Every finding on record at Pruitthealth - Warner Robins LLC

Based on observations, staff interviews, and review of the facility policy titled Labeling, Dating, and Storage and Patients/Resident's Personal Food, the facility failed to ensure items stored in the reach in cooler, walk in cooler, and dry food storage area were labeled, dated, and not beyond their expiration date. In addition, the facility failed to ensure that resident food items stored in 2 of 2 nourishment rooms were labeled and dated. This deficient practice had the potential to adversely affect 54 of 54 residents receiving an oral diet.Findings include:On 02/27/2026 at 7:50 AM, the initial kitchen observation tour began with Certified Food Manager (CFM) and revealed the following concerns: 1. The reach-in cooler contained three juice containers that did not have an open date. Directions on the box said to use contents within seven days of opening.2. The walk-in cooler contained rice that was not dated.3. The walk-in cooler contained two boxes of juice thawing that did not have the date in which the box was put in the cooler to begin the thawing process.4. There were four potatoes in a box that were not labeled or dated. 5. There was a tray with purple onions containing one storage bag with a purple onion contained within, but the bag was not labeled or dated. 6. There was a box with four red peppers in it and one of the peppers had a fuzzy white substance growing on it.7. There was a box containing green peppers with two green peppers with a fuzzy white substance growing on them. 8. In the dry food storage area there were three boxes of fudge rounds and five loose fudge rounds that were not labeled or dated with an open date or an expiration date. 9. In the dry food storage area there was a storage bag with sprinkles that also had a scoop stored in the sprinkles and the bag was not labeled with an in date or an expiration date. During interview at the conclusion of the tour on 02/27/2026, CFM A acknowledged that the juice containers were opened this morning but should have been dated once opened. CFM A reported that the rice was made yesterday and confirmed it should have been dated. CFM A also confirmed that the morning cook is responsible for checking food items to determine what needs to be pulled at the beginning of each shift. Lastly, CFM A reported that the boxes with the juice were pulled yesterday but should have been dated when placed in the walk-in cooler. Interview on 02/28/2026 at 2:32 PM with CFM B who stated that items in the refrigerator should have a received date, out date, and an open date. She revealed staff were just in-serviced yesterday and today about labeling and dating. CFM B reported that the thawing juice boxes should have the received date from the supplier, pull date (date from freezer), and a use by date (10 days from the thawing process.) She stated when a shipment comes in, they follow the first in and first out process. CFM B stated that vegetables must be moved around in the box to visualize what is in the box and all dietary staff are responsible for ensuring that the produce is still of good standard and if snack boxes are used, then the whole box is used or a receive date and use by date are added. CFM B stated if the box is damaged the contents need to be placed in a storage bag and include a use by date and confirmed scoops should be stored separate from the product being scooped. During an interview and observation tour on 03/01/2026 at 10:40 AM, of the Nourishment Room located at the corner of 300/400 Hall with Licensed Practical Nurse (LPN) CC, the following concerns were confirmed:1.There were two thickened liquid containers in the refrigerator, opened but did not have an open date and per the directions on the containers, should be discarded seven days after opening. 2. On the counter there were loose snack cakes that were not labeled or dated. There are multiple boxes of fudge cakes and oatmeal cakes with a received date and use by date but not an open date. 3. In the refrigerator there were two plates with food in a bag, but the bag was labeled with a resident's name but did not have the date that the item was placed in the refrigerator.LPN CC reported that the items in the refrigerator should have been labeled and dated to have a use by date.During an observation tour and interview on 03/01/2026 at 11:51 AM of the Nourishment Room located at the corner of 100/200 Hall with the Director of Health Services (DHS), the following concerns were confirmed: One package of cheddar cheese crackers did not have an expiration date.Review of the policy titled Labeling, Dating, and Storage revised 11/11/2022, documented Procedure: 1. Food and beverage items will have an identifying label as well as a received date and open date, as applicable, for items prepared onsite, a 'use by' date will also be indicated. 2. Foods will be stored in their original or approved container and, if opened, shall be wrapped tightly with film, foil, etc. 3. Bulk food dispensing utensils (scoops) shall be stored: a. In a clean, protected location if the scoops are used only with food that is not a time/temperature controlled for safety.Review of the policy titled Patients/Resident's Personal Food revised 08/12/2024, documented Procedure: 6. Foods requiring refrigeration must be stored in the nursing units' nourishment refrigerators or in existing individual in-room refrigerators. Those items stored in the nursing units' nourishment refrigerators must be kept to a minimum due to limited space. The main facility kitchen food storage refrigerators will not be used. All food items requiring refrigeration must be labeled and dated. Any opened (non-condiment) foods will be discarded after 48 hours. Condiments will be discarded per the manufacturer's expiration date.

Based on observation and staff interviews, the facility failed to ensure dietary staff pureed fried fish in a manner to avoid compromising the nutritive value. This deficient practice had the potential to place eight of eight residents who received a pureed diet at risk of decreased nutritional intake. Findings include: Observation on 2/1/2025 at 11:30 am of Dietary [NAME] AA preparing puree fried fish for the lunch meal revealed she placed eight fried fish filets in the food processor bowl and began to puree. The cook then added eight slices of bread to the food processor bowl with the fried fish and pureed both together. Dietary [NAME] AA added three cups of vegetable broth to the food processor bowl and pureed the contents until desired puree consistency. Further observation revealed no recipe was available, and no documentation was available to guide the puree production. In an interview on 2/1/2025 at 11:30 am, Dietary [NAME] AA revealed that she always added bread to food items when she prepared puree foods. Dietary [NAME] AA stated that she was trained to add one slice of bread per serving of pureed food. Dietary [NAME] AA revealed that she had never seen a recipe for guidance for puree food preparation and had never seen any documentation regarding adding bread slices when pureeing foods. In an interview on 2/1/2025 at 11:40 am, the Dietary Manager (DM) revealed that bread should not be added to any food items being pureed. The DM stated that there was no recipe for pureed fried fish and no documentation to indicate that bread slices should be added when preparing pureed food items. In an interview on 2/2/2025 at 11:35 am, the DM and the Administrator revealed the facility did not have a policy regarding food preparation.

Based on observations, staff interviews, and review of facility policies titled Food Ordering, Receiving, and Storage, Receipt and Storage of Food & Supplies, and Pot/Pan Washing and Sanitation, the facility failed to discard leftover and expired food, label and date leftover foods, remove dented cans from storage shelves, maintain the cleanliness of the walk-in refrigerator and dry storage areas, and avoid wet nesting of steam table pans to prevent bacterial growth. These deficient practices had the potential to promote foodborne illnesses associated with bacterial growth and cross-contamination for 56 of 58 residents consuming an oral diet from the kitchen. Findings include: Review of the facility policy titled Food Ordering, Receiving, and Storage, revised [DATE], revealed the Procedure section included . 9. Dented cans should be kept in a separate designated area, with a dented can sign, and away from regular stock. Review of the facility policy titled Receipt and Storage of Food & Supplies, revised [DATE], revealed the Procedures section included . 6. All storage areas will be clean, organized, and ready to receive deliveries. 9. Bent and/or damaged cans and/or supplies should not be placed on storeroom shelves or bins. These items are to be placed in a labeled designated area and stored separately to be picked up by the vendor. Review of the facility policy titled Pot/Pan Washing and Sanitation, revised [DATE], revealed the Procedures section included Air dry pots and pans on the drain-board. Inspect for cleanliness and store pots and pans inverted in a clean, dry, protected area. 1. Observation on [DATE] at 8:30 am of the walk-in refrigerator revealed the following: - a rectangle-shaped clear plastic container labeled Potato Wedges prepared date ,d+[DATE] and use by date ,d+[DATE]. - a small square clear plastic container labeled peach slices prepared ,d+[DATE] - a small square clear plastic container labeled chocolate pudding prepared ,d+[DATE] - an open case of four-ounce yogurt cups with a received date of [DATE] and a use-by date of [DATE]. - a yellow/light orange liquid substance was on top of three white buckets with lids. Observation on [DATE] at 9:00 am of the clear door reach-in refrigerator in front of the steam table revealed a small clear plastic container with six four-ounce yogurt cups with a best-by date of [DATE]. During an interview on [DATE] at 9:00 am, the Dietary Manager (DM) confirmed that the yogurt cups in the reach-in refrigerator had a use-by date of [DATE]. The DM stated the dietary staff should have reviewed the date on the yogurt and discarded it. During a continued interview with the DM, she confirmed the case of yogurt cups in the walk-in refrigerator had a received date of [DATE] and a use-by date of [DATE]. She further stated dietary staff should have looked at the date on the case and discarded it. The DM confirmed that the rectangle clear plastic container had leftover potato wedges with a prepared date of ,d+[DATE] and a use-by date of ,d+[DATE]. The DM stated that the dietary cook should have reviewed the dates on the leftover containers and discarded them. The DM further revealed that leftovers should be discarded five days after preparation. The DM confirmed that the sliced peaches and chocolate pudding, both with prepared dates of ,d+[DATE], should have been discarded. Further interview with the DM revealed that the facility did not have a policy for leftover food items, and further stated that leftovers should be discarded five days after the prepared date since that was a general practice that dietary was to use. The DM confirmed the yellow/orange liquid on top of several white-colored buckets and stated the liquid was orange juice that leaked from the case stored above the white buckets. The DM stated that dietary staff should have cleaned the spill immediately. 2. Observation on [DATE] at 8:40 am of the walk-in freezer revealed a round chocolate cake layer with no label or date. Observation on [DATE] at 8:10 am of the walk-in freezer revealed that the round chocolate cake layer continued to have no label or date. During an interview on [DATE] at 8:10 am, the DM confirmed that the chocolate cake layer had no label or date. The DM further stated that she was unsure where the cake layer came from since they do not serve residents any round-shaped cakes. 3. Observation on [DATE] at 8:45 am of the dry storage area revealed a large can of baby corn with a dent on the bottom seal. Continued observation of the dry storage area revealed a white powdery substance on the tops of several cans of food and on the floor. During an interview on [DATE] at 9:10 am, the DM confirmed that the can of baby corn had a dent at the bottom seal. The DM stated that dietary staff should have noticed the dent and placed the can in the dented can area. The DM also confirmed that there was a white powdery substance on top of several cans of food, on the food storage shelf, and on the floor. The DM stated that dietary staff should have noticed the white substance and cleaned from the cans, shelf, and floor. The DM revealed that dietary staff cleaned the dry storage area daily. Observation on [DATE] at 8:20 am of the dry storage area revealed a large can of green beans on the food storage shelf with a large dent to the side of the can. Continued observation revealed a white powdery substance was on top of several food cans and on the food storage rack. During an interview on [DATE] at 8:20 am, the DM confirmed that the can of green beans had a dent on the side. The DM revealed that dietary staff had recently put food away and that the dented can should have been placed in the dented can area and not on the storage shelf for usage. The DM confirmed that there was a white powdery substance on top of several cans and on the food storage shelf. The DM revealed she cleaned the cans and the food shelf on [DATE] and did not know where the white substance was coming from. The DM further revealed that dietary staff should be cleaning after any spillage. 4. Observation on [DATE] at 8:50 am of the pot and pan rack revealed a stack of four square steam table pans. The pans were pulled apart, and the top pan had moisture inside. A stack of three medium-sized rectangle pans was pulled apart, and the top pan had moisture inside. During an interview on [DATE] at 9:15 am, the DM confirmed that the square steam table pan and the rectangle pan were stacked and stored with moisture inside. The DM stated that dietary staff should allow pans to dry completely before stacking.

Based on staff interviews and record review, the facility failed to ensure that transfer notices were provided for two of two residents (R) (R50 and R62) reviewed for hospital transfers. This failure created the potential for R50 and R62 to be uninformed about their rights related to hospital transfer and subsequent return to the facility. Findings include: 1. Review of electronic medical record (EMR) for R50 revealed diagnoses that included, but not limited to, acute upper respiratory infection, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and vascular dementia. Review of the EMR under the Census tab indicated that R50 was transferred to the hospital on 5/7/2024 and returned on 5/15/2024. Further review revealed an additional transfer to the hospital on 1/22/2025. There was no documentation found in the EMR to indicate that R50 was provided a copy of the transfer notice upon transfer to the hospital. During an interview on 2/2/2025 at 10:50 am, Agency Licensed Practical Nurse (LPN) BB reported that when a resident was transferred to the hospital, a face sheet, orders, and code status were sent to the hospital. During an interview on 2/2/2025 at 11:10 am, the Assistant Director of Nursing (ADON) reported that when residents were transferred to the hospital the following is provided: demographics sheet, medications, orders, diagnosis, contact information, bed hold information, and transfer notice. However, no transfer notice was found for R50. 2. Review of the EMR for R62 under the Census tab revealed an admission on 11/4/2024 and a billing stop date of 11/17/2024. R62 did not return to the facility on ce transferred to the hospital on 11/17/2024. R62 had diagnoses that included, but not limited to, hypertension, congestive heart failure, and hip fracture. Review of Progress Notes dated 11/17/2024 indicated that R62 was transferred to the hospital due to a complaint of difficulty breathing. During an interview on 2/2/2025 at 11:28 am, the Administrator reported that the former company did not provide transfer notices for residents when transferred to the hospital.

Based on staff interviews, record review, and review of facility policy titled Bed Hold Acknowledgement Form, the facility failed to ensure that bed hold notices were provided for two of two residents (R) (R50 and R62) reviewed for hospitalization . This failure had the potential to place R50 and R62 at risk of denial of re-admission and loss of their room following hospitalization . Findings include: Review of the facility policy titled Bed Hold Acknowledgment Form, revised 12/6/2022, revealed the Policy: Bed Holds section included . The second notice, which specifies the duration of the bed hold policy, will be issued at the time of any transfer. 1.Review of electronic medical record (EMR) for R50 revealed diagnoses that included, but not limited to, acute upper respiratory infection, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and vascular dementia. Review of the EMR under the Census tab indicated that R50 was transferred to the hospital on 5/7/2024 and returned on 5/15/2024. There was a second hospitalization that began on 1/22/2025. There was no documentation found in the EMR to indicate that R50 was provided a copy of the bed hold notification upon transfer to the hospital. During an interview on 2/2/2025 at 10:50 am, Agency Licensed Practical Nurse (LPN) BB reported when a resident was discharged to the hospital, a face sheet, orders, and code status were sent to the hospital. She further reported that she did not provide the bed hold notice and stated Social Services or Admissions may be responsible for the bed hold. During an interview on 2/2/2025 at 11:10 am, the Assistant Director of Nursing (ADON) reported that when residents were transferred to the hospital the following was provided: demographics sheet, medications, orders, diagnosis, contact information, bed hold information, and transfer notice. The ADON reported that when under the previous owners, she was not aware that bed hold notices were sent out with residents. 2. Review of the EMR for R62 under the Census tab revealed an admission on 11/4/2024 and a billing stop date of 11/17/2024. R62 did not return to the facility on ce transferred to the hospital. R62 had diagnoses that included, but not limited to, hypertension, congestive heart failure and hip fracture. Review of a Progress Notes dated 11/17/2024 revealed R62 was transferred to the hospital due to a complaint of difficulty breathing. During an interview on 2/2/2025 at 11:28 am, the Administrator reported that she did not send a bed hold notice when R62 was discharged to the hospital. The Administrator further reported that the former company did not provide bed hold notices for residents.

Based on observations, resident and staff interviews, record review, and review of the facility policy titled Care Plans, the facility failed to ensure a comprehensive person-centered care plan was developed for the use of psychotropic medications for one of five residents (R) (R12) reviewed for the use of unnecessary medications. This deficient practice had the potential to place R12 at risk for not receiving treatment and/or care according to their needs. Findings include: Review of the facility policy titled Care Plans, revised July 27, 2023, revealed the Policy Statement was 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. The Admission Comprehensive Plan of Care section included .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, as 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 the clinical record revealed R12 had diagnoses including, but not limited to, major depressive disorder, mood disorder due to known physiological condition, and dementia with other behavioral disturbance. Review of R12's Quarterly MDS dated [DATE] revealed Section N (Medications) documented the resident received an antianxiety medication. Review of the Physician's Orders revealed an order dated 1/15/2025 for mirtazapine 15 milligrams (mg) (a medication used to treat depression), one tablet once a day. Review of R12's care plan revealed there was no care plan developed for psychotropic medication use. During an interview on 2/2/25 at 11:08 am, the MDS coordinator acknowledged that R12 did not have a care plan developed for the use of psychotropic medication and should have one. She stated the normal process was for care plans to be updated during daily morning meetings.

Based on staff interviews and record review, the facility failed to ensure that the Infection Control and Prevention Program policies were reviewed annually. This deficient practice had the potential to increase the risks of exposure to infectious diseases to all residents, staff, and visitors. The facility census was 58. Findings include: During the review of infection control policies, there was no evidence of an annual review of the infection control policies. In an interview on 2/1/2025 at 10:23 am, the Infection Preventionist (IP) reported that the antibiotic stewardship and infection control surveillance programs were discussed in the quarterly Quality Assurance Performance Improvement (QAPI) meetings, but she was unsure when the entire infection control program or policies had been reviewed by the Interdisciplinary Team (IDT). In an interview on 2/2/2025 at 12:10 pm, the Director of Nurses (DON) reported that she was unable to provide evidence of an annual review of the infection control program and policies. In a post-survey telephone interview on 2/11/2025 at 2:20 pm, the DON stated she had worked at the facility for four years and was unsure when the infection control program and policies had been reviewed, revised, and approved by the IDT. She further stated she was unable to provide documentation of the last review of the infection control program or policies.

Based on observations, staff interviews, record review, and a review of the facility policy's titled, Implanted Venous Port (Mediport) - Accessing, and Implanted Venous Port (Mediport) - De-Accessing, the facility failed to assess the competency of nursing staff caring for implanted venous ports for one of three Resident (R) (#8) receiving Intravenous (IV) antibiotics every four hours. This failure had the potential for residents to have a decline in health status. Findings include: A review of the facility assessment dated [DATE], on page 17 under the heading Competencies, revealed skills of all staff are assessed during orientation with post test for all key clinical areas. New nurses receive an individualized educational program that includes completion of standardized modules through Relias learning. Basic competencies included but were not limited to intravenous care and management (RN Staff), hand hygiene, and infection prevention. A review of the policy titled Implanted Venous Port (Mediport) - De-Accessing, last reviewed January 2014 and updated to competency 6/17/2023, revealed the procedure to remove the port needle is to stabilize the port with thumb and index finger on the sides of port with other hand pull the port needle straight upward and out of port using a steady upward motion the needle will have a safety device covering the needle. A review of policy titled Implanted Venous Port (Mediport) - Accessing, last revised September 2011, made into competency 6/17/2023, revealed the process to set up a sterile field included wash hands, on a clean surface open central line dressing kit or glove packaging to use as a sterile field. Empty all items except saline for injection and heparin onto this field and remove air bubbles from syringes. Don sterile gloves. Record review of the electronic medical record (EMR) revealed R#8 was admitted to the facility with diagnoses listed but not limited to infection and inflammatory reaction due to internal left knee prosthesis subsequent encounter. Record review of the most recent Admission Minimum Data Set (MDS) assessment for R#8 revealed a Brief Interview for Mental Status (BIMS) of 13, which indicated the resident was cognitively intact. Record review of the care plan for R#8 indicated a focus of care on infection of the left knee prosthetic. Goals included but were not limited to free from complications related to infections and antibiotic use; infection will resolve. Interventions included but were not limited to maintain universal precautions, monitor left knee for increased pain, swelling, or heat and notify Medical Doctor (MD), monitor temperature/pulse per protocol, monitor/document/report to MD signs/symptoms of delirium. Record review of nursing notes revealed that on 8/19/2023 at 1:53 p.m., the nurse documented a missed dose of antibiotic due to an unsuccessful attempt to change the port needle. Record review of nursing notes revealed that on 8/19/2023 at 10:13 p.m., the nurse documented R#8 called the nurse with concerns about her port access and complained of burning at the insertion site, and the nurse noted minimal swelling; the Nurse Practitioner (NP) was notified, a new order was given to remove the port needle and start a peripheral IV. Observation on 8/19/2023 at 8:50 a.m. revealed Licensed Practical Nurse (LPN) AA entered the room and observation of an IV bag that contained the last dose of antibiotic hanging from the IV pole still connected to R#8's port upon entry to the room. The IV tubing was connected directly to the tubing of the port needle (Huber needle) without a needleless access device. Observed LPN AA remove the IV tubing of the last antibiotic dose and connect a normal saline flush to the end of the port needle tubing without a needleless access device, and she clamped the tubing. LPN AA did not check for blood return, then she attached the antibiotic dose that was currently due to the access device. She then set the rate on the IV tubing to 100 milliliters (ml)/ hour (hr). Interview on 8/19/2023 at 9:10 a.m. with LPN AA revealed that it is a normal occurrence to find the port needle tubing without a needleless access device, and if it does have the device, it is not usually covered. She revealed that the needleless access devices are kept in the facility's locked supply cabinet (cubex) in the medication room and stated that agency nurses do not have access to this system but have to get an employed nurse to access this for them. Observation on 8/19/2023 at 11:40 a.m. with Registered Nurse (RN) BB present observed the Infection Preventionist (IP) remove the port dressing, de-access the port, and attempt to re-access the port. She cleansed the needleless device with an alcohol wipe, she flushed the port with 5 ml of saline and 3 ml of heparin flush and clamped the tubing. She removed the transparent dressing over the port needle. The IP then performed hand hygiene and opened the sterile package for accessing the port. The skin covering the port was again cleansed and allowed to dry; the IP then attempted to access the port unsuccessfully. The port needle was removed, and again the IP did not activate the needle safety device, she placed the needle on the table and access was unsuccessful. Interview on 8/19/2023 at 11:00 a.m. with the IP and the Treatment Nurse revealed the needleless access devices are kept on the treatment care, and all nurses have access to the cart. Interview on 8/19/2023 at 12:10 p.m. with the Director of Nursing (DON) revealed that the Assistant Director of Nursing (ADON) normally changes the port needles, flushes ports, and changes the dressings on the ports. The DON further revealed that the facility has no competency check off for port care, accessing/de-accessing, or dressing changes of ports. She stated that the IP was a new nurse, and she assumed that she learned about port care in nursing school and was competent in port care because of this. The DON stated that the ADON was not working on 8/19/2023. She stated that she does not possess the skill/knowledge to access/de-access ports or change the dressings properly.

Based on observations, staff interviews, record review, and review of the facility policy titled, Administering Medications, the facility failed to ensure one of three Resident (R) (#8) is free of significant medication errors. Findings include: A review of the policy titled, Administering Medications, revised December 2012, revealed the policy statement was medications shall be administered in a safe and timely manner, and as prescribed. Under section title Policy Interpretation and Implementation, number 7 revealed the individual administering medications must check the label three (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medications. Record review of the care plan for R#8 indicated a focus of care on infection of the left knee prosthetic. Interventions included but were not limited to administering antibiotics as ordered by the Medical Director (MD). Record review of the Electronic Medical Record (EMR) for R#8 revealed a physician order for oxacillin sodium in dextrose intravenous solution 2 gram (GM)/50 milliliters (ml) (oxacillin sodium in dextrose). Record review of the Electronic Medication Administration Record (E-MAR) revealed oxacillin sodium in dextrose intravenous solution 2 GM/50ML (oxacillin sodium in dextrose) use one dose intravenously every four (4) hours for osteomyelitis for 42 days, (start date 8/2/2023). 100 doses were signed off as given. Observation on 8/19/2023 at 8:50 a.m. of a medication pass with LPN AA revealed LPN AA mix and administer oxacillin 2GM/ 100 ml NS at 100 ml/hrs, via dial-a-flow tubing. Interview on 8/19/2023 at 4:45 p.m. with the Director of Nursing (DON) confirmed and verified that the IV medication oxacillin on hand was oxacillin sodium 2 GM attached to a 100 ml bag of normal saline, which the nurse mixes prior to administration. The DON verified and confirmed that the physician ordered oxacillin sodium in dextrose intravenous solution 2 GM/50 ml. She verified that this was not the same as the order and that the nurses should have caught this. She stated she expected the nurses to read the medication label verify the dilution solution and compare these with the MAR and the physician's order, and if these differ, the nurse should contact the physician for direction/clarification.

Based on observations, staff interviews, record review, and a review of the facility's policy titled, Infection Control, Implanted Venous Port (Mediport) - Accessing, Administering Medications and the facility assessment, the facility failed to implement infection control practice during the care of a resident receiving medications via a port and during change of needle device to access the port for one of three Resident (R) (#8) receiving intravenous (IV) antibiotic therapy every four hours. These failures had the potential of exposing patients to infections due to cross contamination. Findings include: A review of the policy titled Infection Control, not dated, revealed the objective of infection control policies and practices are listed as but not limited to prevent, detect, investigate, and control infections in the facility. A review of the policy titled Implanted Venous Port (Mediport) -Accessing, last revised September 2011, made into competency 6/17/2023, revealed the process to set up a sterile field was described as wash hands, on clean surface open central line dressing kit or glove packaging to use as a sterile field. Empty all items except saline for injection and heparin onto this field, remove air bubbles from syringes. Don sterile gloves. Cean port area with antiseptic cleaning solution. Hold the saline syringe with sterile gauze (to preserve sterile gloves), attach syringe to needleless connection device and [NAME] tubing and the port needle with saline. A review of policy titled Administering Medications, revised December 2012, revealed the policy statement was medications shall be administered in a safe and timely manner, and as prescribed. Under section title Policy Interpretation and Implementation number 22 revealed staff shall follow the established facility infection control procedures (e.g. handwashing, antiseptic techniques, gloves) for the administration of medications as applicable. A review of the facility assessment dated [DATE], on page 17 under heading Competencies revealed skills of all staff are assessed during orientation with post test for all key clinical areas. New nurses receive an individualized educational program that includes competition of standardized modules through Relias learning. Basic competencies included but not limited to intravenous care and management (RN Staff), hand hygiene, and infection prevention. Requested policy specific to administering IV medications, the corporate nurse Registered Nurse (RN) BB stated the policy titled Administering Medications, revised December 2012, included administration of IV medications. Record review of the electronic medical record (EMR) revealed R#8 was admitted to the facility with diagnoses listed but not limited to infection and inflammatory reaction due to internal left knee prosthesis subsequent encounter. Record review of the EMR revealed for R#8 revealed a physician order for RN to change port needle weekly and as needed and change dressing to port (right chest) every Friday and as needed. Observation on 8/19/2023 at 8:50 a.m. revealed Licensed Practical Nurse (LPN) AA performed hand hygiene in the hallway and Director of Nursing (DON) a pair of gloves upon entering the room. LPN AA removed the previous antibiotic dose and left the room. Upon her return, she had obtained a needleless access device. She donned a pair of gloves (no hand hygiene) and opened the needleless access device package, removed the saline flush from the end of the tubing on the port needle, and then attached the needleless access device to the tubing of the port needle. She then placed the access device on the resident's chest. She obtained a new saline flush and flushed the port without cleansing the end of the access device. Interview with LPN AA on 8/19/2023 at 9:10 a.m. revealed she stated she should have performed hand hygiene when she returned to the room and re-gloved her hands prior to removing the saline flush and attaching the needleless access device. She stated she should have cleansed the end of the needleless access device with an alcohol wipe prior to flushing and connecting the antibiotic tubing to the port needle tubing. She stated she was in a hurry, and she was very tired. Observation on 8/19/2023 at 11:40 a.m. with RN BB present observed the IP, with gloved hands after performing hand hygiene, prepared a table for her supplies by cleaning it with a facility approved disinfectant and allowed the table to dry. She doffed her gloves, performed hand hygiene, and donned clean non-sterile gloves. She then placed supplies needed to de-access the port onto her table. The IP then performed hand hygiene and opened the sterile package for accessing the port. Using a non-sterile gloved hand, the IP removed the drape from the package and placed it on the table to create a sterile field; she donned non-sterile gloves and began adding supplies to the sterile field by picking up items and placing them on the field. She dropped the port needle onto the sterile field; then, she attached an extension set with a needleless access device to the tubing of the port needle. The IP placed the clear dressing on the sterile field with a gloved hand, opened the saline and heparin-flush, dropped it onto the sterile field, donned sterile gloves, without performing hand hygiene, and then cleansed the skin over the port with the cleaning device from the sterile field. RN BB stepped in and began instructing the IP. The table was cleansed again with facility approved disinfectant and allowed to dry. A sterile field was prepared appropriately with the assistance and direction of RN BB. Interview on 8/19/2023 at 12:10 p.m. with DON revealed the Assistant Director of Nursing (ADON) had worked with the IP one day the previous week to train, but she stated the IP did not demonstrate to the ADON setting up a sterile field and maintaining the sterile field or access a port utilizing sterile technique.

Based on surveillance video observations, interviews, record review, and review of the facility policy titled Abuse Policy and Procedure, the facility failed to ensure that one resident (R) (#1) was free from abuse, from a total sample of eight residents. Using the reasonable person concept, psychosocial harm was identified for R#1 related to fear of sexual abuse after multiple encounters in her room with the alleged perpetrator, Floor Technician AA. Findings include: The facility had an Abuse Policy and Procedure last updated 8/22/2016. The policy documented that verbal, sexual, and mental abuse were prohibited. Review of the clinical record revealed R#1 to be a [AGE] year-old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the 8/12/20 Minimum Data Set (MDS) assessment revealed that R#1 was assessed as having impaired cognition and communication (rarely/never understood and rarely/never understands), needing assistance with Activities of Daily Living (ADL's) and using a wheelchair for mobility. R#1's care plan included that she demonstrated physical behaviors, such as scratching others, had poor impulse control, and disrobed at times. The facility utilized an outside company contracted to provide housekeeping services. Floor Technician AA was a newly hired employee with the contracted company to work at the facility. A review of personnel information revealed that a background check was completed on 6/29/20 and did not contain any negative findings. His date of hire was 7/1/20. Further review of personnel information revealed that Floor Technician AA had electronically signed as completing education on Patients-Residents' Rights: Abuse-Neglect and the Elder Justice Act form for In Service Program on 7/1/20. During interviews on 8/17/20 at 1:02 p.m. and 8/18/20 at 3:30 p.m. the Housekeeping Supervisor confirmed that Floor Technician AA was hired on 7/1/20. He stated that AA spent 7/1/20 and 7/2/20 in orientation at the facility, and 7/7/20 was his first day on the floor. A review of facility reported incidents revealed a Facility Incident Report Form, dated 7/7/20, that documented an incident of staff to resident abuse. The form included that the incident involved R#1 and Floor Technician AA. Floor Technician AA was listed as the alleged perpetrator. Further review of the form revealed the date of the incident as 7/7/20 and included possible inappropriate contact between Floor Technician AA and R#1. R#1's physician and responsible party were notified. The police were also notified. The form documented the additional steps the facility took including Floor Technician AA not being allowed to return to work and abuse in-service education being provided to staff. The facility's accompanying investigation of the incident included that R#1 was assessed on 7/7/20 with no signs of injury noted, and she was sent to the hospital on [DATE], where a rape kit was collected with results pending. Further review of the facility's investigation, which included resident interviews, staff written statements, timeline of video surveillance observations, Floor Technician AA's personnel record information and time clock information, and abuse in-service education information, revealed that the facility determined that they could not say with certainty what had occurred. During an interview on 8/11/20 at 10:35 a.m., the Administrator stated that she was grateful for the staff they had at the facility on 7/7/20 because they saw something and said something, and she felt that prevented something more from happening. Nursing staff assessed R#1 on 7/7/20 and did not see any signs of trauma. She was sent out the following day to the hospital, and the report did not indicate any trauma. A review of hospital emergency department documentation from 7/8/20 revealed that R#1 was brought in after a possible sexual assault. Further review of the documentation revealed that the resident was comfortable and in no apparent distress and that a Sexual Assault Nurse Examiner (SANE) nurse completed an exam on the resident. R#1 returned to the facility on [DATE] with an order to follow up with her personal care physician. However, a further review of clinical records, staff written statements, the police report, interviews with staff and law enforcement, and review of video surveillance supports that an abusive situation existed between Floor Technician AA and R#1 on 7/7/20. A review of the Police Department's Incident/Investigation Report from 7/7/20 revealed that on 7/7/20 at 6:14 p.m., an officer responded to the facility in reference to a possible sexual assault. A review of the video surveillance revealed that between 2:08 p.m. and 4:07 p.m. on 7/7/20, Floor Technician AA entered and exited R#1's room seven times. Prior to entering and exiting R#1's room multiple times, the floor technician can be seen on surveillance video on the 100 hall, moving down the hallway with a housekeeping cart, wiping down the hallway handrails, passing by R#1's room and then returning. A timeline of Floor Technician AA's movements on 7/7/20 entering and exiting R#1's room were observed on the video surveillance as follows: 1. Floor Technician AA entered R#1's room at 2:08 p.m. and exited at 2:09 p.m. 2. Floor Technician AA entered R#1's room with a cleaning cloth at 2:10 p.m. and exited with the cloth at 2:11 p.m. 3. Floor Technician AA entered R#1's room with plastic trashcan liners at 2:15 p.m. and exited with the trashcan liners at 2:16 p.m. 4. Floor Technician AA entered R#1's room at 2:47 p.m. and stayed in the room, with the housekeeping cart pulled to the door entryway until 3:10 p.m. During this time frame of 23 minutes, Floor Technician can be seen coming to the door entrance at intervals (2:48 p.m., 2:49 p.m., 2:52 p.m., 3:04 p.m., 3:06 p.m., and 3:08 p.m.) and taking items off the housekeeping cart or looking around or walking around the cart, or sweeping the entryway, then going back out of sight into the room. At 3:10 p.m. the Housekeeping Supervisor is seen coming by R#1's room and stopping. Floor Technician AA exits the room and they talk in the hallway before both walk off at 3:12 p.m. 5. Floor Technician AA entered R#1's room with no cleaning supplies at 3:26 p.m. exited two minutes later at 3:28 p.m. 6. Floor Technician AA entered R#1's room at 3:32 p.m. with no supplies. Two minutes later at 3:34 p.m., he is seen back in view at her door entrance balling up a hospital gown. He then exits the room and goes to a linen cart in the hall and appears to remove another gown and reenter the room at 3:35 p.m. He remains in the room, out of the sight of the camera for 11 minutes until 3:46 p.m., when he walks out of R#1's room quickly to a room directly across the hall, and then exits quickly out of that room, and walks down the hall, looking around. 7. Floor Technician AA re-enters R#1's room one minute later at 3:47 p.m. and stays out of sight in the room until he can be seen coming into view, hovering at her doorway four minutes later at 3:51 p.m., and goes back in the room, out of camera view and stays in the room, out of sight for 15 minutes. At 4:05 p.m. Certified Nursing Assistant (CNA) AA passes by R#1's room and glances in that direction as she moves further down the hall to a male resident in a wheelchair. As CNA AA is coming back up the hall with the male resident in the wheelchair, within the minute at 4:06 p.m., she is seen glancing back towards R#1's room as she passes by, briefly going out of camera view. Within that same minute, at 4:06 p.m. CNA AA, Registered Nurse (RN) DD, and CNA CC can be seen entering R#1's room. One minute later, at 4:07 p.m. RN DD and CNA CC exit the room and Floor Technician AA exits the room behind them and is seen leaving the hall. Further review of surveillance video from a different camera showed that after he left R#1's room at 4:07 p.m., Floor Technician AA walked down the back hallway and appeared to reach down and zip up his pants. During interviews with the Housekeeping Supervisor on 8/17/20 at 1:02 p.m. and 8/18/20 at 3:30 p.m. and review of his written statement, the Housekeeping Supervisor revealed that Floor Technician AA had been with him throughout the day, on 7/7/20 and he had given him tasks not hard to complete by himself; the simplest of tasks to see how he would catch on. Prior to seeing the floor technician in R#1's room, he had given him the task of cleaning the blinds and windows while he (the Housekeeping Supervisor) made rounds on his other employees. When the Housekeeping supervisor was seen on camera on 7/7/20 at 3:10 p.m. talking to Floor Technician AA, outside of R#1's room, he stated he had observed the floor technician in the room cleaning the window blinds and that R#1's gown was pulled down. The Housekeeping Supervisor stated he knows the resident will sometimes pull her clothes off so he asked Floor Technician AA why her gown was down; did he see her do it, and the floor technician said he did not know. The Housekeeping Supervisor stated that he had the floor technician come out of the room and talked to him about the situation, to not go in a room in that situation, to give respect and go to another room or area and let the nurse know. However, as seen on the surveillance video, after being directed out of R#1's room on 7/7/20 at 3:10 p.m. by his supervisor, Floor Technician AA returns to R#1's room three more times, with no housekeeping supplies. In addition, the last two times that the floor technician entered R#1's room on 7/7/20 at 3:32 p.m. and 3:47 p.m., were after he had already clocked out of work for the day. A review of the Attendance Report with Actual Time Stamp revealed that Floor Technician AA clocked out on 7/7/20 at 3:32 p.m., but did not leave the facility, returning to R#1's room instead. The facility's investigation included a written statement from Floor Technician AA. The written statement documented that he noticed several times during and after his shift that the resident appeared uneasy, as if she was afraid of falling from the bed, that he lended his help even after his shift while waiting for a ride home, that he noticed her struggling with her gown and that it was dirty, so he got her another one. The statement included that his pants were unzipped from using the bathroom. Floor Technician includes in the statement that he did not have a reason to linger after clocking out and he realizes how silly and strange it looked and that he should have called for the help of a nurse or staff. During an interview on 8/12/20 at 11:30 a.m. RN DD confirmed that she was the charge nurse for R#1 on 7/7/20 from 3:00 p.m. to 7:00 p.m. She stated that on 7/7/20 she was at the nursing station with two CNA's (BB and CC) and one of them walked down the hall and as she came back up the hall, she heard the CNA talking and saying something about doing an incident report because R#1 may be on the floor because he says she's on the floor. RN DD walked into R#1's room with the two CNA's and saw that the floor technician (Floor Technician AA) was standing at the foot of the bed and R#1 was on the right side of the bed. While they were all in the room, CNA BB made eye contact with her to alert her to look at Floor Technician AA's pants, so she looked down and his pants were unzipped. RN DD stated she asked him what happened, and he was fidgety and said he was trying to help R#1, that she was falling out of the bed. He walked into the bathroom for a quick second and then left out of the room. RN DD included that after Floor Technician AA left the room, she noticed a balled up paper towel at the end of R#1's bed, a balled up gown on the window sill and a wet washcloth sitting on the sink. She asked the CNA's about them and CNA BB said she had not had those items when she last changed her. RN DD also stated that when they went to reposition R#1 in the bed, before they moved her, they noticed her brief was pulled to the side, it was not undone but was stretched to the side. RN DD stated she left the room to report the incident to Director of Nursing (DON) EE, and they returned to the room and completed a skin assessment. RN DD stated there were no signs of trauma. A review of RN DD's incident note dated and timed 7/7/20 at 4:20 p.m. revealed documentation of a red area to the right lower back and right hip area. RN DD confirmed the red areas were observed and looked like they could have been from resting on the right side of the bed. RN DD stated that she talked with R#1 and asked her if anyone had hurt her and she shook her head yes. RN DD stated that CNA BB asked R#1 the same thing and she shook her head yes to her too. RN DD stated that she reported this to DON EE and to the police officer who was at the facility by then. The police officer went to talk to R#1, but she would not respond to his questions. RN DD stated that R#1 is not really verbal, that she shakes/nods her head to respond and may make noise, and she will say the word no, but you cannot carry on a conversation with her. Also, if she is not familiar with you, she will not respond at all. RN DD stated that R#1 is familiar with her and she thinks that is why she responded to her question. During an interview on 8/12/20 at 5:14 p.m., CNA CC confirmed that on 7/7/20 she came on shift at 3:00 p.m. that day. Later in the shift, she was sitting at the nursing station talking to RN DD. CNA BB came up the hall and said R#1 fell so she (CNA CC) and RN DD and CNA BB went to the room. CNA CC saw Floor Technician AA standing over R#1. R#1 was on the opposite side of the bed than she is normally on; she was on the right side of the bed, not the left side and was partially on the chair. The floor technician was standing on the right side of the bed by R#1. CNA CC said she thought it was an odd position because R#1 never gets up on the right side; she gets up on the left side of the bed where her floor mat is. The CNA stated that the floor technician went into the bathroom, was acting nervous, and then he left the room. She stated he had a shocked facial expression. CNA CC said R#1's diaper was loose and there was another gown in the room by the window sill, and there was a brown paper towel balled up on the bed, a rag in the bathroom, and a broken blue mask in the room on the floor where the chair and R#1 was. CNA CC asked CNA BB if she had left R#1's brief loose and she said no and that she had not brought in the other gown either. CNA CC indicated that after the incident the resident was not herself for a while, she was timid, but was back to herself now. During an interview on 8/13/20 at 3:05 p.m. CNA BB confirmed that she was R#1's CNA on 7/7/20 for day and evening shifts. She revealed that on 7/7/20, she was walking down the hall and noticed R#1's door was cracked open and someone, a figure, was at the bottom of the bed. CNA BB said when she went into R#1's room (with CNA CC and RN DD) and R#1's brief was unhooked on the right side and her gown was halfway off. Floor Technician AA's pants were unzipped, and he was holding the resident's hands and said she was dreaming she was falling. He walked into the restroom and then walked out of the room. CNA BB said there was a washcloth in the bathroom and a paper towel in the trashcan in the bathroom and that she had not used a cloth on R#1 or her roommate prior to that. CNA BB indicated that she asked the resident, after the incident, if she was okay and she shook her head no. She also asked her if anyone hurt her and she shook her head yes. CNA BB stated that R#1 can say things like yes, no, stop and you're mean and she hits (at staff). CNA BB stated that later on that day (on 7/7/20) R#1 was crying. The CNA further stated that R#1 was a fighter (during care), and had been that morning, but was the total opposite after that incident. The facility submitted the initial Facility Incident Report Form to the State Survey Agency of the incident involving R#1 and Floor Technician AA, on 7/7/20 and a follow up summary of their investigation of the events on 7/10/20. In addition, a review of in-service records and sign in sheets revealed the facility began in-servicing staff on abuse on 7/7/20 and continued on 7/9/20. Additional employees were in-serviced on 8/12/20. Behavioral Health Services were obtained for R#1 for weekly visits. A review of the behavioral health services Nurse Practitioner notes from 7/14/20, 7/21/20 and 7/28/20 revealed that R#1 was stable and at her baseline. Floor Technician AA's employment was terminated. A review of the separation notice, dated 7/10/20, documented that the last period of employment was 7/1/20 through 7/7/20. The facility submitted an additional update to the State Survey Agency on 8/10/20. The updated information included that Floor Technician AA had been arrested by law enforcement and that he had a bond hearing on 8/4/20 and bonded out. The floor technician was charged with criminal attempt to commit rape and elderly abuse. During an interview on 8/13/20 at 9:59 a.m., Detective FF confirmed that Floor Technician AA had been arrested and charged with criminal intent to commit rape and elderly abuse based on statements from the nurses, her interview with Floor Technician AA and video evidence. She confirmed that evidence had been collected from the facility on 7/8/20 and that results of the evidence and rape kit were pending. R#1 has impaired cognition and communication and does not have a Brief Interview of Mental Status (BIMS) score. She has limited verbalizations, so the full extent as to how she was harmed psychosocially cannot be determined. However, a reasonable person would have some degree of fear following the repeated encounters initiated by Floor Technician AA with R#1 on 7/7/20.

Based on observation, record review, and staff interviews, the facility failed to follow the care plan for one of three residents requiring a mechanical lift for transfers (R#34). Findings include: Review of the clinical record revealed R#34 with [DIAGNOSES REDACTED]. R#34's current Quarterly Minimum Data Set ((MDS) dated [DATE] revealed section C-Cognition Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment and section G-Functional Status documented resident needs extensive assistance with two-person assist for transfers. R#34 had a care plan indicating to transfer using a mechanical lift for all transfers. Review of the CNA Kardex revealed resident requires the use of a mechanical lift for transfers. Review of the Nurses Note for R#34 on 6/19/19 at 2:00 p.m. revealed the nurse observed an area on the resident's right foot was tender to touch, had an area of discoloration, and a moderate amount of [MEDICAL CONDITION]. The physician was notified and ordered an x-ray and ultra sound of the right foot. The resident's sister reported she was in the room when Certified Nursing Assistant (CNA) CC transferred resident without using the mechanical Hoyer lift and the resident cried out in pain. Further review of the Nurses Note revealed CNA CC was asked and confirmed she did not use a mechanical Hoyer lift to transfer R#34 and she transferred the resident into the bed by herself. An interview held on 7/17/19 at 1:49 p.m. with the Minimum Data Set (MDS) Coordinator, Licensed Practical Nurse (LPN) AA revealed the care plans are updated immediately to include the resident's type of transfer and the CNA Kardex is updated to include the use of a mechanical lift for all transfers. An interview held on 7/17/19 at 2:11 p.m. with the Administrator revealed when R#34 was transferred by a CNA incorrectly and sustained an injury he immediately investigated it and started a Performance Improvement Plan (PIP). He had the education staff conduct an in-service on safe transfers. CNA CC was disciplined and educated on the use of a mechanical lift and how to view residents Kardex. His expectations included CNA CC should have looked at the residents Kardex for type of transfer and then used the proper transfer method. He further indicated CNA CC did not look at the Kardex nor transfer the resident according to the Kardex which stated to use a mechanical lift. Interview on 7/17/19 at 2:46 p.m. with the DON revealed she expected CNA CC to follow the care plan and the Kardex related to the use of a mechanical lift. Review of the CNA CC personnel file revealed she was hired on 6/19/19. The form titled CNA Competency Checklist which included mechanical lift was not completed. Review of the employees Relias online trainings for (MONTH) and (MONTH) 2019 indicated no education on how to transfer a resident or use of the Kardex. Review of the document titled Employee Orientation Checklist indicated subjects reviewed included lifting/moving residents and resident information was initialed by CNA CC. The document was not dated. Cross Refer F689

Based on observation, record review, and staff interviews, the facility failed to ensure the appropriate device was used for one of three residents (R) reviewed that required a mechanical lift for transfers (R#34). Findings include: Review of the clinical record revealed R#34 with [DIAGNOSES REDACTED]. R#34's current Quarterly Minimum Data Set ((MDS) dated [DATE] revealed section C-Cognition Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment and section G-Functional Status documented resident needs extensive assistance with two-person assist for transfers. Observation of R#34 on 7/17/19 at 12:10 p.m. revealed R#34 was out of bed in a wheel chair. A mechanical lift pad was noted under the resident. At 1:13 p.m., the resident was observed in the bed and the mechanical lift pad was noted in the resident's wheelchair. Review of the Nurses Note for R#34 on 6/19/19 at 2:00 p.m. revealed the nurse observed an area on the resident's right foot was tender to touch, had an area of discoloration, and a moderate amount of [MEDICAL CONDITION]. The physician was notified and ordered an x-ray and ultra sound of the right foot. The resident's sister reported she was in the room when Certified Nursing Assistant (CNA) CC transferred resident without using the mechanical Hoyer lift and the resident cried out in pain. Further review of the Nurses Note revealed CNA CC was asked and confirmed she did not use a mechanical Hoyer lift to transfer R#34 and she transferred the resident into the bed by herself. Review of an X-ray ordered for R#34 on 6/21/19 of the resident's right foot/ankle revealed mild [MEDICAL CONDITION] changes and no fracture. Review of an ultra sound ordered for R#34 on 6/21/19 of the residents right lower leg revealed the results were negative for a [MEDICAL CONDITIONS]. R#34 had a care plan indicating to transfer using a mechanical lift for all transfers. Review of the CNA Kardex revealed resident requires the use of a mechanical lift for transfers. R#34's fall risk assessment completed on 6/23/19 indicates resident is confined to a chair and is unable to independently come to a standing position. An interview held on 7/17/19 at 1:49 p.m. with the Minimum Data Set (MDS) Coordinator, Licensed Practical Nurse (LPN) AA revealed the care plans are updated immediately to include the resident's type of transfer and the CNA Kardex is updated to include the use of a mechanical lift for all transfers. An interview held on 7/17/19 at 2:11 p.m. with the Administrator revealed when R#34 was transferred by a CNA incorrectly and sustained an injury he immediately investigated it and started a Performance Improvement Plan (PIP). He had the education staff conduct an in-service on safe transfers. CNA CC was disciplined and educated on the use of a mechanical lift and how to view residents Kardex. His expectations included CNA CC should have looked at the residents Kardex for type of transfer and then used the proper transfer method. He further indicated CNA CC did not look at the Kardex nor transfer the resident according to the Kardex which stated to use a mechanical lift. Interview on 7/17/19 at 2:46 p.m. with the DON revealed she expected CNA CC to use the mechanical Hoyer lift for R#34. An interview held on 7/18/19 at 9:00 a.m. with CNA BB, who is an agency CNA, revealed she knows how to look at the Kiosk and pull up the Kardex to see if a resident needs a mechanical Hoyer lift for transfer. An interview held on 7/18/19 at 9:20 a.m. with CNA CC revealed she has received education on the use of a Mechanical Hoyer lift during orientation and after the transfer with R#34. She indicated she knew how to use the mechanical lift but was not aware how to find out who needed a mechanical lift for transfers. Review of the CNA CC personnel file revealed she was hired on 6/19/19. The form titled CNA Competency Checklist which included mechanical lift was not completed. Review of the employees Relias online training indicated no education on how to transfer a resident or use of the Kardex. Review of the document titled Employee Orientation Checklist indicated subjects reviewed included lifting/moving residents and resident information was initialed by CNA CC. The document was not dated.

Based on observation, record review, and staff interviews, the facility failed to follow Physician orders [REDACTED].#39) who received nutrition through a [DEVICE] (a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications). Findings include: A record review revealed R#39 was admitted to the facility on [DATE] including a hospital re-admission on 7/1/19 with [DIAGNOSES REDACTED]. Review of the Physician orders [REDACTED]. During observations on 7/16/19 at 9:06 a.m. and 12:49 p.m., 7/17/19 at 10:30 a.m. and 3:10 p.m., and 7/18/19 at 9:05 a.m. and 1:01 p.m., R# 39 was observed in bed or up the chair with the tube feeding of [MEDICATION NAME] 1.2 running at 70cc/hr. During an interview on 7/18/19 at 10:18 a.m., LPN EE confirmed the tube feeding order for R# 39 is 22 hours and is not being turned off for two hours as specified by the Physicians order. During an interview on 7/18/19 at 10:31 a.m., the Director of Nursing (DON) revealed the Physicians order should have been followed for the tube feeding of [MEDICATION NAME] 1.2 at 70cc/hr for 22 hrs. She stated the process is that the nurses receiving the physicians' orders are responsible for updating the Medication Administration Record [REDACTED]. The DON confirmed the Physicians order was not being followed and the tube feeding was not documented as being turned off two hours out of 24 hours as ordered by the physician. Further interview with the DON on 7/18/19 at 11:19 a.m. revealed the facility does not have a policy or procedure guide on how to carry out physician orders [REDACTED].

Based on record review and staff interview, the facility failed to provide one (1) resident (R#31) of three (3) residents with the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) CMS form that was discharged from Medicare Part A coverage. Findings include: Review of the Notice of Medicare Non-Coverage form for R#31 revealed the services ended on 6/8/17. Review of the therapy notes revealed R#31 remained in the facility and continued to receive skilled services. R#31 was discharged from skilled services on 8/14/17 the 87th day of the 100 days coverage period. During an interview with the Social Worker on 8/23/17 at 2:31 p.m. she revealed that she is responsible for issuing the Notice of Medicare Non-Coverage forms to the residents or responsible party. She also revealed she issued the Notice of Medicare Non-Coverage form to R#31 on 6/5/17 since services would end on 6/8/17. She also revealed that R#31 remained in the facility and continued to receive skilled services; however she did not know to issue the SNFABN form. During an interview with the Business Office Manager on 8/23/17 at 4:00 p.m. she revealed R#31 was discharged from skilled services on th 87th day of the 100 days of coverage. The Business Office Manager also revealed she did not know to provide SNFABN to residents or their responsible party.

Based on record review and staff interview the facility failed to implement a nutritional supplement order in a timely manner, for one resident (R#1). Three residents were reviewed for nutrition concerns. The facility census was 59. Review of the clinical record for R#1 revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS), for R#1) dated 8/1/16 revealed that Section V Care Area Assessment (CAA) Summary revealed that nutritional status triggered as a concern and that it was documented that nutritional status would be addressed in the resident's care plan. Review of a care plan: I am at risk for weight loss and impaired nutrition related to recent weight loss related to [MEDICAL CONDITION] for R#1, dated 8/2/16, revealed the following documented interventions: Give me supplements as ordered, I require a full liquid diet. Review of a dietary note dated 7/29/16, for R#1, in pertinent part, revealed the following, resident admitted with stage IV [MEDICAL CONDITION] under hospice care with recent resection of colon with surgical wound; has an [MEDICAL CONDITION]; is on a Full liquid diet; po (oral) intake is fair at this time consuming 25 - 50% on average .At nutrition risk related to diagnosis; unavoidable weight loss is expected related to [DIAGNOSES REDACTED]. RX protein supplement 30 milliliters (ml) twice daily if appropriate through hospice to provide 30 g (grams) of protein. Review of PAR note dated 8/10/16 revealed the following documented, in pertinent part: Resident discussed in PAR due to recent weight loss. Current weight 110 pounds, 10 pound weight loss since admission, on 7/25/16. Continues full liquid diet per MD order. Protein supplement added. Review of the August 2016 Medication Administration Record, [REDACTED]. Interview on 3/18/17 at 3:37 p.m., with the Director of Nursing (DON) revealed that when a resident is admitted with a wound or with a [DIAGNOSES REDACTED]. Once the RD recommends the nutritional supplement then the order for the nutritional supplement pends for the physician's approval. The DON revealed that the process to receive physician approval for a nutritional supplement is a quick response meaning usually a day or two. Further interview with the DON revealed that the DON confirmed that the RD recommended that R#1 have a Protein supplement on 7/29/16; however, the order for the Protein supplement was not written until 8/10/16. The DON revealed that she could not explain the delay from 7/29/16, the date the supplement was ordered, until 8/10/16, the date the order was written.

Based on observations, resident interview, and staff interview the facility failed to ensure that one (1) resident #73, was aware that personal trust fund monies were available on weekends and holidays from a sample of twenty-two (22) resident fund accounts. Findings include: Observation of Banking hours were posted on the Financial Services office door as Monday through Friday from 8:00 a.m. to 4:30 p.m. Thursday hours are 1:00 p.m. to 4:30 p.m. No hours were noted for weekends. It was reported by resident #73 that funds could not be accessed on weekends because there was no one in the office. Further observation of building found no notice of funds availability in any area. Interview with Licensed Practical Nurse (LPN) CC on 10/21/15 at 9:00 a.m. revealed that there were funds available on the weekend in the A hall medication cart. When asked if the residents knew it was available she stated she didn't know. Interview with Certified Nursing Assistant DD, on 10/21/15 at 9:15 a.m. revealed that if residents wanted anything from the vending machines on the weekends, she just gives them the money. Interview with LPN EE, on 10/21/15 at 9:25 a.m. revealed that she thinks there is money available on the A Hall medication cart, but she was not sure. Interview with Financial Services Technician BB, on 10/21/15 at 9:45 a.m. revealed that there was money available on the weekends. She stated that $10.00 is left in an envelope in Hall A medication cart and if anyone needs any money they can ask the Registered Nurse. When asked how did the residents know that there was money available on the weekends she stated she wasn't sure. She verified that there was no posting of banking hours listed in the building except on her door and the weekends and holidays were not addressed.

Based on financial record review and staff interview, the facility failed to return trust fund money to one (1) resident's family member within thirty (30) days after discharge from a review of eight (8) discharged residents. Resident Q expired in the facility on [DATE] and a refund check was written on ,[DATE] to the family. Interview with Financial Services Technician BB, on [DATE] at 3:45 p.m. revealed that the Corporate Business Office approval must be received before a check can be written. Interview with the Administrator on [DATE] at 4:00 p.m. revealed that the expectation is that the Business Office in the facility keeps track of refund money that needs to be paid and ensures it goes out before the 30 day limit.

Based on record review and staff interview, the facility failed to ensure that care was provided in accordance with the Plan of Care for two (2) residents (#68 and #15) regarding monitoring of specific behaviors related to antipsychotic drug therapy of twenty two (22) sampled residents. Findings include: Record review for Resident #68 revealed a Quarterly Minimum Data Set (MDS) assessment having an Assessment Reference Date of 07/07/15 which documented, in Section I - Active Diagnoses, that the resident had [DIAGNOSES REDACTED]. Section N - Medications documented that the resident received antipsychotic medication. The current October 2015 physician's orders [REDACTED].#68 specified that the resident had a [DIAGNOSES REDACTED]. Resident #68's Care Plan identified a Focus area dated 07/10/15 which referenced the resident's receipt of psychotic medication and drug related complications. Care Plan interventions related to Resident #68 receipt of [MEDICAL CONDITION] medications ([MEDICATION NAME]) included, but was not limited to monitor, record, and report to the physician, behavior symptoms not usual to the person. Review of Resident #68 Electronic Medication Administration Record (eMAR), revealed no evidence of monitoring specific behaviors regarding [MEDICATION NAME] therapy (to ensure the identification and reporting of specific behaviors, if they developed, to the physician per the Care Plan referenced above) for July 2015, August 2015, September 2015, and October 2015. Review of [DIAGNOSES REDACTED].#15 showed a [DIAGNOSES REDACTED]. Review of Physician order [REDACTED]. Review of the Care plan showed that the resident had care plans for the use of [MEDICAL CONDITION] medication and listed as an intervention that the [MEDICAL CONDITION] medication would be monitored for effectiveness with monitoring of behaviors as well as monitoring of side effects of the medication . Review of Nursing Care plan for resident #15 showed that behaviors were to be monitored as well as the effectiveness of [MEDICAL CONDITION] medication. Review of Medication Administration Record showed documentation of resident # 15 being monitored for side effects of medications but behaviors were not being documented. Interview with Licensed Practical Nurse EE, on 10/20/15 at 3:56 p.m. confirmed that this resident was not being monitored for behaviors and other residents on [MEDICAL CONDITION] medications were being monitored for behaviors and behaviors were documented on the Medication Administration Record. Review of Monthly Consultant Pharmacy Report on 10/21/15 at 7:57 a.m. showed that the pharmacist visited and reviewed medications on the following dates 09/22/15, 08/17/15, 07/23/15, 06/15/15, 05/23/15, 04/19/15, 03/22/15. During an interview on 10/21/15 at 2.10 p.m. with the Director of Nursing revealed that a review of the eMAR for Resident #68 and #15 confirmed the absence of evidence of specific behavior monitoring.

Based on record review and staff interview, the facility failed to ensure adequate monitoring for adverse consequences, to include specific behaviors, for two (2) residents (#68 and #15) who received an antipsychotic medication, of twenty-two (22) sampled residents. Findings include: Record review for Resident #68 revealed a Quarterly Minimum Data Set (MDS) assessment having an Assessment Reference Date of 07/07/15 which documented, in Section I - Active Diagnoses, that the resident had [DIAGNOSES REDACTED]. Section N - Medications documented that the resident received antipsychotic medication. The current October 2015 physician's orders [REDACTED].#68 specified that the resident had a [DIAGNOSES REDACTED]. Review of the Electronic Medication Administration Record (eMAR) for Resident #68 revealed that the facility was providing ongoing monitoring of the adverse side effects related to the resident's [MEDICATION NAME] antipsychotic drug therapy. However, further review of Resident #68's eMAR revealed no evidence of monitoring for specific behaviors regarding the [MEDICATION NAME] drug therapy for the months of July 2015, August 2015, September 2015, and October 2015. During an interview with Licensed Practical Nurse (LPN) AA conducted on 10/20/15 at 3:43 p.m. stated that behavior monitoring of residents on antipsychotic medication is performed and documented on the eMAR each shift. Review of Resident #68 eMAR with LPN AA confirmed that there was no evidence that specific behavior monitoring had been performed. Review of [DIAGNOSES REDACTED].#15 revealed [DIAGNOSES REDACTED]. Record review of Physician order [REDACTED]. Record review of the Care plan for resident #15 showed that resident had care plans addressing the following: Impaired Cognitive function related to [MEDICAL CONDITION] and depression, Use of [MEDICAL CONDITION] medications related to behavior management with [DIAGNOSES REDACTED]. Review of Social Service Note for resident #15 dated 07/27/15 showed that resident #15 was showing symptoms of depression and was offered counseling which the resident refused. Review of Nursing Care plan for resident #15 showed that behaviors were to be monitored as well as the effectiveness of [MEDICAL CONDITION] medication. A review of the Medication Administration Record showed documentation of resident #15 being monitored for side effects of medications, but behaviors were not being documented. Interview with Licensed Practical Nurse EE on 10/20/15 at 3:56 p.m. confirmed that this resident was not being monitored for behaviors and other residents on [MEDICAL CONDITION] medications were being monitored for behaviors and behaviors would be documented on the Medication Administration Record. During an interview with the Director of Nursing (DON) conducted on 10/21/15 at 2:10 p.m. revealed she expects nurses to monitor residents on antipsychotic medications for specific behaviors each shift and document observations on the eMAR. At the time of this interview, the eMAR's of Residents #68 and #15 were reviewed with the DON and he/she acknowledged the absence of evidence of specific behavior monitoring for the residents.