Every finding on record at Hospital Authority of Brooks County, Georgia, The

Based on observations, staff interviews, and review of the facility's policy titled Food Receiving and Storage, the facility failed to discard expired foods and to ensure food items were properly labeled and dated in the dry pantry and in the refrigerator/freezers to prevent foodborne illness. The deficient practice had the potential to affect 133 out of 140 residents receiving an oral diet.Findings include:Review of the facility's undated policy titled, Food Receiving and Storage revealed under Dry Food Storage: 4. Dry foods that are stored in bins are removed from original packaging, labeled and dated ( use by date). Such foods are rotated during a first in-first out system. Under Refrigerated/Frozen Storage: 7. Refrigerated foods are labeled, dated and monitored so they are used by their use by date, frozen, or discarded.During a tour of the kitchen on 8/26/2025 at 9:00 am with the Assistant Director of Food Service, revealed, the following concerns:1. Observation of the dry pantry revealed four one gallon of red cooking wine with an expiration date of 8/4/2025.2. Observation of the walk-in cooler revealed a green plastic container labeled tomatoes with a use by date of 8/22/2025; a blue plastic container labeled lettuce with a use by date of 8/23/2025; a red plastic container labeled tomatoes with a use by date of 8/24/2025 and a foam container wrapped in plastic wrap, labeled EL, dated 6/26/2025.3. Observation of Unit A refrigerator contained a sandwich covered in plastic wrap not labeled or dated.4. Observation of Unit B refrigerator/freezer revealed one gallon of chocolate ice cream with an expiration date of 3/29/2025 and two plastic containers unlabeled or dated.Interview and rounding on 8/26/2025 at 9:00 am with the Assistant Director of Food Service confirmed the identified concerns. She revealed there should not have been any expired food, or any items not labeled or dated in the dry storage area, walk in cooler, or any of the hall refrigerators/freezers. She revealed all staff was responsible for ensuring expired items were discarded and to ensure all items were labeled and dated.Interview on 8/26/2025 at 10:00 am with Assistant Director of Nursing (ADON) revealed the kitchen staff was responsible for ensuring expired food items were removed and that food items were labeled and dated on all Unit refrigerators/freezers.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, Self-Administration of Medications by Patients/Residents, the facility failed to ensure two Residents (R) (R96 and R125) did not have unauthorized, unsecured medications at bedside. In addition, the facility failed to ensure authorized medications for self-administration was securely stored at bedside for R129. This deficient practice had the potential to allow unauthorized access of medications to other residents and visitors in the facility. The sample size was 56 residents.Finding include:Review of the undated facility's policy titled Self-Administration of Medications by Patients under the Intent statement revealed, Each patients who desires to self-administer medication is permitted to do so if the nursing centers' interdisciplinary team has determined that the practice would be safe for the patient and other patients of the nursing center and that the patient is able to accurately self-administer. Ability to appropriately self-administer medications should be documented in the documented in the patient's care plan. This evaluation of the patient 's ability to correctly and safely self-administer medications is subject to periodic re-evaluations based on changes in the patient's status.1. Review of clinical records for R96 revealed the following diagnoses but not limited to personal history of other disease related to respiratory system, lymphocytic colitis, and cognitive communication deficit.Review of the Significant Change Minimum Data Set (MDS) Assessment for R96 dated 5/22/2025 revealed, Section C (Cognitive Patterns) a Brief Interview for Mental Status Score (BIMS) score of 15 which indicated little to no cognitive impairmentObservation on 8/26/2025 at 11:29 pm of R96's room revealed prescription medication (a tube of zinc oxide paste topical ointment) labeled with the resident's name lying on the dresser. At the time of observation, R96 reported that an unidentified nurse administered (applied) the medication to his body parts and left the medication in his room.Review of clinical records for R96 revealed an omission of a completed assessment to determine whether or not the resident was capable of Self-Administration of Medications.Review of the Physician Order Form and Medication Administration Record (MAR) both dated August 2025 for R96 revealed that the resident had an order in place for the prescription.During an observation and interview on 8/26/2025 at 2:18 pm of R96's room with Registered Nurse (RN) AA, she confirmed the medications at the resident's bedside. RN AA also confirmed that R96 had not been assessed to self-administer medications independently. She reported being unsure of how the medications was left in the resident possession. RN AA then proceeded to remove the medications from the room and gave the medication to Charge Nurse Licensed Practical Nurse (LPN) BB (the assigned floor nurse).During an interview on 8/26/2025 at 4:22 pm with LPN BB, she confirmed that resident was not assessed to self-administer medications. She reported being unaware of medication being left in the resident room.Interview conducted on 8/28/2025 at 10:39 am with the Director of Nursing (DON) revealed that she was unaware of R96 having medicated cream within his possession. She stated that her expectation was that the nurses should not leave the cream in the resident room. She further stated that applying the cream for treatment requires the expertise of a nurse. 2. Review of clinical records for R125 revealed the following diagnoses but not limited to pleural effusion in other conditions classified elsewhere, hypoosmolality/hyponatremia, myocardial infarction, and cognitive communication deficit.Review of the Quarterly MDS Assessment for R125 dated 7/5/2025 revealed, Section C (Cognitive Patterns), a BIMS score of 13 which indicated little to no cognitive impairmentObservation on 8/26/2025 at 11:29 pm of R125's room revealed a bottle of cold medicine and a bottle of tums over-the-counter medication on resident's bedside table. During an observation on 8/26/2025 at 4:31 pm, RN AA confirmed that medications was in the room. She also confirmed that R125 had not been assessed to administer medications per her knowledge. RN AA then proceeded to remove the medications out of room and gave the medicine to LPN BB (assigned floor nurse).During an interview on 8/27/2025 at 10:41 am, the DON revealed that she was unaware R125 had unauthorized medications in her room. She further revealed that R125 was not approved to self-administer medications at the time of the survey findings. She reported that after the deficient practice was identified by the Survey Team and brought to the facility's attention, her Assistant Director of Nursing(ADON) completed a self-administer medications assessment that same day (8/26/2025) to allow the resident to self-administer medications. 3. Review of clinical records for R129 revealed the following diagnoses but not limited to diastolic congestive heart failure.Review of the Significant Change MDS assessment dated [DATE] for R129 revealed, Section C (Cognitive Patterns), a BIMS score of 15 which indicated little to no cognitive impairments.Observation and interview on 8/26/2025 at 10:15 am of R129's bathroom revealed two tubes of prescription medicated creams hanging on the handle bar. R129 revealed that she uses the cream to apply on her bottom for rash. She reported that nurses were aware. She reported that she independently used the cream daily as a treatment for a rash.During an observation of R129's bathroom on 8/26/2025 at 4:20 pm with RN AA, she confirmed that the medication was openly hanging on the handle bar in the bathroom and was not properly stored in the bedside drawer. She reported that per her knowledge R129's was not assessed to administer the cream. RN AA then proceed to remove the cream out of the bathroom and gave it to LPN BB (assigned floor nurse).Review of clinical records for R129 revealed an assessment for Self-Administration for medications dated 6/20/2025 and application for medicated cream.During an interview with the DON on 8/27/2025 at 9:30 am, she confirmed that R129 was approved to self-administer medicated creams however, the medicated cream should not have been stored in the bathroom and should have been in the resident's bedside drawer. Cross Refer F656

Based on observations, staff interviews, and review of the facility's policy titled Environmental Services Policy-cleanliness and homelike environment, the facility failed to ensure vents were free from dust and grime build up in eight residents rooms on two of six halls, A and B (Rooms 37, 38, 39, 40, 68, 66, 70, 71). Findings include: Review of the facility's undated policy titled Environmental Services Policy-cleanliness and homelike environment revealed, .3. Inspection and Oversight: Routine inspections of resident rooms and common areas will be conducted to ensure compliance with cleanliness and homelike standards. Environmental services supervisors will complete weekly rounds and document findings. Concerns identified during nursing or administrative rounds will be communicated and addressed within 24 hours. 1. Observation on 8/26/2025 at 12:05 pm and on 8/27/2025 at 10:43 am of room [ROOM NUMBER] revealed, a dirty vent grate/grille with a black substance on the front slats. 2. Observation on 8/26/2025 at 12:06 pm and on 8/27/2025 at 10:39 am of room [ROOM NUMBER] revealed, a dirty vent grate/grille with a black substance on the front slats. 3. Observation on 8/26/2025 at 12:07 pm and on 8/27/2025 at 10:37 am of room [ROOM NUMBER] revealed, a dirty vent grate/grille with a black substance on the front slats. 4. Observation on 8/26/2025 at 12:08 pm and on 8/27/2025 at 10:34 am of room [ROOM NUMBER] revealed, a dirty vent grate/grille with a black substance on the front slats. 5. Observations on 8/26/2025 at 10:53 am revealed the air vent and slats covered in a black substance along with dust build up in room [ROOM NUMBER]. 6. Observations on 8/26/2025 at 10:54 am revealed the air vent and slats covered in a black substance along with dust build up in room [ROOM NUMBER]. 7. Observations on 8/26/2025 at 11:08 am revealed the air vent and slats covered in a black substance along with dust build up in room [ROOM NUMBER]. 8. Observations on 8/26/2025 at 11:18 am revealed the air vent and slats covered in a black substance along with dust build up in room [ROOM NUMBER]. Interview on 8/27/2025 at 2:47 pm with Maintenance II revealed that vents in the resident's rooms were possibly cleaned in May of 2025 but he was unsure. Interview on 8/27/2025 at 2:48 pm with Lead Engineering Assistant JJ revealed he and staff clean the vent grates/slats about every six months. Interview on 8/27/2025 at 2:50 pm with the Maintenance Supervisor revealed they clean the vents about every two months. He was unsure when the vents were last cleaned. He said summer months were worse but admitted he didn't increase cleaning or the monitoring of the vents. He confirmed the vents were covered in dust and grime. He admitted that he and his crew started cleaning the vents on the A hall on the night of 8/26/2025 due to him receiving a text and picture from an employee that this surveyor was taking pictures of the vents in resident's rooms. He revealed the facility dropped the ball. When asked if he thought it was good for residents to breathe the dust/black substance, he said no, we should have ensured the vents were clean. Observation and interview on 8/28/2025 at 10:00 am during a walk-through with the Environmental Supervisor confirmed that all of the identified vents were dirty.

Based on observations, staff and resident interviews, record review, and review of the facility's policies titled, Care plans, Comprehensive Person-Centered, and Self-Administration of Medications by Patients, the facility failed to develop and implement a person-centered, comprehensive care plan for three of 18 Residents (R) (R59, R101, and R129). Specifically, they failed to implement the care plan for oxygen (O2) therapy related to not administering O2 per the physician order for R59; failed to develop a care plan for O2 use, water humidification, and posting signage for R101; and failed to develop a care plan for self-administration of medication for R129. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs, and a diminished quality of life.Findings include: Review of the facility's policy titled, Care plans, Comprehensive Person-Centered revised March 2022 revealed, Policy Statement, A comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Under Policy Interpretation and Implementation, 1. The Comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or significant Change in Status), and no more than 21 days after admission . 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The comprehensive, person-centered care plan includes measurable objectives and timeframes .describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Assessments of resident's are ongoing and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team reviews and updates the care plan .at least quarterly . Review of the facility's undated policy titled, Self-Administration of Medications By Patients revealed, .Ability to appropriately self-administer medications should be documented in the patient care plan. 2. The results of the interdisciplinary team assessment are recorded in the Patient Care Plan, which is placed in the patient 's medical record. 1. Review of clinical records for R59 revealed diagnoses that included but were not limited to Chronic Obstructive Pulmonary Disease (COPD), and chronic respiratory failure with hypoxia. Review of physician orders dated 4/16/2025 revealed orders for oxygen at two (2) liters per minute (LPM) via nasal canula, continuous. Review of care plan dated 1/30/2024 and revised on 7/22/2025 for R59 revealed a diagnosis of COPD and chronic respiratory failure with hypoxia. Interventions included but not limited to: Administer oxygen as prescribed or per standing order. Observations on 8/26/2025 at 10:25 am and 4:10 pm revealed R59's oxygen setting at one (1) LPM. Observation on 8/27/2025 at 10:34 am revealed R59's oxygen setting at 1-1.5 LPM. Observation on 8/27/2025 at 10:37 am with Assistant Director of Nursing (ADON) EE confirmed the R59's oxygen order was for 2 LPM by looking in the electronic health record. She then confirmed R59's oxygen was set on 1 to 1.5 and not at 2 LPM. She revealed her expectations were for nurses to check the oxygen settings during medication pass. Interview on 8/27/2025 at 1:00 pm with the Minimum Data Set (MDS) Coordinator revealed she develops and enters care plans along with other members of the interdisciplinary team and that all staff were aware of care plans and updates through clinical meetings. She revealed that all staff were expected to follow care plans and interventions including oxygen setting rates set on their prescribed rate. She confirmed the physician orders for R59 was for 2 LPM. Interview on 8/27/2025 at 1:00 pm with the Assistant Director of Nursing (ADON) EE confirmed the facility failed to follow the care plan for R59 related to oxygen. She revealed she expects her nurses to check the rates during medication pass and rounds and to provide care per the physician orders and care plans. 2. Review of clinical records for R101 revealed, diagnoses that included but not limited to, Alzheimer's disease, dementia, psychotic disorder with delusions, major depressive disorder, and anxiety disorder. Review of physician's order dated 8/27/2025 revealed O2 at 2-4 liters per minute (LPM) via nasal cannula (NC) to keep sats >90% (saturation above 90%); order dated 4/30/2024, change the oxygen tubing and humidifier bottle every Sunday. Continued review revealed an order dated 4/16/2024 for O2 at 2-4L per NC every 8 hours as needed for low O2 sat apply if o2 sats fall below 90%-discontinued 8/27/2025. Review of the care plan dated 10/2/2024, last revised on 4/9/2025 for R101 revealed, there was no care plan problem, goal, or interventions for O2 use. Observation on 8/26/2025 at 12:05 pm and on 8/27/2025 at 10:43 am of R101 lying in bed receiving O2 running at 2 LPM via NC from the O2 concentrator at bedside. There was no sign posted on the door or inside room [ROOM NUMBER] that indicated O2 was in use. During an observation and interview on 8/28/2025 at 12:00 pm, the DON (Director of Nursing) confirmed R101 was receiving O2, confirmed the flow rate was not set at 2 LPM and confirmed there was no sign posted that indicated oxygen was in use. The DON revealed her expectation for a resident on O2 therapy, that they should have an order, have a specific flow rate number, the order must be followed, and be care planned for O2 use including water humidification and signage posted. 3. Review of clinical records for R129 revealed the following diagnoses but not limited to diastolic congestive heart failure. Review of the Significant Change MDS assessment dated [DATE] for R129 revealed, Section C (Cognitive Patterns), a BIMS score of 15 which indicated little to no cognitive impairments. Observation and interview on 8/26/2025 at 10:15 am of R129's bathroom revealed two tubes of prescription medicated creams hanging on the handle bar. R129 revealed that she uses the cream to apply on her bottom for rash. She reported that nurses were aware. She reported that she independently used the cream daily as a treatment for a rash. During an observation of R129's bathroom on 8/26/2025 at 4:20 pm with RN AA, she confirmed that the medication was openly hanging on the handle bar in the bathroom and was not properly stored in the bedside drawer. She reported that per her knowledge R129's was not assessed to administer the cream. RN AA then proceed to remove the cream out of the bathroom and gave it to LPN BB (assigned floor nurse). Review of clinical records for R129 revealed an assessment for Self-Administration for medications dated 6/20/2025 and application for medicated cream. Review of the care plans for R129 revealed that there was no focus area to self -administer medications. Interview on 8/27/2025 at 9:30 am, the DON confirmed R129 did not have care plan to self-administer medication and that her ADON created a care plan after it had been identified during the survey on 8/26/2025. Interview on 8/27/2025 at 10:30 am with the MDS Coordinator confirmed that the care plan for self-administration of medications was not created until yesterday (8/26/2025). She stated that the protocol was that once a resident was approved to self-administer medication by the IDT (Interdisciplinary Treatment Team), the care plan would be initiated to communicate to staff that the resident was capable of self-administering medications. Cross Refer F695, F554

Based on observation, resident and staff interviews, record review, and review of the facility's policy titled Smoking Policy, the facility failed to ensure that precautions were in place for the safety of two of four Residents (R) (R118 and R58) during smoke breaks. Specifically, the facility failed to ensure that an uncovered ash tray was not filled with trash and R58's extinguished cigar butts was not placed in a N-95 (disposable facepiece respirator) mask hanging from a rollator. This had the potential to place residents in designated smoking areas at risk for safety.Findings include:Review of the facility's policy titled Smoking Policy, with a revision date of 3/25/2023 under the Purpose statement revealed, To provide a source for evaluation of the resident's ability to safely hold, light, smoke, and extinguish their cigarette.1. Review of the Electronic Medical Record (EMR) for R118 revealed that he was admitted to the facility on [DATE] with diagnoses that included but were not limited to sequelae of cerebral infarction, hemiplegia and hemiparesis affecting right dominant side, dementia with agitation, chronic obstructive pulmonary disease (COPD), and nicotine dependence.Review of the Quarterly Minimum Data Set (MDS) for R118 dated 5/20/2025 revealed, Section C (Cognitive Patterns) a Brief Interview for Mental Status score of 12, which indicated a mild cognitive impairment; Section E (Behavior) revealed, that the resident experiences verbal symptoms directed towards others and other behavioral symptoms not directed towards others and Section GG (Functional Abilities and Goals) revealed that he had functional limitations in range of motion to upper and lower extremities with impairment to one side and required supervision for all activities of daily living.Review of the care plan for R118 dated 4/25/2025, revealed that he is a smoker with Interventions that included but not limited to: cigarettes and lighters to be kept in the medication room and dispensed by the nurse, conduct smoking safety evaluation on admission and as needed, and to educate him on the facility's tobacco/smoking policy. An observation of smoking on 8/27/2025 at 12:32 pm revealed R118 observed smoking outside in the designated smoking area, which was located outside the entrance of unit E, near the flagpole. During this observation, it was noted that there was a fire blanket, fire extinguisher, and two ash trays. R118 was noted with cigarettes and a lighter and was seated next to one of the ash trays. The uncovered ash tray was noted to have cigarette butts and trash that was overflowing. Interview on 8/27/2025 at 3:46 pm with Registered Nurse (RN) LL revealed, Unit E was the dementia unit and there were no smokers on this unit. He stated that the only smokers that the facility had were on the second floor and were allowed to come downstairs and go out to the smoking area. He stated that he was unsure who was responsible for maintaining the ash trays.Interview on 8/27/2025 at 3:51pm with RN MM revealed that there were only five smokers. She stated that the smokers needed to have a general evaluation completed and would include evaluation and any concerns noted during the assessment. She then stated that she assume that it was the responsibility of either maintenance or housekeeping to check and empty the ash trays.Interview on 8/27/2025 at 3:57 pm with the Maintenance Assistant (MA) NN revealed that he was new at the facility and was not aware whose job it was to empty and check the ash tray for the smokers but stated, he would find out.Interview on 8/27/2025 at 4:45 pm with the Director of Nursing (DON) revealed that she was unsure who was responsible for maintaining the ash tray.Interview on 8/27/2025 at 4:55 pm with the Administrator revealed that staff were just educated, and that environmental services will check the ash trays two times a day and maintenance will check it at the end of their shift from now on.2. Review of the EMR for R58 revealed that he was admitted to the facility with diagnoses that included but were not limited to Parkinson's disease with dyskinesia (abnormal, involuntary, or uncontrolled muscle movements), and dementia.Review of the Quarterly MDS for R58 dated 6/10/2025 revealed, Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) score of five, which indicated severe cognitive impairment; Section GG (Functional Abilities and Goals) revealed, that he required supervision or touching assistance with mobility.Review of the care plan dated 4/24/2024 for R58 revealed that he is a smoker with Interventions that included but were not limited to: cigarettes and light to be kept in the medication room and dispensed by the nurse, conduct smoking safety evaluation on admission and as needed, and to educate him on the facility's tobacco/smoking policy.Review of the smoking safety assessment dated [DATE] for R58 revealed, he had balance problems while sitting and standing and follows the facility's policy on location and time of smoking.Observation and interview on 8/28/2025 at 10:53 am with R58 revealed that when he was told he could smoke, the only thing they instructed me to do was to turn in his cigars and lighter. As he was walking in, it was noted that his extinguished cigar butts were in an N-95 mask, that was hanging from his rollator.An interview was conducted on 8/28/2025 at 11:53 am with the Social Services Director (SSD) revealed that social services was responsible for completing the smoking assessments quarterly. The SSD revealed that if a resident was assessed and needed to be supervised, then the resident would need to go outside to smoke with either a nurse or a Certified Nursing Assistant. She stated that education was provided to the residents, that includes the smoking policy. She stated that if R58 extinguished his cigars out in his mask and not in the ash tray, then he must have been nervous because he knows better. She concluded the interview and revealed that they just received education about making sure that the residents that smoke were safe, and that housekeeping was made responsible for checking the ash tray two times a day.

Based on observations, record reviews, staff interviews, and review of the facility's policy titled, Oxygen Administration, the facility failed to ensure that the physician's order for oxygen administration was followed for one Resident (R) (R59), failed to post proper signage outside of residents' rooms informing that oxygen was in use for three residents (R101, R145 and R11), failed to have an oxygen order for one resident (R11), and failed to ensure a humidification bottle was used for one resident (R145) out of 18 residents that received oxygen therapy. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs and a diminished quality of life.Findings include: Review of the facility's undated policy titled Oxygen Administration under the section Preparation revealed, 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Under the section, equipment and supplies: The following equipment and supplies will be necessary when performing this procedure. 3. Humidifier bottle 4. no smoking/oxygen in use signs. Under, steps in the procedure 2. Place an oxygen in use sign on the outside of the room entrance door. Close the door. 12. Check the mask, tank, humidifying jar, etc. to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that water level is high enough that the water bubbles as oxygen flows through. 1. Review of clinical records for R59 revealed diagnoses that included but were not limited to Chronic Obstructive Pulmonary Disease (COPD), and chronic respiratory failure with hypoxia. Review of physician orders dated 4/16/2025 revealed orders for oxygen at two (2) liters per minute (lpm) via nasal canula, continuous. Observations on 8/26/2025 at 10:25 am and 4:10 pm revealed R59's oxygen setting at one (1) liter per minute (LPM). Observation on 8/27/2025 at 10:34 am revealed R59's oxygen setting at 1-1.5 LPM. Observation on 8/27/2025 at 10:37 am with Assistant Director of Nursing (ADON) EE confirmed the R59's oxygen order was for 2 LPM by looking in the electronic health record. She then confirmed R59's oxygen was set on 1 to 1.5 and not at 2 LPM. She revealed her expectations were for nurses to check the oxygen settings during medication pass. She further revealed that she was going to provide training and education for her staff. Interview on 8/28/2025 at 12:00 pm with the Director of Nursing (DON) revealed all orders should be specific for the liter to be set at, and that the concentrator should be set as ordered. 2. Review of clinical records for R101 revealed, diagnoses that included but not limited to, Alzheimer's disease, dementia, psychotic disorder with delusions, major depressive disorder, and anxiety disorder. Review of physician's orders dated 8/27/2025 revealed, orders that included but not limited to oxygen (O2) at 2-4 liters LPM via nasal cannula (NC) to keep sats >90% (saturation above 90%), as well as an order dated 4/30/2024 to change the O2 tubing and humidifier bottle every Sunday. Continued review revealed an order dated 4/16/2024 for O2 at 2-4L per NC every 8 hours as needed for low O2 sat apply if O2 sats fall below 90%-discontinued 8/27/2025. Observation on 8/26/2025 at 12:05 pm and on 8/27/2025 at 10:43 am of R101 lying in bed receiving O2 running at 2 LPM via NC from the O2 concentrator at bedside. There was no sign posted on the door or inside room [ROOM NUMBER] that indicated O2 was in use. Observation on 8/28/2025 at 10:20 am of R101 sitting up in bed receiving O2 running at 2 LPM via NC from the O2 concentrator at bedside. There was no sign posted on the door or inside room [ROOM NUMBER] that indicated O2 was in use. 3. Review of clinical records for R145 revealed diagnoses that included but were not limited to chronic obstructive pulmonary disease (COPD), dependence on supplemental oxygen, and interstitial pulmonary disease. Review of the physician orders for R145 revealed that she was to receive oxygen at three (3) liters per minute via nasal cannula, and staff to change oxygen tubing and humidifier every night shift on Sundays. An observation and interview with R145 on 8/26/2025 at 10:49 am revealed that she was receiving oxygen at 3 LPM via nasal cannula. During that observation it was noted that there was no humidification for the oxygen and that there was no oxygen in use signage on the door. R145 revealed that she was supposed to be on three or four liters of oxygen and that she thought she was receiving humidified air. Observation on 8/27/2025 at 12:40 pm revealed that R145 was observed receiving oxygen at 3 liters via nasal cannula with no humidification with no oxygen in use signage on the door. Interview on 8/28/2025 at 10:15 am with Licensed Practical Nurse (LPN) KK revealed that she was educated by the O2 supplier that in the state of Georgia, residents did not need humidification. She also confirmed that she did not post signage of oxygen in use until yesterday afternoon for R145. During an observation and interview on 8/28/2025 at 12:00 pm, the DON (Director of Nursing) confirmed R101 was receiving O2, confirmed the flow rate was not set at 2 LPM and confirmed there was no sign posted that indicated oxygen was in use. During the walk-through the DON also confirmed that R145 was on O2, did not have water humidification, or signage that indicated O2 use. The DON revealed they had magnetic and paper signs at the nurses' station, and nurses were responsible for posting the sign when O2 was in use. The DON stated her expectations were that the nurses should never put oxygen on a resident without a physician's order, all orders should have a specific flow rate and not a range, the oxygen should be set at the flow rate ordered and staff must not adjust the flow rate without an order, water humidification should be used if the O2 setting was set at two or above, and there should always be a sign posted notifying that oxygen was in use inside the room. The DON also stated that if an order was unclear, or if there was not an order to increase the flow rate if needed, the nurse must always notify the physician for clarification or a new order before adjusting the O2. 4. Review of clinical records for R11 revealed the following diagnoses that included but were not limited to heart failure and morbid obesity. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for R11 revealed, Section C (Cognitive Pattern) a Brief Interview for Mental Status (BIMS) score of four which indicated severe cognitive impairment; Section O (Special Treatments and Programs) was not assessed for oxygen therapy. Observation on 8/26/2025 at 11:16 am revealed R11 was receiving oxygen at one (1) LPM via NC from the concentrator. Continued observation of R11's room revealed there was no oxygen sign posted on the inside or outside of the resident's room or door. During an observation on 8/26/2025 at 4:16 pm with Registered Nurse (RN) AA, she confirmed that R11 oxygen flow rate was set at 1 liter. RN AA revealed she was unsure of the clarity of physician order and proceeded to adjust the flow rate to two (2) liters. During a follow up observation on 8/27/2025 at 10:00 am and 8/28/2025 at 10:00 am , R11 was observed lying in bed receiving oxygen at a flow rate of 1 liters via NC from the concentrator. Review of the Physician Order Form (POF) dated August 2025 for R11 revealed there was no order for oxygen use. Review of care plans dated 7/9/2025 for R11 revealed, a focus area for oxygen use and intervention that included but not limited to Provide oxygen as indicated by Resident condition and /or provider order. Interview on 8/27/2025 at 11:11 am with MDS Coordinator RN CC and RN DD confirmed that the resident did not have an order for oxygen therapy. Both staff confirmed that the care plan for oxygen therapy was created in error and confirmed the order for oxygen should have been followed up prior to creating a care plan for oxygen usage. Interview on 8/28/2025 at 12:10 pm with the DON confirmed that R11 did not have oxygen signage on the door that indicated oxygen use. She confirmed that resident did not have supporting diagnoses or orders for oxygen. She stated that her expectation were for the nurses to follow up with the physician to ensure the resident have an order prior to administering oxygen. Cross Refer F656

Based on record review, interviews and review of the facility's policy titled Abuse/Neglect Prevention Program, the facility failed to ensure that one of nine sampled Residents (R) (R1) was protected from alleged abuse by staff as evidence that the staff continued to provide care for R1 and was not suspended during the allegation investigation. Findings include: Review of the facility's undated policy titled Abuse/Neglect Prevention Program revealed, 4. Reporting Practices: H. Facility action in mistreatment, neglect, abuse of residents , or misappropriation, exploitation of resident property . 2. Upon discovery of alleged abuse, the staff member(s) will be immediately suspended pending investigation. Review of medical records revealed, R1 was admitted with the following diagnoses that include but are not limited to emphysema, chronic pulmonary edema, chronic obstructive pulmonary disease, hemiplegia and hemiparesis following cerebra infarction, dementia, and hypertension. Review of the Progress Notes dated 1/28/2025 which indicated a late entry for 1/27/2025 revealed that R1 had stated that the Certified Nurse Aide (CNA) (identified as CNA MM) shoved the neck pillow behind her head. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) came to the unit and had a conversation with R1 to see if the situation to be resolved. Review of the Time of Attendance dated 1/23/2025 through 2/5/2025 revealed CNA MM continued to work on 1/27/2025 and did double shift on 1/28/2025. Review of the (Named) law enforcement MISC INCIDENT REPORT dated 2/26/2025 revealed that CNA MM was still assigned to R1 as recently as 2/25/2025. It is noted that the facility DON was questioned as to why CNA MM was providing care to R1 the day prior. After asking this question, CNA MM was given another assignment. During an interview on 6/23/2025 at 2:07 pm, CNA MM revealed that R1 had asked her to adjust her neck pillow. She stated that she had slid the pillow under R1 head without lifting her head. The next day when CNA MM entered the R1 room, she hesitated because R1 had said that she had hurt her neck. She continued to state this so she had asked CNA NN to go into the room with her and told CNA NN to take care of the resident. She stated that she stood by the door while CNA NN completed tasks requested by R1. During an interview on 6/23/2025 at 3:19 pm CNA NN revealed, she entered R1's room with CNA MM and that when she asked CNA MM why she could not put on a bib. CNA MM had explained to her that R1 had accused her of choking her. During an interview on 6/24/2025 at 1:10 pm the Administrator revealed that she did not consider the incident (regarding the neck pillow) on 1/27/2025 as abuse. And that she reported the neck pillow incident on 1/28/2025 because the ombudsman stated that the resident had alleged abuse. She revealed that the facility policy does not state that the staff had to be sent home but only reassigned to another section.

Based on record review, interviews and review of the facility's policy titled Abuse Reporting , the facility failed to report an allegation of abuse to the State Survey Agency (SSA) within the required time frame for one of nine sampled Residents (R) (R1). Findings include: Review of the facility's undated policy titled Abuse Reporting revealed, under the Policy Statement that All personnel must promptly report an incident or suspected incident of resident abuse, including injuries of an unknown source and misappropriation of resident property. This includes the facility's identification of residents whose person histories render them at risk for abusing other residents. Under the Policy Interpretation and Implementation revealed, 3. When an alleged or suspected case of mistreatment, neglect, or abuse is reported, the facility Executive Director, or his/her designee, will notify the following persons or agencies of such incident: a. Office of Regulatory Services, Long Term Care Section, Compliance Coordinator. b. Resident Representative and/or responsible party c. Ombudsman Protective Services. d. Law Enforcement officials (as deemed appropriate). e. Attending physician. Review of the medical records revealed R1 was admitted with the following diagnoses that include but are not limited to emphysema, chronic pulmonary edema, chronic obstructive pulmonary disease, hemiplegia and hemiparesis following cerebra infarction, dementia, and hypertension. Review of the progress note dated 1/28/2025 which indicated a late entry for 1/27/2025 revealed R1 wanted her neck pillow adjusted. Licensed Practical Nurse (LPN) RR was called into the room and R1 stated that Certified Nursing Assistant (CNA) MM had shoved the pillow behind her head. Review of the (Named) law enforcement MISC INCIDENT REPORT dated 2/26/2025 revealed law enforcement was dispatched to the facility to take a complaint from R1 for simple assault. Review of the Facility Incident Report Form dated 1/28/2025 revealed that the incident occurred on 1/27/2025 and was reported on 1/28/2025 to the state agency. During an interview on 6/24/2025 at 11:27 am, the Director of Nursing (DON) revealed that she was responsible for state reportable. The DON revealed that on the 1/27/2025, it was initially reported to her as rough handling. She further revealed, the Ombudsman came the next day on 1/28/2025 and went to the Administrator to inform her that the incident on 1/27/2025 should be reported as abuse. During an interview on 6/24/2025 at 1:10 pm, the Administrator revealed that R1 had requested for law enforcement to make an assault charge.

Based on staff interview, record review, and review of the facility policy titled, Notice of Medicare Non-Coverage (NOMNC), the facility failed to correctly issue Medicare Part A beneficiaries completed form CMS (Centers for Medicare and Medicaid Services) 10123 Notice of Medicare Non-Coverage (NOMNC) and CMS-10055 Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) when the residents' completed therapy or skilled nursing services for three of three residents (Resident (R) 61, R130, and R394) reviewed for beneficiary notices. Findings include: Review of the facility's undated policy titled, Notice of Medicare Non-Coverage (NOMNC) stated, .The effective date your {insert type} services.Fill in the type of services ending, {home health, skilled nursing.} Insert the name and telephone numbers (including TTY) of the applicable. Review of the facility's undated policy titled, Financial Liability Notices stated, . SNFs must use the SNFABN when applicable for SNF Prospective Payment System services (Medicare Part A). SNFs will continue to use the ABN Form CMS-R-131 when applicable for Medicare Part B items and services. 1. Review of R61's undated Face Sheet located in the Census tab of the electronic medical record (EMR) revealed she was admitted on [DATE] for rehabilitation and remained in the facility for long-term care (LTC.) The Census tab also revealed the resident began a skilled Medicare A stay on 11/22/2023. Her last covered date (LCD) was 1/29/2024. Review of R61's NOMNC and SNFABN dated 1/30/2024, provided by the facility revealed R61 was issued a NOMNC that did not include the type of services that were ending, the date indicated for LCD was 1/30/2024, and did not include the TTY (teletypewriters) number, a special telecommunications equipment for the deaf or hard of hearing. The date indicated on the form for R61's LCD was the day her payor source would revert to Medicaid. The SNFABN issued by the facility was form CMS-R-131 a Medicare Part B notice. R61 had Medicare Part A days available and should have received form CMS-10055 for Medicare Part A services since she was remaining in the facility for LTC. 2. Review of R130's undated Face Sheet, located in the Census tab of the EMR revealed she was admitted to the facility on [DATE]. The Census tab also revealed the resident began receiving Medicare A skilled services on 9/06/2023 and her LCD was 10/17/2023. Review of R130's NOMNC and SNFABN dated 10/18/2023, provided by the facility revealed the NOMNC stated her services would end on 10/18/2023, did not include what services were ending, used the discharge date as the LCD, and did not include the TTY (teletypewriters) number a special telecommunications equipment for the deaf or hard of hearing. The date indicated on the form for R130's LCD was the day her payor source would revert to Medicaid. The SNFABN issued by the facility was form CMS-R-131a Medicare Part B notice. R130 had Medicare Part A days available and should have received form CMS-10055 for Medicare Part A services since she was remaining in the facility for LTC. 3. Review of R394's undated Face Sheet located in the Census tab of the EMR revealed he was admitted on [DATE] for rehabilitation services with a plan to return home. The Census tab also revealed the resident's LCD was 2/23/2024. Review of R394's NOMNC and SNFABN forms dated 2/24/2024, provided by the facility revealed the resident was issued a NOMNC stating his services would end on 2/24/2024, the services ending was not identified, and did not include the TTY number. The date entered was R394's actual discharge date from the facility. He was also issued a CMS-R-131 for Medicare Part B services. He should not have received one as he was being discharged from the facility. During an interview with Administrative Assistant (AA) 1 on 3/26/2024 at 3:05 PM revealed she thought she used the correct form for the SNFABN and did not realize the CMS-10055 and CMS-R-131 were different. She was not aware the TTY number was required to be on the NOMNC, the type of services ending, and that the LCD was the date required on page one not the discharge date .

Based on observation, staff interview, record review, and review of the facility policy titled, Medication Administration, the facility failed to ensure the interdisciplinary team had determined it was appropriate for a resident to self-administer medications for one of 32 sampled residents (Resident (R) 72). Specifically, the facility failed to ensure R72 did not have nystatin powder (a medication to treat yeast infection) on her bedside table unsecured. Findings include: Review of the facility' undated policy titled, Medication Administration revealed, under Procedural Guidelines number 2. Medications are administered in accordance with written orders of the attending physician. 3. Patients are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. Review of R72's undated Face Sheet located in the resident's electronic medical record (EMR) under the Census tab revealed R72 was admitted to the facility with diagnoses which included candidiasis (yeast infection). Review of R72's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/07/2024 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of five out 15 which indicated the resident was severely cognitively impaired. During an observation on 3/25/2024 at 10:56 AM, nystatin powder 100,000 unit/gm [grams] apply BID (twice a day) to affected areas for yeast was on R72's bedside table. During an observation and interview on 3/25/2024 at 11:18 AM, Licensed Practical Nurse (LPN)1 stated, We keep that on the med [medication] cart in the treatment box. The resident [R72] is not able to use this medication by herself. I may have left it [nystatin powder] in here [R72's room] by accident. Review of R72's medical record revealed no documented evidence R72 was determined to be safe in the self-administration of nystatin powder. During an interview on 3/26/2024 at 3:45 PM, the Director of Nursing (DON) confirmed R72 had not been determined to safely self-administer nystatin powder.

Based on record review, Staff interview, and review of the facility policy titled, Transfer/Discharge Policy, the facility failed to ensure the ombudsman was notified after residents were emergently transferred to the hospital for two of two residents reviewed for transfers (Resident (R) 70, and R124). This failure had the potential to affect the resident and/or their representative on their appeal rights if desired. Findings include: Review of the facility's policy titled, Transfer/Discharge Policy, dated 11/17/2017, revealed .Copies of emergency transfers must also still be sent to the ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis, as long as the list meets all requirements for content of such notices . 1. Review of R70's undated Face Sheet located in the resident's electronic medical record (EMR) under the Census tab revealed R70 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Review of R70's Nurses Notes, dated 1/27/2024, located in the resident's EMR under the Clinical Documentation tab revealed R70's daughter requested R70 to be transferred to the emergency room for continuation of cough despite treatment. R70 was admitted to an acute care hospital for pneumonia. Review of R70's EMR revealed no documented evidence that the ombudsman was notified of R70's transfer to the hospital. During an interview on 3/28/2024 at 12:31 PM, the Director of Social Services (DSS) stated, We [facility] have never notified the ombudsman when a resident goes out to the hospital. We only notify the ombudsman if it is an unsafe discharge. During an interview on 3/28/2024 at 1:30 PM, the Administrator stated, I [Administrator] was not aware that we were not notifying the ombudsman. 2. Review of R124's undated Face Sheet located in the resident's EMR under the Census tab revealed R124 was admitted to the facility on [DATE]. Review of R124's Nurses Notes, dated 2/24/2024, located in the resident's EMR under the Clinical Documentation tab revealed R124 was transferred to the hospital. Review of R124's EMR revealed no documented evidence that the Ombudsman was notified of R124's transfer to the hospital.

Based on staff interview, record review, and review of the facility policy titled, Bed-Hold Policy, the facility failed to ensure residents and/or their representative received a written bed hold notice after emergent transfers to the hospital for two of two residents reviewed for transfers (Resident (R) 70 and R124). This failure had the potential to contribute to possible denial of re-admission and loss of the resident's home following a hospitalization for residents transferred to the hospital. Findings include: Review of the facility's policy titled, Bed-Hold Policy, dated 11/17/2017 revealed, .The facility notifies the resident at the time of admission and again prior to a hospital transfer or therapeutic leave of its bed-hold and return policies . 1. Review of R70's undated Face Sheet located in the resident's electronic medical record (EMR) under the Census tab revealed R70 was admitted on [DATE] and readmitted to the facility on [DATE]. Review of R70's Nurses Notes, dated 1/27/2024, located in the resident's EMR under the Clinical Documentation tab revealed R70's daughter requested for R70 to be transferred to the emergency room for continuation of cough despite treatment. 2. Review of R124's undated Face Sheet located in the resident's EMR under the Census tab revealed R124 was admitted on [DATE] and readmitted to the facility on [DATE]. Review of R124's Nurses Notes, dated 2/24/2024, located in the resident's EMR under the Clinical Documentation tab revealed R124 was transferred to the hospital. During an interview on 3/28/2024 at 12:16 PM, the Administrator stated, They told me we weren't doing the notifications of bed holds since COVID. During an interview on 3/28/2024 at 12:17 PM, the Administrative Assistant (AA) 1 stated, We did bed holds in the past for Medicaid residents for when our beds were full. I just have not been instructed to do them once COVID occurred.

Based on observations, staff interview, and record review, the facility failed to implement a comprehensive care plan regarding the use of a hand roll and splint for one of 32 sampled residents (Resident (R) 72). This placed the resident at risk for unmet care needs. Findings include: Review of R72's undated Face Sheet located in the resident's electronic medical record (EMR) under the Census tab revealed R72 was admitted to the facility on [DATE] with diagnoses which included stroke, hemiplegia, and contracture of left wrist. Review of R72's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/07/2024 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of five out of score of 15 which indicated the resident was severely cognitively impaired. Review of R72's Plan of Care [comprehensive care plan] located in the resident's EMR under the Clinical Documentation tab revealed, .Apply splints/braces per MD [medical doctor] orders . Observations were made on 3/25/2024 at 10:56 AM, 3/26/2024 at 2:35 PM, 3/27/2024 at 8:49 AM, 1:53 PM, and 4:02 PM. During these observations, there were no left-hand roll or splints observed to have been applied to R72. During an interview on 3/28/2024 at 10:22 AM, Certified Nursing Assistant (CNA) 2, stated, I didn't know that she needed a hand roll or splint. I last worked with her [R72] two weeks ago and I didn't know it then either.

Based on observation, staff interviews, record review, and review of the facility's policy titled, Oxygen Administration, the facility failed to clean respiratory equipment for two of two sampled residents reviewed for respiratory care (Residents (R) 115 and R83). Findings include: Review of the facility's undated policy titled, Oxygen Administration, revealed, under Intent: It is our intent to provide oxygen safely and accurately to appropriate patients/residents. Under Infection Control Policy of O2 (Oxygen) Humidifier Bottles number 6. The external black filter should be washed with soap and water once each week and PRN (as needed). Dry with towel and reinsert. Do not discard unless it is damaged. 1. Review of R115's undated Face Sheet located in R115's electronic medical record (EMR) under the Census tab revealed R115 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD) and chronic respiratory failure. Review of R115's Physician Order, dated 4/20/2023, located in the resident's EMR under the Orders & Results tab revealed continuous O2 [oxygen] at 3 lpm (liters per minute) via nasal cannula. Review of R115's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 12/20/2023 and located in the resident's EMR under the MDS tab revealed, the facility assessed R115 to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R115 was cognitively intact. The MDS documented R115 was receiving oxygen therapy. Observation on 3/25/2024 at 2:15 PM revealed R115's oxygen concentrator was located next to her bed. The oxygen concentrator had a dirty air intake filter. During an observation and interview on 3/27/2024 at 3:45 PM, Licensed Practical Nurse (LPN) 3 confirmed R115's concentrator air intake filter was dirty, and that the resident's nasal cannula was unbagged and lying on top of the oxygen concentrator. LPN3 stated, The nasal cannula should be in a bag and not just on top of the concentrator. The intake filter is dirty and needs to be cleaned. 2. Review of R83's undated Face Sheet, located in R83's EMR under the Census tab revealed R83 was admitted to the facility on [DATE] with diagnosis which included chronic obstructive pulmonary disease (COPD) and emphysema. Review of R83's Physician Order, dated 12/13/2023, located in the resident's EMR under the Orders & Results tab revealed continuous O2 [oxygen] at 3 lpm via nasal cannula. Review of R83's quarterly MDS, with an ARD of 3/09/2024 and located in the resident's EMR under the MDS tab revealed the facility assessed R83 to have a BIMS score of 15 out of 15 which indicated R83 was cognitively intact. The MDS documented R83 was receiving oxygen therapy. Observation on 3/25/2024 at 10:57 AM revealed R83's concentrator to have a dirty air intake filter. During an observation and interview on 3/27/2024 at 3:50 PM, LPN3 confirmed R83's concentrator air intake filter was dirty. The LPN stated, The intake filter is dirty and needs to be cleaned.

Based on observations, staff interviews, record review, and review of the facility policies titled, Maintaining Patency of a feeding Tube (Flushing) and Medication Administration-General Guidelines, the facility failed to ensure the medication error rate was less than five percent for two of five residents (Resident (R) 93 and R133) resulting from three errors out of 26 opportunities for a medication error rate of 11.54 percent. Findings include: Review of the facility's undated policy titled, Maintaining Patency of a feeding Tube (Flushing), revealed under General Guidelines number 3. Flush enteral feeding tubes with 15 ml [milliliters], or prescribed amount, of warm water before and after administration of medications. If administering more than one medication, flush with 15 ml, or prescribed amount, of warm water between each medication. Review of facility's policy titled, Medication Administration-General Guidelines, dated October 2017, revealed under Procedural Geuidelines: number 2. Medications are administered in accordance with written orders of the attending physician. 1. Review of R93's undated Face Sheet located in the resident's electronic medical record (EMR) under the Census tab, revealed R93 was admitted to the facility on [DATE] with diagnoses which included hypertension. Observation on 3/27/2024 at 8:40 AM of medication administration with Licensed Practical Nurse (LPN) 5 revealed the LPN obtained R93's blood pressure which was 126/58. The LPN stated, His [R93's] blood pressure med [medicine] will be held due to his [R93] low blood pressure. As LPN5 was preparing the medication to be administrated to R93, the medication label documented the lisinopril [blood pressure medicine]/hctz [hydrochlorothiazide which is a diuretic] 20-25 mg (milligrams) po (by mouth) daily. There were no parameters noted on the medication label. Continued observation revealed LPN5 did not administer this medication to R93. Review of the Medication Orders under the Clinical Documentation tab located in the EMR, revealed lisinopril/hctz 20-25 mg (milligrams) po (by mouth) daily with a start date of 12/30/2023. Review of the Medication Administration Record (MAR), dated March 2024, under the Clinical Documentation tab located in the EMR, revealed a N which represented the medication, lisinopril/hctz was not administrated on 3/27/2024 at 8:00 AM. During an interview on 3/27/2024 at 11:15 AM, the Director of Nursing (DON) confirmed there were no parameters ordered by the physician in regard to holding this blood pressure medication. During an interview on 3/27/2024 at 2:16 PM, LPN5 stated, After the DON spoke to you, she instructed me [LPN5] to call the doctor and notify him [doctor] that I held the blood pressure medication .Whenever the nurse holds a medication, they are to notify the doctor as soon as they can. Typically, I [would notify the doctor as soon as I had time to make the call. 2. Review of R133's undated Face Sheet located in the resident's EMR under the Census tab, revealed R133 was admitted to the facility with diagnoses which included hypertension, stroke, and Parkinson's disease. Observation on 3/27/2024 at 2:00 PM of medication administration with LPN5 revealed the LPN obtained R133's blood pressure which was 147/84. The LPN prepared Sinemet (medication used to treat symptoms of Parkinson's disease) 25-100 mg [milligrams] take one tablet via [by] peg [percutaneous endoscopic gastrostomy] three times a day, and hydralazine (used to treat high blood pressure) 25 mg take one tablet via peg three times a day. Continued observation revealed LPN5 crushed the two tablets together, administrated the medications, and then flushed the resident's peg tube with 50 milliliters of warm water by R133's peg tube. Review of the Medication Orders under the Clinical Documentation tab located in the EMR, revealed orders for Sinemet 25-100 mg (milligrams) take one tablet via (by) peg tube three times a day and hydralazine 25 mg take one tablet via peg tube three times a day. Review of the MAR, dated March 2024, under the Clinical Documentation tab located in the EMR, revealed G which represented the medications Sinemet, and hydralazine was administrated on 3/27/2024 at 2:00 PM. During an interview on 3/27/2024 at 2:13 PM, when asked how R133's two medications were to be administered via the resident's peg tube, LPN5 stated, I really don't know. During an interview on 3/27/2024 at 4:08 PM, the DON stated, The med [medicines] are to be administrated one at a time and the nurse is to flush the peg tube before and after each medication that is given.

Based on observation, staff interview, and review of the facility policy titled, Standard Precautions, the facility failed to ensure proper contact time after cleaning the glucose meter for one of 32 sampled residents (Resident (R) 67). Findings include: Review of the facility's undated policy titled, Standard Precautions revealed, under observations: number 10. Small non-disposable equipment such as glucose meter [glucometers], scissors, and thermometers (V/S [vital sign] machines) are cleaned and appropriately disinfected after each use for individual resident care. Under observation during point of care includes but not limited to 1. Glucose meters are to be cleaned after each use with hydrogen peroxide wipes. Review of the undated CloroxPro product catalog located at https://www.cloroxpro.com/products, revealed Clorox Hydrogen Peroxide healthcare wipes had a contact time of one minute. Observation on 3/28/2024 at 11:32 AM revealed Registered Nurse (RN) 1 obtained a fingerstick blood glucose on R67 by using the blood glucose strip that was placed into the glucometer to measure the reading of the blood glucose. After the glucometer was used on R67, RN1 cleaned the glucometer with a hydrogen peroxide wipe and then immediately placed the glucometer in the medication cart drawer used for storing the glucometer. During an interview on 3/28/2024 at 11:43 AM, when asked if she had waited for the glucometer to dry before putting it away, RN1 stated, No, I cleaned it and then put it away. During an interview on 3/28/2024 at 4:05 PM, Licensed Practical Nurse Quality Assurance (QA) 1 stated, The dry time for the hydrogen peroxide wipe is one minute.

Based on observation and staff interview, the facility failed to ensure daily staffing information was accurately completed, and readily available in a readable format to residents and visitors. Findings include: Review of the facility's untitled daily staffing documents dated 11/21/2023 through 11/26/2023, and 1/22/2024 through 1/27/2024, provided by the facility revealed the daily staffing documents were missing the total hours worked by Certified Nursing Assistants (CNAs), Licensed Practical Nurses (LPNs), and Registered Nurses (RNs). Observations on 3/25/2024 at 10:40 AM, 3/26/2024 at 1:30 PM, and on 3/27/2024 at 1:00 PM of the staff posting which was posted on the bulletin board on the G/H hallways revealed the postings failed to include the staffing hours. Observations on 3/25/2024 at 11:00 AM, 3/26/2024 at 1:45 PM, and 3/27/2024 at 12:10 PM, of the staff posting which was posted on the whiteboard in the lounge revealed the postings failed to include the staffing hours. During an interview on 3/28/2024 at 12:35 PM, the Nursing Scheduler (NS) 1 stated, The Staff postings are posted every morning in seven locations in the facility (one per unit) and one in the lounge. The postings contain the number of each member of staff working but does not contain the hours worked. During an interview on 3/28/2024 at 2:00 PM, the Administrator stated, We do not have a policy for the posting of staffing information.

Based on observations, staff interviews and review of the Maintenance Director's Job Description, the facility failed to ensure resident's furniture was in good and functional condition related peeling wallpaper in one bathroom (Room 95), missing drawer handles, broken drawer handles, loose drawer handles, and broken drawers that would not open on one of six units observed. Findings include: Review of the Property Management Director Job Description dated revised 5/2008, revealed: 6. Administers and implements the preventive maintenance program to ensure uninterrupted operation of the entire facility. Monitors its applications to assure maximum effectiveness and provides appropriate documentation of this program. 7. Coordinates the repair of equipment and/or recommends the replacement of, additions to, equipment or physical plant as necessary. Room observations held on 7/12/22 at 9:00 a.m. and 7/13/22 at 11:00 a.m. on the facility E hall revealed: 1. In Room 95 revealed peeling wallpaper on wall in bathroom, strong urine odor present. Room concerns included dark brown dresser missing one (1) handle and 1 handle was loose, light brown dresser had two (2) missing handles. 2. In Room 97 B bed dresser was missing 1 handle. 3. In Room 101 B bed dresser drawers were broken and was unable to open. 4. In Room 102 A and B bed dressers were missing handles. 5. In Room 103 A bed dresser had missing and loose handles. 6. In Room 104 B bed had broken and was unable to open and missing handles. Observation rounds and interviews held on 7/13/22 at 11:55 a.m. with the facility Maintenance Director and Assistant Director of Nursing (ADON) revealed concerns that were identified on the 7/12/22 and 7/13/22 related to peeling wallpaper, missing handles on dressers, loose dresser handles, and broken dresser drawers. The Maintenance Director made a list of dressers that need to be fixed and indicated he would put in a maintenance order. He indicated anytime something needed to be fixed it needed to be reported. During an interview on 7/14/22 at 8:50 a.m. with the Administrator it was revealed she had been made aware of the problem with the broken dressers and the dressers with missing handles. The Administrator reported that she would expect staff to report items that need to be fixed. She indicated the facility does not have a policy to address furniture that is not in good repair. She further indicated the facility will be totally renovated next year but did not have a specific time when this would take place.

Based on observations, staff interviews and review of the facility policy titled, Environmental Cleaning and Disinfection the facility failed to store patient care equipment (wash basins, bed pans, and urinals) in a sanitary manner in the residents' bathrooms, to prevent the spread of infection on one of six units observed. Finding include: Review of the facility policy titled Environmental Cleaning and Disinfection not dated revealed: 16. g. An appropriate disinfectant that is registered with the EPA .is being used. Disinfectants used for cleaning after each use, known contamination includes bed pans, washbasins, urinals, or any other care item used for direct resident care. Items after cleaning should be placed in the bedside stand or shelf in the closet. Room observations held on 7/12/11 at 9:00 a.m. and 7/13/2022 at 11 a.m. on the facility E hall revealed the following in the shared bathrooms: 1. In room [ROOM NUMBER] bathroom there were two washbasins on the covered tub area that were not labeled or covered. 2. In room [ROOM NUMBER] bathroom there was one washbasin and one urinal on the covered tub area that were not labeled or covered. 3. In room [ROOM NUMBER] bathroom there were four washbasins and one bed pan on covered tub area that were not labeled or covered. 4. In room [ROOM NUMBER] bathroom there were three washbasins and one urinal on covered tub area that were not labeled or covered. 5. In room [ROOM NUMBER] bathroom there were two washbasins on covered tub area that were not labeled or covered. 6. In room [ROOM NUMBER] bathroom there were two washbasins on covered tub area that were not labeled or covered. 7. In room [ROOM NUMBER] bathroom there was one washbasin on covered tub area that was not labeled or covered. 8. In room [ROOM NUMBER] bathroom there were three washbasins on covered tub area that were not labeled or covered. 9. In room [ROOM NUMBER] bathroom there was one washbasin on covered tub area that was not labeled or covered. 10. In room [ROOM NUMBER] bathroom there was one washbasin on covered tub area that was not labeled or covered. Observation rounds and interviews held on 7/13/22 at 11:55 a.m. with the facility Maintenance Director and Assistant Director of Nursing (ADON) who confirmed concerns that were identified on the 7/12/22 and 7/13/22 related to storage of bed pans, wash basins, and urinals. The ADON verified the bedpans, washbasins and urinals were not stored correctly and could cause an infection control problem. An interview held on 7/14/22 at 8:50 a.m. with the Administrator who revealed she was made aware of the problem with the storage of the wash basins, bed pans, and urinals. The Administrator reported that bed pans, wash basins, and urinals should be stored correctly.

Based on record review and staff interviews the facility failed to follow the care plan for two of 6 sampled residents (R#1 and R#6) regarding notifying Physician of changes in skin condition for R#1 and following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: 1. Review of the Resident Information form revealed R#1 was admitted to the facility on [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) for R#1 dated 5/22/2021 revealed Section C-Cognition: Brief Interview of Mental Status (BIMS) score of 05 indicating severe impairment to cognition; Section G-Functional status: resident required supervision with dressing, eating, toileting, bed mobility, transfers, locomotion, personal hygiene, and bathing; Section M-Skin: Resident reviewed for other problems, open lesion, ulcer, rashes, cuts, cancer lesion was marked as none of the above was present. Review of the plan of care dated 6/15/17 revealed that R#1 had a pressure ulcer/alteration in skin integrity actual or potential related to history of [CONDITION(S)] on arms; history of impetigo; the right eye and right/left ear squamous cell skin cancer. The right ear cancer (growth). Goals included maintain skin integrity with a target date of 8/22/2021 and continue to monitor right ear cancer/report changes to hospice/MD as needed with a target date of 8/31/2021. There were interventions that included but limited to if a wound occurs, the wound care nurse was to assess/record/ report to Physician as needed for skin conditions and the presence of any new areas; body audits per protocol; monitor skin for increase of [CONDITION(S)] or infection; if a wound occurs, monitor for signs and symptoms of infection to wound such as redness, swelling elevated temperature, purulent drainage, odor, and notify MD as indicated. Review of Complete Interdisciplinary Notes timed 7:10 and dated 7/14/2021 revealed R#1 had copious amounts of blood on pillow and the right ear was cleaned with normal saline, patted dry, applied gauze sponge and then applied roll gauze around head and ear. There was no indication that the Physician was made aware of this. 2. Review of the Resident Information form revealed Resident #6 was admitted to the facility on [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the plan of care initially dated 10/25/2013 revealed that Resident #6 had a skin integrity/pressure ulcer actual or potential related to decrease in activities of daily lying (ADL) abilities and decrease mobility. The care plan was updated on 6/7/2021 to reflect a diabetic ulcer to the right great toe. The care plan had interventions that included body audits per protocol, and a treatment order for the right great toe diabetic ulcer. The treatment order for the great right toe was noted as discontinued on 7/13/2021. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Complete Interdisciplinary Notes (Nursing Notes) with an entry dated 6/30/21 revealed that the dorsal right hallux (great big toe) was healing, and no open wound. The right hallux dressing was continued for two weeks. An observation on 7/22/2021 at 2:36 p.m. of R #6 lying in bed. He had a dressing on his right great toe that was dated 7/19 at 12 noon. During an interview on 7/23/2021 at 1:36 p.m. with the Registered Nurse (RN) Minimum Data Set (MDS) Coordinator VV revealed that she was aware of the dressing to the right great toe, and she had gone to R#6's room and removed the dressing dated 7/19/2021 at 12 noon. She stated that when she looked on the care plan, she saw that she had discontinued the dressing on 7/13/2021. During an interview on 7/28/2021 at 10:57 a.m. with LPN FF wound care nurse revealed that she was not aware that doctor had an end date of 7/13/2021 for the treatment to the right great toe and she had placed a dressing on R#6's right great toe on 7/19/2021. Cross refer F684

Based on observations, record reviews and staff interviews, it was determined that the facility failed to ensure that two residents (#8 and #17) did not experience a decline in function with activities of daily living (ADLs), from a total sample of 27 residents. Findings include: 1. Resident #8 had [DIAGNOSES REDACTED]. On the the 9/23/10 quarterly Minimum Data Set (MDS) assessment, licensed nursing staff coded the resident as needing limited assistance of one person for bed mobility and ambulation. Nursing staff documented in the Monthly Summaries dated 2/7/11 and 1/3/11 that at times the resident was able to take a few steps with assistance. According to the 2/9/11 nurses' notes, the resident was transferred to another unit. During the initial tour of the facility on 3/28/11 at 10:45 a.m., licensed nurse "AA" stated that the resident was non-ambulatory and was restrained with a lap buddy when seated in the wheelchair. "AA" explained that the lap buddy was used because of the resident's history of trying to get out of the chair without assistance. A review of the medical record revealed that a lap tray or lap buddy restraint had been used since July 2010 while the resident was seated in the wheelchair. During an interview on 3/29/11 at 9:50 a.m., the restorative certified nursing assistant (RCNA) stated that the resident had not been seen by the restorative nursing program (RNP). On 3/29/11 at 1:20 p.m., certified nursing assistant (CNA) "DD" stated that the resident was unable to ambulate, and two people were required to safely transfer the resident. On 3/29/11 at 3:30 p.m., licensed nurse "EE" stated that the resident had not walked since being transferred to that unit about one month ago. On the 3/17/11 quarterly MDS assessment, licensed nursing staff coded the resident to have had a decline in his/her activities of daily living (ADL) of needing extensive staff assistance with bed mobility and as having been non-ambulatory. During an observation of two CNAs transferring the resident from the bed to the wheelchair and back to the bed on 3/29/11 at 3:00 p.m., he/she was unable to completely straighten his/her knees in order to obtain a balanced, upright standing position. Despite the resident's decline in ambulation, review of the medical record did not reveal any evidence that staff had developed or implemented any interventions to address the resident's identified functional decline. On 3/30/11 at 12:50 p.m., the Director of Nursing stated that the resident had not walked since moving to that unit because of not being familiar with the staff and staff not being familiar with the resident. 2. Resident #17 had [DIAGNOSES REDACTED]. A review of the nurse's notes revealed that resident #17 had been restrained with a table top or lap tray device since at least September 2010 because of a history of falls. On the 10/2/10 annual MDS for the comprehensive assessment, licensed nursing staff coded resident #17 as requiring limited assistance with bed mobility, transfers, ambulation, hygiene and dressing, and extensive assistance with locomotion. During the initial tour of the facility on 3/28/11 at 10:30 a.m., licensed nurse "AA" stated that resident #17 was non-ambulatory and required the assistance of two persons to perform a pivot transfer. On the 11/3/10 physical therapy discharge note, the physical therapist (PT) documented that resident #17 was ambulating 75 feet with hand held assistance. The PT documented that the resident would be followed by the RNP for continued exercises and ambulation. However, a review of the clinical record revealed no evidence that the facility had provided the RNP for that resident. During an interview on 3/30/11 at 9:50 a.m., the Restorative (Nursing Program) CNA stated that the resident was not being provided restorative nursing services and had not ever been on the RNP caseload. On the 12/16/10 quarterly MDS assessment, licensed nursing staff coded the resident as having had a decline in ADLs, requiring extensive assistance with bed mobility, transfers, dressing and hygiene, was dependent with locomotion and was non-ambulatory. On 3/30/11 at 10:00 a.m., licensed nurse "BB" stated that the resident was non-ambulatory. Licensed nurse "BB" stated that the resident had been able to stand in the past but could not stand now. On 3/30/11 at 10:15 a.m., CNA "CC" stated that the resident was non-ambulatory. Despite the resident's decline in ADLs as coded on the 12/16/10 MDS, licensed nursing staff failed to thoroughly evaluate his/her decline or to develop any interventions to improve his/her functional status. During an observation of two CNAs transferring the resident from a sit to stand position on 3/30/11 at 1:30 p.m., he/she was not able to spread his/her feet apart without the physical assistance of one CNA. The resident pushed all of his/her weight to the right side and did not have any weight placed on his/her left leg. He/She was not able to completely straighten his/her knees for a balanced, upright standing position.

Based on record review, it was determined that the facility failed to provide appropriate interventions to prevent further falls for one (#4) of six residents with falls from a total sample of 27 residents. This failure resulted in actual harm for resident #4. Findings include: Resident #4 had care plan interventions since 9/17/10 to address his/her memory loss, impaired decision making skills and risk of falling. Licensed nursing staff had reviewed the care plan to address his/her problem of falling after each of the resident's falls. According to nursing staff's documentation, the resident fell on [DATE], 10/4, 10/21,11/26,1/27/11, 1/30, 1/31, 2/17, 3/18, and 3/27/11. The nurses notes indicated that the resident fell between 6:30 p.m. and 8:35 p.m. on 1/4/10, 10/21/10, 1/27/11, 1/30/11 and 2/17/11 and between 10:30 p.m. and 1:20 a.m. on 9/23/10, 11/26/10 and 1/20/11. Although seven of the nine falls were during the evening or night hours, there was no evidence the facility had evaluated specific factors which may have contributed to or caused those seven falls or the effectiveness of care plan interventions to prevent his/her falls. The facility had not developed effective individualized care plan interventions to prevent his/her falling. After the fall on 10/4/10, staff documented that the resident's chair in his/her room was replaced to prevent possible further falls out of the chair. After the fall on 10/21/10, staff documented that Speech Therapy provided services for safety orientation from 10/26/10 through 11/22/10 because of the resident's memory loss and the recent falls. The resident was discharged from speech therapy services on 11/22/10. The resident continued to fall. Nursing staff noted that the resident had sustained a hematoma to the right side of his/her head as a result of the fall on 1/31/11. Nursing staff documented that the resident also sustained a hematoma to the right side of his/her head as a result of the fall on 3/27/11. Nursing staff documented on the resident's care plan after each fall (9/23/10, 10/4/10, 10/21/10, 11/26/10, 1/27/11, 1/31/11, 2/17/11 and 3/18/11) that the resident was reminded to use his/her walker and the call light. However, those interventions required responses of which the resident was not capable based on the facility's assessment of his/her impaired memory and decision making skills. There were not any revisions or more effective interventions implemented between 10/21/10 and 10/25/10 or from 11/22/10 until after the resident sustained [REDACTED]. After the resident's fall on 3/27/11, the facility staff requested that the resident be screened for rehabilitative services. Physical therapy services completed a therapy screen on 3/29/2011 and documented that an evaluation was indicated.

Based on record review, staff interview, and hospital document review, it was determined that the facility failed to ensure that adequate supervision was provided to prevent injury during a wheelchair-to-bed transfer for one (1) resident (#1) from a survey sample of five (5) residents. This failure resulted in harm by causing a large laceration on the right lower leg of Resident #1. Findings include: Record review for Resident #1 revealed a 03/05/2009 intervention on the plan of care to prevent falls which specified for the resident to be transferred with the assistance of two (2) persons. However, a 05/21/2009, 1:45 p.m. nursing note documented that the resident was assisted to bed from the wheelchair by only one (1) certified nursing assistant (CNA). When the resident had been put to bed, the CNA noted blood on the resident's right pants' leg. The CNA notified the charge nurse, who assessed the resident's right lower leg and documented a large laceration to the back of the leg which extended from the mid-calf of the outer leg down to the ankle area. Documentation indicated that the physician was immediately notified and that the resident was immediately transferred to the hospital. Hospital documentation indicated that the hospital physician described the wounded area as a 30 centimeter (cm.) to 35 cm. curved laceration, down to the fascia. During interviews with the DON and Administrator conducted on 06/02/2009 at 4:30 p.m., these staff members both acknowledged that the laceration on the resident's right lower leg had occurred during the 05/21/2009 transfer when the CNA had failed to use a two-person transfer, per the resident's plan of care. Cross refer to F323 for more information regarding Resident #1.

Based on record review, staff interview, and hospital document review, it was determined that the facility failed to ensure that adequate supervision was provided to prevent injury during a chair-to-bed transfer for one (1) resident (#1) from a survey sample of five (5) residents. This failure resulted in harm by causing a large laceration on the right lower leg of Resident #1. Findings include: Record review for Resident #1 revealed that a new intervention had been added to his/her plan of care to prevent falls on 03/05/2009. This intervention specified for the resident to be transferred with the assistance of two persons. According to the 05/21/2009, 1:45 p.m. nursing notes, the resident was being assisted to bed from the wheelchair by only one (1) certified nursing assistant (CNA). During the transfer, the resident exhibited agitation as he/she was being transferred to the bed from the wheelchair. When the resident had been put to bed, the CNA noted blood on the resident's right pant's leg and immediately reported this to the charge nurse. The charge nurse went to check the resident's right lower leg and found a large laceration to the back of the right leg. The nurse documented that the laceration extended from the mid-calf of the outer leg down to the ankle area. The Unit Manager for this unit and the Director of Nursing (DON) were immediately notified of the area of laceration on the resident's right lower leg. The wound was cleaned with normal saline, and Steri-Strips and a pressure bandage were applied. Documentation indicated that the physician and the family were immediately notified, and that the resident was immediately transferred to the hospital for repair of the laceration. Hospital documentation indicated that the hospital physician described the wounded area as a 30 centimeter (cm.) to 35 cm. curved laceration, down to the fascia. During interviews with the DON and Administrator conducted on 06/02/2009 at 4:30 p.m., these staff members both acknowledged that the above incident had occurred on 05/21/2009, and that their investigation of the incident had revealed that the laceration on the resident's right lower leg had occurred during the transfer. They also acknowledged that the CNA involved in this incident had failed to use a two-person transfer per the resident's plan of care, thus resulting in the large laceration on the back of the resident's right leg.