Every finding on record at Lynn Haven Health and Rehabilitation

Based on observations, staff interviews, and record review, the facility failed to ensure oxygen circuits were properly stored for two of 23 residents (R) (R1 and R26) on respiratory care. This deficient practice had the potential to place R1 and R26 at increased risk of respiratory infection. Findings include:1. Review of the admission Minimum Data Set (MDS) for R1, dated 8/27/2025, revealed Section I (Active Diagnoses) documented diagnoses included, but were not limited to, pneumonia. Section O (Special Treatments, Procedures, and Programs) documented that the resident received oxygen. Review of the physician's orders for R1 revealed an order dated 8/22/2025 for oxygen at two liters per minute via nasal cannula every eight hours for pneumonia. Further review revealed an order dated 8/21/2205 for albuterol sulfate 2.5 milligrams (mg)/3 milliliters (ml) solution for Observations on 9/23/2025 at 11:54 am, 9/24/2025 at 2:05 pm, and 9/25/2025 at 10:31 am in R1's room revealed an incentive spirometer on the dresser, uncovered and not in use.In an interview on 9/25/2025 at 11:42 am, Registered Nurse (RN) KK stated she had not noticed the uncovered incentive spirometer during rounds and confirmed it should have been covered. She further stated the negative outcome of leaving it exposed was the potential for bacterial buildup, which could lead to infection when used.2. Review of the Quarterly MDS for R26, dated 8/13/2025, revealed Section I (Active Diagnoses) documented diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD).Review of the physician's orders for R26 revealed an order dated 5/9/2025 for albuterol sulfate 0.63 mg/3 ml solution one vial via nebulizer every six hours as needed for shortness of breath or wheezing.Observations on 9/23/2025 at 11:14 am, 9/24/2025 at 2:08 pm, and 9/25/2025 at 10:23 am in R26's room revealed a nebulizer mouthpiece on the dresser, uncovered with visible debris present.In an interview on 9/25/2025 at 11:47 am, RN KK revealed that during her morning rounds, she checked respiratory equipment and ensured it was bagged when not in use. She confirmed the nebulizer should have been covered and acknowledged the negative outcome could be inhaling particles and increased infection risk.In an interview on 9/25/2025 at 12:00 pm, the Director of Nursing (DON) revealed that incentive spirometers and nebulizers were expected to be bagged when not in use. The DON stated that staff were expected to check respiratory equipment during rounds to ensure compliance. She stated that a negative outcome of leaving equipment uncovered was an infection risk.An interview on 9/25/2025 at 12:54 pm with the Administrator confirmed his expectation that incentive spirometers and nebulizers should be covered when not in use. He stated that a negative outcome of failure to do so could be an infection risk.

Based on observations, staff interviews, record review and review of facility's policy titled, Medication Administration- General, The facility failed to ensure that three out of four residents (R) R12, R25 and R39 were free of medication error rate above 5% or greater. This failure had the potential of putting all residents in the facility at risk of receiving wrong or no medication which could potentially have life threatening consequences. The facility census was 65.Findings include:A review of the facility's policy titled, Medication Administration- General, reviewed 4/15/2025 under topic, Guideline, revealed that, Medications are administered in accordance with a valid prescriber order. If a medication order seems to be unrelated to the patient's current diagnoses or condition(s), the prescriber is contacted for clarification prior to administration of the medication. This interaction with the prescriber is documented in the nursing notes or elsewhere in the medical record as appropriate. Prior to medication administration the Nurse or Certified Medication Aid (CMA): Reads the administration directions on the MAR and verifies correct medication, dose and directions for use. During an observation of medication pass on 9/24/2025 at 8:30 am with CMA AA revealed her administering medications to R12 was administered Fluticasone/salmeterol 50 mcg one puff and Tiotropium Bromide 18mcg one puff. A record review of R12 physician orders revealed tiotropium bromide 18 mcg capsule with inhalation device (tiotropium bromide) 2 Puffs Inhalation 1 time per day. Interview on 9/24/2025 at 8:54 am with CMA AA revealed her stating that she usually puffs only once because she says it makes her shaky. CMA AA stated that she has been in the facility for 3.5 years and usually works on wing 1 but works on wing 2 on my pickup days. She confirms that R12 was to receive two inhalations of the medication. She stated that if she hadn't disposed of the used pill (powder) she would have gone back to give that second puff. CMA stated that in this situation she would go and ask the nurse what to do. During a medication pass observation on 9/24/2025 at 9:03 am with CMA BB revealed her administering medications to R39. CMA BB administered acetaminophen 325mg 2 tablets (tabs), aspirin 81mg 1tab chewable, certavite 1tab, preservision 1capsule (cap), atenolol 50mg 1tab, escitalopram 20mg 1tab and vit D3 1tab. During a review of R39 physician orders on 9/24/2025 at 9:20 am revealed that calcium carbonate 500 mg-vitamin D3 10 mcg (400 unit) chewable tablet 1 tablet by mouth 1 time per day was not administered. During an interview on 9/24/2025 at 9:30 am with CMA BB revealed her stating that the medication was administered. She stated that the medication came prepackaged along with other medications from the pharmacy and that she had discarded the package and was unable to present it when requested. During a medication pass observation on 9/24/2025 at 9:03 am with CMA BB revealed her administering medications to R25. CMA BB administered calcium 600mg 1tab, docusate sodium 100mg 1tab, loratadine 10mg 1tab, divalproex sprinkles 125mg 1cap, preservision 1tab, paroxetine 20mg 1tab, propranolol Hydrochloride (HCL) 20mg 1tab, quetiapine 25mg 1tab and liquacel 16/2.5grams 30ml in 4oz water. During a review of R25 medications on 9/24/2025 at 9:45 am revealed Systane complete 0.6 % eye drops (propylene glycol) 1 drops instill in both eyes 2 times per day and multiple vitamin-minerals tablet 1 tablet by mouth 1 time per day was not administered. Instead, CMA BB administered liquacel 16/2.5grams 30ml in 4oz water which was not listed in R25 medication orders. During an interview on 9/24/2025 at 9:50 am with CMA BB revealed her stating that Systane complete 0.6 % eye drops were not in the medication cart and she would have to inform the nurse for direction. CMA BB also stated that she administered the liquacel instead of the multiple vitamin-minerals tablet 1 tablet because R25 received her medications crushed and the liquid is easier for her to swallow. During an interview on 9/24/2025 at 11:21 am with Licensed Practical Nurse (LPN) II revealed that she will contact the pharmacy to reorder the missing medications and the Nurse Practitioner regarding all three residents. She stated that whenever the CMAs have a medication issue that they are to notify her immediately for assistance. LPN II stated that she will also contact the pharmacy for the list of prepackaged medications for R39. During an interview on 9/24/2025 at 11:40 am with Nurse Practitioner (NP) JJ revealed that she recently added calcium to R39 medications following blood work that indicated low levels of calcium. She stated that R39 was already on Vitamin D3 and therefore added calcium carbonate 500 mg-vitamin D3 10 mcg (400 unit) chewable tablet 1 tablet by mouth 1 time per day. NP JJ further stated that calcium carbonate 500 mg-vitamin D3 10 mcg (400 unit) is a different medication from the Vitamin D3 and that R39 requires both medications. During another interview on 9/24/2025 at 2:30 pm with LPN II revealed that the list of prepackaged medications sent by the pharmacy was regarding R39 and that calcium carbonate 500 mg-vitamin D3 10 mcg (400 unit) chewable tablet 1 tablet by mouth, 1 time per day was not on the list. LPN II confirmed that the medication was not a prepackaged medication and admitted to checking the list and the medication cart minutes before to verify that it was correct. She admitted that the list was correct and that the medication was instead a floor stock medication that should have been administered by CMS BB. During a telephone interview on 9/24/2025 at 2:50 pm with Certified Pharmacy Tech (CPT) HH revealed that she confirmed sending the list to the facility. CPT HH admitted to sending the list of prepackaged medications to the facility at the request of LPN II. She confirmed that the list is correct and that all prepackaged medications are delivered to the facility on Wednesdays to be used starting on Fridays and that the last package should end on Thursday night. CPT HH also stated that the facility should have an additional package of medication for R39 for tomorrow's use. She also stated that calcium carbonate 500 mg-vitamin D3 10 mcg (400 unit) chewable tablet is listed in her system as a facility floor stock medication and confirmed that it is not one of the prepackaged medications sent by the pharmacy. During an interview on 9/24/2025 with the Director of Nursing (DON) revealed that she conducts spot checks and gets on the cart with the CMA and watch them do medication pass and documents results at least every three months. DON stated that all CMAs are aware that they should report all medications issues to the charge nurse. She also stated that she conducts an annual skills training with all CMAs, and the results are documented in their records. DON stated that if the CMA fails any training, then she is re-educated. DoneDB

Based on observations, staff interviews, and review of the facility's policies titled Hand Hygiene and Meal Service, the facility failed to ensure infection control practices were followed during a meal in the dining room. This deficient practice had the potential to place the residents at risk of infection due to cross-contamination. The census was 65. Findings include:A review of the facility's policy titled Hand Hygiene, reviewed 12/27/2024, revealed the Purpose section included, Hand hygiene is the single most important means of preventing the spread of infection. The use of gloves does not replace hand washing. The Guideline section included, Gloves should not be used as a substitute for hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment. Perform hand hygiene immediately after removing gloves. A review of the facility's policy titled Meal Service, reviewed 12/27/2024, revealed the Guideline section included, Meals should be served under sanitary conditions. Associates will follow safe food handling techniques. Associates should wash hands before starting tray distribution. Associates should wash hands and change gloves between task and between patient contact. Observation on 9/23/2025 at 11:20 am of lunch in the dining area revealed Dietary Aide (DA) CC and DA FF serving meals to residents seated in the dining room. DA CC and DA FF were observed entering the kitchen, touching the kitchen counter and kitchen door before re-entering the dining room and placing meal trays on the tables in front of residents. DA CC and DA FF were not observed performing hand hygiene between tasks. Observation on 9/23/2025 at 11:35 am of lunch in the dining area revealed Certified Medication Aide (CMA) DD was observed entering the dining room and sitting at a table with two residents. She put on gloves before assisting one resident at the table with the meal, then removed her gloves and put on another pair before assisting the other resident with the meal. Observation revealed that hand hygiene was not performed between glove changes or between assisting each resident with the meal. CMA DD was then observed adjusting one resident's wheelchair at the table before returning to assist another resident with his meal without performing hand hygiene. Observation on 9/23/2025 at 11:52 am of lunch in the dining area revealed CMA EE was observed transporting a resident in a wheelchair into the dining room and placing her at a table. CMA EE was observed placing a chair between the two residents at the table, putting on gloves, and then assisting one resident with her meal. CMA EE was then observed removing her gloves, placing them in her pocket, before putting on another pair and beginning to assist the other resident at the table without performing hand hygiene at any point during the dining process. Observation on 9/23/2025 at 12:00 pm of lunch in the dining area revealed CMA GG entered the dining room, put on gloves, assisted a resident with opening a drink, placed a straw in the cup, removed her gloves, and placed them in her pocket. CMA GG was then observed putting on a new pair of gloves to assist another resident in the dining room with setting up her utensils. Observation on 9/23/2025 at 12:20 pm of lunch in the dining area revealed the Dietary Manager (DM) entering the dining room pushing a cart full of goods for the kitchen. She was observed stopping to adjust a resident's wheelchair and rubbing the resident's arm. She was then observed opening a cup and packets of condiments for another resident at the table without performing hand hygiene.In an interview on 9/23/2025 at 12:30 pm, DA CC and DA FF both confirmed that they did not perform hand hygiene at any time while assisting residents with the lunch meal. DA CC and DA FF stated that they had not received education on hand hygiene and were still learning the job. In an interview on 9/23/2025 at 12:40 pm, the DM stated she should have performed hand hygiene, and didn't realize she hadn't. The DM stated that she was aware that hand hygiene should have been performed prior to assisting the resident with her meal and was aware that the dietary staff had not performed hand hygiene during the lunch meal. In an interview on 9/23/2025 at 12:40 pm, CMA DD stated she had not performed hand hygiene at any time during the lunch meal. She stated that she was aware that she should have performed it. In an interview on 9/23/2025 at 12:45 pm, CMA EE confirmed she did not perform hand hygiene while assisting residents with the lunch meal, nor between glove changes. She stated she should have performed hand hygiene between glove changes, between tasks, and should have discarded the dirty gloves into a trash can. In an interview on 9/23/2025 at 1:00 pm, CMA GG confirmed she did not perform hand hygiene at any time while in the dining room assisting residents with lunch. She stated that she should have performed hand hygiene upon entering the dining room and between glove changes. She further stated that she should have discarded dirty gloves in a trash can. In an interview on 9/25/2025 at 3:15 pm, the Assistant Director of Nursing (ADON)/ Infection Preventionist (IP) stated she was aware of staff not performing hand hygiene while assisting with residents with lunch. She stated that she had provided several in-services on infection control throughout the year, and it was an ongoing issue.

Based on resident and staff interviews and record reviews, the facility failed to provide showers/baths for two residents (R) (R268 and RA) who were dependent on staff for activities of daily living (ADLs). The sample size was 31 residents. The deficient practice placed R268 and RA at risk for unmet needs and a diminished quality of life. Findings include: 1. A review of R268's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed section C (Cognition) documented a Brief Interview of Mental Status (BIMS) score of 10 (indicating moderate cognitive impairment), section GG (Functional Abilities and Goals) documented R268 required extensive assistance with baths/showers, section I (Active Diagnoses) documented R268 had diagnoses including but not limited to Parkinson's disease, dementia, and sickle-cell disease. A review of the ADL plan of care revealed that R268 was scheduled for a bath/shower on Mondays, Wednesdays, and Fridays on the day shift. A review of ADL documentation for April 2024 revealed that R268 received a bath/shower on 4/1/2024 and 4/3/2024. The facility could not provide documentation that R268 received a bath/shower at any other time in April 2024. In an interview on 5/5/2024 at 9:33 am, the Assistant Director of Nursing (ADON) and Senior Nurse Consultant confirmed there was no documentation that the resident had more than two baths in April 2024. The Senior Nurse consultant stated there were issues with the electronic documentation system that caused documentation not to be captured, and they were aware of the issue. However, there was no backup system in place for documentation of ADL care. 35062 2. A review of RA's MDS Admission assessment dated [DATE] revealed section C (Cognition) documented a BIMS score of 14 (indicating intact cognition), section GG (Functional Abilities and Goals) documented R A was dependent with setup or clean up assistance with a bath/shower, section I (Active Diagnoses) documented morbid obesity, difficulty in walking and muscle weakness. In an interview on 5/3/2024 at 9:32 am, RA revealed she received a bath yesterday. However, it had been a while since she had a bath. She was unaware of the bath schedule. She stated she was sometimes offered a bath, but normally she must request one. RA stated she would request a bath, and they would pass her by if she was asleep. She stated she must sometimes wait until days later to get a bath. A review of ADL documentation dated 5/5/2024 revealed RA was scheduled to receive a bath/shower on Mondays, Wednesdays, and Fridays on the night shift and required substantial/maximal assistance. However, a review of the Bath Schedule Wing 1, updated 5/2/2024, revealed RA was scheduled for a bath/shower on Tuesdays, Thursdays, and Fridays on the day shift. A review of bathing data from the electronic medical record revealed the resident did not receive a scheduled bath/shower on 2/28/2024, 3/1/2024, 3/8/2024, 3/15/2024, 3/18/2024, 4/5/2024, 4/10/2024, 4/12/2024, 4/15/2024, 4/19/2024, 4/24/2024, and 4/26/2024. Upon request, the facility could not provide further documentation for baths/showers for RA. In an interview on 5/5/2024 at 10:06 am, Registered Nurse (RN) BB revealed RA's schedule just changed, but she believed the resident requested a bath based on what was best for her schedule. She was unaware of any issues with the resident not receiving a bath as scheduled. In an interview on 5/5/2024 at 10:20 am, the ADON revealed they do not have a policy related to baths/showers. She stated that they find out the residents' preferences and schedule them. In an interview on 5/5/2024 at 10:58 am, Certified Nursing Assistant (CNA) CC revealed RA's bath/shower schedule just changed to Tuesday, Thursday, and Saturday on the day shift on 5/2/2024. She reviewed the bath/shower sheet dated 5/1/2024, and it was documented that the resident was asleep, and a bath/shower would be provided later if needed. She was unaware of who documented that information.

Based on observations, resident and staff interviews, and a review of the facility policy titled 3.1 HR Conditions of Employment: Standard of Conduct Smoking Guidelines, the facility failed to implement their smoking policy and procedures regarding designated smoking areas for staff. The census was 67 residents (R). Findings include: A review of the facility policy titled 3.1 HR Conditions of Employment: Standard of Conduct Smoking Guidelines, dated 2019, revealed the intent of the guidelines was to promote safety for associates, patients, customers, and visitors. The guidelines revealed that smoking was only permitted in a designated smoking area. A review of R34's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed section C (Cognition) documented a Brief Interview for Mental Status (BIMS) score of 14 (indicating little to no cognitive impairment.) During an interview on 5/3/2024 at 9:50 am, R34 stated the night staff, especially on weekends, were not answering the call lights. He added that when they answer it, they turn it off and do not address the issues. He stated he had reported it to the Administrator, who said he would try to fix the problem, but nothing had been resolved. He further stated that from 1:00 am to 5:00 am, he hears the facility's front door slamming shut constantly. He stated he did not know why staff was going in and out of the door so many times as no residents were on the porch. He further stated that cigarette butts were on the porch every morning. An observation of the facility's front patio on 5/4/2024 at 4:05 am revealed that Licensed Practical Nurse (LPN) AA exited the facility's front door and lit a cigarette. LPN AA sat on the patio chairs and smoked until 4:12 am. She extinguished her cigarette on the ground, threw the cigarette butt into the trashcan next to the fire extinguisher, and reentered the facility. An observation of the facility's front patio on 5/4/2024 at 5:00 am revealed that LPN AA exited the facility's front door and lit a cigarette. At 5:07 am, the facility's Administrator arrived in the parking lot. Observation revealed LPN AA put her cigarette out on the ground, threw the cigarette butt into the trash can next to the fire extinguisher, and reentered the facility. During an interview with the Administrator on 5/4/2024 at 5:09 am, he stated the facility was smoke-free for the residents, but the staff was permitted to smoke on the back patio. The Administrator noted the back patio was equipped with a fire extinguisher, ashtrays, and a fire-retardant container for cigarette butts. He stated the staff was not permitted to smoke anywhere else on facility grounds. The Administrator acknowledged an employee was smoking on the front porch when he arrived, but he could not identify the employee as it was dark outside. During an interview with LPN AA on 5/4/2024 at 5:20 am, she stated staff was permitted to smoke on the back porch of the facility. She stated that she heard coyotes and was uncomfortable smoking on the back porch. She further stated she did not know if she was allowed to smoke in her car and added that she was not familiar with all the facility rules related to smoking. LPN AA stated she knew she was not supposed to smoke on the front porch and did not know if the trash can on the front porch was rated for fire or a safe place to dispose of cigarette butts. An observation of the trash can on the facility's front porch on 5/4/2024 at 7:34 am revealed that it contained paper products, cups, and other paper materials. An observation of the facility's back patio on 5/4/2024 at 8:13 am revealed fire-retardant canisters for the disposal of cigarette butts only and a fire extinguisher attached to the wall, which was within the inspection date.

Based on observations, staff interviews, and review of the facility's policy titled, Test Water Temperature, the facility failed to ensure that hot water temperatures in resident bathrooms remained below 110 degrees Fahrenheit (F). This deficient practice affected two of four halls (Hall 2A and Hall 2B - in rooms 48, 53, 57, 59, and 61). Findings include: Review of policy titled Test Water temperature (undated) revealed the following: 1. Ensure patient room water temperatures are between 105 degrees F and 115 degrees Fahrenheit (or as specified state requirements). Georgia - shall not exceed 110 degrees. 2. Test temperature in shower areas 3. Text temperature at mixing valve. Observations on 4/14/2023 from 9:13 a.m. until 10:15 a.m. revealed the following: In room [ROOM NUMBER] the hot water in the bathroom stings hands. In room [ROOM NUMBER] the hot water in the bathroom stings hands. In room [ROOM NUMBER] the hot water in the bathroom stings hands. In room [ROOM NUMBER] the hot water in the bathroom stings hands. In room [ROOM NUMBER] the hot water in the bathroom stings hands. On 4/14/2023 a hot water temperature tour was conducted from 3:35 p.m. through 3:49 p.m. with Maintenance DD and the Interim Administrator and the following was revealed: 1. In room [ROOM NUMBER] the hot water temperature was 124.4 degrees F. 2. In room [ROOM NUMBER] the hot water temperature was 121 degrees F. 3. In room [ROOM NUMBER] the hot water temperature was 120.5 degrees F. 4. In room [ROOM NUMBER] the hot water temperature was 120.3 degrees F. 5. In room [ROOM NUMBER] the hot water temperature was 121.6 degrees F. A follow up tour of the hot water temperatures in the identified rooms was conducted on 4/14/2023 from 4:54 p.m. through 5:03 p.m. with the Plumbing Representative and Corporate Consultant DD revealed: 1. In room [ROOM NUMBER] the hot water temperature was 98 degrees F. 2. In room [ROOM NUMBER] the hot water temperature was 99 degrees F. 3. In room [ROOM NUMBER] the hot water temperature was 100 degrees F. 4. In room [ROOM NUMBER] the hot water temperature was 100 degrees F. 5. In room [ROOM NUMBER] the hot water temperature was 98 degrees F. At the end of the tour Corporate Consultant DD agreed to provide monitoring through the night for all halls to ensure that the hot water temperatures do not exceed 110 degrees F. Review of Quality Improvement Data Collection Grid revealed the following: 1.On 4/14/2023 from 7 p.m.-8 p.m. and 10 p.m.-11 p.m. no hot water temperatures over 110 degrees F. 2.On 4/15/2023 from 1 a.m.-2 a.m., 3 a.m.-4 a.m., 6 a.m.-7 a.m. - no hot water temperatures over 110 degrees F. Observation and interview on 4/16/2023 at 10:47a.m. with the Interim Administrator the online waterlog report titled Logbook Documentation was reviewed. The log did not specify which rooms were being checked nor did it identify follow up if the hot water temperature was over 110 degrees F. The Interim Administrator confirmed that on 3/13/2023 and 3/13/2023 the hot water temperatures were identified on Hall 2B and C with temperatures of 115.3- and 113.1-degrees F and on 3/15/2023 at 117.3 degrees F. The temperatures were then reported that the Maintenance Assistant HH checked rooms randomly and if the water temperature is over 110 degrees F, he rechecks the hot water heater and rechecks. The Interim Administrator confirmed that the waterlogs do not reflect which rooms Maintenance HH is checking nor that he is rechecking if temperatures are over 110 degrees F. Interim Administrator reported that when checking the hot water temperatures rooms should be identified on the water temperature log and if hot water temperatures were readjusted. She further revealed that hot water temperatures should continue to be checked to see if they are out of range to determine the root of the problem. The Interim Administrator reported that if hot water was out of range maintenance personnel should have notified the Maintenance Supervisor and if continued issues the Administrator should have been notified as well. Interview on 4/16/2023 11:27 a.m. with Maintenance Assistant FF revealed that she was responsible for checking the hot water temperatures in the past. She continued to report if the hot water temperature were over 109 degrees F the supervisor notified, other rooms were checked, the mixing valve lowered, and then the temperatures would be rechecked. At the time of exit on 4/16/2023 there were no hot water temperatures over 110 degrees F.

Based on observations, staff interviews, and a review of the facility's policy titled, Laundry Services, Disposal of Sharps, and Infection Prevention Plan, the facility failed to ensure dust buildup in the laundry room to prevent cross contamination. The facility also failed to dispose of items containing blood in an appropriate manner. Findings include: 1. Review of policy titled Laundry Services (dated 2020) revealed: Guidance - Separating Clean from Dirty in the laundry - Areas should be cleaned on a regular schedule. The tour of the laundry room was on 4/15/2023 beginning at 8:31 a.m. revealed the following: 1.There was dust build up noted on the wall behind the washing machines. 2.There was dust build up on the emergency shower device. 3. There was dust build up on the fan that was located on the wall near the dryers. Interview on 4/15/2023 at 8:51 a.m. with Laundry Aide GG revealed the dust buildup on the walls, fans, and shower device were confirmed. At the time of the observation clean laundry was in the dryer. Laundry Aide GG reported that she dusts whenever she has time to do so. The Housekeeping Supervisor and Maintenance Assistant FF were also present during the tour. Maintenance Assistant FF reported that dusting of the laundry room is done monthly and it is a part of the monthly report of duties that has to be performed. Maintenance Assistant FF could not recall the last time she dusted but agreed to provide documentation of this monthly task. Observation and interview on 4/16/2023 at 11:47 a.m. with Interim Administrator provided a copy of the online maintenance report for the laundry room and confirmed that dusting was not indicated as a task. The Interim Administrator reported that her expectation was for all areas in the laundry room to be dust free. 45811 2. During a review of policy, Infection Prevention Plan, The Infection Prevention Plan provides an overview of the infection prevention practices of the center that is charged with the promotion of a healthy and safe environment to reduce the risk of infections in patients, staff, and visitors and others in the healthcare environment. The goals of the infection prevention program include to prevent and control the transmission of infectious and communicable diseases and to maintain a sanitary environment for personnel and patients. A review of policy, Disposal of Sharps it was revealed; The facility shall discard contaminated sharps into the sharps container marked biohazard. Contaminated sharps shall be discarded immediately or as soon as feasible into designated containers. Contaminated sharps will be discarded into containers that are closable, puncture resistant, leak proof on sides and bottom, and color-coded red. Observation on 4/15/2023 at 11:35 a.m. CMA AA completed a finger stick blood sugar procedure; during the procedure it was revealed CMA AA put on gloves, cleaned the finger, put a barrier on the table, and cleaned the meter before and after use; at the end of the procedure CMA AA took the used lancet and wrapped it in a napkin and put it in a plastic cup and then she put the plastic cup in the regular trash container on the medication cart; when asked about disposal of the lancet stated she wrapped it in the cup and put it in the trash; RN CC was standing nearby and informed CMA AA the lancet goes in the biohazard sharp container. RN CC put on gloves and took the plastic cup out of the trash container and put it in the sharps container. Interview with Registered Nurse (RN) CC on 4/15/2023 at 11:40 a.m. revealed lancets are discarded in the biohazard sharps container. Interview on 4/15/2023 at 12:20 p.m. with Director of Nursing (DON) revealed lancets should go in the sharps container and not the regular trash. She indicated she would take the CMA through a finger stick competency check today.

Based on observation, staff interview, record review, and a review of the facility's policy titled, Medication Storage in the Care Center, the facility failed to ensure that one of four medication carts were locked when the carts were out of view or unattended by the nurse or CMA. This failure had the potential to affect nine Residents who wander. Findings include: During a review of policy, Medication Storage in the Care Center, it was revealed medications and biologicals are stored safely, securely, and properly. Only licensed nurses, consultant pharmacists, and those lawfully authorized to administer medications are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended to by persons with authorized access. Observation of Hall B on 4/15/2023 at 8:57 a.m. a medication cart was found unlocked from 8:57 a.m. to 9:13 a.m.; Licensed Practical Nurse (LPN) BB noticed the surveyor monitoring the unlocked cart and went down the hall and locked the cart. Interview on 4/15/2023 at 9:13 a.m. with LPN BB she verified the medication cart was unlocked and that it should be locked whenever the cart is unattended. Interview on 4/15/2023 at 11:00 a.m. with Registered Nurse (RN) CC revealed she was responsible for the medication cart on Hall B, and she would make sure it was locked. Interview on 4/15/2023 12:20 p.m. with Director of Nursing (DON) revealed the medication cart on Hall B was unlocked; the DON states medication carts and treatment carts are locked if not in use or if someone is not standing by the cart. Today, the DON provided education on locking medication carts today to staff that were in the facility.

Based on record review and staff interviews, the facility failed to assure the correct order was on file based on resident's choice per the Physician order [REDACTED].#44)). The sample size was 29 residents. Findings include: Review of medical record for R# 45 revealed the [DIAGNOSES REDACTED]. Further review of the medical record revealed a Physician order [REDACTED].N.D.) - Do Not Attempt Resuscitation which was signed by the resident and Physician on [DATE]. There was another POLST for Attempt Resuscitation which was signed by resident on [DATE] and the Physician on [DATE]. Review of the orders revealed orders for both Do Not Resuscitate (DNR) and Full Code. Interview on [DATE] at 1:27 p.m. with Licensed Practical Nurse (LPN) AA who initially reported resident code status of DNR but then reported she was not sure of what the code status is because in the computer it is showing both DNR and full code. LPN AA reported that she would have looked in the computer first and then the book if the resident was in crisis. However, she reported that she would have done CPR because it was not clear. Interview on [DATE] at 1:29 p.m. with Resident Care Coordinator (RCC) BB reported that nurses could also look into the code status book to check resident status. When RCC opened the book for review it revealed a POLST for AND. RCC BB reported that R#45 should be full code. On [DATE] at 1:47 p.m. the Social Services Director (SSD) provided copy of POLST dated [DATE] indicating attempt resuscitation (CPR) R#45. Interview with SSD on [DATE] at 2:02 p.m. who reported that a discussion is had with family/resident regarding advance directives/code status during admission. This information is then reviewed during care plan meetings. Once the POLST is signed by the resident/family it is then placed in a folder for the Physician to sign. Once signed by the Physician SSD retains the original and places a copy in the POLST book on each wing. SSD reported that she did not put the newest POLST in the book for R#45. Interview on [DATE] at 2:05 p.m. with RCC BB who reported that once the POLST is signed by the resident and physician an order is then placed in the computer system. RCC BB reported that she created an order for [REDACTED].

Based on observation and staff interviews, the facility failed to provide maintenance services to ensure resident living areas were safe, comfortable, and sanitary for rooms (#14, #21), on Unit-1, Hall-A, and Hall-B. Findings Include: 1. Unit-1, Hall-A, Room 14 bathroom observations: On 03/09/15 at 3:00 p.m. observation revealed the bathroom in Room 14, to have a foot and a half (1 1/2 foot) crack in the ceiling over the toilet, with exposed partially hanging sheet rock with exposed insulation. A nail was noted at the right side of the crack, loosened but partially holding the sheet rock in place. Observations on 03/10, 3/11, and 3/12 revealed the bathroom ceiling exposed, and unchanged. Exposed sheet rock partially hanging, with exposed insulation. 2. Unit-1, Hall-B, Room 21 bathroom observations: Observation on 03/09/15 at 5:30 p.m. revealed the ceiling of the bathroom in Room 21 had hanging sheet rock with exposed insulation, with the ceiling appearing to be sagging downwards. Observation on 03/10/15 at 3:30 p.m. revealed the ceiling in Room 21's bathroom nailed into place. A crack line was still visible. An interview on 03/12/15 at 11:08 a.m. with Environmental Aide, "CC" revealed that the ceiling in Room #21 bathroom had been cracked and exposed for at least a month and that she told the Maintenance Director the same day she found it needing repair, about a month ago. Interview on 03/12/15 at 9:05 a.m. with Certified Nursing Assistant (CNA) "AA" revealed that Maintenance had been informed at least verbally. Interview on 03/12/15 at 9:10 a.m. with CNA "BB" revealed that she was uncertain when she observed the ceiling in room 21 bathroom, but it was a week ago, at least, and was unaware if maintenance was notified. Interview on 03/12/15 at 9:00 a.m. with the Maintenance Director revealed that although he does not do daily, or weekly rounds in rooms, staff notifies him of areas needing repairs by filling out the Maintenance repair book forms. He also stated that the Administrator was aware of the issues with the ceiling. He signs the repair book as indication that a repair was completed. He also revealed that he has no Logs to show that rooms are checked periodically. Interview on 03/12/2015 at 9:22 a.m. with the Administrator revealed that although the ceiling in Room 14 was discussed in Quality Performance Improvement (QAPI) meeting on 02/19/15, the facility had to prioritize what areas were fixed over other areas. The Administrator further revealed there was no concern regarding exposed partially hanging sheet rock, or exposed insulation in the bathrooms of room 14 and 21, posing any safety risks to the residents in those rooms. Continued interview revealed that other maintenance issues took priority over the exposed ceilings in Rooms 14 and 21 being repaired in a timely manner. He further revealed that he had no documentation to show that a Contractor had been notified to do repairs in the building and that he had only spoken with the Contractor verbally over the phone.

Based on record review and staff Interview, the facility failed to update and revise the care plan for one resident (#6) receiving high risk medications from a sample of twenty-five (25) residents. Findings include: Record review for resident #6 revealed a Minimum Data Set ((MDS) dated [DATE]. The current plan of care was initiated on 0/13/14 and the most recent update and revision was on 09/18/14. Record review for the resident revealed that she was prescribed medications for pain management, Anxiety, insulin for management of Diabetes Mellitus and blood thinning medication for the management of [MEDICAL CONDITION]. An interview with the MDS coordinator on 03/12/15 at 3:41 p.m. revealed that no care plan conference had been held for the assessment dated [DATE] and therefore no revision or updates had been done.

Based on record review, staff interview, and resident interview the facility failed to ensure that resident #8 was free from accident hazards from a sample of twenty-five (25) residents. Findings include: Resident #8 was a fifty nine (59) year old long term care resident that had a history of [REDACTED]. Review of the Quarterly Minimum data set (MDS) assessment dated [DATE] and the Annual MDS assessment dated [DATE] revealed that the resident required extensive assistance of two plus ( 2+) persons for bed mobility, transfers, dressing, and toileting. Review of the Care Plan revealed the following; that the resident was at risk for falls related to [DIAGNOSES REDACTED]. The Falls Intervention Plan (FIP) was updated on 11/18/14: two (2) people with all transfers in sling and lift and on 02/14/15: two (2) person assistance bed mobility and ADL. Review of the Activities of daily living (ADL) Care Plan revealed for transfers the Level of support was for two or more person physical assistance. Self performance the resident was not able and was totally dependent. The resident required equipment of a Sling lift for transferring. Review of the resident Fall Log revealed that the resident had two (2) falls in the last six (6) months on 11/18/14 resident #8 fell to the floor, witnessed, in the hallway, injury treatment done in the facility and on 02/14/14 resident #8 fell to the floor, witnessed, in his room, injury treatment done in the facility. Review of the clinical record revealed that the nurses documented on 11/18/15 a Situation, Background, Assessment and Recommendations (SBAR) form which revealed that the resident had a fall out of the sling lift. Continued review of the SBAR revealed that the resident was in the sling being lifted and slid out of the sling pad to the floor, resident was with a Certified Nursing Assistant (CNA) at the time of this incident. The nursing notes revealed that the resident stated that the bed was not under his good leg and it got caught on wheelchair. The resident told staff that the CNA tried to catch me but she could not. Intervention was to remind CNA to use 2 person assist and the correct lift pad. Further review of the clinical record revealed that the nurses documented on 02/14/15 a SBAR form which revealed that the resident had a fall with left knee and hip discomfort. Continued review of the SBAR revealed that the resident was rolled in bed causing fall out of bed to the floor. The nursing notes revealed that the resident was being cared for in bed and rolled out of bed with a CNA during change. Intervention was to have two (2) staff members during care reinforced strongly. Review of the In-Service for Lifts and Infection Control which was completed on 01/23/15 revealed that staff was educated to use 2 associates when using the mechanical sling lift. Interview on 03/12/15 at 9:50 a.m. with the resident revealed that he recalled the fall he had in November when he slid out of the sling when the CNA was using the lift. The resident revealed that there was only one (1) CNA that was assisting him to get from his wheelchair to the bed. The resident revealed that his feet got caught up and he slid to the floor. Continued interview revealed that he recalled the fall he had in February. The resident revealed that a CNA was washing him in bed and turned him onto his side, he grabbed the positioning bar, he had to cough and all of a sudden his feet slid out of the bed followed by the rest of his body. The resident confirmed that only one (1) CNA was assisting him with his grooming and re-positioning in bed when he fell . Interview on 03/12/15 at 10:50 a.m. with the Wing 2 Resident Care Coordinator (RCC) and the Director of Nursing (DON) revealed that the resident uses a sling lift for all transfers. They both confirmed that two (2) staff members should assist when transferring residents in the sling lift. The RCC confirmed that there was only one (1) CNA with the resident while using the sling lift on 11/18/14. The DON revealed that she did an in-service in January with all staff regarding proper usage of all the lifts in the facility. Continued interview with the RCC and DON revealed that the resident requires two (2) person assist with bed mobility and transfers. The RCC confirmed that on 02/14/15 there was only one (1) CNA that was turning the resident in bed while bathing him and there should have been two (2) staff present for any bed mobility.

Based on observation and staff interview the facility failed to maintain the cleanliness of the stand-up mixer to be free of food debris; failed to properly discard expired milk from the walk-in refrigerator. Census was ninety-one (91) residents. Findings include: Observation on 03/09/15 at 10:10 a.m. of the stand-up mixer revealed that there was some off-white food debris under the mixing arm by the motor. The food debris covered an area that was four (4) inches in width and five (5) inches in length. Interview on 03/09/15 at 10:10 a.m. with the Dietary Manager (DM) revealed that he expects staff to clean the mixer after each use. He confirmed that there was dried food debris under the mixing arm of the stand-up mixer. Observation on 03/09/15 at 10:20 a.m. of the walk-in refrigerator revealed twelve (12) half gallon containers of whole milk. Upon further observation one (1) half gallon of whole milk had an expiration date of 03/03/15. Interview on 03/09/15 10:20 a.m. with the DM revealed that he expects the dietary staff to review expiration dates of all food items and discard or to let him know so he can get credit from the distributor. The DM confirmed that the milk was expired and was in the walk-in refrigerator for staff to potentially use.

Based on observations and staff interview, the facility failed to serve in room meals on three (3) of three (3) meal carts under sanitary conditions on one (1) of two (2) Units (Unit 1). Findings include: 1. Observation on 9/19/13 at 8:20 a.m., revealed three (3) meal carts, on Unit One which contained residents' breakfast trays, were covered by a plastic overlay. Continued observation revealed that nursing staff rolled the plastic overlay covering two (2) sides of the cart on top of the cart during the delivery of the room trays. Further observation revealed that the bacon, toast, and biscuits in a saucer on the individual resident trays inside the cart were uncovered during the remainder of the breakfast service. 2. Observation on 9/19/13 at 12:40 p.m., revealed three (3) meal carts on Unit One which contained resident's lunch trays, were covered by a plastic overlay. Continued observation revealed that nursing staff rolled the plastic overlay covering three (3) sides of the cart on top of the cart during the delivery of the room trays. Further observation revealed that the rolls and jello were uncovered on the resident trays inside the cart during the remainder of the lunch service. Interview with the Director of Nursing (DON) on 9/19/13 at 2:05 p.m., revealed that it is her understanding that the plastic cover on the meal carts are to stay down to protect the integrity of the meal. Continued interview revealed that the staff are to unzip the plastic cover, but not roll it up and/or throw it up on top of the cart, this helps maintain the warmth/coolness of the meal items as well as to prevent any contamination. 3. Observation on 9/16/13 at 12:55 p.m. revealed three (3) meal carts, on Unit One (1) which contained residents' lunch trays, were covered by a plastic overlay. Continued observation revealed that nursing staff pulled the plastic overlay pulled away from the cart during the delivery of the room trays. Further observation revealed that the bread, rolls and grapes in a bowl on the resident trays inside the cart were uncovered during the remainder of the lunch service. 4. Observation on 9/17/13 at 8:02 a.m., revealed three (3) meal carts on Unit one (1) which contained the resident breakfast trays were covered by a plastic overlay. Continued observation revealed that the meal cart was opened and uncovered during the delivery of room trays. Further observation revealed that the toast in a saucer on the resident trays was uncovered during the remainder of the breakfast service.

Based on record review, and staff interviews, the facility failed to remit the ending balance in the trust fund account within thirty (30) days of death for one (1) random resident, and (1) resident ("A") from a sample of twenty-nine (29) residents. There were a total of twelve (12) residents that expired in the last six (6) months with trust fund accounts. Findings include: Review of the Expired Residents List from [DATE] through ,[DATE] revealed that there were a total of twelve (12) residents with trust fund accounts. The facility failed to convey the balance of the trust account within thirty (30) days to the resident's estate for two (2) residents as follows: 1. One (1) random resident had a date of death of [DATE], with an outstanding balance of $8.05. This was not remitted to the responsible party until [DATE], thirty-nine (39) days after death. 2. Resident "A" had a date of death of [DATE], with an outstanding balance of $188.00. This was not remitted to the responsible party until [DATE], forty (40) days after death. Interview with the Administrative Assistant/ Accounts Payable, and the Regional Financial Comptroller on [DATE] at 10:00 a.m., revealed that they were aware that funds should be disbursed within thirty (30) days of death; however, concurred that these funds were not refunded within this timeframe for either resident.

Based on record review and staff interviews, the facility failed to develop a comprehensive care plan for anticoagulant use for one (1) resident (#8) from a total sample of twenty-nine (29) residents. Findings include: Review of physician orders [REDACTED]. Review of the resident's care plans dated 8/28/13 revealed no evidence that a comprehensive care plan had been developed related to anticoagulant therapy. Interview with the Charge Nurse for Wing 1 on 09/18/13 at 8:40 a.m., revealed that the resident is monitored for side effects of anticoagulants and medications in general. Continued interview revealed that any adverse effects would be documented in nurses notes and the physician would be notified. Interview with the Minimum Data Set (MDS) Coordinator "BB" on 09/18/13 at 10:51 a.m., revealed that the interventions under the skin care plan should include monitoring for bleeding and monitoring of labs.

Based on observations, record review, and staff interviews, the facility failed to revise the care plan related to an indwelling urinary catheter to reflect the behavior of noncompliance with positioning of the drainage bag for one (1) resident (#93)from a total sample of twenty-nine (29) residents. Findings include: Resident # 93 was admitted to the facility in June, 2013 with an indwelling urinary catheter and the following Diagnoses: [REDACTED]. Observation of resident # 93 on 09/16/13 at 12:45 p.m., revealed the resident in his room eating lunch, with the catheter hanging at the bedside without a privacy bag. Continued observation at 3:30 p.m. revealed the resident lying on his bed with the catheter bag lying on the bed beside him. Observation of resident # 93 on 09/17/13 at 8:55 a.m., revealed the catheter bag lying on the bed beside him, without a privacy bag. A second observation at 1:15 p.m., revealed the resident lying on his bed, fully clothed, with the catheter bag lying bedside him, half full of urine. Observation of the resident on 09/17/13 at 5:30 p.m., revealed that he was in his room seated at his bedside with his dinner tray and his catheter on the bed beside him. Review of the Comprehensive Care Plan dated 07/02/13 revealed that the resident was care planned as having an indwelling catheter. Continued review revealed that the behavior of pulling on his catheter was careplanned but there was no evidence that the care plan was revised to include behavior of noncompliance with the positioning of his foley catheter bag. Review of the three (3) Care Plan Conference meetings dated 06/12/13, 06/19/13, and 07/23/13 revealed no evidence of discussion of the resident's non-compliance with keeping the foley catheter bag draining at the bedside. Interview with Certified Nursing Assistant (CNA) "DD" on 09/17/13 at 1:30 p.m., revealed that the resident does not like for staff to take care of his catheter bag because he has had this bag for five (5) years; however, she will dump the bag if full, emptying throughout the day. Continued interview revealed that she checks on resident to ensure that he is not lying on his catheter bag because he keeps the bag on the bed beside him next to his leg. Further interview revealed that the nurses and unit manager are aware that the resident prefers to have his urine bag beside him on the bed and his refusal of care and indicated that it is in his plan of care. Interview with the Director of Nursing (DON) on 09/17/13 at 2:00 p.m., revealed that she is aware that resident moves the urine bag himself; however, unsure if this has been addressed in his plan of care. Interview with the MDS Coordinator "BB" on 09/17/13 at 2:15 p.m., revealed that she was unaware of resident keeping his foley catheter on the bed next to him.

Based on record review and staff interview, the facility failed to obtain labs in a timely manner for one (1) resident (#92) from a total sample of twenty-nine (29) residents. Findings include: Review of the Physician order [REDACTED]. Review of the Central Georgia Diagnostics Laboratory and Imaging Services revealed results of the general chemistry panel dated 10/11/12 and 4/11/13; however, there was no evidence that the Chem-8 was drawn in December 2012 and/or June 2013. Interview with Licensed Practical Nurse (LPN) "AA" on 9/19/13 at 9:33 a.m., revealed that the resident should have had an Chem-8 drawn in June, 2013; however, there was no evidence that the laboratory test had been completed as ordered.

Based on observation, record review, facility policy/procedure review and staff interview, the facility failed to provide incontinence care in a manner to decrease the likelihood of a Urinary Tract Infection for one (1) resident (#89) of the sampled twenty-nine (29) residents. Findings include: Observation on 6/24/10 at 9:05 a.m. of incontinent care for resident #89, performed by Certified Nursing Assistant (CNA) "AA", revealed the CNA cleaned the resident by washing with periwash, wiping from back to front and using the same area of the washcloth. Review of the clinical record revealed a Minimum Data Set ((MDS) dated [DATE] and 11/7/09, which indicated that the resident had a history of [REDACTED]. Interview on 6/24/10 at 9:15 a.m. with the CNA revealed that she had been taught to wipe from back to front. Further interview revealed that the CNA had been working at the facility since October 2009, but had not had any inservices on incontinence care. Interview on 6/24/10 at 9:25 a.m., with the Resident Care Coordinator (RCC) revealed that the CNA was employed by an agency who contracted with the facility. Review of the facility's, "Nurse Aide Trainee Competency Checklist; Perineal Care for Female Patients" revealed to wash the pubic area first moving from the pubic area to the anal area using a different section of the washcloth with each downward stroke. Always wash downward toward the anus to prevent infections.

Based on record review, and staff interview, the facility failed to educate residents and/or responsible parties of the risk and benefits of the Influenza and/or Pneumococcal vaccinations for one (1) resident (#63), of the sampled twenty-nine (29) residents. Findings include: Review of the clinical record for resident #63, revealed no evidence that the resident and/or responsible party was educated on the risk and benefits of the Influenza and/or Pneumococcal vaccination. Interview on 06/23/10 at 9:38 a.m. with the Director of Nursing (DON) revealed that resident #63, is currently the only resident in the facility that has refused the immunization. Continued interview revealed that the resident refused the vaccination in 2009,. There was no evidence on the clinical record of the signed refusal.