Every finding on record at Reserve at Appling of Journey LLC, The

Based on observation, staff interviews, record review, and review of the facility's policies titled Hand Hygiene and Enhanced Barrier Precautions (EBP), the facility failed to ensure nursing staff performed hand hygiene and used personal protective equipment (PPE) while administering medications via gastrostomy tube (G-Tube [a tube surgically inserted through the abdominal wall into the stomach to provide nutrition and medication]), while suctioning the tracheostomy (a surgically created hole in the trachea to provide an airway and facilitate breathing), and during perineal care for one of 18 residents (R) (R23) on EBP. The deficient practice had the potential to place R23 at increased risk of unmet needs and medical complications and to increase the spread of infection due to cross-contamination for the 80 residents residing in the facility.Findings include:Review of the facility's policy titled Hand Hygiene, revised 4/1/2025, revealed the Policy Explanation and Compliance Guidelines section included, . 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to the attached hand hygiene table.6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. The Hand Hygiene Table listed conditions when hand hygiene should be performed either with soap and water or with either soap and water or alcohol based hand rub (ABHR is preferred). The list included: Before preparing or handling medications. Before and after handling clean or soiled dressings, linens, ., when, during resident care, moving from a contaminated body site to a clean body site, after assistance with personal body functions (e.g. (such as), elimination, hair grooming, smoking).Review of the facility's policy titled Enhanced Barrier Precautions, reviewed 4/2/2025, revealed the Policy Explanation and Compliance Guidelines section included, .3. Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray (i.e., wound irrigation, tracheostomy care). b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. 4.High-contact resident care activities include: a. Dressing. b. Bathing. c. Transferring. d. Providing hygiene. e. Changing linens. f. Changing briefs or assisting with toiletin. g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes. h. Wound care: any skin opening requiring a dressing.1. Review of the electronic medical record (EMR) for R23 revealed diagnoses that included, but were not limited to, cerebral infarction, acute respiratory failure, paralysis of vocal cords, tracheostomy status, gastrostomy status, dysphagia, failure to thrive, type 2 diabetes, and dementia.Review of the Quarterly Minimum Data Set (MDS) assessment for R23, dated 8/7/2025, revealed Section K (Swallowing and Nutritional Status) documented the resident had a feeding tube. Section O (Special Treatments, Procedures, and Programs) documented the resident received oxygen, suctioning, and tracheostomy care while a resident. Review of the Order Summary Report for R23 revealed an order dated 3/28/2025 of Resident is on enhanced barrier precautions related to tracheostomy and G-tube every shift.Review of the Medication Administration Record (MAR) for 23, dated August 2025, revealed an entry stating, Resident is on enhanced barrier precautions related to tracheostomy and G-tube every shift and initialed by the nursing staff as completed each shift for the month.Observation on 8/26/2025 at 12:00 pm, during medication administration observation, revealed that LPN AA was observed preparing medications or R23. Observation revealed that she donned (put on) gloves without sanitizing her hands, removed the medications from the medication cart, crushed them, and dissolved them in individual cups of warm water. During the medication preparation, she realized that one medication was missing and needed to retrieve it from another cart. She removed her gloves, did not perform hand hygiene, walked to another cart, returned, and donned a new pair of gloves without sanitizing her hands. After the medications were prepared, LPN AA placed the cups on a tray, entered the resident's room, and placed the tray on the bedside table. She then put on new gloves and did not sanitize or wash her hands. Continued observation revealed that LPN AA did not don a gown. Observation revealed signage on the resident's door indicating that the resident was on EBP, and PPE supplies were readily available in the room. Upon completion of medication administration, she washed her hands and left the room. In an interview on 8/26/2025, after the medication administration, LPN AA stated that her hands were clean since they had been inside gloves, and she did not believe they needed to be sanitized after glove changes. She confirmed that she did not don a gown when providing care to R23, who has a G-Tube and a tracheostomy. She explained that EBP was a new practice in the facility and had only recently been implemented.2. Observation on 8/27/2025 at 3:47 am revealed Certified Nurse Aide (CNA) CC and CNA DD performed peri-care for R23. Observation during the care revealed the CNAs did not don gowns before providing the care and did not perform hand hygiene between glove changes during the care. In a concurrent interview on 8/27/2025, following the observation, CNA CC and CNA DD confirmed they did not don gowns before providing peri-care to R23 and stated they were unaware they should. 3. Observation on 8/27/2025 at 4:12 am, revealed Registered Nurse (RN) BB walked in the hall, heard R23 coughing, and entered R23's room, sanitized her hands, and donned gloves, but did not don additional PPE, despite PPE supplies being readily available upon entry. After completing the procedure and exiting the room, she removed her gloves and sanitized her hands. In an interview immediately following the observation, RN BB acknowledged she should have used PPE but stated she was in a rush to suction the resident.In an interview on 8/26/2025 at 3:35 pm, the Infection Preventionist (IP) stated her expectation was for staff to follow EBP when providing high-contact care and to perform hand hygiene as outlined on the Hand Hygiene Table. She stated staff had received education on EBP and hand hygiene, and skills check offs were conducted. The IP further stated her expectation was for staff to wash or sanitize their hands between glove changes, and that the use of gloves is not a substitute for hand hygiene.In an interview on 8/26/2025 at 4:00 pm, the Director of Nursing (DON) stated that nursing staff were expected to follow infection control practices, including using PPE for high-contact care such as tracheostomy care or tube feeding. She reported that staff were educated on EBP and hand hygiene, emphasizing that gloves do not replace handwashing or sanitizer. She added that staff are expected to gown when providing direct care and that PPE supplies were readily available in resident rooms.

Based on observations, staff interviews, and review of the facility's policy titled Ice Machines and Portable Ice Carts, the facility failed to ensure the dietary ice machine was free from buildup. This deficient practice had the potential to place the 76 residents receiving nutrition or hydration from the kitchen at risk of foodborne illness. Findings include: Review of facility policy titled Ice Machines and Portable Ice Carts, revised April 2025, revealed the Policy section stated, It is the policy of this facility to ensure that ice machine machines/carts are working in proper order, cleaned, and maintained as per Federal, State, local or facility guidance, according to manufacturer's instructions and current standards of practice. The Compliance Guidelines section included, 1. Ice machines will be cleaned at a frequency specified by the manufacturer or, if manufacturer specifications are absent, at a frequency necessary to preclude accumulation of soil or mold. 3. The maintenance director or other designee is responsible for cleaning and maintaining the ice machine at the facility. Observation and interview on 8/25/2025 10:09 am in the kitchen area with the Dietary Manager (DM) revealed that the interior of the ice machine contained dark brown and black buildup. The DM confirmed the dark brown and black buildup was inside the ice machine. The DM revealed that she and the kitchen staff had made attempts to remove the dark brown and black buildup, but it would not go away. In an interview on 8/27/2025 at 1:05 pm, the DM revealed that the Maintenance Director was responsible for cleaning the ice machine, and cleaned it monthly. The DM stated that the kitchen staff attempts to clean the ice machine at times. The DM confirmed the ice machine needed to be cleaned due to the dark brown substance found inside the ice machine. In an interview on 8/27/2025 at 1:41 pm, the Maintenance Director revealed he cleaned the ice machine monthly, and confirmed he was responsible for ensuring the ice machine was cleaned. The Maintenance Director confirmed there was dark brown buildup inside the ice machine, and he was unaware of the buildup prior to the interview. In an interview on 8/27/2025 at 1:50 pm, the Administrator confirmed the inside of the ice machine contained dark brown buildup. The Administrator stated she expects the Maintenance Director and kitchen staff to clean the ice machine regularly and thoroughly during each cleaning.

Based on observation, staff interviews, record review, and review of the facility policies titled Medication Storage and Medication Administration Policy, the facility failed to ensure that medications, biologicals, and supplies were stored following manufacturers' recommendations, or those of the suppliers, in one of four medication carts and two of two medication rooms. This deficient practice has the potential to place residents at risk of receiving medications or biologicals with altered effectiveness. Findings include:Review of the facility policy titled Medication Storage, revised 4/9/2025, included, The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. Review of policy titled Medication Administration, revised 4/9/2025, included, . 13. Identify expiration date. If expired, notify nurse manager.A review of the manufacturer's instructions on the electrolyte bottle revealed that once the electrolyte bottle is open, it is good for 48 hours under refrigerated conditions.A concurrent observation and interview on 8/26/2025 at 11:17 am of one of two medication carts on Hall A, with Certified Medication Assistant (CMA) KK, revealed one insulin pen with an open date of 7/15/2025 and a discard date of 8/11/2025. CMA KK confirmed the insulin pen should have been discarded on 8/11/2025. Continued observation revealed an open, unlabeled container of thickener in the bottom drawer with a date on the container of 6/23. CMA KK stated that the thicker was good for 30 days after opening, and stated she was unsure how long it had been opened or what the date of 6/23 indicated. Further observation revealed two bottles of electrolyte solution in the cart, unrefrigerated, with open dates of 8/20/2025 and 8/25/2025. CMA KK stated she was unaware that the electrolyte solution was only good for 48 hrs and needed to be refrigerated. She stated she had given residents the orange solution on this date with medications. She further stated that the orange electrolyte solution had not been refrigerated, and was unsure when the purple electrolyte solution, dated 8/25/2025, was last used.Concurrent observations and interviews on 8/26/2025 at 11:52 am of the front medication storage room, with the Assistant Director of Nursing (ADON), revealed one saline enema expired 6/2023, one hemorrhoidal ointment expired 5/2025, multi-vite liquid expired 2/2025, and one box of bisacodyl suppositories expired 1/2025. Observations of the back medication storage room revealed one box of bisacodyl suppositories expired 1/2025, one adult liquid acetaminophen expired 7/2025, lubricating jelly expired 2/28/2023, and control solutions for a glucometer expired 8/17/2025. The ADON verified the findings in the medication storage rooms. The ADON stated that expired medications should not be stored in the medication storage rooms. In an interview on 8/26/2025 at 1:11 pm, the Staff Coordinator and Central Supply Clerk stated that she checked supplies on Monday, Wednesday, and Friday. She stated that the supplies were rotated, and she checked constantly for expired items. She verified the expired items. In an interview on 8/27/2025 at 2:33 pm, the Director of Nursing (DON) stated she was surprised that there were expired medications and supplies found. She stated the pharmacy consults with the DON and reviewed medication carts, and she completed random checks of the medication storage rooms and carts.

Based on observations and staff and resident interviews, the facility failed to maintain a safe, functional, and sanitary environment by not repairing roof leaks in one of two shower rooms (Shower Room A) and the facility's dining room. This deficient practice had the potential to place the 80 residents residing in the facility at risk of living in an unsafe and unsanitary environment. Findings include:The facility's policy on environmental maintenance was requested, but was not provided.Observation on 8/27/2025 at 3:21 am in Shower Room A revealed the ceiling protruding downward with visible brown stains around the light fixture.In an interview on 8/27/2025 at 3:21 am, Certified Nursing Assistant (CNA) SS revealed that the Shower Room A ceiling leaked when it rained and stated the leak caused the ceiling area to protrude down. In a concurrent observation and interview on 8/27/2025 at 11:35 am, observation in the Dining Room revealed brown discolored areas on the dining room ceiling. Kitchen Aide PP stated that the leak in the middle of the dining room had been a known problem for over a year. She further stated that when it rains, staff place trash cans and towels to collect the water as needed.In an interview on 8/27/2025 at 11:40 am, the Maintenance Director stated that the ceiling had leaked for some time. He stated that staff attempted to repair it themselves by applying silicone, which did not help. He further stated that the issue has persisted for over a year and that he had several local companies come to provide estimates, which he provided to the Administrator.In an interview on 8/27/2025 at 11:45 am, the Administrator confirmed that the ceiling in the Dining Room and Shower Room A leaked when it rained, and stated that several companies evaluated the leaks. She reported that the companies advised it was difficult to identify the source of the leaks and recommended replacing the roof. She further stated she had emailed the owner regarding the issue, but could not provide the estimates.During the resident council meeting on 8/27/2025 at 3:00 pm, residents reported ongoing issues with roof leaks in the Dining Room and in Shower Room A.

Based on observation, staff interviews, record review, and review of the facility's policy titled Comprehensive Care Plans, the facility failed to implement care plan interventions for one of 18 residents (R) (R23) requiring Enhanced Barrier Precautions (EBP). This deficient practice had the potential to place R23 at risk of unmet care needs and a diminished quality of life. Findings include:Review of the facility's policy titled Comprehensive Care Plans, revised 2/5/2025, revealed the Policy Explanation and Compliance Guidelines included, 1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. All services provided or arranged by the facility, as outlined by the comprehensive care plan, must meet professional standards of quality.3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being.6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress.Review of the electronic medical records (EMR) for R23 revealed diagnoses that included, but were not limited to, cerebral infarction, acute respiratory failure, paralysis of vocal cords, tracheostomy status, gastrostomy status, trach/PEG [percutaneous endoscopic gastrostomy tube] dependent, dysphagia, failure to thrive, type 2 diabetes, and dementia.Review of the Quarterly Minimum Data Set (MDS) assessment for R23, dated 8/7/2025, revealed Section K (Swallowing and Nutritional Status) documented the resident had a feeding tube. Section O (Special Treatments, Procedures, and Programs) documented the resident received oxygen, suctioning, and tracheostomy care while a resident. Review of the care plan for R23, revised 2/24/2025, revealed a Focus area of the resident had a tracheostomy (a surgically created hole in the trachea to provide an airway and facilitate breathing). Interventions included the resident being on EBP related to tracheostomy and G-Tube (a tube surgically inserted through the abdominal wall into the stomach to provide nutrition and medication) status. Observation on 8/26/2025 at 12:00 pm revealed Licensed Practical Nurse (LPN ) AA did not put on a gown while administering medication to R23 through the G-Tube. In an interview following the observation, LPN AA confirmed she did not wear a gown during medication administration through the G-Tube and stated she did not review the care plans daily. Observation on 8/27/2025 at 3:47 am revealed Certified Nurse Aides (CNAs) CC and DD did not put on gowns during glove changes while providing perineal care for R23. In concurrent interviews following the observation, CNA CC and CNA DD confirmed they did not wear a gown while providing perineal care to R23, and stated they should have reviewed the care plan to refresh themselves on the resident's required care.Observation on 8/27/2025 at 4:12 am revealed Registered Nurse (RN) BB did not put on a gown while suctioning R23's tracheostomy. In an interview following the care, RN BB stated she should have put on a gown before performing the suctioning and further stated she would look in the orders and the care plan to determine whether EBP were required.In an interview on 8/26/2025 at 3:35 pm, the Infection Preventionist (IP) confirmed EBP was on the care plan for R23. She stated the care plan instructed nursing staff how to care for a resident. She emphasized her expectation was for staff to follow care plan interventions, including using EBP for high-contact care.In an interview on 8/26/2025 at 4:00 pm, the Director of Nursing (DON) stated her expectation was for nurses to review care plans routinely, as they are individualized and updated as resident conditions change. She emphasized that nurses must be familiar with resident goals and interventions in order to provide appropriate care, and she expected nursing staff to follow EBP.In an interview on 8/27/2025 at 10:28 am, the MDS Coordinator stated that all nursing staff involved in a resident's care were expected to review the care plan so they know how to provide care according to resident-specific needs.(Cross-reference F880)

Based on record review, staff interviews, and review of the facility's policy titled Resident Rights Regarding Treatment and Advance Directives, the facility failed to ensure the comprehensive person-centered care plan was updated for one of 52 sampled residents (R) (R82).Findings include:Review of the facility's policy titled, Resident's Rights Regarding Treatment and Advance Directives dated [DATE] under the section titled Policy Explanation and Compliance Guideline included, . 7. During the care planning process the facility will identify, clarify, and review with the resident or legal representatives whether they desire to make any changes related to any advance directives. 9. Any decision-making regarding the resident's choice will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care.Review of the admission Record for R82 revealed admission on [DATE]. The Advanced Directive section documented a DNR (Do Not Resuscitate).Review of the admission Minimal Data Set (MDS) for R82, dated [DATE], revealed that Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 13 (indicating little to no cognitive impairment). Review of the care plan for R82, revised [DATE], revealed a Focus of has a physician's order that includes a status of full code. Goal included that the staff will administer CPR (Cardio-Pulmonary Resuscitation) if the resident had an arrest through the next review date. Interventions included ensuring a Full Code order on the chart, ensuring staff were aware of code status through designated systems, monitoring for changes in the code status and updating as needed, and beginning CPR after the absence of vital signs, calling 911, and notifying the physician and family/responsible party. Review of the Physician Orders for R82 revealed an order dated [DATE] for DNR. Review of the Georgia POLST form for R82 revealed a signed POLST order for a DNR status, signed by the resident on [DATE] and the physician on [DATE].In an interview on [DATE] at 10:50 am, the Admission/Social Worker stated that when a resident was admitted , she provided the POLST form to the resident and/or representative at admission. She stated that after the form was completed by the resident or resident representative, she sent the form to the physician and notified the department heads of the resident's code status. She further stated the resident was considered a full code until a POLST was completely completed and signed by all parties. She stated that the Director of Nursing (DON) changed the resident's code status in the electronic medical system. In an interview on [DATE] at 2:47 pm, the DON stated the MDS Coordinator was responsible for updating the care plan for residents. She further stated she communicated daily with the MDS Coordinator at 2:00 pm during the daily team meeting.In an interview on [DATE] at 11:02 am, the MDS Coordinator revealed that the Social Worker completed the care plans for the advance directive. She stated that care plans should be updated immediately when there is a change in code status. The MDS Coordinator confirmed R82's care plan stated the resident was a full code, and the POLST forms stated the resident was a DNR. She stated she was unaware of the resident's change in code status.

Based on observations, staff interviews, and record review, the facility failed to deliver oxygen (O2) per physician order for one of eight residents (R) (R74) receiving O2 therapy. The deficient practices had the potential to place R74 at risk of respiratory complications.Findings include:Review of the electronic medical record (EMR) for R74 revealed diagnoses, including but not limited to shortness of breath (SOB).Review of the Quarterly Minimum Data Set (MDS) assessment for R74, dated 6/5/2025, Section C (Cognitive Patterns) documented a Brief Interview of Mental Status (BIMS) score of 1, indicating severe cognitive impairment. Section O (Special Treatments, Procedures, and Programs) documented that oxygen was not administered while a resident.Review of the Order Summary Report for R74 revealed an order dated 8/18/2025 for O2 at 2 liters per minute (LPM) via a nasal cannula (NC) every shift for SOB. Observations on 8/25/2025 at 11:29 am and 8/26/2025 at 9:17 am revealed R74 was receiving O2 via a NC. Further observation revealed that the flow rate for the O2 was set at 3 LPM. During an observation and interview on 8/26/2025 at 4:08 pm, Licensed Practical Nurse (LPN) OO revealed she was unaware of the O2 order for R74. LPN OO stated the nurse should check the O2 rate each shift, and further stated she had not checked R74's O2 flow rate this date. During an interview on 8/26/2025 at 4:23 pm, the Director of Nursing (DON) confirmed the O2 order for R74 was 2 LPM. The DON stated the O2 flow rate should be checked every shift, and O2 should be administered as ordered by the physician.

Based on observation, staff and resident interviews, and record review, the facility failed to ensure one of 52 sampled residents (R) (R34) was treated with dignity during dining. This deficient practice had the potential to place R34 at risk of a diminished quality of life or feeling intimidated when staff fed her while standing over her.Findings include: Review of the admission Minimum Data Set (MDS) for R34, dated 6/10/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 00 (indicating severe cognitive impairment). Section I (Active Diagnoses) documented diagnoses, including, but not limited to, Down syndrome, non-Alzheimer's dementia, and a history of transient ischemic attack without deficit. Section GG (Functional Abilities and Goals) documented that R34 required set-up and cleanup assistance with meals.Review of the care plan for R34, dated 6/8/2025, revealed that R34 had activities of daily living (ADL) self-care performance deficit and is at risk for not having her needs met in a timely manner related to her Down Syndrome and muscle weakness. The interventions include providing her with set up with meals/eating, extensive assistance with oral hygiene, toileting, dressing, and personal hygiene. The amount of assistance required could vary from day to day.Observations on 8/25/2025 at 1:06 pm, 1:15 pm, and 1:19 pm revealed Certified Nursing Assistant (CNA) VV standing over R34 while assisting her with lunch meal in the resident's room. In an interview on 8/25/2025 at 1:25 pm, CNA VV confirmed that she stood over R34 while feeding the resident. CNA VV stated that there was no chair in the room to sit in. In an interview on 8/27/2025 at 2:20 pm, the Assistant Director of Nursing (ADON) stated that staff should not stand over the resident when feeding them, and should sit when feeding a resident.In an interview on 8/27/2025 at 2:33 pm, the Director of Nursing (DON) stated that staff should not stand over a resident while feeding them.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled Nail Care, the facility failed to provide nail care for three of 52 sampled residents (R) (R66, R50, and R81). This deficient practice had the potential to place R66, R50, and R81 at risk of unmet needs and a diminished quality of life. Findings include: Review of the facility's policy titled Nail Care, reviewed 1/14/2025, revealed the Policy Explanation and Compliance Guidelines section included, . 3. Routine cleaning and inspection of nails will be provided during ADL [Activities of Daily Living] care on an ongoing basis. 4. Routine nail care, to include trimming and filing, will be provided on a regular schedule . Nail care will be provided between scheduled occasions as the need arises. Record review of a letter from a podiatrist dated June 9th, 2023 revealed, This letter is to inform you that podiatrist will no longer provide services to your facility. Due to changes at your facility, we are unable to provide podiatric care to our standards for our residents. Please accept this notice effective immediately. 1. Review of the admission Record for R66 revealed admission on [DATE] with diagnoses including, but not limited to, lack of coordination, muscle weakness, and hemiplegia and hemiparesis following cerebral infarction affecting the left side. Review of the Quarterly Minimum Data Set (MDS) assessment for R66, dated 6/15/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 8 (indicating moderate cognitive impairment). Section GG (Functional Abilities and Goals) documented that the resident was dependent for all ADLs. In an interview and observation on 8/25/2025 at 1:39 am, R66 stated his fingernails and toenails are awfully long. He stated he had asked a nurse about trimming his nails and was informed that a podiatrist must clip his toenails since he had diabetes. Observation revealed extremely long and jagged fingernails and toenails. In an interview and observation on 8/26/2025 at 1:41 pm, observation revealed the resident's fingernails remained extremely long and jagged. R66 stated that he just wished they would trim his toenails and cut his fingernails. In an interview on 8/27/2025 at 3:35 am, Licensed Practical Nurse (LPN) EE revealed that bath sheets were completed by the Certified Nursing Assistants (CNAs). The bath sheets go to the Wound Care Nurse first, who notes any skin abnormalities, including hand and foot nails. Any nail abnormalities were referred to the podiatrist, especially those of people with diabetes who require special nail care. In an interview on 8/27/2025 at 3:43 am, CNA FF revealed that she would identify the need for nail care on shower day, and if she noted fingernails or toenails that needed trimming, she would trim them. She stated that if the person had diabetes, she would give the bath sheet to the Wound Care nurse and alert her of the need. She stated she wasn't sure what happened after that. In an interview on 8/27/2025 at 7:04 am, LPN GG/Wound Care Nurse stated weekly skin assessments were conducted by the Charge Nurse. LPN GG stated the nurse reported abnormal nail findings and further stated nurse aides aren't allowed to cut diabetic residents' nails. LPN GG stated the facility had trouble finding a podiatrist. In an interview on 8/27/2025 at 7:14 am, the Director of Nursing (DON) stated the facility had not had a podiatrist to provide nail care for residents since at least April 2024. The DON stated that residents who request podiatry services were sent to a podiatrist. In an interview on 8/27/2025 at 7:23 am, the Administrator stated the facility had not had an on-site podiatrist for a while, and when there was a dire need, they schedule residents to go to an outside appointment. 2. Review of the MDS assessment for R50, dated 7/30/2025, revealed that Section C (Cognitive Patterns) documented a BIMS score of 1 (indicating severe cognitive impairment). Section I (Active Diagnoses) documented diagnoses of, not all-inclusive, Parkinson's disease, dyskinesia, muscle weakness, and need for personal care. Section GG (Functional Abilities and Goals) documented that R50 was dependent on staff for personal care. Review of the care plan for R50, dated 7/5/2025, revealed that R50 had an ADL self-care performance deficit and was at risk for not having her needs met in a timely manner because of her diagnoses, which include Parkinson's, cervical disc disorder, and edema. The interventions included providing her with extensive assistance with personal hygiene, showering, bathing, and dressing. An observation and interview with the Resident Representative (RR) for R50 on 8/25/2025 at 12:58 pm revealed that fingers and toenails were long. RR expressed that they should not have to address the need for nail trimming with the facility because they should be keeping up with nail care. RR stated they had reported to the nurse about the long nails. RR stated that the facility painted nails but did not cut them. RR further stated that her fingernails were so long and dirty that she had to cut them last week. 3. Review of the MDS assessment for R81, dated 7/1/ 2025, revealed that Section C (Cognitive Patterns) documented a BIMS score of 5 (indicating severe cognitive impairment). Section I (Active Diagnoses) documented diagnoses of, not all-inclusive, need for assistance with personal care, generalized muscle weakness, metabolic encephalopathy, chronic obstructive pulmonary disorder, and malignant neoplasm of the prostate. Section GG (Functional Abilities and Goals) documented that R81 required maximal assistance from staff for personal care, including nail grooming. Review of the care plan for R81, dated 4/29/2025, revealed that R81 had an ADL self-care performance deficit and is at risk for bathing, hygiene, dressing, and grooming deficits related to his diagnoses, including but not limited to chronic obstructive pulmonary disorder, hypertension, and prostate cancer. The interventions included providing him assistance and encouraging independence with bathing, grooming, and dressing. R81 has the potential for alteration in skin integrity related to fragile skin due to impaired mobility and incontinence. Interventions include good skin care and podiatry care as ordered. A review of the physician's orders for R81 revealed no order for podiatry. Observation and interview with R81 on 8/25/2025 at 11:45 am revealed the resident with long fingernails and toenails. He stated his fingernails or toenails had not been trimmed in eight months. In an interview on 8/25/2025 at 11:39 am, the RR for R81 stated the resident's fingernails or toenails had not been trimmed since she moved into the facility in June. Observation and interview with R81 on 8/26/2025 at 10:20 am revealed that his finger and toenails remain long. He expressed that he would like them cut. Observation and interview with R81 on 8/28/2025 at 9:17 am revealed that he was resting in bed and stated the facility has not addressed his toes yet. A Hospice nurse was present in the room. In an interview on 8/28/2025 at 9:55 am, the Hospice RN Case Manager stated that he did not cut nails. He stated that he refers residents to the facility for nail care. In an interview on 8/28/2025 at 9:33 am, the Nurse Practitioner (NP) stated that he did not address nail care, and a referral was made to the wound care nurse or to the podiatrist for residents with diabetes.

Based on record review, staff interviews, and review of the Payroll Based Journal (PBJ) [NAME] Report for the first quarter (Q1) of Fiscal Year 2024, the facility failed to accurately report direct care staffing data to the Centers for Medicare and Medicaid (CMS). The facility census was 89 residents. Findings include: Review of the PBJ [NAME] Report for October 1 through December 31, indicated as Q1, documented the following triggered metrics: One-Star Staffing Rating Excessively Low Weekend Staffing Failed to have Licensed Nursing Coverage 24 Hours/Day for 10/10/2023, 11/21/2023, 12/5/2023, 12/6/2023, 12/23/2023, and 12/26/2023 Interview on 4/7/2024 at 9:50 am, the Administrator revealed the Director of Finance submits the staffing data that is retrieved from the time clock system. She stated salaried employees do not always clock in and out and that Agency staff were not clocking in and out through the facility time clock until January of this year. She stated if the Director of Finance was missing Registered Nurse (RN) hours he would email the Administrator and ask for those hours. She stated she would respond back in an email with the information he requested by reviewing her nursing schedule sheets. During further interview, she stated she did not think to give him the agency staffing hours, which include RNs, Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs). She stated the invoices from the staffing agency come to the facility and the facility forwards the invoices to the Accounts Payable Department. She stated that is where the Director of Finance would get the agency nursing hours to include in the PBJ Report. Telephone interview on 4/7/2024 at 11:28 am, the Director of Finance confirmed he is responsible for reporting the data for PBJ report. He stated he generates a report from the time clock system, and that is how he gets the staffing hours to report. He stated when he has questions about the hours from the report, he sends the Administrator an e-mail asking for the staffing hours. He stated he looks at the invoices for agency staff, if they are available at the time he submits the PBJ data. Review of the Administrators Nursing Hours Sheets from October 2023 to April 2024 revealed that the facility has had licensed nurses in the facility 24 hours a day and there has been no excessively low weekend staffing. This information was verified with the Administrator comparing the schedules, time sheets of agency staff, and time clock punches from the system for October 1, 2023, through December 31, 2023. Administrator provided copies of the Staffing Agency to confirm the facility had weekend staff, including licensed nursing coverage in the facility 24 hours a day.

Based on record review, staff interviews, and review of the policy titled Advanced Beneficiary Notices, the facility failed to provide a Notice of Medicare Noncoverage (NOMNC) Centers for Medicare and Medicaid Services (CMS) form 10123 and Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) CMS form 10055 for three of three residents (R) (R340, R341, R342) who were reviewed after being discharged from Medicare Part A Services. Findings: Review of the policy titled Advanced Beneficiary Notices dated 12/1/2022 revealed the policy of the facility is to provide notices regarding Medicare eligibility and Coverage. Policy Explanation and Compliance Guidelines: number 5. c) A notice of Medicare Non-Coverage (NOMNC), form CMS-10123, shall be issued to the resident/representative when Medicare covered service(s) are ending, no matter if the resident is leaving the facility or remaining in the facility. This informs the resident on how to request an appeal or expedited determination from their Quality Improvement Organization (QIO). i. This notice is used when all covered services end for coverage reasons. Review of the facility-completed worksheet titled Beneficiary Notice-Residents discharged Within the Last Six Months, revealed there was a total of 10 residents discharged from Medicare Part A services and all were discharged from the facility. R340, R341, and R342 were selected for review for Beneficiary Notices. Review of R340 clinical record indicated that Medicare Part A services were initiated on 8/18/2023 for rehab services for multiple rib fractures and dislocation of L1-L2 lumbar vertebrae. Review of the Beneficiary Notices revealed that neither the NOMNC form CMS-10123 or the SNFABN form CMS-10055, were provided to the resident or the residents representative before discharge from the facility on 8/30/2023. Review of R341 clinical record indicated that Medicare Part A services were initiated on 8/29/2023 for skilled services for generalized muscle weakness, and gastronomy status. Review of the Beneficiary Notices revealed that neither the NOMNC form CMS-10123 or the SNFABN form CMS-10055, were provided to the resident or the residents representative before discharge from the facility on 9/8/2023. Review of R342 clinical record indicated that Medicare Part A services were initiated on 11/21/2023 for rehab services for displaced intertrochanteric fracture of right femur and muscle wasting and atrophy. Review of the Beneficiary Notices revealed that neither the NOMNC form CMS-10123 or the SNFABN form CMS-10055 were provided to the resident or the residents representative before discharge from the facility on 12/14/2023. Interview on 4/7/2024 at 8:18 am, the Social Services Director (SSD) revealed there were not any residents who received notification of their Medicare Part A benefits ending, or conversation with the residents or responsible party about their right to appeal the decision for the termination of benefits. During further interview, the SSD stated she was directed by the Regional Nurse Manager to call the residents that were listed on the Beneficiary Notice list after the surveyor inquired about the notification. Interview on 4/7/2024 at 9:30 am, the Administrator revealed she was unaware the residents and resident representatives were not receiving notice of Medicare Part A benefits were ending. She stated the Regional Nurse Manager will educate the SSD on the process of the issuing the Beneficiary Notices to residents and their responsible parties, including the appeal process.

Based on record review, interviews, and review of policy titled Pneumococcal Vaccine, the facility failed to provide education, offer, or administer pneumonia vaccinations for three of five residents (R) (R29, R71, R68) reviewed for pneumonia vaccinations. Findings include: Review of policy titled Pneumococcal Vaccine dated 12/1/2022 documented the policy is to offer residents and staff immunization against pneumococcal disease in accordance with current Centers for Disease Control (CDC) guideline and recommendation. Policy Explanation and Compliance Guidelines: Number 1. Each resident will be assessed for pneumococcal immunization upon admission, Self -report of immunization shall be accepted. Any additional efforts to obtain information shall be documented, including efforts to determine date of immunization or type of vaccine received. Number 2. Each resident will be offered a pneumococcal immunization unless it is medically contraindicated, or the resident has already been immunized. 3. Prior to offering the pneumococcal immunization, each resident or the resident's representative will receive education regarding the benefits and potential side effects of the immunization with the education documented in the clinical record. 1. Review of the clinical record revealed R29 was admitted to the facility on [DATE] with diagnoses including but not limited to metabolic encephalopathy, epilepsy. schizoaffective disorder and Moderate Intellectual Disabilities (ID). Resident has a State appointed legal guardian who has power of attorney for healthcare. Review of R29's admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was coded as two, which indicated severe cognitive impairment. Review of the immunization tab in the electronic medical record (EMR) for R29 revealed there was no evidence that the pneumonia or influenza vaccines were administered. Consent form in the EMR was blank with no signatures. Review of the Medication Administration Records (MAR) January 2024 through April 2024 revealed no documentation that R29 was offered or administered received the pneumonia/influenza vaccine. 2. Review of the clinical record revealed R71 was admitted to the facility on [DATE] with diagnoses including but not limited to Alzheimer's disease and chronic obstructive pulmonary disease (COPD). Resident had a designated responsible party as emergency contact. The residents most recent quarterly MDS assessment dated [DATE] revealed a BIMS score of three, indicating severe cognitive impairment. Review of the immunization tab in the EMR for R71 revealed there was no evidence that the pneumonia vaccine was administered to R71. Residents responsible party signed consent for the pneumonia vaccine dated 5/23/2023. Review of the May 2023 MAR revealed no documentation that the pneumonia vaccine was administered to R71. 3. Review of the clinical record revealed R68 was admitted to the facility on [DATE] with diagnoses including but not limited to cerebral vascular accident and depression. Resident had a designated responsible party as emergency contact. Review of the quarterly MDS assessment dated [DATE] revealed that R68 had a BIMS score of 15 indicating that the resident was able to complete the assessment. Review of the immunization tab in the EMR for R68 revealed there was no evidence that the pneumonia or influenza vaccines were administered. There was no evidence of a signed consent form. Review of May 2023 MAR revealed no documentation that the received the pneumonia/influenza vaccines. Interview on 4/7/2024 at 11:55 am, the Assistant Director of Nursing (ADON) stated that she reviewed the resident's EMR and was unable to locate any documentation to verify that R29, R71, and R68 had received a pneumonia vaccine since admission to the facility or prior to the resident's admission.

Based on record review, staff interviews, and review of the facility document titled, Instructions for Completing the Medication Administration Clinical Skills Checklist, the facility failed to ensure that care and services were provided according to accepted standards of practice. Specifically, the facility failed to complete Medication Administration Clinical Skills Checklist for 11 of 12 certified Medication Aides employed at the facility. Findings: Review of the undated facility document titled Instructions for Completing the Medication Administration Clinical Skills Checklist indicated the licensed healthcare professional who administers the medication aide training program must personally validate the unlicensed staff's competency for tasks or skills associated with administering certain medications in the facility. Prior to allowing unlicensed staff to administer medications, the unlicensed staff is also required to successfully pass a computerized written, competency test approved by the Department of Community Health. Review of the facility employee records for the Certified Medication Aides revealed no evidence the Medication Administration Clinical Skills Checklist were completed for 11 of the 12 CMA's currently employed in the facility. Interview on 4/7/2024 at 9:00 am, the Business Office Manager (BOM) revealed she is responsible for ensuring that the employee files are kept up to date and have all required information. She confirmed the CMA competency checklists were not in any of the requested employees files and she was unable to locate them. During further interview, the BOM revealed that the Regional Nurse Consultant (RNC) instructed her to disclose to the survey team that the CMA competencies were completed 12/15/2023, and she would look for the checklists for the employees requested. Interview on 4/7/2024 at 9:40 am, the Director of Nursing (DON) revealed that all the facility CMA's were already in place when she started in December 2023. She stated that she has had little experience with the process of the CMA certification and was not aware of the competencies that were required. During further interview, revealed that she was unable to locate the CMA's competency checklist and did not know where they were stored. She stated going forward there will be skills check offs completed for all CMA's quarterly. Interview on 4/7/2024 at 9:45 am, the Administrator stated that the CMA skills competencies were kept in the DON's office, but she is unable to locate them at this time. She stated the process for the CMA competency check-off is for the Pharmacy Consultant, the DON, or another Registered Nurse will ensure CMA's are competent in medication administration by utilizing a check off tool and demonstration during medication pass, to be completed quarterly. During further interview, she stated all competencies and skill check-off lists will be part of each employee file, so they are readily available.

Based on observations, interviews, and review of the facility policy titled Preventive Maintenance Program, the facility failed to ensure that it was maintained in a safe, clean, and comfortable home-like environment in seven resident rooms on three of three halls (A10, B6, B7, B8, B13, C17, and C18) including dirty floors and walls, dirty privacy curtains, and scuffed walls, chipped paint, and peeling wallpaper. The census was 89. Findings: Review of the policy titled Preventive Maintenance Program, dated 12/1/2022 indicated the policy is that a Preventive Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Policy Explanation and Compliance Guidelines: Number 2. The Maintenance Director shall assess all aspects of the physical plant to determine if preventative Maintenance (PM) is required. Required PM may be determined from manufacturer's recommendations, maintenance requests, ground rounds, life safety requirements, or experience. Number 3. If preventative maintenance is required, the Maintenance Director shall decide what tasks need to be completed and how often to complete them. Observation on 4/5/2024 at 8:37 am and at 1:48 pm, in room A10 revealed a dark dried substance on the bathroom floor that appeared to be human waste (feces). This condition has been present in the bathroom for approximately five hours. Observation on 4/5/2024 at 8:58 am, in room C18 revealed water holding in the bathroom sink. Interview on 4/5/2024 at 9:00 am, R62 reported that water holding in the sink has been an issue since his admission. R62 reported the sink issue was reported to an unidentified nurse weeks ago. Observation on 4/5/2024 at 9:16 am, in room B6 revealed black marks on the wall leading into the bathroom, a hole in the wall by the bathroom, food particles on the floor at the bedside, a urinal half filled with urine on a bedside dresser, hole in the wall under the television, black marks and a brown stain in the middle and the outer rim of the privacy curtain between the A bed and B bed. Observation on 4/5/2024 at 9:18 am, in room C17 revealed wall near A bed with dark black scuff marks and dark black scuff marks on the bathroom door. Observation on 4/5/2024 at 9:39 am, in room B7 revealed the corner of the wall by the bathroom paint is missing and the wall has black marks, the wallpaper on the wall is peeling at the base board (under the T.V), black scuff marks on the wall between A bed and B bed, and behind B bed. Observation on 4/5/2024 at 9:54 am, in room B8 revealed a hole in the wall at the baseboard under the television. Observation on 4/5/2024 at 10:17 am, in room B13 revealed the baseboard strip coming off the wall by A bed, missing paint and black scuff marks on the wall, wheelchair for resident in A bed had thick layer of dust and debris noted all over wheelchair. Interview on 4/5/2024 at 2:05 pm, Housekeeper DD revealed housekeepers are to clean the resident's rooms daily, and the bathrooms in the morning and in the afternoon. She verified the dried substance (feces) on the bathroom floor. She indicated it should not still be there if it was there during the morning hours. Interview on 4/5/2024 at 2:10 pm, with Environmental Account Manager CC revealed the Certified Nursing Assistant (CNA) or the nurse on the hall should have cleaned the feces up when it happened. She stated the housekeeping staff can clean and mop the floors after the feces is gotten up. Confirmation rounds conducted on 4/7/2024 at 9:30 am, the Administrator, Account Manager for Environmental Services, and the Maintenance Director, confirmed identified concerns noted during all three days of survey. Interview on 4/7/2024 at 9:45 am, Account Manager for Environmental Services revealed the housekeeping staff clean resident rooms in the morning and again in the afternoon before leaving for the day. During further interview, Account Manager revealed there is not a policy for cleaning, but stated there was a five step and seven step process that is followed. Housekeeper DD confirmed that the privacy curtains were stained with a brown substance and would be removed for cleaning. Interview on 4/7/2024 at 10:00 am, the Maintenance Director revealed he and his assistant make rounds every morning to see what repairs need to be completed for the day. He stated there is a hanging basket on the maintenance door for work order sheets for the staff to complete for any repairs needed. During further interview, the Maintenance Director stated the concerns identified during the survey would be placed on a list to be completed. Interview on 4/7/2024 at 10:10 am, the Administrator stated that she expects the facility to be always maintained in a clean and homelike environment for the residents that reside in the facility. She stated that repairs to be done when identified. 39844 36377

Based on observations, record review, interviews, and review of the policy titled Call Lights: Accessibility and Timely Response, the facility failed to ensure two residents (R) (R15 and R20) had their call light placed within their reach when they were in bed, creating the potential for their needs to not be addressed timely. Findings Include: Review of the policy titled Call Lights: Accessibility and Timely Response dated 12/1/2022 indicated the policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing to allow residents to call for assistance. Policy Explanation and Compliance Guidelines: Number 5. Staff will ensure the call light is within reach of the resident and secured, as needed. Number 6. The call system will be accessible to residents while in their bed or other sleeping accommodation within the resident's room. 1. R20 was admitted to the facility on [DATE] with diagnoses of but not limited to dementia, anxiety, and mood disturbance. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] for R20 documented a Brief Interview for Mental Status (BIMS) score of three, indicating poor cognition. Review of the care plan for R20 revised on 3/5/2024 revealed resident has the potential for falls due to unsteady gait at times and will ambulate about the facility. Interventions to care include answer call light promptly, encourage to ask for assistance, and keep call light within reach. Observation on 4/5/2024 at 8:37 am and 1:48 pm, revealed R20 lying in the bed, with the call light on floor and not within reach of the resident. 2. R15 was admitted to the facility on [DATE] with diagnoses of but not limited to dementia, mood disturbance, and muscle weakness. Review of the Admission MDS assessment dated [DATE] documented a BIMS score of 10 indicating moderate cognitive impairment. Review of the care plan for R15 revised 3/15/2024 revealed resident is at risk for falls related to dementia and encephalopathy. Interventions to care include answer call light promptly and encourage to call for assistance. Observation on 4/5/2024 at 9:03 am and 1:50 pm, revealed R15 lying in the bed, with the call light on floor and not within reach of the resident. Interview on 4/7/2024 at 9:23 am, the Administrator revealed she would expect all call lights to be in reach of the residents at all times.

Based on observations, record review, resident and staff interviews, and review of the policy titled Promoting/Maintaining Resident Dignity, the facility failed to ensure residents rights were not violated, and dignity was maintained for two residents (R) (R53 and R71). Specifically, the facility posted notification in front lobby prohibiting visitation for R53 and failed to maintain the privacy and dignity during the provision of incontinent care for R71. The sample size was 46. Findings include: Review of the policy titled Promoting/Maintaining Resident Dignity, dated 12/1/2022, documented the policy is to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each residents individuality. Compliance Guidelines: Number 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect residents rights. Number 4. The resident's former lifestyle and personal choices will be considered when providing care and services to meet the resident's needs and preferences. Number 12. Maintain resident privacy. 1. Observation on 4/5/2024 at 7:35 am, 4/6/2024 at 8:00 am, and 4/7/2024 at 8:00 am, upon entrance into the front lobby, revealed a sign posted near the visitors sign-in book visible to others, prohibiting visitation by indicating R53 is not to have any visitors other than a certain family member. If any visitors show up, please call family member immediately. revealed prohibited visitation instructional sign remained posted in the same location visual to others. Review of the clinical record revealed R53 was admitted to the facility on [DATE] with diagnoses including but not limited to cerebrovascular disease, diabetes mellitus, and hypertension. The residents most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of eight, indicating moderate cognitive impairment. Interview on 4/6/2024 at 3.00 pm, R53 revealed that he loves to have visitors and stated he was unaware of the notice posted in the lobby indicating there were visitation limitations for him. During continued interview, he reported that he only received visits from one family member, the family member who directed facility to prohibit R53's visitation rights. R53 reported he wanted visits from former friends. Interview on 4/6/2024 at 2:10 pm, the Social Service Director (SSD) and Assistant Director of Nursing (ADON) both confirmed using the front entrance daily but reported being unaware of the notice posted in the front lobby prohibiting visitation for R53. They confirmed this was a dignity issue and could not explain why the notice was posted in view of everyone who entered the facility. The ADON removed the sign from the lobby. Interview on 4/6/2024 at 2:14 pm, Receptionist UU stated the notice regarding R53 visitation has been posted at the desk for approximately two to three months. She was unaware of which staff posted the sign. Interview on 4/6/2024 at 4:14 pm, Regional Nurse Consultant confirmed that she placed the notice in the front lobby indicating restricted visitation for R53 based on the family members request. She stated that she should have placed the sign on the nurse's med cart. She confirmed that this was a dignity issue. 2. Observation on 4/5/2024 at 9:42 am, Certified Nursing Assistant (CNA) MM provided perineal care to R71, residing in B bed, without the privacy curtains being completely pulled and the window blinds were open, not providing full visual privacy. The residents roommate was in the room during the care. Review of the clinical record revealed R71 was admitted to the facility on [DATE] with diagnoses including but not limited to metabolic encephalopathy, pulmonary embolism (PE), vascular dementia, chronic obstructive pulmonary disease (COPD), and hypertension. The residents most recent quarterly MDS assessment dated [DATE] revealed a BIMS score of three, indicating severe cognitive impairment. Interview on 4/7/2021 at 1:59 pm, CNA MM revealed being unaware that privacy curtains should be completely pulled around the bed. He stated that he didn't notice the window blinds were open. He confirmed that he received training on resident dignity. Interview on 4/7/2924 at 10:15 am, the Director of Nursing (DON) reported that her expectations are that staff protect the resident rights at all times, including dignity during the provision of care. During further interview, she reported being unaware of staff posting R53's visitation restrictions in the front lobby of the facility. She stated staff will be educated regarding residents rights and dignity and providing privacy during care.

Based on record review, interviews, and review of the policy titled Care Planning-Resident Participation, the facility failed to conduct care plan meetings and ensure that residents and/or their families were invited to participate in care planning for one of 46 sampled residents (R) R5. Findings include: Review of the policy titled Care Planning-Resident Participation dated 12/1/2022 revealed the policy is the facility supports the resident's right to be informed of and participate in his or her care planning and treatment. Policy Explanation and Compliance Guidelines: 1. The facility will inform the resident in a language he or she can understand of their rights regarding planning and implementing care, including the right to be informed of their health status. 7. The facility will honor the residents choice in individuals to be included in the care planning process. 10. The facility will discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences, and allow them to see the care plan . The facility will obtain a signature from the resident and/or resident representative after discussion or reviewing of the care plan. Review of the clinical record revealed R5 was admitted to the facility on [DATE] with diagnoses including but not limited to adult failure to thrive, heart failure, Alzheimer's disease, dementia, mood disturbance and anxiety. The most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of two, indicating very poor cognition. Review of R5's electronic medical record progress notes revealed there was no documentation indicating R5's family had been invited to the resident's care plan meetings or that a care plan meeting was held. Further review revealed no signatures of resident representative participation in care plan meetings. Interview on 4/6/2024 at 4:06 pm, the MDS Coordinator stated she works remotely and does the MDS's for this facility as well as another facility. She stated comes to the facility on occasion. She stated they have not been having care plan meetings with each department or with families. Interview on 4/6/2024 at 4:10 pm, the Regional Nurse Consultant (RNC) revealed the facility has gone through multiple MDS Coordinators in the last year. She confirmed that care plan meetings have not been taking place. Interview on 4/7/2024 at 11:51 am, R5's Power of Attorney (POA) revealed he has no concerns related to his mother's care. He indicated he used to be called for the care plan meetings but has not been contacted in a long time. He stated he doesn't recall the last time he attended a meeting. Cross Refer F657

Based on record review, staff interviews, and review of the policy titled Resident Assessment-Coordination with PASRR Programs, the facility failed to ensure that two residents (R) (R29 and R85) were assessed for Level II Pre-Admission Screening/Resident Review (PASRR) and coordinate services, if warranted. The sample size was 46. Findings include: 1. Review of the clinical record revealed R29 was admitted to the facility on [DATE] with diagnoses including but not limited to schizoaffective disorder and Moderate Intellectual Disabilities (ID). Review of R29's admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was coded as two, which indicated severe cognitive impairment. Section I indicated diagnosis of schizophrenia. The PASRR section of the MDS (Item A 1500) indicated there was no PASRR Level II completed. Review of Psychiatric Diagnostic Evaluation dated 3/13/2024 listed diagnoses and assessed resident for the following mental illness schizoaffective disorder and bipolar disorder. Review of PASSR Level 1 Assessment for R29 dated 1/9/2024, revealed that Level 1 documentation indicated yes for bipolar disorder, no for schizoaffective disorder, and no for resident has ID or developmental disability prior to age 18. There was no evidence that Level II PASRR assessment was completed and in the medical record for reference. Further review of the screening instrument revealed If the nursing facility admits the applicant and discovers information that was not disclosed to the PASRR screeners, the nursing facility is required to contact the [screening authority] immediately. 2. Review of the clinical record revealed R85 was admitted to the facility on [DATE] with diagnoses including but not limited to schizoaffective disorder-bipolar type and anxiety disorder. Review of R85's admission Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS score of 15, indicating no cognitive impairment. Section I indicated diagnosis of schizophrenia. Section N indicated psychotic medications were received routinely. The PASRR section of the MDS (Item A 1500) indicated there was no PASRR Level II completed. Review of PASSR Level 1 Assessment for R85 dated 3/4/2024, revealed that Level 1 documentation indicated no for bipolar disorder, no for schizoaffective disorder, and no for resident has ID or developmental disability prior to age 18. There was no evidence that Level II PASRR assessment was completed and in the medical record for reference. Further review of the screening instrument revealed If the nursing facility admits the applicant and discovers information that was not disclosed to the PASRR screeners, the nursing facility is required to contact the [screening authority] immediately. Interview on 4/6/2024 at 1:58 pm, the Social Service Director (SSD) confirmed that R29 and R85 did not have a PASRR Level II. She reported inability to submit the forms for both residents due to lack of access to the GAMMIS website.

Based on record review, interviews, and review of the policy titled Comprehensive Care Plans the facility failed to revise the care plan to reflect current code status for one resident (R) R5. The sample size was 46. Findings include: Review of the policy titled Comprehensive Care Plans dated 12/1/2022 revealed the policy is the facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives ad timeframes to meet a residents medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessments. Policy Explanation and Compliance Guidelines: 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. Review of R5's clinical record revealed an admitted [DATE]. Diagnoses include but not limited to adult failure to thrive, heart failure, Alzheimer's disease, dementia, mood disturbance and anxiety. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R5 had an annual comprehensive care plan that was last updated on 7/3/2023. Review of the care plan initiated 8/12/2022 and revised 2/4/2024 documented resident Code status to be honored by staff per resident/family specifications. Interventions to care include Full Code status to be followed per resident/family request during review period. Review of R5's advanced directive form titled Physician Orders for Life Sustaining Treatment (POLST) signed on 6/28/2023 indicated resident was a Do Not Resuscitate (DNR). Review of R5's Physician orders revealed an order dated 6/30/2023 for a DNR. Interview on 4/6/2024 at 4:06 pm, the MDS Coordinator stated she works remotely and does the MDS's for this facility as well as another facility. She stated she comes to the facility on occasion. During further interview, she stated she has not been updating the residents' care plans. She verified the care plan did not reflect R5's current status of DNR. Interview on 4/6/2024 at 4:10 pm, the Regional Nurse Consultant (RNC) revealed the facility has gone through multiple MDS Coordinators in the last year. She indicated the care plan should reflect the current DNR status and should have been updated. She stated it is unacceptable and replied, staff should look at the Physician's orders for correct code status. During further interview, she indicated the care plan should have been updated during the last MDS update. Interview on 4/7/2024 at 11:51 am, R5's Power of Attorney (POA) revealed he has no concerns related to his mother's care. He confirmed that R5 is to be a DNR.

Based on record review, interviews, and review of policy titled COVID-19 Prevention, Response, and Reporting, the facility failed to ensure documentation was available regarding the education, offering, and administering the COVID-19 vaccine for one of five sampled residents (R) (R) R29. Findings include: Review of undated policy titled COVID -19 Prevention, Response and Reporting documented the policy is to ensure that appropriate interventions are implemented to prevent the spread of COVID-19 and promptly respond to any suspected or confirmed COVID-19 infections. Policy Explanation and Compliance Guidelines: Number 3. The facility should offer resources and counseling to healthcare personnel, residents, and visitors on the importance of receiving COVID-19 vaccinee and staying up to date with all recommended COVID -19 vaccine doses. Number 28. The Infection Preventionist, or designee, will monitor and track COVID -19 related information to include but not limited to: c. Staff and resident vaccination status. Review of the clinical record revealed R29 was admitted to the facility on [DATE] with diagnoses including but not limited to metabolic encephalopathy, epilepsy. schizoaffective disorder and Moderate Intellectual Disabilities (ID). Resident has a State appointed legal guardian who has power of attorney for healthcare. Review of R29's admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was coded as two, which indicated severe cognitive impairment. Review of R29's immunization record revealed no historical evidence that any COVID-19 vaccinations had been administered to resident, and no evidence documenting that the facility staff educated, offered, or administered the COVID-19 vaccine to resident since admission to the facility. Interview on 4/7/2024 at 10:15 am, the Infection Control Preventionist (ICP) confirmed that R29 tested positive for Covid 19 on February 22, 2024, during her stay in the facility. Interview on 4/7/2024 at 12:20 pm, the ICP stated she looked through R29's electronic medical record (EMR) and was unable locate any documentation regarding the COVID-19 vaccine was offered or given to resident. She reported that she does not have access to the Georgia Immunization Registry (GRITS) to search for immunization records for residents. During further interview, she stated the Social Service Director (SSD) is responsible for obtaining consent forms for all vaccines on admission to the facility. Once the family or resident consents to receiving the vaccine, she would administer the vaccine to the resident. Interview on 4/7/2024 at 1:15 pm, the SSD reported that R29 had a legal guardian, and the legal guardian never submitted the consent forms to allow the facility to proceed with vaccinations for Covid 19, Influenza, and pneumoccal vaccines. The process is to include the immunizations consent forms in the resident 's Admission Package. The consent forms would be uploaded in the system for IPC access. Interview on 4/7/2024 at 2:30 pm, the Director of Nursing (DON) stated that the SSD is responsible for getting the consent forms for vaccinations at the time of resident's admission to the facility. She stated that the ICP is responsible for making sure that residents have consent forms and receive vaccinations they consented for. She stated she was unaware that R29 was not given the COVID-19 vaccine after admission.