Every finding on record at Pruitthealth - Toccoa

Based on observation, record review, interviews, and facility policy review, the facility failed to ensure the right to be treated with respect and dignity, and for staff to use respectful and appropriate identifiers, during meal service for four of 31 sampled residents' (Resident (R) 9, R95, R11, and R58) reviewed for dignity. This failure had the potential to contribute to a negative outcome related to the promotion and respect of resident well-being and quality of life.Findings include:Review of the facility's policy titled, Resident Rights, revised 12/1/2023, revealed It is the policy of this healthcare center to promote and protect the rights of the patients/residents residing in the center.the center will make every effort to assist the patient/resident in understanding and exercising his/her rights to assure the patient/resident is always treated with respect, kindness, and dignity.1. Review of R9's admission Record found in the Profile tab of the electronic medical record (EMR), revealed she was originally admitted with diagnoses including but not limited to hypertensive heart disease without heart failure, poly osteoarthritis, and muscle weakness.Review of R9's quarterly Minimum Data Set (MDS) located in the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 6/18/2025, revealed a Brief Interview for Mental Status (BIMS) assessment with no score out of 15, which indicated severe cognitive impairment. The resident was revealed to be independent while eating.During an observation on 8/25/2025 at 1:59 PM, R9 was observed in bed receiving assistance with her lunch. A staff member was observed standing next to the resident's bed while providing complete assistance with R9's meal. The staff member continued to stand and provide full assistance during the meal service, without being seated next to the resident.During an additional observation on 8/27/2025 at 12:30 PM, a meal tray cart was observed wheeled down to Station Two Nurse Station and parked there. Numerous staff gathered around the large rack of meal trays and were heard in large numbers asking each other who would be assisting the feeders, and which residents were the feeders.2. Review of R95's admission Record found in the Profile tab of the EMR, revealed she was admitted with diagnoses including but not limited to Alzheimer's disease, carotid sinus syncope, dysphagia, and muscle weakness.Review of R95's annual MDS assessment located in the MDS tab of the EMR, with an ARD of 07/23/25, revealed a BIMS assessment with no score out of 15, which indicated severe cognitive impairment. She was documented as dependent while eating.During an observation on 8/27/2025 at 12:38 PM, Certified Nurse Aide (CNA) 4 was observed assisting R95 with her meal. R95 was observed seated in her wheelchair while CNA4 sat on the resident's bed leaning over to assist the resident. CNA4 stated that there were not enough chairs available in all the residents' rooms to sit in while assisting with meals, so this was why she sat on the resident's bed.3. Review of R11's admission Record found in the Profile tab of the EMR, revealed she was admitted with diagnoses of but not limited to including Alzheimer's disease, muscle weakness, and dysphagia.Review of R11's significant change MDS assessment located in the MDS tab in the EMR, with an ARD of 7/31/2025, revealed a BIMS assessment with a score of six out of 15 which indicated severe cognitive impairment. She was revealed to be independent while eating.During an observation on 8/27/2025 at 12:41 PM, R11 was observed in bed while being assisted with her lunch by Unit Manager (UM) 5. UM5 stood over R11, while providing full meal assistance. UM5 said that she had not seen a chair to sit in, proceeded to look around the room and saw a chair. She stated that she probably could have used that chair. She continued to stand and assist R11 with her meal.4. Review of R58's admission Record found in the Profile tab of the EMR, revealed she was admitted with diagnoses including but not limited to dementia, cervical disc disorder with myelopathy, muscle weakness, and difficulty in walking.Review of R58's quarterly MDS assessment located in the MDS tab in the EMR, with an ARD of 8/4/2025, revealed a BIMS assessment with a score of nine out of 15, which indicated moderate cognitive impairment. She was revealed to be independent while eating.During an observation on 8/27/2025 at 12:43 PM, R58 was observed sitting in bed receiving assistance with her lunch. The Receptionist was observed standing at the bedside of R58 providing full assistance with the meal. There was a chair observed across the room that was not in use. The Receptionist stated that she had stopped to assist the resident and had not thought of getting the chair to sit next to the resident before helping.During an interview on 8/28/2025 at 10:59 AM, Licensed Practical Nurse (LPN) 1 said that if a resident required assistance with meals, the staff should sit down next to them. LPN1 said staff should not stand when assisting residents. LPN1 said that she was aware that staff used the term feeders to refer to residents during mealtimes but had not considered if it was right or wrong.During an interview on 8/28/2025 at 11:05 AM, CNA6 said that if a resident required assistance with meals, the staff should sit in a chair next to the resident to assist. She said that staff used the term feeders to refer to those residents that require assistance with meals. She was not aware if it was an appropriate term or not. During an interview on 8/28/2025 at 1:50 PM, the Administrator confirmed that staff should sit when assisting residents with their meals, and to not sit on the residents' beds. She confirmed staff should never use words such as feeders to refer to residents requiring assistance with meals.

Based on observations, record review, and resident and staff interviews, the facility failed to ensure call lights were within reach for one of 31 sample residents (Residents (R) 58) reviewed for accommodation of needs and preferences. Specifically, the facility failed to ensure residents had access to their call lights to best assist the residents in maintaining and/or achieving their independent functioning, dignity, and well-being to the extent possible.Findings include:Review of R58's admission Record found in the Profile tab of the electronic medical record (EMR), revealed she was admitted with diagnoses including but not limited to dementia, cervical disc disorder with myelopathy, muscle weakness, and difficulty in walking.Review of R85's quarterly Minimum Data Set (MDS) located in the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 8/4/2025, revealed a Brief Interview for Mental Status (BIMS) assessment with a score of nine out of 15, which indicated moderate cognitive impairment. R58 was observed on 8/25/2025 at 12:36 PM resting in bed with the call light button out of reach and sight of the resident. R58 was again observed on 8/26/2025 at 4:02 PM resting in bed with her call light on the floor behind the bed and out of reach.R58 was again observed on 8/27/2025 at 10:20 AM resting in bed. The call light was on the floor under the resident's bed against the wall.R58 was again observed on 8/28/2025 at 9:50 AM resting in bed with the call light still on the floor behind the bed out of reach.During an interview on 8/28/2025 at 9:51 AM, R58 stated that she did not have a call light, looked around her bed, and again stated she did not have a call light for use.During an interview on 8/28/2025 at 9:54 AM, Unit Manager (UM) 4 said that staff should ensure call lights were accessible to the residents.During an interview on 8/28/2025 at 9:56 AM, Certified Nurse Aide (CNA) 6 said that call lights should be pinned to the residents or placed near them.During a concurrent interview on 8/28/2025 at 9:59 AM, UM4 and CNA6 went into R58's room and both confirmed the resident's call light was on the floor against the wall, under the bed, and out of reach of the resident. They pinned the call light to the resident. During an interview on 8/28/2025 at 10:03 AM, the Administrator stated that call lights should always be placed in reach of the resident.During an interview on 8/28/25 at 2:10 PM, the Administrator stated that the facility did not have a policy regarding accommodation of needs or call light accessibility for residents.

Based on observations, interview, record review, and review of the facility policy titled, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property, the facility failed to protect the resident's right to be free from physical abuse by another resident for one of three residents (R)(R84) reviewed for abuse. R205 hit R84 on 11/2/2025 and again on 11/12/2025. This created the potential for R84 to experience injuries, pain, and/or psychosocial distress including fear. Findings include: Review of the facility's policy titled, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property, dated 10/21/2025, revealed It is the policy of [corporation] and its affiliated entities (collectively, the Organization) to actively preserve each patient's right to be free from verbal, sexual, physical, and mental abuse .This policy applies to the entire Organization . individuals who come into contact with patients (including other patients).1. Review of R205's undated Resident Face Sheet, located in the electronic medical record (EMR) under the Resident tab, revealed R205 was admitted to the facility on [DATE] with diagnoses of dementia, psychotic disturbance, mood disturbance, and anxiety. R205 resided on the locked Memory Support Unit (MSU).Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/28/2025 and located in the EMR under the RAI (Resident Assessment Instrument) tab, revealed R205 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated moderately impaired cognition. R205 was not documented as exhibiting any behavioral indicators. R205 was on hospice services.Review of R205's Care Plan, initiated on 8/14/2025 and located under the RAI tab of the EMR, revealed a problem of Resident has socially inappropriate/disruptive behavioral symptoms as evidenced by increased confusion and agitation, sexually inappropriate. 10/23/2025 Depakote increased. 11/2/2025 altercation with another resident, stop sign added to door 11/6/2025. 11/12/2025 altercation with another resident. The goal was Resident will not exhibit socially inappropriate/disruptive behavior through next review. Interventions included: administer medications as ordered /monitor effectiveness started on 8/14/2025; avoid overstimulation started on 8/14/2025; when resident starts to become socially inappropriate/disruptive, provide comfort measures, stop sign started on 11/2/2025; room change initiated on 11/12/2025; and behavior management program started on 11/13/2025.2. Review of the undated Resident Face Sheet, located in EMR under the Resident tab, revealed R84 was admitted to the facility on [DATE] with diagnoses of dementia, psychotic disturbance, mood disturbance, and anxiety. R84 resided on the locked MSU.Review of the significant change MDS, with an ARD of 9/12/2025 and located in the EMR under the RAI tab, revealed R84 had a BIMS score of three out of 15, which indicated severely impaired cognition. R84 exhibited fluctuating signs and symptoms of delirium including inattention and disorganized thinking. R84 was identified with worsened behavior; however, the specific behaviors were not identified. R84 was on hospice services.Review of R84's Care Plan, initiated on 5/7/2025 and located in the EMR under the RAI tab, revealed a problem of Presence of behavioral symptoms . wanders unsafely . 11/2/2025 resident wandered in another resident's room and was involved in an altercation. The goal was for R84 not to harm herself or others. Approaches included: redirection with folding laundry, enjoys sweeping and cleaning tables started on 5/7/2025, administer medications/monitor effectiveness per physician orders initiated on 5/7/2025, intervene as needed to protect the rights and safety of others; approach in a calm manner, divert attention, remove from situation, and take to another location as needed started on 5/7/2025, and refer for mental health evaluation as needed started on 5/7/2025.3. During the survey, observations were made on the MSU where both R84 and R205 resided.a. During an observation on 11/20/2025 at 10:10 am, R84 was lying in bed on her side. She was lying under the covers; however, was awake. R84 appeared confused but stated she was doing ok and this was an ok place to live. R84 stated she was not afraid of anyone. R84 was noted to be elderly, thin, and frail in appearance. The door to room was open.During an observation on 11/21/2025 at 12:27 pm, R84 was walking independently in the dining room and staff guided her to a chair in the dining room to eat lunch. R84 sat down and then got up less than a minute later and walked out of the dining room. R84 was observed to walk up and down the hallway continuously through 12:50 pm when the surveyor left the unit. Two staff followed and redirected R84 while she was wandering in the hallway. She walked to the end of the hall where R205's room was located; staff ensured she did not enter R205's room. R205 was sitting on his bed right by the door, eating his lunch.During an observation on 11/21/2025 at 12:38 pm, R205 was eating lunch by himself in his room with his tray on the overbed table. R205 denied there had been resident/s who wandered into his room. R205 stated he liked living in the facility.4. Review of a Nurse's Note, dated 11/2/2025 and located in the EMR under the Progress Notes tab, revealed, [R84] came to CNA's (sic) [Certified Nursing Assistant] from another resident's room and stated he [R205] hit her back. looked and slight red handprint to her back. No other injuries were noted. notified DON, [Director of Nursing]. Notified resident's husband, [name], Doctor [name], and also notified [name] at hospice. Asked other resident [R205] and he states, 'I sure the hell did hit her, she was going through my stuff.' separated residents and will keep them away from one another.Review of the facility's Five-Day Investigation, submitted to the State on 11/6/2025 revealed, On 11/2/2025 [R84] came to CNAs stating, that man knocked me in the back. CNAs immediately notified charge nurse and [R84] was assessed for injuries. A small, reddened area was found on [R84's] back. The charge Nurse and CNAs then questioned [R205] about the event and [R205] admitted to hitting [R84] in back stating 'she was in here plundering my shit.' There was no witness to altercation. [R205] has BIMS of 12 and in memory support d/t [due to] wandering behaviors . Monitored closely to ensure no further contact made. Review of R84's Nurse's Notes, dated 11/03/2025 and located in the EMR under the Progress Notes tab, revealed redness to her back without injury noted from the altercation on 11/4/2025. No further entries were found in Progress Notes regarding any additional effects from the incident occurring on 11/2/2025.5. Review of R84's Nurse's Note, written by Licensed Practical Nurse (LPN) 3, dated 11/12/2025, and located under the Progress Notes tab of the EMR, revealed, Witnessed per CMA [Certified Medical Assistant] that this patient was coming out of patient's room [R205] and that he [R205] hit her [R84] to back of her left shoulder/arm due to being in his room. Patient [R84] removed from his room. Review of the facility's Five-Day Investigation, dated 11/19/2025 and provided by the facility, revealed, On 11/12/2025, staff witnessed [F205] hit [R84] to back of left arm/shoulder. [R84] was wandering into [R205's] room and he became upset and yelled for her to get out. [R205] then hit [R84] with closed hand . [R84] assessed for injury and pain in the back area. No injury or marking were found on [R84]. Video surveillance was conducted to establish a trend in [R84] wandering habits. It was noted that [R84] wanders predominantly on the right side of hallway/room . [R205] was moved to another room on the left side of the hallway due to [R84] habits to decrease the risk of further interactions. [R205] was given behavioral medication to decrease agitation . 6. During an interview on 11/20/2025 at 3:04 pm, the Administrator stated R205 was moved to the other side of the hall after the altercations with R84. The Administrator stated R84 tended to wander into rooms on the right side of the hallway. The Administrator verified that R205 hit R84 and stated it was due to her wandering into his room. The Administrator stated R84 had not been injured by R205, further stating the staff could not prevent all altercations from occurring on the MSU unit due to the behavior of the residents who resided there.During an interview on 11/20/2025 at 4:59 pm, the Social Services Director (SSD) stated R205 was under the care of hospice, and they had been adjusting his medications with recommendations from his psychotherapist. The SSD stated R205 had three recent psychotherapy visits. The SSD stated staff tried to keep a closer eye on R84 due to her wandering into R205's room and verified R205 had a room change on 11/12/2025. During an interview on 11/21/2025 at 10:07 am, LPN1 stated she was the primary charge nurse at night on the MSU. LPN1 stated R205 had good and bad nights, and on his bad nights he was disruptive. LPN1 stated he had calmed down over the past two weeks. LPN1 stated R205's cognition varied and that he was sometimes alert and made sense and other times he did not make sense. LPN1 stated R205 exhibited sundowning behaviors at night. LPN1 stated R84 wandered a lot and was in and out of rooms until about 10:00 PM. LPN1 stated R84 was easy to redirect and did not exhibit aggressive behaviors. LPN1 stated she was not working on either shift when R205 hit R84. During an interview on 11/21/2025 at 2:17 pm, LPN3 stated she was the primary nurse on MSU for day shift. LPN3 stated R205 typically stayed in his room. LPN3 stated she was working on 11/12/2025 when the second incident of R205 hitting R84 occurred. LPN3 stated CMA1 witnessed the incident on 11/12/2025. LPN3 stated R84 was coming out of R205's bathroom and R205 hit her. LPN3 stated the residents were separated and she assessed R84 and she did not have any injuries. LPN3 stated R84 wandered continuously. LPN3 stated staff tried to redirect her, but she would go back to pacing and into rooms. LPN3 stated there had been some medication changes for R84 due to her being too sleepy and not eating after a prior medication change which resulted in the medication being decreased. LPN3 stated after the first incident on 11/02/2025, the staff put a stop sign on R205's room but R84 continually removed it. During an interview on 11/21/2025 at 2:47 pm, CMA1 stated on 11/12/2025 she saw R84 coming out of R205's bathroom and R205 hit her before she could intervene. CMA1 stated R205 hit R84 on left side of her arm and back. CMA stated she told R205 he could not hit R84, sat him down on the bed, and took R84 out of the room and got the nurse. CMA1 stated when R205 hit R84, R84 did not react saying ow and it did not appear that she knew what happened. R84 kept walking after she was hit. CMA1 stated she tried to keep R84 in the dining room with her and gave her towels to fold. CMA1 stated activity staff also tried to keep R84 busy when they were on the unit. During an interview on 11/21/2025 at 3:11 pm, the Director of Nursing (DON) stated that R84's medications had been adjusted. She stated R84's dose of Depakote (antiseizure medication) had resulted in her sleeping too much and not eating with weight loss occurring. The DON stated the Depakote was decreased and R84's wandering increased. The DON stated R84 had a medication change yesterday with hope to address the wandering without resulting in sleepiness and weight loss. The DON stated it was difficult to balance her medications.

Based on staff interview, document review, and facility policy review, the facility failed to report the results of the investigation of sexual abuse to the State Survey Agency (SSA) within five working days of the incident for one of one resident (Resident (R) 68) reviewed for abuse out of a total sample of 31 residents. Specifically, R71 removed her clothes and incontinence brief and climbed into R68's bed.Findings include:Review of the facility's policy titled, Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property, dated 11/15/2024, indicated Procedure, 2.A written report of the investigation .should be submitted to the appropriate agency within five working days of the occurrence.Review of the facility investigation, provided by the Administrator, into the allegation of sexual abuse, revealed that on 7/31/2025 at 5:25 AM, R71 was unclothed sitting at the end of R68's bed in their room. The file indicated that the SSA was initially notified on 7/31/2025 at 6:20 AM. However, the final report of the investigation was not sent to the SSA until 8/11/2025.During an interview on 8/26/2025 at 12:44 PM, the Administrator confirmed the results of the investigation were not submitted timely within five days to the SSA. The Administrator stated that she was out of the country at the time of this incident and that the Administrative Assistant was informed of the incident, reported the initial report to the SSA, and then sent the results of the abuse investigation to the SSA.

Based on interviews, record review, document review and review of the facility's policy, the facility failed to complete a thorough investigation of an allegation of sexual abuse for two of 31 sampled residents (Resident (R) 68 and R71). The facility's failure to complete a thorough investigation placed residents at risk of being unprotected from abuse.Findings include:Review of the facility's policy titled, Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property, dated 11/15/2024, indicated Procedure, 1. Documentation of the investigation should include. Signed statements from pertinent parties. Interview should be conducted of all individuals who have relevant information.Written signed statements from any involved parties should be obtained. patients involved, reliable patients who may have witnessed the incident.Review of the facility investigation, provided by the Administrator, into the allegation of sexual abuse, revealed that on 7/31/2025 at 5:25 AM, R71 was unclothed sitting at the end of R68's bed in their room. The investigative file did not include a statement from R68 or from R49 who was the third resident who shared the room with R68 and R71.Review of R68's electronic medical record (EMR) under the Resident Assessment Instrument (RAI) tab, the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/30/2025 indicated a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated R68 was cognitively intact. Review of R71's EMR under the RAI tab, the admission MDS with an ARD of 7/28/2025 indicated a BIMS that the resident was rarely/never understood, short-and long-term memory, therefore, a BIMS score was not obtained.Review of R49's EMR under the RAI tab, the quarterly MDS with an ARD of 8/25/2025 indicated a BIMS score of nine out of 15, which indicated R49's cognition was moderately impaired.During an interview on 8/25/2025 at 3:48 PM, R68 stated that she remembered when her roommate (R71) came to her side of the bed and was not wearing any clothes. R68 stated that R71 did not get in her bed. I used my call light to have the nurse come and help her.During an interview on 8/26/2025 at 2:18 PM, the Administrator confirmed that the investigative file contained all the interviews that were conducted. The Administrator confirmed that the file did not contain an interview with R68 or R49. The Administrator stated that R49 should have been interviewed even though her BIMS score was nine, to determine if she witnessed the incident. The Administrator stated that she was out of the country at the time of this incident and that the Administrative Assistant was informed of the incident and conducted the investigation. The Administrator confirmed it was not a thorough investigation.

Based on observations, resident and staff interviews, record review, and facility policy review, the facility failed to ensure residents' care plans were revised to reflect current level of care for two of 31 sample residents (Resident (R) 2 and R22) reviewed for care plan revision. This failure had the potential to affect resident care outcomes. Findings include: Review of facility's policy titled, Care Plans with a revision date of 7/27/2023 noted Policy Statement: It is the policy of the health care center for each patient/resident to have a person-centered baseline care plan followed by a comprehensive care plan developed following completion of the Minimum Data Set (MDS) and Care Area Assessment (CAA) portions of the comprehensive assessment according to the Resident Assessment Instrument (RAI) Manual and the patient/resident choice.Care Plan Review and Update: 1. Comprehensive care plans should be reviewed not less than quarterly according to the Omnibus Budget Reconciliation Act (OBRA) MDS schedule, following the completion of the assessment. Care plan updates/ reviews will be performed within seven days of each quarterly assessment, each acute change in condition, and as needed following each hospital stay. 2. Discontinued problems, goals, or approaches should be indicated directly on the care plan. A line should be drawn through the discontinued item. Updates to the care plan should be made with any changes in condition at the time the change in condition occurred. 1. Review of R2's Face Sheet located under the Resident tab of the electronic medical record (EMR) revealed the resident was admitted with diagnoses of but not limited to acute and chronic respiratory failure with hypoxia and hypercapnia (low oxygen levels with high carbon dioxide levels), chronic obstructive pulmonary disease (COPD), systemic inflammatory response syndrome (SIRS) (inflammation throughout body), shortness of breath, acute pulmonary edema, and pleural effusion (fluid on lungs). Review of R2's admission MDS located in the EMR under the RAI with an Assessment Reference Date (ARD) of 6/4/2025 revealed a Brief Interview for Mental Status (BIMS) score of six out of 15, which indicated R2 had severe cognitive impairment. Functional Abilities revealed dependent for hygiene. Review of R2's Orders located under the Resident tab of the EMR revealed Oxygen (O2) at two liters per minute (LPM) through nasal cannula (NC) PRN (as needed) to maintain oxygen level above 90% twice a day 7:00 AM - 7:00 PM, 7:00 PM - 7:00 AM for acute and chronic respiratory failure with hypoxia, start date 7/18/2025. Review of R2's Care Plan located under the Resident tab in the EMR revealed oxygen at 3.5 LPM through nasal cannula continuous. Twice a day 7:00 AM - 7:00 PM, 07:00 PM - 7:00 AM, start date 6/2/2025. During an observation on 8/25/2025 at 11:48 AM, R2 was sitting in a wheelchair in her room with a surgical mask on and using O2 through NC at two LPM with humidification. During an observation on 8/25/2025 at 1:50 PM, R2 was in her room with O2 at 2 LPM through NC. During an observation on 8/26/2025 at 1:47 PM, R2 was observed sitting in their room with O2 at 2 LPM through NC. During an interview on 8/28/2025 at 10:23 AM, the Case Mix Coordinator confirmed R2's care plan should have been revised when the physician's order changed from 3.5 LPM of O2 to 2 LPM. She also confirmed the care plan should be revised so staff knew how much O2 the resident needed administered. During an interview on 8/28/2025 at 10:44 AM, the Assistant Director of Nursing (ADON) confirmed R2's care plan should have been revised when the physicians order changed from 3.5 LPM of O2 to 2 LPM. She also confirmed the care plan should be revised to continue the same plan of care for R2, and so staff were aware. 2. Review of R22's admission Record found in the Profile tab of the EMR, revealed she was originally admitted with diagnoses including but not limited to acute cystitis without hematuria, chronic kidney disease, retention of urine, and metabolic encephalopathy. Review of R22's quarterly MDS located in the MDS tab in the EMR with an ARD of 7/2/2025, revealed a BIMS assessment with a score of 14 out of 15, which indicated intact cognition. The resident was revealed to require the use of an indwelling catheter. The resident did not reject care. Review of R22's Care Plan, initiated on 7/3/2025 and located in the EMR under the Care Plan tab, revealed the resident required the use of an indwelling catheter due to a neurogenic bladder. The goal was to have catheter care managed appropriately as evidenced by not exhibiting signs of infection or urethral trauma. Approaches documented and initiated on 7/3/2025 included to assess drainage, to record the amount, type, color, odor, and to observe for leakage. Additional approaches, initiated on 7/3/2025, included to report urinary tract infections (UTIs), provide catheter care every shift and as needed, to keep the catheter system a closed system as much as possible, and to position the bag below the level of the bladder, to store the collection bag inside a protective dignity pouch. An approach, initiated on 7/10/2025, included to provide enhanced barrier precaution. An approach was not initiated until 8/27/2025, after the observations and interviews noted below, to include that per resident preference, to not put the catheter bag on the rail and that the resident gets up to go to the bathroom at night. During an observation on 8/25/2025 at 3:06 PM, R22 was observed asleep in bed. The catheter bag was observed resting directly onto the floor without an additional privacy bag or barrier protecting the bag from possible contaminants. During an observation on 8/26/2025 at 11:40 AM, R22 was observed asleep in bed. The catheter bag was observed resting directly onto the floor without an additional privacy bag or barrier protecting the bag from possible contaminants. During an interview on 8/27/2025 at 12:00 AM, Licensed Practical Nurse (LPN) 2 confirmed the catheter bag was lying directly on the floor. LPN2 said the catheter bag should have been hung from the side of the bed, off the floor. She said that R22 was the only resident who refused to allow the catheter bag to be placed off the floor. LPN2 stated that there had been no discussion about having a barrier between the resident's catheter bag and the possible contaminants on the floor. During an interview on 8/27/2025 at 10:15 AM, R22 stated that she liked to have the catheter bag on the floor so she could get back and forth to the bathroom without having to unhook it. She stated that she did not care if there was any type of barrier to protect the catheter bag from the contamination on the floor. During an interview on 8/28/2025 at 2:10 PM, Unit Manager (UM) 4 said that R22 did not like to have the catheter bag hung up so that she could get around to the bathroom. UM4 said that the facility staff had not tried to put up any type of barrier between the floor and the catheter bag. She confirmed that the current placement of the catheter bag could increase the risk of a UTI. UM4 stated that they had not updated the care plan to include R22's refusals of care related to the catheter. During an interview on 8/28/2025 at 3:05 PM, the ADON stated that the nurses could revise care plans. She said that she was aware that R22 liked to move around her room and did not have her catheter bag hung up off the floor. ADON confirmed that if the care plan had been revised to show the resident's noncompliance, they could have come up with a plan to ensure a barrier or some other plan was attempted to help prevent future UTIs.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure residents' fingernails were kept clean and trimmed for one of one resident (Resident (R) 100) reviewed for activities of daily living of 31 sample residents. This failure had the potential to affect resident care including personal hygiene in the facility. Findings include:Review of facility's policy titled, Documentation: Charting Activities of Daily Living (ADLs) Policy Statement: with a revision date of02/18/2021 noted it was required for Activities of Daily Living (ADL) care given by Certified Nursing Assistants and Nurses to be documented under Care Assist in patient's/ resident's Electronic Healthcare Record (EHR).Review of R100's Care Plan located under the Resident tab in the EHR revealed provide assistance with all ADLs as needed with a start date of 7/23/2024.Review of R100's discharge Minimum Data Set (MDS) located in the EHR under the RAI [Resident Assessment Instrument] with an Assessment Reference Date (ARD) of 12/4/2024 documented a Staff Assessment for Mental Status (SAMS) score of zero, which indicated R100 was independent in decision making. Personal hygiene was marked as dependent helper did all the effort.During an observation on 8/25/2025 at 11:40 AM, R100's fingernails were observed with brown/ reddish substance underneath. Fingernails were jagged.During an observation on 8/25/2025 at 3:20 PM, R100's fingernails were observed with brown/ reddish substance underneath. Fingernails were jagged.During an observation on 8/26/2025 at 1:51 PM, R100's fingernails were observed with brown/ reddish substance underneath fingernails. Fingernails were jagged.During an interview on 8/26/2025 at 2:04 PM, Certified Nurse Aide (CNA) 5, at R100's bedside, confirmed R100's fingernails were dirty with a brown substance underneath and that they were jagged and needed to be trimmed. She stated fingernail care should be done as needed and confirmed they could cause injury.During an interview on 8/26/2025 at 2:10 PM, Registered Nurse Unit Manager (RNUM) at R100's bedside, confirmed R100's fingernails were dirty with a brown substance underneath the fingernails and that they were jagged. She stated nail care should be done as needed.During an interview on 8/26/2025 at 2:56 PM, Assistant Director of Nursing (ADON) at R100's bedside, confirmed R100's fingernails were dirty with a brown substance underneath the fingernails and that they were jagged. She stated they should be cleaned and trimmed as needed.

Based on observation, resident family and staff interviews, record review, and policy review, the facility failed to provide an ongoing activity program to meet the individual interests and needs to enhance the quality of life for one of one resident (Residents (R) 70) reviewed for activities out of a total sample of 31 residents. Failure to provide activities as care planned has the potential to affect the resident's physical, mental, and psychosocial well-being.Findings include:Review of the facility's policy titled, Activities Program, dated 9/28/2023, indicated Policy statement.provides an ongoing program of Activities designed to meet the physical, mental and psychosocial well-being of each resident.7. After review the Activities Assessment, and preference for Customary routine activities in the EHR [electronic health record], the IDT [Interdisciplinary team] designated specific activities for individual residents in the resident's care plan based on their likes/dislikes, preferences, and impairments. 8. The activity participation will be recorded by the Activities Director/Assistant in the EHR. Participation will be completed for each resident per each activity.Review of R70's electronic medical record (EMR) revealed R70 was admitted to the facility on [DATE]. Review of R70's EMR quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/20/2025 and 5/27/2025 indicated a Brief Interview for Mental Status (BIMS) score was not obtained due to resident did not understand or was not understood.Review of R70's EMR under the Resident Assessment Instrument (RAI) tab revealed R70's Care plan, dated 6/6/2025, indicated resident will exhibit pleasure by smiling from one-on-one visits. The approach included, one on one visits in room one time weekly and call resident by name.The Administrator was asked to provide R70's activity assessment and provided the document titled, Preferences for customary and routine activities, dated 5/22/2020, which indicated the question while you are at this facility, how important is it to you to listen to music. The response to the question indicated, not assessed. The remaining activity questions were scored with the response not assessed. The section that indicated staff's assessment of daily and activity preferences indicated, receive a shower, listening to music and participating in religious activities or practices. The Administrator provided another document titled, Preferences for customary and routine activities, dated 10/16/2019. The Administrator did not provide any current documents titled, Preferences for customary and routine activities.During an observation on 8/25/2025 at 11:05 AM, R70 was lying in bed with no activity occurring in the room. There was no radio, music, or television (TV). The closest TV was located on the shelf between R71's bed and the resident in the middle bed. The TV was turned so that R70 could not see the TV screen, however, the resident in the middle bed could see the TV screen.During an interview on 8/25/2025 at 4:55 PM, R70's Family Member (F) 1 stated that she had not seen a radio in R70's room and that staff did not bring music in for R70 to listen to. F1 stated that R70 would like gospel music.Observation on 8/27/2025 at 8:55 AM revealed R70 lying in bed and there was no activity occurring, no music playing, or TV for the resident to watch.During an interview on 8/27/2025 at 10:58 AM, the Activities Director (AD) stated that she provided R70 one to one activities (1:1) which would include applying lotion to her hands and playing gospel music from her cell phone. The AD confirmed that R70 did not have a TV or radio on her side of the room. The AD stated that she had music on her cell phone and that she took her cell phone into R70's room for her to listen to gospel music.Review of R70's activity calendars, dated March 2025 through August 2025, provided by the AD, revealed the following 1:1 activities that occurred:3/4/2025 applied lotion to hand.3/25/2025 played music and AD danced.4/3/2025 informed of today's activities.4/10/2025 played music.4/24/2025 applied lotion to hands.5/15/2025 played music and danced to make resident laugh.5/29/2025 applied lotion to hands and legs.6/19/2025 applied lotion to hands.8/12/2025 massaged hands.8/14/2025 played music and brushed hair.During an interview on 8/27/2025 at 12:36 PM, the AD stated that she did not contact the family regarding what activities the resident liked or did not like. She stated that she had not spoken to F1. The AD stated that she just asked the staff what they thought should be provided for R70's activities.

Based on record review, interview, and facility policy review, the facility failed to ensure that the resident and their resident representative (RR) received a written notice of transfer with the required components and written bed hold notice with the appeals process and contact information for three residents (Resident (R) 8, R41, and R81) reviewed for facility initiated emergent transfer to the hospital in the sample of 31 residents. This failure had the potential to affect the resident and RR by not having the knowledge of how to appeal the transfer, if desired, and how to contact the Office of the State Long-Term Care Ombudsman.Findings include: Review of the facility's policy titled, Discharges, dated 3/30/2023, failed to address for facility initiated emergent transfer to the hospital, what the notice of transfer document would include and who would receive the document. Review of the facility's policy titled, Bed Hold Acknowledgment form: Georgia, dated 1/11/2024, indicated Policy.the notice which specifies the duration of the bed hold policy will be issued at the time of any transfer. In case of emergency transfer, notice at the time of transfer means that the family and /or undersigned parties is provided with written notification within 24 hours of the transfer. 1.Review of R8's electronic medical record (EMR) revealed in the Census tab, that R8 was sent to the hospital on 5/13/2025 for gastrointestinal bleed (GI bleed) and returned to the facility on 5/19/2025; was sent to the hospital on 5/29/2025 for rectal bleed and returned to the facility on 6/5/2025 and was sent to the hospital on 8/4/2025 due to change of condition and unresponsive and returned to the facility on 8/4/2025. The Social Service Director (SSD) provided the written notice of transfer documents and bed hold documents for the 5/13/2025, 5/29/2025, and 8/4/2025 discharges to the hospital. Review of the written notice of transfer document revealed the documents lacked evidence of the resident's appeal rights and information regarding the name, address, and telephone number of the Office of the State Long-Term Care Ombudsman. The notice of transfer document and bed hold document lacked evidence that the resident and the RR received the documents. During an interview on 8/27/2025 at 12:45 PM, the SSD confirmed that the notice of transfer document did not include the required information. She stated that they had not been asked to add the appeals process or the Ombudsman's contact information to the notice of transfer. The SSD stated that if the RR wanted the information, they would need to call the facility. During the interview, the SSD confirmed there was no documented evidence that the resident and the RR received the notice of transfer and bed hold documents in that the documents were blank for the resident's and the RR signatures. 2. Review of R41's Face Sheet located under the Profile tab of the EMR revealed R41 was admitted to the facility on [DATE] with diagnoses of sepsis, pulmonary disease, dementia, history of falling, major depressive disorder, anxiety disorder, and type II diabetes. Review of facility's untitled form letter regarding R41's notice of transfer, located in the SSD's Office, indicated R41 was transferred to the hospital on [DATE] due to pneumonia. The form letter indicated .The Appeal Process is as follows: (no explanation provided) The Office of the State Long Term Care Ombudsman information is listed below: (nothing was listed) Please contact the facility with any questions at (phone number not provided) Sincerely, Social Services. 3. Review of R81's Face Sheet located under the Profile tab of the EMR revealed R81 was admitted to the facility on [DATE] with the diagnoses of Alzheimer's disease, vascular dementia, anxiety disorder, bipolar disorder, major depressive disorder, acute respiratory failure, and UTI (urinary tract infection). Review of the facility's untitled form letter regarding R81's notice of transfer, located in the SSD's office, indicated R81 was transferred to the hospital on [DATE] due to Heart. The form letter indicated .The Appeal Process is as follows: (no explanation provided) The Office of the State Long Term Care Ombudsman information is listed below: (nothing was listed) Please contact the facility with any questions at (phone number not provided) Sincerely, Social Services. During an interview on 08/27/25 at 9:05 AM, SSD stated she usually mailed out the notice of transfer to the responsible party the day after the date of the transfer. SSD said she was aware of the resident's right to appeal a transfer. During a follow up interview on 08/27/25 at 12:45 PM, the SSD stated she had not been asked to put the appeals process/contact information on the bed hold notice. SSD said the responsible party would call her if they needed information on the process of appeal and she would provide the information to the responsible party. During an interview on 08/28/25 at 3:30 PM, the Administrator stated the facility did not have a policy regarding the transfer process for a resident.

Based on observations, staff interviews, and review of the facility's policy titled How to Puree Foods, the facility failed to follow the recipes to ensure puree foods were prepared by methods to conserve nutritive value, flavor, and appearance. This deficiency had the potential to affect all twelve residents that received a puree diet. The facility census was 102 residents. Findings include: Review of the facility's policy titled How to Puree Foods under Preparation steps revealed: Number 1. Depending on the resident's dietary restrictions, follow the proper recipe to prepare the regular consistency food item. Number 2. Portion out the prepared food according to the number of pure 'ed portions needed, remember to include a little extra to make up for the loss of volume when pureeing. Number 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). Number 7. Taste and add seasonings while pureeing. The pureed food should be just as flavorful as the regular consistency food. Under the section titled, Common Mistakes revealed, Number 3. Not following the recipes; Number 4. Puree food has no flavor. Under the section titled, Simple Solutions revealed, Number 3. Follow proper recipe for restrictions; Number 4. Taste, add seasoning as you puree. Review of the lunch menu for 3/20/2024 revealed menu items included cheeseburger on bun, mashed potatoes, California blend vegetables, and brownie. Observation and Interview on 3/20/2024 at 10:32 am revealed the Dietary aide (DA) II pureed three bean salad as an alternative for the California blend vegetables. The DA II did not measure out the amount of three bean salad to puree for twelve residents who received a puree diet. The DA II poured broth from the three-bean salad using a large ice cream scoop. Interview with the DA II revealed he did not measure out the amount of three bean salad needed for 12 residents who received a pureed diet, nor did DA II taste the three-bean salad after it was pureed to ensure flavor. The DA II reported he was supposed to follow a recipe to make the pureed item but did not because he was familiar with making the pureed food item. Observation and Interview on 3/20/2024 at 10:55 am with revealed DA II preparing pureed food items for the lunch menu. DA residents grilled hamburger patties in the blender to puree for 12 residents who received a pureed diet and two of the 12 residents received double portions. The DA II reported that each resident was supposed to receive one-ounce (oz) portions of pureed beef patty. The DA II blended the hamburger patties with the desired consistency was not met. The DA II then added broth from the hamburger patties using a large ice cream scoop with the number eight on it. The consistency of the pureed meat was cheeked by the DA II using his gloved hand mashing the beef patty mixture together after he used the sanitizer to wipe the prep table off. The DA II returned the meat mixture back in the blender with the remaining meat mixture. After blending the meat mixture for about 30 more seconds the DA II added broth (no precise measurement) from the hamburger patties to the mixture using a large ice cream scoop. The DA II added four more large ice cream scoops of broth, at that point, satisfied with the consistency, he poured the pureed beef patties into a metal container for holding. The DA II did not follow a recipe as he pureed the hamburger patties. Interview on 3/20/2024 at 11:13 am the Dietary Manager (DM) revealed there was no recipe for the DA II to follow to puree for hamburger patty, and each resident should receive three ounces of meat. The DM retrieved a blue binder filled with different recipes, but there was not a recipe for puree hamburger patties, this was confirmed by the DM at this time. Observation and Interview on 3/20/2024 at 11:26 am revealed the DA II preparing (mashed potatoes) for the lunch menu. The DA II added an unmeasured amount of water to a pot and placed the pot on the stove to boil, he then added one teaspoon (tsp) of salt, one tsp of pepper, and one Tablespoon (TSBP) of parsley to the pot of water. Interview at this time with the DA II confirmed he did not measure the amount of water he placed in the pot to make the mashed potatoes. Next, he added one eight oz of milk (used small measuring cup that was found in drawer), added an unmeasured number of instant potatoes to the milk/water mixture, and stirred until desired consistency was reached. Review of the recipe for mashed potatoes revealed for a serving size of 25: instant potatoes 1.10 lbs (pounds)., margarine 4.00 (ounces), Hot water 2.25 (Quarts), Black Pepper .50 (Tsp). Further review of the recipe revealed it did not call for one tsp of salt or one TBSP of parsley, which DA II added to the mashed potatoes he prepared. Interview on 3/20/2024 at 11:30 am with the DM confirmed recipes should be used for all food items prepared.

Based on observations, staff interviews and review of the facility's policy titled Patients/Residents' Personal Food, the facility failed to maintain sanitary resident nourishment refrigerators in the unit pantries, failed to store food items properly in the resident nourishment refrigerators and failed to dispose of expired food items in a timely manner in the resident nourishment pantries for two of three units (Blue Unit and Memory Care Unit). The facility had a census of 102 residents. Findings include: Review of the facility's policy titled Patient/Residents' Personal Food dated [DATE] revealed, Number 7. Nursing/housekeeping partners will be responsible for the disposal of outdated foods maintained in the patient/resident's room and those stored in the nursing units' nourishment refrigerators/freezers. Observation on [DATE] at 12:24 pm of the resident nourishment station on the blue unit revealed in the resident refrigerator one single 12 ounce (oz) can of coke zero in a gray plastic bag unlabeled/undated, one 17 oz can sparkling ice starburst drink unlabeled/undated, one small cup of tuna labeled/dated with a name that was not a resident's name. Further observation of the resident nourishment station refrigerator revealed one 16 oz bottle of purified drinking water that had been opened unlabeled/undated. Interview on [DATE] at 12:37 pm with Licensed Practical Nurse, Unit Manager (LPN, UM) FF, confirmed the unlabeled/undated items in the resident nourishment station refrigerator. She revealed she was not aware of who the items belonged to, and they should not have been in the refrigerator unlabeled/undated. Observation and interview on [DATE] at 12:47 pm of the resident nourishment pantry and refrigerator on the Memory Care Unit (MCU) revealed residents' snacks labeled with names but no date of when food items were opened. Continued observations revealed two opened bags of brown cereal that was unlabeled/undated and out of its original packaging in a plastic container; five packs of cheese crackers labeled with a resident's name with a best by date of [DATE]; four packs of peanut butter crackers with a best by date of [DATE]; seven packs of cream cheese and chive crackers with a best by date of [DATE], one pack dated [DATE], and two packs dated [DATE]; and one opened box of mini coconut cakes with two cakes remaining with a best by date [DATE] that were discolored with a black and yellow substance. Interview with Registered Nurse (RN) HH confirmed the items were expired and were not labeled and dated once removed from the original packaging. Observation and interview on [DATE] at 1:58 pm of the resident nourishment refrigerator revealed an assortment of open salad dressings unlabeled/undated; two containers of mayonnaise unlabeled/undated; one large bottle of coconut water unlabeled; one highly caffeinated sparkling 16 oz canned drink unlabeled/undated; three resident beverage cups filled with thickened liquids labeled with residents' names dated [DATE]; and one deli meat sandwich dated [DATE]. Further observation revealed there was a brown substance noted on the bottom inside of the refrigerator. Interview with RN HH confirmed that the highly caffeinated sparkling 16 oz canned drink belonged to her, that both staff and residents used the salad dressings, and that the food items were outdated that belonged to the residents. RN HH confirmed the food items should have been discarded after three days and that the refrigerator should be cleaned regularly. Interview on [DATE] at 2:03 pm with RN HH revealed she was responsible for cleaning the refrigerator on the MCU.

Based on observations, staff interviews, record review, and review of the facility's policies titled Infection Prevention-Hand Hygiene, and Medication Administration: General Guidelines, the facility failed to perform proper infection control processes as evidenced by two of six staff (Licensed Practical Nurse (LPN) JJ and LPN KK) observed not performing proper hand hygiene during meal tray pass, one of four staff (Certified Medication Aide/Certified Nursing Assistant (CMA/CNA) DD observed for medication administration who failed to properly prepare insulin for one Resident (R) (R73), and two of four staff (CMA/CNA EE and CMA/CNA DD) that failed to properly handle medications during medication administration for two residents (R87 and R73). The facility census was 102 residents, and the sample size was 46 residents. Findings include: 1. Review of the policy titled Infection Prevention-Hand Hygiene dated 8/15/2023, under the Policy Statement revealed, [Name] partners will improve hand hygiene practices and reduce Healthcare Associated Infections (HAIs) by complying with the recommendations established by Healthcare Infection Control Practices Advisory Committee (HICPAC0, Society for Healthcare Epidemiology of America ([NAME]), Association for Professionals in Infection Control (APIC), Infectious Disease Society of America (IDSA), World Health Organization (WHO) Hand Hygiene Task Force, and Center for Disease Control and Prevention (CDC). Under the section titled, D. Indications Requiring Hand Wash or Hand Rub Number 1. Before and after contact with the resident. Number 8. After contact with inanimate objects (i.e., including medical equipment) in the immediate vicinity of the resident. Unde the section titled, E. Indications Requiring Hand Wash revealed, Number 1. Before handling food. Number 3. Before and after assisting a resident to eat. Observation on 3/19/2024 at 12:15 pm during lunch, staff were observed during meal tray pass for proper infection control practice. At 12:18pm, LPN JJ was observed pulling a meal tray from the meal tray cart. She entered room [ROOM NUMBER] and placed the tray on the bedside table that was on the side of the room with the window. After preparing the tray for that resident, she exited the room. She approached the meal tray cart and pulled a second tray off the cart and then re-entered room [ROOM NUMBER] and placed the tray on the table of the resident on the side of the room closer to the exit door. Observation on 3/19/2024 at 12:20 pm revealed LPN KK observed pulling a tray from the meal tray cart before entering a resident's room. She was observed leaving the room without the tray and proceeded to approach the meal tray cart pulling a second tray from the cart before entering another resident's room. She was then observed, exiting the room without the tray, and returning to the meal tray cart for another tray. Interview on 3/19/2024 at 12:34pm with LPN KK revealed that hand hygiene should have been completed before and after each resident contact, which included before and after each tray pass. She confirmed that she didn't perform hand hygiene each time she was required to do. Interview on 3/19/2024 at 12:36pm with LPN JJ revealed that hand hygiene should be performed before and after each resident contact and before and after each meal tray that was passed. She then stated, I am not going to lie to you, I did not perform hand hygiene each time that I was required to do so when I passed the trays. Interview on 3/21/2024 at 1:06 pm with the Director of Health Services (DHS) revealed it was her expectation that all staff perform hand hygiene before passing a meal tray and then when the staff member exits the room before pulling the next tray. She then stated that if there was anything good that came out of the COVID 19 pandemic, it was that corporate allowed them to place hand sanitizer dispenses at the inside of the rooms at the doors of residents' rooms. 47146 2. Review of the facility's policy titled Medication Administration: General Guidelines dated 5/31/2023 under the Policy Statement revealed, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medications. Review of the Face Sheet for R73 revealed the resident was admitted to the facility with diagnoses listed but not limited to type II diabetes mellitus with diabetic neuropathy. Review of physician orders dated 8/25/2022 included but not limited to Humulin 70/30 insulin six units subcutaneous twice a day (10:00 am and 10:00 pm) ordered. Review of the care plan dated 8/25/2022 revealed a problem listed as potential for complications related to diabetes mellitus with the intervention listed but not limited to administer medications as ordered. Observations and interview on 3/20/2024 of CMA/CNA DD attempted to draw insulin from a multidose vial of Humulin 70/30 into a syringe for R73, she did not clean the rubber septum on top of the vial. Prior to puncturing the vial, the surveyor stopped CMA/CNA DD who verified she did not clean the septum of the vial and that she was going to draw the medication into a syringe without cleaning the septum of the vial. CMA/CNA DD confirmed she should have cleaned the septum with alcohol wipe and allowed it to dry before drawing any of the medication into a syringe. Interview on 3/20/2024 at 12:05 pm with the Director of Health Services (DHS) revealed that her expectation was that the nurse or CMA administering injectable medications were to clean the septum of top of the vial with an alcohol wipe and allow the top to dry prior to withdrawing medication for injection from the medication vials. 3. Observation and interview on 3/20/2024 at 8:55 am revealed CMA EE observed preparing medications for R87during medication pass. She removed a medication from a punch card into her bare hand and placed the medication into a medication cup. She attempted to take the medication to the resident when the surveyor stopped her. CMA EE verified she punched the medication out of the card into her bare hand and confirmed she was going to take the medication to the resident to administer the medication. She stated that she should have removed the medication from the card into a cup instead of her hand. Observation and interview on 3/20/2024 at 9:15 am revealed CMA/CNA DD observed preparing medications for R73 during medication pass. She removed a medication from a card and attempted to punch it into a medication cup, the medication landed on the cart. She picked up the medication with her bare, ungloved hand and placed the medication into a medication cup. CMA/CNA DD stated she should not have picked up the medication and placed it in the medication cup but should have discarded the medication immediately and documented it with the nurse. She further revealed she should have replaced it with a new tablet for R73 after wasting the dropped medication. Interview on 3/20/2024 at 12:05 pm with the DHS revealed her expectation of the nurses and CMA's administering medication from a punch card was to pop the medication out of the care into a medication cup. She stated she expected them to waste medications following proper procedures if they touched the medication with bare hands or if the medication was dropped.

Based on observations, record review, staff interview, and review of the facility's policy titled, Care Plan, the facility failed to follow the care plan for one of 46 sampled residents (R) (R37) related to providing assistance with showers and baths. Findings Include: Review of the facility's policy titled Care Plan dated 7/27/2023 revealed under Admission Comprehensive Plan of Care, Number 3. The comprehensive person-centered care plan is developed to include measurable goals and timeframes to meet a patient/resident's medical, nursing and psychosocial needs, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial needs that are identified in the comprehensive assessment. Review of Resident Face Sheet for R37 revealed diagnoses that included but not limited to Parkinson's disease, muscle weakness, difficulty in walking, unsteadiness on feet, muscle weakness, and other lack of coordination. Review of Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) was coded as 15, indicating that the resident had no cognitive impairment. Section GG (Functional Abilities and Goals) revealed that R37 required supervision or touching assistance with showering and bathing, touching assistance, and supervision. Review of the care plan dated 10/5/2023 for Activities of Daily Living (ADL) Functional Status/Rehabilitation Potential revealed R37 required assistance with ADL care as needed. Review of the Point of Care ADL Report (MDS 3.0) for R37 from 2/20/2024 through 3/21/2024 revealed documentation that staff provided the resident assistance with bathing on 3/1/2024, 3/5/2024, and 3/18/2024. Further review revealed bathing was coded as activity did not occur from 2//20/2024-2/29/2024, 3/3/2024-3/4/2024, 3/4/2024-3/6/2024, 3/6/2024-3/17/2024 and 3/19/2024-3/20/2024. There was no ADL data recorded on 3/2/2024 and 3/21/2024 for bathing. Interview on 3/20/2024 at 12:45pm with the Director of Health Services (DHS) revealed when asked how the Certified Nursing Assistants (CNAs) would know if a resident were to be provided a sponge bath or shower, DHS revealed that CNAs should follow the care plan unless residents request something different. Interview on 3/20/2024 at 5:00 pm with the Assistant Director of Health Services and the DHS revealed that the expectation was for staff to provide two to three showers per week but at minimum two showers per week for each resident who preferred showers. Cross Reference F677

Based on observations, staff interviews, record review, and review of the facility's titled Medication Storage in Healthcare Centers and Medication Administration: General Guidelines, the facility failed ensure the medication cart was locked when unattended for one out of five medication carts and failed to obtain orders from a physician to allow one out of 46 sampled Residents (R) (R55) the ability to self-administer medications prior to leaving medications at the bedside. Findings include: Review of the facility's policy titled Medication Storage in Healthcare Centers reviewed and revised on 3/1/2024, under the Policy Statement revealed, Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those tot the supplier. The medication supply is accessible only to licensed nursing personnel and pharmacy personnel. Respiratory Therapist may access medications used in the provision of respiratory services. Under the section titled Procedure Number 2 revealed Only licensed nurses and the pharmacy personnel are allowed access to medications. Respiratory Therapists may access medications used in the provision of respiratory services. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. Review of the facility's policy titled Medication Administration: General Guidelines last reviewed on 5/31/2023 under the Policy Statement revealed, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medications. Under the section titled Procedure Number 3 revealed Patients/residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with the procedures for self-administration of medications. Number 16 revealed During routine administration of medications, the medication cart is kept in the doorway of the patient/resident's room, with the drawers facing inward and all other sides closed and locked. No medications are kept on top of the cart, and all outward sides [NAME] be inaccessible to patient/resident or others passing by. 1. Observation on 3/20/2024 at 8:10 am of Licensed Practical Nurse (LPN) LL preparing medication for R77 in the main hallway near the station one nurses' desk revealed, LPN LL walking away from the medication cart to take medications to R77. The medication cart was left unattended and unlocked for three minutes. Interview on 3/20/2024 at 8:13 am with LPN LL confirmed she had left the medication cart unattended and unlocked while she administered medication to R77. She stated she got preoccupied with R77 and forgot to lock the medication cart. 2. Review of the Resident Face Sheet for R55 located in the Electronic Health Record (EHR) revealed Resident (R)55was admitted to the facility with diagnoses listed but not limited to unspecified sequelae of cerebral infarction. Review of R55 Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/18/2024 revealed a Brief Interview for Mental Status (BIMS) of 15, which indicated R55 was cognitively intact. Review of R55's care plans last reviewed/revised date of 3/1/2024 revealed there was no care plan that addressed self-administration of medication. Review of physician's orders for R55 revealed there was no order for self-administration of medications. Observation and interview on 3/20/2024 at 9:08 am with Certified Medication Aide (CMA)/ Certified Nursing Assistant (CNA) DD of her taking a cup of medications to R55 and immediately exiting the room. Interview with CMA/CNA DD revealed she had left R55 medications at his bedside because he administered his own medications. Observation and interview on 3/20/2024 at 9:37 am with CMA/CNA DD of R55 resting quietly in bed with medications in medication cup on his over bed table. Interview with CMA/CNA DD verified and confirmed the medications she prepared earlier that morning were located on the over bed table. CMA/CNA DD stated, she reminded R55 he needed to take his medications and he did so while she watched. She confirmed it was not ok to leave medications at the resident's bedside. Interview on 3/20/2024 at 5:00 pm with the Director of Health Services (DHS) confirmed R55 did not have an order to self-administer medications, nor was a care plan developed to allow for him to self-administer medications. She stated there was a nursing assessment to self-administer medications, but she stated the expectation was for residents to have a physician order to self-administer medications and a care plan to reflect this as well. She stated she expected the nurses and CMA to check the care plan and physician order to verify a resident can self-administer medications and if they have a question they are expected to ask. She stated she expected the nurse and the CMA when administering medications to remain with the resident until all medications are taken.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, Documentation: Charting Activities of Daily Living (ADLs) the facility failed to ensure that one of 46 sampled residents (R) (R37) had the necessary assistance with ADLs. Findings include: Review of the facility's policy titled, Documentation: Charting Activities of Daily Living (ADLs) dated 1/11/2024 revealed that the responsibility of the person completing the documentation on the Certified Nuse Assistant (CNA) /ADL flowsheet is to code the maximum amount of support the patient/resident received over the entire shift irrespective of frequency. For utilizing Care Assist, ADLs should be documented at the point of care each time care is given. The software will determine the most dependent episode. Review of R37's Resident Face Sheet located in the Electronic Health Record (EHR) revealed diagnoses included but not limited to Parkinson's disease, muscle weakness, difficulty in walking, unsteadiness on feet, muscle weakness, and other lack of coordination. Review of Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) was coded as 15, indicating that the resident had no cognitive impairment. Section GG (Functional Abilities and Goals) revealed that R37 required supervision or touching assistance with showering and bathing, touching assistance, and supervision. Review of the Green Hall Shower Schedule located in the shower room revealed R37 scheduled bath days were Tuesdays, Thursdays, and Saturdays. Further review revealed on 3/21/2024, 3/23/204, 2/27/2024, 3/2/2024,3/12/2024, 3/14/2024, 3/16/2024 there was no documentation to support R37 received or refused a shower. Review of the Point of Care ADL Report (MDS 3.0) for R37 from 2/20/2024 through 3/21/2024 revealed documentation that staff provided the resident assistance with bathing on 3/1/2024, 3/5/2024, and 3/18/2024. Further review revealed bathing was coded as activity did not occur from 2//20/2024-2/29/2024, 3/3/2024-3/4/2024, 3/4/2024-3/6/2024, 3/6/2024-3/17/2024 and 3/19/2024-3/20/2024. There was no ADL data recorded on 3/2/2024 and 3/21/2024 for bathing. Interview on 3/20/2024 at 12:45 pm with Certified Nursing Assistant (CNA) AA revealed that the facility's process to assure residents get showers was that they are assigned shower days. CNA AA revealed that they ask residents if they want a shower on assigned days, if they refuse, they put REF or refused on the weekly chart for that day. If residents get a shower, they either initial or put done on the chart to track for each day. CNA AA revealed that residents were offered showers three days during the week. During an interview on 3/20/2024 at 1:00 pm with R37, the resident revealed she filed a grievance during a Resident Council meeting related to help with showers. Review of the Resident Council Department response form dated 11/28/2024 revealed during a meeting, R37 requested help with showers and other concerns. Interview on 3/20/2024 at 1:05 pm with Licensed Practical Nurse BB revealed that each resident should be offered three showers per week. If the chart shows a blank for a day, which meant either they forgot to initial or write refused on the chart. She also revealed that if that was not the case, then the resident was never offered the opportunity to shower. Interview on 3/20/2024 at 5:00 pm with the Assistant Director of Health Services and the Director of Health Services revealed that the expectation was for staff to provide two to three showers per week but at minimum two showers per week for each resident who prefers showers. She stated staff would document the showers given and refused on the shower sheets and sometimes in the EHR. Cross Reference F656

Based on observations, resident and staff interviews, and record review, the facility failed to ensure that the call light communication system was functioning adequately to allow the resident to call for assistance in one room (room [ROOM NUMBER]A) on one of five halls. The sample size was 46 residents. Findings include: Record Review of R71's Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Section A (Identification Information) revealed entry date of 12/15/2023; Section C (Cognitive Pattern) Brief Interview for Mental Status (BIMS) score of nine; Section I (Active Diagnosis) Debility, Cardiorespiratory Conditions. Observation and Interview on 3/20/2024 at 9:15 am, in room [ROOM NUMBER] A revealed, the call light was lying on the floor. The call light was inspected by the surveyor and was nonfunctional. Interview with Resident (R) R71, revealed, she was high risk for falls and had to resort to yelling or using her roommate's call light for assistance. Further Interview on 3/20/2024 at 9:55 am with R71 revealed her call light had been nonfunctional since her admission at the facility. Observation and Interview on 3/20/2024 at 10:05 am with the Director of Health Services (DHS) inspected the call light and verified the call light was nonfunctional. DHS revealed this was unacceptable and would have it replaced promptly.

Based on observations, resident and staff interviews, the facility failed to ensure a safe/clean/comfortable/homelike environment in one of 14 resident rooms (room [ROOM NUMBER]) on the Magnolia Hall. Specifically, a metal plate was observed on the bathroom door in room [ROOM NUMBER] to have a hole with sharp, jagged edges. The deficient practice had the potential to cause injury to residents and staff. Findings include: Observations and interview on 3/19/2024 at 10:18 am of the bathroom door in room [ROOM NUMBER] revealed a metal plate attached to the door on the side facing the resident room with a hole with edges that were noted to be sharp and jagged. Interview with Resident (R) (R10) revealed when the room door opens, it would hit the bathroom door and that the doorknob of the room door created the hole. He stated he was uncertain of how long the door had been damaged. Observations on 3/20/2024 at 7:42 am in room [ROOM NUMBER] revealed the bathroom door had a metal plate attached to the door which had a hole in the metal plate noted to have sharp, jagged edges exposed. Observations on 3/20/2024 at 10:30 am in room [ROOM NUMBER] revealed the bathroom door had a metal plate attached to the door which had a hole in the metal plate noted to have sharp, jagged edges exposed. Walking rounds made with the Administrator and the Maintenance Director on 3/20/2024 at 12:00 pm, both verified and confirmed the bathroom door in room [ROOM NUMBER] had a metal plate which had a hole in the metal plate with sharp, jagged edges. The Maintenance Director stated he was not aware of the hole in the metal plate on the bathroom door. Interview on 3/21/2024 at 11:15 am with the Administrator revealed his expectation regarding the condition of resident rooms was that staff report repairs needed in the system that they report and make maintenance requests. He stated all nurses have access to the system to create a maintenance request and if other staff notice a repair needed, they should report the issue to their direct supervisor, or a nurse who would enter a maintenance request into the system for them.

Based on observations, interviews, and review of the policies titled Medication Storage in the Healthcare Centers and Controlled Substances for Healthcare Centers, the facility failed to ensure that two of six medication carts and one of two treatment carts on one of two units (unit one) were locked and secured when unattended and out of the view of the nurse. In addition, facility failed to ensure that narcotics were counted and documented at the beginning and end of each shift on one of six medication carts (Unit one). The census was 98. Findings include: 1. Review of the policy titled Medication Storage in the Healthcare Centers revised 9/15/17, revealed the policy is medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. Procedure number 2. Only licensed nurses and the pharmacy personnel are allowed access to the medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. Observation on 1/24/23 at 8:50 a.m. revealed one treatment cart located on unit one was unlocked, with the keys hanging from the lock, not within view of a nurse. The cart was located against a wall and near the resident dining room with the drawers facing the hallway. Observation on 1/24/23 at 8:53 a.m. with the Administrator verified the treatment cart to be unattended and unlocked with the keys hanging from the lock. The Administrator stated the cart should be locked and secured when left unattended. Interview on 1/24/23 at 2:15 p.m. with Licensed Practical Nurse (LPN) JJ revealed she was responsible for the treatment cart on unit one, and stated she was aware she had left the cart unlocked, unattended, and with the keys in the lock. She stated she must have forgotten to remove the keys and lock it. Observation on 1/26/23 at 8:46 a.m. revealed medication cart located on unit one Yellow Hall was unlocked, unattended, and out of view of a nurse. The cart was located between rooms [ROOM NUMBERS] with the drawers facing the hallway. LPN HH was observed to walk by the unlocked cart three times, without locking it. Observation on 1/26/23 at 8:48 a.m., the Director of Health Services (DHS) walked past the unlocked medication cart on unit one Yellow Hall, turned around and walked back to the cart and locked it. Observation on 1/26/23 at 8:49 a.m., LPN HH approached the cart and stated she heard a resident screaming and forgot to lock the cart when she walked away from it. The DHS verified at this time the cart to have been left unlocked and unattended in a resident hallway. Observation on 1/26/23 at 2:49 p.m., medication cart on unit one-Green Hall, revealed the medication cart unlocked, unattended, and out of view of a nurse. The cart was positioned against a wall across the hallway from the dining room entry door with the drawers facing the hallway. One resident in a wheelchair was observed self-propelling by the unlocked and unattended cart. Observation on 1/26/23 at 2:51 p.m. the Infection Control Preventionist (ICP) approached the unlocked medication cart on unit one-Green Hall and locked it. At this time, he confirmed the medication cart was left unlocked and unattended and stated the cart should have been locked when left unattended. Interview on 1/26/23 at 2:53 p.m. with the DHS, revealed her expectations are that all medication and treatment carts are to be locked and secured when left unattended. She stated she is not sure when the last education covering medication storage was provided. 2. Review of the policy titled Controlled Substances for Healthcare Centers revised 4/28/21 revealed the policy statement of [name] is that medications listed as controlled substances (Schedule I-V) under federal or state regulations will be properly stored with maintained accountability. Reconciliation of controlled substances will be performed at the end of each shift by licensed professional nurses. The section titled Accounting revealed: 1. A physical inventory of all controlled substances is conducted at each shift change by the oncoming and outgoing licensed professional nurses. 2. The inventory is documented on the Controlled Drug Shift Audit Sheet. Review of the Controlled Drug Shift Audit Sheet Form - 12 Hour Shifts forms located on top of the medication cart on unit one-Green Hall, dated 12/26/22 - 1/25/23 revealed missing signatures for shift change controlled medication count for the dates of 12/26/22, 1/2/23, 1/3/23, 1/4/23, 1/5/23, 1/6/23, 1/14/23, 1/15/23, 1/23/23. The review revealed there were 30 missing signatures verifying the controlled substances for the cart was counted and that the count was correct. Interview on 1/25/23 at 9:20 a.m. with LPN HH, revealed nurses are required to count the controlled medications at each shift change and sign the Controlled Drug Shift Audit Sheet Form - 12 Hour Shifts to verify the controlled substance count was performed. She verified there were missing signatures on multiple dates and stated she is unaware of the reason for the lack of signatures. She revealed the signatures are the proof that controlled medications were counted at the shift change. Interview on 1/25/23 at 9:30 a.m. with the DHS, revealed her expectations are that controlled medications are counted at each shift change and each nurse's signature verifies the count on the Controlled Drug Shift Audit Sheet Form - 12 Hour Shifts is correct. At this time, she reviewed the Controlled Drug Shift Audit Sheet Form - 12 Hour Shifts dated 12/26/22 - 1/23/23 and verified there were missing nurse signatures on multiple dates. She stated the nursing staff received education regarding counting of controlled medications and signing the Controlled Drug Shift Audit Sheet Form - 12 Hour Shifts within the past month. She stated she is unsure why there were missing signatures on the form, after the in-service was completed. Review of an in-service education form dated 1/16/23 revealed it to include controlled drug shift audit sheet form is expected to be signed during shift change. There were seventeen nursing signatures on the sign in sheets for the in-service.

Based on observations, interviews, record review, facility documentation, and policy review, the facility failed to maintain an effective Infection Control Program (ICP) to prevent the spread of infections by not ensuring staff donned required Personal Protective Equipment (PPE) prior to entering COVID-19 positive room for one resident (R) (R#19) and failed to ensure staff washed/sanitized their hands during the provision of wound care for one resident (R) (R#144). In addition, the facility failed to properly store continuous positive airway pressure (CPAP) mask for R#344. The sample size was 38. Finding include: 1. Review of the policy titled COVID-19 Isolation and Cohorting Process revised 1/9/23 procedure: III. 9. Entering or exiting confirmed positive (level 1) or suspected of COVID-19 infection (level 2) room. 2) Personal Protective Equipment (PPE) will be used in each transmission-based precautions (TBP) room and changed accordingly: a) N95 mask; b) Eye protection; c) PPE donned properly. Review of the clinical record revealed R#19 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation, COVID-19, anemia, bipolar disorder, schizophrenia, adult failure to thrive and depression. The resident's most recent annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of five, indicating severe cognitive impairment. Section G revealed resident required extensive assistance with activities of daily living (ADL's) and supervision with eating. Review of the care plan revised 1/27/2023 revealed resident is at risk for COVID-19. Further review of the care plan documented resident tested positive for COVID-19 on 1/21/2023. Approaches to care include contact droplet isolation precautions. Review of Physician Order Report dated 12/25/2022 through 1/25/2023 revealed an order for Special Contact Droplet Isolation Precautions Covid two times daily, with an open-ended order date 1/21/2023. Observation on 1/24/2023 at 9:05 a.m. revealed R#19 was on Transmission Based Precautions (TBP) for COVID-19. The door was closed, PPE cart noted outside the door, and signage on the door indicated: *STOP/[NAME] *Special Droplet Contact Precautions *All Healthcare Personnel must: clean hands before entering and when leaving room, wear gown when entering room and remove before leaving, wear N95 mask or higher level of respirator before entering and remove after exiting, protective eyewear (face shield or googles), wear gloves when entering room and remove before leaving. Observation on 1/24/2023 at 10:38 a.m. Certified Nursing Assistant (CNA) AA, entered room [ROOM NUMBER] (R#19's room) wearing a face shield and mask. R#19, in room [ROOM NUMBER] bed A, was on TBP for testing positive for COVID-19. CNA AA did not have on any gloves or gown when entering the room, nor did she sanitize her hands before entering the room. She was observed taking vital signs on the two residents in the room, without wearing gloves. Signage on the door indicated to wear gown, N95 mask, eyewear, and gloves. Interview on 1/24/2023 at 10:38 a.m. with CNA AA, stated she was aware R#19 was on precautions for COVID-19. During further interview she stated she did not have to wear a gown or gloves if she was not doing patient care. Interview on 1/24/2023 at 10:53 a.m. the Director of Nursing (DON) revealed she would expect all staff who entered the room to wear the appropriate PPE that includes a gown, gloves, N95 mask and a face shield. Observation on 1/24/2023 at 11:08 a.m. Housekeeper (HK) BB, entered room [ROOM NUMBER], which was on TBP for COVID, wearing a mask under her nose and a face shield. She did not put on a gown, sanitize her hands, or don gloves prior to entering the room. She was observed removing the garbage from the room and placing in her cart garbage can. Continued observation revealed she did not sanitize her hands prior to leaving the room or after putting the garbage in the cart's garbage bag. HK BB stated she floats to other halls and was unaware that the resident was on precautions or had COVID-19. Interview on 1/24/2023 at 11:18 a.m. with the DON and the Administrator indicated this is unacceptable and the DON went down the hall. The Infection Preventionist (IP) conducted an on-the-spot education on PPE. 47146 2. Review of the undated facility document titled Dressing a Wound revealed a checklist that identifies steps needed to dress a wound. It also provides rationales as to why these steps are performed. The use of this content is for educational purposes only and should only be used as a guide in performing this skill. Any federal, state, and local regulations and protocols must be observed, in addition to supplemental rules applied at the organization. Review of the clinical record revealed R#144 was admitted to the facility on [DATE] with diagnoses including surgical amputation, gangrene, cellulitis of left toe, acute osteomyelitis left ankle and foot, hemiplegia and hemiparesis following cerebral infarction. The resident's admission MDS dated [DATE], revealed a BIMS score of 15, indicating no cognitive impairment. Section G revealed resident required extensive assistance with activities of daily living (ADL's). Section M revealed resident had surgical wound care to feet. Review of the care plan initiated on 1/6/2023 revealed R#144 was admitted to the facility with amputation of second and third left toes with open surgical wound. Approaches to care include Quality Surgical Management (QSM) to evaluate and treat amputation to left toes, treatment as ordered to amputation site, skin assessment weekly, and assess for presence of risk factors/eliminate risk factor to extent possible. Observation on 1/25/2023 at 10:56 a.m. Licensed Practical Nurse (LPN) CC performing wound care for R#144 left foot surgical wound. LPN CC reviewed orders for wound care, gathered supplies, prepared a clean surface for supplies, but did not place a protective barrier on the table. She provided privacy for the resident, explained procedure to resident and obtained permission for surveyor to observe wound care. She performed hand hygiene, donned gloves, removed soiled dressing, and discarded in the trash. She assessed the wound, and doffed gloves. She then donned a clean pair of gloves without performing hand hygiene, and reapplied dressing according to the physician orders. Removed trash from room then removed gloves and performed hand hygiene. Interview on 1/25/2023 at 11:10 a.m., LPN CC stated she only changed her gloves after she removed the soiled dressing and confirmed she did not perform hand hygiene. She stated she should have performed hand hygiene after removal of old dressing and prior to donning new gloves for placement of new dressing. Interview on 1/26/2023 at 10:45 a.m. with the Infection Preventionist (IP) stated the expectation is for the nurse to sanitize/wash hands between glove changes during wound care. He stated the facility doesn't have a policy but uses a check list for the wound care nurse to follow as well as for observation of nurses during training in wound care. Interview on 1/26/2023 at 10:47 a.m. with the Director of Health Services (DHS) revealed her expectation related to findings during observation is that the nurse would sanitize her hands between glove changes. 46691 3. Review of the undated procedure document titled Continuous Positive Airway Pressure (CPAP) Use revealed the objective was to administer CPAP to a patient according to the standard of care. One unnumbered checklist step revealed to clean and disinfect the equipment and store it properly. Review of the clinical record revealed R#344 was admitted to the facility on [DATE] with diagnoses including encephalopathy, chronic respiratory failure, diabetes, depression, sleep apnea, atrial fibrillation, chronic obstructive pulmonary disease (COPD), and hypertension (HTN). The resident's admission MDS dated [DATE], revealed a BIMS score of 13, indicating no cognitive impairment. Sections G and O were not completed. Review of the care plan initiated on 1/16/2023, revealed resident had potential for complications related to pneumonia and diagnosis of chronic obstructive pulmonary disease, congestive heart failure, and respiratory failure. Approaches to care include change respiratory supplies weekly and as needed, wash mask weekly with warm soapy water and allow to air dry, follow principles of infection control and universal/standard precautions. Observation on 1/24/2023 at 11:00 a.m. in room [ROOM NUMBER], revealed R#344's CPAP mask lying on top of the CPAP machine unbagged, uncovered, and exposed to the environment. Observation on 1/25/2023 at 10:40 a.m. in room [ROOM NUMBER], revealed R#344's CPAP mask lying on the floor next to residents bed, unbagged, uncovered, and exposed to the environment. Interviews on 1/24/2023 at 11:00 a.m., R#344 stated staff provide assistance with applying the CPAP mask at night, and removing the mask in the morning. During further interview, she stated she had not observed the mask to be placed into a protective bag. Interview on 1/25/2023 at 10:20 a.m. with CNA GG revealed R#344 required supervision to limited assistance with most ADLS. She further revealed the nurses provide all oxygen related care and monitoring. Interview on 1/25/2023 at 10:50 a.m. with LPN HH stated the night shift nurses are responsible for assisting residents with placement and removal of CPAP masks and maintenance of supplies. She stated that CPAP masks should be kept in a bag when not in use. At this time, LPN HH verified R#344's CPAP mask to be lying on the floor, unbagged, uncovered, and exposed to the environment. Interview on 1/25/23 at 1:48 p.m. with the Director of Health Services (DHS) stated her expectations are for CPAP masks to be stored in a protective bag and located on the bedside table or other surface area off of the floor.

Based on record review and staff interview, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. There were no Registered Nurses in the facility for at least eight consecutive hours on 12/18/22 and 1/21/23. The facility census was 98. Findings include: Review of past 30 days of daily staffing grids revealed there was no RN on duty for the minimum eight consecutive hours per day on 12/18/2022 and 1/21/2023. Interview on 1/25/2023 at 1:30p.m., the Director of Health Services (DHS) confirmed there was no RN coverage for eight consecutive hours on Saturday 1/21/2023. She stated there was no RN on duty during the 24-hour period. During further interview, the DHS revealed the scheduled RN was given her shift off by the Assistant Director of Health Services (ADHS), not realizing there was no other RN scheduled to work. She stated it is her expectation that a RN be on duty for at least eight hours per day. Interview on 1/25/2023 at 1:40p.m., the Administrator confirmed there was no RN coverage on Saturday 1/21/2023. She stated she was unaware until Monday the facility had no RN coverage and revealed the ADHS had given the scheduled RN the day off, unaware there was no other RN scheduled. Further interview revealed it is her expectation that the facility has at least eight-hour RN coverage daily. Interview 1/26/2023 at 9:45a.m., the Administrator revealed she was aware of the lack of RN coverage on 12/18/2022. She stated she was informed by the corporate office when it was identified while reporting the Payroll Based Journal (PB & J) report. The Administrator stated the facility does not have a specific policy for RN coverage and the facility follows CMS guidance and regulations regarding staffing. Interview on 1/26/2023 at 10:00 a.m., the DHS confirmed there was no RN coverage on 12/18/2022.

Based on resident record review, hospital History And Physical review, hospital Discharge Summary review, staff interview, and review of the Georgia Practical Nurses Practice Act, the facility failed to ensure that for one (1) resident (#1), on a total survey sample of eleven (11) residents, transfer medication orders were transcribed by nursing staff upon the resident's admission to the facility, in accordance with professional standards of quality. This failure resulted in an interruption in drug therapy for Resident #1, who had [DIAGNOSES REDACTED].#1. It was therefore determined that an immediate and serious threat to resident health and safety existed on March 23, 2010, and was removed on April 13, 2010, at which time the facility implemented a plan to remove the immediate jeopardy. Findings include: The Georgia Practical Nurses Practice Act, 43-26-32, 7(a), indicates that the practice of licensed practical nursing includes the implementation of services, and 7(d) indicates that the nurse administers medications. Record review for Resident #1 revealed a hospital History And Physical form which documented that the resident had resided in the hospital from 03/14/2010 to 03/23/2010. The hospital Discharge Summary listed discharge [DIAGNOSES REDACTED]. A nursing facility Nurse's Note of 03/23/2010 at 2:00 p.m. documented the resident's admission to the facility from the hospital. Review of the resident's hospital Admission/Discharge Medication Order Sheet transfer physician's orders [REDACTED].) dose of the [MEDICAL CONDITION]/hypertension medication [MEDICATION NAME] twice daily; a 25 mg. dose of the diuretic [MEDICATION NAME] twice daily; a 16 mEq. dose of Potassium Chloride twice daily; a 5 mg. dose of [MEDICATION NAME] twice daily; a 10 mg. dose of [MEDICATION NAME] twice daily; and, a 250 mg. dose of Magnesium Oxide twice daily. However, review of the facility's March 2010 physician's orders [REDACTED]. to the nursing facility. The March 2010 Medication Record documented that [MEDICATION NAME] therapy was actually initially administered on 03/30/2010, and [MEDICATION NAME], Potassium Chloride, [MEDICATION NAME] and Magnesium Oxide were actually initially administered on 03/31/2010, approximately one (1) week after the resident's admission. During an interview conducted on 04/08/2010 at 3:40 p.m., Nurse "AA" stated that due to a resident friend's question regarding insulin on 03/29/2010, she had called the physician to inquire about insulin therapy for the resident. During an interview conducted on 04/07/2010 at 3:30 p.m., Nurse "BB", the facility's Minimum Data Set Coordinator, stated that on 03/30/2010 during the process of assessing Resident #1 for completion of the resident's Minimum Data Set, she had discovered that the entire second page of hospital transfer orders, which included [MEDICATION NAME], Potassium Chloride, [MEDICATION NAME], and Magnesium Oxide had been omitted. During an interview conducted on 04/08/2010 at 3:40 p.m., the Director of Nursing acknowledged that the admission medication orders referenced above were missed for Resident #1. Despite the resident's [DIAGNOSES REDACTED]. This resulted in an interruption of seven (7) days of the resident's insulin therapy, an interruption of eight (8) days in the resident's medications [MEDICATION NAME], and Potassium Chloride, [MEDICATION NAME], and [MEDICATION NAME] for [DIAGNOSES REDACTED]. Cross refer to F309 and F333. It was determined that the immediate jeopardy was removed as of 04/13/2010, by which time the facility had completed the following actions: 1. On 04/12/2010, the facility established a New Admission/Readmission Medication and Laboratory Reconciliation Tracking Tool Process, by which a New Admission/Readmission Medication and Lab Reconciliation Tracking Tool form will be completed each day. Monday through Friday, the form will be completed by the Assistant Director of Nursing during the morning clinical meeting, and on Saturdays and Sundays, the form will be completed by the weekend supervisor. All new admissions and readmissions from the past 24 hours will be addressed to ensure all medications are transcribed accurately and that all medications have been received from the pharmacy. All laboratory orders will be verified to ensure they are ordered and drawn in accordance with Policy and Procedure and physicians' orders. In addition, all orders will be verified. Specifically, for each new admission/readmission, the Tracking Tool form will document assessment of the following: correct medication transcription to both the medical record and the Medication Administration Record; timely receipt of medications from the pharmacy; assessment of laboratory orders to ensure accuracy per physicians' orders; assessment of laboratory test scheduling to ensure each ordered laboratory test is scheduled as ordered; and, verification of all other physician orders. 2. On 04/12/2010, the facility implemented the use of the Tracking Tool Process form for review of all new admissions/readmissions during the morning clinical meeting. 3. On 04/12/2010, the facility conducted staff inservice training with the majority of facility registered/licensed nursing staff to provide training on the new Tracking Tool Process, and reiterated facility policy regarding the initial sign-off and transcription of all new physicians' orders. The four remaining nursing staff received this inservice training on 04/13/2010. 4. On 04/12/2010, the facility developed a Performance Improvement Plan to be utilized by the facility's Quality Assurance Committee to ensure the ongoing review and monitoring of new admissions/readmissions to ensure the correct transcription and review of all physicians' orders, including those involving laboratory testing. 5. On 04/13/2010, the facility performed an audit of all existing resident medical records to ensure that all physicians' orders were current and correct. Based on these corrective plans which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice had been removed on April 13, 2010. However, the effectiveness of these corrective plans could not be fully assessed to ensure ongoing application and completion. The facility had implemented the interventions referenced above and conducted staff inservice training on the Tracking Tool Process, with the majority of nursing staff having received inservice training on 04/12/2010, but with four (4) nursing staff having received this training on the morning of 04/13/2010, the last day of this complaint survey. Also, the use of the Tracking Tool Process form had been implemented on 04/12/2010, and had thus been utilized in only one morning clinical meeting (04/13/2010), and there had been no actual resident admission/readmission during the previous 24 hours of the initiation of the Tracking Tool Process. Additionally, the results of the Performance Improvement Plan reviews are to be reviewed and assessed by the facility's Quality Assurance Committee on an ongoing basis. The initial review had not been completed by this Committee as of the 04/13/2010 exit date of this survey, but rather would be reviewed in the next upcoming meeting of the Committee on 04/20/2010. Therefore, the noncompliance continues, with the scope and severity level of the deficiency decreased to the "D" level.

Based on resident record review, hospital Discharge Summary review, hospital Admission/Discharge Medication Order sheet review, and staff interview, the facility failed to ensure that one (1) resident (#1), on a total survey sample of eleven (11) residents, received drug therapy in accordance with physician's orders [REDACTED]. This failure to provide the ordered drug therapy for Resident #1, who had [DIAGNOSES REDACTED].#1. It was therefore determined that an immediate and serious threat to resident health and safety existed on March 23, 2010, and was removed on April 13, 2010, at which time the facility implemented a plan to remove the immediate jeopardy. Findings include: Record review for Resident #1 revealed a hospital Discharge Summary from a 03/14/2010 to 03/23/2010 hospital admission, which listed discharge [DIAGNOSES REDACTED]. A nursing facility Nurse's Note of 03/23/2010 at 2:00 p.m. documented the resident's admission to the facility after transfer from the hospital. The hospital Admission/Discharge Medication Order Sheet transfer physician's orders [REDACTED]. However, review of the facility's March 2010 physician's orders [REDACTED]. These omitted orders included [MEDICATION NAME], 25 units each morning; a 25 milligram (mg.) dose of the [MEDICAL CONDITION]/hypertension medication [MEDICATION NAME] twice daily; a 25 mg. dose of the diuretic [MEDICATION NAME] twice daily; and, a 16 mEq. dose of Potassium Chloride twice daily. Further record review, to include review of the March 2010 Medication Record, revealed no evidence to indicate that any of the ordered medications referenced above were administered to the resident from the 03/23/2010 date of admission until a 25 unit dose of [MEDICATION NAME] was documented on the Medication Record as having been administered on 03/30/2010. This Medication Record also documented the initial administration of [MEDICATION NAME], and Potassium Chloride beginning on 03/31/2010, eight (8) days after the resident's facility admission. During an interview conducted on 04/08/2010 at 3:40 p.m., Nurse "AA" stated that due to a resident friend's question regarding insulin on 03/29/2010, she called the physician and was informed by the physician that the facility already had an order for [REDACTED]. During an interview conducted on 04/07/2010 at 3:30 p.m., Nurse "BB", the facility's Minimum Data Set Coordinator, stated that on 03/30/2010 during the process of assessing Resident #1 for completion of the resident's Minimum Data Set, she had discovered the resident had a transfer order for insulin which had been omitted on admission, and discovered that the entire second page of hospital transfer orders, which also included [MEDICATION NAME], and Potassium Chloride, had been omitted. She stated that she informed Nurse "AA" of this omission on 03/30/2010. During an interview with Nurse "AA" conducted on 4/08/10 at 3:40 p.m., the nurse stated she was unformed of the omitted transfer orders on 3/30/2010. She stated that the physician was then informed on 03/30/2010 via telephone, at which time the orders were resumed. During an interview conducted on 04/08/2010 at 3:40 p.m., the Director of Nursing acknowledged that the admission medication orders referenced above were missed for Resident #1. Despite the resident's [DIAGNOSES REDACTED]. This resulted in an interruption of seven (7) days in the resident's insulin therapy, and an interruption of eight (8) days in the resident's medications [MEDICATION NAME], and Potassium Chloride for [DIAGNOSES REDACTED]. Cross refer to F309. It was determined that the immediate jeopardy was removed as of 04/13/2010, by which time the facility had completed the following actions: 1. On 04/12/2010, the facility established a New Admission/Readmission Medication and Laboratory Reconciliation Tracking Tool Process, by which a New Admission/Readmission Medication and Lab Reconciliation Tracking Tool form will be completed each day. Monday through Friday, the form will be completed by the Assistant Director of Nursing during the morning clinical meeting, and on Saturdays and Sundays, the form will be completed by the weekend supervisor. All new admissions and readmissions from the past 24 hours will be addressed to ensure all medications are transcribed accurately and that all medications have been received from the pharmacy. All laboratory orders will be verified to ensure they are ordered and drawn in accordance with Policy and Procedure and physicians' orders. In addition, all orders will be verified. Specifically, for each new admission/readmission, the Tracking Tool form will document assessment of the following: correct medication transcription to both the medical record and the Medication Administration Record; timely receipt of medications from the pharmacy; assessment of laboratory orders to ensure accuracy per physicians' orders; assessment of laboratory test scheduling to ensure each ordered laboratory test is scheduled as ordered; and, verification of all other physician orders. 2. On 04/12/2010, the facility implemented the use of the Tracking Tool Process form for review of all new admissions/readmissions during the morning clinical meeting. 3. On 04/12/2010, the facility conducted staff inservice training with the majority of facility registered/licensed nursing staff to provide training on the new Tracking Tool Process, and reiterated facility policy regarding the initial sign-off and transcription of all new physicians' orders. The four remaining nursing staff received this inservice training on 04/13/2010. 4. On 04/12/2010, the facility developed a Performance Improvement Plan to be utilized by the facility's Quality Assurance Committee to ensure the ongoing review and monitoring of new admissions/readmissions to ensure the correct transcription and review of all physicians' orders, including those involving laboratory testing. 5. On 04/13/2010, the facility performed an audit of all existing resident medical records to ensure that all physicians' orders were current and correct. Based on these corrective plans which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice had been removed on April 13, 2010. However, the effectiveness of these corrective plans could not be fully assessed to ensure ongoing application and completion. The facility had implemented the interventions referenced above and conducted staff inservice training on the Tracking Tool Process, with the majority of nursing staff having received inservice training on 04/12/2010, but with four (4) nursing staff having received this training on the morning of 04/13/2010, the last day of this complaint survey. Also, the use of the Tracking Tool Process form had been implemented on 04/12/2010, and had thus been utilized in only one morning clinical meeting (04/13/2010), and there had been no actual resident admission/readmission during the previous 24 hours of the initiation of the Tracking Tool Process. Additionally, the results of the Performance Improvement Plan reviews are to be reviewed and assessed by the facility's Quality Assurance Committee on an ongoing basis. The initial review had not been completed by this Committee as of the 04/13/2010 exit date of this survey, but rather would be reviewed in the next upcoming meeting of the Committee on 04/20/2010. Therefore, the noncompliance continues, with the scope and severity level of the deficiency decreased to the "D" level.

Based on resident record review, hospital History And Physical review, hospital Discharge Summary review, hospital Admission/Discharge Medication Order Sheet review, and staff interview, the facility failed to ensure that one (1) resident (#1), on a total survey sample of eleven (11) residents, received drug therapy in accordance with physician's orders [REDACTED]. In addition, once the facility was made aware of the missed medications and resultant interruption in drug therapy, the medications [MEDICATION NAME], Potassium Chloride, [MEDICATION NAME], and Magnesium Oxide were ordered via the routine pharmacy procedure and not delivered until the following day, resulting in a total of eight (8) days missed for these medications. This failure to provide the ordered drug therapy for Resident #1, who had [DIAGNOSES REDACTED].#1. It was therefore determined that an immediate and serious threat to resident health and safety existed on March 23, 2010, and was removed on April 13, 2010, at which time the facility implemented a plan to remove the immediate jeopardy. Findings include: Record review for Resident #1 revealed a hospital History And Physical form which documented that directly prior to the resident's initial admission to the nursing facility, the resident had resided in the hospital from 03/14/2010 to 03/23/2010. This hospital History and Physical documented that the resident was significant for [MEDICAL CONDITION] and hypertension, further documenting that the resident had New York Heart Association Class IV [MEDICAL CONDITION]. The hospital Discharge Summary listed discharge [DIAGNOSES REDACTED]. The hospital Admission/Discharge Medication Order Sheet documented that while in the hospital, the resident had physicians' orders for [MEDICATION NAME], 25 units each morning; a 25 milligram (mg.) dose of the [MEDICAL CONDITION]/hypertension medication [MEDICATION NAME] twice daily; a 25 mg. dose of the diuretic [MEDICATION NAME] twice daily; a 16 mEq. dose of Potassium Chloride twice daily; a 5 mg. dose of [MEDICATION NAME] twice daily; and, a 10 mg. dose of [MEDICATION NAME] twice daily. The hospital History and Physical referenced above also documented that prior to the resident's hospital admission, the resident had been on multiple medications while at home, including the diuretics [MEDICATION NAME] 25 mgs. twice daily and [MEDICATION NAME] 80 mgs. daily. However, the hospital Medication Order Sheet documented that while in the hospital, the [MEDICATION NAME] diuretic therapy had been discontinued and the resident had been maintained utilizing [MEDICATION NAME] diuretic therapy. Further record review for Resident #1 revealed a nursing facility Nurse's Note of 03/23/2010 at 2:00 p.m. which documented the resident's admission to the facility after transfer from the hospital. The facility's March 2010 Medication Record documented that the resident had [DIAGNOSES REDACTED]. Review of the resident's hospital Admission/Discharge Medication Order Sheet transfer physician's orders [REDACTED]. These orders were signed by the physician who had attended the resident while in the hospital and who was also the resident's facility attending physician. Review of the facility's March 2010 physician's orders [REDACTED]. However, further review of these facility physician's orders [REDACTED]. These omitted orders included [MEDICATION NAME], 25 units each morning; a 25 milligram (mg.) dose of the [MEDICAL CONDITION]/hypertension medication [MEDICATION NAME] twice daily; a 25 mg. dose of the diuretic [MEDICATION NAME] twice daily; a 16 mEq. dose of Potassium Chloride twice daily; a 5 mg. dose of [MEDICATION NAME] twice daily; a 10 mg. dose of [MEDICATION NAME] twice daily; and, a 250 mg. dose of Magnesium Oxide twice daily. Further record review, to include review of the March 2010 Medication Record, revealed no evidence to indicate that any of the medications referenced above, which had been ordered on the Admission/Discharge Medication Order Sheet transfer orders, were administered to the resident from the 03/23/2010 date of admission until a 25 unit dose of [MEDICATION NAME] was documented on the Medication Record as having been administered on 03/30/2010, seven (7) days after the resident's facility admission. This Medication Record also documented the initial administration of [MEDICATION NAME], Potassium Chloride, [MEDICATION NAME] and Magnesium Oxide on 03/31/2010, eight (8) days after the resident's facility admission. During an interview conducted on 04/07/2010 at 1:20 p.m., Nurse "AA" stated that a friend of the resident had come to facility on 03/29/2010 and had brought it to this nurse's attention that the resident was not receiving insulin therapy. During another interview conducted on 04/08/2010 at 3:40 p.m., Nurse "AA" stated that due to the friend's question regarding insulin, she called the physician to inquire about insulin therapy for the resident, and was informed by the physician that the facility already had the order for insulin. The nurse further stated she told the physician that there was no order for insulin (despite the hospital transfer order for [MEDICATION NAME] referenced above), so she wrote a new order for [MEDICATION NAME]. There was, however, no evidence to indicate that Nurse "AA" reviewed the resident's medical record at that time to determine if there was an existing insulin order as the physician had stated. During an interview conducted on 04/07/2010 at 3:30 p.m., Nurse "BB", the facility's Minimum Data Set Coordinator, stated that on 03/30/2010 during the process of assessing Resident #1 for completion of the resident's Minimum Data Set, she had discovered that the resident did have a transfer order for insulin which had been omitted from the resident's transcribed facility admission orders [REDACTED]. She stated that she informed Nurse "AA" of this omission on 03/30/2010. During an interview with Nurse "AA" conducted on 4/08/10 at 3:40 p.m., the nurse stated she was informed of the transfer orders that had been omitted for Resident #1 after the morning meeting of 03/30/2010. She stated that the physician was then informed on 03/30/2010 via telephone shortly after lunch about the medications ordered on the second page of hospital transfer orders that were not transcribed and administered since the resident's admission on 3/23/2010, at which time the orders were resumed. The nurse stated that the medications should have been immediately obtained from the emergency box or from the pharmacy and the 5:00 p.m. doses administered on 03/30/2010, however, facility staff failed to immediately obtain the medications, so they were not administered until the routine 9:00 a.m. medication pass on 3/31/2010. Thus, even though these medications had already been omitted from 03/23/2010 to 03/30/2010, the medications were administered only after having been obtained via routine pharmacy delivery on 03/31/2010, resulting in a total of eight (8) days missed for the six (6) medications [MEDICATION NAME], Potassium Chloride, [MEDICATION NAME] and Magnesium Oxide. During an interview conducted on 04/08/2010 at 3:40 p.m., the Director of Nursing acknowledged that the admission medication orders referenced above were missed for Resident #1. Despite the resident's [DIAGNOSES REDACTED]. This resulted in an interruption of seven (7) days of the resident's insulin therapy, and interruption of eight (8) days in the resident's medications [MEDICATION NAME], and Potassium Chloride, [MEDICATION NAME], and [MEDICATION NAME] drug therapy for [DIAGNOSES REDACTED]. It was determined that the immediate jeopardy was removed as of 04/13/2010, by which time the facility had completed the following actions: 1. On 04/12/2010, the facility established a New Admission/Readmission Medication and Laboratory Reconciliation Tracking Tool Process, by which a New Admission/Readmission Medication and Lab Reconciliation Tracking Tool form will be completed each day. Monday through Friday, the form will be completed by the Assistant Director of Nursing during the morning clinical meeting, and on Saturdays and Sundays, the form will be completed by the weekend supervisor. All new admissions and readmissions from the past 24 hours will be addressed to ensure all medications are transcribed accurately and that all medications have been received from the pharmacy. All laboratory orders will be verified to ensure they are ordered and drawn in accordance with Policy and Procedure and physicians' orders. In addition, all orders will be verified. Specifically, for each new admission/readmission, the Tracking Tool form will document assessment of the following: correct medication transcription to both the medical record and the Medication Administration Record; timely receipt of medications from the pharmacy; assessment of laboratory orders to ensure accuracy per physicians' orders; assessment of laboratory test scheduling to ensure each ordered laboratory test is scheduled as ordered; and, verification of all other physician orders. 2. On 04/12/2010, the facility implemented the use of the Tracking Tool Process form for review of all new admissions/readmissions during the morning clinical meeting. 3. On 04/12/2010, the facility conducted staff inservice training with the majority of facility registered/licensed nursing staff to provide training on the new Tracking Tool Process, and reiterated facility policy regarding the initial sign-off and transcription of all new physicians' orders. The four remaining nursing staff received this inservice training on 04/13/2010. 4. On 04/12/2010, the facility developed a Performance Improvement Plan to be utilized by the facility's Quality Assurance Committee to ensure the ongoing review and monitoring of new admissions/readmissions to ensure the correct transcription and review of all physicians' orders, including those involving laboratory testing. 5. On 04/13/2010, the facility performed an audit of all existing resident medical records to ensure that all physicians' orders were current and correct. Based on these corrective plans which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice had been removed on April 13, 2010. However, the effectiveness of these corrective plans could not be fully assessed to ensure ongoing application and completion. The facility had implemented the interventions referenced above and conducted staff inservice training on the Tracking Tool Process, with the majority of nursing staff having received inservice training on 04/12/2010, but with four (4) nursing staff having received this training on the morning of 04/13/2010, the last day of this complaint survey. Also, the use of the Tracking Tool Process form had been implemented on 04/12/2010, and had thus been utilized in only one morning clinical meeting (04/13/2010), and there had been no actual resident admission/readmission during the previous 24 hours of the initiation of the Tracking Tool Process. Additionally, the results of the Performance Improvement Plan reviews are to be reviewed and assessed by the facility's Quality Assurance Committee on an ongoing basis. The initial review had not been completed by this Committee as of the 04/13/2010 exit date of this survey, but rather would be reviewed in the next upcoming meeting of the Committee on 04/20/2010. Therefore, the noncompliance continues, with the scope and severity level of the deficiency decreased to the "D" level.