109: Observed brown stained area on the ceiling, scuff marks on walls, peeling paint on the bathroom wall next to sink, on ceiling of bathroom and on door frame outside of bathroom. Observation on 7/11/2017 at 8:41 a.m. of room 210 revealed: the ceiling to have brown stained area two feet long by six inches wide over the window and a brown stain area on the ceiling over the resident ' s bed next to window six foot long by four inches wide. Observation on 7/11/2017 9:20 am room of 204 revealed: the ceiling of the bed next to window was noted to have a brown circular area ten inches in diameter. Observation on 7/11/2017 10:05 am. of room 207: revealed the ceiling above bed next to window along privacy curtain rail a brown stain eighteen inches long and six inches wide. Observation on 7/11/2017 at 11:22 a.m. of room 106 revealed: noted holes in wall of bathroom where the towel bar once was. The wall next to the closet was chipped, areas patched but not painted. The bottom drawer of the dresser had scratches along the entire bottom drawer. Observation 7/12/2017 at 8:00 a.m. began room to room checks beginning with hall three. The following issues were noted in room # 302,304,306 all these room ' s bathroom doors had splintering holes at the handles sizes three inches long by two inches wide varying to two inches long by two inches wide. Room 110- The bathroom the wall entering on the right one foot x one inch scuff marks on right lower wall and under grab bar in bathroom scratched areas with paint removed six inches by six inches. Room 119- The bathroom overhead vent in the bathroom has a brown stained area on right front edge 4 inches by 3 inches. Behind the left side of the sink were three scuffed areas one foot long and two inches wide. Room 106- The bathroom right side wall 1 foot above handrail has 3 holes in wall ranging in sizes one inch to three inches. Room 102 - The residents room area behind the resident ' s recliner were several holes in the wall partially patched but not painted over. Ranging in sizes of one to two inches covering an area two foot by one foot. Room 201- In the bathroom area behind the sink and the commode a two foot by two foot area patched roughly but not painted, also the floor molding behind toilet and to the right of the toilet are unattached lying on floor. Room 202- The bathroom door at the handle has a one inch by one inch area where wood is scuffed away Room 204- The bathroom door has a splintered area at handle four inches by two inches. Sprinkler head in resident ' s room has area ten inch by ten inch surround sprinkler head with missing plaster. Room 205- The bathroom door has a splintered area at handle five inches by 1 inch. The wall at the bathroom sink patch of paint peeled away one foot by one and one half feet. within resident ' s room left side of wall at door. Room 206- The bathroom door has a splintered area at handle six inches by one inch. Room 209- The bathroom door indented area at handle two inch by two inch appears to have been partially patched. Inside the bathroom on the right side of the commode paint peeling and base board missing with brownish black discoloration where baseboard is missing. In resident ' s room on left side of call light patched area left unpainted eight inch by ten inch. Room 211-- The bathroom door had a splintered area at handle six inch by one inch. Room 212- The bathroom door at the handle had splintered area six inch by two inch. Room 213- The resident ' s room on left side base of wall sheetrock skinned away six inches wide over entire base of wall. Bathroom walls all have peeling paint. Bathroom door has a partially patched hole two inches by one inch. Interview 07/12/2017 at 9:44 a.m. with the Maintenance Director he stated they have a computer generated schedule of maintenance checks weekly, monthly, every three, six months and annually. Work orders come up in between. Recently began a new system that all work orders are keyed into the computer anyone in the building that has access to a computer can put in a work order. Prior to that he had a clip board at the nurse ' s station that everyone wrote down any issues and he would check it periodically throughout the day and take care of the issues. Now he checks the computer periodically to see if there are any issues he needs to take care of. Maintenance director provided a copy of his Annual Work History report which revealed a schedule of what is to be done weekly, monthly, every three, six months and annually. Noted that resident's doors are to be checked every three months and resident ' s room are to be checked every six months. The Maintenance Director revealed that when he checks the rooms for general maintenance repairs. When ask about the issues found in rooms Maintenance director states that they have a regional painter that is hired through corporate that comes around periodically to do patch work on walls and paint he further stated the Administrator calls and lets them know when painting or patching needs to be done. He doesn't recall exactly when the painter was here last but he thought it had been within the last 6 months. Maintenance Director further revealed that he hasn't received any work orders for the doors or paint issues. Observation and interview 07/13/2017 12:00 p.m. with the Maintenance Director of all the rooms that had the noted concerns. He acknowledged all the areas of concerns. Wrote them all down. The Maintenance director demonstrated that the door entering the resident's room and the bathroom door handles hit causing the holes in the bathroom door. Ask why some bathroom doors noted to have a hard brown piece of plastic around the door handle on the outside. He stated yes the Administrator hired someone to put that on all the doors to protect them. The gentleman began the job but never completed it and they have been trying to find material to match it to complete the job. Further interview and Observation with the Maintenance Director revealed that he looks where wheelchair foot rest have hit the walls and scuffed them up. He reported that he has talked with the Administrator about ordering some plastic boarding and putting it up about three feet high on the wall to help with this problem. He knows there are several issues of painting that need to be addressed. Interview 07/13/2017 12:58 p.m. with the Administrator regarding environmental issues in the facility stated that she and the Maintenance Director have discussed options of how to fix the scuffed marks and holes in the walls caused by the wheel chairs but Ethica the company that manages them has a design team that they have to go through and they have been back and forth in discussions with them and also the owner of the building in regards to the wall issues but nothing has been resolved. Recommendations of how to fix things have been made but no one has made a decision on what to do to fix it. She states I should have pushed maintenance to finish out the job and get it painted but I did not.

Based on observation, record review, and staff interview, the facility failed to maintain one of one walk-in coolers in proper working order as evidenced by leaking onto the floor of this cooler. There were 56 residents that consumed an oral diet. Findings include: During initial tour of the kitchen on 7/10/17 beginning at 10:19 a.m., the walk-in cooler floor was observed to have a layer of clear fluid, mostly in the front right corner. During further observation, a strip of ice approximately three inches wide was observed on the floor at the entry into the walk-in freezer (which was located within the walk-in refrigerator). During interview with the Certified Dietary Manager (CDM) at this time, she stated that her staff had reported the leaking to her, but she was not specific as to how long the cooler had been leaking. During interview with the CDM on 7/10/17 at 3:00 p.m., she stated that an outside vendor had done repair work on the walk-in cooler, but that the exact cause of the leaking was not identified, and that a hose was positioned into a drain pipe to help drain the liquid on the floor. Review of the vendor's Service Order revealed this work was completed on 7/6/17. On 7/11/17 at 4:30 p.m., a monitoring form was observed taped to the outside of the walk-in cooler, and was signed by staff as they monitored the cooler hourly for water in the floor. During interview with the CDM on 7/13/17 at 8:00 a.m., she stated that the Maintenance Director had contacted another outside vendor to address the leaking in the walk-in cooler. Review of the Work Order from this vendor revealed that it was dated 7/13/17, and that the walk-in freezer and cooler combination unit had condensation inside.

Based on observation, review of the Centers for Disease Control (CDC) 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, review of the facility's policy on administration of eye drops and staff interview, it was determined that the facility failed to ensure that a Licensed Practical Nurse (LPN) washed his/her hands and wore gloves during the administration of nasal spray and eye drops for one resident (#18) and failed to wear gloves during the administration of insulin for one resident (#68) of three residents observed for medication administration from a sample of 20 residents. Findings include: According to the CDC's 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, hand hygiene was the single most important practice to reduce the transmission of infectious agents in healthcare settings. Hand hygiene included handwashing with soap and water or in the absence of visible soiling of hands, alcohol-based products approved for hand disinfection could be used. Gloves should be used to prevent contamination when there was potential direct contact with blood or body fluids, mucous membranes, nonintact skin or other potentially infectious material Review of the facility's policy on the administration of eye drops revealed that staff should wash hands prior to the administration of eye drops. 1. During observation of medication administration on 8/19/15 at 8:25 a.m., Licensed Practical Nurse (LPN) ZZ failed to wear gloves prior to administering [MEDICATION NAME] nasal spray to resident #18. After the administration of the nasal spray, ZZ cleaned the tip of the [MEDICATION NAME] bottle with a tissue and recapped the bottle. Without washing/sanitizing his/her hands and without wearing gloves, ZZ then administered Artificial Tears eye drops in each of the resident's eyes which had the potential of introducing harmful germs from the resident's nose into his/her eyes. 2. During observation of medication administration on 8/19/15 at 9:00 a.m., LPN ZZ used sanitizer but, failed to wear gloves prior to the subcutaneous administration of 52 units of [MEDICATION NAME] 70/30 Insulin to resident #68. On 8/19/15 at 10:35 a.m., the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) who was responsible for infection control stated that they expected staff to wear gloves during the administration of nasal spay and eye drops and to wash/sanitize hands and change gloves between the administration of nasal spray and eye drops. On 8/20/15 at 2:40 p.m., the DON stated that she expected staff to wear gloves as a standard precaution during the administration of Insulin.

Based on observations and staff interview the facility failed to ensure that food items in the walk-in freezer were stored under sanitary conditions to prevent contamination. The facility census was fifty-nine (59). Findings include: Observation on 10/14/14 at 11:00 a.m. of the walk-in freezer revealed that there was an ice build-up and an icicle on the Freon pipe located behind the air condenser which was at the back of the freezer. Continued observation revealed that there was an open case of frozen pre-made waffles directly under the ice buildup and icicle coming from the Freon pipe. The case of frozen waffles had an ice formation that was three (3) inches in diameter and three (3) inches in height adhered to the cardboard flap. Inside the case of waffles were ice crystals. Further observation of the walk-in freezer revealed that there was a case of pita bread sitting on the top shelf of a wire rack on the right side of the air condenser. The case of pita was open and had ice formation adhered to the cardboard flap. Observation on 10/15/14 at 4:10 p.m. of the walk-in freezer revealed that there was an icicle that was 1 ? inches in length and one fourth (1/4) inch in diameter coming from the Freon pipe located at the back side of the air condenser. The icicle was observed to be directly hanging over an open cases of chopped spinach and pre-made waffles. Continued observation of the open case of chopped spinach revealed that there was an ice buildup that covered one side of the packages of spinach. Observation of the open case of pre-made waffles revealed that there were ice formation on the open flaps of the box as well as ice inside the case and surrounded every package of wrapped waffles. Interview on 10/15/14 at 4:10 p.m. with the Dietary Manager revealed that she was aware that there were icicles coming from the air condenser and that this was occurring due to the freezer defrost cycle. She acknowledged that the open cases of chopped spinach,pre-made waffles and pita bread all had ice buildup on the outside and inside of the cases, which came from icicles dripping from the air condenser.

Based on record review and staff interview, the facility failed to follow physician orders [REDACTED]. Findings include: Review of the clinical record for resident #32 revealed that the resident had a [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no evidence in the clinical record that the physician had discontinued the fluid restriction. Interview with the Director of Nursing (DON) at 10:30 a.m. on 1/23/13, revealed that there is no formal communication with the [MEDICAL TREATMENT] center unless the resident has an issue. If the resident has a problem, then the center would notify the nursing staff, and the staff would document this information. Continued interview revealed that the Nurse Practitioner (NP) communicates with the [MEDICAL TREATMENT] center on a weekly basis and that the resident's nephrologist communicates with the center very closely as well. She concurred that the resident is on a fluid restriction. Interview with the DON at 10:50 a.m. on 1/24/13, revealed that the resident was on fluid restriction in November 2012 of 1500 cc per day but the restriction was enforced only in November 2012 and had not been enforced since. Continued interview at 11:20 a.m. revealed that when the [MEDICAL TREATMENT] center sends the facility a communication, the nurse gets the communication and is responsible for ensuring that any physician's orders [REDACTED]. Interview on 1/23/12 at 1:00 p.m. with Licensed Practical Nurse (LPN) "CC" revealed that the resident was on fluid restrictions at one point; however, she did not think the resident was currently on fluid restriction.

Based on observation, record review and staff interviews the facility failed to monitor bed and/or chair alarms for proper functioning for twelve (12) residents who used alarms and failed to maintain the alarms in proper working order for three (3) residents (#3, #5, and #57) of the twelve (12) residents with alarms. Findings include: 1. Resident #57 is an [AGE] year old admitted [DATE] with [DIAGNOSES REDACTED]. Review of the Falls Intervention Plan (FIP) revealed he had interventions put into place after falls, including pressure sensitive alarms on bed and chair added 5/16/12. Further review of the care plan revealed that on 1/20/13 the alarm had malfunctioned and was replaced. Review of the resident's care plan revealed he was at risk for injury related to falls. Review of the narrative on the Situation/Background/Assessment/ Recommendations (SBAR) form completed 1/20/13 at 4:00 a.m. after the resident's fall, revealed a bed alarm was in place but malfunctioned and was not heard. Interview with the Minimum Data Set (MDS) coordinator on 1/22/13 at 2:06 p.m. revealed the resident fell on [DATE] when he got out of bed and tried to walk without help; he was found on the floor in his room but had no injuries. Interview with the Assistant Director of Nursing (ADON), who is in charge of the Falls Program, on 1/23/13 at 11:58 a.m. revealed that she checks alarms every three (3) days, but the nurses check the alarms daily. She revealed that there is no log kept to document that alarms are tested . Interview with the DON on 1/23/13 at 3:38 p.m. confirmed she had no list of residents who have alarms; this information used to be on the Certified Nursing Assistant's (CNA's) care plan, but management did not have a list. She further revealed there is no plan in place (log) to document that alarms are being checked. She revealed that if the CNA finds that an alarm is not working, she is to report it to the Licensed Practical Nurse or DON. 2. Observation on 1/23/13 at 1:48 p.m. with Licensed Practical Nurse (LPN) "EE" revealed resident #3 lying on her bed asleep. LPN "EE" could not locate the bed alarm on resident #3's bed. Observation on 1/23/13 at 1:50 p.m. with certified nursing assistant (CNA) "DD" revealed Resident #3 was lying on her bed alarm and when lifted by CNA "DD" and LPN "EE" to check the alarm, the alarm did not sound. The resident was lifted higher to remove the bed alarm and the alarm did not sound. The alarm was not in working order and this was confirmed with LPN "EE" and CNA "DD". A replacement, functioning bed alarm was placed on the resident's bed. Interview on 1/23/13 at 1:51 PM with CNA "DD" revealed the battery in the bed alarm unit for resident #3 was dead. CNA "DD" revealed she was instructed to inform her charge nurse when she found a bed or chair alarm that was not functioning. CNA "DD" was not aware of any routine or scheduled bed/chair alarm checks for the facility. Review of the medical record revealed Resident #3 had a care plan dated 9/14/12 for risk for injury related to a history of falls, getting up unassisted, urinary/bowel incontinence, osteoporosis, degenerative joint disease, and antidepressant use. The interventions revealed See Fall Intervention Plan (FIP). Review of the FIP revealed the original date for selected interventions was 5/26/11 for Alarms, Pressure sensitive on bed and Alarms, pressure sensitive on chair. 3. Observation of resident #5's room on 1/23/12 at 1:50 p.m. revealed a bed alarm monitor connected to the siderail but not attached to the bed pressure pad alarm. Continued observation revealed that the pressure pad alarm connector was between the sheets and mattress, in the middle of the bed but was inoperable because it was broken. Interview on 1/23/13 at 1:50 p.m. with CNA "AA" confirmed that the pressure pad bed alarm for resident #5 was broken Review of progress note dated 12/23/12 at 2:45 pm revealed that the resident was heard calling out and when staff entered the room, the resident was found sitting on floor beside bed. The bed was in the lowest position. The resident was examined and no injuries were observed. The chair alarm had been removed from the resident's clothing by the resident but the pressure pad alarm was on the bed. Review of the resident care plan revealed that a pressure sensitive alarm had been applied to bed as an intervention for falls management. Interview with the Director of Nursing (DON) at 2:30 p.m. on 1/23/13 revealed that when the Certified Nursing Assistant (CNA) gets residents up out of either their beds and/or wheelchairs and the alarms are not working, then she and/or the charge nurse is notified and the alarm is replaced. Interview with Certified Nursing Assistant (CNA) "AA" on 1/24/13 at 9:34 a.m., revealed that when an alarm is discovered not working then she notifies the maintenance director. Interview with the Maintenance Director on 1/24/13 at 9:40 a.m., revealed that the alarms use nine (9) volt batteries, which he keeps in stock. The staff write him notes and leave them at the nursing station, which he checks once a day, and fixes any problems that may occur. Interview with Licensed Practical Nurse (LPN) "BB" on 1/24/13 at 9:43 a.m., revealed that if the CNA comes to her about any alarms, then she will go check the alarm and see if the alarm works, if it does not work, she can replace it with other alarms, which are kept in the supply room.