Every finding on record at Marietta Center for Nursing and Healing

Based on observation, staff interviews, and the facility's policy titled, Sanitation, the facility failed to maintain the kitchen in a sanitary manner when wet paper towels were stored directly on top of a clean silverware tray containing six rolled sets of silverware intended for resident use. This deficient practice had the potential to contaminate clean food-contact surfaces and affect the 137 residents who received meals prepared in the kitchen, out of a total of 145 residents.Findings include:Observation on 07/23/2026 at 9:25 AM in the kitchen revealed wet paper towels resting directly on top of a clean silverware tray containing six rolled sets of silverware intended for resident use. A personal water bottle was also observed stored adjacent to the clean silverware tray.During an interview on 07/23/2026 at 9:27 AM, Dietary [NAME] 1 stated the wet paper towels observed on the clean silverware tray should not be stored there.During an interview on 07/23/2026 at 9:39 AM, the Registered Dietitian (RD) acknowledged the wet paper towels should not have been stored on the clean silverware tray and stated the practice was not consistent with facility sanitation expectations.During an interview on 07/23/2026 at 6:25 PM, the Administrator stated the expectation was for the kitchen to be maintained in a clean and sanitary condition at all times. The Administrator stated infection prevention and food sanitation practices were monitored through daily rounds, review of kitchen logs and temperature logs, and monthly sanitation audits.Review of the facility's policy titled, Sanitation, issued April 2024, revealed, The food service area shall be maintained in a clean and sanitary manner . 2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use or proper cleaning . 6. Between uses, cloths and towels used to sanitize kitchen surfaces will be soaked in containers filled with approved sanitizing solution .

Based on observations, staff interviews, and the facility's policy titled, Medication Administration, the facility failed to ensure infection control was maintained for one of five residents (R) (R33), observed during medication administration. Specifically, the facility failed to ensure that pills were not touched with bare hands during medication administration, which increased the risk for cross contamination and infection.Findings include:During observation and interview of medication administration on 07/22/2026 at 9:29 AM with Licensed Practical Nurse (LPN) 6, LPN6 was popping pills from the bubble packs into a cup for R33 when one of the pills stuck to the bubble pack. LPN6 pulled the lisinopril 40 milligram (mg) tablet out of the bubble pack with her bare hand and placed it into the pill cup with the other pills. LPN6 confirmed she removed the pill with her bare hand and placed it in the pill cup with the other pills. LPN6 then checked R33's blood pressure and determined it was outside of the parameters for the administration of lisinopril. LPN6 removed the lisinopril from the cup using a spoon, discarded the pill, and administered the rest of the pills to R33.During an interview on 07/23/2026 at 6:33 PM, the Director of Nursing (DON) stated, it was would not be acceptable for a nurse to touch a pill with their bare hands. She stated she expected the pill to be discarded prior to placing it in a pill cup with other pills.Review of the facility's policy titled, Medication Administration, revised April 2025, indicated, Medications are administered . in a manner to prevent contamination or infection . Remove medication from source, taking care not to touch medication with bare hand.

Based on record review, resident and staff interviews, and the facility policies, Medication Administration and Medication Errors, the facility failed to administer scheduled blood pressure, anticoagulant, and muscle relaxant medications as ordered for one of four residents (R) (R109). This deficient practice had the potential to result in increased blood pressure, increased pain, increased swelling, and increased risk of stroke, placing the resident at risk for adverse outcomes.Findings include:1. Review of R109's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R109 was admitted to the facility on [DATE] with diagnoses not limited to, edema (swelling), chronic pain, chronic kidney disease- stage 4 (severe), bilateral primary osteoarthritis of knee, atrial fibrillation, and essential (primary) hypertension.Review of R109's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/21/2026 and located under the MDS tab of the EMR, revealed R109 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated R109 had little to no cognitive impairment.Review of R109's Orders, located under the Orders tab of the EMR, revealed R109 had the following physician's orders:a. Irbesartan (a blood pressure medication) 300 milligrams (mg) every day shift for hypertension, which originated on 02/16/2026;b. Metoprolol tartrate (a blood pressure medication) 50 mg one time a day for hypertension, which originated on 02/16/2026;c. Spironolactone (a diuretic medication) 25 mg one time a day for edema, which originated on 02/16/2026;d. Apixaban (an anticoagulant medication) 5 mg two times a day for atrial fibrillation, which originated on 02/16/2026;e. Methocarbamol (a muscle relaxant) 750 mg two times a day for pain, which originated on 03/18/2026;f. Tylenol 325 mg two tablets by mouth two times a day for pain, which originated on 02/27/2026.During an interview on 07/20/2026 3:55 PM, R109 stated that they had not received their medications.Review of R109's medication administration record (MAR), dated July 2026, on 07/20/2026 at 4:08 PM, and located under the Orders tab of the EMR, revealed:a. Irbesartan scheduled for administration at 9:00 AM was blank;b. Metoprolol scheduled for administration at 9:00 AM with a blood pressure check was blank;c. Spironolactone scheduled for administration at 9:00 AM was blank;d. Apixaban scheduled for administration at 9:00 AM was blank;e. Methocarbamol scheduled for administration at 8:00 AM was blank; andf. Tylenol scheduled for administration at 9:00 AM was blank.During an interview on 07/20/2026 at 4:15 PM, Licensed Practical Nurse (LPN) 1 stated, she started her shift at 12:30 PM. LPN1 reviewed R109's MAR for the day shift on 07/20/2026 and stated, that none of the charting or medications had been documented as administered.During an interview on 07/20/2026 at 4:52 PM, LPN9 stated that an agency nurse had been responsible for administrating medications and had ended her shift after 8:00 AM and that Certified Nursing Assistant-Medication Technician (CNAMT) 2 was assigned to the cart to administer medications.During an interview on 07/20/2026 at 5:15 PM, CNAMT2 stated, she was responsible for passing medications from 7:00 AM until after 9:00 AM and had administered medications to three residents, all on C hall and stated she did not administer medications to R109.Further review of R109's MAR, dated July 2026, revealed an as needed dose of oxycodone (a narcotic pain medication) was administered on 07/20/2026 at 9:15 PM for a pain level of eight out of 10.During an interview on 07/23/2026 at 6:44 PM, the Director of Nursing (DON) stated, she expected the unit manager to have proper handoff and effective communication. The DON confirmed the missed blood pressure and anticoagulant medications were missed and stated the omissions would be considered significant medication errors.Review of the facility's policy titled, Medication Administration, revised April 2025, indicated, Medications are administered . as ordered by the physician and in accordance with professional standards of practice . Ensure the six rights of medication administration are followed: right resident, right drug, right dosage, right route, right time, and right documentation . Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician.Review of the facility's policy titled, Medication Errors, revised September 2023, indicated, . Definitions: 'Medication error' means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication; or accepted professional standards and principles which apply to professionals providing services. 'Significant medication error' means one which causes the resident discomfort or jeopardizes his/her health and safety . The facility shall ensure medications will be administered as follows: according to physician's orders .

Based on record review, staff interviews, and the facility policy titled, MDS 3.0 Completion, the facility failed to ensure that a discharge Minimum Data Set (MDS) assessment was completed to accurately reflect the discharge status for one of 45 residents (R) (R141). This deficient practice had the potential to result in inaccurate and incomplete resident assessment information being maintained by the facility.Findings include:Review of R141's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R141 was admitted to the facility on [DATE].Review of R141's progress notes revealed a note dated 02/16/2026, that documented R141 was discharged to an assisted living facility.Review of the Minimum Data Set (MDS) tab, located in the EMR, failed to reveal a completed discharge MDS.During an interview on 07/21/2026 at 3:10 PM, the MDS Coordinator (MDSC) confirmed R141 was discharged on 02/16/2026 and verified there was no discharge MDS completed. The MDSC revealed she did not know why the assessment was not completed. Review of the facility's policy titled, MDS 3.0 Completion, dated 10/25, revealed, Policy: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. Definitions: OBRA Assessment'' refers to an assessment mandated by the Omnibus Budget Reconciliation Act of 1987, which specifies a Minimum Data Set (MDS) of core elements for use in assessing nursing home residents. Policy Explanation and Compliance Guidelines: . 2. Types of OBRA Assessments: .f. Discharge Assessment - completed using the discharge date as the ARD (Assessment Reference Date). Must be completed within 14 days of the discharge date /ARD .

Based on observations, staff interviews, record review, and the facility's policy titled, Medication Reordering, the facility failed to ensure medications were available for administration for two of five residents (R) (R11 and R33) observed during medication administration. This deficient practice had the potential to affect the residents' health by delaying treatment for conditions including hypertension, heart disease, congestion, vitamin deficiency, and glaucoma.Findings include:1. Review of R11's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R11 was admitted to the facility on [DATE] with diagnoses not limited to, major depressive disorder, schizoaffective disorder, essential (primary) hypertension, and atrial fibrillation.During an observation of medication administration on 07/22/2026 at 8:45 AM, Licensed Practical Nurse (LPN) 5 indicated R11's hydralazine, digoxin, and Mucinex 600 milligrams (mg) were not available for administration. LPN5 checked the medication cart and medication rooms for the ordered medications. LPN5 contacted the provider for a one-time order change from Mucinex 600mg to guaifenesin 400 mg and for clonidine if R11's blood pressure remained high.Review of R11's Medication Administration Record (MAR), dated July 2026, revealed:a. The order for hydralazine HCl [hydrochloride] [a blood pressure medication] Oral Tablet 50 MG [milligrams] Give one tablet by mouth two times a day for HTN [hypertension] Hold for SBP [systolic blood pressure] < [less than] 110, which originated on 07/08/2026, scheduled for administration on 07/22/2026 at 8:00 AM, was not administered with a code entered 5=hold/See Progress Notes. The systolic blood pressure was documented as 132.b. The order for Digoxin [an antiarrhythmic medication] Oral Tablet 125 MCG [micrograms] (Digoxin) Give 125 mcg by mouth one time a day for heart failure, which originated on 04/14/2026, scheduled for administration 07/22/2026 at 9:00 AM, was not administered with a code entered 9=Other/See Progress Notes.c. The order for Mucinex Oral Tablet Extended Release 12 Hour (Guaifenesin) Give 600 mg by mouth two times a day for congestion give two tabs po bid [twice a day], which originated on 04/13/2026, scheduled for administration on 07/22/2026 at 9:00 AM, was not administered and left blank.Review of a progress note, dated 07/22/2026 at 09:43 AM, revealed, Writer was informed that resident was in need of refills for the following medications: Hydralazine 50mg, Digoxin 125mcg, and Guafenesin 600mg. [Nurse Practitioner] has been notified. An order to hold the 600mg Guafenesin has been confirmed. An order for 400mg Guafenesin has been confirmed and administered. Resident received Metoprolol 25mg and Lisinopril 20mg for BP [blood pressure]. Charge Nurse will monitor BP and report/record any readings out of range immediately. Writer called [pharmacy] and both Digoxin and Hydralazine will be delivered at 2:00 PM on [sic] today. Resident is his own Authority and has been notified of all actions. [R11] is currently in room and denies any other concerns at this time. Updates to follow.During an interview on 07/22/2026 at 10:52 AM, LPN 9 reviewed R11's electronic MAR and verified hydralazine was last ordered 07/08/2026 and received on 07/18/2026. Digoxin was last ordered on 06/21/2026 and received on 06/21/2026. Mucinex is an over-the-counter [OTC] medication. LPN 9 stated staff are expected to reorder medications when the card reaches the blue area [when a limited number of doses remain].2. Review of R33's admission record revealed R33 was admitted to the facility on [DATE] with diagnoses not limited to, vitamin deficiency, major depressive disorder, and anxiety disorder.During an observation of medication administration on 07/22/2026 at 9:29 AM, LPN 6 indicated R33's multi-vitamin with iron, latanoprost (a glaucoma eye drop medication), and Refresh eye drops (lubricating eye drop medication) were not available for administration. LPN 6 checked the medication cart and medication rooms for the ordered medications. LPN 6 contacted the provider for a one-time order change from multi-vitamin with iron to multi-vitamin with minerals.Review of R33's MAR, dated July 2026, documented:a. Tab-A-Vite/Iron Tablet (Multiple Vitamins-Iron) Give one tablet by mouth one time a day for vitamin supplement, which originated on 11/18/2025, scheduled for administration on 07/22/2026 at 9:00 AM, was marked as administered.b. Multi-Vitamin/Minerals Oral Tablet (Multiple Vitamins w/Minerals) Give one tablet by mouth one time only for Supplement for one Day, which originated on 07/22/2026, was administered on 07/22/2026 at 10:11 AM.c. Latanoprost Ophthalmic Solution 0.005 % (Latanoprost) Instill one dose in both eyes one time a day for glaucoma, which originated on 08/27/2025, was scheduled for administration on 07/22/2026 at 9:00 AM and was marked as not administered with a code entered 9=Other/See Progress Notes.d. Refresh Tears Ophthalmic Solution (Carboxymethylcellulose Sodium (Ophth)) Instill one drop in both eyes two times a day for dry eyes, which originated on 09/17/2025, was scheduled for administration on 07/22/2026 at 9:00 AM and was marked as administered.Review of a progress note for R33 dated 07/11/2026 at 11:15 AM, regarding Latanoprost eye drops, did not indicate why the medication was not administered.During an interview on 07/22/2026 at 10:46 AM, the Assistant Director of Nursing (ADON) stated, pill card medications should be ordered when they reach the blue section of the card through the computer or staff should call the pharmacy. She also stated over-the-counter (OTC) medications are now ordered by the facility and are on order.During an interview on 07/22/2026 at 10:52 AM, LPN 9 stated that the Latanoprost eye drops were last ordered on 07/04/2026 and received on 07/05/2026.During an interview on 07/22/2026 at 12:38 PM, the Medical Records Clerk/Central Supply (MRC) stated, she orders the OTC medications every two weeks on the first and third Wednesdays of every month. She stated she just ordered Mucinex 600mg on 07/22/2026. The MRC stated she was unsure if multi-vitamins with iron were available to order. She stated she wasn't notified that the facility was out of stock but would order. The MRC further stated she ordered artificial tears and red eye drops but is unable to order Latanoprost.During an interview on 07/23/2026 at 6:33 PM, the Director of Nursing (DON) stated, she expected all medications to be available for administration. She stated when nurses get to the blue area on card, the nurse should be reordering the medication.Review of the facility's policy titled, Medication Reordering, revised November 2023, indicated, It is the policy of this facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biologicals in a timely manner to meet the needs of each resident . The facility will utilize a systematic approach to provide or obtain routine and emergency medications and biologicals in order to meet the needs of each resident. Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner. Each time a nurse is administering medications, available levels should be monitored to prevent delays in and ensure availability of medications .

Based on record review, interviews, and facility policy titled, Confidentiality of Personal and Medical Records, the facility failed to protect the privacy and confidentiality of one resident (R) (R168) when the resident received another resident's medications. This deficient practice resulted in the unauthorized disclosure of another resident's medication information to Resident 168 and the resident's representative and had the potential to disclose the resident's medical conditions, treatment information, and other protected health information.Findings include:Review of R168's admission record, documented the resident was admitted to the facility on [DATE] with diagnoses not limited to, of cerebral infarction, dementia, and altered mental status. R168 was discharged on 06/23/2026.Review of R68's discharge Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/23/2026, documented the resident had a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated the resident was severely cognitively impaired.During a phone interview on 07/22/2026 at 4:21 PM, the complainant (C1) stated that R168 was discharged from the facility on 06/23/2026 with another resident's medications. C1 stated that the facility subsequently sent a staff member to deliver R168's medications and retrieve the other resident's medications.During an interview on 07/23/2026 at 12:24 PM, Licensed Practical Nurse-Unit Manager (LPN) 4 confirmed R168 was discharged with another patient's medications. LPN 4 stated that this incident violated the resident's right to privacy and confidentiality.During an interview on 07/23/2026 at 4:32 PM, Certified Nurse Aide/Medication Technician (CNAMT) 1 stated she was working on the medication cart when R168 discharged and mistakenly gave LPN 11 another resident's medication. CNAMT 1 acknowledged that she should have verified the medications with LPN 11 before they were provided to the resident.During an interview on 07/23/26 at 6:44 PM, the Director of Nursing (DON) stated she expected staff to give the correct medications to the correct resident.Review of the facility's policy titled, Confidentiality of Personal and Medical Records, revised November 2023, documented, This facility honors the resident's right to secure and confidential personal and medical records . The protected health information may be released only: to the individual, or their resident representative where permitted by law; . Information regarding one resident should not be shared with other residents or visitors.

Based on staff and family interviews, record review, and the facility's policy titled Resident Personal Funds, the facility failed to provide quarterly statements for the personal funds account for one of 45 residents (R) (R19) reviewed for personal funds. This deficient practice had the potential to leave Resident 19 and the resident's representative uninformed about the balance of the resident's personal funds account.Findings include:Review of R19's undated admission Record, located in the electronic medical record (EMR) Profile tab, revealed R19 was admitted to the facility on [DATE] with diagnoses including but not limited to, dementia, chronic obstructive pulmonary disease. Further review of the admission Record revealed that Family (F) 1 was R19's power of attorney.Review of R19's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/01/2026, revealed the resident had a Brief Interview for Mental Status (BIMS) score of four out of 15, which indicated R51 was severely cognitively impaired.During a phone interview on 07/20/2026 at 4:45 PM, F1 stated they had never received any statements about R19's personal funds account.During an interview on 07/21/2026 at 3:23 PM, the Business Office Manager (BOM) confirmed R19 had an active resident funds account. The BOM stated she knows to send quarterly statements to the family or representatives of residents who do not handle their own money, but admitted she does not have any documentation to show that quarterly statements had been sent to R19's representative.Review of the facility's policy titled, Resident Personal Funds, revised on April 1, 2024, revealed, Policy Explanation and Compliance Guidelines: 3. The individual financial record must be available to the resident through quarterly statements and upon request .

Based on observations, staff interviews, record review, and review of the facility policies titled, Transmission-Based (Isolation) Precautions and Hand Hygiene, the facility failed to follow infection control protocols and precautions measures for one of eleven residents (R) (R2) with wounds. The deficient practice had the potential to spread microorganisms and infections.Findings include: Review of the facility policy titled, Transmission-Based (Isolation) Precautions date implemented 10/1/2022 and revised 9/12/2022 indicated under Policy, It is our policy to take appropriate precautions to prevent transmission of pathogens. f. The facility will have PPE (personal protective equipment) readily available near the entrance of the residence room and will don (put on) appropriate PPE before or upon entry into the environment of a resident on transmission-based precautions. Review of the facility policy titled, Hand Hygiene revised June 2025 indicated under Policy, staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility.6. a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Review of the admission Record revealed that R2 was admitted to the facility with diagnoses of, but not limited to anxiety disorder, gastro-esophageal reflux disease without esophagitis, other asthma, colostomy status epilepsy, not intractable, with status epilepticus, other neuromuscular dysfunction of bladder, quadriplegia, pressure ulcer of sacral region, Stage 4, bipolar disorder, osteomyelitis of vertebra, sacral and sacrococcygeal region, subluxation of C5/C6 cervical vertebrae, sequela, unspecified protein-calorie malnutrition, local infection of the skin and subcutaneous tissue, muscle weakness (generalized), other lack of coordination, need for assistance with personal care, cognitive communication deficit, depression. Observation and interview on 9/24/2025 at 11:51 am in room B16 (R2's room) revealed a posting outside of room door instructing that EBP was required for close contact with resident, and no PPE visibly available for resident care or visitors observed in room. No EBP station was hanging from residents' door as observed for other rooms in the hallway with EBP signage postings. Resident was bed bound and verbal, with an air pressure relief mattress, and heel boots on both feet. Wound care was observed performed by Licensed Practical Nurse (LPN) CC. LPN CC donned PPE and clean gloves before entering the residents' room. The treatment table was sanitized and prepped with wound care supplies per physician orders in the hallway prior to entering R2's room. The nurse ensured incontinence care was performed prior to wound care observation. Certified Nursing Assistant (CNA) BB entered the room, obtained gloves from the wall in R2's room without sanitizing hands before moving the residents' bedside table. CNA BB then assisted the nurse with repositioning R2 to their side without donning PPE prior to care. CNA BB held the resident in place while the nurse removed the old wound dressing. The nurse removed a scantly soiled packing and dressing, removed soiled gloves and donned clean gloves without first sanitizing her hands. The surveyor stopped LPN CC from continuing with wound care to first sanitize their hands before continuing care. LPN CC had to leave the room to retrieve their hand sanitizer that was locked in the treatment cart, then retrieved a new box of gloves as the box of gloves on the treatment table was empty. When CNA BB was asked why they didn't have PPE on while they assisted the nurse with wound care, isn't the resident on enhanced barrier precautions, CNA BB stated, I'm not sure. The surveyor pointed to the signs posted on the residents' room door. CNA BB stated, Oh, yes. I should have PPE on. The surveyor asked CNA BB, Why is hand hygiene important? CNA BB responded, To stop the spread of germs. LPN CC returned to the room with gloves and hand sanitizer. LPN CC sanitized their hands and donned new gloves. LPN CC removed the old dressing; no date was observed on the dressing. No odor or discolored discharge were observed with the wound. Wound was a circular decubitus ulcer, Stage 4, 5 cm x 3 cm with healthy pink flesh, scant discharge present with pocketing but no tunneling present. LPN CC discarded the soiled gauze and gloves. LPN CC sanitized their hands. LPN CC explored in her pants pockets for a pen to date the 4 x 4 gauze. LPN CC donned clean gloves. The surveyor stopped LPN CC a second time from continuing with wound care to first sanitize their hands before donning new gloves before continuing care. LPN CC sanitized their hands and donned clean gloves before gauze packing and clean 4 x 4 dressing dated 9/24/2025 were applied. Clean wound dressing supplies were handled in a way to prevent cross-contamination. Then LPN CC removed the trash and put soiled gloves in a trash bag at the foot of the bed. LPN CC and CNA BB repositioned the resident and applied foam wedges and pillows and adjusted resident in bed. CNA BB doffed (removed) soiled gloves after picking up R2's empty cup that fell off the bedside table to the floor while LPN CC stabilized R2. CNA BB reached in their scrub pocket for new gloves and donned gloves without first sanitizing or washing hands. CNA BB repositioned resident's bedside table in reach of R2. CNA BB doffed gloves and then washed hands with soap and water in the residents' restroom. LPN CC doffed gloves and gown in the trash, sanitized the treatment table, then sanitized hands after service was completed. An interview on 9/24/2025 at 12:15 pm with Unit Manager Registered Nurse (RN) AA revealed that LPN CC and CNA BB did not follow infection control and enhanced barrier precautions during the wound care observation. RN AA reported that staff have been in-serviced on hand hygiene and EBP. RN AA stated that they were surprised that LPN CC and CNA BB did not follow infection prevention protocols during the observation. RN AA stated that they would in-service nursing staff again.

Based on observations, staff interviews, and review of the facility policies titled Food Receiving and Storage and Refrigeration and Freezers, the facility failed to ensure opened food items in the dry storage area and walk-in refrigerator were labeled and dated, and failed to remove a dented can from the food storage rack to prevent usage. The deficient practices had the potential to place 117 residents who received an oral diet from the kitchen at risk of contracting a foodborne illness. Findings include: Review of the facility policy titled Food Receiving and Storage, issued April 2024, revealed at bullet point seven, All foods stored in the refrigerator or freezer will be covered, labeled, and dated. Review of the facility policy titled Refrigeration and Freezers, issued April 2024. revealed at bullet point seven, Use by or open dates will be labeled on food items once opened. Observation on 6/13/2025 at 8:24 am of the dry storage area revealed an open five-pound bag of egg noodles being stored with no open date. Continued observation of the dry storage area revealed a food storage rack with canned foods. A large can of Northern Beans was observed with a dent on the bottom seal. Observation on 6/13/2025 at 8:27 am of the walk-in refrigerator revealed an open packet of ham slices with no label or date, a clear plastic container with chopped lettuce with no label or date, and an opened bag of parsley with no open date. Observation on 6/13/2025 at 8:39 am of a large rectangular clear plastic bin under the food preparation table revealed that inside the bin were an open box of instant mashed potatoes, two open five-pound bags of grits, and an open package of gravy mix. None of these food items had an open date. During an interview on 6/13/2025 at 8:50 am, the Director of Dietary (DD) confirmed that the bag of egg noodles had no open date. He stated that the noodles were used for a meal last night, and the cook did not place an open date. The DD stated that dietary staff are to date food items after they have been opened. The DD confirmed that the can of Northern Beans was stored in the food storage rack and had a dent on the bottom seal. The DD stated that the delivery driver uses the can to prop open the door to the kitchen to make it easier to deliver items. The DD stated that the delivery driver slammed the door into the can, causing the dent. The DD stated that once the delivery driver is done propping open the door, the can is returned to the rack. The DD revealed that the can should not have been returned to the rack with the dent. During an interview on 6/13/2025 at 8:55 am, the DD confirmed that the packet of sliced ham did not have a label or date. The DD stated the sliced ham was not labeled or dated due to the staff using it to make sandwiches. At the time of observation and interview, all staff were assembling breakfast meal trays, and no one was in the process of making sandwiches. The DD confirmed that the container containing chopped lettuce had no label or date and that the label likely fell off. There was no label found on the floor or on the food storage rack. The DD confirmed that the bag of parsley had been opened and was not labeled with an open date. During an interview on 6/13/2025 at 9:00 am, the DD revealed that he does not expect staff to date open food items stored in the clear plastic bin under the food preparation table. The DD stated that the entire bin is dated and, therefore, individual items do not need to be dated. The DD confirmed that there was no label on the bin with a date. The DD revealed that the cook likely removed the label from the food storage bin. During an interview on 6/13/2025 at 9:00 am, Dietary [NAME] AA revealed that he did not remove any stickers from the bin and did not notice any stickers on the food storage bin.

Based on observations, staff interviews, and review of the facility policy titled Disposal of Garbage and Refuse, the facility failed to ensure two of two dumpster's side doors were closed and failed to ensure the ground surrounding the dumpsters was free from trash debris. The deficient practice had the potential to promote the harboring of pests, insects, and other organisms and create the potential for disease transmission by pests and rodents. The facility census was 124 residents. Findings include: Review of the facility policy titled Disposal of Garbage and Refuse, revised April 2024, revealed at bullet point seven that refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded. Surrounding area shall be kept clean so that the accumulation of debris and insect/rodent attractions are minimized. Observation on 6/13/2025 at 9:10 am of the dumpster area revealed the facility had two medium-sized dumpsters for general trash. Observation of the dumpster on the right-hand side revealed that the side door on the right side was open, exposing trash inside. Continued observation revealed the ground surrounding both dumpsters had trash debris such as plastic water bottles, plastic gloves, plastic cups, paper, and plastic silverware. During an interview on 6/13/2025 at 9:10 am, the Director of Dietary (DD) confirmed that the side door to the dumpster was open. The DD confirmed that there was trash debris on the ground surrounding the dumpsters. Continued interview with the DD revealed that he observed the dumpsters/dumpster area at least once a day, but often more, to ensure the dumpster top lids are closed, side doors are closed, and bottom drainage plugs are in place. The DD stated that all departments use dumpsters, and all staff are responsible for ensuring that dumpster doors are closed and that there is no trash on the ground. Observation on 6/14/2025 at 9:20 am of the dumpster area revealed that the dumpster on the right-hand side had the left side door open. Observation on 6/15/2025 at 11:10 am of the dumpster area revealed that both dumpsters had all side doors open, and trash bags were spilling out. During an interview on 6/15/2025 at 11:10 am, the Director of Maintenance (DM) confirmed that the side doors to both dumpsters were open and confirmed that trash bags were spilling out. The DM revealed that all staff were to assist with ensuring dumpster side doors were closed and all trash was contained inside. The DM revealed that housekeeping was responsible for keeping the ground surrounding the dumpster area clean. During an interview on 6/15/2025 at 11:10 am, the DD confirmed that all of the side doors to both dumpsters were open, and trash bags were spilling out. The DM confirmed that there was trash on the ground surrounding the dumpsters. During an interview on 6/15/25 at 11:15 am, the Lead Housekeeper (LH) revealed that housekeeping staff were to make sure the dumpster side doors were closed after use. The LH confirmed that the side doors to both dumpsters were open, with trash spilling out. The LH stated that housekeeping staff were responsible for keeping the ground surrounding the dumpsters free from trash and was not sure when the task was last completed.

Based on observations, staff interviews, and record review, the facility failed to maintain safe water temperatures to ensure residents were free from potential accident hazards, as evidenced by water temperatures exceeding 120 degrees Fahrenheit (F) in one of five shower rooms (South Hall Shower Room). The deficient practice had the potential to place residents who use the shower at increased risk of burns. Findings include: Review of a facility-provided document titled Instructions Testing and Logging Water Temperatures revealed the document included instructions of 1. For burn prevention, federal guidelines advise that you keep domestic water temperatures below 120 degrees Fahrenheit, although this temperature can still cause burns if exposure reaches five minutes. Many states have even stricter standards that set maximum temperatures lower than 120 degrees Fahrenheit. Although 100 degrees Fahrenheit is considered a safe water temperature for bathing. Observation and interview with the Maintenance Director on 6/14/2025 at 9:12 am revealed that the water in the South Hall Shower measured 122 degrees F with the facility's calibrated thermometer. A sink tested at 9:10 am, in the same location, measured 126 degrees F. The Maintenance Director revealed he usually attempted to maintain water temperatures between 106 and 108 degrees F. The Maintenance Director stated that when checking temperatures, he allowed the water to run until it reached what he considered the proper temperature. He explained it took time to recirculate. He stated that the issue with temperature fluctuation may be due to the proximity of each hall to the water heaters. The Maintenance Director stated he would immediately adjust the water temperatures and confirmed the South Hall shower room would be taken out of order while temperature adjustments were made. The Maintenance Director stated he was not aware of any accidents due to hot water temperatures. Interview on 6/14/2025 at 2:54 pm with the [NAME] President of Property Management (VP) stated they had a runaway mixing valve which required readjustment. He reported the water heater had been changed approximately two months ago. The VP stated the facility preferred to maintain water temperatures between 100 and 106 degrees F, and the water temperatures were monitored weekly. He confirmed that staff checked nearby rooms to ensure the temperatures were not more than 110 degrees F. Observation on 6/14/2025 at 3:00 pm in the South Hall shower room revealed a water temperature reading of 108 degrees F for both the shower and sink. Observation on 6/15/2025 at 9:05 am and 9:07 am in the South Hall revealed water temperature readings of 106 degrees F at the sink and 102.6 degrees F in the shower, respectively. A Resident Council meeting was held on 6/15/2025 and revealed that no residents had concerns with hot water temperatures. A review of the grievance logs revealed no grievances related to hot water temperatures. Interview on 6/15/2025 at 12:14 pm with the Administrator revealed the expectation was that water temperatures be maintained between 100 and 110 degrees F. The Administrator reported that staff monitors temperatures daily through spot checks rather than checking every fixture. He confirmed adjustments were made when discrepancies were identified. He acknowledged the potential for a negative outcome, including the risk that residents could get burned.

Based on observations, staff interviews, record review, and review of facility policies titled Personal Protective Equipment and Transmission-Based (Isolation) Precautions, the facility failed to protect residents from infection by not wearing personal protective equipment (PPE), when providing care to one of two residents (R) (R328) on Contact Precautions. The deficient practice had the potential to cause the spread of infections to other residents, staff, and visitors. Findings include: Review of the facility policy titled Personal Protective Equipment, revised January 2025, revealed under Policy: The facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitors, and other staff. Under Policy Explanation and Compliance Guidelines: All staff who have contact with residents and their environments must wear personal protective equipment as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or potentially infectious materials is likely. Review of the facility policy titled Transmission-Based (Isolation) Precautions, revised 9/12/2024, revealed under Policy: It is the policy of the facility to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' modes of transmission. Under Policy Explanation and Compliance Guidelines: .8. Contact Precautions- .c. When caring for residents on contact precautions, staff should wear a gown and gloves for all interactions that may involve contact with the residents or potentially contaminated areas in the residents' environment. Review of R328's electronic medical record (EMR) revealed that he was admitted to the facility with a diagnosis that included, but was not limited to, unspecified acute conjunctivitis (infection of the conjunctivae) of the right eye. Review of R328's admission Minimum Data Set (MDS) assessment revealed that the assessment was in progress. Review of R328's Clinical Physician's Orders revealed an order dated 6/14/2025 for ciprofloxacin HCL [hydrochloride] ophthalmic 0.3 percent (an antibiotic medication), instill 2 drop in the right eye four times a day. Further review revealed an order dated 6/13/2025 for Infection Precautions - contact, every shift. Review of R328's medication administration record (MAR) revealed the ophthalmic drops were documented as administered as ordered. An observation on 6/14/2025 at 8:54 am revealed that Licensed Practical Nurse (LPN) BB entered the room of R328 without putting on PPE. At that time, it was noted that the resident was on contact isolation. An observation on 6/14/2025 at 8:59 am revealed that LPN BB entered the room of R328 without putting on PPE. An interview on 6/14/2025 at 9:05 am outside R328's room, LPN BB stated that Contact Precautions meant that if he was going to be providing care, especially if the antibiotic eye drops were to be administered, he would need to be using PPE. He then stated that he did not need to use PPE every time he went into the room. An interview on 6/14/2025 at 1:14 pm with the Infection Preventionist (IP) revealed that it is her expectation that any staff caring for a resident in Contact Precautions needed to apply the appropriate PPE required for that isolation. An interview on 6/14/2025 at 1:16 pm with the Director of Nursing revealed that it was her expectation that staff wear appropriate PPE when providing care for any resident in Contact Precautions.

Based on observations, staff interviews, and review of the facility's policy titled, Use By Dating Guidelines, the facility failed to ensure food items were properly stored, labeled, and dated, and expired food items were disposed of in a timely manner. In addition, the facility failed to ensure the kitchen areas (tile and ceiling) were maintained in a sanitary condition free from debris, grease, and dirt build-up. The deficient practice had the potential to affect 123 residents receiving an oral diet. Findings include: Review of the undated facility policy titled Use By Dating Guidelines documented . In Dry Storage Areas all unopened items must be labeled with a receiving or delivery date. Once item opened, it must be dated with the open date and use by date. Refrigerate open items per guidelines. The tour of the facility kitchen on [DATE] at 9:15 am with Dietary Manager (DM) KK revealed the following observations: Observation of the following items in the reach-in-refrigerator revealed a bag of French toast (cooked) dated [DATE], a bag of garlic bread (uncooked removed from the original container wrapped in plastic wrap) with an open date of [DATE] and no expiration date, and a bag of cornbread in a plastic zipper bag dated [DATE]. Observation of the facility walk-in-cooler revealed roast beef (cooked) in a plastic bag dated [DATE], a pan of chicken pieces (cooked) no date, Italian sausage (cooked) inserted in a freezer bag dated [DATE], and coleslaw that was prepared in a small plastic container dated [DATE]. Observation of the facility panty revealed corn flake cereal and oat o's cereal (removed from the original container and stored in plastic container) not labeled with an expiration date, a large container of peanut butter marked in large black numbers ,d+[DATE] (review of manufacture date revealed an expiration date of [DATE]). Observation of toasted bread (sliced toast) in a bin under the food preparation counter in a large plastic container with a date of [DATE]. DM KK stated the bread was cooked on [DATE] and was being used for puree ingredients. She confirmed that the toast should have been refrigerated, not stored at room temperature, and discarded. Observation of the kitchen floor revealed a buildup of dark, sticky substances coating the tile near the stove area directly under the oven and counter directly below the hood. Dark greyish substances and dark brown, speckled substances were observed covering the tile around the ceiling vent. Interview at the time of all observations on [DATE] at 10:20 am, DM KK stated that the food items should include an expiration date or used by date. She confirmed that her staff was only writing open dates and failing to include used by date/expiration date. DM KK confirmed that dry food items or any food items taken out of the original bag should be stored with a label that tracks the expiration date from the original product. DM KK identified substances on the kitchen tiles as oil, grease, and dirt build-up. DM KK was unable to recall the last time the kitchen floor was deep cleaned. She stated that her staff was responsible for the deep cleaning of the kitchen flooring. The DM KK stated that she felt the substance on the ceiling could possibly be mold substances.

Based on observations and staff interviews, the facility failed to ensure that the dumpster area was maintained in sanitary condition as it relates to dumpster lids being secured tightly and fitted at all times The deficient practice had the potential to promote the harboring of pests, insects, and other organisms that could affect all residents in the facility. Findings include: Observation and interview on 2/13/2024 at 10:20 am of the facility dumpster with Dietary Manager (DM) KK revealed three of three dumpsters in the dumpster area were filled with trash to capacity. A closer observation of the dumpster lids revealed that each dumpster consists of two lids (a left lid and a right lid). All the lids were badly damaged, allowing trash exposure and preventing the trash from being securely contained. Three of three of the dumpsters had lids (either the right or left lid) that were folded downward/sunken into the dumpster resulting in large bags of trash and boxes piled high and resting on top of the lids. Three of three of the dumpster lids (either the right or left lid) were badly dented causing the lid to lift up, leaving large gaps preventing a tight, secure fit. DM KK confirmed the condition of the dumpsters. She reported that the lid should be closed at all times in order to contain the trash. She confirmed that the dietary and housekeeping staff are trained to ensure dumpster lids are closed and to report any damage to the dumpsters. DM KK reported being unaware of the dumpster condition. DM KK could not recall the last time that she visited the dumpster to determine how long the problem existed. Observation and interview on 2/14/2024 at 7:55 am of the facility dumpster area revealed no changes in the condition of the dumpster area from the previous day. The Administrator confirmed the condition of the badly damaged lids. She reported being unaware of the condition of the facility garbage/refuse area. She could not recall the last time she visited the dumpster area. She stated that the maintenance department was responsible for the upkeep and maintenance of the dumpster. The Administrator stated, my plan is to have the dumpster lids replaced or to get new dumpsters. Interview on 2/14/2024 at 12:55 pm with Maintenance Director LL, he reported being unaware of the condition of the dumpsters. He could not recall the last time that he visited the dumpster to determine how long the problem existed. He confirmed being in charge of the upkeep of the maintenance condition of the facility garbage/refuse area. He reported that the importance of having the lids tightly secured and fitted was to prevent access to rodents, pests, and water.

45813 Based on observations, resident and staff interviews, record review, and review of the facility policies titled, Resident Self-Administration of Medications and Medication Administration, the facility failed to ensure five of 41 sampled residents (R) (R22, R39, R90, R81, and R1) reviewed for self-administration of medications did not have medications stored at the bedside. This deficient practice had the potential to allow residents to administer the medications in an unsafe manner. Findings include: A review of the facility's undated policy titled Resident Self-Administration of Medication, revealed the Policy Statement: A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. 4. The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment Form, which is placed in the resident's medical record. 7. Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the other resident's rooms or to confused roommates of the resident who self-administers medication. The following conditions are met for bedside storage to occur: a. The manner of storage prevents access by other residents. Lockable drawers or cabinets are required only if locked storage is ineffective. b. The medications provided to the resident for bedside storage are kept in the containers dispensed by the provider pharmacy. 8. All nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage, Unauthorized medications are given to the charge nurse for return to the family or responsible party. 13. The care plan must reflect resident self-administration and storage arrangements for such medications. A review of the facility's undated policy titled Medication Administration, revealed Policy: A licensed nurse, Med Tech, or medication aide, per state regulations will administer medications to patients. 8. Administer medications. 8.2: Remain with patient until administration is complete. Do not leave medications at the patient's bedside. 1. Review of R22's record revealed resident was admitted to the facility 1/29/2024 with diagnosis to include but not limited to diabetes mellitus, anxiety disorder, depression, and cerebral infarction. A review of the Admission Minimum Data Set (MDS) dated [DATE] revealed in section C - Cognitive Patterns: Brief interview for Mental Status (BIMS) score of 14, indicating no cognitive impairment. Observations on 2/13/2024 at 10:27 am, and at 12:50 pm revealed multiple medications at R22's bedside on the dresser to include a bottle of 8-Hour Arthritis Pain Relief 650 mg (milligram) tablets, a tube of zinc oxide ointment, a box of Hydroxcut weight loss electrolytes drink mix, a tube of Triple Action Relief Foot Cream, a bottle of loperamide hydrochloride (anti-diarrheal) oral solution, a box of effervescent antacid, and a bottle of nasal spray. R22 informed the surveyor his wife brought the medications to him, and he uses the medications. Review of R22's electronic medical record (EMR) under the Order tab revealed that R22 did not have a current order for the medications at the bedside. Review of R22's care plan revealed there was nothing implemented in the plan of care allowing resident to self-administer or store medications at the bedside, Further review of the EMR revealed that R22 did not have an assessment to self-administer medications or keep medications at the bedside. Interview and walking rounds on 2/13/2024 at 12:53 pm with LPN Unit Manager AA revealed that R22 should not have any medications at the bedside. LPN AA verified all medications at the bedside, and with R22's permission, removed the medications. LPN AA verified R22 did not have current orders, self-administration assessment, or care plan for the medications retrieved from his room. Interview on 2/13/2024 at 1:10 pm with RN DD revealed upon arrival to work, she peeked in on R22. RN DD further stated, she later went into R22's room to administer his am medications but did not notice the medications on his bedside table. RN DD stated that she was aware residents are not supposed to have medications in the room but are required to be locked up. Review of the EMR revealed R39 was admitted to the facility with diagnosis to include but not limited to diabetes mellitus, depression disorder, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed in Section C - Cognitive Patterns: Brief interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Section GG - Functional Abilities and Goals revealed R39 had an impairment on one side of his upper extremity. Observations on 2/13/2024 at 9:44 am and at 12:24 pm revealed a bottle of fluticasone propionate nasal spray and two Stiolto Respimat Aerosol (breathing medication) on R39's bedside table within resident's reach. Review of R39's EMR under the Order tab revealed R39 did have orders for fluticasone propionate nasal suspension 50 MCG/ACT [micrograms per actuation] (Fluticasone Propionate (Nasal Spray) 1 spray in each nostril one time a day for nasal congestion and Stiolto Respimat 2.5-2.5 MCG/ACT Aerosol, solution 2 puff inhale orally one time a day for COPD [chronic obstructive pulmonary disease]. However, the order did not indicate whether R39 may self- administer medications or if medications could be stored at R39's bedside. Review of R39's care plan revealed there was nothing implemented in the plan of care allowing resident to self-administer or store medications at the bedside, Further review of R39's EMR revealed a Medication Self-Administration Screen dated 5/29/2023 which indicated R39 was allowed to self-administer albuterol sulfate inhalation nebulization solution (2.5mg/3 ml (milliliter) 0.083%. Staff will continue to store and administer medications. Interview on 2/13/2024 at 9:50 am with R39 revealed he had always been allowed to keep his inhalers and nasal spray at the bedside to administer himself as he needed it. R39 stated the staff was aware that he had the medications, and the nurse reorders the medications and brings it to his room when the pharmacy delivers it to the facility. Interview and walking rounds on 2/13/2024 at 12:57 pm with LPN Unit Manager AA revealed R39 should not have any medications at the bedside. LPN AA verified all medications at the bedside and with R39's permission, removed the medications. LPN looked at the current orders and verified R39 did have orders for the medications, but not to be kept at bedside for self-administration. LPN AA also verified R39's care plan did not allow the resident to keep medications at the bedside. LPN AA also verified R39 had a self-administration assessment in the record to self-medicate nebulizer solution only, not inhalers or nasal spray. Interview on 2/13/2024 at 1:22 pm with LPN BB revealed she was aware R39 had the inhalers and nasal spray on his bedside table. LPN BB further stated she had informed the administrative staff, and they did not put an order in for R39 to keep the medications at bedside, nor did they remove the medications from the room. LPN BB further stated R39 keeps the medications himself to administer because he refuses to allow the nurses to administer the inhaler and nasal spray. Review of R90's EMR revealed resident was admitted to the facility with diagnosis to include but not limited to diabetes mellitus, muscle weakness, need for assistance with personal care, and Guillain-Barre Syndrome. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed in Section C - Cognitive Patterns: Brief interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Observations on 2/13/2024 at 10:51 am upon entering R90's room, resident had a plastic cup of medications on the table in front of him. R90 stated the nurse gave him the medications and left. Resident further stated he had not taken the medications because the nurse did not give him the ibuprofen he requested. Further observations revealed RN DD down the hall administering medications, she confirmed she left the medications at R90's bedside and stated the resident told her she did not have to watch him take his medications. At 11:06 am RN DD was observed back in R90's room asking him to take the medications she had previously left with him. Interview on 2/13/2024 at 1:36 pm with the Director of Nursing (DON) revealed nurses are expected to stay with residents to ensure medications are swallowed prior to leaving the room. The DON further stated that residents should not have medications at their bedside if they have not been assessed and have an order and a care plan indicating they are safe to self-medicate. RN DD confessed to the DON that she had given R90 his medications and walked away prior to ensuring R90 had consumed the medications. The DON also stated residents are not allowed to have medications at the bedside to self-administer unless they have been assessed by the nurse and deemed safe to do so. The DON further stated in this case, there would be an assessment, an order, and a care plan indicating resident was safe to self-medicate. 2. Observation on 2/13/2024 at 11:21 am revealed the following medication within visual sight on the bedside nightstand and in an open cart in R1's room: A prescription bottle of amoxicillin (labeled with the res ident's name and identified information), an unidentified bottle of white pills with the prescription labeled removed, a bottle of over the counter (OTC) eye drops, a bottle of pure moist [NAME] hydraclyde eye drops, three bottles of allergy eye drops, a bottle of Tylenol pills, a bottle of nose spray, and a container of calcium tablets. At the time of observation on 2/13/2024 at 11:21 am, R1 revealed that she received the antibiotic (Amoxicillin) and the unlabeled prescription bottle of pills that she identified as Tylenol/pain medication from her dentist. R1 reported that a family member provided transportation to the dentist last month. She reported having extractions of her bottom teeth. She reported not telling the facility staff about the medications. She stated that all the OTC meds were from her daughter. R1 reported taking the medication without staff supervision. Review of R1 's EMR revealed the following diagnoses but not limited to cardiac pacemaker, congestive heart failure, chronic pulmonary heart disease, and respiratory failure with hypoxia. Review of R1's quarterly MDS dated [DATE] revealed a BIMS score of 14, indicating intact cognition. R1 was assessed for partial assistance to supervision assistance with the majority of her Activities of Daily Living (ADL). Review of R1's January 2024 physician orders revealed no physician order for self-administration of medications. Continued review of the physician orders revealed the following active medications but not limited to oxycodone HCl (hydrochloride) 30 mg, take every six hours for pain (start date 7/28/2023), Narcan nasal liquid 4mg/4ml (milliliter) one application every twenty four hours as needed for opiate overdose, Xtampza ER oral capsule ER 12 hours abuse deterrent 18 mg (oxycodone) give one capsule by mouth two times a day for pain, levalbuterol tartrate inhalation aerosol 45 mcg two puffs, cetirizine HCl oral tablet 10 mg give one tablet by mouth one time a day for seasonal allergies, and digoxin 125 mcg daily. A later review of the physician order revealed that a new order for amoxicillin 500 mg (three times a day) was added on 2/13/2024 due to staff removing the resident's personal prescription bottle of amoxicillin from her room. Review of R1's assessment's records revealed that no self-administration assessment evaluation was initiated by the facility staff to indicate the resident competency level to self-administer medications. Review of the care plans in R1's clinical record revealed an omission of a plan of care to self-administrate medications. Interview on 2/13/2024 at 11:45 am with the Administrator, Licensed Practical Nurse (LPN) HH, and Unit Manager LPN JJ, conducted at the time of the observation of R1's bedside medications revealed that all the medications were confirmed and verified by all the mentioned staff. Unit Manager JJ reported that the unidentified medication in the unlabeled prescription bottle could not be determined. LPN HH and Unit Manager LPN JJ reported being unaware of medications at the bedside. LPN HH confirmed that R1 was not approved for self-administration of medications. LPN HH stated that R1 was not capable of taking her medications without supervision. The Administrator reported her expectation was that staff should have been aware of residents having unauthorized medications in their room. Interview on 2/15/2024 at 11:22 am with the Social Worker revealed having no record of R1's dental visit. Observation on 2/13/2024 at 11:24 am revealed R81 lying in bed and a small bottle of eye drops dry eye relief 1 FL OZ /30 ml (one fluid ounce/30 milliliter) sitting on the bedside within visual sight. Review of R81's EMR revealed the following diagnoses but not limited to chronic atrial fibrillation, acute kidney failure, and pleural effusion not yet classified. The quarterly MDS dated [DATE] assessed a BIMS score of 13, which indicates cognition intact with no cognitive impairments. R81 was assessed for partial to substantial assistance with upper body Activities of Daily Living Skills. Range of Motion (ROM) assessed for no impairment for upper/lower body. Review of R81's February 2024 physician orders documented the following medications but not limited to Norco oral tablet 10-325 mg (hydrocodone-acetaminophen)-give 1 tablet by mouth four times a day for pain, acetaminophen oral tablet 500 mg give two tablet by mouth every six hours as needed for pain, Eliquis (blood thinner) 5 mg give 1 tablet by mouth two times a day, tamsulosin HCl (for urine flow issues) 0.4 mg give 1 capsule by mouth one time a day. Review of R81's physician orders revealed no order for self-administration of medications. Review of R81 care plans revealed no plan of care to self-administer medications. R81 had a Self-Administration Medication Assessment evaluation form in his record dated 9/28/2023 that stated, refresh eye drops/bedside with resident and resident to self-administrate medications with supervision. An interview and observation on 2/13/2024 at 11:15 am of the observation of R81's bedside medications with the Administrator, Licensed Practical Nurse (LPN) HH, and Unit Manager LPN JJ. The medications were confirmed and verified by the above-mentioned staff. LPN HH and Unit Manager LPN JJ reported being unaware of medication (eye drop) at the bedside. LPN HH confirmed that R81 was not approved for self-administration of medications. She only had one resident on A Hall who was approved to self-administer medication. Unit Manager LPN JJ removed the medication (eye drop) from the room. The Administrator reported her expectation as that staff should have been aware of residents having unauthorized medications in their room. Interview on 2/13/2024 at 11:24 am with the Administrator, Licensed Practical Nurse (LPN) HH, and Unit Manager LPN JJ, R81 stated to Unit Manager LPN JJ he was using the eye drops every 12 hours and that the nurse (unidentified nurse) gave it to him. He reported that he did not have anyone watching him (supervising him taking the eyedrops). Interview on 2/15/2024 at 11:10 am with the DON, he reported that his expectation was that staff should conduct routine room audit checks. He identified the problem area as a system failure due to long-term residents having the right to order their own stuff online. This makes it hard for nursing staff to track and check residents' personal packages. When inquired if certified nursing assistant staff have a role in monitoring for unauthorized medication and products, he stated that all staff are educated on room monitoring. However, Certified Nursing Assistants (CNAs) are trained on safety and not trained to know medications and bottles. He stated that the CNAs would receive extra hands-on training. The DON stated that R1 received antibiotic medication from the dentist. He had no comment on the unidentified, unlabeled pain medication. He explained the facility's process for self-administration of medications approval depends on an assessment and a discussion of the resident by the Interdisciplinary Team (IDT). The IDT team would meet to discuss the resident.

47146 Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Oxygen (O2) Administration, the facility failed to change and date O2 tubing weekly for three of 41 sampled residents (R) (R36, R84, R54), to clean O2 and CPAP (continuous positive airway pressure device) filters for two of 41 sampled residents (R36 and R61), and to have orders for CPAP use for one of 41 sampled residents (R50). Findings include: Review of the facility policy titled Oxygen Administration date reviewed/revised December 2022, revealed under Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences. Under the subsection titled Policy Explanation and Compliance Guidelines revealed under number one: oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as possible when the situation is under control. Section number five revealed under subsection b: staff change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. Subsection five, c revealed: Staff change the humidifier bottle when empty, every 72 hours or per facility policy, or as recommended by the manufacturer. Subsection five, e revealed: Staff keep delivery devices covered in a plastic bag when not in use. Number seven revealed: The cleaning and care of equipment shall be in accordance with the facility policies for such equipment. 1. Review of the electronic medical record (EMR) revealed R36 was admitted to the facility with diagnoses listed but not limited to chronic respiratory failure with hypercapnia. Review of R36's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/5/2024 revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicates R36 was cognitively intact. Review of R36's care plan indicated a focus of oxygen therapy related to chronic respiratory failure (date initiated on 10/11/2023, created on 12/20/2022 by MDS Coordinator, revised on 10/12/2023 by MDS Coordinator). Goals included but not limited to R36 will have no signs or symptoms of poor oxygen absorption (date initiated 10/22/2023, created 12/20/2022 by MDS coordinator; revision on 1/16/2024 by MDS Coordinator). Interventions included but not limited to administer CPAP/BiPAP setting as ordered at hour of sleep (initiated 10/12/2023), Oxygen setting - Oxygen via nasal cannula (NC) as ordered, humidified (initiated 10/11/2023), and monitor for signs/symptoms of respiratory distress and report to physician as needed: respirations, pulse oximetry, increased heart rate, restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis, cough, pleuritic pain, accessory muscle usage, skin color (date initiated 10/11/2023). Review of the EMR revealed physician's orders for R36 included but was not limited to Cleanse CPAP mask and tubing with warm soapy water and dry daily one time a day for obstructive sleep apnea, CPAP maintenance cleanse start date 12/15/2023, CPAP or BiPAP (breathing device with inspiratory and expiratory pressures) 12/8, Oxygen liter flow (for bleed in): four liters per minute (LPM), apply at hour of sleep and remove in morning. Interface type: nasal pillows/mask/full face mask humidification (if appropriate) heated or cool fill humidifier with sterile or distilled water; Oxygen at 4.5 liters per minute via nasal cannula, check oxygen saturation every shift. Observations on 2/13/2024 at 3:43 pm of R36 wearing CPAP, observed the vent on back of the CPAP machine where the filter was located was covered with a grey fuzzy substance, and O2 tubing for humidifier bottle was dated 12/7 and only connected to the humidifier bottle but not the concentrator. The NC tubing was not dated. Observations on 2/14/2024 at 10:42 am of R36 while out of the facility for an appointment, observed CPAP mask stored on top of a dresser behind a fan with a stuffed animal on top of it with the vent on the back of the CPAP machine covered with a grey fuzzy substance, the O2 concentrator (oxygen machine) was on, the NC tubing was missing, and the tubing from the humidification bottle was labeled 12/7. Interview on 2/13/2024 at 3:42 pm with R36 revealed that she had not noticed any staff member cleaning her CPAP mask CPAP machine or changing the tubing for her O2. Interview and observations made on 2/14/2024 at 11:30 am with Unit Manager JJ, he verified and confirmed the vent on back of R36's CPAP machine was covered with a grey fuzzy substance. He verified and confirmed the tubing from the humidifier bottle was dated 12/7. He verified and confirmed the CPAP mask was left on top of R36's dresser behind a fan with a stuff animal on top of it. He stated he was not sure who was responsible for cleaning filters for the CPAP machines. He stated the O2 tubing should be changed every week and labeled with the current date. He revealed the date on the humidifier bottle tubing was the date tubing was changed. He stated the CPAP should be stored inside a clear bag, not on top of the dresser. Review of EMR revealed R84 who was admitted to the facility with diagnoses listed but not limited to acute and chronic respiratory failure, pneumonia, and asthma. Review of R84 quarterly MDS with an ARD of 1/2/2024 revealed a BIMS score of 15, which indicates R84 was cognitively intact. Section O (special treatments, procedures, and programs) revealed she received respiratory therapy seven days during the look back period. Review of R84's care plan indicated a focus of risk for respiratory deficit related to asthma/chronic respiratory failure (initiated 10/19/2022) and oxygen therapy related to ineffective gas exchange (initiated 9/27/2023). The goals included but were not limited to R84 will have no signs or symptoms of poor oxygen absorption (initiated 10/19/2022 & 9/27/2023). Interventions included but were not limited to monitor for signs/symptoms of respiratory distress and report the physician as needed, oxygen settings: oxygen via nasal cannula per physician orders (initiated 9/27/2023) and elevate head of bed (initiated 10/19/2022). Review of the EMR revealed physician's orders for R84 included but was not limited to oxygen tubing change weekly, label each component with date and initials every night shift every Wednesday. Oxygen at three liters per minute via nasal cannula, check oxygen saturation every shift for oxygen use / breathing. Observations on 2/13/2024 at 3:30 pm of R84's O2 tubing not being labeled. Observations on 2/14/2024 at 10:29 am of R84's NC not being labeled. Observations and interview on 2/14/2024 at 11:30 am with Unit Manager JJ, he verified and confirmed the O2 tubing on the O2 concentrator which R84 uses was not labeled with the date it was changed. He stated NC tubing should be changed weekly and dated. Review of the EMR revealed R54 was admitted to the facility with diagnoses listed but not limited to chronic obstructive pulmonary disease (COPD) and asthma. Review of R54 quarterly MDS with an ARD of 12/20/2024 revealed a BIMS score of 15, which indicates R54 was cognitively intact. Section I (active diagnoses) revealed cardiorespiratory conditions and chronic obstructive pulmonary disease (COPD). Section O (special treatments, procedures, and programs) revealed R54 received oxygen therapy. Review of R54's care plan indicated a focus of COPD related to impaired oxygenation (initiated 10/19/2022). Goals included but not limited to R54 will be free of signs / symptoms of respiratory infections. Interventions included but are not limited to monitoring signs / symptoms of acute respiratory insufficiency, monitor and document anxiety, monitor document report signs / symptoms of respiratory infection. Review of the EMR revealed physician's orders for R54 included but not limited to oxygen tubing change weekly, label each component with date and initials, every night shift every Wednesday, oxygen at two liters per minute to keep oxygen saturation greater than 92 percent as needed for breathing (start date 10/2/2022). Observations on 2/13/2024 at 2:55 pm of R54's O2 tubing dated 1/2/2024. Observations on 2/14/2024 at 10:17 am of R54's O2 tubing dated 1/2/2024. Interview and observations made on 2/14/2024 at 11:52 am with Unit Manager JJ, he verified and confirmed the O2 tubing for R54 was dated 1/2/2024 and stated O2 tubing should be changed and dated each week. Interview on 2/15/2024 at 12:14 pm with the Director of Nursing (DON) revealed O2 tubing should be changed weekly and dated, and all respiratory supplies should be stored inside a plastic bag, including but not limited to CPAP, BiPAP masks/tubing's, NCs, and aerosol generating devices. He stated filters for CPAP, BiPAP, and O2 concentrators should be cleaned weekly for dust, grime, and sponge filters should be air dried after cleaning. He stated he expected the nursing staff to adhere to the policies and procedures of the facility. He stated he expected the nursing staff to change and date all respiratory supplies weekly, when they are not in use store in a plastic bag, and clean filters and equipment weekly allowing sponge filters to air dry. 2. A review of the EMR for R61 revealed he was admitted to the facility with diagnoses including but not limited to chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure with hypercapnia, acute and chronic respiratory failure with hypoxia, heart failure, and acute on chronic diastolic (congestive) heart failure. A review of the most recent quarterly MDS assessment dated [DATE], revealed R61 had a BIMS score of 15, which indicated resident was cognitively intact. Section O (Special Treatments and Programs) revealed resident received oxygen therapy. A review of a care plan dated 2/13/2024 revealed R61 had a diagnosis of congestive heart failure and respiratory illness and required continuous oxygen therapy. Observations on 2/13/2024 at 10:14 am, during initial screening and at 2:17 p.m. revealed R61 observed out of bed to wheelchair, O2 NC attached to the concentrator lying on the residents bed. The O2 concentrator was on with the flow settings at 2 LPM. The filter on the O2 concentrator had a white/light grey, fuzzy substance over the vent covering the filter, and the humidifier bottle was empty. There was also an O2 cylinder on the back of R61's wheelchair; the NC attached was not properly stored while not in use. Observation 2/14/2024 at 8:26 am revealed R61 out of bed to wheelchair. The O2 cylinder on the back of the wheelchair with tubing hanging was not properly stored while not in use. Further observation revealed R61 wearing O2, and the concentrator was on. The humidifier bottle was now dated 2/13/2024. The vent covering the filter of the O2 concentrator continues to have a white/light grey, fuzzy substance. Observation 2/14/2024 at 10:59 am revealed R61 out of bed to wheelchair. R61 was not wearing O2 at the time of this observation. The O2 concentrator was on, and the attached NC was lying on the floor not properly stored. The O2 cylinder on the back of the resident's wheelchair had a NC attached but was not properly stored while not in use. Observation on 11/4/2023 at 8:56 am revealed the O2 NC tubing was now dated 11/3/2023, the humidifier bottle remained empty, and the O2 concentrator's filter continues to have a white/light grey, fuzzy substance on the entire filter. Interview and walking rounds 12/14/2024 at 11:07 am with LPN Unit Manager AA revealed she was not sure who was responsible for changing or washing the filters on the O2 concentrators, but she would find out. LPN Unit Manager AA further stated that the NCs and all other respiratory tubing should be changed and dated weekly and stored in a clear drawstring plastic bag when not in use. LPN Unit Manager AA verified the fuzzy substance on the vent cover of the filter on the O2 concentrator and the NC were not properly stored while not in use. Interview 2/14/2024 at 12:28 pm with the DON revealed the Certified Nursing Assistants (CNA's) and Nurses are responsible for ensuring the respiratory tubing is stored in a plastic bag when not in use. The DON further stated that the tubing is changed and dated weekly. The DON further stated that the filters are also changed and washed weekly on the night shift. Observation and interview 2/14/2024 at 2:31 pm with R61 revealed the tubing on the O2 concentrator was now bagged in a plastic bag. The filter cover continued to have a white/light grey, fuzzy substance. The tubing on the O2 cylinder on the back of resident's wheelchair was still not bagged while not in use. R61 stated the tubing on the back of the chair was old tubing and it had not been changed in months. R61 further stated that the tubing to the concentrator was changed and placed in the plastic bag today. R61 further stated that he had not witnessed staff cleaning or washing the concentrator filter and she was not aware that the concentrator had a filter. Interview 12/15/2024 at 8:35 am with CNA CC revealed that she was aware that the respiratory tubing should be stored in a plastic bag. She stated that the night shift was responsible. CNA CC stated she had witnessed tubing not in bag while not in use, but she was busy and honestly forgot to do it. A review of the EMR for R50 revealed he was admitted to the facility with diagnoses including but not limited to anxiety disorder and heart failure. A review of an admission MDS assessment dated [DATE], revealed R50 had a BIMS score of 15, which indicated resident was cognitively intact. The initial tour of the facility on 2/13/2024 at 10:13 am revealed a CPAP machine on R50's dresser along the side of his bed. R50 stated he wore the CPAP at night and removed it upon waking each morning. R50 stated he has had the machine since admission to the facility.

Based on observations, staff interviews, record review, and review of the facility policies titled, Hand Hygiene, PPE Source Control, Standard Precautions Infection Control, and Infection Prevention and Control Program, the facility failed to utilize personal protective equipment (PPE) properly in an isolation room for one of one resident (R) (R95) on transmission based precautions and failed to perform hand hygiene between residents when delivering resident meals to resident rooms for seven of eight residents on the East-C hall. The deficient practice had the potential to spread infection to other residents and staff. The facility census was 127 residents. Findings include: Review of the facility policy titled Hand Hygiene date reviewed/revised June 2023 revealed under Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Under the section titled Policy Explanation and Compliance Guidelines number one revealed staff will perform hand hygiene when clinically indicated, using proper technique consistent with acceptable standards of practice. Number three revealed alcohol-based hand rub with 60 - 95 percent alcohol is the preferred method for cleaning hands in most clinical situations. Wash hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom. Review of the facility policy titled PPE Source Control date reviewed/revised December 2022 revealed under Policy: The facility promotes appropriate use of personal protective equipment (PPE) to prevent the transmission of pathogens to residents, visitors, and other staff. Review of the facility policy titled Standard Precautions Infection Control date reviewed/revised 9/12/2022 revealed: All staff are to assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Therefore, all staff shall adhere to Standard Precautions to prevent the spread of infection to residents, staff and visitors. Under the subheading Policy Explanation and Compliance Guidelines revealed number two (a): Using personal protective equipment (PPE) revealed all staff who have contact with residents and or their environments must wear PPE as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or potentially infectious materials is likely. Number two (b) revealed: Multiple factors determine the appropriate selection of PPE for a particular task. Refer to the facilities Personal Protective Equipment Policy for indications and considerations for use of PPE. Review of the facility policy titled Infection Prevention and Control Program date reviewed/revised May 2023 revealed under Policy: The facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Under the sub-heading titled Policy Explanation and Compliance Guidelines, number two revealed: All staff are responsible for following all policies and procedures related to the program. Number five: isolation protocol (transmission-based precautions) revealed: A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by the current CDC [Centers for Disease Control and Prevention] guidelines. 1. Observation on 2/14/2024 at 1:17 pm of Certified Nursing Assistant (CNA) PP performed hand hygiene prior to delivering and setting up the first tray for residents on the East-C Hall. She then delivered trays to another seven of eight residents on the hall but did not perform hand hygiene between each tray that was delivered to the residents. Interview with CNA PP on 2/14/2024 at 1:22 pm, she stated she utilized hand sanitizer once prior to delivering the first tray on the East-C Hall. She stated she did not use hand sanitizer, nor did she wash hands with soap and water between delivering each tray. She stated she was the only staff passing trays and she had to get them to the residents as soon as possible. She stated the dietary staff had delivered trays to the unit she was assigned to (East-B Hall) and she had to go so she could deliver trays to residents on the East-B Hall. Interview on 2/14/2024 at 2:00 pm with Unit Manager JJ revealed that staff should perform hand hygiene between delivering and setting up each resident's meal tray. He stated he expected the CNAs to perform hand hygiene either utilizing soap and water or hand sanitizer between delivering each tray to a resident. Interview on 2/15/2024 at 12:14 pm with the Director of Nursing (DON) revealed that staff should perform hand hygiene before delivering and between each tray delivered utilizing hand sanitizer if they choose or soap and water, but they should use soap and water every third time they need to perform hand hygiene. He stated his expectation was that they perform hand hygiene before delivering meal trays and between each meal tray delivered to residents. 2. Observation on 2/13/2024 at 12:58 pm on hall E revealed CNA FF went into room E2 without PPE for droplet/contact precautions. Supplies were available for staff located on the door which included face mask, gowns, and gloves. Face shields were not available at the time that CNA FF entered the room. The procedure for wearing PPE was on the front door including how to enter and exit the room. CNA FF entered the room to deliver lunch to R95. CNA FF did not put on a gown, gloves or face shield. She did not remove the face mask once she exited the resident's room. She sanitized her hands. She entered other residents' rooms to deliver lunch with the same face mask on. Interview on 2/13/2024 at 1:05 pm on Hall E, CNA FF revealed that she never puts on PPE when entering resident R95's room to deliver lunch. Interview on 2/13/2024 at 1:15 pm with the DON revealed that all staff had been trained on using PPE equipment for droplets/ contact precautions. 49681

Based on record review, staff interview, and review of the facility policy titled, Comprehensive Care Plans, the facility failed to follow a care plan for one of 41 sampled residents (R) (R42) related to wound care. The deficient practice had the potential to cause R42 to not receive treatment and/or care according to their needs. Findings include: Review of the facility policy titled Comprehensive Care Plans with a review date of 9/12/2022 revealed under Policy Explanation and Compliance Guidelines: The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented as needed. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. Review of R42's electronic medical record (EMR) revealed that he had diagnoses including non-pressure chronic ulcer of left thigh and punctate keratitis. Review of the most recent quarterly Minimum Data Set (MDS) for R42 dated 1/2/2024 revealed R42 had a surgical wound. Review of R42's Physician's Orders revealed that he was receiving treatment to the left inner thigh: Cleanse wound with wound cleanser. Pat dry. Apply Calcium Ag. [algonate] Cover with ABD [abdominal] pad. Change daily and as needed (PRN) two times a day AND as needed. Review of the care plan for R42 revealed a care plan for surgical wound to the left thigh was initiated on 10/22/2022. The care plan listed individualized interventions to include treatment as ordered. Review of the treatment administration record (TAR) for December 2023 for R42 revealed daily treatment to residents left inner thigh was not documented as completed on 12/3/2023, 12/6/2023, 12/9/2023, 12/10/2023, 12/13/2023 - 12/17/2023, and 12/21/2023 through 12/28/2023. The order changed to twice daily on 12/28/2023. The treatment to the surgical wound was not documented as completed on 12/29/2023 and 12/31/2023 at 9 am and 9 pm. In addition, the treatment was not documented as completed on 12/30/2023 at 9 pm. Review of the TAR for January 2024 revealed the twice daily treatment to R42's inner thigh was not documented as completed on 1/1/2024, 1/4/2024, 1/5/2024, 1/7/2024, 1/8/2024, 1/14/2024 through 1/17/2024, 1/21/2024, 1/22/2024, 1/27/2024 - 1/29/2024, 1/2/2024, 1/6/2024, 1/18/2024 through 1/20/2024, 1/23/2024, 1/26/2024 at 9:00 am, and 1/30/2024 at 9:00 pm. Review of the TAR for February 2024 revealed the twice daily treatment to R42's inner thigh was not documented as completed on 2/1/2024 through 2/3/2024, 2/7/2024, 2/13/2024, 2/4/2024 and 2/11/2024 at 9:00 am, and 2/10/2024, 2/11/2024 and 2/14/2024 at 9:00 pm. Interview 2/15/2024 at 10:19 am with the RN MDS Coordinator revealed R42's wound care plan was updated 10/9/2023. The RN MDS Coordinator verified that if the staff were not abiding by the physician's orders for wound care, the plan of care was not being followed.

Based on observations, record review, and review of the facility policy titled, Activities of Daily Living (ADL), the facility failed to give a dependent resident the appropriate assistance with eating meals and to ensure meals in their room in a timely manner for one of 41 sampled residents (R) (R25). The deficient practice had the potiential to cause weight loss for R25. Findings include: Review of the undated facility policy titled Activities of Daily Living revealed under Policy: Based on the comprehensive assessment of a patient and consistent with the patient's needs and choices, the Center must provide the necessary care and services to ensure that a patient's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrates that such diminution was unavoidable. Activities of daily living (ADLs) include: Hygiene-bathing, dressing, grooming, and oral care; Mobility-transfer and ambulation, including walking; Elimination-toileting; Dining-eating, including meals and snacks; Communication-including speech, language, and other functional communication systems. Practice Standards: 1.2. A patient who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of the electronic medical record (EMR) for R25 revealed diagnoses including but not limited to Todd's paralysis (postictal paralysis), aphasia, need for assistance with personal care, other lack of coordination, muscle weakness (generalized), need for assistance with personal care, other lack of coordination. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE] for R25 revealed a Brief Interview for Mental Status (BIMS) score of 99, which indicates R25 was not able complete the interview-resident is rarely or never understood. Section GG (Functional Abilities and Goals) indicated full dependence on staff with ADL's, including eating. Review of the care plan for R25 revealed interventions to monitor, document, and report PRN (as needed) any of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals. The resident has potential nutritional problem r/t [related to] texture modified diet, use PEG [percutaneous endoscopic gastrostomy] tube. R25 has an ADL self-care performance deficit r/t activity intolerance, disease process 2/28/2023. Observation on 2/14/2024 at 9:35 am of R25 being feed by a Certified Nurse Assistant (CNA). Breakfast consists of eggs, grits, and milk. Resident was eating very good with assistance. Observation on 2/15/24 at 9:37 am of R25 with a breakfast tray to the left side of her bed. It appeared that she was set up prepared to eat. Food was all over her clothes, face, and hands. It appeared as though she was trying to feed herself. I observed resident (R) R25 silverware was still in the napkin wrapped up and the milk was unopened.

Based on observations, resident and staff interviews, record review, and review of the facility policies titled, Wound Treatment Management and Charting and Documentation, the facility failed to provided treatment and care in accordance with professional standards for two of 41 sampled residents (R) (R42 and R81) related to failure to document wound care was performed as ordered by the physician. The deficient practice had the potential to cause further decline and possible infection of wounds. Findings included: Review of the facility policy titled Wound Treatment Management dated August 2023 revealed under Policy Statement: To promote wound healing of various types of wounds, it is the policy of the facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Policy Explanation and compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing changes. 6. c. The facility will follow specific physician orders for providing wound care. 7. Treatments will be documented on the Treatment Administration Record (TAR) or in the electronic health record. Review of the facility policy titled Charting and Documentation revised July 2017 revealed in the Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medial record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Under the section Policy Interpretation and Implementation: 2. The following information is to be documented in the resident's medical record, C - treatments or services performed. 7. Documentation of procedures and treatments will include: a. care-specific details, including: a. the date and time the procedure/treatment was provided, b. the name and title of the individual(s) who provided the care; c. the assessment data and/or any unusual findings obtained during the procedure/treatment; d. how the resident tolerated the procedure/treatment; e. whether the resident refused the procedure/treatment; f. notification of family, physician, or other staff, if indicated, and; g. the signature and title of the individual documenting. 1. Review of the Electronic Medical Record (EMR) revealed that R42 had a diagnosis of but not limited to non-pressure chronic ulcer of left thigh, rosacea, lack of coordination, morbid (severe) obesity due to excess calories, local infection of the skin and subcutaneous tissue, punctate keratitis, bilateral, and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed in Section C - Cognitive Patterns: Brief interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Section M - Skin Condition revealed R42 had a surgical wound. R42 had a care plan related to surgical wound with an initial date of 8/24/2023. Review of the current physician orders in the EMR revealed R42 had an order for the Left inner Thigh: Cleanse wound with wound cleanser. Pat dry. Apply Calcium Ag. [alginate] Cover with ABD [abdominal] Pad. Change daily and as needed (PRN) two times a day. Start date 12/28/2023. Review of the Treatment Administration Record (TAR) for December 2023 revealed daily treatment to R42's left inner thigh was not documented as completed on 12/3/2023, 12/6/2023, 12/9/2023, 12/10/2023, 12/13/2023 through 12/17/2023, and 12/21/2023 through 12/28/2023. The order changed to twice daily on 12/28/2023. The treatment to the surgical wound was not documented as completed on 12/29/2023 and 12/31/2023 at 9:00 am and 9:00 pm. In addition, the treatment was not documented as completed on 12/30/2023 at 9:00 pm. Review of the TAR for January 2024 revealed the twice daily treatment to R42's inner thigh was not documented as completed on 1/1/2024, 1/4/2024, 1/5/2024, 1/7/2024, 1/8/2024, 1/14/2024 through 1/17/2024, 1/21/2024, 1/22/2024, 1/27/2024 through 1/29/2024, 1/2/2024, 1/6/2024, 1/18/2024 through 1/20/2024, 1/23/2024, and 1/26/2024 at 9:00 am, and 1/3/2024 at 9:00 pm. Review of the TAR for February 2024 revealed the twice daily treatment to R42's inner thigh was not documented as completed on 2/1/2024 through 2/4/2024, 2/7/2024, 2/13/2024, 2/11/2024 at 9:00 am, and 2/4/2024, 2/10/2024, 2/11/2024 and 2/14/2024 at 9:00 pm. Wound observation 2/14/2024 at 9:27 am revealed R42's wound observation with LPN wound nurse GG. Wound Nurse GG explained the procedure to R42. Supplies were gathered, provided privacy, resident repositioned, and was assessed for pain. Hand hygiene was performed, the wound was assessed, the wound was cleansed, and application of medications and dressings as ordered by the physician was performed. R42 was assessed for pain and repositioned. R42 tolerated the procedure well and was appreciative of the dressing change. Hand hygiene was performed within standard practice throughout the procedure. Interview on 2/13/2024 at 10:52 am with R42 revealed the facility had finally hired a wound nurse to do his dressing changes. R42 further stated the previous wound nurse left a couple of months ago, so the care of his wound was not being treated consistently. He stated that the wound care was sometimes done by the hall nurses and at other times he had to care for his own wound, despite it being on his backside. Interview on 2/14/2024 at 9:19 am with the Wound Nurse Practitioner revealed R42's wound was a chronic wound that he has had for 4 years. She further stated that R42 cannot reposition himself, so the goal for him was to reduce the risks of the wound getting infected. Interview on 2/14/2024 at 9:21 am with LPN Wound Nurse GG revealed she just started as the wound nurse approximately 2 weeks ago. LPN GG stated prior to her being promoted to the wound nurse position, the facility did not have a wound nurse, so the nurses assigned to the residents with wounds were responsible to do wound care. LPN GG further stated nurses are required to document the wound care was complete in the EMR. Interview on 2/14/2024 at 3:54 pm with the Director of Nursing (DON) revealed the last wound nurse did leave in November 2023. The DON further stated at that time the former DON was overseeing the wound program and the nurses assigned to the residents with wounds were responsible for ensuring residents wound care was done. The DON further stated that the new wound nurse started the position about 2 weeks ago. The DON stated that when the wound treatments are performed it should be documented in the EMR on the TAR. The DON stated during that time the facility utilized a lot of agency nurses, so accountability was hard. During a follow-up interview on 2/15/2024 at 9:18 am with the DON, he verified the treatments for R42 and R81 were not documented as completed as ordered by the physician. The DON also stated the wound nurse was responsible for treatment on Mondays, Wednesdays, and Fridays and the hall nurses are responsible for treatment on all other days. The DON further stated the nursing administration staff are new to their perspective roles so the audits for compliance are not being done yet. 47146 2. Observation of wound care for R81's sacral wound with LPN Wound Care Nurse GG and the Wound Care Nurse Practitioner (NP) revealed LPN Wound Nurse GG consulted the wound care orders, assessed the resident's pain, assembled supplies, cleaned the overbed table with facility approved disinfectant, allowed proper wet time, then she utilized a barrier for the table which she placed her supplies for the wound treatment. She performed hand hygiene utilizing soap and water before starting and throughout the treatment at each glove change and upon exiting the room. She assisted R81 onto his right side. She removed the old dressing, discarded all soiled dressings into a biohazard bag, doffed (took off) gloves, performed hand hygiene, then donned (put on) clean gloves. The Wound Care NP, after performing hand hygiene with hand sanitizer, donned clean gloves and measured the wound, after which she doffed her gloves, performed hand hygiene with hand sanitizer, then donned clean gloves and assisted LPN Wound Nurse GG with positioning of the resident. LPN Wound Nurse GG cleansed the wound as directed in the physician orders, doffed gloves, performed hand hygiene, then donned clean gloves. She then provided the wound treatment as directed in the physician orders, covered the wound with a dressing and labeled the dressing with the date and her initials. She doffed her gloves, performed hand hygiene, and donned clean gloves. She gathered the biohazard bag and discarded all dressing wrappings and the barrier from the table. She cleaned the table again with facility approved disinfectant, then removed the biohazard trash from the room. She reassessed the residents pain level before leaving the resident. Review of R81's physician orders included but not limited to sacrum pressure stage IV (four) cleanse with 1/4 strength Dakin's solution (wound cleanser), pat dry, apply no sting skin prep to peri (around)-wound, apply calcium algenate -AG, cover with bordered gauze, every day. Start date 12/13/2023. Review of R81's care plan revealed a focus of R81 has a pressure ulcer stage four (4) to sacrum related to history of ulcers, bowel incontinence, and immobility (date initiated 9/13/2023, created by MDS coordinator, Revision on 12/13/2023 by reimbursement specialist). Goal was R81's pressure ulcer will show signs of healing and remain free from infection by/through review date (date initiated 9/13/2023 by MDS coordinator; revision of 9/28/2023 by reimbursement specialist). Interventions included but not limited to administer treatments as ordered and monitor for effectiveness (date initiated/created 9/13/2023 by MDS Coordinator) Review of R81's TAR for the sacral wound in December 2023 revealed daily wound care orders were started on 12/13/2023. Review of the TAR revealed there were only three dressing changes documented for the sacral wound between 12/13/2023 through 12/31/2023, on 12/13/2023, 12/28/2023, and 12/30/2023. Review of R81's TAR for January 2024 revealed daily wound care to the sacral wound ordered and there were eight dressing changes documented for the entire month of January. Dressing changes were documented as completed only on 1/2/2024, 1/16/2024, 1/18/2024, 1/19/2024, 1/20/2024, 1/24/2024, 1/29/2024, and 1/30/2024. Review of R81's TAR for February 2024 revealed daily wound care to the sacral wound, and between 2/1/2024 and 2/14/2024 there were six dressing changes documented as completed. Dressing changes were documented as completed on 2/2/2024, 2/3/2024, 2/5/2024, 2/6/2024, 2/12/2024, and 2/14/2024. Interview on 2/15/2023 at 11:43 am with LPN HH revealed that the charge nurse completes wound care as ordered when the wound care nurse is not working and documents the care given on the TAR. She stated she does not have any trouble finding time to complete the care assigned to her. She stated if she feels she needs assistance with a task she asks the unit manager for assistance. Interview with LPN NN on 2/15/2024 at 11:49 am revealed the wound care nurse works five days a week, Monday through Friday. She stated the wound care nurse completes all the wound care on the days she is working. She stated on Saturday and Sunday it is the responsibility of the LPN -Charge Nurse to complete and document the wound care completed on the TAR. She stated she has not had trouble completing wound care for residents when working without a wound care nurse. Interview with the DON on 2/15/2024 at 12:14 pm, he confirmed and verified R81's December TAR between 12/13/2023 through 12/31/2023 the nurses documented only three dressing changes for R81's daily sacrum wound dressing changes, January TAR between 1/1/2024 through 1/31/2024 the nurses documented only eight dressing changes, and the February TAR between 2/1/2024 through 2/14/2024 the nurses documented only six dressing changes. He revealed his expectation was that wound care be performed as ordered by the physician and documented on the TAR. He stated he expected the nurse performing the wound care should follow through with the orders and document care and wound care given to the resident in the EMR. He stated he thinks the nurses have been prioritizing patient care over documentation, therefore not documenting the care they have given.

Based on observations, interviews, and record review, the facility failed to ensure that five of 43 sampled residents (R) (R30, R24, R4, R25, and R31) were provided Activities of Daily Living (ADL) care. Psychosocial harm was identified for R30 related to her becoming tearful and expressing feelings of humiliation when she was ignored, and staff refused the resident incontinence care. Findings included: A review of the facility policy last updated December 2022 titled, Quality of Life-Dignity, documented each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Residents shall be always treated with dignity and respect. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. Staff shall always speak respectfully to residents. Demeaning practices and standards of care that compromise dignity is prohibited. Staff shall promote dignity and assist residents as needed by, promptly responding to the residents' request for toileting assistance. A review of the facility policy titled Incontinence, and last updated January 2022, documented the following: Based on a comprehensive assessment all residents that are incontinent will receive appropriate treatment and services. Residents that are incontinent of bladder and bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible. 1. A review of R30's comprehensive care plan (CCP) initiated on 12/7/2022, staff documented R30 had self-care performance deficit related to weakness. The care plan directed staff to assist with toileting, dressing and personal hygiene. A review of R30's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident presented with a Brief Interview for Mental Status (BIMS) score of 15 out 15, indicating R30 was cognitively intact. It was further documented that R30 required one person assistance with toileting and personal hygiene. During an observation on 10/11/2023 at 9:52 am, R30 was sitting in her wheelchair, her waist area was partially exposed, and gown untied. R30 explained with a tearful voice to Medical Records Staff NN, I need help. Medical Records Staff NN was observed to tell the resident, Calm down. R30 stated staff had been ignoring her calls for incontinent care for more than two hours. Medical Records Staff NN said to the resident, Don't talk to me like that. Two LPNs sat at the nurse's station facing R30, Licensed Practical Nurse (LPN) JJ and LPN SS. During an interview on 10/11/2023 at 10:05 am, R30 stated at 7:45 am she started feeling sick with diarrhea and had a bowel movement (BM), while she sat on her wheelchair, reached the call light and no one answered. R30 attempted to clean herself and was unsuccessful. She stated that at 8:05 am, she wheeled to the nurse's station and informed LPN JJ she needed assistance. LPN JJ said staff were busy passing trays and she told R30 she will not be assisted until staff finished passing trays and to go back to her room. R30 waited another thirty to forty-five minutes and asked LPN JJ for assistance the second time. LPN JJ said R30 was impatient and will have to wait until Certified Nursing Assistant (CNA) MM is done passing trays. LPN JJ said, You know we don't assist residents with incontinent care when passing out trays. CNA MM brought her breakfast while she sat on her soiled brief and left the room and continued passing trays. R30 said she felt humiliated, ashamed, and embarrassed. R30 stated at 10:20 am, MM cleaned her up. R30 concluded, it was unfair to be served breakfast while she sat in a soiled brief. During an interview on 10/11/2023 at 11:02 am, LPN JJ revealed staff started serving breakfast at 7:35 am. R30 called for assistance with incontinent care at approximately 7:50 am, LPN JJ told the resident to stay in her room. At approximately 8:10 am, LPN JJ notified CNA MM to assist R30 with incontinent care. At that time CNA MM had started passing food trays. R30 was visibly upset and said she had a BM and needed assistance, since 7:45 am. LPN JJ stated she had four CNA's working on her assigned hall. LPN JJ stated management instructed staff to refrain from assisting residents with incontinent care when staff are passing out trays due to cross contamination. During an interview on 10/11/2023 at 11:15 am, R30 revealed it was the second time she sat on her BM for several hours. R30 stated, in August 2023, at approximately 3:30 pm, she sat on her BM for over four hours. R30 stated, she screamed for an hour and half. R30 eventually called a friend and her friend called 911. Emergency Medical Services (EMS) arrived at 8:00 pm that night and R30 went to hospital. During an interview on 10/11/2023 at 11:12 am, CNA LLL revealed she clocked in at approximately 7:00 am. CNA LLL stated when a resident requires incontinent care during meal serve, they will continue serving breakfast until completely done and then assist the resident. CNA LLL stated she was passing trays when the R30 requested incontinent care and stated that the nurses do not assist with incontinent care. During an interview on 10/11/2023 at 11:45 am, LPN LL revealed she started her shift at 7:00 am, and at approximately 8:45 am, R30 asked her for assistance with incontinent care. She stated that at the time, she was passing medications and CNA MM was assisting other residents. Approximately ten minutes later, R30 returned and needed assistance with incontinent care. LPN LL stated that she told R30 staff were busy at the time. LPN LL stated she was not aware R30 had a BM and said, It's never appropriate for staff to serve a resident a meal while they sat on their BM. All residents should be treated with dignity and respect. During an interview on 10/11/2023 at 11:54 am, CNA MM revealed at approximately 8:45 am, R30 asked for assistance with incontinent care, and she told R30 to go back to her room. CNA MM stated, at that time, she was busy passing out trays and that the staff were given directions to not provide incontinent care while passing out trays due to cross contamination. During an interview on 10/11/2023 at 12:14 pm, Medical Records Staff NN stated she knew R30 was seated on her own BM and needed assistance but that she tried to explain to R30 staff were not expected to assist residents with incontinent care during meal serve due to cross contamination. 2. A review of R24's CCP initiated on 12/2/2022 staff documented, R24 had self-care performance deficit related to Hemiplegia (a severe form of complete paralysis of half of the body) and impaired balance. The care plan directed staff to assist with toileting, dressing, undressing and personal hygiene. A review of R24's quarterly MDS assessment dated [DATE], revealed that R24 presented with a BIMS score of 15 out 15 meaning, indicating the R24 was cognitively intact. It was further documented that R24 required one-person assistance with toileting and personal hygiene. During observation and interview on 9/27/2023 at 11:14 am, R24 was sitting in his wheelchair in the hallway reading a book. R24's thighs and genital area partially uncovered by a sheet, R24 wore a diaper without pants and was fully exposed from the thigh up to the genital area. R24 opened his closet and stated he did not have any pants to wear. Two shirts were in R24's closet. There were no plants in R24's closet. R24 stated it takes over two weeks and several days to get his personal clothes back from the laundry. R24 stated, staff do not care and concluded, he feels embarrassed and disrespected. During an interview on 9/27/2023 at 11:20 am. LPN III, revealed R24 was alert and oriented and enjoys reading. LPN III stated she was not aware R24 was not wearing pants and that it is up to the CNA's to make sure residents are dressed. During an interview on 10/2/2023 at 10:20 am Registered Nurse (RN) QQ revealed all residents must be fully dressed when they are up in bed, stated all staff are expected to monitor and to make sure all residents are treated with dignity and respect. Staff should make sure residents are fully clothed when residents are out of bed. During an interview on 10/2/2023 at 1:20 pm, R24 revealed on 10/27/2023 he spent the whole day without pants. R24 stated he was frustrated and embarrassed. Observation revealed four pairs of pants and four shirts in R24's closet. 3. A review of R4's CCP initiated on 10/19/2022 staff documented, R4 had baseline ADL functions. The care plan directed staff to assist with toileting, dressing and personal hygiene. A review of R4's quarterly MDS assessment dated [DATE] revealed that R4 presented with a BIMS score of 15 out 15, indicating that R4 was cognitively intact. It was further documented that R4 required one-person assistance with toileting and personal hygiene. During an observation and interview on 10/3/2023 at 8:15 am R4, revealed on 9/14/2023, she had a bowel movement, waited for assistance from staff for at least four hours. R4 eventually called her daughter for assistance before the staff came to her aide. During an interview on 10/11/2023 at 11:30 am with resident R4 revealed the staff would not provide incontinent care for over two hours. R4 stated that last Wednesday evening, 10/4/2023, dinner was served late around 7:15 pm. R4 stated she experienced a bowel movement with the first bite of food. R4 stated she turned on the call light and the certified nursing assistant stated incontinent care would be done after the trays were served. R4 stated she thought it would be around 15 to 20 minutes, but it turned out to be two hours of sitting in soiled-bowel movement brief. R4 stated she could not eat the meal because of the humiliation she had felt. R4 stated the smell of the bowel movement had caused a loss of appetite. R4 stated the CNA stated she could not provide incontinent care while the trays were out. 4. A review of R25's annual MDS assessment dated [DATE] revealed that R25 presented with a BIMS score of 13 out 15, indicating that R25 was cognitively intact. It was further documented that R25 required one-person assistance with toileting and personal hygiene. A review of R25's CCP initiated on 10/6/2022 staff documented, R25 had self-care performance deficit related to dementia and depression. The care plan directed staff to allow sufficient time for toileting, dressing and personal hygiene. During an observation and interview on 10/3/2023 at 9:01 am, R25 was observed lying in his bed. R25 revealed in June 2023, he laid in bed with soiled clothes for over an hour. According to R25 staff stated they were busy passing out trays. 5. A review of R31's CCP initiated on 10/18/2022 staff documented R31 had related baseline functions on admissions. The care plan directed staff to assist with toileting, dressing and personal hygiene. A review of R31's quarterly MDS assessment dated [DATE] revealed that R31 presented with a BIMS score of 15 out 15, indicating R31 was cognitively intact. It was further documented that R31 required one-person assistance with toileting and personal hygiene. During an observation and interview on 10/3/2023 at 9:15 am, R31 was observed lying in his bed and revealed in July 2023, staff did not assist him with incontinent care, when he soiled his diaper from 3:15 pm to 8:30 pm and served him supper while he sat in a soiled diaper and linen. A review of the Grievance Report, on 10/3/2023 at 10:30 a.m., revealed Ombudsman CCC had reported the residents complained of not receiving incontinent care. The Grievance Report listed two complaints, dated 8/21/2023 and 9/15/2023, of residents not receiving timely incontinent care. The Grievance Report also revealed the complaint on 8/21/2023 had concerned incontinent care not being performed during mealtimes. A review of the Grievance Report, on 10/3/2023 at 11:00 a.m., revealed the grievance dated 8/21/2023's resolution stated incontinent care was not to be given during mealtimes. During an interview on 9/27/2023 at 2:51 pm, Ombudsman CCC revealed he received numerous reports from residents. Ombudsman CCC stated residents reported to him they were discouraged and intimidated when they insisted on reporting complaints to the State or the Ombudsman. Ombudsman CCC revealed he received multiple complaints, regarding residents who were left soiled for several hours. An interview on 10/2/2023 at 12:52 pm, with LPN UU revealed stated incontinent care was not performed while the trays were out. LPN UU stated this would be cross-contamination. During an interview on 10/2/2023 at 12:54 pm, LPN LL revealed incontinent care would be given after the trays were passed out. LPN LL had not been sure if this was the facility's policy or if it had been something they had always done. During an interview on 10/2/2023 at 12:57 pm, LPN JJ stated incontinent care was given after the meal trays were served and that the staff did not perform incontinent care while the trays were out. During an interview on 10/10/2023 at 6:00 am, CNA YY stated incontinent care could not be performed while the meal trays were out on the floor. During an interview on 10/11/2023 at 3:30 pm, CNA OO stated she was instructed to continue passing trays when a resident required incontinent care during meal serve. CNA OO stated she was not expected to provide incontinent care according to facility policy during meal service and this has been a long-standing facility policy. During an interview on 10/11/2023 at 1:30 pm, the Director of Nursing, (DON) revealed, when a resident requests incontinent care while staff were passing out trays, she expected another staff member to assist the resident. As soon as a resident requested assistance with incontinent care the normal wait time should be approximately five to ten minutes. A period of one or two hours waited time for incontinent care is considered excessive and a delay in care. Serving food when a resident is seated on their BM is not a facility policy. The DON stated any of the nursing staff should have assisted R30 with incontinent care. 49479

Based on observations, interviews, and record review, the facility failed to ensure that three of 43 sampled residents (R) (R30, R24, and R4) were treated with dignity related to providing Activities of Daily Living (ADL) care. Psychosocial harm was identified for R30 related to her becoming tearful and expressing feelings of humiliation when she was ignored, and staff refused the resident incontinence care. Findings included: A review of the facility policy last updated December 2022 titled, Quality of Life-Dignity, documented each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Residents shall be always treated with dignity and respect. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. Staff shall always speak respectfully to residents. Demeaning practices and standards of care that compromise dignity is prohibited. Staff shall promote dignity and assist residents as needed by, promptly responding to the residents' request for toileting assistance. 1. A review of R30's comprehensive care plan (CCP) initiated on 12/7/2022, staff documented R30 had self-care performance deficit related to weakness. The care plan directed staff to assist with toileting, dressing and personal hygiene. A review of R30's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident presented with a Brief Interview for Mental Status (BIMS) score of 15 out 15, indicating R30 was cognitively intact. It was further documented that R30 required one person assistance with toileting and personal hygiene. During an observation on 10/11/2023 at 9:52 am, R30 was sitting in her wheelchair, her waist area was partially exposed, and gown untied. R30 explained with a tearful voice to Medical Records Staff NN, I need help. Medical Records Staff NN was observed to tell the resident, Calm down. R30 stated staff had been ignoring her calls for incontinent care for more than two hours. Medical Records Staff NN said to the resident, Don't talk to me like that. Two LPNs sat at the nurse's station facing R30, Licensed Practical Nurse (LPN) JJ and LPN SS. During an interview on 10/11/2023 at 10:05 am, R30 stated at 7:45 am she started feeling sick with diarrhea and had a bowel movement (BM), while she sat on her wheelchair, reached the call light and no one answered. R30 attempted to clean herself and was unsuccessful. She stated that at 8:05 am, she wheeled to the nurse's station and informed LPN JJ she needed assistance. LPN JJ said staff were busy passing trays and she told R30 she will not be assisted until staff finished passing trays and to go back to her room. R30 waited another thirty to forty-five minutes and asked LPN JJ for assistance the second time. LPN JJ said R30 was impatient and will have to wait until Certified Nursing Assistant (CNA) MM is done passing trays. LPN JJ said, You know we don't assist residents with incontinent care when passing out trays. CNA MM brought her breakfast while she sat on her soiled brief and left the room and continued passing trays. R30 said she felt humiliated, ashamed, and embarrassed. R30 stated at 10:20 am, MM cleaned her up. R30 concluded, it was unfair to be served breakfast while she sat in a soiled brief. During an interview on 10/11/2023 at 11:02 am, LPN JJ revealed staff started serving breakfast at 7:35 am. R30 called for assistance with incontinent care at approximately 7:50 am, LPN JJ told the resident to stay in her room. At approximately 8:10 am, LPN JJ notified CNA MM to assist R30 with incontinent care. At that time CNA MM had started passing food trays. R30 was visibly upset and said she had a BM and needed assistance, since 7:45 am. LPN JJ stated she had four CNA's working on her assigned hall. LPN JJ stated management instructed staff to refrain from assisting residents with incontinent care when staff are passing out trays due to cross contamination. During an interview on 10/11/2023 at 11:15 am, R30 revealed it was the second time she sat on her BM for several hours. R30 stated, in August 2023, at approximately 3:30 pm, she sat on her BM for over four hours. R30 stated, she screamed for an hour and half. R30 eventually called a friend and her friend called 911. Emergency Medical Services (EMS) arrived at 8:00 pm that night and R30 went to hospital. During an interview on 10/11/2023 at 11:12 am, CNA LLL revealed she clocked in at approximately 7:00 am. CNA LLL stated when a resident requires incontinent care during meal serve, they will continue serving breakfast until completely done and then assist the resident. CNA LLL stated she was passing trays when the R30 requested incontinent care and stated that the nurses do not assist with incontinent care. During an interview on 10/11/2023 at 11:45 am, LPN LL revealed she started her shift at 7:00 am, and at approximately 8:45 am, R30 asked her for assistance with incontinent care. She stated that at the time, she was passing medications and CNA MM was assisting other residents. Approximately ten minutes later, R30 returned and needed assistance with incontinent care. LPN LL stated that she told R30 staff were busy at the time. LPN LL stated she was not aware R30 had a BM and said, It's never appropriate for staff to serve a resident a meal while they sat on their BM. All residents should be treated with dignity and respect. During an interview on 10/11/2023 at 11:54 am, CNA MM revealed at approximately 8:45 am, R30 asked for assistance with incontinent care, and she told R30 to go back to her room. CNA MM stated, at that time, she was busy passing out trays and that the staff were given directions to not provide incontinent care while passing out trays due to cross contamination. During an interview on 10/11/2023 at 12:14 pm, Medical Records Staff NN stated she knew R30 was seated on her own BM and needed assistance but that she tried to explain to R30 staff were not expected to assist residents with incontinent care during meal serve due to cross contamination. 2. A review of R24's CCP initiated on 12/2/2022 staff documented, R24 had self-care performance deficit related to Hemiplegia (a severe form of complete paralysis of half of the body) and impaired balance. The care plan directed staff to assist with toileting, dressing, undressing and personal hygiene. A review of R24's quarterly MDS assessment dated [DATE], revealed that R24 presented with a BIMS score of 15 out 15 meaning, indicating the R24 was cognitively intact. It was further documented that R24 required one-person assistance with toileting and personal hygiene. During observation and interview on 9/27/2023 at 11:14 am, R24 was sitting in his wheelchair in the hallway reading a book. R24's thighs and genital area partially uncovered by a sheet, R24 wore a diaper without pants and was fully exposed from the thigh up to the genital area. R24 opened his closet and stated he did not have any pants to wear. Two shirts were in R24's closet. There were no plants in R24's closet. R24 stated it takes over two weeks and several days to get his personal clothes back from the laundry. R24 stated, staff do not care and concluded, he feels embarrassed and disrespected. During an interview on 10/2/2023 at 10:20 am Registered Nurse (RN) QQ revealed all residents must be fully dressed when they are up in bed, stated all staff are expected to monitor and to make sure all residents are treated with dignity and respect. Staff should make sure residents are fully clothed when residents are out of bed. During an interview on 10/2/2023 at 1:20 pm, R24 revealed on 10/27/2023 he spent the whole day without pants. R24 stated he was frustrated and embarrassed. Observation revealed four pairs of pants and four shirts in R24's closet. 3. A review of R4's CCP initiated on 10/19/2022 staff documented, R4 had baseline ADL functions. The care plan directed staff to assist with toileting, dressing and personal hygiene. A review of R4's quarterly MDS assessment dated [DATE] revealed that R4 presented with a BIMS score of 15 out 15, indicating that R4 was cognitively intact. It was further documented that R4 required one-person assistance with toileting and personal hygiene. During an observation and interview on 10/3/2023 at 8:15 am R4, revealed on 9/14/2023, she had a bowel movement, waited for assistance from staff for at least four hours. R4 eventually called her daughter for assistance before the staff came to her aide. During an interview on 10/11/2023 at 11:30 am with resident R4 revealed the staff would not provide incontinent care for over two hours. R4 stated that last Wednesday evening, 10/4/2023, dinner was served late around 7:15 pm. R4 stated she experienced a bowel movement with the first bite of food. R4 stated she turned on the call light and the certified nursing assistant stated incontinent care would be done after the trays were served. R4 stated she thought it would be around 15 to 20 minutes, but it turned out to be two hours of sitting in soiled-bowel movement brief. R4 stated she could not eat the meal because of the humiliation she had felt. During an interview on 10/11/2023 at 3:30 pm, CNA OO stated she was instructed to continue passing trays when a resident required incontinent care during meal serve. CNA OO stated she was not expected to provide incontinent care according to facility policy during meal service and this has been a long-standing facility policy. During an interview on 10/11/2023 at 1:30 pm, the Director of Nursing, (DON) revealed, when a resident requests incontinent care while staff were passing out trays, she expected another staff member to assist the resident. As soon as a resident requested assistance with incontinent care the normal wait time should be approximately five to ten minutes. A period of one or two hours waited time for incontinent care is considered excessive and a delay in care. Serving food when a resident is seated on their BM is not a facility policy. The DON stated any of the nursing staff should have assisted R30 with incontinent care. The DON stated all residents to be treated with dignity and respect. 49479

Based on record review, and staff interview, the facility failed to ensure that one of five residents (R) (R16) reviewed for misappropriation was free from misappropriation of their personal property. Psychosocial harm was identified when R16 revealed facility staff took her keys and went to her house without her permission causing her fear of retaliation if reported. Findings included: A review of R16's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that R16 presented with a Brief Interview for Mental Status (BIMS) score of 14 out 15, indicating that R16 was cognitively intact. A review of the facility policy, titled, Abuse and Neglect and Exploitation procedure Policy and last revised [DATE], documented, Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful temporary, or permanent, use of resident's belongings or money without the resident's consent. Exploitation means taking advantage of a resident for personal gain using manipulation. The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property and exploitation. The policies to include, identifying, correcting, and intervening is situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified registered license residents and staff in sufficient numbers to meet the needs of the residents, and assure that stuff assigned have knowledge of the individual residents' care needs and behavioral symptoms. During an interview on [DATE] at 11:52 am, Certified Nursing Assistant (CNA) DD revealed she worked in Central Supply and had not performed CNA duties for over a year. She was familiar with R16 and called R16 grandmother. She confirmed that on several occasions, she took money from the resident, including a time in [DATE]. She stated that R16 wrote a check in the amount of $40.00 in her name, and she deposited the check in her own account. CNA DD stated that she took the money and bought a phone for the resident. She further confirmed that she did not inform anyone at the facility, including the administrator. CNA DD stated that she went to R16's house a few times. She stated that in [DATE], R16 gave CNA DD two personal checks which CNA DD deposited in R16's account and that R16 received personal checks every month. She stated that she and R16 had a personal relationship, but they are not related. During an interview on [DATE] at 12:30 pm, R16 revealed CNA DD and Psychotherapist GG took her keys and went to her house without her permission. She stated that she was afraid of what they would do to her and so she told her friend what was going on. She was afraid to make a report to the administrator due to retaliation. R16 stated that she is not related to CNA DD or Psychotherapist GG. She stated that CNA DD was overly friendly and called R16 her adopted grandmother. R16 stated that she did not give CNA DD and Psychotherapist GG keys to her house and that she felt it was strange for a staff member to call her adopted grandmother. She stated that CNA DD was unprofessional and that on multiple occasions, CNA DD she went to her house and entered through the back door. She stated that she was unaware if some of her valuables are missing but knows that CNA DD took checks from her purse and insisted she would deposit the checks. She stated that CNA DD deposited her deceased husband retirement checks into her account for five months from February 2023 to [DATE], but the checks have since been stopped. During an interview on [DATE] at 3:06 pm, Social Services Director (SSD) EE revealed R16 no longer has a family. She was not aware that CNA DD was making numerous trips to R16's house. She stated that resident keys are considered resident property and taking the resident's keys without permission is misappropriation. During an interview on [DATE] at 3:31 pm, Business Manager RR revealed all residents' checks are deposited in the resident trust funds. She stated that meddling with residents' funds, taking gifts, and making unauthorized deposits or withdrawals into the resident account without facility knowledge is not allowed. During an interview on [DATE] at 3:52 pm with a friend of R16, she stated that they had been friends for over thirty years. Prior to the resident's admission at the facility, she assisted R16 the resident with chores including trips to the bank. She was aware, for the past eight months, CNA DD had been going to R16's house without the resident's permission. She was very concerned about R16's wellbeing. CNA DD said her husband wanted the resident's car, took R16's keys and went to the resident house with Psychotherapist GG without R16's permission. R16, said CNA DD asked her where her wedding rings were in her house. In [DATE], CNA DD said she would be depositing the resident checks. Resident was afraid to report to the administrator due to fear of retaliation. R16 said she was afraid of CNA DD and Psychotherapist GG. In [DATE], the resident was very concerned and stressed out, and eventually got admitted in hospital. At the hospital the resident told the physician, facility staff were taking advantage of her and said she was afraid of retaliation. In [DATE], R37 went to the resident's bank to verify the deposits and was informed R16 had a zero balance in her account. During an interview on [DATE] at 4:50 pm, Administrator BB was notified of the allegations regarding misappropriation and revealed, the business office handles all residents' funds. Staff were not allowed to take gifts or money from residents. During an interview on [DATE] at 11:07 am Psychotherapist GG revealed he was contracted by the facility and is a Psychotherapist. He had conversations with R16. R16 revealed CNA DD had previous knowledge about the location and condition of her house. He understood CNA DD was aware of the location and condition of R16's house and R16 had no family. He discussed with CNA DD about the condition of the resident's house. He believed it was suspicious CNA DD had been inside the resident's house without facility knowledge. Did not report to the administrator or his supervisor regarding his suspicions. Was not aware of anything in writing granting CNA DD or himself permission to gain access to R16's personnel property. CNA DD knew intimate details about R16's house. During an interview on [DATE] at 2:19 pm the facility Regional Director, (RD) AA, revealed facility staff are not permitted to visit residents' homes without facility knowledge. Facility staff should not be involved in the disposition of resident's property. Facility staff were not supposed to gain access to R16's property. During an interview on [DATE] at 11:20 am CNA HHH revealed she has been working at the facility for over four years. She stated that some residents are afraid to report allegations due to retaliation. Residents are afraid to come forward. Some staff use intimidation tactics to silence the residents from speaking up. During an interview on [DATE] at 1:04 pm Psychotherapist GG revealed he wanted to clarify certain information. On [DATE], CNA DD said she went to R16's house. CNA DD said she had been inside R16's house before. On [DATE], he took the resident keys from the resident' room. Drove to the resident's house without facility knowledge and did not inform the administrator or his supervisor. He believed it was okay to go to the resident's house, since CNA DD had a relationship with the resident. The resident offered him the keys. He saw three vehicles at the resident's house. He did not enter the residence. During an interview on [DATE] at 3:41 pm [NAME] President (VP) EEE, revealed her company provides therapy services at the facility. Psychotherapist GG was assigned to provide therapy services only at the facility. Psychotherapist GG was not permitted to visit any residential home. Was not aware Psychotherapist GG was going to R16's house. That was outside the scope of the services the company provides. During an interview on [DATE] at 8:21 am Licensed Practical Nurse, (LPN) JJ, revealed she was the Unit Manager and worked with CNA DD. On numerous occasions, CNA DD took cash from the resident purse and would say she was purchasing items for the resident. LPN JJ never saw any items purchased for the resident. CNA DD said the R16 was her grandmother. Did not report to the administrator and did not verify their relationship on the resident's Face Sheet (a medical summary used by staff which includes next of kin and patient information). During an interview on [DATE] at 1:30 pm the Director of Nursing revealed all staff received in-service training regarding abuse, neglect, and misappropriation reporting. Unit managers were considered part of management and they also received training. Unit managers understand the roles and responsibilities of management and that taking a resident property without permission is misappropriation of resident property. During an interview on [DATE] at 1:07 pm the facility Regional Director AA revealed that residents' keys are considered resident property. Taking resident keys without permission is considered misappropriation of resident property.

Based on staff interviews and review of the clinical records, it was determined that the facility failed to follow the plan of care related to wound care of the left pinky finger for one resident (#1) from three residents sampled for wounds. This resulted in the resident being hospitalized with dry gangrene of the area. An abbreviated survey was initiated on 1/10/19 and concluded on 2/3/19 to investigate complaint number GA 960 to determine compliance with Federal and State Long Term Care Requirements, 42 CFR, Part 483, Subpart B, Requirements for Long Term Care Facility. The allegation of deficient practice related to resident neglect was substantiated. The following deficiencies were cited. The census on 2/3/19 was 126. A determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 1/30/19 at 5:05 p.m. the facility's Administrator and the Director of Health Service (DHS), were informed of an Immediate Jeopardy (IJ). The non-compliance related to the Immediate Jeopardy was identified to have existed on 12/27/18. At the time of the exit on 2/3/19, the State Survey Agency had not received an acceptable Creditable Allegation of Compliance, therefore, the IJ was ongoing. The immediate jeopardy is outlined as follows: The IJ was determined to exist as of 12/27/18, when R#1 cut the tip of the left pinky finger with a fingernail clipper. Clinical staff treated and applied a self-adhering bandage/wrap to the finger. The resident was transferred to the hospital on [DATE] and diagnosed with [REDACTED].#1 being hospitalized , subsequently the affected area was surgically removed. Immediate Jeopardy was related to the facility's non-compliance with the program requirements as follows: CFR:483.21(b)(1)Develop/Implement Comprehensive Care Plan (F656 Scope and Severity: J) CFR:483.21(b)(3)(i)Services Provided Meet Professional Standards (F658 Scope and Severity: J) CFR:483:25 Quality of Care (F684 Scope and Severity: J) CFR 483.70 Administration (F835 Scope and Severity: J) Additionally, Substandard Quality of Care was identified with the requirements at CFR:483:25 Quality of Care (F684 Scope and Severity: J). Findings include: Review of the clinical records revealed Resident (R) #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the records revealed orders for R#1 which included: Eliquis 5 mg twice a day; [MEDICATION NAME] 75 mg daily; and an order dated 12/27/18 to cleanse the wound on the resident's left pinky finger with normal saline, pat dry, apply triple antibiotic ointment, and cover with a dry dressing every three days and as needed until healed. A review of an Event Evaluation dated 12/27/18 revealed that R#1 sustained the injury to his left pinky finger while clipping his fingernails that day. The Event Evaluation further documented that the Physician and family were notified and that first aid was completed; this included cleansing of the wound with normal saline, the application of triple antibiotic ointment, and coverage with a dry dressing. A care plan was developed on 12/27/18 for a clipped left 5th digit tip. The goal was for the resident's wound to remain free of infection and show evidence of healing in 30 days. Staff interventions included: report changes in skin status to physician; wound care as ordered, see current treatment record and physician's orders [REDACTED]. It was documented on the Medication Administration Record (MAR) dated 12/27/18 included a Treatment Procedure order Cleanse wound to left pinky finger with NS (normal saline) ,pat dry, apply TAO (triple antibiotic ointment) and cover with dry drs(dressing) Q (every) 3 days and PRN (as needed) until healed. The MAR was signed treatment administered on 12/27, 12/28, 12/29, 12/30 and 12/31. There was no documented evidence with a description of the wound on the left pinky finger. During an interview on 1/10/19 at 2:20 p.m. with Licensed Practical Nurse (LPN) AA she revealed R#1 clipped the pinky finger on his left hand with a nail clipper while he was attempting to clip his own nails on 12/27/18. The wound was bleeding, so this nurse cleansed the area with normal saline and applied triple antibiotic ointment and a 4x4 pressure dressing. This nurse said further that the pressure dressing would not stay in place so she also wrapped the finger with a self-adhesive bandage to cover it. She called the Physician some time before the end of her shift (she could not recall what time) and advised him of the injury. LPN AA stated the Physician agreed with the treatment she had provided when she called and did not give any new orders. Therefore, she wrote the wound care treatment (minus the Self- Adhering Wrap ) she had provided on a telephone order sheet and then added the order to the electronic records to be completed on the evening shifts. The telephone order sheet was left on the resident's chart to be signed by the Physician when next he came to the facility. Review of the Nurse's Notes dated 1/1/19 at 10:49 p.m. documented that the resident's family came to visit that day and became concerned at the finger's appearance. A family member ask when had staff last looked at the finger or changed the dressing. Staff informed the family that the dressing was due to be changed that same day. Upon being summoned by the family, two nurses went to the resident's room to assess the finger. When the dressing was removed in the presence of the family, the nurse observed the finger to be discolored. The nurse called the Physician and advised him of the situation, and the Physician gave orders for the resident to be transported to the hospital to rule out schema of the left pinky finger.

Based on record review, review of policy and procedures, review of the Georgia Nurse Practice Act (chapter 410-10), family and staff interviews, the facility failed to ensure services met professional standards as evidenced by the provision of ongoing wound care to one resident (#1) without a physician's orders [REDACTED]. Failure to follow the physicians orders for wound care resulted in the resident being hospitalized , subsequently, with a [DIAGNOSES REDACTED]. R#1 had an AV shunt on the left arm at the time that a self-adhering (constrictive) dressing was applied. The sample size was three. An abbreviated survey was initiated on 1/10/19 and concluded on 2/3/19 to investigate complaint number GA 960 to determine compliance with Federal and State Long Term Care Requirements, 42 CFR, Part 483, Subpart B, Requirements for Long Term Care Facility. The allegation of deficient practice related to resident neglect was substantiated. The following deficiencies were cited. The census on 2/3/19 was 126. A determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 1/30/19 at 5:05 p.m. the facility's Administrator and the Director of Health Service (DHS), were informed of an Immediate Jeopardy (IJ). The non-compliance related to the Immediate Jeopardy was identified to have existed on 12/27/18. At the time of the exit on 2/3/19, the State Survey Agency had not received an acceptable Creditable Allegation of Compliance, therefore, the IJ was ongoing. The immediate jeopardy is outlined as follows: The IJ was determined to exist as of 12/27/18, when R#1 cut the tip of the left pinky finger with a fingernail clipper. Clinical staff treated and applied a self-adhering bandage/wrap to the finger. The resident was transferred to the hospital on [DATE] and diagnosed with [REDACTED].#1 being hospitalized , subsequently the affected area was surgically removed. Immediate Jeopardy was related to the facility's non-compliance with the program requirements as follows: CFR:483.21(b)(1)Develop/Implement Comprehensive Care Plan (F656 Scope and Severity: J) CFR:483.21(b)(3)(i)Services Provided Meet Professional Standards (F658 Scope and Severity: J) CFR:483:25 Quality of Care (F684 Scope and Severity: J) CFR 483.70 Administration (F835 Scope and Severity: J) Additionally, Substandard Quality of Care was identified with the requirements at CFR:483:25 Quality of Care (F684 Scope and Severity: J). Findings include: Review of the Georgia Nurse Practice Act, chapter 410-10, revealed that licensed and registered nurses are required to: assess their patients in a systematic, organized manner; initiate nursing actions to assist the patient to maximize his/her health capabilities; evaluate with the patient the status of any goals as a basis for reassessment and reordering of priorities; function within the legal boundaries of nursing practice; and determine that care performed is based on the orders/directions of a licensed physician or other similarly licensed professional. Review of the clinical records revealed Resident (R) #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the electronic medical (EMR) records revealed orders for R#1 which included: Eliquis 5 mg twice a day; [MEDICATION NAME] 75 mg daily; and an order dated 12/27/18 to cleanse the wound on the resident's left pinky finger with normal saline, pat dry, apply triple antibiotic ointment, and cover with a dry dressing every three days and as needed until healed. During an interview on 1/10/19 at 10:58 a.m. with A, the family member of R#1, revealed the resident was admitted to the facility in early (MONTH) for rehabilitation. On (MONTH) 27, another family member B received a call from the facility saying the resident had sustained a cut the tip of one of his fingers with a finger nail clipper. During the call, staff reported to family member B that the injury was bleeding, but that the injury was being taken care of. Family member B reported this to family member A who visited the facility the following day, 12/28/18, where he saw the resident's finger wrapped in a bandage. Family member B accompanied by another member of the family visited with R#1 on 1/1/19. When these family members pulled the bandage away to peek at the finger, they reported to A that there was a noticeable difference in the area below the bandage when compared with the area around the bandage. The finger, in question, looked smaller than the resident's other fingers, and was black while the surrounding areas and other fingers were white. When the family members had the nurses remove the outer bandage, they discovered that there were two bandages wrapped on top of each other - the wound was covered by a Band Aid, then the Band Aid was wrapped in gauze, then the gauze was wrapped in an elastic bandage (family member A described this as a bandage similar to what one would use to wrap one's knee). The nurses took the bandages away before the family could take them. However, family member A said the bandage/dressing the family found on the resident's finger when they visited on 1/1/19 appeared to be the same one he saw on the resident's finger when he visited on 12/28/18. He was convinced it was the same bandage because the family members that visited on 1/1/19 took pictures which they forwarded to him. In those pictures, the bandage appeared the same. Family member A met the resident and other family members at the hospital later that day. The resident was admitted to the hospital for a couple of nights and was seen by the surgeon. The surgeon advised that surgery would be too dangerous, given the resident's health conditions, and recommended that the finger be left to wither and fall off on its own - let the body expel it - because it had dry gangrene. During a telephone interview on 1/11/19 at 3:01 p.m., family member B said R#1 was still wearing what appeared to be the original bandage when the family visited on 1/1/19 and this prompted them to ask when it was last changed. Family member B also said he remembered the wound was wrapped in several layers. A review of an Event Evaluation dated 12/27/18 revealed that R#1 sustained an injury to his left pinky finger while clipping his fingernails that day. The Event Evaluation further documented that Physician BB and family member B were both notified and that first aid was completed; this included cleansing of the wound with normal saline, the application of triple antibiotic ointment, and coverage with a dry dressing. There is no documentation in the clinical record of an assessment with a description of the extent of the injury to the finger. On 1/1/19 the resident was transferred to the hospital for evaluation of the left pinky finger. Review of the Nurse's Notes dated 1/1/19 at 10:49 p.m. documented that the resident's family came to visit earlier that day. Sometime after the family arrived in the facility, one of the family members went to the nurses' station asking for staff to take a look at the resident's injured finger because the family was concerned about the finger's appearance. The family member asked when had staff last looked at the finger or changed the dressing, and staff informed the family that the dressing was due to be changed that same day. Upon being summoned by the family, two nurses went to the resident's room to assess the finger. The staff removed the dressing in the presence of the family and the same family member began to scream, asking whether the nurse had seen the finger before that moment and demanding that the family be allowed to speak to the Physician. The note documented that nurse told the family that staff would call the Physician. The nurse called the Physician and advised him of the situation, and the Physician gave orders for the resident to be transported to the hospital to rule out ischemia of the left pinky finger. A review of a Nursing Home to Hospital Transfer Form dated 1/1/19 revealed under the clinical information field: check for ischemia on left pinky finger A review of the report from the hospital to which the resident was transported revealed the resident was seen on 1/1/19 beginning at 11:54 p.m. with a chief complaint: necrosis. The resident presented with discoloration of the left fifth finger, and a history taken from the resident/family revealed the resident had sustained a cut to his finger about a week before and a dressing was applied. When the dressing was removed earlier in the day, discoloration was noted. An examination completed by hospital staff revealed dry gangrene of the resident's left fifth finger from the metacarpophalangeal (MP) joint. The rest of the hand was described as well perfused, warm, and pink. The hospital record also documented the resident has an AV fistula to the lower left arm with a positive thrill bruit. The report from the hospital also documented that the resident was discharged from that facility in early (MONTH) following a cardiac valve procedure with complications of cardiogenic shock and left lower leg ischemia. During an interview on 1/10/19 at 2:20 p.m. with Licensed Practical Nurse (LPN) AA she revealed R#1 clipped the pinky finger on his left hand with a nail clipper while he was attempting to clip his own nails on 12/27/18. The wound was bleeding, so this nurse cleansed the area with normal saline and applied triple antibiotic ointment and a 4x4 pressure dressing. LPN AA further stated that the pressure dressing would not stay in place so she also wrapped the finger with a self-adhering bandage to cover it. She called the Physician some time before the end of her shift (she could not recall what time) and advised him of the injury. LPN AA stated the Physician agreed with the treatment she had provided when she called and did not give any new orders, so she wrote the wound care treatment (minus the self-adhering bandage) she had provided on a telephone order sheet and then added the order to the electronic records to be completed on the evening shifts. The telephone order sheet was left on the resident's chart to be signed by the Physician when next he came to the facility. LPN AA said this process was customary. LPN AA said she provided care for the resident on the day following the injury - 12/28/18 - and again on 12/31/18. Based on the orders she received (change every three days or as needed), the wound was required to have a dressing change on the evening shift on 12/30/18. She did not work at the facility on the evening shift, nor did she work on 12/30. Further, unless there was swelling, redness, or bleeding, she would not have needed to change the dressing on an as needed basis. Review of the facility's User Learning form revealed that LPN AA started a training course titled Skin integrity Systems (SIS) What Every Facility Has to Know and DO, the form revealed a due date of 10/19/18, it was noted on the form that LPN AA completed the training on 1/3/19 (after the incident with R#1). An interview on 1/10/19 at 3:35 p.m. with LPN EE revealed that she never treated R#1 during the time he had his injury. However, when a resident in the facility sustains a minor injury such as a cut or skin tear, the charge nurses (such as herself) are allowed to clean the area with normal saline and place a dry dressing on the area. The nurse will then write a telephone order for the treatment that was done. The nurse also calls the Physician. When the Physician is called, if he/she makes changes to what the nurse has done, then those orders are written. If not, the original telephone order written by the nurse stands. If a resident sustains an injury, the nurse should monitor that injury/area every day. If there are signs of bleeding or swelling, then the nurse should check the injury. If the dressing appears to be too tight, or the resident complains of discomfort, then the nurse should also check the area/injury. This is just common/standard practice. A review of a Nurses' Note 12/28/18, the day following the injury, revealed the nurse documented only that the resident had a skin tear to finger, dressing intact. A review of a Weekly Skin Integrity Evaluation dated 12/28/18 revealed the resident was described as having a skin tear to the left finger with dressing in place. There was no evidence of an assessment to determine the extent of the injury. A review of a Daily Skilled Nurses' Notes of 12/31/18 and 1/1/19 revealed the nurses documented on both days that the resident had no skin conditions. Review of (MONTH) (YEAR) Medication Administration Record (MAR) revealed that three nurses had signed off on the order for wound care of the pinky finger on 12/28, 12/29, 12/30, and 12/31/18. During an interview on 1/10/19 at 4:45 p.m. with the Director of Nursing (DHS) it was revealed if the nurses signed off on the order for the dressing to be changed every three days and as needed, she could only assume that they provided the care ordered on those days. There was no way to know the exact care that was provided without talking to the nurses in question. The self-adhering wrap bandage (which was used to wrap the resident's finger) is not usually used by the nurses in the facility to wrap wounds/injuries, nor is it kept on the carts. The facility does keep some in the supply area but this is usually used for wrapping venous wounds etc. With a minor injury, the nurse should have covered the area with a dressing, but not applied the self-adhering wrap bandage. However, the resident sustained [REDACTED]. The DHS said she would not normally recommend that type of dressing for a minor skin tear or cut, but under the previously outlined circumstances, she was not willing to say it was incorrect to do so. After the incident with R#1, the DHS said she educated the nurses in the proper use of the self-adhering wrap bandage because she wanted to be assured that, were they to use this type of bandage, they were well-versed in how to appropriately apply and periodically check its application. A further review of the Medication Administration Record (MAR) for (MONTH) (YEAR) revealed that LPN CC was the nurse who signed on 12/30/18 and LPN DD signed on 12/29/18 and 12/31/18 as having completed the wound care orders for the resident's left pinky finger. There were no progress notes regarding the status of the residents injury until 1/1/19 when the resident required hospitalization to evaluate the wound. During a telephone interview on 1/11/19 at 10:30 a.m. with LPN CC it was revealed that he cared for R#1 the weekend of 12/29/18 and 12/30/18. He remembered changing the dressing on the resident's finger on one of those days, but he was not sure which. This nurse said he did not recall, the type of dressing he removed or applied to the resident's finger. In particular, he did not remember if it included a wrapped bandage. If a resident has a wound with a dressing, the nurse said it is his usual practice to check the dressing and area daily on his shift for signs of bleeding, swelling, etc. Normally, he would document that he had checked the area of the wound. However, he was unsure whether he had documented this on his shifts that weekend. During a follow-up interview on 1/11/19 at 11:09 a.m. with the DHS it was revealed if the Physician gives a wound care order that a dressing is to be changed as needed, it should be changed if soiled, bleeding, etc. This would involve the use of nursing judgment. The nurses are expected to monitor a wound/dressing area every shift. However, she would not expect them to document this unless there was a concern. If there were no concerns, they should also use their nursing judgment whether to document this or not. For a skin tear, the Physician would not normally order self-adhering wrap. However, if a self-adhering wrap or other such bandage is used, she expects staff to also check this bandage at least once every shift and as they encounter the resident throughout the shift. They should look for [MEDICAL CONDITION], redness, and check whether the resident is experiencing discomfort. For minor wounds, the wound care nurse would only be notified to assess the resident if the charge nurse has a concern. If the wound care nurse also has a concern, she will call the physician for new orders. The facility has no standing orders for wound care. If a resident is bleeding, then the nurse needs to take immediate steps to stop the bleeding before calling the Physician. At that point, the Physician will give a treatment order. The nurse will write the order and complete the treatment per the physician's orders [REDACTED]. During an interview on 1/11/19 at 11:36 a.m. with Physician BB, it was revealed that he was not notified on 12/27/18 that R#1 had sustained an injury to his finger, and had not given orders for the staff at the facility to treat the injury. He said that the nurses are expected, of course, to provide needed emergency treatment when a resident sustains an injury. However, they are required to then call and receive orders from the Physician. He was not aware that R#1 had sustained an injury to his finger until he received a call from one of the nurses at the facility around 8:00 p.m. on 1/1/19 stating that the resident's finger was discolored. He asked the nurse for additional information such as motor, pulse, pain, sensory and she left to reassess the wound/finger for the information he required. When the nurse called him again about 10 minutes later, she informed him that the finger was still discolored, despite the bandage having been removed, and that it was gray to black in color. He also learned at that time that the nurse had applied a self-adhering wrap or similar bandage to the affected area at the time the resident sustained [REDACTED]. Under those circumstances, it is possible he would have given an order for [REDACTED]. Knowing that the self-adhering wrap bandage was used, however, he felt that, in all likelihood, this contributed to the condition for which he gave orders for the resident to be sent to the emergency room . During a telephone interview on 1/11/19 at 1:39 p.m. with LPN DD it was revealed that she did not remember R#1, nor could she recall the wound care orders she completed on his behalf or whether his wound was covered with a self-adhering bandage. Unless the order directed that the resident's dressing was to be changed on a certain day, the nurse would only change it on an as needed basis if it was soiled, falling off, bleeding, etc. On a day-to-day basis during her shift, she would normally assess the area of a wound to see if it was clean, or if there was any drainage or similar circumstances that needed to be immediately addressed. She was educated during orientation that she did not need to document if no problems were observed on her assessment of a resident. Her signature on the MAR did not signify that she had changed the dressing on the days indicated. She would sign the MAR for the wound care on the days she worked even if the wound did not require a dressing change. Review of the undated policy, physician's orders [REDACTED]. The original order remains on the chart, the Director of Nursing gets the yellow copy, and the white copy is given to medical records to obtain the Physician's signature. A review of the paper chart for R#1 revealed the chart copy of telephone order written by LPN AA on 12/27/18 for the resident's wound on the left pinky finger remained unsigned. The attending Physician was listed as Physician BB. Review of the white copy of the telephone order dated 12/27/18 when retrieved from medical records revealed the Physician had documented in the signature field: Not notified until 1/1/19.

Based on record review, staff and family interviews and review of facilities Guidelines titled Care of Skin Tears & Abrasion, it was determined that the facility failed to ensure wound care was provided to one resident (R), #1 in accordance to the written physician's telephone order. This resulted in R#1 being hospitalized , subsequently, with a [DIAGNOSES REDACTED]. The sample size was three residents. An abbreviated survey was initiated on 1/10/19 and concluded on 2/3/19 to investigate complaint number GA 960 to determine compliance with Federal and State Long Term Care Requirements, 42 CFR, Part 483, Subpart B, Requirements for Long Term Care Facility. The allegation of deficient practice related to resident neglect was substantiated. The following deficiencies were cited. The census on 2/3/19 was 126. A determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 1/30/19 at 5:05 p.m. the facility's Administrator and the Director of Health Service (DHS), were informed of an Immediate Jeopardy (IJ). The non-compliance related to the Immediate Jeopardy was identified to have existed on 12/27/18. At the time of the exit on 2/3/19, the State Survey Agency had not received an acceptable Creditable Allegation of Compliance, therefore, the IJ was ongoing. The immediate jeopardy is outlined as follows: The IJ was determined to exist as of 12/27/18, when R#1 cut the tip of the left pinky finger with a fingernail clipper. Clinical staff treated and applied a self-adhering bandage/wrap to the finger. The resident was transferred to the hospital on [DATE] and diagnosed with [REDACTED].#1 being hospitalized , subsequently the affected area was surgically removed. Immediate Jeopardy was related to the facility's non-compliance with the program requirements as follows: CFR:483.21(b)(1)Develop/Implement Comprehensive Care Plan (F656 Scope and Severity: J) CFR:483.21(b)(3)(i)Services Provided Meet Professional Standards (F658 Scope and Severity: J) CFR:483:25 Quality of Care (F684 Scope and Severity: J) CFR 483.70 Administration (F835 Scope and Severity: J) Additionally, Substandard Quality of Care was identified with the requirements at CFR:483:25 Quality of Care (F684 Scope and Severity: J). Findings include: Review of the clinical records revealed Resident (R) #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the records revealed orders for R#1 which included: Eliquis 5 mg twice a day; [MEDICATION NAME] 75 mg daily; and an order dated 12/27/18 to cleanse the wound on the resident's left pinky finger with normal saline, pat dry, apply triple antibiotic ointment, and cover with a dry dressing every three days and as needed (PRN) until healed. A review of an Event Evaluation dated 12/27/18 revealed that R#1 sustained the injury to his left pinky finger while clipping his fingernails that day. The Event Evaluation further documented that the Physician and family were notified and that first aid was completed; this included cleansing of the wound with normal saline, the application of triple antibiotic ointment, and coverage with a dry dressing. During an interview on 1/10/19 at 2:20 p.m. with Licensed Practical Nurse (LPN) AA she revealed R#1 clipped the pinky finger on his left hand with a nail clipper while he was attempting to clip his own nails on 12/27/18. The wound was bleeding, so this nurse cleansed the area with normal saline and applied triple antibiotic ointment and a 4x4 pressure dressing. This nurse said further that the pressure dressing would not stay in place so she also wrapped the finger with a self-adhesive bandage to cover it. She called the Physician BB some time before the end of her shift (she could not recall what time) and advised him of the injury. LPN AA stated the Physician agreed with the treatment she had provided when she called and did not give any new orders. Therefore, she wrote the wound care treatment (minus the self-adhesive bandage) she had provided on a telephone order sheet and then added the order to the electronic records to be completed on the evening shifts. The telephone order sheet was left on the resident's chart to be signed by the Physician when next he came to the facility. A review of the Nurse's Note dated 1/1/19 at 10:49 p.m. documented that the resident's family came to visit that day and became concerned at the finger's appearance. A family member asked when had staff last looked at the finger or changed the dressing. Staff informed the family that the dressing was due to be changed that same day. Upon being summoned by the family, two nurses went to the resident's room to assess the finger. When the dressing was removed in the presence of the family, the nurse observed the finger to be discolored. The nurse called the Physician and advised him of the situation, and the Physician gave orders for the resident to be transported to the hospital to rule out ischemia of the left pinky finger. A review of a Nursing Home to Hospital Transfer Form dated 1/1/19 revealed under the clinical information field: check for ischemia on left pinky finger. A review of the report from the hospital to which the resident was transported revealed the resident was seen on 1/1/19 beginning at 11:54 p.m. with a chief complaint of necrosis. The resident presented with discoloration of the left fifth finger. History taken from the resident/family revealed the resident had sustained a cut to his finger about a week before and a dressing was applied. When the dressing was removed earlier in the day, discoloration was noted. An examination of the left fifth finger from the metacarpophalangeal (MP) joint revealed dry gangrene. During an interview on 1/11/19 at 11:36 a.m. with Physician BB, it was revealed that he was not notified by staff on 12/27/18 that R#1 had sustained an injury to his pinky finger, nor had he given the orders noted in the resident's record for the wound treatment that was applied. Physician BB said that he first became aware of the resident's injury when he received a call from a nurse at the facility around 8:00 p.m. on 1/1/19 stating that the resident's finger was discolored. He also learned at that time that the nurse had applied a self-adhesive or similar bandage to the affected area at the time the resident sustained [REDACTED]. Under those circumstances, it is possible he would have given an order for [REDACTED]. During a follow-up interview with the Physician BB on 1/11/19 at 11:47 a.m. he revealed that he could not say how long it might have taken for the bandage, in question, to create the ischemia he suspected when he sent R#1 to the emergency roiagnom on [DATE]. He said it could take several hours or even a day for the affected finger to get to that state, but without knowing how tightly the bandage was applied, it was difficult to say. Interview with the Director of Healthcare Service (DHS) on 1/30/19 at 10:30 a.m. revealed that she was notified of the injury to R#1 finger on 12/28/18 during morning meeting. She reviewed the incident report on 12/28/18 that stated that the Physician was notified and an order was given on the treatment and dressing of the wound. On 1/4/19 during morning meeting, she was informed that the resident was transported to the hospital on [DATE] to rule out ischemia and that the use of self-adherent dressing was used to dress the wound. On 1/30/19 at 11:00 a.m. with the Wound Care nurse revealed that she was on leave when resident #1 finger was injured and treated with the use of the self-adhesive dressing. However, she stated that the treatment cannot be used without a physician's orders [REDACTED]. An interview with the resident 's son A on 1/30/19 at 4:22 p.m., he stated that his father finger became infected and was surgically removed and continue to remain hospitalized . A second interview on 1/31/19 at 12:15 p.m. with LPN AA revealed that on 12/27/18 she was informed by a Certified Nursing Assistant (CNA) that R#1 had cut his finger and it was bleeding. The LPN went into R#1's room where she observed the tip of his left small finger, was bleeding and R#1 informed her that he was clipping his nails and accidentally clip the tip of his finger. She cleaned the area with normal saline and applied triple antibiotic ointment and covered it with a 4 x 4 and a self-adhesive dressing and dated it. LPN AA stated that she notified the resident son of the incident. LPN AA initiated treatment for [REDACTED]. The schedule dressing change was placed on the 3-11 shift. (sic) A review of the paper chart for R#1 revealed the chart copy of telephone order written by LPN AA on 12/27/18 for the resident's wound (minus the Self- Adhering Wrap ) on the left pinky finger remained unsigned. The attending Physician was listed as Physician BB. Review of the telephone order dated 12/27/19 revealed that Physician BB had documented in the signature field: Not notified until 1/1/2019. During a post survey interview on 2/13/19 at 2:45 p.m. with Administrator CC regarding the morning meeting the DHS referred to learning of R#1 hospitalization on [DATE]. The Administrator states that Clinical Morning Meetings were held on 1/2/19 and 1/3/19 and the DHS was in attendance on both days. It was also learned that all notification of accidents and incidents are done via 24 hour report books which are reviewed at the morning meetings. Review of the Situation Background Assessment Recommendation (SBAR) communication form and progress form revealed documentation that the resident wound dressing was changed on 12/27/18, 12/29/18 and on 1/1/19 on the 3-11 shifts. Review of the clinical record dated 1/1/19 at 8:12 p.m. the nurse described the finger as being discolored on the lower part of the finger and had blood flow. At 8:20 p.m. the Physician orders [REDACTED]. Review of the hospital record revealed a [DIAGNOSES REDACTED].#1 was admitted to the hospital for treatment and was discharged from the facility. Review to the facility's Guidelines dated 6/1/15 titled Care of Skin Tears & Abrasion. Step #15 c. states If the abrasion is draining moderate to large amount of fluid, cover the wound with a non-adherent transparent film or non adhesive dressing (not a sterile dressing or strip) as per Physicians order. Change the film every seven (7) days or as needed as per Physicians order.

Based on interviews and review of clinical records it was determined that the Administration failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to ensure each resident attained or maintained the highest possible level of physical, mental and psychological well-being. Resident #1 injured his finger on 12/27/18. The Administrator was unaware of the extent of the injury until 1/4/19. The facility census was 123. An abbreviated survey was initiated on 1/10/19 and concluded on 2/3/19 to investigate complaint number GA 960 to determine compliance with Federal and State Long Term Care Requirements, 42 CFR, Part 483, Subpart B, Requirements for Long Term Care Facility. The allegation of deficient practice related to resident neglect was substantiated. The following deficiencies were cited. The census on 2/3/19 was 126. A determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 1/30/19 at 5:05 p.m. the facility's Administrator and the Director of Health Service (DHS), were informed of an Immediate Jeopardy (IJ). The non-compliance related to the Immediate Jeopardy was identified to have existed on 12/27/18. At the time of the exit on 2/3/19, the State Survey Agency had not received an acceptable Creditable Allegation of Compliance, therefore, the IJ was ongoing. The immediate jeopardy is outlined as follows: The IJ was determined to exist as of 12/27/18, when R#1 cut the tip of the left pinky finger with a fingernail clipper. Clinical staff treated and applied a self-adhering bandage/wrap to the finger. The resident was transferred to the hospital on [DATE] and diagnosed with [REDACTED].#1 being hospitalized , subsequently the affected area was surgically removed. Immediate Jeopardy was related to the facility's non-compliance with the program requirements as follows: CFR:483.21(b)(1)Develop/Implement Comprehensive Care Plan (F656 Scope and Severity: J) CFR:483.21(b)(3)(i)Services Provided Meet Professional Standards (F658 Scope and Severity: J) CFR:483:25 Quality of Care (F684 Scope and Severity: J) CFR 483.70 Administration (F835 Scope and Severity: J) Additionally, Substandard Quality of Care was identified with the requirements at CFR:483:25 Quality of Care (F684 Scope and Severity: J). Finding include: On 1/30/19 at 4:00 p.m. interview with former Administrator CC revealed that he was the Administrator at the facility from 6/1/17 until 1/16/19 and had recently been reassigned to another position in the facility. He revealed that he was unaware of R#1 injury and the dressing treatment until 1/4/19 after the resident was admitted to the hospital. He revealed that the Director of Nursing (DHS) and staff responded to the incident to prevent a further incident by removing all the self-adhering dressing from treatment carts. The Administrator stated he informed the phlebotomist not to leave any of the dressing behind after drawing resident's blood for the lab. He later followed up with a family member on the status update of the residents health. During an interview on 1/30/19 at 4:05 p.m. with the current Interim Administrator revealed that he started working at this facility on 1/16/19. During an interview on 1/31/19 at 2:02 p.m. the Regional Vice President stated that he and his team which includes: The Clinical Vice President, State Operation Manager as well as the Regional Consultant is overseeing and working directly with the facility on a daily basis to ensure that the A[NAME] is developed and ensure that the agreement with the State is carried out. He also stated that the current Interim Administrator at the facility agreed to stay on as the Administrator until he replaced. The expectation of hiring a permanent Administrator should be within the next 30 days. and ask that if he can be any service to call him directly. During a post survey interview on 2/13/19 at 2:15 p.m. Administrator CC it was clarified that he was notified of the incident regarding R#1 on 1/1/19 by Physician BB. Continued interview with Administrator CC it was learned that he did not attend the facility's Clinical Morning Meetings. Refer to F 656, F 658, F 684