Every finding on record at Pine Knoll Path of Journey LLC

Based on observations, staff interviews, and review of the facility policy titled, Food Safety Requirements, the facility failed to ensure the kitchen environment was maintained in a safe, clean, and sanitary manner to prevent foodborne illness. These deficient practices had the potential to affect 96 of 100 residents receiving oral diets from the kitchen.Findings include: Review of the facility's policy titled Food Safety requirements, dated 2/1/2024, documented, 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, prepared, distributed and served in accordance with professional standards for food service safety. In addition, the Policy Definition of Contamination means, The unintended presence of potentially harmful substances including, but not limited to microorganisms, chemicals, or physical objects. Documented in the Policy Explanation and Compliance Guidelines, number 1 (b) Storage of food in a manner that helps prevent deterioration or contamination of food, including from growth of organisms., and number 7 (d ) Dietary staff must wear hair restraints (e.g., hairnet, hat, and/or beard restraint hair to prevent hair from contacting food.Upon entry into the kitchen for initial observation tour on 05/17/2026 at 12:30 PM, Food Service Manager (FSM) was on the serving line for the lunch meal, so the Administrator completed the tour on the FSM's behalf and revealed the following:A ventilation grate under the three-compartment sanitation sink which contained a significant accumulation of gray particulate matter. The Administrator confirmed the observation and indicated the vent required cleaning. Five opened cans of diced peaches containing juices were sitting next to the kitchen ice machine. The Administrator confirmed the observation; but was unaware why the cans had not been properly disposed.A brown substance on wall of dry storage area by shelving for canned goods. Administrator confirmed the observation but was unable to identify what the brown substance was or its source. She stated the wall would be cleaned promptly. During a secondary tour of the kitchen on 05/18/2026 at 9:11 AM, the FSM confirmed the dirty ventilation grate had the potential for food contamination. She stated she was unsure who was responsible for cleaning the grates; but would ensure it was cleaned at least every three months. In addition, the FSM stated the peaches were served for a meal the prior day and the Activity Department asked Dietary staff to save the cans for an activity project. Otherwise, the cans would have been disposed of in the trash.On 05/18/2026 at 9:21 AM, during the interview and observation with FSM, the wall had not yet been cleaned. FSM indicated she thought the substance was chocolate. On 05/19/2026 at 12:59 PM, interview and observation with Dishwasher (DW) DW KK revealed he had facial hair and was not wearing a beard restraint. DW KK stated he had worked in the department almost a year and was aware of the importance of wearing a hair restraint to prevent hair from contaminating foods and food surfaces. The FSM confirmed the observation. On 05/19/2026 at 1:05 PM, a fan was observed pointing in the direction of clean dishes in the dishwasher area. The fan had a significant accumulation of gray particulate matter on the grill. DW KK stated he uses the fan to help dry the dishes after they are washed. This observation was confirmed by the FSM who took the fan out of service for immediate cleaning. On 05/20/2026 at 2:39 PM, interview with the FSM and Administrator revealed the Administrator had held a QAPI (Quality Assurance Performance Improvement) meeting to discuss the potential sanitation observations in the kitchen. The Administrator stated she expected all parts of the kitchen to be clean and in good repair, items should be appropriately labeled, dated and stored properly. All items were cleaned and, anything that needed to be disposed of would be disposed of properly. The Administrator stated staff were expected to be well trained and have competencies in maintaining a clean and safe kitchen environment to serve residents. On 05/20/2026 at 4:41 PM, observation of Dietary Aide (DA) DA LL revealed he had facial hair and was not wearing a beard restraint. DA LL secured a beard restraint after the observation was brought to the attention of the FSM.

Based on observations, and staff interviews, the facility failed to ensure the outdoor garbage and refuse area was maintained in a sanitary manner. The deficient practice increased the risk of attracting and harboring pests. The facility census was 100. Findings include: Upon entry into the kitchen for initial observation tour on 05/17/2026 at 12:30pm, Food Service Manager (FSM) was on the serving line for the lunch meal, so the Administrator completed the tour on the FSM's behalf and revealed the following observations of the outside refuse and dumpster area:Cardboard boxes were overflowing from a gray colored trash receptacle without a lid. The Administrator confirmed the cardboard boxes were improperly disposed of and uncovered. She stated the boxes were from a Central Supply Department delivery on Friday [05/15/2026], and the Central Supply Manager normally breaks down boxes for disposal. [NAME] sink was lying on the dumpster platform next to the dumpster. The Administrator confirmed the observation and stated the Maintenance Director had removed the sink from the kitchen by the ice machine on Friday [05/15/2026] and left the sink on the dumpster platform. The Administrator stated that Maintenance was creating a secondary Food Preparation Station in the kitchen. Three bread trays were on the ground propped against the outdoor freezer unit with a trash lid propped on top. The Administrator confirmed the observation but was unclear as to why the racks were situated in the area. 05/20/2026 at 2:39 PM, interview with the FSM and Administrator revealed the Administrator had held a Quality Assurance Performance Improvement (QAPI) meeting to discuss the dumpster and refuse areas. The Administrator stated anything that needed to be disposed of would be disposed of properly. The Administrator stated staff will be trained and complete competencies in maintaining a clean and safe environment. A Dumpster Sanitation and Refuse Policy was requested but not provided by the facility.

Based on observations, staff and resident interviews, record review, and review of the facility's policy titled, Catheter Care, the facility failed to perform catheter care using proper cleaning technique for one of four sampled residents (R) (R48). This deficient practice increased the risk of urinary tract infection (UTI), resistant bacterial strains, and sepsis for R48. Findings include:Review of the electronic medical record (EMR) revealed that R48 was admitted to the facility on [DATE], with pertinent diagnoses including, but not limited to, pressure ulcer of the sacral region, stage 4, and pressure ulcer of the left heel, stage 4.Review of R48's Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of 15, which indicated little to no cognitive impairment. Section GG, functional status, revealed that the R48 used a wheelchair for mobility and required setup and cleanup for meals and oral hygiene. R48 was dependent on staff for toileting, hygiene, showering, and bathing and required substantial assistance with upper and lower body dressing.Review of R48's care plan dated 05/06/2026, documented a problem of, I have a (Foley) Catheter r/t {related to} pressure ulcer. Interventions included, but were not limited to: Check tubing for kinks each shift with CNA (Certified Nursing Assistant) responsibleEmpty Foley catheter every Shift and prn (as needed)Foley cath strap in placeFoley catheter care every shiftObserve/document for pain/discomfort due to the catheter Observe/record/report to MD {physician} for s/sx {signs and symptoms} UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul-smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns.Review of Physician's Orders for R48 included, but were not limited to:Catheter care every shift and PRN every shiftCatheter: Foley catheter 16FR (French) with 10ml {milliliter} balloon to bedside bag r/t stage 4 sacral woundFoley catheter: may change Foley PRN as needed for woundDuring an observation and interview on 05/19/2026 at 3:34 PM, R48 confirmed the Foley catheter bag at bedside. During an observation on 05/19/2026 at 9:10 AM of R48's Foley care, performed by CNA AA revealed R48 was lying in bed. Permission from R48 was granted for surveyor observation. CNA AA was already in the room, wearing a gown and gloves, and had just finished incontinence care on the roommate. CNA AA stated R48 was wet, the catheter was leaking, and there was a moderate amount of urine in the tubing at this time. CNA AA pulled R48's covers back, and there was a Foley tubing holder on R48's right leg, but the tubing was not secured to it. CNA AA emptied the catheter bag into a urinal, and while dumping the urine, she left the catheter bag on the bed above the level of the bladder and left the resident exposed. She returned wearing the same gloves, did not perform hand hygiene, and took some wipes from the resident's bedside table. With one wipe, she wiped the resident's outer labia area from front to back, then trailed back to the front with the same wipe. Then, with the same wipe, she wiped the Foley tubing from distal to proximal toward the urinary meatus. When asked if this is her normal way of performing Foley and peri care, CNA AA stated that she usually uses a bath basin and a washcloth, and it's done during her bed bath, but the water was slow to get warm this morning. When asked about cleaning the inner labia, CNA AA obtained another wipe and cleaned them from front to back.During an interview with Licensed Practical Nurse CC on 05/19/2026 at 10:10 AM, she confirmed that her process for Foley catheter care and her expectation was the CNA perform Foley care every shift and use proper hand hygiene and personal protective equipment (PPE). They should either use warm water and wash clothes or wipes and first wash the outer labia from front to back. Then, with a clean part of the washcloth or a new wipe, clean the inner labia from front to back. Then, with another clean washcloth or wipe, wash the Foley tubing from the urinary meatus outward and clean the tubing. During an interview with the Infection Preventionist LPN on 05/19/2026 at 10:15 AM, confirmed that her process for foley care was the CNA should perform hand hygiene, and wear proper PPE (personal protective equipment) and first clean posterior area first if there is a bowel movement then remove gloves and perform hand hygiene and apply clean gloves and start with a clean wash cloth and warm water or a clean wipe and clean the labia and then with a new wipe clean the catheter and wipe the tubing away from the urethra.During an interview with the Director of Nursing (DON) on 05/20/2026 at 2:00 PM, it was confirmed that further education was needed for the CNAs on catheter care. The DON stated her expectations for Foley catheter care were that all tubing is secured with a securement device and that Foley care was aseptic and performed every shift.Review of the facility's policy titled Catheter Care, revised 11/5/2025, section under Compliance Guidelines revealed under female care.8. Gently separate the labia to expose the urinary meatus. 9. Wipe from front to back with a clean cloth moistened with water and perineal cleaner or soap. 10. Use a new part of the cloth or a different cloth for each side. 11. With a new moistened cloth, starting at the urinary meatus, moving out, wipe the catheter, making sure to hold the catheter in place so as not to pull on the catheter. 12. Dry area with a towel.

Based on observations, staff and resident interviews, record reviews, and review of facility policy titled, Oxygen Concentrator, the facility failed to ensure the respiratory equipment and supplies were maintained, administered, and available according to standards of practice for five of 30 residents (R) (R5, R41, R101, R13, and R23), sampled for respiratory care. Specifically, the facility failed to maintain clean oxygen (O2) concentrator filters, remove surface dirt from the O2 concentrator, ensure the nasal cannula was connected to the O2 humidification bottle, and failed to keep an additional tracheostomy tube at the bedside. These deficient practices had the potential to place residents at risk for respiratory infection, blood O2 desaturation, and delayed intervention for a respiratory emergency. Findings include: 1. Observation conducted on 05/17/2026 at 3:10 PM revealed that R5 was receiving oxygen at 2 liters per minute (LPM) via nasal cannula (NC) from an O2 concentrator (self-contained device used to produce oxygen.) The oxygen concentrator filter was visibly dirty, with dust and lint accumulated on its surface. Observations conducted on0 5/18/2026 at 8:50 AM, revealed that R5 was receiving O2 at 2 LPM via NC from an O2 concentrator, and the concentrator filter was visibly dirty, with dust and lint accumulated on its surface. During a review of the electronic medical record (EMR), it was revealed that the R5 was admitted to the facility on [DATE], with pertinent diagnoses, which included, but not limited to, chronic respiratory failure with hypoxia, congestive heart failure (CHF), and shortness of breath (SOB.) During a record review of physician orders for R5, it was documented: O2 at 2 LPM via NC, related to CHF for every shift, dated 04/06/2026. Change oxygen tubing and set up weekly, one time a day every Sunday for Chronic Obstructive Pulmonary Disease (COPD), dated 05/10/2026. During a record review of the care plan for R5, it was documented, I have altered respiratory status r/t {related to} CHF, chronic respiratory failure with hypoxia, and SOB. In addition, I will have no complications related to SOB through the review date, and Observe and document changes in orientation, increased restlessness, anxiety, and air hunger. During an Observation on 05/18/2026 at 2:15 PM, revealed R5 was receiving oxygen at 2 LPM via NC through an O2 concentrator. The concentrator filter remained visibly soiled with accumulated dust and lint, while the resident continued to use the equipment. 2. Observation conducted on 05/17/2026 at 1:00 PM, revealed that R41 was receiving O2 at 2 LPM via NC from an O2 concentrator. The O2 concentrator filter was visibly dirty, with dust and lint accumulated on its surface. Observation conducted on 05/18/2026 at 8:50 AM, revealed that R41was receiving O2 at 2 LPM via NC from an O2 concentrator, and the concentrator filter was visibly dirty, with dust and lint accumulated on its surface. During a review of the EMR, it was revealed that R41 was admitted to the facility on [DATE], with pertinent diagnoses which included, but not limited to, COPD, unspecified asthma uncomplicated, chronic respiratory failure with hypoxia, and SOB. During a record review of physician orders for R41, it was documented: O2 at 2 LPM via NC, as needed to maintain O2 saturation above 92% {percent} related to SOB dated 05/07/2026. Check O2 saturation (SpO2) every shift as needed, dated 05/07/2026. During a record review of the care plan for R41, it was documented that R41 had altered respiratory status related to COPD, asthma, chronic respiratory failure with hypoxia, allergic rhinitis, SOB, and history of COVID19. In addition, the care plan documented, Oxygen at 2 liters per minute via nasal cannula as needed to maintain oxygen saturation above 92%. During an Observation on 05/18/2026 at 2:15 PM, revealed R41 was receiving O2 at 2 LPM via NC through an O2 concentrator. The concentrator filter remained visibly soiled with accumulated dust and lint, while the resident continued to use the equipment. 3. Observation conducted on 05/17/2026 at 2:44 PM, revealed that R101 was receiving O2 at 3 LPM via NC from an O2 concentrator. The O2 concentrator filter was visibly dirty, with dust and lint accumulated on its surface. Observation conducted on 05/18/2026 at 8:50 AM, revealed that R101 was receiving oxygen at 3 LPM via NC from an O2 concentrator, and that the concentrator filter was visibly dirty, with dust and lint accumulated on its surface. Observation conducted on 05/18/2026 at 2:15 PM, revealed the O2 concentrator was in use by R101, and the concentrator filter remained visibly covered with dust and lint. During a review of the EMR, it was revealed that R101 was admitted to the facility on [DATE], with pertinent diagnoses which included, but not limited to, acute and chronic respiratory failure with hypercapnia, COPD, chronic atrial fibrillation, SOB, chronic respiratory failure with hypoxia, and CHF. During a record review of physician orders for R101, it was documented: O2 at 3 LPM via NC every shift to keep O2 level above 92% or SOB dated 03/09/2026. During a record review of the care plan for R101, it was documented that R101 was noted to have altered respiratory status related to CHF, COPD, acute on chronic respiratory failure with hypoxia and hypercapnia, respiratory acidosis, Influenza B, sleep apnea, SOB, and history of COVID-19. Interventions included monitoring for shortness of breath, cyanosis, labored breathing, use of accessory muscles, and other signs of respiratory distress, with physician notification as needed. The care plan further documented O2 administration at 3 LPM via NC and a goal for the resident to remain free from respiratory complications through the review date. During interviews on 05/18/2026, at 1:40 PM, Certified Nursing Assistants (CNA) CNA EE and CNA FF stated that residents receiving oxygen therapy were monitored for respiratory distress, oxygen equipment issues, and changes in condition, and that any concerns were reported to nursing staff promptly. During an interview on 05/18/2026 at 1:45 PM, Licensed Practical Nurse (LPN) LPN GG stated oxygen concentrators were monitored to ensure the equipment remained functional and humidification bottles did not become dry. She stated that an outside company cleaned the oxygen concentrator filters and further stated that residents who received oxygen therapy were monitored for signs of respiratory distress and changes in oxygen status. During an interview on 05/18/2026 at 2:15 PM, Unit Manager LPN HH confirmed the concentrator filter observed in use by R5 was really very dirty and stated she would address it immediately. During an interview on 05/18/2026 at 2:25 PM, the Administrator confirmed the filters were visibly soiled and stated that the facility used an outside vendor to maintain the oxygen concentrators approximately every three months. During an interview on 05/19/2026 at 9:22 AM, with the Director of Nursing (DON), she was informed that observations noted visible accumulations of dust and lint on O2 concentrator filters. The DON confirmed that the concentrator filters were soiled and that O2 administration equipment should be maintained in a clean and sanitary condition. She stated that her expectation was for staff to routinely monitor, clean, and maintain O2 concentrator filters to ensure proper functioning of the equipment and to reduce the risk of infection control concerns and compromised respiratory care for residents receiving oxygen therapy. During a record review of the document titled, Rental and service contract, between [name of contracted group] and Pine [NAME] Nursing and Rehab Center, dated 5/7/2024, under EXHIBIT A, documented: The company will perform the following services upon request of the client.2.c provide orientation for all company employees, agents or representatives.2. Ensure company employees fully comply with the policies and procedures of the company and client.3. Perform preventative maintenance and services to all client-owned and rented oxygen concentrators and equipment on schedule determined by the client and company, including but not limited to filter changes. During a record review of the facility's policy titled, Oxygen Concentrator, dated 2/1/2024 and revised 2/16/2024, documented, .1. Staff responsible for the use and care of oxygen concentrators receive training on oxygen safety and functionality of the device.2. Oxygen is administered under orders of the attending physician except in the case of an emergency.3. The nurse shall verify the physician's orders for the rate of flow and route of administration of oxygen (mask, nasal cannula, etc.) .5. a Follow the manufacturer's recommendation for the frequency of cleaning filters and servicing the device.5c.4 The main body cabinet should be dusted when needed and can be wiped clean with a damp cloth and mild household cleaner if necessary.5. f The oxygen concentrator should have a preventive maintenance due sticker with an expiration date. 4. Review of the EMR for R13 revealed, she was admitted to the facility with diagnoses, that included, but not limited to, gastrostomy status, anoxic brain damage, tracheostomy status, and chronic respiratory failure with hypoxia. Observation on 05/18/2026 at 10:36 AM revealed, R13 was lying in her bed breathing through a tracheostomy (trach) tube with O2 bled (connected to the tracheostomy tubing) at 2 LPM. She was in no apparent distress. The O2 concentrator was dirty and there was no additional trach tube at the bedside for emergency use. Observation on 05/19/2026 at 11:00 AM revealed that R13 was lying in her bed breathing without distress through a trach tube with O2 bled in at 2 LPM. The O2 concentrator was dirty and there was no additional trach tube at the bedside for emergency use. Observation on 05/20/2026 at 11:35 AM with LPN GG, confirmed the dirt on the surface of the O2 concentrator and the absence of an additional trach tube at the bedside. She stated the O2 concentrator surface should be wiped down at least weekly with the change of supplies and there should always be an extra trach tube at the bedside for emergency use. 5. Review of the facility's policy titled, Oxygen Administration, revised 2/14/2024, section titled Policy Explanation and Compliance Guidelines: documented, . 1. Oxygen is administered under the orders of a physician. Review of the EMR revealed R23 was admitted to the facility on [DATE], with pertinent diagnoses, which included, but not limited to, COPD, respiratory failure with hypoxia, diastolic heart failure, and obstructive sleep apnea (OSA.) Review of R23's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15, which indicated little to no cognitive impairment. Section GG, functional status, revealed that R23 required maximum staff assistance for activities of daily living (ADLs), with two-person assistance for transfers, baths, dressing, and turning. Review of R23's care plan dated 05/08/2026, indicated a problem of altered respiratory status r/t chronic respiratory failure, COPD, CHF, Bronchitis, history of OSA, SOB, allergic rhinitis, and cough. Interventions included, but were not limited to: Administer medication/puffers as ordered. Monitor for effectiveness and side effects. Maintain a clear airway by encouraging the residents to clear their own secretions with effective coughing. If secretions cannot be cleared, suction is ordered or required. Monitor /document changes in orientation, increased restlessness, anxiety, and air hunger. Monitor for s/sx (signs and symptoms) of respiratory distress and report to MD (physician) PRN (as needed): Increased Respirations; Decreased Pulse oximetry; Increased heart rate (Tachycardia); Restlessness; Diaphoresis; Headaches; Lethargy; Confusion; Hemoptysis; Cough; Pleuritic pain; Accessory muscle usage; Skin color changes to blue/grey. OXYGEN SETTINGS: O2 2 LPM via nasal cannula continuously to keep SpO2 above 92% uses 2 or more pillows due to SOB r/t COPD. Review of the Physician's Orders for R23, dated 04/07/2026 included, but was not limited to, 02 at 2LPM via nasal cannula continuously to keep Sp02 above 92%. During an observation on 05/17/2026 at 2:15 PM with R23, it was revealed she was alert and oriented and pleasant, lying in bed, with good hygiene. She was wearing 02 via NC at 3.5 LPM. During an observation and interview on 05/19/2026, at 11:50 AM, R23 was in her room and stated there was no air coming through her NC. On further investigation, the O2 concentrator was covered with a blanket and a lift pad, and the LPM was 3.5 LPM. An interview with LPN BB on 05/19/2026 at 12:00 PM confirmed that when we entered R23's room, after removing the blankets and lift pad from R23's O2 concentrator, the hose from the concentrator to the humidifier bottle was not attached, and the resident was not getting any oxygen. LPN BB measured R23's SpO2, which registered 88%. LPN BB confirmed that the concentrator was set to 3.5 LPM, and her physician's order is for 2 LPM. LPN BB stated that they check the oxygen flow on the concentrators every shift. An interview with the DON on 05/20/2026 at 11:38 AM revealed that she believed the resident could adjust the LPM on the concentrator herself. The DON stated her expectation for checking 02 LPM on all the concentrators was that it should be done every shift by the charge nurses.

Based on observation, staff interview, and review of the facility policies titled, Dating and Labeling and Food Storage - Refrigerators and Freezers, the facility failed to discard food in the walk-in refrigerator by the use by date, to label opened food items in the walk-in refrigerator and dry storage area, and to follow recipes in the preparation of puree foods. This deficient practice had the potential to affect 102 residents receiving an oral diet. Findings include: Review of the facility policy titled Dating and Labeling dated [DATE] and revised [DATE] stated under Policy Statement: The kitchen will ensure food safety by maintaining proper dates and labels to all goods and ready to eat food products. Under Procedures, item two stated, Label products in storage with date the package was opened. Item four stated Ready to eat foods must be dated with a 72 hour use by date and discarded when expired. Item ten stated Discard all foods that expire immediately. Review of the facility policy for Food Storage - Refrigerators and Freezers dated [DATE] and revised [DATE] revealed under Refrigerator Food Storage item two section ii. All foods delivered by an approved vendor that are stored under refrigeration must be properly labeled and dated. Item iii. Stated Label with common name of food and Item iv. Date by which it should be consumed or discarded (use be date). Observation on [DATE] at 9:15 am during a tour of the kitchen with [NAME] NN (the Certified Dietary Manager (CDM) was on vacation) revealed one-walk-in refrigerator/cooler that had breakfast and snack items including but not limited to eggs, cheeses, sour cream, lunch meats, chicken and beef bases, mayonnaise, jelly, whipped spread, apple sauce, jelly and other condiments. Randomly checked foods revealed expired pasta salad on [DATE], lemon tea thickener expired [DATE], an expired bag of cut lettuce expired [DATE], and tomato bisque soup stored in aluminum steam table pan and not properly sealed or dated. There was a one-door reach in freezer containing bagged and undated waffles, broccoli florets, and chicken patties. The bag of chicken patties was open and not sealed or labeled/dated. During an interview on [DATE] at 2:15 pm with the CDM, she indicated the items would be used within the day. She added that all staff were responsible for ensuring items were labeled and dated before placing them into cooler or freezers. During observation on [DATE] at 4:50 pm the same one-door upright single freezer, the same undated waffles, broccoli florets and chicken patties were still present and not labeled or dated. Observation on [DATE] at 9:25 am of pantry dry goods revealed an open bag of cornbread stuffing with no seal and no label or date. Menus posted in the hall were out of date, alternate menus were offered. Interview on [DATE] at 9:20 am with the CDM revealed that she acknowledged the presence of Styrofoam food take out containers being used due to a broken dishwasher. She stated that maintenance was responsible for ordering the part and that she could provide the date ordered and the expected delivery date. The CDM stated that staff were to use the FIFO (first in, first out) method when putting away delivered food products.

Based on observations, staff interviews, record review, and review of the facility policy titled, Handwashing/Hand Hygiene, the facility failed to ensure that all staff used proper hand hygiene during resident care. This failure had the potential to cause widespread infections among residents and staff. Findings include: Review of the policy titled Handwashing/Hand Hygiene Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infection. #2 states All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. During observation of west wing on 4/9/2025 at 7:49 am, Certified Nursing Assistant (CNA) FF entered room [ROOM NUMBER] answering a call light, and hand hygiene was not done at the alcohol dispenser outside the room or with soap and water in room [ROOM NUMBER]. The alcohol dispenser located outside of room [ROOM NUMBER] was half full and operational. During observation of west wing on 4/9/2025 at 7:58 am agency CNA GG leaving room [ROOM NUMBER] without hand hygiene or obtaining linens and re-entered the room without using hand hygiene. The alcohol dispenser outside of room [ROOM NUMBER] was full and operational. During observation of east wing on 4/9/2025 at 8:41 am, CNA II entered room [ROOM NUMBER] without using hand hygiene. The alcohol dispenser outside of room [ROOM NUMBER] was full and operational. Interview on 4/9/2025 at 7:51 am with CNA FF, she revealed she had received several inservices from the IP (Infection Preventionist) nurse on hand hygiene and she knew that she should use the alcohol gel between residents and soap and water after resident personal care. CNA FF revealed that she sometimes forgot hand hygiene when entering and exiting rooms. Interview on 4/9/2025 at 7:58 am with agency CNA GG revealed that she understood she should use soap and water before passing trays and with resident care, and alcohol gel should be used when going in and out of residents' rooms. GG CNA confirmed she did not use hand hygiene or alcohol when leaving and reentering room [ROOM NUMBER] with clean linen. Interview on 4/9/2025 at 8:47 am with CNA II revealed had been instructed on when and what kind of hand hygiene to use for best practice. CNA II stated she received inservices on hand hygiene every 2 weeks. CNA II confirmed she was aware that she should use hand hygiene when entering a resident's room, but sometimes forgot when she is in a hurry. Interview on 4/9/2025 at 1:43 pm with Licensed Practical Nurse (LPN)-Infection Preventionist (IP) revealed that she instructed all staff to wash hands with soap and water after performing personal care on a resident who has had a bowel movement, and any time hands were visibly soiled. She also instructed the staff to use alcohol gel between resident rooms, upon entering and exiting the room. Interview on 4/9/2025 at 4:10 pm with the Director of Nursing (DON) revealed that her expectation was for all staff to follow the hand hygiene policy.

Based on resident and staff interviews, record review, and review of the facility policy titled, Administering Medications, the facility failed to ensure that Physician Orders for medication were followed for one of 25 residents (R) (R11) reviewed for professional standards. Specifically, R11 did not receive inhaler medication on 5/12/2023 or 5/13/2023. The findings include: Review of the facility policy titled, Administering Medications revealed .3. Medications must be administered in accordance with the orders, including any required time frame. Record review noted R11 was admitted with diagnoses including chronic obstructive pulmonary disease (COPD). Review of the medication administration record (MAR) for R11 identified that R11 was prescribed an inhalant, Breztri Aerosphere 160-9-4.8mcg [micrograms]. According to the Physician's Order, R #11 was to take two (2) puff inhalations orally two (2) times a day for the diagnosis of COPD. Further review of the MAR revealed the nursing staff did not administer the Breztri Aerosphere per Physician's Order on 5/12/2023 and 5/13/2023. Interview on 10/4/2023 at 10:16 am via telephone with R11, who no longer lives at the facility revealed she did not receive all of her inhaler treatments per physician order while residing at the facility. Interview on 10/4/2023 at 2:23 p.m. with the Director of Nursing (DON), the DON stated the facility failed to give a nebulizer treatment to R11 on 5/12/2023 and 5/13/2023 and was not able to identify why the medication was not given.

Based on observations, interviews, record review, and review of the facility policy titled Quality of Life - Dignity, the facility failed promote, maintain, and protect a resident's dignity for two of seven residents (R) (R#36 and R#95) with a urinary catheter. Findings included: Review of the policy titled Quality of Life - Dignity dated 2001 and revised 8/2009 revealed the policy statement of: Each resident shall be cared for in a manner that promotes and enhances quality of life, respect, and individuality. Policy and implementation item numbered 11: Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: a. Helping the resident keep urinary catheter bags covered. 1. On 1/31/23 at 10:20 a.m. an observation and interview with R#36 revealed was in bed in her room. A urinary catheter drainage bag containing yellow urine was observed secured to the bed frame and not in a privacy bag. The bag was visible in the room and from the hallway. R#36 revealed she was unsure how long she had the urinary catheter and was unsure if there was a privacy bag for it. On 2/1/23 at 8:35 a.m. an observation of R#36 revealed was in bed in her room. A urinary catheter bag containing yellow urine was observed secured to the bed frame and not in a privacy bag. The bag was visible in the room and from the hallway. On 2/1/23 at 11:45 a.m. R#36 was observed to be self-propelling in a wheelchair in the hallway just outside of the resident dining room. Urinary catheter bag was observed to be attached to the lower back of the wheelchair in a privacy bag. On 2/2/23 at 9:50 a.m. an observation of R#36 revealed was in bed in her room. A urinary catheter bag was observed to be secured to the bed frame and without a privacy bag. The bag was visible in the room and from the hallway. Clinical record review revealed R#36 was admitted on [DATE] with diagnosis including paraplegia (complete), retention of urine, neuromuscular dysfunction of the bladder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed sections: C- indicated a Brief Interview for Mental Status (BIMS) score of 14 (indicating resident was cognitively intact), D - mood severity score of 3, E - behaviors not exhibited, G - required extensive assistance of 2 persons for bed mobility, total dependence of 2 persons for transfers, total dependence of 1 person for toileting, dressing and personal hygiene, required set-up assistance for eating, H - had an indwelling catheter. Review of the physician's orders revealed (not all inclusive): 1/22/23: change indwelling catheter on 21st of each month and as needed (prn) - 20 French with a 30 milliliter (ml) balloon. 10/13/22: Foley catheter: catheter care every shift and prn. Review of the care plan revealed a focus area of had a suprapubic catheter. A goal was to show no signs of a urinary infection through the next review date. Approaches included to check the tubing for kinks every shift, monitor for signs of discomfort due to the catheter, monitor for signs of a urinary infection. Review of the medication administration record (MARS) dated 11/1/22-1/31/23 revealed catheter cares were documented as provided as ordered. On 2/1/23 at 12:35 p.m. an interview with Licensed Practical Nurse (LPN) HH revealed urinary catheter bags are kept inside a privacy bag unless the bag is being emptied or changed. She revealed certified nursing assistants (CNAs) are responsible for assuring catheter bags are in privacy bags and further revealed all nursing staff should assure catheter bags are placed in privacy bags. Observation of R#36 with LPN HH verified the catheter bag was not in a privacy bag. On 2/2/23 at 9:55 a.m. an interview with CNA II revealed CNAs provides catheter cares with ADLs cares. He revealed urinary catheter bags should be in a privacy bag when the resident is out of the room or in the wheelchair and was unsure if the privacy bag was needed when the resident was in their bed. He revealed he works prn (as needed) and completes online training through Relias online program and had not received specific instruction about urinary catheter privacy bags. 2. On 01/31/23 at 11:39 a.m. observation of R#95 revealed was in bed in his room. A urinary catheter bag was observed with yellow urine and was attached to the bedframe and not in a privacy bag, visible to anyone in the room. On 2/1/23 at 8:50 a.m. observation and interview of R#95 revealed was in bed in his room. Resident revealed he had a urinary catheter due to urinary retention and was unsure if the bag was in a privacy bag. He revealed he is on transmission-based precautions (TBP) and normally is out of bed in a wheelchair a few times a week. Observation revealed urinary catheter bag lying on the floor next to resident's bed and without a privacy bag and visible to anyone in the room. On 2/1/23 at 1:55 p.m. observation of R#95 revealed was in bed in his room and the urinary catheter bag was lying on the floor next to resident's bed and without a privacy bag and visible to anyone in the room. R#95 revealed he is unaware of the location of the catheter bag. On 2/2/23 at 9:00 a.m. observation of R#95 revealed was in bed in his room. Observation revealed a urinary catheter bag secured to the bed frame with yellow urine, without a privacy bag and visible to anyone in the room. Clinical record review revealed R#95 was admitted on [DATE] with diagnosis including acute kidney failure, retention of urine, altered mental status. Review of the admission MDS dated [DATE] revealed: sections C- BIMS score of 2 (indicating severe cognitive impairment), D - mood severity score of 9, E - behaviors not exhibited, G - required limited to extensive of 1-2 persons for all activities of daily living (ADLs), H - had indwelling catheter. Review of the physician's orders revealed (not all inclusive): 1/22/23: Foley Catheter: Foley Catheter 16 French with 10ml balloon to bedside bag. 11/1/22: Foley catheter: Catheter care every shift and prn. Review of the care plan revealed a focus of had a urinary catheter due to urinary retention. The goal was to remain free from catheter related trauma through the next review date. Interventions included to check the tubing for kinks each shift, empty the catheter every shift and prn, catheter care every shift, monitor for discomfort related to the catheter. Review of the MARS dated 1/1/23-1/31/23 revealed no documented urinary catheter cares or a section for catheter cares. On 2/1/23 at 2:00 p.m. an interview with LPN LL revealed CNAs are responsible for assuring urinary catheter bags are secured in a privacy bag and maintaining the bag off the floor. Observation with LPN LL of R#95 verified the urinary catheter bag to be lying on the floor and not in a privacy bag with urine visible. She verified there was not a privacy bag visible in R#95's room. She revealed she will educate CNAs to assure a privacy bag is in place for R#95. On 2/2/23 at 9:40 a.m. an interview with CNA KK revealed urinary catheter bags should always be in a privacy bag. She revealed she was unaware of a resident not having a urinary catheter privacy bag. She further revealed the privacy bags are kept in the supply closet and available to staff as needed. On 2/2/23 at 10:45 a.m. an interview with the DON revealed her expectation is for urinary catheter bags to be secured in a privacy bag regardless of the location of the resident. She revealed she plans to educate staff to place urinary catheter collection bags in privacy bags regardless of the resident's location and to ensure urinary catheter bag privacy bags are readily available and easily accessible to staff in the supply rooms.

Based on observations, staff interviews, and review of facility document titled, Housekeeping In-Service Training, Bathroom Cleaning with a revised date of March 2020, the facility failed to maintain a safe, clean, sanitary environment related to a build-up of whit fuzzy material on vent covers in six of six adjoining bathrooms 211/212, 216/217, 218/219, 220/221, 222/223, 224/225, and bathroom [ROOM NUMBER] on the West Wing. The deficient practice had the potential to affect 39 residents residing in 13 rooms on the West Wing. The sample size was 22. Findings included: Review of facility document titled, Housekeeping In-Service Training, Bathroom Cleaning, revealed the purpose of: To provide all housekeeping employees with a complete outline of the equipment and supplies necessary to perform the daily routine of a bathroom cleaning. Daily cleaning will ensure optimum levels of cleanliness and sanitation, prohibit the spread of infection and bacteria, and maintain the outward appearance of the facility. The section titled Steps in the Daily Cleaning of a Resident and Public Bathroom number nine revealed: High dust any ceiling fixtures: vents, lights, corners, and edges, etc., using a high duster with extension. The facility did not provide a housekeeping policy. Observations on 1/31/23 at 10:20 a.m., 2/1/23 at 11:30 a.m., and 2/2/23 at 10:40 a.m. revealed a buildup of white fuzzy material on the ceiling vent covers in shared resident bathrooms 211/212, 216/217, 218/219, 220/221, 222/223, 224/225, and unshared bathroom [ROOM NUMBER] on the West Wing. On 2/2/23 at 11:20 a.m. a walking tour with the Director of Housekeeping and Regional Manager AA verified the presence of white fuzzy material on the ceiling vents in the listed restrooms. The Director of Housekeeping revealed one of the housekeeping staff had been out of work, there was not a replacement and housekeeping was short staffed. She verified the vents should be clean and she would have them cleaned today. On 2/3/23 at 11:33 a.m. an interview with the Administrator revealed her expectations are for routine cleaning to be performed as scheduled and for daily cleaning to include restroom vents. On 2/2/23 at 1:15 p.m. an interview with the Director of Housekeeping revealed resident rooms and restrooms are scheduled to be cleaned daily. She revealed the ceiling vents should be checked daily and cleaned as needed. A review of the bathroom cleaning schedule provided by the Director of Housekeeping revealed resident bathrooms are scheduled to be cleaned daily and the steps included to high dust any ceiling fixtures: vents, lights, corners and edges, etc. using a high duster with extension. A review of the daily cleaning check off list dated 1/1/23-1/31/23 and initialed by housekeeping staff revealed West Wing resident rooms and restrooms were documented to have been cleaned daily. The Director of Housekeeping revealed she was unsure of the date the vents were cleaned and she had no explanation for the vents to have fuzzy material on them. She further revealed she plans to provide education to housekeeping staff about cleaning all areas of the resident room and restroom to include the ceiling vents. She revealed she plans to perform daily random checks of resident rooms and restrooms to ensure rooms are being cleaned.

Based on observations, interviews, review of the policies titled Storage of Medications, Administering Medications and Controlled Substances, and review of the document titled Omnicare Medication Storage Guidelines, the facility failed to ensure treatment dressings were stored properly, failed to ensure that one oral inhaled medication was labeled with an open date, two ophthalmic solutions were labeled with an open date, three ophthalmic solutions were discarded after use by date on one of five medication carts (Unit 1 - Cart 1), failed to ensure that four ophthalmic solutions were labeled with an open date, six ophthalmic solutions were discarded after use by date, and five Insulin pen injectables were labeled with an open date on one of five medication carts (Unit 2- Cart3), failed to ensure medications and injection supplies were stored securely and that resident identifying information was secure and not accessible on one of five medication carts when unattended (Unit 2 - Cart 3), failed to ensure that one of five medication carts (Unit 2 - Cart 1) was locked and secured when unattended and out of the view of the nurse, and failed to ensure that controlled medications were counted and documented at the beginning and end of each shift on three of five medication carts (Unit 1- Cart 1, Unit 2 - Cart 1, Unit 2- Cart 3). The sample size was 22. Findings included: 1. A. Review of the undated policy titled Storage of Medications revealed the policy statement of: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The policy interpretation and implementation sections numbered: 2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4.The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. B. Review of the undated policy titled Administering Medications revealed policy interpretations and implementation section numbered 7. During administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse or aide. The cart must be clearly visible to the personnel administering medications. C. Review of the document titled Omnicare Medication Storage Guidance dated 2022 revealed: page 4: ophthalmic products should be dated when opened and discard unused portion after 28 days, page 5: latanoprost ophthalmic solution should be dated when opened and discard after 6 weeks, page 9: Trelegy Ellipta inhaler should be dated when opened and discard after 6 weeks, page 10: Basaglar pen should be discarded 28 days after opening, page11: Novolog pen should be discarded 28 days [NAME] opening. 1. Observations on 1/31/23 at 10:30 a.m. and 2/1/23 at 8:45 a.m. of R#93's room revealed five boxes (containing ten dressings per box) of Reinforced Gelling Fiber +Ag 4-inch by 4.75-inch wound dressing and one open box containing seven dressings located on the windowsill just above the heating unit. Interviews with R#93 on 1/31/23 at 10:30 a.m. and 2/1/23 at 8:45 a.m. revealed she was unaware how long the boxes of treatment dressings had been in her room and was unsure who placed them in her room. She revealed she had a place on her left thigh and the wound care nurse changed a dressing on the areas daily. Clinical record review revealed R#93 had a Brief Interview for Mental Status (BIMS) of 15, indicating is cognitively intact and required extensive assistance of two persons for transfers. Review of the physician's orders revealed an order for wound care to include applying a dressing to left thigh every two days. Review of the wound care administration (WARS) revealed documentation of daily wound care to include applying alginate calcium with sliver dressing and cover with super absorbent pad. On 2/1/23 at 11:50 a.m. an interview with LPN JJ revealed all treatment supplies including dressings were stored in the treatment cart or in the medication storage room. At 11:52 a.m. observation of R#93 room with LPN JJ verified the boxes of dressings to be located on the windowsill in R#93's room. She revealed treatment dressings are normally delivered to the facility in boxes, the shipping label may contain the resident's name and the box could be delivered to the resident's room by the activity department. She removed the dressings from the room. On 2/2/23 at 10:05 a.m. an interview with the Activity Director revealed she delivers mail and packages to residents. She further revealed she often assists residents with opening packages and if a package contains medical supplies, she notifies the nurse or the Director of Nurses (DON). She revealed she was unaware of opening any packages containing medical supplies for R#93. On 2/3/22 at 10:50 a.m. an interview with the DON revealed her expectation is for any packages that contain medical supplies to be reported to her or the unit manager. She revealed she was unaware of any medical supplies being stored in a resident room. She further revealed she plans to provide education to all nursing staff to assure resident rooms do not contain medical supplies. 2. On 1/31/23 at 5:15 p.m. observation of medication cart on Unit 2-Cart 1 revealed two open Lubricant Eye Drops Ultra 15 milliliters (ml) without an open or discard date, three Lubricant Eye Drops Ultra 15ml with open date beyond 28 days, one Artificial Tears 15ml with open date beyond 28 days, one Trelegy Ellipta inhaler without an open or discard date. On 1/31/23 at 5:35 p.m. Licensed Practical Nurse (LPN BB) verified the absence of open dates and beyond use dates for the listed medications. She revealed she normally dates all medications when she opens them and was unsure if ophthalmic solutions and oral inhaled medications should be dated when opened. On 1/31/23 at 5:45 p.m. observation of medication cart on Unit 2-Cart 3 revealed four open Artificial Tears Lubricant Eye Drops 15ml without an opened or discard date, six open Artificial Tears Lubricant Eye Drops 15ml with open date beyond 28 days, one open latanoprost 0.0005% ophthalmic solution 2.5ml with open date beyond 6 weeks, two Novolog Pen 100 units without an open date, three Basaglar Pen without an open date. On 1/31/23 at 6:00 p.m. LPN CC verified the absence of open dates and beyond use dates for the listed medications. She revealed she was unsure if ophthalmic solutions and oral inhaled medications should be dated when opened. She further revealed Insulin pens should be dated when opened. 3. On 2/2/23 at 10:13 a.m. observation of an unattended medication cart located on Unit 2 against a wall between rooms [ROOM NUMBERS] with the drawers and computer screen facing the hallway. The following items were observed to be located on top of the cart and easily accessible: the computer screen was opened with R#73's medical information visible, one glass ampule of injectable Promethazine 25milligram (mg)/ml, one Lantus Pen injector 100 units/ml with the injector needle attached, one ipratropium-albuterol inhalation solution 0.5-2.5/3ml single dose container, one 30ml medication cup that contained one oval shaped brown tablet and one round pale yellow tablet, one 3 cc syringe, one hypodermic needle in an opened packet. On 2/2/23 at 10:15 a.m. RN EE approached the cart and verified the computer screen was open with R#73's medical information visible and the listed medications and medical supplies were left unattended on the top of the medication cart. He revealed the medications in the cup were for R#73 and verified the name of each medication. He further revealed he had left the cart unattended with the medications, supplies and the open computer screen on top of the cart when he went to the nurse's station to call a provider about a medication order. He revealed he normally does not leave medications or medical supplies unattended. He further revealed he should have closed the computer screen and secured the medications and injection supplies in a locked cart. 4. On 2/2/23 at 3:49 p.m. observation of a medication cart located at Unit 2 in front of the nurse's station and with the drawers facing the hallway revealed the cart to be unlocked and unattended. There were no personnel within site of the cart. One resident was observed propelling past the unlocked cart in her wheelchair. At 3:52 p.m. LPN MM approached a medication cart located to the immediate left of the unlocked cart and walked away from the carts. At 3:55 p.m. LPN MM walked past the unlocked cart. At 4:00 p.m. two residents were observed propelling past the unlocked cart in her wheelchair. At 4:01 p.m. LPN MM approached the medication cart located next to the unlocked cart and rolled the cart down the hallway and past the unlocked cart. At 4:04 p.m. the Director of Nurses (DON) approached the cart and locked it. On 2/1/23 at 8:00 a.m. an interview with the DON revealed her expectations are for ophthalmic solutions, oral inhalers, and Insulin pens to be labeled with an open or a discard date when opened. She revealed she plans to provide education to nursing staff to ensure proper labelling of ophthalmic solutions, oral inhalers, and Insulin pens. On 2/2/23 at 8:51 a.m. a telephone interview with Pharmacist GG of Omnicare of Atlanta Pharmacy Services revealed that Omnicare of Atlanta Pharmacy Services provides their associated facilities with guidelines for discarding medications and expects the facility to follow those guidelines. On 2/2/23 at 10:30 a.m. an interview with the DON revealed her expectations are for medications, injection supplies, and resident medical information to be secured when unattended and to never be left unattended on the medication carts. She revealed she plans to provide education to the nurses about securing resident medical information, medications, and injection supplies at all times. On 2/2/23 at 4:05 p.m. an interview with the DON revealed her expectations are for medication carts to be locked and secure when left unattended and when not in clear site of the nurse. She revealed she plans to educate nursing staff about the importance of ensuring they lock the medication carts when they are left unattended. 2. Review of the undated policy titled Controlled Substances revealed the policy statement of: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. Policy interpretation and implementation section numbered 7: Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty ans the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of nursing Services. On 1/31/23 at 5:30 p.m. observation of the controlled substance sign-out book on Unit 2 Cart 1 medication cart revealed the document titled Controlled Medication Count Sheet (8-hour shift) dated 1/1/23-1/31/23 revealed 57 missing signatures. The missing signatures were verified with LPN BB. At 5:35 p.m. an interview with LPN BB revealed she was aware the controlled medication count sign-out sheet should be signed by the off going and oncoming nurse at each shift change after the nurses count the controlled medications to verify the counts are correct. She revealed she signs appropriately and was unsure why there were missing signatures. The sheet revealed signatures of two nurse at the most recent shift change. On 1/31/23 at 5:55 p.m. observation of the controlled substance sign-out book on Unit 2 Cart 3 medication cart revealed the document titled Controlled Medication Count Sheet (8-hour shift) dated 1/1/23-1/31/23 revealed 97 missing signatures. The missing signatures were verified with LPN CC. At 6:00 p.m. an interview with LPN CC revealed she was aware the controlled medication sign-out sheet should be signed by each nurse at shift change after controlled medication counts and she thinks nurses just forget to sign the form. The sheet revealed signatures of two nurse at the most recent shift change. On 2/1/23 at 10:25 a.m. observation of the controlled substance sign-out book on Unit 1 Cart 1 medication cart revealed the document titled Controlled Medication Count Sheet (8-hour shift) dated 1/1/23-1/31/23 revealed 61 missing signatures. The missing signatures were verified with LPN DD. At 10:30 a.m. LPN DD revealed she was aware the controlled medication sign-out sheet should be signed by the nurses at each shift change after the count of the controlled medications to verify the medications were counted and the count was correct. She further revealed that nurses forget to sign the sheet and she had no other explanation for the missing signatures. The sheet revealed signatures of two nurse at the most recent shift change. On 2/1/23 at 11:05 a.m. observation of the controlled medication count sheets for medication carts Unit 2 Cart 1, Unit 2 Cart 3, Unit 1 Cart1 with the DON verified the missing signatures. An interview with the DON revealed her expectations are for the controlled medication count sheet to be signed at each shift count by the oncoming and off going nurse, after the medications are counted and verified to be correct. She further revealed nurses had received education to include controlled medication count sheets and she plans to reeducate the nursing staff over the controlled medication count sheets.

Based on observation, interviews, record review, and policy review, the facility failed to ensure storage of nebulizer mask in a manner to prevent cross contamination for one of 14 residents (R) (R#93) receiving nebulizer administration. Findings included: 1. Review of the policy titled Administering Medications Through a Small Volume (Handheld) Nebulizer dated 2001 and revised October 2010 revealed a purpose of to safely and aseptically administer aerosolized particles of medication into the resident's airway. The section titled Steps in the Procedure line number 29 stated: When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. On 1/31/23 at 10:30 a.m. and 2/1/23 at 8:45 a.m. observations of R#93's room revealed a nebulizer machine on the bedside table with a nebulizer mask lying on top of the table, not in a protective bag and exposed to the environment. On 1/31/23 at 10:30 a.m. and 2/1/23 at 8:45 a.m. interviews with R#93 revealed she had not used the nebulizer in a few days. She revealed she used the nebulizer for excessive cough. She further revealed she is unsure if the mask is ever placed into a protective bag. A review of the clinical record revealed that R#93 is an [AGE] year-old female admitted on [DATE] with diagnosis including (not all inclusive) acute respiratory failure with hypoxia, shortness of breath. A review of the quarterly Minimum Data Set (MDS) dated [DATE] for R#93 revealed: section C revealed a Brief Interview for Mental Status (BIMS) score of 15 (indicating is cognitively intact), section G revealed R#93 required extensive assistance of one person for bed mobility, personal hygiene, and toileting and required extensive assistance of two persons for transfers. A review of the physician's orders revealed an order dated 1/13/23: ipratropium-albuterol inhalation solution 0.5-2.5 milligrams (mg)/3 milliliters (ml), 1 inhalation inhale orally every 6 hours as needed for wheezing. A review of the care plan revealed a focus of altered respiratory status with a goal of will have no signs of poor oxygen absorption. Approaches included: administer oxygen and puffers as ordered and monitor for side effects, monitor for signs of respiratory distress and report to the physician. A review of the Medication Administration Record (MARS) dated 1/1/23-1/31/23 revealed R#93 received ipratropium-albuterol inhalation solution 0.5-2.5mg/3ml one inhalation on 1/17/23, 1/18/23, 1/22/23, 1/30/23. There was no documentation to indicate care of the nebulizer mask. A review of the nurses' notes revealed no documentation to indicate care of the nebulizer mask. On 2/2/23 at 9:45 a.m. an interview with Certified Nursing Assistant (CNA) II revealed he worked prn (as needed) and revealed the nurses are responsible for oxygen and other respiratory cares and equipment cares. He revealed he is aware to report any concerns to the nurse. He revealed he completes online training through Relias online and is unaware if he had completed any respiratory courses. Review of the Alliant information reflects training in infection control and does not indicate training in respiratory cares. On 2/1/23 at 12:30 p.m. an interview with Licensed Practical Nurse (LPN) HH revealed the nurses are responsible for providing respiratory services and nebulizer masks should be placed in a protective bag when not in use. Observation of R#93 nebulizer mask with LPN HH verified the mask to be lying on the bedside table, not in a bag and exposed to the environment. She was unable to locate a protective bag for the mask in the room. She revealed she will locate and place the mask in a protective bag. On 2/1/23 at 12:40 p.m. an interview with the Director of Nursing (DON) revealed her expectation is for nebulizer mask to be placed in a protective bag when not in use. She revealed the nursing staff is responsible for ensuring nebulizer mask are in a protective bag when not in use. She revealed she plans to educate nursing staff to place the nebulizer mask in bags when not in use.

Based on observations, policy review and staff interviews, the facility failed to ensure medications were dated appropriately when opened to determine the discard date, in one of five medication carts; failed to ensure all biological's were labeled and refrigerator was locked in one of one medication rooms; and failed to discard expired biological's and medical supplies prior to expiration date in two of two medication storage rooms. The census was 95 residents. Findings include: Review of the facility policy titled, Instructions for Preparing Non-Controlled Drugs for Return in the State of Georgia , revised August 1, 2021, indicated that Per state regulations in Georgia, when non-controlled drugs are expired, discontinued from use or the patient for whom they were ordered is no longer a patient, these drugs shall be immediately removed from the active stock and inventoried by two people. The inventory should be signed and dated by the two individuals. The original inventory should be kept by the facility and a separate copy of the inventory with the drugs until final disposition. Review of the policy titled, Storage of Medications, revised April 2007 indicated that 3. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biological's. All such drugs shall be returned to the dispensing pharmacy or destroyed. 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biological's shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. 9. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications must be stored separately from food and must be labeled accordingly. Review of the policy titled, Labeling of Medication Containers, revised April 2007 revealed that all medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations. 2. Any medication packaging or containers that are inadequately or improperly labeled shall be returned to the issuing pharmacy. Observation on 9/29/2021 at 11:05 a.m. with Registered Nurse (RN) AA, 100 Hall medication storage room revealed the following: one bottle of [MEDICATION(S)] 10 mg with an expiration date of 7/2021; one 32 ounce bottle of [MEDICATION(S)] with an expiration date of 8/2021; two bottles of slow magnesium with calcium with an expiration date of 8/2021; one bottle of magnesium 250 mg with an expiration date of 8/2021; one 16 ounce bottle of Geri-[MEDICATION(S)] DM with an expiration date of 3/2021; three bottles of 625 mg fiber [MEDICATION(S)] with an expiration date of 7/2021; one 12 ounce bottle of [MEDICATION(S)] liquid with an expiration date of 3/2021 and one unopened and one opened Influenza vaccine with an expiration date of 6/10/21. Observation on 9/29/2021 at 12:10 p.m. 100 Hall medication cart revealed the following: one opened bottle of acidophilus in medication cart and not refrigerated (as recommended per label), one opened bottle of [MEDICATION(S)] 3 mg with no open date; one opened bottle Senna plus with no open date; one opened bottle [MEDICATION(S)] 500 mg with no open date; one opened bottle Aspirin 325 mg with no open date; one opened bottle stool softener 100 mg with no open date; one opened bottle of [MEDICATION(S)] 10 mg with no open date; one opened container [MEDICATION(S)] with no open date; one opened bottle of calcium 600 mg with no open date; one opened bottle of [MEDICATION(S)] 600 mg with no open date; one opened box of [MEDICATION(S)] nebulizer treatments with no open date; one open and used [MEDICATION(S)] cream with no open date; one open bottle of [MEDICATION(S)] nasal spray, for a discharged resident with no open date; one opened bottle of gel rite hand sanitizer with an expiration date of 3/2020. Interview on 9/29/2021 at 12:45 p.m. with RN AA, confirmed the expired drugs and opened medications with no open dates for 100 Hall medication cart and 100 Hall medication storage room. Observation on 9/29/2021 at 2:30 p.m. 200 Hall medication storage room with the DON revealed the following: one bottle of liquid iron supplement with an expiration date of 12/2020; one bottle of earwax softener drops with no open date; three Huber needle infusion sets with an expiration date of 8/31/21; one packet of liquid protein with an expiration date of 8/11/2021; one package of sore throat [MEDICATION(S)] with no open date; two boxes of Brava powder with an expiration date of 8/5/2;, [MEDICATION(S)] 2 mg box with no open date; one bottle of Preser Vision eye vitamin and mineral supplement with an expiration date of 7/2021; one body of Enstiller foam with an expiration date of 9/2020; one package of Tylenol suppository 650 mg with an expiration date of 7/1/21; 12 packs of [MEDICATION(S)] Powder with an expiration date of 12/28/2020; one packet of thickener with an expiration date of 6/18/2021; one iodine stick with an expiration date of 3/19/21; one box of iodine swabs with an expiration date of 8/2021; three eight ounce cans of Glucerna 1.5 with an expiration date of 5/2021; two bottles of total B with C vitamin with an expiration date of 8/2021; two 16 ounce bottles of peroxide-one bottle with an expiration date of 1/2021 and one bottle with no open date; two bottles of 625 mg Fiber [MEDICATION(S)] with an expiration date of 5/21; one [MEDICATION(S)] injectable pen with an expiration date of 1/1/21; one bottle of [MEDICATION(S)] eye drops with an expiration date of 3/2021. Emergency kit contents: 16 tablets of [MEDICATION(S)] 250 mg with an expiration date of 8/31/2021; three tablets of [MEDICATION(S)] 875/125 mg tablets with an expiration date of 8/21/2021 and one tablet with an expiration date of 9/17/2021; [MEDICATION(S)] 250 mg, one tablet with an expiration date of 8/13/2021 and one tablet with an expiration date of 9/25/2021; two tablets of [MEDICATION(S)] 100 mg with an expiration date of 8/20/2021 and one tablet with an expiration date of 7/11/2021; one 20 mg pill in the kit without a label. IV box contents: four bottles of sterile water with an expiration date of 4/2021; three 100 milliliter (ml) normal saline infusion bags with an expiration date of 8/2021; three 5 ml/50 u/ml [MEDICATION(S)] syringes with an expiration date of 8/31/21; two 5 ml/500 u/ml [MEDICATION(S)] syringes with an expiration date of 4/30/2; 25 female luer lock caps with an expiration date of 3/6/2021. Observation on 9/29/21 at 3:00 p.m. with the DON revealed 200 Hall medication room refrigerator is not locked, with the lock sitting on top of the counter beside refrigerator. Interview on 9/29/2021 at 3:01 p.m. with LPN GG stated that the refrigerator hasn't been locked since they (facility) did not have controlled medications stored in the refrigerator. Interview on 9/29/2021 at 3:35 p.m. with Licensed Practical Nurse (LPN) KK confirmed that all medications/supplies were expired/no open date. Observation on 9/29/2021 at 4:00 p.m. 100 Hall medication room emergency kit revealed the following: 18 tablets of [MEDICATION(S)] 250 mg with an expiration date of 8/31/2021; eight tablets of Methylprendnisolone 4 mg with an expiration date of 4/30/2021 and eight tabs with an expiration date of 3/7/2021; five tablets of [NAME] 10 mg with an expiration date of 8/29/2021; eight tablets of [MEDICATION(S)] 300 mg with an expiration date of 7/10/2021; one tablet of [MEDICATION(S)] 100 mg with an expiration date of 8/19/2021; three tablets of [MEDICATION(S)] 250 mg with an expiration date of 9/1/2021 and two tablets with an expiration date of 8/10/2021; two tablets of [MEDICATION(S)] 500/125 mg with an expiration date of 4/22/2021 and one tablet with an expiration date of 9/15/2021; one tablet of [MEDICATION(S)] 250 mg with an expiration date of 7/16/2021; one sulfa tablet with an expiration date of 7/17/2021; five tablets of [MEDICATION(S)] 30 mg with an expiration date of 6/30/2021; one tablet of [MEDICATION(S)] 20 mg with an expiration date of 8/18/2021; four tablets of [MEDICATION(S)] 125 mg with an expiration date of 6/30/2021; three tablets of [MEDICATION(S)] 12.5 mg with an expiration date of 7/9/2021; three tablets of carbamazepin 200 mg with an expiration date of 6/30/2021; five tablets of [MEDICATION(S)] ER 7 mg with an expiration date of 8/31/2021; one tablet of [MEDICATION(S)] 1 mg with an expiration date of 4/30/2021 and five tablets with an expiration date of 7/12/2021; four tablets of [MEDICATION(S)] 10 mg with an expiration date of 6/2/2021 and two tablets with an expiration date of 7/23/2021; two tablets of [MEDICATION(S)] 100 mg with an expiration date of 6/25/2021; five tablets of [MEDICATION(S)] 125 mcg with an expiration date of 8/20/2021. Interview on 9/29/21 at 5:00 p.m. with DON verified all above meds are expired. She further states that she doesn't know what to say. The e-kits and IV boxes come from the pharmacy, and they should have realized there were expired medications in those boxes.

Based on observations, staff interviews, review of the facility policy titled, Covid-19 Screening Procedure and review of staff training records it was determined the facility failed to follow the protocol and procedures for screening staff and visitors upon entrance to the facility. In addition, the facility failed to provide effective infection control practices related to medication administration for two of 27 medication opportunities. The facility census was 95 Residents. Findings include: 1. Review of the policy titled, Covid-19 Screening Procedure dated 1/11/2021 documented: Purpose: Upon entrance to the facility, staff, visitors, and residents returning from leave of absence will be screened for signs and symptoms of COVID-19 using a contact less infrared thermometer and electronic device (iPad) to store screening questions and data. Procedure: The temperature of Employee, Contract Employee, Visitor, and Residents returning from leave of absence will be obtained by standing in front of the wall-mounted infrared thermometer. If person is unable to stand and/or the wall-mounted infrared thermometer is not functioning, the screener will use the handheld infrared thermometer. 1. The screener will enter the temperature for the selected employee, employee visitor and resident onto the iPad. 2. The screener will ask the screening questions to the employee, contract employee, and visitor and resident onto the iPad. 3. Prior to submitted the answers, the screener will review and verify the accuracy of the data entered. 4. Data will be stored / retained in the facility computer database. Review of Inservice Covid-19 Visitor Screening dated 3/6/2020 and attendance record revealed was attended by Receptionist HH, Receptionist 00 and Human Resources (HR). The attendees' received instructions on screening visitors each time they enter the facility and if symptomatic, visitors should be asked to leave the facility. Review of Inservice training regarding screening procedures revealed the topic of screening process was held on 3/19/21, 3/24/21, and 5/10/21 with signed attendance sheets attached. Content was as follows: Receptionist and assigned screeners are responsible for conducting active screening during the hours they are on duty. When there is no receptionist on duty, the nursing department is responsible for screening ALL who enter the facility. Visitors arriving for window visits must be screened per protocol. Per DPH, screening is to be an active process, meaning that the screener obtains the temperature and verbally asks the screening questions of the person being screened. For any high temps and/or yes questions, the person MUST NOT enter the facility, and the Director of Nursing (DON) must be notified. Passive screening is not ideal. We should do our very best to conduct ACTIVE screening. If passive (self-screening) must be done, the East Wing cart 2 nurse will be responsible for reviewing and co-signing the screening log at intervals during each shift. The screening process is vital to keeping Covid-19 out of the facility, The following schedule was included with the training documentation: M-F (Monday through Friday) 6:00a.m. - a.m.- screener at the front 8:00a.m. - 4:00 p. m. receptionist on duty (receptionist break from 2:00 p. m.-3:00 p. m.) 4:00 p. m. - 7:00 p. m. receptionist on duty 7:00 p. m. - 6:00a.m. East Wing cart 2 nurse Saturdays and Sundays: 9:00a.m. - 5:00 p. m.-receptionist on duty 5:00 p. m - 9 :00a.m.-East Wing cart 2 nurse The screening log are monitored for compliance daily. Review of Cypress Door Screening (Pine [NAME] Report) reconciled by Timecard Detail report of all employees working the past three days revealed that: On 9/28/2021: 17 staff were not screened On 9/29/2021: 23 staff were not screened On 9/30/2021: 13 staff were not screened Observation on 9/28/2021 at 6:30 a.m. revealed day shift staff entering the front building walking past the screening station and continuing down the hallway without being screened. Observation on 9/28/2021 at 6:45 a.m. Surveyors entered the facility, the DON greeted the surveyors and walked them to the conference room without screening any of the other surveyors. Observation on 9/28/2021 at 6:50 a.m. upon entrance to the facility, there was no Covid screening performed. Hand sanitizer, a thermometer and masks were observed upon entrance; however, the survey team was not screened. There were no visible signs or instructions to stop and self-screen upon entrance. Observation on 9/29/2021 at 8:30 a.m. Surveyor entered facility with Receptionist HH sitting at desk and failed to obtain temperature check or screen upon entrance or instructed how to perform and log screening. Observation on 9/29/2021 at 8:30 a.m. upon entrance to the building; a receptionist was seated to the right of the nurse's station. Receptionist HH did not screen the surveyor or instruct surveyor to self-screen. After asking for, and receiving the code to log into the system, the Surveyor proceeded with self-screen using IPAD and checking temp with device on wall. No hand sanitizer was located at screening area or near the entrance and no hand sanitizer was offered. Two containers of Sani-wipes, which are not recommended to be used on skin, were on the table. Continued observation revealed Emergency Medical Services (EMS) personnel enter building to pick up resident for a routine patient transport without being screened. Interview on 9/29/2021 at 8:30 a.m. with Receptionist HH, after not being asked to self-screen, Receptionist HH stated, the process for screening is to use the wall mounted I-pad located on the left side of the hallway and thermometer on the wall. No instructions or information was freely given. Receptionist HH stated, use the wipes on the counter when hand sanitizer was not visible at the screening area. When an additional inquiry was made for hand sanitizer, the receptionist pointed to the nurse's station further down the hallway and said there was hand sanitizer there. Observation on 9/30/2021 at 9:29 a.m. revealed there were no Covid screenings encouraged, and limited screenings performed the duration of the survey process for the six survey team members. Interview on 9/29/2021 at 2:10 p.m. with Receptionist HH revealed she works as a receptionist and her duties include helping with the screening process. She stated she sits at the reception desk and lets people in and out of the door. She revealed the staff know the process to screen and she does not promote or remind them. Further interview revealed she does not stop people because they should know they have to screen and should stop before they clock in and should not have to be told. Continued interview revealed when EMS comes into the building some stop for screening, and some do not. Receptionist HH stated she does not ask EMS to screen if they pass the screening area without stopping and that she does not stop people because they should know they have to screen and should stop before they clock in. Interview on 9/29/2021 at 3:20 p.m. with Licensed Practical Nurse (LPN) KK revealed staff screen themselves at the beginning of each shift but are not reminded if they forget. Further interview revealed she has forgotten to screen herself if she was in a hurry to clock in or running late to report. Interview on 9/29/2021 at 4:50 p.m. with the DON/Infection Control Preventionist (ICP) revealed the screening logs are reviewed for compliance daily by the Staffing Coordinator and the Ward Clerk. The DON stated that if they see that a staff person has failed to screen, they will use the failure as, a teachable moment and instruct the staff member on screening procedures and importance of screening right on the spot. The DON stated the front receptionist and all staff have been verbally in-serviced to screen everyone. Continued interview revealed she was unaware the receptionist had not been requiring screening prior to entry and was unaware so many staff had not been completing the screening process. The DON revealed her expectation is for all staff and visitors to follow the screening procedures. Interview on 9/30/2021 at 1:00 p.m. with the Staffing Coordinator and the Ward Clerk revealed they are responsible for comparing the schedule and screening logs daily. Further interview revealed when they get to work each morning, they check the on- duty staff to see if they have screened themselves. After completing a review of day shift, they check the previous evening and night shift employees to see if they were screened. Continued interview revealed when an employee fails to screen, they send an email to the DON and Administrator regarding reeducation on the screening process. 2. Observation on 9/29/2021 at 10:15 a.m. of Licensed Practical Nurse (LPN) FF revealed LPN FF administered [MEDICATION(S)] (an inhalation medication used to prevent asthma attacks) to R#18, she donned gloves, held the inhaler to the resident's mouth. She then took the inhaler out of the room and placed it in the medication cart. LPN FF did not wash or sanitize hands. Observation on 9/29/2021 at 10:20 a.m. revealed LPN FF administered eye drops to R#1, she donned gloves, and administered the eye drops as ordered. She then returned and placed the eye drops in the medication cart. LPN FF did not wash or sanitize her hands. Interview on 9/29/2021 at 10:25 a.m. with LPN FF revealed that she failed to wash her hands with soap and water and failed to use hand sanitizer. LPN FF stated that she just forgot to wash her hands and that she should have done so.

Based on observations, record review, staff interviews and policy review, the facility failed to follow the care plan for one resident (R) R#16 for documentation of respiratory status each shift; also failed to develop a care plan for two residents (R) R#87 and R#89 for Oxygen therapy. The sample size was 40 residents. Findings Include: Review of the facility policy titled Comprehensive Care Plans dated 12/2017 revealed the center policy is develop and implement a comprehensive person-centered care plan for each resident, consistent with resident's rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the resident's comprehensive assessment. 1. Review of the clinical record for R#16 revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's most recent annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was not coded, which indicated severe cognitive impairment. Section G revealed resident was dependent for all care provided. Section O revealed resident required Oxygen, suctioning and [CONDITION(S)] care. Review of the care plan initiated on 8/4/2020 and revised on 6/30/2021, revealed to monitor and document respirations, depth, and quality each shift as ordered. Review of the EMR vitals log for R#16 revealed the last date that respiration rate was documented was 7/29/2021. Review of electronic medical record (EMR) nursing notes/health status notes dated 3/3/2021 to 9/30/2021 revealed no evidence that respirations were not documented each shift as ordered. Interview on 9/29/2021 at 11:14 a.m. with Licensed Practical Nurse (LPN) BB, at the East Wing Nurse's Station, revealed she has been employed at the facility for [AGE] years. LPN BB stated [CONDITION(S)] care is provided at the beginning of every shift. She stated that monitoring Oxygen levels and respirations is a part of the [CONDITION(S)] care process. LPN BB stated [CONDITION(S)] care is documented in the Treatment Administration Record (TAR). During further interview, LPN BB stated she was unable to locate R#16 TAR record. LPN BB stated she has gotten accustomed to doing the [CONDITION(S)] care, and she forgets to complete the documentation. Interview on 9/29/2021 at 12:07 p.m. with Director of Nursing (DON), in her office, revealed she is unable to recall the last time training was completed for respiratory/[CONDITION(S)] care. She stated she was not aware that [CONDITION(S)] care was not being documented for R#16. During further interview, she confirmed there was no documentation in R#16's EMR for the past six months. 2. A review of the clinical record for R #89 revealed resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was not coded, which indicated severe cognitive impairment. Section G revealed resident required extensive/total assistance of two persons for all care provided. Section O revealed no evidence resident required Oxygen currently, or prior to admission. Review of the care plan initiated on 8/27/2021 revealed resident has altered respiratory status and difficulty breathing. Interventions to care include monitor for signs and symptoms of respiratory distress and report to Physician as needed and position resident with proper body alignment for optimal breathing pattern. There is no evidence of an intervention that resident uses Oxygen therapy. Review of the care plan initiated on 9/30/2021 revealed resident is on Oxygen therapy related to ineffective airway exchange. Interventions to care include provide extension tubing or portable tanks if resident is ambulatory, Oxygen at two liters (L) via nasal cannula (N/C) and position resident to facilitate ventilation/perfusion matching. Review of the undated Pine [NAME] Nursing and Rehab Nursing Report revealed Oxygen Needs-resident on 02 marked as no. Review of the September 2021 Order Summary Report revealed the order for Oxygen administration was not ordered until September 30, 2021. Observation on 9/28/2021 at 11:07 a.m. revealed Oxygen concentrator at R#89 bedside is running at 2 L, with N/C tubing wrapped around bed rails. Observation on 9/29/2021 at 7:58 a.m. revealed R#89 lying in bed with head of bed elevated and oxygen in use at 2 L via N/C. Interview on 9/29/2021 at 8:20 a.m. with Registered Nurse (RN) BB, confirmed R#89 had an Oxygen concentrator in his room and that he was using Oxygen, via N/C. During further interview, she confirmed there was no PO for resident to use Oxygen. Interview on 9/29/2021 at 8:30 a.m. with the DON, revealed that residents on oxygen should have an order before it is applied. She stated the order can be received from the Physician or the Nurse Practitioner. The DON confirmed that R#89 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] 3. A review of the clinical record for R #87 ([NAME]) revealed resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) coded as 13, which indicated no cognitive impairment. Section G revealed resident required extensive/total assistance of one-two persons for all care provided. Section O revealed no evidence resident required Oxygen currently, or prior to admission. Review of the care plan initiated on 3/11/2019 revealed resident has altered respiratory status related to [CONDITION(S)]. Interventions to care include monitor for difficulty for breathing and remind resident not to push beyond endurance; monitor, document and report any signs/symptoms of infection. There is no evidence of an intervention that resident uses Oxygen therapy. Review of the September 2021 Order Summary Report revealed no evidence of an order for [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observations, record reviews, staff interviews, and review of facility undated policy titled Oxygen Administration the facility failed to ensure five (5) of eight (8) residents (R) R#16, R#55, R#82, R#87, and R#89 who were receiving oxygen therapy had a written order for treatment. The facility also failed to ensure that one (1) of two (2) residents with a [CONDITION(S)] R#16 had written care instructions including oxygen therapy for [CONDITION(S)] care. Findings include: Observation of R#82 on 9/28/21 at 10:36 a.m. revealed resident was receiving oxygen per nasal cannula at 2 liters per minute (L/M). Review of resident medical records revealed no written order for oxygen therapy. Observation on 9/29/21 at 7:58 a.m. of R#89 revealed resident was in bed with oxygen per nasal cannula at 2 L/M, head of bed was elevated tube feeding infusing at 50 Milliliters per hour. Review of R#89 medical record revealed resident did not have a written order for oxygen administration. Interview with RN AA (registered nurse) confirmed on 9/29/21 at 8:20 a.m. that R#89 did have oxygen on and there was a concentrator in the resident's room. Further interview with staff also revealed that there was no written order for resident to have oxygen in resident's chart. There are standing orders that available for staff to go by that are in each residents' charts that the physician has approved. Continued review of R#89 chart also revealed that on hospital report there was no mention of resident receiving oxygen therapy. Interview with DON on 9/29/21 at 8:30 a.m. revealed that resident's that are on oxygen should have an order before it is applied. The order can be received from the physician or the Nurse practitioner. DON also confirmed that R#89 and R#82 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of facility policy titled oxygen Administration on 9/30/21 at 8:36 a.m. revealed under Preparation number 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Interview with RNCC on 9/30/21 at 9:52 a.m. revealed that resident's that are on oxygen therapy should have an order that indicates how much oxygen and for how long the oxygen is to be administered. The order is usually on the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] On 9/30/2021 at 12:02 R#89 care plan dated 9/16/2021 did not reveal any indication of oxygen use. Residents did receive care within professional standards though no orders were noted. Record reviews Electronic and paper chart for R #87 revealed no orders for Oxygen. Record reviews Electronic and paper chart for R #24 revealed no orders for Oxygen. Observation 9/27/21 at 8:57 a. m. R# 87 in his room in bed finishing breakfast. Head of bed elevated. O2 via nasal cannula at 2 liters per minute with humidification was being administered. Tubing was labeled with date of 9/27/21. R# 87 Revealed I had problems breathing and they put me on oxygen and then it gave me pneumonia. Observation 9/29/21 at 8:30a.m. R#87 in his room revealed lying in bed, eyes closed. Receiving O2 on at 2 liters per minute via nasal cannula, no respiratory distress noted. Observation 9/28/21 8:35 a. m. of R#24 resting in bed eyes close head of bed elevated call light within reach. O2 via nasal cannula with humidification 2 liters per minute tubing dated 9/26/21 no respiratory distress noted. Observation on 9/29/21 at 4:30 p. m. revealed she is not currently receiving any type of Physical therapy and is not interested in receiving at this time. O2 via nasal cannula with humidification 2 liters per minute. tubing dated 9/26/21 no respiratory distress noted. During an interview on 9/28/21 at 11:00a.m. with R#87 revealed he has been using oxygen for a while and he was unsure if it had been weeks or months. Further interview revealed he was having issues breathing so they gave him oxygen to use. Stated that he thought using oxygen had given him pneumonia. Denied any respiratory distress at time of interview. During an interview on 9/29/21 at 4:20PM. with R#24 revealed she has used oxygen for a long time not sure when it was started does not need it all the time. Further revealed the nurses change the tubing every week. During an interview on 9/30/21 at 9:30a.m. with Licensed Practical Nurse LPN NN revealed when a resident is using O2 they have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further revealed they would not be using O2 if it wasn't ordered, and the order should be on the chart but was unable to locate the orders for R#87 and R#24. During an interview on 9/30/21 at 9:05 a. m with LPN JJ Revealed I only work part-time as far as I know the Dr. writes orders before a Resident is started on oxygen therapy. Was unable to find order on chart for R#87 and R#24. Resident #16 Review of Resident #16's clinical record did not reflect physician orders for the usage of a [CONDITION(S)] compressor or [CONDITION(S)] care. Observation completed on 9/30/21, 10:14 a.m.- 10:47 A.M. Resident observed with 35% Automatic tube compensation in place. [CONDITION(S)] care and tracheal suctioning performed by Staff BB with appropriate standards of practice. There were no infection control concerns as sterile technique was utilized. Staff Interviews: Staff BB, Licensed Practical Nurse (LPN), East Wing Nurse's Station, 9/30/21 at 10:50 a.m. Staff BB verified there was no order in the record for [CONDITION(S)] care or the use of the [CONDITION(S)] compressor for R #16. Staff BB checked the Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . According to Staff BB [CONDITION(S)] care is provided at the beginning of every shift as required by the care plan. Director of Nursing (DON), Registered Nurse (RN), DON office, 9/30/21 at 11:00 a.m. Director of Nursing (DON) reported she was not aware there was no order in the record for the [CONDITION(S)] compressor or [CONDITION(S)] care. DON reviewed the medical record and confirmed there was no order. DON stated, the nurses, Assistant Director of Nursing and DON were responsible for ensuring the orders were current and she would follow up on the missing order. DONE

Based on record review, staff interviews and policy review, the facility failed to ensure that pre and post [CONDITION(S)] assessments were conducted for one resident (R) R#88, reviewed for [CONDITION(S)] services. In addition, the facility failed to ensure ongoing communication between the facility and the [CONDITION(S)] center for resident R#88. Review of the facility's Resident Census and conditions of Residents dated 9/28/2021 revealed two residents were receiving [CONDITION(S)] services. Findings include: Review of the facility policy titled Clinical Standards of Care-[CONDITION(S)], dated 8/2003, revealed the resident receiving [CONDITION(S)] treatment will be appropriately assessed for complications. The facility interdisciplinary team and members of the [CONDITION(S)] treatment center will communicate and collaborate to assess, develop, implement, evaluate, and revise the residents' plan of care. Guidelines: 9. Post [CONDITION(S)] assessment includes but is not limited to vital signs, weight post [CONDITION(S)] (may have been obtained at [CONDITION(S)] center), vascular access condition, sense of well-being, mental status, and other conditions or complications. Review of the clinical record for R#88 revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's most recent Annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 15, indicating no cognitive impairment. Section O revealed resident was receiving [CONDITION(S)]. Review of updated care plan for R#88, revised 7/28/2021, revealed resident is at risk for complications related to hemodialysis for the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions for care include Hemodialysis (HD) on Monday/Wednesday/Friday at 5:30 a.m., check for thrill and bruit every shift, administer and monitor effectiveness of medications, check shunt site for signs/symptoms of infection, pain, or bleeding daily and prn, monitor shunt by palpating for thrill and auscultating for bruit every shift and notify my physician of absence of thrill or bruit, notify physician if bleeding, pain, signs/symptoms of infection of shunt site, or [CONDITION(S)] catheter site. Review of the facility [CONDITION(S)] Communication Form revealed missing post-[CONDITION(S)] nursing assessment of blood pressure, temperature, pulse rate, vascular access condition, presence of bruit and thrill, mental status and sense of well-being on approximately 90% of R#88 [CONDITION(S)] forms. Interview on 9/30/2021 at 9:20 a.m. with Licensed Practical Nurse (LPN) GG, revealed nurses are supposed to document on the [CONDITION(S)] communication form the residents' Blood Pressure, Pulse and Temperature and check the [CONDITION(S)] site for bruit and thrill, after they return from [CONDITION(S)]. During further interview, she stated the [CONDITION(S)] book sometimes is not returned with resident. Interview on 9/30/2021 at 9:25 a.m. with LPN JJ stated that upon residents return from [CONDITION(S)], they are to check the shunt, Blood Pressure, monitor resident, and inquire if there were any problems with [CONDITION(S)]. Interview on 9/30/2021 at 9:30 a.m. with Director of Nursing (DON) stated her expectation is for nursing staff to complete the [CONDITION(S)] Communication Form each time residents return from [CONDITION(S)]. The DON verified that the [CONDITION(S)] Communication Form was not being completed.

Based on observation, interview, review of training documentation, and review of facility policy titled, Interim Policy for Suspected or Confirmed Coronavirus the facility failed to ensure residents' rooms were properly disinfected in accordance with appropriate standard and transmission-based precautions. Qualified Environmental Protection Agency (EPA)-registered disinfectants were being used to clean residents' rooms that required specific timelines for the product to dwell on surfaces on two of two wings (West and East wings). In addition, one unlabeled spray bottle of disinfectant and one mislabeled spray bottle of disinfectant were identified on the cleaning cart on the East Wing. Findings include: Review of the Infection Prevention and Control Manual revealed a policy entitled Interim Policy for Suspected or Confirmed Coronavirus (dated 2/21/2020). According to the policy the facility would minimize exposure to respiratory pathogens and promptly identify residents with clinical features and an epidemiologic risk for the COVID-19 and would adhere to Standard, Contact, and Airborne Precautions, including the use of eye protection. Procedures included cleaning and disinfecting the room and equipment using products that had Environmental Protection Agency (EPA)-approval against emerging [MEDICAL CONDITION] pathogens. The procedure referenced to the EPA.gov website for disinfectant usage against COVID-19. 1. A tour of the West Wing of the facility was conducted on 6/23/2020 at 10:35 a.m. There were no resident rooms noted with signs to designate isolation or contact precautions. Residents were observed to randomly enter and exit their rooms while wearing masks. A cleaning cart was noted to be stationed in the hallway and a housekeeping staff person (Staff #GG) was observed to be mopping a resident's room. Interview was conducted in a hallway on the West Wing on 6/23/2020 at 10:40 a.m. with Staff GG. The staff person stated he/she had been employed for approximately two (2) weeks and worked in housekeeping, cleaning the West Wing area. Staff GG indicated he/she was using Comet disinfectant spray to clean the surface areas of resident rooms, and waited five (5) minutes after spraying disinfectant before wiping the surface clean. When questioned regarding the disinfectant recommendation for time the product should remain on a surface before wiping, Staff GG removed the bottle of Comet disinfectant spray from the cart and read the label. Review of the label for the Comet disinfectant spray revealed instructions to allow a dwell time of 10 minutes on all surfaces before wiping so the disinfectant would be effective in achieving the products advertised kill rate of bacteria [MEDICAL CONDITION]. 2. A tour of the East Wing was conducted on 6/23/2020 at 11:10 a.m. there was one resident room with the door closed and a sign on the door designating Droplet Precautions should be used when entering the room. A cleaning cart was noted in a hallway and a housekeeping staff person (Staff FF) was mopping a resident's room. There were no residents observed to be out of their rooms on the East Wing. Interview was conducted in a hallway on the East Wing on 6/23/2020 at 11:20 a.m. with Staff #FF. Staff FF indicated being aware there was a resident on the unit who required staff to use infection control precautions. Staff #FF stated he/she had Comet disinfectant spray on the cleaning cart to use when cleaning residents' bathrooms. The staff person described spraying the disinfectant onto a surface area and immediately wiping it off. Staff FF presented two (2) additional spray bottles that were stored on the cleaning cart. One of the spray bottles was not labeled to identify the name of the product or directions for use. The other spray bottle presented had a label on the bottle; however, Staff #FF stated the label was wrong because he/she had poured a different type of disinfectant into the bottle but had not changed the label. Staff #FF was not sure what cleaner was in the spray bottle. Staff FF stated he/she used both disinfectant spray bottles to clean surfaces in residents' rooms. Staff FF described spraying the disinfectant directly onto a cleaning cloth and then wiping surfaces. Staff #FF stated he/she did not spray the disinfectant products directly onto the surfaces being cleaned and there was no dwell or contact time allowed before wiping the surfaces. Interview was conducted in the staff development office on 6/23/2020 at 12:25 p.m. with the Housekeeping (HK) Manager (Staff EE). Staff EE stated when Covid-19 came around a change was made in the disinfectant products used by the facility to comply with the approved EPA-registered disinfectants. The facility used three (3) different disinfectant products and it was at the discretion of the HK as to which of the 3 products they used. Staff EE stated the policy was that HK staff used the Comet disinfectant spray specifically for bathrooms. Violet and Plum disinfectants were the names of the remaining two (2) disinfectant products, and according to Staff EE all the disinfectant products came in bulk, with HK staff filling the spray bottles from the larger containers. Staff EE stated labels were always printed and available for HK staff to place on the spray bottle each time one was filled for use. According to Staff EE, all the HK staff had received in-service training that specified all spray bottles when filled with a disinfectant, should be labeled to show the correct name and directions for use. Additionally, staff should never use a disinfectant product from a bottle that was not labeled or pour disinfectant into a bottle that was labeled with a different product name. Staff EE stated the HK staff had been trained following the Covid-19 outbreak and change in disinfectant products used by the facility, the rule of thumb was when cleaning, to leave the disinfectant spray on the surface for a minimum of 10 minutes. Staff EE stated using a dwell time of 10 minutes for all disinfectant cleaners would ensure the product could breakdown mucus membranes, etc. Staff EE stated he/she conducted random monitoring of cleaning carts and HK staff while cleaning. However, Staff EE did not indicate identifying concerns related to staff failure to ensure disinfectant products remained on surfaces being cleaned less than the required dwell time of 10 minutes before being wiped clean. Interview was conducted in the staff development office on 6/23/2020 at 12:50 p.m. with the Administrator. The Administrator identified designation of the East Wing as being a Covid-19 unit. The facility had one resident who resided on the East Wing who tested positive for Covid-19 and was currently under droplet precautions. The wing was further used for new admissions and readmissions from the hospital where residents remained quarantined for 14-days while staff monitored for signs or symptoms of infection, to include Covid-19. According to the Administrator, housekeeping services was a contracted service. The HK Manager and staff participated in facility provided in-services related to Infection Control and Covid-19. The HK Manager also provided separate in-services for the HK staff that covered areas pertinent to their job duties and responsibilities. Review of in-service training records revealed Staff #GG and Staff FF both participated in a facility provided training on 6/9/2020 entitled Daily Isolation Room Cleaning. Both the HK staff members also participated on 6/9/2020 in an in-service entitled Intro to Infection Control. In addition, the Housekeeping Manager (Staff EE) presented documentation that showed both Staff #GG and Staff FF had participated in an in-service training entitled Cleaning Procedures for Covid-19 (date not documented) and a training on 6/23/2020 (after concerns with disinfectant use were identified) entitled Isolation Room Procedures for Covid-19. Review of information obtained from the Environmental Protection Agency (EPA) government website revealed when using disinfectants, the EPA defines dwell time as the amount of time a sanitizer or disinfectant must be in contact with the surface and remain wet, in order to achieve the product's advertised kill rate.

Based on interview and record review, review of a policy titled Abuse, Neglect and Exploitation the facility failed to notify the State Survey Agency (SSA) within the required two-hour time period after Resident (R) #1 sustained an injury of unknown source, a hematoma (bruise) on his forehead. This failure affected one resident (R#1) of three sampled residents. Findings include: Review of the undated face sheet in the Electronic Health Record (EHR) revealed R#1 was admitted to the facility in the spring of 2019 and his [DIAGNOSES REDACTED]. Review of the 7/29/19 Quarterly Minimum Data Set, section C, revealed R#1's Brief Interview for Mental Status (BIMS) score to be three out of 15, signifying severe cognitive impairment. Review of section G revealed R#1 required extensive assistance for nearly all Activities of Daily Living (ADLs). Review of a 7/21/19 at 7:35 p.m. progress note revealed a large hematoma was noted on R#1's forehead, the previous shift denied knowledge of the injury, R#1 could not provide history of the hematoma, and the injury was unwitnessed. Review of the policy titled Abuse, Neglect and Exploitation, updated on 12/2017, revealed revealed Injuries of Unknown Source to be defined as the source of the injury was not observed by any person or the source of the injury could not be explained by the resident. Further review revealed the definition to also include the injury was suspicious because of the extent of the injury or the location of the injury. Further review revealed an immediate investigation should take place when abuse is suspected, such as an injury of unknown origin. An interview with the Administrator on 8/29/19 at 2:40 p.m. revealed that she first became aware of R#1's injury of unknown origin to his forehead on 7/22/19, the day after it was first documented by the duty nurse. The Administrator stated all injuries of unknown origin must be reported to the SSA within two hours of discovery, with no exceptions. The Administrator stated the nurse did not report this injury to her when it occurred. The Administrator further revealed that she was the Abuse Coordinator for the facility. An interview with the Regional Nurse Consultant (RNC) on 8/29/19 at 3:00 p.m. revealed that he agreed that R#1's injury of unknown origin occurred on 7/21/19 at about 7:35 p.m. and was not reported to the SSA until the following day, outside the required two-hour time window for reporting injuries of unknown source to the SS[NAME]

Based on observation, interview, document review, and policy review, the facility failed to ensure the kitchen was maintained in a sanitary manner for 108 residents out of 111 residents in the facility who received meals from the kitchen. The failure to ensure the kitchen was clean and adequately maintained created the potential for the spread of foodborne illness. Findings include: The initial kitchen observation/inspection was conducted with the Dietary Manager on 9/23/18 from 9:00 a.m. to 9:30 a.m. with the following sanitation issues noted: a. The hand washing sink was three-quarters full of soapy grey water, and it was not draining. The surveyor washed her hands and the water level in the sink raised to within a few inches of the top of the bowl. The Dietary Manager stated it was draining slowly and would eventually drain completely. He stated it was an intermittent problem. The white caulking along the top edge of the sink and the wall was peeling away from the wall and was discolored with a dark green/black substance along the seam. b. The dish machine was a low-temperature dish machine. A dietary aide was in the process of washing dishes. The Dietary Manager stated the dishes were sanitized by chlorine. The Dietary Manager checked the chlorine level using a chlorine test strip and the test strip did not change color which indicated there was no chlorine sanitizer present. At least one tray of dishes had been run through and was sitting on the stainless counter of the clean side of the dish machine. The Dietary Manager pushed the button on the machine to prime the chlorine line to get the chlorine to come out of the five-gallon bucket located on the floor next to the dish machine. The Dietary Manager ran a second cycle and again the dish machine did not register as having any chlorine present. The Dietary Manager stated the chlorine line was clogged. He stated the protocol was for staff to test the chlorine level three times a day, prior to washing dishes for breakfast, lunch and dinner. He stated this ensured that chlorine was being administered before doing the dishes. The Dietary Manager worked on the dish machine while the surveyor continued the kitchen inspection. c. There was a plastic cart with three shelves on which clean dishes were stored. There were crumbs and food spills on all three levels of the cart in which clean items were stored. There were two 3-sectioned off-white colored plastic plates stored as clean. The surfaces of both plates were scored, cracked with a black substance in the cracks, and the eating surface area of the plates were stained a rust color. A third 3-section plate was noted with food particles adhered to the eating surface; it was stored as clean. d. There were numerous crumbs, food particles, and food spills noted on the floor along the wall where the shelving for clean dishes was stored. e. On the shelves with clean dishware, two small clear plastic juice cups were stained brown. f. A white plastic plate on the plate warmer was discolored with a yellow substance on the eating surface. g. There was a large clear rectangular plastic bin stored with silverware rolled in paper napkins for residents' meals. The interior of the bin was soiled with multiple food spills of an orange color. h. There were several areas of a hardened black substance of approximately 2 inches in diameter and a half an inch thick stuck to the tile floor next to a large metal plate which covered the grease trap. The substance was affixed to the tile and did not move when the surveyor pushed it with the toe of her shoe. i. There were approximately 15-floor tiles that were significantly cracked on the floor by the three-sink pot washing area. The cracks were observed to go all the way through the tile from one end to another or multiple cracks within a tile. There was a second area of floor tiles with eight (8) tiles located by the steam table in which the floor tiles were also significantly cracked and damaged. The tiles were damaged to a degree which made the surface uncleanable. j. The wall located behind the grease trap and double sink that had a caved-in section of several feet in size. In this area, there was an area with paint missing, cracks in the wall, and a patched area. Dirt was also observed in the cracked area. k. Most of the floor of the walk-in refrigerator was covered with a layer of rust. The rust made the surface of the floor uncleanable. l. Near the end of the initial inspection at 9:25 a.m., the Dietary Manager stated the dish machine was now working properly. The Dietary manager stated he had to work the air out of the line and it was now administering chlorine. There were crumbs noted on the clean side of the stainless counter of the dish machine. The Dietary Manager ran a cycle of the machine and then checked the chlorine level which read 50 parts per million according to the test strip; this was the minimum level required for sanitization per the dish machine specifications affixed to the dish machine. The Dietary Manager and surveyor went and looked at the log where staff recorded their check of the sanitizer level prior to washing dishes. The log was blank for the pre-breakfast dishwashing check on this date. The Dietary Manager stated the Dietary Aide must have been nervous and had forgotten to check the sanitizer before initiating dishwashing. The Dietary Manager verified, had the surveyor not requested the chlorine level be checked, all the breakfast dishes could have been washed without any sanitizer present. m. The shelf on which the dish racks (in which dishes were placed for running through the dishwasher) were stored in between use had a layer of grime between one quarter to one-eighth inch in width along a horizontal seam of the shelf that was approximately three feet long. On 9/26/18 from 10:20 a.m. - 10:51 a.m. a second sanitation inspection was made with the Dietary Manager and the following sanitation issues were noted: a. The hand washing sink was two-thirds full of grey soapy water. The water was not draining. The green/black substance observed on 9/24/18 continued to be present along the caulking that was coming away from the wall along the top edge of the sink. b. There were racks of clean dishes on the stainless counter on the designated clean side of the dish machine. The Dietary Manager stated the staff had finished washing the breakfast dishes about 10 minutes ago. The Dietary Manager initiated a cycle of dishwashing and checked the chlorine level with a test strip. The chlorine level read half-way between 10 and 50 ppm (approximately 30 ppm). The Dietary Manager verified the level was less than the required 50 ppm. He primed the chlorine by pressing the button located on the dish machine and ran a second cycle. He checked the chlorine level, and it was 100 ppm. The Dietary Manager stated the service provider for the dish machine came out to the facility on Monday (9/24/18) after the initial kitchen inspection with the surveyor. The Dietary Manager stated the service provider serviced the machine and told him it was functioning properly. After priming the dish machine, the Dietary Manager ran another cycle, tested the chlorine level and again it read between 10 and 50 ppm. The Dietary primed the line a third time, ran a cycle, checked the chlorine and it read 100 ppm. The Dietary Manager and surveyor went and reviewed the log and staff had been recording 50 ppm of chlorine consistently. During the dish machine observations, a layer of a black substance approximately 12 in diameter was noted to be affixed to the inside stainless surface of one of the interior walls of the dish machine. The surveyor and Dietary Manager scraped it, and it was a sticky adhesive substance adhered to the stainless-steel surface. The Dietary Manager stated he did not know what the substance was and stated the interior of the dish machine was cleaned once a week using a delimer and the substance should come off with the deliming process. There were numerous small food particles and a piece of plastic garbage on the stainless counter of the clean side of the dish machine. The Dietary Manager stated staff was to keep the clean side of the stainless steel counter and the designated clean side of the dish machine area clean. c. The shelf on which the dish racks (previously noted on 9/24/18) were stored in between use continued to have a layer of grime between one quarter to one-eighth inch in width along a horizontal seam that was approximately three feet long. d. The floor drain, approximately six inches in diameter, located across from the double sink had standing water in it up to the level of the floor tile, approximately 1/8 inch above the top of the metal drain plate. The Dietary Manager stated this was an intermittent problem and he would notify maintenance about it. e. At 10:45 a.m., the Maintenance Assistant entered the kitchen and used an auger to clean the line to the hand washing sink. He stated he was just informed of the standing water in the sink and verified maintenance had not been notified previously. He cleared the line; there was a 5-gallon bucket with grey water that he indicated had been drained from the sink. The Maintenance Assistant stated he unclogged the sink; there had been accumulated sediment present. The Maintenance Assistant said it was now functioning properly. The Maintenance Assistant was asked if he knew about the standing water in the floor drain and he stated he did not. f. A metal vent on the wall (approximately two feet by three feet in size) around the three-sink pot-washing area was filled with a thick layer of accumulated dust. g. The cracked floor tiles previously noted on 9/24/18 remained in the same damaged condition. h. The areas of hardened black substance stuck to the tile floor remained the same as noted on 9/24/18. The Dietary Manager stated this area had been cleaned previously with degreaser and it was likely hardened accumulated grease. i. The damaged area of the wall by the grease trap and near the double sink was in the same condition as noted on 9/24/18. The Dietary Manager stated he put in a work order to replace it a while ago, but it had not been repaired yet. j. The plastic cart with three shelves was soiled on the top and bottom shelves with pieces of rice, crumbs and food spills. There were a few napkins with rolled silverware sitting on the soiled top shelf on the cart. k. Four, three-sectioned plastic plates stored as clean were observed. All four were stained a rust color with black cracks noted. The Dietary Manager removed them and stated he would throw them away. A dietary staff member retrieved brand new three-section plates from a storage area and removed them from plastic storage bags to replace the discarded plates. l. There were numerous crumbs and food particles along the wall where the shelving was located for storing clean dishes and on the floor under the dish machine. A third observation was made with the Dietary Manager on 9/26/18 at 11:52 a.m. The hand washing sink was a third full of grey soapy water. After the surveyor and a dietary staff member washed their hands, it was two thirds full of soapy water and was not draining. When the surveyor left the kitchen at 12:05 p.m. the water had drained from the handwashing sink. The Dietary Manager showed the surveyor the floor drain that had standing water in it previously. The water had been drained; the Dietary Manager stated maintenance pumped the line this morning after it was observed with standing water. An observation in the kitchen was made with the Dietary Manager on 9/26/18 at 1:30 p.m. An Independent Service Contractor was in the kitchen working on the dish machine. The Independent Service Contractor stated he increased the setting from 50 ppm to 100 ppm for the administration of the chlorine sanitizer to ensure it met the minimum requirement. He noted 125 ppm was the fail-safe, desired level to ensure proper sanitization, indicating it was a preferred practice to set the level higher than the minimum amount of 50 ppm to ensure adequate sanitization. The Independent Service Contractor stated the chlorine was now registering 100 ppm. A cycle of dishwashing was observed, the Dietary Manager used a chlorine test strip to check the sanitizer; it read 100 ppm. The Independent Contractor was asked about the adhesive-like substance adhered to the interior wall of the dish machine; he stated it was likely potato starch and delimer (phosphoric acid) would remove it. The Independent Contractor reported the machine should be delimed every two weeks to prevent the build-up of potato starch. The Dietary Manager stated the service contractor for the dish machine provides service when needed but does not come out on a regular basis for preventive maintenance. The Maintenance Director (MD)was interviewed on 9/27/18 at 12:25 p.m. in the surveyor conference room and stated the facility had employed him for about three years. He stated it was an old building, built in the late 1950s or early 1960s. He stated he was not aware of any major renovation in the kitchen since the facility was built; however, said he had replumbed the lines in the kitchen twice. The Maintenance Director stated that maintenance did not generally leave the unresolved issue in the maintenance notification and tracking system unresolved overnight. He stated the maintenance department was notified of the issue with the handwashing sink on 9/26/18 and his assistant addressed it right away by pushing a rod through to clear the line (it was first observed on 9/24/18). He stated that he was not aware it continued not to drain. When asked about the issue with the standing water in the floor drain, he stated he was aware of that, and it was due to a crushed line underneath the concrete. He stated they addressed it by sucking the water out with a Wet/Dry Vacuum when it backed up. The MD stated that the Dietary Manager was capable of doing this. When asked about the damaged wall near the double sink, he stated he did not know what was wrong with the wall or why it was wet. He stated he planned to replace it with waterproof sheetrock when his schedule allowed. He stated he would have to remove the sink to install the sheetrock. When asked about the cracked areas of the tile floor, he stated it had been discussed, but it would require shutting down the kitchen from preparing meals for over a week and no plan was in place to do this. He stated he had patched the tiles and re-grouted them. When asked about the caulking on the handwashing sink, he stated he was notified of that today (first noticed by the surveyor on 9/24/18) and it had been addressed. The Maintenance Director stated both he and his assistant worked full time performing maintenance. A request was made of all service documentation regarding the dish machine for the last three months. Review of the Service Call documents revealed a representative from Ecolab came twice during the previous three months as follows: a. The 9/18/17 Service Call record revealed the product dispenser sanitizer line was damaged with the cause identified as being, equipment. The sanitizer line was replaced to improve cleaning. The sanitizer in ppm was documented as 0 observed, and 50 adjusted. b. The 9/24/18 Service Call (following the surveyor's observations on 9/24/18) record revealed the dispensing system squeeze tubes were worn. The worn squeeze tubes were replaced to improve cleaning. The sanitizer in ppm was documented as 0 observed, and 100 adjusted. c. The Dishmachine Lease Agreement was dated 4/24/14. The contract indicated the service contract company provided the single rack dish machine and was responsible for parts and service to maintain the equipment in good condition. The agreement neither specified the frequency with which the service compnay would service the dish machine, nor the procedure/process or the response time for obtaining service when the machine was not functioning properly. Work orders/maintenance records - A request was made of the Dietary Manager for all dietary related work orders filed or completed with the maintenance department over the last three (3) months. Work orders were: a. On 6/21/18 Work Order # was created to address the problem of, floor tiles need repair. The Dietary Manager requested the work order and it was closed out by the Maintenance Director on 6/22/18. b. On 7/13/18 Work Order # was created to address, kitchen sink leaking. It was created and closed out on 7/13/18 by the Maintenance Director. c. On 8/22/18 three work orders were created as follows: Work Order # was created to address, sink needs silicone; Work Order # was created to address, tile loose; Work Order # was created to address, clean behind dishwasher. All three work orders were created and closed out on 8/22/18 by the Maintenance Director. d. On 9/7/18 Work Order # was created to address, kitchen sink is clogged. It was created and closed out on 9/7/18 by the Maintenance Director. The weekly Cleaning Checklists for (MONTH) (YEAR) were reviewed. The document consisted of a table with the cleaning items individually listed in the first column. There was a column for each day from Sunday through Friday (no column for Saturdays). Staff was to mark a check for the items cleaned on the designated days. The last column was titled assigned. None of the documents indicated who was assigned or who completed the assignments (documented the check mark). Review of the weekly Cleaning Checklists showed many assignments were not checked as having been completed: a. Clean all shelf (Rack) and carts - This was not documented as being checked off for any of the 24 days reviewed. b. Rolling racks and carts need cleaning: AM & PM - This was documented as having been cleaned 16 times during the 24 days reviewed. The Cleaning Checklists did not include cleaning the floor, cleaning the dish machine area, or deliming the dish machine. The Dietary Manager was asked for the kitchen sanitation policy. The Dietary Manager provided a one-page, undated document titled Weekly Dietary F-Tags Review and indicated this was the sanitation policy. The document included 24 areas to be audited for kitchen sanitation with a column in which a yes-or-no could be checked. If the answer was No on the audit sheet, the corrective action was to be documented. The document included auditing areas of: dietary staff verbalizing corrective actions for unacceptable temperatures or parts per million; kitchen equipment being clean, grease free, dust free, free from carbon build-up, and in good repair, kitchen floors being clean, free from grease and debris; walls and vents being clean, grease free, and dust free; all dishes and utensils being intact, not chipped or cracked, stored clean and free from build-up; and the department cleaning schedule posted and complete. The undated Dishwashing (mechanical) Policy indicated the kitchen would wash, rinse and sanitize dishware after each meal. The procedure included: scraping waste off dishes, ; rinsing dishes thoroughly; loading dishes into appropriate rack; loading dish rack into dishwashing machine; allowing dishes to dry on racks; removing dishes and inspecting for cleanliness and dryness and putting away clean dishes. Staff was also directed to monitor and record dish machine temperatures to ensure proper sanitization and using a chlorine test strip to ensure adequate parts per million. The Dietary Director or designee was directed to spot check and log temperature and ppm readings prior to each usage.

Based on policy and manual review, record review, and interview, the facility failed to ensure one resident (R#36) out of four residents reviewed for falls received adequate supervision and assistive devices to prevent accidents. On 6/29/18 R#36 experienced a fall from a mechanical stand-up lift that was operated by two Certified Nurse Assistants (CNAs) resulting in the resident hitting her head. The facility failed to investigate this fall to determine the circumstances and take corrective actions. Therefore, there was a lack of evidence to show interventions were put in place to address the root cause of the fall. This failure jeopardized the safety of R#36 and other residents being transferred using the stand-up mechanical lift. Findings include: Review of the Fall Policy revealed the following: The Fall Management Standard of Practice dated 11/15/07, revealed the standard was to, Identify residents at risk for falls and implement interventions to minimize fall occurrences and injury related to falls . Practice guidelines included the following requirements: 2. A Fall Risk Evaluation and Care Plan will be completed when the resident is identified to be at risk for falls or has had a fall to ensure that appropriate interventions are put into place . 3.3.1 A colored leaf shall be placed outside the resident's room by their name; 3.3.2 A colored leaf shall be placed above the resident's bed . 4. The Fall Risk Evaluation and Care plan is (sic) revised after each fall. 2. The User Manual Stand Up Patient Lift RPS350-1 for the SARA lift indicated the following requirements: a. Under the heading of Using the Sling, Stand Assist Slings: Before lifting the patient, make sure the bottom edge of the stand assist sling is positioned on the lower back of the patient and the patient's arms are outside the stand assist sling. Stand Assist Slings: The belt MUST be snug, but comfortable on the patient, otherwise the patient can slide out of the sling during transfer, possibly causing injury . Be sure to check the sling attachments each time the slings removed and replaced, to ensure that it is properly attached before the patient is removed from a stationary object (bed, chair or commode). b. Under the section Lifting the Patient, the user manual read, Individuals that use the standing patient sling MUST be able to support the majority of their own weight, otherwise injury may occur . DO NOT move the patient if the patient sling is not properly connected to the attachment points of the patient lift. Check that the patient sling is properly connected to the attachment points BEFORE lifting the patient. c. Under the heading of Transferring the Patient, the user manual indicated, DO NOT move the patient if the sling is not properly connected to the attachment points of the stand-up lift. Check that the sling is properly connected to the attachment points prior to lifting a patient. If any attachments are not properly in place, correct the problem. d. Under the heading of Performing Maintenance, the user manual indicated regular maintenance was required to assure proper operation. This included inspecting all pivot points and fasteners for wear and checking casters and axle bolts every six months to check for tightness and wear. R#36 was admitted to the facility on [DATE]; her [DIAGNOSES REDACTED]. The 6/19/18 Significant Change Minimum Data Set (MDS) under the Hearing, Speech and Vision section revealed the resident's speech was unclear. Under the Cognitive Patterns section, the resident was documented with a Brief Interview for Mental Status (BIMS) score of 9 out of a total of 15 which indicated she was moderately impaired in cognition (score of 8 - 12). Under the Functional Status section, the resident was documented as requiring extensive staff assistance for bed mobility, dressing, toilet use, and hygiene. The resident was documented as being totally dependent on two staff for transfers. The resident was recorded as not walking during the assessment period and for transfers between the bed and chair or wheelchair, being unsteady and only able to stabilize with human assistance. Under Range of Motion, the resident was documented with upper extremity limitation on one side and lower extremity limitation on both sides. The resident was documented as not having any falls since the previous MDS assessment. Review of the Resident Handling Evaluation dated 5/2/18, revealed the resident had a history of [REDACTED]. Review of the 6/10/18 Fall Risk Evaluation indicated the resident's fall risk score was 14, indicating she was at high risk for falls (score > 10 indicating high fall risk). Risk factors included ambulation and incontinence status, balance problem while standing, balance problem while walking, decreased muscular coordination, required use of a wheelchair, prescription of medications - hypoglycemic, antihypertensive, narcotic, and [MEDICAL CONDITION] medications, and pre-disposing diseases [MEDICAL CONDITIONS]. Review of the care plan revised on 5/30/18 revealed the resident was at risk for falls due to a history of falls, limited mobility, and medication use. The goal was, I will have falls and/or injuries minimized thru (sic) management of risk factors while maintaining maximum independence and quality of life through review date. Interventions included anticipating and meeting the resident's needs, assisting with activities of daily living (ADLs) as needed, placing on the fall program, and referring to maintenance for necessary equipment repair. The care plan revised on 5/30/18 for the problem of limited physical mobility directed staff to use the SARA lift for transfers. Review of a Progress Note written by Licensed Practical Nurse (LPN) AA for the fall occurring on 6/29/18 read in full, Resident fell from SARA lift approximately 10:40 am witnessed fall by 2 CNAs. No noticeable injuries but resident stated that she felt like[***] Vital signs BP (blood pressure) 145/68, P (pulse) 76, T (temperature) 97.5, R (respiration) 18. Resident was reported to have hit the back of her head on the corner of her bed during the fall. CNAs lifted resident with MAXI lift (mechanical lift) and resident wanted to go out to front porch for a while. Resident observed to be doing well at this time. The #629 Witnessed Fall report revealed the fall occurred in the resident's room on 6/29/18. Under the heading of Nursing Description, the report documented in full, Resident observed on the floor. Statement from witness was that the resident slid out of SARA lift to the floor hitting the back of her head on the footboard of the bed. Under the heading of Immediate Action Taken, the report indicated the resident was transferred with the Maxi lift to the wheelchair by the CNAs. Vital signs and neuro checks were done. The resident was noted to have a small knot on back of head presumably from where she hit her head on the footrest of the bed. The resident was to be evaluated for handling status. Neither the 6/29/18 nursing Progress Note nor the #629 Witnessed Fall report included information regarding how the resident slid out of the lift which had safeguards in place to prevent such an incident. There was no information such as whether the belt around her torso was sufficiently tight, whether she was unable to bear weight and stand and as a result slid out during the transfer, whether the sling was correctly hooked to both sides of the lift, whether the resident raised her arms during the transfer, and the sling slid over her head, or whether there was an equipment malfunction with the lift or sling causing the resident to slip to the floor. There was no information from the CNAs who transferred the resident to illustrate what happened or where they were in the room during the transfer. There were no witness statements from the CNAs. The root cause of the fall was not determined. A Neurological Assessment initiated on 6/29/18 at 10:40 a.m. revealed the resident's neurological signs were checked for 72 hours following the fall in accordance with the instructions on the form with no adverse outcome noted. However, a new Fall Risk Evaluation was not completed following the fall on 6/29/18 in accordance with the Fall Management Standard of Practice dated 11/15/07. Review of the Resident Handling Evaluation dated 7/2/18 revealed the resident was re-evaluated for the use of the lift due to the fall that occurred on 6/29/18. The resident was assessed being appropriate for the SARA lift. The resident's care plan for fall risk was updated on 7/2/18. The only information added was documentation of a fall occurring on 6/29/18. No new interventions were added per the facility's Fall Management Standard of Practice dated 11/15/07, to show appropriate interventions were identified and implemented to minimize fall related to the SARA lift. Review of Maintenance Work Orders regarding the mechanical lifts from 9/2/17 through the 9/27/18 revealed there had been no evaluation of the SARA lift in response to the resident's fall on 6/29/18. The Maintenance Director provided a Work History Report from 9/2/17 - 9/29/18. The report indicated the lifts were inspected on a weekly basis. An attempt to interview R#36 was made on 9/26/18 at 4:22 p.m. in her room. The resident shook her head up and down to indicate Yes she remembered the fall from the SARA lift. However, the resident was not able to verbalize what happened. The resident's speech was unclear and was barely audible. Although there was a paper leaf on the wall above the resident's bed, there was no leaf on the door into the room in accordance with the Fall Management Standard of Practice dated 11/15/07. Interview with the Maintenance Director was conducted on 9/27/18 at 12:12 p.m. in the surveyor conference room. The Maintenance Director stated he inspected the lifts once a week which included the wheels, batteries, bearings, and boon. He stated it was recorded in the computerized maintenance system that tracked maintenance requests and the work completed. He stated he had replaced casters and the hand pin controller on the SARA lifts indicating there were two SARA lifts in the facility. He stated he had replaced the motor on one of them. When asked if there had been any issues with the SARA lifts not functioning properly during transfers, or if he had inspected the lift following R#36's fall on 6/29/18, he stated he was not aware of any specific issues with the SARA lift causing a fall and had not inspected it because of a specific fall. The Administrator and Director of Nursing (DON) were interviewed together on 9/26/18 at 3:44 p.m. in the Administrator's office. The Administrator stated she did not know what happened during R#36's fall from the SARA lift on 6/29/18. The Administrator stated the facility did not always have witness statements (when asked for witness statements from the two CNAs involved in the fall) when falls occurred. The Administrator stated the interdisciplinary team would have talked it over after the stand-up meeting the next day. The DON stated two CNAs transferred the resident to the bed and stated the resident was acutely ill at the time of the fall on 6/29/18. The DON stated when the resident was transferred to the bed, and she slipped to the floor. The DON stated if the resident was ill and could not bear weight, she could fall out of the lift. The DON stated the resident was safe again for transfer using the SARA lift and had been evaluated since the fall. When asked if it was an error on the part of the CNAs regarding the transfer on 6/29/18 or an equipment malfunction, the DON stated, I cannot say what happened. The Administrator was asked for the contact information of the two CNAs who were transferring the resident with the SARA lift and the contact information for LPN AA who completed the assessment/wrote the nursing note on 6/29/18. The Administrator provided the contact information for CNA BB and LPN AA. However, the Administrator stated on 9/27/18 at 2:58 p.m. that she was not sure who helped CNA BB with the SARA lift transfer on 6/29/18. The Administrator stated she looked at the schedule and could not determine if LPN AA helped CNA BB transfer the resident or if it was another CNA. CNA EE was interviewed on 9/26/18 at 4:25 p.m. in the shower room on 200 hall. CNA EE demonstrated how the SARA lift worked. When asked how a resident could slip out of the lift, she stated, A resident could slip out if the sling unbuckled during the transfer or if it was not buckled to start with. When asked if she had been in-serviced about how to use the SARA lift after R#36's fall on 6/29/18, she stated she had not. She stated she had heard that R#36 fell during a transfer but did not know how. Two unsuccessful attempts were made to interview CNA BB via telephone on 9/27/18 at 10:24 a.m. and again and 2:39 p.m. CNA BB did not answer the phone and voicemail was not set up; the surveyor could not leave a message. LPN AA was interviewed on 9/27/18 at 3:20 p.m. via telephone. She stated she was working on 6/29/18 when R#36 fell while being transferred with the SARA lift and documented what happened in the nursing notes on 6/29/18. When asked who the two CNAs were and how the resident sustained [REDACTED]. LPN AA stated she did not know who was helping CNA BB complete the transfer and stated she was not present when the fall occurred. LPN AA said she tried to find out what happened when falls occurred; in this instance, however, she verified that she did not find out the details regarding how the fall occurred. LPN AA stated she did not know if the fall was due to error on the part of the CNAs, due to equipment malfunction, or due to another cause. Registered Nurse (RN) CC, the Restorative Coordinator was interviewed on 9/27/18 at 11:33 a.m. in the surveyor conference room. RN CC stated there should always be two staff when the SARA lift was used. She explained how the transfer should be conducted: the belt should be fastened around the resident's torso, staff should make sure it was snug, the resident's arms should be on the outside of the sling and the resident should hold onto the bar. Both sides of the sling should be placed over the hooks on the top bar, one staff is the spotter, one staff operates the control which lifts the resident up. The resident should have her feet on the tray and stand as the lifting occurs. The spotter is responsible for staying beside the resident in case the resident moves around during the transfer. The spotter should have their hand on the resident's back during the transfer and is the designated safety person who could assist in lowering the resident if a fall occurred. RN CC stated the resident had to be able to bear some weight for a successful transfer. When asked how a resident could slip out during a transfer, she stated a resident could slip out if they lifted their arms up, the sling could go over their head and come off. RN CC stated she had never heard of this or seen this occur before. RN CC also stated if the resident pulled their arms over the straps or if straps came undone they could fall. RN CC stated if the sling was clipped on both sides at the top, even if a resident could not bear weight, the clips would hold the resident if he or she could not bear weight if the sling around the resident's torso did not come unfastened. RN CC stated she had completed the Resident Handling Evaluation dated 7/2/18 after the R#36's fall on 6/29/18. RN CC stated she was present at the interdisciplinary review of the fall that occurred the day after the fall. She stated the interdisciplinary team and nurse were responsible for coming up with interventions following a fall. She stated she did not know how the resident slipped out of the lift and verified it would have been helpful to know the details of the fall when coming up with an appropriate intervention. RN CC stated CNAs were educated on lifts when they were hired and annually. RN CC stated restorative aides were responsible for checking the condition of the slings weekly. RN CC and the restorative aide/CNA DD reviewed the condition of all four SARA lift slings during this interview time, and they were all in satisfactory condition. CNA DD verified the restorative aides checked the condition of the slings weekly. The Restorative aide was interviewed on 9/26/18 12:01 p.m. during the review of SARA lift slings in the shower rooms. When asked how a resident could fall out of the SARA lift, she stated the belt around the resident's torso could come over his or her head if the buckle unlocked or if the resident put his or her arms up and slipped out. She stated she did not know what happened with R#36's fall. When asked if CNAs were in-serviced following R#36's fall, she stated there had not been any in-services on the SARA lift. During an interview on 9/27/18 at 11:11 a.m. in the Administrator's office, the Administrator stated, We started education for CNAs related to the lift use last night (9/26/18). The Administrator stated R#36 currently used the SARA lift because the Maxi lift was more restrictive, and the resident was able to use the SARA lift safely. The Administrator provided the Individual Competency Validation Record for CNA BB which showed she had been checked off as competent for transfer techniques on 5/29/18. Because the identification of the second staff involved in the transfer on 6/29/18 was unknown, their Individual Competency Validation Record was not provided.