Every finding on record at Oaks Health CTR at the Marshes of Skidaway Island

Based on record review and staff interviews, the facility failed to protect one of two residents (R) (R115) sampled for falls during Activities of Daily Living (ADL) care. Harm was identified to have occurred on 12/16/2024 when R115 fell while receiving ADL care, resulting in bilateral femoral fractures and a right humeral fracture. Findings include: Review of the Electronic Medical Records (EMR) revealed an admitted [DATE] with a diagnosis of post-polio syndrome, cognitive impairment of unknown etiology, abnormal gait and mobility, hypertensive heart disease without heart failure, contracture right and left foot, and muscle weakness. Record review of the most recent quarterly Minimum Data Set (MDS) for R115 dated 11/12/2024 revealed a Brief Interview for Mental Status (BIMS) score of 05, indicating severe cognitive impairment. Section GG (Functional Abilities and Goals) documented that R115 was dependent on staff for self-care and mobility requires two persons assistance for ADL care. The helper does all of the effort. The resident does none of the effort to complete the activity. A review of the Fall Incident Report for R115 dated 12/16/2024 at 7:37 am revealed at approximately 6:19 am, nursing was alerted to the room by Certified Nursing Assistant (CNA) BB. The CNA BB stated she was changing R115's bed linen when she rolled out of bed and hit her head on the floor. The CNA was unable to catch her, so she rolled off the bed onto the floor. Resident noted to have a hematoma to the right side of her head as well as skin tear to lower right extremity. Both areas were bleeding, and pressure was applied and bleeding controlled. R115 was helped back to bed. Resident was alert and oriented with in her base line. Hospice was notified at 6:27 am and recommend sending resident out to hospital. R115's family member was notified. A report was given to the local hospital at 6:40 am. R115 left the facility via Emergency Medical Services (EMS) at 7:25 am. A review of the hospital Discharge Plan dated 12/16/2024 revealed a disposition of 1. Bilateral femoral fractures, 2. Right humeral fracture. Patient is a Do Not Resuscitate (DNR) and under hospice care at nursing home facility. Interview with the Director of Nursing (DON) on 1/18/2025 at 11:48 am revealed she got a call from the nurse that R115 fell out of bed while CNA BB was putting clean linen on the bed. She stated R115 had a skin tear and a hematoma to her head. DON stated that the doctor gave an order to send R115 to the emergency room (ER) for evaluation. DON stated R115 had injuries of bilateral broken femurs. She stated that a CNA provided care, and R115 rolled out the bed, but CNA BB could not catch the resident. She stated that R115 was on Hospice prior to the fall. Interview with the Medical Director (MD) on 1/18/2025 at 4:17 pm revealed he is familiar with R115 and her care; he stated that she had a fall about a year and a half ago prior to this fall. The MD stated that when R115 was in the hospital, the doctor, along with her family, wished to not repair her femurs due to the risk of surgery being too high. The MD further revealed that the death certificate listed atherosclerotic heart disease (plague builds up and hardens inside arteries) as the immediate cause of death and that R115 also had osteoporosis. He stated that she was under hospice services, had declined prior to her death, and had other natural comorbidities. Interview with CNA BB on 1/19/2025 at 5:58 am revealed she confirmed that she was providing care for R115 on the day of her fall. CNA BB explained that it was towards the end of the shift. She stated that the nurse told her that R115 had a soiled brief. CNA BB reported that she had changed R115 before by herself. She reported that she cleaned R115 up well first and then began changing the linens on the bed. CNA BB stated that the fitted sheet was on the bed, and she instructed R115 to turn on her side and hold on to the bed rail. She further revealed that R115 began moving forward, and she tried to catch her from falling, but she slipped out of her hands and fell . CNA BB reported that R115 seemed to have increased confusion on that day and tried getting out of bed multiple times during her shift. Interview with a Licensed Practical Nurse (LPN) CC on 1/19/2025 at 1:17 pm during the morning medication pass revealed that R115's legs were hanging out of the bed. She asked CNA BB to help her straighten R115 up in bed, and that she was soiled. She stated that she asked CNA BB if help was needed, and CNA BB said no, she had changed her by herself. LPN CC revealed she was later called by CNA BB to R115's, and she saw the resident on the floor in a sitting position with a pool of blood on the floor and a small hematoma on her head, to which she applied pressure and called 911. She stated that R115 never lost consciousness. She revealed that she got help from the upstairs nurse. She further revealed that she noticed a skin tear on the lower right leg, and the LPN CC contacted the hospice nurse, who recommended that she be sent to the ER. She further revealed that the DON was contacted through phone text message. She stated the DON did not come to the facility at that time. A review of the death certificate signed date of 1/31/2025 revealed the cause of death as atherosclerosis heart disease. Further review revealed that R115 was admitted to hospice care on 10/2/2024.

Based on interviews and record reviews, the facility failed to ensure that the care plan was followed for Activities of Daily Living (ADL) ensuring that care was provided by the appropriate number of staff, to prevent accidents, for one of 14 residents (R) (R115), sampled for care plans. Harm was identified to have occurred on 12/16/2024 when R115 fell while receiving ADL care, resulting in bilateral femoral fractures and a right humeral fracture. Findings include: A review of the undated facility policy titled Care Plans, Comprehensive Person-Centered revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. A review of the care plan for R115 date initiated 9/20/2024, revised 12/24/2024, revealed that R115 requires staff assistance for ADLs. Requires maximum to total assistance with ADL care, including but not limited to bed mobility, transfers, locomotion, and toileting. Two persons assistance for ADL care. A review of the Fall Incident Report for R115 dated 12/16/2024 at 7:37 am revealed that the Certified Nursing Assistant (CNA) BB stated she was changing R115's bed linen when she rolled out of bed and hit her head on the floor. The CNA was unable to catch her, so she rolled off the bed onto the floor. Interview on 1/19/2025 at 5:58 am with CNA BB revealed that management normally tells staff what assistance is needed. She reported that she does not remember how many people were needed to provide care for R115 but remembered that when she was in training (day shift), sometimes one person was caring for R115, and there were other times that there were two persons providing care. CNA BB further revealed that it depended on how busy the CNAs were to determine if a second CNA would be available to offer assistance. A nurse is not always available on the night shift due to performing other tasks. She stated that the Director of Nursing (DON) provided a list of residents who were two-person assistance, and the nurse came to help whenever needed. She stated that the Assistant Director of Nursing (ADON) has watched her do a bed change with a resident in bed and signed off on it. Interview with Licensed Practical Nurse (LPN) CC on 1/19/25 at 1:17 pm revealed that she was unaware that R115 was a two- person assistance while she was in bed. LPN CC stated that she rarely needs assistance with R115, and she and CNA BB had just finished repositioning the resident on the bed before the incident. She stated that after the incident, she received education on two-person assistance. Post survey interview with the Assistant Director of Nursing (ADON) on 1/31/2025 at 1:50 pm revealed the cardex comes from the electronic medical record and staff should print the cardex each shift. The ADON stated care plans are communicated by walking rounds each shift between the CNAs about their residents, and staff should have the cardex on hand. The nurses also do walking rounds each shift. The ADON further revealed that the cardex is specific to each resident showing their activities, bowel and bladder, behavior, nutrition, and precautions. Staff should communicate to each other whether a resident is a one- or two-person assistance with ADLs. Cross reference F689

Based on observation, staff interview, record review, and review of the facility policies titled Standard Precautions, Dressings, Dry/Clean, and Laundry Services, the facility failed to ensure infection control practices were adhered to during wound care for one of three residents (R) (R12) reviewed for wound care. The facility also failed to ensure laundry practices were conducted so as not to cause cross-contamination of clean linen with soiled linen. The deficient practices had the potential to increase R12's risk of infections due to cross-contamination during wound care and had the potential to place all residents residing in the facility at risk of infections due to cross-contamination due to inappropriate handling of linen. Findings include: Review of the facility's undated policy titled Standard Precautions revealed the Policy Interpretation and Implementation section included 1. Standard precautions apply to the care of all residents regardless of suspected or confirmed presence of infectious disease. The Hand Hygiene section included b. Hand hygiene is performed with alcohol-based hand rub (ABHR), or soap and water (1) before and after contact with the resident; (2) before performing an aseptic task; (3)before moving from work on a soiled body site to a clean body site on the same resident ; (4)after contact with items in the resident's room; and after removing gloves. Review of the facility's undated policy titled Dressing, Dry/Clean revealed the Steps in the Procedure section included 1. Clean bedside stand, establish a clean field. 2. Place the clean equipment on the clean field, arrange supplies so they can be easily reached. 5. Wash and dry your hands thoroughly. 6. Put on clean gloves, loosen tape and remove soiled dressing. 8. Wash and dry your hands thoroughly. Record review revealed R12 had diagnoses of, but not limited to, pressure ulcer of sacral region and pressure-induced deep tissue damage of sacral region. Review of R12's Admission Minimum Data Set (MDS) dated [DATE] revealed Section M (Skin) documented the resident had an unhealed stage four pressure ulcer/injury over the bony prominence. Review of R12's Physician Orders revealed an order dated 12/31/2024 to cleanse the sacral wound with wound cleaner, apply Medihoney (a product used to treat wounds and burns) to wound bed only and cover with foam dressings one time daily. Review of R12's care plan revealed the resident had altered skin integrity related to a pressure wound to the sacral area. The goal indicated skin areas will not worsen through the next review date. Interventions, dated 9/21/2024, included observing for signs and symptoms of infection and notifying the physician if present. Roho cushion in place. Resident states a pillow on top of the cushion is most comfortable. Treatments per physician orders. Air Mattress in place. During wound care observation on 1/18/2025 at 10:15 am conducted by Registered Nurse (RN) AA revealed RN AA came to the conference room to get the surveyor for wound care observation for R12 with the wound care supplies in her ungloved hands that included a tube of Medihoney, dry gauze, Opti foam dressing, and wound cleanser. Observation revealed RN AA took the supplies into the resident's room and placed them on the overbed table that was located against the wall on the left side of the room. Once RN AA donned gloves and a gown, she then placed the supplies on the bedside table by the resident's bed without cleaning or disinfecting the area or placing a barrier on the table to place the supplies on. Continued observation revealed no wound dressing on the area of R12's wound, and the resident was sitting on the side of the bed. RN AA cleaned the wound with the wound cleanser and wiped the area with the dry gauze on the resident's table. After cleaning the wound, the nurse did not remove her gloves to wash or sanitize her hands before applying the Medihoney to the wound bed. Further observation revealed RN AA squeezed an undisclosed amount of Medihoney onto her right index finger, applied it directly to the resident's wound bed with her finger, and applied the Opti foam dressing. In an interview on 1/18/2025 at 10:30 am, RN AA confirmed that she did not provide a clean surface to place the wound care supplies on during R12's wound care. Further interview revealed RN AA confirmed that she did not wash or sanitize her hands at any time during the wound care treatment. RN AA revealed that she was unaware that she should wash her hands and change her gloves during the wound care procedure. In an interview on 1/18/2025 at 11:00 am, the Director of Nursing (DON) revealed that when completing wound care, the nurse should first check the order to ensure that the proper treatment was being completed. Once the order has been verified, the nurse should gather supplies and ensure the area where the supplies will be resting is cleaned and sanitized and a barrier placed on the table. Further interview revealed the expectation was that during wound care, the nurse should change gloves between dirty and clean process during wound care and wash and sanitize hands during those glove changes. In an interview on 1/18/2025 at 2:00 pm, the Administrator revealed that the staff should follow infection control practices when completing wound care and other tasks with residents. 36200 2. Review of the facility policy titled Laundry Services, dated 2014, revealed . 6. Laundry Handling: The community must implement procedures that prescribe how clean laundry and soiled laundry is to be handled. Proper linen handling according to a written procedure will help avoid cross-contamination of clean and soiled laundry. This is an important infection control consideration. Use of universal precautions will reduce the risk of exposure to laundry staff to pathogenic microorganisms. During the initial laundry tour on 1/18/2025 at 10:12 am with the Executive Director, observation revealed no laundry staff present at that time. Observation in the dirty laundry area revealed two clear trash bags with housekeeping cleaning towels and tablecloths in them, sitting on top of full containers of laundry detergent and on the floor next to the laundry detergent. During observation and interview on 1/18/2025 at 10:15 am, Housekeeper/Laundry Staff EE reported that she placed the towels in the plastic bags and put them in the soiled room because she had to work in housekeeping as well and had to put them somewhere until she was able to come back to the laundry room to finish processing them. During an interview on 1/18/2025 at 11:42 am, the Director of Nursing (DON) stated that best practice would be for cleaned items to not be stored in the soiled laundry area, even if they were in bags. She stated the clean items would have to be relaundered.

Based on observation, staff interviews, record review, and review of the facility policy titled Administering Medications, the facility failed to ensure a medication order was clarified with the physician prior to administering the medication to one of five residents (R) (R12) observed for medication pass. This deficient practice had the potential to place R12 at risk of avoidable medical complications due to a medication dosage order not being clarified prior to administration. Findings included: Review of the facility policy titled Administering Medications, dated 2001, revealed the Policy Statement was Medications are administered in a safe and timely manner, and as prescribed. The Policy Interpretation and Implementation section included 10. The individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Review of the medical record for R12 revealed diagnoses included, but not limited to, spinal stenosis in cervical region, polyarthritis, polyneuropathy, idiopathic gout, osteoporosis, and sacrococcygeal disorders. Review of R12s Physicians Orders revealed an order dated 9/21/2024 for celecoxib (a medication used to treat mild to moderate pain), one capsule by mouth one time a day. During observation of medication administration by Registered Nurse (RN) AA on 1/18/2025 at 8:45 am, R12 was administered celecoxib 200mg. In an interview on 1/18/2025 at 2:00 pm, RN AA confirmed celecoxib 200 mg was administered to R12 and confirmed the physician's order did not specify the dosage to be administered. In an interview on 1/19/2025 at 9:00 am, the Assistant Director of Nursing (ADON) stated all nurses can transcribe physician orders. She verified that R12's order for celecoxib was not transcribed accurately and should specify a dosage. In an interview on 1/19/2025 at 10:00 am, the Director of Nursing (DON) stated nursing staff was responsible for transcribing physician orders. The DON further stated the consulting pharmacist normally reviewed physician orders when ordered and monthly.

Based on observations, staff and resident interviews, record review, and review of the facility policies titled Administering Medications and Self-Administration of Medications, the facility failed to ensure medications were not left at the bedside of two of 14 sampled residents (R) (R7 and R215) who were not assessed for medication self-administration. This deficient practice had the potential to place R7 and R215 at risk for the unsafe use of medications. Findings: Review of the facility policy titled Administering Medications, dated 2001, revealed the Policy Statement was Medications are administered in a safe and timely manner, and as prescribed. The Policy Interpretation and Implementation section included 27. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. Review of the facility policy titled Self-Administration of Medications, dated 2001, revealed the Policy Statement was Resident have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. 1. Review of the medical record for R7 revealed diagnoses that included, but not limited to, anxiety, constipation, and atrial fibrillation. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed R7 had highly impaired vision and a Brief Interview of Mental Status score (BIMS) of 15 (indicating little to no cognitive impairment). Review of the Physician's Orders for R7 revealed no order for over-the-counter medication for stomach relief or diclofenac sodium gel (a topical medication used to treat pain). There also was no order for self-administration of medication for R7. During an observation and interview on 1/18/2025 at 4:57 pm in R7's room, stomach relief pills were found sitting in the window seal, and diclofenac sodium topical gel was found on the overbed table. The Administrator confirmed the medications in the room and informed R7 that the items would have to be removed. 2. Review of the medical record for R215 revealed diagnoses that included, but not limited to, a personal history of transient ischemic attack (TIA), cerebral infarction without residual deficits, unspecified dementia, mild without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Physician's Orders for R215 revealed no order for medication to treat fever blisters or Voltaren (a topical medication used to treat pain). There also was no order for R215 to self-administer medications. During an observation and interview on 1/18/2025 at 10:40 am with R215, a bottle of pills used to treat fever blisters was observed on the floor by R215's chair, and a tube of Voltaren was observed on the nightstand beside the bed. The Director of Nursing (DON) confirmed that the medications were in the room. The DON expressed that she was unaware the resident had the medications and stated there were no residents in the facility who had been assessed to self-administer medications at this time. The DON informed R215 that she would need to remove the medications because there was no order for them, and the resident reported that she had been taking the medications for years. During an interview on 1/19/2025 at 5:41 am, Licensed Practical Nurse (LPN) DD reported if residents had an order for medication self-administration, they were able to keep medications at their bedside and self-administer.

Based on record review and staff interview, the facility failed to ensure that Minimum Data Set (MDS) assessments were completed annually and upon admission for three residents (R) (#3, #4 and #65) of 13 sampled residents. Findings include: 1. Review of R#3's MDS listings revealed that a Quarterly MDS with an Assessment Reference Date (ARD) date of 3/4/22 was the last MDS completed. 2. Review of R#4's MDS listings revealed that a Quarterly MDS with an ARD date of 2/24/22 was the last MDS completed. 3. Review of R#65's MDS listings revealed that an Entry MDS with an ARD date of 4/30/22 was the last MDS completed. Review of an alphabetical resident census revealed that R#3, R#4 and R#65 were currently residents in the facility. Interview with Social Services Director on 7/7/22 at 12:10 p.m. revealed the sections competed by their department are C, D, E, V which are completed by social services when there is a new admission or significant change. The MDS coordinator gives out the schedule of when the assessments are due to be completed. The care plans are scheduled in accordance with the assessment due date that is provided by the MDS coordinator once the schedule is received the care plan meetings are set up by the social services department with the families and the residents. Interview with MDS Coordinator on 7/7/22 at 1:24 p.m. revealed staff started in the middle of March at this facility doing MDS. There was a calendar that was created every month that showed the ARD and Care Plan date that is given to Social Services Director (SSD) and Activities Director that indicated when assessments were due for completion. If an admission comes in after the calendar goes out, an email is sent out to let the staff member know of the ARD date for that resident. Continued interview also revealed that the calendar is kept on coordinators' laptop for review. During the interview it was also disclosed that staff member was not sure exactly how the assessments were missed. When the calendar is created every resident is reviewed at that time. Further interview also revealed that calendar of assessments for July had been created for residents upcoming assessments. The process for annual assessments is to print off the previous MDS and talk to the residents to find out how their pain is, see if there have been any changes that have not been brought up in morning meetings, bowel, and bladder habits. Interview with Director of Nursing (DON) on 7/7/22 at 2:36 p.m. revealed the MDS's were placed in a Performance Improvement Plan (PIP) in April and were being monitored weekly by pulling the CMS report. There was no indication that any assessments were late or had not been submitted. Further interview also revealed that DON acknowledged that the system that was used to ensure that the MDS assessments were completed was ineffective. During interview it was also disclosed that going forward the mechanism for ensuring assessments are completed is to manually check every resident's chart for completion.

Based on record review and staff interview, the facility failed to ensure there was a Physician' Order for a wound treatment for one resident (R) (#64) and failed to document when the treatment order was completed. The sample size was 13 residents. Findings include: Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan revealed R#64 has alteration in skin integrity R/T (related to) stage II to his coccyx. - Observe for s/s (signs/symptoms) of infection and notify physician if present. Turn and reposition at least every two hours. Interview with Licensed Practical Nurse (LPN) AA on 7/6/22 at 1:00 p.m. revealed R#64's pressure areas have healed. She confirmed that there was not a treatment order for wound care. LPN AA stated she was told by the off going nurse that R#64 had a pressure ulcer to his sacrum, and what treatment to put on it. LPN AA further stated she provided wound care to R#64 when she worked. Interview with the Director of Nursing (DON) on 7/7/22 at 2:24 p.m. revealed R#64 had a stage II area to the inner side of his right buttock. She stated there was apparently no treatment order however they were putting [MEDICATION(S)] on the area every three days. DON stated she gave the order to use [MEDICATION(S)] as a treatment. DON stated that she knew what to use on the wounds because she was a WOCN (Wound, Ostomy, and Continence Nurse), but she did not keep her certification up. DON stated she ran it by the Physician and that he stated that it was okay to use [MEDICATION(S)]. DON further stated she did not write the order and apparently it got missed. Further interview with the DON confirmed there is not a treatment administration record or anywhere for the nurses to document when they did R#64's wound care.

Based on record review and staff interview, the facility failed to ensure that Minimum Data Set (MDS) assessments were completed quarterly for two residents (R) (#1 and #2) of 13 sampled residents. Findings include: 1. Review of a listing of R#1's completed and transmitted MDS revealed that a Quarterly MDS with an Assessment Reference Date (ARD) of 2/26/22 was the last MDS completed. 2. Review of R#2's MDS listings revealed that a Quarterly MDS with an ARD date of 3/2/22 was the last MDS completed. Review of an alphabetical resident census revealed that R#1 and R#2 were currently residents in the facility. Interview with Social Services Director on 7/7/22 at 12:10 p.m. revealed the MDS coordinator gives out the schedule of when the assessments are due to be completed. The care plans are scheduled in accordance with the assessment due date that is provided by the MDS coordinator and once the schedule is received the care plan meetings are set up by the social services department with the families and the residents. Interview with MDS Coordinator on 7/7/22 at 1:24 p.m. revealed staff started in the middle of March 2022 at this facility doing MDS. There was a calendar that was created every month that showed the ARD and Care Plan date that is given to Social Services Director (SSD) and Activities Director. During the interview it was also disclosed that staff member was not sure exactly how the assessments were missed. When the calendar is created every resident is reviewed at that time. Further interview also revealed that calendar of assessments for July had been created for residents upcoming assessments.

Based on record review, private duty sitter, physician, consultant pharmacist, and facility staff interviews, the facility failed to correctly transcribe a change in medication for [MEDICATION NAME] (a medication used to treat overactive bladder) for one of five residents reviewed for medication regimen. Specifically, the facility failed to transcbribe [MEDICATION NAME] twice a day to once a day when the medication was changed to an extended-release (ER) form, resulting in the resident receiving the drug more often than ordered since 9/22/18. Findings include: Review of R#8's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of R#8's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that she had short-and long-term memory problems, and was frequently incontinent of urine. Review of R#8's (MONTH) (YEAR) Medications (Medication Administration Record-MAR) revealed an order for [REDACTED]. Review of R#8's (MONTH) (YEAR) MAR indicated [REDACTED]. Further review of this (MONTH) MAR indicated [REDACTED]. Review of pharmacy medication history forms revealed that [MEDICATION NAME] chloride 5 mg two times daily was ordered on [DATE], and [MEDICATION NAME] chloride ER 5 mg two times daily was ordered on [DATE]. Review of R#8's Physician order [REDACTED]. Review of R#8's Consultant Pharmacist Communication to Physician dated 9/12/18 revealed: Quality Indicator: Potentially inappropriate drug-[MEDICATION NAME] 5 mg QD (every day). [MEDICATION NAME] ([MEDICATION NAME]) is not recommended for use in patients over 65 due to increased sedation and [MEDICATION NAME] effects in the elderly. It has a higher risk for [MEDICATION NAME] effects than some of the newer agents for OAB (overactive bladder)/bladder spasms. With this in mind, please consider changing the current order to [MEDICATION NAME] 5 mg daily or [MEDICATION NAME] ER 5 mg qd. Physician Response to Recommendation/Finding (signed by the physician on 9/20/18): I agree. Change to [MEDICATION NAME] ER 5 mg po (by mouth) daily for urge incontinence. During interview with the Director of Nursing (DON) on 8/29/19 at 9:39 a.m., she verified the physician agreed with the consultant pharmacist's communication on 9/20/18 to change R#8's [MEDICATION NAME] to 5 mg of the ER form daily. She stated during further interview that the nurse that transcribed this order changed the [MEDICATION NAME] to the extended release form, but failed to change the frequency on the original order from twice a day to once a day. The DON verified that R#8 had received two daily doses of the ER form of the [MEDICATION NAME] since 9/20/18, instead of the ordered daily dose. Review of the drug information embedded in the Orders section of the facility's electronic health record for [MEDICATION NAME] Extended-Release-Oral, revised (MONTH) (YEAR), revealed: Uses: This is a long-acting form of [MEDICATION NAME] that is used to treat overactive bladder and urinary conditions. How to Use: Take this medication by mouth, usually once a day, or as directed by your doctor. Side Effects: Dry mouth, drowsiness, headache, dizziness, nausea, vomiting, upset stomach, stomach pain, constipation, diarrhea, blurred vision, dry eyes, unusual taste in mouth, dry/flushed skin, stuffy nose, and cough may occur. During interview with private duty sitter AA on 8/29/19 at 11:14 a.m., she stated that she had worked with R#8 for about five years. She further stated that R#8 was not a complainer, but had not complained of anything like a dry mouth, drowsiness, or headache, and that she rarely had nausea. She stated during continued interview that the resident had no problems passing her urine, but had occasional hard stools for which the staff would give her a laxative. During interview with R#8's attending physician on 8/29/19 at 11:28 a.m., she stated that [MEDICATION NAME] was not a good drug for older people, but that R#8 had a terrible problem with stress incontinence. She further stated that she had written several Progress Notes about the [MEDICATION NAME]'s use. The physician stated during continued interview that the extended release form of the [MEDICATION NAME] was better tolerated in older adults regarding potential side effects such as dry mouth. She further stated that she was not aware that R#8 had been receiving the ER [MEDICATION NAME] twice a day, but that this dose would not be toxic, and she would not consider it to have a significant impact on the resident. Review of the attending physician's Progress Notes revealed: 8/7/18: Oxybutinin trial to stop has failed with worsening of urinary symptoms. 12/21/18: Urge incontinence-failed taper of [MEDICATION NAME] ([MEDICATION NAME]) with increase in complaints, responded to reinstitution. 7/25/19: Tolerating [MEDICATION NAME] for urge incontinence-it has helped with the frequency complaints. 8/26/19: Urge incontinence-on oxybutinin-relapsed off it-was resumed. During an interview with the facility's Consultant Pharmacist BB on 8/29/19 at 1:00 p.m., he stated that the form and dose of [MEDICATION NAME] that he saw ordered most often was ER version, 10 mg once daily. He further stated that sometimes the ER version did not last a full 24 hours, and so giving 5 mg of the ER form of [MEDICATION NAME] twice a day might prevent any lapse in the 24-hour coverage better than a single daily dose of [MEDICATION NAME] ER 10 mg. The Consultant Pharmacist stated during continued interview that he did not feel that giving R#8 [MEDICATION NAME] ER 5 mg twice a day was excessive, but added that he did not like this drug due to it's [MEDICATION NAME] properties. He stated that the ER version was better than the immediate-release version of [MEDICATION NAME] as far as having fewer side effects, but that when the immediate-release version was changed to the extended-release version last September, he would have expected that they gave it once a day first before giving it twice a day.

Based on record review, consultant pharmacist, and facility staff interviews, the consultant pharmacist failed to report an irregularity to the physician regarding the extended-release (ER) form of [MEDICATION NAME] (a medication used to treat overactive bladder) being given twice a day instead of once a day as ordered by the physician since 9/22/18, after a recommendation made by the consultant pharmacist. A total of five residents' medication regimens were reviewed. Findings include: Review of R#8's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of R#8's (MONTH) (YEAR) Medications (Medication Administration Record-MAR) revealed an order for [REDACTED]. Review of R#8's Consultant Pharmacist Communication to Physician dated 9/12/18 revealed: Quality Indicator: Potentially inappropriate drug-[MEDICATION NAME] 5 mg QD (every day). [MEDICATION NAME] ([MEDICATION NAME]) is not recommended for use in patients over 65 due to increased sedation and [MEDICATION NAME] effects in the elderly. It has a higher risk for [MEDICATION NAME] effects than some of the newer agents for OAB (overactive bladder)/bladder spasms. With this in mind, please consider changing the current order to [MEDICATION NAME] 5 mg daily or [MEDICATION NAME] ER 5 mg qd. Physician Response to Recommendation/Finding (signed by the physician on 9/20/18): I agree. Change to [MEDICATION NAME] ER 5 mg po (by mouth) daily for urge incontinence. Review of R#8's (MONTH) (YEAR) MAR indicated [REDACTED]. Further review of this (MONTH) MAR indicated [REDACTED]. Review of R#8's Physician order [REDACTED]. During interview with the Director of Nursing (DON) on 8/29/19 at 9:39 a.m., she verified the physician agreed with the consultant pharmacist's communication on 9/20/18 to change R#8's [MEDICATION NAME] from the immediate-release form twice a day to 5 mg of the ER form once daily. The DON further stated that the nurse transcribed the frequency of the ER [MEDICATION NAME] incorrectly as twice a day, and she verified that R#8 had received two daily doses of the ER form of the [MEDICATION NAME] since 9/22/18, instead of the ordered daily dose. She further stated that she did not know why the pharmacist did not catch this error. During an interview with the facility's Consultant Pharmacist BB on 8/29/19 at 1:00 p.m., he stated that he had only been reviewing residents' medications for about two months at this facility. He further stated that he did not feel that giving R#8 [MEDICATION NAME] ER 5 mg twice a day was excessive, but added that he did not like this drug due to it's [MEDICATION NAME] properties. He stated during continued interview that when the immediate-release version was changed to the extended-release version last September, he would have expected that it be given once a day first, before giving it twice a day. Review of 2019 Consultant Pharmacist Activity Report and Record of Medication Regimen and Chart Reviews revealed that there was NO recommendation activity for R#8 in the months of February, April, June, and July. Further review of these reports revealed that R#8 had recommendation activity in January, March, and May, but none of the recommendations addressed that the [MEDICATION NAME] was being given more often than ordered. Cross-refer to F 684.

Based on staff interview, record review and review of the facility's policy titled Abuse Investigation and Reporting, the facility failed to report an allegation of abuse to the State Survey Agency (SSA) within the required time frame for one resident (R#3) on an sample of 16 residents. Findings include: Review of the Skilled Nursing Facility Incident Report Form dated 11/10/17 indicated that on 11/8/17 at 3:30 p.m. R#3 told a staff member that a Certified Nursing Assistant (CNA) grabbed her by the arm and hurt her. The resident further stated she was scared to go back to her room if the CNA was there. The resident's physician was notified on 11/8/17 at 3:40 p.m., however, the initial report was not sent into the state agency until 11/10/17. During an interview on 09/08/18 at 02:22 p.m., the Administrator stated according to the report the facility became aware of the allegation of abuse on 11/8/17 at 3:30 p.m In addition, she confirmed the initial report was not sent to the SSA until 11/10/17 at 6:31 p.m The Administrator further stated she was not aware that the time frame for reporting allegations of abuse to the SSA was two hours after the facility became aware of the suspected abuse. Review of the facility policy titled Abuse Investigation and Reporting dated (MONTH) (YEAR) stated suspected abuse will be reported within two hours. During an interview on 09/09/18 at 11:22 a.m., the Administrator stated the policy had been updated in (MONTH) (YEAR) to reflect the changes in the requirements. She further stated the allegation should have been reported within two hours of the allegation being made.

Based on observation, record review, and staff interview, the facility failed to provide wound care in a manner to prevent possible cross-contamination between clean and soiled dressing supplies; to sanitize scissors used to cut dressing supplies before and after use; to remove soiled dressing items from the room after treatment completion; and to remove gloves and perform hand hygiene prior to other care for one resident (R) (R#13). The sample size was 16 residents. Findings include: Review of R#13's clinical record revealed that he had [DIAGNOSES REDACTED]. Review of a wound care center report dated 9/4/18 for R#13 revealed [DIAGNOSES REDACTED]. Further review of this report revealed that the pressure ulcer to the gluteus had healed. Review of the Wound Assessments section of this report revealed that the wound to the right lateral foot had an open wound status with measurements of 0.1 by 0.1 by 0.1 centimeters, and a small amount of red and brown serosanguinous drainage. Review of a dermatologist's Wound Care Instructions dated 8/16/18 revealed that R#13 had an unspecified procedure to the right frontal scalp and posterior scalp. Review of R#13's (MONTH) (YEAR) Treatment Record (TAR) revealed a treatment ordered 8/16/18 to clean wounds to the posterior and right frontal scalp with soap and water, dry, apply Mupirocin ointment, and cover with a Band-Aid daily. Further review of this TAR revealed a treatment dated 9/4/18 to cleanse the right lateral foot wound with soap and water, and apply a foam dressing to cover every two days. On 9/8/18 at 1:40 p.m., Registered Nurse (RN) AA was observed performing wound care to R#13's right lateral foot as well as the two wounds to his scalp. The nurse was observed to place the dressing supplies directly on the resident's overbed table after removing his personal items off of it. Further observation revealed that RN AA did not clean or sanitize the top of the overbed table, nor place a clean barrier on the table, before putting the dressing supplies on it. The gauze wrap and foam dressing to the right lateral foot were removed, and a small amount of drainage was observed on the foam dressing. RN AA was observed to pull her gloves off over the dressing, and placed the soiled dressing on top of the overbed table with the clean dressing supplies. RN AA was then observed to pick up a pair of blue-handled scissors with the appearance of office-type scissors which had not been cleaned or sanitized prior to use, and she cut a piece of foam dressing and placed it over the foot wound. The nurse then taped the foam in place, and wrapped the foot with a gauze dressing which she cut with the same pair of scissors. The nurse was observed to change her gloves a total of four times during this part of the procedure, and all of them were placed directly on the overbed table among the clean dressing supplies after each pair was removed. After the foot wound care was completed, the nurse picked up the used pile of gloves, and disposed of them in the trash can across from R#13's bed. Continued observations at this time revealed that RN AA performed treatments to the wounds on R#13's scalp after finishing the wound care to the foot. She removed the existing Band-Aids on R#13's scalp with gloved hands, then removed the gloves around the old Band-Aids, and placed the used gloves on the overbed table. RN AA was then observed to clean both scalp [MEDICAL CONDITION] with a pair of clean gloves, removed the gloves when done, and placed them on the overbed table. She then donned clean gloves, applied a new Band-Aid to one of the scalp [MEDICAL CONDITION], removed the gloves and put them on the overbed table. RN AA was then observed to put on a clean pair of gloves, and put a clean Band-Aid on the second scalp lesion. Without removing her gloves and washing or sanitizing her hands, RN AA was observed to lower the height of the bed with the electric control, and then picked up the pile of used gloves from the overbed table, and disposed of them in the trash can in the resident's bathroom. RN AA then put the clean, unused dressing supplies back in a plastic bag still wearing the same pair of gloves that she had applied the second Band-Aid with, and wiped off the top of the overbed table with a wet paper towel before removing her gloves and sanitizing her hands. RN AA was then observed to place R#13's box of tissues, a bottle of water, and his television remote control back on his overbed table. Continued observations at this time revealed that RN AA left R#13's room, and placed the plastic bag with the remaining clean dressing supplies back in the treatment cart. Further observations revealed that she did not remove the trash can liners with the soiled gloves and dressing supplies from R#13's room, and she was observed to place the pair of blue-handled scissors on a hook at the nurse's station without first cleaning or sanitizing it. During interview with the Director of Nursing (DON) on 9/9/18 at 9:13 a.m., she stated that her expectations for wound care was that the overbed table or a corner of the bed have a clean barrier placed on top of it before putting the dressing supplies down. She stated during further interview that soiled dressing supplies and gloves should be put in a clear plastic bag (if the resident was not on isolation), taken out of the room and disposed of in the soiled utility room after the treatment was over. The DON stated that soiled dressing supplies should not be placed on top of the overbed table with the clean supplies. She further stated that the blue-handled scissors kept at the nurse's station were meant more for cutting paper, but could be used for cutting dressing supplies as long as they were cleaned with a sanitizing cloth. During interview with RN AA on 9/9/18 at 10:13 a.m., she verified that she did not provide a clean barrier for R#13's dressing supplies that she placed on the overbed table the previous day. She verified during further interview that she had placed the soiled gloves on the overbed table, but felt like she separated the clean items from the dirty items. She verified that she did not remove the trash can liners from R#13's after the treatment was over, but stated that she went back to the resident's room later and removed them. RN AA verified during continued interview that she did not sanitize the scissors used to cut the dressing supplies before or after the wound care, and did not realize that bandage scissors were available in the treatment cart. Review of the facility policy Dressings, Dry/Clean revised (MONTH) 2013 revealed: Steps in the Procedure: 1. Clean bedside stand. Establish a clean field. 2. Place the clean equipment on the clean field. 3. Tape a biohazard or plastic bag on the bedside stand or use a waste basket below clean field. 18. Discard disposable items into the designated container. 19. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly. 22. Clean the bedside stand.

Based on record review, staff interview, the facility policy titled, Antipsychotic Medication Use the facility failed to document the intended duration of therapy for one resident (R) (R#8) that had orders for an as needed (prn) [MEDICAL CONDITION] medication beyond the 14 days. The sample size was 16 residents. Findings include: Record review revealed that R#8 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set Assessment for R#8 dated 7/27/18, documented that the resident's mood as having trouble falling asleep two to six days, feeling tired seven to eleven days, short tempered two to six days. The resident did not exhibit any behaviors, the resident received an antipsychotic seven days (on a routine basis), and R#8 received an antidepressant seven of the seven day during the look back period. Record review of the (MONTH) Physician order for [REDACTED]. Review of the Medication Administration Records for R#8 revealed the resident was administered [MEDICATION NAME] 0.5mg every eight hours as needed as follows: 10 times in (MONTH) (YEAR), eight times in (MONTH) (YEAR), ten times in (MONTH) of (YEAR), seven times in (MONTH) of (YEAR), and two times in (MONTH) of (YEAR). Review of a Consultant Pharmacist Communication to Physician form dated 12/27/17, documents the following: R#8 currently has an order for [REDACTED]. If the attending physician or prescribing practitioner believes that it is appropriate for the prn order to extend beyond 14 days he or she must document their rationale and indicate the duration of the prn order. If the order needs to continue please document the following for our orders: Rationale: (left blank) Duration: (left blank) Physician response to recommendation finding: I agree - blank Other: checked - (please write a brief statement below concerning the rationale for your response to this recommendation. Physician signature dated 12/29/17 Hand written note documents: depression - managed by psychiatry Review of the Consultant Pharmacist Communication to Physician dated 7/19/18, documents that the resident has an order for [REDACTED]. record. Further reveal that options indicted for continued use was left blank. A handwritten note at the bottom documents: Long standing severe depression Rx (prescription) per psychiatry. Interview on 9/8/18 at 2:50 p.m. with the Assistant Director of Nursing (ADON) revealed that the resident has not seen a psychiatrist or had any psychiatry services since she was admitted to the LTC facility. Interview on 9/9/18 at 11:02 a.m. with the ADON revealed that R#8 was admitted with an order for [REDACTED]. Interview on 9/9/18 at 11:12 a.m. with the Director of Nursing (DON) and ADON revealed that the resident has received [MEDICATION NAME] 0.5mg prn since (MONTH) and confirmed that there was not a stop date for the medication and that there should be. Review of the facility policy titled, Antipsychotic Medication Use last revised (MONTH) (YEAR), revealed the following: page 3, #14 the need to continue PRN orders for [MEDICAL CONDITION] medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN will be indicated in the order.

Based on observation, record review and staff interviews, the facility failed to wash or sanitize hands when delivering and/or setting up meal trays during two of two dining observations, and failed to store clean linen in a manner to prevent potential cross-contamination from the soiled laundry. The facility census was 17 residents, and the sample size was 16 residents. Findings include: 1. During observations in the Mulberry dining room at breakfast on 9/22/17 beginning at 8:03 a.m., Certified Nursing Assistant (CNA) AA was observed to do the following: She served a resident in the dining room their tray and set it up for them, and placed a cloth napkin across their chest. She then obtained another tray off the cart, handled the resident's muffin with her bare fingers, placed a napkin in the resident's lap, and then obtained another tray from the cart. She pushed a resident's walker away, placed a napkin on the resident's chest, and handled their muffin with her fingers. She then removed a tray from the cart and took it to the assisted living unit, and had to enter numbers on a keypad to unlock the door and use the door handle to come in and out of the unit. She then took another tray off the cart back on the long-term care unit, and took it into resident (R) #14's room. CNA AA knocked on the door before entering, turned on the light, took a tube of lotion into the bathroom, positioned the overbed table, touched the siderail, raised the head of the bed, and repositioned the covers. She was then observed to unwrap the silverware from the napkin, placed the napkin on the resident's chest, moved the pillow under the resident's head, and handled the muffin with her fingers. CNA AA was then observed to get another tray off the cart at 8:20 a.m., and took it to the last resident to be served in the dining room, sat down, unwrapped the silverware, and fed the resident. At no time during these observations was CNA AA observed to use hand sanitizer or wash her hands. During continued dining observations at this time, Licensed Practical Nurse (LPN) BB was observed to pick up a knife and spoon that R #22 had pushed off the table, and then picked up the resident's muffin and broke it in half without performing hand hygiene first. A second dining observation was done on 9/23/17 at 12:09 p.m. in the Peachtree dining room and resident rooms, and one randomly-observed CNA was observed to do the following: The CNA was observed to serve R #19 her lunch tray and when in the room touched the bathroom door twice, came out of the room back to the cart and got a covered dessert, and took it back down to the resident. The CNA then got another meal tray off the cart and served an unsampled resident, and when doing so she was observed to knock on the door and move the overbed table. The CNA was then observed to close the door, came back to the cart to get this resident a covered dessert off the cart, knocked on the door and re-entered the room. At no time was the CNA observed to perform hand hygiene. During interview with the Director of Nursing on 9/24/17 at 9:28 a.m., she stated that staff should wash their hands or use hand sanitizer before they started serving meals, and use hand sanitizer if they touched something other than the tray itself or if they went from feeding one resident to another. She further stated that if staff went from room to room to deliver trays, they should be using hand sanitizer after leaving each resident room. Review of the facility's Handwashing/Hand Hygiene policy revised August 2015 revealed the following: Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water before and after direct contact with residents; after contact with objects in the immediate vicinity of the resident; before and after eating or handling food; and before and after assisting a resident with meals. Review of a handout used during a facility inservice entitled Hand Washing revealed: Make sure you wash your hands before and after direct resident contact when appropriate; before and after eating or handling food; before and after any direct resident care. 2. During interview with Laundry employee CC in the facility's laundry room on 9/24/17 at 8:42 a.m., she stated that she never stored the clean and dirty laundry carts side by side. Observation of the Soiled Linen Room inside of the laundry room at this time revealed that there was a cart that was covered on the top and all sides that was full of clean linens. However, further observation revealed that there was an open gap on the sides where the cover was not secured to the frame of the cart, which allowed exposure of the clean linens to the open air. Further observation revealed that approximately two-thirds of the linen was in plastic bags, with the other linens not enclosed including some towels on the bottom shelf that were visible through the gap in the covering to the cart. Continued observation revealed a soiled linen cart stored in this room that was approximately 18-inches from the clean linen cart. Review of a sign on the door leading into the laundry room's Soiled Linen Room revealed Do Not Bring Clean Linens In This Area. During interview with Laundry employee CC at this time revealed that they had stored laundry this way as long as she could remember. During interview with the Administrator at this time (who was present in the Laundry during these observations), she stated that she did not know if the storage of clean and soiled items had always been done this way, but that she was surprised to see the clean laundry stored in the Soiled Linen Room. During interview with the Director of Environmental Services Director on 9/24/17 at 9:42 a.m., she stated that they had a lack of storage in the Laundry room, and that clean and soiled laundry had always been stored this way. She further stated that the clean linen cart should be covered tighter so that there were no gaps exposing the clean linens. Review of the facility's Laundry Services Provided by On-site Laundry dated 2015 noted: Proper linen handling according to a written procedure will help avoid cross contamination of clean and soiled laundry. Clean linen carts will be covered during transport and storage. DONE

Based on record review and staff interview, the facility failed to ensure that background checks were performed in states where new applicants had previously recently worked for three of five employees hired in the past six months. The sample size was 16 residents. Findings include: 1. Review of an Authorization to Conduct Criminal History form dated 7/13/17 revealed that Licensed Practical Nurse (LPN) DD had listed past residences in the last seven years of Hinesville, Georgia. However, review of her Employment Record revealed that she had worked for a staffing agency in Florida from 10/15/12 to 1/15/14. Review of the Candidate Notification form revealed that the background check had been conducted in Georgia only. 2. Review of an Authorization to Conduct Criminal History form dated 4/13/17 revealed that Certified Nursing Assistant (CNA) EE listed no cities/states of past residences over the last seven years. Review of her Employment Record revealed that she worked for a staffing service with a telephone area code from south central Pennsylvania from November of 2009 to June of 2013. Review of the website for this staffing agency revealed that they served the staffing needs throughout South Central Pennsylvania. Review of the Candidate Notification form revealed that a background check was done in Georgia only. 3. Review of an Authorization to Conduct Criminal History form dated 3/29/17 revealed that LPN FF listed that she had lived in Georgia and Pennsylvania in the last seven years. Review of her Employment Record revealed that she had worked at a facility in Pennsylvania from January 2007 to March of 2012. Review of her Candidate Notification form revealed that a background check had been done in Georgia only. During interview with the Administrator on 9/24/17 at 11:14 a.m., she verified that background checks had been done for Georgia only for LPNs DD and FF, and CNA EE. She further stated that the facility staff that requested background checks did it only for the state listed by the applicant on the front of the Authorization to Conduct Criminal History forms. She verified that CNA EE had not listed any residences on this form for the past seven years, but there was no evidence that her Employment Record had been checked to see if she had worked outside Georgia. The Administrator verified during further interview that despite documentation that LPNs DD and FF had worked in Florida and Pennsylvania respectively, background checks were not conducted in those states. She further stated that she attempted to contact LPN DD to verify her employment in Florida, but was unable to reach her. During continued interview, the Administrator stated that if a new applicant had worked in another state in the past seven years, that a background check should have been done in that state. Review of the facility's Criminal Background Check policy with a revision date of January 2017 noted that the minimum standard must ensure that persons have not been found guilty of, or entered a plea of nolo contendere (no contest) or guilty to, any offense prohibited under any statue of the State of Georgia or under any similar statute of another jurisdiction. DONE

Based on observation, record review, and staff interview, the facility failed to consistently document the administration and consumption of nutritional supplements for two (2) residents (R7 and R18), to be able to determine if the nutritional interventions were effective. The sample size was sixteen (16) residents. Findings include: Review of R18's Significant Change Minimum Data Set ((MDS) dated [DATE] revealed that they had severe cognitive impairment. During review of their Alteration in Nutrition care plan related to cognitive and functional decline revealed that the resident was at risk for weight loss, and that they refused to allow feeding assistance at times and had a slow decline in weight. Review of the physician's orders [REDACTED]. During observation on 01/12/16 at 12:29 p.m., R18's lunch tray, including a nutritional supplement drink, was left uneaten. During interview with Certified Nursing Assistant (CNA) CC at this time, they stated that the resident refused to eat any of their lunch. Review of the resident's tray ticket revealed that the resident was on a regular diet with eight ounces of strawberry Ensure and Coke with all meals. During interview with CNA CC on 01/13/16 at 9:18 a.m., they stated that the Kitchen provided the supplement on each meal tray and that they (the CNA) recorded the consumption of the supplement at meals in a computerized system located in the hallway. During further interview, the CNA stated that the resident usually consumed these supplements, but it may take them several hours and they had to be encouraged. During interview with the Assistant Director of Nursing (ADON) on 01/13/16 at 2:55 p.m., they stated that the charge nurse was responsible to see if the CNA gave the supplement, and if the resident was consuming it. During further interview and record review, the ADON provided R18's Consumption report for December and January, and verified that there was very few times that the consumption of the supplement was documented. Further review of this Consumption report revealed that of the one hundred and seven meals recorded between 12/01/15 and 01/13/16, documentation of consumption of the nutritional supplement was recorded only twenty-four times. During interview with CNA CC on 01/14/16 at 8:30 a.m., they stated that the nurses gave the between-meal supplements. During interview with Licensed Practical Nurse (LPN) BB on 01/14/16 at 9:41 a.m., they stated that they provided the supplement at 10:00 a.m. and 2:00 p.m., and that it was documented in the computerized Medication Administration Record [REDACTED]. During further interview with LPN BB, they stated that it was difficult to get R18 to drink the supplement, as all the resident liked to drink was Coke. 2. R7 was identified with a low Body Mass Index (BMI) of 20.7 which identified him/her with a BMI less than the required 22. Record review revealed a Dietary recommendation and physician's order [REDACTED]. Review of the daily consumption report on 1/13/16 at 3:35 p.m. with the Assistant Director of Nursing (ADON) revealed the supplement log for R7 was empty. It was confirmed that there was no record of the percentage of supplement consumed by R7. Interview on 1/14/16 at 9:48 a.m. with AA , Certified Nursing Attendant (CNA) revealed that all consumption of meals and supplements are logged daily in the computer by the CNA ' s. Interview on 1/14/16 at 9:48 a.m. with BB revealed that she only documents if R7 received the supplement but is unaware of the actual amount consumed.

Based on record review and staff interview, the facility failed to include the total number of hours worked by direct care staff on the nurse staffing posting for four (4) of five (5) days of the survey. The facility census was nineteen (19) residents. Findings include: During initial tour of the facility on 01/10/16 beginning at 4:30 p.m., the posting of the nurse staffing information was seen by the Peachtree nurse's station. During further observations on each day of the survey on 01/11/16 at 11:45 a.m.; 01/12/16 at 12:20 p.m.; 01/13/16 at 12:34 p.m.; and 01/14/16 at 8:38 a.m. revealed that the nurse staffing information lacked the total number of hours worked. During interview with the Director of Nursing (DON) on 01/14/16 at 8:38 a.m., they stated that a staff nurse completed this form, and that they (the DON) went back later to fill in the total number of hours worked by the staff. Review of the nurse staffing information forms from 09/01/15 to 01/14/16 revealed that none of the forms included the total number of hours worked by the nursing staff, except for on 01/10/16.

Based on record review, facility policy and staff interviews, the facility failed to monitor for potential side effects for one (1) of two (2) residents (#5) receiving an Antipsychotic medication from a sample of seventeen (17) residents. Findings include: Resident #5 was admitted to the facility on [DATE]st, 2013 with [DIAGNOSES REDACTED]. Review of January 2015 physician orders [REDACTED]. (an Antipsychotic) 25 milligrams (mg) daily. Review of the Electronic Medical Record (EMR) for resident #5 revealed no evidence of monitoring for potential side effects of an Antipsychotic medication. Interview with the Assistant Director of Nursing (ADON) on 2/3/15 at 3:50 p.m. revealed that there was no form in the EMR for monitoring potential side effects of Antipsychotic medications. Interview with the Director of Nursing (DON) on 2/4/15 at 1:00 p.m. confirmed that there was no consistent monitoring for potential side effects of an Antipsychotic medication performed for resident #5. Interview on 2/4/15 at 1:45 p.m. with the ADON confirmed no consistent monitoring for potential side effects of an Antipsychotic medication was conducted for resident #5. The ADON, who is also the Minimum Data Set (MDS) coordinator, stated that Abnormal Involuntary Movement Scale ( AIMS ) were conducted on 1/3/14, 3/7/14, 4/22/14, 7/22/14, and 2/3/15 on resident #5. On 2/5/15 at 8:35 a.m. the ADON produced a facility policy on Antipsychotic Medication Use which stated in #14 of the Policy Interpretation and Implementation that Nursing staff shall monitor and report any of the following side effects to the Attending Physician: Sedation, Orthostatic [MEDICAL CONDITION], Lightheadedness, Dry mouth, Blurred vision, Constipation, [MEDICAL CONDITION], Increased psychotic symptoms ([MEDICATION NAME]), Extrapyramidal effects, Akathisia, [DIAGNOSES REDACTED], Tremor,Rigidity,Akinesia, or tardive dyskinesia.

Based on observation and staff interview, the facility failed to prepare and serve one (1) food on the menu at a temperature to prevent food borne pathogens for nineteen (19) of twenty (20) residents. Findings include: Observation on 1/14/14 at 1:20 p.m. of temperatures taken of foods on the steam table, revealed the beef tips that were being served were at a temperature of 115 degrees Fahrenheit (F.). Interview at that time with the Food Service Director confirmed that all hot foods should be at least 135 degrees F.

Based on observation, record review and staff interview, the facility failed to ensure all medications were within the manufacturer's specified dates for one (1) resident medication and three (3) house stock medications. Findings include: Observation on 1/14/14 at 1:05 p.m. with Licensed Practical Nurse (LPN) "AA" revealed Milk of Magnesia (MOM) for resident #13 to have an expiration date of 04/2013. Record review revealed the resident had a current physician's orders [REDACTED]. Interview on 1/14/14 at 1:10 p.m. with LPN AA revealed that the resident had received this expired medication on 1/13/14. Further observation in the medication storage room revealed Bisacodyl 5 milligram (mg) tablets expired 11/13 and two (2) boxes of Biscolax suppositories 10 mg. expired 12/13. Interview on 1/14/14 at 1:20 p.m. with LPN "AA" confirmed that the expired medications should not be given.