Every finding on record at PruittHealth - Lanier

Based on observations, staff interviews, and review of the facility's policies titled, Pot/Pan Washing and Sanitation and Ice Machines (Handling/Scoops), the facility failed to prevent wet-nesting in stored steam pans to avoid the potential for bacterial growth and the facility failed to ensure that the ice machine was properly cleaned to prevent bacteria growth. The facility census was 97 and 92 residents received an oral diet.Findings include: 1. Review of the facility policy titled, Pot/Pan Washing and Sanitation revealed under Procedure: 1. Air dry pots and pans on the drain board. Inspect for cleanliness and store pots and pans inverted in a clean, dry, protected area.Observation on 06/12/2026 at 8:40 AM of the pot/pan rack revealed there was a stack with six medium sized square steam table pans. The top two pans were pulled apart, and the inside of both pans were wet. A stack with three small square steam table pans were pulled apart and the top two pans were wet inside.During an interview on 06/12/2026 at 8:40 AM, the Dietary Manager (DM) confirmed that the steam table pans identified were stacked together wet. The DM stated that dietary staff were expected to air dry pans completely before stacking so that bacteria did not develop.2. Review of the facility policy titled, Ice Machines (Handling/Scoops) revealed under Policy Statement: It is the policy of Pruitthealth to maintain safe and sanitary conditions when serving ice to prevent cross contamination and the spread of bacteria.Observation on 06/13/2026 at 8:45 AM, of the ice machine, revealed it was located in the main dining room and was locked with only staff able to access the ice. Continued observation of the inside of the ice machine revealed a white plastic ice slide/shoot. The bottom edge of this ice slide/shoot had a brown/black type substance that went across the entire bottom edge. A white colored paper napkin was provided by the DM. This paper napkin was used to wipe/touch the bottom edge, and the brown/black substance was able to be removed.During an interview on 06/13/2026 at 8:45 AM, the DM confirmed that the brown/black substance was removed using the white colored paper napkin provided. The DM confirmed that the substance being able to be removed indicated that the ice slide/shoot was not clean. The DM stated that the inside of the ice machine and filters were cleaned once a month by maintenance, but she had assigned herself the task of ensuring the ice machine was clean inside and out, weekly. The DM stated that when she was ensuring the inside of the ice machine was clean, she looked at the ice slide/shoot, she did not notice any substance on ice slide/shoot when she last viewed on Monday (06/08/2026).

Based on staff interviews, records review, and review of the facility's policy titled, MDS Assessment Accuracy, the facility failed to ensure an accurate Minimum Data Set (MDS) assessment was completed for one of 45 sampled residents (R) (R52). Specifically, the facility failed to accurately code the use of a wander/elopement alarm for R32. This failure placed the resident at risk for medical complications and unmet needs. Findings include: Review of the facility's policy titled, MDS Assessment Accuracy, dated 12/6/2022, Policy Statement revealed the following: It is the policy of this healthcare center that each Minimum Data Set (MDS) reflects the acuity and the medical status of each patient/resident in accordance with acceptable professional standards and practices. Review of R32's electronic medical record (EMR) revealed R32 was admitted to the facility with diagnoses that included but not limited to, schizophrenia, dementia, major depressive disorder, and unspecified psychosis. Review of R32's Quarterly MDS assessment with an Assessment Reference Date (ARD) of 3/28/2025 for Section P (Restraints) revealed a wander/elopement alarm was not used. Review of R32's physician orders revealed orders that included but not limited to, wander guard worn on necklace holder with start date of 11/15/2024. Review of R32's care plan with last reviewed/revised date of 11/15/2024 revealed Problem: risk for elopement as evidenced by exit seeking behavior. Wander guard work on necklace holder per resident's preference. Approaches included but not limited to: Check wander guard device for proper functioning and placement per facility protocol or manufacture's recommendations. Review of R32's progress notes from 3/30/2025 revealed Resident noted wearing wander necklace. No attempts made to exit the building. Interview with MDS Coordinator on 5/9/2025 at 10:35 am revealed that R32 wears a wander guard necklace because R32 did not like arm or ankle bracelet. MDS Coordinator confirmed that Section P of the most recent quarterly MDS assessment was incorrect, and that she would submit a modification for that assessment.

Based on observations, interviews, and record reviews, the facility failed to ensure reasonable accommodation of need related to keeping the call light within reach while in bed to call for staff assistance for two out of 45 sampled residents (R) (R31 and R37). Findings include: 1.Review of electronic health records (EHR) revealed, R31 admitted to the facility with diagnoses that included but not limited to liver cell carcinoma, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance ,and anxiety, dysphagia, oropharyngeal phase, encounter for palliative care, pain, unspecified, and fracture of unspecified part of neck of right femur. Review of R31's Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C (Cognitive Patterns), a Brief interview of Mental Status (BIMS) score of 00 indicating severely impaired cognitive skills; Section GG (Functional Abilities and Goals) indicated R31 required substantial/maximal assistance from staff with activities of daily living (ADLs), used wheelchair and required supervision or touching with mobility. 2. Review of EHR revealed R37 admitted to the facility with diagnoses that included but not limited to heart failure, chronic obstructive pulmonary disease, muscle weakness (generalized), difficulty in walking, and osteoarthritis. Review of R37's Quarterly MDS dated [DATE] revealed Section C (Cognitive Patterns), a BIMS score of 15 indicating that resident's cognitive skills were intact. Section D did not indicate any depression or mood disorders; Section GG (Functional Abilities and Goals) indicated R37 required partial/moderate assistance from staff with ADLs and mobility. An observation on 5/6/2025 at 10:47 am revealed the call light cords for R31 and R37 were tied up and hanging by the wall with the call box. Both R31 nor R37 were lying in bed and could not reach their call light. An observation on 5/7/2025 at 8:04 am revealed the call light cords for R31 and R37 were still tied up and hanging by the wall with the call box. Both R31 and R37 were lying in bed and could not reach their call light. An interview on 5/6/2025 at 10:58 am with R37 revealed that if they (R37 and R31) need help he would have to ambulate to the door and holler for someone to come and help. He revealed that he help take care of his roommate, R31. An interview on 5/8/2025 at 2:34 pm with Certified Nursing Assistant (CNA) NN revealed that all the residents should always have their call lights within reach while they were in bed.

Based on record review and staff interview, the facility failed to ensure that the Minimum Data Set (MDS) assessment was transmitted within 14 days of completion to the Centers for Medicare and Medicaid Services (CMS) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system for one of 45 sampled residents (R) (R25). Findings include: Review of the MDS Discharge assessment dated [DATE] for Section A (Identification Information) revealed, R25 readmitted into the facility on [DATE] was discharged home on 1/3/2025. Further review revealed that the discharge assessment had not been transmitted. During an observation and interview on 5/9/2025 at 3:45 pm, R25 MDS discharge assessment dated [DATE] was reviewed with the MDS Coordinator. The MDS Coordinator verified the assessment showed as completed in the facility record keeping system. When asked why the assessment stated complete, and CMS data showed it had not been transmitted, the MDS Coordinator stated that surveyor would need to speak with Clinical Reimbursement Consultant KK who may be able to clarify. Interview on 5/9/2025 at 4:00 pm with Clinical Reimbursement Consultant KK, confirmed R25's discharge assessment should have been done within 14 days and transmitted. She stated, I can't explain it except, that it was human error.

Based on observations, record review, resident and staff interviews, the facility failed to provide Activities of Daily Living (ADL's) for one of 45 sampled residents (R) (R5). Specifically, the facility failed to provide nail care for R5. This failure had the potential to affect the resident's comfort, body image and increase the risk for infections. Findings include: Review of the electronic health record (EHR) revealed R5 was admitted with diagnoses that included but not limited to altered mental status, difficulty in walking, and cerebral infarction. Review of R5's Quarterly Minimum Data Set (MDS) dated [DATE] for Section C (Cognitive Patterns) revealed, a Brief Interview for Mental Status (BIMS) of 12, indicating the resident was cognitively intact; Section GG (Functional Abilities and Goals) revealed, R5 had impairment to the lower extremities and required maximal assistance with showers, upper and lower body dressing. Review of R5's care plan with a revised date of 12/28/2024 revealed R5 was care planned for ADL decline related to (r/t) sepsis, acute renal failure, acute metabolic encephalopathy and atrial fibrillation. The care plan revealed R5 ADL needs will be met and independence potential maximized within constraints of disease through next review. Review of R5's physician orders dated 12/27/2024 revealed R5 may have podiatry care as needed. In an interview and observation conducted on 5/6/2025 at 11:32 am, R5 revealed his toenails were long and that he was unable to put on his shoes. He revealed he had never gotten his toenails cut since he had been in the facility and stated that he had told the staff members several times. R5 further revealed that the last time the podiatrist was in the building, he was told he was not on the list. Observation of R5's toenails revealed they were long, yellow, and thick. In an interview conducted on 5/7/2025 at 11:01 am with CNA BB confirmed that R5's toenails were long but explained that CNAs were not permitted to cut toenails, as this was the responsibility of a podiatrist. She stated that when a CNA notices long toenails, the expectation was to report it to the nurse, who then makes the necessary appointment. However, CNA BB admitted she had not reported it, due to being busy and forgetting. In an interview conducted on 5/7/2025 at 11:07 am with Licensed Practical Nurse (LPN) CC (100 Hall Floor Nurse) revealed, she does not know how often the podiatrist visits and has never seen the podiatrist during her shifts. LPN CC explained that the need for podiatry care depends on the structure and condition of the toenails. She stated that normally she informs the charge nurse when a resident needs a podiatry appointment, but in this case, she did not make a direct report regarding R5. LPN CC also recalled that the resident recently asked her to cut his toenails, but she told him she could not due to his condition. She acknowledged that she should have reported the concern to the charge nurse but intended to speak directly to the podiatrist on the next visit. In an interview conducted on 5/9/2025 at 10:30 am with the Regional Nurse Consultant (RNC) revealed, that when staff observe a resident with long toenails, the expectation was to refer the concern to the social worker, who ensures the resident was added to the podiatry list. She emphasized the importance of timely referrals, noting that delays could lead to negative outcomes, such as ingrown toenails and continued overgrowth. In an interview conducted on 5/9/2025 at 10:31 am with the Interim Administrator (IA) confirmed that staff were expected to notify Social Services when a resident was identified as needing toenail care, so that they could be added to the podiatry appointment list. She stated that failing to do so may result in longer toenails and the development of ingrown toenails.

Based on observations, record review, resident and staff interviews, the facility failed to follow physician orders for one of 45 sampled residents (R) (R7) related to (r/t) behavior monitoring. This deficient practice had the potential to cause undetected changes in the resident's mental status and/or behavior. Findings include: A review of the electronic health record (EHR) for R7 revealed he was admitted with the following diagnosis that included but not limited to vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety and unspecified dementia, and unspecified severity, with agitation. A review of R7's Admission Minimum Data Set (MDS) dated [DATE] for Section C (Cognitive Patterns) revealed, a Brief Interview for Mental Status (BIMS) of 13, indicating he was cognitively intact. A review of R7's care plan with a start date of 1/20/2025 revealed a care plan for psychotropic drug use (r/t) dementia with behavioral disturbance and anxiety disorder. The care plan indicated R7 would benefit from medication use without side effects through the next review. A review of R7's physician orders revealed a prescription for olanzapine 5 milligrams (mg) (antipsychotic). The medication was prescribed for unspecified dementia, unspecified severity, with psychotic disturbance, and is to be administered once daily at night. Additionally, R7 had a prescription for memantine 5 mg (N-AMETHYL-D-aspartate (NMDA) receptor antagonist /cognitive enhancer), to be taken orally twice a day. This medication was prescribed for unspecified dementia, unspecified severity, with agitation, and was ordered on 1/17/2025 Further review of R7's physician orders dated 1/18/2025 revealed, R7 required behavior monitoring to be documented every shift (days and nights); Behavior monitoring instructions direct staff to chart observed behaviors using the following scale: 0 = None Observed,1 = Sad Mood/Tearful, 2 = Anxious Mood/Attention Seeking, 3 = Insomnia, 4 = Cursing/Screaming, 5 = Threatening, 6 = Physical Aggression (Hits/Scratches), 7 = Sexually Inappropriate, 8 = Wanders, 9 = Spits, 10 = Refuses Treatment/ADLs, 11 = Destroys Property, 12 = Disrobes Inappropriately, 13 = Delusions, 14 = Hallucinations, 15 = Disorganized Speech, 16 = Disorganized Behavior, 17 = Flat Affect, and 18 = Other - Describe in Progress Notes. Record review of R7's Medication Administration Record (MAR) for February, March and April 2025 revealed the following days with no charting of behavior monitoring: on 3/8/2025 for day shift, on 2/8/2025 for day shift, on 2/9/2025 for night shift, and on 4/26/2025 for day shift. In an interview conducted on 5/8/2025 at 10:24 am, with Certified Nursing Assistant (CNA) NN revealed, that if she noticed any changes in a resident, she would report it to the nurse and check back on the resident in a little bit. CNA NN reported that there was no designated place for CNAs to document this information. She added that if she observes unusual behavior, such as a resident being itchy or agitated, she informs the nurse. In an interview conducted on 5/8/2025 at 10:40 am with Licensed Practical Nurse (LPN) CC, revealed R7 has had some recent issues and noticed that she's been having more outburst crying more often. LPN CC stated the resident also verbalized I don't want to be here, and usually she's in great spirits. LPN CC stated she contacted the nurse practitioner twice to let her know R7's behavior. LPN has seen R7 today and confirmed she was fretful, anxious, and seems confused. In an interview conducted on 5/8/2025 at 10:54 am with Director of Nursing (DON) revealed, that her expectation was for staff to report all resident changes and for nurses to contact the provider for direction and document in SBAR (Situation, Background, Assessment, Recommendation) format. The DON emphasized that nurses were expected to know the indications for medications and monitor for side effects, while CNAs were expected to report any changes or unusual behaviors. She added that all staff should monitor residents during daily care activities. In an interview conducted on 5/9/2025 at 10:27 am with Regional Nurse Consultant (RNC) revealed, her expectation was that appropriate documentation to be maintained. She added that failure to document or address behaviors could result in worsening behavior. In an interview conducted on 5/9/2025 at 10:29 am with the Interim Administrator (IA) revealed, her expectation was that documentation be completed daily and to follow physician orders. She noted that failure to follow up could result in behavioral deterioration.

Based on observations, staff interviews, record review and review of facility's policy Test Water Temperatures, the facility failed to keep residents free of accident hazards as evidenced by water temperatures above 110 degrees Fahrenheit ( F) in 16 out of 48 resident rooms (102, 104, 103, 105, 106, 108, 110, 112, 114, 116, 201, 203, 210, 212, 213, and 215). The deficient practices had the potential to cause injury to residents residing in these rooms. Findings include: Review of the facility's provided document titled, Test Water Temperatures revealed, 1. For burn prevention, federal guidelines advise that you keep domestic water temperatures below 120 degrees Fahrenheit, although this temperature can still cause burns if exposure reaches five minutes. Many states have even stricter standards that set maximum temperatures lower than 120 degrees Fahrenheit, although 100 degrees Fahrenheit is considered a safe water temperature for bathing. 2. Test temperatures in shower areas 1.Observations on 5/6/2025 from 12:22 pm to 12:47 pm for water temperature checks in rooms located on the100 Hall with the Maintenance Director (MD) using the facility's digital thermometer revealed water temperature measurements in the following: rooms [ROOM NUMBERS] at 125 degrees F, rooms [ROOM NUMBERS] at 126 degrees F, rooms [ROOM NUMBERS] at 130 degrees F, rooms [ROOM NUMBERS] at 130 degrees F, rooms [ROOM NUMBERS] at 129 degrees F, In an interview conducted on 5/6/2025 at 12:15 pm and 12:36 pm, the MD revealed that water temperatures were supposed to be over 100 F but no higher than 110 F. He reported that he conducted water temperature testing once a week, selecting random rooms from each hall as well as the shower rooms. According to him, testing was completed the previous week, and at that time, he did not observe any rooms with elevated water temperatures. The MD confirmed that the water temperatures were currently reading high. He stated that when checking water temperatures, he typically allows the water to run for 5-10 seconds before taking a reading. Follow-up Observation on 5/6/2025 at 5:41 pm with the MD of water temperature checks revealed water temperature measurements in the following: room [ROOM NUMBER]-104 at 102.3 F, room [ROOM NUMBER]-105 at 102.1 F room [ROOM NUMBER]-108 at: 102.0 F room [ROOM NUMBER]-112 at 101.9 F room [ROOM NUMBER]-116 at 102.1 F 47947 2. Observations on 5/6/2025 from 12:43 pm to 12:47 pm for water temperature checks in rooms located on the 200 Hall with the Maintenance Director (MD), using the facility's digital thermometer revealed water temperature measurements in the following: rooms [ROOM NUMBERS] at 126 degrees F, rooms [ROOM NUMBERS] at 127 degrees F, rooms [ROOM NUMBERS] at 127 degrees F. Follow-up Observation on 5/6/2025 from 6:00 pm to 6:05 pm with the MD using the facility's digital thermometer revealed water temperature measurements in the following: rooms [ROOM NUMBERS] at 107 degrees F, rooms [ROOM NUMBERS] at 107 degrees F, rooms [ROOM NUMBERS] at 108 degrees F. In an interview conducted on 5/6/2025 at 5:41 pm, the MD revealed that he had made several adjustments to various valves and two water tanks to regulate water temperatures. He also stated that a plumber had been contacted to assist with the issue. Interview on 5/6/2025 at 5:50 pm with the Maintenance Director (MD) confirmed that when he went to adjust the water temperature, the water heater thermostat was showing 130 degrees Fahrenheit. The MD revealed that he had conducted a weekly check of the thermostat to ensure the water temperature remained under 110 degrees, however he was unsure why the temperature had gone up. In an interview conducted on 5/9/2025 at 10:32 am, the Regional Nurse Consultant (RNC) revealed that water temperatures was expected to be maintained between 100 F and 110 F. The RNC also revealed, that the Maintenance staff were responsible for checking water temperatures on a weekly basis. She emphasized that maintaining temperatures within this range was essential to prevent negative outcomes, such as residents being burned. In an interview conducted on 5/9/2025 at 10:34 am, the Interim Administrator confirmed the expectation that water temperatures were to be checked and maintained weekly, and should consistently remain between 100 F and 110 F. She also noted that a potential negative outcome of noncompliance was that residents could get burned. In a follow-up interview on 5/9/2025 at 1:59 pm, the MD confirmed that the expectation was to maintain water temperatures within the regulatory range of 100 F to 110 F. He acknowledged that failure to maintain proper temperatures could result in negative outcomes, including the risk of residents being burned. Review of the facility's records revealed that no residents sustained burns injuries related to hot water temperatures.

Based on observations, staff interviews, record review, and review of the facility's policy titled How to Puree Foods, the facility failed to ensure that dietary staff followed recipes for preparing puree food items to avoid compromising the nutritive value and flavor for eight of 88 residents receiving a pureed diet. Findings include: A review of an undated facility's policy titled How to Puree Foods under the section titled What is the correct pureed texture revealed, Pureed foods should be soft and moist, cohesive (holds together, not runny), smooth (without lumps) and spoon-thick (does not flow or drip continuously through fork prongs). Properly pureed foods should be 'swallow ready' and not require chewing. Under the section titled Preparation Steps revealed,1. Depending on the resident's dietary restrictions, follow the proper recipe. 5. If required, gradually add a small amount of liquid (2-3 tablespoons) while continuing to process to form a very smooth puree (moist mashed potato consistency); Do not add water. (a.) Add a small amount of hot liquid for hot foods, such as gravy, sauce, or cooking liquid, to the cooked hot foods. (b.) Add a small amount of cold liquid for cold food, such as milk or fruit juice. Review of the undated recipe titled Wild [NAME] - 1/2 Cup revealed notes for pureed: Measure desired #of servings into food processor. Blend until smooth. Add liquid if product needs thinning. Add commercial thickener if product needs thickening. Review of the undated recipe titled Baked Ham - 3 Oz revealed notes for pureed: Measure desired # (number) of servings into food processor. Blend until smooth. Add broth or grave if product needs thinning. Add Commercial thickener if product needs thickening. During the preparation of puree rice on 5/7/2025 at 10:50 am, Dietary [NAME] MM was observed placing 10 heaping spoonful of cooked rice into a standard blender bowl. She then added an unmeasured amount of water and then began to puree the rice. Once the desired consistency was achieved, she placed the rice into a steam table pan. During the preparation of puree food items on 5/7/2025 at 10:55 am, Dietary [NAME] MM was observed preparing puree baked ham. She placed an unmeasured amount of sliced baked ham with chipotle peach glaze into a standard blender bowl and began to puree. Dietary [NAME] MM stopped the blender and added an unmeasured amount of water and continued the puree process. Once the puree baked ham was at a desired consistency, Dietary [NAME] MM placed the ham into a steam table pan. Interview with Dietary [NAME] MM on 5/8/2025 at 2:45 pm revealed that sometimes she adds water when she prepares rice or meat to make it smooth. Interview with Dietary Manager on 5/8/2025 at 2:50 pm confirmed that Dietary [NAME] MM should not be using water to prepare puree. She stated that Dietary [NAME] MM will be re-educated over the puree process.

Based on observation and staff interviews, the facility failed to replace a missing privacy curtain and to ensure full visual privacy for one of 48 rooms (room [ROOM NUMBER]). The facility census was 88 residents. Findings include: A review of the facility' Resident Council Minutes Report dated 4/30/2025 revealed, residents had a concern about privacy which stated, Make sure drapes are being closed even if door is closed. An observation on 5/6/2025 at 9:55 am revealed that the privacy curtain for 308-A bed was missing preventing full visual privacy. An interview on 5/6/2025 at 9:57 am with Licensed Practical Nurse (LPN) LL confirmed that she was aware that the privacy curtain was missing for 308-A bed and that it prevented full visual privacy. An observation on 5/8/2025 at 9:37 am revealed the privacy curtain was still missing for 308 A-bed preventing full visual privacy. An interview on 5/8/2025 at 2:30 pm with the Housekeeping Supervisor revealed that he was unaware that there was a privacy curtain missing and he would correct it. Observation and interview on 5/9/2025 at 2:45 pm with the Housekeeping Supervisor revealed he was not aware of the privacy curtain missing in room [ROOM NUMBER] and understood that it did not ensure full visual privacy for the residents during patient care. He stated it was the Maintenance Director's responsibility to install the curtains.

Based on observations, staff interviews, and review of the facility policy titled, Infection Control - Housekeeping Services, the facility failed to maintain a clean and homelike environment for residents in 12 of 49 resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]). This deficient practice had the potential to place residents at risk for living in an unsanitary and unsafe living environment and a potential for diminished quality of life. Findings include: Review of the facility policy titled, Infection Control - Housekeeping Services, revised 10/16/2023, revealed Policy Statement: It is the policy of this facility to ensure housekeeping services will be performed on a routine and consistent basis to ensure an orderly, sanitary, and comfortable environment. The section titled Routine Cleaning of Horizontal Surfaces stated 1. In patient/resident care areas, cleaning of non-carpeted floors and other horizontal surfaces will be performed daily and more frequently if spillage or visible soiling occurs. Observations on 6/17/2024 from 10:50 am to 11:59 am revealed the following: room [ROOM NUMBER] - The window screen had holes in it, the window blind was broken, trash was on the floor, the bathroom door had scrapes, and a small painted panel on the door. room [ROOM NUMBER] - There was a basin under the sink filled with approximately two inches of water and pipes dripped slowly under the sink into the basin, there were scrapes on the bathroom door with a small painted panel on the door, the bathroom door frame had gouges into the wood and was missing paint. room [ROOM NUMBER] - A cable outlet box was pulled out from the wall one-fourth to one-half an inch, gray duct tape held a sponge-like material on the window edges, the bathroom door had scrapes and rusted areas, and paint was peeling off the wall by the sink. room [ROOM NUMBER] - The window screen was pulled away from the window, two unlabeled urinals were hanging from the handrail by the commode, which was a bathroom used by residents from two rooms, the bathroom door had scrapes and dents in it, and paint was peeling on the wall by the sink. room [ROOM NUMBER] - Dirt and debris were observed behind the entry door and along the floor edges in the bathroom, the wall had scrapes, only one of two lightbulbs worked in the bathroom, and scrapes were seen on the bathroom doors. room [ROOM NUMBER] - Dirt was observed along the edges of the floor, the walls had scrapes, the front part of the air conditioner had dirt on it and was pulled loose from the right side, trash was on the floor, the bathroom door had scrapes, and the wall/floor molding was separating from the wall. room [ROOM NUMBER] - A dark brown substance was observed on the closet drawers, there was dirt on the floor along the wall edges, red color stains were observed on the air conditioner's wood-encased box, different floor patterns/color tiles were in the room, the bathroom had a brown substance on the seat of the stool riser down the stool, and large area of brown discoloration was observed on the floor by the stool, caulking was missing from around the stool, a brown substance was on the toilet paper roll, and the sink was loose from the wall. room [ROOM NUMBER] - The bathroom had trash on the floor, only one of two lightbulbs worked in the bathroom, the bathroom was missing flooring and the flooring was rolled and raised, three boards were observed stacked on top of each other along the bathroom wall, and the trash can had a three by four inch piece missing. room [ROOM NUMBER] - The vinyl molding was separated from the wall, the bathroom door frame was scraped and the paint was peeling, the privacy curtain was pulled together and held in place with disposable gloves, no window screen was on the window, tile was missing from the windowsill, lights were not working in the bathroom, and there was a buildup of a brown/rust colored debris along the bathroom door frame. room [ROOM NUMBER] - The air conditioner edges had a brown color on them, there were different patterns/color tiles on the floor, chipped and missing floor tiles were observed, a buildup of dirt was along the edges of the wall, the paint had peeled and was hanging down in the bathroom, there was no toilet paper holder, the wall paint had peeled and was missing around the sink, only one of two light bulbs worked in the bathroom and white tape held up the black television cords. room [ROOM NUMBER] - The bathroom door had gouges and missing paint, wood was missing along the door edges, four different floor tiles were in the room, only one of two bathroom lights worked, and the light on the ceiling in the middle of the room had missing paint around it. room [ROOM NUMBER] - The bathroom doors had gouges and missing facing, the bathroom door frame was missing wood and had scrapes, dirt and debris were seen on the floor behind the room door, caulking was missing around the toilet, no toilet paper holder was in place, the bathroom ceiling paint had peeled and was hanging down, and different patterns/color floor tiles were observed in the room. During an interview with Housekeeper OO, the housekeeper in charge while the Housekeeping Director was on vacation, on 6/18/2024 at 12:41 pm, she stated each housekeeper had their own hall that they were responsible for. Housekeeper OO stated at the present time, they only had two housekeeping carts so they shared with each other.

Based on observations, interviews, record reviews, and review of facility policy titled, Medication Administration: Enteral Tubes, the facility failed to ensure that care and services were provided according to accepted standards of practice for two of seven residents (R) (R6 and R9) reviewed for medication administration. Specifically, the facility failed to administer R6 medications in a timely manner; and failed to follow procedure for enteral medication administration for R9. Findings include: Review of the facility policy titled, Medication Administration: Enteral Tubes dated revised 1/12/2024 revealed, Procedure & [and] Key Points: 8. Flush the tube with 15 ml [milliliters] water or per physician's order. 9. Remix the medication. Place the first medication into the syringe. After medication has been given, flush with 5 [five] ml of water or per physician orders then place the next medication into the syringe (then repeat for each medication given). 10. Allow medication to flow down the tube via gravity. Give gentle boosts with the plunger (approximately 1 [one] inch down) if the medication will not flow by gravity. Repeat if necessary. Do not push medications through the tube. 1. Review of the closed record of R6 revealed an admitted [DATE] at 6:38 pm from the hospital with diagnoses which included, malignant neoplasm of brain, glioblastoma multiforme, insomnia, hypercholesterolemia, major depressive disorder, gastro esophageal disorder, and history of hepatitis B. Review of Resident R6's physician orders included the following medication orders: Dabigatran etexilate (treat and prevent blood clots), 150 milligrams (mg) two times a day scheduled for 9:00 am and 5:00 pm, Dexamethasone (steroid) two mg two times a day scheduled for 9:00 am and 5:00 pm, Famotidine (used to treat acid in the stomach) 20 mg two times a day scheduled for 9:00 am and 9:00 pm, levetiracetam, (used to prevent seizures) 500 mg every 12 hours scheduled for 9:00 am, and 9:00 pm, Mirtazapine (antidepressant) 15 mg at bedtime scheduled for 9:00 pm, Trazodone (antidepressant, helps with sleep) 100 mg at bedtime scheduled for 9:00 pm. Review of R6's Medication Administration Record (MAR) for 12/2022 revealed the resident did not receive their dexamethasone until 12/3/2024 at 5:00 pm, did not receive the famotidine, levetiracetam, mirtazapine or trazodone until 12/3/2024 at 9:00 pm, and did not receive the dabigatran etexilate until 12/4/2024 at 9:00 am. In an interview with Unit Manager GG on 6/18/2024 at 9:30 am, she stated the staff enter the medication orders in the computer and they directly go to the pharmacy to be filled. The pharmacy delivered every evening, and they utilized an on-call pharmacy to get medications from also. The nurses could also obtain medications from the Emergency Medication Cabinet System. Review of the facility provided list of contents of the Emergency Medication Cabinet, put in place on 12/2022, revealed the cabinet contained: famotidine, levetiracetam, mirtazapine, and trazodone, all medications R6 was prescribed. Further review revealed staff did not utilize the Emergency Medication Cabinet to administer the residents' medications ordered by the physician. In an interview with the Director of Health Services (DHS) on 6/18/2024 at 1:31 pm, she stated the nurses could enter medication orders into the computer up to 5:30 pm and still receive the medication from the pharmacy that same evening. DHS stated if the medication was not delivered the staff could then use the emergency supply of medications until the resident's medication came in. 2. Review of R9's Physician Orders revealed the order dated 3/13/2024 for baclofen (muscle relaxant) 10 mg via the gastroesophageal (g-tube) three per day. Further review of the Physician orders revealed an order dated 3/13/2024 to flush the g-tube with 15 milliliters (mls) of water before and after medications and five mls between each medication. Observation during the medication pass on 6/18/2024 at 12:12 pm for R9 revealed Registered Nurse (RN) NN crushed Baclofen, 10 mg and added five ml of water. RN NN turned off the g-tube feeding. She then checked placement by instilling five ml of air and listening to the abdomen and then checked for residual. RN NN poured the Baclofen into the syringe, without flushing the tubing with the ordered water first. The Baclofen did not flow down the tubing and the RN NN used the piston of the syringe to push the medication down the tubing. RN NN followed with a 15 ml water flush. During an interview with RN NN on 6/18/2024 at 12:19 pm, she stated the nurse should flush with 15 ml of water prior to giving medication through the g-tube and confirmed she did not flush the g-tube prior to giving the medication.

Based on observations, staff interviews, record review, and review of facility policy titled Enhanced Barrier Precaution (EBP), the facility failed to follow infection control practices during direct contact care for one of 11 residents (R) (R9) on Enhanced Barrier Precautions (EBP) during incontinent care and the administration of medications through a gastrostomy tube (G-tube) (a tube surgically inserted through the skin into the stomach to deliver nutrition, hydration, and medication). These failures had the potential to expose residents to infections due to cross-contamination. Findings included: Review of the facility policy title, Enhanced Barrier Precaution (EBP), dated 4/30/2024, revealed 3. Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray (i.e., wound irrigation, tracheostomy care). b. PPE [personal protection equipment] is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. The policy further stated, 4. High-contact resident care activities include: a. Dressing b. Bathing c. Transferring d. Providing hygiene e. Changing linens f. Changing briefs or assisting with toileting g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes h. Wound care: any skin opening requiring a dressing. Review of R9's clinical record revealed diagnoses included pneumonia, vascular dementia, quadriplegia, cerebral infarction, and major depressive disorder. Review of R9's quarterly Minimum Data Set (MDS), dated [DATE], revealed section GG (Functional Abilities and Goals) documented R9 was dependent on staff for ADLs, section H (Bowel and Bladder) documented R9 was always incontinent of bowel and bladder, section K (Swallowing/Nutritional Status) documented R9 had a feeding tube and received 51 percent or more of total calorie intake and 501 cubic centimeter or more per day by the feeding tube. Review of the care plan dated 4/11/2024 revealed the resident was on EBP due to having a G-tube, with an intervention to wear a gown and gloves during close-contact care. The care plan further revealed the resident had urinary incontinence, with an intervention for staff to anticipate and provide incontinence care as needed. Review of the Physician's Orders dated 4/9/2024 revealed an order for enhanced barrier precautions, with special instructions to wear a gown in addition to gloves during close contact care. Observation on 6/18/2024 at 9:54 am. revealed Certified Nursing Assistant (CNA) PP provided incontinence care for R9 while providing a bed bath. Observation revealed the resident was lying on her back and the CNA unfastened the brief and used a cloth with soap and water to clean between the legs and the frontal area. Further observation revealed that CNA PP did not change the position of the wipe with each swipe. CNA PP then turned the resident to their left side and cleaned between the buttocks without changing the position of the wipe with each swipe. Additional observation revealed CNA PP wore a mask and gloves but did not wear a gown. Observation during G-tube medication administration for R9 on 6/18/2024 at 12:12 pm revealed Registered Nurse (RN) HH wore a mask and gloves but did not wear a gown. In an interview with RN HH on 6/18/2024 at 12:19 pm, she stated she should have worn a gown when administering G-tube medications. In an interview with the Director of Health Services (DHS) on 6/18/2024 at 1:31 pm, she stated the staff should wear a gown and gloves when working with a resident on EBP and should change the position of the cloth with each wipe during incontinence care. In an interview with CNA RR on 6/19/2024 at 9:53 am, she stated when providing incontinence care the staff should clean front to back and change the position of the wipe/cloth with each swipe.

Based on observation, record review, interviews, and review of the SNF Outpatient Dialysis Services Agreement, the facility failed to ensure that transportation services were consistently provided for one resident (R) (R#404) of three residents reviewed for dialysis transportation services. Findings include: Review of the SNF Outpatient Dialysis Services Agreement dated February 18, 2015, revealed Obligations of the Nursing Facility Number 4. Transport and Referral of ESRD Residents: Letter A. the nursing facility shall be responsible for arranging for suitable and timely transportation if the end stage renal disease (ESRD) resident to and from the ESRD Dialysis Unit, including the selection of the mode of transportation, equipment associated with this type of transfer, and all costs or transportation expenses associated with such transfer. Review of the clinical record revealed resident was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, end stage renal disease (ESRD), anemia in chronic kidney disease (CD), hypertension (HTN), chronic obstructive pulmonary disease (COPD), anxiety disorder, and depression. The resident's most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 10, which indicates moderate cognitive impairment. Section O revealed the resident was receiving Dialysis. Review of the care plan revised 4/27/2023 revealed resident has potential for complications related to hemodialysis for diagnosis of ESRD. Interventions to care include dialysis three times per week, on Tuesday, Thursday, and Saturday with chair time 11:15 a.m. Review of the Physician's Orders (PO) for the month of May 2023 revealed an order dated 5/16/2023 for dialysis three times per week at 10:00 a.m. on Tuesday-Thursday-Saturday (T/TH/S) and dialysis transportation [provider name] three times per week Tuesday/Thursday/Saturday pickup 10:15 a.m. Review of the facility Grievance Logs dated 3/24/2023 through 5/20/2023 revealed R#404 missed his dialysis appointments on the following days; 3/25/2023, 3/27/2023, 4/15/23, 5/4/23, 5/6/23, and 5/20/23. Further review revealed the reason for the missed dialysis appointments was due to transportation not showing up to pick up the resident. Review of the Grievance Log date 5/8/2023 indicated R#404 was sent to the hospital due to systemic swelling/edema as a result of missed dialysis appointments. The Hospital Admission diagnosis was Non-adherence to Medical Treatment. Review of the Progress Note dated 3/25/2023 at 2:50 p.m. revealed resident did not go for dialysis due to transportation. Dialysis center made aware. Review of the Progress Note dated 3/27/2023 at 7:07 p.m. indicated resident missing his appointment at dialysis on Saturday. Transportation representative stated they would try to get transportation sometime for resident today if they could. Review of the Progress Note dated 4/15/2023 at 6:28 p.m. revealed resident did not go to dialysis today. Nurse Practitioner (NP) made aware. Review of the Progress Note dated 4/23/2023 at 6:22 p.m. revealed resident did not go to dialysis due to transportation. Review of the Progress Note dated 4/28/2023 at 11:29 a.m. indicated patient continues to dialyze on T/TH/S. SW (Social Worker) at facility attempting to switch schedule to M/W/F due to two missed sessions on Saturdays due to transportation. Review of the Progress Note dated 5/4/2023 at 2:45 p.m. indicated patient continues to dialyze on T/TH/S. Patient missed Wednesday session due to transportation. Will continue to advocate for patients' continuity and consistency in transportation to dialysis. Review of the Progress Note dated 5/4/2023 at 2:58 p.m. revealed resident unable to go to dialysis today due to transportation problems. Resident rescheduled for Saturday 5/6/2023 per staff member. NP notified. Review of the Progress Note dated 5/6/2023 at 4:02 p.m. revealed resident did not go for dialysis today due to transportation. NP notified, new order to send resident to the ER to be dialysate [sic]. Review of the Progress Note dated 5/6/2023 at 7:15 p.m. indicated resident came back from hospital. Resident did not do dialysate [sic], just do some labs done [sic]. Review of the Progress Note dated 5/8/2023 at 2:30 p.m. revealed resident missed hemodialysis on 5/4 and 5/6 systemic swelling/edema noted. Resident denies SOB (shortness of breath) Weks [sic] NP notified with new order to transfer to ER (emergency room )for eval and tx (treatment). Brother made aware. Review of the Progress Note dated 5/16/2023 at 7:04 p.m. recorded as a late entry on 5/17/2023 at 3:09 a.m. indicated resident was admitted with diagnosis of nonadherence to medical treatment, ESRD on dialysis. Dialysis 3 X 1 week, left arm with a fistula, bruit and thrill present. Interview on 5/24/2023 at 10:00 a.m., Licensed Practical Nurse (LPN) EE revealed the facility Nurse Navigator sets up transportation for residents outside appointments. She stated the facility has a van with designated drivers that can be used for transporting residents to appointments. She stated R#404 is scheduled to go to dialysis on Tuesday, Thursday, and Saturday of each week, and revealed he has missed a few of his appointments due to transportation not picking him up at times. During further interview, she stated that if resident misses his dialysis, she informs the physician and will monitor resident for shortness of breath. Interview on 5/24/2023 at 10:15 a.m. with Registered Nurse (RN) HH revealed she will assist with the transportation process by reviewing the doctor's order and then makes the transportation appointment. During further interview, she stated the resident must be able to sit in a wheelchair and/or be physically able to get in the van, in order to use the facility van as the mode of transportation. She stated the facility must have a designated driver for the van available in order to take residents to appointments. and the driver must be available and not on another run. Interview on 5/24/2023 at 10:45 a.m. Human Resources (HR) II stated if the transportation company did not pick up residents for scheduled appointments, the facility would communicate with the dialysis center about the transportation concern. She stated residents must be able to sit up in a wheelchair in order to be transported in the facility van. Interview on 5/24/2023 at 10:55 a.m. Assistant Maintenance Director revealed he can drive the van and will take residents to appointments if needed. He stated he checks daily to see if he has any transportation trips to run. During further interview, he stated he has taken residents to various appointments including dialysis but has not taken R#404 to any dialysis appointments. He stated the van drivers can also work on Saturdays, if needed. Interview on 5/24/2023 at 12:30 p.m. Administrator revealed the facility van can be used to transport residents to appointments. She stated the maintenance staff do not work on the weekend but has implemented a policy to rotate drivers to be on call for Saturday appointments.

Based on observations and staff interviews, the facility failed to ensure that ten hollow plastic handrails were maintained for safe use on two of the three halls (200 Hall and 300 Hall). The deficient practice had the potential to affect residents and visitors utilizing rails for assistance with ambulation. Findings include: Observation on 3/28/2023 at 9:00 a.m. revealed six handrails on the 300 halls, that had busted and cracked areas with sharp points sticking out and holes that had jagged, sharp edges. The rails were located between the soiled utility room and medication room, as well as between residents' rooms 304-306, 306-308, 310-312, 312-314, and 314-316. Observation on 3/28/2023 at 10:20 a.m. revealed four handrails on the 200 hall that had cracked areas with jagged, sharp edges, located between resident rooms 208/210, 211/213, 209/211, and 216. A walk-through tour was conducted on 3/30/2023 at 11:30 a.m. with the Director of Maintenance which confirmed the cracked, jagged, and sharp areas on the 200 and 300 halls. Interview on 3/30/2023 at 11:30 a.m. with the Director of Maintenance revealed he had not noticed the cracked areas or holes and there were no work orders pending for the repair of the rails to his knowledge. The Director of Maintenance placed tape over each unsafe area on the 200 hall and 300 halls after the walk-through tour was completed.

Based on observations, staff interviews, and review of the facility policy titled, Cleaning Schedules the facility failed to ensure that the main kitchen was kept clean and sanitary. Specifically, the facility failed to ensure routine cleaning of the hood vent and the kitchen floor were conducted consistently in the main kitchen. Findings include: Initial walk through on 3/28/2023 at 8:45 a.m. of the kitchen with the Dietary manager revealed the hood over the main stove in the kitchen had streaks of grease streaming from the top of the hood down to the bottom lip of the hood. There was a build up of dirt and debris noted on the top of the hood that extended from the top crease at the connection site of the ceiling to the outer ledge of the hood on all three sides. Continued observation also revealed a moderate amount of a black greasy substance on the floor between the portable oven and the stove with a thick buildup of dust and debris noted on the oven and stove connections. Review of the hood cleaning schedule revealed the last professional cleaning was scheduled for 4/23/2023. A follow up walk through on 3/29/2023 at 9:00 a.m. of the main kitchen revealed all previous observations of the hood over the main stove had streaks of grease streaming from the top of the hood down to the bottom lip of the hood. There was a buildup of dirt and debris noted on the top of the hood that extended from the top crease at the connection site of the ceiling to the outer ledge of the hood on all three sides. Continued observation also revealed a moderate amount of a black greasy substance on the floor between the portable oven and the stove with a thick buildup of dust and debris noted on the oven and stove connections. All observations were confirmed with the Dietary Manger during the walk through. A review of the facility policy titled, Cleaning Schedules, dated September 2001, Under Policy revealed It is the Dietary manager's responsibility to develop and enforce the cleaning schedules and to monitor the completion of assigned cleaning tasks to promote a sanitary environment . Under Guidelines number 4. The Dietary Manger will conduct routine sanitation checks and maintains a file of completed checks. Interview on 3/29/2023 at 4:17 p.m. with Dietary manager revealed her expectation of the dietary staff is to conduct daily routine cleaning of the kitchen and surface areas. Further interview also revealed that there is currently not a cleaning schedule in place for the kitchen. Interview on 3/29/2023 at 4:27 p.m. with the Administrator revealed her expectation of the dietary staff is to keep the kitchen environment clean and sanitary.

Based on observations, interviews, record review, and review of the policies titled Self-Administration of Medications by Patients/Residents and Medication Administration: General Guidelines, the facility failed to assess one of 39 residents (R) (R#16) for the ability to self-administer medications prior to leaving medications at the bedside. Specifically, the facility failed to ensure R#16 was assessed to self-administer TUMS and antifungal ointment that were stored at residents' bedside. Findings include: Review of the policy titled Self-Administration of Medications by Patients/Residents dated 4/1/1998 and revised 1/28/2020 revealed the policy statement of: Each patient/resident who desires to self-administer medication is permitted to do so if the healthcare center's Licensed Nurse and physician have determined that the practice would be safe for the patient/resident and other patients/residents of the healthcare center. The procedure section revealed lines numbered 2. If the patient/resident desires to self-administer medications, an assessment is conducted by the Licensed Nurse to assess the individual's cognitive, physical, and visual ability to carry out this responsibility. 3. If the licensed nurse determines the patient/resident to be capable of self-administration of medications, the attending physician must write an order to that effect that includes specific medications based off of the Self-Administration Medication Observation. Review of the policy titled Medication Administration: General Guidelines dated 4/1/1998 and revised 4/10/2019 revealed procedure line numbered 3. Patients/residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. Observation on 3/28/2023 at 10:00 a.m. of resident #16 revealed one open tube of Medline Remedy Antifungal Ointment (a medication used to treat skin fungus) 2.5oz (ounce) container and one open container of TUMS (a medication used to treat upset stomach and heartburn) 72 count sitting on the overbed table. On 3/28/2023 at 12:16 p.m. and on 3/29/2023 at 8:45 a.m., observation of R#16 revealed one TUMS 72 count bottle and one Medline Remedy Antifungal Ointment 2.5oz. tube sitting on the over bed table. Review of the physician's orders revealed there was not a physician's order for TUMS, antifungal cream, or for self-administration of medications. Review of the medication administration record (MARS) dated 1/2023, 2/2023, and 3/2023 did not include TUMS or antifungal ointment. Record review for R#16 revealed resident was admitted to the facility with diagnoses of dementia, Alzheimer's disease, and major depressive disorder. Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed R#16 had a Brief Interview for Mental Status (BIMS) score of 13 indicating resident was cognitively intact. Review of the care plan revealed there was not a care planned intervention for self-administration of medications. Continued record review did not reveal an assessment completed for R#16 to self-administer medications. Interview on 3/28/2023 at 10:00 a.m. with R#16 revealed that she took the TUMS and used the ointment as she felt she needed to. Further interview also revealed that her daughter brought the TUMS to her, and resident was unsure where the ointment came from. Interview on 3/29/2023 at 8:50 a.m. with Licensed Practical Nurse (LPN) AA revealed she was unaware of residents self-administering medications and that medications should not be in resident rooms. She revealed the requirements for a resident to keep medications in the room and self-administer were to have a physician's order, an assessment for self-administration, resident education, and proper storage of the medication. At 8:53 a.m. observation of R#16 room with LPN AA verified one open tube of Medline Remedy Antifungal Ointment 2.5oz and one open container of TUMS 72 count sitting on the overbed table. Interview on 3/30/2023 at 1:45 p.m. with the Director of Health Services (DHS) revealed her expectations were for medications to not be left in the resident rooms except with a physician's order, a completed self-medication administration assessment, and the resident was educated on safe self-medication administration. She revealed medications should be secured in the locked medication cart or medication storage room.

Based on observations, staff interviews, record review, and review of the facility policy titled, Restorative Nursing Program, the facility failed to ensure brace/splint was applied for one of 11 residents (R) #29. Specifically, the facility failed to ensure R#29 splint was applied to residents left hand as ordered by the physician. Findings: Review of a policy titled Restorative Nursing Program with a revision date of 11/4/2021, revealed that it is the policy of the healthcare center to provide restorative nursing which actively focuses on achieving and maintain optimal physical, mental, and psychological functioning and well being of the resident. The scope of the policy applies to all PruittHealth-affiliated healthcare centers that provide a Restorative program. Observation on 3/28/2023 at 10:10 a.m. revealed R# 29 was noted to be resting in the bed no braces were noted to his left upper extremity. Observation on 3/28/2023 at 1:05 p.m. revealed the resident was noted to be laying in the bed with eyes closed, and no brace on his left upper extremity. Observation on 3/29/2023 at 11:15 a.m. R#29 was noted laying in the bed with no brace on his left upper extremity. Review of the electronic medical record for resident R #29, revealed that he was admitted to the facility with diagnoses that included but were not limited to acute kidney failure, hemiplegia, type 2 diabetes, developmental disorder, anxiety, contracture of left wrist and hand, aphasia, dysphagia, and depression. Review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed in Section C (Cognitive Pattern) a Brief Interview for Mental Status (BIMS) score of three (3) indicating severe cognitive impairment. Review of Section G (Functional Status) revealed resident requires extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. Interview on 3/30/2023 at 1:35 p.m. with the Director of Health Services (DHS) revealed that the restorative program was not working due to staffing issues and the program needed to be changed. Interview on 3/30/2023 at 1:45 p.m. with the Regional Nurse Consultant, revealed that the restorative program was broken, and she was in the process of revamping the whole program. She stated that the revision of the program was going to start with the nurses. She stated that the day shift nurses were to be responsible for placing braces on the residents and the night shift nurses would remove them. She stated that prior to Monday 3/26/2023, there was no way of documenting splint applying and removal. Since Monday, there is a form for documentation, and it is on each of the medication carts. during the day shift and then remove later during the shift. She stated that it had just started back up last week, Monday, 3/20/2023.

Based on observations, interviews, record review, and review of the facility document titled Your Rights as a Patient, the facility failed to ensure that one of 39 residents (R#55) was provided showers according to his preferences. Findings include: Review of the undated document titled Your Rights as a Patient provided by the facility, revealed page 30, Self Determination: You have the right to self-determination, including but not limited ot the following rights: b. To make choices about aspects of your life in the center that are significant to you. Observation on 3/28/2023 at 10:30 a.m., 3/28/2023 at 2:15 p.m., and 3/29/2023 at 9:50 a.m. revealed R#55 was lying in bed, dressed in a stained and wrinkled hospital type gown, and residents' fingernails were dirty, long, and jagged. Interview on 3/28/2023 at 10:30 a.m. with R#55 revealed he had not had a shower in six weeks and would like to have a shower at least once per week. He revealed he had asked staff for a shower and was informed he would be provided with one when there was time. Record review for R#55 revealed resident was admitted to the facility with diagnoses of right knee osteoarthritis, muscle weakness, difficulty in walking, and depression. Review of the Admission minimum data set (MDS) dated [DATE] revealed: section C ( Cognitive Pattern) revealed a brief interview for mental status (BIMS) was coded as 10 (indicating moderately impaired cognition); section F (Preferences for customary Routine and activities) indicated the choice of a tub bath, shower, bed bath, or sponge bath was somewhat important to R#55; section G (Functional Status) indicated R#55 was coded as total dependent for bathing. Review of the care plan revealed a goal of resident's activities of daily living (ADL) needs will be met and independence potential maximized within constraints of disease through next review. Review of the nurse's progress dated 1/12/2023 through 3/27/2023 did not reveal documented refusal of ADL care or showers. Review of the electronic medical record (EMR) point of care (POC) documentation revealed R#55 received a shower on 1/19/2023 and 3/22/2023; and received a bed bath on 1/24/2023, 1/25/2023,1/27/2023, 2/5/2023, 2/22/2023, 2/23/2023, 2/25/2023, 3/1/2023, 3/2/2023, 3/7/2023, 3/10/2023, 3/17/2023, 3/18/2023. Interview on 3/29/2023 at 9:20 a.m. with Certified Nurse's Assistant (CNA) DD revealed if a resident declines care, she informs the nurse and re-attempts later. She further revealed she reported changes in mood or behavior to the nurse. She revealed CNAs are given assignments daily and include bath/shower schedule. Further interview also revealed she documented ADLs that included baths/showers in the EMR and on a paper document that is given to the nurse at the end of the shift. She revealed nail care was included in ADL care. She revealed she was unsure when R#55 had a shower or nail care. Interview on 3/29/2023 at 9:30 a.m. with Licensed Practical Nurse (LPN) EE revealed the CNAs were responsible for providing shower/baths. She revealed the bath/shower schedule is assigned based on resident preference and the schedule is in the shower logbook for the CNAs to view. She revealed all baths/showers and refusal of care should be documented. She further revealed she was unsure when R#55 had a shower or if he had refused showers. Interview on 3/29/2023 at 11:30 a.m. with Senior Nurse Consultant (SNC) Registered Nurse (RN) FF revealed residents should receive baths/showers as they desire. Observation of R#55 with SNC/RN FF verified resident had jagged, dirty fingernails. Interview with R#55 revealed he had not had a shower in a few weeks and would like a shower, would like one every Sunday, would like his fingernails trimmed and cleaned, and would like his face to be shaven. Interview on 3/30/2023 at 1:15 p.m. with the Director of health Services (DHS) revealed her expectations were for residents to receive baths/showers per the resident's preference, and that nail care would be included in bath/shower care. She revealed the facility did not have an ADL or bath/shower policy.

Based on observation, interviews, and review of the facility policies titled, Storage of Pharmaceuticals, Enteral Products and Supplies and Medication Administration: General Guidelines, the facility failed to ensure that one of three medication carts (200 Hall cart) was locked and secured when the cart was out of view of the nurse. Specifically, the facility failed to ensure the medication cart on the 200 was locked and medications secured when not in use. Findings include: Review of the policy titled Storage of Pharmaceuticals, Enteral Products and Supplies dated 8/1/2008 and revised 6/1/2017 revealed the policy statement of: All pharmaceuticals and enteral products are stored under proper conditions with regard to sanitation, temperature, light, moisture, ventilation, safety, and security. Review of the policy titled Medication Administration: General Guidelines dated 4/1/1998 and revised 4/10/2019 revealed procedure section line numbered 16: During routine administration of medications, the medication cart is kept in the doorway of the patient/resident's room, with open drawers facing inward and all other sides closed and locked. No medications are kept on top of the cart, and all outward sides must be inaccessible to patients/residents or others passing by. Observation on 3/28/2023 at 10:45 a.m. of medication cart located on the 200 Hall and between rooms 211/213 with the compartment openings facing the hallway revealed the cart to be unlocked, unattended and to have one 30ml (milliliter) medication cup containing seven tablets/capsules and one Wixela oral inhaler (a medication used to treat asthma) sitting on top of the cart. There was not a nurse observed in the hallway or in the area. During the observation one resident was noted ambulating in the hallway by the medication cart. At 10:49 a.m. Registered Nurse (RN) CC approached the cart and identified she was responsible for the medication cart and confirmed the cart was unlocked, unattended and that the medications were sitting on top of the cart. Interview on 3/28/2023 at 10:49 a.m. with RN CC revealed the medications that were left unattended on top of the medication care were Flomax two capsules (a medication used to treat urinary retention), Hydralazine one tablet (a medication used to treat high blood pressure), Lexapro one tablet (a medication used to treat depression and anxiety), Eliquis 1 tablet (a medication used to treat blood clots and strokes), and Zoloft one tablet (a medication used to treat depression, anxiety, post traumatic stress disorder). Further interview confirmed that the medications were within view of and easily accessible to residents and others. She revealed she should have secured the medications in the locked cart and should have locked the cart before leaving it. Interview on 3/30/2023 at 12:00 p.m. with the Director of Health Services (DHS) revealed her expectations were for the medication carts to be locked and secured when out of the eyesight of a nurse and medications should not be left unsecured.

Based on observations, record review, staff interview, and review of the facility policy titled, Respiratory Equipment Changeouts, the facility failed ensure that the oxygen (02) tubing was changed according to the physician's order for one of 11 Residents (R) (R#215). The deficient practice had the potential to affect R#215 respiratory status by increasing the potential of a respiratory infection. Findings include: Review of the facility policy titled, Respiratory Equipment Changeouts dated 6/1/2009 with a revised date of 1/25/2022, revealed under Policy statement: To provide guidelines to help prevent infections associated with respiratory equipment and to prevent transmission of such infections to patients/residents and staff. Under: Oxygen Therapy Equipment, Nasal Cannula (low flow) and tubing shall be changed weekly. Observation on 3/28/2023 at 11:32 a.m. of R#215 revealed resident was up in wheelchair in room with oxygen on at 1 liter. Oxygen tubing appeared cloudy and brown tinged. Further inspection of the tubing revealed a discolored piece of taping on the tubing that was with a faded ink dated 3/2/2023. Observation on 3/29/2023 at 10:35 a.m. of R#215 revealed resident with oxygen tubing on which was dated 3/2/2023. Record review revealed resident was admitted to the facility with the diagnoses to include congested heart failure (CHF), atrial fibrillation, pulmonary hypertension, and pleural effusion. Review of the Physician Orders dated 3/24/2023 revealed change respiratory supplies weekly once a day on Monday and as needed. Interview on 3/30/2023 at 2:36 p.m. with Director of Health Services (DHS), revealed that the oxygen tubing is expected to be changed as ordered by the physician and to be logged on the Medication administration record once tubing has been changed.

Based on record review, interviews and review of the Georgia Board of Nursing, Rule 410-10-.01 Standards of Practice for Registered Nurses, facility policies titled Occurrences, Lippincott Procedures - Fall Management, Lippincott Procedures - SBAR Communication, Competency: Baseline, Annual, and Ongoing, the facility failed to properly assess, provide services, or notify the Physician for a fall for one of nine residents (Resident (R) #4,). Actual harm identified on 4/4/2020 when the resident fell and suffered a fractured femur/hip which was not identified until 4/7/2020, resulting in a delay in treatment of [REDACTED]. Findings include: Review of the Georgia Board of Nursing Rule 410-10-.01 Standards of Practice for Registered Nurses, 2. (a) 1. Assess the patient/client in a systematic, organized manner (b) Standard related to the registered nurse's responsibilities as a member of the nursing profession and related responsibility to apply the nursing process. The registered nurse shall: 2. Accept responsibility for individual nursing actions and continued competence; 3. Communicate, collaborate, and function with other members of the health team to provide optimum care. Review of facility policy titled Occurrences reviewed 9/9/2019 revealed Reporting Occurrences: 1. Occurrences are to be reported to the Charge Nurse immediately, no matter how minor they may appear. 2. Patient/resident care software incident entry must be completed on the shift the occurrence took place. 4. Partners witnessing an occurrence involving a patient/resident must report details of occurrence to his/her Charge Nurse as soon as possible. Medical Attention: Upon arrival, the licensed nurse will be responsible for providing immediate medical attention as follows: observes and [MEDICATION NAME] all occurrence victims, checks vital signs, provides first aid if indicated, notifies attending physician or designee, informing them of the occurrence and patient/resident's condition, implements the physician's instructions/orders, if indicated, notifies the responsible party. Occurrence Documentation: 1. The licensed nurse will be responsible for completing the following occurrence documentation requirements prior to the end of the shift when the occurrence took place. This documentation will be noted in the patient/resident's clinical records and in the occurrence reporting software program, obtain any witness statements that may be needed before end of shift, the occurrence report completed in its entirety in the software program. Review of falls procedures titled Lippincott Procedures - Fall Management revised 2/3/2017 revealed (company name) requires: Fall risk assessment to be completed on every resident on admission, readmission, significant change, and quarterly. Do not move a patient until you fully evaluate his status to prevent further injury if an injury has occurred as a result of the fall. Perform necessary measures for pain relief. Perform a post fall assessment to determine the root cause of the fall. Documentation: After a fall, complete a detailed incident report to help track frequent patient falls so that you can use prevention measures with high-risk patients. Make sure that the incident report documents where and when the fall occurred, how the patient was found, and what position he was in. Include the events preceding the fall, the names of witnesses, the patient's reaction to the fall, and a detailed description of the patient's condition, based on assessment findings. Record the names of people you notified of the fall, including the practitioner and the patient's health care power of attorney, and the dates and times that you notified them. Include a copy of the practitioner's report. Also note whether the practitioner sent the patient for diagnostic tests or transferred him to another unit. Include all the information about the fall in the patient's record. Also document his vital signs and ongoing monitoring for a severe complication of the fall. Review of facility policy titled SBAR (Situation, Background, Assessment, Recommendations) Communication revised 8/12/2016 revealed SBAR communication breaks communication down into four steps: 1. Situation-a concise description of the patient's current situation, which may include such information as the admitting [DIAGNOSES REDACTED]. Background-the historical or current patient data relevant to the patient's current problem, 3. Assessment-a summary of the nurse's analysis of the current situation after considering the data gathered in the background step, 4. Recommendation-a statement of what the nurse believes will resolve the situation, along with the time frame in which a response is expected; this step commonly involves interaction between the sender and receiver and may include questions about the patient's care. Completing the procedure: develop a follow up plan as needed in collaboration with the person receiving your communication. Document the procedure. Complications: Failure to comply with a systematic approach such as SBAR communication may lead to patient care errors. Documentation: Document the name of the receiver of the SBAR communication; the date, time, and content of the communication (using the SBAR communication format); the interventions performed as a result of the communication; and the patient's response to those interventions. Review of policy titled Competency: Baseline, Annual, and Ongoing reviewed 3/5/2019 revealed Policy Statement: All partners will demonstrate baseline competency prior to functioning independently in their assigned role. Competencies are assessed annually on low-volume, high-risk, and problem-prone procedures. Competency is also required for new equipment, new procedures, changes in regulation, and changes in evidence-based practice. Competency/clinical competency is a shared responsibility between the partner and their supervisor to ensure patient safety and quality outcomes. Definitions: Competency - the partner's ability to perform skills and/or demonstrate knowledge associated with specific job role. Problem-Prone include procedures that are the subject of incident reports, error reporting forms, or quality assurance performance improvement activities. Review of medical record for R#4, revealed the resident was admitted to the facility on [DATE], from the hospital, with the diagnoses, including, repeated falls, low back pain, and difficulty walking. Review of Nurse's Notes for R#4 dated 4/2/2020 at 10:24 p.m. revealed the resident was admitted to the facility, from the hospital, with [DIAGNOSES REDACTED]. Alert with confusion. Verbally responsive and able to make needs known, clear lung sounds, no respiratory distress noted, no cough, no congestion. Skin dry and warm to touch. Abdomen non distended with bowel sounds active in all 4 quadrants, requires extensive assist with ADLs. Incontinent of B&B (Bowel and Bladder). No [MEDICAL CONDITION] on any of the extremities. Bed in low position. Review of the resident's the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of six, indicating the resident has severe cognitive impairment. It further revealed the resident requires extensive assistance for getting out of bed and changing position in bed. Special treatments include OT (Occupational therapy) and PT (Physical Therapy). Review of the resident's care plan initiated on 4/2/2020 revealed the resident is as risk for falls with interventions (updated on 4/7/2020), to keep the bed in a low position, assist for toileting and transfers as needed, cue for safety awareness, keep environment safe and place call light within reach. Additionally, the resident is care planned for impaired mobility with interventions that include Physical Therapy (PT) and Occupational Therapy to evaluate and treat as ordered, provide assistive device as ordered and monitor patient/resident progress/response to therapy. And to notify the Physician of any changes in Activities of Daily Living (ADL) decline. Review of Nurse's Notes dated 4/4/2020 at 10:15 a.m., signed by Licensed Practical Nurse (LPN) JJ, revealed the resident's family member called and stated that the resident broke her leg. Resident is moving all extremities but states it hurts. The resident, per the family member, had surgery on that leg. Wing nurse (RN AA) notified to give her pain medication. This nurse called the family member and advised her pain mediation will be given. Review of the Progress Notes dated 4/6/2020 at 10:52 a.m., signed by LPN NN, revealed R#4 is complaining of pain in the right upper leg, resident unable to work with therapy due to pain. Nurse Practitioner (NP) OO notified, new order for X-ray to right hip, femur, and knee. Review of Occupational (OT) Daily Treatment Note, by OT therapist, dated 4/6/2020 at 5:54 p.m. revealed Educated resident on recommendation for Right Low Extremity (R LE) X-ray due to significant change in function since Friday (4/3/2020) assessment. Nurse and Physician (MD) orders X-ray. Further (therapy) to be withheld. Review of the 24 Hour Shift Report sheets for 4/2/2020 through 4/7/2020 revealed there was no documentation of the resident having a fall on 4/4/2020 or during this time frame. A review of the Medication Administration Record [REDACTED]. The administration of [MEDICATION NAME] 5/325 mg is documented as the following: 4/3/2020 at 2:36 p.m. and 9:54 p.m., 4/6/2020 at 9:11 a.m., 4/7/2020 at 9:26 a.m. Review of the Progress Notes, dated 4/7/2020 at 4:27 a.m., signed by RN LL revealed the resident alert with confusion and requires extensive assist with ADL's. Resident still with complaint (c/o) of pain in her right thigh area when touched. Called X-ray to upgrade order to STAT order at 12 midnight, X-ray done around 1:30 a.m., [MEDICATION NAME] given for pain management. Review of the radiology report dated 4/7/2020 at 5:31 a.m. revealed of the right femur results: there is a fracture involving the intertrochanteric femur with mild displacement. The remainder of the femur is intact. Conclusion: Right [MEDICAL CONDITION] as described. A handwritten note on the bottom of the X-ray report revealed new order, send to ER (emergency room ) per NP OO. Review of an Event Summary-Safety Events, dated 4/8/2020, by the former Director of Health Services (DHS), RN BB revealed that RN AA stated to the RN BB that R#4 was found in the floor beside her bed on 4/4/2020 at 9:30 a.m. RN AA assessed the resident and stated the resident did not have any deformity or injury noted and was helped back to bed by RN AA. RN AA then gave R#4 a pain medication, that she was prescribed. RN AA stated that R#4 remained stable throughout her shift. The former DHS (RN BB) notified the Physician and family of the fall today, 4/7/2020. Review of the ED (Emergency Department) Provider Note, dated 4/7/2020 at 11:07 a.m., revealed the resident presents from nursing facility after having an X-ray done for right hip pain, showing intertrochanteric right [MEDICAL CONDITION]. Patient does have a shortened and externally rotated right lower extremity with an intertrochanteric fracture. A telephone interview on 1/26/2021 at 12:06 p.m. with the family member of R#4 revealed that the resident had called her on 4/4/2020 to say that the resident had broken her leg. She was unable to determine exactly the circumstances, although the resident did say she had fallen. She then called the facility to have someone check R#4. The family member indicated that the nurse knew that resident's leg was broken and still allowed her to have therapy. She reported the therapist is the one who got the staff to look at the leg. She cannot imagine the pain that R#4 must have been in. An interview on 1/27/2021 at 2:53 p.m. with LPN JJ revealed she recalled answering the phone when R#4s family member called who was frantic and upset. LPN JJ explained to the family that she would go and check on the resident and would call her back. LPN JJ observed the resident, in her bed, and was found to be able to move everything, did not grimace and did complain of pain. LPN JJ revealed that she did not specifically ask the resident if her right leg was hurting and nor did she check the resident's leg for redness or swelling. LPN JJ notified RN AA that the resident was complaining of pain and wanted pain medication. Continued interview with LPN JJ revealed that the facility fall protocol, is to examine the resident, check vital signs, ask them about pain, then transfer the resident to a surface of their choice. She would then notify the doctor and the family and include instructions in the event documentation for the fall. She was not assigned to the resident on 4/4/2020 but had notified RN AA that the family member had call the facility after the resident had called the family member. A telephone interview on 1/28/2021 at 9:30 a.m. with RN AA revealed she did recall the incident on 4/4/2020 with R#4. RN AA revealed that the resident did sustain a fall and indicated CNA MM found her on her bottom on the floor next to her bed. When they went to assist her, the resident revealed that she was trying to go to the bathroom. They assessed her, got her up and put her back in bed. RN AA revealed that the resident did not cry out in pain or voice complaints of any pain. RN AA further denied having any conversation with LPN JJ indicating the only conversation she had about this incident was with the (former) DHS, RN BB when she called to tell her about completing the occurrence report. RN AA revealed that she takes responsibility for not completing the occurrence report but there was a lot going on that morning and it was busy. RN AA further indicated that she notified RN BB (former DHS) that she was in New York and would do the report on her return, in 14 days. She was later notified by RN BB that she was terminated because she did not do the occurrence report. A telephone interview on 1/28/2021 at 10:59 a.m., RN BB (former DHS), revealed the facility's falls protocol was for staff to assess the patient, notify the DHS, the Physician and family. The nurses do the initial report, and management closes out the fall occurrence report. RN BB had a vague recollection of the nurse not notifying anyone and that she did not find out until she returned on her scheduled workday. RN BB revealed that the corporate nurse was then made aware of the incident and the facility nurse RN AA was terminated because she did not complete a fall report. RN BB revealed that RN AA never documented the incident and did not notify anyone of the fall. Review of the facility Staffing Sheets dated Saturday, 4/4/2020 and Sunday, 4/5/2020, revealed that RN AA was scheduled each day during the 7:00 a.m. and 7:00 p.m. shift. Review of a Facility Investigation report dated 4/15/2020 revealed the incident was reported to the State Survey Agency (SSA) on 4/8/2020. The investigation Summary/Conclusion revealed Upon the conclusion of the investigation, and in receiving statements from the resident and staff, this injury is felt to be a result of the fall on 4/4/2020. Continued review of the Investigation Report revealed a summary of the telephone interview with the family member of R#4 and the Administrator dated 4/8/2020, which documented that the family member had spoken to the resident, via telephone on 4/4/2020, who stated her leg was torn. The family member did not know what the resident was saying or describing; therefore, the family member contacted the Nurse's Station and spoke to a nurse. The family member shared that the resident had hurt her leg and was able to make out, from the resident, that the resident got herself off the floor. Further review of the Investigation Report revealed a telephone interview with RN AA and the former DHS (RN BB) dated 4/8/2020. RN AA shared that the CNA had reported that the resident had a (sic) fallen and that RN AA went in to look at the resident, but reported the resident was ok, no complaints of pain. RN AA reported that she had not completed a progress note or incident report of the fall. RN AA stated that she forgot to do so. Review of the personnel file of RN AA revealed that she had completed online training on the following topics: Effective Communication, Code of Conduct, Phase 3 Implementation and Trauma-Informed Care. Facility was unable to locate baseline competency skills records for RN AA. Continued review revealed a document dated 4/10/2020 with the following: Action-Termination, Reason-Unsatisfactory Performance and an effective date of 4/10/2020. Additionally, there is a State of Georgia Department of Labor Separation Notice for RN AA dated 4/14/2020, indicating her period of last employment was 10/29/2019 to 4/10/2020.

Based on record review, interviews and review of facility policies titled Occurrences, Lippincott Procedures - Fall Management, Lippincott Procedures - SBAR Communication, the facility failed timely assess and document a fall one of nine residents (R) ( #4). Actual harm was identified when R#4 fell on [DATE] and suffered a right femur/[MEDICAL CONDITION] resulting in hospitalization on [DATE] and surgery on 4/8/2020. Findings include: Review of facility policy titled Occurrences reviewed 9/9/2019 revealed Reporting Occurrences: 1. Occurrences are to be reported to the Charge Nurse immediately, no matter how minor they may appear. 2. Patient/resident care software incident entry must be completed on the shift the occurrence took place. 4. Partners witnessing an occurrence involving a patient/resident must report details of occurrence to his/her Charge Nurse as soon as possible. Medical Attention: Upon arrival, the licensed nurse will be responsible for providing immediate medical attention as follows: observes and [MEDICATION NAME] all occurrence victims. checks vital signs. provides first aid if indicated. notifies attending physician or designee, informing them of the occurrence and patient/resident's condition. implements the physician's instructions/orders, if indicated. notifies the responsible party. Occurrence Documentation: 1. The licensed nurse will be responsible for completing the following occurrence documentation requirements prior to the end of the shift when the occurrence took place. This documentation will be noted in the patient/resident's clinical records and in the occurrence reporting software program. obtain any witness statements that may be needed before end of shift. the occurrence report completed in its entirety in the software program. Review of falls procedures titled Lippincott Procedures - Fall Management revised 2/3/2017 revealed the Facility requires: Fall risk assessment to be completed on every resident on admission, readmission, significant change, and quarterly. Do not move a patient until you fully evaluate his status to prevent further injury if an injury has occurred as a result of the fall. Perform necessary measures for pain relief. Perform a post fall assessment to determine the root cause of the fall. Documentation: After a fall, complete a detailed incident report to help track frequent patient falls so that you can use prevention measures with high-risk patients. Make sure that the incident report documents where and when the fall occurred, how the patient was found, and what position he was in. Include the events preceding the fall, the names of witnesses, the patient's reaction to the fall, and a detailed description of the patient's condition, based on assessment findings. Record the names of people you notified of the fall, including the practitioner and the patient's health care power of attorney, and the dates and times that you notified them. Include a copy of the practitioner's report. Also note whether the practitioner sent the patient for diagnostic tests or transferred him to another unit. Include all the information about the fall in the patient's record. Also document his vital signs and ongoing monitoring for a severe complication of the fall. Review of facility policy titled SBAR (Situation, Background, Assessment, Recommendation) Communication revised 8/12/2016 revealed that the SBAR communication breaks communication down into four steps: 1. Situation-a concise description of the patient's current situation, which may include such information as the admitting [DIAGNOSES REDACTED]. Background-the historical or current patient data relevant to the patient's current problem, 3. Assessment-a summary of the nurse's analysis of the current situation after considering the data gathered in the background step, 4. Recommendation-a statement of what the nurse believes will resolve the situation, along with the time frame in which a response is expected; this step commonly involves interaction between the sender and receiver and may include questions about the patient's care. Completing the procedure: develop a follow up plan as needed in collaboration with the person receiving your communication, document the procedure. Complications: Failure to comply with a systematic approach such as SBAR communication may lead to patient care errors. Documentation: Document the name of the receiver of the SBAR communication; the date, time, and content of the communication (using the SBAR communication format); the interventions performed as a result of the communication; and the patient's response to those interventions. Review of facility posting titled Meet your Nurse Practitioner (NP) revealed call your NP when a member experiences: Changes in condition, Abnormal imaging or testing, Falls or Adverse Event, Changes in condition include but are not limited to:. Fall, Leg Pain, New or suspected fracture . Review of the medical record for R#4 revealed the resident was admitted to the facility, on 4/2/2020, from the hospital, with the following [DIAGNOSES REDACTED]. Review of Nurse's Notes for R#4 dated 4/2/2020 at 10:24 p.m. revealed the resident admitted with [DIAGNOSES REDACTED]. Alert with confusion. Verbally responsive and able to make needs known, clear lung sounds, no respiratory distress noted, no cough, no congestion. Skin dry and warm to touch. Abdomen non distended with bowel sounds active in all 4 quadrants, requires extensive assist with ADLs. Incontinent of B&B (Bowel and Bladder). No [MEDICAL CONDITION] on any of the extremities. Bed in low position. Review of the resident's the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of six, indicating the resident has severe cognitive impairment. It further revealed the resident requires extensive assistance for getting out of bed and changing position in bed. Pain management is identified with occasional pain and a severity score of seven. Special treatments include OT (Occupational therapy) and PT (Physical Therapy). Review of the fall risk tool for R#4, dated 4/2/2020, revealed a total fall risk score of 17 points indicating she was a high fall risk. Review of the resident's care plan initiated on 4/2/2020 revealed the resident is as risk for falls with interventions (updated on 4/7/2020), to keep the bed in a low position, assist for toileting and transfers as needed, cue for safety awareness, keep environment safe and place call light within reach. Additionally, the resident is care planned for impaired mobility with interventions that include Physical Therapy (PT) and Occupational Therapy to evaluate and treat as ordered, provide assistive device as ordered and monitor patient/resident progress/response to therapy. It further revealed she is as risk for pain with interventions that included administering pain medication per Physician orders, report to the Physician if the resident does not experience a reduction or relief of pain after receiving the medication. And to notify the Physician of any changes in Activities of Daily Living (ADL) decline. Review of Nurse's Notes dated 4/4/2020 at 10:15 a.m., signed by Licensed Practical Nurse (LPN) JJ revealed the resident's family member called and stated that the resident broke her leg. Resident is moving all extremities but states it hurts. The resident, per the family member, had surgery on that leg. Wing nurse (RN AA) notified to give her pain medication. This nurse called the family member and advised her pain mediation will be given. Review of an Event Report dated 4/6/2020 at 10:52 a.m., by LPN NN, revealed R#4 is complaining of pain in the right upper leg, resident unable to work with therapy due to pain. NP OO notified, new order for X-ray to right hip, femur, and knee. Review of the Physician's Admission History and Physical dated 4/6/2020 revealed the reason for the appointment was resident was a new admission. Resident admitted into facility for rehabilitation following hospitalization for generalized weakness, frequent falls, and left hip pain. Assessment included pain in right leg and left hip. Recommended treatment for [REDACTED]. Review of Physical Therapy (PT) note dated 4/6/2020 at 4:43 p.m.revealed Patient already up in wheelchair but sacral sitting and when patient assisted to upright sitting and moving the R (right) leg patient started grimacing and clutching R thigh. Notified hall nurse who stated patient already received pain meds. Assisted by PTA (Physical Therapy Assistant) attempted to stand patient with FWW (Front Wheeled Walker) but unable to with patient complaining of pain again to R LE (Right Lower Extremity). Talked to nursing regarding new onset of pain, complaints to R thigh area and significant decline in function as patient had walked with PT about 30 feet with moderate to minimum assist on evaluation on 4/3/2020. Nurse to get order for x-ray to R LE. Transferred patient back to bed with assist of CNA with total assist by 2. Review of an Event Report dated 4/7/2020 at 4:27 a.m., by Registered Nurse (RN ) LL, resident still complaining (c/o) pain in her right thigh area when touched, called X-ray to upgrade order to STAT (immediately) Order at 12:00 a.m. (Midnight). X-ray done around 1:30 a.m., per X-ray tech only able to X-ray of right hip which will show the knee and femur due to R#4 being non-compliant. [MEDICATION NAME] (for pain) given for pain management. Review of the 24 Hour Shift Report sheets for 4/2/2020 through 4/7/2020 revealed there was no documentation of the resident having a fall on 4/4/2020 or during this timeframe. An entry on 4/7/2020, 7:00 p.m. to 7:00 a.m., revealed R#4 resident with pain in her (R) (right) leg, x-ray done, awaiting result. Review of an Event Summary-Safety Events, dated 4/8/2020, by the former Director of Health Services (DHS) RN BB revealed RN AA stated to the DHS (former) RN BB that R#4 was found in the floor beside her bed on 4/4/2020 at 9:30 a.m. RN AA assessed the resident and stated the resident did not have any deformity or injury noted and was helped back to bed by RN AA. RN AA then gave R#4 a pain medication, that she was prescribed. RN AA stated that R#4 remained stable throughout her shift. The former DHS (RN BB) notified the Physician, family of the fall today, 4/7/2020. Review of the radiology report dated 4/7/2020 at 5:31 a.m. revealed of the right femur results: there is a fracture involving the intertrochanteric femur with mild displacement. The remainder of the femur is intact. Conclusion: Right [MEDICAL CONDITION] as described. A handwritten note on the bottom of the X-ray report revealed new order, send to ER (emergency room ) per NP OO. Review of Nurse's Note dated 4/7/2020 at 9:44 a.m. revealed an order from NP received to send resident out to hospital for right [MEDICAL CONDITION]. Also, resident's family member notified of transfer. Review of Nurse's Note dated 4/7/2020 at 7:53 p.m. revealed it was reported to the (former) DHS by RN AA who was the resident's primary nurse on 4/4/20 at 9:30 a.m. that resident was found by RN AA sitting in the floor. Resident denied any injury or pain. No injury was noted by RN AA. Resident was helped back to bed and resident was given pain medication. Resident remained stable during the remainder of the shift. Upon direct report of the fall staff notified the Physician and resident's family was notified. A Situation, Background, Assessment, Recommendations (SBAR) put in system as well on this date 4/7/2020. DHS (former) was notified of fall this date 4/7/20. Review of the ED (Emergency Department) Provider Note, dated 4/7/2020 at 11:07 a.m., revealed the resident presents from nursing facility after having an X-ray done for right hip pain, showing intertrochanteric right [MEDICAL CONDITION]. Patient does have a shortened and externally rotated right lower extremity with an intertrochanteric fracture. The Physician discussed with family practice who will admit the patient for further management and orthopedic consultation. Review of the hospital History and Physical dated 4/7/2020 at 3:17 p.m. revealed Assessment and Plan: Intertrochanteric [MEDICAL CONDITION] femur with medial angulation and slight impaction. Ortho consulted for management. History of Present Illness: The family member stated the resident started complaining (c/o) of right hip pain three days ago and had an X-ray (XR) done on her right hip yesterday. The reading of the X-Ray then came back today showing fracture therefore the resident was transferred to the hospital for further treatment. Review of the Physician (MD) Consult (Orthopedic) note dated 4/8/2020 revealed The Orthopedic Surgeon believes this patient would benefit from a (sic) intramedullary fixation of the left hip, benefits were reviewed with the family, they wish to proceed. Procedure completed on 4/8/2020. An interview on 1/27/2021 at 2:53 p.m. with LPN JJ revealed she recalled answering the phone when R#4s family member called who was frantic and upset. LPN JJ explained to the family that she would go and check on the resident and would call her back. LPN JJ observed the resident, in her bed, and was found to be able to move everything, did not grimace and did complain of pain. LPN JJ revealed that she did not specifically ask the resident if her right leg was hurting and nor did she check the resident's leg for redness or swelling. LPN JJ notified RN AA that the resident was complaining of pain and wanted pain medication. Continued interview with LPN JJ revealed that the facility protocol, if a resident has a fall is to examine the resident, check vital signs, ask them about pain, then transfer the resident to a surface of their choice. She would then notify the doctor and the family and include instructions in the event documentation for the fall. She was not assigned to the resident on 4/4/2020 but had notified RN AA that the family member had called the facility after the resident had called the family member. A telephone interview on 1/28/2021 at 9:30 a.m. with RN AA revealed she did recall the incident on 4/4/2020 with R#4. RN AA revealed that the resident did sustain a fall and indicated CNA MM found her on her bottom on the floor next to her bed. When they went to assist her, the resident revealed that she was trying to go to the bathroom. They assessed her, got her up and put her back in bed. RN AA revealed that the resident did not cry out in pain or voice complaints of any pain. RN AA further denied having any conversation with LPN JJ indicating the only conversation she had about this incident was with the former DHS, RN BB when she called to tell her about completing the occurrence report. RN AA revealed that she takes responsibility for not completing the occurrence report but there was a lot going on that morning and it was busy. RN AA further indicated that she informed RN BB (former DHS) that she was in New York and would do the report on her return, in 14 days. She was later notified by RN BB that she was terminated because she did not do the occurrence report. A telephone interview on 1/28/2021 at 10:59 a.m., RN BB (former DHS), revealed their falls protocol at this facility was for staff to assess the patient, notify the DHS, the Physician and family. The nurses do the initial report, and management closes out the fall occurrence report. RN BB had a vague recollection of the nurse not notifying anyone and that she did not find out until she returned on her scheduled workday. RN BB revealed that the corporate nurse was then made aware of the incident, and the facility nurse RN AA was terminated because she did not complete a fall report. RN BB revealed that RN AA never documented the incident and did not notify anyone of the fall. An interview on 1/28/2021 at 11:47 a.m. with CNA KK revealed that she assisted CNA MM who was taking care of R#4, and recalls it was on a Saturday morning. CNA MM needed help and the resident was complaining of pain. They were going to change her, but she was in a lot of pain and complaining of pain in her right hip. After they changed the resident that she advised CNA MM to let the nurse know of the resident's pain. She indicated the leg/hip did not look bad or abnormal and revealed that she was not aware of the resident's fall. CNA KK further revealed that on Monday morning (4/6/2020) she recalls the Physical Therapist asked them about the resident because R#4s hip/leg looked different. An interview on 1/28/2021 at 4:12 p.m. with RN LL revealed that she does not remember if she was involved in this situation with R#4, however she did obtain the STAT order from the doctor. RN LL does not remember but if she had requested the X-ray Stat then she must have assessed the resident and noticed that she was still in pain. A telephone interview on 1/28/2021 at 4:14 p.m. with the Physician, of record at that time, revealed he does not recall R#4 but does recall her name He revealed that typically the Nurse Practitioner (NP) or Physician Assistant (PA) are the day to day providers for the residents. The facility will typically call the NP first if the facility does not know what to do. He further revealed that typically when he assesses a resident who says they are in pain; he will observe the area for visible changes and range of motion then make his recommendations from this assessment. An interview on 1/29/2021 at 8:51 a.m. with CNA MM revealed she reports everything she sees to the nurse and that she vaguely remembers this event, with R#4. She further revealed that the resident was tiny. She revealed that another CNA (CNA KK) assisted her and that the resident was in a lot of pain, complained of pain, which they reported to the RN AA. An interview on 1/29/2021 at 9:06 a.m. with Nurse Practitioner OO revealed she does not remember R#4 but would have mentioned it in her note if she had received a call from the facility about this resident. Review of the facility Staffing Sheets dated Saturday, 4/4/2020 and Sunday, 4/5/2020, revealed that RN AA was scheduled each day during the 7:00 a.m. and 7:00 p.m. shift. The schedule indicated that CNA MM was scheduled from 6:00 a.m. through 10:00 p.m. on 4/4/2020 and 4/5/2020. Review of a Facility Investigation report dated 4/15/2020 revealed the incident was reported to the State Survey Agency (SSA) on 4/8/2020. The investigation Summary/Conclusion revealed Upon the conclusion of the investigation, and in receiving statements from the resident and staff, this injury is felt to be a result of the fall on 4/4/2020. Continued review of the Investigation Report revealed a summary of the telephone interview with the family member of R#4 and the Administrator dated 4/8/2020, which documented that the family member had spoken to the resident, via telephone on 4/4/2020, who stated her leg was torn. The family member did not know what the resident was saying or describing; therefore, the family member contacted the Nurse's Station and spoke to a nurse. The family member shared that the resident had hurt her leg and was able to make out, from the resident, that the resident got herself off the floor. Further review of the Investigation Report revealed a telephone interview with RN AA and the former DHS (RN BB) dated 4/8/2020. RN AA shared that the CNA had reported that the resident had a (sic) fallen and that RN AA went in to look at the resident, but reported the resident was ok, no complaints of pain. RN AA reported that she had not completed a progress note or incident report of the fall. RN AA stated that she forgot to do so. Review of a signed written statement by CNA MM, dated 4/7/2020, revealed she was check up (sic) on my patient. I saw the R#4 on the floor at 1:03 (without an indication of a.m. or p.m.) on 4/4/2020, then called the nurse. Review of the personnel file of RN AA revealed that she had completed online training on the following topics: Effective Communication, Code of Conduct, Phase 3 Implementation and Trauma-Informed Care. Facility was unable to locate baseline competency skills records for RN AA. Continued review revealed a document dated 4/10/2020 with the following: Action-Termination, Reason-Unsatisfactory Performance and an effective date of 4/10/2020. Additionally, there is a State of Georgia Department of Labor Separation Notice for RN AA dated 4/14/2020, indicating her period of last employment was 10/29/2019 to 4/10/2020.

Based on record review, interviews and review of facility policies titled Occurrences, Lippincott Procedures - Fall Management, and SBAR Communication, the facility failed to notify the Responsible Party and the Physician of a fall for one of nine residents ((R) #4) resulting in a delay in treatment of [REDACTED].#4 fell on [DATE] and suffered a right femur/[MEDICAL CONDITION] resulting in hospitalization on [DATE] and surgical intervention on 4/8/2020. Findings include: Review of facility policy titled Occurrences reviewed 9/9/2019 revealed Reporting Occurrences: 1. Occurrences are to be reported to the Charge Nurse immediately, no matter how minor they may appear. 2. Patient/resident care software incident entry must be completed on the shift the occurrence took place. 4. Partners witnessing an occurrence involving a patient/resident must report details of occurrence to his/her Charge Nurse as soon as possible. Medical Attention: Upon arrival, the licensed nurse will be responsible for providing immediate medical attention as follows: observes and [MEDICATION NAME] all occurrence victims. checks vital signs. provides first aid if indicated. notifies attending physician or designee, informing them of the occurrence and patient/resident's condition. implements the physician's instructions/orders, if indicated and notifies the responsible party. Review of falls procedures titled Lippincott Procedures - Fall Management revised 2/3/2017 revealed the Facility requires: Fall risk assessment to be completed on every resident on admission, readmission, significant change, and quarterly. Do not move a patient until you fully evaluate his status to prevent further injury if an injury has occurred as a result of the fall. Perform necessary measures for pain relief. Perform a post fall assessment to determine the root cause of the fall. Documentation: After a fall, complete a detailed incident report to help track frequent patient falls so that you can use prevention measures with high-risk patients. Make sure that the incident report documents where and when the fall occurred, how the patient was found, and what position he was in. Include the events preceding the fall, the names of witnesses, the patient's reaction to the fall, and a detailed description of the patient's condition, based on assessment findings. Record the names of people you notified of the fall, including the practitioner and the patient's health care power of attorney, and the dates and times that you notified them. Include a copy of the practitioner's report. Also note whether the practitioner sent the patient for diagnostic tests or transferred him to another unit. Include all the information about the fall in the patient's record. Also document his vital signs and ongoing monitoring for a severe complication of the fall. Review of facility policy titled SBAR (Situation, Background, Assessment, Recommendation) Communication revised 8/12/2016 revealed that the SBAR communication breaks communication down into four steps: 1. Situation-a concise description of the patient's current situation, which may include such information as the admitting [DIAGNOSES REDACTED]. Background-the historical or current patient data relevant to the patient's current problem, 3. Assessment-a summary of the nurse's analysis of the current situation after considering the data gathered in the background step, 4. Recommendation-a statement of what the nurse believes will resolve the situation, along with the time frame in which a response is expected; this step commonly involves interaction between the sender and receiver and may include questions about the patient's care. Completing the procedure: develop a follow up plan as needed in collaboration with the person receiving your communication, document the procedure. Complications: Failure to comply with a systematic approach such as SBAR communication may lead to patient care errors. Documentation: Document the name of the receiver of the SBAR communication; the date, time, and content of the communication (using the SBAR communication format); the interventions performed as a result of the communication; and the patient's response to those interventions. Review of facility posting titled Meet your (Company name) Nurse Practitioner (NP) revealed call your the NP when a member experiences: Changes in condition, Abnormal imaging or testing, Falls or Adverse Event, Changes in condition include but are not limited to:. Fall, Leg Pain, New or suspected fracture . Review of the medical record for R#4 revealed the resident was admitted to the facility on [DATE], from the hospital, with the following [DIAGNOSES REDACTED]. Review of Nurse's Notes for R#4 dated 4/2/2020 at 10:24 p.m. revealed the resident was admitted , to the facility, with [DIAGNOSES REDACTED]. Alert with confusion. Verbally responsive and able to make needs known, clear lung sounds, no respiratory distress noted, no cough, no congestion. Skin dry and warm to touch. Abdomen non distended with bowel sounds active in all 4 quadrants, requires extensive assist with ADLs. Incontinent of B&B (Bowel and Bladder). No [MEDICAL CONDITION] on any of the extremities. Bed in low position. Review of the resident's care plan initiated on 4/2/2020 revealed the resident was at risk for falls with interventions (updated on 4/7/2020), to keep the bed in a low position, assist for toileting and transfers as needed, cue for safety awareness, keep environment safe and place call light within reach. Additionally, the resident was care planned for impaired mobility with interventions that include Physical Therapy (PT) and Occupational Therapy to evaluate and treat as ordered, provide assistive device as ordered and monitor patient/resident progress/response to therapy. And to notify the Physician of any changes in Activities of Daily Living (ADL) decline. Review of Nurse's Notes dated 4/4/2020 at 10:15 a.m., signed by Licensed Practical Nurse (LPN) JJ, revealed the resident's family member called and stated that the resident broke her leg. Resident is moving all extremities but states it hurts. The resident, per the family member, had surgery on that leg. Wing nurse (Registered Nurse (RN) AA) notified to give her pain medication. This nurse called the family member and advised her pain mediation will be given. Review of an Event Report dated 4/6/2020 at 10:52 a.m., by LPN NN, revealed R#4 is complaining of pain in the right upper leg, resident unable to work with therapy due to pain. NP OO notified, new order for X-ray to right hip, femur, and knee. Review of an Event Report dated 4/7/2020 at 4:27 a.m., by RN LL, resident still complaining (c/o) pain in her right thigh area when touched, called X-ray to upgrade order to STAT (immediately) Order at 12:00 a.m. (Midnight). X-ray done around 1:30 a.m. Review of the 24 Hour Shift Report sheets for 4/2/2020 through 4/7/2020 revealed there was no documentation of the resident having a fall on 4/4/2020 or evidence of a fall during this time frame. Review of the Physician's Admission History and Physical dated 4/6/2020 revealed the reason for the appointment was resident was a new admission. Resident admitted into facility for rehabilitation following hospitalization for generalized weakness, frequent falls, and left hip pain. Assessment included pain in right leg and left hip. Recommended treatment for [REDACTED]. Review of the radiology report dated 4/7/2020 at 5:31 a.m. revealed of the right femur results: there is a fracture involving the intertrochanteric femur with mild displacement. Conclusion: Right [MEDICAL CONDITION] as described. A handwritten note on the bottom of the X-ray report revealed new order, send to ER (emergency room ) per NP OO. Review of an Event Summary-Safety Events, dated 4/8/2020, by the (former) DHS RN BB revealed RN AA stated to the DHS (former) RN BB that R#4 was found in the floor beside her bed on 4/4/2020 at 9:30 a.m. RN AA assessed the resident and stated the resident did not have any deformity or injury noted and was helped back to bed by RN AA. RN AA then gave R#4 a pain medication, that she was prescribed. RN AA stated that R#4 remained stable throughout her shift. The former DHS (RN BB) notified the Physician, family of the fall today, 4/7/2020. Review of Nurse's Note dated 4/7/2020 at 9:44 a.m. revealed order from NP received to send resident out to hospital for right [MEDICAL CONDITION]. Also, resident's family member notified of transfer. Review of Nurse's Note dated 4/7/2020 at 7:53 p.m. revealed it was reported to Director of Health Service (DHS) by Registered Nurse (RN) AA who was the resident's primary nurse on 4/4/20 at 9:30 a.m. that resident was found by RN AA sitting in the floor. Resident denied any injury or pain. No injury was noted by RN AA. Resident was helped back to bed and resident was given pain medication. Resident remained stable during the remainder of the shift. Upon direct report of the fall staff notified the Physician and resident's family was notified. A Situation, Background, Assessment, Recommendations (SBAR) put in system as well on this date 4/7/2020. DHS (former) was notified of fall this date 4/7/20. Review of the ED (Emergency Department) Provider Note, dated 4/7/2020 at 11:07 a.m., revealed the resident presents from nursing facility after having an X-ray done for right hip pain, showing intertrochanteric right [MEDICAL CONDITION]. Patient does have a shortened and externally rotated right lower extremity with an intertrochanteric fracture. An interview on 1/27/2021 at 2:53 p.m. with LPN JJ revealed she recalled answering the phone when R#4s family member called and was frantic and upset. LPN JJ explained to the family that she would go and check on the resident and would call her back. LPN JJ observed the resident, in her bed, and was found to be able to move everything, did not grimace and did complain of pain. LPN JJ revealed that she did not specifically ask the resident if her right leg was hurting and nor did she check the resident's leg for redness or swelling. LPN JJ notified RN AA that the resident was complaining of pain and wanted pain medication. Continued interview with LPN JJ revealed that the facility protocol, if a resident has a fall is to examine the resident, check vital signs, ask them about pain, then transfer the resident to a surface of their choice. She would then notify the doctor and the family and include instructions in the event documentation for the fall. She was not assigned to the resident on 4/4/2020 but had notified RN AA that the family member had called the facility after the resident had called the family member. A telephone interview on 1/28/2021 at 10:59 a.m., RN BB (previous DHS), revealed their falls protocol at this facility was for staff to assess the patient, notify the DHS, the Physician and family. The nurses do the initial report, and management closes out the fall occurrence report. RN BB had a vague recollection of the nurse not notifying anyone and that she did not find out until she returned on her scheduled workday. RN BB revealed that the Corporate Nurse was then made aware of the incident, and the facility nurse RN AA was terminated because she did not complete a fall report. RN BB revealed that RN AA never documented the incident and did not notify anyone of the fall. An interview on 1/28/2021 at 4:12 p.m. with RN LL revealed that she does not remember if she was involved in this situation with R#4, however she did obtain the STAT order from the doctor. RN LL does not remember but if she had requested the X-ray Stat then she must have assessed the resident and noticed that she was still in pain. An interview on 1/29/2021 at 9:06 a.m. with Nurse Practitioner OO revealed she does not remember R#4 but would have mentioned it in her note if she had received a call from the facility about this resident. Review of a Facility Investigation report dated 4/15/2020 revealed the incident was reported to the State Survey Agency (SSA) on 4/8/2020. The investigation Summary/Conclusion revealed Upon the conclusion of the investigation, and in receiving statements from the resident and staff, this injury is felt to be a result of the fall on 4/4/2020.

Based on record review, staff and family interviews, and review of the hospital emergency records, the facility failed to ensure that one resident (R A) of three sampled residents receiving enteral feeding and water flushes through a gastric feeding tube, to follow the Physician order [REDACTED]. This failure resulted in actual harm to R A who was hosptalized on [DATE] for severe dehydration, acute [MEDICAL CONDITION] and a urinary tract infection. Findings include: Review of R A clinical record, revealed the resident was admitted to the facility on [DATE] after a hospital stay for a stroke with left side [MEDICAL CONDITION] and dysphagia. The resident has a history of [MEDICAL CONDITION] Fibrillation (AFib), [MEDICAL CONDITIONS], Type 2 diabetes, [MEDICAL CONDITIONS], Hypertension, [MEDICAL CONDITION], and obesity. The resident was admitted to the facility with a Gastric Feeding tube (GT). Review of resident's Physician orders [REDACTED]. Flush tube before and after feeding with 20 ml of water. Administer 200 ml of water flushes every six hours, additionally a Physician order [REDACTED]. Review of the Nutritional Screening and Assessment Form dated 4/21/17 revealed the resident was assessed by the Registered Dietitian who felt the enteral feeding orders met the resident's nutritional and hydration needs. Given via bolus gravity route, Glucerna 1.5 350 ml, four times per day equaled 1400 ml, 200 ml water flushes every six hours equaled 800 ml per day and 20 ml before and after Glucerna equaled 160 ml for a daily total of 2360 ml per day. Review of the SBAR (Situation, Background, Assessment, Recommendation) dated 4/28/17 revealed the resident had Respiratory Distress and Altered Mental Status (AMS). The resident's vital signs, at this time, were: Blood pressure: 109/67, Pulse: 56-114, Temperature: 99.4 (which did not indicate by what manner the temperature was taken), Pulse Oximetry: 81% on room air, Blood Sugar: 234. The Physician's Nurse Practitioner (NP) was contacted on 4/28/17 at 9:00 p.m Review of the Nursing Notes on the SBAR form revealed Resident noted to be lethargic, very sleepy and skin slightly cold to touch. Also with labored breathing, respiratory rate 24 breaths per minute (bpm), HOB (head of bed) kept elevated, O2 Sat (Oxygen Saturation) 81% RA (room air). O2 (Oxygen) applied at 5 L/min (liters per minute) via mask. Saturation increased to 93-94%. Family at bedside. Family wants him sent to ER (emergency room ) stat (immediately). Lung sound with Bibasilar Crackles (base of both lungs). On call MD, who is the NP, informed with order to transfer to ER by 911. Resident left the building at 9:10 p.m. Signed by an unknown nurse. Review of the Medication Administration Record [REDACTED] Review of the MAR for 20 ml of water before and after the Glucerna 1.5 revealed that on the following days and time there was no evidence that the water was given via bolus gravity route: 4/22/17 at 4:30 p.m., 4/23/17 at 4:30 p.m., 4/26/17 at 11:30 a.m. and 8:30 p.m., 4/27/17 and 4/28/17 at 7:30 a.m., 11:30 a.m. and 4:30 p.m Review of the MAR for the 200 ml water flush revealed that on the following days and time there was no evidence that the water flushes were given via bolus gravity route: 4/23/17 at 12:00 a.m., 4/24/17 at 6:00 a.m. and 12:00 a.m., 4/25/17 at 12:00 a.m., 4/26/17 at 12:00 p.m., 4/27/17 at 6:00 a.m., 12:00 p.m. and 12:00 a.m., on 4/28/17 at 12:00 p.m. An interview with the family member, of R A, on 5/5/17 at 3:07 p.m. revealed that on admission to the emergency room (ER) the resident was diagnosed with [REDACTED]. The family member also reports visiting the resident multiple times per day while the resident was in the facility. The family member reports that the resident had heavy sweating which became much worse on Wednesday, April 26, and by Thursday the nurse suggested that the family member get a fan for the resident's room due to profuse sweating which the nurse stated was due to the resident's stroke. The family member revealed that on 4/28/17 at 8:00 p.m. upon returning to the facility, the resident was unresponsive and drenched in sweat and urine. The family member alerted the nurses on the hallway to the resident's condition and insisted the resident be sent to the hospital immediately. An interview with Registered Nurse (RN) AA on 5/5/17 at 5:44 p.m. revealed that she was working as the supervisor on 4/28/17, when the resident was sent to the hospital. She revealed that the floor nurse had asked her to help assess this resident. She revealed the resident's heart rate was very irregular which is why she recorded the pulse rate as 54-114. She stated that resident was alert but non-verbally responsive. She revealed that the resident did not appear dehydrated because his skin turgor was ok although she admits this was not documented. An interview with the Director of Nursing (DON) and the Administrator on 5/5/17 at 6:01 p.m. revealed that the Licensed Practical Nurse (LPN) who was working that night is no longer available. The DON says the family member contacted her during the day on 4/28/17 and was concerned the redness on the resident's face was due to an allergic reaction to the blood thinner. The DON stated that she told the family member that the blood thinner was necessary and the redness was another condition which was being treated. The DON did call the NP about the family member's concern and the DON checked the resident herself. The DON did not feel there had been a change in the resident's condition, at this time. An interview on 5/5/17 at 6:14 p.m. with LPN BB revealed that she had taken care of the resident several times during the week before discharge to the hospital. While reviewing the MAR indicated [REDACTED]. She could not explain why she did not sign off on the MAR but believes she gave the treatments. The hospital records were requested, in writing to the hospital, on 5/5/17 at 4:15 p.m. although they were not received until 5/9/17. Review of the ER record revealed the resident was received via ambulance on 4/28/17 at 21:47 (9:47 p.m.). The vital signs recorded on 4/28/17 at 22:24 (10:24 p.m.) were as follows: Blood Pressure: 100/75, Pulse: 75, Respirations: 26, Temperature: 102.8 rectally, Oxygen Saturation: 100% on non-rebreather at 15 L. History of Present Illness: According to EMS (Emergency Management Services), family member noted confusion started at 7:00 p.m. last night, which is over 24 hours ago. The evening, 3 hours ago, he became significantly lethargic, unresponsive to painful stimuli. Review of the hospital ER Doctor Notes dated 4/29/17 revealed the resident's differential [DIAGNOSES REDACTED]. ED course: Upon arrival, patient was found covered in feces and urine. It took nurses staff significant amount of time to clean him up. We were able to establish 2 peripheral IV (Intravenous). Patient received IV fluid bolus, total of 3 L (liters) in sequential orders. Patient also received Tylenol for fever. EKG (electrocardiogram) shows [MEDICAL CONDITION] with RVR (rapid ventricular response). Chest x-ray show no acute abnormalities. CBC (Complete Blood Count) shows elevated white cell count of 19.1. High hemoglobin 17.7. High hematocrit 56 %. Elevated Sodium 156, chloride 114 and BUN 49. Creatinine is normal. Elevated blood glucose 317. This is consistent with his severe dehydration. Diagnosis: [REDACTED]. Admit patient inpatient on telemetry unit. A second visit was made on 5/11/17 after the hospital records were received to further investigate. An interview with the Nurse Practitioner (NP) EE on 5/11/17 at 11:25 p.m. revealed that she had seen the resident on 4/27/17 and that the Physician had seen the resident on 4/25/17. She reveals that nutritional orders are based upon the Registered Dietitian's recommendations. She does not remember anything out of the ordinary for this resident but does remember that he was chronically ill. She revealed that it is up to nursing staff to follow the physician's orders [REDACTED]. A telephone interview on 5/11/17 at 12:06 p.m. with Certified Nursing Assistant (CNA) DD revealed that the resident was sweating profusely when she took care of him which required her to change his gown every two hours. CNA DD confirmed that the CNA's check the resident's temperature then reports the vital signs to the nurses. She revealed that the temperature was checked under the arm for this resident, although sometimes orally, but is not recorded as to how the temperature is taken. She then stated that she add a degree to the temperature when taken under the arm. She did not report the resident sweating to the nurses because they were aware. A telephone interview with the LPN CC on 5/11/17 at 12:45 p.m. revealed she was aware of the resident's sweating but did not think it was a problem nor did she document the resident's sweating. She revealed that the family member had said this was normal for the resident. The family member did bring a fan to use in the resident's room. She revealed that she took the resident's temperature by Axillary method (under the arm) but she does not document how the temperature is taken. Review of the vital signs recorded on the Skilled Daily Nurses Note dated 4/24/17 by LPN CC revealed the resident's temperature was recorded as 97.0 degrees Fahrenheit. LPN CC could not say how the temperature was taken or if the temperature was accurate since there is a conversion needed depending upon how the temperature was taken. A telephone interview on 5/11/17 at 2:59 p.m. with the Registered Dietitian reveals she does not remember the resident but for residents with Congested Heart Failure ([MEDICAL CONDITION]) she uses 25-30 ml/kilogram to determine the resident's fluid needs. She revealed that she will be in the building tomorrow and would like an opportunity to review the chart then speak to me. An interview on 5/11/17 at 3:50 p.m. with the DON and Administrator revealed that they could not determine if the resident's temperature of 99.4 degrees was accurate on discharge on 4/28/17 as the type of temperature was not recorded. A telephone interview on 5/12/17 at 10:40 a.m. with the Registered Dietitian revealed that after reviewing the resident's record that she does feel her nutritional assessment met the needs of the residents. She revealed that since she was in the building on the day of the resident's admission the nutritional assessment could be completed on admission, 4/21/17. She was not informed of the resident's sweating which might have altered the fluid needs. She makes the recommendation and assumes the physician's orders [REDACTED]. A follow up telephone interview with the family member on 5/12/17 at 10:59 a.m. revealed that the resident did not have sweating before being admitted to the facility which became much worse on Wednesday. The family member revealed that during the multiple daily visits to see the resident that only once were the nurses observed giving anything through the feeding tube.

Based on clinical record review, family and staff interviews and review of the State of Georgia Rule 410-10.02 Standard of Practice for Licensed Practical Nurses (LPN) the facility failed to maintain professional nursing standards of quality as evidenced by not ensuring that enteral feeding and water flushes where documented or given to one resident (R A) who was hospitalized with urinary tract infection, severe dehydration, electrolyte imbalance, acute [MEDICAL CONDITION] and pneumonia. The sample size was three and the census was 92. Findings include: Review of the State of Georgia Rule 410-10-02 Standards of Practice for Licensed Practical Nurses (LPN) 1. The practice of licensed practical nursing means the provision of care for compensation, under the supervision of a physician [MEDICATION NAME] medicine, a dentist [MEDICATION NAME] dentistry, a podiatrist [MEDICATION NAME] podiatry, or a registered nurse [MEDICATION NAME] nursing in accordance with applicable provisions of law. Such care shall relate to the promotion of health, the prevention of illness and injury, and the restoration and maintenance of physical and mental health through acts authorized by the board, which shall include, but not be limited to the following: d) Administering treatments and medications by various routes 3. Documentation a) Failing to maintain a patient record that accurately reflects the nursing assessment, care, treatment, and other nursing services provided to a patient. Review of R A clinical record, revealed the resident was admitted to the facility on [DATE] after a hospital stay for a stroke with left side [MEDICAL CONDITION] and dysphagia. The resident has a history of [MEDICAL CONDITION] Fibrillation (AFib), [MEDICAL CONDITIONS], Type 2 diabetes, [MEDICAL CONDITIONS], Hypertension, [MEDICAL CONDITION] and obesity. The resident was admitted to the facility with a Gastric Feeding tube (GT). Review of resident's Physician orders [REDACTED]. Flush tube before and after feeding with 20 ml of water. Administer 200 ml of water flushes every six hours. Review of the Nutritional Screening and Assessment Form dated 4/21/17 revealed the resident was assessed by the Registered Dietitian who felt the enteral feeding orders met the resident's nutritional and hydration needs. Glucerna 1.5 350 ml, via bolus gravity route, four times per day equaled 1400 ml, 200 ml water flushes every six hours equaled 800 ml per day and 20 ml before and after Glucerna equaled 160 ml for a daily total of 2360 ml per day. Review of the Medication Administration Record [REDACTED].m Review of the MAR for 20 ml of water before and after the Glucerna 1.5 revealed that on the following days and time there was no evidence that the water was given via bolus gravity route: 4/22/17 at 4:30 p.m., 4/23/17 at 4:30 p.m., 4/26/17 at 11:30 a.m. and 8:30 p.m., 4/27/17 and 4/28/17 at 7:30 a.m., 11:30 a.m. and 4:30 p.m Review of the MAR for the 200 ml water flush revealed that on the following days and time there was no evidence that the water flushes were given via bolus gravity route: 4/23/17 at 12:00 a.m., 4/24/17 at 6:00 a.m. and 12:00 a.m., 4/25/17 at 12:00 a.m., 4/26/17 at 12:00 p.m., 4/27/17 at 6:00 a.m., 12:00 p.m. and 12:00 a.m., on 4/28/17 at 12:00 p.m. An interview with LPN BB on 5/5/17 at 6:14 p.m. who, per the Director of Nursing (DON), had taken care of the resident several days. LPN BB confirmed her initials on the MAR for 4/25/17 and 4/26/17. When ask about the missing signatures, during the time that she was assigned, she revealed that she couldn't explain it but would think she gave either the bolus feeding or the water flush but could not confirm. She realizes it is her responsibility to sign off whenever a treatment or medication is given. An interview on 5/5/17 at 6:01 p.m. with the Administrator and the DON revealed they had both started in 2017. The DON provided the minutes for a Nurses Meeting dated 2/23/17 which documents that she had recognized that there were holes the MARs for insulin and vital signs with a signature sheet for this meeting. Registered Nurse (RN) AA and LPN CC had signed in for this meeting. The DON says that all treatments and medications should be given and signed off as given by the nurses. She agrees that there are multiple dates and times without a signature for the enteral feeding and water flushes for this resident. The DON did not provide how this was being monitored or how often. The DON revealed that the nurse working on the 3-11 p.m. shift on 4/28/17 was not available. Cross refer to 327