Every finding on record at Madison Health and Rehab

Based on record review, staff interviews, and review of the facility's policy titled Advanced Beneficiary Notice/Written Notice of Non-Coverage, the facility failed to ensure notifications of discontinuation of Medicare Part A benefits were issued in a timely manner for two of three residents (R) (R4 and R42) reviewed for beneficiary notification. Specifically, R4 and R42 were not issued a Notice of Medicare Non-Coverage (NOMNC) (Form CMS-10123) when their Medicare Part A services ended. This deficient practice had the potential to place R4 and R42 at risk of not understanding appeal rights and/or the termination of the current level of care against the resident's/representative's wishes.Findings include:Review of the facility's undated policy titled Advanced Beneficiary Notice/Written Notice of Non-Coverage, revealed the policy section included, It is the policy of (name of facility) to provide residents and/or the resident representatives timely and accurate information about the end of their Medicare services to allow a decision to be made about continuation of services if desired. The Procedure section included, Near the completion of a Medicare service stay, the resident and/or resident representative will be provided with both an ABN (Advanced Beneficiary Notice of Non-Coverage) or SNF ABN (Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage) and a NOMNC.1. Review of the facility-provided documents for R4 revealed the Medicare Part A skilled services episode start date was 05/16/2026, and the last covered day of Medicare Part A services was 06/21/2026. The facility initiated the discharge from Medicare Part A when benefit days were not exhausted, and the resident remained in the facility. There was no evidence that the facility issued a NOMNC to R4 or the responsible party, providing the opportunity to continue skilled services at the resident's cost if Medicare did not reimburse.2. Review of the facility-provided documents for R42 revealed the Medicare Part A skilled services episode start date was 02/05/2026, and the last covered day of Part A service was 04/10/2026. The facility initiated the discharge from Medicare Part A when benefit days were not exhausted, and the resident remained in the facility. There was no evidence that the facility issued a NOMNC to R42 or the responsible party, providing the opportunity to continue skilled services at the resident's cost if Medicare did not reimburse.In an interview on 08/08/2026 at 1:00 PM, the Social Services Director (SSD) stated she was notified by the therapy department when a resident was to be discharged from therapy, and she issued an SNF ABN notice to the resident or resident representative with a two-day notice. She stated she then notified the Business Office Manager (BOM) of the therapy discharge and Medicare Part A discharge. She confirmed she had not issued a NOMNC notice to R4, R42, or their representatives, and was unaware that she should have.In an interview on 08/08/2026 at 1:10 PM, the BOM stated that she had not provided NOMNC notices to R4, R42, or their representatives, and was unaware that she should have.In an interview on 08/08/2026 at 3:40 PM, the Administrator stated that when residents were discharged from Medicare Part A, the SSD and BOM were responsible for providing the required notices in the required time frame. She stated she was unaware the notices were not provided. She further stated the SSD and BOM had not received recent education on providing the required notices of non-coverage upon discharge from Medicare Part A coverage.

Based on observations, staff interviews, and review of the facility's policy titled, Medication Storage in the Facility, the facility failed to dispose of expired medical supplies in one of one medication storage rooms. This deficient practice had the potential to place residents at risk for infection and ineffective treatment. The facility census was 66 residents. Findings include: A review of the facility's policy titled Medication Storage in the Facility, effective date of [DATE], under Policy revealed, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendation. those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications. Under the section titled Procedures revealed, (L.) Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal (see Section IE: DISPOSAL OF MEDICATIONS AND MEDICATION-RELATED SUPPLIES), and reordered from the pharmacy (see IC3: ORDERING AND RECEIVING MEDICATIONS FROM THE DISPENSING PHARMACY), if a current order exists. Observation and interview on [DATE] at 3:24 pm of the medication storage room with Licensed Practical Nurse (LPN) BB revealed, in the top drawer of a plastic container there was a [Name of enteral feeding pump] safety screw spike set with expiration date of ,d+[DATE]; there were multiple [Name of enteral feeding pump] pump sets with expiration date of [DATE]; a bucket with medical supplies that contained a female catheter kit with expiration date of [DATE]; and in the cabinet were temperature probe covers with expiration dates for both [DATE] and [DATE]. Interview with LPN BB confirmed the dates on all the expired items. LPN BB verbalized that the Assistant Director of Nursing (ADON) was responsible for ensuring items in the medication storage room was not expired. LPN BB also confirmed that the house keeping supervisor completed the orders for over the counter (OTC) medications and supplies as needed. An interview on [DATE] at 10:37 am with the ADON revealed, that he was responsible for ensuring medications and supplies in the medication storage room were not expired. He also confirmed that he had removed all the expired items out of the medication storage room.

Based on observations, staff interviews, record review, and review of the facility's policy titled Resident's Rights Policy and Procedure, the facility failed to ensure that the right to respect, dignity and privacy was maintained by displaying clinical information related to incontinence care and pressure ulcer care that was posted openly in the room for one out of 26 sampled residents (R) R63. Findings include: Review of the undated facility policy titled, Resident's Rights Policy and Procedure, for the section titled Purpose revealed, The facility protects and promotes the rights of each resident admitted in order to provide a dignified existence, self-determination, and communication with an access to persons and services inside and outside the facility. The facility will protect and promote the rights of each resident. Under section titled Policy, subsection titled Privacy and Confidentiality revealed under number one, You have a right to respect and privacy in your medical, personal, and bodily care program. Your case discussion, consultation, examination, treatment, and care shall be confidential and shall be conducted in privacy. Review of R63's electronic medical record (EMR) revealed R63 was admitted to the facility on with pertinent diagnoses that included but was not limited to nontraumatic intracranial hemorrhage. Review of R63's Significant Change Minimum Data Set (MDS) dated [DATE] revealed under Section C (Cognitive Patterns), a Brief Interview for Mental Status (BIMS) was not considered due to the resident being rarely understood; Section GG (Functional Abilities and Goals) revealed R63 was dependent on assistance for all care; Section H (Bladder and Bowel) revealed R63 was always incontinent of bladder and bowel; Section M (Skin Conditions) revealed, R63 was at risk for pressure ulcers, has one stage three pressure ulcer, and has pressure relieving devices for bed and chair. Review of R63's care plan initiated on 11/8/2024 revealed a focus of a lifestyle change resulting from admission in which the resident shows indicators of depression per staff assessment and has a history of expressing sadness over his lost role and status. Interventions were to provide as many situations as possible which give control over environment and care delivery. An observation on 5/19/2025 at 1:40 pm in R63's room revealed a sign above the bed that read 100A No diapers at night. Keep heel boots on at all times, particularly while in the bed. Use the wedge to keep him off of his left side. An observation on 5/21/2025 at 9:20 am in R63's room revealed the sign above the bed was still present. An interview on 5/21/2025 at 9:24 am with Certified Nursing Assistant (CNA) AA revealed, she assisted R63 with changing his briefs and that he required total care assistance. When asked about the sign above his bed, she was not sure and had to go in to the room to remember its contents. She read the sign and stated that the resident wears no diapers at night to avoid excess moisture and that he had bed sores. She stated that the facility posted the sign as reminders for people who have not worked with R63 in a while. She stated that they had a meeting regarding the information on the sign, so she already knew the care and did not have to refer to it anymore. When asked how long the sign has been there, she stated that the sign has 5/6 (May 6th ) written on it. An interview on 5/21/2025 at 9:49 am with Licensed Practical Nurse (LPN) BB revealed when asked about the sign above R63's bed, LPN BB could recall specifically what it said. She stated that she just took the sign down. When asked why, she stated that the resident's name was on there, that was not something they should have a sign for, and that staff should already know specifically what was on there. She stated that she did not know how long the sign had been posted. An interview on 5/21/2025 at 1:45 pm with the Director of Nursing (DON) revealed when asked about the sign above R63's bed, the DON stated that signs above the bed was placed for staff communication so that things would not be missed. She further stated that the purpose of the signs were so that staff would know important information. When asked about the facility's process with placing signs in the residents' rooms, she stated that the signs were only for the staff to ensure resident safety, and they do not ask residents or family for permission. She stated that a potential negative outcome for posting signs displaying clinical information visible to any visitors could be a violation of the Health Insurance Portability and Accountability Act (HIPAA).

Based on observations, interviews and record review, the facility failed to ensure the resident environment was free from accident hazards for one out of 26 sampled residents (R) (R19). Specifically, the facility failed to replace an assistance device to prevent accidents as evidence by the bed control was defective with exposed wires present. Findings include: Review of Admission Record revealed R19 was admitted with diagnoses that included but not limited to, cerebrovascular disease affecting right dominant side, muscle weakness, unsteadiness on feet, abnormal posture, and other pulmonary embolism without acute cor pulmonale. Review of R19's quarterly Minimum Data Set (MDS) dated [DATE] for Section C (Cognitive Patterns) revealed, a Brief Interview for Mental Status score of five which indicated severe cognitive impairment; Section GG (Functional Abilities and Goals) revealed, the resident had impairment on one side to upper and lower extremity and was dependent on staff with mobility. Observation and Interview on 5/19/2025 at 1:49 pm of R19 lying in bed watching television. Further observation revealed, R19 was unable to let the head of the bed up due to the bed control not working. R19 stated, the bed control not working properly upsets me. I have to mess with the wires sometimes to get it to work. I think it's a shortage in the wires. This has been going on a while, and it happens too regularly. R19 then proceeded to show the exposed wires on the cord. Observation on 5/21/2025 at 10:35 am of R19's bed control revealed, it was not working with exposed wires present. Interview on 5/21/2025 at 10:37 am with the Assistant Director of Nursing (ADON) confirmed that the wires on the bed control were exposed. ADON also confirmed that maintenance was responsible for replacing the bed control and other defective equipment. He also stated that maintenance was supposed to do regular checks at least quarterly. Interview on 5/21/2025 at 1:55 pm with Maintenance revealed that he completed weekly random room checks for safety concerns. He also stated that the Certified Nursing Assistants would usually let him know if anything was broken in the rooms between checks. An environmental policy was requested from the facility but was not made available upon the survey exit.

Based on observations, staff interviews, and review of the facility's policies titled, Food Storage, Dietary Safety Rules, Dishwashing, and Cooking pots and Steam Table Insert Storage Policy & Procedure, the facility failed to label, and date opened food items in the freezers, walk-in refrigerator, and dry storage area; failed to ensure male staff cover facial hair while in the kitchen; and failed to store pans properly to prevent wet nesting and cross contamination. This affected 61 of 62 residents receiving an oral diet. Findings include: 1. Review of the facility's policy titled, Food Storage revealed all items must be covered, labeled, and dated. All foods that have been opened and partially used shall be dated and sealed before returning to a storage area. Observation on 3/24/2023 at 8:20 a.m. of the reach in freezer near the milk refrigerator revealed a one gallon container of vanilla ice cream that had been opened with no open date. Observation on 3/24/2023 at 8:25 a.m. of the reach in freezer near the fryer revealed a plastic resealable bag with two frozen waffles with no label or date. This freezer also had a clear plastic bag with four chicken strips that had no label or date. Observation on 3/24/2023 at 8:30 a.m. of the walk-in refrigerator revealed a large stainless steel bowl and a small stainless steel bowl both covered with foil that had no label or date. Further observation revealed a one gallon container of barbeque sauce that had been opened with no open date. Observation on 3/24/2023 at 8:35 a.m. of the dry storage area revealed an opened 24 ounce package of pink lemonade drink mix that was not securely wrapped with no open date. Further observation revealed a clear plastic bag of bran cereal that had been opened on the storage shelf with no open date. Also, a clear plastic resealable bag containing potato chips was found with no label or open date. Interview on 3/24/2023 at 8:45 a.m. with the Kitchen Manager (KM) confirmed that the vanilla ice cream, waffles, and chicken strips in the freezers had no label or date. The KM confirmed that the foiled covered bowls in the walk-in refrigerator and the barbeque sauce all had no labels or dates. The KM confirmed that the pink lemonade mix was not securely wrapped and had no open date and confirmed there were no labels or open dates on the bran cereal and potato chips. Continued interview with the KM revealed that dietary staff should have dated all opened items before storage. She expects staff to securely wrap opened food items before storage as well. 2. Review of the facility's policy titled, Dietary Safety Rules revealed: Hair nets and/or caps should be worn. Observation on 3/25/2023 at 11:30 a.m. revealed dietary cook DD was preparing food items in the kitchen and not wearing any covering over his facial hair. Observation on 3/25/2023 at 5:15 p.m. revealed dietary cook DD was serving resident's food without wearing a restraint over his facial hair. Observation on 3/26/2023 at 9:15 a.m. of dietary cook DD revealed he had facial hair that was not covered while in the food preparation area. Interview on 3/26/2023 at 9:15 a.m. with dietary cook DD revealed that he acknowledge that he should be wearing a beard restraint. He stated that they do not have any beard restraints to wear. Interview on 3/26/2023 at 9:15 a.m. with the KM revealed that male staff with facial hair should be wearing a beard restraint. KM stated that she has been having difficulties purchasing beard restraints from their food supplier. 3. Review of the facility's policy titled, Dishwashing revealed: allow clean dishes to air dry completely before storing. Review of the facility's policy titled, Cooking pots and Steam Table Insert Storage Policy & Procedure revealed: pots and pans will be stored in a manner that keeps them inverted to prevent the collection of dust of debris in them. Steam table inserts used for food holding will be stored inverted in a manner that protects their food contact surfaces from being contaminated. Observation on 3/26/2023 at 9:10 a.m. of the stacked steam table pans revealed that all the stacked pans were stored in the upright position and not covered. A food service grade toaster was located on this pan rack and breadcrumbs were noted on the shelf near the upright stored steam table pans. Continued observation revealed when a stack of three medium sized rectangle steam table pans were pulled apart there was visible moisture/water inside two of the pans. Interview on 3/26/2023 at 9:10 a.m. with the KM confirmed that the steam table pans were not covered with plastic or inverted on the storage shelf. The KM confirmed that the toaster breadcrumbs were on the pan shelf and had the potential to contaminate clean pans. Continued interview with the KM revealed that she expects staff to allow pans to air dry before stacking. Also, the KM revealed that she did not realize that pans needed to be stored either inverted or covered to prevent contamination.

Based on record review, staff interviews, and review of facility policy titled, Abuse Prohibition, Policy and Procedure, the facility failed to complete a background check screening process for two of 10 nursing staff reviewed. Findings include: Review of the facility policy titled, Abuse Prohibition, Policy and Procedure revised [DATE] revealed it is the intent of this facility to actively preserve each resident's right to be free from mistreatment, neglect, abuse, or misappropriation of resident property. Procedures: 1. Screening and Hiring Practices: B. Prior to hiring an employment applicant, the nursing home shall request a criminal record check from GCIC (Georgia Crime Information Center) for Licensed Staff and have applicant submit to a GCHEX (Georgia Criminal History Check System) fingerprint background check for all other staff to determine whether the applicant is Satisfactory for Employment. Review of the facility employee files revealed the following: 1. Licensed Practical Nurse (LPN) EE was hired on [DATE] with no background check completed. 2. LPN FF was hired on [DATE] with no background check completed. LPN EE and LPN FF had active, unencumbered nursing licenses and there were no concerns identified related to abuse or neglect within the facility. Interview on [DATE] at 9:30 a.m. with Human Resources Staff GG revealed the facility did not do the background checks on the new nurses because they were exempt from the fingerprint background check conducted through the state. She stated the owner of the previous company they used for background checks died and they have just recently heard back from a new company that they reached out to. She stated that their local sheriff department does not do background checks. Review of email correspondence from background check company revealed communication to the facility on [DATE], and again on [DATE] with facility login/ password information, with consent and authorization forms.

Based on record review, staff interview, and review of the facility's policy titled, Automatic Stop Orders, the facility failed to ensure a stop date was implemented, not to exceed 14 days for antipsychotic medications, for one of six residents (R) (R#10) reviewed for unnecessary medications. Specifically, the facility failed to implement a stop date for antipsychotic medication ordered as needed (PRN) for R#10, increasing the potential for adverse consequences. Findings include: A review of the facility's policy, Medication Orders-Stop Orders, effective date 11/28/2017, revealed PRN orders for psychotropic drugs are limited to 14 days. A further review revealed PRN antipsychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. A review of the medical record revealed the resident was admitted to the facility with a past medical history of dementia without behaviors, malnutrition, edema, hypothyroidism, hyperlipidemia, dehydration, acidosis, bipolar, major depressive disorder (MDD), anxiety disorder, hypertension (HTN), gastroesophageal reflux disease (GERD), atrial fibrillation (A-Fib), constipation, muscle weakness, acute kidney failure, nausea with vomiting, unsteadiness, altered mental status, and shortness of breath (SOB). A review of the Physician Orders for R#10 dated 3/1/2022 through 3/31/2023 revealed a medical doctor's (MD) order for haloperidol 0.5 milliliters (ml) (2.5 milligrams (mg)) via intramuscular (IM) injection every 12 hours PRN for anxiety. The order had a start date of 2/4/2023, but the order had no stop date. A review of a telephone order for R#10 dated 2/4/2023 at 10:30 a.m. revealed an MD telephone order for Haldol, 0.5 ml (2.5 mg), via IM, every 12 hours PRN for agitation. The order did not have a stop date. A review of the Medication Administration Record (MAR) revealed that staff administered R#10 Haldol 0.5 ml (2.5 mg) via IM injection on 2/4/2023, 2/9/2023, and 2/25/2023. Interview on 3/24/2023 at 12:15 p.m. with the Director of Nursing (DON) verified the PRN Haldol order for R#10 had no stop date. However, the DON stated the medication should have a stop date and she did not know why the medication did not. The DON revealed that she was unaware of the 14-day stop date for psychotropic medications.

Based on observation, record review, and staff interviews, the facility failed to ensure dietary staff followed recipes for preparing pureed foods to avoid compromising the nutritive value, flavor, or appearance. This affected seven of 61 residents receiving an oral diet. Findings include: Review of the recipe for puree chicken revealed for 10 servings to process until smooth 10 - two ounce portions chicken, two tablespoons plus one and one half teaspoons food thickener, and one and one fourth cup chicken broth. Review of the recipe for sweet potatoes (yams) was to place canned yams in mixing bowl, mash, and whip on high speed until smooth. For pureed diets top whipped sweet potatoes with one tablespoon of butter. Review of the recipe for Italian green beans for 10 servings revealed to process until smooth 10 and one half cups prepared green beans. Add three tablespoons plus one teaspoon of food thickener. Observation on 3/25/2023 at 11:30 a.m. of dietary cook DD preparing puree chicken strips, yams and green beans revealed no recipes were seen or used as reference during preparation. Dietary cook DD started with puree chicken strips by placing 14 chicken strips in the food processor bowl. Using a three ounce scoop, the cook then added 10 and one half scoops of food thickener and three quarts of water to the food processor bowl and pureed. The cook added an additional half scoop of food thickener and pureed it again. The cook placed the pureed chicken strips in a steam table pan. When placed in the pan, the pureed chicken had a soup like consistency. Next dietary cook DD pureed yams by placing four cups of cooked yams in the food processor bowl and using a three ounce scoop added seven scoops of food thickener and three quarts of water. The cook pureed and added another half scoop of food thickener. The pureed yams were placed in a steam table pan and also had a soup like consistency. After the chicken and yams, dietary cook DD pureed the green beans by placing four cups of cooked green beans in the food processor bowl and used a three ounce scoop adding 10 and one half scoops of food thickener and three quarts of water and pureed. The pureed green beans also had a soup like consistency. Interview on 3/25/2023 at 11:30 a.m. with dietary cook DD revealed that the amount of food thickener and water he added to the chicken, yams, and green beans was based on his experience. Dietary cook DD stated that sometimes he uses chicken broth instead of water. The cook revealed that he doesn't taste the puree after preparation. Dietary cook DD revealed that there is a binder that contains the recipes for puree foods, and he stated that he did review the recipes for the foods items prepared. Interview on 3/25/2023 at 12:00 p.m. with the Dietary Manager (DM) revealed she expects the dietary cook to follow recipes for puree food items. The DM revealed that water should not have been used, but another liquid such as milk, broth, or gravy should have been used to add flavor. The DM stated that she is not in the kitchen often when the dietary cook is preparing puree foods and was not aware that recipes were not being followed.

Based on staff interviews, record review, and review of the facility's policy titled, Facility COVID-19 Vaccination Plan, the facility failed to ensure 100 percent (%) of all current staff that were providing care for facility residents were fully vaccinated against COVID-19. Findings include: Review of the facility's policy titled, Facility COVID-19 Vaccination Plan, revealed . All staff members will be given information on vaccination from the CDC [Centers for Disease Control and Prevention] about the SAR-CoV-2 [COVID-19] vaccine that is available to our facility through the local health department and/or the facility's pharmacy provider. Vaccination will be encouraged but not required. Should a staff member decline vaccination, medical or religious exemption will be required to continue working in the facility. Review of the facility's Covid-19 data for fully/partially vaccinated staff submitted to the National Health and Safety Network (NHSN) as of 3/25/2023 documented the staff vaccination rate at 100.0%. However, the 100.0 rate was including the 3 partially vaccinated staff members. Calculation of the facility staff's vaccination rate per the NHSN Matrix as of 3/24/2023: Completely vaccinated=80 Granted exemptions=14 Partial vaccinated staff=3 Interview on 3/25/2023 at 1:38 p.m. with the Infectious Control Preventionist (ICP) revealed the facility's policy does not require staff to be vaccinated. She stated unvaccinated staff were educated as well as ongoing in-service education about the proper usage of personal protective equipment (PPE) and handwashing techniques. There were three staff members not vaccinated. All three staff members were interviewed regarding the additional preventive measures used to protect the residents. Interview on 3/25/2023 at 2:40 a.m. with Certified Nursing Assistant (CNA) AA revealed that she had received in-service education on COVID 19, infection control and hand hygiene. She stated that she used the appropriate PPE; face masks, face shields, hand sanitizers, and gloves as needed. No religious or medical exemption was applied for or approved. Interview on 3/25/2023 at 2:45 a.m. with CNA BB revealed that she did not take the second dose of the COVID-19 vaccine due to the facility's new policy of making it not mandatory for staff. CNA BB revealed that she had received in-service education on COVID-19, infection control, and hand hygiene. She stated that she used the appropriate PPE as needed and wore a N-95 mask when the county transmission rate was high. No religious or medical exemption was applied for or approved. Interview on 3/25/2023 at 2:47 a.m. with CNA CC revealed that she did not take the second dose of the COVID-19 vaccine due to how it made her feel. She revealed she was a new employee and did receive in-service education on COVID 19, infection control, and hand hygiene. She stated that she used the appropriate PPE as needed. No religious or medical exemption was applied for or approved.

Based on record review, resident and staff interviews, and review of the facility policy titled Abuse Prohibition Policy and Procedure, that the facility failed to immediately report an allegation of abuse to the state survey agency (SSA) and failed to report the results of abuse investigations to the SSA for two residents (R) of three residents (R#3 and R#7) of three sampled residents reviewed for abuse. This deficient practice had the potential to affect the safety of the residents in the facility. Findings included: Review of a facility policy titled, Abuse Prohibition Policy and Procedure, dated 6/13/2017, revealed, Once a complaint or situation is identified involving alleged mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property the incident will be immediately reported. The Administrator or designee will immediately notify the Complaint Investigation Intake and Referral Unit [state agency] and the legal representative and/or interested family member of the incident and the pending investigation. The Ombudsman and Police Department will also be notified as appropriate. The policy also indicated, A written report of investigation will be submitted to the administrator and to the Long-Term Care Section Complaint Coordinator [state agency], within five (5) working days of the incident. 1. Review of an Admission Record revealed the facility admitted R#3 with diagnoses that included dementia with behavioral disturbance, major depressive disorder, anxiety disorder, hypertension, and altered mental status. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed R#3 had a Brief Interview for Mental Status (BIMS) score of eight, which indicated moderate cognitive impairment. The MDS indicated the resident had delusions and behavioral verbal symptoms directed towards others. Review of a Care Plan, initiated 7/1/2021, revealed R#3 often hallucinated/had delusions. Interventions included always approaching the resident calmly and unhurriedly and speaking in a calm voice; redirecting topics to good thoughts and/or happy memories of the resident's loved ones and/or the resident's dog; and giving the resident time to process thoughts and emotions without judgement. Review of Nurse's Notes, dated 6/20/2022 at 11:00 p.m., revealed R#3 was yelling at the Certified Nursing Assistants (CNAs) that someone raped her. According to the note, the CNAs attempted to tell R#3 that she was safe, and nothing happened. R#3 became upset and aggressive toward the CNAs and began following them into other residents' rooms. There was no documented evidence the sexual abuse allegation was reported to the SSA. Review of Conflict Resolution Meeting, notes dated 6/21/2022, revealed the Administrator met with R#3 concerning the allegation, which was that two young African American men raped the resident at the nursing home. The notes indicated R#3 could not name the attackers and named a few different homes, hospitals, or transport vehicles where the resident claimed the events had happened. According to the notes, the facility started an investigation and contacted the police department. Police Detective GG informed the Administrator the rape allegation had already been investigated, and the results of the investigation revealed no evidence to substantiate the allegations made by the resident. There was no documented evidence that the facility reported R#3's allegation of sexual abuse to the SSA. Review of a Police Department Incident Report, dated 5/1/2021 to 5/19/2022, revealed on 05/19/2022, Police Detective GG received a call from a staff member from the Area Agency on Aging (AAA), Employee OO. AAA Employee OO stated that she received a call from R#3, who stated they had been raped at the nursing home. AAA Employee #OO revealed she had tried to gather more information from the resident, but R#3 was unable to provide additional information other than that the rape was reported to a nurse and that the resident was afraid of the nurse. Interview on 1/10/2023 at 8:30 a.m., R#3 asserted that staff at the facility had raped her. She could not give the name of the person who allegedly raped her, nor when the rape occurred. In addition, R#3 did not know the name of the staff member who was notified of the incident. R#3 then indicated the rape did not occur at the facility. She stated she was raped a long time ago when she worked for the draft board and screened men for the Vietnam War. R#3 revealed that she was hired and worked with a woman but could not recall her name. R#3 further stated that the woman she worked with turned into a man, who then raped her. Interview on 1/10/2023 at 10:12 a.m., the Administrator revealed that late on 6/20/2022, R#3 reported to CNAs that she had been raped. Staff then the allegation to the Administrator. The Administrator revealed the resident initially stated the rape occurred at the nursing home but could not give the date, time, nor the staff involved. She revealed that when R#3 was interviewed, R#3 then stated the rape occurred at a few different homes, hospitals, or in transport vehicles. She further revealed that the police department was notified on 6/21/2022 and they informed the Administrator that an investigation of the rape allegation had been completed and was not validated. The Administrator revealed the police had not informed the facility of the allegation and she did not find out that the police had investigated the allegation until she talked to them on 6/21/2022. 2. Review of an Admission Record revealed the facility admitted R#7 with diagnoses that included major depressive disorder, nontraumatic intracranial hemorrhage, aphasia, cerebral infarction, and nontraumatic intracerebral hemorrhage. Review of the annual Minimum Data Set (MDS), dated [DATE], revealed R#7 had a Brief Interview for Mental Status (BIMS) score of four, which indicated severe cognitive impairment. The MDS indicated the resident could sometimes express ideas and wants and sometimes understood others. Review of a Care Plan, dated as revised on 2/4/2022, revealed the resident had severely impaired cognitive skills and had limited communication with a diagnosis of aphasia. A planned intervention was to allow the resident adequate time to express their needs. Review of a Social Service Progress Note, dated 10/12/2022, revealed R#7 was hallucinating and believed there were men coming out of the resident's bathroom at night trying to attack the resident. According to the note, there was no evidence that men had been in the bathroom and the social worker revealed that the resident may have been seeing the roommate without a wig and thought the roommate was a man. The note indicated the resident also showed signs of a urinary tract infection. The facility moved R#7 to a different room, and R#7's family member was notified of the incident. There was no documented evidence the facility reported the allegation to the SSA and no documentation an investigation report was submitted. Interview on 1/11/2023 at 9:11 a.m., Social Services stated R#7 had been hallucinating and had been observed speaking to a person who was not present. When the resident told the Social Services employee that two men had come out of the resident's bathroom, the employee went into the bathroom, and there were no men in the resident's bathroom. R#7 was in a semi-private room that was shared with another semi-private room. Social Services revealed the resident's roommate had major hair loss and wore a wig during the day; however, when the roommate used the bathroom at night, the resident did not have a wig on, and Social Services stated the roommate may have looked like an African American male to R#7. For the resident's comfort, Social Services stated the resident was moved to another semi-private room with a resident who was not mobile. R#7 had not had any more concerns with men in the bathroom. Social Services employee stated she notified the Administrator of R#7's allegation. Interview on 1/11/2023 at 10:37 a.m., the Director of Nursing (DON) revealed R#7 had been hallucinating and pointed to the bathroom. She was afraid there were men in her bathroom that wanted to harm her. The DON stated she went into the resident's room and the bathroom, and there was no one in the bathroom. The DON stated R#7's roommate got up at night without a wig on, and staff determined the resident was afraid of the roommate. According to the DON, the social worker, the Administrator, the DON, and the resident's family agreed on moving R#7 to a different room with a resident who was not mobile. Interview on 1/11/2023 at 8:34 a.m., the Administrator stated R#7's family member reported the resident saw two African American men coming out of her bathroom who threatened to beat the resident. The family member voiced concern regarding the incident. Social Services was notified and began an investigation. R#7 could not speak clearly but when Social Services interviewed the resident, the resident indicated the African American men were still in the room. Social Services went into the bathroom, and there were no men in the bathroom. The Administrator stated they determined the resident's roommate, who was African American, wore a wig in the daytime, but at night the wig was removed, and R#7 had mistaken the roommate as a man. According to the Administrator, neither an initial report nor a five-day investigation report was filed with the SSA.

Based on record review, resident and staff interviews, and review of the facility policy titled, Abuse Prohibition Policy and Procedure and facility policy review, it was determined that the facility failed to thoroughly investigate an allegation of sexual abuse for one resident (R) of three sampled residents reviewed for abuse. The deficiency had the potential to affect the safety of the residents in the facility. Findings included: Review of a facility policy titled, Abuse Prohibition Policy and Procedure, dated 6/13/2017, revealed Once a complaint or situation is identified involving alleged mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property, the following investigation and reporting procedures will be followed: - The description of the alleged complaint is written on the investigation form including the type of allegation (i.e. [such as], physical abuse, verbal abuse, etc. [et cetera]). Any physical evidence and description of emotional state will be documented. - Information gathering - The following information will be gathered: What allegedly occurred? Who is the alleged victim? Who allegedly did it? (Who is the suspect or physical description); Who did they do it to? (Who is the resident); What happened: (be specific about the event that occurred): When did it happen? (Be as specific as you can with date and time it occurred); Where it happened (the residents room, bathroom, dining room, etc.) Why? (Or any extenuating circumstances that you might have information about. For example, the resident became very combative and was hitting at the aide and the aide hit back). Include cognitive status of victims and residents who are witnesses. - Document the description of the injury. Describe size, color, appearance, and location of any injuries and what treatment was rendered, if any. - Interviews will be conducted of all pertinent parties. Written signed statements from any involved parties will be obtained and notarized, if possible. Statements will be gathered from the suspect, person making accusations, resident involved, reliable residents who may have witnessed the incident, and any other persons who may have some information. Identify any possible conflicts between witnesses. - Past performances and/or previous incidents of involved parties will be evaluated. Review schedule and assignments showing when and where suspect was working at time of alleged incident. - Describe actions taken by facility to protect resident(s) and to prevent a possible reoccurrence during the investigation. Review of the Admission Record for R#3 revealed the resident was admitted with diagnoses that included dementia with behavioral disturbance, major depressive disorder, anxiety disorder, hypertension, and altered mental status. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed R#3 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderate cognitive impairment. The MDS indicated the resident had delusions and behavioral verbal symptoms directed towards others. Review of a Care Plan, initiated 7/1/2021, revealed R#3 often hallucinated/had delusions. Interventions included always approaching the resident calmly and unhurriedly and speaking in a calm voice; redirecting topics to good thoughts and/or happy memories of the resident's loved ones and/or the resident's dog; and giving the resident time to process thoughts and emotions without judgement. Review of Nurse's Notes, dated 6/20/2022 at 11:00 p.m., revealed R#3 was yelling at the Certified Nursing Assistants (CNAs) that someone raped the resident. According to the note, the CNAs attempted to tell R#3 that they were safe, and nothing happened. Review of Conflict Resolution Meeting, notes dated 6/21/2022, revealed the Administrator met with R#3 concerning the resident's allegation, which was that two young African American men raped the resident at the nursing home. The notes indicated R#3 could not name the attackers and named a few different homes, hospitals, or transport vehicles where the resident claimed the events had happened. According to the notes, the facility started an investigation and contacted the police department. Police Detective HH informed the Administrator the rape allegation had already been investigated, and the results of the investigation revealed no evidence to substantiate the allegations made by the resident. There was no documented evidence that the facility completed the investigation. Review of a Police Department Incident Report, dated 5/1/2021 to 5/19/2022, revealed the investigation or R#3's abuse allegation was cleared on 6/17/2022 and was unfounded. According to the report, on 5/19/2022, a staff member from the Area Agency on Aging (AAA), Employee OO called Police Detective GG. AAA Employee OO advised that she had received a call from R#3, who stated they had been raped at the nursing home. AAA Employee OO revealed she had tried to gather more information from the resident, but R#3 was unable to provide additional information other than that the resident had reported the rape to a nurse but was afraid of the nurse. On 6/10/2022, Police Detective GG met R#3's daughter at the facility and interviewed the resident about the reported rape. R#3 reported being drugged and then raped by a nursing home staff member shortly after the she was admitted to the facility, which was over two years ago. The report indicated R#3 had been at the facility for a year. According to the report, the case was closed as unfounded due to no evidence to substantiate the allegations made by R#3. Interview on 1/10/2023 at 8:30 a.m., R#3 asserted that staff at the facility had raped her. Resident #3 could not give the name of the person who allegedly raped the resident nor when the rape occurred. In addition, she did not know the name of the staff member who was notified of the incident. R#3 then indicated the rape did not occur at the facility. The resident stated they were raped a long time ago when the resident worked for the draft board and screened men for the Vietnam War. R#3 revealed a woman hired the resident and the resident worked with that woman. The resident could not remember the name of the woman but stated the woman was very nice at first but then turned into a man, and the man raped her. Interview on 1/10/2023 at 10:51 a.m., Police Detective GG revealed he met with the resident's family member, who stated R#3 had told the family member a couple of times about being raped at the facility but could never give details of what happened. When the resident was she reported the incident had happened two years ago, could not give any details, and there was no evidence to substantiate the rape allegation. Interview on 1/10/2023 at 10:12 a.m., the Administrator revealed that late on 6/20/2022, R#3 reported to CNAs that R#3 had been raped. The Administrator revealed the resident initially stated the rape occurred at the nursing home and when interviewed, stated the rape occurred at a few different homes, hospitals, or transport vehicles. The Administrator stated the police department was notified on 6/21/2022 and learned that the police had completed an investigation of the rape allegation previously and determined it was not validated. The Administrator stated she did not complete an investigation of the allegation because Police Detective GG had done an investigation and had no evidence to substantiate the rape allegation.

Based on interviews and record review the facility failed to employ a qualified Dietary Manager. This had the potential to affect 60 of 60 residents residing in the facility. Findings include: Review of dietary certifications in the kitchen did not reveal evidence of a 'Certified' or qualified Dietary Manager. An interview on 6/7/2021 at 10:05 a.m. with the Dietary Manager (DM) revealed she took over the position of DM approximately one year ago but has been working at the facility since November 2016. She indicated she does not have a DM Certification and is not currently enrolled in a Certified Dietary Manager course at this time. An interview on 6/10/2021 at 10:32 a.m. with Administrator revealed the DM has been with them for several years. He reported the DM started as a dining room attendant and kitchen aide. When the previous DM left, they promoted her March 2019, to DM because she showed the most drive. The Administrator confirmed that he is aware of the regulatory requirements for a qualified dietary manager and further confirmed the DM does not have a certification. He revealed trying to get her set up to go through the course, but this has not happened. An interview on 6/10/2021 at 2:08 p.m. with the Chief Operating Officer (COO) revealed he was unaware the facility could contact a contract agency to provide full time qualified staff in the DM position while they recruited. He further reported they have been encouraging the DM to enroll in a Certification course. The COO provided an email, dated May 5, 2021, requesting assistance with seeking applicants for their CDM position at this facility. The email is addressed to the President of the Certified Dietary Manager Association off Georgia.

Based on observations, interviews and review of policies titled Food Storage, Food Production, and General Food Preparation and Handling, the facility failed to properly label food items, failed to properly thaw meat, failed to maintain clean equipment, and failed to keep staff drinks separate from facility foods. This had the potential to affect 60 of 60 residents residing in the facility. Findings include: Review of facility policy titled Food Storage dated 2013 revealed . 4. All containers must be legible and accurately labeled and dated. 8. All stock must be rotated with each new order received. Rotating stock is essential to assure the freshness and highest quality of all foods. a. old stock is always used first (first in - first out method), c. Food should be dated as it is placed on the shelves. d. Date marking to indicate the date or day by which a ready to eat, potentially hazardous food should be consumed, sold, or discarded will be visible on all high risk food (see chart on next page). e. Foods will be stored and handled to maintain the integrity of the packaging until ready for use. Review of facility policy titled Food Production dated 1998-1999 revealed . e. Thawing - Policy: Food shall be thawed in a safe and sanitary manner. Procedure: . 4. Foods which have not completely thawed by production time may be thawed under cold running water. 5. Equipment: a. All food service equipment should be cleaned, sanitized, dried, and reassembled after each use. Review of facility policy titled General Food Preparation and Handling dated 2013 revealed . 3. Food Preparation a. Meats, fish and poultry are defrosted using safe thawing practices: . In the sink, submerging the item under cold water (<70 F) that is running fast enough to agitate and float off loose ice particles. An observation on 6/7/2021 at 10:05 a.m. of the kitchen revealed that reach-in freezer number one with frozen meats, starches and vegetables with no label or date indicating when it was delivered, what the item is or the use by date, and a personal bottle of water on the top shelf. An observation on 6/7/2021 at 10:07 a.m. of the kitchen revealed that reach-in freezer number two with frozen meats in a zip lock bag dated May 2, 2021, without the name of the meat, an opened bag secured with a wire tie that is unlabeled and undated, a zip lock bag with several meat patties also unlabeled and undated. An observation on 6/7/2021 at 10:16 a.m. of the fryer revealed a power outlet next to the fryer heavily soiled with what appears to be grease and food debris. Additionally, there is piping behind the fryer also heavily soiled with what appears to be grease and dust. An observation on 6/7/2021 at 10:17 a.m. of the meat slicer revealed the slicer to be uncovered with food debris on the on the blade and device that holds the meat in place while slicing. An observation on 6/7/2021 at 10:20 a.m. of the walk in cooler revealed a take-out bag with a resident name and dated 6/6/2021. No use by or discard date is visible. An observation on 6/7/2021 at 10:20 a.m. of the walk in freezer revealed two bags of frozen meats not labeled or dated with a delivery date or 'use by' date. An observation on 6/7/2021 at 10:21 a.m. of the walk in cooler revealed a take-out Styrofoam cup with straw sitting atop a food container. It further revealed an unlabeled, undated zip lock bag of block sliced yellow cheese. An observation on 6/7/2021 at 10:26 a.m. of the pantry revealed an undated zip lock bag of brownie mix, multiple #10 cans of vegetables, pudding, fruits without delivery dates, use by dates or best by dates. An observation on 6/7/2021 at 10:29 a.m. of a prep sink revealed two packages of ham sitting in standing water. An interview and observation on 6/7/2021 at 2:26 p.m. with the Dietary Manager confirmed the above observations. She indicated she was not aware that packages coming out of boxes required a label with item name or date. She further indicated she was not aware of pantry items requiring a label or date of deliver, use by or best by dates.

Based on observation and staff interview the facility failed to ensure that privacy curtains provided full visual privacy, which included a total of 11 of 12 rooms on one hall. Findings include: During the initial tour on 6/7/2021 between 10:45 a.m. and 12:00 p.m. observation revealed resident privacy curtains with a width space/gap which did not ensure full visual privacy coverage during patient/resident care, including rooms 100, 123, 125, 127, 129, 131, 132, 133, 134, 135, and 136. An observation and interview was conducted on 6/10/2021 at 10:35 a.m. with Certified Nursing Assistant (CNA) BB in room 127 revealed that the CNA stated the curtains are not the correct size to go around the resident to provide privacy during care. An interview and observation was conducted on 6/10/2021 at 10: 30 a.m. with the Maintenance Assistant (MA) and Environmental Supervisor (EVS) revealed that both became aware of the privacy curtain width for approximately two weeks. The EVS revealed that every room in the facility had the same privacy curtains except room 130. The EVS stated the Environmental Service Department had installed the privacy curtains and that during the installation the EV staff reported that the curtains did not provide full visual privacy although staff were instructed to continue to install the curtains. The EVS revealed that she did not make the Administrator aware that the width of the privacy curtain did not provide full visual privacy to the residents because the Administrator was the person that place the order for the privacy curtains. The EVS revealed that the CNA supervisor was made aware that the privacy curtains did not provide privacy to the residents, although she did not initiate an in-service training for her staff on what to do to ensure each resident will maintain dignity and privacy when receiving patient care. The Maintenance Assistant (MA) revealed at this time that a resident complained a week ago, that the curtain not providing privacy which was reported to the Administrator. The MD measured the privacy curtain, the curtain was pulled around to the front part of the resident's bed were the ceiling track stops there was a gap that measured 67 inches. An interview on 6/10/2021 at 10:45 a.m. with Floor Tech (FT) FF, stated it was his responsibility to install the new privacy curtains and when he noticed the width of the privacy curtains were not wide enough to provide full privacy to the residents it was reported to the Administrator. The FT stated he was instructed to continue to installed the new curtains in all the resident's rooms although the width of the privacy curtains provide the resident with privacy. An interview was conducted on 6/10/2021 at 11:00 a.m. with CNA Supervisor GG revealed that she was aware that the curtain width was not adequate to provide privacy to the residents. The CNA stated she did not provide the other CNA's on the unit in-service on an alternate way to provide the resident with privacy. An interview on 6/10/2021 at 12:30 p.m. with the Administrator stated he was made aware of the privacy curtains two weeks ago, by the EVS. The Administrator stated he did not in-service the staff on alternate way to provide the resident with privacy. The Administrator stated he has not purchased any new privacy curtains to replace the ones that are currently installed. An interview was on 6/10/2021 at 12:40 p.m. with Resident A revealed that she had reported to the Administrator that the privacy curtains were note wide enough to completely go around her bed and her roommate's privacy curtain was not wide enough to completely go around her bed. The resident stated that she was unable to block the light from her roommate's window because the privacy curtains were not wide enough. She further stated that her roommate was unable to block the light from her television because her privacy curtain was not wide enough.

Based on observation, staff interviews and the review of the policy titled, Maintenance Department Policy and Procedure the facility failed to provide a safe/clean/comfortable/ homelike environment on one out of two halls (front hall) and two out of two shower rooms. The facility census was 60. Findings include: Review of the policy titled, Maintenance Department Policy and Procedure dated 3/18/2020 indicated; To Assure proper maintenance of the physical plant. General Facility Maintenance: The department will do ongoing monitoring of the facility for areas needing repair. Miscellaneous: Leaks and areas of moisture should be fixed promptly and drywall, ceiling tiles and other materials should be replaced. An observation on 6/8/2021 at 9:33 a.m. room 100 of the bathroom shared by two residents, and the area around the toilet was orange-brown rust color and the toilet paper holder was rusted. An observation on 6/8/2021 at 9:39 a.m. of the water fountain located between room 100 and 123 covered in brown substance with paper in the water fountain. An observation on 6/8/2021 at 9:58 a.m. of room 123 the bathroom occupied by one resident. Around the toilet, the sink, and the baseboard under the sink was an orange-brown rust color. An observation on 6/8/2021 at 10:02 a.m. of room 127 of 8 brown stained ceiling tiles. The ceiling tile near bed A was stained and bulging. An observation on 6/8/2021 at 10:10 a.m. of room 129 revealed one brown stained bulging ceiling tile over the B bed. An observation on 6/8/2021 at 10:15 a.m. of room 131 revealed one brown stained bulging ceiling tile over the B bed. Around the toilet an orange-brown rust color. An interview and observation was conducted on 6/10/2021 at 10:45 a.m. to 10:59 a.m. with the Maintenance Assistance. The MD confirmed the following: The MD stated the orange-brown color rust stains around the toilets in room 100, 123, and 131 was not rust but from water damage. He confirmed toilet paper holder in room 100 was rusted. Room 127 with eight stained ceiling tiles with one stain bulging ceiling tile over near bed A. The water fountain located between room 100 and 123 covered in brown substance with paper in the water fountain. The second water fountain was dirty with a plug sitting on top. The MD stated the water fountains were not working but should be clean or removed. The bathroom in room 123 the sink, and the baseboard under the sink orange-brown rust color. Room 129 bulging ceiling tile above the resident in 129-B. Room 131 one bulging ceiling tile above the resident in 131-B. An observation on 6/10/2021 at 11:05 a.m. of the Master Bath 1 with five areas separated with shower curtains and the Master Bath 2 with one shower and toilet area. The following was observed: Prior to entering the Master bath 1, on the floor was cardboard with blue tape. Observation upon entering the Master Bath 1 to the right is the toilet room area where an approximately 2 feet of ceramic floor tile were missing. The toilet and toilet bowl was dirty and the area around the toilet has clutter. The outside of the shower/toilet room area the ceiling vent was rusted and the ceiling tile around the vent had brown stains. The ceiling tile also had missing pieces. As you enter the shower to your right the area around the shower door and base board had a heavy brown substance and the shower had missing pieces of ceiling tile. The whirlpool/bathtub was dirty with rust stains. Standing in front of the whirlpool/bathtub to your right the floor was covered with green color substance. The shower on the left, upon entering the Master Bath 1, had a white bucket with a yellow substance that smelled of urine. The base board and floor was covered with a heavy brown substance. The seven hanging shower curtains had stains and were dirty. The floor in the shower room was dirty with visible hairs, black and brown stains, missing paint on the ceramic tile and two dirty shower chairs. The inside of the door of the Master Bath 1 had missing wood. The Master Bath 2 entrance had missing and cracked ceramic floor tile. The Master Bath 2 was dirty and cluttered around the toilet and toilet bowl. The Master Bath 2 shower room has missing ceiling tile, there were missing ceramic tile, a brown substance was observed around the base board, the shower chair was dirty, the chair in the bathroom cushion was torn and the eye wash station was dirty. An interview on 6/10/2021 at 11:30 a.m. with Certified Nursing Assistant (CNA) HH, revealed that the Master Bath 1 is utilized for residents who are totally dependent on assistance and that Master Bath 2 is utilized for residents who need some or little assistance with bathing. She stated residents are given baths and showers daily in both Master Baths. The CNA confirmed that Master Bath 2 was dirty. An interview and observation was conducted with on 6/10/2021 at 11:40 a.m. the Environmental Service Supervisor (EVS) on 6/10/21 at 11:40 a.m. revealed the housekeeping staff maintain and clean master baths (both 1 and 2) multiple times per day and she confirms that both Master Bath 1 and 2 were dirty and unkept.

Based on observation, record review, policy review and staff interviews, the facility failed to develop a individualized person-centered care plan for activities for three (3) residents (R) (R A, R B, R C) of three (3) residents reviewed to ensure that measurable objectives and timeframe to meet resident's individual needs were included. Findings include: Review of the facility's undated policy, titled: Care Plan Policy and Procedure indicated the purpose is the identification of problems and developing solutions providing individualization and coordination of resident care. Information to be included in the care plan is care necessitated by patient needs and include: Social, Spiritual, Emotional and Physical. 1. Review of the clinical record for R A revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 13, indicating no cognitive impairment. Section F 0500 indicated preferences are very important to resident. Section F 0800 does not reveal any type of preferences checked for resident. Review of residents care plan initiated 10/3/17 revealed there was no indication that nursing staff had developed or implemented specific goals with interventions to address the residents preferences for activities. Interview on 3/12/19 at 12:40 p.m. with Certified Nursing Assistant Supervisor (CNA) AA, stated that she helps get residents to activities but does not typically stay and assist with any of the activities. She further stated that she does not do any 1:1 activities for residents. She stated that all the residents are out of their rooms, and if they don ' t participate in the main activity, they can do individual things, like music therapy with the IPODS or word find books or coloring books. Observation on 3/11/19 at 9:20 a.m., revealed R A sitting at the front lobby, with coloring book and color pencils on her tabletop, but not actively coloring. Observation on 3/11/19 at 9:45 a.m. revealed a small bible study group in dining room. Resident A was not in attendance at this group activity. There was no staff member present during the activity. Observation on 3/12/19 at 9:20 a.m., revealed resident A was sitting at the front lobby, not engaged in any type of activity. Observation on 3/13/19 at 9:30 a.m., revealed bible study being held in cafeteria. Resident A was not in attendance at this group activity. There was no staff member was present during the activity. 2. Review of the clinical record for R B revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 14, indicating no cognitive impairment. Section F 0500 indicated preferences are somewhat important to resident. Section F 0800 does not reveal any type of preferences checked for resident. Review of residents care plan initiated 4/9/15 revealed there was no indication that nursing staff had developed or implemented specific goals with interventions to address the residents preferences for activities. Observation on 3/11/19 at 9:20 a.m., revealed R B sitting at the front lobby, with coloring book and color pencils on her tabletop, but not actively coloring. Observation on 3/11/19 at 9:45 a.m. revealed a small bible study group in dining room. Resident B was not in attendance at this group activity. There was no staff member present during the activity. Observation on 3/12/19 at 9:20 a.m., revealed resident B was sitting at the front lobby, not engaged in any type of activity. Observation on 3/13/19 at 9:30 a.m., revealed bible study being held in cafeteria. Resident B was not in attendance at this group activity. There was no staff member was present during the activity. 3. Review of the clinical record for R C revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 14, indicating no cognitive impairment. Section F 0500 indicated preferences are very important to resident. Section F 0800 does not reveal any type of preferences checked for resident. Review of residents care plan initiated 1/28/19 revealed there was no indication that nursing staff had developed or implemented specific goals with interventions to address the residents preferences for activities. Observation on 3/11/19 at 9:20 a.m., revealed R C sitting at the front lobby, with coloring book and color pencils on her tabletop, but not actively coloring. Observation on 3/11/19 at 9:45 a.m. revealed a small bible study group in dining room. Resident C was not in attendance at this group activity. There was no staff member present during the activity. Observation on 3/12/19 at 9:20 a.m., revealed resident C was sitting at the front lobby, not engaged in any type of activity. Observation on 3/13/19 at 9:30 a.m., revealed bible study being held in cafeteria. Resident C was not in attendance at this group activity. There was no staff member was present during the activity. Interview on 3/13/19 with the Administrator, stated all residents are encouraged to get up, and most all of them get out of bed every day and placed in the dayroom. She stated that the activities and restorative programs go hand in hand, as indicated on the care plan under restorative nursing, as far as filling the day with activities, such as walking, grooming and nail care. When asked if those types of activities, such as walking, grooming and nail care, were considered activities of daily living (ADL), she stated not when they are incorporated into the restorative program on the care plan. Cross Refer F679

Based on observations, record review, policy review, resident and staff interviews, the facility failed to ensure an ongoing program of activities based on activity preference assessments for three (3) residents (R) (R A, R B, R C) of three (3) residents reviewed. These residents were not provided with person-centered activities that would meet their individual needs. Findings include: Review of the facility policy titled Activities Program Policy and Procedure undated, revealed the purpose of this program is to ensure the facility involves the residents in an ongoing program of activities that are designed to appeal to his/her interests and to enhance the resident's highest practicable level of physical, mental, and psychosocial well-being. Points to remember: 1.) Activities refer to any endeavor, other than routine ADL's, in which a resident participates that is intended to enhance his/her sense of well-being and to promote or enhance physical, cognitive, and emotional health. They include activities that promote self-esteem, pleasure, comfort, education, creativity, success and independence. 2.) One-to-one programming refers to programming provided to residents who will not, or cannot, effectively plan their own activity pursuits, or residents needing specialized or extended programs to enhance their overall well-being. 3.) Person appropriate refers to each resident that has a personal identity and history that involves activities that should be relevant to the specific needs, interests, culture, and background. 4.) Combination of large group and small group, one-to-one, and self-directed activities in a system that supports the development, implementation and evaluation of the activities provided to the residents in the facility. 4.) Care planning involves identification of the residents interests, preferences and abilities. 5.) Goals should be based on measurable objectives and focused on desired outcomes, not merely on attendance at a certain number of activities per week. 1. Review of the clinical record for R A revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 13, indicating no cognitive impairment. Review of the Preferences for Routine and Activities section F 0500 noted the primary respondent for the questions was the resident, which revealed the following: it was very important for her to listen to music she likes, be around animals, keep up with the news, do things with groups of people, do favorite activities and go outside for fresh air. Section F 0800 does not reveal any type of preferences checked for resident. Review of R A admission activity assessment dated (MONTH) (YEAR), revealed resident currently enjoys 17 out of 19 activity preferences offered, including arts/crafts, shopping trips, outdoor activities, gardening, helping others, pets/animals and beauty shop/manicures. Further review of the admission assessment revealed Activity Plan: no notations are indicated for individualized care plan for activities. Review of residents care plan initiated 10/3/17 revealed there was no indication that nursing staff had developed or implemented specific goals with interventions to address the residents preferences for activities. Review of the activity interest and attendance records for the past three (3) months reveal resident has been actively participating in ESA/snack time, movement, memory and grooming (MM&G), porch sitting, 1:1 activities/self directed activities and TV/talking and games, family visits and BINGO. Observation on 3/11/19 at 9:20 a.m., revealed R A sitting at the front lobby, with coloring book and color pencils on her tabletop, but not actively coloring. Observation on 3/11/19 at 9:45 a.m. revealed a small bible study group in dining room. Resident A was not in attendance at this group activity. There was no staff member present during the activity. Observation on 3/12/19 at 9:20 a.m., revealed R A was sitting at the front lobby, not engaged in any type of activity. Observation on 3/13/19 at 9:30 a.m., revealed bible study being held in cafeteria. Resident A was not in attendance at this group activity. There was no staff member was present during the activity. Interview on 3/12/19 at 11:54 a.m., with R A stated there could be more activities offered and not a variety of activity choices. She stated it's the same stuff every day. She further stated the facility doesn't provide any extra materials for independent activities, such as crossword books or word searches. She states the facility has only one activity a week and that is bingo. Interview on 3/12/19 at 12:40 p.m. with Certified Nursing Assistant Supervisor (CNA) AA, stated that she helps get residents to activities but does not typically stay and assist with activities. She further stated that she does not do any 1:1 activities for residents. She stated that all the residents are out of their rooms, and if they don ' t participate in the main activity, they can do individual things, like music therapy with the IPODS or word find books or coloring books. 2. Review of the clinical record for R B revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 14, indicating no cognitive impairment. Review of the Preferences for Routine and Activities section F 0500 noted the primary respondent for the questions was the resident, which revealed the following: it was very important for her to do her favorite activities and somewhat important for her to listen to music she likes, be around animals, to things with groups of people, and participate in religious preferences. Section F 0800 does not reveal any type of preferences checked for resident. Review of R B admission activity assessment dated (MONTH) 2012, revealed resident currently enjoys 8 out of 10 activity preferences offered, including arts/crafts, spiritual/religious groups, outdoor activities and pets/animals. Further review of the admission assessment revealed Activity Plan: no notations are indicated for individualized care plan for activities. Review of residents care plan initiated 4/9/15 revealed there was no indication that nursing staff had developed or implemented specific goals with interventions to address the residents preferences for activities. Review of the activity interest and attendance records for the past three (3) months reveal resident has been actively participating in ESA/snack time, movement, memory and grooming (MM&G), porch sitting, 1:1 activities/self directed activities and TV/talking and games. Observation on 3/11/19 at 9:20 a.m., revealed R B sitting at the front lobby, with coloring book and color pencils on her tabletop, but not actively coloring. Observation on 3/11/19 at 9:45 a.m. revealed a small bible study group in dining room. Resident B was not in attendance at this group activity. There was no staff member present during the activity. Observation on 3/12/19 at 9:20 a.m., revealed R B was sitting at the front lobby, not engaged in any type of activity. Observation on 3/13/19 at 9:30 a.m., revealed bible study being held in cafeteria. Resident B was not in attendance at this group activity. There was no staff member was present during the activity. Interview on 3/12/19 at 2:17 p.m., R B stated she chooses not to participate in activities because they do not offer any that interest her. She stated that the staff do not come and encourage her to participate in activities. Resident has spoken to Social Services Director (SSD) about offering different activities such as sewing. She stated that the SSD responded saying she will work on it but resident hasn't seen any changes. Interview on 3/13/19 at 10:56 a.m. with SSD, stated she remembers having a conversation with R B about her interest in activities, stating she wanted to do things with her hands. She stated that she talked with the Activity Director (AD) about residents ' requests. She further stated that the AD did a couple of activities with resident for a few weeks, like rolling yarn and painting, but they don't do them anymore. She's not sure why not though. She stated she did not make any type of documentation about R B conversation with her about the activities program. 3. Review of the clinical record for R C revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 14, indicating no cognitive impairment. Review of the Preferences for Routine and Activities section F 0500 noted the primary respondent for the questions was the resident, which revealed the following: it was very important for her to have books, newspapers and magazines to read, listen to music she likes, be around animals and keeping up with the news. Section F 0800 does not reveal any type of preferences checked for resident. Review of R C admission activity assessment dated [DATE], revealed resident currently enjoys 8 out of 19 activity preferences offered, including arts/crafts, BINGO, reading, social visits and pets/animals. Review of residents care plan initiated 1/28/19 revealed there was no indication that nursing staff had developed or implemented specific goals with interventions to address the residents preferences for activities. Review of the activity interest and attendance records for the past two (2) months reveal resident has been actively participating in ESA/snack time, movement, memory and grooming (MM&G), mid day stretch/fresh face, 1:1 activities/self directed activities and TV/talking and games. Observation on 3/11/19 at 9:20 a.m., revealed R C sitting at the front lobby, with coloring book and color pencils on her tabletop, but not actively coloring. Observation on 3/11/19 at 9:45 a.m. revealed a small bible study group in dining room. Resident C was not in attendance at this group activity. There was no staff member present during the activity. Observation on 3/12/19 at 9:20 a.m., revealed R C was sitting at the front lobby, not engaged in any type of activity. Observation on 3/13/19 at 9:30 a.m., revealed bible study being held in cafeteria. Resident C was not in attendance at this group activity. There was no staff member was present during the activity. Interview on 3/12/19 at 11:46 a.m., with R C, stated that there are not enough activities at the facility and not a variety of activity choices. She stated she'd rather sit in her room, because the activities are boring. She further stated the facility doesn't provide any extra materials for independent activities, such as crossword books or word searches. She states the facility has only one activity a week and that is bingo. Interview on 3/13/19 at 11:06 a.m., with Activity Director (AD), stated that there are two (2) main activities for the day, one in the morning, which is MM&G, which stands for movement, music and grooming. She stated there are only about six (6) residents who participate in that activity. She stated they have Bingo on Mondays and Saturdays in the afternoon, and there are about 12 residents who participate in that activity. She states there is Bible study on Monday/Wednesday and Sunday afternoons, provided by outside volunteers. She stated that she will go around and remind certain residents of the scheduled activities for the day. She further stated she does not do any type of 1:1 activity with residents, other than providing music therapy via IPODS for a couple of residents. She stated she documents on the activity flow sheet to show which residents are participating and their level of participation. She further stated that she completes activity flow sheets for all residents in the facility. Interview on 3/13/19 with the Administrator, stated all residents are encouraged to get up, and most all of them get out of bed every day and placed in the dayroom. She stated that the activities and restorative programs go hand in hand as far as filling the day with activities, such as walking, grooming and nail care. When asked if those types of activities, such as walking, grooming and nail care, were considered activities of daily living (ADL), she stated not when they are incorporated into the restorative program. She stated that there are various activities being offered and residents are given a monthly calendar to view for when activities are offered. She further stated that all residents are getting some sort of activity daily, as evidenced by the daily activity participation records.

Based on observations, policy review and interviews, the facility failed to ensure that it was maintained in a safe, lean and comfortable home-like environment in six resident rooms (rooms 101, 102, 103, 104, 105 and 136 on two of three halls. The census was 68 and sample size was 36. Findings include: Review of the undated facility policy titled Housekeeping Policy and Procedure indicated the purpose of housekeeping is one of the most important environmental services that plays a major role in providing a healthy, comfortable environment. OBRA requires housekeeping services necessary to maintain a sanitary, orderly and comfortable interior. This service makes a significant contribution to facility-wide sanitary practices and prevents the spread of disease-causing organisms. Review of Maintenance Log revealed there was no routine check for safety of the slip strips in resident rooms. Observation on 9/4/18 at 11:37 a.m., revealed in room [ROOM NUMBER]-1 privacy curtain with three patches of dark brown colored circular areas on bottom portion of curtain; air conditioner (AC) vent face grill with moist black substance between louvers; bathroom has slip strip in front of toilet peeling up on one end. Observation on 9/4/18 at 11:41 a.m., revealed in room [ROOM NUMBER]-1 resident personal fan grill with thick layer of brown dust present; strong urine odor present in bathroom. Observation on 9/4/18 at 11:45 a.m., revealed in room [ROOM NUMBER] slip strip in bathroom peeling up on one end. Observation on 9/4/18 at 11:47 a.m., revealed in room [ROOM NUMBER] slip strip in bathroom peeling up on one end. Observation on 9/4/18 at 11:55 a.m., revealed in room [ROOM NUMBER] slip strip in bathroom peeling up on one end; strong urine odor present in bathroom. Observation on 9/4/18 at 1:45 p.m., revealed in room [ROOM NUMBER] scuff marks noted on bottom of door panel and chipped off wood part of lower bathroom door; Scuff marks on door frame; and slip strip in bathroom peeling up on one end. Interview on 9/6/18 at 8:59 a.m., with Housekeeper DD stated that she cleans every room everyday. She stated that she sweeps and mops the floors, dusts the blinds, window sills and the furniture, if needed. She empties the trash, cleans the bathroom, including the toilet and sink. She further stated that she restocks the supplies, such as hand soap, hand sanitizer and gloves in the resident rooms. On 9/6/18 at 2:30 p.m., walking rounds with Administrator verified the identified environmental concerns. She further stated there is a daily walking rounds checklist the facility uses, but it does not cover things like the slip strips on the floor. She stated that there is not a policy per say on when things are looked at. She stated that staff are assigned daily to do compliance rounds, where they look for things such as unbagged/unlabeled personal care equipment, privacy curtains, and anything that needs to be addressed by specific departments. Interview on 9/6/18 at 2:30 p.m., with Maintenance Director, stated that staff notify him of repairs needed in the facility, either by word of mouth, or a hand written work order. He tries to prioritize requests based on need. He further stated there is not a routine for checking the slip strips in the rooms, but staff sometimes tell him about them peeling up. He further stated he was not aware of any of the environmental concerns identified during the survey until Administrator informed him post walk through. He provided to surveyor a copy of the checklist for Maintenance, which is broken down into daily tasks, weekly tasks and monthly tasks, and checking the slip strips was not listed on the checklist. Interview on 9/6/18 at 4:31 p.m., with Administrator, stated that she could not find any documentation from the Compliance rounds for the past two years.

Based on observation, record review, policy review and staff interviews, the facility failed to follow develop a person centered care plan to reflect release and exercise all extremities for lap tray restraint for one resident (R) #51. The sample size was 36. Findings include: Review of the facility policy title Care Planning d\revised (MONTH) 30 (YEAR), revealed it is the policy of(NAME)Health and Rehab, that we will provide a care plan for each resident. It will include an initial admission care plan within 48 hours of admission to the facility. A comprehensive care plan will be completed for all residents by the 14th day after admission. The purpose of the care plan is to provide an overall representation of the resident's care and will provide a tool of communication to staff for those needs. Review of the clinical record for R #51 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 3, indicating severe cognitive impairment. Section P-physical restraints-chair prevents rising used daily. Review of R #51 updated care plan, dated 8/15/18, did not have evidence that R #51 had a care plan problem to include exercising all extremities with release of lap tray every two (2) hours. Interview on 9/5/18 at 12:08 p.m., with Registered Nurse EE stated that interventions are placed on the care plans and that any licensed staff can update care plans to reflect new interventions being added. Interview on 9/6/18 at 12:14 p.m., with Certified Nursing Assistant (CNA) CC stated that she releases resident lap tray every two hours when taking him to bathroom or changing his soiled clothing. She further stated that she does not do any type of exercises when the tray is released. Interview on 9/6/18 at 2:14 p.m., with Director of Nursing (DON) stated that her expectation is that nurses update the are plans with interventions for falls as soon as the problem is identified. She stated the nurse on the floor working with the resident is responsible for updating the care plan. She verified that R #51 care plan had problem for use of lap tray restraint, but did not include intervention to release tray and exercise all extremities every two hours. Cross Refer F684

Based on observation, record review, policy review and staff interviews, the facility failed to follow the Physician order [REDACTED].#51) related to release of lap tray restraint and exercising of all extremities. The sample size was 36. Findings include: Review of the undated Policy titled Physical Restraint Policy and Procedure revealed physical restraints are devices used to provide greater safety, prevent injury, and/or enable and promote functional independence for a resident. For temporarily removing restraints should be done every two hours for at least ten minutes to exercise the resident. Review of the Physician order [REDACTED]. Review of the clinical record for R #51 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 3, indicating severe cognitive impairment. Section P-physical restraints-chair prevents rising used daily. Review of daily Certified Nursing Assistant (CNA) worksheets dated 6/29/18 through 8/30/2018 do not reflect that lap tray was released with exercising of all extremities was performed every two hours, as ordered by physician. Interview on 9/5/18 at 3:41 p.m., with CNA BB stated she works restorative and also works on floor. She stated that R#51 is walked daily for at least 15 minutes, she also sets him up for brushing his teeth. She does not do any type of upper extremity exercise for R#51. Interview on 9/6/18 at 12:14 p.m., with CNA CC stated that she releases R #51 lap tray every two (2) hours when taking him to bathroom or when changing his soiled clothing. She stated that resident had been falling a lot and since he has the lap tray, he is not able to get up without assistance from staff. She further stated that she does not do any type of exercises when the tray is released. Interview on 9/6/18 at 12:58 p.m., with Administrator stated that toileting resident is proof that the restraint was released; and resident is toileted every two hours. She further stated that restorative aide walks resident daily, and the restraint is released at that time. When asked about the physician order [REDACTED]. She could not locate anything on the restorative worksheet or the Activities of Daily Living (ADL) worksheet to reflect exercising all extremities had been completed.