Every finding on record at Nurse Care of Buckhead

Based on observations, staff interviews, and facility document review, the facility failed to ensure that the Facility Assessment included an accurate and comprehensive review of the facility's resident population, including the identified secure memory unit located on the fifth floor. The failure to identify a secure unit for dementia care or behavioral health meant the facility assessment plan had potentially missed critical care needs, updating the assessment to reflect residents needing secured care, and revising emergency/care plans to include secure protocols and dedicated spaces. This deficient practice had the potential to affect the care provided to the facility population and the training required for both direct and indirect care staff. Findings include:Review of the Facility Assessment, dated 4/28/2025, revealed it did not include any indication or recognition of an identified secured memory unit located on the fifth floor of the facility. Facility-provided documentation revealed four individual resident units on four floors of the building, with the resident population evenly distributed across the four residential floors. Facility-provided documentation revealed that 53 residents resided on the fifth floor of the facility, accounting for approximately 25% of the facility's current population. This population was not identified in the current Facility Assessment to ensure appropriate assessments and monitoring were in place for the safety of all facility residents.Observations on four of four survey days revealed that access to the fifth floor was limited by the keypad and code provided to staff. This code was required to access the fifth-floor elevators when leaving the unit. During staff interviews, this was identified as the secured unit, and the residents were not provided with this access code.During an interview on 12/8/2025 at 11:15 am, Certified Med Tech (CMT) 4 stated that the fifth floor was a secure unit, and a code was necessary in order to use the elevator.During an interview on 12/10/2025 at 11:46 am, Certified Nursing Assistant (CNA) 10 stated that residents on the fifth floor were assisted to get up and down the elevator because they were not told the elevator code. CNA10 said that the fifth floor had been the Dementia and Behavioral unit since she had worked at the facility for three years. She stated that the staff would need to help someone get into the elevator because they were not permitted to give out the codes to anyone.During an interview on 12/10/2025 at 11:51 am, Registered Nurse (RN) 5 stated that the fifth floor was the Dementia Behavioral unit. RN5 stated that none of the residents knew the code to get on the elevator.During an interview on 12/10/2025 at 11:56 am, Charge Nurse Licensed Practical Nurse (CNLPN) stated that, since she had worked at the facility, the fifth floor had been the memory care and behavior unit. She stated that none of the residents knew the code to get on the elevator. CNLPN stated that the residents on the fifth floor were elopement risk residents.During an interview on 12/10/2025 at 12:10 pm, the Administrator stated that the fifth floor was not considered a secure unit but rather a mechanism for keeping residents at risk of elopement and wandering safe. She stated that the facility had installed an elevator keypad on the fifth floor in August or September of 2025. She stated that there were residents on the fifth floor who were at risk of elopement. She confirmed residents on this floor did not know the elevator keypad code to exit the unit.During an interview on 12/11/2025 at 5:18 pm, the Director of Nursing stated that the fifth-floor residents were identified as the dementia population. She stated that the facility worried about wandering for those residents. She stated the keypad for this unit was already in place when she started working at the facility in September 2025.During a follow-up interview on 12/11/2025 at 5:40 pm, the Administrator stated that although the facility had not called the fifth floor the secured unit, any person who could not leave the unit when they wanted to would be considered secured. She stated the facility went secured after Resident (R) 4 had eloped. She confirmed that the facility tended to have more wanderers with a risk of elopement, and that they would need to review the accuracy of the Facility Assessment, specifically for the 25% of the population residing on the fifth floor.

Based on observations, resident and staff interviews, and record review, the facility failed to ensure incontinence pads were available for one resident (Resident (R) 21), reviewed for incontinence supplies from a sample of 45. This failure had the potential to increase skin breakdown for R21.Findings include:Review of R21's Resident Face Sheet, located in the resident's electronic medical record (EMR) under the profile tab, revealed the resident was admitted to the facility on [DATE] with a diagnosis of acute kidney failure, morbid obesity, and retention of urine.Review of R21's annual Minimum Data Set (MDS), located in the resident's EMR under the MDS tab with an Assessment Reference Date (ARD) of 11/07/2025, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R21 was cognitively intact. The MDS revealed R21 required substantial/maximal assistance with toileting and was always incontinent.Review of R21's Care Plan, revised 10/21/24 and located in the EMR under the Care Plan tab, revealed, .[Resident name] has the potential for pressure ulcer/injury development related to morbid obesity, incontinency and the need for assist [sic] with toileting, hygiene, bed mobility and transfers.During an interview on 12/08/2025 at 12:12 PM, R21 said he wore a size 5X brief and required one at all times. He said several weeks ago, during the weekend, he was told by staff that they were out of his size of briefs and did not have any incontinent pads. R21 said they used a draw sheet instead of an incontinence pad, which caused discomfort when he had a bowel movement, as he typically does not get out of bed. He said he rarely gets out of bed.During an interview on 12/11/2025 at 12:54 PM, R21 said that after he was transferred into bed after his shower, he did not have an incontinence pad under him; currently, he has only a draw sheet. He stated it feels bad because I know I have to sit in urine for a while.During an observation and interview on 12/11/2025 at 9:00 AM, in the second-floor central supply closet with the Unit Manager Registered Nurse (UMRN), he confirmed there were no incontinence pads in the closet. During an observation and interview on 12/11/2025 at 9:15 AM, in the third-floor central supply closet with Unit Manager Licensed Practical Nurse (UMLPN) 2, she confirmed there were no incontinence pads in the closet. During an interview and observation on 12/11/2025 at 9:2025 AM, the central supply closet was observed, and no incontinence pads were available. The Central Supply Manager (CSM) confirmed he was currently out of incontinence pads. The CSM said he places orders on Mondays, and the orders are received on Fridays. He said he orders according to the census, and that is how his budget is determined. He said he must be compliant with the budget and said quite often it is very difficult to have enough incontinence supplies because of the limited budget.During an interview on 12/11/2025 at 5:39 PM, the Director of Nursing (DON) and the Administrator stated that incontinence supplies should always be available for all residents.

Based on staff interviews, record review, and review of the facility policy titled Insulin Administration, the facility failed to administer insulin as ordered by the physician for one of three residents (Resident (R) 40) reviewed for medication administration out of a sample of 45. This failure had the potential to cause the resident to have uncontrolled blood sugar levels. Findings include:Review of the facility's policy titled Insulin Administration, dated 06/2025, revealed, Policy: Special precautions should be followed when administering insulin . The type of insulin, dosage requirements, strength, and method of administration should be verified to ensure that it corresponds with the order on the medication sheet and the physician's order. Any discrepancies should be reported to the Charge Nurse or designee. The resident's physician should be notified of any discrepancies or adverse drug reactions .Review of R40's Face Sheet, located in the electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus with hyperglycemia, hyperlipidemia, and acquired absence of the right and left leg below the knee.Review of R40's quarterly Minimum Data Set (MDS), located in the resident's EMR under the MDS tab and with an Assessment Reference Date (ARD) of 11/04/2025, revealed R40 had a Brief Interview for Mental Status (BIMS) score of twelve out of 15, indicating R40 was moderately cognitively impaired. It was recorded the resident received insulin on six of the last seven review days.Review of R40's Physician Orders tab of the EMR revealed an order, dated 12/18/2024, for Humulin 70/30 Subcutaneous Suspension (70-30), an insulin, 100 Units/ML (milliliter), inject 48 units subcutaneously in the morning at 6:00 AM. There were no physician parameters for this medication.Review of R40's Medication Administration Record (MAR) tab of the EMR revealed: August 202025 - the medication was not administered on 08/11/2025 and 08/22/2025 at 6:00 AM. The failure to administer scheduled Humulin was not documented or justified in the EMR. September 202025 - the medication was not administered on 09/03/2025, 09/06/2025, 09/07/2025, 09/14/2025, 09/17/2025, 09/22/2025, and 09/29/2025 at 6:00 AM. The Progress Notes, located in the EMR under the Progress Notes tab for 09/20/2025, revealed that Humulin was held due to blood sugar levels that were not associated with the scheduled Humulin, but rather the sliding scale insulin. October 2025 - the medication was not administered on 10/05/2025, 10/20/2025, and 10/30/2025 at 6:00 AM. The failure to administer scheduled Humulin was not documented or justified in the EMR on 10/05/2025 and 10/20/2025. The Humulin was documented as not administered on 10/30/2025 due to on route from pharm (pharmacy). November 2025 - the medication was not administered on 11/01/2025, 11/15/2025, 11/24/2025, 11/26/2025, 11/27/2025, and 11/29/2025 at 6:00 AM. The Progress Notes located in the EMR, revealed that Humulin was held on 11/01/2025 because resident has not eaten yet. The failure to administer scheduled Humulin was not documented or justified in the EMR on 11/15/2025, 11/24/2025, 11/27/2025, or 11/29/2025. On 11/26/2025, it was documented on route.Review of R40's Physician Orders tab of the EMR revealed an order, dated 12/18/2024, for Humulin 70/30 Subcutaneous Suspension (70-30) 100 Unit/ML (milliliter), inject 30 units subcutaneously in the evening at 5:00 PM. There were no physician parameters for this medication.Review of R40's MAR tab of the EMR revealed: August 2025 - the medication was not administered on 08/15/2025, 08/18/2025, 08/20/2025, and 08/29/2025 at 5:00 PM. The failure to administer scheduled Humulin was not documented or justified in the EMR on 08/15/2025 or 08/18/2025. The Progress Notes located in the EMR revealed that Humulin was held due to blood sugar levels that were not associated with the scheduled Humulin, but the sliding scale insulin on 08/20/2025, and was not administered on 08/29/2025 due to Pending pharmacy delivery. September 2025 - the medication was not administered on 09/27/2025 at 5:00 PM. The failure to administer scheduled Humulin was not documented or justified in the EMR. October 2025 - the medication was not administered on 10/10/2025, 10/2025/2025, and 10/28/2025 at 5:00 PM. The failure to administer scheduled Humulin was not documented or justified in the EMR. November 2025 - the medication was not administered on 11/28/2025 at 5:00 PM. The Progress Notes located in the EMR revealed that Humulin was held due to blood sugar levels that were not associated with the scheduled Humulin, but rather the sliding scale insulin.During an interview on 12/10/2025 at 9:00 AM, R40 stated that she did not know why the facility did not administer her diabetic medications as ordered. R40 said that when she did not eat well, the nurses would sometimes not give her the scheduled diabetic medications. She stated this was an ongoing concern for the maintenance of her blood sugar.During an interview on 12/11/2025 at 10:08 AM, the Nurse Practitioner stated that she expected insulin orders to be followed as written by the physician. She stated if a resident had a scheduled Humulin order, then it should be given as ordered. The Nurse Practitioner stated if the resident had a sliding scale insulin order, it was to accommodate what additional insulin R40 would need after the Humulin had been given. She stated a resident needing both scheduled Humulin and a sliding scale insulin was often caused by the resident not having well managed blood sugars. During a concurrent interview on 12/11/2025 at 12:18 PM, Registered Nurse (RN) 4 and Unit Manager Licensed Practical Nurse (UMLPN) 1 confirmed that R40 received scheduled Humulin as well as sliding scale insulin. RN4 stated that R40 would receive Humulin regardless, and the sliding scale insulin would be administered according to the blood sugar levels. RN4 stated that a nurse would have to place a documented note in the EMR about why a resident had not received their scheduled medications. She stated the nurse could document a refusal, but otherwise, the Humulin insulin should be administered. UMLPN1 stated that scheduled Humulin should be given and would not be held for normal blood sugars. Upon review of R40's MAR, she stated she was not sure why a nurse would have held the Humulin, especially with blood sugars that were fine.During a follow-up interview on 12/11/2025 at 1:58 PM, UMLPN1 stated that she had reviewed the MAR for R40 and could see that Humulin had been held inappropriately. She stated that it was not okay to hold NPH Insulin (Neutral Protamine [NAME]) because it functioned differently from the sliding scale insulin. She stated nurses needed to give the Humulin insulin as ordered.During an interview on 12/11/2025 at 5:13 PM, the Director of Nursing (DON) stated that if a resident had a standing order for a medication, the nurse should give it as ordered. She stated that nurses should talk to the provider if they were worried about blood sugars being too low, such as below 70. The DON stated that if the resident's blood sugars were approximately 105-130, she would expect Humulin orders to be followed.

Based on interviews, record review, and review of the facility's policies titled Applied Body Mechanics - Resident Handling Techniques and Wandering and Missing Residents, the facility failed to ensure one of 45 sampled residents (R) (R21) was safely transferred. In addition, the facility failed to ensure adequate supervision and monitoring for three of 45 sampled Rs (R4, R5, and R3) related to elopement. These deficient practices had the potential to place R21, R4, R5, and R3 at risk of avoidable accidents, injuries, and a diminished quality of life.Findings include: Review of the facility's policy titled, Applied Body Mechanics – Resident Handling Techniques, dated 06/2025, revealed, . Use mechanical lift devices (e.g., full-body lift) when transferring or repositioning residents who are heavy, cannot bear weight, and are not able to cooperate. The mechanical device, not the caregivers, does the living Portable lift devise (sling type) are used to lift residents who are totally dependent, are partial or non-weight bearing, are very heavy, or have other physical limitations. Mechanical lifts are generally used for.chair or floor to bed, for bathing and toileting. A review of the facility's policy titled Wandering and Missing Residents, dated 05/2025, revealed that it is the policy of the Center to ensure the safety and well-being of each resident within the environment of the center while meeting their needs and sustaining a quality of life they can enjoy. Residents are not considered wandering or missing if the resident is on center premises/being chaperoned by the Center staff or a family member. Through security management system residents will have freedom to ambulate safely while maintaining a functioning egress to the doors. 1. Review of R21's undated Resident Face Sheet, located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with a diagnosis of muscle weakness and morbid obesity. Review of R21's annual Minimum Data Set (MDS), located in the resident's EMR under the MDS tab with an Assessment Reference Date (ARD) of 11/07/25, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R21 was cognitively intact. The MDS revealed R21 did not use a wheelchair, required substantial/maximal assistance with lying to sitting on side of bed, sit to stand was not attempted due to medical conditions or safety concerns, and chair/bed to chair transfer was not attempted due to medical conditions or safety concerns. Review of R21's Care Plan, revised 10/21/24 and located in the EMR under the Care Plan tab, revealed, .[Resident name] has a deficit in activities of daily living (ADL) self-care performance deficit r/t (related to muscle weakness. There was no outcome identified. Interventions included .chair /bed to chair transfer-substantiate/max assistance. created 04/19/25. Review of R21 weights under the Weights and Vitals tab, R21 weighed 323 lbs (pounds) on 11/13/25. The weights were obtained using a mechanical lift. During an interview on 12/11/25 at 12:54 PM, R21 said he had just returned from his shower. He said, My shower was good, only they dropped me when they tried to get me into bed. He said there were five staff members in the room. He said he had not stood up in a while, so it was difficult. He said he was not injured during the incident. During an interview on 12/11/25 at 1:05 PM, Certified Nurse Aide (CNA) 5 said that, after R21's shower, she and the (Unit Manager Licensed Practical Nurse) UMLPN 2 were in the process of transferring R21 to bed when his feet started to bend towards the back of his chair. She said, then she and UMLPN2 lowered him to the floor. She said the Maintenance Director (MD) and the Maintenance Tech (MT) entered the room after the UMLPN 2 called out to the MT as he was walking by R22's room. CNA 5 said after the MD and the MT came in, both the Assistant Directors of Nursing (ADON) and ADON2. She said they all lifted R21 from the floor to his bed. CNA 5 stated that, normally, they would use a mechanical lift on a resident of that size, and said she did not know why they did not use the lift that day. During an interview on 12/11/25 at 1:05 PM, UMLPN 2 said they needed the MD, the MT, and two CNAs to lift R21. She said normally a resident the size of R21 would require a mechanical lift, but they did not use one; she did not know why. UMLPN 2 said they did not use a gait belt to assist with his transfer During an interview on 12/11/25 at 1:23 PM, the Physical Therapist (PT) said prior to R21's shower, we (PT and Occupational Therapist (OT)) were completing an evaluation to determine his balance when sitting on his bed, upper body dressing and upper body range of motion (ROM) while using a gait belt (sturdy fabric strap placed around a person's waist to help caregivers safely assist them with walking, standing, or transferring between surfaces). The PT said R21 had multiple barriers, including balance, morbid obesity, neuropathy, and a diabetic leg wound. He said he doubted R21 would ever stand again. The OT said that after they completed the evaluation, they asked the UMLPN 2 how they were going to transfer R21 after the shower. The OT said UMLPN 2 said they would use a mechanical lift. Both the PT and OT agreed that if a resident required more than two people to assist with a transfer, a mechanical lift should be used. The OT said R21 required more than two people for a transfer. The OT said if staff were concerned about the transfer, they could have asked therapy for assistance. During an interview on 12/11/25 at 1:48 PM, the MT said that while walking by R21's room, he noticed the PT, OT, UMLPN 2, and CNA5 assisting R21. R21 had a gait belt on, and the four staff members picked R21 up and placed him in the shower chair. After the shower, MT stated he was called by the UMLPN 2 over the walkie-talkie to come into R21's room. When he arrived, R21 was lying on the floor, and there were two CNAs in the room and UMLPN2. The MD entered the room and ADON and ADON 2 next. MT said he did not see a gait belt on the resident or a mechanical lift in the room. He said there were three staff at R21's head, one staff on each side of R21, and two staff at R21's feet. The MT said they lifted R21 into his bed from the floor. During an interview on 12/11/25 at 2:06 PM, ADON2 said that when he walked in the room, R21 was lying on the floor, flat on his back. He said a resident R21's size, they would typically use a mechanical lift. During an interview on 12/11/25 at 5:29 PM, the Restorative CNA (RCNA) said that a resident would need a mechanical lift based on their weight and disabilities. She stated R21 always required a mechanical lift. During an interview on 12/11/25 at 5:39 PM, the Director of Nursing (DON) and the Administrator agreed that staff should follow R21's transfer status and use a mechanical lift. 2. Review of R4's Resident Face Sheet found in the EMR under the Profile tab revealed R4 was admitted to the facility on [DATE], with diagnoses that included schizophrenia, history of falling, vascular dementia, and major depressive disorder. Review of the MDS found under the MDS tab of the EMR with an ARD of 09/19/25, revealed R4 was assessed to have scored a zero out of 15 on the BIMS, which indicates severe cognitive impairment. The resident was also coded as needing supervision while ambulating. A review of R4's elopement evaluation scores (Moderate Risk 5-8, High Risk 9-11) revealed that R4 was determined to be at moderate risk for elopement. The scores included on 06/08/25, he scored a two, on 07/05/25, he scored a seven, on 07/12/25, and on 08/07/25, he scored a four, and on 11/08/25, he scored an eight. A review of the Comprehensive timeline – Elopement incident for R4's elopement indicated that on 07/05/25 at 9:00 AM, the receptionist observed R4 coming down from the 5th floor unit to the 1st floor, unaccompanied. The receptionist made multiple calls to the 5th-floor unit, but contact was unsuccessful. At 10:30 AM, the receptionist realized that R4 was no longer in the front lobby or seated near the kitchen door. The receptionist contacted the 5th-floor unit to confirm if R4 had returned to his floor, and the 5th-floor staff verified that R4 was not accounted for, and an emergency alert was initiated. At 10:38 AM, a code orange (code for elopement). The intercom system was inoperable, and staff went to every floor to advise other staff of code orange, and a review of the video surveillance was initiated. At 10:40 AM, R4 was located across the street from the facility by a staff member. R4 ambulated across the street and was found alone sitting in the triangle where facility staff usually smoke. There were no staff in the area at the time, and residents did not smoke. Further review of the incident revealed that R4 was alert and oriented to person and place only. R4 was noted to be confused, impulsive, an active exit seeker, and a wanderer. A review of the Root Cause Analysis: Elopement/Exit Seeking Events, dated 07/05/25, in the section titled Why did the above happen? revealed that the incident occurred due to a failure in communication, a lack of immediate staff response, and the absence of appropriate safety systems for residents identified as elopement risks. Although the receptionist recognized the resident near the exit door and tried to notify nursing staff, the call went unanswered, and no further steps were taken to ensure the resident's safe return to his unit. There was no escalation process in place to address unanswered calls or to prompt in-person intervention. Additionally, there were no physical safeguards or secure access to prevent the residents from exiting the facility unnoticed. As a result, the residents remained unsupervised in a public area and were able to leave the premises without staff awareness. Further review of the form in the section titled Process involvement revealed that the fifth floor, which houses multiple residents with cognitive impairment and exit-seeking tendencies, is not a secure unit. There was no formal process or standard protocol in place for lobby management of at-risk residents. Additionally, there was no system to alert staff when residents identified as elopement risks accessed or left the building. This highlights procedural weaknesses in both physical security and staff communication practices. A review of R4's Care plan, found under the Care Plan tab of the EMR updated on 07/05/25, revealed R4 was at risk for wandering/elopement, identified exit seeking, exploring his environment, and others' rooms, which included the intervention to place R4 on one-on-one monitoring until cleared by the medical provider. No further interventions were updated in the care plan after the date of 07/05/25. 3. Review of R5's Resident Face Sheet located in the resident's EMR under the Profile tab revealed R5 was admitted to the facility on [DATE] with admitting diagnoses that included a history of falling, type 2 diabetes, and cognitive communication deficit. Review of the MDS found under the MDS tab of the EMR with an ARD of 09/15/25, indicated R5 was assessed with a BIMS score of 11 out of 15, indicating that R5's cognition was moderately impaired. R5's mobility was determined to be independent with the use of a wheelchair. A review of the elopement risk scores under the assessments tab of R5's EMR revealed that R5 was moderately at risk for elopement. On 06/08/25, she scored a seven, on 07/05/25, and on 08/07/25, she scored a six, and on 11/21/25, she scored an eight. A review of the signed staff statement, provided by the facility, dated 06/08/25, by Receptionist (RCP) 1 stated that she was on the phone when she saw R5 quickly scoot out of the main doors. RCP1 put the phone down and asked Licensed Practical Nurse (LPN) 11 to go outside and bring R5 back inside. A review of the signed staff statement, provided by the facility, dated 06/08/25, by LPN11 stated she was coming out of the elevator when another resident told her that a resident had just gone outside. When the Administrator asked LPN11 if RCP1 spoke with her, LPN11 stated that RCP1 may have said something to her, but there was a lot going on in the lobby, and she just went looking for the resident who got out of the main door. She found R5 just past the end of the carport. LPN11 asked R5 to come back inside, but was reluctant. Then, RCP1 came outside to help me get R5 back inside the building. A review of the form titled Elopement Drill form found in the Facility Reported Incident packet, dated 06/08/25, revealed that some staff did not know what code orange was when asked, Did the staff respond immediately to their search assignments? A review of the form titled Elopement Drill form found in the facility reported incident packet, dated 06/08/25, also revealed that the facility intercom was not working in all areas, staff needed more training on code meaning and code response, and the elopement protocol needs further review. A review of R5's Progress Note located under the Progress Note tab of the EMR dated 06/08/25, by Registered Nurse (RN) 3 revealed, R5 was reported to have exited the front door from the main lobby and proceeded into the parking lot. R5 remained on facility grounds and did not leave the facility campus. Per RCP1, the nursing staff was alerted. Assigned nurse LPN11 escorted R5 back into the facility without protest or complications and safely returned to the designated unit, and was joyfully received by the floor staff. A review of R5's Care Plan, located under the Care Plan tab of the EMR, dated 06/09/25, revealed that R5 was at Risk for wandering / Elopement, evidenced by wandering and exploring her environment and seeking new environments. The care plan included updated interventions that included identifying if there are triggers for wandering / eloping, identifying if there is a pattern and purpose of wandering, and Social Services to facilitate a family conference for support, distracting the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. 4. Review of R3's Resident Face Sheet located under the resident's EMR under the Profile tab revealed the resident was initially admitted to the facility on [DATE] on the 4th floor with diagnoses that included nontraumatic intracranial and intracerebral hemorrhage, dysphagia, and cognitive communication deficit. Review of R3's quarterly MDS located under the resident's EMR, under the Profile tab, with an ARD of on 08/05/25, indicated the resident had a BIMS score of 15 out of 15, indicating that R3's cognition is intact. A review of R3's Elopement Risk Assessment, dated 07/05/25, revealed that R3 scored a zero, indicating that R3 was not at risk for elopement. A review of the Facility Reported Incident 5-day investigation, dated 08/13/25, further revealed that staff discovered that R3 was last seen at 10:30 PM on 08/06/25 and that the assigned nurse, LPN10, responded by stating that R3 was just downstairs and took no further action. At 3:30 AM on 08/07/25, LPN10 noted that R3 was not in his room and failed to notify the house supervisor as required. A review of the signed staff statement, dated 08/07/25, by LPN10 revealed that upon printing the unit census and doing a head count for her shift, it was reported to her that R3 was not in his room. LPN10 further stated that upon receiving the medication cart keys the night before, she did rounds, but she did not enter all the rooms while administering medications to the residents assigned to her. A review of a Progress Note, located in the EMR under the Progress Note tab, dated 08/07/25, by LPN10, revealed that R3 was reported missing from the 2nd floor unit at 7:20 AM and has not been in his bed or the unit throughout the 11:00 PM to 7:00 AM shift. A review of a Progress Note, located in the EMR under the Progress Note tab, dated 08/07/25, by LPN11, revealed that he contacted the resident via his cellphone number, but there was no answer. LPN11 also contacted the family, and voicemail picked up the call without any callback throughout his shift. A review of a Progress Note, dated 08/09/25, by UMLPN1 revealed that R3 has not returned to the facility. UMLPN1 contacted the family, but it only continued to ring with no answer, and left a voicemail message to find out if they knew where R3 was. A review of a Progress Note, located in the EMR under the Progress Note tab, dated 08/10/25, by the Administrator revealed that she contacted the family and continued not to get any call backs. She contacted the local hospitals to see if R3 was admitted . She also contacted the R3's cellphone number, but no call back was received either. A review of a Progress Note, located in the EMR under the Progress Note tab, dated 08/13/25, by the Administrator revealed that R3 returned to the facility on [DATE] at 2:30 PM, was ambulating without assistance, accompanied by three friends. The Administrator inquired if they could do a physical assessment, and R3 said, No. R3 stated he would like to leave the facility, and the Administrator offered him to sign an AMA [against medical advice] form, but he refused to sign and left the facility campus.

Based on staff interviews, record review, and review of the facility's policy titled Prevention of Resident Abuse, Neglect, Mistreatment or Misappropriation of Property, the facility failed to conduct a thorough investigation for incidents of potential abuse for seven of ten residents (Resident (R) 1, R2, R24, R25, R35, R36, and R37) reviewed out of 43 sampled residents, for potential physical resident-to-resident abuse for R1 and R2, R24 and R25, and R35 and R36, and verbal resident-to-resident abuse for R35 and R37. The failure to investigate potential allegations of abuse for facility residents placed the residents at risk of abuse.Findings include: Review of the facility's policy titled Prevention of Resident Abuse, Neglect, Mistreatment or Misappropriation of Property, dated 07/2025, revealed, . Each resident has the right to be free from verbal, sexual, physical and mental abuse . [Investigation] .All suspected cases of abuse or misappropriation of resident's property will be fully investigated by the Administrator, Abuse Coordinator, or designee.Interview person reporting the allegation.Interview all associates, residents and family members involved.Continue investigation to determine if other residents may be at risk for similar occurrences . 1. Review of R1's admission Record, found in the electronic medical record (EMR) under the Profile tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia. Review of R11's quarterly Minimum Data Set (MDS), located in the resident's EMR under the MDS tab with an Assessment Reference Date (ARD) of 11/13/2025, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R1 was cognitively intact. Review of R2's admission Record located in the EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included cognitive communication deficit. Review of R2's quarterly MDS, located in the resident's EMR under the MDS tab with an ARD of 11/13/2025, revealed a BIMS score of six out of 15, indicating R2 had moderate cognitive impairment. Review of the Facility Incident Report Form, dated 08/23/2025, revealed, A resident reported concerns regarding interactions between [R1] and [R2]as the two have been observed kissing.The Facility Incident Report Form revealed the initial incident between R1 and R2 occurred on 08/23/2025. The facility investigation revealed that the responsible party was notified, and staff education titled Staff Education: Resident Rights & Consent in Relationship was provided to staff. The investigation did not include resident interviews. 2. Review of R24's admission Record located in the EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia, severe with psychotic disturbance. Review of R24's care plan located in the resident's EMR under the Care Plan tab, revised on 09/18/2025, revealed R24 was cognitively impaired. Review of R2025's admission Record located in the EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included vascular dementia. Review of R2025's care plan located in the resident's EMR under the Care Plan tab, revised 11/07/2025, revealed R2025 was cognitively impaired. Review of a Facility Incident Report Form, dated 11/27/2025, revealed, [R24] was observed walking behind [R25], who was seated in a chair. During this interaction, [R24] made contact with [R25] using a plastic utensil, resulting in a skin tear to [R24]'s hand and finger. The Facility Incident Report Form revealed the initial incident between R24 and R25 occurred on 11/27/2025 and was reported timely to the governing agency. During an interview on 12/11/2025 at 5:39 PM, the Administrator said she was not aware that she should interview residents when she was investigating abuse. She said she thought she should only interview residents if they witnessed the incident. 3. a. Review of R36's admission Record, found in the EMR under the Profile tab, revealed that the resident was admitted to the facility on [DATE] with diagnoses including dementia and cognitive communication deficit. Review of R36's five-day MDS, located in the resident's EMR under the MDS tab and with an ARD of 07/20/2025, revealed R36 had a BIMS score of six out of 15, indicating severe cognitive impairment. b. Review of R35's admission Record, found in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses including other sequelae of cerebral infarction and vertigo of central origin. Review of R35's quarterly MDS, located in the resident's EMR under the MDS tab and with an ARD of 10/29/2025, revealed R35 had a BIMS score of 15 out of 15, indicating R35 had no cognitive impairment. Review of Facility Incident Report Form, dated 10/16/2025, revealed a potential incident of Other-Inappropriate touching between residents, on 10/08/2025, that staff allegedly reported R35 was seen with his hand between the legs of R36 on top of her brief. The facility immediately separated R35 and placed residents on different floors. Both residents were placed on increased observation. Trauma, skin, and pain assessments were completed for both residents. No injuries, redness, or discolorations were identified. The responsible party, the physician, and the police were notified of the allegation. Investigation revealed: R35 denied touching the resident sexually. Certified Med Tech (CMT) 2 was the only identified witness, and documented that she observed R35, .resident was touching between her legs (R36).asked why are you touching her, please remove yourself now. CMT2 documented that she got the patient safe, and then told the unit manager. Five additional staff were interviewed, but none witnessed the incident. The investigation determined that .both residents were clothed, and no behavior was observed that definitely indicated sexual intent.staff member intervened immediately, and both residents were calm and cooperative following the redirection. Record review revealed there was an incomplete investigation of the alleged resident-to-resident abuse incident between R35 and R36 on 10/08/2025. Witness statements were completed only for the potential assailant R35, five CNAs, and the one staff witness (CMT2) at the facility. Additional residents from the facility were not interviewed to determine if they felt safe residing on the same unit with R35, or if they had experienced any resident-to-resident abuse from R35. During an interview on 12/11/2025 at 4:10 PM, CMT2 stated that she was the only person to see the incident between R35 and R36. She said she observed R35 sitting near R36. She said R35 was observed placing his hand on her upper thigh. CMT2 said she went over and removed his hand before he could actually place it in her private area. CMT2 stated, he never had a chance to actually touch her groin or brief area. She said that she had additional staff help to separate them and keep R36 safe, and then she reported it. During an interview on 12/11/2025 at 5:40 PM, the Administrator said that for abuse investigations, she would interview staff and residents if they had been present for the alleged abuse incident. She stated that she was not aware that she should interview other residents, but confirmed she should be more diligent about getting more resident interviews and witness statements. 4. a. Review of R37's admission Record located in the EMR under the Profile tab revealed an admission date of 10/24/24 with a medical diagnosis that included bipolar and dementia. Review of R37's annual MDS assessment located in the MDS tab in the EMR, with an ARD of 10/06/2025, revealed a BIMS assessment with a recorded score of 15 out of 15, which indicated no cognitive impairment. b. Review of R35's admission Record, found in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses including other sequelae of cerebral infarction and vertigo of central origin. Review of R35's quarterly MDS, located in the resident's EMR under the MDS tab and with an ARD of 10/29/2025, revealed R35 had a BIMS score of 15 out of 15, indicating R35 had no cognitive impairment. Review of Facility Incident Report Form, dated 09/18/2025, revealed a potential incident of Other-Inappropriate comments, on 09/18/2025, that R37 alleged R35 was making sexually inappropriate comments.and comes in her room without permission. The facility immediately separated R35 and placed him on one-to-one supervision during the investigation. The responsible party, physician, and police were notified of the allegation. The investigation revealed: R35 confirmed he had made comments to R37, intended no harm, sat with her at meals, and was not aware that it was a concern to R37. R35 agreed to move to a different floor. R37 was interviewed and stated that R35 had told her he wanted to get into bed with her to keep her warm. R37 also stated there had been no physical contact with R35. The investigation revealed during a trauma assessment for R37, that she had a history of domestic violence, child abuse, and sexual harassment. The facility substantiated the allegation between R35 and R37 for inappropriate resident-to-resident verbal conduct and boundary violation. Record review revealed there was an incomplete investigation of the alleged resident-to-resident abuse incident between R35 and R37 on 09/18/2025. Witness statements were completed only for the potential assailant R35, the resident victim R37, one CNA, and the maintenance director at the facility. Neither the CNA nor the maintenance director observed a concern with R35 and R37 interactions. No additional staff were interviewed to determine if they had observed any other potential resident-to-resident abuse concerns with R35. Additional residents from the facility were not interviewed to determine if they felt safe residing on the same unit with R35, or if they had experienced any resident-to-resident abuse from R35. During an interview on 12/11/2025 at 5:40 PM, the Administrator said that for abuse investigations, she would interview staff and residents if they had been present for the alleged abuse incident. She stated that she was not aware that she should interview other residents, but confirmed she should be more diligent about getting more resident interviews and witness statements.

Based on staff interview, record review, and review of the facility's policy titled Prevention of Resident Abuse, Neglect, Mistreatment or Misappropriation of Property, the facility failed to report allegations of abuse within two hours and/or submit timely investigations for four of ten (R1, R2, R24, R25, R36 and R35) reviewed for abuse out of a total of 43 sample residents. This deficient practice had the potential to place residents at increased risk of abuse. Findings include:Review of the facility's policy titled Prevention of Resident Abuse, Neglect, Mistreatment or Misappropriation of Property, dated 07/2025, revealed, . Each resident has the right to be free from verbal, sexual, physical and mental abuse . [Investigation] findings should be reported to the appropriate governing agencies . 1. a. Review of R1's admission Record, found in the electronic medical record (EMR) under the Profile tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia. Review of R11's quarterly Minimum Data Set (MDS), located in the resident's EMR under the MDS tab and with an Assessment Reference Date (ARD) of 11/13/2025, revealed R11 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R1 was cognitively intact.b. Review of R2's admission Record, located in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses that included cognitive communication deficit.Review of R2's quarterly MDS, located in the resident's EMR under the MDS tab and with an ARD of 11/13/2025, revealed R2 had a BIMS score of six out of 15, indicating R2 was moderately cognitively impaired.Review of Facility Incident Report Form, dated 08/23/2025, revealed, A resident reported concerns regarding interactions between [R1] and [R2] as the two have been observed kissing.The Facility Incident Report Form revealed the initial incident between R1 and R2 occurred on 08/23/2025 and was reported timely to the governing agency.Review of the External Email Re: Report 202025-09121 revealed the final investigation of the incident between R1 and R2 that occurred on 08/23/2025 was submitted to the governing agency on 09/15/2025.2. a. Review of R24's admission Record, located in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia, severe with psychotic disturbance.Review of R24's Care Plan, located in the resident's EMR under the Care Plan tab and revised on 09/18/2025, revealed R24 was cognitively impaired.b. Review of R25's admission Record, located in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses that included vascular dementia.Review of R25's Care Plan, located in the resident's EMR under the Care Plan tab and revised 11/07/2025, revealed R25 was cognitively impaired.Review of a Facility Incident Report Form, dated 11/27/2025, revealed, [R24] was observed walking behind [R25], who was seated in a chair. During this interaction, [R24] made contact with [R25] using a plastic utensil, resulting in a skin tear to [R24]'s hand and finger. The Facility Incident Report Form revealed the initial incident between R24 and R25 occurred on 11/27/2025 and was reported timely to the governing agency. Review of the External Email Re: Report 202025-13275 revealed the final investigation of the incident between R24 and R2025 that occurred on 11/27/2025 was submitted to the state agency on 12/09/2025.During an interview on 12/11/2025 at 5:39 PM, the Administrator stated she knew her investigations were late. She stated she submits them for review to her leadership, but did not follow up in a timely manner. The Administrator stated she was working on being more timely.3. a. Review of R36's admission Record, found in the EMR under the Profile tab, revealed that the resident was admitted to the facility on [DATE] with diagnoses including dementia and cognitive communication deficit.Review of R36's five-day MDS, located in the resident's EMR under the MDS tab and with an ARD of 07/20/2025, revealed R36 had a BIMS score of six out of 15, indicating severe cognitive impairment. b. Review of R35's admission Record, found in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses including other sequelae of cerebral infarction and vertigo of central origin.Review of R35's quarterly MDS, located in the resident's EMR under the MDS tab and with an ARD of 10/29/2025, revealed R35 had a BIMS score of 15 out of 15, indicating R35 had no cognitive impairment.Review of Facility Incident Report Form, dated 10/16/2025, revealed an incident of Other-Inappropriate touching between residents. The Facility Incident Report Form revealed the initial incident between R36 and R35 occurred on 10/08/2025. The final investigation of the incident between R36 and R35 that occurred on 10/08/2025 was submitted to the state agency on 10/23/2025.During an interview on 12/11/2025 at 5:40 PM, the Administrator said that she wanted the initial incident report submitted in two hours, and the completed investigation should be turned in within five days. She stated that she was not sure why the initial report was late, but confirmed that sometimes things were late due to documentation being reviewed by additional parties prior to being submitted to the state agency.

Based on observation, interview, and record review the facility failed to ensure services were provided in accordance with professional standards of practice for two of seven residents (R) (R49 and R87) who are dependent on dialysis three times weekly for end-stage renal disease (ESRD) received reliable transportation to attend life-sustaining dialysis treatments. This failure resulted in missed dialysis sessions and avoidable hospitalizations due to volume overload and severe hyperkalemia. On 6/3/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, the DON, and Regional Director of Clinical Operations (RDCO) were informed of the Immediate Jeopardy (IJ) for F656, F698, and F835 on 6/3/2025 at 11:14 am. The noncompliance related to the IJ was identified to have existed on 5/6/2025. An Acceptable IJ Removal Plan was received on 6/5/2025 related to Comprehensive Care Plans, C.F.R. 483.21; Dialysis, C.F.R. 483.25(l); and Administration, C.F.R. 483.70. Based on observations, record reviews, interviews, and a review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice were removed on 6/5/2025. Findings included: 1. A review of the electronic medical record (EMR) revealed that R49 was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to, hypertensive chronic kidney disease with stage 5 chronic kidney disease, end-stage renal disease, major depressive disorder, and anxiety disorder. A review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R49 had a Brief Interview for Mental Status (BIMS) score of eight, indicating moderate cognitive impairment. A review of R49 Physician's Orders revealed an order dated 10/24/2023 for the resident to receive dialysis services at 11:15 am on Tuesday, Thursday, and Saturday. A review of R49 care plan date initiated on 3/5/2021 revealed a focus category of resident is at risk to experience adverse reactions and altered psychosocial wellbeing r/t transportation issues w/ dialysis transportation. The outcome was for R49 will be free from increased s/s of adverse reactions r/t issues w/ dialysis transportation thru the next review. Interventions Contact Transportation [NAME] QA and Standing Order Supervisor for inquiry/complaint number. Ensure an alternate dialysis time option for resident. A review of R49 medical record discharge note R49 was sent to the hospital on 5/19/2025, after exhibiting symptoms of shortness of breath and elevated potassium levels. It was noted on 5/19/2025 that R49 was admitted to ICU for monitoring. R49 was admitted from 5/20/25 through 5/22/2025, and again from 5/25/2025 through 5/27/2025, for complications related to missed dialysis, including severe hyperkalemia and volume overload 2. A review of the EMR revealed that R87 was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to, type 2 diabetes mellitus without complications, chronic pulmonary edema, essential (primary) hypertension, anemia in chronic kidney disease, other hyperlipidemia, hyperkalemia end end-stage renal disease, and dependence on renal dialysis. A review of a Quarterly MDS assessment dated [DATE] revealed R87 had a BIMS score of 15, indicating Intact cognitive function. A review of R87's physician's orders revealed an order dated 5/28/2025 for the resident to receive dialysis services at 11:15 am on Tuesday, Thursday, and Saturday. A review of R87 care plan date initiated on 2/16/2023 revealed a focus category of resident needs hemodialysis related to end-stage renal failure. Risk for missing dialysis due to refusals/transportation issues. The outcome for R87 will have no s/sx of complications from dialysis through the review date. Interventions If R87 misses dialysis: 3. Attempt to secure other means for transportation. A review of R87 hospital discharge diagnoses dated 5/17/2025 at 10:57 am revealed hyperkalemia due to diminished renal excretion due to missed hemodialysis. On 5/28/2025 at 12:17 pm, R87 confirmed that he had missed a dialysis appointment again on 5/27/2025 and stated that over the past weeks, he believed he had missed dialysis at least three times or more. A review of the nursing progress notes dated 5/19/ 2025 at 8:30 pm revealed R87 complained of mild pain and cramps in the left arm. Recorded vital signs were as follows: Blood Pressure was 135/82; Heart Rate was 90 BPM (beats per minute); Respiratory Rate was 18 breaths per minute; Temperature was 98.2 degrees Fahrenheit (F); and Oxygen Saturation was 98% (percent). R87's sister requested a hospital evaluation. A physician's order was received. At 11:00 pm, R87 was transported to an acute care hospital via stretcher, accompanied by two paramedics. Interview on 5/28/25 at 12:57 pm, the Dialysis Facility Administrator (FA) YYYY confirmed that R87 completed appointments scheduled in May on the 3rd, 13th, 22nd, and 24th. The social worker disclosed that R87 was hospitalized due to missing two consecutive treatments. It was shared that the facility confirmed the missed appointments were due to transportation issues and to be seen three times a week. The FA YYYY explained that the dialysis doctor contacted the facility and ordered R87 to be sent to the hospital for treatment. Additionally, FA YYYY confirmed that the facility discounted R87's transportation on May 6th. The previous transportation company was canceled, and the facility began using its own. The current transportation company operates only with one truck. FA YYYY further explained that she has called the facility at least two to three times regarding R87 appointments, yet it seems that no one is concerned about ensuring he attends them. During an interview on 5/29/2025, at 1:35 pm with the Social Worker (SW) LLL, it was confirmed that the social work department is not responsible for dialysis transportation, but rather it is the responsibility of the nursing department and/or the Director of Nursing. During an interview on 5/29/2025 at 1:47 pm with the Director of Nursing (DON), it was confirmed that she acknowledged her awareness of residents missing their appointments and she did not conduct any scheduling of transportation. During an interview on 5/29/2025 at 2:02 pm with the Assistant Director of Nursing (ADON), she revealed she had no role in coordinating dialysis transportation. She occasionally verified that the previous central supply clerk scheduled appointments. She expressed that the current system is inadequate, leading to missed appointments for residents. During an interview with the Administrator on 5/30/2025 at 10:12 am, he acknowledged that the central supply clerk was responsible for coordinating dialysis transportation. The Administrator also admitted that he was unaware multiple residents had been hospitalized in May due to missed dialysis treatments and stated that the nursing team had not informed him. Furthermore, the Administrator was unable to confirm that the transportation barrier was discussed in QAPI. On 6/2/2025, at 1:05 PM, an interview with the Administrator and the Administrator's Assistant confirmed that residents R49 and R87 were both utilizing state state-funded (Medicaid) transportation company. Per Administrator Assistance, the state-funded transportation company has a history of being difficult, the appointment process is antiquated, and appointments must be arranged through phone calls, faxes, and/or emails. The Administrator's Assistant disclosed that the facility is required to carry out these tasks, and the Central Supply clerk (CSC) was initially responsible for this. However, the Central Supply clerk transitioned from the role of Certified Nurse Assistant (CNA) on 4/28/2025 but left the facility as the CSC on May 21, 2025. The Administrator Assistant confirmed she assumed these responsibilities after his termination, but just returned from her vacation, having departed on May 24, 2025, and returned on May 31, 2025. Both individuals indicated that there is no proactive plan in place to prevent missed appointments; they simply wait to see if state state-funded transportation company arrives on the date of the appointment. If not, they contact their brokerage transportation company, but confirmed that sometimes they are not able to accommodate the residents due to the short notice, so they call the physician. Interview on 6/2/2025 at 3:56 pm with the Medical Director confirmed her awareness of the hospitalization of both residents. She emphasized the importance of arranging transportation, ensuring access is ready, and providing necessary medications. She expressed concern that even one missed appointment per month is a significant issue and should be viewed as a red flag for the facility's operations. Interview conducted on 6/4/2025 at 9:17 am, with Dialysis Facility Administrator ZZZZ, who confirmed and provided the dates missed for chair appointments for residents R49 and R87. Resident R87 failed to attend seven out of twelve scheduled dialysis treatments on 6/6/2025, 6/8/2025, 6/10/2025, 6/15/2025, 6/17/2025, 6/20/2025, and 6/27/2025. Consequently, after missing two consecutive treatments, the dialysis physician directed the facility to transfer the resident to the hospital on 6/15/2025 for emergency dialysis. Similarly, Resident R49 missed seven out of twelve dialysis treatments on 6/7/2025, 6/9/2025, 6/19/2025, 6/21/2025, 6/23/2025, 6/26/2025, and 6/28/2025. R49 was sent to the hospital on 6/19/2025, after displaying symptoms of shortness of breath and elevated potassium levels. FA ZZZZ indicated that the dialysis physician had to recommend sending residents to the hospital, and although the dialysis service has initiated and coordinated transportation for R87, as per our agreement, the facility remains responsible for these actions. The facility implemented the following actions to remove the IJ: 1. Administration Education: The RDCO educated the Administrator, Assistant Administrator, and DON on 6/3/2025, ensuring reliable transportation services for dialysis residents. Transportation aides and licensed nursing staff were educated on the importance of scheduling appointments, follow-up of appointments, and preparing residents for their required dialysis treatments. No licensed nurses will work until the education on this care plan implementation has been completed. 2. Root Cause Analysis: On 6/3/2025, the [NAME] President of Operations (VPO), the Administrator, Assistant Administrator, the DON, the RDCO, and the Medical Director (MD) discussed the root cause of F698. The center's administration identified the root cause of this issue as the facility did not have a dedicated dialysis transport provider, nor consistent follow-up if transportation failed to arrive to transport the resident. 3. Audit of Current Dialysis Residents: A 100% audit of all current dialysis resident records has been initiated to determine if reliable transportation to and from dialysis appointments is available. 4. Systemic Change in Practice Plan: DON, the ADON, the Administrator, the Assistant Administrator, and the Transportation Aide will hold a weekly meeting to review all dialysis transportation schedules. Any scheduling conflicts or changes in scheduling companies will be addressed to ensure timely dialysis appointments. 5. Ad Hoc Quality Assurance Performance Improvement (QAPI) Meeting: An Ad Hoc QAPI Meeting was held at 4:30 pm on 6/4/2025, which included the Administrator, Assistant Administrator, the MD, the DON, the RDCO, and the VPO. Citation F698 was discussed, along with its root cause, a corrective action plan, education, and systemic changes in practice necessary to remove the immediacy and correct the deficiency. 6. Based on the steps above, the facility alleged that the immediacy was removed on 6/5/2025. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Verified on 6/6/2025 by interview with the Administrator and the RDCO. The sign-in sheet was reviewed, and the contents of the education provided were confirmed. Education was provided on 6/3/2025. Interviews were conducted on 6/6/2025 through 6/8/2025 with the following employees and revealed that they received education and were able to provide appropriate answers related to the in-service: 6/6/2025 at 1:57 pm with Certified Medication Administration Technician (CMAT) ZZZ; 6/6/2025 at 2:02 pm with Licensed Practical Nurse (LPN) LLLL; 6/6/2025 at 2:07 pm with LPN MMMM; 6/6/2025 at 2:12 pm with LPN ZZ; 6/6/2025 at 2:17 pm with LPN NNNN; 6/6/2025 at 2:22 pm with LPN OOOO; 6/6/2025 at 2:27 pm with LPN DD; 6/6/2025 at 2:32 pm with LPN PPPP; 6/6/2025 at 2:37 pm with LPN QQQQ; 6/6/2025 at 2:42 pm with LPN RRRR; 6/6/2025 at 2:47 pm with LPN EE; 6/6/2025 at 2:52 pm with LPN SSSS; 6/6/2025 at 2:57 pm with LPN YYY; 6/6/2025 at 3:02 pm with LPN WW, 6/6/2025 at 3:07 pm with LPN OOO; 6/6/2025 at 3:12 pm with LPN TTTT; 6/6/2025 at 3:27 pm with the ADON; 6/6/2025 at 3:32 pm with the DON; 6/7/2025 at 12:03 pm with LPN KK; 6/7/2025 at 12:10 pm with LPN UUUU; 6/7/2025 at 12:12 pm with CMAT RRR; and 6/7/2025 at 12:30 pm with CMAT BBB. 2. Verified by interview on 6/6/2025 with the Administrator and the Director of Clinical Operations that a meeting was held on 6/3/2025 to discuss the root cause analysis. The sign-in sheet and confirmation email from the attendees were reviewed and confirmed. The contents of the root cause analysis, which were provided to the participants, were reviewed and verified. 3. Verified on 6/6/2025 by interview with the Administrator and the RDCO that the residents’ records were updated to reflect transport arrangements for dialysis. 4. Verified by interview on 6/6/2025 with the Administrator and the RDCO that there will be a weekly meeting with the MDS Coordinator, DON, ADON, and the Unit Managers (UMs) to review all care plans that MDS assessments have been recently completed to ensure dialysis and dialysis transportation have been addressed and to ensure care plans are implemented promptly. 5. Verified by interview on 6/6/2025 with the Administrator and the RDCO that an Ad Hoc meeting was held on 6/4/2025 at 4:30 pm to discuss the root cause, a corrective action plan, education, and systemic changes in practice necessary to remove the immediacy and correct the deficiency. The sign-in sheet and confirmation email from the attendees were reviewed and confirmed. The contents of the root cause analysis, which were provided to the participants, were reviewed and verified. 6. Based on the information in the AOC, it was determined that the immediacy was removed on 6/5/2025.

Based on record review, staff interviews, and review of the Job Description for the Administrator and the Director of Nursing (DON), it was determined that the facility's Administration did not adequately address issues related to Dialysis and Transportation procedures. Furthermore, they failed to provide sufficient oversight and supervision related to dialysis transportation for two of seven residents (R) (R49 and R87). The facility administration failed to establish systems or offer administrative support to guarantee that residents receive the physician-ordered life-sustaining dialysis treatments. This oversight led to numerous missed dialysis appointments and subsequent hospitalizations. On 6/3/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, the DON, and Regional Director of Clinical Operations (RDCO) were informed of the Immediate Jeopardy (IJ) for F656, F698, and F835 on 6/3/2025 at 11:14 am. The noncompliance related to the IJ was identified to have existed on 5/6/2025. An Acceptable IJ Removal Plan was received on 6/5/2025 related to Comprehensive Care Plans, C.F.R. 483.21; Dialysis, C.F.R. 483.25(l); and Administration, C.F.R. 483.70. Based on observations, record reviews, interviews, and a review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice were removed on 6/5/2025. Findings included: A review of the undated Administrator Job Description revealed it is the Administrator's job to lead and direct the overall operations of the facility in accordance with customer needs, government regulations, and company policies, with a focus on maintaining excellent care for the residents while achieving the facility's business objectives. A review of the undated Director of Nursing Job Description revealed it is the job of the DON to manage the overall operations of the Nursing Department in accordance with Company policies, standards of nursing practices, and governmental regulations so as to maintain excellent care of all residents' needs. 1. A review of the electronic medical record (EMR) revealed that R49 was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to, hypertensive chronic kidney disease with stage 5 chronic kidney disease or end-stage renal disease, major depressive disorder, and anxiety disorder. A review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R49 had a Brief Interview for Mental Status (BIMS) score of eight, indicating moderate cognitive impairment. A review of R49 Physician's Orders revealed an order dated 10/24/2023 for the resident to receive dialysis services at 11:15 am on Tuesday, Thursday, and Saturday. A review of R49 care plan date initiated on 3/5/2021 revealed a focus category of the resident is at risk of experiencing adverse reactions and altered psychosocial wellbeing related to transportation issues with dialysis transportation. The outcome for R49 will be free from increased signs and symptoms of adverse reactions related to issues with dialysis transportation through the next review. Interventions included contacting transportation and the standing order supervisor for inquiry complaint number. Ensure an alternate dialysis time option for the resident. A review of R49's medical record discharge note, R49 was sent to the hospital on 5/19/2025, after exhibiting symptoms of shortness of breath and elevated potassium levels. It was noted on 5/19/2025 that R49 was admitted to the ICU for monitoring. R49 was admitted from 5/20/25 through 5/22/2025, and again from 5/25/2025 through 5/27/2025, for complications related to missed dialysis, including severe hyperkalemia and volume overload 2. A review of the EMR revealed that R87 was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to, type 2 diabetes mellitus without complications, chronic pulmonary edema, essential (primary) hypertension, anemia in chronic kidney disease, other hyperlipidemia, hyperkalemia, end-stage renal disease, and dependence on renal dialysis. A review of a Quarterly MDS assessment dated [DATE] revealed R87 had a BIMS score of 15, indicating intact cognitive function. A review of R87's physician's orders revealed an order dated 5/28/2025 for the resident to receive dialysis services at 11:15 am on Tuesday, Thursday, and Saturday. A review of R87 care plan date initiated on 2/16/2023 revealed a focus category of resident needs hemodialysis related to end-stage renal failure. Risk for missing dialysis due to refusals/transportation issues. The outcome for R87 will have no signs and symptoms of complications from dialysis through the review date. Interventions included that if R87 misses dialysis, the facility staff were to attempt to secure other means for transportation. A review of R87 hospital discharge diagnoses dated 5/17/2025 at 10:57 am revealed hyperkalemia due to diminished renal excretion due to missed hemodialysis. The facility implemented the following actions to remove the IJ: 1. Administration Education: On 6/3/2025, the RDCO educated the Administrator, Assistant Administrator, and DON on administering the facility in a manner that ensured dialysis residents received the necessary transportation services to attend hemodialysis appointments. On 6/3/2025, the Administrator, Assistant Administrator, and the DON reviewed their job descriptions to clarify expectations and aspects of leadership in the administration of the facility's operations. 2. Root Cause Analysis: On 6/3/2025, the root cause of F835 was discussed with the [NAME] President of Operations (VPO), the Administrator, Assistant Administrator, the DON, the RDCO, and the Medical Director (MD). The facility's administration identified the root cause of this issue as the facility did not have a dedicated dialysis transport provider, and did not have a consistent follow-up provider if transportation failed to arrive to transport the resident. This barrier prevented the center from being administered effectively to meet the residents' dialysis transportation needs. 3. Systemic Change in Practice Plan: Weekly, the Administrator, Assistant Administrator, and the DON will hold a meeting to discuss the center's policies and progress in implementing procedures, ensuring the appropriate administration is in place to run the facility effectively. 4. Ad Hoc Quality Assurance Performance Improvement (QAPI) Meeting: An Ad Hoc QAPI Meeting was held at 4:30 pm on 6/4/2025, which included the Administrator, Assistant Administrator, the MD, the DON, the RDCO, and the VPO. Citation F835 was discussed, along with its root cause, a corrective action plan, education, and systemic changes in practice necessary to remove the immediacy and correct the deficiency. 5. Steps Taken with Medicaid Contractors: Other Medicaid Dialysis Contractors have been researched. Permanent Medicaid Dialysis Contractors have been assigned to residents.A new transportation [NAME] will provide back-up transportation services for dialysis residents. 6. Based on the steps above, the facility alleged that the immediacy was removed on 6/5/2025. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. A review of the sign-in sheets revealed that education was completed on 6/3/2025 by the RDCO. Education was provided to the Administrator, Assistant Administrator, DON, and ADON. The job descriptions for Administrator, Assistant Administrator, DON, and ADON were provided and were signed as having been reviewed. Interviews were conducted on 6/6/2025 with the following employees and revealed that they received education and were able to provide appropriate answers related to the in-service: 6/6/2025 at 3:27 pm with the ADON, the DON, the Administrator, and the Assistant Administrator. 2. Discussion conducted on 6/3/2025, members in attendance consisted of VPO, Administrator, Assistant Administrator, DON, RDCO, and MD. Members not in person were informed via telephone, with confirmation receipt via. Email presented. 3. A review of the removal plan documentation revealed that the facility will conduct weekly meetings on Mondays at 9:30 am to ensure compliance with the first meeting scheduled for 6/9/2025. 4. A review of the sign-in sheets dated 6/4/2025 revealed that the Ad Hoc QAPI meeting was conducted with Administrator, Assistant Administrator, MD, DON, RDCO, and VPO in attendance. 5. Email communication between the facility and the transportation contractor was reviewed. The dialysis transportation contractor revealed residents were on a running schedule for pickup. The contract was observed with a new transportation [NAME] as backup transportation. During an observation on 6/3/2025 at 10:58 am and on 6/4/2025 at 9:00 am, residents requiring dialysis were observed being transported out of the facility timely manner for appointments. 6. Based on the information in the AOC, interviews and observations, it was determined that the immediacy was removed on 6/5/2025.

null null null Based on observations, interviews, record review, and review of facility policy titled Care Plan, the facility failed to develop or implement a comprehensive care plan for six of 106 sampled residents (R) (R49, R87, R96, R109, R80, and R180) related to dialysis for R49 and 87; related to Post Traumatic Stress Disorder (PTSD) for R96; related to activities of Daily Living (ADL) care for R109; related to pain management for R80; and related to positioning for R180. On 6/3/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, the DON, and Regional Director of Clinical Operations (RDCO) were informed of the Immediate Jeopardy (IJ) for F656, F698, and F835 on 6/3/2025 at 11:14 am. The noncompliance related to the IJ was identified to have existed on 5/6/2025. An Acceptable IJ Removal Plan was received on 6/5/2025 related to Comprehensive Care Plans, C.F.R. 483.21; Dialysis, C.F.R. 483.25(l); and Administration, C.F.R. 483.70. Based on observations, record reviews, interviews, and a review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice were removed on 6/5/2025. Findings included: A review of the facility's policy titled Care Plan dated August 2022 documented: Intent: It is the policy of the facility to create Care Plans in accordance with State and Federal regulations. Procedure: Each resident admitted to the nursing home facility shall have a plan of care. The plan of care must consist of: a. Physician's orders, diagnosis, medical history, physical exam, and rehabilitative or restorative potential. Resident care plan means a written plan developed, maintained, and reviewed not less than quarterly by a registered nurse, with participation from other facility staff and the resident or his or her designee or legal representative, which includes a comprehensive assessment of the needs of an individual resident, the type and frequency of services required to provide the necessary care for the resident to attain or maintain the highest practicable physical, mental, and psychosocial well-being, a list of services provided within or outside the facility to meet those needs, and an explanation of service goals. The facility will develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. At the resident's option, every effort must be made to include the resident and family or responsible party, including a private duty nurse or nursing assistant, in the development, implementation, maintenance, and evaluation of the resident's plan of care. 1. A review of the electronic medical record (EMR) revealed that R49 was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to, hypertensive chronic kidney disease with stage 5 chronic kidney disease, end-stage renal disease, major depressive disorder, and anxiety disorder. A review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R49 had a Brief Interview for Mental Status (BIMS) score of eight, indicating moderate cognitive impairment. A review of R49's care plan was initiated on 11/1/2022 with a focus on diagnoses of end-stage renal disease, bilateral kidney cancer, nephrectomy, and receiving dialysis. The interventions included, but were not limited to, encouraging R49 to go for the scheduled dialysis appointments. It was noted on 5/19/2025 that R49 was admitted to the Intensive Care Unit (ICU) in an acute care hospital for monitoring. A review of the care plan dated 3/5/2021 revealed that R49 was at risk of experiencing adverse reactions and altered psychosocial wellbeing related to transportation issues with dialysis transportation. The outcome was that R49 would be free from increased signs and symptoms of adverse reactions related to issues with dialysis transportation through the next review. Interventions included contacting the transportation [NAME] and the standing order supervisor for the inquiry or complaint number. Ensure an alternative dialysis time option is available for the residents. A review of the EMR discharge note revealed that R49 was sent to the hospital on 5/19/2025, after exhibiting symptoms of shortness of breath and elevated potassium levels. It was noted on 5/19/2025 that R49 was admitted to ICU for monitoring. R49 was admitted from 5/20/25 through 5/22/2025, and again from 5/25/2025 through 5/27/2025, for complications related to missed dialysis, including severe hyperkalemia and volume overload. During an interview conducted on 6/4/2025 at 9:17 am, Dialysis Facility Administrator ZZZZ confirmed and provided the dates missed for chair appointments for residents R49 missed seven out of twelve dialysis treatments on 6/7/2025, 6/9/2025, 6/19/2025, 6/21/2025, 6/23/2025, 6/26/2025, and 6/28/2025. R49 was sent to the hospital on 6/19/2025, after displaying symptoms of shortness of breath and elevated potassium levels. 2. A review of the EMR revealed that R87 was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to, type 2 diabetes mellitus without complications, chronic pulmonary edema, essential (primary) hypertension, anemia in chronic kidney disease, other hyperlipidemia, hyperkalemia end end-stage renal disease, and dependence on renal dialysis. A review of a Quarterly MDS assessment dated [DATE] revealed R87 had a BIMS score of 15, indicating Intact cognitive function. A review of the care plan created on 2/16/2023 indicated that R87 needed hemodialysis related to end-stage renal failure. Interventions included hemodialysis on Tuesdays, Thursdays, and Saturdays, and if R87 missed dialysis, an attempt would be made to secure alternative transportation. During an interview on 5/28/25 at 12:57 pm, Dialysis Facility Administrator (FA) YYYY and the Social Worker disclosed that R87 was hospitalized due to missing two consecutive treatments. It was shared that the facility confirmed the missed appointments were due to transportation issues and to be seen three times a week. The FA YYYY explained that the dialysis doctor contacted the facility and ordered R87 to be sent to the hospital for treatment. The previous transportation company was canceled, and the facility began using its own. The current transportation company operates only with one truck. 3. A review of the EMR revealed that R96 was admitted to the facility on [DATE] with a diagnosis that included, but was not limited to, PTSD. A review of the admission MDS dated [DATE] documented that R96 presented with a BIMS score of one, which indicated R96 had severe cognitive impairment and had an active diagnosis of PTSD. A review of the care plan in the EMR revealed there was no active, comprehensive care plan for PTSD. During an interview on 6/2/2025 at 12:09 pm, MDS Coordinator KKK confirmed there was no care plan for R96's diagnosis of PTSD. She stated that the nursing staff, as well as herself and the other MDS Coordinators, were responsible for developing the comprehensive care plan related to the PTSD care area, and that it was not done. She further stated that if there was no care plan for PTSD, R96 was at risk for not receiving the appropriate care. During an interview on 6/2/2025 at 1:08 pm, the DON revealed she confirmed there was no comprehensive care plan for PTSD for R96. She stated that the responsibility for ensuring there was a care plan developed for R96's PTSD was a collaborative effort between the MDS coordinators and the nursing department. She further stated it was important for a comprehensive care plan to include a plan of care for the diagnosis of PTSD to ensure that R96 received appropriate services to manage his condition. During an interview on 6/5/2025 at 12:14 pm, the Assistant Director of Nursing (ADON) revealed that R96 could be missing out on care that he should be receiving for his condition since there was no comprehensive care plan. She stated that R96 would need various interventions related to that diagnosis. 4. A review of the facility's admission records revealed that R109 was admitted to the facility on [DATE] with diagnoses that included restlessness and agitation, major depressive disorder, fall on same level, dysphagia, aphasia, atherosclerotic heart disease of native coronary artery without angina pectoris, cerebral ischemia, muscle weakness (generalized), and history of falling. A review of the Quarterly MDS dated [DATE] revealed that R109 presented with a BIMS score of nine, indicating moderate cognitive decline; had impairment on one side; that R109 required a wheelchair for mobility; required partial/ moderate assistance with toileting and upper body dressing; required substantial/ maximal assistance with lower body; and that R109 was ordered antipsychotic, antidepressant, and antiplatelet medications. A review of R109 care plan revised on 4/15/2025, revealed a focus area stating that R109 has an Activities of Daily Living (ADL) self-care performance deficit related to limited mobility, history of Cerebral Vascular Accident (CVA).” Outcome revealed that R109 will improve the current level of function in bed mobility, transfers, eating, dressing, toilet use, and personal hygiene through the review date. Interventions include to promote dignity by ensuring privacy, toilet use: require one person staff participation to use toilet, transfer: require two person staff participation with transfers, bed mobility: require two person staff participation to reposition and turn in bed, bathing: check nail length and clean on bath day and as necessary, report any changes or necessity for trimming to the nurse, bathing: is totally dependent on staff to provide a bath and as necessary, bathing: provide with a sponge bath when a full bath or shower cannot be tolerated, personal hygiene/oral care: require one person staff participation with personal hygiene and oral care, dressing: require one person staff participation to dress and eating: require supervision and setup help with meals. A review of the Physician's orders revealed the use of Seroquel oral tablet 100 milligrams (mg) (quetiapine fumarate) give one tablet by mouth at bedtime, Seroquel oral tablet 50 mg (quetiapine fumarate) give 50 mg by mouth one time a day, sertraline hcl oral tablet 100 mg (sertraline hcl) give one tablet by mouth one time a day. During an observation/ interview on 5/27/25 at 11:53 am, R109 was observed sitting on his bed. Left-sided weakness was observed with contracture of the left hand. All fingernails on both hands were long, with black substances underneath each nail. R109 stated that he had asked for help sometime this year and still has not gotten it. He stated that he has asked the staff to cut his nails on more than one occasion, but no one has done it. R109 stated that his nails keep breaking. He said, “I don't want them to break because it hurts when it breaks.” He stated that he has difficulty opening his closet and drawers due to the long fingernails. During a second observation on 5/29/2025 at 10:36 am with R109 revealed his fingernails had not been cut, cleaned, or filed. He revealed that his Certified Nursing Assistant (CNA) had been in to bring him supplies earlier. He stated that sometimes they take a long time to come to him, so he does the best he can to provide his own self-care. During an observation on 5/30/2025 at 12:42 pm, R109 revealed his fingernails still had not been cut, cleaned, or filed. R109 stated he is still waiting for someone to cut them for him. He further stated that if he were able, he would have cut them himself by now. During an interview on 5/30/2025 at 1:30 pm with CNA FF revealed that she has been working in the facility for about three years and is familiar with the resident, but stated that she is normally not his aide. She added that she is his aide just for today. CNA FF stated that CNAs do not cut fingernails, activities usually do nails, we don't do nails. We can clean them but not clip them, and I have never seen a nail file in this facility. During a fourth observation on 6/2/2025 at 9:01 am with R109 revealed himself lying in bed holding his fingers. He stated that still no one has come to cut them and doesn't want them to break while he is sleeping. 5. A review of the facility's admission record for R80 revealed that she was admitted to the facility on [DATE] with diagnoses that include insomnia, pyoderma gangrenosum, personal history of other venous thrombosis and embolism, paresthesia of skin, non-pressure chronic ulcer of other parts of right lower leg limited to breakdown of skin and lymphedema. A review of the Quarterly MDS assessment dated [DATE] revealed that R80 presented with a BIMS score of 15, indicating that R80 is cognitively intact; presented with lower extremities impairment on both sides that require the use of a wheelchair for mobility; required substantial/ maximal assistance with toileting, partial/ moderate assistance with showers, upper body dressing and personal hygiene; that R80 was dependent with lower body activities of care; received scheduled pain medication for occasional pain that does not interfere with activities; and was ordered anticoagulant, opioid and diuretic medication. A review of R80 care plan revised on 4/4/2025 revealed a focus area of Pain medication Therapy (opioid), both PRN and routine, also to be given prior to wound care. Outcome revealed, will be free of any discomfort or adverse side effects from pain medication through the review date. Interventions include, Administer medication as ordered, review (FREQ) for pain medication efficacy. assess whether pain intensity acceptable to resident, no treatment regimen or change in regimen required; Controlled adequately by therapeutic regimen no treatment regimen or change in regimen required but continue to monitor closely; Controlled when therapeutic regimen followed, but not always followed as ordered; Therapeutic regimen followed, but pain control not adequate, changes required. A review of the physician's orders revealed oxycodone HCL tablet 5 milligram (mg), give 5 mg by mouth before wound care, and oxycodone HCL tablet 5 mg, give 5 mg by mouth every six hours for pain. Pain: Assess pain level. Initial and score every shift and as needed. 0=No Pain/1-4=Mild Pain/ 5-7=Moderate Pain/ 8-10=Excruciating pain, every shift for pain monitoring. Treatment: cleanse the right posterior calf with wound cleanser/ normal saline (WC/NS). Apply alginate and wrap with kerlix, cleanse the left posterior calf with WC/NS. Apply alginate and wrap with kerlix. During an interview on 5/27/2025 at 2:44 pm, R80 revealed that her wound is doing better now, and they are giving me my medication, but I have reported them because they sometimes refuse to give me my pain medication. I constantly ask them why they are refusing to give me my medication, and they told me that they don't think I need it. The last time I had to tell them I'm gonna snitch on them to the state if they don't give it to me, and so they have been giving it to me lately. R80 stated that she sometimes refuses her treatment because she is in so much pain, because the nurse refuses to administer her pain medication. A review of R80 medication administration records for several days during the months of August 2024, September 2024, March 2025, and May 2025 revealed missing signatures on the Medication Administration Record (MAR). A review of the nurse's notes dated 8/6/2024 revealed medication out of stock. A review of the nurse's notes dated 11/10/2024 revealed medication not administered, waiting for pharmacy delivery, phone call to pharmacy and MD. A review of the nurse's notes dated 11/11/2024 revealed oxycodone HCL tablet 5 mg give 5 mg before wound care every Monday, Wednesday, and Friday for wound care to be given before wound care Med on order. A review of the nurse's notes dated 5/5/2025 revealed Medication is on order. A review of the nurse's notes dated 5/28/2025 revealed oxycodone HCL tablet 5 mg give 5 mg by mouth every six hours for pain. Awaiting pharmacy. A review of the nurse's notes dated 5/31/2025 revealed oxycodone HCL tablet 5 mg give 5 mg by mouth every six hours for pain, unavailable. During an interview on 6/5/2025 at 11:54 am, Licensed Practical Nurse (LPN) EE stated, “I do part-time, and I do a cart audit before I leave each day I'm here and reorder medication as needed. If I hear a resident say they did not get their medication, I do a grievance, and it goes to the DON. I have not heard anything about residents' missing medications.” During an interview on 6/5/2025 at 12:07 pm with Certified Medication Aide (CMA) NNN revealed that she has been working in the facility for about a year and a half and has always worked on the third floor in the hall in question. CMA NNN admitted to having had instances where residents run out of medications, and it is not in the cart. She stated that if the patient does not have medication, I call the pharmacy and reorder it. Once the pharmacy is notified, then you let the nurse know and document in progress notes what was said.” During an interview on 6/2/2025 at 1:08 pm, the DON stated, Medications for the residents are reordered by faxing the order to the pharmacy or by calling the pharmacy.” She stated that the main fax machine was at the front desk, and the nurse is required to fax the paper script to the pharmacy for reordering the medications. The DON also stated that for pain medications, it's a different process. A script is needed, and it has to be signed by the doctor and sent to the pharmacy.” The DON stated that the nurse is to follow up with the pharmacy, which will give a code or a number to remove the medication from the pyxis if available, and if the medication is not in the pyxis, the resident is offered an alternative until the medication is received. DON stated that the nurses on the units are responsible for ordering and reordering the medications in a timely manner before the stock is completely out. She stated that the medications are to be ordered within a week of them finishing, so the pharmacist has enough time to send the medication. She confirmed that there were gaps in the MAR for some residents who did not receive their pain medication and stated that, if it's not documented, it was not done. My expectation from the nurses if there is a problem where the fax and the pyxis system are down, they should notify me, and I will get in contact with the pharmacy regarding the medication.” 5. A review of the EMR revealed that R180 was admitted on [DATE] with diagnoses including but not limited to dysphagia following nontraumatic intracerebral hemorrhage, tracheostomy, respiratory failure, and morbid obesity. BIMS score of 99 due to dysphagia. A review of the care plan revealed no focus, outcome, or interventions for R180 in regards to positioning/repositioning to preserve skin integrity and promote movement of extremities. An interview was completed on 5/29/2025 at 9:05 am with a family member of R180, who revealed he visits on weekends due to his work schedule. He is concerned with her sitting in urine and feces for long periods of time. She is not getting physical therapy anymore due to her insurance, per the therapy team. She is not getting up out of bed due to staffing. She only lies in bed, which makes him concerned about her skin breaking down. He makes her medical decisions when they contact him. He has not been invited to any of her care conferences since she was admitted . He was not aware of, nor had he reviewed, a document called a care plan. An interview was completed on 6/5/2025 at 4:08 pm with DON, who confirmed R180 did not have a task in the medical record to prompt staff to position R180 frequently and document in this area. During the interview, the DON added the task that stated, turn and re-position frequently, as tolerated for comfort and pressure relief when in bed. DON confirmed that the current care plan for R180 did not include a focus and interventions for frequent repositioning. The facility implemented the following actions to remove the IJ: 1. Education for Licensed Nurses: The licensed nurses, to include the administrative nurses of the DON, ADON, the MDS Nurses, and the Unit Manager (UM), were educated on 6/3/2025 by the RDCO on completing comprehensive care plans related to dialysis and dialysis transportation. New hire orientation for licensed nurses will encompass training to ensure care plans are implemented for patients, including dialysis and dialysis transportation. Staff Education: 37 of 40 licensed nurses have been educated so far. No licensed nurses will work until the education on this care plan implementation has been completed. 2. Root Cause Analysis: On 6/3/2025, the [NAME] President of Operations (VPO), the Administrator, the Assistant Administrator, the DON, the RDCO, and the Medical Director (MD) discussed the root cause of F656. The center's administration identified the root cause of this issue as the facility did not have a dedicated dialysis transport provider, nor consistent follow-up if transportation failed to arrive to transport the resident. 3. Audit of Current Dialysis Care Plans: A 100% audit of all current dialysis care plans has been reviewed to ensure accuracy of the information and care plan implementation. 4. Systemic Change in Practice Plan: Weekly, the MDS nurses, the DON, the ADON, and the UM will hold a meeting to review all care plans for which MDS assessments have been recently completed to ensure dialysis and dialysis transportation have been addressed and to ensure care plans are implemented promptly. An Ad Hoc QAPI Meeting was held at 4:30 pm on 6/4/2025, which included the Administrator, Assistant Administrator, MD, DON, RDCO, and VPO. Citation F656 was discussed, along with its root cause, a corrective action plan, education, and systemic changes in practice necessary to remove the immediacy and correct the deficiency. 5. Based on the steps above, the facility alleged that the immediacy was removed on 6/5/2025. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Verified on 6/6/2025 by interview with the Administrator and the RDCO. The sign-in sheet was reviewed, and the contents of the education provided were confirmed. Education was provided on 6/3/2025. Interviews were conducted on 6/6/2025 through 6/8/2025 with the following employees and revealed that they received education and were able to provide appropriate answers related to the in-service: 6/6/2025 at 1:57 pm with Certified Medication Administration Technician (CMAT) ZZZ; 6/6/2025 at 2:02 pm with Licensed Practical Nurse (LPN) LLLL; 6/6/2025 at 2:07 pm with LPN MMMM; 6/6/2025 at 2:12 pm with LPN ZZ; 6/6/2025 at 2:17 pm with LPN NNNN; 6/6/2025 at 2:22 pm with LPN OOOO; 6/6/2025 at 2:27 pm with LPN DD; 6/6/2025 at 2:32 pm with LPN PPPP; 6/6/2025 at 2:37 pm with LPN QQQQ; 6/6/2025 at 2:42 pm with LPN RRRR; 6/6/2025 at 2:47 pm with LPN EE; 6/6/2025 at 2:52 pm with LPN SSSS; 6/6/2025 at 2:57 pm with LPN YYY; 6/6/2025 at 3:02 pm with LPN WW, 6/6/2025 at 3:07 pm with LPN OOO; 6/6/2025 at 3:12 pm with LPN TTTT; 6/6/2025 at 3:27 pm with the ADON; 6/6/2025 at 3:32 pm with the DON; 6/7/2025 at 12:03 pm with LPN KK; 6/7/2025 at 12:10 pm with LPN UUUU; 6/7/2025 at 12:12 pm with CMAT RRR; and 6/7/2025 at 12:30 pm with CMAT BBB. 2. Verified by interview on 6/6/2025 with the Administrator and the RDCO that a meeting was held on 6/3/2025 to discuss the root cause analysis. The sign-in sheet and confirmation email from the attendees were reviewed and confirmed. The contents of the root cause analysis, which were provided to the participants, were reviewed and verified. 3. Verified on 6/6/2025 by interview with the Administrator and the RDCO that the residents’ care plans were updated to reflect transport arrangements for dialysis. 4. Verified by interview on 6/6/2025 with the Administrator and the RDCA that there will be a weekly meeting with the MDS, DON, ADON, and the UM to review all care plans that MDS assessments have been recently completed to ensure dialysis and dialysis transportation have been addressed and to ensure care plans are implemented promptly. Verified by interview on 6/6/2025 with the Administrator and the RDCO that an Ad Hoc meeting was held on 6/4/2025 at 4:30 pm to discuss the root cause, a corrective action plan, education, and systemic changes in practice necessary to remove the immediacy and correct the deficiency. The sign-in sheet and confirmation email from the attendees were reviewed and confirmed. The contents of the root cause analysis, which were provided to the participants, were reviewed and verified. 5. Based on the information in the AOC, it was determined that the immediacy was removed on 6/5/2025.

Based on observations, staff and resident interviews, and review of the facility's policies titled Falls and Fall Risk, Managing and Self-Administration of Medication”, the facility failed to provide an environment free of accident hazards for three of 106 sampled residents (R) (R371, R14, and R159) related to failing to conduct a fall risk assessment and implement fall interventions after a fall that resulted in a major injury for R371 and failed to secure medications at the bedside for R14 and R159. Harm was identified as having occurred on 7/3/2024, when R371 had not been assessed after a fall, resulting in a delay in diagnosis and treatment for a left displaced femoral neck fracture and a closed left hip fracture. Findings included: 1. A review of the facility's policy titled, Falls and Fall Risk, Managing, with a revised date of March 2018, revealed that Based on previous evaluations and current date, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. A review of the electronic medical record (EMR) revealed that R371 was admitted to the facility on [DATE] and discharged from the facility on 10/31/2024. Pertinent diagnoses during his residence at the facility included, but were not limited to, history of falling, unsteadiness on feet, muscle weakness, other abnormalities of gait and mobility, fracture of unspecified part of neck of left femur, and fall on same level from slipping, tripping, and stumbling without subsequent striking against object. A review of R371's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicates R371 was cognitively intact; that R371 displayed no rejection of care; that R371 required supervision during a sit-to-stand transfer; required supervision (touching assistance) to walk ten feet; and that R371 had an indwelling catheter. A review of R371's care plan dated 9/14/2023 documented that R371 was at high risk for falls related to deconditioning and being unaware of safety needs. Goals included that R371 would be free of falls. Interventions included, but were not limited to, encouraging the resident to call for assistance before transferring self-unassisted and maintaining a clear pathway free of obstacles. A review of a nurse's note dated 6/30/2024 documented, PAR [Patients at risk] Review for Falls: IDT [interdisciplinary team] met to discuss falls. PAR review for fall. The resident experienced falls on 6/22/24. The resident was assisted to the bathroom by two staff members. The resident stated he was trying to get his wallet when he fell into the tub. The resident continued to be impulsive. Staff assisted the resident off the floor. It was documented that there were “No injuries noted.” The family and physician were notified of the incident. The new intervention included the completion of a fall screening. Staff were reeducated on not leaving residents unattended while in the bathroom. R371 remained on Weekly PAR Review. Last fall: 5/4/2024, 5/17/2024, and 6/20/2024. A review of the nurse's notes in R371's EMR revealed no documentation on 7/3/2024, the day of the fall that resulted in injury. A review of a nurse's note dated 7/5/2024 in R371's Unrevealed that at approximately 12:00 pm on 7/5/2024, R371 complained of pain in the left thigh and knee. The resident was asked what had happened, and he stated he had fallen a few days prior. It was documented that the resident had a history of falls. The resident voiced no other concerns, and upon assessment, there were no bruising or open areas noted at the time of the reported incident. The Nurse Practitioner (NP) was notified and ordered an x-ray and as-needed (prn) pain medication. A review of a nurse's note dated 7/5/2024 in R371's EMR documented an acute visit note by the NP that she was called by nursing staff with a report that R371 was complaining of left leg and knee pain due to a recent fall. On her arrival at the facility, R371 was assessed for pain and injury and stated that he had sustained a fall three days ago while he was trying to go into the restroom. It was documented that R371 stated that he tripped over his Foley catheter because it was too long. The NP assessed R371’s leg and knee; the resident flinched when his leg was touched or raised. It was documented that R371 stated that his pain level was seven out of ten with movement. Verbal orders were given to staff for a view x-ray of R371's left leg and knee, and instructions to staff to continue to assist R371 with ADL care as needed and continue pain management. A review of a radiology report dated 7/7/2024 in R371's EMR documented an acute left femoral neck fracture. A review of a nurse's note dated 7/8/2024 in R371's EMR documented a phone encounter signed by the NP that the X-Ray results showed left femur fracture. Verbal order given to send patient out to hospital for further evaluation and treatment. Under Assessment, the NP documented ICD codes of Abnormal x-ray of femur, Femur fracture, left, and Fall with injury. A review of a nurse’s note dated 7/8/2024 in R371's EMR documented, Writer received X-ray results, NP notified of results and writer was given an order to send to (emergency room) for evaluation/treatment (related to) X-ray results; 911 was notified and resident to be sent to hospital, report was given to hospital that this resident is impulsive and has a (history) of falls - he was (complaining of) pain and on call (physician) was notified and x-ray order was obtained; daughter made aware of transfer; and (R371) aware that he is going to the hospital, all safety measures are in place, will continue with (plan of care). A review of a hospital Discharge summary dated [DATE] documented that R371 was admitted to the hospital on [DATE] and discharged on 7/12/2024. Under section titled Discharge Diagnoses, a left displaced femoral neck fracture and a closed left hip fracture were documented. Section titled Care Timeline revealed an arthroplasty, hip, bipolar was performed on 7/9/2024. A review of an undated Witness Statement Form, Certified Nursing Assistant (CNA) CCC stated that he observed [R371] on the floor from tripping over his cat. bag. I helped him into the wheelchair and back into bed, and he replied that he was okay. This occurred on 7/3/2024. I let the nurse on duty know at the time it was [Licensed Practical Nurse (LPN) DDD], this occurred around 11:45 am.” A review of an Employee Counseling Form dated 7/11/2024 revealed LPN DDD was terminated with details that stated, Resident fell on 7/3/2024 and was reported to [LPN DDD] by a CNA on duty. The nurse did not report the fall or do a risk assessment pertaining to the fall. The fall resulted in injury. When the nurse was questioned, she stated she did not recall a fall. A review of a final summary dated 7/14/2024 of the facility reported incident documented a conclusion that documented that it was determined by the Interdisciplinary Team (IDT) team that [R371's] fracture had occurred when he fell from his room on 7/3/2024. [CNA CCC] had reported to the charge nurse [LPN DDD] that [R371] had fallen. However, [LPN DDD] did not document or assess [R371] . On 7/5/2024, [R371] complained of left leg pain. Orders were obtained to get an X-ray of the left hip and leg area. An X-ray was obtained, and results revealed a fractured left femur. Family and (physician were notified of the results. Orders received to send [R371] to ER. [R371] was scheduled for surgery for left femur fracture. [R371] will be returning to the facility. Investigation also revealed that [LPN DDD] failed to follow facility policies regarding incidents/falls. [LPN DDD] failed to assess and document [R371's] incident after it was reported to her. Due to these reasons, [LPN DDD] was terminated from her position at the facility. [CNA CCC] received education on not getting a resident off the floor until the nurse assessed them after a fall. During an interview on 6/3/2025 at 9:27 am, the Human Resources Director confirmed that LPN DDD was terminated on 7/8/2025 for violating company policy/procedure and is not eligible for rehire. During a phone interview on 6/7/2025 at 11:30 am, CNA CCC revealed that R371 always tried to get up and go back and forth to the restroom without asking. He noticed the resident on the floor, picked the resident off the floor, and then went to the nurses' station to report it to the nurse. He told the nurse that the resident fell, and that the nurse said, “Okay.” He stated that the nurse did not make any sudden moves to assess the resident after he reported the fall. During an interview on 6/6/2025 at 9:26 am, the Director of Nursing (DON) revealed R371 resided at the facility before she sated working at the facility. The DON stated that when a resident falls, there should be an immediate physical assessment, neuro assessment, pain assessment, vitals taken, notification to the physician and family, documentation, follow-up, X-ray, and other interventions as indicated, such as hospitalization. The DON confirmed that, according to the facts, the nurse did not assess the resident following the fall. The DON confirmed that she does not see any care plan interventions regarding tripping over his catheter bag. The DON further confirmed that the CNA should not have moved the resident before the resident was assessed, and the charge nurse should have assessed immediately following the fall. The DON stated that potential negative outcomes of not meeting these expectations following a resident's fall could result in injuries they are not aware of. 2. A review of the facility's policy titled Self-Administration of Medication, dated April 2022, under section titled General Guidelines, number one documented, A resident may not be permitted to administer or retain any medication in his/her room unless so ordered, in writing, by the attending physician and approved by the Interdisciplinary Care Plan Team. A review of R14's EMR revealed R14 was admitted to the facility on [DATE] with pertinent diagnoses that included osteoarthritis, asthma, rheumatoid arthritis, and cognitive communication deficit. A review of R14's quarterly MDS assessment dated [DATE] revealed a BIMS of 15, indicating R14 was cognitively intact. A review of R14's physician orders revealed no order for an inhaler or any topical medications. Additionally, there was no order for self-administration of medications. A review of R14's EMR revealed no assessment for self-administration of medications. During an observation on 5/27/2025 at 11:00 am of R14's bedside table revealed a pill bottle with an unknown opaque substance inside and a name on the bottle that is not R14's or any responsible party listed in R14's EMR. Further observation revealed an inhaler on the bedside table. An interview with R14 during this time revealed that she uses the inhaler often, sometimes two to three times a day. When asked about the pill bottle, she stated there is some eczema medication inside. During an observation on 5/28/2025 at 5:49 pm of R14's bedside table revealed the same pill bottle with opaque substance and the inhaler. During an observation on 5/29/2025 at 9:45 am of R14's bedside table revealed the same pill bottle with opaque substance and the inhaler. During an interview on 5/29/2025 at 9:48 am with Certified Medication Aide Technician (CMAT) SS revealed that R14 does not use an inhaler or any topical medications according to R14's physician orders. She further confirmed these medications should not be at the bedside and that all of R14's medications should be administered through the facility staff. She further confirmed that they can only give what the physician prescribed. During an interview on 6/6/2025 at 8:59 am with the DON confirmed that the pill bottle with opaque substance and the inhaler should not be kept at R14's bedside, and they need to do an assessment for self-administration. The DON confirmed she does not see any order for creams and confirmed the pill bottle was something the facility probably did not know anything about and possibly the family brought in. The DON further confirmed she does not see an order for an inhaler and stated that family possibly brought that in as well. 3. A review of the facility's policy titled Self-Administration of Medication dated April 2022 documented Policy: The purpose of this procedure is to establish uniform guidelines concerning the self-administration of drugs. General Guidelines: 1. A resident may not be permitted to administer or retain any medication in his/her room unless so ordered, in writing, by the attending physician and approved by the Interdisciplinary Care Plan Team. A review of the facility's Electronic Medical Records (EMR) documented R159 was re-admitted to the facility on [DATE] with a diagnosis of, but not limited to, major depressive disorder. A review of the Medicare 5-Day MDS dated [DATE] documented that R159 presented with a BIMS score of 14, which indicated R159 had intact cognition, and presented with a diagnosis of major depressive disorder. A review of the care plan documented no evidence of a care plan for self-administration of medication. A review of Physician's Orders documented no evidence of physicians' orders for self-administration of medication. A review of the facility's documents revealed no evidence of approval of medication self-administration by the interdisciplinary team. An observation on 5/27/2025 at 2:40 pm revealed one bottle of vitamin C 500 milligram (mg) tablets, one bottle of vitamin D3 Softgels, and one bottle of vitamin E Softgels in a container on R159's bedside table. During an interview at this time, R159 stated the tablets belonged to her and she took them whenever she wanted to take them. An observation on 5/28/2025 at 9:46 am revealed one bottle of vitamin C 500 milligram (mg) tablets, one bottle of vitamin D3 Softgels, and one bottle of vitamin E Softgels in a container on R159's bedside table. During an interview at this time, R159 stated she had had the tablets for weeks and had been taking them whenever she wanted to take them. During an interview on 5/28/2025 at 9:48 am, Licensed Practical Nurse (LPN) DD revealed she confirmed there was one bottle of vitamin C 500 mg tablets, one bottle of vitamin D3 Softgels, and one bottle of vitamin E Softgels in a container on R159's bedside table. LPN DD stated she did not know the tablets were there at R159's bedside. She stated R159 should not have the medications at her bedside without the nurses' knowledge, and that she was the regular nurse on this unit, and she was not aware of the medications at R159's bedside. LPN DD stated the doctor should be aware of it and order the medications if R159 were to get them. She also stated R159 was not ordered for self-administration of medications, and there was no process in place for her to self-administer medication. She further stated the tablets may interact with other medications she was taking, interact with medications given by the nurses at the facility, and worst-case scenario, she may have a negative reaction to the medications. During an interview on 5/31/2025 at 10:47 am, CNA QQQ revealed that she stated the residents should not have medications at the bedside. She stated she would let the nurse know because R159 may take more than what she should be taking if the nurse was giving her the same medications. During an interview on 6/2/2025 at 1:08 pm, the DON revealed her expectations were for the residents not to have medications at the bedside. She stated that the nurses need to manage the residents' medications to know what medications are being given by the facility. She stated the nurses were to follow up with the medical doctor to see if the doctor wanted the resident to receive those medications and go through the process of allowing the resident to have the medication. The DON stated the process involved physicians' orders, the IDT allowing self-administration of medications, and it be care was planned, and that process was not in place.

Based on observations, staff interview, record review and review of the facility's policy titled, Coordination- Pre-admission Screening and Resident Review (PASARR) Program, the facility failed to coordinate/ incorporate PASARR recommendations into for four of four resident (R) (R12, R104, R117, and R33) assessment, care planning and transitions of care. This failure had the potential to cause duplication of services and failure to provide the services necessary for individuals with mental disorders, intellectual disability, or a related condition for level two residents. Findings included: A review of the undated facility policy titled Coordination Pre-admission Screening and Resident Review (PASARR) Program revealed that the facility will coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and efforts. Incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a residence assessment, care planning, and transitions of care. 1. A review of the electronic medical record (EMR) records for R12 revealed that he was admitted on [DATE] with diagnoses that include bipolar disorder, schizoaffective disorder, morbid obesity, anxiety disorder, induced subacute dyskinesia, and drug-induced secondary parkinsonism. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed A Brief Interview of Mental Status (BIMS) score of 15, indicating no cognitive deficits. Section A of the MDS revealed that R12's PASARR II assessment indicated No. Section D revealed that R12 very rarely suffers from social isolation. Section E reveals no behavior exhibited. Section GG revealed lower extremities impairment on both sides, wheelchair, dependent with lower body dressing, showers, and toilet hygiene. Section N reveals antipsychotic, antiplatelet, and anticonvulsant medication use. A review of the care plan dated 4/4/2025 revealed that R12 was at risk for altered mood or behavior related to the diagnosis of schizoaffective disorder, bipolar disorder, anxiety disorder, and insomnia, and that R12 would have an improved mood state, happier, with no signs or symptoms of depression, anxiety, or sadness through the review date. The interventions included administering medications as ordered, monitoring/documenting for side effects, and assessing effectiveness. Behavioral health consults as needed (psycho-geriatric team, psychiatrist, etc.) and educate the resident regarding expectations of treatment, concerns with side effects and potential adverse effects, evaluation, and maintenance. Focus area revealed, has an Activities of Daily Living (ADL) self-care performance deficit, personal assistance myself except for. The outcome states, Residents' needs will be met. The interventions include assisting R12 with ADL care as needed, Physical Therapy/ Occupational Therapy (PT/ OT) evaluation and treatment as per MD orders. A review of the physician orders revealed Abilify oral tablet 10 milligrams (mg), HCL 100 mg, Depakote delayed release 500 mg, give one tablet daily, and Depakote 500 mg, give four tablets by mouth at bedtime for schizoaffective disorder. A review of the PASARR II recommendations, dated 8/20/2024 revealed, There's diagnosis of bipolar disorder and he's been taking psychotropic medications consistent with such diagnosis, to include two psychotropics; for this reason and due to onset of major stressors and possibility of extended stay, specialized mental health services are recommended during stay. Specifically, psychiatric care for assessment and medication monitoring, individual counseling for adjustment and coping and other emotional support and the development of an individualized care plan, one incorporating his needs and preferences for improved and sustained health stability, behavioral and physical, behavioral health monitoring is recommended. Follow up with the outpatient psychiatric provider is recommended. Initial observation and interview on 5/27/2025 at 12:19 pm with R12 revealed him lying in bed staring at the ceiling. R12 stated that he would like to get out of bed every day, but they get him up once a week whenever they can due to the Hoyer and short staff and due to his weight. He stated that he mostly stays in bed and gets very few visits from staff, but they come whenever he rings for help. R12 stated that he is from Kentucky but likes being here in Georgia because this is where his wife is from, and she passed away, and being here makes me feel close to her when I feel sad. R12 further stated that they would like to do activities or some kind of recreation with other people. During an observation on 5/28/2025 at 11:01 am, R12 was lying in bed watching TV. He stated that he informed the Certified Nursing Assistant (CNA) that he would like to get out of bed today, but was told that they were short-staffed and so she couldn't get him up. R12 stated that he understands and is just grateful to be able to stay here so he can be close to his wife. 2. A review of the facilities' admission records R104 revealed that R104 was admitted to the facility on [DATE] with diagnoses that include dementia with agitation, paranoid schizophrenia, major depressive disorder, hallucinations, and cognitive communication deficit. A review of R104 admission MDS assessment dated [DATE], revealed a BIMS score of 11, indicating minimal cognitive deficits. Section A of the MDS revealed that R104 PASARR II assessment indicated No. A review of R104's care plan, revised on 6/6/2025, revealed a focused area stating, has a diagnosis of paranoid schizophrenia, brief psychotic disorder, hallucinations, and a problem related to social environment. Level II. Outcome revealed, will have fewer episodes of behaviors through the review date. Interventions included administering medications as ordered. Monitor/document for side effects and effectiveness, anticipate and meet needs, approach in a calm manner, document behaviors and resident response to interventions. Focus area states, diagnosis of paranoid schizophrenia, hallucinations and brief psychotic disorder. Outcome reveal, will remain free of drug related complications, including movement disorder, discomfort, hypertension, Constipation or cognitive impairment to review date. Interventions include, administer medications as ordered. Monitor/ document for side effects and effectiveness, observe for hypotension tardive dyskinesia, excessive sedation, or AMS; promptly report such to the MD, observe for signs of hallucinations or other psychotic episodes; Promptly report such to the MD. Focus area also includes, uses antidepressant medications for poor appetite. Outcome states will show decreased episodes of sign and symptoms of depression through the review date. Interventions include, educate the resident/family/caregiver about risks, benefits and the side effects and/ or toxic symptoms of (Specific: antidepressant drugs being given), give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness. Antidepressant side effects: dry mouth, dry eyes, Constipation, urinary retention, suicidal ideations. Monitor/document/report to MD PRN ongoing signs and symptoms of depression on altered by antidepressant meds: sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, negative mood/ comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, change in condition, change in weight/ appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, constant reassurance. A review of the physician orders revealed mirtazapine 15 milligrams one tablet at bedtime for poor appetite, melatonin tablet 3 mg by mouth at bedtime for sleep. A review of the PASARR II recommendations dated 11/30/2021 revealed that it should be noted that R104 Presentation could be considered as behavioral and psychological symptoms of dementia; however, given that psychiatric medication management has been beneficial and that schizophrenia is reported to be a historical diagnosis the following specialized mental health services are recommended: behavioral health assessment/ Service plan development for ongoing assessment of R104 needs and development of an individualized treatment plan. Her son should be included in all treatment and transition planning:- Diagnostic/ ongoing psychiatric care to assess R104's mental status, monitor her psychiatric symptoms, and manage her psychotropic medications. 3. A review of R117's admission records revealed that R117 was admitted to the facility on [DATE] with a diagnosis that included bipolar disorder, intellectual disabilities, Ogilvie syndrome, and chronic pain. A review of R117 admission MDS, dated [DATE], revealed a BIMS score of 15, indicating no cognitive deficits. Section A of the MDS revealed that R117 PASARR II assessment indicated No. Brief review of R117 care plan, last reviewed on 5/27/2025, revealed a focus area stating, has impaired cognitive function/ dementia or impaired thought process related to bipolar disorder, intellectual disabilities, disease process, acute respiratory failure with hypoxia. Resident has a PASSR [sic] level 2 related to severe mental illness. The outcome states, will maintain current level of cognitive function through the review date. Interventions include, refer resident to cycle therapy for PASRR support services, administer meds as ordered, ask yes/ no questions in order to determine the residents needs, break tasks into one step at a time, cue, reorient and provides as needed, keep the routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion, and present just one thought, idea, question or command at a time. A review of the Physician's orders revealed the use of mirtazapine 15MG, 0.5 tablet daily for depression, Seroquel 100 MG, 1.5 Tab 2 times daily for bipolar disorder, Buspirone HCL 5MG, one tablet three times a day related to bipolar disorder. A review of R117 PASARR II recommendations, dated 8/8/2023, revealed, due to her long history of mental illness and recent changes in her psychiatric medications I am recommending PASRR (behavioral health) services. The recommendations are as follows: a behavioral health assessment that includes her goals and preferences. As psychiatrist to continue to monitor psychiatric medications and manage psychiatric symptoms. Her intellectual limitation should be addressed in MD S. She may require long time or repetition to learn new information. Regarding undesired behaviors, the SNF should learn what triggers these behaviors and try to minimize them if possible. In addition, offer positive reinforcements with the desired behaviors is exhibited. 4. A review of the admission records for R33, revealed an admission date of 4/11/2025 with diagnosis that include, schizophrenia, major depressive disorder, mild cognitive impairment, and hemi plegia and hemiparesis following cerebral infarction. A review of R33 admission MDS, dated [DATE], revealed BIMS score of 12 indicating minimal cognitive deficits. Section A of the MDS revealed that R33 PASARR II assessment indicated No. A review of R33's care plan last revised on 6/6/2025 revealed a focus area stating, has diagnosis schizophrenia/ schizoaffective disorder; Resident exhibiting signs and symptoms of vulgar and verbally aggressive behaviors. PASARR level II. Outcome states, resident will be free from increased silent symptoms of impulsivity, poor coping skills and verbal aggression toward others through next review. The interventions include, calling staff out of their names, knocking items off medication cart and the desk area--ER evaluation. Do not encroach nor argue w/ the resident to allow for calming, make notifications to residents RP of residents exhibited behaviors, as appropriate and provide reality orientation to resident, as tolerated and refer resident for geri psych support provider services as appropriate. Focus area reveals, has impaired cognitive function/ dementia or impaired thought process related to impaired decision making, neurological symptoms. Outcome states, will be able to communicate basic needs on a daily basis through the review date. Interventions include, administer meds as ordered, ask yes/ no questions in order to determine needs, break tasks into one step at a time, cue, reorient and supervise as needed, discuss concerns about confusion, disease process, NIH placement with R33/ family/ caregivers. Focus area reveals, has mood problem related to schizophrenia, depression. Outcome states, will have improved mood state (happier, calmer appearance, no signs or symptoms of depression, anxiety or sadness) through the review date. Interventions include, administer medications as ordered. Monitor/ document for side effects and effectiveness, educate R33/ family/ caregivers regarding expectations of treatment, concerns with side effects and potential adverse effects, evaluation, and maintenance. Monitor/ record mood to determine if problems seem to be related to external causes, i.e., medications, treatments, concerns over diagnosis. Monitor/ record/ report to MD PRN acute episode feelings of sadness; Loss of pleasure and interest in activity; Feelings of worthlessness or guilt; Changing appetite/reading habits; Change in sleeping habits; diminished ability to concentrate; Change in psychomotor skills, monitor/ record/ report to MD PRN mood patterns signs and symptoms of depression, anxiety, sad mood as per facility behavior monitoring protocols. A review of the physician's orders revealed the use of Seroquel 150 milligrams two times per day for aggressive behaviors. A review of R33 PASARR II dated 12/15/2021, recommendations reveal that due to symptoms of schizophrenia and major depressive disorder, including agitation, verbal aggression, and paranoia, specialized psychiatric services are recommended. Recommended specialized services for SMI include behavioral health assessment/ service plan development to assess history, symptoms, needs, and to develop an individualized plan of care. Individual counseling to help recognize triggers for mood episodes, depression, anxiety, and coping. During an interview on 6/2/2025 at 12:08 pm, the Social Worker (SSW) MM and SSW LLL revealed that it is the responsibility of the social workers to complete and maintain the resident's MDS and care plan. SSW LLL stated that they had previously covered only short-term residents and, only recently, about a few months been assigned to other residents in the building. She stated that she is a bit familiar with the residents and is still getting to know them. SSW MM stated that the Social Services Director (SSD) would be better suitable to assist with the responses. During an interview on 6/2/2025 at 12:19 pm, SSD DDDD stated that all four residents R12, R33, R117 and R104 currently had a PASARR II with recommendations on the care plan completed by the social work department and that all recommendations were accepted and is being followed. SSD DDDD stated that they have psychological services through ***** Healthcare services at least monthly and has recommendation for inhouse psychological services overseen by a psychiatrist as needed. SSD DDDD admitted that the recommendations documented in the EMR differ from those listed on the care plans but stated that a PASARR II is usually picked up on admission and captured by the MDS department; therefore, she was not sure why it wasn't. SSD DDDD also stated that social work completes the parts on the MDS they are responsible for and the MDS team should do the rest, but she was unsure who completes what areas. During an interview on 6/2/2025 at 1:08 pm, MDS Coordinator KKK revealed that she was new to MDS and had only been working in the facility since October 2024. MDS KKK confirmed that R12, R104, R33, and R117 were all coded as No on their admission MDS assessment. She stated that all assessments were completed before she worked in the facility, but denies ever looking at his admission records since then. MDS KKK stated that she is still learning the MDS process and usually follows whatever was done on the previous assessment.

Based on observations, resident and staff interviews, records review and review of the facility's policies titled Infection Prevention and Control Program, Standard Precautions, Water Management Program, Wound Care, Hand Hygiene, Pressure Ulcer Treatment, and Housekeeping and Laundry Services, the facility failed to maintain infection control processes and procedures related to (1) failing to maintain a sanitary living environment for four of ten resident rooms (224, 225, 227 and 305); (2) failed to comply with proper hand hygiene practices; (3) failed to comply with appropriate infection control practices regarding laundry services; (4) failed to maintain an effective Infection Prevention and Control Program (ICPC), and Antibiotic Stewardship program and a Water Management Program; and (5) failed to maintain a clean field and practice proper enhanced barrier precautions during wound care for two residents (R) R206 and R146. This failure had the potential to put all residents, staff, visitors, and volunteers at an increased risk of infection. The facility census was 212. Findings included: A review of the undated facility policy titled Infection Prevention and Control Program (IPCP) revealed that the elements of the Infection Prevention and Control Program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, employee health and safety, identifying recording and correcting (ICP) incidents, investigating and reporting communicable diseases and conducting an annual review of the ICP program; that the infection prevention and control committee is responsible for reviewing and providing feedback on the overall program; and that surveillance data and reporting information is used to inform the committee of potential issues and trends. Some examples of committee reviews may include whether physician management of infection is optimal, whether antibiotic usage patterns need to be changed because of the development of resistant strains, whether information about culture results or antibiotic resistance is transmitted accurately and in a timely fashion, and whether there is appropriate follow-up of acute infections. The committee meets monthly and consists of team members from across disciplines, including the medical director. Surveillance will be ongoing, systemic collection, analysis, interpretation, and dissemination of data to: monitor trends of infection and pathogen, detect outbreaks, monitor staff adherence to IPC practices, identify performance improvement opportunities, track progress towards priorities, and identification on annual IPC risk assessment. Antibiotic usage is evaluated, and practitioners are provided feedback on reviews. Data gathered during surveillance is used to oversee infections and spot trends. Important facets of infection prevention include: identifying possible infections or potential complications of existing infections, instituting measures to avoid complications or dissemination, educating staff and ensuring that they adhere to proper techniques and procedures, enhancing screening for possible significant pathogens, immunizing residents and staff to try to prevent illness, implementing appropriate isolation precautions when necessary and following established general and disease specific guidelines such as those of the Center for Disease Control (CDC). Our antibiotic stewardship program promotes appropriate use of antibiotics, includes a system of monitoring to improve outcomes and reduce antibiotic resistance (ensuring antibiotics are prescribed for the correct indication, dose, and duration to appropriately treat residents), and includes the development of protocols and a system to monitor antibiotic use. A review of the facility policy titled Standard Precautions dated April 2022 revealed that standard precautions will be used in the care of all residents regardless of their diagnosis or presumed infection status. Standard precautions apply to blood, body fluids, secretions, and excretions regardless of whether or not they contain visible blood, non-intact skin, or mucous membranes. The policy interpretation and implementation revealed, wash hands immediately after gloves are removed, between resident contacts, and when otherwise indicated to avoid transfer of microorganisms to other residents or environments. Wash hands between tasks and procedures on the same resident to prevent cross-contamination of different body sites. Remove gloves promptly after use, before touching non-contaminated items in environmental surfaces, and before going to another resident, and wash hands immediately to avoid transfer of microorganisms to other residents or environments. Where a gown is used to protect skin and prevent soiling of clothing during procedures and resident care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, excretions, or cause soiling of clothing. Ensure that environmental surfaces, bed rails, bedside equipment, and other frequently touched surfaces are promptly cleaned. Handle, transport and process used linen soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposure, contamination of clothing, and avoids transfer of microorganisms to other residents and environments. A review of the undated facility policy titled Water Management Program (Legionella) Policy Template revealed that Legionella and other waterborne pathogens, such as Pseudomonas original PSA, spread through droplets of water and contaminated devices using facility water, such as ice machines and showers. The facility's water management program is overseen by the water management team. The team consists of internal and external partners who play a role in the water management system for our facility. The water management team consists of the following representatives: Infection Control Officer, Facility building manager/ Facilities Director, Medical Director, Facility Administrator, Risk Manager/ Regulatory/Manager, Local water department representative, and Water maintenance contractor representative. The facility conducts a weekly review of all culture results for cases of identified Legionella. All cases of healthcare-associated pneumonia are reviewed for involvement of Pseudomonas species or Legionella. The infection control officer reviews surveillance reports monthly with the Quality Improvement/Infection Prevention Committee and with the Water Management Program Team. The Water Management Team reviews the facility water system and program design annually and makes appropriate changes based on applicable results, regulations, and standards. The Water Management Program is approved annually by the Quality Improvement/ Infection Prevention Committee. A review of the facility policy titled Housekeeping and Laundry Services dated August 2022 revealed that the facility will provide housekeeping and laundry services necessary to maintain a sanitary, orderly, and comfortable interior to include: Clean bed and bath linens that are in good condition. A review of the facility policy titled Wound Care, with a revised date of October 2010, documented that it is the facility's procedure to use disposable cloth (paper towel is adequate) to establish a clean field on the resident's overbed table and place all items to be used during procedure on the clean field. A review of the facility policy titled Standard Precautions dated April 2022 documented that the process is that staff will wear a gown (clean, non-sterile) to protect skin and prevent soiling of clothing during procedures and resident care activities that are likely to generate splashes or sprays of blood, body fluids, secretions or excretions or cause soiling of clothing. A review of the facility policy titled Pressure ulcer treatment dated April 2022 documented that this procedure may involve potential/ direct exposure to blood, body fluids, infectious disease . Protective Barriers That May Be Needed: Gown (as needed); equipment and supplies; and personal protective equipment. 1. During the initial tour of the facility on 5/27/2025 at 10:30 am, a foul odor was observed on every floor. room [ROOM NUMBER] was observed with linen soiled with a brown and yellow substance on the resident's bed. room [ROOM NUMBER] was observed with a large amount of yellow liquid on the floor under the resident's wheelchair. Observation of room [ROOM NUMBER] revealed brown stains on the privacy curtains and walls. room [ROOM NUMBER] was also observed with brown stains on the wall behind the bed from the floor to the ceiling, as well as on the privacy curtain. During an observation on 5/27/2025 at 3:00 pm, a foul odor was observed on every floor. room [ROOM NUMBER] was observed with the bed made up, and the linen was observed to be soiled with a brown and yellow substance. room [ROOM NUMBER] was observed with a moderate amount of yellow liquid on the floor under the resident's wheelchair. Observation on room [ROOM NUMBER] observed with brown stains on the privacy curtains and walls, and room [ROOM NUMBER] was observed with brown stains on the wall and privacy curtain. During an observation on 5/28/2025 at 5:30 pm revealed a foul odor remained on every floor. Linen soiled with brown and yellow stains remained on the bed in room [ROOM NUMBER], large yellow and brown stains remained on the floor of room [ROOM NUMBER], along with a small amount of liquid and dried markings on the floor under the resident's wheelchair. Observation of room [ROOM NUMBER] revealed that the brown stains on the privacy curtains and walls remained in room [ROOM NUMBER]. During an interview on 5/29/25 at 12:09 pm with the Director of Environmental Services (EVS) and the MD. The MD revealed that his facility rounds are done daily on each floor and that he has a designated person who does the rounds to make sure all the beds are working, and all equipment is working properly. He stated that he has been working in the facility for about 30 days and was aware of the many tasks to be done to get the facility up to code, but admits that building requires a lot of work. EVS Director stated that his rounds are done every two hours daily to make sure the work is being done. He stated that each floor has a full-time employee who has been working in the facility for a while. EVS director stated that he has a good team and they have been doing a great job keeping the facility up, but admits that his assistant could be doing a better job at holding people accountable for things not being done. During a facility tour on 5/29/2025 at 2:20 pm with the MD and EVS Director revealed both confirmed brown and yellow stains on curtains and walls, as well as yellow liquid with dried brown areas on the floors. Both confirmed the increased number of flying insects throughout the facility and foul odor on each unit. EVS director admitted that his assistant could be doing a better job at rounding and holding individuals accountable for tasks not done. He stated that he has not done any in-service on IP or proper cleaning techniques this year and that the educator usually does this, but he wasn't aware of when it was last done. MD stated that he currently has a long list of work orders that he is addressing, and painting the walls was one of them. He also stated that the entire building needs renovating, and he is tackling one task at a time. 2. During an observation/ Interview on 6/2/2025 at 9:16 am with Certified Nursing Assistant (CNA) CCCCC revealed her emerging from room [ROOM NUMBER] still wearing her gloves and no PPE. Further observation revealed a sign on the door of room [ROOM NUMBER] indicating Enhanced Barrier Precautions. CNA CCCCC stated that I don't know why that sign is there, but it's not supposed to be right there. CNA CCCCC stated that she is unsure why the sign was there when the resident does not have an infection. She also stated that she does not remember when the infection control in-service was given last and was unaware of what barrier precautions mean or why PPE was required. 3. During an observation of the laundry room on 5/29/2025 at 12:25 pm, accompanied by the Environmental Services Director (EVS) revealed four commercial dryers with one down and not in use. Two commercial washers were observed in use with laundry solutions provided by Clean Slate. No personal protective equipment (PPE) was observed to be readily available in the laundry room. A single box of gloves was observed propped under a large fan blowing air toward the soiled laundry bins. Clothes were observed in plastic bags on the floor of the laundry room, and the eye wash station was observed with no piping connection or eye wash liquid available. The faucet was observed with water pouring onto the floor of the laundry room. Clean and dirty laundry were observed entering and exiting through the same door with no designated separation/ sorting area. Four bins containing soiled laundry/ linen were observed toward the entrance of the door, with one nestled in between the two dryers, with an empty bin in front. Air vent observed with large amounts of dust and dander. A large amount of lint was observed in the dryer lint trap. During an interview/ Observation on 5/29/2025 at 12:34 pm with Laundry Tech (LT) YY revealed him removing bags containing clothing from the soiled bin and placing them onto the floor. No PPE was observed being used. LT YY stated that he uses gloves to sort the laundry when they are not in bags, but admits to not using a mask, gown, or goggles unless he sees that there is blood. He admits that the clothing in the bags on the floor of the laundry room was, in fact, residents' clothing and stated, That's how they come down for washing. He denies receiving IP education within the past year but admits to receiving it in the past. He stated that the bin in front of the soiled bin nestled in-between the dryers was for clean laundry removed from the washers or dryers. LT YY also stated that he cleans the lint traps every three hours, but admits to not keeping a record of the removal. During an interview on 5/29/2025 at 12:45 pm with the EVS director revealed that he has been working in the facility for two years and that he is currently down two positions in housekeeping, but has part-timers that have been covering the shifts as well as his assistant and me. He stated that he currently has only two laundry staff working because one was off. We do our own laundry in the facility, and there are three full-time laundry attendants during the day and two part-timers in the evening who distribute the laundry. He admitted that he is aware of the eye wash station and that he has made many changes to the facility since taking the position, but is unable to change everything. EVS director stated that he speaks to the staff about IP in the morning meetings, but has no documentation to prove it. EVS director stated that the laundry room only has one door; therefore, there is nothing I can do about that. He stated that he checks the lint trap himself but admits to not keeping records. He also stated that his assistant could do a better job at holding people accountable for not doing their jobs. During an interview on 5/29/2025 at 1:08 pm with LT BBBBB revealed that he had only started working at the facility today but had received in-services during orientation on laundry services, using PPE, hand hygiene, and cross-contamination. 4. During an observation on 5/28/2025 at 4:00 pm, review of the infection prevention (IP) records revealed that there is no line listing or infection tracing being monitored according to the regulations of infection control and prevention. Infection plotting graph observed with no use of an infection surveillance checklist, nor a data collection tool being used to track current or past infections. The staff and resident immunization records were not available, nor were there records of COVID-19 monitoring, tracking, or teaching. No documentation of immunization for Flu, Pneumonia, or Covid-19 vaccine being offered, or record of administration for staff or residents. Antibiotic stewardship policy/ protocols program, an ICPC committee, water management program, nor Antibiotic stewardship tracing and surveillance. During an interview on 5/29/2025 at 11:11 am with the Staff Development/ Infection Control Nurse (IP) revealed that she started on April 16, 2025, initially as part-time time then recently accepted the full-time position. IP stated that this is her first IP job, but she has been certified since 11/6/2022. IP admits to not having any COVID-19 monitoring or education document, as she is still getting herself together. She also stated that she has no documentation or update of education that was presented to staff regarding the offering of the vaccine, nor did she have access to a refusal list. IP admits to not having an infectious disease tracking system or percentage rate, but stated she recently got McGeer's forms but has not used them yet. IP stated that she is aware of the criteria but admits to not having the ABT stewardship program or a committee at this time and therefore has not been using it. IP stated that she is aware that there is much work to be done in order to get up to standard, and it will take some time. She also stated that the facility has not had an IP since July of 2024 and that the corporate office had someone assisting periodically with IP issues, but admits that as of this time, no one seems to have knowledge of who it was or what was done. IP stated that all the documents from the past IP books disappeared when the previous IP left, which is why she is unable to locate the appropriate data required and was using the little information she currently has as she is still learning this role. IP also stated that she was unaware of the incorporation of the water management program with infection control and stated she thought that was the job of the Maintenance Director (MD). During an interview on 5/29/2025 at 1:46 pm with the MD revealed that he was not aware of any practices done on a regular basis to address the prevention of legionella disease. MD stated that he has only been working in the facility for about 30 days and has not heard anything about water management. MD stated that he was told by the previous MD that someone came out in January to check the boiler and placed a sticker there, but was not sure what it meant. He stated that he mainly concentrates on fixing the building, but will get with the administrator to go over the topic. MD stated that this is the first time it has been brought to his attention that he is responsible for the dead lags, but stated that he was aware of it being a thing where he used to work. 5. During an observation of wound care on 5/31/2025 at 12:39 am, Licensed Practical Nurse (LPN) TTT was observed providing wound care to R206. During the observation, there was an enhanced barrier precaution sign on R206's door, and LPN TTT did not put on a gown to conduct wound care. During wound care, LPN TTT did not sanitize her hands after removing used gloves and before putting on a clean pair of gloves. Further observations revealed LPN TTT placed a clean pad on the resident's bed with the dressing supplies, and R206's right foot was on top of the pad and touching the supplies at times during the wound care. During an interview on 5/31/2025 at 1:00 pm, LPN TTT stated she did not know she was supposed to wear a gown during wound care, and after reading the sign on the door, she was now aware she should have worn it. She stated there was no personal protective equipment (PPE) available to use since none was in the hallways, near the residents' rooms, or any PPE that was easily accessible. She confirmed and verified she did not sanitize her hands between glove changes, which would prevent infection of the resident. LPN TTT confirmed she placed a pad on R206's bed and stated that instead of placing a pad on the resident's bed, she should have used a bedside table to prevent contamination of her clean field. She stated she should have cleaned the resident's bedside table and used it instead of placing the pad with her dressing supplies on R206's bed. She further stated that the resident's foot on the pad with supplies and placing dirty things on the pad would cause infection to the resident. During an interview on 6/5/2025 at 12:14 pm, the Assistant Director of Nursing (ADON) stated that the nurses should ensure proper precautions and practices were followed during care to ensure the residents' conditions are not worsened. During an interview on 6/5/2025 at 12:42 pm, the Director of Nursing (Don) stated that she expected the nurses to practice and maintain standards of practice during all procedures. A review of medical record for R146 revealed R146 was admitted to the facility on [DATE] with BIMS score of 99 due to diagnosis of aphasia and dysphagia. R146 has diagnoses that include, but are not limited to, aphasia following cerebral infarction, dysphasia, pedal ulcers, and pressure ulcer of sacral region, stage four. Observation completed on 6/2/2025 at 2:29 pm, of wound care and infection control practices for R146.R146 was observed laying in bed on his back, alert and watching television. He was greeted by certified medication assistant technician (CMAT) CC, who was working as a certified nurse assistant this shift, and licensed practical nurse (LPN) DD. LPN DD cleaned bedside table with Sani-cloth and allowed to air dry. CMAT CC opened sterile dressing with clean gloved hands. Placed wound cleanser bottle on table, along with rolled gauze, ABD pads and collagen pads. Removed soiled gloves, washed hands and placed clean gloves on. Observed care was initiated without following full enhanced barrier precautions. LPN DD removed gloves and left room to obtained disposable gowns to continue care. CMAT CC and LPN DD initiated full enhanced barrier precaution protocol after care began by doning gowns, gloves and masks. CMAT CC prepared a wash basin with water only. CMAT CC removed soiled linen and dropped into plastic bag on the floor. CMAT CC and LPN DD turned R146 to his left side. R146 was observed with visible stool in rectal area. CMAT CC used gloved right hand to take a wash cloth and moistened with water from the basin to remove the stool. LPN DD removed all dressings from sacral and buttock area, dated 5/30/2025. CMAT CC grabbed unlabeled perineal wash bottle from roommates bedside table, with same soiled gloved hand used to remove stool and proceeded to spray his buttocks area and wiped with a clean cloth towel. LPN DD proceeded to spray all open wounds with wound cleanser. CMAT CC removed soiled gloves and donned clean gloves and double layered with a second set of gloves on both hands. CMAT CC and LPN DD began to prep gauze for application, opening the packs and handling the sterile gauze with clean gloved hands and stacking it. LPN DD used drain sponge to pat wound areas dry. LPN DD placed collagen gauze in the sacral wound followed by a sterile abdominal gauze. CMAT CC moved the wash basin with dirty water and placed on bedside table used for dressing supplies. While LPN DD reached for outer wound dressing, CMAT CC used her soiled gloved hands to remove the abdominal gauze from the stage IV wound bed, folded it in half and reapplied to the wound bed. LPN DD covered the abdominal gauze with a cover dressing. Wound dressings were not dated. A dressing was observed on right upper back dated 5/30/2025. LPN DD did not change it. LPN DD removed gown and gloves and donned clean gown and gloves. While wash basin with dirty water remained on bedside table used for dressing supplies, LPN DD proceeded to prepare dressings for right calf and left foot wound care. CMAT CC also placed perineal wash bottle used for perineal care on the bedside table along with wash basin with soiled water and clean dressings used for wound care. LPN DD proceeded to wash left heel with wound cleanser while CMAT CC held left leg up for access. LPN DD dressed left heel wound with Santyl and dry dressing. LPN DD did not date the wound dressing. LPN DD removed gloves and washed hands. CMAT CC began assisting LPN DD in opening additional wound dressings wearing soiled gloves. CMAT CC proceeded to remove old dressing from right upper calf. LPN DD donned clean gloves and proceeded to prepare collagen dressing for application. With clean gloves, LPN DD moved the perineal wash bottle that was handled CMAT CC during perineal care, to the end of the bedside table, and picked up wound cleanser bottle to wash wound. LPN DD removed soiled gloves and donned clean gloves. CMAT CC opened wound dressing for LPN DD, handed it to the nurse to apply to the wound and proceeded to raise the right leg again with no change of gloves. LPN DD applied and secured the wound dressing to the right leg and CMAT CC lowered the right leg. LPN DD began cleaning off the bedside table with both perineal and wound cleanser bottles still on bedside table. LPN DD removed gloves, cleaned hands with soap and water and donned clean gloves. CMAT CC positioned R146 with clean linen. LPN DD exited the room with wound care supplies in left hand and soiled bag in right hand wearing no gloves. Interview completed on 6/2/2025 at 3:40 pm with LPN DD, who recalled infection control observations during wound care that were not in compliance. She confirmed that they should have entered the room prepared with all personal protective equipment (PPE) for enhanced barrier precautions before beginning perineal and wound care. She confirmed that CC CMAT double gloved stating, I know they are not supposed to do that. She confirmed that the perineal wash bottle and wash basin with dirty water, handled by CMAT CC with soiled gloves, were placed on the clean bedside table alongside the wound care dressing supplies. She confirmed that she forgot to date the wound dressings prior to exiting the room. She confirmed that to promote healing she should make sure she is using good infection control practices and reposition frequently to make sure the resident offloads to promote wound healing.

Based on observations, staff interviews, record review, and review of the facility policy titled Infection Prevention and Control Program, the facility failed to establish an Infection Prevention and Control Program (IPCP) and an Antibiotic Stewardship program. The facility failed to develop and implement protocols to optimize and monitor the treatment of infections and reduce the risk of adverse events from unnecessary or inappropriate use of antibiotics. This failure had the potential to place all residents, staff, visitors, contracted staff, and volunteers at risk for infection and the development of antibiotic-resistant organisms. The facility census was 212. Findings included: A review of the undated facility policy titled Infection Prevention and Control Program revealed that The elements of the Infection Prevention and Control Program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, employee health and safety, identifying, reporting and correcting ICP incidents, investigating and reporting communicable diseases and conducting an annual review of the IPC program. The facility will record infections based on policies and procedures for system of surveillance and data to be collected by SBAR criteria and antibiotic stewardship program for infection site, pathogen, signs and symptoms, resident location and summary analysis of number of residents who developed infection; Staff observations; identification of unusual outcomes, trends and patterns; and how the data will be communicated/shared. This will be presented to the infection prevention and control committee monthly. Our antibiotic stewardship program promotes appropriate use of antibiotics, includes a system of monitoring to improve outcomes and reduce antibiotic resistance (ensuring antibiotics are prescribed for correct indications, dose, and duration to appropriately treat residents) and includes the development of protocols and a system to monitor antibiotic use. Antibiotic stewardship protocols include: reports related to monitoring antibiotic usage and resistance data, monitoring of antibiotic use, frequency and mode or mechanism of feedback to prescribing practitioners regarding antibiotic resistant data, their antibiotic use and their compliance with facility antibiotic use protocols, standardized tools and criteria for assessing for infections, and modes and frequency of education on facilities antibiotic stewardship program and protocols. IPCP and its standards, policies, and procedures will be reviewed annually to ensure effectiveness and that they are in accordance with current standards of practice. Periodic facility assessment may identify components of IPCP that need updating related to changes in population or facility characteristics. A review on 5/28/2025 at 4:00 pm of the infection prevention (IP) records revealed that there is no line listing or infection tracing being monitored according to the regulations of the infection control and prevention program. Infection plotting graph observed with no use of an infection surveillance checklist, being used percentage rate calculation of current infections documented. The staff and resident immunization records were not available, along with data for the last Coronavirus disease (COVID-19) outbreak and monitoring. Antibiotic stewardship program policy and protocols, along with the signed committee program, were also not available for evaluation. During an interview on 5/29/2025 at 11:11 am, the Infection Control Preventionist Nurse (ICPN) revealed that she was hired by the facility on 4/16/2025, initially as part-time, and that she recently accepted the full-time position. She stated that this was her first Infection Preventionist job, but has been certified as an ICPN since 11/6/2022. She admits to not having an infectious disease tracking system or percentage rate, but stated she recently got the forms and has not implemented them yet. IP stated that she was aware of the Mc. Greer's criteria, but admits to not having the Antibiotic Stewardship Program or a committee at this time, and therefore has not been using it. She stated the facility has not had an Infection Control Program since July 2024 and that she is working on forming an Infection Control Committee. She further stated that all the immunization records from the past years could not be found and stated that everything disappeared when the previous (ICPN) left, so she had to start from scratch with creating and developing the program. She stated that she is currently keeping a running log of residents currently on antibiotics, but admits to it not being updated this past month (May 2025). During an interview on 6/2/2025 at 9:32 am, the Director of Nursing (DON) revealed that she was aware of the Infection Control Program issues and missing documentation. She stated that she was made aware that an interim corporate personnel member had been visiting the facility and assisting with the Infection Control Program, but that the individual had been terminated. The DON stated, It is possible she either took or destroyed all the documentation. The DON confirmed that she was not certified as an ICPN and stated that it was her expectation for the ICPN to start from the bottom and work on everything related to infection control. The DON stated that she did not have contact information for the previous ICPN.

Based on observations, staff interviews, records review and review of the facility policy titled Infection Prevention and Control Program (IPCP), the facility failed to minimize the risk of influenza and pneumococcal disease by ensuring that four of four newly admitted residents (R) (R48, R54, R96 and R217) residents (R) and staff were educated on the risks and benefits of immunizations; were provided opportunities to receive immunizations; and failed to maintain documentation of the information/education provided, the administration of, or the refusal of vaccinations. This failure placed the entire facility at risk for increased complications or even death related to an outbreak of the influenza or pneumococcal virus. Findings included: A review of the undated facility policy titled Infection Prevention and Control Program revealed the following: Immunization is a form of primary prevention. Widespread use of the influenza vaccine in the nursing facility is strongly encouraged. Policies and procedures for immunization include the following: Process for administering the vaccines, who should be vaccinated, contraindications to vaccination, potential facility liability and release from liability, obtaining direct and proxy consent, and how often, monitoring for side effects of vaccination, and availability of the vaccine, and who pays for it. During a review of the electronic medical record (EMR) for residents admitted to the facility within the last 30 days, it was revealed that the immunization records for R48, R54, R96 and R217 contained no documentation of vaccines being received, offered, declined, or contraindicated and there was no documentation in the EMR indicating that education was provided to residents or their representatives. During a review of the information provided by the facility related to the facility's Infection Control Program, there was no documentation presented related resident immunization records or information related to vaccines being offered to staff or residents; there was no documentation related to vaccine monitoring or vaccine education; and there was no documentation related to tracking or trending i.e. line listing of monitoring. During an interview on 5/29/2025 at 11:11 am, the Staff Development Nurse/Infection Control Preventionist Nurse (ICPN) revealed that she was hired on 4/16/2025 as part-time and only recently accepted the full-time ICPN position. She stated that she has been certified as an Infection Preventionist since 11/6/2022, but had no formal training in the field and was awaiting a friend to come and help her. She stated that the friend was scheduled to come earlier that week, but was canceled due to the state survey team arriving. She admitted to not having any documentation of offering the vaccines, resident refusals, or contraindications for staff or residents for this influenza season. The ICPN stated that she did not have an infection tracking system and was not aware if there were any outbreaks in the facility. She stated the facility has not had an Infection Control Program since July 2024 and that she is working on forming an Infection Control Committee. She further stated that all the immunization records from the past years could not be found and stated that everything disappeared when the previous (ICPN) left, so she had to start from scratch with creating and developing the program. A review of the EMR revealed that R54 presented with a Brief Interview of Mental Status (BIMS) score of 15, indicating that R54 is cognitively intact. During an interview on 6/1/2025 at 5:00 am, R54 stated that he was never offered any vaccines on admission. He stated that if it had been offered, he may have opted to receive the vaccinations, but confirmed he was not provided with that information. During an interview on 6/2/2025 at 9:32 am, the Director of Nursing (DON) revealed that she has been working at the facility since 2/17/2025. She confirmed that she was aware of the Infection Control Program concerns regarding missing information. She stated that there was an individual in the ICPN role when she started, but that the individual was terminated. The DON stated that it was a possibility that the terminated employee either took the information with her when she left or destroyed all the documentation.

Based on observations, staff interviews, records review, and a review of the facility's policy titled Infection Prevention and Control Program, the facility failed to develop and implement policies and procedures to ensure the availability of Coronavirus disease (COVID-19) vaccine to all staff and residents, offer COVID-19 vaccine, educate staff and residents/resident representatives regarding the risk, benefits and potential side effects of the COVID-19 vaccine and keep proper documentation surrounding vaccination, refusal or contraindications for four of four sampled residents (R) (R48, R54, R96 and R217). Findings included: A review of the undated facility policy titled Infection Prevention and Control (IPC) Program revealed that, The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, employee health and safety, identifying, recording and correcting IPC incidents, investigating and reporting communicable diseases and conducting an annual review of the IPC program. Outbreak management is a process that consists of: determining the presence of an outbreak, managing the affected residents, preventing the spread to other residents, documenting information about the outbreak, reporting the information to appropriate state and local authorities. when required, educating the staff and the public, monitoring for reoccurrences, reviewing the care after the outbreak has subsided, and recommending new or revised policies to handle similar events in the future. During a review of the records provided by the Infection Control Preventionist Nurse (ICPN) on 5/28/2025 at 4:00 pm, it was determined that there were no current residents in the facility with a positive diagnosis of COVID-19. The documentation revealed that there was no record indicating the last COVID-19 outbreak nor its monitoring. During an interview with the ICPN, at this time she stated that she was unaware of any policies or procedures related to COVID-19 handling, and COVID-19 education was not readily available nor was there documentation on information for management present for review. She provided the Infection Control Book and confirmed that the book contained no education material for the COVID-19 vaccine; no immunization record related to residents and/or staff being offered, receiving, or declining the vaccine; and no guidelines on management, monitoring, or preventing a COVID-19 outbreak. A review of all new admissions within the last 30 days revealed four out of four residents (R48, R54, R96 and R217) had no documentation in their Electronic Medical Records (EMR) indication that the COVID-19 immunization was offered, received, or declined and no documentation that the education was provided to residents or their representatives regarding the risk and benefits of the vaccine. During an interview on 5/29/2025 at 11:11 am, the ICPN revealed that she was hired by the facility on 4/16/2025, initially as part-time, and that she recently accepted the full-time position. She stated that this was her first Infection Preventionist job, but has been certified as an ICPN since 11/6/2022. She confirmed that she had not developed or implemented an Infection Control Program; that she did not know about the last COVID-19 outbreak in the facility; and that she was not aware of the policies and procedures surrounding COVID-19. She stated that she was aware that there should be monitoring, but had not initiated any at this time. She stated that there was much work to be done to get up to standard and that it will take some time. She stated that the facility has not had an ICPN since July 2024 and that no one had knowledge of the records or monitoring because the Infection Control books disappeared when the previous IPCN left, which is why she is unable to locate the appropriate data required. She stated that she will be receiving some assistance from a friend in the coming days, who will educate her on how to properly do the job. During an interview on 6/2/2025 at 9:32 am, the Director of Nursing (DON) revealed that she was aware of the Infection Control Program issues and missing documentation. She stated that she was made aware that an interim corporate personnel member had been visiting the facility and assisting with the Infection Control Program, but that the individual had been terminated. The DON stated, It is possible she either took or destroyed all the documentation. The DON confirmed that she was not certified as an ICPN and stated that it was her expectation for the ICPN to start from the bottom and work on everything related to infection control. The DON stated that she did not have contact information for the previous ICPN.

Based on observations, resident and staff interviews, and review of facility policies titled Safe Environment and Maintenance service, the facility failed to maintain a safe, functional, and sanitary environment in 14 of 108 resident rooms (214, 217, 218, 224, 225, 226, 322, 325, 326, 405, 417, 421, 505, and 526) related to resident rooms containing debris in packaged terminal air conditioner (PTAC) units, dirty air vents in common areas, and holes/cracks in drywall and doors. Findings included: A review of the facility policy titled Safe Environment revealed the following: Policy Statement: The facility will provide (9)(a) housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. A review of the facility policy titled Maintenance service dated 3/6/2018, under Policy Statement revealed: Maintenance Service shall be provided to all areas of the building, grounds, and equipment. Under Policy Interpretation 2. (d) Maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order. 2. (i) Providing routinely scheduled maintenance service to all areas. During observations on 5/29/2025 between 9:00 am and 10:00 am, the facility's PTAC air filters in the resident rooms 214, 217, 218, 224, 225, 226, 405, 417, 421, 505, and 526 were observed to have soiled air filters with a thick accumulation of dust, dirt, and debris. Originally white, the air filters appeared dark due to contaminants. When lifted for inspection, they released visible dust clouds and were clogged with a dense layer of grime. During an interview and observation on 5/29/2025 at 12:25 pm, the Maintenance Director confirmed the buildup on PTAC filters in rooms 214, 217, 218, 224, 225, 226, 405, 417, 421, 505, and 526. It was also confirmed that the PTAC unit was not working in room [ROOM NUMBER]; there were multiple stained and missing ceiling tiles in rooms [ROOM NUMBER], and throughout the facility; and there were torn window screens and chipped paint throughout the facility. Continued observation also revealed a broken door to room [ROOM NUMBER], a hole in the wall in room [ROOM NUMBER], and the toilet not working in room [ROOM NUMBER]. During the interview at this time, the Maintenance Director revealed that it was the responsibility of the maintenance department to change and clean the PTAC filters and make sure they were working properly. He stated that the maintenance department was also responsible for changing stained ceiling tiles, replacing missing ceiling tiles, and repairing all broken items in the facility. During an observation and interview on 6/2/2025 at 1:45 pm, a family member of the resident in room [ROOM NUMBER]A revealed that the resident has been at the facility since 2020 and stated that the room is never cleaned. She stated that there were times when she cleaned the room herself. She went on to say that there were cobwebs in the corners, sticky substances on the wall and floor. A review of the facility's grievances log revealed that there have been multiple reports/grievances regarding the uncleanliness of the room and odors throughout the facility. An observation on 6/8/2025 at 11:35 am revealed stained ceiling tiles in the residents' room on the third floor. An observation on 6/8/2025 at 11:43 am revealed stained ceiling tiles in the hallway by the shower room on the fourth floor. An observation on 6/8/2025 at 11:44 am revealed an air vent on the fourth floor to the left of the elevator with gray and black debris and dust on it. An observation on 6/8/2025 at 11:50 am revealed an air vent on the fifth floor to the left of the elevator with gray and black debris and dust on it. During an interview on 6/9/2025 at 1:10 pm, the Administrator revealed he expects the maintenance department or the housekeeping department to report any environmental issues in TELS and address the concern right away.

Based on record review, staff interviews and review of the facility's policy titled Quality Assurance and Performance Improvement (QAPI) Program, the facility failed to develop and implement action plans; measure the success of actions and track performance; conduct at least one process Improvement Plan (PIP) and regularly review, analyze and act on data collected for three of 106 sampled residents (R) (R80, R2, R55, and R392) not receiving scheduled medications. Findings included: A review of the facility's policy titled Quality Assurance and Performance Improvement (QAPI) Program, revised February 2020, documented that the QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include tracking and measuring performance; establishing goals and thresholds for performance measurement; identifying and prioritizing quality deficiencies; systematically analyzing underlying causes of systemic quality deficiencies; developing and implementing corrective action or performance improvement activities; and monitoring or evaluating the effectiveness of corrective action/performance improvement activities, and revising as needed. 1. A review of R80's medication administration record for several days during August 2024, September 2024, March 2025, and May 2025 revealed missing signatures on the Medication Administration Record (MAR). A review of the Nurses Notes (NN) dated 8/6/2024 revealed that medication was out of stock. A review of the NN dated 11/10/2024 revealed that medication not administered, waiting for pharmacy delivery, phone call to pharmacy and MD. A review of the NN dated 11/11/2024 revealed oxycodone HCL tablet given 5 mg by mouth before wound care every Monday, Wednesday, and Friday for wound care to be given before wound care Med on order. A review of the NN dated 5/5/2025 revealed Medication is on order. A review of the NN dated 5/28/2025 revealed oxycodone HCL tablet, give 5 mg by mouth every six hours for pain awaiting pharmacy. A review of the NN dated 5/31/2025 revealed oxycodone HCL tablet, given 5 mg by mouth every six hours for pain, was unavailable. 2. A review of R2's April 2025 MAR revealed several gaps in Percocet administration. A review of R2's May 2025 MAR revealed several gaps in Percocet administration. 3. A review of R55's January 2025 MAR revealed a four-day gap, a nine-day gap, and a five-day gap in her Percocet administration. A review of R55's February 2025 MAR revealed two five-day gaps and a six-day gap in her Percocet administration.A review of R55's May 2025 MAR revealed several holes in medication administrations for Eliquis and budesonide with the code of 13, indicating the medications were not administered. A review of R55's June 2025 MAR revealed budesonide, hydrocortisone, Zyrtec, and Eliquis with the code of 13, indicating the medications were not administered. 4. A review of R392's August 2024 MAR revealed holes in the MAR for ten doses consecutively from 8/6/2024 to 8/9/2024. A review of the QAPI minutes dated 5/2/2025 revealed that it was documented on the agenda to address residents not receiving their medications. The minutes reflected that the administrator documented that multiple medications were unavailable, it was an ongoing issue, and they were to develop a PIP. During an interview on 6/2/2025 at 1:08 pm, the Director of Nursing (DON) revealed that she started working at the facility in February 2025, and she confirmed that since then, there were instances when the residents were out of medications, including pain medications. She confirmed and acknowledged that there were gaps in the MAR for the residents, and if the residents did not refuse or say they did not want it at a specific time, it was likely that the medications were not ordered in a timely manner, and the facility was waiting on the pharmacy to deliver the medications to the facility. She confirmed that this had happened on a few occasions when the residents did not receive their medications because the medications were not ordered timely manner. She stated that the nurses on the units were responsible for ordering and reordering the medications in time for the resident to receive them and not allow them to run out. The DON stated that medications for the residents were reordered by faxing the order to the pharmacy or by calling the pharmacy. She stated that there was a fax machine in the medication rooms on each unit, but they were not operational yet. She stated that the main fax machine was at the front desk on the first floor, and the staff were required to fax the paper script to the pharmacy for reordering the medications from that fax machine. She stated there is a pyxis on the second floor and it is available 24 hours with additional medications for the facility. The DON further stated there was no set schedule for the medications to get to the facility, and it was dependent on different variables, such as if the medications were ordered early enough. During an interview on 6/5/2025 at 1:08 pm, the Administrator revealed that he was aware there were residents in the facility who were not receiving their medications in a timely manner. He stated that when he started on 4/22/2025, he was made aware of this issue. He stated the issue was discussed in QAPI, and he went through the minutes of QAPI and stated that in January 2025, there was documentation of issues involved with the residents not receiving their medications. He stated that the January meeting was held on 1/31/2025, which reflected the issues that took place in December 2024. The January meeting did not have any interventions mentioned about residents not receiving their medication, and there was also no PIP. He stated QAPI met on 3/28/2025, for February 2025, and there was no intervention mentioned there either. The next meeting was on 5/2/2025, which would have addressed the issue in April 2025. The administrator confirmed there were no PIPs in place to address the issue of residents not receiving their medications. He confirmed that the issue was placed on the agenda in the 5/2/2025 meeting to address the issues involved. The administrator again confirmed that there was no PIP in place from January 2025 to the present, 6/5/2025. He stated that in the 5/2/2025 QAPI meeting, the Medical Director was present, and she expressed her concerns that medications were unavailable to the residents and inquired about what was going on with it. An investigation was conducted on 5/21/2025, and they found that the fax machine was not working. The fax machine and the Pyxes were not working at the same time, so the nurses could not get medications out of the Pyxes, and they could not fax scripts to the pharmacy for ordering medications since both the fax machine and the Pyxes were down at the same time. He stated the pyxis machine was not working from April 2025 to May 2025, and it was fixed on 5/22/2025. He stated that the investigation pointed to the Certified Medication Assistant Technicians (CMAT) not ordering or reordering medications before they were finished. He stated that a few of the CMATS were terminated, and in-service training was provided to other CMATs as well as the nurses regarding ordering and reordering medications. He stated the in-service included when and how to order medications, as well as the need to notify the nurse right away before medications were completed, so that they may be ordered from the pharmacy. The in-service also included for the nurses and the CMATs to look for missing medications in the central storage areas where they would have multivitamins and other over the counter medications as well as getting someone to look in the pyxes in the meantime before they say that medications were not available at all and also in-service was done to order medications in the facility's electronic health record system. He stated that when residents do not receive their medications, it is considered a medication error. The Administrator confirmed that since the QAPI meeting on 5/2/2025, there were still residents who were not receiving their medications. He confirmed that there was no effective follow-up to ensure that the interventions that were put in place were effective. He confirmed the interventions were not effective since there were residents who were still not receiving their medications in the month of May 2025 and as recently as 6/6/2025. He stated that an audit should have been done as one of the interventions addressed in the 5/2/2025 QAPI meeting, and he confirmed that there was no documentation that an audit was done, and he was unaware if the audit was done. He confirmed there was no PIP in place to address the issue, and he confirmed that there was no efficient or effective follow-up to ensure that the issue was addressed. He confirmed the QAPI system was not effective.

AMENDED Based on staff interviews, resident interviews, and record review, the facility failed to ensure that routine and as-needed (PRN) medications were available for administration to three of 106 sampled residents (R) (R2, R55, and R394). This deficient practice had the potential to cause delays in physician-ordered medical interventions. Findings included: 1. A review of R2's electronic medical record (EMR) revealed R2 was admitted to the facility on [DATE], and pertinent diagnoses included but were not limited to Alzheimer's Disease, chronic pain syndrome, sickle-cell disorder, and fusion of the spine in the cervical region. A review of R2's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15, which indicates R2 was cognitively intact, and that R2 was taking an antidepressant and an opioid medication. A review of R2's care plan, revised 5/8/2025, indicated a focus on R2 being at risk for pain/discomfort related to generalized pain and sickle cell. Goals included that R2's pain will be effectively managed through the next review date. Interventions included but were not limited to administering pain medication as ordered by the physician. A review of R2's care plan, revised 2/18/2025, indicated a focus of R2 on pain medication therapy related to a history of chronic pain. Goals included being free from any discomfort or adverse side effects from the pain medication reaction. Interventions included, but were not limited to, administering medication as ordered. A review of R2's Physician's Orders included, but was not limited to, an order dated 4/4/2025 for Percocet oral tablet 10-325 mg (milligram) (oxycodone with acetaminophen) with directions to give one tablet orally every six hours as needed for pain management related to chronic pain syndrome. A review of R2's April 2025 Medication Administration Record (MAR) revealed several gaps in Percocet administration. A review of R2's May 2025 MAR) revealed several gaps in Percocet administration. During an interview on 5/27/2025 at 11:55 am with R2 revealed that she had concerns about her pain medication not being reordered timely. R2 stated that her Percocet ran out last week causing her to not be able to have it for two days and thus being in more pain. She stated that she went to the Director of Nursing (DON) about this, and the DON said she would be on it. During an interview on 6/2/2025 at 1:08 pm, the DON stated that the nurses on the units are responsible for ordering and reordering the medications in time for the resident to receive it and not allow it to run out. The DON further stated that the medications are to be ordered within a week of the medication finishing, so that the pharmacist has enough time to send the medication before it is finished. She stated that medications for the residents are reordered by faxing or calling the pharmacy. She stated there is a new program that the facility is working on, which was just implemented one to two weeks ago, so that the facility could reorder medication through a link on the EMR directly into the pharmacy database. She stated that there is a fax machine in the medication rooms on each unit, but they are currently not operational. She stated that the main fax machine is located at the front desk, and the nurse is required to fax paper scripts to the pharmacy. The DON further stated there was no set schedule for the medications to be delivered to the facility. The DON further stated that she had instances where the residents ran out of medications, including pain medications. She confirmed that there were gaps in the MAR for some residents who did not receive their pain medication. She confirmed and acknowledged that these medications are PRN, and if the resident did not refuse or say they did not want it at that time, it is likely that the medication was not ordered timely and the facility was waiting on the pharmacy to send the medication and deliver it to the facility. She confirmed that this has happened on a few occasions where the residents did not receive their pain medications because the medications were not ordered timely. The DON confirmed that one resident who has been affected by this is R2. During a phone interview on 6/5/2025 at 6:45 pm, Pharmacy Tech EEE revealed that the facility can refill meds electronically from the EMR, by fax, or by phone. She stated that the pharmacy does not autofill for the facility, and that nurses have to request a refill for medications to be refilled. Pharmacy Tech EEE further stated that after re-ordering, medications are generally delivered to the facility within a 24-48-hour window or same day if they have it in stock. The pharmacy tries to advise nurses to refill medications two days in advance, so residents are not without their medications. 2. A review of R55's EMR revealed R55 was admitted to the facility on [DATE], and pertinent diagnoses included but were not limited to paroxysmal atrial fibrillation, chronic obstructive pulmonary disease (COPD), hypertension, osteoarthritis, and long-term use of anticoagulants. A review of R55's quarterly MDS assessment dated [DATE] revealed a BIMS of 15, which indicates R55 was cognitively intact, and that R55 was taking an anticoagulant, a hypoglycemic, and an opioid medication. A review of R55's care plan, revised 5/2/2025, indicated a focus on R55 having hypertension and paroxysmal atrial fibrillation. Goals included that R55 will remain free from signs and symptoms of hypertension through the review date. Interventions included but were not limited to give R55 anti-hypertensive medications as ordered to monitor side effects such as orthostatic hypotension and increased heart rate (tachycardia), and effectiveness, and to not discontinue medication abruptly but to begin tapering off. A review of R55's care plan, revised 5/2/2025, indicated a focus on R55 at risk for pain/discomfort related to generalized pain and osteoarthritis. Goals included for R55's pain to be effectively managed through the next review date. Interventions included but were not limited to administering R55 pain medication as ordered by the physician. A review of R55's care plan, revised 5/2/2025, indicated a focus of R55 on anticoagulant therapy related to atrial fibrillation. Goals included that R55 will be free from discomfort or adverse reactions related to anticoagulant use. Interventions included but were not limited to taking/giving medication at the same time each day. A review of R55's Physician's Orders included but was not limited to an order dated 1/1/2024 for budesonide inhalation suspension 0.5mg/2ml (milliliters) with directions to inhale 2ml orally every 12 hours for shortness of breath related to chronic obstructive pulmonary disease, an order dated 12/24/2024 for Eliquis oral tablet 2.5 mg (apixaban) with instructions to give one tablet by mouth two times a day for anticoagulant, an order dated 5/25/2025 for hydrocortisone external cream 2.5% topical with directions to apply to left leg topically every day and evening shift for erythema for two weeks, an order dated 12/24/2024 for lisinopril oral tablet 20 mg with directions to give one tablet by mouth one time a day for hypertension, an order dated 12/24/2024 for metoprolol tartrate oral tablet 100 mg with directions to give one tablet by mouth two times a day for hypertension, an order dated 3/4/2024 for Percocet oral tablet 7.5-325 mg (oxycodone with acetaminophen) with directions to give one tablet by mouth every six hours as needed for pain, an order dated 12/11/2023 for Zyrtec allergy oral tablet 10 mg with directions to give one tablet by mouth one time a day for allergies. A review of R55's January 2025 MAR revealed a four-day gap, a nine-day gap, and a five-day gap in her Percocet administration. A review of R55's February 2025 MAR revealed two five-day gaps and a six-day gap in her Percocet administration. A review of R55's May 2025 MAR revealed several holes in medication administrations for Eliquis and budesonide with the code of 13, indicating the medications were not administered. A review of R55's June 2025 MAR revealed budesonide, hydrocortisone, Zyrtec, and Eliquis with the code of 13, indicating the medications were not administered. During an interview on 5/27/2025 at 12:41 pm with R55 revealed she has sometimes gone four to ten days without her medications and had concerns regarding re-ordering her medications. R55 stated that she is out of metoprolol, her heart medication, today and was told yesterday there was one dose left. R55 further stated that not having her metoprolol usually makes her heart rate fluctuate. She added that she went ten days without her pain medication, Percocet, in January. She went without her lisinopril in February or March for about six days, which caused her blood pressure to go up. R55 further stated she has been without her blood thinner, Eliquis, so many times, and once went five days without it a few months ago. R55 added that she recently went six days without the medication for her nebulizer medication, budesonide, which led her to start wheezing and use her inhaler, which she uses only when she is without her nebulizer. R55 clarified that all these medications are scheduled except for her PRN Percocet. R55 stated that she was a nurse for 51 years and would sometimes call the pharmacy herself during times when she went without her medications for about five days, so she knows that the re-ordering is done. During an interview on 5/28/2025 at 4:53 pm with R55 revealed that she is still without her metoprolol, which would be the 2nd day without it. R55 stated she asked the nurse to call the pharmacy again and will personally call the pharmacy tomorrow. She stated she has experienced issues with medication re-ordering for the whole eight years as a resident in the facility. R55 stated she has been to the hospital three times without getting her budesonide in 2023. She stated she currently has about four doses of budesonide left. When asked if she feels different due to missing doses of her metoprolol, she stated that today her heart rate is 95, but her normal range is 60s to 80s. She stated that this morning her heart rate was 111, and last night it was 115. She stated that she told the Certified Medication Aide Technician (CMAT) on duty that her heart rate was high, and the CMAT told her she would call the pharmacy again. R55 further stated that she asks for her Percocet twice a day. During an interview with R55 on 5/29/2025 at 9:53 am revealed that she received her metoprolol this morning. During an interview on 6/2/2025 at 1:08 pm, the DON stated that the nurses on the units are responsible for ordering and reordering the medications in time for the resident to receive them and not allow them to run out. The DON further stated that the medications are to be ordered within a week of the medication finishing, so that the pharmacist has enough time to send the medication before it is finished. She stated that medications for the residents are reordered by faxing or calling the pharmacy. She stated there is a new program that the facility is working on, which was just implemented one to two weeks ago, so that the facility could reorder medication through a link on the EMR directly into the pharmacy database. She stated that there is a fax machine in the medication rooms on each unit, but they are currently not operational. She stated that the main fax machine is located at the front desk, and the nurse is required to fax paper scripts to the pharmacy. The DON further stated there was no set schedule for the medications to be delivered to the facility. The DON further stated that she had instances where the residents ran out of medications, including pain medications. There is a pyxis, and the nurse is to follow up with the pharmacy, which will give the nurse a code or a number to remove medications from the pyxis if it is available in the pyxis, which is replenished by the pharmacist monthly. If the medication is not in the pyxis, the resident is offered an alternative until the medication is received from the pharmacy. The DON checked the gaps in R55's MAR and confirmed that there were days the resident did not receive Percocet. She confirmed and acknowledged that this medication is PRN, and if the resident did not refuse or say they did not want it at that time, it is likely that the medication was not ordered timely manner and the facility was waiting on the pharmacy to send the medication and deliver it to the facility. She confirmed that this has happened on a few occasions where the residents did not receive their pain medications because the medications were not ordered timely. During an interview on 6/5/2025 at 1:59 pm, R55 revealed she went four to five days without her budesonide and finally received it today. She reiterated that the last time this medication was unavailable to her, she began wheezing. She also stated that her Zyrtec and hydrocortisone were unavailable to her today. During an interview on 6/5/2025 at 2:15 pm, Licensed Practical Nurse (LPN) WW confirmed that the budesonide was not available from 5/31/2025 to 6/3/2025. She also confirmed that the Zyrtec and hydrocortisone were unavailable on 6/3/2025. During a phone interview on 6/5/2025 at 6:45 pm, Pharmacy Tech EEE revealed that the facility can refill meds electronically from the EMR, by fax, or by phone. She stated that the pharmacy does not autofill for the facility, and that nurses have to request a refill for medications to be refilled. Pharmacy Tech EEE further stated that after re-ordering, medications are generally delivered to the facility within a 24-48-hour window or same day if they have it in stock. The pharmacy tries to advise nurses to refill medications two days in advance, so residents are not without their medications. During an interview on 6/6/2025 at 9:12 am, the DON confirmed that R55's lisinopril, Eliquis, metoprolol, and budesonide medications most likely were not available to be administered to her. The DON stated that there is a known issue with these medications not being available due to reordering issues. The DON further stated that potential negative outcomes include a lack of stability for the residents. 3. A review of R394's EMR revealed she was admitted to the facility on [DATE] with pertinent diagnoses including Parkinson's Disease. A review of R394's Discharge MDS assessment dated [DATE] revealed a BIMS score of 15, which indicates R394 was cognitively intact. A review of R394's physician orders revealed an order dated 7/4/2024 for Rytary oral capsule extended release 36.25-145 mg (carbidopa-levodopa) with directions to give two capsules by mouth three times a day for Parkinson's. A review of the MAR dated August 2024 revealed holes in the MAR for ten doses consecutively from 8/6/2024 to 8/9/2024. A review of the hospitalization record dated 8/14/2024 revealed R394 went to the emergency room on 8/14/2024 for muscle spasms. During an interview on 6/6/2025 at 9:58 am, the DON revealed that R394 resided at the facility months before she started working at the facility. She confirmed the emergency room visit was for muscle spasms on 8/14/2024. The DON also confirmed some holes in R394's 8/2024 MAR for her Parkinson's medications leading up to the hospitalization, and confirmed from the MAR that it is possible these medications were not administered timely manner or due to availability.

Based on observation, staff interviews and resident interviews, facility records, and review of facility policy titled Temperatures, the facility failed to provide meals that were prepared by methods that conserve nutritive value, flavor, and appearance, and provide meals that were palatable, attractive, and held at a safe and appetizing temperature. Specifically, the facility failed to ensure that food items served for breakfast were at or above 135 degrees Fahrenheit (F). These deficient practices had the potential to affect 207 of the 212 residents receiving an oral diet. Findings included: A review of the undated facility policy titled Temperatures revealed that All hot food items must be cooked to appropriate temperatures, held, and served at a temperature of at least 135 degrees Fahrenheit (F). Food should be transported as quickly as possible to maintain the temperature for delivery and service. If food transportation time is extensive, food should be transported using a method that maintains temperatures (i.e., hot/cold carts, pellet systems, insulated plate bases and domes, etc.). A review of the Georgia Department of Public Health Food Service Establishment Inspection report dated 12/3/2024 indicated compliance status No under section 3-1B. Food received at proper temperature, 5-1A. Proper cooking time and temperature, 5-1B. Proper reheating procedure for hot holding, and 6-1C. Proper cooling time and temperature. During an observation and interview on 5/27/2025 at 1:32 pm, Resident (R) 9 shared that the food delivered to the rooms is mostly cold, requires reheating, and is not covered. A tray was observed with food that was visible outside of the top cover. Review of resident Quarterly Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident is cognitively intact and able to answer questions appropriately. During a breakfast meal service observation and the examination of the Steam Temperature Table were taken by the Assistant Dietary Manager GGGG conducted food temperature checks on 5/29/2025 at 7:26 am, revealed: Puree eggs, initially at 128 degrees F, were reheated and subsequently retested at 143 degrees F. Mechanical sausage, which started at 95 degrees F, was reheated and then retested at 155 degrees F. Omelet eggs, also beginning at 95 degrees F, were reheated and retested at 100 degrees F, followed by another retest at 147 degrees F. The waffle, initially at 103 degrees F, was reheated and retested at 146 degrees F. At the time of receiving the food, the temperature meal tray delivery to the residents had already begun. A review of sampled test breakfast tray on 5/29/2025, at 8:51 am, revealed test tray that was retrieved from Fourth floor cart food temperatures were not within professional guidelines as evidenced by the following: Omelet at 116-degree F, Grits at 114-degree F, and Oatmeal at 110-degree F. All temperatures were taken by the Dietary Manager and confirmed at time of observation. During an observation on 5/29/2025, at 8:56 am, on the third floor revealed that there was no bottom base to the plate warmer sitting in the cart; awaiting to be distributed. During an observation on 6/6/2025, at 1:11 pm, revealed that a food tray was being delivered to the second floor on top of a warmer storage cart without a bottom base plate warmer. During an interview on 5/28/2025, at 2:30 pm, members of the resident council meeting expressed that weekend food was cold and unsatisfactory, stating, You better have money and Uber because of extended wait times. During an interview on 6/3/2025, at 9:36 am, Dietary Aid (DA) IIII revealed that she was responsible for preparing breakfast and lunch. During the morning hours, breakfast is typically served with eggs, grits, oatmeal, and bread. Unfortunately, the steam table does not maintain the proper temperature; there seems to be an issue with the wells, as the bottom of the pan remains hot while the top surface does not. Many residents have reported that their food is cold, but the Certified Nurse Assistant or nurses often neglect to reheat and return the food to the kitchen to be replated, which sometimes forces me to ensure there is enough food available instead of relying on them to reheat it in the microwave on the floor. During an interview on 6/3/2025, at 09:56 am, DA JJJJ confirmed that he was responsible for the food carts' delivery to the floors, which involves notifying the nurse and initiating the sign-off process for the first cart. DA JJJJ explained that certain floors execute their distribution process differently from our established policy; they will not serve food to residents until all carts are present on the floor, while others will proceed differently. During an interview on 6/9/2025 at 2:02 pm, the Administrator stated that he was aware of complaints from residents regarding the food being served cold. Further interview indicated that he anticipated the residents' meals to be served hot according to their preferences, both when delivered to their rooms and in the dining room. The Administrator mentioned that he would assess the process, implement a Performance Improvement Plan (PIP), and investigate the necessary repairs for the various equipment.

Based on observations, staff interviews, and reviews of the he facility policies titled General Food Preparation and Handling, Uniform Policy, and Food Brought in from the Outside, the facility failed to properly discard expired food and ensure that food items were labeled and dated in the kitchen refrigerator, freezer, dry storage, and emergency supply area. The facility also failed to maintain sanitary practices concerning hand hygiene, covering of hair with restraints, and up-to-date sanitizer test strips for dietary staff in the kitchen. These deficiencies had the potential to impact 207 out of the 212 residents who were on an oral diet. Findings included: A review of the undated policy titled General Food Preparation and Handling indicated in section Food Preparation-H. Food will be prepared and served with clean tongs, scoops, forks, spoons, spatulas, or other suitable implements to avoid manual contact with prepared foods. A review of the undated policy titled Uniform Policy indicated that all employees will adhere to the Food & Nutrition policy on the proper wearing of a uniform required to work in the department. Dietary Aids and Floor Supervisor: hair nets. Cooks: hair nets or approved chef hats, in black. A review of the undated policy titled Food Brought in from Outside revealed that food or beverages should be labeled and dated to monitor for food safety. Food and beverages that have past the manufacturer's expiration date should be thrown away. During the kitchen initial brief tour conducted on 5/27/2025, at 9:53 am with the Dietary Manager (DM), it was observed upon entering that the Assistant Dietary Manager (ADM) GGGG was not wearing a beard net. DM confirmed during observation that all dietary staff should be wearing beard guards and hair restraints in the kitchen. Observation in the dry storage pantry revealed unlabeled and undated items, which included one 11.3 oz turkey gravy, two 14 oz chicken gravies, three 24 oz country gravies, seven 2.75 oz au jus gravy mixes, and 13 unlabeled silver packets as confirmed by the DM; seasonings from rice packets, along with two 24-oz lemonades, one of which had been opened, and an observation of one unlabeled and undated opened 5-pound bag of dry pasta. Furthermore, there were two 15-oz cans of white potatoes with an expiration date of December 2023. The Dietary Manager validated that all findings in the dry storage did not have an open or expiration date on items. The refrigerator revealed an unlabeled and undated opened 5-gallon container of pickles, along with 5 pounds of open cheese, which consisted of unwrapped yellowish slices of block cheese, and a one-gallon container of a brown liquid identified as onion soup, also without labels or dates. Furthermore, there was a 4-quart egg salad with an expiration date of 5/23/2025. The Dietary Manager verified all observations concerning the unlabeled and undated items and stated during the interview that she instructs staff to only indicate the date opened on packages. The freezer revealed there was one opened 5-pound bag of diced onions that was unlabeled, undated, with no expiration information, along with 32 prepared beverages, four 40-oz baby baker potatoes, four bags containing six bagels each, and four 5-pound bags of brown liquids identified as gravy. Additionally, two opened 5-pound bags of triangle hash brown were observed unwrapped and without labels. During an observation on 5/28/2025, at 4:42 pm in the kitchenette located on the fifth floor, multiple unlabeled and undated items were found in the residents' refrigerator. In the refrigerator, there were two bagged food items that were both unlabeled and undated food substances, along with one plastic container. During an observation on 5/28/2025 at 4:50 pm in the kitchenette located on the fourth floor, there was observed six unlabeled and undated brown paper bags were observed along with three plastic bags with an unknown food substance. Additionally, there were five 8-oz milk cartons with an expired date of 5/25/2025 (two cartons of skim milk and three cartons of whole milk). During an observation on 5/28/2025 at 5:00 pm, in the kitchenette located on the third floor, there was an unlabeled and undated box of pizza, a Styrofoam plate, and three plastic bags with food substance. There was also an expired box of chicken dated 5/27/2025. During an observation on 5/28/2025 at 5:08 pm in the kitchenette located on the second floor, there was an uncovered peanut butter and jelly sandwich with an expired date of 5/22/2025, two unlabeled and undated brown paper bags with an unknown food substance, and in the freezer was a 12-oz chicken roll box with an expired date of 3/3/2025. The Dietary manager confirmed this observation and stated that the kitchen staff was not responsible for the kitchenettes on the floors; that the CNAs and nursing staff are responsible. During an observation on 5/30/2025, at 8:10 am, ADM GGGG conducted a test of the sanitizing sink using Hydrion QT-40 test strips. The expiration date for the first test strip was expired with the date 6/1/2023, while the second attempt with a different set of test strips had expired on 5/1/2022. ADM GGGG confirmed that he was supposed to check the inventory, including the test strips, when the company was called to install the new system approximately two to three months ago, but he must have overlooked this task. ADM GGGG also confirmed that all capsules had expired. During an observation on 5/30/2025 at 8:17 am, [NAME] IIII was seen handling eggs and turkey bacon with her hands while preparing meals for residents; no kitchen utensils were observed for the selection. An emergency food check was conducted on 6/2/2025 at 8:40 am for unlabeled, dated, or expired items. Two boxes of 120-count chips were observed with an expiration date of 5/6/2025. Two (6 count) one-gallon waters were observed with an expiration date of 2/28/2025. Completed tour of emergency water supply. The Dietary Manager revealed the facility does not have enough emergency water supply on hand to support the requirement of a minimum of one gallon per day per resident. During an observation on 6/8/2025 at 1:00 pm, of the Assistant Manager and without beard guard, and the Dietary Aid without beard guard and hair net. During an interview on 6/3/2025 at 9:24 am, the Dietary Aid (DA) HHHH revealed that the dietary staff were expected to ensure that the labeled tasks were completed. DA HHHH confirmed that she observed instances where tasks were not completed. DA HHHH stated that failure to adhere to food handling could lead to cross-contamination. DA HHHH confirmed she was unaware that the test strips in the bag had expired, as she typically tests the sanitizer in the three-compartment sinks. DA HHHH stated that test strips were provided by the company, and when the company came in a couple of months ago, the staff assumed the strips were valid, but they did not check. During an interview on 6/3/2025, at 9:36 am, with Dietary Aid/Cook IIII stated that breakfast was typically served with eggs, grits, oatmeal, and bread. She stated that meat was only provided with breakfast on certain days unless a resident specifically requested it. DA IIII stated that the reason she used her hands during serving was due to a lack of sufficient utensils, such as tongs and scoops, although she had been informed that an order had been placed. She stated, We also face significant challenges in keeping plates and forks, as they are frequently left in residents' rooms. A sweep is conducted every two to three months, but I suspect that the CNAs are not retrieving them from the residents' rooms. During an interview conducted on 6/9/2025 at 12:28 pm, the Assistant Dietary Manager GGGG revealed that the staff were without management for several months, and they lacked support from corporate.