Every finding on record at Peachtree Nursing and Rehabilitation LLC

Based on observations, record reviews, and interviews, the facility failed to keep track of when to discard refrigerated food items through labeling and dating the items. This failure had the potential to negatively impact (through foodborne illness) 139 residents residing at the facility by exposing them to food items that may have spoiled.Findings include:An observation on 11/18/25 at 8:50 AM, during the Flash Tour. completed with the Director of Food and Nutrition Service (DFNS), of the kitchen revealed numerous food items located in the reach in refrigerators were not labeled or dated. The food items were as followed: cooked chicken breasts in a steam table pan, sliced ham covered by plastic wrap, opened packets of hot dogs, roast beef, fresh and cooked yellow squash located in a partially filled steam table pan, fresh broccoli, sliced cheese wrapped in plastic wrap, pork chops located in a partially filled steam table pan, raw fish located in a steam table pan, raw chicken breast located in a steam table pan, raw hamburger wrapped in plastic wrap, a container of ranch dressing, a container of coleslaw, and a bowl of marinara sauce. During an interview on 11/18/25 at 9:10 AM, the DFNS confirmed that all the food items listed above were in the reach in refrigerators and they were not labeled or dated. The DFNS stated this practice was unacceptable and all the items should have been labeled and dated. The DFNS said it was the responsibility of the cooks to maintain the reach in refrigerators and ensure items were labeled and dated. DFNS said all staff had received training regarding the labeling and dating of refrigerated food items. The DFNS stated the kitchen was short staffed yesterday. The DFNS instructed her staff to remove the undated items from the refrigerator.During an interview on 11/20/25 at 11:05 AM, the DFNS explained the kitchen staff had daily huddles and provided documentation that labeling and dating of refrigerated items was reviewed during February, April, May, June and July of 2025.Huddles completed closer to the survey date did not address labeling and dating items placed in the refrigerator. During an interview on 11/20/25 at 11:25 AM, Cook2 stated she did not know what happened on 11/18/25, or why she did not check the reach in refrigerator at the beginning of her 5:00 AM morning shift. Cook2 stated it was a rare occurrence that unlabeled and undated food items were in the reach in refrigerator. Cook2 confirmed she was aware all items needed to be dated and labeled once placed in the refrigerator.During an interview on 11/20/25 at 11:35 AM, Cook1confirmed it was the cook's responsibility to ensure items were labeled and dated in the reach in refrigerator. Cook1 explained that upon arriving for a shift she checked the reach in refrigerator for properly labeled and dated items. Cook1 confirmed she was aware all items needed to be dated and labeled once placed in the refrigerator. Review of the facility's undated policy titled, Food Service Requirements indicated, Policy: It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food will also be stored.in accordance with professional standards for food service safety. Definitions.Food service safety refers to handling, preparing, and storing food in ways that prevent foodborne illness. Foodborne illness refers to an illness caused by the ingestion of contaminated food or beverages. Policy Explanation and Compliance Guidelines: 1. Food safety practices shall be followed throughout the facility's entire food handling process.3. Facility staff shall inspect all food, food products.for safe transport and quality upon delivery/receipt and ensure timely and proper storage.c. Refrigerated storage.Practices to maintain safe refrigerated storage include.iv. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen/discarded.

Based on interviews, record review, and policy review, the facility failed to ensure physician orders for code status matched the residents' Physician Orders for Life Sustaining Treatment (POLST) and wishes for two of four residents (Resident (R) 57 and R49) reviewed for advance directives out of 29 sampled residents. This failure increased the likelihood of causing severe harm or death if CPR (Cardiopulmonary Resuscitation) was performed or withheld against a resident's wishes.Findings include:1. Review of the admission Record, located in the electronic medical record (EMR) under the Profile tab revealed R57 was admitted to the facility on [DATE] and returned from a hospital stay on [DATE]. R57 had diagnoses which included cerebral infarction (stroke) and sepsis (a life-threatening condition where the body's response to an infection damages its own tissues and organs).Review of the Care Plan, tab of the EMR revealed an intervention, revised on [DATE], under the focus area cognitive loss/decision making poor which instructed, Talk with resident and family [regarding] health care decisions: Code status, medications, treatments if needed, notify [provider] and document.Review of a POLST, form, dated [DATE], and located in the EMR under the Documents tab revealed that R57 checked the box Allow natural death [and] - do not attempt resuscitation [DNR] and signed the form.Review of a hospital Post Acute Transfer Summary, dated [DATE] and located in the EMR under the Documents tab revealed discharge orders for full code status (perform CPR) upon R57's discharge from the hospital.Review of R57's Order Summary Report, located in the EMR under the Orders tab revealed an order for full code dated [DATE].Review of the EMR revealed no documentation of a discussion with R57 regarding code status upon his return from the hospital. A new POLST was not completed.Review of R57's significant change Minimum Data Set (MDS) with an assessment reference date (ARD) of [DATE] and located under the MDS tab of the EMR revealed he scored 12 out of 15 on his Brief Interview for Mental Status (BIMS) which indicated moderate cognitive impairment. Review of a Care Plan Conference Summary, dated [DATE] and located in the EMR under the Documents tab of the EMR revealed, Neither resident nor family participated in the care plan meeting. [R57] remains a full code. The document was signed by the former Social Services Director (SSD).During an interview on [DATE] at 12:42 PM, R57 responded that if his heart stopped beating and he stopped breathing, he did not want CPR done. I feel if my heart stops, it's my time to go. They [facility staff] asked me about that a long time ago, and I signed a paper.During an interview on [DATE] at 3:29 PM, Licensed Practical Nurse (LPN) 1 stated she looked at the Profile tab of the EMR to identify code status. In addition, POLST forms were located under the Documents tab. LPN1 verified that R57's code status order was for full code while his POLST reflected DNR and stated she was unsure what to do if they did not match.During an interview on [DATE] at 3:35 PM, Unit Manager (UM) 1 stated that she looked at the Profile tab of the EMR to verify what the residents' orders were for code status. Nurses entered orders into the EMR based on the Post Acute Transfer Summary orders from the hospital. If there were no orders, the nurses called the hospital to obtain orders. Nurses did not talk to the residents about their wishes regarding code status; social services had that discussion.During an interview on [DATE] at 3:51 PM, Registered Nurse (RN) 1 stated she located a resident's code status orders by looking at the Profile tab of the EMR. Nurses entered code status orders based on the hospital's discharge orders. If there were no written orders from the hospital, nurses called the hospital for clarification.During an interview on [DATE] at 4:12 PM, the former SSD stated if she noticed that a code status order changed during a resident's hospitalization, social services or the nurse practitioner followed up with the resident regarding their wishes. The former SSD reviewed code status orders, but not POLSTs, at residents' quarterly care plan meetings. If a resident was not present at the meeting, the former SSD did not follow up with them about their code status wishes. The former SSD verified there was no documentation in the EMR that anyone followed up with R57 or R49 on their wishes regarding code status. The SSD stated they could run a report on code status orders. During an interview on [DATE] at 4:45 PM, the Director of Nursing (DON) stated that nurses looked at the residents' orders for code status which were reflected on the home page, or profile, of the EMR to determine whether to perform CPR. The DON expected someone, likely social services, or the physician, to reach out to the resident or family if they noticed a discrepancy with code status orders and POLSTs upon a resident's return from the hospital.During an interview on [DATE] at 7:36 PM, the Administrator stated she expected a POLST to be updated, given to the nurse practitioner to sign, and new orders entered into the EMR when a resident returned from the hospital.2. Review of R49's undated admission Record, located in the EMR under the Profile tab, revealed she was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure, Reiter's disease, and cervicalgia. Review of R49's Physician's Orders, dated [DATE], located in the EMR under the Orders tab, revealed an order for full code. Review of R49's POLST, dated [DATE] and located in the electronic medical record (EMR) under the Documents tab, revealed to attempt CPR. No other POLST was found in the medical record.Review of R49's Physician's Orders, dated [DATE], located in the EMR under the Orders tab, revealed an order for full code. Review of R49's Psychosocial Note, dated [DATE], located in the EMR under the Prog Notes tab revealed CODE STATUS: Care plan meeting held this morning. Neither resident nor family participated. Resident remains a FULL CODE per current MD [physician] order.Review of R49's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], located in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Review of R49's Hospital Discharge Orders, dated [DATE], located in the EMR under the Documents tab, revealed orders for DNR/DNI. There was no documented evidence of why R49's code status was changed to DNR/DNI. There was no documented evidence that R49 had been involved in changing the code status. Review of R49's Hospital Discharge Orders, dated [DATE], located in the EMR under Documents tab, revealed orders for DNR/DNI. There was no documented evidence of why R49's code status was changed to DNR/DNI. There was no documented evidence that R49 had been involved in changing the code status. Review of R49's comprehensive Care Plan, dated [DATE], located in the EMR under the Care Plan tab revealed a DNR/DNI code status. Review of R49's Psychosocial Note, dated [DATE], located in the EMR under the Prog Notes tab revealed CODE STATUS: Care plan meeting held [DATE]. Neither resident nor family participated. Resident remains a DNR/DNI per current MD order.Review of R49's Physician's Orders, dated [DATE], located in the EMR under the Orders tab, revealed an order for DNR/DNI. During an interview on [DATE] at 12:34 PM, R49 stated she wanted CPR and had completed a form in the past.During an interview on [DATE] at 3:36 PM, Unit Manager (UM) 2 confirmed she deleted R49's old orders and entered the new orders from hospital discharge orders dated [DATE] which included an order for DNR/DNI. UM2 stated she did not know who was responsible for completing the POLST to reflect the change in the resident's code status.During an interview on [DATE] at 4:13 PM, the Admissions Director, former SSD, stated the POLST was reviewed in the quarterly care plan meetings, and R49 did not attend the last care plan meeting held on [DATE] so her code status remained a DNR/DNI per the physician order. The former SSD verified there was no documentation in the EMR that anyone followed up with R49 after she returned from the hospital and there was not a process in place to identify these issues. Review of the facility's Advanced [sic] Directives policy, dated [DATE], revealed: Upon admission/readmission, the facility Social Services Director will inform and educate the resident, or POA [power of attorney] in writing about the right to refuse medical and surgical treatment and their right to an advance directive. The Social Services Director will assist the resident/POA in updating preferences for care and treatment at all quarterly care plan meetings, and anytime there is a re-admission to the facility. The social worker will maintain the Advance Directive DNRO [do not resuscitate order] log on a weekly basis and will update at each care plan review or with each new admission/readmission. A POLST is a form developed as a more specific and detailed DNR [Do Not Resuscitate]. Like a DNR, the form is completed with the resident's doctor and based on end-of-life decisions. Once signed, doctors and other medical professionals must honor the instructions on the POLST.

Based on interviews, record review, and policy review, the facility failed to ensure residents were free from abuse and neglect for one of four residents (Resident (R) 49) reviewed for abuse and neglect out of 29 sampled residents. The facility neglected the resident when Certified Nurse Aide (CNA) 1 removed the call light out of the resident's reach. CNA 1 intimidated R49 when she stood over her and told the resident not to use the call light again. These failures had the potential to cause unmet care needs. Findings include:Review of R49's undated admission Record, located in the Electronic Medical Record (EMR) under the Profile tab, revealed she was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure, Reiter's disease, and cervicalgia. Review of R49's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/29/25 and located in the EMR under the MDS tab, revealed R49 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Review of R49's Nursing Progress Note, dated 10/30/25 and located in the EMR under the Prog Notes tab, revealed, Spoke with resident's daughter concerning agency staff removing call light out of residents reach. Daughter was notified that agency staff will not be returning to the building. Daughter said thank you and expressed no other concerns.Review of a Facility Incident Report Form, dated 10/30/25 and provided by the facility, revealed at 5:30 AM on 10/30/25, Licensed Practical Nurse (LPN) 3 entered R49's room after hearing R49 yelling for help and saw her call light laying on the back of her bed out of reach. R49 told LPN3 that CNA1 removed the call light and told her not to use it again. LPN3 reported it to Charge Nurse (CN) 2. CN2 went to R49's room and found the call light hanging behind the head of the bed on the floor. R49 reported to CN2 that CNA1 came into the room after she pressed the call light for incontinent care and moved the call light behind her head, stood over her, and told her not to use it again because she continued to call for help. CN2 attached the call light around the bed rail and provided incontinent care to R49. CNA1 admitted to CN2 that she removed the call light from R49 because she kept calling for assistance and told her to stop using it. CN2 also told CNA1 not to go back to R49's room, all call lights must be answered, and to ask for help if she needed help in caring for the residents. The Director of Nursing (DON) reported the incident to the agency and told them not to send CNA1 back to the facility.During an interview on 11/21/25 at 11:27 AM, R49 stated she woke up from sleep and pressed her call light because she was wet and needed to be changed. R49 stated CNA1 came into her room, put the call light behind her head, and stood over her and told her not to use the call light again because she had been calling for assistance all morning. R49 indicated she felt intimidated by CNA1 when she was standing over her. R49 also indicated that when CNA1 left her room, she yelled for help until LPN3 came into her room and she reported the incident to her. R49 confirmed CN2 provided incontinent care and placed her call light on her bed rail within her reach.During an interview on 11/20/25 at 9:56 AM, the Administrator confirmed R49 was neglected and abused on 10/30/25 when CNA1 removed R49's call light from her reach, did not provide incontinent care, and told R49 not to call for assistance anymore. During an interview on 11/20/25 at 1:13 PM, CNA1 confirmed R49 rang for assistance on 10/30/25 around 5:15 AM, she went into her room, threw her call light out of her reach, and told her to stop pressing the call light. CNA1 also confirmed CN2 told her not to move the resident's call lights and not to return to R49's room. CNA1 stated she was busy with her other assigned residents on the floor, got stressed out, and needed assistance with the residents. CNA1 stated R49 called for assistance many times that shift.During an interview on 11/20/25 at 2:36 PM, CN2 confirmed that LPN3 reported she heard R49 yelling for help, she entered her room, and saw her call light hanging from the wall on the floor out of R49's reach. CN2 confirmed R49 told her CNA1 came into her room after she pressed the call light, moved it where she could not see it, and told her not to press it again. CN2 stated she provided incontinent care to R49 and placed her call light on the bed rail. CN2 stated she removed R49 from CNA1's assignment, reported R49 had been neglected to the DON, and completed a grievance/complaint form regarding the incident. During an interview on 11/20/25 at 11:50 AM, LPN3 stated she heard R49 yelling for help from her room. When she entered the room, the call light was behind R49's head on the back of the bed. LPN3 stated R49 was upset due to CNA1 removing the call light and telling her not to use it again after R49 pressed the call light when she needed incontinent care. LPN3 indicated she reported the neglect to CN2. CN2 went to R49's room, attached her call light to the bed rail, and provided incontinent care to R49.During an interview on 11/21/25 at 9:26 AM, the DON confirmed CNA1 neglected and abused R49 when she placed her call light out of her reach, did not provide incontinent care for her as requested, and stood over R49 and told her not to use the call light again.Review of the facility's policy titled, Prohibition of Resident Abuse & Neglect, revised 01/20/25, revealed, It is the policy of [the nursing home] that each resident will be free from abuse, neglect, corporal punishment, misappropriation of resident property, and exploitation. Our facility practices ZERO tolerance of resident abuse, neglect, mistreatment, exploitation, or misappropriation of property by anyone including staff members, other residents .

Based on interviews, record review, and policy review, the facility failed to ensure abuse and neglect by staff was reported timely to the Director of Nursing (DON) and to the State Survey Agency (SSA) when a resident's call light was placed out of reach, and told not to use the call light anymore by Certified Nursing Assistant (CNA)1 for one of four residents (Resident (R) 49) reviewed for neglect out of 29 sampled residents. Findings include:Review of R49's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/29/25, located in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact.Review of R49's Nursing Progress Note, dated 10/30/25, located in the EMR under the Prog Notes tab, revealed Spoke with resident's daughter concerning agency staff removing call light out of residents reach. Daughter was notified that agency staff will not be returning to building. Daughter said thank you and expressed no other concerns.Review of a Facility Incident Report Form, dated 10/30/25 and provided by the facility, revealed the facility performed an investigation and confirmed neglect and abuse occurred on 10/30/25 at 5:30 AM. It was reported to the State Survey agency on 10/30/25 at 10:30 AM. The investigation revealed Licensed Practical Nurse (LPN) 3 entered R49's room after hearing R49 yelling for help and saw her call light laying on the back of her bed out of reach. R49 told LPN3 that CNA1 removed the call and told her to not to use it again. LPN3 reported it to Charge Nurse (CN) 2. CN2 went to R49's room and found the call light hanging behind the head of the bed on the floor. R49 told CN2 that CNA1 came into the room after she pressed the call light for incontinent care and moved the call light behind her head, stood over her, and told her not to use it again because she continued to call for help. CN2 attached the call light around the bed rail and provided incontinent care to R49. CNA1 admitted to CN2 that she removed the call light from R49 because she kept calling for assistance and told her to stop using it during an interview. CN2 reported the allegation of neglect to Unit Manager (UM) 1 at the end of her shift and then UM1 reported it to the Director of Nursing (DON) around 8:00 AM. The DON reported the allegation of abuse and neglect to the Administrator at 8:30 AM.During an interview on 11/20/25 at 9:56 AM, the Administrator confirmed she was not notified of the allegation of mental abuse and neglect of R49 when LPN3 and CN2 observed the call light was not in reach, the resident stated she was told not to use it again, and incontinent care was not provided by the CNA on 10/30/25 at 5:30 AM. The Administrator stated she was notified by the DON after she arrived at work around 8:30 AM on 10/30/25. The Administrator stated allegations of abuse should be reported within two hours to the SSA, so she did not meet the required timeframes.During an interview on 11/20/25 at 2:36 PM, CN2 confirmed LPN3 reported she heard R49 yelling for help, she entered her room, saw her call light hanging from the wall on the floor , and R49 told her CNA1 came into her room after she pressed the call light, moved it where she couldn't see it, and told her not to press it again. CN2 stated she completed a grievance/complaint form and gave it to UM1 to give to the DON but did not report it to the DON. CN2 stated abuse should be reported within two hours, but she was not sure if it was abuse or neglect, so she did not report it timely.During an interview on 11/20/25 at 11:50 AM, LPN3 stated she heard R49 yelling for help from her room. When she entered the room the call light was behind her head on the back of the bed. LPN3 also stated R49 was upset due to CNA1 removing the call light and telling her not to use it again after R49 had pressed the call light when she needed incontinent care. LPN3 indicated she reported neglect to CN2 immediately on 10/30/25 around 5:30 AM. CN2 went to R49's room, attached her call light to the bed rail, and provided incontinent care to R49.During an interview on 11/21/25 at 9:26 AM, the DON confirmed UM1 reported the allegation of abuse and neglect to her at 8:00 AM and she reported it to the Administrator at 8:30 AM on 10/30/25.Review of the facility's policy titled Prohibition of Resident Abuse & Neglect, revised 01/20/25, provided by the facility, revealed . Reporting 1. Any witnessed, alleged, or suspected violations involving mistreatment, neglect, or abuse, . MUST BE REPORTED IMMEDIATELY TO THE EMPLOYEE'S SUPERVISOR. 2. The supervisor must immediately notify the Administrator and/or the Director of Nursing. 3. Abuse allegations (abuse, neglect, exploitation or mistreatment, . will be REPORTED IMMEDIATELY to the appropriate authorities by the Administrator and/or Director of Nursing including but not limited to, local law enforcement agencies, NJDOH [New Jersey Department of Health], and Ombudsman in compliance with regulatory requirements .

Based on interviews, record review, and policy review, the facility failed to ensure another method to call for assistance was provided when a resident's call light malfunctioned and was removed from the resident's wall for one of four residents (Resident (R) 157) reviewed for call lights out of 29 sampled residents. This failure had the potential to result in residents' care needs not being met by nursing staff. Findings include:Review of R157's undated admission Record, located in the electronic medical record (EMR) under the Profile tab revealed she was admitted to the facility on [DATE] with diagnoses that included cerebrovascular accident (CVA), hemiplegia following CVA, and mild protein calorie malnutrition. R157 expired in the facility on [DATE]. Review of R157's change in condition Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated the resident was cognitively intact.Review of a Facility Incident Report Form, dated [DATE] and provided by the facility, revealed at 8:59 AM on [DATE], Family Member (FM) 157 notified the Administrator R157's daytime caregiver found the call light cord rolled up on the bedside table, and it was not in the wall while there the last two mornings. The investigation revealed that Certified Nursing Assistant (CNA) 2 removed the call light cord from the wall due to it malfunctioning as it was turning on without anyone pressing it every 15 to 20 minutes. The call light malfunction was recorded in the maintenance workbook on [DATE] by CNA2. The call light cord was found to be in working order on [DATE] by the Maintenance Technician. The Director of Nursing (DON) verified the call light was in place and properly functioning on [DATE]. The Maintenance Technician T verified the call light was properly functioning and in place again on [DATE]. CNA2's undated written statement revealed R157 pulled the call light out of the wall because she was aggravated that it kept turning on without pressing it on [DATE]. The call light was not placed back in the wall, and another means to communicate with nursing staff was provided to the resident. CNA2 informed the agency CNA assigned to R157 on the evening shift on [DATE] of the malfunctioning call light and told her to round on the resident every one to two hours. An interview conducted by the Administrator on [DATE] with R157 revealed someone removed the call light out of the wall on [DATE], she was not provided with another means to communicate with staff, but care was provided for her. CNA2 was suspended during the investigation and terminated on [DATE]. An interview was attempted with FM157 on [DATE] at 7:00 PM, 7:05 PM, and 7:15 PM, but the phone call was not returned. An interview was attempted with CNA2 on [DATE] at 4:10 PM, 5:15 PM, and 5:20 PM, but the phone call was not returned. During an interview on [DATE] at 4:14 PM, Licensed Practical Nurse (LPN) 6 confirmed that CNA2 and her observed the call light turning off and on without R157 pressing the call light and she saw the call light laying across her abdomen during medication administration on [DATE]. LPN6 stated CNA2 did not inform her that she removed R157's call light from the wall and she did not see CNA2 remove it from the wall. During an interview on [DATE] at 8:27 AM, the Administrator stated her investigation revealed the call light was not accessible to R157 when CNA2 removed the call light and did not provide her with another means to communicate with nursing staff on [DATE] and there was no evidence of neglect or abuse. The Administrator stated during an interview with R157, she said someone removed the call light from the wall, but she did not know who did it a few days ago and all her care needs were met. Review of the facility's policy titled Call Lights: Accessibility and Timely Response, dated [DATE], provided by the facility, revealed Policy: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. Policy Explanation and Compliance Guidelines: . 5. Staff will ensure the call light is within reach of resident and secured, as needed . 8. Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied. (Examples include: replace call light, provide a bell or whistle, increase frequency of rounding, etc.) .

Based on observations and staff interviews, the facility failed to ensure food items in the kitchen cooler were properly stored and labeled with open or discard dates, failed to dispose of expired foods in a resident nourishment pantry, and failed to ensure an ice maker was maintained in a clean and sanitary manner. The deficient practices placed the 106 residents (R) who consumed an oral diet from the kitchen at risk for avoidable foodborne illness. Findings include: The Food Safety policy was requested and was not provided. Observations of the kitchen cooler on [DATE] at 9:15 am revealed the following: One industrial-size cooking sheet containing seasoned chicken was covered with plastic wrap with a light orange substance on the wrap without a label indicating a stored or discard date. Trays of bacon without a label indicating a stored or discard date. Opened condiments, including a wing sauce/glaze, strawberry topping, and salad dressing, without a label indicating a stored or discard date. A pan of green beans without a label indicating a stored or discard date. A pan of unknown food items covered with aluminum foil without a label indicating a stored or discard date. A plastic tub of noodle soup with a cooler stick in it, uncovered and without a label indicating a stored or discard date. Sliced pepperjack cheese, sliced sharp cheese, and cheese cubes without labels indicating a stored or discard date. Observation of the fresh vegetable area in the cooler revealed a clear plastic tub labeled as squash containing a bag of cauliflower, without a label indicating a stored or discard date. Observation on [DATE] at 2:00 pm of a resident nourishment pantry on B Floor revealed a refrigerator/freezer containing an open box of a frozen dessert product without an opened or discard date with a manufacturer's expiration date of [DATE]. Observation on [DATE] at 2:16 pm of a resident nourishment pantry on A Floor revealed an industrial ice machine with ice in it. When wiped along the interior of the ice machine with a paper towel, there was a build-up of a dark brown/black substance on the paper towel. Observations of the kitchen cooler on [DATE] at 11:15 am revealed the following: One industrial-size plastic bowl containing seasoned chicken without a label indicating a stored or discard date. Open condiments, including chicken wing sauce, soy sauce, and salad dressing, without labels indicating a stored or discard date. One package of sliced pepper jack cheese without a label indicating a stored or discard date. Observation of the fresh vegetable area in the cooler revealed a clear plastic tub labeled as squash containing long green leafy vegetables, without a label indicating a stored or discard date. In an interview on [DATE] at 9:15 am, the Certified Dietary Manager (CDM) revealed she did not know what the thick orange substance was on the plastic covering the chicken. She stated she was not sure why the staff did not label the open food items and that she was constantly educating them on labeling opened items properly. In an interview on [DATE] at 3:30 pm, the Administrator revealed the ice makers were cleaned weekly and had been cleaned earlier that day around 10:00 am. In an interview on [DATE] at 11:15 am, Sous Chef BB revealed all opened food items should be dated when opened, and it was a continual work in progress to remind and educate staff on dating opened items. In an interview on [DATE] at 12:37 pm, the CDM revealed she continues to educate staff during huddles on labeling and expiration dates. She stated the clear bins should be labeled and dated correctly with the discard date on them.

Based on observation, staff interviews, and a review of the facility policy titled Quality of Care and Quality of Life-Accommodation of Needs, the facility failed to provide dining assistance to one of 13 residents (R) (R38) selected for dining observation. The deficient practice placed R38 at risk for unmet care needs and a diminished quality of life. Findings include: A review of the facility policy titled Quality of Care and Quality of Life-Accommodation of Needs, dated July 8, 2021, revealed the Policy was To define a process to accommodate individual needs and preferences to the extent possible for residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being consistent with residents' assessment and plan of care. The Definitions section included ADLs [Activities of Daily Living]: . Dining, including eating meals and snacks. The Procedure section included Staff Attitudes and Behaviors: 3.1 Accommodate individual needs and preferences; staff attitudes and behaviors must be directed towards assisting the residents in maintaining independence, dignity, and well-being to the extent possible and in accordance with the resident's wishes. A review of the electronic medical record (EMR) for R38 documented she was admitted to the facility with diagnoses including Alzheimer's disease, unspecified dementia, psychotic disturbance, mood disturbance, anxiety, and unspecified psychosis. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of zero (indicating severe cognitive impairment) and section GG (Functional Abilities and Goals) documented that R38 required setup or clean-up assistance for eating - the helper sets up or cleans up and resident completes the activity. A review of the care plan for R38 documented a Focus area initiated on 5/11/2021 and revised on 4/27/2023 for ADLs that stated the resident needs up to limited assistance from one staff member due to CVA [cerebral vascular accident], dementia, and varying cognitive and physical abilities. The Goal, initiated on 5/11/2021 and revised on 5/31/2024, was for the resident to receive assistance with ADLs, to be cleaned and groomed, and to have meals served by staff through the next review date. The Interventions for Eating included the following: 1. One staff member to set up trays and monitors for any choking or difficulty swallowing. 2. Resident can feed herself when OOB [out of bed]. She needs supervision and cues to finish. 3. If a resident is in bed, turn on the soft light and have the resident positioned upright in bed. 4. Set up her tray, cut food, open containers, and have utensils in reach as well as other items. 5. Assist the resident to start feeding herself. If she refuses the tray, offer ice cream from the tray, thicken fluids, and give the resident a cold nutritional beverage. The interventions were initiated on 5/11/2021 and revised on 7/24/2024. Observation of R38 during the dinner meal on 7/24/2024 at 4:52 pm in her room revealed she was positioned upright in bed with her dinner tray on the bedside table across her lap. She was eating ice cream with her right hand fingers. The meal tray held a plate of food with a mechanical soft texture and two juice containers opened with straws inserted. The flatware was still wrapped and inaccessible to R38. In an interview with Unit Support Associate (USA) GG on 7/24/2024 at 5:00 pm in R38's room, he stated he did not deliver the meal tray to R38 and confirmed the flatware was still wrapped, inaccessible to R38, and should have been unwrapped and within the resident's reach as part of the meal setup. In an interview with Licensed Practical Nurse (LPN) HH on 7/24/2024 at 5:05 pm in R38's room, she confirmed the flatware was still wrapped and should have been opened and placed within R38's reach during the meal setup. She unwrapped the flatware. In an interview with Certified Nursing Assistant (CNA) II on 7/24/2024 at 5:20 pm, she stated she delivered the meal tray to R38 and should have unwrapped the flatware and placed it within reach of the resident as part of the meal setup. She stated that if she did not do that, it was simply an oversight.

Based on observations and staff interviews, the facility failed to provide an environment free from chemical hazards for one of four residents (R) (R91) reviewed for accident hazards. This deficient practice placed R91 at risk for avoidable chemical incidents, injuries, and a diminished quality of life. Findings include: A policy was requested and was not provided. A review of R91's clinical record revealed diagnoses including, but not limited to, unspecified dementia and cognitive communication deficit. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 4 (indicating severe cognitive impairment) and section GG (Functional Abilities and Goals) documented R91 required supervision with ambulation. A review of the care plan revised on 7/17/2024 revealed a focus area of cognitive losses, resident with memory deficit related to diagnosis of dementia. An observation on 7/23/2024 at 11:37 am revealed R91 lying on her bed sleeping. An observation of R91's bathroom revealed a three-tier cart with two cans of disinfectant spray, one container of all-purpose cleaner with bleach, two containers of disinfectant wipes, an aerosol spray can containing an unknown substance, and a spray bottle of air freshener. An observation on 7/24/24 at 5:44 pm revealed R91 sitting in her room in a chair. An observation of R91's bathroom revealed two containers of disinfectant wipes, an aerosol spray can containing an unknown substance, and two cans of disinfectant spray on a three-tier cart. An observation on 7/25/2024 at 10:40 am revealed an aerosol spray can with a blue top containing an unknown substance in R91's bathroom. During an interview and observation on 7/25/2024 at 10:49 am, Wound Care Nurse (WCN) EE confirmed the aerosol spray can with an unknown substance in R91's bathroom, and she removed it. She stated it was not the expectation of the facility for residents to have chemical items in their rooms. She further stated that R91's family brings the items in, places them in the bathroom, and states they feel like R91 knows what to and what not to do with them. She stated when staff finds those items, they remove them from the residents' room and alert the family. An interview with Bath Technician (BT) DD on 7/25/2024 at 10:57 am revealed she had not seen any household chemicals in R91's bathroom. She stated if she were to see any type of household chemicals in a resident's room, she would put them in a higher place so the residents would not be able to reach them. In an interview on 7/25/2024 at 11:26 am, WCN EE revealed chemicals were not allowed in resident rooms. Nurse FF revealed that R91's family was in and out of the facility throughout the day, and staff constantly educated the family on what was allowed in the bathroom. Registered Nurse (RN) FF stated the expectation was for staff to remove chemical items from a resident's room and take them to the nurse. She confirmed the process had not been followed for removing chemical items from the resident's room.

Based on staff interviews, record review, and review of the facility policy titled, Advance Directive, the facility failed to update the care plan for one of five sampled Residents (R#17) related to code status. Findings include: Record review of the facility policy titled Advance Directive with a revision date of [DATE], revealed under the change in condition, 3.3, initiate a new life-sustaining treatment (RPLST) form and update the care plan to reflect changes, or if no changes have been made, to document the date of review and discussion; Care Plan Review 4.1; all residents will be reviewed at care plan for advance directive and/or RPLST; 4.2 existing RPLST will be reviewed. If there is no change, sign, and date the RPLST form. Record review for R#17 revealed that the resident was admitted to the facility on [DATE]. Diagnosis included but was not limited to encephalopathy, systemic inflammatory response syndrome, the presence of a cardiac pacemaker, and vascular dementia. Record review of the care plan for R#17, revised on [DATE], included Do Not Intubate (DNI) status: Resident to have Cardio-Pulmonary Resuscitation (CPR), no intubation, per new orders [DATE]. Record review of the physician's orders for R#17 revealed a Do Not Resuscitate (DNR) order date of [DATE]. Interview on [DATE] at 6:29 p.m. with the [NAME] Care Coordinator revealed that the code status is reviewed at the quarterly care plan meeting. If there is a change in the code status, order the charge nurse sends an email to the Interdisciplinary team (IDT) team. Interview on [DATE] at 6:29 p.m. with the MDS Coordinator revealed that during the morning meeting, the charge nurse reports information about the residents, including any changes, and the MDS Coordinator will update the care plan in relation to the code status. Interview on [DATE] at 6:45 p.m. with a Registered Nurse (RN) 1 and the Director of Nursing (DON) revealed that the term DNI means Do Not Intubate; the Resident will receive CPR and maybe medications during an emergency but no intubation; the term DNR means Do Not Resuscitate; there will be no CPR, intubation, or medications. The DON and RN 1 confirmed that the physician order on [DATE] was a DNR order, but the code status on the care plan was a DNI.

Based on record review, review of policy Advance Directives, and staff interviews, the facility failed to provide written documentation for one of four Residents (R#396) reviewed. Findings include: Review of medical record for R#396 revealed Full Code Status. Review of progress notes did not reveal that written information was provided to resident related to right to formulate an Advance Directives. An interview was conducted on 6/6/18 at 11:10 a.m. with Patient Financial Services (PFS) Representative, who reported that she does not discuss advance directives during the admissions process but social services does this. During interview on 6/6/18 at 11:40 a.m. with the facility Social Services Director (SSD) she explained the facility process for providing information regarding Advance Directives revealed that she discusses this with the resident and family on admission. She reported that she explained what a full code and each code status means and explained to residents what a Do Not Resuscitate (DNR) means and what do they want to happen. It was explained that if a resident asked for written information about advanced directives then the packet titled Georgia Advance Directive For Health Care would then be provided to the resident. The Social Services Director states she puts a note in the progress notes section of the resident's chart. She also stated that the admitting nurse on the floor also discusses Advance Directives with the resident and charts this information on the Long Term Care Admissions Assessment. An interview on 6/6/18 at 3:10 p.m. with SSD who reported that advance directive information forms were found in Meditech, which was the system that was used previously but not being used now. However, the advance directive information forms are no longer being utilized. It was further expressed that these forms have not been utilized in over a year. An interview on 6/7/18 at 12:27 p.m. with the Executive Director who reported that the facility talks with residents on admission and during the admission nursing assessment regarding the desire to formulate an advanced directive. When questioned about written information provided to residents the Executive Director reported that she thought the regulations required only having a written policy. An interview on 6/7/18 at 2:15 p.m. with PFS Representative who reported that there is no advance directives information provided in the admissions packet provided to residents. She further reported that she thought social services was responsible for discussing this information with the residents. Advanced directives policy reviewed. Policy: #8205-16 page 2 of 6 Informing of patient of rights and options A. During the inpatient, outpatient surgery, or the emergency department admitting process the patient must be asked if he/she has an advance directive. 1. Included in the admission material is information regarding advance directives and the directive for final health care. 3. If the patient desires not to discuss the issue further, the fact that the patient has no advance directive must be documented in the medical record at the time of assessment.

Based on record review and staff interview, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to the resident or responsible party upon discharge from Medicare Part A services to indicate that they understood the contents of the form for two of three residents (R) reviewed (#9 and #23). Findings include: Review of a Beneficiary Notice-Residents discharged Within the Last Six Months form, provided by the facility, revealed that R #9 was discharged off Medicare Part A skilled services on 3/9/18 and remained in the facility afterwards with benefit days remaining. Further review of this form revealed that R #23 was discharged off skilled services on 1/518, and remained in the facility with benefit days remaining. There was no evidence provided that the SNFABN was provided to either R#9 or R#23. During an interview on 6/7/18 at 8:35 a.m. with Minimum Data Set (MDS) representative GG it was reported that prior to surveyors coming into the facility she was not aware to use SNFABN form when residents discharged from Medicare Part A services. MDS GG confirmed that she did not provide SNFABN forms for R#9 and R#23. It was reported that copies of the SNFABN forms were provided to her on 6/5/18 to begin using.

Based on observation, interview, review of the facility policy titled Self-Administration of Medications, and record review, the facility failed to assess the ability to self-administer [MEDICATION NAME] nebulizer treatments for one resident (R) (#62) out of 48 sampled residents. Findings include: Observation on 6/4/18 at 8:48 a.m. revealed one unopened package of individual [MEDICATION NAME] sulfate inhalation solution and six loose solution vials in a cup. During an interview at this time, R#62 stated that he does his own nebulizer treatments and that he did one last night. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] documented R#62 with a Brief Interview of Mental Status (BIMS) score of 15 indicating cognition intact and active [DIAGNOSES REDACTED]. Review of the (MONTH) (YEAR) Physician Orders revealed an order dated 3/3/18 for [MEDICATION NAME] inhalation solution 2.5 milligram (mg)/ 3 milliliter (ml), one unit dose vial per nebulizer every three hours as needed for shortness of breath. Review of the Medication Administration Record [REDACTED]. Observation on 6/07/18 at 9:13 a.m. revealed [MEDICATION NAME] nebulizer solutions were no longer in R#62's room. Interview with Licensed Practical Nurse (LPN) AA on 6/7/18 at 9:17 a.m. revealed that R#62 was doing his own nebulizer treatments but the medication has now been removed from the room. She stated that he is a very difficult resident who insists on doing the treatments himself and will curse at staff if not allowed to do things his way. Interview with the Director of Nursing (DON) on 6/07/18 at 11:17 a.m. revealed that R#62 has not been assessed to self-administer nebulizer treatments because he used to be a nurse and thinks he can do whatever he wants to do without understanding current practice. DON stated staff should not be leaving any medications in the room for him to self-administer. Policy titled Self-Administration of Medication with no revision date documented the following: A. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility. The resident is reassessed at each quarterly care plan review. D. Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the rooms of, or room with, residents who self-administer. The following conditions are met for bedside storage to occur: 1) the manner of storage prevents access by other residents. Lockable drawers or cabinets are required. 2) the medications provided to the resident for bedside storage are kept in the containers dispensed by the dispensing pharmacy.

Based on observations, staff interviews, record review and review of the facility's Infection Control Isolation Precautions Policy, the facility failed to ensure staff members followed contact isolation procedures when entering the room of one Resident (R) (#38) of 48 sampled residents. Findings include: During observation of the East Hall on 6/4/18 at 10:55 a.m. revealed that Certified Nurse Aide (CNA) DD was observed entering R#38's room with gloves on but no gown. Observed on the outside of R#38's room there was a yellow cart labeled isolation cart that was noted to the right of the door. There was also a sign that was posted to R#38's door which indicated, Stop Infection Prevention Contact Isolation in addition to standard precautions, visitors see nurse before entering; clean hands upon entering and leaving; wear a gown; wear gloves. Observation on the same day at 11:05 a.m. revealed CNA GG entering R#38's room wearing a gown and gloves. It was observed while the door was open CNA DD was providing care to R#38. Further observation at 11:08 a.m. of CNA DD exiting the room along with CNA GG. CNA DD did not use the sanitizer which was located on the isolation cart outside of R#38's room. CNA DD went to the nurse's station restroom and was observed washing her hands. Another observation on the same day at 11:10 a.m. revealed that CNA DD re-entered R#38's room wearing gloves but no gown. CNA GG summoned CNA DD out of the room and was heard instructing CNA DD to place a gown on and to carry a red bag into the room to place items that come in contact with the resident. A review of R#38's Admission Record, dated 5/25/18, noted pertinent [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of two, and the resident was assessed as always incontinent of bladder. The resident was admitted from an acute hospital. Review of the resident's care plan dated 6/4/18 and revised on 6/5/18 reveals Isolation: Resident has drug resistance bacteria in urine. Need contact isolation. Interventions for the above include: Assist family and visitors to follow isolation precautions; keep resident's room tidy; Keep resident's hands clean, give resident bath daily (date initiated 6/5/18); Isolation cart outside door. Staff to maintain isolation (date initiated 6/4/18); nursing to give antibiotics as ordered. Resident has dementia. Nursing to remind her that she is isolation at this time. A record review of the document titled, Health Status Progress Note dated 6/2/18 at 13:43 (military time) noted, Patient resting quietly in bed. Is alert and oriented x2 respirations are even and unlabored. Skin is warm and dry to touch. No present c/o (complaint) any pain or discomfort. Takes medications crushed in pudding without difficulty. Can make all needs known to staff and requires moderate to complete assistance with activities of daily living. Patient has a Heplock (a device for ongoing intravenous therapy) to left forearm is patient and intact for intravenous (IV) therapy. Patient is on contact isolation for [MEDICAL CONDITION] (MRSA). Patients son at bedside (sic). An interview was conducted with CNA DD on 6/6/18 at 8:24 a.m. regarding her understanding of what she should do when entering and exiting a resident's room that is on contact isolation. CNA DD stated, that she would put on a gown and gloves. She further stated that she removes her gown and gloves before she leaves the room and places them in a biohazard red bag. When asked how she determined whether or not a resident is on isolation she stated, whenever they have a cart and sign on the door this indicates they are on isolation and from that I determine what I need to put on. CNA DD states, she received training on how to care for a resident on contact isolation during orientation. She indicates that she has been working at the facility a little over a month. CNA DD confirmed that R#38 was on contact isolation. CNA DD was asked how was she aware of this resident being on contact isolation. She stated, because of the yellow cart outside the door. Observation on 6/6/18 at 7:53 a.m. during the observation of breakfast trays being passed physical therapy assistant (PTA) BB was observed taking a tray into R#38's room without gloves or a gown. There was a contact isolation sign posted on the resident's door as well as a yellow isolation cart with gloves and hand sanitizer sitting on top of the cart outside the door. Observation, at this time of PTA BB inside R#38's room touching the bedside table and moving the bed away from the wall and then placing it back against the wall in its previous position. PTA BB elevated the head of R#38's bed and set the food tray up and positioned the bedside table in R#38's reach. Further observation at 7:57 a.m. revealed PTA BB exited the room without washing or sanitizing his hands. An interview and observation at 8:00 a.m. on 6/6/18 with PTA BB who was asked to explain his understanding of the procedure he should follow when he enters a room of a resident on contact isolation. PTA BB stated, I would put on a gown and gloves, whatever the sign says. PTA BB was asked if he would walk back down the hall to point out the last room he came out of. He confirmed that he had just come out of R#38's room. PTA BB also confirmed that there was a contact isolation sign on R#38's door as well as an isolation cart outside of the door. PTA BB further revealed that I did not pay attention, I did not notice the cart. I was busy looking at the ticket and didn't even look at the cart. The door was open, and I did not notice the sign on the door. Maybe if the door was closed or pulled up, I would have saw the sign. I mainly work in the hospital. I was just helping pass trays. An interview on 6/6/18 at 8:30 a.m. with Charge Nurse CC, Registered Nurse (RN) regarding her expectations of her staff when they go into the room of a resident who is on contact isolation she revealed that she expects the staff to stop and observe what is on the door and follow the instructions listed on the sign outside of the door. Charge Nurse CC states she expects a cart with required personal protective equipment (PPE) to be located outside the resident's door and that the cart is properly stocked. She further stated, if my staff have any questions regarding a resident on contact isolation they can contact the Staff Development/Infection Control Nurse or myself. If it is a CNA they should ask the nurse or they can call us regarding infection control and PPE. An interview with the Staff Development/Infection Control Nurse Licensed Practial Nurse (LPN) on 6/6/18 at 8:38 a.m. revealed that I expect staff to follow the guidelines for whatever the particular infection is. The Staff Development/Infection Control Nurse further revealed that if we get someone who is incontinent [MEDICAL CONDITION] in their urine, I expect the staff to put on a gown, gloves and to use hand sanitizer. The Staff Development/Infection Control Nurse stated that this information is covered in general orientation. The Staff Development/Infection Control Nurse further stated the standards and expectations in the hospital are the same as the nursing home in regard to what is expected of staff in caring for a person on contact isolation. The Staff Development/Infection Control Nurse provided a copy of the facility's policy titled Infection Control Isolation Precautions and provided in-service records of staff working in the facility. An interview was conducted with the Director of Nursing (DON) on 6/6/18 at 9:11 a.m. revealed that she expects her staff to follow the precautions whatever the needed precautions may be. She further revealed that if a resident was incontinent and [MEDICAL CONDITION] in their urine then certainly gloves and if it is a risk of you having to come in contact with the resident then you should go ahead and follow precautions and place a gown on also. Review of the facility policy Infection Control Isolation Precautions with a release date of (MONTH) 2011 revealed on page four of 25 in the section Transmission Based Precautions the following, contact precautions apply when transmission occurs from one person to another or the transfer of an infectious agent through a contaminated intermediate object to a person. Hands of personnel are usually cited as the most important contributors to indirect contact transmission. Use hand hygiene before entering the room. Wear gloves and a gown to enter the patient's room. Remove gloves and gown and use hand hygiene before exiting the room. Review of the facility's in-service transcript log revealed CNA DD completed a course titled Course 63 Strategies to Prevent the Spread of Infection, on 4/12/18 with a score of 100. The objectives of the course included the following: Recognize the impact of the spread of infections on patients, team members and the environment. Discuss infection prevention strategies for standard and transmission (isolation) based precautions Describe the team member's role and responsibility in preventing the spread of infection.

Based on observation, interview and record review it was determined that the facility failed to follow physicians orders, to administer medications as ordered, for two residents (R) (#3, #4), out of 43 residents. This was observed on 2 of 3 halls on the second floor. During facility tour it was observed on Hall B South that Registered Nurse (RN) # AA was preparing to administer medication at 10:30 a.m. that were ordered for administration at 8:00 a.m. for Resident (R) # 3. Observation of the medication packet revealed that medications were to be administered at 8:00 a.m. RN AA confirmed that medication were being given late. Continuing the facility tour, it was observed on Hall B West, Licensed Practical Nurse (LPN) #BB pushing medication cart to the nurses station at 10:45 a.m. When interviewed, it was determined that she had just completed administering 8:00 a.m. medications for residents on West hall. She identified Resident (R) # 4 as the resident she just compeleted administration for. LPN BB confirmed that medication were being given late. Interview on 3/25/17 at 3:30 p.m. with the Administrator and Director of Nursing (DON) revealed that Resident # 2's daughter came and talked with them about her concern regarding the [MEDICAL CONDITION] medication being given late and inconsistently. They confirmed that they had called in the nurse and she admitted that she had given medication late. She was reprimanded and had to write a paper on the medication, adverse reactions and side effects and the issues that could develop if given late of inconsistently. They had an incident report but would not release a copy, but did give surveyor a copy of paper written by nurse and the assignment sheets for that hall with a typed reminded to give resident's medication on time. The Administrator and the DON confirmed that the facility had issues with late medications in the past, but thought it had been resolved.

Based on record reviews, staff interviews, observations and review of the facility's Skin and Wound Care Protocol, it was determined that the facility failed to ensure that the appropriate care was provided to promote healing of existing pressure sores for four (4) residents (#2, #3, #4 and #5) of six (6) residents with pressure sores, from a total sample of eight (8) residents. Findings include: Review of the facility's policy for Prevention and treatment of [REDACTED]. Interview with the Director of Nursing on 5-4-16 at 6:30 p.m. revealed that she could not provided evidence of a weekly wound log. She stated that residents with current pressure areas were discussed in a weekly nursing meeting, but no measurements of current wounds were provided each week. 1. Resident #2 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the 2-10-16, 5:38 p.m. Admission Summary Progress Note (PM) revealed that the sacrum/coccyx had very purple discoloration. The 2-11-16 at 11:39 am Skin/Wound Progress Note (SWPN) documented no open areas to the feet. Further record review revealed that there was no assessment of the sacrum one week later, on 2-17-16. Resident #2 had a follow-up appointment with the Orthopedic physician on 2-19-16. Review of the PN for 2-19-16 at 4:42 p.m. revealed that a family member had reported to the writer that the Orthopedic physician had informed her that the resident had two open areas on the coccyx that were not being treated. There was a 2-19-16 at 5:04 p.m. PN late note that documented that the resident had a pressure sore to the coccyx, red and skin broken, Sensicare applied. There was no documentation in the record on 2-19-16 of the size of the open areas or if there was any drainage or the size of the area of the redness. The first measurement of these areas were on the 2-23-16 at 4:33 pm SWPN, with the following measurements, two small open area in between the buttocks folds. The outer measures, 0.6 cm by 1.4 cm, pink and the inner area is right beside the other area and measured 0.4 cm by 1 cm, pink. An order was obtained on 2-23-16 for Sensicare to bottom after each incontinent episode. Interview with LPN AA Treatment (TX) nurse on 4-13-16 at 6:00 p.m. revealed that she stated that the areas had healed. However, there was no documentation in the record that the areas in between the buttock folds had been reassessed weekly or any documentation if and when the areas had healed. On the 2-23-16 at 4:33 p.m. SWPN, there was documentation of a fluid blister, measuring 5 cm by 4 cm, on the left (L) heel. There were weekly descriptive notes of the L heel skin pressure sore on 3-4-16 and 3-9-16. However, further record review revealed no documentation that the L heel pressure sore had been assessed on 3-16-16 or 3-23-16. The 3-4-16 at 7:20 a.m. SWPN documented that the L heel had an unstageable, black eschar areas, measuring 3.5 cm by 5 cm,(NAME)boots to bilateral heels. On 3-9-16 at 2:53 p.m. the SWPN documented that the L heel had an unstageable, 5 cm by 3 cm by 0,(NAME)boots to bilateral feet. Interview with the LPN AA TX nurse on 4-13-16 at 6:00 pm revealed that she had not documented any descriptive notes of the L heel pressure sore on 3-16-16 and 3-23-16. Observation of the resident with the LPN AA TX nurse on 4-13-16 at 4:50 p.m. revealed that the resident had both heels floated on a pillow. She did not have the(NAME)boots on. The L heel had an area hard eschar, partially peeling off. The L heel was not boggy. There were no other open areas on the resident noted during this skin check. The LPN AA TX nurse stated at that time that the resident would sometimes refuse the(NAME)boots. 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An initial Skin/Wound Assessment of 12-28-2015 documented no skin breakdown. A 3-2-2016 SWPN documented that the resident had a stage two (2) to coccyx, 2 cm by 2 cm by 0.1 cm, first identified on that date. This noted also documented Sensicare protective ointment to area, waffle cushion in chair, physician notified. There was a 3-2-16 physician's orders [REDACTED]. Review of the electronic treatment assessment record (ETAR) for March 2016 revealed no documentation that the treatment had been done as ordered on 3/5, 3/6, 3/12, 3/13, 3/15, 3/19, 3/20 and 3/26/16. Continued record review revealed there was a 3-9-16 SWPN that documented that the stage two was healing 1 cm by 0.8 cm by 0.1 cm, Sensicare applied, no drainage. There was no weekly assessment of the stage two on the coccyx on 3-16-16. The next SWPN was not until 3-21-16 , at which time documentation revealed a stage two to coccyx, healing 1 cm by 0.5 cm by 0.1 cm, granulating, no drainage. The next SWPN was not done until 3-29-16, and documented a stage two to the coccyx, continues to heal 0.7 by 0.3 cm by 0.1 cm, pink wound bed. There was no weekly assessment of the stage two on the coccyx on 4-5-16 and not before the resident was sent to the hospital on 4-7-16 for evaluation and treatment of [REDACTED]. The resident returned from the hospital on 4-20-16. A Skin/Wound Assessment of 4-20-16 documented a stage two, 1 cm by 0.5 cm by 0.1 cm pressure area to the coccyx. There was a 4-20-16 readmission physician's orders [REDACTED]. Per interview with the Assistant Director of Nursing on 5-3-16 at 4:00 pm. that the licensed staff worked twelve hour hour shifts. Review of the April 2016 TAR revealed no documentation that this treatment was done as ordered on 4/2, 4/3 and 4/4/16. The above record review was confirmed during an interview with Licensed Practical Nurse (LPN) Treatment (TX) nurse AA on 5-4-16 at 4:00 p.m. The facility failed to assess the stage two pressure area on the coccyx weekly and failed to follow physician's treatment order to the stage two pressure area on the coccyx. During observation of the resident on 5-4-16 at 5:30 pm. with LPN AA, TX nurse, the resident was sitting up in her recliner in her room. She was on a pressure relief cushion. She refused to go to bed for a check of her skin. She stated that she could breath better when she was sitting up in the chair. 3. Resident #5 had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to review of the Nursing Admission Assessment/Initial Skin and Wound, it was documented that the resident had a pressure area on the right buttock. It was documented that Sensicare ointment was applied to the area. There was an initial plan of care of 4-6-16 that documented stage two to right buttock with an intervention for Sensicare during care and as needed. There was no documentation that this intervention had been followed from 4-7-16 to 4-10-16. Interview with the LPN TX nurse AA on 4-13-16 at 6:00 p.m. revealed that she could not provide documentation that the physician had been notified of the pressure area on the right buttock on 4-6-16. An order was obtained on 4-11-16 to apply Sensicare to right buttocks daily until open area healed. Review of the TAR for April 2016 revealed that there was no documentation that the Sensicare had been applied to the right buttocks on 4-16-16. Further record review revealed that there was no documentation in the clinical record that the pressure sore had been assessed/described, in regards to size, stage, drainage and color on 4-6-16. The pressure sore on the right buttock had not been assessed/described until four (4) days later, on 4-10-16, at which time it was described as a 2.0 centimeter (cm) by 1.5 cm by 0.1 cm pressure sore on the right buttock, without documentation in regards to stage, drainage or color. The above record review was confirmed during interview with with LPN TX nurse AA on 4-13-16 at 6:00 p.m She stated that the 4-6-16 pressure sore on the right buttock had not been reported to her until 4-11-16. The resident was discharged on [DATE] to Hospice House. The facility failed to notify the physician timely on 4-6-16 of the pressure area on the right buttock. The facility failed to do an initial complete assessment of the pressure area on right buttock on 4-6-16. The facility failed to do the treatment to the pressure area as ordered. 4. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A SWPN of 4-26-16 at 2:59 p.m. revealed a stage two to coccyx, 1.3 cm by 0.6 cm by 0.1 cm and an unstageable, to L heel, purple and painful to touch, measures 2 cm by 1 cm. A physician's orders [REDACTED]. Interview with the LPN AA TX nurse on 5-4-16 at 2:35 p.m. revealed that when Sensicare was ordered to be applied during care, that the certified nursing assistants (CNA) were responsible for applying the Sensicare. Interview with LPN BB on 5-4-16 at 6:15 p.m. revealed that there was no where in the clinical record where the CNAs could document that they were applying the Sensicare during care. Interview with the LPN AA TX nurse on 5-4-16 at 2:35 p.m. revealed that she stated that the L heel was worse on this date, 5-4-16 and the TX order had been changed to cleanse with Carraklenz, place [MEDICATION NAME] to wound bed, cover with 4 by 4, secure with kling and tape daily. She stated that the sacrum was healed. However, observation of the resident with LPN AA TX nurse on 5-4-16 at 6:00 p.m. revealed the following. The resident was up in a wheelchair with her feet down and not elevated. She was sitting on a pillow. The resident requested to be placed in bed. Upon examination of the resident's coccyx, it was noted to have an open area, stage two, approximately 1 cm. Sensicare cream was observed to be around the open area but not on it. LPN AA obtained a tube of Sensicare for the resident, then applied it by squeezing some of the Sensicare to the open area and rubbing it over the open areas. She did not clean off the old Sensicare cream from over the open area before applying the new cream. Measure of the open area on the coccyx on 5-4-16, 6:20 p.m. revealed that it was a stage two, 1.3 cm by 0.6 cm by 0.1 cm.

Based on observation and staff interview the facility failed to properly store food in walk in freezer to prevent condensation accumulation on the store food items. The facility census was one-hundred and thirty (130) residents. Finding includes: Observation on 7/13/2015 at 9:50 a.m. revealed the stand-up freezer had accumulation of two (2) to three (3) inches of ice build-up at the top of freezer with condensation and ice on the top of ice cream cups, sorbet and might shakes supplements. Interview with Dietary manager during this observation revealed that maintenance is responsible for maintaining equipment in the kitchen which includes the stand-up freezer.

Based on observation and staff interview, the facility failed to maintain an odor-free environment on two (2) floors (second and third floors) of two (2) floors observed. Findings include: During an observation on the third floor conducted on 09/17/2012 at 10:00 a.m., a strong urine odor was noted on two (2) halls (halls of resident rooms C19-C36 and C37-C55). During an observation conducted on 09/17/2012 at 10:45 a.m., an unpleasant strong urine odor was noted when exiting the third floor elevator. During an observation on 09/17/2012 at 10:56 a.m., conducted on the second floor near the end of the middle hall near the linen carts, a strong urine odor was noted. Also, urine odors were noted between the dining area and day area, not near any specific resident. During an observation conducted on 09/17/2012 at 11:15 a.m. on the third floor, a strong urine odor was noted near room C39 and near where the a three (3) bag soiled linen cart sat. This linen cart was noted with one bulging bag filled with soiled linen. During an observation conducted on 09/17/2012 at 1:00 p.m., a urine odor was noted on the third floor in the middle walkway area between the day room and dining area nearer the middle hall. During an observation conducted on 09/17/2012 at 3:21 p.m., a urine odor was noted near the third floor near C19, and also at the elevator. Both areas with urine odors were acknowledged by Nurse "DD" during an interview conducted at the time of this observation. During an interview with the Administrator conducted at 4:00 p.m. on 09/17/2012, she stated linen carts were supposed to be emptied during morning rounds by approximately 10:30 a.m. She stated there were new carts on the rehabilitation unit which had lips around them to capture odor, and that the facility had ordered more of this type of linen cart.

Based on observation, review of manufacturers instructions, and staff interview the facility failed to ensure appropriate sanitation for the three (3) compartment sink. Findings include: Observation of the kitchen on 8/13/12 at 12:40 p.m., revealed Dietary staff "AA" cleaning a cutting board. Staff rinsed the cutting board, dried the edges with a cloth, and then placed it on a counter for use. The three (3) compartment sanitizer sink was empty. Review of the manufacturers instructions, hanging on the wall above the three (3) compartment sink, indicated that the sanitizer solution in the three (3) compartment sink should be 200 Parts Per Million (PPM). All utensils/pans should be immersed for one (1) to two (2) minutes, and then allowed to air dry. The cleaning bucket should have also been 150-200 PPM to sanitize counter tops. Interview with "AA" on 8/13/12 at 12:45 p.m. revealed that she did not know how much sanitizer was needed in the sanitizer sink, or how long pans and utensils should be immersed for sanitation. Continued interview revealed that "AA" also did not know how to prepare the cleaning bucket, or the appropriate amount of sanitizer that should be used for proper cleaning of cooking area counters. Interview on 08/13/12 at 12:55 p.m. with Dietary Manager "BB" revealed that she was unaware of sanitary guidelines for (PPM) related to the three (3) compartment sanitary sink or the cleaning bucket.

Based on observations, staff interviews, and the facility policy, the facility failed to ensure that oxygen equipment was maintained appropriately in five (5) of five (5) resident rooms on the C Hall and for two (2) residents (#106 and #239) from a sample of twenty (26) residents. Findings include: 1. Observations on 8/15/12 at 8:00 a.m. and 1:00 p.m. , and on 8/16/12 at 8:00 a.m. revealed resident # 106 receiving Oxygen (O2) via nasal cannula (N/C) at 2/L/min. The filter on the oxygen concentrator was covered with a thick gray substance. 2. Observations on 8/15/12 at 8:00 a.m., 10:00 a.m. and 1:00 p.m. of the oxygen concentrator in room C21 revealed the filter was missing. 3. Observations on 8/15/12 at 1:00 p.m. of oxygen concentrator filters in rooms C12, C34, C48, and C55 had oxygen filters that were covered in a thick grey substance. Interview on 8/16/12 at 8:45 a.m. with Licensed Practical Nurse (LPN) "NN" revealed that the nurses are responsible for cleaning the filters weekly but there is nothing in place to assure that the filters are cleaned as scheduled. Interview on 8/16/12 at 9:00 a.m. with Registered Nurse (RN) "DD" revealed that the nurses are responsible for cleaning the filters on the concentrators weekly. Continued interview revealed that there is nothing in place to make sure that the filters were cleaned weekly as scheduled. Review of the Cleaning and Maintenance Procedures/Oxygen Systems policy indicated that there is once a week cleaning and Maintenance Schedule that provides instruction in cleaning. 4. Observations conducted on 8/14/12 at 7:30 a.m. and 9:00 a.m. revealed the Continuous Positive Airway Pressure ([MEDICAL CONDITION]) mask for resident #239 lying face down uncovered on the residents bed side chair. Staff Nurse "CC" took the mask from the chair and placed it face down on the bedside table. Further observations conducted on 8/14/2012 at 2:30 p.m., 8/15/12 at 9:00 a.m. and on 8/16/12 at 8:30 a.m. revealed the [MEDICAL CONDITION] mask remained on the bedside table face down without covering. Interview with Charge Nurse "DD" conducted on 8/16/2012 at 9:00 a.m. revealed her expectation for her nurses was to clean the mask and place it in a protective bag between uses.

Based on observation, review of facility policy for medication administration, resident and staff interviews, and review of the Georgia Nurse Practice Act, the facility failed to ensure that medication was administered appropriately for one (1) resident ("Z") from a sample of twenty six (26) residents. Findings include: Observation 8/14/12 at 8:00 a.m. ,during medication pass for resident "Z", revealed that Registered Nurse (RN) "CC" administered [MEDICATION NAME] 50 micrograms (mcg) two (2) sprays to each nostril without instructing the resident to blow her nose prior to the inhalation. Twenty (20) seconds after administering the [MEDICATION NAME], the nurse administered [MEDICATION NAME] 18mcg one (1) inhalation but did not instruct the resident to inhale twice in order to obtain all medication. Continued observation revealed that after ten (10) seconds an [MEDICATION NAME] Diskus 250-50 was administered with out instruction to exhale then inhale and hold breath for at least ten (10) seconds. The resident was not instructed to rinse and spit after administration of the medications. Review of the facility policy for delivering aerosolized medications by a metered dose inhaler (MDI) revealed the resident should be instructed to breathe in as deeply as possible, and to hold their breath for five (5) to ten (10) seconds. The nurse should wait two (2) to five (5) minutes between administration of each different MDI medication. The resident should be instructed to rinse and spit after administration of those medications per Micromedex instructions. Interview with resident "Z" on 8/16/12 at 10:35 a.m. revealed that she had never been educated of the importance of rinsing and spitting after inhalation medications. Observation on 8/16/12 at 10:35 a.m. revealed three (3) medications, [MEDICATION NAME] Diskus, and [MEDICATION NAME] nasal spray on the residents' bedside table. The resident revealed that the nurse had left the medications for the resident to self administer. Interview on 8/16/12 at 10:40 a.m. with Licensed Practical Nurse (LPN) "HH" revealed that she left the medications in the residents' room. Continued interview revealed that she knew she was supposed to administer the medications but the resident was able to self administer. Interview on 8/16/12 at 11:20 a.m. with the Director of Nurses (DON) revealed that all nurses are trained to instruct residents in appropriate medication administrations and are also instructed not to leave medications in the resident's room. Interview on 8/14/12 at 2:15 p.m. RN "CC" revealed that she was unsure of the wait time between different inhalation medications. Continued interview revealed that she confirmed that there was very little wait time between three (3) inhalation medications for resident "Z". Review of the Georgia Registered Nurse Practice Act 43-26-3, revealed that the "Practice of nursing as a registered professional nurse" means to practice by performing for compensation any of the following: - Administering, ordering, and dispensing medications accurately. Review of the Georgia Practical Nurses Act 43-26-32 revealed that the "Practice of nursing as a licensed practical nurse" means the provision of care for compensation which shall include: -Administering medication accurately