Every finding on record at Muscogee Manor & Rehabilitation CTR

Based on observations, staff interviews and record review, the facility failed to place open dates on two bottles of glucose test strips in two of four medication carts. This deficient practice had the potential to cause abnormal blood sugar readings and worsening of the residents' medical conditions.Findings include:Review of the facility's documents demonstrated a policy was requested from the facility for blood sugar strips however no policy was provided.Observation and interview on 02/21/2026 at 1:27 PM during review of the medication cart 1 on the [NAME] Wing revealed one bottle of blood sugar test strips was in the cart with no open dates. Licensed Practical Nurse (LPN) DD was present during the review and confirmed the bottle of blood sugar test strips had no open date.Observation and interview on 02/21/2026 at 1:43 PM during review of the medication cart 2 on the [NAME] Wing revealed one bottle of blood sugar test strips were in the cart with no open dates. LPN EE was present during the review and confirmed the bottle of blood sugar test strips had no open date. Record review of the facility's Checklist for Blood Sugar documented number 60. Blood Glucose monitoring solution/strips dated. (Expires 3 months after first use).Interview on 02/22/2026 at 8:52 AM with the Assistant Director of Nursing (ADON) confirmed the opening date should be placed on the glucose strip bottle when they are first opened. She stated the nurses would not know when the days are up since the strips would be effective for only a certain time period after opening.Interview on 02/22/2026 at 8:55 AM with the Director of Nursing (DON) revealed it is her expectation for open dates to be placed on the bottles of glucometer strips upon opening. She stated after the bottle is opened there was a certain time period within which they should be used. The DON stated that if the strips had no open date and the time period passed within which they should be used, the efficacy of the strips may not be what they should be, and the resident may have inaccurate blood sugar readings.

Based on observations, resident and staff interviews, and review of the facility's policies titled Privacy Policy, Medication Administration General Guidelines, and Electronic Medical Records, the facility failed to ensure that private, clinical information was not visible to unauthorized staff, other residents, and visitors for three of 42 sampled residents (R) (R51, R62, and R43) and one of three medication carts. This deficient practice had the potential to place R51, R62, R43, and other residents at risk for protected health information to be viewed by unauthorized individuals. Findings include: Review of the facility's policy titled Privacy Policy, revised 09/10/2023, documented under the Policy: The nursing facility industries recognize their responsibility to keep information about you secure and confidential. Review of the facility's policy titled Medication Administration General Guidelines dated 01/2025, documented under Medication Administration: . 18. Resident's health information needs to remain private. Medication Administration Records [MARs] containing resident health information must not be visible when not in direct use (Paper MAR closed, Electronic Health Record information hidden). Review of the facility's policy titled Electronic Medical Records, revised 02/21/2025, documented under Procedures: . 3. Only authorized staff will be permitted access to the electronic medical records system. 9. Our electronic medical records system has safeguards to prevent unauthorized access. 1. Review of the quarterly Minimum Data Set (MDS) assessment for R51, dated 12/02/2025, Section C (Cognitive Patterns) documented a Brief Interview for Mental Status score of 06 which indicated severe cognitive impairment and Section K (Swallowing/Nutritional Status) documented that the resident received a mechanically altered diet at the time of the assessment. Review of the care plan for R51, revised 03/04/2025, documented a plan for the resident being at risk for altered nutrition. Review of the physician's orders for R51 revealed an order dated 08/07/2025, renal (dialysis) diet, minced & moist (5) texture, regular/thin consistency, with a 1500 milliliter fluid restriction and no dairy products. Review of the electronic medical record (EMR) for R51 revealed diagnoses including, but not limited to, end-stage renal disease and type 2 diabetes. Review of the progress notes for R51 revealed no evidence that the signage in the resident's room was requested by the resident or the representative. Observations on 02/20/2026 at 09:54 AM and 2:25 PM, and 02/21/2026 at 8:08 AM and 2:30 PM, revealed R51 lying in bed. Observations of the room revealed a sign on the wall above the head of the bed stating that the resident was to have no milk products or pudding. Another sign had instructions for aspiration precautions. In attempted interviews, R51 was unable to answer questions about the signage. 2. Review of the quarterly MDS assessment for R62, dated 12/30/2025, revealed that Section C (Cognitive Patterns) documented a BIMS score of 99 which indicated severe cognitive impairment and Section H (Bladder and Bowel) documented that the resident had an ostomy. Review of the care plan for R62 revised 01/16/2026, documented the resident had a colostomy. Interventions included changing the colostomy per protocol and checking the colostomy bag at least two times per shift. Review of the physician's orders for R62 revealed an order dated 12/23/2025 for colostomy care per facility protocol, every shift, including checking the stoma area and reporting redness or irritation. Review of the EMR revealed diagnoses including, but not limited to colostomy status, cognitive communication deficit, and unspecified intellectual disabilities. Review of the progress notes for R62 revealed no evidence that the signage in the resident's room was requested by the resident or the representative. Observations on 02/20/2026 at 08:25 AM, 2:25 PM, and 02/21/2026 at 8:15 AM and 2:28 PM revealed R62 in a wheelchair in his room. Observations revealed a sign posted on the wall next to the bed stating the resident has a colostomy bag and to make sure to change it when the bag is full. Another sign was posted on the wall indicating a turning schedule. In attempted interviews, R62 was unable to answer questions about the signage. 3. Review of the quarterly MDS assessment for R43, dated 11/18/2025, revealed that Section C (Cognitive Patterns) documented that BIMS was not conducted because the resident was rarely/never understood and Section K (Swallowing and Nutritional Status) documented that the resident had a feeding tube at the time of the assessment. Review of the physician's orders for R43 revealed an order dated 03/24/2023, for enteral feed in the evening. Review of the EMR revealed diagnoses including, but not limited to, mild protein-calorie malnutrition. Review of the progress notes for R43 revealed no evidence that the signage in the resident's room was requested by the resident or the representative. Observations on 02/20/2026 at 09:15 AM and 02:55 PM, and 02/21/2026 at 8:22 AM, 12:20 PM, and 2:20 PM revealed R43 in bed with head of the bed (HOB) elevated. Observation of R43's room revealed a sign posted on the wall behind the head of the bed stating that the resident was a tube feeder, with instructions to elevate the head of the bed at all times. In attempted interviews, R43 was unable to answer questions about the signage. In an interview on 02/21/2026 at 2:45 PM, Certified Nurse Aide (CNA) JJ stated that the wall signage in resident rooms was placed to inform staff of residents' care needs. She stated she relied on the signs to inform her of the care required. In concurrent observations and an interview on 02/21/2026 at 2:55 PM, Licensed Practical Nurse (LPN) KK confirmed the signage in R51, R62, and R43's rooms. She stated she was unsure who placed the signs and that they had been on the wall for more than a few months. She stated that CNAs ask nurses when they have questions or concerns about resident care, and that nursing staff hold huddles to discuss resident care as needed. In an interview on 02/21/2026 at 3:05 PM, LPN/Unit Manager (UM) FF stated that the nursing and care plan team determined which residents needed medical instructional signage posted in their rooms. She stated the signs were placed to ensure the resident's care needs were communicated. LPN FF stated that nursing staff had huddle meetings to discuss resident care needs. In an interview on 02/21/2026 at 3:15 PM, LPN BB stated that medical instructional signage was placed in resident rooms to provide staff with instructions on resident care needs. She stated the signage contained medical information and should not be placed in the view of visitors. In a concurrent interview on 02/21/2026 at 3:30 PM, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) stated that the Interdisciplinary Team (IDT) discussed and decided on the placement of medical information signage in resident rooms. They stated the signs were used to provide staff with information about the residents' care needs. The ADON stated there were no concerns with the signage being on the residents' walls. 4. Observation and interview on 2/21/2026 at 9:03 AM revealed Registered Nurse Supervisor (RNS) CC left the laptop screen open on the medication cart and walked away from the medication cart to go to the nurses' station on the East Hall. Information was visible on the screen, and a member of staff passed the medication cart while RNS CC was away from the cart. RNS CC confirmed she did not lock the screen on the laptop, and it should have been locked. She stated she was looking for the button earlier to lock the screen, but she was not familiar with that laptop and was not able to lock the screen. RNS CC stated that if the screen was not locked and the resident's information was visible on the screen, anybody could see the resident's information and that would be a breach of the resident's privacy and information. Interview on 02/21/2026 at 4:55 PM with the Assistant Director of Nursing (ADON) revealed that she stated the laptop screens should be locked when not in use to protect the resident's privacy. Interview on 02/21/2026 at 5:00 PM with the Director of Nursing (DON) revealed, she stated her expectations were for the nurses to lock the laptop screens when not in use. She stated that if the nurses stepped away from the laptops, the screens were to be locked because a resident could see information about another resident and it would be a HIPAA (Health Insurance Portability and Accountability Act) violation.

Based on record reviews, staff interviews, and the facility policy titled Medication Administration Subcutaneous Insulin, the facility failed to follow physician ordered protocol for finger stick blood sugar results and failed to accurately administer insulin from a pen device for two residents (R) (R83 and R51) from a sample of 25 residents receiving insulin. The deficient practice increased the risk of poor clinical outcomes. Findings include:1. Review of the facility protocol titled Dr. (name) Insulin Protocol dated 08/08/2024, documented under Monitoring: 3) Call MD {Medical Doctor} for FSBS that are <50 mg/dl.Review of the electronic medical record (EMR) revealed R83 was admitted to the facility on [DATE]. The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed R83 had a Brief Interview for Mental Status (BIMS) score of 99 indicating severe cognitive impairment. The resident had a diagnosis of but not limited to Diabetes Mellitus (DM) and was receiving insulin.Review of a Physician Order dated 01/15/2026, documented, Insulin Protocol: Call MD For FSBS {finger stick blood sugar} that Are <50mg/dl {50 milligrams per deciliter is a unit to measure blood sugar levels in blood} as needed for DM.Review of the Medication Administration Record (MAR) documented a blood sugar result on 01/25/2026 of 46 and on 02/15/2026 a result of 43. Review of the MAR and EMR revealed no evidence that the physician was notified of the blood sugar results of less than 50. Interview with Licensed Practical Nurse (LPN) II on 02/22/2026 at 10:50 AM revealed she is agency and stated she was not sure about the blood sugar or insulin protocol and thinks it is specific to each resident. LPN II stated each resident will have physician orders on the protocol like giving glucose gel or juice and when to notify the physician of low blood sugar. Interview with the Assistant Director of Nursing (ADON) on 02/22/2026 at 12:25 PM revealed she spoke with the two nurses on the dates the blood sugar results were below 50. The ADON stated the two nurses gave the resident a juice and rechecked the blood sugar but failed to document the results of the recheck. The ADON confirmed they did not call the physician as ordered and they should have for the blood sugars of 43 and 46.2. Review of the facility's policy titled Medication Administration Subcutaneous Insulin dated 01/2023, documented Subcutaneous insulin, Policy: To administer subcutaneous insulin as ordered and in a safe, accurate and effective manner. Page 6. C. Keep the injection button pressed all the way in. Slowly count to 10 before you withdraw the needle from the skin. This ensures that the full dose will be delivered. Review of the Electronic Medical Records (EMR) documented R51 was admitted to the facility on [DATE] with diagnosis included but not limited to Diabetes Mellitus. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] documented Section C (Cognition) Brief Interview for Mental Status (BIMS) score of 06 which indicated R51 had severe cognitive impairment, Section I (Active Diagnosis) R51 had Diabetes Mellitus, and Section N (Medication) R51 received insulin.Review of the care plan dated 12/01/2025, documented for R51 Focus: The resident has Diabetes Mellitus. Goal: The resident will be free from any signs and symptoms (s/sx) of hypoglycemia through the review date. Intervention: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness.Review of Physician's Orders dated 06/10/2025, documented medication included but not limited to Lantus Solostar subcutaneous solution pen-injector 100 unit/ml (insulin glargine) inject 15 unit subcutaneously every morning and at bedtime related to type 2 diabetes mellitus with hyperglycemia. Observation and interview on 02/21/2026 at 8:17 AM during medication administration revealed that Licensed Practical Nurse (LPN) AA did not leave the insulin pen in place for at least 10 seconds after pushing the button on the insulin pen during insulin pen administration. LPN AA confirmed she did not hold the insulin pen in place long enough after injecting the insulin and she removed it too quickly. She stated if the insulin pen was not held in place when the insulin was injected, some of the insulin may spill out when the pen was removed and the resident would not receive the correct amount of insulin.Interview on 02/21/2026 at 4:55 PM with the Assistant Director of Nursing (ADON) confirmed insulin pen needles should be held in place for at least 10 seconds for all the insulin to be administered to the resident. The ADON stated the insulin pen should not be removed immediately because the insulin could leak out from the site and the resident would not receive all the medication.

Based on observations, staff interviews, record review and review of the facility's policy titled Medication Administration General Guidelines, the facility failed to follow acceptable standards of practice when administering medications for one resident (R) (R62) from a sample of 42 residents. The deficient practice had the potential to increase the risk of poor clinical outcomes. Findings include:Review of the facility's policy titled Medication Administration General Guidelines, dated 01/2025, documented Medication Administration 2. Obtain and record any vital signs as necessary prior to medication administration. In addition, 20. The resident is always observed after administration to ensure that the dose was completely ingested. If only a partial dose is ingested, this is noted on the MAR (medication administration record), and action taken as appropriate.Review of the Electronic Medical Records (EMR) documented R62 was re-admitted to the facility on [DATE] with diagnosis included but not limited to hypertension.Review of the Quarterly Minimum Data Set (MDS) dated [DATE] documented Section C (Cognition) Brief Interview for Mental Status (BIMS) score of nine which indicated R51 had moderate cognitive impairment and Section I (Active Diagnosis) hypertension.Review of the comprehensive care plan revised 09/23/2025, revealed there was no written care plan addressing hypertension and/or associated medications.Review of Physician's Orders dated 12/23/2025, documented and order for metoprolol tartrate 50 milligrams (mg) give 1 tablet orally two times a day for hypertension.Observation and interview on 02/21/2026 at 8:50 AM during medication administration, Licensed Practical Nurse (LPN) BB administered metoprolol 50 mg tablet to R62 without checking a pulse or blood pressure prior to administering the metoprolol medication. LPN BB confirmed there were no parameters ordered or checked for the use of metoprolol. She stated metoprolol was not to be administered if the resident's heart rate was less than 60 beats per minute (bpm). LPN BB further stated that R62 had heart rate readings of less than 60 bpm on a few occasions based on his vital signs record. LPN BB stated the nurses were responsible to find out from the doctor if there should be parameters before administering the blood pressure medications and to ensure metoprolol was not administered if R62's heart rate was less than 60 bpm.Record review of R62's EMR vital signs monitoring revealed R62 had heart rates below 60 beats per minute (bpm) on:02/11/2026 58 bpm02/02/2026 57 bpm01/28/2026 54 bpm01/28/2026 59 bpm01/16/2026 58 bpm01/12/2026 59 bpmInterview on 02/21/2026 at 4:55 PM, the Assistant Director of Nursing (ADON) stated the nurses should call the doctor for parameters on certain medications such as metoprolol. She confirmed if there were no parameters assessed; the resident's heart rate could drop when they take metoprolol.Interview on 02/21/2026 at 5:00 PM, the Director of Nursing (DON) stated the nurses should recognize if there was a need for metoprolol to have parameters and to call the doctor for parameter orders. The DON confirmed the resident's heart rate could fall when they take metoprolol and the nurses should reach out to the doctor for advice on getting parameters when administering the medication.Interview on 02/21/2026 at 10:56 AM, the Pharmacist stated the resident should be monitored for drop in blood pressure and drop in heart rate when receiving metoprolol.

Based on observation, interview, record review, the facility's policy titled Care Plan Policy, the facility failed to develop and/or implement a comprehensive care plan related to oxygen and medication parameters for two residents (R) (R62 and R70) from a sample of 42 residents. The deficient practice had the potential to increase the risk of clinical complications for R62 and R70. Findings include: Review of the facility's policy titled Care Plan Policy reviewed September 2025, documented under Procedure: 6. It is the responsibility of the Care Plan Coordinator to review timely a resident's status and any change in needs following a hospital stay or any other unexpected event as deemed appropriate. It is also the responsibility of the Care Plan Coordinator to ensure concerns/changes for a resident's care plan is updated. 7. It is the responsibility to review timely a resident's status and any change in needs following a hospital stay or any other unexpected event as deemed appropriate. 1. Review of the Electronic Medical Records (EMR) documented R62 was re-admitted to the facility on [DATE] with diagnosis included but not limited to hypertension. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] documented Section C (Cognition) Brief Interview for Mental Status (BIMS) score of 09 which indicated R51 had severe cognitive impairment and Section I (Active Diagnosis) indicated R62 had hypertension at the time of the assessment. Review of the comprehensive care plan revised 01/16/2026, revealed there was no documented evidence that R62 had a care plan for hypertension. Review of Physician's Orders for R62 dated12/23/2025, documented including but not limited to metoprolol tartrate 50 milligrams (mg) give 1 tablet orally two times a day for hypertension. Observation and interview on 02/21/2026 at 8:50 AM during medication administration revealed, Licensed Practical Nurse (LPN) BB administered metoprolol 50 mg tablet to R62 and there was no parameter for the metoprolol medication. LPN BB confirmed there were no parameters for the metoprolol and the resident's heart rate was last checked on 02/19/2026. She stated metoprolol was not to be administered if the resident's heart rate was less than 60. She further stated that R62 had heart rate readings of less than 60 beats per minute (bpm) on a few occasions. LPN BB stated the nurses were responsible to find out from the doctor if there should be parameters before administering the blood pressure medications and to ensure metoprolol was not administered if R62's heart rate was less than 60 bpm. Record review of R62's EMR vital signs monitoring revealed R62 had heart rates below 60 beats per minute (bpm) on: 02/11/2026 58 bpm 02/02/2026 57 bpm 01/28/2026 54 bpm 01/28/2026 59 bpm 01/16/2026 58 bpm 01/12/2026 59 bpm Record review of R62's EMR vital signs monitoring revealed the last set of vital signs were done on 2/19/2026. Interview on 02/22/2026 at 7:47 AM with Nurse Manager (NM) FF revealed, she confirmed there was no care plan for hypertension for R62. She stated the nurses and NM were responsible for ensuring the care areas for the residents were included in the care plans. NM FF stated that hypertension should be on the care plan because the resident was admitted with hypertension. She further stated that R62 had a history of CVA and there was no care plan for hypertension and monitoring. Interview on 02/21/2026 at 7:53 AM with the MDS Coordinator GG revealed, she confirmed there was no care plan for hypertension regarding R62. She stated if a resident was admitted and was treated for hypertension, there should be a written care plan addressing the hypertension. She stated R62 was admitted with, treated for and received medication for hypertension. The MDS Coordinator stated that the care area for hypertension should be on the care plan because it was pertinent to the resident and it was an indicator to be care planned. Interview on 02/21/2026 at 7:53 AM with the Director of Nursing (DON) revealed, she stated her expectations were for the care areas for the residents to be care planned by the nurse managers and MDS Coordinator. The DON further stated that the care plan outlines the care of the residents and a negative outcome could result. Cross reference F755 2. Record review of the facility policy titled Oxygen Therapy Guidelines, revised 12/05/2025 documented, The following guidelines will be adhered to in all oxygen therapy patients at all times for any resident receiving oxygen therapy, and those orders will be followed. Water bottles, or humidifiers may be used in conjunction with oxygen concentrators up to 6 liters of flow via nasal cannula. It is not required that these devices be used if the liter flow is 2 LPM {liters per minute} or less unless the patients request it or there are visible signs of drying out of the nasal passages (blood -tinged nasal discharge or congestion). Any time the liter flow rate is above 2 LPM via nasal cannula, humidification may be added to the oxygen concentrator. These should be checked daily and changed when empty. Review of the electronic health record (EHR) for R70 revealed a diagnosis of but not limited to emphysema, asthma, and acute respiratory distress. Record review of R70's Annual Minimum Data Set (MDS) dated [DATE], revealed under Section O: (Special Treatment, Programs, and Procedures) that R70 was receiving oxygen. Section C: (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) score of 07, which indicated little to no cognitive impairment. Record review of the physician orders documented an order dated 02/03/2025, that R70 should receive oxygen 4 lpm {four liters per minute} via nasal cannula every day and night shift for dx: {diagnosis} emphysema and asthma. In addition, an order dated 02/03/2025 documented Oxygen: tubing and humidifier change every day shift every Monday. Record review of R70's care plan revised 02/05/2025, documented a focus area for oxygen therapy which stated She {R70} is currently on 02 @ 4 lpm NC {oxygen at four liters per minute nasal cannula}. The intervention listed documented, Administer oxygen and monitor O2 sat as ordered. An observation on 02/20/2026 at 9:35 AM, 12:01 PM, and 3:37 PM revealed R70 lying in bed receiving oxygen from an oxygen concentrator by nasal cannula at a flow rate of 3.5 LPM per minute instead of the physician ordered 4 LPM. In addition, there was no humidifier bottle attached to the oxygen concentrator per physician orders. An observation on 02/21/2026 at 9:36 AM, revealed R70 lying in bed receiving oxygen from a concentrator by nasal cannula at a flow rate of 4 LPM without a humidifier bottle attached and in use on the oxygen concentrator. An observation and interview on 02/21/2026 at 1:59 PM with Licensed Practical Nurse (LPN) CC confirmed R70 lying in bed receiving oxygen from an oxygen concentrator by nasal cannula at a flow rate of 4 LPM which is the correct rate compared to observation on 02/20/20/2026. However, LPN CC confirmed there was no humidifier bottle attached and in use on the oxygen concentrator per physician orders and should be used with R70. Interview on 02/22/2026 at 11:49 AM with the Director of Nursing (DON) and Administrator both confirmed it is the expectation for staff to ensure the resident is receiving oxygen at the correct flow rate and with a humidifier bottle according to the physician orders. Interview with the MDS Nurse on 02/22/2026 at 11:58 AM stated that her expectation is for staff to follow the care plan. Cross reference F695

Based on observations, staff interviews, record review, and review of the facility's policy titled Oxygen Therapy Guidelines, the facility failed to ensure that one of 11 residents (R) (R70) receiving oxygen was administered oxygen therapy in accordance with the physician orders. This deficient practice had the potential to place R70 at risk for respiratory complications and a diminished quality life.Findings include:Record review of the facility policy titled Oxygen Therapy Guidelines, revised 12/05/2025 documented, The following guidelines will be adhered to in all oxygen therapy patients at all times for any resident receiving oxygen therapy, and those orders will be followed. Water bottles, or humidifiers may be used in conjunction with oxygen concentrators up to 6 liters of flow via nasal cannula. It is not required that these devices be used if the liter flow is 2 LPM {liters per minute} or less unless the patients request it or there are visible signs of drying out of the nasal passages (blood -tinged nasal discharge or congestion). Any time the liter flow rate is above 2 LPM via nasal cannula, humidification may be added to the oxygen concentrator. These should be checked daily and changed when empty.Review of the electronic health record (EHR) for R70 revealed a diagnosis of but not limited to emphysema, asthma, and acute respiratory distress.Record review of R70's Annual Minimum Data Set (MDS) dated [DATE], revealed under Section O: (Special Treatment, Programs, and Procedures) that R70 was receiving oxygen. Section C: (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) score of 07, which indicated little to no cognitive impairment.Record review of the physician orders documented an order dated 02/03/2025, that R70 should receive oxygen 4 lpm {four liters per minute} via nasal cannula every day and night shift for dx: {diagnosis} emphysema and asthma. In addition, an order dated 02/03/2025 documented Oxygen: tubing and humidifier change every day shift every Monday.Record review of R70's care plan revised 02/05/2025, documented a focus area for oxygen therapy which stated She {R70} is currently on 02 @ 4 lpm NC {oxygen at four liters per minute nasal cannula}. The intervention listed documented, Administer oxygen and monitor O2 sat as ordered.An observation on 02/20/2026 at 9:35 AM, 12:01 PM, and 3:37 PM revealed R70 lying in bed receiving oxygen from an oxygen concentrator by nasal cannula at a flow rate of 3.5 LPM per minute instead of the physician ordered 4 LPM. In addition, there was no humidifier bottle attached to the oxygen concentrator per physician orders.An observation on 02/21/2026 at 9:36 AM, revealed R70 lying in bed receiving oxygen from a concentrator by nasal cannula at a flow rate of 4 LPM without a humidifier bottle attached and in use on the oxygen concentrator. An observation and interview on 02/21/2026 at 1:59 PM with Licensed Practical Nurse (LPN) CC confirmed R70 lying in bed receiving oxygen from an oxygen concentrator by nasal cannula at a flow rate of 4 LPM which is the correct rate compared to observation on 02/20/20/2026. However, LPN CC confirmed there was no humidifier bottle attached and in use on the oxygen concentrator per physician orders and should be used with R70. Interview on 02/22/2026 at 11:49 AM with the Director of Nursing (DON) and Administrator both confirmed it is the expectation for staff to ensure the resident is receiving oxygen at the correct flow rate and with a humidifier bottle according to the physician orders.

Based on observations, interviews, record review, and review of the facility's policy titled Self-administered Medication, Treatments, the facility failed to ensure that one resident (R) (R57) of 42 sampled residents swallowed medication before leaving the resident's room. This deficient practice had the potential to increase the risk of clinical complications. Findings include:Review of the facility policy titled Self-administered Medication, Treatments reviewed 06/20/2023, documented under Policy Statement: Self-administered medications and treatments must be carefully monitored and recorded in Medication Administration Record (MAR) and Treatment Administration Record (TAR) and Self-administration of medications or treatments by residents is permitted by a physician order that includes dosage, route, and any special instructions.A review of the clinical record for R57 revealed an admission date of 11/02/2016 with diagnoses including but not limited to unspecified bipolar disorder, current episode mixed, severe, with psychotic features ,vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, bipolar disorder, current episode mixed, moderate, tremor, unspecified, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of the quarterly Minimum Data Set (MDS) for R57 dated 02/03/2026 revealed a Brief Interview for Mental Status (BIMS) score of 03 indicating severe cognitive impairment.A review of the current comprehensive care plan revised 02/19/2026, revealed there was no plan documented for self-administration of medication. A review of the electronic medical record revealed there was no evidence for completion of an assessment for self-administration of medications. During observation and interview on 02/20/2026 at 9:20 AM, R57 was sitting up in bed. There was a clear small cup with water and a blue pill floating on the water sitting on the bedside table. When asked about the cup contents, R57 stated it is a pill and kept looking at the pill in the cup with water.During observation on 02/20/2026 at 9:30 AM, the clear cup containing a blue pill and water was still sitting on the bedside table next to R57.During an interview on 02/20/2026 at 9:50 AM with Licensed Practical Nurse (LPN) (LPN DD), she stated she gave the blue pill (divalproex sodium) to R57 this morning. LPN DD stated that R57 usually swallows the medication and was not sure why she did not swallow the pill.During an interview on 02/21/2026 at 10:00 AM with Unit Manager LPN HH regarding her expectation of staff related to medication administration, LPN HH stated she expects the staff to stay in the resident's room to ensure residents swallow the medication before they leave the room. LPN HH confirmed that R57 was not assessed for self-administration of medications.

Based on observations, staff interviews, record reviews, and review of the facility's policies titled, Food Storage, Floor Stock, and Accepting Food Deliveries, the facility failed to ensure proper labeling and storage of food with open and expiration dates, failed to discard food items by the expiration dates, and failed to properly cover opened food items. This deficient practice had the potential to affect 85 residents who received food orally. Findings included: Review of facility's policy titled, Food Storage dated 2021, revealed under section titled Procedure: 2. Food should be dated as it is placed on the shelves if required by state regulation. 3. Date marking should be visible on all high-risk food to indicate the date by which a ready-to-eat, TCS food should be consumed, sold, or discarded. Refrigerated Food Storage: 2. All foods should be covered, labeled, and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. Frozen Foods: 3. All foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. Review of facility's policy titled, Floor Stock dated 2021, revealed under section titled Procedure: 2.c. The food and nutrition services staff will: Rotate stock and remove outdated items. Record review of facility's policy titled, Accepting Food Deliveries dated 2021, revealed under section titled Procedure: 4. Perishable foods will be properly covered, labeled, and dated and promptly stored in the refrigerator or freezer as appropriate. Observation on [DATE] at 9:24 am with the Food and Nutrition Manager (FNM) revealed and confirmed the following items in the walk-in cooler: Five clear boxes of cheddar cheese slices with no expiration date. One clear box of Swiss cheese slices with no expiration date. One container of [named brand] low fat cottage cheese with an expiration date of [DATE]. Observation on [DATE] at 9:31 am with the FNM revealed and confirmed the following items in the freezer: Three bags of turkey burgers with no expiration date. Nine cups of milkshakes in clear containers with no expiration date. One opened bag of beef patties not properly sealed with no expiration date. One opened bag of French toast sticks not properly sealed with no expiration date. One opened bag of strawberries not properly sealed with no expiration date. One opened bag of biscuits not properly sealed with no expiration date. One opened bag of French fries not properly sealed with no expiration date. Nine loaves of bread with no expiration date. Observation on [DATE] at 9:40 am with the FNM revealed and confirmed the following items in the pantry: One opened jug of [name brand] golden barbeque sauce that was opened and not refrigerated. Nine bags of mini marshmallow with an expiration date of [DATE]. Observation on [DATE] at 10:06 am of the resident pantry located on the [NAME] Wing, with the FNM, revealed and confirmed the following expired foods items: One [name brand] prune juice with an expiration date of [DATE]. Three graham honey crackers with an expiration date of [DATE] and [DATE]. Two original graham crackers with the expiration of [DATE] and [DATE]. One sugar lemon cookie with an expiration date of [DATE]. Observation on [DATE] at 10:33 am of the resident pantry located on [NAME] Wing with the FNM revealed and confirmed: 21 packages of [name brand] easy mix instant food thickener with an expiration date of [DATE]. The FNM discarded the expired packages. Interview on [DATE] at 10:56 am the FNM revealed her expectation that everyone in the kitchen know that expired foods were a no and that they work as a team to oversee and label food items and throw out any expired food items before the expiration date. Interview on [DATE] at 10:07 pm the FNM revealed she was not in charge of checking to see if the resident pantries had any expired food items. FNM further revealed the unit secretary assigned to that floor was normally responsible for checking the resident's pantry for any expired food items, but they currently don't have one. Interview on [DATE] at 10:10 am the Licensed Practical Nurse (LPN) AA in charge of the [NAME] Wing revealed she had not looked in the drawers for expired items and she only checked the juices. Interview on [DATE] at 10:18 am the Administrator revealed that everything should be labeled upon entry and should have an expiration date on it. He revealed there shouldn't be any expired items because the FNM did rounds every day to check food items. He further revealed his expectation that all food items would be properly closed. The Administrator further revealed the unit managers oversee verifying all expired items in the residents' pantries.

Based on staff interviews and record review, the facility failed to submit for a Preadmission Screening and Resident Review (PASRR) Level II for a mental health diagnosis for one of 33 residents (R) (R82). This deficient practice had the potential for R82 not receive services and/or care according to his needs. Findings included: The facility revealed they did not have a policy on PASARR. Record review for R82 revealed pertinent diagnoses/conditions included secondary malignant neoplasm of bone (primary diagnosis), vascular dementia (12/7/2020), anxiety disorder, and psychosis not due to a substance or known physiological condition (4/27/2023). Review of Physician Orders included and order for treatment and evaluation as needed with [name] behavioral health services, refer to [name] related to cognitive decline, and Consult: Psychiatric/Psychology Services evaluation and treat as needed. Interview on 11/21/2024 at 10:00 am the Social Service Director (SSD) revealed clinical information was entered into the Georgia Medicaid Management Information System (GAMMIS) by the hospital; if the hospital did not enter the information the facility would enter the information. Criteria for Level II included depression, anxiety, insomnia, schizophrenia, and major depressive disorder. The SSD was made aware of changes in the diagnosis by communicating with the providers and staff during clinical meetings. Interview on 11/21/2024 at 12:30 pm with the SSD revealed R82 had diagnoses of dementia and unspecified psychosis not due to a substance or known physiological condition. She revealed she was in the process of submitting a Level II for R82 that day. Interview on 11/21/2024 at 12:45 pm with the Medical Records Coordinator revealed that for new admissions from the hospital that a DMA-6 was completed, and this document indicated the resident had diagnoses appropriate for admission to the facility. If the resident would be at the facility more than 30 days, the hospital would enter information in the Georgia portal; this information was shared with the facility. Diagnoses or criteria for Level II included dementia, schizophrenia, combative behaviors, and trouble adapting. The care plan nurse would identify behaviors and communicate this information to the appropriate person or the staff member responsible for submitting Level II. If a resident had a diagnosis of dementia, and other mental disorders, the Medical Records Coordinator revealed a Level II should be submitted. Interview on 11/21/2024 at 2:15 pm with the Administrator and Administrator in training revealed the hospital sends the PASARR information with the resident when they were admitted . Any kind of mental health diagnosis would be used to submit a Level II. Interview on 11/21/2024 at 10:00 am the SSD revealed for admission there were two clinical liaisons who communicated with providers to get documents; depending on what hospital they come from the information may be entered into GAMMIS by the hospital; if the hospital did not enter the information the facility would enter the information; Criteria for Level II includes mental health diagnoses. She used diagnoses when residents came into facility to see if a Level II would be triggered. Criteria for Level II included depression, anxiety, insomnia, Schizophrenia, major depressive disorder. SSD will talk with providers in building and during clinical meetings; this was how SSD was made aware of any change in diagnoses, through ongoing communication. Interview on 11/21/2024 at 12:30 pm the SSD revealed diagnoses for R82 included dementia and unspecified psychosis not due to a substance or known physiological condition. She revealed she was in the process of submitting a Level II for R82. The PASRR Level I was reviewed and revealed admission 12/7/2020. Interview on 11/21/2024 at 12:45 pm the Medical Director Coordinator revealed, for new admissions from the hospital, basically the DMA-6 stated resident could be admitted ; if Level I indicated less than a 30-day stay they do not have to key in information; if the resident would be here more than 30 days, the hospital would enter information in Georgia portal; this information was shared with the facility; if the resident stayed long term a new Level I was done and the facility was responsible for getting a new Level I. If admitted from another nursing home the level 2 was transferred. If the person came from home the facility would submit the information. Diagnoses or criteria for Level II included dementia, Schizophrenia, combative behaviors, and trouble adapting. The care plan nurses would identify behaviors and communicate this information to the appropriate person or who was responsible for submitting a Level II. If a resident has a diagnosis of Dementia and other mental disorders, they will still submit a Level II. Interview on 11/21/2024 at 2:15 pm with the Administrator and Administrator in training revealed there was someone who handled the PASARR process; the hospital sends the PASARRs with the resident. Any kind of mental health diagnosis would be used to submit a Level II.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Care Plan Policy, the facility failed to ensure that a care plan was developed and/or implemented for three of 23 residents (R) (R19, R24, and R6). Specifically, the facility failed to implement the care plan for (R19 and R24) for monitoring and recording meal intake and the facility failed to develop and implement a care plan for (R6) for oxygen use. Findings included: Review of the policy titled Care Plan Policy review/revision date March 28, 2024, revealed under Procedure, Number 5. It is the responsibility of the care plan coordinator to review timely a resident's status and any change in needs following a hospital stay or any other unexpected event as deemed appropriate. It is also the responsibility of the care plan coordinator to ensure concerns/changes for a resident are care planned and/or updated. 10. The CNA task record will be updated during the care plan conference to refect interventions defined on the care plan. 11. The DON, Nurse Manger and Licensed Charge Nurses are responsible for ensuring provision of care in accordance with the care plan. 1. Review of the clinical record revealed R19 was admitted to the facility with diagnoses of but not limited to Alzheimer's disease, vascular dementia, and major depressive disorder. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] assessed a Brief Interview for Mental Status (BIMS) score of 5, which indicated severe cognitive impairment. Review of the care plan revised on 8/31/2024 revealed [R19] was at risk for weight loss secondary to periods of confusion, impaired cognition, inattention, edentulous status and disorganized thinking at times. Interventions included, give diet, fluids, supplements, snacks as ordered, record percentage eaten, offer food replacement for less than 25% (percent) food not consumed. Review of the Nutritional Task-Amount Eaten for September through November 2024 revealed that the percentage of meal eaten by R19 varied from 0% to 100%. Continued review revealed there was no documentation for intake percentages for 9/1/2024, 9/4/2024, 9/8/2024, 9/11/2024 to 9/12/2024, 9/15/2024 to 9/16/2024, 9/18/2024 to 9/20/2024, 9/22/2024, 9/25/2024 to 9/26/2024, 9/28/2024, 9/30/2024 to 10/1/2024, 10/3/2024 to 10/7/2024, 10/11/2024, 10/13/2024 to 10/16/2024, 10/20/2024, 10/23/2024 to 10/25/2024, 10/27/2024 to 11/3/2024, 11/6/2024 to 11/14/2024, and 11/17/2024 to 11/18/2024. 2. Review of the clinical record revealed R24 was admitted to the facility with diagnoses of but not limited to adult failure to thrive, major depressive disorder, and abnormal weight loss. Review of the Quarterly MDS assessment dated [DATE] assessed a BIMS score of 14, which indicated little to no cognitive impairment. Review of the care plan revised 8/31/2024 revealed [R24] was at risk for changes in weight and nutritional deficits. [R24] is edentulous and receives a mechanically altered diet of soft and bite sized. Interventions included give diet, fluids, supplements, snacks as ordered, record percentage eaten. Review of the Nutritional Task-Amount Eaten for September through November 2024 revealed R24 consumed between 51-75% and 76-100% of meals. Continued review revealed there was no documentation for intake percentages from 9/1/2024 to 9/2/2024, 9/4/2024, 9/6/2024, 9/8/2024, 9/10/2024 to 9/13/2024, 9/15/2024 to 9/16/2024, 9/18/2024, 9/20/2024 to 9/23/2024, 9/25/2024 to 10/6/2024, 10/8/2024, 10/11/2024, 10/16/2024 to 10/18/2024, 10/20/2024 to 10/23/2024, 10/25/2024 to 10/27/2024, 10/29/2024, 11/1/2024 to 11/6/2024, 11/8/2024 to 11/12/2024, 11/14/2024 to 11/16/2024, and 11/19/2024 to 11/20/2024. Interview on 11/21/2024 at 12:20 pm Registered Nurse (RN) DD confirmed that percentage of amount eaten should be documented for every meal, and CNAs were responsible for documenting this information in facility electronic medical records (EMR) system daily. Interview on 11/21/2024 at 12:30 pm with Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that if the care plan had interventions to record percentage of consumed meals, it should be recorded daily and for every meal. CNAs were responsible for documenting consumed amounts in the EMR system, and to report them to the nurses. 44959 3. Review of the clinical record revealed R6 was admitted to the facility with diagnoses of but not limited to chronic obstructive pulmonary disease (COPD), emphysema, chronic bronchitis, atherosclerotic heart disease of native coronary artery without angina pectoris. Review of the Quarterly MDS assessment dated [DATE] for R6 assessed a BIMS score of 10, indicating moderate cognitive impairment. Review of Section O (Special Treatments and Programs) reported oxygen use. Review of a Physician order dated 3/25/2024 revealed O2 (oxygen) at 2 liters per minute to keep O2 Sat 92% and above every shift for SOB, oxygen tubing and neb tubing change every Monday every day shift every Monday oxygen: tubing and humidifier change every Monday Review of R6 care plan dated 11/6/2024 revealed there was no care plan with specific goals and interventions for oxygen use. Observation during initial screening on 11/19/2024 at 10:00 revealed R6 in bed with the oxygen on and the oxygen was set at 2.5 L/M. Additional observations on 11/19/2024 at 12:20 pm, and on 11/20/2024 at 10:05 am revealed R6 had on oxygen and the oxygen was set at 2.5 L/M. Interview on 4/10/2024 at 10:19 am Licensed Practical Nurse (LPN) EE confirmed that R6's oxygen was on and set at 2.5 liter, and that the respiratory therapist checked the oxygen during visits and decided what level it should be set at unless there was a change by the physician. Interview on 11/21/2024 at 9:40 am the MDS Coordinator CC revealed that she was responsible for creating the care plan for oxygen for R6. She revealed that she linked the oxygen to COPD and had planned to go back to look at it to create a care plan for oxygen with more detailed goals and intervention but did not create the plan. Interview with DON and ADON on 11/21/2024 at 10:00 am regarding their expectation from staff when it came to physician order and care plan, the DON revealed that she expected staff to follow any physician order that was implemented. The DON revealed that if oxygen was ordered at 2 liters that she expected staff to set the oxygen at 2 liters and nothing more. She revealed that care plans were implemented according to diagnosis and if there was an order for oxygen that it should care planned.

Based on observations, staff interviews, record reviews, and review of the facility's policy titled Accident/Hazard Prevention, the facility failed to ensure a working door alarm to prevent the elopement of one of 31 residents (R) (R73) housed on a COVID unit. This failure had the potential to place R73 at risk for avoidable accidents and adverse consequences. Findings included: Review of the policy titled, Accident/Hazard Prevention initiated 6/10/2023 revealed, It is our policy to assure safety for our resident, employees, and visitors through the utilization of a program designed to reduce the likelihood of accidents. The Safety Program included: 5. Compliance monitoring will be completed as indicated by administration, DON/ADON, and maintenance director to include, but is not limited to storage of chemicals, locked medicine carts, locked med rooms, water temperature, spills, obstructive hallways, slippery floors, burned out light bulbs, torn window screens, broken glass, proper disposal of trash and garbage, electrical cords, and accessible spray containers. 6.Maintenance request notebooks are located at each nurse's station for utilization by any employee to request prompt attention to needed repair work. Record review of the Admission Record for R73 revealed diagnoses of but not limited to Alzheimer's disease with early onset, dementia, and wandering. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Section C- Cognitive Patterns assessed a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment, Section I - Active Diagnoses-progressive neurological condition, hypertension, hyperlipidemia, Alzheimer's disease, non-Alzheimer's dementia, anxiety disorder, depression, Section P - Restraints and Alarms-not used. Review of R73's care plan dated 2/20/2024 revealed focus area, Wander/Elopement [R73] is at risk for injuries r/t (related to) wandering. R73 is on a closed dementia unit and can ambulate at will without assistance. R73 has diagnoses (dx) of dementia and has cognitive deficits. Goal: Safety will be maintained through the review date. Interventions included distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book and providing structured activities. Review of nurses note dated 2/17/2024 at 4:45 pm revealed R73 was redirected several times during the afternoon shift, attempted leaving COVID isolation wing, noted ambulating without assistance, denies pain/Shortness of Breath (SOB) at this time, will continue with the current plan of care. Review of nurses note dated 2/17/2024 at 6:40 pm revealed R73 was noted outside by neighbors of this facility, neighbors summoned police, police returned R73 to facility. Observation on 11/19/24 at 11:27 am revealed R73 currently housed on the [NAME] Wing/locked unit. Interview on 11/21/24 at 10:40 am with Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed R73 was moved from the locked unit due to COVID, an alarm was placed on the door of the unit to ensure safety. R73 was last seen in her room at 5:50 pm washing her hands. The facility received a call around 6:40 pm stating that R73 was located at another facility about one minute away. R73 was able to bypass two doors to exit the facility. Interview on 11/21/2024 at 11:35 am with Maintenance Director (MD) revealed a system failure occurred with the alarm that was placed on the COVID unit, resulting in R73 being able to bypass two doors to exit the facility. Interview/walkthrough on 11/21/2024 at 11:55 am with MD revealed a door alarm was placed on the COVID unit where R73 was placed due to COVID. R73 was able to exit the unit due the alarm system failure and proceed to door two located in the hallway across from therapy as R73 pressed a green button to exit the facility. Interview on 11/21/24 at 1:00 pm with Licensed Practical Nurse (LPN) AA revealed R73 was moved to another unit due to COVID. R73 was not on one-on-one monitoring, but an alarm was placed on the door to ensure the resident's safety. Interview on 11/21/2024 at 2:13 pm with Administrator and Administrator in training revealed an assessment was completed upon admission, all wanderers or elopement residents are placed on the [NAME] Wing (lock down unit) so they can wander as they please. Administrator revealed there was an alarm on the door on the COVID unit, but it was inoperable, but after moving residents to that unit due to COVID, a working alarm was placed on the door. The Administrator revealed R73 should not have been moved from her unit, they were trying to figure things out with COVID going on, moving forward they had learned to keep residents who wander in their same environment.

Based on observations, resident and staff interviews, record reviews, and review of the facility's policy titled, Oxygen, Therapy, the facility failed to ensure oxygen was administered as ordered by the physician for one of twelve residents (R) (R6) receiving oxygen. The deficient practice had the potential to place R6 at risk for medical complications, and a diminished quality of life. Findings included: Review of the facility policy titled, Oxygen, Therapy Guidelines, review/revision date June 21, 2023 revealed under Purpose, This protocol would enable the Respiratory Therapist or Nurse to monitor and adjust the oxygen therapy to meet preset criteria and it will be done more quickly and seamlessly than the conventional way of responding to potentially serious changes in the patient condition , calling the physician and then obtaining an order to make necessary changes. Further review under Clinical Responsibilities 11, the following guidelines will be adhered to in all oxygen therapy patients at all times. The physician will be contacted within 24 hours so that an order may be received for the new liter flow if a change is made by the RT or nursing. Review of the clinical record revealed R6 was admitted to the facility with diagnoses of but not limited to chronic obstructive pulmonary disease, emphysema, chronic bronchitis, atherosclerotic heart disease of native coronary artery without angina pectoris. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R6 had a Brief Interview for Mental Status (BIMS) score of 10, indicating little to no cognitive impairment. Review of Section O (Special Treatments and Programs) indicated oxygen use. Review of the Physician orders dated 3/25/2024 revealed O2 (oxygen) at 2 liters per minute (LPM) to keep O2 Sat (saturation) 92% (percent) and above every shift for SOB (shortness of breath), oxygen tubing and neb tubing change every Monday, every day shift; oxygen: tubing and humidifier change every Monday Observation during initial screening on 11/19/2024 at 10:00 revealed R6 in bed with the oxygen on and the oxygen was it was set at 2.5 LPM. Additional observations on 11/19/2024 at 12:20 pm, and on 11/20/2024 at 10:05 am, revealed R6 in bed with the oxygen on and it was set at 2.5 LPM. Interview on 11/20/2024 at 10:19 am Licensed Practical Nurse (LPN) (LPN EE) confirmed that R6's oxygen was set at 2.5 liters and revealed that the Respiratory Therapist decided what level it should be set at unless there was a change by the physician. Interview on 11/21/2024 at 9:40 am with the MDS Coordinator 1 revealed that she was responsible for creating R6's care plan for oxygen. She revealed that she linked the oxygen to COPD and had planned to go back and look at it to create a care plan for oxygen with more detailed goals and interventions, but did not create the plan. Interview on 11/21/2024 at 10:00 am with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), the DON revealed her expectation from staff when it comes to physician orders and care plan, she expected staff to follow any physician order that was implemented on the floor. DON revealed that if oxygen was ordered for 2 liters that she expected staff to set the oxygen to 2 liters and nothing more. She revealed that care plans were implemented according to diagnoses and if there was an order for oxygen that it should be care planned.

Based on observations, staff interviews, record reviews, and review of facility's policy titled, Food Service Policy and Procedures, the facility failed to prepare food by methods that conserve nutritive value, flavor, and appearance of food. Specifically, the facility failed to use a recipe when preparing pureed food. This deficient practice has the potential to affect 13 residents who were ordered a pureed diet. Findings included: Review of the facility's undated policy titled, Food Service Policy and Procedure, under the section titled Pureed Diets revealed, To ensure that residents who have been placed on a puree diet receive the best possible product without compromising flavor and, texture food & nutrition will at all times adhere to strict preparation procedure. 1. Meats starches & vegetables will be placed in the food processor until well blended. 2. Gravy or broth will be gradually added to products until a gravy like texture has been achieved. When processing starches and vegetables, use the liquid that is strained from the starch or vegetable. Do not use plain tap water. Do not overly add liquid as this will affect the nutritional value. 3. Staff will then gradually add thickener (Thick-It) two teaspoons per four-ounces of food. Example, if you have processed 20 ounces of chicken, you would need to gradually add a total of 10 teaspoons of thickener to the chicken that is being processed. 4. Food & Nutrition staff will taste all products to ensure the desired flavor has been achieved. 5. Food processors will be clean prior to processing another product. Clean between uses. 6. When processing liquids such as water or fruit juices staff will add three to three and a half teaspoons to achieve a nectar consistency and 3 and a half to four teaspoons to achieve a honey consistency. 7. Always refer to instructions provided on each individual recipe Observation on 10/30/2024 at 10:00 am, and interview at that time, revealed [NAME] BB prepping boiled spaghetti to be pureed. The Food and Nutrition Manager (FNM) approached with a document outlining instructions for pureeing food, which was placed in front of [NAME] BB. Upon reviewing the document, [NAME] BB looked confused. When asked about the document, [NAME] BB revealed that was the first time she had seen the document. Further questioning about the process revealed that [NAME] BB measured the spaghetti by breaking it in half and placing it in a container. [NAME] BB was then observed using a ladle to scoop thickened powder from a bag, which she added to the grinder. When asked about the specific measurement of thickened powder, [NAME] BB explained that she used the size of the ladle as a reference, rather than following any precise measurement or recipe. [NAME] BB revealed that based on her experience working in the kitchen for a long time, she simply knew how much to add. [NAME] BB further revealed that the puree was intended for 10 residents, and that the desired consistency was supposed to be nectar thick. [NAME] BB did not refer to a formal recipe for guidance. Interview on 11/20/2024 at 10:56 am with the FNM revealed that her expectations were for cooks to be properly trained, follow recipes, and execute their duties correctly. FNM revealed being aware that the cook was not following the recipe but revealed that she could print them out for reference. The FNM clarified that the intended consistency for the puree was a nectar-thick liquid, and it was meant to serve 12 residents. Interview on 11/21/2024 at 10:20 am the Administrator revealed his expectations were that dietary staff were trained and knew how to properly puree items, and there should be a recipe followed for pureed diets.

Based on resident and staff interviews, record reviews, review of the facility's policy titled, Advance Directive Policy, and review of the facility's Admission Agreement-Statement of Acknowledgement, the facility failed to provide residents or resident representatives written information regarding choices and the right to accept or refuse medical or surgical treatment for one of seven sampled residents (R) (R56). This deficient practice had the potential to affect the resident or representative's ability to make informed decisions about their care. Findings included: Review of the policy titled, Advance Directive Policy, reviewed/revised date 11/21/2024 revealed under Policy Statement: It is the policy of [facility name] to establish, implement and maintain written policies and procedures for advance directive. Each resident with a decision-making capacity has the right to make their own decisions related to his/her medical care. An integral component of self-determination is the right to make choices pertaining to one's health, including the right to refuse or alter treatment plans, to accept or refuse medical or surgical treatment, refuse to participate in experimental research and to formulate advance directives. If a resident does not have decision-making capacity, this right may be exercised by an appropriately authorized representative for the resident. Review of the undated form titled, Admission Agreement-Statement of Acknowledgement, revealed under section six, Please check all statements that apply: The Resident has executed an Advance Directive. The Resident has not executed an Advance Directive. The Resident has not executed an Advance Directive but would like to obtain additional information about advance directives. There was no statement marked. Record review for R56 revealed medical diagnoses of but not limited to anoxic brain damage, tachycardia, and protein calorie malnutrition. Review of Physician Orders included oxycodone HCl oral tablet 5 mg (milligram) give 1 tablet by mouth every hour as needed for pain/shortness of breath, please consult [name] Hospice per family request; admit Hospice- Dx (diagnosis) protein calorie malnutrition, and DNR (Do Not Resuscitate); POLST. Review of the care plan included, [R56] presents with a deteriorating/terminal condition/need for hospice, DNR. Self-care revealed the resident has a deficit in his self-care ability. He is blind in both eyes and hard of hearing. He is now fed by staff and needs maximum dependance assist from staff for activities of daily living (ADL) care. [R56] and his family have elected to make him a DNR. Interventions included, Complete/update Advanced Directives document. Interview on 11/19/2024 2:30 pm the Administrator in training revealed if the resident was unable to comprehend the information on the Advance Directive, the document should be provided to the family or resident representative for their signature. Interview on 11/21/2024 at 10:10 am the Social Service Director (SSD) revealed that advanced directives was a form in the admission packet. The SSD would give the document to the residents and/or family, and there was information for power of attorney, living will and code status. Once SSD gave the information to the residents/family member and they did not have any questions, they would sign the admission agreement and/or the POLST. If the resident was unable to sign the document, the family would sign it. Interview on 11/21/2024 at 2:15 pm the Administrator and Administrator in training revealed residents/representatives were given information about advance directives during the admission conference. The admission packet was completed by Social Services. If the resident was not able to document on the form, the responsible party would sign.

Based on observations, interviews, staff interviews, and review of the policy titled, Medication Storage in The Care Center the facility failed to ensure that three of eight medication carts and one of three treatment carts were locked when the carts were out of view of the nurse. Additionally, one bottle of eye drops requiring refrigeration was unrefrigerated and an inhaler was not stored properly. Findings include: A review of the Policy titled, Medication Storage in The Care Center (Reviewed and Updated 2012) revealed: Intent: Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedural Guidelines: 2. Only licensed nurses, the consultant pharmacist, and those lawfully authorized to administer medications are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. 11. Medications requiring refrigeration or temperatures between 2 degrees C (36 degrees F) And 8 degrees Celsius (46F) are kept in a refrigerator with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label. An observation on 2/14/2023 at 10:51 a.m. on the South Wing revealed a medication cart labeled cart 3 positioned outside room [ROOM NUMBER] with drawers positioned toward the hallway. The cart was unlocked and unattended. Licensed Practical Nurse, (LPN) AA approached the cart at 10:53 a.m. and moved the cart to the next room and began preparing medication of another resident. Then upon seeing the surveyors observing the cart she yelled down the hallway, bring the keys at 10:53 a.m. Registered Nurse, (RN) BB handed the keys to LPN AA . LPN AA acknowledged the cart had been left unattended and unlocked. An observation 2/14/2023 at 10:58 a.m. revealed at the South Wing nurses station unlocked and unattended was cart 2. LPN CC revealed the cart was unlocked and should have been locked even though the cart was being shared by two nurses. The RN BB revealed cart 2 was being shared by two nurses and should be locked while unattended. RN BB revealed it is her expectation that the medication carts be locked when unattended. An observation 2/14/2023 at 11:10 a.m. on the West Wing (the locked Dementia unit) a treatment cart was observed unlocked and unattended. The treatment cart contained dressing supplies and treatment medications including. Medi- Honey, Bacitracin ointment, Neosporin ointment, wound cleaner, hydrogen peroxide, vitamin D ointment and Hibiclens liquid. An interview with the RN DD revealed the treatment cart does not have a key but should be secured by turning the knob to a locked position. An observation 2/14/2023 at 11:18 a.m. on the North Wing revealed positioned outside room [ROOM NUMBER] the medication cart was and unlocked and unattended. LPN EE acknowledged the cart was unlocked and unattended and should have been locked. Observation on 2/15/2023 at 8:37 a.m. On the West Wing medication Cart 1 The following storage issues were observed during medication pass with LPN LL. Symbicort 80/4.5 inhaler not labeled with resident name or in a box. LPN LL revealed it belonged to (R#37) and returned it to an empty box with her name on it and stated it should have been stored in the labeled box in the residents drawer. Additionally, Latanoprost .005% eye drops 2.5 Milliliters (ml) labeled with resident name (R# 37) was observed unopened. The product label revealed the eye drops should be kept refrigerated until opened. Eye drops were stored in med cart and were not refrigerated. LPN EE confirmed the Latanoprost eye drops should have been stored in the refrigerator until opened and she revealed she did not know why it was in the medication cart unopened or how long the eye drops had been unrefrigerated. An interview on 2/16/2023 at 8:55 a.m. with Unit Manager, LPN FF revealed when the medication cart is unattended it should be locked, and the screen shut off. An interview on 2/16/2023 at 8:59 a.m. with RN GG revealed when a nurse is not at the Medication Cart administering medications the cart should be locked. An interview on 2/16/2023 at 9:02 a.m. with the Director of Nurses (DON) revealed her expectation is for Medication Carts to be locked when unattended and all medications should be stored per manufactures' recommendations. Further interview revealed medications should be stored in the container from the pharmacy labeled with the resident's name. An interview 2/16/2023 at 9:10 a.m. with the Administrator revealed medication carts should be locked when a nurse is not with it or when medication cart is not in view.

Based on observation, record review, staff and resident interviews, the facility failed to accommodate the needs for one of 30 sampled residents (R) (#48) related to providing a wheelchair for mobility out of the room. Findings include: Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R#48 had a Brief Interview of Mental Status (BIMS) score of 14 indicating cognitively intact. The resident required two person total dependance with transfer, one person limited assistance with locomotion on and off the unit and used a wheelchair for mobility device. The resident had a diagnosis of paraplegia. Review of the Progress Notes revealed on 1/19/2023 R#48 had a fall out of his wheelchair. Resident discussed in PAR (patient at risk) meeting on 1/20/2023 related to medication started for muscle spasms and the wheelchair would need to be repaired to include additional fall prevention measures of anti-tippers. Observations on 2/14/2023 at 10:31 a.m., 2/15/2023 at 9:33 a.m., and 2/16/2023 at 3:45 p.m. revealed resident in bed reading a book or watching a movie on his tablet. No wheelchair was observed in the resident's room. During interview on 2/14/2023 at 10:31 a.m., R#48 stated he would get out of the bed if he could, but he did not have a wheelchair. Resident #48 stated his wheelchair needed anti-tippers and has been with maintenance since 1/19/2023. Review of an invoice revealed anti-tippers were ordered on 1/20/2023. Observation and interview with the Maintenance Director on 2/15/2023 at 9:02 a.m. revealed resident equipment in need of repair is repaired and returned to the resident as soon as possible. The repaired wheelchair for R#48 was in an empty room across the hall from the resident's room. The Maintenance Director brought the wheelchair to R#48, and the resident confirmed that was his wheelchair and that he had not seen it since his accident on 1/19/2023. Interview with Certified Nursing Assistant (CNA) KK on 2/15/2023 at 9:16 a.m. revealed she had not seen R#48 in his wheelchair since they took it after he fell about a month ago. CNA KK stated R#48 was out of bed to activities once in the Geri-chair but did not enjoy it due to the lack of mobility the Geri-chair provided. Interview with Registered Nurse (RN) HH on 2/15/2023 at 9:19 a.m. revealed the resident had not been up out of bed since his wheelchair accident due to a part that was needed for the wheelchair. She stated maintenance is scheduled to complete the repair. Interview with Licensed Practical Nurse (LPN) AA on 2/15/2023 at 9:21 a.m. revealed she cannot recall the last time she seen R#48 out of bed since his wheelchair accident. Interview with CNA JJ on 2/15/2023 at 9:37 a.m. revealed she is very familiar with R#48. She stated that due to a part needing to be ordered for his wheelchair, the resident has not had a wheelchair at bedside to accommodate his needs. CNA JJ had not assisted the resident out of bed since 1/19/2023. Review of Nurse's Note dated 2/15/2023 revealed resident up to recliner wheelchair with anti-tippers in front and back. Resident does not look positioned right in chair. Writer requested OT (occupational therapy) to assess for positioning of resident in chair . Seemed to be a problem with mechanism in letting the recliner part of wheelchair. Writer and OT explained that ordering another wheelchair would probably be best due to safety concerns. Interview with the Rehab Director on 2/16/2023 at 10:06 a.m. revealed a request was made for her to evaluate the positioning of the resident in the wheelchair. She stated this was the first time since 1/19/2023 a request or concern had been made regarding resident in the wheelchair. Due to the resident having concerns related to his positioning in the wheelchair, the rehab department requested a new wheelchair for safety measures. Review of the undated Purchase Order revealed a tentative order request for a Tracer Sx5 Reclining Wheelchair with elevated leg rest, which will allow for the same locomotion as the previous wheelchair.

Based on record review, staff interview, and review of the facility policy titled, Protection of Resident Funds, the facility failed to maintain a surety bond sufficient to cover the resident trust fund account balance for 107 of 108 residents with a trust fund account at the facility. The facility also failed to ensure the surety bond obligee was the Georgia Department of Community Health. Findings include: A review of the undated policy titled Protection of Resident Funds revealed the section titled Assurance of Financial Security to state: The facility will purchase a surety bond in an amount sufficient to assure the security of all personal funds of residents deposited with the facility. Review of the resident trust fund bank statements for the past six months revealed: In August 2022, the beginning balance was $195,023.64 and the ending balance was $185,612.10. In September 2022, the beginning balance was $185,612.10 and the ending balance was $192.370.14. In October 2022, the beginning balance was $192,370.14 and the ending balance was $189,699.65. In November 2022, the beginning balance was $189,99.65 and the ending balance was $208,203.61. In December 2022, the beginning balance was $208,203.61 and the ending balance was $194,246.23. In January 2023, the beginning balance was $194,246.23 and the ending balance was $163,521.91. A review of the surety bond #141593323 with the description of Resident's Fund Bond revealed effective dates were October 1, 2022, through October 1, 2023, and had a bond amount of $90,000.00. The surety bond revealed the obligee to be State of Georgia, Department of Labor, 148 [NAME] Young International Boulevard Northeast Suite 850, Atlanta, Georgia 30303-1751. On 2/16/2023 at 8:00 a.m. an interview with the Administrator revealed the surety bond was for the resident fund account. He further revealed the obligee was mistakenly made to the Georgia Department of Labor and that he plans to have that corrected to the Georgia Department of Community Health. He further revealed he plans to increase the bond amount to an amount that covers the resident fund balance amount. He revealed his expectations are for the surety bond amount to be equal to or greater than the total amount in the resident fund account. On 2/16/2023 at 1:17 p.m. an interview with the Administrator verified on 2/14/2023 the surety bond amount to be $90,000.00 and the resident fund account balance to be between $163,521.91 to $208,203.61 for the months of August 2022 through January 2023. He verified 107 residents had funds in the resident fund account.

Based on observation, record review, staff and Resident interviews, and review of the Facility's Assessment the facility failed to provide sufficient nursing staff on four of four wings; North Wing, West Wing, South Wing, and [NAME] Wing; f to achieve the highest practicable level of well-being for all Residents. The facility census was 114 Residents. Findings include: Review of the Facility Assessment revised 4/2021 revealed a staffing plan as follows: In order to achieve personal care centered, foster excellence in the nursing services and promote continuity of care we take and look at the needs of our residents. We believe in consistent staffing for the benefit of the resident. This provides them with a sense of comfort along with the ability to make friendships and get to know the staff, plus staff will know slight changes in the resident. To develop the assignments, we look at the acuity of the residents. By checking their AD looking into behaviors and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/10/2021 at 12:41 p.m. with Resident (R) #4 on North Wing, he revealed he has waited as long as an entire shift to get help when he was incontinent. He stated the facility does not have enough staff to take care of everyone. During an interview on 5/10/2021 at 1:27 p.m. with R#92 on South Wing she revealed she does not feel there is enough staff in the building and stated she often must wait for long periods of time before she can get assistance and added she has had to wait up to 3 hours. During an interview on 5/10/2021 at 2:24 p.m. R#2 on South Wing she revealed there is not enough staff and added that she is able to do most things herself but needs assistance at times and no one shows up. During an interview on 5/10/2021 at 2:59 p.m. with R#27 on South Wing he revealed there is not enough staff and has to wait for long periods of times before he can get assistance but added he knows the staff are busy and are doing the best they can. During an interview on 5/10/2021 at 3:59 p.m. with R#7 on North Wing he revealed he is supposed to get a bath on Tuesday, Thursday, and Saturday but is told by staff that they do not have enough staff to get him into the shower because he requires a lift and there are not enough people to safely take him to the shower. He stated she does get a bed bath but would like, at some point, to have a shower. During an interview on 5/10/2021 with Licensed Practical Nurse (LPN) QQ for North Wing, she revealed there was a Certified Nursing Assistant (CNA) out on North Wing for today. She stated when someone calls out, they call out to the Supervisor on duty, and it is that Supervisor's responsibility to get coverage for that call out. She stated, according to the schedule, the CNA who was supposed to work today was actually off and added it would be the Staffing Coordinators responsibility to get that position filled. LPN QQ revealed that the Staffing Coordinator was stationed in their sister facility and is responsible for staffing two locations. LPN revealed for today on North Wing there are two LPN's and two CNA's but there should be three CNA's. During an interview on 5/11/2021 at 7:15 a.m. with LPN RR, revealed she is staffed by the facility through Agency and has been working in the facility regularly since February 2021. She revealed she works in different areas of the facility when on the schedule and was on North Wing from 11:00 p.m. to 7:00 a.m. last night. She stated for North Wing there was one nurse, two CNA's, and one RN Supervisor for 33 residents. She revealed CNA's work a lot of split shifts and explained that some CNA's will agree to stay and work three or four hours on the next shift leaving only one CNA for all residents the remainder of that shift but sometimes they will have a CNA agree to come in early to help out the last couple of hours of a shift but added even when this happens the residents are lacking in turning, repositioning, and incontinent care. LPN RR revealed that the facility is painfully understaffed, and residents must wait long periods of time after using their call lights to get the help they need. She revealed residents are staying wet longer than they should and added this causes discomfort for the residents. She revealed weekends are especially understaffed and added the weekends are even worse related to wait times for the residents in receiving care. LPN RR stated she worked on South Wing a month ago with a Nurse Supervisor who would not even try to get a replacement for a call out and told them they would be ok but added that it is the residents who suffer from the lack of staffing. During an interview on 05/11/21 at 8:20 a.m. with RN SS on North Wing she revealed when someone calls out for the oncoming shift, and it is agency, she will call agency to get a replacement but if a staff member of the facility calls out, she will, if the employee has not worked a double already, she asks an off-going employee if they would be willing to stay. She stated the biggest problem with Agency staffing is that they are not open and will not answer their phone in the middle of the night or early morning so she must wait for the day shift RN Supervisor (RN AA) to come in and try to get someone to fill the vacancy. RN SS stated there is no definite process to get replacement staff for call outs. She stated there is an as needed (PRN) pool but no one will answer their phone. RN SS revealed the residents are not being turned and repositioned during the night. She stated the CNA's do dry rounds every two hours and there was no time for them to turn and reposition because they do not have enough staff. She stated she helps out with med pass and even with CNA duties when they are short but stated that the residents suffer related to, they are staying in one spot because they are not being turned and repositioned like they should be. She stated she has not seen any evidence of wounds or skin conditions related to this but added there is discomfort for the residents and if this shortage of staff continues there is the potential for skin breakdown and worsening pressure sores. RN SS stated Staffing Coordinator VV is responsible for staffing this facility and their sister facility and added she is located in the other facility. During an interview on 5/11/2021 at 10:23 a.m. with R#97 on South Wing revealed the nurse only comes by one time per week and stated it takes a long time for the staff to respond to her call light. She revealed she has not had a shower in 2 to 3 months. R#97 stated she was not getting changed in a timely matter when she was soiled. During an interview on 5/11/2021 at 10:25 a.m. with LPN YY on South Wing she revealed she feels resident care suffers because there are not enough staff members to provide the necessary care for the residents need. She stated they do the best they can to take care of the residents but there just are not enough people to help with the residents. During an interview on 5/11/2021 at 10:28 a.m. RN AAA on South Wing she revealed she does not feel the facility has sufficient staff to provide adequate resident care. She stated the Certified Nursing Assistants (CNAs) sometimes have between 15-20 residents to take care of on their assignment and added they do the best they can but sometimes the residents do have to wait for long periods of time before someone can get to them. During an interview on 5/12/2021 at 6:50 a.m. with LPN BB, Agency Nurse, on West Wing, she revealed she works 40 hours per week in the facility on the day shift Monday through Friday. She stated the facility has a shortage of both nurses and CNA's and added they had one CNA on Monday for 7:00 a.m. to 3:00 p.m., two CNA's Tuesday on 7:00 a.m. to 3:00 p.m., and today they have four CNA's for 7:00 a.m. to 3:00 p.m. LPN BB revealed Residents are not gotten out of bed or showered due to lack of staff to do so. During an interview on 05/12/2021 at 7:00 a.m. with CNA HH on North Wing she revealed she worked 3:00 p.m. to 11:00 p.m. the previous shift and volunteered to stay over and do night shift because there was only one CNA scheduled for that shift. She revealed there are 33 residents on the North Wing and most of them are incontinent and require changing every two hours and added that there is no way one CNA can manage that by themselves. She revealed that even with two CNA's sometimes they cannot get around again to everyone during the shift, but they do the best they can. CNA HH revealed not having the allotted number of staff for a shift is a frequent occurrence and the facility is constantly asking staff to stay over or work extra. She revealed what bothers her most is that the residents have to wait long periods of time and sometimes stay wet or soiled for a significant amount of time and stated at times it is over an hour but added thankfully there has been no major skin issues but only some redness and discomfort from laying in one place all the time. During an interview on 05/12/21 at 7:15 a.m. with CNA UU, from a staffing Agency, revealed she has been coming to this facility regularly for five years and works on the 7:00 a.m. to 3:00 p.m. shift. She stated she feels so bad for the residents because there is not enough staff to even be able to give them showers and they are being washed off while in the bed. CNA UU stated R #65 has been begging her for a shower for two weeks and there has not been enough staff, so she has not been able to give her a shower and has been washing her off for the last two weeks. She stated if enough staff show up today, she is planning on getting some showers done today. She revealed there is not enough staff to get them up and certainly not enough staff to use a lift that requires two people for safety. CNA UU revealed the weekend schedule is mostly blank with maybe two positions filled for the whole facility and added it is very difficult to find staff to come in and work, so the bare minimum gets done on the weekend. She revealed that she has worked so much extra that if she is being honest, lately she has called in some due to being exhausted. CNA UU revealed the same people are volunteering to work and help and they are getting exhausted and burned out. During an interview on 5/12/2021 at 8:20 a.m. with LPN MM on South Wing she revealed there are not enough CNAs to give the residents the care they need and stated most residents on the South Wing are extensive to totally dependent with Activities of Daily Living (ADLs). CNAs do not have time to give the residents baths, feed them, get them dressed, or out of bed before it is time for them to leave for the day. During an interview on 5/12/2021 at 11:10 a.m. with CNA ZZ on South Wing she revealed she has a difficult time getting to all of her residents. She stated she has between 10-15 residents on her assignment and added that the resident care does suffer because she always feels rushed to get to them all. During an interview on 5/12/2021 at 11:26 a.m. with RN CC on West Wing, the behavior/dementia wing, she revealed the facility has a staffing problem. RN CC revealed they use agency staff to work a lot of their shifts, but stated agency does not usually work the weekend or holidays and added most of the regular facility staff left two months ago. RN CC revealed she is currently on workman's compensation and has limited duties but does work about every day including the weekends and stated she assists with feeding the residents. She revealed the residents are not getting their scheduled showers and added that they might get one shower a week, but they do get washed in the bed every day. RN CC revealed the residents are getting turned and changed but not getting out of bed and added that most residents require a lift to get up and added it is too unsafe to get them up with a lift without sufficient staff. She revealed she has asked repeatedly for more staff because the residents in this unit require more care as most need assistance with meals, take longer to feed, or feed themselves, are total care, have behaviors and require constant monitoring. RN CC did not feel residents were losing weight or getting more wounds due to the lack of staff at this time and stated the staff that are here work very hard to get things done. She revealed that she has two nurses and four CNAs today and stated today is a good day. During an observation on 5/10/2021 at 11:00 a.m. on North Wing revealed there was no residents observed to be up out of bed and there were no residents observed to be up in chairs. During an observation on 5/10/2021 at 4:00 p.m. on North Wing revealed residents remained in bed. During an observation on 5/11/2021 at 10:00 a.m. on North Wing revealed residents in bed. There were no residents observed up in chairs. During an observation on 5/11/2021 at 3:30 p.m. on North Wing revealed residents remained in bed. During an interview on 5/13/2021 at 9:30 a.m. with RN AA revealed on the Staffing Sheet P/U means shift was picked up by a regular staffed employee and that the others are agency staff who worked the shift. She revealed for North Wing there should be four CNA's, West Wing should have four CNA's, South Wing should have six CNA's, and [NAME] Wing should have two CNAs to provide adequate care to the residents. RN AA revealed recently, it is getting so bad, and staff are leaving or going to PRN status. She revealed, because she has very little staff, when she does get someone to agree to work, they beg not to be put in certain areas such as South Wing because there are 46 residents and not enough staff to help. She revealed her first concern about not having enough staff in the building is that residents are not getting good quality care and added staff are not able to get residents up out of bed every day because there are not enough staff to get them up safely. She stated she comes in, in the morning and does rounds to see if they have enough staff and will move staff around as necessary. She stated the Unit Secretary sets up appointments, arranges transportation, answers call lights, and is a CNA. RN AA revealed there is one CNA that strictly goes to doctor appointments with residents. She revealed her biggest concern is there is not enough staff, CNA's, to adequately provide care to the residents but stated they do the very best they can. Review of the staffing sheets revealed on Saturday 5/8/2021 7:00 a.m. to 3:00 p.m. North Wing had two LPN's and two CNAs for 33 residents but needed 4 CNAs. The West Wing had two LPN's and two CNAs for 27 residents but needed four CNAs. The South Wing had three LPN's and three CNAs for 47 residents but needed six CNAs, and [NAME] Wing (Rehab Wing) had one LPN and one CNA for seven residents but needed two CNAs. Review of the staffing sheets revealed on Saturday 5/8/2021 3:00 p.m. to 11:00 p.m. North Wing had two LPN's and one CNAs for 33 residents but needed four CNAs. The West Wing had one LPN's (needed three LPNs) and three CNAs for 27 residents but needed four CNAs. The South Wing had two LPN's and four CNAs for 47 residents but needed six CNAs, and [NAME] Wing (Rehab Wing) had one LPN and two CNA for seven residents. Review of the staffing sheets revealed on Saturday 5/8/2021 11:00 p.m. to 7:00 a.m. North Wing had one LPN's (Needed two) and two CNAs for 33 residents but needed three CNAs. The West Wing had one LPN (Needed two LPNs) and two CNAs for 27 residents but needed four CNAs. The South Wing had two LPN's and two CNAs for 47 residents but needed four CNAs, and [NAME] Wing (Rehab Wing) had one LPN and two CNAs for seven residents. Review of the staffing sheets revealed on Sunday 5/9/2021 7:00 a.m. to 3:00 p.m. North Wing had two LPN's and three CNAs for 33 residents but needed four CNAs. West Wing had two LPN's and three CNAs for 27 residents but needed four CNAs. The South Wing had two LPN's the entire shift and one LPN until 1:00 p.m. and two CNAs, one CNA for the entire shift and one CNA until 2:00 p.m., for 47 residents but needed six CNAs. The [NAME] Wing (Rehab Wing) had one LPN and one CNA for seven residents but needed two CNAs. Review of the staffing sheets revealed on Sunday 5/9/2021 3:00 p.m. until 11:00 p.m. the North Wing had two LPN's and three CNAs for 33 residents but needed four CNAs. The West Wing had two LPN's (needed 3 LPNs) and three CNAs for 27 residents but needed four CNAs. The South Wing had two LPN's and two CNAs for 47 residents but needed six CNAs, and The [NAME] Wing (Rehab Wing) had one LPN and two CNA for seven residents. Review of the staffing sheets revealed on Sunday 5/9/2021 11:00 p.m. to 7:00 a.m. the North Wing had one LPN's (Needed two) and two CNAs for 33 residents but needed three CNAs. The West Wing had one LPN's (needed two) and one CNAs for 27 residents but needed four CNAs. The South Wing had two LPN's (a 3rd LPN came in early on day shift at 5:00 a.m.) and three CNAs for 47 residents but needed four CNAs. The [NAME] Wing (Rehab Wing) had one LPN and two CNA for seven residents. During a four hour long continuous observation on 5/13/2021 from 10:30 a.m. to 2:30 p.m. on the North Wing outside of the rooms for R#58, R#78, and R#51 revealed no one entered the resident's room during that time. Review of the 4/26/2021 Quarterly Minimum Data Set for R#58 in Section (C) Cognition revealed a Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment. Section (G) Function Status revealed the resident is totally dependent upon staff for ADLs. Review of the 3/19/2021 Quarterly MDS for R #78 revealed in Section (C) Cognition that no assessment for cognition should be done because the resident was never or rarely understood. Section (G) Functional Status revealed the resident is totally dependent upon staff for ADLs. Review of the 3/2/2021 Quarterly MDS for R #51 revealed in Section (C) Cognition that no assessment for cognition should be done because the resident was never or rarely understood. Section (G) Functional Status revealed the resident is totally dependent upon staff for ADLs. During an interview on 5/12/2021 at 2:35 p.m. with RN AA on North Wing she revealed she was sitting behind the nurse station working on setting up appointments for residents and making arrangements for transportation because the Unit Secretary was out, and she normally makes those arrangements for the residents and she did not notice there had not been anyone in the rooms of R#51, R#58, and R #78 for four hours. She revealed all three residents are totally dependent upon staff for care and that someone should have gone in and turned the resident and checked them for incontinence twice in a four-hour period. During an interview on 05/12/2021 at 9:00 a.m. with the Director of Nursing (DON), Staffing Coordinator VV, and the HR Director, who revealed she is present because she is Staff Coordinator VVs direct Supervisor, Staff Coordinator VV revealed she has helped in the facility as a CNA and with staffing since December of 2020 but in February 2021 she stated she began the job of Staffing Coordinator for the facility and a sister facility. She revealed she is not stationed in this facility but stated when a staff member calls out on night shift it is the responsibility of the night Supervisor to try to get a replacement and added it is the same process for the other shifts. The DON stated if the Supervisor cannot get a replacement, she will stay over until the RN AA gets in around 9:00 a.m. so she can work on getting someone to fill the position for the shift. Staffing Coordinator VV explained that she has a program that she uses to do the facility schedule with and added she takes the full-time employees and places them on the schedule and then she tries to get agency or regular facility staff to fill in the vacant shifts on the schedule and then sends it down to the RN AA. Staffing Coordinator VV revealed it is very difficult, due to Covid-19, to get anyone to work. HR Director stated employee's calling out should call out to the Nurse Supervisor on duty two hours prior to their shift to give the facility time to find a replacement. DON revealed the night supervisor has a book with the names and numbers of staff, and agency numbers, to call to work on getting a replacement for the call out and added that she has not heard of problems related to a decline in resident care from staff. HR Director revealed the facility is using agency staff daily and that the facility must have two Licensed Practical Nurses for each shift for each Wing and one CNA per 10 residents and stated right now they staff a total of 59 CNA's but are grossly understaffed. Staffing Coordinator VV stated she currently does the schedule for one to two weeks at a time and gives it to the RN AA. During this time the staffing book was reviewed with the Staffing Coordinator and she revealed there was a lot of open shifts available for CNA's and LPNs on various dates and added that she tried to get them scheduled but no one wants to work especially on weekends so she fills what she can and sends the schedules to the RN AA. HR Director revealed she did a job fair last week and there was a total of 60 people come through but stated she has ads in the local newspaper that links the jobs available to online job sites. She stated she places job openings with various public sites. She stated all applications come to her and she sends them to the facility for the DON to call and set up interviews. HR Director stated they offer shift differentials for nights and weekends and recently gave a $750.00 bonus to all staff as well as, during Covid, gave them additional pay on the hour but added they are not offering any sign on bonuses or incentives at this time. DON stated a lot of times she will call and set up interviews and they will not show, and she will call again to try and set up another interview but most of the time they don't answer. HR Director stated up until last quarter, October 2020 to December 2020, they averaged 350 applications per quarter for four facilities for all departments, and this quarter January 2021 to March 2021 they received 77. DON stated she, RN AA, and the Administrator have come in on various weekends to help pass trays, feed residents, pass medications, assist with care, because of the lack of staff and added that the wound care nurse has come in and worked some Saturdays as well but when she isn't here the nurse taking care of the resident is responsible for the wound care and stated they have a Wound Care Agency Nurse who has been with them for six months that helps out with wound care through the week and on weekends. She revealed she was aware the residents were not being gotten up and that showers were not being done because there was not enough staff to get them up safely and verified most, if not all of the residents on North and South Wing, are totally dependent on staff for ADLs. HR Director revealed over 16 hours in a shift would be a safety issue and staff may not work over 16 hours at a time and cannot go beyond working a double shift. During an interview on 5/12/2021 at 9:55 a.m. with RN AA she revealed she has worked in the facility for [AGE] years. She revealed that the HR Director made the decision to change how staffing was done about two to three months ago and put Staffing Coordinator VV over staffing for two facilities including this facility. RN AA stated she was happy doing staffing and it was good because she works in the facility and has a good relationship with staff, and they would work well with her and pick up shifts when needed. She revealed when Covid hit a lot of staff left and it became more difficult to staff the facility because people were afraid. RN AA revealed even though it was more difficult, staffing was still better when she was doing it because she had a better relationship with staff and the agencies they utilized. She revealed she does not know why the decision was made to move a needed CNA for resident care into a Staffing Coordinator position but added Staffing Coordinator VV did staffing at the sister facility she came here from and she helped her with staffing when she came to the facility. RN AA stated Staffing Coordinator VV was sending her staffing sheets one day at a time and she told her that she needed a whole week at a time because one day at a time did not provide her with enough time to cover the available shift that she (Staffing Coordinator VV) did not get covered, so she just started sending her, this week, the schedules for 2 weeks at a time. RN AA confirmed that Staffing Coordinator VV is putting the staff on the schedule who are currently employed by the facility and leaving her (RN AA) with the responsibility to fill any vacant shift. She revealed she and the DON and others come out to the floor and help pass trays and with resident care when needed but only those who are trained to provide resident care may do so and added that she has and will come in on weekends when needed and stated they really are doing the best they can. During an interview on 5/12/21 at 12:35 p.m. with RN WW for North Wing she revealed she has worked in the facility for eight years. She stated she works Monday through Friday 7:00 a.m. to 3:00 p.m. and added there have been weekends that she has had to come in because there was no nurse to work and pass medications, especially on holidays. She stated they have some Agency nurses who are permanent staff, one being CNA UU on North Wing. RN WW revealed that they do their best to get the resident's showers and get them up out of bed but most of the time they only have two CNAs for 33 residents who reside on the North Wing and it takes two CNAs to get a resident up safely using a lift and most residents on North Wing require a lift. She revealed, even though most days they work with only two CNAs, there had not been any falls that have resulted in a major injury and no new or worsening pressure sores. She revealed the residents do have to wait longer times for assistance and some wait as long as an hour to be turned and repositioned or to receive incontinent care and added that the nurses help out as much as they can. RN WW revealed today there are three CNAs on the North Wing so some residents will receive showers today. She stated staffing was much better when RN AA, who is always in the facility, was doing staffing because she knows all the staff and is familiar with the residents and the facility needs but added that with staffing shortage everywhere she doesn't know that at this point if it mattered who was doing staffing because there is a problem in all facilities right now with staffing due to Covid.

Based on observations and staff interviews the facility failed to ensure the sanitary handling of garbage and refuse at the kitchen loading dock and dumpster area. The facility census was 116 residents. Findings include: During the initial observation of the facility dumpster area with the Food Service Director (FSD) on 5/10/2021 at 2:10 p.m., a moderate amount of trash was observed on the loading dock, the steps to the grounds, the gated hosing area on the loading dock for washing/storing housekeeping and maintenance equipment, and along the grounds from the loading dock to the trash compactor where trash and garbage spillage was noted, including used gloves. In an interview with the FSD on 05/10/21 at 2:15 p.m., revealed he stated kitchen and housekeeping shared the duty of keeping the trash compactor area clean. He stated there was no schedule to clean the trash compactor area, but they kept an eye on it regularly. During observation of the loading dock and dumpster area with Housekeeping Supervisor on 05/10/2021 at 4:31 p.m., he stated his staff did share responsibility for keeping the dumpster area clean, and he believed the trash spillage by his staff occurred because the trash receptacles were likely too heavy for many of his staff to lift and empty into the trash compactor.

Based on observations, staff interviews, and review of the facility policy titled, Medication Storage in the Care Center the facility failed to discard expired biologicals prior to the expiration dates in two of four medication storage rooms. Findings Include: Review of the facility policy titled, Medication Storage in the Care Center, copyrighted 2019, revealed: Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction, and reordered from the pharmacy, if a current order exists. An observation on 5/13/21 at 8:28 a.m. of the West Wing medication room revealed three unopened bottles of aspirin 325mg with an expiration date printed on the bottles of April 2021. Expired medications verified by the Licensed Practical Nurse (LPN) LPN BB. An interview on 5/13/21 at 8:28 a.m. with LPN BB revealed she checks the medication room for need to order more floor stock and looks for expired medications. She also indicated the Unit Manager (UM) checks the room for need and expired medications. An interview held 5/13/21 at 10:07 a.m. with the West Wing Registered Nurse (RN) RN UM revealed 11p.m. to 7 a.m. shift is responsible for checking the medication carts two times a week for expired medications and the need to order any medications. An observation on 5/13/21 at 8:46 a.m. of the South Wing medication room revealed: One (1) expired vial of [MEDICATION(S)] labeled expires 30 days after opening; vial was labeled opened on 3/25/21 and expired 4/24/21. 1 bottle of Multivitamin with Minerals with an expiration date printed on the bottle of April 2021. 1 bottle of Magnesium [MEDICATION(S)] with an expiration date printed on the bottle of April 2021. 2 Control Solutions for testing Glucometers with an expiration date printed on the bottle of 1/31/21 and 2/15/21. 1 bottle of Antiseptic Wound Cleanser with an expiration date printed on the bottle of January 2021. 3 BD Vacutainer UA preservative tubes with an expiration date printed on the tubes of 4/30/21. 4 [CONDITION(S)] Care Trays with an expiration date printed on the trays of 4/16/21. 5 Clorox Germicidal Bleach Wipes with an expiration date printed on the wipes of 4/24/21. An interview on 5/13/21 at 9:10 a.m. with the Licensed Practical Nurse (LPN) LPN OO confirmed the above items were expired. She indicated she was not sure who is responsible for checking the cabinets for expired medications or supplies. An interview on 5/13/21 at 9:12 a.m. with the South Wing RN UM confirmed the above items were expired. She indicated the Central Supply Clerk rotates the floor stock medications when she refills the cabinets. She further indicated all charge nurses are responsible to check for any expired items in the medication room. An interview on 5/13/21 at 9:23 a.m. with the Director of Nursing (DON) indicated it is her expectation for all nurses to check the medication rooms for expired medications and supplies.

Based on staff interview, record review, and review of the facility policy titled, Pressure Ulcer Management the facility failed to conduct routine skin assessments as care planned for one of three residents (R#1) at risk for pressure ulcers. Actual Harm was identified to have occurred on 5/28/19, when a wrist watch was removed from R#1's left arm and revealed three unstageable pressure ulcers. Findings include: The facility had a Pressure Ulcer Management policy that included a section for Prevention of Pressure Ulcers. Along with several other interventions, the list included weekly body audits and daily skin inspections. Resident (R) #1 had a care plan, dated 2/25/19, for the presence of a stage four pressure ulcer to the right hip. The care plan problem also included that R#1 was non-ambulatory, incontinent, required total assistance with bed mobility and transfers. The care plan was updated on 5/9/19 to include a Deep Tissue Injury (DTI) of the right heel and again on 5/20/19 to include that the stage four pressure ulcer to the right hip had healed. The care plan included an intervention for skin assessments to be completed by nursing staff per protocol. However, a review of the clinical record revealed that the skin assessments had not been completed weekly per protocol, as care planned. A review of the Weekly Skin Integrity Review forms revealed that weekly skin assessments had not been completed after 5/1/19, until 5/31/19. Further record review revealed that on 5/28/19, while preparing R#1 for transport to the hospital for evaluation, three unstageable, eschar covered pressure ulcers were identified to the left wrist, after a watch was removed from her arm. During an interview on 6/11/19 at 12:25 p.m., with the Licensed Practical Nurse (LPN) Treatment Nurse revealed that the head to toe skin assessments are to be completed weekly by the nurses assigned to the residents. Cross refer to F686

Based on staff interviews, record review and review of the facility policy titled, Pressure Ulcer Management the facility failed to identify a pressure ulcer timely for one of three residents (R#1) reviewed and failed to complete routine skin assessments for one of three residents (R#2). Actual Harm was identified to have occurred on 5/28/19, when a wrist watch was removed from R#1's left arm and revealed three unstageable pressure ulcers were found. Findings include: 1. Review of the facility policy titled, Pressure Ulcer Management revealed a section for the Prevention of Pressure Ulcers. Along with several other interventions, the list included weekly body audits and daily skin inspections. The facility also had a Weekly Skin Assessment procedure. The procedure documented that as an integral part of the pressure ulcer prevention program, a skin assessment would be completed at a minimum of every week. Resident (R) #1 had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Annual assessment dated [DATE] documented that R#1 had a Brief Interview Score of three indicating severe cognitive impairment. This MDS assessment also documented that the resident was totally dependent on staff for bed mobility, eating, dressing, and personal hygiene, and the resident had impairment to bilateral upper and lower extremities, with one stage four facility acquired pressure ulcer. Review of a Braden Scale dated 5/14/19 documented that documented R#1 scored a 13 which indicated that the resident was at a moderate risk for developing pressure ulcers. Record review revealed that R#1 had a history of [REDACTED]. There was a care plan in place, dated 2/25/19, for pressure ulcers that included R#1 was non-ambulatory, incontinent, required total assistance with bed mobility and transfers with an intervention for skin assessments to be completed by nursing staff per protocol. A review of the Treatment Administration Record (TAR) book revealed a Weekly Skin Integrity Review schedule at the front of the book. R#1 was scheduled to have skin assessments completed weekly, on Thursdays on the 11:00 p.m. to 7:00 a.m. shift. However, a review of the clinical record revealed that even though the Skin Integrity form for 5/1/19 was dated and signed, it was blank. In addition, further review of the Weekly Skin Integrity Review forms dated: 5/8/19, 5/15/19, and 5/22/19 revealed that these forms were not signed or dated, and review also revealed that these forms were blank without any evidence of documentation that weekly skin assessments had been completed for R#1. Record review revealed a Nurses note dated 5/28/19, when R#1 was received back to the facility from the hospital, that documented the following: Resident back to the facility via stretcher. While preparing resident for transport (to the hospital) Certified Nursing Assistant (CNA) removed a watch from the resident's left arm. The residents arm began to bleed. An imprint of the watch was imbedded in the resident's arm. Review of a Physician's order dated 5/28/19 revealed the following wound care orders: Clean left wrist (posterior and anterior wound) with wound cleanser or normal saline. Apply moist gauze to eschar part/area. Apply 4 x 4 gauze, apply roll gauze. Change daily and prn (as needed) for 14 days. Record review revealed a Wound Assessment Departmental Note dated 6/1/19 that documented the following: On 5/28/19 new area to left posterior wrist unstageable pressure with measurements of 1.5 centimeters (cm) x 5.0 cm x 0.1 cm soft eschar 100%, small red exudate peri wound (tissue surrounding the wound) and foul odor. Interview on 6/11/19 at 11:27 a.m. with Licensed Practical Nurse (LPN) BB revealed that she used to be the Unit Manager but stepped down but is training the new Unit Manager. LPN BB pulled the shower schedule and reviewed it with surveyor. The shower schedule revealed that Resident #1 was not included on the schedule. Per LPN BB, R#1 came over from the East wing and they are incorporating her into the bath schedule. However, review of the schedule revealed that neither R#1, nor her roommate, were on the list. LPN BB then stated that R#1 gets daily bed baths and that jewelry should be removed during a bed bath. Further interview with LPN BB revealed that she is unsure who put the watch on R#1. The daily assignment sheets were reviewed with LPN BB for (MONTH) 2019 and revealed that LPN BB did not see R#1's name included on the list for a shower or for a bedbath. During an interview on 6/11/19 at 12:25 p.m., with the Treatment Nurse, revealed that after nursing staff removed a watch from the resident's wrist staff notified her to assess R#1's wrist. The Treatment Nurse stated the ulcers were dark eschar with bleeding around them and odor. She also stated, that due to the odor, that she felt that the watch had been on the resident's arm for a while. The Physician was notified, and treatment orders were obtained. Interview on 6/11/19 at 2:50 p.m. with the Director of Nursing (DON) and review of the Weekly Skin Integrity forms and Daily Skin Check forms with the DON revealed that the Daily Skin Check Report forms (completed by the CNA's) are to be completed any time they (the CNAs) change or bathe a resident and that the head to toe assessments are to be completed by the nurses daily. Further review with the DON revealed that the form dated 5/1/19 was signed, but blank, and the forms dated 5/8, 5/15 and 5/22/19 were blank as well. During an interview on 6/12/19 at 12:07 p.m. with Emergency Medical Technician (EMT) AA, who assisted in transporting the resident to the hospital on [DATE], revealed that when the nurse removed a piece of jewelry from the resident's left arm, the area he saw under it was black and necrotic and bleeding around the wound. Phone interview on 6/12/19 at 12:25 p.m. with LPN AA, the LPN on duty on 5/28/19, and the nurse assigned to R#1. Per LPN AA, she, and a CNA, were getting R#1 ready for transport and she saw some blood on the resident's arm and removed the watch. LPN AA stated she could tell it (the watch) had been there for a while because she kind of had to peel it (the watch) off. 2. Record review revealed that R#2 had [DIAGNOSES REDACTED]. She had a care plan problem in place since 6/25/18 for having the potential for skin breakdown related to requiring assistance with bed mobility and bowel and bladder incontinence. A further review of the care plan and clinical record revealed that the resident had a history of [REDACTED]. A review of the Treatment Administration Record (TAR) book revealed a Weekly Skin Integrity Review schedule at the front of the book. R#2 was scheduled to have a skin assessment completed weekly, on Saturdays on the 11:00 p.m. to 7:00 a.m. shift. However, a review of the Weekly Skin Integrity Review forms revealed that the skin assessments had not been completed weekly since 2/2/19, the skin assessments had only been completed, for R#2, on the following dates: 2/24/19, 3/9/19, 4/20/19, 5/18/19, and 6/8/19. During an interview on 6/11/19 at 12:25 p.m., the licensed practical nurse (LPN) Treatment Nurse stated that the head to toe skin assessments are to be completed weekly by the nurses assigned to the residents. During an interview on 6/12/19 at 2:56 p.m., the Physician stated he expected the nurses to routinely assess the resident's skin.

Based on observations, staff interviews, record reviews, review of the facility's policies and procedures, and review of documentation about the facility's surface disinfectant, it was determined that the facility failed to maintain an Infection Control program that ensured proper infection control and provision of aseptic technique to prevent cross contamination and prevent indirect contact transmission of a blood borne infection or a microscopic pathogen by failing to ensure that five (5) nurses cleaned and/or disinfected glucometers between use on 12 residents (#3, #5, #18, "A", "B","D", "E", "F", "G", "H", "I", and "J") and to monitor implementation of their infection control policy and procedures. These practices effected 12 insulin dependent, sampled residents but had the potential to effect all 42 of the residents whose blood sugar levels required monitoring. The facility also failed to ensure that licensed nursing staff wore gloves during the administration of insulin to two residents ("A" and "D") that had the potential for exposure to blood and body fluids in a sample of 12 residents. Therefore, it was determined that an immediate jeopardy existed for 42 residents who had diabetes and required fingerstick blood glucose monitoring on August 11, 2010 when a plan of correction was implemented by the facility to remove the jeopardy. It was determined that the immediate jeopardy was removed on August 12,2010 and the scope and severity was lowered to an "E" level. However, the facility remains out of compliance in order to ensure that licensed nursing staff continues to implement the correct procedures to clean and disinfect blood glucose testing machines; that supervisory nursing staff continues to monitor to ensure that blood glucose testing machines are clean and disinfected with an EPA approved germicidal disinfectant which is labeled effective against blood borne pathogens; and that the Quality Assurance committee monitors the facility's interventions to ensure that the infection control policies and procedures are implemented as planned. The Center for Disease Control's (CDC) section "Diabetes Care Procedures and Techniques" of the "Recommended Infection-Control and Safe Injection Practices to Prevent Patient-to-Patient Transmission of Blood Borne Pathogens", recommended that if a glucometer used for one patient must be re-used for another patient, then the device must be cleaned and disinfected. Hand hygiene was to be performed immediately after the removal of (contaminated) gloves and before touching other medical supplies intended for use on other residents. In the Centers for Medicare and Medicaid Services (CMS) October, 2009 "Infection Prevention and Control Training", it was documented that, when cleaning a glucometer, or any other object potentially contaminated with blood, either an EPA approved germicidal disinfectant which was labeled effective against Hepatitis B (HBV), or a 1:10 bleach to water (minimal) concentration must be used. Alcohol was not included as an EPA approved germicidal disinfectant. On 8/11/10 at 10:50 a.m., licensed nursing staff "BB" stated there had been an inservice in which staff were instructed to clean the glucometer with alcohol before use. On 8/11/10 at 3:20 p.m., the Director of Nursing stated that the facility did not have a policy and procedures for the cleaning and disinfection of the glucometers between resident use. She stated that licensed nursing staff had been inserviced on 4/29/10 to use Cavi-wipes to clean and disinfect the glucometers and that each medication cart was supposed to be provided with a container of the Cavi-wipes. There was documentation of a 4/29/10 in-service for licensed nursing staff on "PDI-blood glucose cleaning and proper disinfectant of glucometer." The Professional Disposables International, Inc. (PDI) information instructed nursing staff to clean glucometers periodically and after visible soiling with an EPA registered disinfectant detergent or germicide. That information was not consistent with the CDC guidelines for cleaning and disinfecting blood glucose machines between use on residents. There was no evidence that licensed nursing staff had been in-serviced on the use of CaviWipes to clean and disinfect glucometers. The licensed nursing staff had failed to clean and disinfect the glucometers with an EPA-registered disinfectant or a 1:10 bleach solution effective against HIV, Hepatitis B and Hepatitis C for residents #3, #5, #18, "A", "B", "D", "E", "F", "G", "H", "I" and "J". 1. On 8/11/10 at 11:30 a.m., licensed nursing staff "CC" failed to clean and disinfect the glucometer before obtaining a finger stick blood sugar level for resident #5. Licensed nurse "CC" removed the glucometer from the case, did not clean or disinfect the glucometer, obtained the resident's finger stick blood specimen, and then returned the glucometer to the case without cleaning or disinfecting the glucometer. There was not any visible blood contamination on the glucometer at that time. 2. On 8/11/10 at 8:19 a.m., licensed nurse "BB" cleaned the glucometer with only an alcohol prep pad before obtaining a finger stick blood sugar level for resident "A." After obtaining the resident's finger stick blood sugar level, licensed nurse "BB" returned the glucometer to the case without cleaning or disinfecting it. 3. On 8/11/10 from 10:17 a.m. to 11:49 a.m., licensed nurse "AA" failed to clean and disinfect the glucometer used between residents "B", #3, and "D." 4. On 8/11/10 at 11:45 a.m., licensed nurse "EE" failed to clean and disinfect the glucometer before and after obtaining a finger stick blood sugar level for resident "I". There was not any visible blood contamination on the glucometer at that time. 5. During an observation of fingerstick blood sugar monitoring on 8/11/10 from 11:53 a.m. to 11:56 a.m., licensed nurse "FF" failed to clean and disinfect the same glucometer between residents "J" and #18. There was not any visible blood contamination on the glucometer at those times. 6. During an observation of a fingerstick blood sugar monitoring for resident "G"on 8/11/10 at 11:00 a.m., licensed nurse "BB" cleaned the glucometer before and after use with an alcohol wipe only. There was no visible blood contamination on the glucometer. 7. During an observation of a fingerstick blood sugar monitoring for resident "H" on 8/11/10 at 11:07 a.m., licensed nurse "BB" cleaned the glucometer before and after use with an alcohol wipe only. There was no visible residue on the glucometer. 8. On 8/11/10 at 11:15 a.m., licensed nurse "CC" failed to clean and disinfect the glucometer before obtaining a finger stick blood sugar level between residents "E" and "F". Licensed nurse "CC" removed the glucometer from the case, did not clean or disinfect the glucometer, obtained the residents' finger stick blood specimens, and then returned the glucometer to the case without cleaning or disinfecting it. There was not any visible blood contamination on the glucometer at that time. 9. During an observation of medication administration for resident "A" on 8/11/10 at 8:19 a.m., licensed nurse "BB" failed to wear gloves when administering 4 units of [MEDICATION NAME] R to the resident. 10. During an observation of medication administration for resident "D" on 8/11/10 at 11:57 a.m., licensed nurse "AA" failed to wear gloves when administering 4 units of [MEDICATION NAME] R insulin to the resident. The facility provided an acceptable Credible Allegation of Compliance on 8/11/10 which included the following: 1. The Administrator and Director of Nursing (DON) consulted and corroborated with the Medical Director to revise the policy and procedures for effective cleaning and disinfecting of glucometers. Completed 8/11/10. 2. The DON met with the RN managers for each floor and instructed them on the revised policy and procedures for cleaning and disinfecting glucometers before and after each use, and between each resident. Completed 8/11/10. 3. The DON and RN managers initiated the revised policy and procedures by having the RN managers perform a demonstration of the proper cleaning and disinfecting of glucometers. Completed 8/11/10. 4. The RN managers had the licensed nurses demonstrate the correct procedures and then made observations of the licensed nurses performing the procedures. Completed 8/11/10. 5. In-service education was conducted to all licensed nurses on duty. All licensed nurses scheduled to work the 11 p.m. to 7 a.m. shift were to be educated prior to conducting any glucometer testing. Licensed nurses would not be assigned to perform blood glucose testing for residents until they had been educated and demonstrated skill proficiency in the revised policy and procedures. Completed 8/11/10. 6. Weekend nursing staff and staff not on-duty during the survey would be in-serviced and compliance verified by demonstration no later than Monday, August 16, 2010. 7. The revised policy and procedures were included in the Orientation program for all newly hired licensed nurses. Completed 8/11/10. 8. The DON was assigned to guide the compliance monitoring. The RN managers and RN weekend supervisor were instructed to conduct daily compliance monitoring. The monitoring would be done at least weekly for the next three months. Implemented 8/11/10. 9. All compliance monitoring would be reviewed by the Administrator and presented to the Quality Assurance committee. Implemented 8/11/10. In a telephone interview on 8/12/10 at 9:20 a.m., the 11 p.m. to 7 a.m. licensed nurse stated that she had been in-serviced last night (8/11/10) and was able to verbally demonstrate the effective procedures to use to clean and disinfect the glucometer. In a telephone interview on 8/12/10 at 10:30 a.m., the 3 p.m. to 11 p.m. licensed nurse stated that she had been in-serviced last night (8/11/10) and was able to verbally demonstrate the effective procedures to use to clean and disinfect the glucometer. Observations of licensed nurse "EE" on 8/12/10 at 11 a.m. revealed that she effectively cleaned and disinfected the glucometer prior to obtaining the blood glucose level for resident "I." Observations of licensed nurse "FF" on 8/12/10 at 11:15 a.m. revealed that she effectively cleaned and disinfected the glucometer prior to obtaining the resident #18's blood glucose level. Observations of licensed nurse "GG" on 8/12/10 at 11:50 a.m. revealed that he effectively cleaned and disinfected the glucometer prior to obtaining resident #15's blood glucose level and before obtaining the blood glucose level for resident "K". The facility provided documentation of the instruction and supervised return demonstrations for effectively cleaning and disinfecting glucometers for licensed nurses "EE", "FF", "GG," and for the licensed nurses who were interviewed by telephone. Therefore, it was determined that the immediate jeopardy was removed on 8/12/10 and the scope and severity was lowered to an "E" level. However, the facility remains out of compliance in order to ensure that licensed nursing staff continues to implement the correct procedures to clean and disinfect blood glucose testing machines; that supervisory nursing staff continues to monitor to ensure that blood glucose testing machines are clean and disinfected with an EPA approved germicidal disinfectant which is labeled effective against blood borne pathogens; and that the Quality Assurance committee monitors the facility's interventions to ensure that the infection control policies and procedures are implemented as planned.

Based on observation, staff interview, and review of the facility's infection control policies and procedures, it was determined that the facility failed to be administered in a manner that ensured that the policy and procedures developed and implemented for the care of blood glucose testing machines were effective against infections including influenza,[MEDICAL CONDITION].[MEDICAL CONDITION], and [MEDICAL CONDITION]; failed to ensure that five nurses were trained and implemented effective procedures to clean and disinfect glucometers between use for 12 of 42 residents whose blood glucose levels were monitored by fingersticks. An immediate jeopardy was identified on August 11, 2010 after observations of blood glucose testing revealed that the licensed nursing staff failed to effectively clean and disinfect glucometers between use by five nurses for 12 residents ( #3, #5, #18, "A", "B", "D", "E", "F","G", "H", "I" and "J"). It was determined by interviews with licensed nurses and the Director of Nurses, and observations of glucose monitoring with the glucometer of five nurses for nine residents on August 12, 2010 that the immediate jeopardy had been removed. Findings include: 1. The facility failed to develop and implement a policy and procedures for the effective cleaning and disinfecting of blood glucose testing machines. Based on an interview with licensed nursing staff, the plan to use alcohol pads for the cleaning and disinfecting of glucometers was not an EPA approved germicidal. See F441 for additional information. 2. The facility failed to maintain an Infection Control program that ensured proper infection control and the provision of aseptic techniques to prevent cross contamination and indirect contact transmission of a blood borne infection or a microscopic pathogen by failing to ensure that five licensed nurses were trained and implemented effective procedures to clean and disinfect glucometers for 12 of 42 diabetic residents who required fingersticks for blood glucose level monitoring. See F441 for additional information. The facility provided an acceptable Credible Allegation of Compliance on 8/11/10 which included the following: 1. The Administrator and Director of Nursing (DON) consulted and corroborated with the Medical Director to revise the policy and procedures for effective cleaning and disinfecting of glucometers. Completed 8/11/10. 2. The DON met with the RN managers for each floor and instructed them on the revised policy and procedures for cleaning and disinfecting glucometers before and after each use, and between each resident. Completed 8/11/10. 3. The DON and RN managers initiated the revised policy and procedures by having the RN managers perform a demonstration of the proper cleaning and disinfecting of glucometers. Completed 8/11/10. 4. The RN managers had the licensed nurses demonstrate the correct procedures and then made observations of the licensed nurses performing the procedures. Completed 8/11/10. 5. In-service education was conducted to all licensed nurses on duty. All licensed nurses scheduled to work the 11 p.m. to 7 a.m. shift were to be educated prior to conducting any glucometer testing. Licensed nurses would not be assigned to perform blood glucose testing for residents until they had been educated and demonstrated skill proficiency in the revised policy and procedures. Completed 8/11/10. 6. Weekend nursing staff and staff not on-duty during the survey would be in-serviced and compliance verified by demonstration no later than Monday, August 16, 2010. 7. The revised policy and procedures were included in the Orientation program for all newly hired licensed nurses. Completed 8/11/10. 8. The DON was assigned to guide the compliance monitoring. The RN managers and RN weekend supervisor were instructed to conduct daily compliance monitoring. The monitoring would be done at least weekly for the next three months. Implemented 8/11/10. 9. All compliance monitoring would be reviewed by the Administrator and presented to the Quality Assurance committee. Implemented 8/11/10. Therefore, it was determined that the immediate jeopardy was removed on 8/12/10 and the scope and severity was lowered to an "E" level. However, the facility remains out of compliance in order to ensure that licensed nursing staff continues to implement the correct procedures to clean and disinfect blood glucose testing machines; that supervisory nursing staff continues to monitor to ensure that blood glucose testing machines are clean and disinfected with an EPA approved germicidal disinfectant which is labeled effective against blood borne pathogens; and that the Quality Assurance committee monitors the facility's interventions to ensure that the infection control policies and procedures are implemented as planned.