Every finding on record at Miller Nursing Home

Based on observations, staff interviews, record review and review of the facility's policy titled, Gastrostomy Tube Feedings, the facility failed to provide appropriate care for a gastrostomy tube (G-tube) (tube inserted into the stomach for nutrition) for one of 71 sampled residents (R) (R83). The deficient practice increased the risk of associated complications for R83.Findings include:Review of the facility's policy titled Gastrostomy Tube Feedings, reviewed 01/20/2023, documented Procedure: The initial gastrostomy tube is inserted in the surgical department by a physician. Position of resident. If resident has gastrostomy, use caution with gastrostomy tube .Review of the facility's electronic Medical Records (EMR) documented R83 was admitted to the facility on [DATE], with the diagnosis included, but not limited to, dysphagia.Review of the Annual Minimum Data Set (MDS) dated [DATE], documented Section C (Cognition) Brief Interview for Mental Status (BIMS) was not conducted as R83 was rarely/never understood, and Section K (Swallowing/Nutritional Status) R83 was coded for tube feeding.Review of the care plan dated 05/07/2026, documented which included, but was not limited to, that R83 required tube feeding due to dysphagia with a goal that R83 will not exhibit signs of complications from feeding tube or enteral feeding solution through the next review and an intervention of total care in eating. enteral formula per MD {physician} order.Review of Physician's Orders dated 04/27/2026, documented which included, but was not limited to, ENTERAL DIET: Mix (500 milliliters [ml] of Osmolite 1.5 kilocalorie (kcal) with 300mL of water in 1 liter bag) via J tube {jejunostomy tube inserted directly into the jejunum} @ {at}100 mL/hr {100 milliliters per hour.} Special Instructions: If unavailable, may substitute with Osmolite 1.2 kcal. Bag is to be changed every 8 hrs {hours.} Every Shift 07:00 AM- 07:00 PM, 07:00PM- 07:00 AM. Observation and interview on 05/15/2026 at 11:53 AM revealed, R83 was sitting in a recliner at station two hallway next to the wound care nurses' station. Further observation revealed Preceptor and Licensed Practical Nurse (LPN) AA pushed a pole with tube feed and pump to R83 and used her gloved hands to plug the G-tube machine into the wall socket. There was another G-tube machine plugged in the same socket and LPN AA removed the other plug and reinserted it into the other socket then plugged the G-tube machine into the socket. LPN AA used the same pair of gloves which she used to plug the machine into the socket to connect the tube feed to R83's G-tube. LPN AA confirmed she used the same pair of gloves to plug the G-tube machine into the wall socket and then connected the tube feed to R83's G-tube. She stated she should have changed her gloves because the plug was not clean and she handled the plug with the same gloves she used to attach the feed to R83's G-tube. LPN AA stated she had to hold R83's G-tube and place her hand on the G-tube area at the tip which is inserted into the G-tube in order to insert the tube. She stated she should have changed her gloves after she plugged in the machine and before she touched his G-tube because R83 could get G-tube complications such as infections.Interview on 05/16/2026 at 11:33 AM with Registered Nurse Supervisor (RNS) CC confirmed that the same pair of gloves should not be used to plug in the feeding machine and worn to attach the tube to the resident's G-tube. She stated the plugs and socket were dirty and had germs on them, so the gloves should have been changed. RNS CC further stated it was improper handling of the G-tube and R83 could have complications of the G-tube such as infection.Interview on 05/17/2026 at 10:06 AM with the Director of Nursing (DON) confirmed, the protocol was that the tube should be connected to the resident first, and then the G-tube machine should be plugged in afterwards. The DON stated the connecting of the tube feed was a clean process and proper handling of the G-tube would be for the nurse to go from clean to dirty. She stated the G-tube should have been attached first and then the machine plugged in afterwards since the plug was considered dirty. The DON further stated a complication of G-tube was introducing bacteria into the G-tube which could also introduce infection to R83.

Based on observations, staff interviews, record review, and review of the facility's policies titled, Hand Hygiene, Infection Control (Donning and Doffing PPE {personal protective equipment}), and Infection Control (Scope of Service), the facility failed to implement infection control practices for one of six sampled residents (R) (R17), reviewed for infection control. Specifically, staff failed to sanitize hands between glove changes related to care of an intravenous (IV) access device (flexible, long tube inserted into a vein for long term use.) This deficient practice increased the risk of clinical complications for R17. Findings include:Review of the facility's policy titled, Hand Hygiene, reviewed March 2026, documented Procedure: If hands are not visibly soiled, use an alcohol-based hand rub for decontaminating hands in the situations listed below. After removing gloves.Review of the facility's policy titled, Infection Control (Donning and Doffing PPE), reviewed March 2026, documented DOFF (Take off) PPE: and bullet number four Perform hand hygiene using an alcohol-based hand sanitizer immediately after removing all PPE.Review of the facility's policy titled, Infection Control (Scope of Service), reviewed March 2026, documented Scope: Methods to assess and meet resident care needs: Systemic, coordinated and continuous approach to improving performance, focusing on surveillance, prevention and control of infections throughout the facility; assure functioning, coordinated process to reduce the risk of nosocomial infections in patients and staff; education of personnel regarding infection control practices; increase community education regarding communicable diseases; compliance with regulatory agency's requirements.Review of the facility's electronic Medical Records (EMR) documented R17 was admitted to the facility on [DATE], with diagnosis which included, but not limited to, bacteremia (bacteria in the blood).Review of the Quarterly Minimum Data Set (MDS) dated [DATE], documented Section C:(Cognition) Brief Interview for Mental Status (BIMS) was not conducted, because R17 was rarely/never understood, and Section O:(Special Treatments, Procedures, and Programs), documented R17 had IV access and received IV medication.Review of care plan dated 03/10/2026, included but was not limited to, R17 had a left femoral peripherally inserted central catheter (PICC) line, with a goal that the PICC line will remain patent and free from signs and symptoms (s/s) of infection, and approach was to change PICC line dressing, using sterile technique, per nursing home (NH) protocol. Review of Physician's Orders dated 02/20/2026, documented which included, but not limited to, Change PICC-line dressing using sterile technique as needed (prn). Change anti-reflux valve with each prn dressing change. As needed PRN.Observation on 05/16/2026 at 11:01 AM during R17's midline dressing change revealed, Registered Nurse Supervisor (RNS) CC changed her gloves and did not sanitize nor wash her hands between glove change. RNS CC did not sanitize her hands between a glove change three times during the procedure: after she removed old outer dressing, after she removed old inner securement dressing and after cleaning the midline site.Interview on 05/16/2026 at 11:05 AM with RNS CC, confirmed she did not wash her hands nor use hand sanitizer between glove changes. She stated she changed her gloves and she should have washed her hands or hand sanitized between glove change and she did not. RNS stated that when she did not wash her hands or hand sanitize between glove changes, it could cause spread of infection, cross contamination and spread of germs to R17.Interview on 05/17/2026 at 9:47 AM with Nurse Practitioner/Infection Preventionist (NP/IP) confirmed that hand hygiene was always to be done prior to putting on gloves and when gloves were removed. He stated hand hygiene was very important and when hand hygiene was performed it included the use of hand sanitizer or soap and water. The NP/IP further stated that when a central line dressing was done it was important to perform hand hygiene during glove changes. He stated that when hand hygiene was not performed between glove changes, it could introduce infectious agents/pathogens to the residents and they could become ill.Interview on 05/17/2026 at 10:06 AM with the Director of Nursing (DON) confirmed, the facility's protocol was that staff should sanitize their hands on entering the residents' room and the signage is there to explain what PPE was needed. The DON stated that anytime they change gloves, they should hand sanitize in between. Once the gloves came off, the staff needed to perform hand hygiene. The DON stated the EMR system generated orders called PICC lines which were used for all central lines including midlines. A negative outcome for the resident was an increased risk of introducing infection to the resident and the resident could have a bacteremia infection.

Based on observations, family and staff interviews, record review, and review of the policy titled, Residents' Rights, the facility failed to protect and promote the rights of one of 71 sampled residents (R) (R88). This deficient practice had the potential to violate the residents' preferences and religious culture.Findings include:Interview on 05/16/2026 at 12:25 PM with Social Services DD confirmed that R88's hair was cut without prior permission. She stated that a night shift nurse cut the hair. She was not sure why the nurse cut the hair but suggested it may have been for cleanliness. She confirmed that the family should have been contacted, and was not, until after the resident's hair was cut.Interview on 05/16/2026 at 12:36 PM with the Director of Nursing (DON) revealed and confirmed that Licensed Practical Nurse (LPN) EE, on the night shift, cut the resident's hair. She stated that it was reported to the nurse by a Certified Nursing Assistant (CNA) that the resident had bugs in her hair. After speaking with the family, it was revealed that the haircut was a cultural concern and that this was the reason the family did not want the haircut. She stated that the nurse was reprimanded and received disciplinary action, because of the situation. The DON confirmed that the nurse did not reach out to the family to inform them prior to the haircut.Observation on 05/16/2026 at 12:50 PM of R88 revealed that the resident's hair was cut. She was observed to have a short afro hairstyle. R88 was on a ventilator with tracheostomy and was nonverbal.Interview via phone on 05/16/2026 at 4:26 PM with LPN EE revealed, she was providing personal care to R88 and observed that the resident's hair was dirty and matted. She stated she saw black looking bugs in R88's hair and made the decision to cut the resident's hair. LPN EE confirmed that she cut R88's hair without obtaining permission from the family. She stated she notified her supervisor, and that her supervisor informed the family. LPN EE stated she was suspended for three days.Interview via phone on 05/16/2026 at 6:25 PM with the family of R88 revealed that she had received a call from the facility informing her that R88's hair was cut. The family of R88 stated that R88 was religious, nonverbal, but if she could speak, she would have refused to have her hair cut. The family of R88 stated she was R88's voice.Review of the electronic medical record (EMR) revealed that R88 was admitted to the facility on [DATE], with pertinent diagnoses including, but not limited to, acute and chronic respiratory failure with hypercapnia (primary), dependence on a respirator/ventilator, contracture of muscle in multiple sites, and contracture of the right wrist.Observation of a photograph on the face sheet revealed R88 wore a large purple bonnet which covered her hair.Review of R88's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was not conducted due to her non-verbal status.Review of the care plan dated 01/19/2026, revealed a problem that R88 had dandruff and required shampoo treatment on Mondays, Wednesdays, and Fridays. The goal was for the resident's hair to remain clean through the review date. The approach directed staff to wash the resident's hair with selenium sulfide on Mondays, Wednesdays, and Fridays. The approach also documented that the family requested that the resident's hair not be cut.Review of R88's physician orders documented the following: Anti Dandruff (selenium sulfide) shampoo, over the counter (OTC), 1% {percent} strength, with an amount of one application, to be applied topically. Special Instructions: Apply to the scalp with bath three times per week. Frequency: Once a day on Monday, Wednesday, and Friday.Review of the progress note dated 06/10/2025 at 11:06 AM, documented that a head to toe skin assessment was completed. The assessment included a description of her hair, which was described as a dread lock hair style and the dreads measured approximately 30 to 36 inches long. The posterior portion of the hair was matted. Staff were unable to fully assess the head and hair to determine the scalp condition.Review of LPN EE Notice of Suspension, dated 01/20/2026 documented an infringement of resident rights by cutting a resident's hair without the resident's or family's consent and failing to provide notification, as well as failing to report an infection risk ( bugs in hair) to the supervisor or provider in a timely manner. The documented expectation was that the employee speak with the family prior to cutting a resident's hair and report all reportable situations to the supervisor, manager, or provider promptly, and the stated consequence for repeated action was termination.Review of the complaint form dated 01/20/2026 documented that the family of R88 filed a complaint regarding a nurse that cut R88's hair dreads without contacting the family, and the family was upset that the dreads were disposed of, as confirmed through the investigation. The resident's hair was cut and the dreads were discarded; the nurse responsible stated she was washing the resident's hair and noticed small bugs, and she admitted she did not notify the family or obtain consent. No bugs were found in the resident's room or on the resident during assessment. Actions taken included bringing in pest control to assess and spray the room, providing discipline and education to the nurse, and removing her from providing care to R88. The facility also initiated 100% staff education during monthly staff meetings and updated social history admission forms to include more cultural preferences. Follow up was completed on 01/31/2026, and the family remained upset about the situation and requested a transfer to a facility in another state. It was additionally noted that the complaint form listed Social Services DD as the individual who took the complaint, and the Administrator's signature also appeared on the form. Review of the policy titled , RESIDENT'S RIGHTS documented The Omnibus Budget Reconciliation Act (OBRA Law), passed by Congress in 1987 and amended in 1989, requires that a nursing facility (nursing home) must protect and promote the rights of each resident (an individual living in a nursing facility), including each of the specific rights listed below. The nursing facility must read you your Federal rights on the day of admission. You also must be informed of your rights under the Georgia Law (Long Term Care Facility Resident's [NAME] of Rights). Freedom of Choice . You have the right to be informed before there are changes in your care or treatment which may affect your well being, to take part in the planning of your care and treatment or changes in your care and treatment, and the right to accept or refuse treatment, unless you have been adjudged incompetent.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, Grievance Policy, the facility failed to ensure that six of 40 sampled residents (R) (R37, R59, R57, R62, R68 and R83) who participated in Resident Council (RC), received a response to their grievances. Specifically, the facility failed to provide a response to grievances and complaints about call lights over a six-month period. The deficient practice had the potential to negatively impact each resident's quality of life and/or dimmish feelings of self-worth for R37, R59, R57, R62, R68 and R83. Findings include: Review of the facility's policy titled, Grievance Policy, revised on 11/15/2016 revealed, Policy: To support each resident's right to voice grievances (e.g., those about treatment, care, management of funds, lost items, or violation of rights). A resident's representative, other family members or advocate may also voice grievances on the resident's behalf. The Nursing Home after receiving a complaint and /or grievance will actively seek a resolution and keep the resident/family member appraised of the progress toward resolution. Continued review revealed under, Procedure: 1) A resident/family may voice or write a complaint and/or grievance to any staff member at any time. 2) The staff member must report the complaint to their supervisor and the supervisor must complete the Complaint Form. The Complaint Form can be found at the Nursing Station, the Social Service Director's office, Director of Nurses' office, and the Administrator's office. 3) Information to be completed includes the person taking the complaint, date of complaint, name of person making complaint, discipline complaint referred to, and a specific description of the complaint. 4) The findings from the complaint investigation are also written, as well as the action taken. The person making the complaint must be informed of the results, and the form signed and dated at that time by the staff member informing the resident or family member of the resolution. Review of the RC meeting minutes showed that call lights had been identified as an on-going discussion at each meeting between June of 2024 through January 2025. The notes did not include any information about who or what problems or concerns were reported, nor did the meeting minutes identify that the facility acted on the grievances or responded to the resident council group. During a RC meeting held on 1/6/2025 at 11:54 am with six residents in attendance, R37, R59, R57, R62, R68, and R8 revealed they did not get a response from the facility about how their concerns with call lights would be addressed. R59 and R68 revealed that call lights had been an ongoing issue, and no one from the facility had responded to the groups concerns. 1. Review of the electronic medical record (EMR) revealed R37 was admitted to the facility with diagnoses of but not limited to Parkinson's disease and seizure disorder. Review of the Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 11/26/2024 revealed R37 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating little to no cognitive impairment. 2. Review of the EMR revealed R59 was admitted to the facility with diagnoses of but not limited to Parkinson's disease and depression. Review of the Annual MDS assessment, with an ARD date of 11/8/2024 revealed R59 had a BIMS score of 15, indicating little to no cognitive impairment. 3. Review of the EMR revealed R57 was admitted to the facility with diagnoses of but not limited to anxiety and depression. Review of the Quarterly MDS assessment, with an ARD date of 11/14/2024 revealed R57 had a BIMS score of 14, indicating little to no cognitive impairment. 4. Review of the Quarterly MDS assessment, with an ARD date of 12/16/2024 revealed R62 had a BIMS score of 14, indicating little to no cognitive impairment. 5. Review of the Quarterly MDS assessment, with an ARD date of 11/14/2024 revealed R68 had a BIMS score of 14, indicating little to no cognitive impairment. 6. Review of the Quarterly MDS assessment, with an ARD date of 10/14/2024 revealed R83 had a BIMS score of 15, indicating little to no cognitive impairment. During an interview on 2/6/2025 at 12:10 pm with the Administrator revealed how grievances voiced by residents who attend the RC meetings were addressed. When a resident identified a grievance, the information would be forwarded to the department head to be investigated, and verbal feedback would be provided to the RC group. She confirmed there was no documentation to identify what was discussed with the council members informing the residents of the resolution.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Dietary Procedure Manual, the facility failed to ensure dietary areas were maintained in a sanitary manner. Specifically, food and supplements were not labeled properly, frozen meats were exposed to air, chemicals were stored with food, handwashing could not be completed without contamination of one's hands, floors were observed with built up substance, and the facility failed to use a sanitizer on kitchen surfaces. The deficient practice had the potential for transmission of food borne illness, and potential to affect 60 of 153 residents who received an oral diet served from the kitchen. (105 residents received partial to total nutrition needs via feeding tubes). Findings include: Review of the facility's policy titled, Dietary Procedure Manual, review date [DATE], under Infection Control-Food Preparation revealed, B. Patient Service: 5. All foods stored in diet kitchen refrigerator should be covered and labeled, dated or in pre-packaged containers . 6. Covered food should be discarded after 72-hours if not consumed . Food Storage: 1. All foods in the refrigerators are covered, labeled, and dated if not in original container . 6. Proper storage techniques including containers, temperatures, coverings, and length of time should be known and practiced by all . Food Storage: 19. Cleaning supplies are stored separately from food supplies . Cleaning: 4. Equipment and work surfaces are cleaned and sanitized before and after each use . 5. Floors are swept and mopped daily . 8. The counters in serving and preparation areas are cleaned with germicidal solution at each workstation after each use . Perishable Food Item Storage-Procedure: Leftover food items are stored in covered containers. Each container is labeled as to the contents and dated. 1. Observation and interview on [DATE] at 10:00 during the initial tour of the dietary department with the Food Service Supervisor (FSS), he revealed the main kitchen was in the process of being remodeled so the food service operation was spread out in several locations. Dietary staff were preparing meals in the physical therapy (PT) kitchen located a couple blocks away. There was a semi-truck freezer located next to the PT kitchen where frozen food was stored. The walk-in refrigerator located in the main kitchen in the hospital was still in use. There was also a makeshift kitchen set up in the facility with a steam table for tray line meal service, refrigerator/freezers and storage area. The following concerns were noted during the initial tour on [DATE] from 10:00 am to 11:02 am: a. Observation and interview with the FSS of the walk-in freezer truck revealed there were two boxes of meat, one bacon and one of pork chops that were not closed. The boxes had been opened and the plastic bag within the box had not been sealed exposing the entire top contents of the meat in the boxes to air. The FSS verified the meat was exposed to air and stated it should be completely covered/sealed. b. Observation and interview in the PT kitchen revealed a small storage room that contained food items such as canned and boxed of food. There were 4 gallons of bleach stored in the room with the food. The FSS verified the bleach should not be stored with food. The only garbage can in the PT kitchen was a 55 gallon can with a lid on it which required touching the potentially soiled garbage can lid with clean hands, which was verified by the FSS. The FSS stated they had a foot operated can in the old kitchen which prevented staff from soiling their hands, but it had not made it over to this temporary kitchen. Also, in the PT kitchenwas a bag of opened and thawed chicken tenders in the refrigerator that was unlabeled and undated. The manufacturer's expiration date was [DATE]. The FSS revealed their system for labeling and dating was to go by the manufacturer's expiration date, and leftovers they would keep for no more than three days. The FSS verified the manufacturer's date on the chicken showed the food was expired, and revealed dietary staff were supposed to label foods with the name of the food and the date the food expired. There was a container of leftover chili dated [DATE]; the FSS verified it was more than three days old. There were two packages of turkey lunch meat (per the FSS) in the reach-in refrigerator, one package opened and the other one not. Neither were labeled with the food item or date. c. Observation and interview in the walk-in refrigerator in the hospital revealed there was black grime on the floor along the edge of the wall and floor and accumulated brown crusty debris in the corner. There was a box half full of individually packaged four ounce [brand name] nutritional shakes in the manufacturer's box which was dated [DATE]. The FSS verified the shakes were past the expiration date. On each carton instructions read, use thawed product within 14 days. The FSS stated they used the manufacturer's expiration dates for the shakes, and she was not aware of the 14-day shelf life once the product was pulled from the freezer and placed in the walk in. 2. Observation and interview on [DATE] from 10:35 am to 11:48 am with the Food Service Manager (FSM) the following concerns were noted: a. Station Five snack area refrigerator contained approximately 20 cartons of [brand name] nutritional shakes. There were no dates to indicate when the shakes had been pulled out of the freezer and thawed. The FSM stated they received the [brand name] nutritional shakes frozen and pulled out what they needed and placed them in refrigeration. The FMS verified the label on the shakes indicated they should be used within 14 days of being thawed. b. The walk-in refrigerator in the hospital kitchen was in the same condition noted on [DATE]. There was black grime and brown crusty debris in the corners and along the walls. The FSM verified it needed to be cleaned. c. The PT kitchen had a bag of unidentified small pieces of meat dated [DATE]. The FSM verified it was a bag of bacon bits, it should be labeled with the food item and date, and it should be disposed of. The FSM stated their policy was to keep leftover food no more than three days, otherwise, they went by the expiration date on the box. The FSM stated staff should label foods with the date it was placed in refrigeration and the date it should be used by. During an interview, the FSM was asked what sanitizer they used for kitchen surfaces. The FSM showed the surveyor a spray bottle of the product [brand name of product]. The FSM stated that it was the product they used to clean the tray line and kitchen surfaces. Review of the label of the product and the Manufacturer's Safety Data Sheet for the product [brand named product] provided by facility revealed the product was a cleaning product and not a sanitizer. Ingredients included sodium dodecylbenzene sulfonate, sodium poly (oxyethylene) dodecyl ether sulfate, and organic sulfonic acid salt.

Based on resident, family, and staff interviews, record review, and review of the facility's policy titled, Grievance Policy, the facility failed to investigate and resolve grievances timely, and failed to report findings in writing to the complainant for one of 30 sampled residents (R) (R146). Specifically, there were two complaints filed for R146 with the same care allegation. The issue was not resolved until the second grievance was filed six months later and the complainants were not notified of findings and resolution. The deficit practice caused issues to be ongoing and the potential for unmet needs and dissatisfaction for R146. Findings include: Review of the facility's policy titled, Grievance Policy, revised 11/15/2016 revealed, Policy: To support each resident's right to voice grievances (e.g. those about treatment, care, management of funds, lost items, or violation of rights). A resident's representative, other family members of advocate may also voice grievance on the resident's behalf. The Nursing Home after receiving a complaint and/or grievance will actively seek a resolution and keep the resident/family member apprised of the progress toward resolution. The Grievance Official representative is Social Service . The person making the complaint must be informed of the results, and the form signed and dated at that time by the staff member informing the resident or family member of the resolution. The policy did not include provisions to provide anything in writing to the person making the complaint. Review of the electronic medical record (EMR) Face Sheet revealed R146 was admitted to the facility on [DATE] and was discharged to a different facility on 12/31/2024. Admission diagnoses included dependence on ventilator and quadriplegia (paralysis affecting all four limbs). Review of the Annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/14/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating little to no cognitive impairment. R146 was impaired in range of motion (ROM) to both sides of her upper and lower extremities. R146 required meal set up for eating and was dependent on staff for the remaining Activities of Daily Living (ADL). 1. Review of the Complaint Log for February 2024 provided by the facility revealed a complaint was filed on 2/19/2024 regarding R146 by Family Member (F) (F146) related to nursing care. Review of the Complaint Form dated 2/19/2024 revealed the complaint alleged Certified Nursing Assistant (CNA)1 did not round regularly and R146 was reported to be raw because of it (not having her brief changed timely). The second concern related to washcloths being used for perineal care. The findings revealed, No rawness noted to peri-area. - Interviewed CNA's - washcloths being used to provide cleanliness to perineal after post BM [bowel movement]/urinary episodes. CNA inconsistent in rounding Q [every 2 hrs [hours] Action taken included, CNA educated/counseled on Q2hr rounds and as needed by resident. Educated to use wipes due to resident's preferences. The individual investigating the incident was Registered Nurse (RN)/Critical Care Coordinator (CCC)1 and the grievance was completed on 2/24/2024. There was a check next to Person making complaint has been informed of results with a resolution dated 2/24/2024. Review of CNA1's personnel file did not include documentation of counseling related to this incident (grievance 1). Review of the care plan revealed it was not updated with her preference for staff not to use washcloths for peri-care following the the first grievance. 2. Review of the Complaint Log for August 2024 provided by the facility revealed a complaint was filed by R146 on 8/5/2024 regarding nursing care. Review of the Complaint Form dated 8/5/2024 revealed R146 reported on 8/3/2024 that CNA2 used rags to wash her when she has asked her not to use rags on her buttocks. Findings from the investigation revealed CNA2 used washcloths for cleaning an incontinent episode. Action taken included planning R146's preferences to use wipes versus washcloths, educating staff to honor her preferences, and explanation to R146 and F146 why the washcloth was used. SW1 was documented as informing the complainant of the results of the grievance as noted by a check mark on the form on 8/6/2024. Review of the care plan, last reviewed/revised on 12/23/2024, revealed, Resident refuses to be cleaned with wash cloth during incontinent [sic] due to discomfort/sensitivity. Approaches included: Clean resident with wipes only per resident preference, use washcloth for cleaning as last resort; explain procedure to resident with a start date of 8/6/2024. During an interview on 2/5/2025 at 1:58 pm, F146 revealed that she and R146 had expressed concerns, and filed formal complaints, about provision of incontinence care for R146's by two CNAs. CNA1 did not provide timely incontinence care, was rough with wiping during incontinence care, ignored and did not address R146's needs. An example was once F146 came into the facility and R146 had not been changed for an extensive period. F146 reported this grievance, and confirmed she had not heard anything back, or provided anything in writing in response to formal complaints. F146 also had concerns with the provision of incontinence care by CNA2. During an interview on 2/6/2025 at 7:44 am with CNA2 revealed R146 was alert and oriented, dependent for incontinence care and brief changes. CNA2 remembered R146 did not want her to use washcloths for peri care and preferred wipes be used. CNA2 stated she had used a washcloth for bowel incontinence to remove excess bowel movement as it was more effective than using a wipe. During an interview on 2/6/2025 at 1:29 pm with Social Worker (SW)1 revealed they did not provide anything in writing to complainants about grievances and notified complainants verbally of. SW1 revealed R146's initial grievance occurred on 2/24/2024 related to CNAs not rounding regularly. A second grievance occurred on 8/5/2024 when CNA2 used wash cloths for peri care after R146 requested they use wipes. During an interview on 2/6/2025 at 1:55 pm, RN/CCC1 verified she investigated the grievance filed on 2/19/2024 by F146. F146 complained that the CNAs were wiping R146 with a wash rag and not using wipes, the wash rags were too rough and irritated her peri area. RN CCC1 revealed the results of grievances were reported back to the complainant verbally; nothing was provided in writing. During an interview on 2/6/2025 at 3:06 pm with the Director of Nursing (DON) revealed the results were reported to the individual who made the complaint orally. The DON stated the complainant could have a copy of the written grievance if they asked for it.

[NAME] Based on observations, staff interviews, record review, and review of the Manufacturers information sheet titled, [Brand name of specialty bed manufacturer], the facility failed to obtain a Physicians order for one of 30 sampled residents (R) (R114) related to a specialty bed. Specifically, the facility failed to obtain a physician's order for use of a [name of bed manufacturer] specialty bed for R114 who was at risk for falls related to cerebral palsy, severe intellectual disability, and a history of falls. Findings include: Review of the Manufacturer's [named specialty bed manufacturer] information sheet provided by the facility revealed [named specialty bed manufacturer] is a domestic manufacturer of custom safety beds, featuring safety side rails, designed to address falls and entrapment for those with physical and cognitive disabilities. Review of the electronic medical record (EMR) revealed R113 was admitted to the facility on [DATE] with diagnoses including cerebral palsy. Review of R114's current physician orders dated 2/5/2025 revealed no order for the [named specialty bed manufacturer. Review of the Annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/26/2024 under the RAI (Resident Assessment Instrument) tab revealed R114 was rarely or never understood, and the Brief Interview for Mental Status was not conducted. R114 was 53 tall (4'5) and weighed 73 pounds. Under the Physical Restraints section, bed rails were not checked as being used. Review of the care plan, dated 11/14/2023, revealed R114 has specialty bed provided by family, R114 is accustomed to this bed from home. The goal was Maintain home life environment for resident to decrease agitation. Approaches in total were Monitor resident for agitation while in bed. Place resident in home like bed safely at bedtimes. Continued review of the care plan revealed Resident at risk for falling R/T [related to] cerebral palsy and severely intellectually impaired. Interventions included: [R114] is in personal specialty crib bed with side panels up while in bed. Observations on 2/4/2025 at 5:19 pm, on 2/5/2025 at 3:44 pm, and on 2/6/2025 at 8:06 am revealed R114's [named specialty bed manufacturer] was a bed with four solid panels (on each side of the bed and at the head and foot of the bed) extending approximately 36 inches above the mattress. The solid panels were in an up position when R114 was in bed per observations. R114 was small in stature and was observed to have movement of her limbs. During an interview on 2/5/2025 at approximately 2:00 pm with the Assistant Director of Nursing (ADON) 3 revealed he was a family member and the emergency contact for R114, and the bed was the same one that R114 used at home prior to coming to the facility. The ADON 3 stated R114 spun around, scooted, rolled over, moved constantly and the bed design kept her from falling out of bed. During an interview on 2/5/2025 at 4:45 pm, Certified Nursing Assistant (CNA) 3 stated R114 required total care, her normal schedule of getting up into a [named specialty chair] around 7:00 am until around lunch time and spent the remainder of the day in her specialty bed. CNA 3 verified R114 was not able to put the slats of the bed down. CNA 3 stated R114 had used the specialty bed since she was admitted to the facility. During an interview on 2/6/2025 at 5:04 pm with ADON 1 revealed the specialty bed had been in use since R114 was admitted to the facility on [DATE]. ADON 1 stated R114 was accustomed to using the bed from home and the goal was to decrease agitation and fussiness and keep R114 from rolling out of bed.

Based on staff interviews, clinical record review, and review of the policy titled Assessments and Care Planning; Care Plans-Comprehensive, the facility failed to document adverse reactions and/or side effects as indicated in each care plan for five residents (R), R#12, R#69, R#83, R#99, and R#129) of sampled residents. Findings include: Review of the facility policy titled, Assessments and Care Planning; Care Plans-Comprehensive, Revised April 2010, revealed: Policy Interpretation and Implementation #3. Each resident's comprehensive care plan is designed to: a. incorporate identified problem areas b. incorporate risk factors associated with identified problems e. reflect treatment goals, timetables and objectives in measurable outcomes g. aid in preventing or reducing declines in the resident's functional status and/or functional levels i. reflect currently recognized standards of practice for problem areas and conditions 1. R#12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment for R#12, dated 4/25/22, documented R#12 required antipsychotic, antidepressant, antianxiety, anticoagulant, and antibiotic medications. Review of the Care Plan reveal for pain for R#12 had an approach to assess/reassess for pain using pain scale. There was also a care plan for antidepressant medications with a need to be monitored for effects/side effects. Lastly, there was a care plan for diagnosis (dx) of anxiety stating that prescribed antianxiety medication and need to be monitored for effects/side effects. Review of the medical record did not reveal any evidence of monitoring for effects and side effects of [MEDICATION(S)] 10 milligram (mg) tablet (tab), [MEDICATION(S)] 10 mg tab, and [MEDICATION(S)] 60 mg capsule. 2. R#69 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE] documented that R#69 received insulin, antianxiety, antidepressant, anticoagulant, antibiotic, and opioid medications. Review of the Care Plan documented revealed the following: 1.[MEDICATION(S)] with an approach of monitor and support signs and symptoms complications related to unusual bleeding from gums, nosebleeds, severe bleeding unable to control, hematuria, hematemesis, black tarry stools, swelling or joint pain, headaches, dizzy or weakness. 2. Care plan for prescribed narcotic analgesics for pain as needed. Need to be monitored for effects/side effects with and approach to assess/reassess for s/s of pain using the appropriate pain scale 3.Care plan for prescribed antianxiety medication due to depression. Needs to be monitored for effects/side effects with an approach of assess effectiveness of drug treatment, resident's mood and the response to the medication; monitor and report signs of sedation, drowsiness, dry mouth, blurred vision, [CONDITION(S)], [CONDITION(S)], muscle tremor, headache, agitation, skin rash, weight gain. 4. Care plan for prescribed antidepressant medication due to depression. Need to be monitored for effects/side effects and an approach that consisted of assess effectiveness of drug treatment, resident's mood and the response to the medication; monitor and report signs of sedation, drowsiness, and dry mouth. Review of the medical record did not reveal any evidence of monitoring for effects and side effects of [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], or [MEDICATION(S)]. 3. R#83 was admitted to the facility on [DATE] with diagnose to include chronic [CONDITION(S)] with [CONDITION(S)], [CONDITION(S)]/ventilator dependence, [CONDITION(S)] disease, Gastrostomy tube, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], other specified depressive episodes, sequelae of cerebral infarction, [CONDITION(S)], other chronic pain, other muscle spasm, traumatic subdural hemorrhage, subsequent encounter, long term (current) use of anticoagulants, chronic kidney disease Review of the Admission MDS assessment dated [DATE], documented R#83 received antidepressant, anticoagulant, antibiotic, and opioid medications. Review of the Care Plan documented the following: 1.Problem related to prescribed pain medications due to muscle spasms and existing pressure areas with an approach that consisted of assess/reassess for s/s of pain using the appropriate pain scale. 2.Problem related to prescribed antidepressant medication due to depression with an approach that consisted of assess effectiveness of drug treatment, resident's mood and the response to the medication. Review of the medical record did not reveal any evidence of monitoring for effects and side effects of [MEDICATION(S)] 10 mg tab twice daily, [MEDICATION(S)] 10 mg tab once, and [MEDICATION(S)] syringe 40 mg/0.4 ml. 4. R#99 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE], documented the BIMS score as immeasurable; Mood score as zero (0), indicating no depression; and exhibited no behaviors. R#99 required total assistance for all ADLs and was vent/[CONDITION(S)] dependent. R#48 also received insulin, antidepressant, anticoagulant and opioid medications. Review of the Care Plan revealed the following: 1.Problem related to prescribed antidepressant medication due to depression; need to be monitored for effects/side effects with approaches of assess effectiveness of drug treatment, resident's mood and the response to the medication; monitor and report signs of sedation 2.Problem related to potential for pain related to impaired mobility with an approach of assess/reassess pain using pain scale. Review of the medical record did not reveal any evidence of monitoring for effects and side effects of [MEDICATION(S)] 10 mg tab, [MEDICATION(S)] 50 mg cap via G-tube q8h for chronic pain syndrome, [MEDICATION(S)] 15 mg, and [MEDICATION(S)] 50 mg tab. 5. R#129 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE] documented that R#129 received insulin, antianxiety, antidepressant, anticoagulant, diuretic, and opioid medications. Review of the Care Plan revealed the following: 1.Problem related to prescribed antianxiety medication with approaches that included monitor for adverse effects and monitor resident's response to medication. 2. Problem related to prescribed antidepressant medication due to depression with approaches that consisted of assess effectiveness of drug treatment, resident's mood and the response to the medication, monitor and report signs of sedation. Review of the medical record did not reveal any evidence of monitoring for effects and side effects of [MEDICATION(S)]. During an interview with the Director of Nursing (DON) on 8/4/22 at 2:00 p.m. she confirmed that licensed nurses do not document daily behavior monitoring or side effects of medications as a routine. She stated they only document adverse events.

Based on observations, record review, interviews, and review of the Resident Assessment Instrument (RAI) Manual the facility failed to correctly complete the Annual Minimum Data Set Assessment (MDS) for two residents (R) R#14 and R#84) of 30 residents reviewed. Findings include: 1.Review of R#14's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#14's current Annual Minimum Data Set (MDS) dated [DATE] revealed Section C-Cognition: not completed; Section D-Mood: not completed; and Section E-Behavior: not completed. 2. Review of R#84's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#84's recent Annual MDS dated [DATE] revealed Section C-Cognition: not completed; Section D-Mood: not completed; and Section E-Behavior: not completed. An interview held on 8/4/22 at 10:08 a.m. with the Licensed Practical Nurse (LPN) MDS Coordinator LPN MDS AA revealed they have two (2) people who do the MDS's. The other one is new. She indicated the Social Worker (SW) is responsible for completing sections C, D, E. She indicated that section C, D, E should have been completed for cognition, mood, and behavior. An interview held on 8/4/22 at 10:21 a.m. with the Director of Nursing (DON) revealed she would expect the SW to completed sections C, D, E. An interview held on 8/4/22 at 11:40 a.m. with SW BB revealed she usually does Sections C, D, E for the residents in her unit which includes R#14 and R#84. She indicated if the resident is unable to answer the questions due to being comatose, she skips the sections. The facility follows the Resident Assessment Instrument (RAI) manual for direction to complete the MDS. Review of the RAI manual revealed: Section C-Cognition: indicated to Code 0, no: if the interview should not be conducted because the resident is rarely/never understood, cannot respond verbally, in writing, or using another method; or an interpreter is needed but not available. Skip to C0700, Staff Assessment of Mental Status. Section D-Mood: indicated Code 0, no: if the interview should not be conducted because the resident is rarely/never understood or cannot respond verbally, in writing, or using another method, or an interpreter is needed but not available. Skip to item D0500, Staff Assessment of Resident Mood. Section E-Behaviors: Code based on behaviors observed and/or thoughts expressed in the last seven (7) days rather than the presence of a medical diagnosis. Check all that apply.

Based on staff interviews and clinical record review, the facility failed to monitor behaviors and side effects for five residents (R) R#12, R#69, R#83, R#99, and R#129) receiving [CONDITION(S)] medications from a sample of 35 residents. Findings include: 1. R#12 was admitted to the facility on [DATE] with diagnoses which included anxiety disorder. Review of the Admission Minimum Data Set (MDS) assessment for R#12, dated 4/25/22, documented R#12 required antipsychotic, antidepressant, antianxiety, anticoagulant, and antibiotic medications. Review of the Medication Administration Record (MAR) for July 2022 revealed R#12 was prescribed and administered the following medications: 1. [MEDICATION(S)] 10 mg tab via G-tube q8h for generalized anxiety disorder 2. [MEDICATION(S)] 60 mg capsule per G-tube once daily for generalized anxiety disorder Continued review of the MAR and medical record revealed no documentation for monitoring of side effects and adverse reactions for [MEDICATION(S)] and [MEDICATION(S)]. 2. R#69 was admitted to the facility on [DATE] with diagnoses which included generalized anxiety disorder and chronic pain syndrome. Review of the quarterly MDS assessment dated [DATE] documented R#69 received insulin, antianxiety, antidepressant, anticoagulant, antibiotic, and opioid medications. Review of the MAR for July 2022 revealed R#69 was prescribed and administered the following medications: 1. [MEDICATION(S)] 5 mg tab; 2 tabs by mouth (po) every (q) 12h for generalized anxiety disorder 2. [MEDICATION(S)] 50 mg tab po once daily for other depressive episodes Further review of the MAR and medical record revealed no documentation related to adverse reactions/side effects for [MEDICATION(S)] and [MEDICATION(S)]. 3. R#83 was admitted to the facility on [DATE] with diagnoses which included other specified depressive episodes. Review of the Admission MDS assessment dated [DATE], documented R#83 received antidepressant, anticoagulant, antibiotic, and opioid medications. Review of the July 2022 MAR for R#83 revealed he was prescribed and administered the following medication: 1.[MEDICATION(S)] 10 mg tab once daily for other specified depressive episodes Further review of the MAR and medical record revealed no documentation related to monitoring for adverse reactions/side effects for [MEDICATION(S)]. 4. R#99 was admitted to the facility on [DATE] with diagnoses which included generalized anxiety disorder, major depressive disorder, and altered mental status. Review of the quarterly MDS assessment dated [DATE], documented received insulin, antidepressant, anticoagulant and opioid medications. Review of the July 2022 MAR for R#99 revealed the following prescribed and administered medications: 1.[MEDICATION(S)] 50 mg tab; ½ tab via G-tube once daily for major depressive disorder Further review of the MAR and medical record revealed no documentation related to monitoring of adverse reactions or side effects of [MEDICATION(S)]. 5. R#129 was admitted to the facility on [DATE] with diagnoses which included anxiety disorder, major depressive disorder, and altered mental status. Review of the quarterly MDS assessment dated [DATE] documented R#129 received insulin, antianxiety, antidepressant, anticoagulant, diuretic, and opioid medications. Review of the MAR for July 2022 revealed the following prescribed and administered medications: 1.[MEDICATION(S)] tablet; crushed 50 mg; administer 25 mg ½ tab via gastric tube. Review of the MAR and medical record revealed no documentation related to monitoring of adverse reactions or side effects of [MEDICATION(S)]. In an interview with the Director of Nursing (DON) on 8/4/22 at 2:00 p.m., she stated the Certified Nursing Assistants (CNAs) document behavior monitoring in their documentation and confirmed licensed nurses do not document daily behavior monitoring or side effects of medications as a routine. She stated they only document adverse events.

Based on observations, record review, interviews, and review of the Resident Assessment Instrument (RAI) Manual the facility failed to correctly code one Minimum Data Set Assessment (MDS) for falls for one resident (R) R#14) of 30 residents reviewed. Findings include: Review of R#14's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#14's current Quarterly MDS dated [DATE] revealed Section J with no falls since admission. Review of R#14's care plans revealed (partial list): 6/18/2022 Resident had a fall. Keep bed in lowest position with brakes locked. An interview held on 8/4/22 at 10:08 a.m. with the Licensed Practical Nurse (LPN) MDS Coordinator LPN MDS AA revealed they have two people who complete the MDS assessments and the other person one is new. LPN MDS AA revealed that she did not complete R#14's MDS dated [DATE] and the person that completed it does not work in facility anymore. She indicated the fall should have been captured under Section J. An interview held on 8/4/22 at 10:21 a.m. with the Director of Nursing (DON) revealed she would expect R#14's MDS to reflect the residents fall. It was reported that the facility follows the Resident Assessment Instrument (RAI) manual for direction to complete the MDS.

Based on record review and staff interviews, and review of the facility's policy titled, Advance Directives the facility failed to obtain a Physician's signature and a concurring Physician's signature for a Physician order [REDACTED].#55, R#42 and R#117). This deficient practice affected 3 of 7 residents reviewed for Do Not Resuscitate. Findings include: Review of Advance Directives Policy revealed: 2. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directives. POLST Additional Guidance for Health Care Professionals III. When a POLST form is signed by an Authorized Person (other than the patient's Health Care Agent) and Attending Physician: I. If Section A indicates Allow Natural Death - Do Not Attempt Resuscitation, this order may be implemented when the patient is a candidate for non-resuscitation as defined in Georgia Code Section 31-39-2(4). A concurring physician signature is Required per Georgia Code Section 31-39-4(c). 1. Review of the medical record for R#55 revealed a POLST with a verbal signature noted for Allow Natural Death with one Physician signature on 9/13/17. There was not any evidence of any documentation that R#55 had a power of attorney for healthcare nor was there a healthcare agent identified. During an interview on 11/5/19 at 4:00 p.m. with the facility's Long-Term Care (LTC) Director revealed that if a resident has a legal next of kin to sign the POLST only one Physician's signature has been gotten and was signed by an authorized person who is not the health care agent. The LTC Director further reported that if there was no legal next of kin two Physician signatures would be needed. The LTC Director reviewed the POLST for R#55 and she confirmed that there was only one Physician signature for R#55. Upon reading the POLST LTC Director acknowledged that a concurring physician's signature was needed when residents do not sign the form and there is not a health care agent. 2. A review of the Quarterly Minimum Data Sets dated 8/20/19 for R#42 revealed that the resident had both long-term and short-term memory problems and was unable to answer the assessment questions. A review of the medical record for R#42 revealed a Physician order [REDACTED]. An interview on 11/6/19 at 10:35 a.m. with the Assistant Director of Nursing confirmed that the resident did not have a healthcare agent and that only one Physician had signed his POLST form. An interview on 11/6/19 at 10:54 a.m. with Social Service CC confirmed that R#42 did not have a healthcare agent on file. Social Service CC brought a POLST in that was signed on 11/6/19 after surveyor inquiry by a second physician. She confirmed that prior to surveyor inquiry that the lack of appropriate signatures for the POLST to be legal had not been identified. 3. A review of the Admission MDS assessment dated [DATE] for R#117 documented both long-term and short-term memory problems with the resident being unable to answer assessment questions. A review of the POLST form dated 4/18/19 for R#117 revealed it was signed by only one Physician, and the responsible party. The resident had no Power of Attorney (POA) or healthcare agent. A review of the Face Sheet identified that R#117 had an Advanced Directive of DNR. An interview on 11/5/19 at 4:06 p.m. with the facility's Long-Term Care (LTC) Director revealed if there was no responsible party or next of kin, we obtain two physician signatures, but if there was a responsible party or a next of kin that they had only been getting one physician signature and the signature of the responsible party. The LTC Director confirmed that based on what was written on the POLST form that there needed to be two concurring Physician signatures if there was no Power of Attorney with a legal healthcare agent. A review of the POLST with the LTC Director for R#117 confirmed that there was the signature of the next of kin and one physician signature and there was no legal healthcare agent for R#117. An interview on 11/6/19 at 11:29 a.m. with the LTC Director again confirmed that R#117 did not have a healthcare agent.

Based on observation and interviews the facility failed to ensure the resident fans on the vent unit were clean and free from dust build up for four of 15 rooms on Unit Two (Rooms: 20, 19, 22, 14). Findings include: The following observations were made: On 11/4/19 at 12:21 p.m. in room [ROOM NUMBER] there was a fan sitting on the table at the foot of Bed B that had a buildup of dust. On 11/4/19 at 1:13 p.m. in room [ROOM NUMBER] there was a fan at the end of Bed A with dust buildup. On 11/4/19 at 1:16 p.m. in room [ROOM NUMBER] at the end of bed A there was a fan with dust buildup On 11/5/19 at 8:09 a.m. in room [ROOM NUMBER] there was a fan with black dust buildup on the blades. On 11/5/19 at 3:10 p.m. in room [ROOM NUMBER] there was a fan with thick dust buildup. On 11/5/19 at 3:18 p.m. in room [ROOM NUMBER] there was dust noted on the fan. On 11/5/19 at 3:20 p.m. in room [ROOM NUMBER] there was dust noted on the fan. On 11/6/19 at 9:21 a.m. in room [ROOM NUMBER] there was dust noted on the fan by the sink. On 11/6/19 at 9:22 a.m. in room [ROOM NUMBER] there was dust noted on the fan. On 11/6/19 at 9:23 a.m. in room [ROOM NUMBER] there was dust build up on the fan. On 11/6/19 at 9:24 a.m. in room [ROOM NUMBER] there was dust noted on the fan. During a tour of Unit Two on 11/7/19 at 9:50 a.m. the Director of Nursing (DON) confirmed that in room [ROOM NUMBER] there was dust and buildup on the fan, in room [ROOM NUMBER] there was dust build up on the fan blade and the fan grille, in room [ROOM NUMBER] there was dust build up on the fan grille and, in room [ROOM NUMBER] there was dust build up on the fan and fan grille. During an interview with the DON on 11/7/19 at 9:58 a.m. revealed the Certified Nursing Assistants (CNAs) should clean fans when they are identified as having dust buildup. The DON further revealed that Maintenance should be notified when there is dust on the fan blades. The DON stated that CNAs should be wiping down the fans daily. There is no policy on personal fans and how often they should be cleaned.

Based on record review and interview the facility failed to transmit resident Minimum Data Assessment (MDS) assessments timely for eight residents (R4, R2, R17, R20, R14, R7, R26 and R10). The facility census was 98. Findings include: Interview on 06/28/18 at 3:29 p.m. with Registered Nurse (RN) AA regarding the Minimum Data Assessments (MDS) revealed that a (MONTH) 10, (YEAR) batch of resident assessments were downloaded but was not uploaded and that it was that the facility's mistake. RN AA revealed that it is the responsibly of the facility to check to make sure that the assessments are uploaded and confirm that the assessments have been received. RN AA revealed that the 5/10/18 file was saved to Downloads, but was never exported, so there was not a receipt alerting her of the batch. Interview on 6/28/18 at 3:30 p.m. with the Director of Nursing (DON) and RN CC revealed that the MDS nurse in the facility is responsible for making sure the download of assessments is complete. The DON inquired with the MDS assessment nurses as to why the assessments were late. At this time, RN CC revealed that the QI data that is reported monthly is generated by reviewing the Resident Assessment Instrument (RAI) MDS schedule and reporting any assessments that haven't been completed by the RAI assessment due date. RN CC revealed that the 5/10/18 batch had been completed and sent to a zip file to be submitted to CMS, which caused the report to drop off the assessment due report however, it was never taken from the zip file and submitted and this caused the assessments to be sent in late. Interview on 6/28/18 at 3:32 p.m. with CC RN MDS revealed she made a file and uploaded the batch to the file and downloaded it to the site but apparently it did not go through. RN MDS CC revealed that when processing MDS assessments we save a zip file in the charting system and from there we must sign into the Quality Improvement and Evaluation System (QIES) submission website and attach the zip file to the state website; however, on 5/10/18, I failed to complete the second step of the process.

Based on observation and interview, it was determined that the facility failed to make the most recent survey results readily available to residents. Findings include: During an interview on 7/13/17 at 2 p.m., Resident (R) A stated she was unaware of the survey report. During an interview on 7/13/17 at 2:20 p.m., RB stated the he did not know where the survey results were kept. An observation on 7/13/17 at 2:40 p.m. revealed a sign posted on the large bulletin board, located across from the Unit 1 nurses station. The sign documented that the survey results were posted at the Nurses Station to be viewed at anytime. However, an observation of the nurses station revealed no visible survey results posted at that time. Registered Nurse (RN) AA was unable to locate the survey results. The Director of Nursing (DON) was able to locate the survey results in a folder in the drawer, behind the nurses station. She confirmed that the results were kept behind the nurses station.

Based on record review and staff interview, the facility failed to ensure liability statements were mailed each month with the balance due indicated to include any past due amounts for one (1) resident (R#4) and failed ensure that resident personal trust funds were disbursed within thirty (30) days of death for one (1) resident (R#9). The sample size was 3 residents. Findings Include: Review of resident a personal allowance account statement dated [DATE] revealed R#4 died on [DATE] and had a personal liability remaining of 1099.00-. Review of the facility general fund account invoice ,[DATE] revealed the 990.21 Trust Fund Account balance for R#4 was paid to the county hospital General Fund on [DATE]. During an interview on [DATE] at 8:15 a.m., the Nursing Home Office Director revealed the facility never sent any liability statements to the R#4 ' s responsible party and it was simply an oversight. During an interview on [DATE] at 9:10 a.m., T revealed she never received a liability statement from the facility for R#4 ' s account. Review of the resident liability statement policy dated [DATE] and revised [DATE] revealed, If check not routed to the Facility, then resident liability statements are mailed at the end of each month with the balance due indicated to include any past due amounts if applicable. 2. Review of Invoice ,[DATE] dated [DATE] revealed 79.22 was paid by check to R#9's Power of Attorney (POA) on [DATE]. Review of R#9's face sheet revealed she expired on [DATE] During an interview on [DATE] at 10:58 a.m., the Nursing Home Office Director revealed she delayed processing the trust fund refund for R#9 out of caution while she verified the mailing address. She added, she should have verified the POA address at the time of notification of death or discharge and that in hindsight, it should have been done differently. Review of the trust fund disbursement policy dated [DATE] and revised [DATE] revealed the policy is to ensure the resident ' s trust fund accounts are processed and closed within 30 days of discharge from the facility or death. Funds will be applied to the resident liability per admissions policy, if applicable. Any remaining funds will be refunded to resident or responsible party, as applicable.

Based on observations, staff interview and facility water temperature monitoring tool the facility failed to maintain safe water temperature for four (4) residents rooms in two(2) of (3) three halls and one (1) of two (2) resident's shower areas. Findings include: During environmental tour of the facility with Maintenance Director conducted 08-24-15 at 10:30 a.m. using facility thermometer the following rooms were identified with water temperatures of 120 degree or above Fahrenheit(F): Room #19 - 128.5 degrees F; Room #2 - 120 degrees F; Room # 7 -122 degrees F; Room #15 - 122 degrees F; Lady's shower room - 125.2 degrees F; these temperatures were confirmed by the Director of Maintenance. Interview with Maintenance Director on 8-24-15 at 10:30 AM revealed he/she was aware the guideline for federal water temperature should be above 120 degrees. Review of Hot Water Tank temperature Check for Station 1 and Station 2 revealed that the water temperature in some instances over 120 degrees.

Based on observations, it was determined that the facility failed to appropriately store ice scoops to prevent contamination on one unit (Unit I) of two units. Findings include: According to the Long Term Care Pocket Guide for Infection Control, staff should not handle ice directly by hand. Ice scoops should be kept on a clean hard surface when not in use and should not be stored in the ice bin. However, observations on Unit 1 revealed that staff had stored ice scoops on the ice inside ice coolers. On 2/21/13 at 9:00 a.m., a cooler was observed in the hallway of Unit 1 across from room [ROOM NUMBER]. The cooler is used to store ice that is served to residents. Staff had not stored the ice scoop on a clean hard surface. Staff had stored the ice scoop inside of the cooler with its handle on the ice and water. On 2/21/13 at 1:15 p.m., a cooler was observed in the hallway of Unit 1 across from room [ROOM NUMBER]. The staff had stored ice scoop inside of the ice cooler with its handle in the ice.

Based on observation, staff interview, and record review, it was determined that the facility failed to ensure that resuscitation equipment was stored in a sanitary manner on one of two units (unit 1)and that respiratory equipment was properly maintained for one sampled resident (#44) and two randomly observed residents of 18 residents receiving respiratory care from a total sample of 34 residents. Findings include: During an interview on 2/21/13 at 1 p.m., the Director of Respiratory Care stated that the respiratory therapists were responsible for cleaning oxygen concentrators and washing out the external filters. However, there was no evidence that the staff had routinely cleaned the oxygen concentrators being for resident #44 and in use in rooms 39A and 39B. 1. Resident #44 had [DIAGNOSES REDACTED]. The resident's plan of care since 5/12/12 included requiring oxygen therapy. The plan of care included an intervention for staff to keep the resident's room free of irritants such as dust, smoke, and cleaning agents. However, it was observed in the resident's room on 2/20/13 at 12:45 p.m. and on 2/21/13 at 12:30 p.m., that the front panel of his/her oxygen concentrator was dusty. The external filters had a thick coating of dust. 2. Random observations in room [ROOM NUMBER] on 2/21/13 at 9 a.m., 9:50 a.m. and 11:05 a.m. revealed that there were two oxygen concentrators being used in that room. The external filter on the oxygen concentrator on the A bed side was coated in dust. The external filter was missing off of the oxygen concentrator on the B bed side of the room. 3. During observations of the emergency cart on Unit I on 2/18/13 at 10:45 a.m., 2/19/13 at 9:00 a.m. and 3:30 p.m., on 2/20/13 at 8:30 a.m. and 3:30 p.m. and on 2/21/13 at 9:15 a.m., a thick layer of dust was noted on the shelves and the base of the suction machine. There was a dried brown substance on the bottom shelf of the cart.

Based on resident and staff interviews and record review, it was determined that the facility failed to speak in a dignified manner to one ("A") of 34 sampled residents. Findings include: During an interview on 2/19/13 at 11:40 a.m., resident "A" stated that the previous night a certified nursing assistant (CNA) on that shift had asked him/her if he/she wanted to go and smell some "s**t" with him. The resident said that he/she felt that the comment was inappropriate and told the CNA to leave. The resident stated that incident upset him/her so, he/she had it to the nurse that was on duty at that time. However, a review of the facility's grievance file revealed that staff had not completed a grievance form about the resident's complaint or started to conduct and investigation. During an interview on 2/21/13 at 1:10 p.m., the Director of Nursing stated that no one had reported the incident to her so, she had not started an investigation yet.