Every finding on record at Pruitthealth - West Atlanta

Based on staff interviews, record review, and review of the facility's policies titled Occurrences and Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to thoroughly investigate a serious bodily injury of unknown source for one of ten sampled residents (R) (R7). Specifically, the facility failed to provide evidence of conducting interviews with R7, with staff who provided care for R7, with other residents, and with other pertinent outside agencies to determine the root cause of a serious bodily injury of unknown source. This deficient practice had the potential to put vulnerable residents at risk for injuries of unknown source to recur.Findings include:Review of the facility's policy titled Occurrences, reviewed 11/17/2025, revealed the Procedure section included, Investigation and Follow-up: . 7. The Administrator's findings will include, but not be limited to: Interview findings. Was abuse ruled out.A review of the facility's policy titled Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, reviewed 10/15/2025, revealed the Procedure section included, . 2. If it appears to a reasonable person that injury of unknown cause has occurred, interviews should be conducted. Signed statements should be gathered from: staff who cared for the patient just prior to and just after injury; other reliable patients in the vicinity nearby area; and any family or visitors who may have noticed anything. Once an injury of unknown source has been identified, staff should observe the patient and watch his or her behavior to see if the source of injury can be identified based on the patient's behavior (e.g., how the patients moves his or her arms, walks, pushed a wheelchair, behaves.).Review of the electronic medical record (EMR) for R7 revealed an admission date of 10/15/2025. Diagnoses included but were not limited to cognitive communication deficit, generalized muscle weakness, need for assistance with personal care, abnormal posture, vascular dementia, and other chronic pain.Review of the admission Minimum Data Set (MDS) assessment for R7, dated 11/13/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 9, indicating R9 had moderate cognitive impairment. Section GG (Functional Abilities and Goals) documented that R7 required extensive assistance for activities of daily living.Review of the care plan for R7, dated 10/17/2025, revealed a focus of R7 was at risk for falls and had a diagnosis of arthritis, noting that R7 had a fall on 10/17/2025. Interventions included but were not limited to frequent rounds at night and assistance for toileting and transfers.Review of the Progress Notes for R7 revealed an entry dated 10/15/2025 that documented R7 was incontinent of bowel and bladder and is a fall risk.Review of the Progress Notes for R7 revealed an entry dated 10/16/2025 that documented R7 can move bilateral upper extremities and lower extremities with some muscle weakness noted and can hold quarter-inch side rails with one staff assist to reposition himself in bed.Review of the Progress Notes for R7 revealed an entry dated 10/17/2025 by Licensed Practical Nurse (LPN) AA that documented a Certified Nursing Assistant (CNA) alerted this nurse the resident was on the floor with his head laying [sic] towards the door/foot of bed. When asked if he was hurt he said no and denied hitting his head. When asked what he was trying to do, he said he was trying to go in the house. This nurse told the resident he was already in the house and in his bed. Also stated not to get out of bed again so he wouldn't fall or hurt himself. He said ok however he is confused.Review of the Progress Notes for R7 revealed an entry dated 10/23/2025 that documented R7 was experiencing low blood sugar and was sent to the emergency room for evaluation. Review of the EMR for R7 revealed hospital documentation with a print date of 11/5/2025 that revealed a summary statement that documented that during this admission, computed tomography (CT) abdomen showed right femur intertrochanteric fracture, and ortho was consulted. Further review of the hospital documentation revealed an X Ray of R7's femur with a clinical indication listed as pelvic/hip pain following trauma. Found down after ground level fall. Under Impression, the findings include similar appearance of comminuted essentially nondisplaced intertrochanteric fracture of the right femoral neck. Review of the EMR for R7 revealed hospital documentation with a print date of 11/7/2025 that revealed under the section titled Right intertrochanteric femur fracture, CT abdomen on admission incidentally revealed a nondisplaced right intertrochanteric fracture, likely related to a fall one week prior. Orthopedic surgery performed rod fixation on 10/27. Review of the investigation of the injury of unknown source provided by the facility revealed a Witness Statement Form dated 10/30/2025 that documented, The Administrator approached us about the resident's fall and if he was in any pain. Following the nurse's documentation, there was no voiced complaints of or signs and symptoms of pain.Further review revealed a second Witness Statement Form dated 10/30/2025 that documented, After reading the facility report, this writer noted no complaints of pain was voiced from a fall that occurred on 10/17/2025. The Administrator approached this writer about the fall and if there was any pain to complete her report. It was noted that the two staff members who wrote and signed these two Witness Statement Forms are identified as MDS on the provided list of department heads.Further review revealed no evidence that interviews were conducted with staff who provided direct care to R7 or regularly encountered R7. Further review revealed no evidence of interviews from or observations of R7, including an evaluation of whether R7 felt safe at the facility, interviews from R7's representative, interviews with other residents, or interviews from pertinent outside sources. Further review revealed no evidence of a thorough investigation into the potential effect of R7's recent unwitnessed fall on 10/17/2025.In an interview on 12/16/2025 at 11:27 am, Certified Medication Aide (CMA) BB stated that, for falls, whether witnessed or unwitnessed, the staff would write a statement describing what had happened and give it to the charge nurse. She further stated that staff do not complete an incident report and instead would write statements. For unwitnessed falls, usually the nurse will order an X-ray to rule out any injuries. She further confirmed that R7 required total care. In an interview on 12/16/2025 at 11:41 am, Unit Manager (UM) CC stated she was the unit manager for R7's care and stated that R7 aspirated and went out to the hospital for aspiration on 10/23/2025. R7 also experienced a fall prior to the hospitalization, and when at the hospital, they found R7 to have a fracture. Regarding the fracture and injury of unknown source, she stated that an investigation was completed by the DHS and that she could not recall writing any statements for the investigation. She further stated that the facility usually writes statements for investigations. She further confirmed that R7 required total care. In an interview on 12/17/2025 at 11:07 am, the Director of Health Services revealed that after a fall, the nurse should evaluate and assess the resident. She stated that for residents with a BIMS score of 9 or below, or with some confusion, she would ask nurses to go ahead and get scans done. The DHS stated that R7 fell on [DATE], and on 10/23/2025, R7 was very congested and difficult to arouse, with a blood sugar level of 42, and was sent to the hospital for low blood sugar levels and congestion. In the hospital, a fracture was discovered, and rod fixation surgery was performed on 10/27/2025. The DHS stated that this fracture was investigated by the abuse coordinator, the Administrator. When asked about the investigation into the injury of unknown source, the DHS stated that she is not sure what investigation was done, and she did not provide any written statement for the investigation. When asked about R7's fall on 10/17/2025, the DHS confirmed R7's documented post-fall response of going in the house indicated confusion. The DHS confirmed that, with R7's confusion and BIMS score, he should have had an X-ray done and sent to the emergency room to rule out any injuries. In an interview with the Administrator on 12/17/2025 at 2:07 pm, she stated that she was the abuse coordinator, and she reports abuse, neglect, and injuries of unknown source to the State Agency. The Administrator stated that the injury of unknown source was reported to the State Agency when the facility was notified by the hospital of an identified fracture. The Administrator confirmed that R7 experienced a fall on 10/17/2025, but she did not determine how the resident fell. The Administrator stated that no statements are collected for unwitnessed falls, but witness statements are collected for injuries of unknown source. When asked how the investigation into R7's serious bodily injury of unknown source was conducted, she stated that she read progress notes, therapy notes, and some interviews. She further stated that the investigation was inconclusive and that she could not determine if the serious bodily injury of unknown source was or was not from the fall. The Administrator stated that potential negative outcomes of not completing a thorough investigation would be not finding the true root cause, which leaves room for error to happen again. The Administrator confirmed that the documents provided were the complete investigation into R7's injury of unknown source, and she further confirmed that the two statements provided were the only statements obtained for the investigation.

Based on observations, staff and resident interviews, record review, and review of the facility's policies titled Care Plans, the facility failed to follow the care plan to prevent complications for one of four sampled residents (R) (R7), who had a care plan focus for nothing by mouth (NPO). This deficient practice had the potential to negatively impact the resident's quality of life, quality of care and services received.Findings include:A review of the facility's policy titled Care Plans, revised 10/21/2025, under the subsection titled admission Comprehensive Plan of Care number four revealed, The care plan approach serves as instructions for the patient/resident's care and provides continuity of care by all partners.Review of R7's electronic medical record (EMR) revealed R7 was admitted on [DATE] with diagnoses that included but was not limited to pneumonia, dysphagia oropharyngeal phase, respiratory failure with hypoxia, and cognitive communication deficit.Review of R7's care plan initiated 10/16/2025 revealed, a focus of nutritional status that documented R7 required a feeding tube related to NPO. Interventions included but were not limited to give feeding and water flushes as ordered.Review of R7's physician's orders included but was not limited to an order dated 10/21/2025 for NPO and an order dated 10/16/2025 for gastrostomy tube (G-Tube).A review of R7's EMR revealed a progress note dated 11/15/2025 that documented R7 was observed with a food tray in front of him and food in his mouth and when R7 was asked to open his mouth, three shrimps were inside his mouth and resident was able to give them the shrimps. Further review documented no coughing, shortness of breath, or respiratory distress was noted at this time and instructions were given by the Director of Health Services (DHS) and Nurse Practitioner (NP) to monitor the resident and if any cough was noted, an X-ray could be ordered. Further review revealed the NPO diet slip was printed and given to kitchen staff and they were educated that resident was NPO.A review of R7's EMR revealed a progress note dated 11/23/2025 that documented that R7 had a change of condition on 11/22/2025 around 6:50 pm and was noted with an oxygen saturation level of 84% (percent) while on nasal cannula and at 2L(liters) on the concentrator. Further review revealed that R7 was documented as using his accessory muscles to breathe, and the NP gave an order to apply a non-rebreather mask on 15L of oxygen, which made the oxygen saturation level rise to 100% and 15 minutes later it came back down to 84%. Further instructions were given to send R7 to the hospital. Emergency medical services were called.A review of R7's EMR revealed hospital documentation with a print date of 12/11/2025 that documented under section titled Hospital Course, R7 was admitted from a nursing home with acute respiratory distress. On presentation, he required noninvasive ventilatory support and was found to have hypoxic respiratory failure with imaging revealing large left and moderate right pleural effusions and upper lobe predominant pulmonary opacities concerning for infectious or inflammatory etiologies. He was managed in the ICU with high-flow nasal cannula, diuresis, and empiric antibiotics, which were discontinued after negative infectious workup and recent antibiotic exposure. A left-sided thoracentesis was performed, removing 700 mL of clear yellow fluid, resulting in improved oxygenation and transition to low-flow oxygen, and subsequently weaned to room air. During his ICU course, he developed acute on chronic encephalopathy with episodes of unresponsiveness and hypoxia, suspected to be postictal following seizures. An interview on 12/17/2025 at 11:07 am with the Director of Health Services (DHS) confirmed that R7's NPO dietary restriction was in his care plan dated 10/16/2025, and R7's care plan was not followed as it should have been on 11/15/2025 when he was given a food tray. The DHS stated that the importance of a comprehensive care plan was to be able to identify the patient and potential negative outcomes of not following a resident's care plan could lead to poor care and medical errors. Cross Reference F689

Based on observations, staff and resident interviews, record review, and review of the facility's policies titled, admission Orders and Diet Order System, the facility failed to provide the appropriate nutritional treatment and services to prevent complications for one of four sampled residents (R) (R7), with dietary orders for nothing by mouth (NPO). Specifically, the facility failed to properly assess R7's dietary needs and clarify dietary orders on admission in addition to the facility failed to follow NPO dietary orders. This deficient practice placed R7 at risk to not receive the necessary care and services to meet nutritional needs.Findings include:Review of the facility's policy titled, admission Orders, issued 11/2002, under the section titled Policy, number one revealed, The orders must be reviewed by the admitting nurse and should at least address the patient/resident's dietary needs, medications (if applicable), and routine care to maintain or improve the patient/resident functional abilities. Number two revealed, The admitting nurse will make every effort to obtain admission orders will be made prior to the patient/resident's arrival. All hospital orders should be reviewed and authorized by the patient/resident's attending physician. It is preferred that this is also done prior to the patient/resident's admission to the healthcare center/agency and should occur no later than at the time of the admission when unable to do so in advance. If an order is illegible or needs further clarification it will be clarified at that time.Review of the facility's policy titled Diet Order System, revised 10/23/2025, under the section titled Policy Statement revealed, It is the policy of [Name] for the Dietary Department and the Nursing Department to have timely and ongoing communication to ensure each patient/resident has the correct diet order.Review of R7's Electronic Medical Record (EMR) revealed R7 was admitted to the facility on [DATE] with diagnoses that included but was not limited to pneumonia, dysphagia oropharyngeal phase, respiratory failure with hypoxia, cognitive communication deficit, generalized muscle weakness, and generalized epilepsy and epileptic syndromes.Review of R7's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Section C (Cognitive Pattern) a Brief Interview for Mental Status (BIMS) score of nine, which indicated R9 had moderate cognitive impairment; Section GG (Functional Abilities and Goals) revealed, R7 required extensive assistance for activities of daily living; and Section K (Swallowing/Nutritional Status) revealed R7 had a feeding tube while a resident. Review of R7's physician's orders included but was not limited to an order dated 10/17/2025 for speech therapy for treatment for oropharyngeal dysphagia, an order dated 10/19/2025 for Levofloxacin 500 milligrams (mg) with instructions to give one tablet daily for five days, an order dated 10/21/2025 for NPO, an order dated 10/16/2025 for gastrostomy tube (G-Tube).A review of R7's EMR revealed a gastroenterology brief note dated 10/9/2025 that documented, prior to admission to the facility, R7 was brought in from his nursing facility on 9/3/2025 after being found bradycardic, hypoxic, and hypotensive. Emergency Medical Services (EMS) noted third-degree heart block, and the patient was admitted to the ICU for management of acute hypoxic respiratory failure requiring intubation, shock requiring vasopressors, and acute encephalopathy. During his ICU course, he was treated for aspiration pneumonia and Klebsiella bacteremia secondary to urinary tract infection, both of which have since resolved. The patient has experienced recurrent aspiration events throughout his hospitalization, ultimately necessitating G-tube placement for long-term nutrition. A review of R7's EMR revealed a progress note dated 10/15/2025 that documented, two ham and cheese sandwiches and ice water were provided to R7 by Licensed Practical Nurse (LPN) LPN AA.A review of R7's EMR revealed a progress note dated 10/16/2025 that documented R7 was observed with an abdominal binder and a G-tube. The Registered Dietician (RD) was notified who reviewed the G-tube orders.A review of R7's EMR revealed a Restorative Nursing Screening Tool Form dated 10/16/2025 that indicated R7's Swallowing was coded as chokes or coughs when swallowing. A review of R7's EMR revealed, a chest X-Ray dated 10/16/2025 indicated the reason for the X-ray was cough. Under the section titled Impression revealed, Probable chronic change cannot rule out developing right upper lung pneumonia.A review of R7's EMR revealed an Event Report dated 10/19/2025 revealed, pneumonia infection with an onset date of 10/17/2025. Chest X-ray demonstrating pneumonia, probable pneumonia, or new infiltrate. A review of R7's EMR revealed a progress note dated 10/21/2025 that documented that R7 continues antibiotic therapy for aspiration pneumonia and noted that R7 was still NPO and gets his medications via G-Tube.Further review of R7's physician's orders included but was not limited to an order dated 10/23/2025 to send to the emergency room for evaluation immediately, an order dated 11/8/2025 for NPO Status until Speech Therapy Evaluation and Treatment, an order dated 11/11/2025 for speech therapy for treatment to address swallow disfunction to improve feeding by mouth safely, an order dated 11/17/2025 for Levofloxacin 750 mg via gastric tube with instructions to give daily for seven days for pneumonia, an order dated 11/19/2025 for oxygen, and an order dated 11/23/2025 to send to the emergency department to evaluate and treat respiratory distress.A review of R7's EMR revealed a progress note dated 11/8/2025 that documented R7's re-admission to the facility and NPO until speech evaluation and treatment.A review of R7's EMR revealed a Speech Therapy Evaluation and Plan of Treatment dated 11/11/2025 documented under Recommendations, No solids are recommended for the patient to swallow solids safely, and NPO for liquids and solids. A review of R7's EMR revealed a progress note dated 11/15/2025 that documented R7 was observed with a food tray in front of him and food in his mouth and when R7 was asked to open his mouth, three shrimps were inside his mouth and resident was able to give them the shrimps. Further review revealed the NPO diet slip was printed and given to kitchen staff and they were educated that the resident was NPO.A review of R7's EMR revealed a Situation, Background, Assessment, Recommendation (SBAR) Communication Form dated 11/15/2025 that revealed the change in condition, symptoms, or signs observed and evaluated was a cough that started on 11/15/2025. Under section titled Background, pneumonia was documented. Under section titled Additional Information revealed, the incident occurred on 11/15/2025 when the resident was given a plate of food.A chest X Ray with date of service of 11/16/2025 revealed the reason for the x-ray was cough. Under the section titled Impression revealed, Bilateral Perihilar and left lower lobe opacity, that may reflect atelectasis/pneumonia versus alveolar edema. A review of R7's EMR revealed a progress note dated 11/23/2025 that documented that R7 had a change of condition on 11/22/2025 at around 6:50 pm and was noted with oxygen saturation level of 84% while on nasal cannula and at 2L on the concentrator. Further review revealed that R7 was documented as using his accessory muscles to breathe, and the NP gave an order to apply a non-rebreather mask on 15L of oxygen, which made the oxygen saturation level rise to 100% and 15 minutes later it came back down to 84%. Further instructions were given to send R7 to the hospital. Emergency medical services were called.A review of R7's EMR revealed a progress note dated 12/11/2025 that documented R7's re-admission to the facility with a hospital discharge diagnosis of pneumonia.A review of R7's EMR revealed hospital documentation with a print date of 12/11/2025 under the subsection titled Hospital Course revealed, R7 was admitted from a nursing home with acute respiratory distress. On presentation, he required noninvasive ventilatory support and was found to have hypoxic respiratory failure with imaging revealing large left and moderate right pleural effusions and upper lobe predominant pulmonary opacities concerning for infectious or inflammatory etiologies. He was managed in the ICU with high-flow nasal cannula, diuresis, and empiric antibiotics, which were discontinued after negative infectious workup and recent antibiotic exposure. A left-sided thoracentesis was performed, removing 700 mL (milliliters) of clear yellow fluid, resulting in improved oxygenation and transition to low-flow oxygen, and subsequently weaned to room air. During his ICU course, he developed acute on chronic encephalopathy with episodes of unresponsiveness and hypoxia, suspected to be postictal following seizures. An interview on 12/16/2025 at 11:27 am with Certified Medication Aide (CMA) BB revealed that any specialized diet should be recognized on the meal ticket found on the food tray and that staff could also see specialized diets on the EMR. An interview on 12/16/2025 at 11:41 am with Unit Manager (UM) CC revealed that for new admissions on a specialized diet, the admitting nurses would go through the hospital discharge papers to review information including diagnoses and any orders. She explained that this was completed by any nurse admitting a new resident, and every nurse was able to assess. The admitting nurse was also expected to get orders from the hospital physician and clarify as needed. She further explained that the Speech Therapist (ST) could also evaluate the resident and enter any orders for specialized diets. She explained that if the ST evaluation recommendation was NPO, those would also be placed into the EMR as an order. The ST would put the orders into the EMR and let the nurses know in person. To communicate specialized diets to the dietary department, nurses should complete a dated communication form with the resident's name and diet. She stated that if the kitchen makes a mistake and sent the wrong tray, staff should be aware of any specialized diets to look out for because those are addressed in the morning huddles that take place daily. She confirmed that NPO diets are communicated in the daily morning huddle meetings and that these meetings had been going on for four months. UM CC confirmed R7 has had two recent hospitalizations. In the first hospitalization, the admitting nurse was not aware of his aspiration risk and gave him two sandwiches on 10/15/2025. She stated that R7 aspirated and went out to the hospital for aspiration. She confirmed that the admitting nurse should not have given him a sandwich as R7 had a G-tube in place at admission. She further stated that R7 was hospitalized a second time because a staff member gave R7 a food tray which resulted in R7 aspirating and going to the hospital. An interview on 12/16/2025 at 12:17 pm with the Dietary Manager revealed that her dietary team was made aware of any specialized diets from communication forms that nurses were to provide for new admissions and re-admissions. She revealed, once she receives the communication form, she would add it into the EMR, which will then populate the specialized diets automatically onto the meal tickets. She revealed, if a resident was NPO, no meal ticket would be printed out. A phone interview on 12/17/2025 at 10:45 am with the Therapy Outcomes Coordinator (TOC) revealed, that the ST communicates her recommendations directly with nursing and dietary and could implement dietary orders. The TOC confirmed that the ST evaluated R7 on 10/17/2025 and noted oropharyngeal dysphagia and risk for aspiration and pneumonia and on 11/11/2025 with recommendations for NPO. The TOC stated the importance of communicating specialized diets quickly and effectively are because it could be life or death for a patient. The TOC stated that potential negative outcomes of ineffective communication of specialized diets include the resident could choke, aspirate, or pass away. An interview on 12/17/2025 at 11:07 am with the Director of Health Services (DHS) revealed she oversees the nursing department. The DHS stated that for new admissions, the admissions coordinator sends the admissions packet including hospital records, notes, and discharge orders to the unit manager or whoever is the admitting nurse. Discharge orders must be verified by two nurses, and nurses should call and clarify old or unclear orders. The DHS confirmed that R7 was admitted by LPN AA on 10/15/2025, who gave him two sandwiches on that day, and LPN AA did not confirm R7's hospital discharge orders upon admission. The DHS further confirmed that on 10/16/2025, a day after R7's admission to the facility, the wound nurse noticed a G-tube and notified the DHS, and this is what indicated that R7's discharge orders still needed to be confirmed. The DHS further confirmed that on 10/16/2025, a day after R7's admission to the facility, R7's physician orders were clarified and confirmed including R7's G-tube orders and NPO orders which the DHS stated should have been identified upon R7's admission to the facility. The DHS further confirmed that R7 was at the hospital for aspiration pneumonia prior to admission to the facility and had choking and swallowing issues prior to admission. The DHS confirmed R7 should not have had the sandwiches on 10/15/2025 or a food tray on 11/15/2025. The DHS stated that on 10/16/2025, the facility called to get a chest x-ray and on 10/19/2025, the chest X-ray results came back and R7 was treated with antibiotics for possible pneumonia. On 10/23/2025 R7 became very congested and difficult to arouse, with blood sugar levels of 42, and was sent to the hospital for low blood sugar and congestion. The DHS stated that the second time R7 aspirated, there was an issue with meal ticket system, in which the incorrect diet was displayed. She explained that nursing could see that R7 was NPO but the meal ticket system displayed a different diet. The DHS confirmed that on 11/15/2025, a certified nursing assistant (CNA) who was not as familiar with R7 gave R7 the food tray due to the meal ticket system issue. The supervisor caught the error and corrected it with the dietary department but had to extract the shrimp from R7's mouth. The DHS confirmed R7 should not have received a food tray on 11/15/2025. The DHS stated that the importance of having clear orders from the discharge physician at the hospital and following correct orders for specialized diets is continuity of care. She further stated that not following correct orders could potentially harm a patient. When asked about the importance of properly assessing and monitoring residents with known aspiration risks and difficulty swallowing, the DHS stated that it was very important and negative outcomes could lead to aspiration pneumonia and death. An interview on 12/17/2025 at 2:07 pm with the Administrator revealed she was aware of the meal ticket system incident and identified the root cause was the connection between the EMR and the meal ticket

Based on observations, staff interviews, record reviews and review of the facility's policies titled, Infection Control-Housekeeping Services, the facility failed to ensure staff followed proper infection control protocols when transporting clean linen from the dryers to the folding area. This failure had the potential to contaminate all clean linen and clean laundry. The facility census was 102.Findings include:A review of the facility's policy titled, Infection Control-Housekeeping Services, reviewed 7/17/2025 revealed that, It is the policy of this facility to ensure housekeeping services will be performed on a routine and consistent basis to ensure an orderly, sanitary, and comfortable environment.During a tour of the laundry services on 9/17/2025 at 9:08 am revealed a covered bin designated for clean laundry was observed with garbage, dirt particles and soiled linen in it. The cover was observed with a liquid substance and dirt particles. The inside of the bin contained used tissue, garbage and a soiled blanket at the bottom. A shelf in the clean laundry room was observed containing folded sheets and blankets uncovered and unbagged.Interview on 9/17/2025 at 9:08 am with the laundry attendants CC and DD confirmed that the linen on the shelf should have been covered. Laundry attendants stated that the blankets have always been kept that way. CC stated that there two bins available for transporting the clean linen from the dryers to the folding area and that the bin present in the room was one of the two. She also confirmed that she was about to use the bin to remove the linen she had just dried to transport then to the folding table. CC also stated that she puts the linen on the cover instead of in the bin when transporting without it being covered. Both laundry attendants admitted that they received in-service on infection control in the laundry department but were unable to state when.Interview with the Housekeeping Supervisor on 9/17/2024 at 9:15 am there were two laundry attendants on the day shift and one at night, seven days per week. She stated that in-services were given by the Corporate Compliance Coordinator (CCC) and herself and that the staff received infection control teachings this year. The Housekeeping Supervisor confirmed that the bin observed with garbage was for clean laundry and stated that she would have the staff clean the bin and wipe it down before the next use. She also stated that she would have the sheets and blankets observed uncovered on the shelf in the dryer room covered immediately. The Housekeeping Supervisor stated that the staff was aware that the bin should be cleaned daily and that all trash should be removed from the bin. She stated that the covers of the bins should also be cleaned daily and that the bin would be cleaned immediately. Interview on 9/17/2025 at 2:50 pm with the Infection Preventionist (IP) revealed that all laundry attendants had been in-serviced on IP (infection prevention) regarding laundry services and infection prevention this year and provided documentation.

Based on record review, staff interviews, 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 other residents for one of five residents (R) (R 113) reviewed for abuse. The deficient practice had the potential to place residents at continued risk of abuse.Findings include:Review of the facility's policy titled Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property review date 11/15/2024 revealed under Policy Statement: It is the policy of 'name of facility' and its affiliated entities (collectively, the Organization) to actively preserve each patient's right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, exploitation, mistreatment, and misappropriation of patient property, (referred to collectively in this policy as abuse, neglect, mistreatment, and exploitation). The Organization and its partners should assure that best efforts are made to prevent any occurrences of any form of abuse, neglect, and exploitation. Under Definitions: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Abuse also included deprivation by an individual, employee, care giver of goods and services that are necessary to maintain the physical, mental, and psychosocial wellbeing.Review of R113's Face Sheet in the electronic medical record (EMR) revealed R113 was admitted with diagnoses of major depressive disorder, restlessness and agitation, cognitive communication deficit, dysphagia following cerebral infarction, altered mental status, and other symptoms and signs involving cognitive functions following cerebral infarction.Review of the admission Minimum Data Set (MDS) located under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 8/31/2024 indicated R113 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating R113 was cognitively intact.Review of the Care Plan located under the Care Plan tab of the EMR, revealed R113 had presence of behavioral symptoms. He frequently refuses medications, and skin observations. 12-26-24 poured water on roommate.Review of the Progress Note, dated 9/23/2024 at 12:42 pm, and located in the EMR under the Resident Progress Notes tab, revealed: Call to room [ROOM NUMBER], noted R113, bleeding from the left side of the eyelid, so this is an altercation between roommates. R113 unplug [sic] the TV while his roommate was watching it. His roommate plug [sic] the TV back then R113 starting cursing his roommate, calling him curse' words, that he liked controlling things around here. The roommate said that R113 swung his arm on him, then he grab [sic] his cane and hit R113. R113 stated that his roommate hit him on his left eyelid and multiple times on the left shoulder. Vital sign taken, 108/80,20, 84, 97.2 02 sat (oxygen saturation) 96% (percent) in room air. Assessment performed, laceration noted with bleeding on the left eyelid, bleeding noted on left lower chin that looks like old wound. Resident reading glasses broken. The area cleanse [sic] with normal saline and protective dressing applied, and wrap round [sic] his head to stop the bleeding. NP (Nurse Practitioner) notified, noted to sent [sic] to hospital for evaluation.Review of the facility's reported investigation and provided by the facility indicated that Police were called on 9/23/2024 and arrived at facility on 9/24/2024 to interview both parties. (Police Report #2422681301). Neither RP (responsible party) nor resident wanted to press charges. R113 has been moved to a different room per his request. The center has substantiated the alleged claim of resident-to-resident abuse due to resident and witness statements.Review of the Progress Note, dated 12/26/2024 at 6:35 am, and located in the EMR under the Resident Progress Notes tab, revealed: resident (R113) reported to staff that his roommate hit him with a cane and as a result he sustained a cut to his lower left eye with small amount of blood. Wound care provided. NP and his family were made aware by the facility DHS (Director of Health Services). NP ordered to send him (R113) to ER (Emergency Room) for evaluations. He (R113) refused complete body skin assessment and V/S (vital signs).Review of Physician Discharge Summary from 1/2/2025 revealed hospital course by problem: assault by roommate and left eye laceration.Review of the facility's reported investigation and provided by the facility, indicated that police did not make an arrest due to the residents' diagnosis and decided the facility could keep both residents apart and safe. The police did stay in the facility until R113 was escorted out by the EMTs (emergency medical technicians). Resident to Resident abuse was substantiated. During an interview on 9/18/2025 at 3:45 pm, the Administrator stated that R113 was moved to a different room, and his care plan was updated after the 12/26/2024 incident.Interview with Social Services Director (SSD) on 9/18/2025 at 4:10 pm confirmed that R113's behavior was discussed with his family, but resident never received behavioral services.

Based on staff interviews, record review, and review of the facility policy titled, Behavior Management, the facility failed to refer one of 21 residents (R) (R31) reviewed for Preadmission Screening and Resident Review (PASRR) for evaluation by the appropriate State-designated authority. This deficient practice has the potential to place R31 at risk of not receiving necessary care and services. Findings include:Review of the facility policy titled Behavioral Management revised 12/17/2024 revealed under the Policy Statement, all patients/residents who display risk behaviors or have the potential for risk behaviors will be evaluated for the Behavior Management Program. Any behavior which impairs the patient/resident's ability to function or interferes with their quality of life or the quality of life of others will be evaluated. A plan of care will be implemented based on the evaluation to prevent, reduce and/or eliminate behaviors. Under Scope: This policy applies to all healthcare center partners. The Behavior Management Program is facilitated by the Social Services Director or designee. Under Determining Placement of Patient/Residents on Behavior Management Program: 1.Patients/residents will be assessed upon admission, readmission, or when there is a change in existing behavior. The 72 Hour Behavior Observation, and the Behavioral Symptom Screening Form are utilized to complete the assessment electronically.Review of the electronic medical record (EMR) for R31 revealed diagnoses that included, but were not limited to, disorganized schizophrenia, other psychoactive substance use, unspecified with psychoactive substance-induced psychotic disorder with hallucinations, depression, and post-traumatic stress disorder (PTSD).Review of the admission Minimum Data Set (MDS) assessment for R31, dated 7/5/2025, revealed in Section A (Identification Information), the resident was not considered by the State Level II PASRR process to have a serious mental illness and/or intellectual disability or related condition. A- No Level II Preadmission Screening and Resident Review (PASRR) Conditions, I-Active Diagnoses, N-Medications-Antipsychotic, Antipsychotic. Section O (Special Treatments, Procedures, and Programs) documents that the residents did not receive psychological therapy.Review of the Physician's Orders for R31 revealed an order dated 9/4/2025 for Psych (psychological) Consult (consultation) r/t (related to) aggressive/argumentative behavior and refusal of all Psych Meds (medications). An order on 7/1/2025 for divalproex-Central Nervous System Agents | Anticonvulsants | Gaba-Mediated Anticonvulsants-500 mg (milligrams).Review of nurses notes on 9/4/2025 at 11:25 am revealed R31 has disruptive behavior frequently. He starts verbally abusive arguments with staff and other residents. He is non-compliant with redirection and teaching; he will start abusive arguments with the Nurse. R31 refuses all Psych medication and Fe (iron) 325 for anemias. He is prescribed Olanzapine and Depakote as Psych medication (related DX (diagnosis)-Schizophrenia.An observation on 9/16/2025 at 3:00 pm revealed R31 having an outburst (yelling and screaming) in the hallway due to him not being invited to the resident council meeting. An Interview on 9/16/2025 at 3:15 pm with Social Services Director (SSD) confirmed that R31's safety and discharge procedures were being reviewed. The SSD stated she conducted an audit when she first began working in October of last year. R31was listed as Level I, but based on his diagnosis, he should have been classified as Level II. The hospital was expected to coordinate with the admissions team prior to his entry into the facility, as the diagnosis was already known at the time of admission. She stated that a referral to psychiatric service name will be submitted, along with a PASSR Level II. R31 should have entered the facility with a Level II classification. She stated PTSD was officially diagnosed on [DATE]. The SSD confirmed R31 did have an outburst in the hallway resulting in him throwing his popcorn and she did meet with him to defuse the situation. An Interview on 9/18/2025 at 10:37 am with the Admissions Director (AD) revealed that her role included speaking with the family and resident after discharge from the hospital and admission into the facility, ensuring that they have a PASSAR Level I. The AD stated it was the social worker's responsibility to follow up with the resident within 72 hours regarding a PASSAR Level II. She confirmed the resident should have a PASSAR Level II.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Occurrences, the facility failed to ensure hazardous chemicals were safely secured for one of four residents (R) (R49) reviewed for accidents. This deficient practice placed residents at risk for avoidable chemical incidents, injuries, and a diminished quality of life.Findings include:Review of the facility's policy titled Occurrences revised 1/11/2024 revealed under the Policy Statement: The healthcare center recognizes that due to the frailty of the patients/residents served, there is an increased risk of occurrences that may result in injury to the patient/resident and/or others. To prevent occurrences, each patient/resident will be observed and assessed for risks. Under Definitions: Occurrence hazards are physical features in the healthcare center environment which may pose a risk to a patient/resident's safety. Review of R49's Face Sheet in the electronic medical record (EMR) revealed diagnoses that include but not limited to attention deficit hyperactivity disorder, and dementia. Review of R49's Quarterly Minimum Data Set (MDS) dated [DATE] revealed in Section C (Cognitive Patterns), a Brief Interview for Mental Status (BIMS) score of 14, which indicated little to no cognitive impairment.Review of R49's care plan dated 9/5/2025 revealed a care plan problem: R49 hoards different items in her room (silverware, plates, other resident personal items, condiments, straws, etc.) Approach: to instruct R49 to refrain from hoarding food items for health safety reasons. Reassure that supplies will be available as needed. Remove excess items with resident involvement. Review of the Safety Data Sheet for [Name] Hydrogen Peroxide 3 Percent (%) revealed the following: Number two Hazard Identification: Classification This chemical is considered hazardous by the 2012 OSHA (Occupational Safety and Health Administration) Hazard Communication Standard (29 CFR1910.1200) Hazard Statements Causes skin irritation and causes serious eye damage. Observations on 9/15/2025 at 1:20 pm and 4:20 pm in R49's room revealed one bottle of [Name] 30-ounce 3% Hydrogen Peroxide stored on top of personal refrigerator within easy reach of R49 and potentially others. R49 was on a leave of absence during both observations. On 9/16/2025 at 8:50 am in R49's room revealed one bottle of [Name] 30-ounce 3% Hydrogen Peroxide stored on top of personal refrigerator within easy reach of R49 and potentially others. Interview on 9/16/2025 at 8:50 am with R49 revealed the hydrogen peroxide was her daughter's and was left on Saturday. R49 stated wandering residents do enter her room at times.Interview on 9/16/2025 at 8:55 am with Certified Nurse Aide (CNA) AA confirmed the hydrogen peroxide should not be stored in the resident's room. Observations on 9/17/2025 at 2:05 pm in R49's room revealed one pair of scissors and one uncapped safety razor stored within reach of R49 and potentially others. Interview on 9/17/2025 at 2:05 pm with R49 revealed she understood scissors and uncapped safety razor left out was a safety concern for other residents. R49 stated she did not have a lock box to store the scissors or razor in a safe manner. Interview on 9/17/2025 at 2:08 pm with Licensed Practical Nurse (LPN) BB revealed that residents should not store scissors or uncapped safety razors at the bedside. Interview on 9/18/2025 at 10:10 am with Director of Health Services (DHS) revealed there should be no chemicals stored in resident rooms for their safety. Her expectation was staff should immediately remove them without violating resident rights. Staff should talk with the resident and call the family for any item that were confiscated for pick-up and explain the policy. The DHS stated her expectation was rooms should be observed during hourly rounding. The DHS confirmed hydrogen peroxide, scissors and uncapped safety razors were all safety risks that should not be out in resident rooms. Interview on 9/18/2025 at 10:20 am with the Administrator revealed hydrogen peroxide, scissors and uncapped safety razors all posed safety risk if located in resident rooms. She stated anything unsafe should be removed immediately.

Based on observations, resident, resident representative and staff interviews, record review and review of the facility's policy titled, Patient/ Resident Choice Meals, the facility failed to provide a therapeutic diet that took into account the resident's clinical condition, and preferences with an equally nutritious meal for one vegetarian resident (R) (R48). The deficient practice resulted in the fluctuation of R48s weight and poor appetite.Findings include:A review of the facility's policy titled Patient/ Resident Choice Meals revised 8/3/2017, under topic Procedure, revealed that, The Dietary Manager or Dietitian will guide the patients/ residents to plan a nutritionally adequate meal. The Dietary Manager or Dietitian will request any necessary food or beverage items needed for the patient/ resident choice meal from (facility) Contracting Department and the VP (Vice President) of Nutrition & Dietary Services if the food or beverage items are not available on their order guide.A review of the admission records for R48 revealed diagnoses of but not limited to atherosclerosis of coronary artery bypass graft(s), with unspecified angina pectoris, unspecified atrial fibrillation, chronic systolic (congestive) heart failure, unspecified protein-calorie malnutrition, vascular dementia, muscle weakness (generalized), other symptoms and signs concerning food and fluid intake.A review of R48's quarterly MDS dated [DATE] revealed a BIMS score of 7, indicating severe cognitive decline.A review of R48's care plan revealed a problem area stating, Preferences Food preferences (Vegetarian diet) Other Preferences with goal(s) of, preferences will be reviewed quarterly and as necessary. And indicated interventions including, preferences will be known to staff, preferences will be discussed quarterly and as necessary, preferences will be honored through the next review. Another problem area stated, is at risk for malnutrition R/T missing and broken teeth, with goal(s) of, Weight will be maintained within acceptable parameters. Interventions included, Keep physician and significant other/designated family member informed of any weight loss, consult with Registered Dietitian (R/D) and follow recommendations, increase caloric intake if indicated, monitor and record percentage of food intake and monitor for weight loss. Additional problem area revealed that R48 is at risk for nutritional decline secondary to being on a vegetarian diet, per her request. The goal(s) included, weight will remain stable through review period. Interventions included, RD consult as needed (PRN), weigh per facility protocol and provide diet per orders.A review of the Physician Orders for R48 included ensure clear 1 carton 237 ml (milliliters) PO (orally) 4x (times) daily (QID) (four time a day) start date 3/12/2025. Regular vegetarian diet, no meat. Eliquis (apixaban) tablet; 2.5 mg; amt: 1; twice a day. Farxiga (dapagliflozin propanediol) tablet; 10 mg; amt: 1; oral once a day. Melatonin tablet; 3 mg; 2; at bedtime.Initial observation on 9/16/2025 at 12:39 pm revealed resident sitting in the dining room having lunch. R48 meal ticked revealed Italian marinated pork loin, brussels sprouts, stuffing and dinner roll. R48 plate revealed a grilled cheese sandwich, green beans and brussels sprouts.Second observation on 9/17/2025 at 12:52 pm revealed R48 having lunch in the dining room with a meal ticket indicating beef tips and mushrooms in [NAME] sauce, green peas, parslied rice and dinner roll. R48's plate consisted of pasta salad, parslied rice and a dinner roll.Third observation on 9/18/2025 at 12:28 pm revealed R48 meal ticket indicating chicken alfredo fettuccine, buttered broccoli and garlic bread. R48 plate reflected black bean quesadilla, tomato soup and broccoli.A review of the menu for week two revealed that R48 has daily vegetarian meals scheduled which included an entree, starch and vegetables. A review of R48 weight logs revealed a weight loss of three pounds (lbs) in May 2025 where she went from 112 lbs (pounds) to 109.4 lbs and another loss of three pounds in June 2025 ending weight of 106 lbs. R48 gained 0.7 lbs in July 2025, but lost 1 lb in August 2025.Interview on 9/18/2025 at 10:19 am with the Social Worker (SW) revealed that she completed the referral for psychological services for R5 due to difficulty adjusting to staff and surroundings. The SW stated that consults (consultations) were posted in R5's records and MDS reviews for changes and new orders in order to develop the care plan. She admitted to having knowledge of the psychiatrist's visit and follow up but denied being aware of the medication ordered and the new diagnosis. Interview on 8/18/2025 at 10:40 am with the MDS Coordinators EE AND FF who stated that they attended the morning meetings where resident changes and new medications were discussed. MDS Coordinator FF admitted that psych consults and medications were discussed as well. The MDS coordinators both confirmed that no care plan was developed for R48's new diagnosis of Depression nor the new medication Sertraline that was started on 6/16/2025. MDS Coordinator EE confirmed the change was documented in the quarterly MDS but stated, I think we missed it. Interview on 9/18/2025 at 10:49 am with the Registered Dietician (RD) revealed that she was aware that R48 was a vegetarian and stated that a vegetarian diet was created for her that met her needs and was equivalent in nutritional value if the menu was followed. The RD stated that R48 was also on a supplement that was increased in the month of February 2025, and again in March 2025, due to excessive weight loss. The RD denied being aware of R48's weight loss in May 2025, due to it not triggering for an excessive weight loss. She denied any intervention from dietary. The RD confirmed that R48's actual meal did not match her meal ticket and upon observation of the menu confirmed that the actual meal did not match either the menu or the ticket. The RD stated that the Administrator ordered the supplies for the menu since the facility did not have a dietary manager for a while. She stated that she was unsure of who informed the Administrator of what to order and added that it was a system glitch that caused the menu to not match the meal ticket.Interview on 9/18/2025 at 3:21 pm with the Administrator revealed she had been assuming the role of dietary manager due to not having one since July 2025. The Administrator confirmed ordering kitchen supplies, food products and meals for the residents. She stated that, I follow our menus, but I do rely on the cooks because they basically know the menus and what's needed in the kitchen. I look at the meal tickets and resident's preferences and add to the order list. The Administrator admitted to not being aware that there was a vegetarian menu specially made for R48 and stated that she was only made aware today, 9/18/2025 by the RD. The Administrator stated, I was not following a vegetarian diet; I was just removing the meat from the regular menu as I was not aware that there is a vegetarian menu. The Administrator stated that she was not aware that there was a shopping list which was used to place orders. She stated that she recently hired a new dietary manager who had been made aware of the shopping list and would be ordering according to the proper practices moving forward.Interview and observation on 9/15/2025 at 7:03 pm with R48 and their son in R48's room. R48's son revealed that R48 was vegetarian and that the meals she had been receiving were not equivalent to a supplemental or nutritious meal. He stated that his family was told that the facility could accommodate her diet but revealed pictures of poorly combined vegetables and starch. R48's son stated that most days R48 barely ate and complained of nausea after eating. He denied having a meeting with the facility to go over her likes and preferences and stated that the only meeting he remembered having was on admission and since then things had drastically gone downhill.

Based on observations and staff interviews, the facility failed to prevent two of two garbage dumpsters from overflowing with excess garbage that prohibited the top lids and side doors from closing causing a potential for pests, rodents, and insects. The facility also failed to ensure one of two garbage dumpsters had a plug-in place to prevent potential leakage of garbage contaminates. The facility census was 101 residents. Findings include: Observation on 5/17/2024 at 9:00 am of the facility garbage dumpsters revealed that the facility had two dumpsters located on the side of the building. The dumpsters were partially surrounded by a wooded area. Continued observation revealed the dumpster on the left side had trash bags overflowing from the top and sides preventing the lids and side doors from closing. The dumpster on the right side had a large brown cardboard box overflowing from the top, preventing the top lid from being closed. A frosted, white colored garbage bag was hanging out of the side door and a tan colored liquid was observed inside the bag. The overflow of trash bags prevented the side door from closing. Further observation of the dumpster on the left revealed the plug was not in place. During an interview on 5/17/2024 at 9:00 am the Dietary Manager (DM) confirmed that trash was overflowing from both garbage dumpsters preventing the lids and side doors from closing. The DM confirmed that the trash bag overflowing out the side door from the dumpster on the right had a tan colored liquid. The DM also confirmed that the left garbage dumpster did not have a plug-in place and would have to ask maintenance if there was one to place. The DM revealed that the garbage dumpsters were emptied by a waste management company daily, usually in the early morning. The DM stated he makes rounds two to three times a day of the dumpsters/dumpster area to ensure lids are closed, side doors shut, and no trash on the ground. During an interview on 5/17/2024 at 9:10 am the Maintenance Director (MD) revealed that the dumpsters are emptied twice a week and are typically picked up in the afternoon. The MD revealed that they can call the waste management company for early pick-up if needed when the garbage dumpsters are full. The MD stated that he had not been made aware that the garbage dumpsters were full and overflowing. The MD revealed that he did not realize that there was no plug-in place for one of the dumpsters and would likely have to go the store and purchase a plug.

Based on observations, staff interviews, and review of a facility document titled, Your Rights as a Patient, the facility failed to ensure a dignified dining experience for three of 46 residents (R) (R31, R68, and R608) on the [NAME] Unit. Specifically, the facility failed to ensure timely meal tray delivery for R31 and R608, pulled R68 backwards in his geriatric chair when leaving the dining area, and residents were referred to as feeders in the dining room during lunch. Findings include: Review of document titled YOUR RIGHTS AS A PATIENT (undated) revealed the following: under Respect and Dignity: You have the right to be treated with respect and dignity. Breakfast observation on 5/17/2024 at 8:37 am revealed 10 residents sitting in the dining room for breakfast. R31 and R102 were sitting at table together. R102 received her breakfast at 8:37 am and R31 did not receive her breakfast until 8:47 am. All residents in the dining room received their breakfast before R31 and some had completed their breakfast prior to her receiving her tray. Lunch observation on 5/18/2024 revealed the first meal cart delivered to the [NAME] Unit at 1:06 pm. There were eight residents in the dining area on this unit when the first cart was delivered. The second cart was delivered at 1:22 pm. R608 was at her table since the first cart was delivered but was the last resident in the dining area to receive a meal tray. At 1:28 pm, R608 began questioning staff about where her food was, and her lunch tray was delivered at 1:31 pm. Observation on 5/18/2024 at 1:23 pm revealed R68 being pulled in his geriatric chair backwards from the dining area to his room by Licensed Practical Nurse (LPN) AA. Observation on 5/18/2024 at 1:22 pm during lunch delivery, staff were standing near the [NAME] Unit nurse station and Certified Nursing Aide (CNA) BB could be heard across the dining area referring to a resident as a feeder multiple times. Interview on 5/19/2024 at 12:38 pm with CNA BB who reported that she recalled referring to a resident as a feeder on the day before. CNA BB denied that she had received any training related to the dignity of residents. However, she reported one way of showing dignity to the resident would be by calling the resident by his/her preferred name. Interview on 5/19/2024 at 12:44 pm with LPN AA, who acknowledged that she had received education related to dignity and patient's rights, reported that R68 does not have good safety awareness and she pulled him backwards because he was insistent on going back to bed and not being in the dining area. Interview on 5/19/2024 at 2:45 pm, the Director of Health Services (DHS) reported that she was not aware of staff referring to residents as feeders, residents not being served meals at the same time, or of residents being pulled backwards. The DHS reported that residents should be treated with respect and those at the same table should receive meal trays around the same time, residents should not be referred to as feeders, and residents in geriatric chairs should not be pulled backwards. The DON further reported that there was no policy related to dignity.

Based on staff interviews, record review, and review of the facility policy titled, Bed Hold Acknowledgment Form: Georgia, the facility failed to provide bed hold information, in writing, at the time of transfer or within 24 hours, for three of 45 residents (R) (R106, R68, and R19) who were transferred to the hospital in the last 120 days. Findings include: A review of the facility policy titled Bed Hold Acknowledgment Form: Georgia, reviewed 1/11/2024, revealed the Policy included Two notices related to the healthcare center's bed hold policy will be issued. The first notice of bed hold policies is given during this admission, which is well in advance of any transfer. The second notice, which specifies the duration of the bed hold policy, will be issued at the time of any transfer. 1. A review of R106's Electronic Medical Record (EMR) revealed he was discharged from the facility to a hospital on 3/31/2024, and there was no documented evidence of a bed hold notification being provided to the resident or the resident representative. A review of the Progress Notes revealed an entry dated 3/31/2024 at 9:15 am, documenting that the resident was sent to the emergency room (ER) for evaluation due to a change in condition. There was no documentation of written bed hold information being provided. In an interview on 5/18/2024 at 1:55 pm, Licensed Practical Nurse (LPN) GG stated she was unaware of a bed hold notice or information to be given to a resident or resident representative at the time of a transfer to the hospital and was unsure who was responsible for providing the bed hold notices to residents/resident representatives at the time of the transfer. In an interview on 5/18/2024 at 2:00 pm, LPN AA stated she was unaware of who was responsible for providing the resident or resident representative the written bed hold notification at the time of transfers out of the facility. She stated she was unaware of a bed hold notice form used by the facility and had not provided the form to any resident or resident representative at transfers. In an interview on 5/18/2024 at 2:10 pm, the Admissions Coordinator stated she provided information about the bed hold policy upon admission as part of the admission packet. She further stated she was not responsible for providing the written bed hold notification at the time of transfers to a hospital. She stated she thought the nurses mailed the notifications to the resident representative if the nurse did not provide it at the time of transfer. In an interview on 5/18/2024 at 2:20 pm, the Director of Health Services (DHS) stated the nurse should provide the written bed hold notification at the time of transfer, make a copy to be scanned into the EMR, and document that the notification was provided in the nurses' progress notes. She verified there was no documentation that R106 or his representative was provided with a written bed hold notification at the time of transfer to the hospital on 3/31/2024. In an interview on 5/19/2024 at 1:57 pm, the Financial [NAME] stated the nurses were responsible for providing the bed hold notifications to the resident or resident representative at the time of a transfer. She stated the Financial office was only responsible for providing the resident and/or resident representative a notice once the resident was out of the facility for seven days. 36200 2. Review of the EMR for R68 revealed he left for a hospital stay on 4/8/2024 and returned to the facility on [DATE]. There was no evidence in the EMR that a bed hold policy was provided to the resident or resident representative when transferred to the hospital. During an interview on 5/19/2024 at 1:58 pm with the Financial Counselor it was reported that nursing staff should have provided the bed hold notice on discharge to the hospital. However, R68 has not had a hospitalization that was more than seven days. The Financial Counselor went on to explain that once a resident has been out of the facility for longer than seven days the Financial Counselor would then send out a notice. During an interview on 5/19/2024 at 2:11 pm with LPN Unit Manager (UM) EE, reported that nursing staff have not been sending out the bed hold notice form but will start doing so in the future. Interview on 5/19/2024 at 3:04 pm with the DHS who reported the bed hold policy was in a book on each unit for nursing. The DHS explained that nursing staff are supposed to send the bed hold policy with a resident when going to the hospital. 35062 3. A review of R19's EMR revealed he was discharged from the facility to a hospital on 4/20/2024, and there was no documented evidence of a bed hold notification being provided to the resident or the resident representative. A Progress Notes dated 4/20/2024 documented the resident was sent to the emergency room (ER) for evaluation due to complaints of chest pain. There was no documentation of written bed hold information being provided.

Based on record review and staff interviews, the facility failed to ensure residents were seen by a physician in the facility at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter, for four of 10 residents (R) (R1, R50, R52, and R72) reviewed for frequency of Physician visits. Findings include: 1. Review of the electronic medical record (EMR) revealed R52 had diagnoses to include but not limited to paranoid schizophrenia, type 2 diabetes mellitus with diabetic chronic kidney disease, anxiety disorder, unspecified, vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, and mood disturbance. Further review of the EMR for the past year did not indicate any physician visits for R52. Review of the EMR for R74 admitted to the facility on [DATE]. R74 admitted under Commercial Insurance and became Medicaid effective 7/17/2024 per the Resident Census. Further review revealed that R74 was seen by the physician on 7/7/2023 and 7/20/2023. There were no other physician visits. During an interview on 5/19/2024 at 11:42 am with the Director of Health Services (DHS), it was reported that as far as she knows the physicians should be seeing the residents at least every 60 days. A telephone interview on 5/19/2024 at 12:22 pm when the Physician returned a phone call to the DHS. The Physician reported that he sees new residents at least once weekly. He went on to say that new residents are seen no less than once per month. It was further reported that his Nurse Practitioner (NP) makes his schedule and that determines which residents are seen when he visits the facility. The Physician went on to say that he feels that he was seeing residents more than what the regulation requires. 38997 2. Review of the Resident Face Sheet for R1 revealed she was readmitted to the facility with diagnoses of, but not limited to acute respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), and pneumonia, unspecified organism. Further review revealed R1 primary payer is Medicaid of __. Review of the resident's annual MDS dated [DATE] Section O-Special Treatments, Procedures, and Programs Received or Performed During the Assessment Period revealed: over the last 14 days, on how many days did the physician (or authorized assistant or practitioner) examine the resident? No physician visits. Review of the EMR for R1 revealed no documented physician visits from January 2023 through May 2024. 46691 3. A review of R50's Face Sheet in the EMR revealed he was admitted with diagnoses including, but not limited to, lack of coordination, muscle weakness, unspecified dementia with behavior disturbances, dysphagia, anxiety, chronic pain syndrome. A review of the Progress Notes for R50 revealed there were no documented physician visits from 5/19/2023 through 5/19/2024. In an interview on 5/19/2024 at 1:45 pm, Corporate Nurse Consultant II stated each resident should have an in-person Physician visit and/or a Nurse Practitioner (NP) visit every 30 days regardless of payment source. She stated the Physician could alternate visits with a NP so long as the Physician provided an in-person visit every 60 days. She verified there were no Physician visits documented in R50's EMR for the last 12 months.

Based on observations, staff interview, and review of the facility policy titled, Food Temperatures, the facility failed to ensure all food items on the steam table were held above 135 degrees Fahrenheit (F) to prevent bacteria growth. The deficient practice affected nine residents ordered a puree consistency diet from a total of 99 residents receiving an oral diet. Findings include: Review of the facility policy titled Food Temperatures revealed: 1. All hot foods served from the steam table must be held at or above 135 degrees F. Steam table temperatures were obtained on 5/18/2024 at 12:45 pm. The Dietary Manager (DM) assisted with taking the food temperatures using the facility's calibrated thermometer. Continued observation revealed the puree beef patty had a temperature of 132 degrees F. During an interview on 5/18/2024 at 12:45 pm, the DM confirmed that the puree beef patty had a temperature of 132 degrees. The DM confirmed that all food items on the steam table need to be held at or above 135 degrees. A continued interview with the DM revealed that there had not been any issues with the steam table not being able to hold food temperatures until that meal.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, Self-Medication, the facility failed to assess one of 40 sampled residents (R) (R71) for the ability to self-administer medications prior to leaving medications at the bedside. The deficient practice had the potential to allow access to medications otherwise not prescribed by a physician to other residents, staff, or visitors. Findings include: Review of the facility policy titled Self-Administration of Medication by Patient/Residents, last reviewed 1/12/2024, under Policy Statement revealed Each patient/resident who desires to self-administer medication is permitted to do so if the healthcare center's Licensed Nurse and physician have determined that the practice would be safe for the patient/resident and other patients/residents of the healthcare center. Medication self-administration also applies to family members who wish to administer medication. Review of the electronic medical record (EMR) for R71 revealed diagnoses that included but not limited to schizophrenia, major depressive disorder, anemia, and chronic kidney disease. Further review of the EMR did not indicate that R71 had been assessed to self-administer medications. During an observation and interview on 5/17/2024 at 8:08 am R71 was observed in bed in their room watching television. Two over the counter products (vapor rub and cough drops) were observed on the nightstand by R71's bed. R71 reported that her family brought the items in for her, and she keeps them in her room. During a subsequent observation on 5/17/2024 at 11:02 am, the vapor rub and cough drops remained at the bedside of R71. During an interview and observation on 5/17/2024 at 11:41 am, Licensed Practical Nurse (LPN) DD reported that residents are able to have medications at the bedside if they had been assessed to do so. LPN DD verified that R71 had not been assessed to have medications at her bedside. At 11:42 am, LPN DD confirmed the medications at the bedside of R71 and then removed them. Interview with LPN DD revealed residents are able to have OTC (over the counter) medications at their bedside if assessed to be able to do so. At 11:42 am, LPN DD confirmed items at the bedside and then removed them and informed R71 that she would get an order for R71 to have the items. Interview on 5/19/2024 at 11:52 am with the Director of Health Services (DHS), she reported that she was not aware of R71 having OTC medications in the room prior to the nurse bringing the items to her on Friday.

Based on record review and staff interview, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to one of three residents (R) (103) reviewed that were discharged from Medicare Part A coverage. Findings include: Review of a Beneficiary Notice-Residents discharged Within the Last Six Months form, provided by the facility, revealed that R103 was discharged off Medicare Part A skilled services on 5/18/2024 and remained in the facility afterwards with benefit days remaining. There was no documented evidence that the SNF ABN was provided to either R103 or the responsible party. During an interview on 5/19/2024 at 2:26 pm, the Administrator revealed that the Financial Controller was new and was familiar with Medicare Part B. They were unaware that the SNF ABN was a required notice for residents discharged from Medicare Part A skilled services who remained in the facility. She confirmed that R103 and/or the responsible party did not receive an SNF ABN.

Based on observations, record review, and staff interviews, the facility failed to provide specialized psychiatric services for one resident (R) (R19) with a serious mental illness (SMI) as recommended by the Preadmission Screening and Resident Review (PASRR) Level II summary. The sample size was 40 residents. Findings include: Review of the electronic medical record (EMR) revealed R19 was admitted to the facility on [DATE] and had a diagnosis of schizophrenia. R19 was receiving Zyprexa (antipsychotic medication) 5 milligrams (mg) at bedtime. Review of the admission Minimum Data Set (MDS) revealed R19 was assessed on the 1/11/2024 Admission as receiving antipsychotic medication. Review of the Georgia PASRR Level II Summary dated 1/24/2024 revealed specialized services for SMI were recommended for R19. The specialized services included behavioral health assessment/ service plan and diagnostic/ongoing psychiatric care. The resident had a corresponding care plan. Review of the EMR revealed no documented evidence that R19 received the recommended specialized services. The was no adverse outcome related to the resident not receiving the services. Observations on 5/17/2024 at 10:42 am, 5/18/2024 at 8:16 am, and 5/19/2024 at 8:10 am revealed R19 was pleasant and exhibited no behaviors. Interview on 5/19/2024 at 11:30 am with Registered Nurse (RN) HH revealed she had not witnessed R19 have any behaviors. Interview on 5/19/2024 at 9:18 am with the Social Worker (SW) revealed R19 should be receiving psychiatry and psychotherapy with (behavioral health services provider). Information should be located under resident documents in the EMR. The SW revealed the consent form was completed by the resident's responsible party and sent to (behavioral health services provider) on 1/10/2024. She stated they usually send an email back when it has been approved. Once approved, they come at least once per month. The SW thought R19 was already receiving the services. She was unable to locate information to support that the resident was receiving services. SW provided an email communication dated 5/19/2024 where she resent the consent and paperwork for treatment.

Based on resident and staff interviews, record review, and review of the facility policy titled, Care Plans, the facility failed to develop a care plan for one resident (R) (R50) of five reviewed for unnecessary medications and failed to implement care plan interventions for one of four residents (R77) reviewed for food/nutrition. Specifically, the facility failed to develop a care plan for the use of antipsychotic and anti-anxiety medication for R50 and failed to implement a care plan for diet as ordered for R77. These failures created the potential for R50 and R77 to not receive treatment and/or care according to their needs. Findings include: A review of the facility policy titled Care Plans, revised 7/27/2023, revealed 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 psychological 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. 4. The care plan approach serves as instructions for the patient/resident's care and provides continuity of care by all partners. The Care Plan Review and Update section included 1. Comprehensive care plans should be reviewed not less than quarterly according to the Omnibus Budget Reconciliation Act (OBRA) Minimum Data Set (MDS) scheduled, following the completion of the assessment. Care plan updates/reviews will be performed within seven (7) days of each quarterly assessment, each acute change in condition, and as needed following each hospital stay. 1. A review of R50's quarterly Minimum data Set (MDS) dated [DATE] revealed Section I (Active Diagnoses) documented dementia and anxiety, Section N (Medications) documented R50 received an antipsychotic and an antianxiety medication. A review of the Physician Orders revealed an order dated 5/31/2023 for haloperidol 0.5 milligrams (mg) (an antipsychotic medication used to treat nervous, emotional, and mental conditions), give one tablet orally every eight hours. Further review revealed an order dated 11/29/2022 for Xanax (a medication used to treat anxiety) 0.5 mg, give one tablet orally every 12 hours. A review of the care plan revealed there were no care plan areas, goals, or interventions for the use of the antipsychotic or anti-anxiety medications. A review of the Medication Administration Record (MARS) dated May 2024, April 2024, and March 2024 revealed medications were administered as ordered. In an interview on 5/18/2024 at 8:20 am, Registered Nurse (RN) HH stated the nurses completed the baseline care plan and the Case Management Director (CDM) completed the comprehensive care plan based on the MDS assessments. She stated the nurses also updated the care plan as needed if there were changes in the residents' condition. In an interview on 5/18/2024 at 12:50 pm, the CMD stated comprehensive care plans were created based on the MDS assessments. She stated care plans were person-centered and should reflect the information on the MDS assessments, the residents' condition and care needs. She further stated if a resident received antianxiety or antipsychotic medications, there should be a care plan area for the medications. She verified that R50's care plan did not contain a care area for an antipsychotic until 5/18/2023, and the resident began receiving an antipsychotic on 5/31/2023. She further verified the care plan did not contain a care area for anti-anxiety medication and that the resident had received anti-anxiety medication since 11/29/2022. She stated this was an oversite and should have been caught at each completed MDS assessment. In an interview on 5/19/2024 at 10:00 am, the Director of Health Services (DHS) revealed the nurses initiated the baseline care plan when a resident was admitted , and the CMD was responsible for completing the comprehensive care plan based on MDS assessment information. The DHS stated the CMD was responsible for ensuring the care plan was updated as needed with each MDS assessment. She stated her expectation was for antipsychotic and antianxiety medications to have a care plan area with interventions relevant to the medications. She verified that R50 did not have a care plan area for the use of antipsychotic medications prior to 5/18/2024, and did not have a care plan area for the use of anti-anxiety medications. 33548 2. Review of the quarterly MDS assessment dated [DATE] revealed R77 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Review of the physician orders revealed R77 was ordered a Controlled Carbohydrate (CCHO) liberalized diabetic and lactose allergy diet. Review of the care plan revealed a concern area for R77 included that they required a therapeutic diet r/t (related to) diabetes and needs regular CCHO diet. Resident does have a lactose allergy. The intervention developed for this concern area was to give diet as ordered. During an interview on 5/17/2024 at 11:50 am, R77 revealed that he was lactose intolerant and was being served foods that contain lactose. Observation on 5/18/2024 at 1:15 pm revealed R77 was served country fried steak with cream sauce and sherbet. Continued observation revealed R77's lunch meal tray ticket stated Allergies: Lactose. Interview and continued observation on 5/18/2024 at 1:18 pm, the Dietary Manager (DM) confirmed that R77 was served cream sauce and sherbet for lunch meal despite meal tray ticket stating allergy: lactose.

Based on observations, resident and staff interviews, and record review, the facility failed to ensure one of 40 sampled residents (R) (R77) was served a lactose free diet as ordered by the physician. The deficient practice caused R77 to be served food items that contained lactose, which R77 was allergic to. Findings include: Review of the electronic medical record (EMR) revealed that R77 had diagnoses that included but not limited to type 2 diabetes, hemiplegia/hemiparesis, chronic kidney disease, and moderate protein calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R77 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Review of the Physician Orders revealed R77 was ordered to receive a Controlled Carbohydrate (CCHO) liberalized diabetic and lactose allergy diet. During an interview on 5/17/2024 at 11:50 am, R77 revealed that he was lactose intolerant, and it was indicated on his meal tray ticket allergy to lactose but had been receiving foods that contained lactose. R77 stated that in the morning he received a cheese omelet and often he was served cereal at breakfast and regular milk was given. Observation on 5/18/2024 at 1:15 pm revealed R77 was served country fried steak with cream sauce and sherbet. Continued observation revealed R77's lunch meal tray ticket stated Allergies: Lactose. Interview and continued observation on 5/18/2024 at 1:18 pm with the Dietary Manager (DM), they confirmed that R77 was served cream sauce and sherbet for the lunch meal. The DM confirmed that R77's meal ticket stated, allergy to lactose. The DM revealed that R77 should not have been served the cream sauce and an alternative dessert should have been offered instead of sherbet. Further interview with the DM revealed that the cream sauce was made with cream of mushroom soup and the DM confirmed that the soup contained milk products. During an interview on 5/19/2024 at 12:00 pm, the DM revealed that there was no facility policy regarding therapeutic diet, food allergies, or lactose intolerance. These policies were requested during the survey.

Based on staff interviews, record review, and review of the facility policy titled, Monitoring of Antipsychotics, the facility failed to ensure that a Gradual Dose Reduction (GDR) assessment was completed at least annually for one of five sampled residents (R) (R50) reviewed for unnecessary psychotropic medication use. This failure had the potential to affect R50's highest practicable mental, physical, and psychosocial well-being. Findings include: A review of the facility policy titled Monitoring of Antipsychotics, reviewed 7/5/2023, revealed the Procedure section stated, 6. Gradual dose reduction is attempted with all patients/residents who receive antipsychotic medications. For patients/residents who have a true psychiatric diagnosis of schizophrenia, a gradual dose reduction assessment will be conducted twice in two separate quarters with at least one month between attempts the first year that the patient/resident is admitted or after the facility has initiated an antipsychotic medication. After the first year, gradual dose reduction assessments will be conducted annually. A review of R50's Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section I (Active Diagnoses) documented dementia and anxiety, and Section N (Medications) documented the resident received antianxiety, antidepressant, and antipsychotic medications. A review of the Physician Orders revealed an order dated 5/31/2023 for haloperidol (an antipsychotic medication used to treat nervous, emotional, and mental conditions), 0.5 milligrams (mg) one tablet oral every eight hours. A review of the Medication Administration Records (MARs) revealed the haloperidol 0.5mg oral tablet was administered as ordered in May 2024, April 2024, and March 2024. A review of a Psychiatry Follow-Up Note dated 3/13/2024 documented Continue current psychiatric medications. A review of the GDRs for R50 revealed the most recent GDR for haloperidol 0.5mg, 1 tablet oral every eight hours was dated 4/27/2023. In an interview on 5/18/2024 at 4:00 pm, the Director of Health Services (DHS) provided an e-mail from the pharmacist dated 5/18/2024 at 3:13 pm stating [R50's name] received Haldol, Xanax, mirtazapine, and PRN (as needed) lorazepam. He is seen regularly by a psychiatric clinician for the purpose of psychiatric evaluation and medication management. Per these progress notes dated 10/23, 1/24, and 4/24, the psych clinician concluded that no med [medication] changes were recommended. In an interview on 5/19/2024 at 10:00 am, the DHS verified there were no other GDRs for the last 12 months for the use of haloperidol for R50. She stated the pharmacist normally conducted a GDR for antipsychotic medications at least annually, and she would expect one to be completed annually for R50 for the use of haloperidol. She verified the last documented GDR for R50's haloperidol was 4/27/2023.

Based on observations, staff interviews, review of the facility policy titled, Medication Storage in the Healthcare Centers, review of the facility-provided documents titled 2024 Insulin Expiration Calendar-28 Day and 2024 Latanaprost and Levemir Expiration Calendar - 6 Weeks (42 Days), and review of manufacturer packet inserts, the facility failed to ensure medications and biologicals were dated when opened, discarded on the discard dates, and stored according to manufacturer recommendations on one of three medication carts (East Unit Cart 2). These deficient practices created the potential for residents to receive medications with altered effectiveness. Findings include: A review of the facility policy titled Medication Storage in the Healthcare Centers, revised [DATE], revealed the Policy Statement included, Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The Procedure section stated, 3. Nurses are required to check all medications for deterioration and expiration before administration. 9. Medications requiring refrigeration are stored at temperatures between 2 degrees Celsius (C) (36 degrees Fahrenheit [F]) and 8 degrees C (46 degrees F) and are kept in a refrigerator with a thermometer to allow temperature monitoring. 11. Multi-dose containers of injectables, ophthalmic (for eyes) and otic (related to the ears) preparations, and inhalers are to be dated (when opened). A review of the facility-provided document titled 2024 Insulin Expiration Calendar-28 Day revealed a chart providing the expiration/discard date of 28 days based on the opened date for each day of the year 2024. A review of the facility-provided document titled 2024 Latanaprost and Levemir Expiration Calendar - 6 Weeks (42 Days) revealed a chart providing the expiration/discard date of 42 days based on the opened date for each day of the year 2024. A review of the manufacturer's packet insert for latanoprost ophthalmic solution revealed the medication should be stored under refrigeration until opened. A review of the manufacturer's packet insert for the Trelegy Ellipta inhaler revealed that it should be discarded six weeks after opening or when the counter reads 0, whichever comes first. A review of the manufacturer's packet insert for the Anoro Ellipta inhaler revealed that it should be discarded six weeks after opening or when the counter reads 0, whichever comes first. A review of the manufacturer's packet insert for the Incruse Ellipta inhaler revealed that it should be discarded six weeks after opening or when the counter reads 0, whichever comes first. Observation on [DATE] at 9:10 am of the East Unit Medication Cart 2 with Licensed Practical Nurse (LPN) FF revealed the following medications stored on the cart, unopened and with a pharmacy label instructing to store in the refrigerator until opened: * insulin lispro 100 units/milliliter (ml) 10 ml vial * Levemir insulin 100 units/ml 10 ml vial * Levemir Flex-Pen * latanoprost ophthalmic solution 0.0005% 5 ml container Further observation revealed the following medications were opened with an expired discard date: * Novolog insulin 100 units/ml 10 ml vial opened [DATE], discard [DATE] * Levemir insulin 100 units/ml 10 ml vial opened [DATE], discard [DATE] * Humalog Kwik Pen opened [DATE], discard [DATE] * Incruse Ellipta inhaler 62.5 micrograms (mcg) opened [DATE], discard [DATE] * Trelegy Ellipta inhaler 200 mcg (62.5mcg/25mcg) opened [DATE] discard [DATE] * Anoro Ellipta inhaler 62.5mcg/25 mcg opened [DATE], discard [DATE] * Anoro Ellipta inhaler 62.5mcg/25 mcg opened [DATE], discard [DATE] In an interview on [DATE] at 8:20 am, LPN FF verified the identified medications. She stated medications with discard dates should be discarded on the discard date, and all medications should be stored and labeled according to manufacturer and pharmacy recommendations. She further stated she was unsure why the medications were not stored, labeled, and discarded correctly and that all nurses who worked the medication cart were responsible for ensuring the medications in the cart were stored, labeled, and discarded correctly. She further stated medications administered past the discard date could be less effective, and the resident could have an altered effect from the medication. In an interview on [DATE] at 10:50 am, the Director of Health Services (DHS) stated her expectations were for insulins, inhalers, and ophthalmic drops to be labeled with open and discard dates and stored according to manufacturer and pharmacy instructions. She stated if a medication was labeled to be stored in the refrigerator until opened, the medication should be stored in the refrigerator until it was opened. She further stated there was a chart located on each medication cart for the nurses to go by when placing the opened and discard dates on insulin, and she expected insulin to be labeled according to the chart and discarded on the discard date. She confirmed that all nurses who worked on the medication carts were responsible for checking medication storage and labeling requirements. She further stated the Unit Managers were responsible for checking the medication carts weekly for proper storage and labeling of medications. She confirmed medications administered past the discard date or not stored as recommended by the manufacturer could cause adverse effects for the resident due to the potential for altered medication effectiveness.

Based on observations, record review, staff interviews, and facility policies the facility failed to ensure two of three residents (R) (R#1and R#9) reviewed for hydration received appropriate services to ensure their highest practicable physical well-being. Specifically, the facility did not follow the physician orders to obtain lab work for R#1 and did not follow the physician orders for enteral feeding and water flushes for R#1. In addition, the facility did not have information available for the Registered Dietician to make an adequate decision as it pertains to the enteral feedings. Actual harm occurred on [DATE] when R#1 was admitted to an acute care hospital with diagnosis of acute sepsis, acute kidney injury, and dehydration with hypernatremia; and on [DATE] when R#9 was observed with signs of dehydration, requiring transfer to an acute care hospital on [DATE] and expired in the hospital. Findings included: A review of the policy titled Enteral Nutrition (Tube Feeding) revised date of [DATE] indicated: Policy Statement: It is the policy . to provide nutrition via an enteral feeding tube when patients/ residents are exhibiting clinical conditions demonstrating that nourishment by mouth is contraindicated. Decisions to continue or discontinue the use of a feeding tube are made through collaboration between the patient/resident, a legal representative, the Physician, Registered Dietitian, and the Interdisciplinary Care Team. The goal is to provide enteral nutrition to the patient/resident in order to achieve and maintain optimal nutritional status. Procedure: 4. The Registered Dietitian will calculate the nutritional needs of the patient/resident. Recommendations will be made to provide enteral nutrition to the patient/resident m order to achieve and maintain optimal nutritional status. A review of the policy titled Hydration: Dietary Services with revised date of [DATE], indicated the following: Policy Statement- It is the policy . that patients/residents will be adequately hydrated. Procedure: 1. The Registered Dietitian will consider risk factors for patients/residents becoming dehydrated. Functional impairments making it difficult to drink or reach for fluids or communicate fluid needs (i.e., aphasia) Dementia in which patient/resident forgets to drink. 3. The Registered Dietitian may calculate daily fluid requirements for all patients/residents fluid requirements. 1. A review of the Electronic Medical Record (EMR), R#1 was admitted to the facility on [DATE] with diagnoses of, but not limited to dementia, gastrostomy status, hyperosmolality, and hypernatremia. A review of the resident's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed a brief Interview for Mental Status (BIMS) score of 99, which indicated the resident was unable to complete the interview; required total assistance with eating; and that R#1's nutritional approach was a feeding tube. Dehydration/Fluid Maintenance and Nutritional Status triggered as an area of concern on the Care Area Assessment. A review of the quarterly MDS assessment dated [DATE] revealed R#1 presented with a BIMS score of 99; that R#1 required total assistance with eating; and the nutritional approach was a feeding tube. A review of the care plan initiated [DATE] revealed that R#1 required a gastrostomy tube (G-tube) feeding. Intervention included administer feeding and water flushes via G-tube per the physician orders. A review of the EMR laboratory results dated [DATE] revealed abnormal laboratory results including, but not limited to, elevated Blood Urea Nitrogen (BUN), glucose, and white blood count (WBC). A review of the Physician Order Report dated [DATE] through [DATE] revealed the following order: start date [DATE] complete blood count (CBC), comprehensive metabolic panel (CMP), C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR). No documented laboratory results are in R#1 EMR. A review of the clinical record revealed that R#1 was admitted on [DATE] and the first documented weight and height was on [DATE]. It was further documented in the clinical record that R#1 returned from the hospital on [DATE] and the first documented weight after her return was on [DATE]. A review of R#1 Nutrition Assessment by the Registered Dietician dated [DATE] revealed height and weight was pending. A review of Nursing Progress Note dated [DATE] revealed R#1 was noted with episode of lethargic during care. Nurse Practitioner gave an order to send to emergency room for evaluation and treatment. The oxygen at 2 liters per minute via nasal cannula, saturation 93 precent blood glucose level 281, (COVID-19 tested ) negative. (Emergency) personnel in facility. Transportation stated resident is being transferred to (an acute care hospital), family member notified. A review of the Hospital Progress Note dated [DATE] revealed the family seen a decline in R#1 mental status over the past (four to five) days to the point (R#1) became nonverbal. The nursing home neglected (R#1); PEG tube dependent but admitted with hypernatremia and dehydration. Documented labs on [DATE] elevated Blood Urea Nitrogen (BUN) 75 Milligrams per deciliter (mg/dl) and elevated Creatinine 2.30 mg. Admission diagnosis Acute sepsis, Acute Kidney Injury, & Dehydration with hypernatremia. A phone interview on [DATE] at 4:49 p.m. with the Nurse Practitioner (NP) stated it has been a long week and she does not have her notes in front of her and cannot remember R#1. NP stated she would review her notes and follow up with the surveyor. No follow up communication was made by the NP. An interview on [DATE] at 12:42 p.m. with the Registered Dietician (RD) stated when a resident is admitted to the facility with a G-tube that involves feeding to meet all the nutritional needs certain information is required to make a professional decision. She stated the following information is needed, diagnosis, current medications, labs, height, and weight. She stated the information is required to calculate the required calories, protein, and free water. She stated R#1 came from the hospital with an order for Nepro and the feeding was not changed upon admission. The RD stated because she did not have the information needed it prohibits her from making a complete and professional assessment to decide of adequate nutritional needs for the resident. The RD stated the facility has an issue with incomplete inaccurate records. She stated in the event she does not have the required information she will not change the feeding and flushes that the hospital was giving. She stated this was discussed with the previous Administrator and her immediate supervisor. The RD has never discussed not having the required information with the current Administrator. She stated when R#1 was readmitted to the facility in ,d+[DATE] with the G-tube that required her to have feeding and free water to meet all nutritional needs there were no weight or labs in the system therefore she did not make any changes. She stated on ,d+[DATE] R#1 had an increase in her BUN so she increased R#1 free water from 40ml continuously to 200 ml every four hours. She also stated the feeding was changed from Nepro to Jevity. The RD stated she cannot be sure that the residents with G-tubes are receiving the free water flushes as ordered. 2. An observation and interview on [DATE] at 11:27 a.m. of R#9 lying in bed. Observation of a pole with feeding pump. There was no feeding or free water hanging. The resident stated, My mouth is dry, and I am thirsty. A review of the EMR revealed R#9 was admitted to the facility on [DATE] with diagnoses of, but not limited to, unspecified atrial fibrillation, congestive heart failure, and gastro-esophageal reflux disease. A review of the admission MDS assessment dated [DATE] revealed R#9 presented with a BIMS score of nine, which indicated moderate cognitive impairment; required total assistance with eating; and nutritional approach was a feeding tube. Dehydration/Fluid Maintenance and Nutritional Status triggered as an area of concern on the Care Area Assessment. A review of the care plan initiated [DATE] revealed that R#9 requires a feeding tube. Intervention to be implemented included administer flush as order. A review of the Physician Order Report dated [DATE] through [DATE] revealed the following order: start date [DATE] end date [DATE] Jevity 1.5 via peg tube at 50 ml/hour and water flushes 50 ml/hour. A review of the Medication Administration Record (MAR) dated [DATE] through [DATE] revealed no documented Jevity 1.5 or water flushes. A review of Nursing Progress Note dated [DATE] revealed: On [DATE] at 11:40 p.m. during night medication pass, this nurse went to give resident (R#9) medications when she was found sweating, very lethargic with shortness of breath. Vital sign was done and obtained blood pressure ,d+[DATE], Pulse 133, temperature 97.7, respiration 34. oxygen saturation 90% on 2 liters nasal cannula. Blood sugar was 211. Abdominal breathing also noted and immediately, resident went unresponsive/took her last breath. The supervisor and other staff were alerted. Noted that resident was made hospice but still full code. Progress note stated that resident's daughter wanted her to remain full code. Cardiopulmonary resuscitation (CPR) initiated and continued until 911 arrived and took over. After serials of treatment and resuscitations by emergency medical staff, resident was transported to (an acute care hospital) for further evaluation and treatments. Family, Nurse Practitioner on call and hospice notified. An interview on [DATE] at 10:46 a.m. with Licensed Practical Nurse (LPN) DD stated R#9 was sent to the hospital last night ([DATE]) and passed away. An interview on [DATE] approximately 12:00 p.m. with the Director of Health Services (DHS). The surveyor requested documentation for R#9 for [DATE] and [DATE] from the Director of Health Services. The Unit Manager presented the surveyor with the requested documents. The UM was asked to review the Medication Administration Record for [DATE] for the Enteral Feeding and water flushes. The Unit Manager stated the residents Enteral Feeding is not required to be on the Medication Administration Record she stated it can be documented on the Treatment Administration Record (TAR). The Unit Manager was asked to show the surveyor where the Treatment record is in the Electronic Medical Record (EMR) system. The Unit Manager left with the requested documents and did not return them. An interview on [DATE] at 3:00 p.m. with the Corporate Registered Nurse (RN) stated the enteral feedings and water flushes are documented on the Medication Administration Record.