Every finding on record at NHC Healthcare Ft Oglethorpe

Based on staff interviews, record review, and review of facility policy, the facility failed to ensure residents reviewed for accuracy of medical records had active physician orders for respiratory care and current pressure ulcer status for one of one resident (Resident (R) 36) reviewed for respiratory care and one of two residents (R22) reviewed for pressure ulcers out of a total of 30 residents in the sample. The deficient practice had the potential for facility residents to not receive appropriate care and services to meet their needs for oxygen usage and wound care treatment.Findings include:Review of the facility's policy titled, Respiratory Manual, dated July 2019, revealed The purpose of delivering oxygen by nasal cannula is to.correct hypoxemia by increasing available alveolar oxygen.diminish the myocardial workload by correcting hypoxemia. Check for a complete physician order.Review of the facility's policy titled, Documentation Guidelines, dated May 2025, revealed Medications and Treatments are administered based on provider orders. Medications and Treatments are documented in the EHR (electronic health record). The nurse/medication technician administering the medication is responsible for assuring: right patient, right medication, right dose, right route, right time. Skin assessments (2) Ongoing skin assessment: All patients' skin is assessed on a weekly basis by a licensed nurse, and findings are documented in the Weekly Skin Observations.1. Review of R36's Face Sheet, located in the electronic medical record (EMR) under the Face Sheet tab, revealed R36 was admitted to the facility with diagnoses that included but not limited to malignant neoplasm of ampulla of [NAME], centrilobular emphysema, and peripheral vascular disease.Review of R36's five day Minimum Data Set assessment MDS located in the MDS tab in the EMR with an Assessment Reference Date ARD of 9/3/2025, revealed a Brief Interview for Mental Status BIMS assessment with a score of thirteen out of 15, which indicated little or no cognitive impairment. The resident was revealed to require the use of intermittent oxygen therapy.Review of R36's Physician Orders, located in the EMR under the Resident tab, revealed there was no specific physician order, nor standing physician order, to identify the required liters per minute (LPM) of oxygen required for R36.Review of R36's Care Plan, initiated on 8/28/2025 and located in the EMR under the Care Plan tab, revealed the resident was at risk for respiratory complications secondary to centrilobular emphysema, anemia and a history of smoking. The goal was to minimize the risk of respiratory complications through the next review. An approach included to administer medications as ordered.During an observation on 9/24/2025 at 3:50 PM, R36 was observed in his room with his oxygen concentrator in use at 3 LPM.During an observation on 9/25/2025 at 7:45 AM, R36 was observed in his room with his oxygen concentrator in use at 3 LPM.During a concurrent interview on 9/25/2025 at 7:50 AM, Registered Nurse (RN)1 and Nurse Practitioner (NP) stated that they had a standing order for two to four LPM for residents, that should be added to the EMR on admission. RN1 confirmed the standing physician order was not in the EMR for R36, and that it should have been added to his physician order. She stated that the nurses rely on the EMR during medication administration. During an interview on 9/26/2025 at 8:10 AM, RN3 stated that when a resident was receiving oxygen, they would refer to the physician orders in the EMR to determine the appropriate LPM for the resident.During an interview on 9/26/2025 at 8:50 AM, the Director of Nursing stated that oxygen orders showing the LPM should be in the EMR for each resident. At 10:31 AM, she confirmed that a complete and accurate EMR for a resident would ensure all physician orders were documented.2. Review of the admission Record located under the Resident tab under the Face Sheet section revealed R22 admitted with diagnoses of but not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, pressure ulcer of sacral region, stage IV and pressure injury of deep tissue right heel. Review of the quarterly MDS with and ARD of 8/19/2025 indicated R22 had a BIMS of 13 of 15, indicating she was cognitively intact. Section M (Skin Condition) indicated R22 had one unhealed stage III wound that was present upon admission, one stage IV wound that was present upon admission and one unstageable wound that was present upon admission. Review of the admission Observation dated 2/26/2025 located under the Resident tab under Observations revealed R22 was admitted with a sacral pressure ulcer. Review of the admission Observation dated 6/3/2025 located under the Resident tab under Observations did not reveal R22 readmitted with any pressure wounds. Review of the Weekly Skin assessment dated [DATE] located under the Resident tab under Observations in the EMR revealed R22's pressure injury stage IV healed and R [right] heal some redness.Review of the Weekly Skin assessment dated [DATE] located under the Resident tab under Observations in the EMR did not reveal R22 had any pressure wounds. Review of the Weekly Skin assessment dated [DATE] located under the Resident tab under Observations of the EMR did not reveal R22 had any pressure wounds. Review of the Weekly Skin Observation dated 9/23/2025 indicated that R22 did not have any wounds or open areas. During an interview on 9/24/2025 at 4:07 PM, LPN4 stated R22 had a sacral wound and a wound on her right heel. During an interview and record review on 9/25/2025 at 10:30 AM, the DON stated R22 still had wounds. She stated LPN1 was a new nurse and did not completely understand how to complete the weekly skin assessments.During a phone interview on 9/25/2025 at 4:26 PM, LPN1 stated she received education regarding how to complete weekly skin assessments. These assessments include a full head to toe assessment. She stated she did not think she was supposed to document old wound data on the weekly skin assessments.During an interview on 9/26/2025 at 7:46 AM, the Assistant Director of Nursing (ADON) stated the weekly skin assessments should include documentation regarding all skin issues. She stated the nurses could make a note to reference wound management notes in the EMR/treatment in place. Her expectation was for the weekly skin assessments to reflect any current and ongoing skin issues. During an interview on 9/26/2025 at 10:28 AM, the DON stated her expectation was for the licensed nurses to document on the weekly skin assessments if there was a dressing intact, document if the resident had an existing wound and to refer to the wound management section of the EMR. She stated the dressing should only be changed if they are visibly soiled. The DON stated she expected the nurses to accurately complete the skin assessments and reference any ongoing issues with the resident's skin to ensure the record was accurate.

Based on observations, record review, resident and staff interviews, and facility policy review, the facility failed to ensure catheter drainage bags were not in direct contact with the floor for one of one resident (Resident (R) 55) reviewed for catheters out of 32 sample residents. In addition, the facility failed to ensure staff performed adequate hand hygiene between residents during medication administration for three residents (R118, R48, and R54) reviewed for medication administration. These deficient practices had the potential to place residents at risk for the spread of infection and cross-contamination and created a risk for an increased potential for urinary tract infectionsFindings include:1. Review of the facility policy titled, MRSA (Methicillin-resistant Staphylococcus aureus) Recommendations by sited, dated February 2025 revealed, .under Patients with Urinary Catheters, indicated keep drainage bags off the floor., but below the level of the patients bladder.Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed that R55 was admitted to the facility with diagnoses that included but not limited to diabetes with neuropathy, hypertension and chronic obstructive pulmonary disease.Review of the 8/25/2025 Comprehensive Care Plan located in the Care Plan tab of the EMR revealed a problem that R55 was at risk for infections/complications due to the use of an indwelling catheter. Review of the EMR revealed that R55 had completed a course of antibiotics due to a urinary tract infection. Review of the Urinalysis, Reflex Microscopic and Culture collected on 9/13/2025 indicated an Escherichia Coli organism. Review of the Physicians Order revealed an order, dated 9/17/2025, for Macrobid 100 milligrams (mg) twice a day. Review of the Medication Administration Report for the Month of September 2025 revealed that R55 had completed a course of Macrobid (an antibiotic used to treat urinary tract infections) 100mg twice a day from 9/17/2025 - 9/23/2025. Observation on 9/25/2025 at 9:54 AM revealed R55's catheter drainage bag was lying directly on the floor. During an interview with Licensed Practical Nurse (LPN) 5, at time of observation, LPN5 confirmed that the catheter drainage bag was lying directly on the floor and should not have been lying on the floor. Interview with the Director of Nursing (DON) on 9/26/2025 at 9:03 AM revealed that the R55's catheter drainage bag should be below the level of the resident's bladder and not lying directly on the floor. 2. Review of the facility's policy titled, Hand Hygiene Policy, dated February 2025, revealed, under Purpose To decrease the number of microorganisms, preventing cross contamination between staff and patients. And under Procedure Provide hand hygiene before and after contact with each patient.Review of the facility's policy titled, Medications Administration -General Guidelines revision date 2/25/2025, revealed under Procedures. item 2: .hand washing refers to washing hands with soap and water. or thoroughly applying an alcohol-based hand rub.The person administering medications adheres to good hand hygiene.after coming into direct contact with a resident. Item 4. Before administering a medication.Observation during medication administration on 9/25/2025 at 7:43 AM revealed Licensed Practical Nurse (LPN) 5 did not don (put on) gloves or perform hand hygiene prior to pouring and administering medications, nor did she perform hand hygiene between R 118, R 48, and R 54. Observation on 9/25/2025 at 6:44 AM revealed LPN5 did not don gloves and did not wash or sanitize her hands prior to pouring and administering R118's morning medications.Observation on 9/25/2025 at 7:19 AM revealed LPN5 did not don gloves and did not wash or sanitize her hands between R118 and (R) 48 and did not wash or sanitize her hands prior to pouring and administering (R) 48's morning medications.Observation on 9/25/2025 at 7:43 AM revealed LPN5 did not don gloves and did not wash or sanitize her hands between R48 and R54 and did not wash or sanitize her hands prior to pouring and administering R54's morning medications. Interview with LPN 5 9/25/2025 at 7:43 AM confirmed that she had not washed or sanitized her hands between residents and did she don gloves or wash and sanitize her hands prior to pouring and administering the resident's morning medications. Interview with the Director of Nursing (DON) on 9/26/2025 at 9:03 AM revealed that her expectation were staff should adhere to the facilities hand hygiene policy. The DON confirmed that facility's hand washing policy required staff to perform hand hygiene when coming into contact with a resident and before administering medication.Review of R58's Face Sheet, located in the EMR under the Face Sheet tab, revealed R58 was readmitted to the with diagnoses that included but not limited to benign prostatic hyperplasia with lower urinary tract symptoms, retention of urine, and overactive bladder. Review of R58's five day MDS located in the MDS tab in the EMR with an ARD of 7/10/25, revealed a BIMS assessment with a score of nine out of 15, which indicated moderate cognitive impairment. The resident was revealed to require the use of an indwelling catheter. Review of R58's Physician Orders, located in the EMR under the Resident tab, revealed, Indwelling urinary catheter.for diagnosis of benign prostatic hyperplasia with urinary retention.Review of R58's Care Plan, initiated on 7/4/2025 and located in the EMR under the Care Plan tab, revealed the resident was at risk for infection related to comorbidities and foley catheter. The goal was for complications related to infection and treatment of infection minimized through the next review. Approaches included observing increased signs and symptoms of infection.During an observation on 9/23/2025 at 10:58 AM, R58 was observed in his room seated in his wheelchair. The resident's catheter bag was observed hanging directly underneath the wheelchair, the bag and tubing touching the floor. The resident was again observed at 11:22 AM in the facility hallway going down the hallway in his wheelchair, with his catheter bag and tubing dragging on the floor.During an observation on 9/24/2025 at 7:55 AM, R58 was observed in his room seated in his wheelchair. His catheter bag was observed touching the floor underneath his wheelchair. The resident was again observed at 8:33 AM with the catheter bag still touching the floor underneath his wheelchair.During an observation and interview on 9/24/25 at 8:35 AM, R58 was again observed seated in his wheelchair with his catheter bag touching the floor. The Infection Preventionist (IP) and Licensed Practical Nurse (LPN) 2, both stood at a medication cart outside R58's room. The IP stated the catheter bag should be off the floor. LPN2 also confirmed the catheter bag should be off the floor.During an interview on 9/24/2025 at 8:39 AM, R58 stated that his catheter tubing had been caught on his wheelchair in the past, and he knew it should not be touching the floor.During an interview on 9/26/2025 at 9:02 AM, the DON stated that catheter bags and tubing should be off the floor.

Based on interviews, record review, and facility policy review titled, Skin Integrity Manual, the facility failed to implement pressure injury interventions, including the removal of a resident's walking boot to perform daily skin checks, to prevent the development of unstageable pressure ulcers for one of three Residents (R) (R172) reviewed for pressure ulcers. This failure caused harm to R172 who developed three avoidable facility acquired unstageable pressure ulcers on her right foot, right heel, and right calf. Findings included: A review of the facility's policy titled Skin Integrity Manual, with a review date of January 2024, indicated, Steps in Prevention of Pressure Injuries Identification of patient at risk . Interventions and Strategies . Prevention Strategies Monitor for pressure when splints, casts, or braces are used Approach Inspect skin around and under splints and braces daily. Inspect skin around edges of cast daily. Report odors emanating from under cast or complaints of pressure or pain to physician. Additional Guidelines Teach CNA [Certified Nurse Aide], patient, and family techniques to observe/monitor when possible. 1. A review of R172's Face Sheet, located in the Resident tab of the electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE] with diagnoses which included major depressive disorder, dementia with anxiety, and fractures of her right tibia, right fibula, and the third, fourth, and fifth right metatarsals which were diagnosed on [DATE].The resident was discharged from the facility on 9/15/2023. A review of R172's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 7/03/2023, provided by the facility, revealed a Brief Interview for Mental Status (BIMS), was not conducted for this assessment. The MDS specified R172 had short-term and long-term memory problems, severely impaired cognitive skills for daily decision making, had not rejected care, required extensive assistance with two or more persons physical assist with bed mobility, required extensive assistance with one-person physical assistance with dressing, experienced a fall with major injury since her prior MDS assessment, was at risk of developing ulcers/injuries and had one or more unhealed pressure ulcers/injuries. A review of 172's Care Plan, provided by the facility, revealed a Problem, with a start date of 5/24/2021, which specified, I am at risk for pressure ulcers and currently have a stage III pressure injury on my coccyx R/T [related to] incontinence, weakness, decreased mobility, and poor intake, declining health, incontinence. The care plan's goal specified My skin will remain intact and my current pressure ulcers will show signs of improvement. Care plan approaches, with a start date of 5/24/2021, specified Report any signs of skin breakdown (sore, tender, red, or broken areas) and Avoid shearing resident's skin during positioning, transferring, and turning. A review of R172's Braden Scale for Predicting Pressure Sore Risk, dated 7/30/2023, completed by Licensed Practical Nure (LPN)4 and provided by the facility, indicated, R172 was at High Risk for pressure sores. During an interview on 4/25/2024 at 10:33 am, R172's family member voiced concerns that R172 developed wounds on her right leg and foot in September 2023 which were acquired while she was a resident at the facility. A review of R172's Orthopedics consultation, dated 8/18/2023, provided by the facility, indicated, Order Information . Displaced [NAME] fracture of right tibia, subsequent encounter for closed fracture with routine healing *Instructions to Assisted Living Home* Note to provider: Daily wound checks. Padding over bony prominences. Patient is to wear cam walker boot for support. A review of a Progress Note, dated 8/21/2023 at 4:50 pm and written by LPN4 located in R172's EMR, specified, Patient out for follow up with ortho on 8/18/2023 for fractures of right foot. Non removable splint removed, and removable boot applied. Boot removed and foot assessed by this nurse. Wound that was present to heel has healed. Foot, ankle, and lower leg are very dry. No other wounds noted. NP [Nurse Practitioner] notified of wound healing. [R172's family member], notified of wound healing. A review of R172's physician's orders, provided by the facility, revealed an order dated 8/22/2023, which indicated, Pt (patient) to wear CAM walker boot for support as tolerated. Assess skin integrity when donning [putting on]/doffing [taking off]. A review of R172's EMR revealed no documentation of the staff's assessment of the resident's skin integrity when donning and doffing the resident's walking boot. During an interview on 4/25/2024 at 9:50 am CNA3 stated she cared for R172 when she had the walking boot applied to her right foot in September 2023. CNA3 stated R172 was dependent on staff for Activities of Daily Living (ADL) care. During further interview on 4/25/2024 at 1:00 pm, CNA3 stated staff did not remove R172's walking boot daily to perform skin checks on the resident's right leg and foot. CNA3 explained R172's walking boot was removed and the skin on her right leg and foot was checked three times per week on the resident's bath days. CNA3 stated she did not recall observing any concerns with the skin integrity of R172's right leg and right foot that needed to be reported to the nurse prior to 9/08/2023. During an interview on 4/25/2024 at 12:35 pm, LPN2 who cared for R172 stated the resident wore a walking boot, but it was not removed daily to check her skin on her right leg and foot. LPN2 explained the CNAs removed R172's walking boot three times per week on her bath days and were to observe the skin on her right foot and leg on these three days. LPN2 stated no concerns regarding the skin integrity on R172's right leg and foot were brought to her attention prior to 9/08/2023. During an interview on 4/25/2024 at 1:48 pm, the facility's current Director of Nursing (DON) stated on 8/22/2023 a physician's order was written for R172 to wear a walking boot on her right leg and the order specified for staff to perform skin integrity checks when donning and doffing the boot. The DON confirmed the physician order did not specify when staff were to remove the boot to perform skin checks and there was no documentation in the resident's EMR of skin checks to resident's right leg and foot when staff donned and doffed the boot. The DON stated the staff did not perform daily skin checks on R172. The DON explained the staff would have removed the walking boot from R172's right foot three times per week on the resident's bath/shower days and performed skin checks on these dates. The DON stated R172's skin checks were completed and documented weekly by the facility's treatment nurse. A review of R172's Weekly Skin Observation, dated 9/01/2023, provided by the facility, indicated, the resident did not have any Wounds, Open, or Red Areas on her right leg or foot. A review of R172's Weekly Skin Observation, dated 9/08/2023, provided by the facility, indicated, the resident had wound/opened/red area to right leg and right foot. The skin observation specified, Wound back of R [right] leg and R foot. A review of R172's Progress Note, dated 9/08/2023 at 2:22 pm, located in the EMR and written by the facility's former DON, indicated, This nurse, wound care nurse and MD called and spoke with [R172's family member] via phone. Informed [R172's family member] of wounds caused by Boot. MD not happy with Boot, new wounds and general current resident condition. [R172's family member's name] agrees with IDT [Interdisciplinary] team about leaving boot off per MD recommendation. MD recommending hospice, r/t poor nutritional intake and overall resident decline. [R172's family member's name] agreed with need for hospice as resident has been on hospice previously . A review of R172's Wound Management Detail Report, dated 9/08/2023, completed by LPN4 and provided by the facility, indicated the resident had an unstageable pressure ulcer on the top of right foot which measured 4.5 centimeters (cm) (length) by 4.2 cm (width), an unstageable pressure ulcer on the right calf which measured 3 cm (length) by 1.5 cm (width), and an unstageable pressure ulcer on the right heel which measured 15 cm (length) by 6.5 cm (width). The report specified, Wound assessed at this time after cam boot removal. Area appears to be from rubbing against inside of cam boot. Noted dry eschar. No bogginess noted. No soft areas noted . No c/o pain or discomfort. Foot elevated on pillows. Poor intake noted. Remains non weight bearing to RLE [right lower extremity]. During an interview on 4/25/2024 at 11:57 am, LPN4 stated she was familiar with R172 and was the facility's treatment/wound care nurse in September 2023 when R172 developed pressure sores on her right foot, heel, and calf. LPN4 explained in September 2023, R172 wore a hard-shelled walking boot on her right foot which had Velcro straps which made it removeable. LPN4 stated on 9/08/2023 R172's right foot walking boot was removed, and she observed new unstageable wounds on the resident's right calf, right heel and right foot which contained necrotic tissue and eschar. LPN4 stated she notified the resident's physician of these new wounds on 9/08/2023. LPN4 reviewed R172's EMR and confirmed on 9/08/2023the resident's right heel wound measured 15 cm by 6.5 cm, the right top of foot wound measured 4.5 cm by 4.2 cm, and the right calf wound measured 3 cm by 1.5 cm. LPN4 explained R172 did not have any wounds to her right heel, calf, and foot on her prior weekly skin assessment. LPN4 stated no concerns were brought to her attention regarding R172's skin integrity on her right calf, heel, and foot during the week prior to her performing the resident's weekly skin assessment on 9/08/2023. A review of R172's Physician Observation Detain List Report, dated 9/08/2023at 1:43 pm, provided by the facility, indicated, Acute visit to [R172]. She is a long-term resident, but I was asked to see her today in [sic] urgent basis. Present at this time with Wound Care Nurse and Director of Nursing at [sic] also present was the patient's floor nurse for the day he will also be here over the weekend. I was asked to look at her right foot. She had a recent fracture two months ago and initially was treated with casting after which she was placed in walking type boot. At the time of the removal of the cast she had a heel DTI [deep tissue injury] which had resolved completely, and the foot was nice and pink. The foot was cool but not cold. There are also new DTI's at the location between the leg and the foot and a large 1 at the heel and another 1 further up the leg medially. These were all new. It appeared that the gauze which had been used to pad the foot from the boot had migrated and caused compression and decrease in her no blood supply to the distal one third or more of the foot. A review of R172's Nurse Practitioner's (NP) Observation Detail List Report, dated 9/11/2023at 1:53 pm, provided by the facility, indicated, [AGE] year-old long term resident is seen today in follow up. She was evaluated by [MD name] on Friday for ischemia and necrosis in her right foot. I am told there was a discussion between her, the DON, and [MD's name] regarding how to proceed with potential follow-up, evaluation, treatment or remove her to hospice given her frailty, poor nutritional status . When questioned regarding pain she nods her head no. She has minimal movement of her right lower extremity, most likely due to diminished range of motion with recent fractures. She denies fever, chills, or any other constitutional symptoms at this time. Full exam as noted below. On exam right foot and toes do not appear to be tender to light palpitation. Staff report no other issues at this time. During an interview on 4/25/2024 at 1:20 pm, the NP who cared for R172 stated the resident was dependent for ADL care and she observed the wounds on the resident's right calf, heel and foot in September 2023. The NP stated when she observed the resident's wounds, they were necrotic. The NP confirmed R172's physician's order dated 8/22/2023, for donning and doffing the walking boot and performing skin checks was not specific to when staff were to perform skin checks. The NP stated she would refer to ortho regarding when staff were to remove and apply the boot and when to perform the resident's skin checks. The NP stated R172 was in and out of Hospice care, very debilitated and frail, and had very poor nutritional status which made wound healing very difficult.

Based on interview, record review, and facility policy review titled, Falls Program, the facility failed to ensure staff provided adequate supervision and assistance device to prevent falls for one of seven Residents (R) (R172) residents reviewed for falls out of a total sample of 31 residents. This failure resulted in harm to R172 who fell in the shower room, while being assisted by only one Certified Nurse Aide (CNA), and as a result she sustained fractures to her right foot, right tibia, and right fibula. Findings included: A review of the facility's policy titled, Falls Program, dated January 2024, indicated, Purpose: To identify patients at risk for falling and to implement the appropriate interventions. Objective: To reduce the patients' risk of falling and related injuries. 1. A review of R172's Face Sheet, located in the Resident tab of the electronic medical record (EMR) revealed the resident was admitted to the facility in 2018 with diagnoses which included history of falling, major depressive disorder, and dementia with anxiety. A review of R172's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 4/06/2023, provided by the facility, revealed a Brief Interview for Mental Status (BIMS), score of two out of 15 which indicated severe cognitive impairment. The MDS also specified that R172 required extensive assistance with two or more persons physical assist with transfers, requiring total assistance with bathing, and was not steady, and only able to stabilize with staff assistance when she moved from a seated to sanding position and during surface-to-surface transfers. A review of 172's Care Plan, located under the RAI 3.0 tab of the EMR, revealed a Problem, with a start date of 9/09/2019, which specified, I am at risk for falls weakness, r/t [related to] declining health, incontinence. The care plan's goal specified I will remain free from injury from fall. Another care plan indicated Problem with a start date of 11/18/2019, specified Limited ability to perform self-care tasks. A care plan approach, with a start date of 12/19/2019, specified, Assist with transfer using: Hoyer lift. A review of a Progress Note, located in the R172's EMR, written by Licensed Practical Nurse (LPN)2 dated 6/14/2023 at 10:19 am, indicated, [Recorded as late entry on 6/14/2023 10:26 pm] Approximately 9:10 am a CNA doing showers alert this nurse for assistance in the shower room. Upon entering this nurse observed the patient in the floor by the grab bar and shower chair. CNA stated, she was sliding down, and I lowered her to the floor. No apparent injuries were noted an [sic] patient denied any pain or injuries. This nurse found the other CNA's and assessed, and they assisted patient back to the shower chair. Intervention should be a Hoyer lift, due to patient not being able to help staff with the transfers. During an interview on 4/25/2024 at 10:33 am, R172's family member voiced a concern that staff dropped R172 on 06/14/23 while providing her with a shower which resulted in the resident's right foot being broken. During an interview on 4/24/2024 at 3:10 am, LPN2 stated she cared for R172 and was on duty on 6/14/2023 when R172 fell in the shower room. LPN2 stated R172 was dependent on staff for care and required two staff to assist with transfers. The LPN explained on 6/14/2023 she heard the CNA10 yell from the shower room door that R172 had fallen. LPN2 stated when she entered the shower room, she observed R172 on the floor and CNA10 was the only staff member with the resident in the shower room. LPN2 stated R172 did not exhibit any signs or symptoms of pain and she was saying Get me off the floor. LPN2 stated she assessed R172 from head to toe for injuries and the resident had no apparent injuries. LPN2 stated she worked the following week and was informed R172 was complaining of right foot pain and an x-ray was ordered. The x-ray revealed the resident had a broken right foot. During an interview on 4/25/2024 at 9:50 am CNA3 stated she cared for R172 and worked on 6/14/2023 when R172 fell in the shower room. CNA3 stated R172 was dependent on staff for care and required total assistance for transfers with two staff and a Hoyer lift. CNA3 stated when R172 fell on [DATE] she heard CNA10 yelling for help in the shower room. CNA3 explained when she entered the shower room, she observed R172 lying on the floor. CNA3 stated R172 was not exhibiting any outward signs of pain but was asking to get off the floor. CNA3 stated the next time she worked with R172 was the following week and she observed bruising on R172's right heel and reported the bruising to LPN2. During an interview on 4/25/2024 at 9:53 am, CNA4 stated she cared for R172 and worked on 6/14/2023 when R172 fell in the shower room. CNA4 stated R172 required total assistance with ADL care but could feed herself with set up. CNA4 explained R172 required two staff with a lift for transfers. CNA4 stated that R172 was at risk of falling and should not be transferred by only one staff member. CNA4 stated on 6/14/2023 she observed the emergency light in the shower room activated and when she entered the shower room, she observed R172 on the floor with one other staff present. CNA4 stated R172 was not exhibiting any signs of pain but was asking the staff present to Get me up. A review of the Progress Note, located in R172's EMR, written by LPN1 dated 6/22/2023 at 5:11 PM, indicated, Wound care nurse noted bruising to the patient's right foot and ankle during dressing change. Patient did have a previous fall on 6/14/2023 with no noted injuries at that time. This nurse reported bruising to NP [Nurse Practitioner] immediately with orders to do an X-RAY stat [immediately]. XRAY showed Tibia/Fibula FX [fracture] and three metatarsal FX's. Family notified and very upset. NP gave order to send to [Hospital] for FX's. A review of R172's 6/22/2023 Emergency Department records, located in the resident's EMR, indicated, Patient presents to the ED [Emergency Department] via EMS [Emergency Medical Services] . Patient has a history of dementia and is unable to contribute to the history. Patient was sent to the emergency room after having a mobile x-ray today that showed multiple fractures, subacute in her foot and ankle. EMS reported a fall several days ago. Patient does not know what happened. I spoke with a nurse [name] at [name is facility] and she read documentation from a fall on 6/14/2023. She states it occurred while the patient was getting a shower in the shower chair and the nurse turned around and the patient was on the floor near the grab bar. Patient is non ambulatory. X-rays reviewed. Splint placed with outpatient f/u [follow up] with center for sports medicine. A review of the facility's investigation of R172's fall on 6/14/2023, provided by the facility, specified, On 6/14/2023, patient [R172's name] was taken to shower room by CNA. At approximately 9:10 am, [LPN 2] stated that CNA asked for assistance in the shower room. LPN stated that patient was in the floor by the grab bar/shower chair. CNA stated that she lowered the patient to the floor. Patient contact [R172's family member] contacted with no answer, voice mail left. Patient noted to have bruising/swelling to right foot on 6/22/2023, X-ray ordered. Subacute fractures noted to third, fourth and fifth metatarsal necks, Subacute fractures to distal tibia/fibula, Osteopenia and soft tissue swelling. Patient sent to [Hospital] on 6/22/2023 and returned on 6/23/2023 with splints and a follow-up at the center for Sports Medicine. A review of the Post Fall Checklist completed by LPN2 specified, Slid out of shower chair and was lowered to the floor. and Educate staff on Hoyer lift for transfers. Review of the Fall Scene Investigation (FSI) specified, Aide giving shower, attempted to stand patient for transfer. The patient could not stand and began sliding and was lowered to the floor. The FSI also specified Not enough assistance or correct assistance was the root cause of the fall. During an interview on 4/25/2024 at 11:30 am, the current Director of Nursing (DON), stated she was not familiar with R172. The DON reviewed R172's EMR and confirmed the resident experienced a fall in the shower room on 6/14/2023 when being assisted by only one CNA. The DON stated the documentation in R172's EMR reflected the resident did not experience additional falls or accidents between 6/14/2023 and 6/22/2023 when the resident was found to have fractures of her right tibia, right fibula, and right foot. During an interview on 4/25/2024 at 1:20 pm, the Nurse Practitioner (NP) stated she was familiar with R172. The NP stated R172 was dependent on staff for ADL care including mobility and did not complain of having pain. The NP specified that R172 could have experienced fractures from the fall on 6/14/2023 and not complained of pain during the following week without experiencing another incident. During an interview on 4/25/2024 at 6:10 pm, the Administrator confirmed on 6/14/2023 R172 experienced a fall in the shower room while being assisted by only one CNA which resulted in fractures.

Based on observations, record reviews, and staff interviews, the facility failed to ensure that direct care nursing staff were evaluated to provide competent nursing care for the residents, by not completing competency/skills checklist for three Licensed Practical Nurses (LPN) and one Registered Nurse (RN). Findings include: Review of facility documentation titled Annual Nursing Competencies Check-Offs, revealed in-service education for nursing personnel were not signed and dated to indicate the personnel completed the trainings to ensure quality care of the residents. The facility was unable to provide annual competencies that were signed and dated for the following randomly selected staff: LPN GG, LPN CC, LPN PP and RN OO. Interview on 10/12/22 at 9:25 a.m. with Certified Nursing Assistant (CNA) NN revealed she has worked at this facility for about four weeks, she has not received any orientation training. She further revealed she shadowed another CAN for one week after being hired and was then assigned independent assignments. Interview on 10/11/22 at 4:43 p.m. with the Director of Nursing (DON) revealed there is currently not a training program or skills checkoff for agency staff when they work at the facility. Interview on 10/11/22 at 8:30 a.m. with CNA NN revealed She stated she doesn't recall receiving any training on dementia care. Interview on 10/11/22 at 8:35 a.m. with CNA II revealed she has been there for four years, and she receives all of her trainings on the online system, but it's been a while since she has done anything on dementia. Interview on 10/11/22 at 9:15 a.m. with CNA KK, revealed she has been a CNA at the facility for five years and her last recollection of dementia training was with an online system about two years ago. Interview on 10/14/22 at 1:11 p.m. with Regional Nurse Consultant (RNC) revealed she was not able to find any additional competency evaluations for the staff selected for review.

Based on document review, facility policy review and interview, the facility failed to provide evidence of Registered Nurse (RN) coverage in the facility at a minimum of eight hours a day, seven days a week for the period of 8/21/22. This absence of RN coverage could have a negative impact on all residents residing at the facility. Findings include: Review of the facility's policy titled Nursing Services dated February 2022 revealed .Twenty-four-hour nursing service is provided by trained partners under the direction of a registered professional nurse who is responsible to the patient for the nursing services provided and accountable to the administration for all nursing outcomes. A registered professional nurse will be on duty 24 hours per day. In all cases there will be 8 consecutive hours of RN coverage a day, 7 days a week. Review of the facility's documents titled, NHC HealthCare Fort Oglethorpe Nursing Staffing dated 8/21/22 revealed there was lack of documentation of an RN being in the Skilled Nursing Facility (SNF) unit on duty a minimum of eight hours a day in a 24-hour period. During an interview on 10/12/22 at 4:20 p.m., the Director of Nursing (DON) confirmed that she had no documentation of RN coverage for the date with omissions identified during the above stated time period.

Based on record review and staff interviews, the facility failed to provide adequate documentation of outbreak testing for COVID-19 in a manner consistent with current standards of practice for all staff on dates 1/3/22 and 1/4/22 for outbreak that started on 12/23/21. Findings include: An interview with the COVID-19 Testing Coordinator/Receptionist on 10/13/22 at 3:15 p.m. revealed that when staff came into test, they were to write down their name and once they tested and the results were provided to her, she entered the results into the National Healthcare Safety Network (NHSN) database. She stated that there was no other form used in this facility. Review of staffing sheets dated for 1/3/22, 1/4/22, and 1/5/22, revealed there were no call outs due to COVID-19 symptoms. Review of the screening log dated for 1/3/22 and 1/4/22, revealed that there were only three staff with symptoms. Only one staff had a note for a negative test. After several request from Director of Nursing and the Regional Nurse Consultant for testing logs, the facility failed to produce documentation that outbreak testing for staff was completed.

Based on observations, interviews, and review of the facility policy titled Medication Storage in the Facility, the facility failed to ensure that two of six medication carts (200 Hall Cart and 400 Hall Cart) were locked and secured when the cart was out of view of the nurse and failed to properly store medication for one of 30 Sampled residents (R) (R#66). Findings include: 1. Review of the facility policy titled Medication Storage in the Facility dated 1/1/19 revealed: 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. B. Only licensed nurses, pharmacy personnel and those lawfully authorized to administer medications are permitted to access medications. Medication rooms, carts and medication supplies are locked when not attended by persons with authorized access. An observation on 10/11/22 at 9:50 a.m. upon entry to the facility, revealed one medication cart on 200 Hall was observed to be unlocked and unattended. Licensed Practical Nurse (LPN) FF returned to the cart in two minutes, and she verified the cart was left unlocked. She further revealed she should always lock the cart when she leaves it and she stated she forgot to lock it. Floor construction was in progress and there were four construction workers in the immediate area. An observation on 10/11/22 at 10:05 a.m. revealed the same medication cart on 200 Hall to be unlocked and unattended for three minutes. The Assistant Director of Nursing (ADON) approached the cart, moved it and locked it. She revealed she moved the cart due to floor construction in progress. She verified the cart was unlocked and revealed it is her expectations for medication carts to be locked when unattended. LPN FF approached the cart in four minutes and verified she did leave the cart unlocked and unattended again. She further revealed she is nervous due to the construction, and she just forgot again. An interview on 10/11/22 at 10:15 a.m. with the Director of Nursing (DON) revealed it is her expectation for all medication carts to be locked when left unattended and it is each nurse's responsibility to lock them before walking away from them. An observation on 10/13/22 at 3:26 p.m. revealed one medication cart located on 400 Hall to be unlocked and unattended for four minutes. LPN PP returned to the cart and verified the cart was left unlocked and unattended. She revealed she was in a resident's room giving medication and that she forgot to lock the cart. An interview on 10/13/22 at 4:10 p.m. with the DON revealed her expectations are for the medication carts to be locked when unattended and it is the nurse responsibility to assure the cart is locked when unattended. She stated she would assure education was provided about locking medication carts and medication storage. 2. Review of the facility policy titled Medication Storage in the Facility dated 1/1/19 revealed: 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. A. The provider pharmacy dispenses medications in containers that meet regulatory requirement, including requirements of good manufacturing practices. Medications are kept in these containers. Transfer of medications from one container to another or return partially used medications to the original container is done only by the pharmacy. B. Only licensed nurses, pharmacy personnel and those lawfully authorized to administer medications are permitted to access medications. Medication rooms, carts and medication supplies are locked when not attended by persons with authorized access. C. All medications dispensed by the pharmacy are stored in the container with the pharmacy label. During an observation of gastric tube feeding for R#66 on 10/13/22 at 11:11 a.m., a medium size square plastic container with a label of Kirkland's Cashews was observed on R#66's shelf to contain an orange powder substance. The top of the lid of the container was labeled with R#66's name and the word Turmeric. On 10/13/22 at 11:12 a.m. an interview with LPN PP revealed the plastic container contained Turmeric powder for R#66 and that he receives it via his feeding tube as ordered. She further revealed she is unsure if it should be kept in the resident's room and stated it has always been kept in the room. She then produced a gallon size plastic bag from a bedside table drawer that contained a plastic bag with orange powder substance with a manufacture's label of Turmeric and she revealed the plastic container is filled from the plastic bag labeled Turmeric by the nurses. A record review of physician's orders revealed (not all inclusive): Boswellia and Turmeric powder 300mg 1 teaspoon (300mg) via gastric tube with meals. A clinical record review revealed that R#66 is a [AGE] year-old male admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed R#66 requires extensive assist for activities of daily living (ADLS) and is dependent for feeding. A review of the care plan revealed it does not address medications to be stored in resident room. An interview on 10/13/22 at 12:03 p.m. with the DON revealed it is her expectation for all medications to be stored securely in the medication carts or in the medication storage rooms. She further revealed for medications to be stored in a resident's room there should be a physician's order and the care plan should address the medication storage. Observation of R#66's room with the DON and she verified the zip lock bag and the plastic container labeled Turmeric in R#66's room.

Based on observation and staff interview, the facility failed to ensure that two handrails were firmly and securely attached to the wall on two of seven halls (100 Hall and 300 Hall) and failed to ensure that handrails were not a safety hazard based on one handrail had a missing end piece with a one-inch piece of silver, firm and sharp object protruding from the end. Findings include: An observation on 10/11/22 at 2:40 p.m. revealed a handrail on the wall between rooms 305 and 307 to have a piece of the handrail missing and to have a one-inch piece of silver, firm and sharp object protruding from the end. An observation on 10/11/22 at 2:45 p.m. revealed a loose handrail on the wall between rooms 111 and 113. When surveyor tugged on handrail, it came loose from the wall and fell to the floor. An observation on 10/11/22 at 2:50 p.m. revealed a loose handrail on the wall between rooms 311-313. R#63 pulled on it as he rolled his wheelchair and the handrail fell from the wall to the floor. The resident was no injured. A walking tour on 10/11/22 at 2:55 p.m. with the Administrator confirmed the loose handrails on the 100 and 300 Hall and the missing piece of handrail with a piece of metal protruding on Hall 300. An interview with the Administrator revealed new handrails had been ordered and would be installed as soon as they were delivered. He revealed he would have maintenance repair the issues today.

Based on observation, record review, the facility failed to place a privacy bag over the indwelling Foley Catheter of one of 30 sampled residents (R) #336. Findings include: Review of the Quarterly Minimum Data Set (MDS) dated [DATE] for R#366 revealed in section (H) Bowel and Bladder - Indwelling Foley Catheter, and always incontinent of bowel. (I) Active Diagnosis (including but not limited to) - [CONDITION(S)] bladder. (N) Medications - antidepressant, diuretic, and opioid seven days a week. Review of the medical record for R#336 revealed that resident admitted from hospital on 9/12/22, with foley catheter need for [CONDITION(S)] bladder. Change catheter monthly. During an observation on 10/11/22 at 1:30 p.m. of R#336 in her room revealed her catheter bag to be hanging, uncovered, on the left side of the frame of the bed and visible from the hallway. During an observation on 10/12/22 at 9:12 a.m. of R#336 in her room revealed her catheter bag to be hanging uncovered, on the left side of the bed frame visible from the hallway. During an observation on 10/13/22 at 11:10 a.m. of R#336 in her room revealed her catheter bag hanging on the left side of the bed frame, uncovered, visible from the hallway.

Based on observations, interviews, record review and policy reviews, the facility failed to assess one of 30 sampled residents (R) R#106 for the ability to self-administer medications before leaving medications at the bed side. Findings include: Review of the facility policy titled Medication Administration - General Guidelines dated 1/1/19 revealed: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). The facility has staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. B. Administration: 1) Medications are administered only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to administer medications. 2) Medications are administered in accordance with written orders of the prescriber. 13) Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. Review of the facility policy titled Medication Storage in the Facility dated 1/1/19 revealed: Medications and biologicals are stored safely, securely and properly following manufacturer recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personal or staff members lawfully authorized to administer medications. An observation and interview on 10/11/22 at 11:10 a.m. and on 10/12/22 at 9:40 a.m. of R#106 revealed one three-ounce tube of Biofreeze, one .45 ounce bottle of [MEDICATION(S)], 1 container of allergy relief nasal spray 50mcg/spray 120 sprays per container, one bottle of Tums 60 tablets, one bottle of [MEDICATION(S)] 0.01% ophthalmic drops, one bottle of Refresh Advanced ophthalmic drops on R#106 bedside table. R#106 revealed that nursing staff provided the medications for her to use and further revealed she has had the medications at her bedside for a long time. On 10/11/22 a review of the clinical record for R#106 revealed resident was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was coded as 15, indicating is cognitively intact. A review of the current care plan revealed no evidence of an assessment for self-administration of medication. A review of the record indicates no evidence of an assessment for self-administration of medication was completed. A review of physician orders revealed R#106 may keep [MEDICATION(S)] 0.01% ophthalmic drops and Refresh Advanced ophthalmic drops at her bedside. An interview on 10/12/22 at 9:40 a.m. with Licensed Practical Nurse (LPN) CC revealed residents are not allowed to keep medications at bedside without a completed self-administration assessment to determine if resident can safely administer medications and a physician's order and interventions addressed in the care plan. An observation of R#106 room with medications present was made with LPN CC and she verified the medications were in R#106's room without proper authorization. An interview on 10/12/22 at 1:40 p.m. with the Director of Nursing (DON) revealed her expectations are that medications are not left in resident rooms without a physician's order and a completed medication self-administration assessment and interventions in the care plan. Observation of R#106's room with the DON and she verified the medications were in R#106's room. Observation of R#106's record with the DON verified R#106 has not had an assessment for self-administration of medications.

Based on record review and interviews with staff, family, and hospital staff, the facility failed to ensure one of three residents (R) (R#109) reviewed for transfer and/or discharge residents was permitted to return to the facility after being transferred to the hospital. Findings include: An interview with R#109's daughter on 10/11/22 at 11:45 a.m., revealed that the resident was due to return from the hospital on 10/10/22. Transportation was set up for 6:00 p.m. The daughter stated that when transportation had arrived, that they told the hospital that the facility did not have a bed for a COVID positive resident. The daughter told the hospital that they would take the resident home so that the resident didn't have to stay another night in the hospital. Interview with Social Service Director (SSD) on 10/14/22 at 10:43 a.m. revealed that the hospital tried to send R#109 back to the facility on the weekend, and she stated that the ADON said that they did not have a room available because the resident was COVID positive. She then revealed that on the following Monday, it was told to her that the family took the resident home. Review of the hospital report dated 10/10/22, revealed that a nurses noted that R#109 was not able to return to facility due to COVID positive status. During an interview on 10/13/22 at 2:00 p.m., the DON revealed that they are able to isolate in place and that is R#109 was ready to be discharged back to the facility, he should have been able to go back to his room.

Based on observations, interviews, and record reviews, the facility failed to provide appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one of 30 sampled residents (R) (R#95). Findings include: A review of the clinical record revealed that R#64 was admitted to the facility 11/20/20 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Quarterly Minimum Data Set (MDS) revealed R#95 has a Brief Interview for Mental Status (BIMS) of zero, indicating sever cognize impairment; requires extensive assistance with dressing, toileting, and personal hygiene. One person assistance was required with eating and bathing. A review of the Restorative Nursing Services Policy with revised date of July 2017 revealed that residents will receive restorative nursing care as needed to help promote optimal safety and independence and goals and objectives are individualized and resident-centered and are outlined in the resident's plan of care. During an observation on 10/11/22 at 9:30 a.m. R#95 presented with a right-hand contracture and there was no brace on his hand nor a handroll in the hand for comfort. During an observation on 10/13/22 at 10:05 a.m. R#95 was observed sitting up in bed with right hand contracture, asked if could open right hand, but could not open it; no brace or handroll in place. During an interview on 10/14/22 at 8:46 a.m., Restorative CNA LL stated that R#95 is not on the list for restorative or range of motion services, the CNA's on the floor should be doing any assistance for contractures with his activities of daily living care. She is not sure if resident has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Record review on 10/14/22 at 9:30 a.m. revealed there is not an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interviews, and record review, the facility failed to follow Physician's Order for one of two residents (R) (R#66) who received nutrition via gastric feeding tube. Findings include: During an observation on 10/11/22 at 10:45 a.m. a syringe and tubing were observed uncovered in a graduate container at bedside. Unable to visualize any type of labeling on either the syringe or tubing. During an observation on 10/12/22 at 10:57 a.m., tube feeding supplies were at R#66 bedside table uncovered and undated syringe. A review of physician's orders revealed Tube Feeding- Change daily and date: irrigation set, syringe, tubing once a Day 7:00 p.m. - 7:00 a.m. A review of R#66's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation on 10/13/22 at 9:40 a.m. of Licensed Practical Nurse (LPN) AA of a bolus tube feeding revealed: LPN AA washed her hands and donned gloves, inserted [NAME] extension tube, checked for residual by aspirating, no residual, feeding was administered by gravity then tube was removed and placed in a graduate container, syringe was not rinsed or the tubing. Upon completion of the feeding, the LPN was interviewed regarding the syringe and tubing care She revealed the syringe is replaced daily but the extension tube is only replaced when the color of the tubing changes from clear to colored from the medication or feeding. LPN AA was unable to confirm the age of the tubing she used was or when it should be replaced. LPN AA revealed it is not documented anywhere when the tubing is changed. LPN AA confirmed there was no date on the feeding tubing or syringe that she had just used. An interview with the Director of Nursing on 10/13/22 at 11:45 a.m. revealed the feeding syringe and tubing should be replaced daily and it is her expectation that the tubing, and syringe be replaced as ordered by the physician.

Based on record review, observation, and staff interview the facility failed to ensure effective communication between the [MEDICAL TREATMENT] center and the nursing staff for one resident (R) (R#3) of two residents receiving [MEDICAL TREATMENT] services. The sample size was 37 residents. Findings include: A review of the resident's record reflects R#3 was admitted initially on 3/18/16 and had a re-entry on 5/1/18 and 6/11/19 with a diagnosis, including but not limited to: hypertensive [MEDICAL CONDITION], heart failure, [MEDICAL CONDITION], end stage [MEDICAL CONDITION], [MEDICAL TREATMENT] dependence, absence of the right leg- below the knee, Diabetes-Type 2 and post-surgical after care of the left heel. A record review of R#3's Minimum Data Set (MDS) Annual assessment, dated 1/2/19, reflects a Brief Interview for Mental Status (BIMS) was conducted with a score of 15, indicating the resident had no cognitive impairment. Section O: Special Treatments and Programs reflects a check mark affirming [MEDICAL TREATMENT]. A review of the physician's orders [REDACTED]. [MEDICAL TREATMENT]- Monday, Wednesday and Friday. A review was conducted of the provided contract for [MEDICAL TREATMENT] services. The [MEDICAL TREATMENT]: Service Agreement-Healthcare of Fort Oglethorpe was signed and dated 8/21/2001. Review of the record reflects the facility form titled [MEDICAL TREATMENT] Communication Form with a revised date of 6/7/18, is to be used as a pre-[MEDICAL TREATMENT] report to be completed by a facility nurse prior to the resident's transfer to the [MEDICAL TREATMENT] center; including vital signs and a check mark assessment of the resident and the shunt site. This form is to be sent with the resident to the center. The second half of the form is a post-[MEDICAL TREATMENT] report to be completed by the [MEDICAL TREATMENT] center with the time [MEDICAL TREATMENT] was started and completed with a post [MEDICAL TREATMENT] weight and vital signs. An area is also indicated for any concerns, food consumption, new orders, complications and/or recommendations. The pre-[MEDICAL TREATMENT] and post-[MEDICAL TREATMENT] sections of the [MEDICAL TREATMENT] Communication Form are to be completed as it pertains to the resident and signed by the facility staff and [MEDICAL TREATMENT] center staff with a contact number. Review of the record indicated four (4) [MEDICAL TREATMENT] Communication Forms were found, those dated 4/1/19, 4/3/19, 4/8/19 and 4/26/19. Two of which (4/1/19 and 4/8/19) were found to be incomplete. No additional forms were found for the months prior to his most recent discharge, or since his readmission on 6/11/19. Review of the electronic Vitals/Data Report Form for months of 4/19 and 5/19 provided by the DON, indicated vital signs were taken on many dates at varying times; however, the forms do not give evidence that the vital signs were taken prior to leaving for [MEDICAL TREATMENT] and after return from [MEDICAL TREATMENT]. A review of the resident's Care Plan, updated last 3/19/19, reflects: staff to assess [MEDICAL TREATMENT] in left upper extremity bruit/thrill/bleeding/complications every shift. Staff to chart for [MEDICAL TREATMENT] prior to and upon return from [MEDICAL TREATMENT]; at risk for alteration in functional status related to activities of daily living secondary to right [MEDICAL CONDITION] and end stage [MEDICAL CONDITION] with [MEDICAL TREATMENT]; at risk for alteration in bladder integrity secondary to occasional incontinence. Patient goes to [MEDICAL TREATMENT] on Monday, Wednesday and Fridays; monitor for weight loss/gain at least monthly; nutrition interventions as indicated. Average the post-weight obtained from [MEDICAL TREATMENT] monthly. Approaches- contact with [MEDICAL TREATMENT] staff as needed regarding nutrition related concerns. Monitor patient's daily weights at [MEDICAL TREATMENT] prn. Assess blood pressure due to hypertension, notify MD as needed. A review was conducted of the provided policy titled [MEDICAL TREATMENT], Care of Patient Following [MEDICAL TREATMENT], not dated. Documentation indicated the following: Purpose: Special cares and precautions are needed for this shunt. Designated partners will perform this care as indicated. Procedure: All patients who require [MEDICAL TREATMENT] will be sent to an off-site renal center. Objective: to identify post [MEDICAL TREATMENT] problems and intervene to prevent excess loss of blood/or loss of the shunt. To identify early signs and symptoms of infection at the shunt site. Resident was observed just returning via stretcher transport from [MEDICAL TREATMENT] on 6/19/19 at 4:00 p.m. He returned to his shared room drowsy stating he was too sleepy to talk. The resident took a few bites of a late lunch provided, and fell asleep. His color appeared good, he appeared well-groomed, wearing his right leg prosthesis, his left leg in a soft protective boot. A wound VAC (a vacuum device, that assists with closure of a wound, known as a wound VAC) canister and tubing to the left foot was securely attached to the bed. Two ¼ rails were elevated, his call light was attached to the bed within reach. Resident #3 was observed returning from the dining room in his wheelchair on 6/20/19 at 8:30 a.m. He had a pleasant and chatty mood, stating he is worried about his left foot, stated he was keeping it in the soft boot and raised when in bed. Stating no pain today and stated he was feeling good. Resident with appeared well-groomed, his hair clean, beard clean and both hair and beard newly trimmed. He stated he was eating good. The foot wound VAC, tubing and cassette were attached securely to the wheelchair. The resident confirmed he is getting his snacks from the kitchen on [MEDICAL TREATMENT] days and confirmed a late lunch is offered when he returns, if he feels like it. During another observation and brief interview with R#3 on 6/20/19 at 3:07 p.m., the resident was observed in the hall self-propelling in his wheelchair, his left foot was in a soft protective boot, the wound VAC tubing and bag with the cassette securely attached to the wheelchair. When asked about his nurses or techs at the [MEDICAL TREATMENT] center, the resident stated he does not know them, saying they always have a different one. When asked if he has snacks over there, he stated yes, sometimes they give him snacks after [MEDICAL TREATMENT], stating he usually eats when he comes back. When asked, he confirmed having no concerns with the transport team. An interview was conducted with Licensed Practical Nurse (LPN) (LPN AA) who confirmed there was no [MEDICAL TREATMENT] Communication Forms located for R#3 in the record with the exception of the four forms found for the month of 4/19. The LPN stated the process is for the nurse to fill it out prior to the resident going to [MEDICAL TREATMENT], but the [MEDICAL TREATMENT] center doesn't always return them. She pointed to their electronic system, where vital signs are recorded prior to and after [MEDICAL TREATMENT] treatments on Mondays, Wednesdays and Fridays. She confirmed the center does not call them unless there are problems, and confirmed the nurses do not call them for a report if the communication form does not return with the resident. A brief interview was conducted on 6/19/19 at 11:20 a.m. with the DON when she provided printed vital signs for R#3. She stated that the center will call if they need an order or if they transfer the resident to the hospital from the center. She stated that in the Medication Administration Record [REDACTED]. She said she did not know how they could get the [MEDICAL TREATMENT] center to fill out communication forms and return them. A phone call was made to the [MEDICAL TREATMENT] center that R#3 attends by the surveyor on 6/20/19 at 12:31 p.m. A request was made to speak to a staff member that would know R#3. Medical Assistant AA stated no [MEDICAL TREATMENT] was being done this day. When asked, who would know the resident, for information about his [MEDICAL TREATMENT], he stated they have had some recent changes in staff, they are using travel nurses that do not know the clients well yet. He confirmed the Nurse Practitioner is new too, but maybe someone could help if I would call another day.

Based on observation, staff interview and review of facility policy titled, Blood Glucose Monitor Maintenance the facility failed to ensure one (1) of four (4) Licensed Practical Nurses (LPN) observed, followed the manufacturer's recommendations and the facility's policy for sanitizing a glucometer (device used to obtain blood sugar measurements) after blood glucose testing was conducted on resident (R) (R#30). The sample size was 37. Findings include: Review of the facility's policy titled, Blood Glucose Monitor Maintenance dated 4/2019, documents the glucometer will be cleaned per manufacturer's recommendation. A glucometer (brand name) blood glucose monitoring system will be provided to each patient requiring finger stick blood glucose checks. Glucometers will be allowed to air dry before replacing in the patient's medication drawer. The monitor will be stored in a plastic, sealable container along with the glucose monitoring strips in the patient's medication drawer on the medication cart. The container will be closed tightly after each use to prevent contamination of the strips. Review of the cleaning product information, for the sanitation disposable wipes determined for use on point of care devices by the facility is PDI Super Sani-Cloth Germicidal Disposable Wipes, EPA# 9480-4. Directions for use: Unfold a clean wipe and thoroughly wet surface, allow treated surface to remain wet for a full two (2) minutes. Let air dry. The manufacture's recommendation documented that the current Environmental Protection Agency (EPA) guidance requires that the treated environmental surface or equipment remain wet for the contact time stated on product label. Additional wipes may be needed to comply with the EPA guidance, however the overall contact time does not change. Four blood glucose testing and glucometer cleaning observations were conducted as follows: on 6/19/19 at 11:30 a.m. with LPN CC on the 300 Hall for R#9; no breach in infection control or technique was observed. At 11:45 a.m. observation with LPN DD on the 100 Hall for R#41; no breach in infection control or technique was observed. At 11:55 a.m. observation with Registered Nurse (RN) RN EE on the 400 Hall for R#32; no breach in infection control or technique was observed. At 12:05 p.m. observation with LPN FF on the 500 Hall for R#30, the LPN was observed removing the resident's glucometer and test strips out of a designated compartment in the medication drawer, applying gloves and performing the blood glucose testing, no breach in technique was observed. Afterwards, she removed her gloves and washed her hands and returned the glucometer to the medication drawer. The glucometer was not cleaned/sanitized after use. The glucometer and strips were not stored per the facility policy. After the observations, a brief interview was conducted with LPN FF on 6/19/19 at 12:09 p.m. She was asked what she uses to clean the glucometer after use, where she stated it is the resident's own glucometer, I don't ever clean it. She stated that each resident has a section in the medication cart for that individual resident's use, if they have devices or special medications just for them. An interview was conducted on 6/19/19 at 12:42 p.m. with the DON where she confirmed there was no diagnosed [MEDICAL CONDITION] active [MEDICAL CONDITION] residents in the facility. She confirmed one resident was diagnosed with [REDACTED]. The DON stated it is the facility policy that each resident getting blood sugar testing has their own glucometer, that none are shared. She confirmed the expectation is that all glucometers are to be cleaned with use, become wet with the Sani-Cloth Wipes and then air dry before storage. Confirming the process makes the glucometer wet for the required two (2) minutes.

Based on observations, record review, and staff interviews, the facility failed to document the intended duration of therapy for one resident (R) (#16) that received PRN (as needed) [MEDICATION NAME] (an antianxiety medication) beyond 14 days and failed to re-evaluate and document the clinical rationale for PRN [MEDICATION NAME] (an antipsychotic medication) beyond 14 days. The sample was 33 residents. Findings include: R#16 was admitted to the facility with [DIAGNOSES REDACTED]., Anxiety Disorder, Restlessness and agitation. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) summary score of two, indicating severe cognitive impairment. R#16 exhibited moods with a severity score of eight, indicating mild depression. No behaviors or rejection of care was exhibited. R#16 received antianxiety and antipsychotic medications all seven days of the look back period. The Care Area Assessment (CAA) triggered [MEDICAL CONDITION] Drug Use with the decision to be care planned. Review of the care plan for R#16 dated 2/6/18 identified the resident was at risk for side effects of [MEDICAL CONDITION] medications related to use of [MEDICATION NAME] ([MEDICATION NAME]) PRN for agitation and use of [MEDICATION NAME]. Approaches included, but not limited to; Explore cause of anxiety and resolve if possible, Administer [MEDICATION NAME] and [MEDICATION NAME] as ordered. Review of the Physician order [REDACTED]. [MEDICATION NAME] 0.5 MG was also ordered on [DATE] to be given one tablet daily scheduled. Review of the Medication Administration Record [REDACTED]. PRN [MEDICATION NAME] was only administered twice in March. Review of the behavior monitoring from (MONTH) (YEAR) through (MONTH) (YEAR) indicated R#16 did exhibit anxiety and/or agitation regularly that did not require medication intervention. Interview on 4/16/18 at 11:45 p.m. with the Consulting Pharmacist EE revealed she has had some problems getting the Hospice Physician to limit PRN [MEDICAL CONDITION] medications to 14 days and documenting a rationale for orders beyond 14 days. She stated she has told the Hospice Phsycian DD that it doesn't matter if a resident is on Hospice, they still must comply with the new PRN regulations. Observation of R#16 on 4/19/18 at 1:50 p.m. revealed the resident in her bed being assisted by staff with eating. No behaviors were noted at this time. Review of the Consultant Pharmacist's Recommendations to Physician form dated 11/28/17 documented: Both PRN [MEDICATION NAME] and PRN [MEDICATION NAME] need a duration stated to comply with new CMS regulations. The Physician checked the box titled other and documented Life (Hospice). The physician signed and dated 12/27/17. During an interview with the Director of Nursing on 4/19/18 at 2:40 p.m., she stated they have discussed the regulations numerous times with Hospice Physician DD and he tells them that the resident is on Hospice so he feels like they are under a different category. The DON stated the Consulting Pharmacist EE has attended meetings and she has told the Hospice Physician DD that Hospice is no different than anyone else and must comply with the regulation. The DON stated R#16 has anxiety and sometimes resists care but she doesn't have aggressive behaviors. The DON stated she only knows of one time R#16 tried to strike out at staff. The Don further stated she talked to the Hospice Physician DD about residents that have an order for [REDACTED]. Interview on 4/19/18 at 3:55 p.m. with the Hospice Physician DD R#16 is under Hospice Services and he cares for her. He stated he thought when a resident is on Hospice and has a life expectancy of less than six months the PRN medications would be short term anyway. He stated they may need the PRN medication at some time as the terminal illness progresses. The Hospice Physician DD stated he does not review the facility's Medication Administration Records (MAR) for behaviors or anxiety and stated he talks to the Hospice Nurse for updates on the resident's status. The Hospice Physician DD stated that he has had conversation last (MONTH) (YEAR) with the facility and the Consulting Pharmacist EE related to the new rule but only about PRN orders could not exceed 14 days.

Based on observations, review of the facility policy titled Respiratory and staff interviews, the facility failed to store and label personal care equipment and respiratory equipment in a sanitary manner to prevent cross contamination on three of seven halls (200 Hall, 300 Hall and 500 Hall). Findings include: Review of the Policy titled Respiratory dated ,[DATE], and revised [DATE] documented Equipment such as oxygen, nebulizers, IPPB machines and suction machine are not shared among patients. 1. Respiratory equipment is dated when placed at bedside and replaced on a schedule. (a.) Oxygen tubing, nasal cannula, or oxygen masks are to be replaced according to the center's schedule. 3. Respiratory equipment (i.e., nasal cannula, aerosols, etc.) at bedside will be covered with a plastic bag when not in use. Observation [DATE] at 11:52 a.m. in room [ROOM NUMBER]B revealed an un-bagged nebulizer with aerosol mask on the nightstand. The nebulizer was dated [DATE] and had residual liquid inside and several dried white spots on the inside sides. Additional observation on [DATE] at 11:30 a.m. revealed an un-bagged nebulizer and aerosol mask dated [DATE] sitting on the night stand underneath two gait belts and a stuffed animal. Observation on [DATE] at 12:15 p.m. of room [ROOM NUMBER]B revealed an un-bagged nebulizer with aerosol mask dated [DATE] clipped to the side on the nebulizer air compressor. Additional observation on [DATE] at 11:35 a.m. revealed the same nebulizer and aerosol mask un-bagged and lying on the bed side table. Observation on [DATE] at 12:57 p.m. in room [ROOM NUMBER]A revealed an un-bagged, un-dated nebulizer with aerosol mask lying on the nightstand. Observation of the bathroom in room [ROOM NUMBER], for which two residents share, revealed two un-bagged bed pans stacked inside one another on the floor under the sink and a bagged wash basin on the floor under the sink. Additional observation on [DATE] at 11:40 a.m. revealed the nebulizer and aerosol mask remained un-bagged and was lying on the nightstand. In the bathroom, the two un-bagged bedpans remained stacked inside one another on the floor under the sink and the bagged wash basin remained on the floor under the sink. Observation on [DATE] at 9:54 a.m. in the bathroom of 507, for which two residents share, revealed a bagged bed pan on the floor under the sink and a bagged wash basin on the floor under the sink. Observations with the Director of Nursing (DON) on [DATE] beginning at 8:50 a.m. and ending at 9:08 a.m. revealed the following: At 8:50 a.m. in room [ROOM NUMBER] revealed one bagged, unlabeled bedpan hanging from the handrail. At 8:52 a.m. in room [ROOM NUMBER], the graduated cylinder labeled with the wrong resident name was removed. Interview with the DON at the time of the observation confirmed that they did have a resident in the facility with the name labeled on the removed graduated cylinder that no longer resides in the facility. Review of the facility's completed and transmitted Minimum Data Set (MDS) assessment revealed one resident that matched the name on the graduated cylinder who expired in the facility on [DATE]. At 8:55 a.m. in room [ROOM NUMBER] revealed one bagged, unlabeled bed pan hanging on the left handrail and one bagged, labeled bed pan hanging from the right handrail. At 9:00 a.m. in room [ROOM NUMBER] revealed the graduated cylinder labeled with the wrong resident name had been removed. Interview with the DON at the time of the observation confirmed they did have a resident by the name labeled on the removed graduated cylinder that no longer resides in the facility. Review of the facility's completed and submitted MDS assessments revealed one resident that matched the name on the removed graduated cylinder who had expired in the facility on [DATE]. At 9:02 a.m. in room [ROOM NUMBER] revealed two bagged, unlabeled urinal hats hanging from the handrails. The graduated cylinder labeled with the wrong resident name had been removed. Interview with the DON at the time of the observation confirmed there was a resident with the name labeled on the removed graduated cylinder and that resident was discharged from the facility last week. Review of the facility's completed and submitted MDS assessments revealed a resident matching the name on the removed graduated cylinder with a discharge date of [DATE]. At 9:06 a.m. in room [ROOM NUMBER]B revealed an un-bagged nebulizer and aerosol mask lying on the nightstand. Interview with the DON at the time of the observation revealed all nebulizers, tubing and aerosol mask are to be bagged when not in use. At 9:08 a.m. in room [ROOM NUMBER] revealed an un-bagged nebulizer and aerosol mask lying on the floor next to the nightstand. At 9:10 a.m. in the bathroom of 507 revealed the bedpan was removed from the floor, was bagged and hanging from the hand rail. At 9:15 a.m. in the bathroom of room [ROOM NUMBER] revealed the two bedpans had been removed from the floor, were bagged and hanging from the hand rail. In 503A the resident was currently receiving a breathing treatment via nebulizer and aerosol mask. The DON confirmed there was no bag on the nightstand to cover the nebulizer after use. Further interview with the DON on [DATE] at 9:16 a.m. revealed the nebulizers, tubing and aerosol masks are to be changed by the nightshift nurses every Sunday night. She stated they are to be labeled, dated and bagged. She stated all staff is responsible for ensuring this expectation. She stated if a nurse administers a breathing treatment and sees that there is no bag or that it not labeled, dated or outdated, they are responsible for making the appropriate corrections. At 9:30 a.m. the DON brought a policy related to respiratory equipment and stated the facility does not have a policy specific to proper storage or labeling of personal care equipment such as bed pans, urinals, wash basins. The DON further stated that it is the responsibility of housekeeping to discard all personal care equipment from a room when a resident has been discharged from that room. Observation on [DATE] at 11:56 a.m. revealed in room [ROOM NUMBER], an unlabeled bedpan in a plastic bag sitting on the floor in the bathroom that was shared by four female residents. Observation on [DATE] at 11:58 a.m. revealed in room [ROOM NUMBER], an unlabeled bedpan, not in a plastic bag, sitting on the floor in the bathroom that was shared by four female residents. Observation on [DATE] at 12:01 p.m. revealed in room [ROOM NUMBER], an unlabeled bedpan in a plastic bag tied to the grab bar in a bathroom shared by four female residents. Observation on [DATE] at 12:04 p.m. revealed in room [ROOM NUMBER], a urine graduated cylinder labeled with room [ROOM NUMBER]B and another resident's name, in plastic bag, tied to grab bar, in bathroom shared by four female residents. Observation on [DATE] at 1:23 p.m. revealed in room [ROOM NUMBER], a urine graduated cylinder labeled with another resident's name, in plastic bag, tied to grab bar, in bathroom shared by two male residents. Observation on [DATE] at 11:17 a.m. revealed two urine measuring hat's without names on them, and a urine graduated cylinder with another residents name on it, in a bathroom shared by two male residents.

Based on observation and staff interview, the facility failed to ensure that five handrails were firmly and securely attached to the wall on two of 7 halls. Findings include: Observation on 4/16/18 at 12:28 p.m. revealed a loose handrail, on the left side of hallway, at the beginning of 300 Hall at the entrance to the assisted dining room. Observation on 4/16/18 at 1:07 p.m. revealed a loose handrail, on the left side of the hallway, between rooms [ROOM NUMBERS]. Observation on 4/16/18 at 3:21 p.m. revealed a loose handrail on the right side entrance to 300 Hall, across from assisted dining room entrance. Observation on 4/17/18 at 10:35 a.m. revealed a loose handrail on the left side of the hallway, outside room [ROOM NUMBER]. Observation on 4/17/18 at 4:30 p.m. revealed a loose handrail on the right side of the hallway, between rooms [ROOM NUMBERS]. Walking tour on 4/17/18 at 10:30 a.m. with Maintenance Assistant, confirmed the loose handrails on the 200 Hall and 300 Hall. Interview on 4/18/18 at 10:00 a.m. with Maintenance Assistant, stated there was no specific time or schedule that hand rails are checked for stability. He stated that staff members either fill out a Maintenance requisition form or call on the phone or let him know in passing, if they notice anything needing repair, from resident equipment to facility machines and hand rails. He stated that he was not aware of the loose handrails in the facility.

Based on observations, resident and staff interviews and record reviews the facility failed to review and revise care plans for two of 32 sampled residents Resident (R)#69 and R#226 by failing to incorporate Minimum Data Set (MDS) supplemental Activities of Daily Living (ADL) form's goals and approaches to maintain R#69's current level of ambulation skills and prevent decline which resulted in staff on unit not assisting R#69 to walk; and failing to include Foley catheter monitoring for R#226 after removal of the catheter. The findings include: 1. Observations on 4/25/17 of R#69 at 8:46 a.m. revealed the resident sitting in a mechanical wheelchair. During an interview with R#69 on 04/25/17 8:46 a.m. he stated, I am no longer qualified for therapy. I have not walked for six weeks, the last time my kids were here. Since I'm not on therapy, I don't get assistance to walk. Record review of R#69's Minimum Date Set (MDS) with Annual Review Date (ARD) 4/18/17 contained an ADL (Annual Review Date) Supplement (Attaining maximum possible Independence) form which contained instructions for those considered for rehabilitation or decline prevention treatment. The form instructed that a '1' be placed for 'Maintenance to prevent decline'. The form had a '1' written in on five approaches which included, Walks in room/ nearby and also contained a handwritten additional note, 'with assist and prosthesis.' An arrow extended the written comment to the following four approaches: walks on unit, walks throughout the building, walks outdoors, and walks on uneven surfaces. Record review of the care plan revealed no inclusion of any of the approaches marked to 'maintain to prevent decline' and no approaches directing staff to walk with R#69. During an interview with the Minimum Data Set Coordinator (MDSC) AA on 4/26/2017 at 11:34 a.m., MDSC AA stated, The ADL supplement information should transfer to the care plan. After review of the care plan in the chart during the interview on 4/26/2017 at 11:34 a.m., MDSC AA stated, It's not typed in here. Should definitely be in here. I will address that. During an interview with LPN AA, on 4/26/2017 at 12:41 p.m., she stated, To Be honest, haven't seen him (R#69) ambulate. Have not been instructed that he should be. 2. The facility failed to update/revise as appropriate the care plan for R#266 who was identified with a Urinary tract infection, [MEDICAL CONDITION] and diagnosed with [REDACTED]. Resident (R#226) was admitted to the facility on [DATE]. On 10/22/2016, R#226 was catheterized to obtain urine for culture and sensitivity and a urinalysis. The nurse documented 1200 cc of urine obtained during the catherization. The physician was notified and orders were given to leave the catheter in place due to [MEDICAL CONDITION] and antibiotics were started for a Urinary Tract Infection [MEDICAL CONDITION]. The interim care plan for R#226 was dated 10/18/2016 and checked Incontinent. The care plan was not revised /updated on 10/22/2016 when the R#226 was treated with antibiotics for a UTI, nor after having the indwelling catheter inserted and diagnosed with [REDACTED]. The Daily Skilled Nurse's Notes document on 10/27/2016 Patient catheter removed this a.m., patient in bladder training with Catheter. On 10/29/2016 the resident was sent to the emergency room and admitted to the hospital with [REDACTED]. Upon readmission to the facility on [DATE], R#226 had an indwelling catheter and her [DIAGNOSES REDACTED]. The interim care plan dated 11/2/2016 was checked off as Incontinence/ Foley, there were no interventions noted on the care plan to include specific information and risks of possible complications resulting from the continuing use of the catheter, such as obstruction, bladder spasms, hematuria and leakage around the catheter or signs and symptoms of UTI's. On 4/26/2017 at 2:37p.m., the Director of Nursing (DON) was interviewed regarding updating /revising care plans, she stated, The nurse who took the (Antibiotic) ABT order on 10/23/2016 should have updated the care plan. When asked about policies, guidelines and training she stated there are no policies or written guidelines regarding the interim care plans. During orientation, clinical guidelines are discussed with the nurses. During an interview with the Minimum Date Set Coordinator (MDSC) AA on 4/24/2017 at 3:45 p.m., regarding the care plan updates and/or revisions the MDSC AA stated, The nurses on the unit should update the interim care plans.