Every finding on record at Pruitthealth - Franklin

Based on observations, staff interviews, and review of facility policy titled Medication Storage in Healthcare Centers, and Medication Administration: Insulin Injections, the facility failed to ensure insulin pens were labeled with correct use by dates in two of three medication carts. This deficient practice had the potential to result in the administration of expired insulin and adverse clinical outcomes.Findings Include:Observation and interview on [DATE] at 9:50 AM of the nurse's medication cart with Licensed Practical Nurse (LPN) AA on Hall 3 and Hall 4 revealed two insulin pens (Insulin Glargine-Lantus and Insulin Lispro-Humalog) stored in individual packaging bags with attached prescription labels. Review of the manufacturer and prescription labeling confirmed insulin pens were to be discarded 28 days after opening. The pens had handwritten open dates of [DATE] and handwritten discard dates of [DATE]. Based on the 28-day manufacturer recommendation, the correct discard date should be [DATE], however, the pens were labeled with a discard date exceeding this timeframe. During the observation, LPN AA was unable to verify the correct beyond-use dating and requested assistance from the Infection Preventionist (IP). The IP reviewed the pens, confirmed the labeling was incorrect, and stated that insulin beyond the 28-day open period may have reduced effectiveness and should not be administered, and proceeded to correct the dates on the pens.Observation and interview on [DATE] at 10:06 AM of the nurse's medication cart with the IP on Hall 3 revealed one insulin pen (Insulin Glargine-Lantus). Review of the manufacturer labeling indicated insulin pens are to be discarded 28 days after opening. The pen had handwritten open date of [DATE] and handwritten discard date of [DATE]. Based on the 28-day manufacturer recommendation, the correct discard date should be [DATE]. During the observation, the IP reviewed the pen, confirmed the labeling was incorrect, and proceeded to correct the date on the pen.Interview on [DATE] at 12:59 PM with the Director of Health Services (DHS) revealed that insulin pen labeling is to be done upon opening, The DHS stated staff are expected to document the open date and calculate a beyond-use date of 28 days. A reference chart is now available to guide staff and further emphasized that insulin should not be used beyond the expiration or beyond-use date.Review of the facility's policy titled Medication Storage in Healthcare Centers, revised [DATE], documented under section Procedures item 11. Multi-dose containers of injectables . are to be dated (when opened). Except where manufacturer recommendations require shorter expiration date . will expire according to the manufacturer's expiration date.Review of the facility's policy titled Medication Administration: Insulin Injections, reviewed [DATE], documented under section Procedure and Key Points item 5. Obtain insulin from the refrigerator . (if vial or pen is being opened for the first time, make sure the date is noted on the date opened/date expired label attached to the insulin vial or pen). If insulin will be used in less than 28 days, it may be stored unrefrigerated on the med cart.Review of the Lantus (insulin glargine injection) package insert on page 11 under the title After Lantus vials have been opened (in-use), provided by the facility documented Store in-use (opened) Lantus vials . at room temperature . for up to 28 days and The Lantus vial you are using should be thrown away after 28 days or if the expiration date has passed, even if it still has insulin left in it.Review of the Humalog (insulin lispro injection) package insert under the title How should I store Humalog?, provided by the facility documented Store opened vials . at room temperature . for up to 28 days and Throw away all opened vials after 28 days of use, even if there is insulin left in the vial.

Based on observations, staff interviews, record review, and review of the facility documents Infection Prevention and Control Plan, Dressing a Wound, and Catheter Care-Foley Catheter, the facility failed to ensure correct infection control practices were implemented. Specifically, staff failed to appropriately dispose of sharps, maintain aseptic technique during wound care, and ensure proper positioning of an indwelling bladder (Foley) catheter collection bag for one resident (R) (R42) from a sample of 32 residents. The deficient practice increased the risk of cross-contamination and infection transmission among residents and staff.Findings Include:Observation on 04/14/2026 at 11:14 AM of R42 in room [ROOM NUMBER] revealed the Foley catheter drainage bag positioned next to the bed touching the floor. Observation and interview on 04/14/2026 at 11:24 AM with Registered Nurse (RN) Unit Manager CC confirmed the catheter drainage bag was on the floor. RN CC stated this was an infection control concern and that the catheter bag should be properly positioned and attached to the bed frame. RN CC stated she would address the issue with the Certified Nursing Assistant (CNA).Observation on 04/15/2026 at 11:16 AM during a blood glucose monitoring procedure with Licensed Practical Nurse (LPN) FF revealed that after completing the procedure, the nurse removed personal protective equipment (PPE) and discarded all used supplies, including a used lancet, into the resident room trash receptacle rather than an approved sharps container. Interview with LPN FF confirmed she disposed of the lancet into the resident's trash and then retrieved the lancet and disposed of it into the sharp's container.Observation and interview on 04/15/2026 at 1:27 PM with LPN II during wound care revealed the clean field was not fully maintained, as portions of the bedside table used to place clean supplies were left uncovered resulting in clean gauze and applicators touching uncleaned portions of the table. In addition, the bedside table was not disinfected after the procedure with items used during the treatment procedure returned to the treatment cart. Specifically, a disinfectant wipe container was returned and unused supplies (4x4 gauze in a paper container) were returned to the treatment cart after being placed on an uncovered surface and handled with contaminated gloves. Interview with LPN II confirmed the bedside table was not disinfected after use, the disinfectant container was not cleaned prior to return to the treatment cart, and supplies that had been placed on the uncovered surface and handled with contaminated gloves were returned to the inside of the treatment cart. LPN II acknowledged these practices were not consistent with infection control standards.Review of the electronic medical record (EMR) revealed R42 was admitted to the facility on [DATE] with pertinent diagnoses including but not limited to urinary retention with indwelling Foley catheter, recurrent urinary tract infections, obstructive and reflux uropathy, generalized weakness, history of cerebrovascular accident with right-sided hemiparesis, and impaired mobility.Review of R42 quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated little to no cognitive impairment. Section H: Bowel and Bladder revealed R42 required an Indwelling Urinary Catheter and was frequently incontinent of bowel.Review of the care plan dated 03/25/2026 for R42, documented a problem of indwelling urinary catheter related to obstructive and reflux uropathy and infection risk. Goals included, but were not limited to, maintaining appropriate catheter care with no signs or symptoms of infection or urethral trauma. Interventions included, but were not limited to, ensuring the drainage bag remained below the level of the bladder, not allowing the catheter or drainage system to touch the floor, providing catheter care, and monitoring for signs and symptoms of urinary tract infection.Review of the Physician's Orders for R42 included but was not limited to:Order dated 03/06/2026 for placement of an indwelling urinary catheter (18 Fr {French} with 10 cc {cubic centimeter} balloon).Order dated 08/29/2025 for implementation of Enhanced Barrier Precautions related to Foley catheter use.Interview on 04/16/2026 at 12:59 PM with the Director of Health Services (DHS) revealed that Foley catheter drainage bags are expected to be positioned below the level of the bladder, secured to the bed or wheelchair, and maintained off the floor to reduce the risk of infection. The DHS stated staff are responsible for ensuring proper catheter positioning in accordance with infection control standards. Regarding sharps disposal, the DHS stated all used sharps, including lancets, must be discarded in designated sharps containers to prevent exposure and injury. In relation to wound care, the DHS stated that staff are expected to adhere to infection control practices to prevent contamination of wounds.Review of the facility's policy titled Infection Prevention and Control Plan, reviewed 11/17/2025, documented .The goals of the program are to decrease morbidity/mortality attributable to infections in residents; prevent and control outbreaks of infection in residents.maintain resident functional status; maintain optimal social environment for residents. Under section Program Objectives item 6. Review and evaluation of aseptic technique, implementation of transmission precautions and high-risk infection control procedures employed in the facility and develop control measures to prevent or minimize transmission of infections. Item 7. Surveillance activities to identify opportunities for the risk of blood/body fluid exposure in partners and implementation of methods for reducing the risks of exposure.Review of the facility's process titled Dressing a Wound, dated 2017, documented the title Supplies and description Assemble supplies on a protective barrier on a bedside table. Further review of the title Clean-up with description Clean reuseable equipment and return supplies to storage. Discard disposable supplies. Clean and disinfect any contaminated surfaces.Review of the facility's process titled Catheter Care-Foley Catheter, dated 2024, revealed the title Catheter Position and description .Coil the tubing on the bed, check for kinks, and ensure the drainage bag is below the bladder.

Based on record review, staff and resident interviews and review of facility process titled Matrix Care: Social Services Director/Social Services Coordinator, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) Level two was submitted for one of 32 residents (R) (R21) reviewed for PASARR II. This deficient practice had the potential to place R21 at increased risk of not receiving required behavioral health support to meet their daily needs. Findings include: Observation and interview on 04/15/2026 at 10:31 AM with R21 revealed that she meets with a psychotherapist weekly, on Tuesdays, and is currently being prescribed medications for her mood. Review of the electronic medical record (EMR) revealed R21 was admitted to the facility on [DATE], with pertinent diagnoses including but not limited to bipolar disorder, mood disorder due to known physiological condition, anxiety disorder, depression, and insomnia.Review of R21's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated little to no cognitive impairment. Section J (Health Conditions) documented diagnoses including anxiety disorder, bipolar disorder, depression, and mood disorder due to a known physiological condition. Section N (Medications) indicated the resident was receiving both antipsychotic and antidepressant medications.Review of R21's care plan dated 03/02/2026, documented problems including behavioral symptoms, resistance to care, use of psychotropic medications, and pain management needs. Goals included reducing maladaptive behaviors such as threatening, yelling, or cursing at others; minimizing refusal of care, and preventing harm to self or others related to refusals, with continued management of bipolar disorder through prescribed medications. Interventions included reducing environmental stimulation (e.g., noise, crowding), maintaining a calm and structured environment, using a calm and acceptance-based communication approach, avoiding triggering topics, and encouraging expression of feelings while clarifying misunderstandings. Additional interventions included setting clear boundaries, educating the resident on disease processes and consequences of noncompliance, monitoring reasons for refusal (e.g., pain, fear, cognition), reinforcing treatment compliance, and utilizing psychiatric consultation and psychosocial therapy as needed. Medication management interventions included administering medications as ordered, monitoring for side effects, implementing non-pharmacological approaches, and completing pharmacist medication reviews.Review of the Physician's Orders for R21 included but was not limited to:Order dated 04/10/2025 for divalproex 125 mg {milligrams} tablet at bedtime for mood disorder due to known physiological condition.Order dated 05/27/2025 for lamotrigine 50 mg once daily for mood disorder due to known physiological condition.Order dated 05/27/2025 for Vraylar 1.5 mg capsule once daily for bipolar disorder.Order dated 08/13/2024 for melatonin 9 mg at bedtime for insomnia.Order dated 08/05/2024 for Behavior Monitoring: includes tracking mood (sad, anxious), aggression, hallucinations, delusions, insomnia, etc. Also included monitoring for psychotropic side effects (e.g. sedation, confusion, EPS {extra pyramidal side effects}).Review of R21's Social Services progress notes from August 2024 through present revealed a history of significant behavioral symptoms, including combative behavior toward staff and roommate, verbal aggression, refusal of medications and care, and interpersonal conflict. Documentation indicated the need for ongoing interdisciplinary team (IDT) involvement, behavior management programming, and continued psychiatric services. Further review revealed R21 continues to receive behavioral health services, including psychotherapy and psychotropic medication management, indicating ongoing mental health needs.Review of facility PASARR tracking documentation and census listing for PASARR Level II determinations revealed R21 was not included on the facility's PASARR Level II tracking list. Review of the EMR also failed to reveal evidence that a PASARR Level II evaluation or determination had been completed for R21.Interview on 04/15/2026 at 12:28 PM with the Social Services Director (SSD) revealed that she was not aware of or responsible for PASARR coordination and referred responsibility to the Director of Health Services (DHS). Interview on 04/15/2026 at 12:32 PM with the DHS revealed he was not responsible for PASARR coordination and indicated he would determine the responsible staff member.Follow-up interview on 04/15/2026 at 1:26 PM with the DHS revealed the Social Services Director is responsible for PASARR coordination. DHS further indicated the Social Services Director was informed of this responsibility on this date. DHS confirmed that R21 did not have a PASARR Level II evaluation completed; however, a referral for PASARR Level II was initiated following identification of the concern.Review of the facility process titled Matrix Care: Social Services Director/Social Services Coordinator, updated 01/27/2025, section Admission revealed From Admissions list, review patients that admitted to the facility with a mental health diagnosis, psychotropics and antipsychotic medications. If they do, they will be added to your Behavior Management Program (Ensure that those patients have been submitted for a PASSR II, if not complete one). Further review of section PASRR/PASARR Level II revealed When there has been a new mental health diagnosis identified OR when the Level I prompts a Level II, the SSD must follow and complete the requests from the requesting organization.

Based on observations, staff and resident interviews, record review, and review of facility policies titled Occurrences, and Medication Administration: General Guidelines, the facility failed to maintain an environment free of accident hazards for two of 32 sampled residents (R) (R55 and R6). Specifically, the facility failed to ensure the environment was free of ingestible hazards including nail polish remover and prescription medications readily accessible to residents. The deficient practice increased the risk of accidental ingestion with injury.Findings include:Observation made on 04/14/2026 at 10:23 AM, in room [ROOM NUMBER] belonging to R55 revealed a single unidentified tablet on the overbed table, not contained in a medication cup and left unattended.Observation and interview on 04/14/2026 at 10:26 AM with Registered Nurse (RN) BB confirmed the presence of the tablet at the bedside. RN BB stated she believed the medication to be senna but was uncertain. RN BB acknowledged that medications should never be left unattended at the bedside and must be administered to the resident with appropriate documentation of administration. RN BB further stated that leaving medications at the bedside presents a safety concern, particularly as some residents may wander and could access unsecured medications. RN BB removed the tablet from the overbed table and stated it would be discarded in the medication waste container.Observation made on 04/14/2026 at 11:01 AM, in room [ROOM NUMBER] belonging to R6 revealed a bottle of acetone (nail polish remover) on the countertop at approximately waist height, accessible to residents.Observation and interview on 04/14/2026 at 11:06 AM with RN BB confirmed the presence of the acetone bottle. RN BB stated the item should be out of reach, but was unsure whether it was included on the facility's exclusion or hazardous items list and stated she would confer with the Unit Manager for clarification.Interview on 04/14/2026 at 11:08 AM with RN Unit Manager CC revealed she was unaware the acetone bottle was present and accessible in the room. RN CC stated the item should be secured or placed out of reach immediately.1. Review of the electronic medical record (EMR) revealed R55 was admitted to the facility on [DATE] and pertinent diagnoses including but not limited to dysphagia following cerebrovascular accident (oropharyngeal phase), aphasia, hemiplegia and hemiparesis affecting the right dominant side, generalized muscle weakness, and history of repeated falls.Review of R55's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 2, which indicated severe cognitive impairment.Section GG, functional status, revealed R55 was impaired on one side for both upper and lower extremities and required extensive assistance for activities of daily living (ADLs).Review of the care plan for R55, revised 03/23/2026 documented Problem included but not limited to Cognitive Loss/Dementia, Goal that included, but not limited to resident will have positive experiences in daily routine, and Approach included but not limited to respect resident's rights to make decisions, Review of the Physician's Orders for R55 included but was not limited to:Order dated 09/06/2022 for Medication Note: Resident takes medication crushed.2. Review of the EMR revealed R6 was admitted to the facility on [DATE] with pertinent diagnoses including but not limited to encephalopathy, history of {Transient Ischemic Attack} TIA/cerebral infarction without residual deficits, dysphagia (oral and oropharyngeal phases), generalized weakness, difficulty walking and unsteadiness on feet, and obesity.Review of R6's quarterly MDS assessment dated [DATE] revealed a BIMS score of 9, which indicated moderate cognitive impairment.Review of the care plan for R6, revised 03/27/2026 documented Problem included but not limited to Cognitive Loss/Dementia, Goal that includes, but not limited to resident will have positive experiences in daily routine, and Approach included but not limited to respect resident's rights to make decisions. Interview on 04/16/2026 at 12:59 PM with the Director of Health Services (DHS) revealed that medications must be administered by the nurse, who is responsible for remaining with the resident until the medication is swallowed. This ensures the medication is taken as prescribed and prevents access by other residents, particularly roommates who may be mobile. The DHS stated hazardous items such as nail polish remover found in resident rooms are expected to be removed immediately upon discovery and that these items pose a safety risk, as residents could access and potentially ingest or misuse them.Review of the facility provided list of wandering residents documented two residents identified for risk of wandering.Review of the facility's policy titled Occurrences, reviewed 11/17/2025, documented The healthcare center recognizes that due to the frailty of the patients/residents served, there is an increased risk of occurrences that may result in injury to the patient/resident and/or others. To prevent occurrences, each patient/resident will be observed and assessed for risks. Appropriate, realistic interventions will be implemented in accordance with their plan of care.Review of the facility's policy titled Medication Administration: General Guidelines, reviewed 07/28/2025, documented under section Procedure item 2. Medications are administered in accordance with written orders of the attending physician. Further review of item 4. Medications are administered at the time they are prepared.Only one patient/resident's medications are prepared and administered at a time.

Based on record review and review of the facility policy titled, Care Plans, the facility failed to develop a care plan for one of 35 sampled residents (R) (R14) to include physical therapy discharge recommendations. Findings include: A review of the facility policy titled, Care plans revealed under Care Plan Review and Update . 2. Updates to the care plans should be made with any changes in condition at the time the change in condition occurred. For MatrixCare users, all updates are made electronically. Review of R14 care plan dated 12/26/2024 indicated a problem of R14 at risk for falling R/T Cerebral Palsey(sic)/impaired mobility. Goals include R14 will remain free from injury. Approach(s) include keep call light in reach while in bed, observe changes in resident's condition that may warrant increased supervision, observe frquently (sic) when OOB in chiar (sic). There was nothing found in the care plan regarding Physical Therapy's (PT) recommendations. Review of the PT discharge evaluation dated 8/21/2019 documented the following, GOAL MET - on 8/21/2019. The patient tolerates upright sitting in personal custom tilt manual wheelchair maintaining proper midline body alignment for 180 minutes or greater daily without negative skin changes. The following documented discharge plans and instructions, Discharge planned for this patient. Recommendations discussed with Nursing caregivers include continued OOB (out of bed) daily to pt's (patient's) personal seating/positioning system tilt manual w/c (wheelchair) with checks every hour for any seating needs and for tilting w/c to various angles for pressure reliefs. Cross reference to F688

Based on observations, staff interviews, record review, and review of the facility policy titled, Restorative Nursing Program, the facility failed to ensure one of 35 sampled residents (R) (R14) did not have a reduction in range of motion due to the facility not providing custom equipment post discharge from physical therapy services. Findings include: A review of the facility policy titled Restorative Nursing Program revised 11/4/2021 documented under Policy, It is the policy of this healthcare center to provide restorative nursing which actively focuses on achieving and maintain optimal physical, mental and psychological functioning and well-being of patient/resident. Review of the electronic medical record (EMR) revealed R14 was admitted to the facility with diagnoses including but not limited to cerebral palsy (primary admission contracture, left wrist, contracture, left hand, contracture, right hand, contracture, right wrist, abnormal posture, pain, unspecified, and muscle weakness (generalized). Review of R14's annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99, which indicates R14 was unable to finish the assessment due to being unable to respond. Section GG, functional status, revealed R14 was dependent on staff due to upper extremities impairment on both sides, lower extremities impairment on one side and benefits from the use of a wheelchair (manual). R14 is dependent on staff in all areas. Review of R14's care plan dated 12/26/2024 indicated a problem of requires total assist with ADL's (activities of daily living) R/T (related to) Cerebral Palsey (sic). Goals included but not limited to [R14] will be kept clean/dry with neat appearance. Approach included but not limited to 1/4 side rails for turning and positioning, 2 person assist (sic) with mechanical lift, Call light within reach while in bed, NPO receives Tube feeding, Total care needed with ADL's, uses geri-chair when OOB ( out of bed). (Activities) Problem of has limited participation in activities r/t impaired mobility/speech. Goal R14 will participate in activities of his liking. Approach(s) of assit (sic) resident to activities when he is OOB, provide setting in which activities are preferred own room, day room, likes to watch cartoons, visit in room [ROOM NUMBER]:1 when resident is not oob. Problem of R14 at risk for falling R/T Cerebral Palsey (sic)/impaired mobility. Goal includes R14 will remain free from injury. Approach(s) include keep call light in reach while in bed, observe changes in resident's condition that may warrant increased supervision, observe frquently (sic) when OOB in chiar (sic). Review of the physical therapy discharge evaluation dated 8/21/2019 documented the following, GOAL MET - on 8/21/2019. The patient tolerates upright sitting in personal custom tilt manual wheelchair maintaining proper midline body alignment for 180 minutes or greater daily without negative skin changes. The following documented discharge plans and instructions, Discharge planned for this patient. Recommendations discussed with Nursing caregivers include continued OOB daily to pt's personal seating/positioning system tilt manual w/c (wheelchair) with checks every hour for any seating needs and for tilting w/c to various angles for pressure reliefs. Observation on 3/4/2025 at 2:32 pm of R14 in his room in the bed revealed he had a cushion that was on the side dresser near the bed. There was no w/c in room at the time. Observation on 3/5/2025 at 11:30 am, observed R14 in their room, in bed watching tv. Observed no w/c in the room. Observation on 3/6/2025 at 1:53 pm, observed R14 in their room, in bed sleeping. Observed no w/c in the room. Interview on 3/6/2025 at 10:30 am with Certified Nursing Assistant (CNA) FF revealed she made sure to check on R14 at least every hour to every hour and a half to make sure he was dry and that his feeding was going. She revealed he did have a wedge, but he did not get up and get in his chair unless he was going to the doctor or the shower. Interview on 3/6/2025 at 1:49 pm with CNA FF revealed R14's w/c was in his closet. Observation on 3/6/2025 at 1:53 pm revealed a manual [facility name] w/c in R14's closet. Interview on 3/6/2025 at 11:33 am with Licensed Practical Nurse (LPN) DD revealed R14 did not get out of bed, but there was no particular reason why at the moment. LPN DD went on to reveal R14 got out of bed to get a shower and that was it. At 1:42 pm LPN DD revealed she did not know where R14's w/c was. Interview on 3/6/2024 at 12:09 pm with CNA II and CNA JJ revealed they were restorative CNA's, and therapy would assign to them what they needed to do daily. The therapist would then show them what to do that was resident specific. The CNA's revealed R14 did not do anything with therapy because he was not on restorative, but he had soft splints for his hands. Interview on 3/6/2025 at 12:15 pm with the Physical Therapist (PT) KK revealed she had worked with R14 regarding positioning so he could safely transfer to the geri-chair (medical recliner) and or shower as well as getting out of bed. She further revealed even though R14 was discharged from physical therapy, the recommendations were implemented immediately and expected to be put in place indefinitely unless a licensed nurse deemed the recommendations to be inappropriate or the recommendations caused harm, at which point the licensed nurse would recommend the resident get an assessment for services again. Interview on 3/6/2025 at 1:32 pm with LPN Unit Manager (AA) revealed R14 did not have a w/c but if they got him up they would get him up in his geri-chair. She revealed she had never seen a w/c for him and that the geri-chair was not in the room and they were not sure where the geri-chair was. Interview on 3/6/2025 at 2:33 pm with the Administrator and DON interview revealed they were unaware of the w/c and revealed R14 did not have a tilt w/c but has had one in the past when he was smaller, but he outgrew it. The DON was not sure if R14 was using that (custom) w/c at that time. The DON further revealed there was no way for R14 to be in the w/c due to his hip. Interview on 3/6/2025 at 4:00 pm with the DON revealed he was able to go into the system and print out documents where R14 did go back to therapy for an OT (occupational therapy) referral where there were no other recommendations at that time.

Based on observations, record review, staff interviews, and review of the facility's policies titled, Handwashing/Hand Hygiene and Enhanced Barrier Precaution (EBP), the facility failed to comply with infection control protocols for three of 25 sampled residents (R) (R38, R34, and R2) by inconsistently practicing hand hygiene and not using personal protective equipment (PPE) as required. The deficient practice had the potential to expose residents to harmful pathogens, increasing the risk of infection and compromising their overall health and safety. Findings include: Review of the facility policy titled Handwashing/Hand Hygiene revised 10/15/2024 revealed under the Policy section D. Indications requiring Hand Wash or Hand Rub. 1. Before and after contact with the resident . 6. When hands move from a contaminated-body site to a clean -body site during resident care. G. Other Aspects of Hand Hygiene. 4. Perform hand hygiene and change gloves during resident care if moving from contaminated body site to a clean body site. Review of the facility policy titled Enhanced Barrier Precaution (EBP) revised 4/3/2024 revealed under the Policy section, 2. Initiation of Enhanced Barrier Precaution: . b. An order for enhanced barrier precautions will be obtained for residents with any of the following: . i. indwelling medical devices ( .urinary catheters .) . 3. Implementation of Enhanced Barrier Precautions: . b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities . 4. High-contact resident care activities include: . b. bathing . d. providing hygiene . f. changing briefs or assisting with toileting. G. device care or use: .urinary catheters . 1. An observation of catheter care for R38 was conducted on 3/5/2025 at 2:36 pm by Certified Nursing Assistant (CNA) BB revealed the CNA introduced herself to the resident, explained the procedure, performed hand hygiene, but did not use PPE (a gown) for the care. Privacy was ensured before she gathered the necessary supplies and assisted the resident into a comfortable position. The CNA filled a basin with warm water and had the resident check the water temperature by placing their hand in the basin. The CNA emptied the full catheter drainage bag into a urinal and then disposed of the urine by flushing it down the toilet. After completing this task, she removed her gloves but did not perform hand hygiene before donning (putting on) a new pair of gloves. She then continued with the catheter care as follows: She placed a protective barrier under the resident's buttocks, used the first washcloth with soap and water to carefully clean around the catheter insertion site where it exits the penis. Using a new, clean section of the washcloth for each stroke, she cleaned the catheter tubing from the insertion site downward toward the drainage bag, ensuring there were no kinks and that the tubing remained at a lower level than the bladder. CNA BB used another clean, moistened washcloth with soap to gently clean the penis and scrotum, ensuring proper hygiene. She used a new washcloth to thoroughly rinse the catheter tubing and the cleaned area, avoiding any soap residue. She dried the catheter tubing and surrounding area with a clean, dry cloth, ensuring no moisture remained. Then CNA BB changed the resident's brief, repositioned them for comfort, and sanitized her hands before leaving the room. During an interview immediately after the procedure, the surveyor asked CNA BB whether she should have worn a gown during catheter care and sanitized her hands after disposing of the urine and changing gloves. She acknowledged the oversight, agreeing it was a fair observation, and admitted that she had failed to wear a gown for a resident on EBP)and should have re-washed her hands after removing her gloves and before putting on a new pair during the procedure. In an interview on 3/5/2025 at 1:50 pm with the Director of Health Services (DHS), he stated that his expectation was for staff to perform hand hygiene immediately after removing gloves and before donning a new pair. In an interview on 3/6/2025 at 2:45 pm with the DHS, he also revealed his expectation for staff was to follow the facility policies and procedure when using PPE for high-contact care of residents on EBP. 2. A. During an observation of a medication pass on 3/6/2025 at 8:40 am for R34, Licensed Practical Nurse (LPN) CC approached the medication cart, logged into her laptop, and began preparing medications without sanitizing her hands. After preparing the medications, she proceeded to the resident's room and administered them. However, she again failed to sanitize her hands upon entering the room, doing so only upon leaving. When interviewed immediately following the medication pass, the surveyor asked LPN CC why she had not sanitized her hands before beginning the task and upon entering the room. LPN CC admitted that she was nervous and had forgotten to do so. In an interview on 3/5/2025 at 1:50 pm with the DHS, he stated he expected staff to follow their policies and sanitize their hands before and after each resident interaction. 2. B. The surveyor observed a medication pass on 3/5/2025 at 5:00 pm for R2 by LPN DD. R2 received medications via a percutaneous endoscopic gastrostomy (PEG) tube and was on EBP precautions for that. The nurse was observed preparing the resident's medications. Upon entering the room, the nurse donned a gown and performed hand hygiene. The PEG site was clean with a clean gauze pad placed underneath. The nurse confirmed PEG tube placement by auscultation (listening with a stethoscope) and checked the residual volume, which measured 10 mL milliliters). LPN DD administered R2's medications per the doctor's orders, one by one, flushing with water before and after each medication administration. After completing the PEG tube medication administration, the nurse changed gloves but did not perform hand hygiene before donning a new pair for administering medication via a different route. The nurse then proceeded to apply topical ointment rubbing it on to the affected area on the resident's right lower extremity. The nurse then changed gloves, performed hand hygiene, and administered insulin as per doctor's order with no observational concerns. When the surveyor questioned the nurse immediately after observing a medication pass about not sanitizing her hands after removing dirty gloves and before putting on a new pair to administer medication via a different route, she acknowledged that she should have performed hand hygiene at that time. In an interview on 3/6/2025 at 2:45 pm with the DHS, he revealed that staff were expected to follow facility policies and procedures when using PPE for high-contact resident care on EBP. Additionally, they must sanitize their hands according to facility guidelines immediately after removing gloves and before putting on a new pair.

Based on interviews and record review, the facility failed to develop a baseline care plan for one of 22 sampled residents (R) (R#154). The baseline care plan did not include the minimum healthcare information necessary to properly care for the resident related to advance directives. Findings include: A review of the facilities policy titled Care Plans last revised on 7/21/21 indicated, Baseline care plans must include minimum healthcare information necessary to properly care for each resident immediately upon their admission, which would address specific health and safety concerns to prevent decline or injury. A review of the clinical record revealed R#154 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R#154 baseline care plan did not address advance directives or code status. During an interview on 10/15/22 at 10:00 a.m. with the Director of Health Services revealed his expectations of staff to complete the baseline care plan for residents within 24 hours of admission. During an interview on 10/16/22 at 8:30 a.m. with the Case Mix Director confirmed residents baseline care plan did not address advance directives or code status. She states a code status should be reflected on all resident's care plan and should have been completed within 48 hours of admission. During further interview, she revealed she is responsible for care plans.

Based on observation, resident interviews, and staff interviews, the facility failed to ensure that resident basins were labeled and stored in a sanitary manner in four bathrooms on the 100 halls affecting ten of 22 samples residents (R) (R#43, R#46, R#10, R#9, R#30, R#25, R#117, R#49, R#102, and R#101). Findings include: An interview with the Nurse Consultant on 10/14/22 at 12:56 p.m. revealed there was no specific policy regarding the labeling of bathroom items, including resident basins. The Nurse Consultant added that their policy was their practice, and the facility's practice was that the staff labeled the resident's basins. All unlabeled basins were supposed to be discarded. An observation of resident bathroom shared by R#43, R#46, R#10 and R#9) on 10/14/22 at 8:40 a.m. revealed six unlabeled basins in the bathroom. During an interview with R#10 on 10/14/22 at 8:23 a.m., she stated that she was able to ambulate to the restroom. She indicated the staff used the basins to help clean up R#9. She confirmed the bathroom was shared with the residents in the adjacent room. An observation of resident bathroom shared by R#30 and R#25 on 10/14/22 at 9:00 a.m. revealed two unlabeled basins. An observation of resident bathroom shared by R#102, R#101, R#117, and R#49 on 10/14/22 at 9:16 a.m. revealed four unlabeled basins. During an interview with the Certified Nursing Assistant (CNA) AA on 10/14/22 at 9:49 a.m., she stated that the basins in the bathrooms were supposed to be labeled with the resident's names. She noted that staff is supposed to throw unlabeled basins away. CNA AA confirmed that she would not know which basin belonged to each resident as they were not labeled. During an interview with the Infection Control Preventionist on 10/14/22 at 9:55 a.m., he confirmed that the basins in the bathrooms were not labeled. He added his expectation of staff was that they label each resident basin in the bathrooms. He stated that if the basins were not labeled, the staff was supposed to throw them away. During an interview with R#46 on 10/16/22 at 9:50 a.m., she stated that she was able to use the bathroom independently. She noted the basins in the bathroom were never labeled with a resident's name or room number. She said the CNAs and nurses used the basins from the bathroom to clean her roommate, R#43. During an interview with R#43 on 10/16/22 at 9:55 a.m., she stated that she was dependent on staff to bathe her and was incontinent of bowel and bladder. She said that her roommate could use the bathroom independently and confirmed the bathroom was shared with the residents in the adjacent room. Additionally, she reported that the staff used the basins in the bathroom to help her clean up in between her shower days.

Based on observation, interview, and policy review, the facility failed to follow Level II infection control policies when providing care on the Level II unit (a unit that had been isolated from other areas of the facility and used for observational purposes for new admission residents, residents going out of the facility for appointments and returning, or residents showing signs or symptoms of possible COVID-19 infection.) This deficient practice placed eight residents with rooms on the Level II unit at higher risk for infection. The facility had a census of 65 residents. Findings include: In an interview on 8/25/20 at 8:15 a.m., the Infection Preventionist (IP), said the Level II unit was for Residents who were newly admitted to the facility, were showing signs or symptoms of COVID-19 infection, or who were going out for treatments (including [MEDICAL TREATMENT].) The Level II unit had a donning and doffing area at the doorway of the unit, as All residents in the unit are assumed to be presumptive positive (for COVID-19.) Review of the signage posted on the entry doorway that led to the Level II COVID-19 unit, which was undated, showed, Before caring for patients with confirmed or suspected COVID-19, health care personnel (HCP) must: . (wear) Face shield or goggles, N95 or higher respirator . One pair of clean non-sterile gloves, isolation gown, . (steps for donning and doffing.) During an observation and interview on the Level II unit on 8/25/20 at 12:20 p.m., Certified Nurse Aide (CNA) EE, was not wearing the proper personal protective equipment (PPE) in the Level II unit as she was passing a meal tray to Resident (R) #7, in room [ROOM NUMBER]B, and used her bare hands to adjust food on the tray and adjust the bed rails. CNA EE wore a torn gown and a surgical mask. At 12:30 p.m. she delivered a meal tray to R#6 in room [ROOM NUMBER]B wearing the same torn gown, which exposed the upper chest area of her scrub top and the right 1/4 length sleeve of the scrub top. She said she did not wear gloves when assisting the residents with meals, and only wore them when she was providing direct care. CNA EE said, I should have changed my gown, but I'm not sure about the gloves. In an interview on 8/25/20 at 12:59 p.m., the Infection Preventionist said, Absolutely she should have changed her gown after she had been touching the surroundings. In an interview on 8/25/20 at 2:18 p.m., the Director of Health Services (DHS) said the expectation was that staff would sanitize between rooms and change their gown, if the gown became contaminated. The DHS stated, At this time there is no one (residents) showing signs and symptoms (of COVID-19.) In an interview on 8/25/20 at 2:51 p.m., the Infection Preventionist said the signage for the Level II unit that had been posted had been sanctioned by the facility, and staff should follow the posted sign, but, the expectation now and the posted PPE notice did not match. Review of the policy, COVID-19 Pandemic New Admissions and Readmission Process for Healthcare Centers, dated 7/29/2020, showed, . II. Level II Person Under Investigation (PUI) Isolation Unit . 2. PPE to follow CDC (Centers for Disease Control) guidelines for droplet precautions to include: Gloves, Gowns . N95 mask in conventional capacity . KN95 mask in contingent or crisis capacity. Note: PPE will be changed between rooms unless in contingent or crisis capacity.

Based on observations, interviews and review of facility policies, the facility failed to dispose of expired food in the walk-in refrigerator and failed to maintain a clean and sanitary environment to prepare resident meals. This practice had the potential to affect 65 of 68 residents receiving an oral diet. Findings include: An initial tour of the kitchen was conducted on [DATE] at 11:10 a.m. The kitchen floor and mat sitting in front of the three-compartment sink had food debris on top of the mat and in the open holes of the floor mat. The shelf and floor next to the fryer was dirty with food debris. An observation of the walk-in refrigerator revealed a container of leftover cooked sweet potatoes with a label on it which read expires on [DATE]. On [DATE] at 8:05 a.m., a second observation of the kitchen was conducted along with the Dietary Manager (DM). The kitchen floor and mat sitting in front of the three-compartment sink was dirty with food debris on the mat and between the holes of the mat, the mat was sticky when walked on. The shelf and floor next to the fryer was dirty with food debris. The DM identified the mat and the floor under the mat was dirty, and the shelf and floor next to the fryer were dirty with debris. A review of the policy titled Cleaning Procedures: Kitchen Area revised [DATE] revealed the policy statement: It is the policy of the facility to maintain a clean and sanitary environment to prepare resident meals. Page two under Kitchen Floors Daily: Sweep and mop daily. Page three under Floor Mats Daily: remove floor mats to cart areas or outside wash area, scrub with hot, soapy solution and rinse by spraying with power hose or spray nozzle attachment on hose. An interview with DM on [DATE] at 8:30 a.m. was conducted. DM revealed kitchen staff who work second shift are to sweep, mop, wipe off shelves, and clean the equipment before leaving for the evening. DM stated he is the only one who removes the floor mats and power washes them outside. He stated the mats are supposed to be cleaned daily, but he just could not get to them in a few days. An interview was conducted with Cook EE on [DATE] at 11:30 a.m. Cook EE revealed she works all shifts as a cook at the facility and she works every other weekend. Cook EE stated the second shift ends at around 7:30 p.m. and the kitchen is closed after that. She revealed the kitchen staff are responsible for sweeping and mopping the floors before closing the kitchen in the evening. Cook EE stated the floor mats are cleaned during the week by the DM, but on weekends or whenever the DM is not at the facility, the mats do not go outside to be cleaned. She stated she lifts the ends of the mats up to sweep and mop as best she can. A second observation of the walk-in refrigerator was conducted with the DM on [DATE] at 8:10 a.m. The walk-in refrigerator revealed a container of sweet potatoes with a label on it which read expires on [DATE], which was identified by the DM. Interview with DM on [DATE] at 8:10 a.m. revealed the sweet potatoes in the container should have been used by [DATE] and been thrown out after that date. A review of the policy titled Labeling, Dating, and Storage revised [DATE] revealed the policy is to follow the proper procedures for labeling, dating, and storage to ensure proper food safety. The procedure under number three revealed prepared food items will be discarded according to the USDA Quick Reference Shelf Life List. Further interview with DM on [DATE] at 8:30 a.m. revealed the cooks are expected to check for expired food and dispose any expired food daily.

Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan by not following the care plan for Foley (indwelling urinary) catheter care and by failing to comply with facility care plan policy for one resident (R#1) of three sampled residents. Findings include: Review of the undated face sheet revealed Resident (R) #1 was admitted to the facility in (YEAR) and his [DIAGNOSES REDACTED]. Review of the 5-day scheduled assessment Minimum Data Set (MDS), section C, dated 12/14/18, revealed R#1 had a Brief Interview for Mental Status (BIMS) score of 00 out of 15, signifying he was rarely or never understood. Review of section H revealed he had an indwelling urinary catheter. An observation of R#1, with Licensed Practical Nurse (LPN) AA, on 1/15/19 at 9:40 a.m. in his room. revealed the resient was in bed, wearing a clean hospital gown and was covered with a clean sheet, with no odors noted. There was a Foley catheter drainage bag resting on the floor of the right side of his bed without a dignity cover on the drainage bag, and a scant amount of clear amber urine was noted in the bag. The catheter tube securing device was not taped to the resident, allowing the indwelling tube to pull downward. Review of R#1's care plan, dated 1/15/19, revealed planning for an indwelling Foley catheter related to sacral wound. Interventions included to not allow tubing or any part of the drainage system to touch the floor, and to store the drainage bag inside a dignity cover. Further review, dated 4/18/18 revealed the catheter was to be checked every shift for patency and proper position of tube and drainage bag. Review of R#1's Physician Orders, dated 12/7/18, revealed an order for [REDACTED].>An intervview with LPN AA on 1/15/19 at 4:25 p.m. revealed that she agreed the Foley catheter bag was uncovered and sitting on the floor during the morning observation and that the catheter tubing was unsecured because the skin adhesive had come loose. The stated this caused traction on the resident's penis. She further revealed that the Foley bag should never be on the floor, and it should always have a dignity cover on it and that the tubing should always be secured to prevent pulling on the resident's penis. She further revealed that it was unacceptable that the drainage bag was uncovered, resting on the floor, and that the tubing was unsecured. An interview on 1/15/19 at 4:55 p.m. with Corporate Registered Nurse (RN) CC revealed that it was possible for a visitor to see the catheter drainage bag if they came in the room and the bag was uncovered. She further revealed that it was unacceptable not to secure the tubing of a Foley catheter in such a way as to prevent pulling on the resident's penis and that the drainage bag should never be on the floor. Review of the Care Plans document, revised 10/5/17, revealed facility policy to be that each resident would have a baseline person-centered care plan followed by a comprehensive care plan after completion of the MDS. Further review revealed this policy applied to nursing and direct care staff, among other members of the Interdisciplinary Team (IDT). Further review revealed the comprehensive person-centered care plan was to describe the services rendered to a resident in order for that resident to achieve the highest practicable physical, mental, and psychosocial outcomes. Cross refer to F690

Based on observation, interview, and record review, the facility failed to provide ongoing care of an in-dwelling urinary (Foley) catheter that was consistent with infection prevention and control procedures for one resident (R#1) of three sampled residents by allowing the urinary drainage bag to be on the floor and by not securing the drainage tubing in a manner to prevent tension on the tubing. Findings include: Review of the undated face sheet revealed R#1 was admitted to the facility in (YEAR) and his [DIAGNOSES REDACTED]. Review of the 5-day scheduled assessment Minimum Data Set (MDS), section C, dated 12/14/18, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 00 of 15, signifying he was rarely or never understood and was cognitively impaired. Review of section G revealed R#1 was totally dependent on caregivers for Activities of Daily Living (ADLs). Review of section H revealed he had an indwelling urinary catheter and was always incontinent of bowel. Review of R#1's care plan, dated 4/18/18, revealed he had an indwelling Foley catheter. Further review revealed interventions included the requirement to check the catheter every shift for patency and proper position of tube and drainage bag. Further review of the care plan, dated 1/15/19, revealed planning for an indwelling Foley catheter related to sacral wound. Further review revealed interventions included to not allow tubing or any part of the drainage system to touch the floor, and to store the drainage bag inside a dignity cover. Review of the resident's Physician Orders, dated 1/15/19, revealed the Foley was to be placed because of the presence of an open sacral (tailbone) wound. A direct observation of the resident with Licensed Practical Nurse (LPN) AA on 1/15/19 at 9:40 a.m. in his room, revealed the resident in bed, wearing a clean hospital gown and was covered with a clean sheet, with no odors noted. There was a Foley catheter drainage bag, attached to the indwelling tube, resting on the floor of the right side of his bed. There was no dignity cover on the drainage bag, and a scant amount of clear amber urine was noted in the bag. The catheter tube securing device was not taped or secured to the resident's leg, allowing the indwelling tube to pull downward. An interview with LPN AA on 1/15/19 at 4:25 p.m. revealed that she was the Wound Treatment Nurse for the facility. She stated she agreed the Foley catheter bag was uncovered and sitting on the floor during the morning observation. She stated she agreed the catheter tubing was unsecured because the skin adhesive had come loose and that this caused traction on the resident's penis. She stated the Foley bag should never be on the floor and it should always have a dignity cover on it. She stated the tubing should always be secured to prevent pulling on the resident's penis. She stated it was unacceptable that the drainage bag was uncovered, resting on the floor, and that the tubing was unsecured. An interview on 1/15/19 at 4:55 p.m. with Corporate Registered Nurse (RN) CC revealed that she would have to check the regulatory language as to whether it was okay to leave a catheter drainage bag uncovered when a resident was in his room. She stated if a resident was in his room then the room itself provided privacy. She stated it was possible for a visitor to see the bag if they came in the room. She also stated it was unacceptable not to secure the tubing of a Foley catheter in such a way as to prevent pulling on the resident's penis. She stated this should be done every time. She stated further a drainage bag should never be on the floor, as it could cause infection. She stated further she would consider unsecured tubing and the drainage bag on the floor to be deficient practice. Review of the Indwelling Urinary Catheter (Foley) Care and Management document, dated 1/15/19, revealed policy that the Foley catheter was to be properly secured so as to provide slack. Further review revealed there should always be slack in the tubing to prevent injury to the urethral lumen or to the bladder wall. Further review revealed the drainage bag should not be placed on the floor to prevent the risk of a Catheter-Acquired Urinary Tract Infection (CAUTI).

Based on observations, interviews and review of facility policy, the facility failed to store and prepare food in accordance with professional standards for food service safety. This practice affected all resident receiving food from the kitchen. The census was 64. The findings included: 1. Observation inside of the facility's kitchen freezer on 8/6/18 at 10:54 a.m. revealed the following food items which were identified by Dietary Manager (DM) LL: one (1) unsealed, unlabeled and undated bag of breaded okra, two (2) unlabeled and undated bags of waffles, two (2) unlabeled and undated bags of French toast, and one (1) unlabeled and undated bag of cookies. Interview with DM LL on 8/6/18 at 11:00 a.m. in the facility's kitchen revealed the food items were improperly stored and were most likely extra food items left over from the menu. DM LL confirmed the frozen food items should have been sealed, labeled and dated before being stored in the freezer. DM LL stated the process for putting foods back into the freezer was to 1) ensure the food item was sealed in its packaging; 2) ensure the food item was labeled with the name of the food; and 3) ensure the food item was dated with an open and discard date. DM LL confirmed the observed food items (breaded okra, waffles, French toast, and cookies) were improperly stored in the freezer. Review of the facility's policy entitled Labeling, Dating and Storage revised 10/18/17 noted the following: 1) Food and/or beverage items will be properly labeled with the name of the item, and a use by date; 2) Foods will be stored in their original containers or in an approved container or wrapped tightly with film, foil, etc. and clearly labeled with the name of the item and the use by date. 2. Observation on 8/7/18 at 12:30 p.m. in Hall 3 of the facility revealed that (ten) 10 lunch meal room trays were transported from the kitchen and onto the hall. Continued observation revealed four of the (ten) 10 plates were not completely covered with plate warmers which left the food (fried chicken, peas, okra, cornbread and peach cobbler) exposed during transport from the kitchen and onto the hall. Interview on 8/8/18 at 11:45 a.m. with DM LL in the facility's kitchen revealed staff were trained to ensure all plates were completely covered with plate warmers during transporting the trays from the kitchen and onto the hallways. 3. Observation on 8/8/18 at 12:05 p.m. in the facility's kitchen revealed Dietary Staff (DS) MM measured food temperatures (temps) on the steam table. While taking the food temps, DS MM dropped a covered thermometer onto the floor, picked it up and then placed it on the counter next to scoops that would be used for serving the food from the steam line. Without replacing or sanitizing the dropped thermometer, and without performing hand hygiene, the DS used the thermometer to take the temps of two additional food items. DS MM did not clean/sanitize the counter where the contaminated thermometer was placed. During an interview with DM LL on 8/8/18 at 12:11 p.m. in the facility's kitchen, DM LL confirmed DS MM should have sanitized or replaced the thermometer before obtaining the last two food temps on the steam line, and the counter should have been cleaned/sanitized. He said staff were trained that anything that dropped onto the floor should either be discarded or sanitized. Interview on 8/8/18 at 12:13 p.m. with DS MM in the facility's kitchen revealed the staff realized she should not have continued to use the dropped thermometer. She stated she should have sanitized or replaced the thermometer, and she should have performed hand hygiene, as well as, sanitized the counter. Review of the facility policy entitled Infection Control - Dining Services revised 10/18/17 noted All partners will wash their hands just before they start to work in the kitchen and when they have used their hands in an unsanitary way .

Based on record review, staff interview and facility policy review, the facility failed to properly follow the process regarding the code status according to advance directive documentation, for two residents (Resident (R)#47 and R#50) of 16 residents reviewed for advance directive documentation. The findings include: 1. Review of the medical record for R#47 revealed the admitted on the Annual Minimum Data Set (MDS), dated [DATE], was [DATE]. [DIAGNOSES REDACTED]. Section C notes a Brief Interview for Mental Status (BIMS) score of 15 indicating R#47 is cognitively intact with decision-making capabilities. Further review of the medical record for R#47 revealed a document titled Durable Power of Attorney (DPOA). This document notes, That I, (name of resident) have made and constituted and appointed, and these present do make, constitute, and appoint (name of spouse) (hereinafter referred to as my attorney), my true and lawful attorney, for me and in my name, place and stead, to do the following acts and exercise the following posers at such time as I become unable to do so myself without substantial difficulty. Number two gives the spouse of R#47 permission to make decisions regarding medical treatment when the DPOA becomes active after R#47 is not able to make decisions for himself. Additional documentation in the medical record revealed a physician's orders [REDACTED]. This document is titled Physician's DNR (do not resuscitate) Order Form for Adult SNF (skilled nursing facility) Patient/Resident Without Decision-Making Capacity with Durable Power of Attorney for Healthcare or Healthcare Agents Georgia. This document notes R#47 has a DPOA and his spouse signed the document on [DATE], noting R#47 to be a DNR. The physician signed the document on [DATE] making R#47 a DNR. Review of the care plan dated [DATE] identifies the problem to be DNR with measurable goal to keep R#47 comfortable as possible and interventions to honor resident request and provide comfort measures. This care plan was updated [DATE] when R#47 was readmitted to the facility. physician's orders [REDACTED].#47 note Code Status***Do Not Resuscitate*** DNR. This order is on the monthly physician order [REDACTED]. Social Services Assessment Form most recently revised [DATE] and completed on [DATE] in R#47's medical record, notes the Status of Advance Directives: Full Code. On [DATE] at 10:00 a.m., interview with the Regional Nurse Consultant in the nurses' station, confirmed the documentation had not been completed correctly. She stated the social services director would be contacting R#47, his spouse and his physician to correctly complete the paperwork. On [DATE] at 9:30 a.m., interview with the Social Services Director in her office, confirmed the documentation had not been completed correctly. She stated she had an assistant who no longer works in the facility who had completed the documentation incorrectly and she had not reviewed the paperwork and did not realize it was incorrect. She stated R#47 did not want to sign the paper because his hands were shaky. She stated she had left a message for the physician, but he had not contacted her as of this time. When asked what gave authority to R#47's wife to sign the DNR form for R#47 when he had full decision-making capability, the Social Service Director had no answer. On [DATE] at 1:00 p.m. interview with the physician by phone revealed he did not realize R#47's had signed the documentation but stated R#47 had expressed his wishes to him so he signed the DNR paperwork. 2. Review of the medical record for R#50 revealed the admitted , on the Annual MDS, dated [DATE], to the facility on [DATE]. Additionally, a MDS for significant change was completed on [DATE] and noted a readmission date of [DATE]. [DIAGNOSES REDACTED]. Section C notes a Brief Interview for Mental Status (BIMS) score of 99 indicating R#59 was not able to complete the interview and is cognitively impaired and not able to make medical decisions. Review of documentation in R#50's medical record notes a form titled Advance Directive Checklist. This form is signed by R#50's son, dated [DATE] and documented, R#50 had formulated an advance directive. A document titled Power of Attorney (POA), dated [DATE], is reviewed from the medical record of R#50. #10 on this form, directs the son of R#50 the power to make any medical decision on her behalf. Review of the monthly physician's orders [REDACTED]. Review of the care plan for R#50 formulated [DATE] identified a problem of Advance Directive: Full Code. The measurable goal is for resident/patient will receive lifesaving procedures through next review. Interventions include administer cardiopulmonary resuscitation (CPR) in the event of [MEDICAL CONDITION], review advance directive with patient every quarter or significant change notify M.D. (medical doctor) of changes. Review of physician's progress note dated [DATE], identified R#50 CODE STATUS: Full. There is no statement from the physician which noted he had completed an assessment of R#50 and had determined she did not have the ability/capacity to make her own decisions. The POLST, titled Physician's DNR Order Form for Adult SNF Patient/Resident without Decision-Making Capacity with Durable Power of Attorney for Healthcare or Healthcare Agent Georgia, was not present in the medical record for R#50. The facility form titled Advance Directives Checklist which would indicate R#50 had received information regarding advance directives was not present in the medical record. There was no facility documentation the Resident or his representative had received information on formulating advance directive. On [DATE] at 10:00 a.m., interview with the Regional Nurse Consultant in the nurses' station, confirmed the documentation had not been completed correctly. She stated the social services director would be contacting R#50's son and her physician to correctly complete the paperwork. On [DATE] at 9:30 a.m., interview with the Social Services director in her office, confirmed the documentation had not been completed correctly. She stated she had an assistant who no longer works in the facility who had completed the documentation incorrectly and she had not reviewed the paperwork and did not realize it was incorrect. She stated R#50 was not capable of signing her own documents. She confirmed there was not statement in R#50's medical record from the physician indicating he had assessed R#50 and could not make her own decisions. She stated she had left a message for the physician, but he had not contacted her as of this time. On [DATE] at 1:00 p.m. interview with the physician by phone revealed he did not realize R#50 did not have the POLST in her medical record. He stated he knew R#50 very well and she was not able to make her own decision and he confirmed he had not documented his assessment and statement that R#50 was not capable of making her own decisions. Review of Statutes Related to Georgia Health Care Decision-Making revealed section [DATE] (c) noted, For purposes of this Code section, inability of any adult to consent for himself shall mean a determination in the medical record by a licensed physician after the physician has personally examined the adult, that the adult lacks sufficient understanding or capacity to make significant responsible decisions regarding his medical treatment or the ability to communicate by any means such decisions. Review of facility policy titled, Do Not Resuscitate Policy: Georgia, issued (MONTH) 2006 and most recently updated ,[DATE], revealed it does not address the statement that should be made by the physician regarding decision making capabilities. Review of facility policy titled, Advance Directives: Georgia effective [DATE] and most recently revised [DATE], revealed in the section titled, Procedure 1. The Advance Directive Checklist, which is in the Georgia Admission Packet, will be completed. 2. If the resident was incapacitated at the time of admission, the healthcare facility shall continue to evaluate the resident's ability to receive information regarding Advance Directives and provide the information to the resident at the appropriate time. This policy does not address the statement that should be made by the physician regarding decision making capabilities.

Based on observations, interviews, record review and review of facility policy, the facility nursing staff failed to ensure a care plan for activities of daily living (ADLs) was developed within the required timeframe, and a part of the comprehensive care plan for one of 16 sampled residents (Resident (R) #41). The findings included: Review of R#41's clinical record revealed the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and required the extensive assistance of two staff for bed mobility. According to the assessment, bed rails were not used as a restraint. Review of R#41's Initial/Annual Observation for a Physical Device Form dated 2/8/18 noted the resident leans to right side of bed. Resident requires extensive assistance for bed mobility and total dependence for transfers. Device to be utilized - bedrail (quarter). Classification of device - Is the patient/resident able to remove easily? 'No;' If No, then: a) Does device restrict access to one's body? 'No;' b) Does device restrict freedom of movement? 'No;' Is this device a restraint? No. Rationale for determination of this device: Resident leans to side in bed. The document was signed by R#41's representative. Observation on 8/06/18 at 3:33 p.m. in R#41's room revealed the resident was lying in bed and had raised bilateral quarter-size bedrails. Observation on 8/7/18 at 3:59 p.m. in R#41's room revealed the resident was lying in bed with the head of the bed elevated approximately 30 degrees. The quarter-size bedrails were up on both sides of bed. Record review on 8/9/18 at 10:45 a.m. of R#41's comprehensive care plan dated 1/23/18 revealed there was not an ADL care plan, and no care plan that addressed the use of quarter-size bedrails. During an interview with the Interim Director of Nursing (DON) at the nurse's station on 8/9/18 at 2:45 p.m., the DON was asked if R#41 had an ADL care plan. The DON said the resident's ADL care plan was not in the paper chart, and she would have the MDS Coordinator to print out the ADL care plan. Review of the first ADL care plan provided by the MDS Coordinator NN on 8/9/18 at 3:00 p.m. revealed the care plan was dated/developed on 8/9/18. Interview at this time with the MDS Coordinator NN revealed the onset date of 8/9/18 as noted on the care plan was in error. The MDS Coordinator NN stated she would reprint the care plan with the correct date. Review of the second printed ADL care plan provided by the MDS Coordinator NN on 8/9/18 at 3:05 p.m. revealed the care plan was developed on 1/8/18. Continued review of the care plan revealed: Problem: At risk for ADL decline related to dementia; Goal: Patient will maintain current level of function x 90 days; Approaches: Allow ample time to perform ADL task, explain all procedures before delivering care even though patient may not totally comprehend, provide privacy while delivering ADL care, assist resident as needed. Interview (at the nurse's station) at this time with the MDS Coordinator NN revealed she was not sure why the first care plan had a date of 8/9/18. Interview at the nurse's station on 8/9/18 at 5:15 p.m. with the DON revealed the DON acknowledged the ADL care plan was not individualized with specific approaches to address the resident's ADL deficits, and the plan did not address the resident's use of quarter-size bedrails for bed mobility. The DON acknowledged there was a problem with the second printed ADL care plan because the onset date of 1/8/18 was eight days prior to R#41's date of admission. During an interview on 8/9/18 at 5:20 p.m. with the MDS Coordinator NN in her office, when asked if the ADL care plan was developed today (8/9/18), she stated it was not. She said she may have hit the wrong button. She could not explain why the onset date of the second ADL care plan printed was eight days prior to the resident's date of admission. Review of the facility's policy entitled Care Plans revised 10/5/17 noted: The comprehensive person-centered care plan is developed to include measurable goals and timeframes to meet patient/resident's medical, nursing and psychosocial needs, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan should describe .the services to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being.

Based on record review and staff interviews, (1) the facility failed to ensure that laboratory results were sent to the physician timely for one resident (R#63) of five residents reviewed for unnecessary medication use; (2) the facility failed to provide evidence that the shunt site was monitored, fluid restrictions were adhered to, and pain was assessed as ordered, and failed to provide evidence that the facility communicated with the [MEDICAL TREATMENT] center about the resident's status for one resident (R#15) of one resident reveiwed for [MEDICAL TREATMENT]; and (3) the facility failed to ensure the correct amount of insulin was administered per sliding scale order and behavior monitoring was charted for one resident (R#56); residents. The sample size was 40 residents Findings include: 1.) A review of the demographics revealed that R#63 was originally admitted to the facility on [DATE] with the relevant [DIAGNOSES REDACTED]. A review of the Physician's Interim Order dated 8/14/17 for R#63 noted that he was ordered to receive the following medications: [REDACTED] * [MEDICATION NAME] (an anticoagulant) 2.5 mg daily except Sunday Wednesday Friday * [MEDICATION NAME] 5 mg Sunday Wednesday Friday ONLY * Recheck [MEDICATION NAME] time (PT) and International Normalized Ratio (INR) in one week A review of the Medication Administration Record [REDACTED] * [MEDICATION NAME] 2.5 mg Monday Tuesday Thursday and Saturday * [MEDICATION NAME] 5 mg Sunday Wednesday Friday A review of the clinical medical record revealed that the last documented PT/INR lab was completed on 8/10/17 and physician was notified of results. During an interview with the Regional Nurse Consultant LL on 8/26/17 at 4:25 p.m. she stated that it is the expectation that when the charge nurse receive the lab, they are to fax or call in the lab result to the physician and place the results in the residents clinical medical record. She confirmed that last lab in R#63's clinical record was for 8/10/17 and that there should be a lab for 8/21/17. At that time Regional Nurse BB was observed to find the lab results dated 8/22/17 on the desk under a stack of papers. She confirmed that the lab was not signed/documented as having been followed up on. On 8/27/17 review of the clinical medical record of R#63 revealed a Physician's Interim Order dated 8/26/17 with the following order: * Discontinue (D/C) [MEDICATION NAME] 2.5 mg * Start [MEDICATION NAME] 5 mg daily * Recheck PT/INR next week on 8/31/17 During an interview with Care Coordinator AA on 8/27/17 at 6:16 p.m. she stated that she called in the lab results for R#63 dated 8/22/17 to the physician on 8/26/17 and that the physician increased the [MEDICATION NAME] to 5 mg daily based on the lab results. A review of the policy related to Anticoagulant Therapy Administration and Monitoring last reviewed 4/20/17 revealed the following: The healthcare center will utilize and maintain the established system below to provide optimal therapeutic outcomes while minimizing associated risk of anticoagulate therapy. The Director of Health Services is responsible for monitoring compliance to this policy Licensed Nurses are responsible for implementation of this policy. The licensed nurse will communicate the patient's laboratory (PT/INR) results to the physician. 2.) Review of the clinical record for Resident (R) #15 revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the August 2017 Physician order [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the MAR for June 2017 revealed 17 instances on the 3:00 p.m. to 11:00 p.m. shift and 10 instances on the 11:00 p.m. to 7:00 a.m. shift for which there was no documentation that the resident's shunt site was monitored, and five days during which there was no indication that fluid restrictions had been adhered to. Review of the MAR for July 2017 revealed that there were 21 instances on the 3:00 p.m. to11:00 p.m. shift for which there was no documentation indicating that the shunt site was monitored, and four days for which there was no indication that fluid restrictions had been adhered to. Review of the nurses' progress notes for the period March 24, 2017 to August 24, 2017 revealed only four instances - 4/7, 4/17, and 4/26 in which it was documented that the resident's shunt site was assessed upon return to the facility. Interview on 8/27/2017 4:20 p.m. with the Care Coordinator/Acting Director of Nursing Services revealed the she expects the nurses to document on the MAR indicated [REDACTED]. Interview on 08/26/2017 at 6:10 p.m. with the Care Coordinator/Acting Director of Nursing Services revealed each resident that receives [MEDICAL TREATMENT] at an outside center should have a [MEDICAL TREATMENT] Center Communication Form accompany the resident to the [MEDICAL TREATMENT] visit. The nurse should document on the form information such as: the date of the [MEDICAL TREATMENT] visit; the resident's name; and whether a snack was sent with the resident. The nurse must then sign the form and send it along with the resident to his/her [MEDICAL TREATMENT] visit. The [MEDICAL TREATMENT] center is responsible for documenting information such as: pre-and post-[MEDICAL TREATMENT] weight; whether medications were given at the visit; any new orders; labs drawn during the visit; and the condition of the shunt site prior to leaving the center. The completed form is then returned to the facility with the resident. The completed forms are filed in the resident's chart under the MAR indicated [REDACTED] Review of the resident's clinical record during this interview with the Care Coordinator revealed no communication forms filed for the resident. After searching the unit, the Care Coordinator located two completed communication forms for the resident; one dated 4/24/17 and the other dated 5/5/17 and advised that no other [MEDICAL TREATMENT] Center Communication Form could be located for this resident. Review of the SNF Outpatient [MEDICAL TREATMENT] Services Agreement between the facility and the [MEDICAL TREATMENT] center with an effective date of 10/15/10 revealed the facility is responsible for ensuring that all medical and administrative information - name, address, telephone number, medications - accompany the resident during [MEDICAL TREATMENT] appointments. 3.) Review of R#56's clinical record revealed she was admitted to the facility on [DATE] with the following pertinent [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. The sliding scale is as follows: B/S Greater than 200: 201-250= 2 units, 251-300=4 units, 301-350=6 units, 351-400=8 units, For B/S >400 = 10 units with recheck in one hour, and if still > 400, notify the physician. The B/S < 60 give OJ or glucose gel & notify the physician. Continued review of the physician's orders [REDACTED]. Review of R#56's June 2017 Medication Administration Record [REDACTED]=281 no documentation of insulin being administered, 6/10/17 at 11:30 a.m. B/S=404 8 units administered, 6/14/17 at 4:30 p.m. B/S=318 8 units administered, 6/18/17 at 9:00 p.m. B/S=300 0 units administered, 6/22/17 at 11:30 a.m. B/S=295 8 units administered. Behavior monitoring was not charted for three days on the 7-3 shift, 13 days on the 3-11 shift and one day on the 11-7 shift. Review of R#56's July 2017 MAR indicated [REDACTED]. Review of R#56's August 2017 MAR indicated [REDACTED]= 350 8 units administered. During further review of the MAR, no documentaton behavior monitoring was charted for 12 days on the 3-11 shift and two days on the 11-7 shift. During an interview with acting Director of Health Services, AA on 8/27/17 at 2:30 p.m., she revealed the June, July and August 2017 MAR's containing missing behavior monitoring and the wrong amounts of insulin were administered per sliding scale order. Review of facility policy titled Medication Administration: Insulin Sliding Scales reviewed 5/3/17 revealed Policy Statement: To accurately calculate the correct amount of insulin to be administered on a sliding scale basis in response to a blood sugar determination. Procedure: Check prescriber's order. Record blood sugar on the paper Medication Administration Record [REDACTED]. After insulin has been administered, the units that have been given should be documented either on the paper MAR indicated [REDACTED]

Based on observation and staff interview, the facility failed to properly clean food preparation, place a thermometer to monitor temperature for one reach in refrigerator, and remove expired food items from one nourishment refrigerator. Findings include: Observation of the nourishment refrigerator on 8/25/17 at 11:07 a.m. on the Hall 500 revealed one can of chocolate glucerna, eight ounce can, with an expiration date of 3/1/17 and a eight ounce can vanilla glucerna with expiration date of 2/1/17. Observation of one reach in refrigerator on 8/25/17 at 12:10 p.m. revealed no thermometer to monitor the temperature. Observation of the conventional oven on 8/25/17 at 12:24 p.m. revealed dark thick black color substances coating on four oven racks inside the oven. Continued observation revealed black crumb thick oily substances coating the bottom of the oven. Interview with the Dietary Manager on 8/25/17 at 12:25 p.m., he confirmed that inside the oven coating the four racks and bottom oven floor panel was grease built up. Continued interview revealed that his expectations are that staff clean the oven accordingly to the weekly cleaning schedule and remove any grease spills daily. Interview with Administrator on 8/27/17 at 5:42 p.m. revealed that his expectations are that kitchen equipment should be cleaned on a regular basis and that dietary staff are responsible for cleaning the oven. Continued interview revealed that the food items in nourishment refrigerator should be tossed out daily based on expiration dates, monitored and labeled with the resident names. He stated that he was a new Administrator and could not find a policy for nourishment refrigerator and any dietary policy on cleaning of equipment.

Based on observations, staff interviews, and record review of facility policy, the facility failed to ensure that two of three medication carts and one of one treatment carts were locked and secured. Findings include: On 8/25/17 at 12:35 p.m. the Treatment Cart was observed parked on the hall near room [ROOM NUMBER]. It was observed unlocked. There were three residents in close proximity of the cart and there was no nurse around. At 12:38 p.m. the Reginal Nurse Consultant LL was observed walking by and confirmed that the treatment cart was open and that it should be locked when the nurse is not using it. On 8/26/17 at 11:56 a.m. the 100 Hall Medication Cart was observed parked near room [ROOM NUMBER] on the outside of the nursing station. There was no nurse around and the cart was observed to be unlocked. There were no residents in close proximity of the cart at this time. Four facility employees walked past the cart. At 11:59 a.m. the Regional Nurse Consultant BB was observed to walked pass the cart and confirmed that the cart was unlocked. She confirmed that it is the expectation that the cart be locked when the nurse is not around. During an interview with Nurse GG on 8/26/17 at 12:01 p.m. she stated that she and Nurse MM were both responsible for the Medication Cart that was observed unlocked. She stated that she last used the cart about an hour and a half ago and that she locked it. During an interview with Nurse MM at 8/26/17 at 12:03 a.m. she stated that she last used the Medication Cart at around 9:00 a.m. and that she had secured it. On 8/26/17 at 3:19 p.m. the Treatment Cart was observed unlocked outside of room [ROOM NUMBER] and the resident's room door was closed. There was no nursing staff around. At 3:22 p.m. Nurse MM was observed to come out of room [ROOM NUMBER]. She stated that she does not lock the treatment cart when she is inside of the resident's rooms doing treatments because Nurse GG has the key to the cart. On 8/26/17 at 3:25 p.m. Nurse GG confirmed that there is only one key to the treatment cart and that she had it on her key ring. She stated that all the nurses share the one treatment cart and that when they are using the cart, they are supposed to come get the key so that they can unlock and lock the cart. She confirmed that the cart is expected to be locked when the nurse is the resident's rooms providing treatments. Nurse MM was observed to go to the nursing station and get the key from Nurse GG. A review of the Medication Storage in the Healthcare Centers last dated 1/9/17 revealed the following: Medication and biologicals are stored safely, securely, and properly following manufacture's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel and pharmacy personnel. Only licensed nursing and the pharmacy personnel are allowed access to medications. Medications rooms, carts, and medication supplies are locked or attended by persons with authorized access.

Based on review of facility records and staff interview, the facility failed to maintain an infection control program designed to provide a sanitary environment for its residents for the period beginning June 2016 to August 2017. The facility census was 78. Findings include: During review of the facility's infection control program with the Care Coordinator/Acting Director of Nursing Services (DNS) on 8/26/17 at 3:05 p.m., it was revealed that the facility failed to maintain an infection control program to investigate, prevent, and control the spread of infection and thus provide a sanitary environment for its residents. The Acting DNS said the facility's Assistant DNS was responsible for administering the infection control program, and after she resigned in May of 2017, no one in the facility had taken over the responsibility of administering the infection control program. The Acting DNS could not give a date on which the facility's infection control program was last active. During an interview with the Regional Nurse Consultant for the facility, BB on 8/27/17 at 4:55 p.m., she revealed that the facility did not have a functioning infection control program since May of 2017 when the Director of Nursing Services went on medical leave and the Assistant Director of Nursing Services resigned. During this interview, the Nurse Consultant provided documentation that demonstrated the facility staff was beginning to collate information on infections for the months of May 2017 through August 2017. This documentation included a Monthly Nosocomial Summary, an Epidemiology Report; and a map of the dispersion of infections throughout the facility, including a monthly percentage of infections. However, the Regional Nurse Consultant said this was the extent of the documentation the facility had for their infection control program. The facility could not locate any other records to indicate the program had been in place for 2016 or 2017, nor could the facility locate their policy related to the infection control program.