Every finding on record at Ridgewood Manor Health and Rehabilitation

Based on observations, staff interviews, record review, and review of the facility policies titled, Food and Nutrition Services Staff Policy, and Preventing Food Borne Illness-Food Handling, the facility failed to ensure food was stored, prepared, and labeled in a safe and sanitary manner, including maintaining the cleanliness of kitchen equipment. This deficient practice affected 79 residents who consume food from the kitchen with the potential to cause cross-contamination and/or food borne illness. Findings Include: On 05/04/2026 at 9:43 AM, an observation of the kitchen area revealed several food items with no label or date of opening. The food items included: observation of cooler revealed two bags of lettuce, one of which was discolored; two cartons of strawberries, one of which had a gray fluffy substance on the strawberry inside of the carton; three pitchers of orange juice, and seven pitchers of apple juice with no opened on dates. In addition, observation of a kitchen storage room revealed a popcorn machine used as a part of resident activities which was unclean and had kernel residue at the base on the inside of the popcorn machine. Finally, the ice machine used by kitchen staff for residents and staff consumption showed a black substance on the inside of the ice machine and when wiped for a clean test, it revealed a reddish/pink-tinged residue on the white paper towel. After the Surveyor observation was completed, the ice machine was taken out of service.On 05/04/2026 at 10:00 AM, an interview with the Assistant Dietary Manager confirmed the expired, unlabeled and unclean items. On 05/05/2026 at 7:03 AM, an interview with the Dietary Manager (DM) confirmed that food items with no date, no opened-on date, spoiled food, and unclean equipment is an unacceptable practice.On 05/05/2026 at 10:43 AM, an interview with Dietary Aide (DA) DA EE revealed that food items should be dated and labeled.On 05/07/2026 at 8:59 AM, an interview with Maintenance Assistance (MA) MA JJ revealed the process for work orders is as follows: maintenance work orders are received verbally by residents or staff, and the maintenance team usually will jump right on it. MA JJ stated maintenance work orders were also entered into the electronic work order system.On 05/07/2026 at 10:56 AM, an interview with the Facility Administrator and the Director of Nursing revealed that both confirmed it was their expectation that staff followed facility policies and procedures as written and confirmed the observations of outdated and unlabeled food items, unclean popcorn machine, and unclean ice machine.Review of the facility's policy titled, Food and Nutrition Services Staff Policy, reviewed/revised on 03/31/2025, documented, .1. The food and nutrition services staff, under the supervision of the Dietician and/or the food and nutrition services manager/dietary manager, will safely and effectively carry out the functions of the Food and Nutrition Services Department.Review of the facility's policy titled, Preventing Food Borne Illness-Food Handling, reviewed/revised 03/31/2025, documented, The purpose of this policy is that food will be stored, prepared, handled, and served so that the risk of foodborne illnesses are minimized.

Based on record review, staff interviews, and facility policy review, the facility failed to develop and implement a comprehensive person-centered care plan that included trauma-informed care related to the resident's experiences in order to eliminate or mitigate triggers that may cause re-traumatization related to the resident's diagnosis of Post Traumatic Stress Disorder (PTSD) for one of one resident (Resident (R)46) reviewed for person-centered care plans for PTSD out of 21 sampled residents. This failure placed the residents at an increased risk for re-traumatization of emotional distress. Findings include: Review of R46's Admission Record located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE]. Review of R46's annual Minimum Data Set (MDS) located in the resident's EMR, under the MDS tab, with an Assessment Reference Date (ARD) of 12/16/24, revealed R46 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 that indicated resident was cognitively intact. The MDS also revealed R46 had a diagnosis of PTSD. Review of R46's Encounter with PCP at [name of physician's group] located in the EMR under the Documents tab dated 04/26/22, revealed her diagnosis of PTSD was related to her past victimization from domestic violence and neglect, and to avoid triggering her PTSD by not talking about her husband or her past married life. Review of R46's Care Plan located in the resident's EMR, under the Care Plan tab, with a revision date of 10/07/24, revealed her diagnosis of PTSD with interventions to avoid PTSD triggers. However, the Care Plan did not identify the cause was a result of past victimization of neglect, domestic violence, and the triggers that could contribute to affecting her emotional and psychological health. During an interview with Certified Nursing Assistant (CNA)3 on 03/27/25 at 12:20 PM, she stated that she was not aware of the triggers that could contribute to R46's re-traumatization related to her diagnosis of PTSD. During an interview with Licensed Practical Nurse (LPN)2 on 03/27/25 at 12:30 PM, she stated she was not aware of the triggers that could contribute to R46's re-traumatization related to her diagnosis of PTSD. During an interview with the Director of Nursing (DON) on 03/27/25 at 12:45 PM, she stated she was not aware of the triggers that could contribute to R46's re-traumatization related to her diagnosis of PTSD. She said she would expect the triggers to be documented in R46's care plan and that R46's care staff should be informed of the triggers. Review of the policy titled, Care Plan revealed each resident will have a comprehensive care plan that reflects resident-centered care and services and in effort to attain or maintain the resident' highest practicable physical, mental, and psychological well-being.

Based on staff interviews, record review, and facility policy review, the facility failed to ensure three (Residents (R) 5, R15, and R59) reviewed out of 12 residents receiving hospice services out of a total sample of 21 residents had visit notes from the hospice agency. These failures could lead to the risk that the needs of these residents are not addressed. Findings include: Review of the facility policy titled, Hospice Services dated 11/01/19 revealed, Supervision/Coordination of Care Each party is responsible for documenting such communication in its respective clinical records to ensure the needs of hospice patients are addressed and met 24 hours a day. 1. Review of R59's Admission Record located in the Profile tab of the electronic medical record (EMR) revealed R59 was admitted to the facility on [DATE] with diagnoses including unspecified dementia, cerebral infarction (stroke), and paraplegia. Review of R59's Orders tab of the EMR revealed an order dated 11/24/23 to admit to hospice services related to ischemic attack (stroke). Review of R59's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD)of 03/11/25 revealed R59 was under hospice care. Review of R59's Care Plan located under the Care Plan tab of the EMR revealed a focus area for hospice services initiated 11/24/23 with an intervention to work cooperatively with hospice team to ensure spiritual, emotional, intellectual, physical and social needs are met. Review of R59's Documents tab of the EMR revealed only Interdisciplinary (IDT) notes, there were no visit notes. 2. Review of R5's Admission Record located in the Profile tab of the EMR revealed he was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease without dyskinesia, chronic obstructive pulmonary disease (COPD), emphysema, and Alzheimer's disease. Review of R5's quarterly MDS with an ARD of 12/26/24 revealed R5 was under hospice care. Review of R5's Care Plan located under the Care Plan tab of the EMR revealed a focus area for hospice services initiated 04/08/22 related to emphysema with an intervention to work cooperatively with hospice team to ensure spiritual, emotional, intellectual, physical and social needs are met. Review of R5's Documents tab of the EMR revealed only ITD notes, there were no visit notes. 3. Review of R15's Admission Record located in the Profile tab of the EMR revealed R15 was admitted to the facility on [DATE]. Review of R15's Medical Diagnosis located in the Medical Diagnosis tab of the EMR revealed R15 was admitted with diagnoses including COPD with (acute) exacerbation. Review of R15's Orders tab of the EMR revealed an order dated 05/15/24 to admit to hospice services. Review of R15's quarterly MDS with an ARD of 02/17/25 revealed R15 was under hospice care. Review of R15's Care Plan located under the Care Plan tab of the EMR revealed a focus area for hospice services initiated 05/15/24 with an intervention to work cooperatively with hospice team to ensure spiritual, emotional, intellectual, physical and social needs are met. Review of R15's Documents tab of the EMR revealed only ITD notes, there were no visit notes. During an interview on 03/26/25 at 10:05 AM the Director of Nursing (DON) stated she had to reach out to hospice for copies of hospice records. She stated hospice usually sent them over and then medical records uploaded them to the Documents tab in the EMR. During an interview on 03/26/25 at 10:13 AM the DON reviewed the notes provided by hospice and stated they were IDT notes only. The DON stated the hospice staff documented their visits using an electronic tablet, and facility staff are required to sign off on the tablet, but the hospice staff did not leave a copy of those visit notes. She stated only the IDT notes were sent over to the facility, then scanned in to the EMR later. The DON stated she would have to ask hospice to send visit notes. During an interview on 03/26/25 at 1:30 PM Medical Records (MR) staff stated hospice faxed their IDT notes over and she scanned them into the Documents section of the EMR, but only the IDT documents. She reviewed the hospice documents in the Documents tab for the hospice residents and was unable to find any visit notes. She stated they did not keep any sort of hospice binder on the unit for hard copy of visit notes either. During an interview on 03/26/25 at 2:00 PM, Licensed Practical Nurse (LPN) 3 stated the hospice staff documented care on their own electronic record via an electronic tablet. Then facility staff signed the electronic note, but facility did not get a copy of the visit notes unless the facility requested it. LPN 3 stated they did not maintain a binder with hard copy of visit notes.

Based on observations, staff interviews, and review of the facility's policy titled, Preventing Foodborne Illness-Food Handling, the facility failed to store stacked pans free from wet nesting to prevent bacterial growth and to discard leftover food items by the use by date in the walk-in refrigerator. The facility census was 77 and the deficient practices affected all 77 residents who received an oral diet. Findings include: 1. Review of the facility's policy titled, Preventing Foodborne Illness-Food Handling revealed that all food service equipment and utensils will be sanitized according to current guidelines and manufacturers' recommendations. Observation on 6/2/2023 at 9:05 a.m. of the pot and pan storage rack revealed a stack of ten medium sized rectangle steam table pans. The top three pans were turned over and all three pans had water/moisture inside. Interview on 6/2/2023 at 9:05 a.m. with the Certified Dietary Manager (CDM) confirmed that all three steam table pans were stacked, and the inside of the pans were wet. The CDM stated that staff should let pans dry completely on the drying rack before stacking. Interview on 6/3/2023 at 1:15 p.m. with the Administrator and CDM revealed that the facility does not have a policy regarding the procedure for dish washing. 2. Observation on 6/2/2023 at 9:00 a.m. of the walk-in refrigerator revealed a square steam table pan with top lid labeled cream cheese with a prep date of 5/18 and use by date of 5/30. When the lid was lifted the pan contained a cream cheese type dip. Continued observation revealed a rectangle foil pan labeled peach cobbler with a prep date 5/30 and a use by date of 6/1. Interview on 6/2/2023 at 9:00 a.m. with the CDM confirmed that the pan labeled cream cheese had a use by date of 5/30 and the pan labeled peach cobbler had a use by date of 6/1 and should have been discarded. The CDM revealed that all staff are responsible for checking leftover labels and discard if needed. The CDM stated that she usually goes through the refrigerators to ensure foods are labeled and dated and discarded if needed but had not yet completed the task.

Based on observations and staff interviews, the facility failed to maintain the walk-in freezer in a manner to prevent ice build-up from forming on the air condenser piping, this failure had the potential to contaminate food items located under the ice. The facility census was 77 and 76 residents consumed an oral diet. Findings include: Observation on 6/2/2023 at 8:55 a.m. of the walk-in freezer revealed a large ice build-up on the piping to the air condenser. The ice build-up was six inches in height and five inches wide on the piping. Interview on 6/2/2023 at 8:55 a.m. with the Certified Dietary Manager (CDM) revealed that she has never seen that ice build-up before. Observation on 6/4/2023 at 8:45 a.m. of the walk-in freezer revealed the ice build-up remained on the piping to the air condenser. The ice build-up was smaller than previous observation due to an attempt at removal. Ice remained at the top of the pipe by the air condenser housing and was the size of a golf ball. Another area on the pipe towards the bottom near the metal food rack also had ice build-up about the size of a golf ball. Continued observation revealed a sealed case of frozen yellow squash located under the air condenser and near the piping. This case of yellow squash had a layer of clear ice build-up on the back part of the lid that was about 12 inches in length, four inches in width, and quarter inch thickness. Interview on 6/4/2023 at 8:45 a.m. with the CDM revealed that she did notify maintenance verbally about the ice build-up in the freezer. The CDM confirmed that ice remained on the piping and was on the lid to the case of yellow squash. Phone interview on 6/4/2023 at 9:05 a.m. with Interim Maintenance Staff (IMS) revealed that the CDM did make him aware of the ice build-up on the pipes to the air condenser. The IMS stated that he did assess the ice and removed what he could. The IMS stated that due to the weekend he would call Monday for heating, ventilation, and air conditioning (HVAC) services to assess the walk-in freezer.

Based on observations, staff interviews, record review, and review of the facility policies titled, Resident Self-Administration of Medications and Medication Administration-General, the facility failed to clinically assess one of 26 sampled residents (R) (R#45) for the ability to self-administer medications prior to leaving medications at the bedside. The deficient practice had the potential to adversely affect the safety of R#45 and other residents in the facility. Findings include: Review of the facility's policy titled, Resident Self-Administration of Medications dated 10/1/2019 and revised 3/13/2023 revealed the purpose was each resident who desires to self-administer medications(s) is permitted to do so if the interdisciplinary team has determined that the practice would be safe for the residents and other residents of the facility. The policy stated residents are provided the opportunity to express their desire to self-administer medications. If the resident indicates they would like to self-administer, the Licensed Nurse will assess the resident's ability to safely administer medications using the Resident Medication Self-Administration Evaluation. The facility will obtain a physician's order for residents to self-administer medication and store medications at bedside. Review of the facility's policy titled, Medication Administration-General dated 10/1/2019 and revised 6/23/2022 revealed the policy was to provide resident medication efficacy and safety by following established principles of medication administration. The policy interpretation and implementation line numbered 5 stated: Residents may self-administer their medications in accordance with the Resident Self-Administration policy. Observation of medication pass on 6/3/2023 at 8:05 a.m. for R#45 with Licensed Practical Nurse (LPN) DD revealed her to leave the following medications in a 30 milliliter (ml) medication cup on R#45's overbed table without observing R#45 take them: aspirin chewable 81 milligram (mg) one tablet (a medication used to prevent pain, fever, and blood clots) atorvastatin calcium 40 mg one tablet (a medication used to lower cholesterol) isosorbide mononitrate extended release 60 mg one tablet (a medication used to treat heart failure) clopidogrel bisulfate 75 mg one tablet (a medication used to prevent blood clots) pantoprazole sodium delayed release 20 mg one tablet (a medication used to treat heartburn and acid-reflux) sitagliptin phosphate 50 mg one tablet (a medication used to lower blood sugar) vitamin B12 100 microgram (mcg) one tablet (a nutrient) vitamin D2 50 mcg one tablet (a nutrient) sertraline 50 mg one tablet (a medication used to treat depression) gabapentin 100 mg one capsule (a medication used to treat seizures) memantine 10 mg one tablet (a medication used to treat symptoms of Alzheimer's disease) ranolazine extended release 500 mg one tablet (a medication used to treat chronic chest pain) acetaminophen 325 mg two tablets (a medication used to treat pain and fever) divalproex sodium delayed release 125 mg one tablet (a medication used to treat seizures) Interview on 6/3/2023 at 8:10 a.m. with LPN DD verified she prepared the listed oral medications for R#45 and left them in a medication cup on his overbed table without observing him take the medications. She revealed R#45 preferred taking his medications with food and she left them for him to take with his meal. She further revealed R#45 did not have a completed self-administration of medication assessment or a physician's order for medication self-administration. She revealed R#45 had impaired cognition and she should have watched him take the medications and not left them in the room. Observation of R#45 on 6/3/2023 at 8:20 a.m. revealed R#45 to be sitting on his bed, eating breakfast. Further observation revealed one empty 30 ml medication cup sitting on the over bed table. Interview of R#45 revealed he did not remember taking the medication but if the cup was empty, he must have taken them. R#45 further revealed he always took his medication with meals. Interview on 6/3/2023 at 9:00 a.m. LPN EE revealed R#45 wanders frequently and his cognition was impaired. She revealed R#45 preferred to take medications with food and normally took medications without concern. She further revealed if a resident declined medications, the nurse should not leave medications at the bedside, and should return later with the medications. Review of the clinical record for R#45 revealed diagnoses including Alzheimer's disease, dysphagia, major depressive disorder, and heart failure. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed: Section C-cognitive patterns, indicated a brief Interview for Mental Status (BIMS) of five (indicating severe cognitive impairment), Section G -functional status, indicated R#45 required set-up help with activities of daily living (ADLS). Review of the Care Plan revealed a focus area for R#45 was severely impaired for decision making ability and cognitive deficit was related to short-term and long-term memory loss. Interventions included administering medication(s) as ordered. Monitor for and document side effects and effectiveness. Further review of the care plan revealed there was not a care plan focus area for resident self-administration of medications. Review of the Physician's Orders for R#45 revealed there was not a physician's order for medication self-administration. Review of the clinical record for R#45 revealed there was not an assessment for self-administration of medications. Review of the medication administration records (MAR) dated 6/2023, 5/2023, and 4/2023 revealed self-administration of medications was not documented on the MAR's. Interview on 6/3/2023 at 12:30 p.m. with the Director of Nursing (DON) revealed her expectations were for medication nurses to observe residents taking their medications when administered and not to leave medications at the bedside. She revealed prior to a resident self-administering medication, a medication self-administration assessment should be completed, and the medication self-administration policy should be followed.

Based on record review and staff interview, the facility failed to ensure that Minimum Data Set (MDS) assessments were accurate for one of 26 sampled residents (R) (R#54) related to transfers. Findings include: Review of the 3/13/2023 Significant Change MDS revealed, in section G - Functional Status, the resident is an extensive 2+ person assist for transfers. Review of the care plan dated 3/3/2023 for R#54 revealed he required assistance with Activities of Daily Living (ADL) related to cognitive deficits, had functional limitations, and tires easily. R#54 had diagnoses of Parkinson's disease, dementia with behavioral disturbance, and Chronic Obstructive Pulmonary Disease (COPD). Interventions include: 3/3/2023 Use Maxi-Move (lift device) with extra-large sling for all transfers. Review of the HLTC Safe Patient Handling Evaluation dated 7/21/2023 revealed that the Arjo's passive and active series of lifts are designed for safe usage with one caregiver. There are circumstances, such as combativeness, obesity, contracture, and others that may dictate the need for a two-person transfer. The evaluation further revealed that R#54 was, as of 7/21/2023, a sit-to-stand lift ([NAME] Flex) 1-person physical assist. Review of the HLTC Safe Patient Handling Evaluation dated 3/3/2023 revealed that the Arjo's passive and active series of lifts are designed for safe usage with one caregiver. There are circumstances, such as combativeness, obesity, contracture, and others that may dictate the need for a two-person transfer. The evaluation further revealed that R#54 is, as of 3/3/2023, a total lift (Maxi Move) 1-person physical assist. Interview and record review on 6/3/2023 at 11:00 a.m. with the Director of Nursing (DON) revealed an assessment was done on R#54 on 3/3/2023 related to use of the lift. She stated the MDS assessment should have been changed to indicate R#54 was a one-person assist with transfers using the lift. DON revealed at the time of the assessment the care plan was updated to show R#54 only required one person assist while using the new lifts. Interview on 6/03/2023 at 11:30 a.m. with the MDS Coordinator revealed she was responsible for putting in Section G: Functional Status, of the assessment. She stated she reviewed the Certified Nursing Assistant (CNA) documentation to determine the resident's functional status. The MDS Coordinator stated she was not aware there had been a change in functional status for R#54 on 3/3/2023 but that she does review the evaluations and progress notes. She revealed she has told staff it is important they let her know when changes related to MDS assessments are made so she can put in the correct information. She revealed they have discussed the concern about informing her of changes when they occur and that things have gotten much better. The MDS Coordinator revealed she was not aware of the evaluation dated 7/21/2022 when R#54 was changed to the [NAME] Flex lift, one person assist.

Based on record review and staff interview, the facility failed to follow the person-centered comprehensive care plan for one of 26 sampled resident (R) R#54 related to utilizing the correct lift for transfers. Findings include: Review of the 3/13/2023 Significant Change Minimum Data Set (MDS) revealed, in section G - Functional Status, the resident was an extensive 2+ person assist for transfers Review of the care plan dated 3/3/2023 for R#54 revealed he requires assistance with Activities of Daily Living (ADL) related to cognitive deficits, has functional limitations, and tires easily. R#54 has diagnoses of Parkinson's disease, dementia with behavioral disturbance, and Chronic Obstructive Pulmonary Disease (COPD). Interventions include: 3/3/2023 Use Maxi-Move (lift device) with extra-large sling for all transfers. Review of the nurse's note dated 5/16/2023 at 1:17 p.m. by Licensed Practical Nurse (LPN) CC revealed, in part, at approximately 2000 [8:00 p.m.], Certified Nursing Assistant (CNA) came to this nurse to report R#54 fell while she was transferring R#54 to bed. Interview on 6/3/2023 at 11:00 a.m. with the Director of Nursing (DON) revealed when the incident occurred with R#54, the CNA did not check the Plan of Care (POC) in the medical record and used the sit to stand device, which was the wrong lift.

Based on staff interview, record review, and review of the facility's policy titled, HLTC Safe Patient Handling, the facility failed to ensure the safety of one of 26 sampled residents (R) (R#54) by use of an incorrect lift resulting in a fall without injury. Findings include: Review of the facility's policy titled, HLTC Safe Patient Handling dated September 2022 revealed the facility will provide a safe work environment by implementing and maintaining a Safe Patient Handling Program that integrates evidence-based practices and technology designed to minimize the risk of injury to residents and staff caused by resident lifting and movement. Review of the HLTC Safe Patient Handling Evaluation dated 3/3/2023. The evaluation revealed that the resident is, as of 3/3/2023, a total lift (Maxi Move) one-person physical assist. Review of the HLTC Safe Patient Handling Evaluation dated 7/21/2023. The evaluation revealed that the resident was, as of 7/21/2023, a sit-to-stand lift ([NAME] Flex) one-person physical assist. Review of the nurse's notes for R#54 dated 5/16/2023 at 1:17 p.m. by Licensed Practical Nurse (LPN) CC revealed at approximately 2000 [8:00 p.m.], Certified Nursing Assistant (CNA) came to this nurse to say resident fell while she was transferring resident to bed. Upon entering the room, the resident was laying on his right side next to his bed on a fall mat. Resident denies pain, zero signs and symptoms of pain. Roommate was present in room but did not witness fall. Zero clutter noted. Resident wearing non-skid socks. Zero injuries. Zero changes with Range of Motion (ROM), Vital Signs (VS): 91/52, 66, 97.7, 20, 93% Room Air (RA). Zero changes with Level of Consciousness (LOC), Bilateral and equal hand grips, Pupils Equal, Round, Reactive to Light and Accommodation (PERRLA). Resident assisted from floor to bed with total lift, by three staff members. Resident Representative (RP) notified and Medical Doctor (MD) notified via tiger text. Immediate long-term interventions: Transfer to bed, assess need for pain meds, offer snack/drink. Long term interventions: Continue tab alarm to bed/chair, non-skid footwear, Fall mat x1. Review of the electronic medical record (EMR) revealed the plan of care indicates R#54 requires use of the Maxi-Move lift device with one person assist. Interview on 6/3/2023 at 11:00 a.m. with the Director of Nursing (DON) revealed an assessment was done on R#54 on 3/3/2023 related to use of the lift and the care plan was updated at the same time. DON explained the lifts are new and are designed so that only one person is required to assist the resident. Interview on 6/03/2023 at 1:50 p.m. with CNA AA revealed the lifts the facility currently have are new and only require one person to use the lift, but she stated if she was not comfortable with that she would get someone to help her. She stated if she was not sure what lift a resident was assessed for she looked on the computer in the plan of care and it says what type of lift the resident requires and how many people should assist. CNA AA revealed education was provided prior to the staff being able to use the new lifts and that they had to be checked off as being able to use them correctly before they were allowed to use them on the residents. Interview on 6/3/2023 at 2:00 p.m. with CNA BB revealed before she used a lift on a resident, she looked in the computer on their plan of care to see which lift they were required to have. She stated the new lifts only require one person to use but if the resident was not steady or she felt uncomfortable she would get another CNA to assist her. CNA stated they received training on the lifts 2 months prior to the lifts arriving and then when they arrived therapy trained them again and they had to be checked off as being able to use them correctly before using them on residents. Review of education provided by the DON revealed on 5/31/2023 an in-service was provided to all staff related to Lift Review. No sign-in sheets were provided and there were no in-services provided indicating the CNA was in-serviced on 5/16/2023 after the incident occurred with R#54. The CNA involved in the incident on 5/16/2023 was unavailable for interview.

Based on record review, staff interviews, and review of the facility's policy titled, Psychotropic Medication Management, the facility failed to ensure a stop date was implemented, not to exceed 14 days for psychotropic medications for two of five residents (R) (R#28 and R#64) reviewed for unnecessary medications. This failure had the potential for medication interaction, adverse reactions, respiratory depression, falls, constipation, and increased anxiety. Findings include: Review of the facility's policy titled, Psychotropic Medication Management, revised 5/3/2022, revealed as needed (PRN) orders for psychotropic medications are limited to 14 days, except if the attending physician believed it was appropriate for the PRN orders to be extended beyond 14 days. The attending physician would document their rationale in the resident's clinical record and indicate the duration and appropriateness of the PRN order. 1. Review of the Medical Doctor (MD) orders for R#28, dated 1/19/2023, revealed the MD ordered Ativan 0.5 milligram (mg), one tablet by mouth (PO) every 24 hours, PRN for agitation. The order had no stop date. Review of the Medication Administration Record (MAR) revealed R#28 was administered lorazepam 0.5 mg PO on 5/10/2023 at 8:52 a.m., 5/17/2023 at 10:52 p.m., and 5/22/2023 at 11:40 p.m., and 6/1/2023 at 11:06 p.m. Review of the Consultant Pharmacist Communication to the Physician dated January 2023 revealed lorazepam 0.5 mg every 24 hours was evaluated for R#28 based on the Centers for Medicare and Medicaid Services (CMS) regulatory limit of 14-day PRN psychotropic drugs. The medication was approved for a period of 90 days to treat agitation. The MD signed the form on 2/8/2023, which would expire on May 9, 2023, after 90 days. 2. Review of the MD orders for R#64, dated 5/2/2023, revealed the MD ordered lorazepam 0.5 mg, one tablet by mouth every 4 hours, as needed. The order had no stop date. Interview on 6/2/2023 at 9:41 a.m. with the Director of Nursing (DON), she stated the Pharmacist was supposed to ensure end dates for medications and review all the residents' medications. She noted the Resident Care Coordinator would audit the charts to ensure the monthly reviews and end dates were completed, but the position still needed to be filled at the facility. The DON stated that she and the Assistant Director of Nursing (ADON) were auditing charts until the facility filled the position. Additionally, the DON acknowledged R#28 and R#64 had a PRN order for lorazepam without an end date. Interview on 6/2/2023 at 9:47 a.m. with the ADON he said he was assisting with the medication chart audits. The ADON indicated that he understood psychotropic medications had an automatic stop date after 14 days unless the physician completed a medication extension form with clinical indications. The ADON explained that he monitored the charts at least monthly to ensure there were stop dates for psychotropic medications. The ADON acknowledged R#28 and R#64 had a PRN lorazepam order that did not have a stop date and had exceeded the 14 days.

Based on observation, staff interviews, and review of the facility's policy titled, HLTC Non-Controlled and Controlled Medication Ordering, Receiving and Storage, the facility failed to ensure one open and punctured insulin vial was discarded on the discard date on one of four medication carts. The deficient practice resulted in resident (R) (R#17) receiving doses from an insulin vial that was past the discard date. Findings include: Review of the facility's policy titled, HLTC Non-Controlled and Controlled Medication Ordering, Receiving, and Storage dated 10/1/2019 with a revision date of 1/7/2022 revealed the purpose was for the facility to comply with all laws, regulations, and other requirements related to medication ordering, receiving, and storing processes for non-controlled and controlled medications. The policy section revealed: 1. Resident medications will be ordered, received, and stored in accordance with all state and federal requirements. Review of the document titled, Insulin In-Use Expiration Dates, located on the medication cart revealed Novolog insulin vials had an expiration date of 28 days once opened. Observation on 6/3/2023 at 9:20 a.m. of Short Hall Station 1 medication cart with Licensed Practical Nurse (LPN) FF revealed one opened vial of Novolog (aspart) insulin (a medication used to treat diabetes mellitus) 100 units per milliliters (ml), 10 ml vial with a label indicating an open date of 4/23/2023 and discard date of 5/21/2023. The pharmacy label indicated the insulin was prescribed for Resident (R)#17. LPN FF verified the vial of Novolog insulin was opened, beyond the discard date, and revealed if it was in the drawer, it was being administered to R#17. Interview on 6/3/2023 at 9:20 a.m. with LPN FF revealed nurses that work on the medication carts were responsible to ensure medications were discarded on the discard date and not administered to a resident. She revealed the vial of Novolog insulin beyond discard date must have gone unnoticed by the nurses. Review of the medication administration records (MAR's) for R#17 revealed R#17 received Novolog two times a day from 5/22/2023 through 6/2/2023 for a total of 24 doses received after the discard date of 5/21/2023. Interview on 6/3/2023 at 12:35 pm with the Director of Nursing (DON) revealed her expectations were for insulin vials to be labeled with an open and a discard date when opened and to be discarded on the discard date.

Based on observations, record review, interviews, and review of the facility policy Care Planning, the facility failed to implement the care plan for three dependent residents (R) R#14, R#30, and R#43 related to not providing shower/bath as scheduled. The sample size was 35. Findings include: Review of facility policy titled Care Planning dated 12/1/2019 revealed the purpose is to provide each resident with an individualized and resident-centered care plan. Number 7. The facility will develop and implement a comprehensive, resident-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 1. Review of the clinical record for R#14 revealed resident was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#14's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment and resident requires extensive assistance with ADLs. Review of the care plan dated 8/3/2021 revealed R#14 has activities of daily living (ADL) self-care deficit related to confusion, dementia, pain in back, neck, and knees. Interventions to care include requires one person assistance with bathing/showers, avoid scrubbing and pat dry sensitive skin, and check nail length and clean/trim on scheduled bath days, and report changes to nurse. Interview on 11/08/2021 at 10:27 a.m. with R#14, she stated she had not received a shower in two weeks. She further stated she is scheduled to receive showers on Tuesdays, Thursdays, and Saturdays. Interview on 11/10/2021 at 8:34 a.m. with R#14, she stated she still had not received a shower. R#14 further stated the staff provided her with bath wipes to wipe herself off when a shower is not provided. 2. Review of the clinical record review for R#30 revealed resident was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#30's Annual MDS dated [DATE] revealed a BIMS score of 15, indicating no cognitive impairment. Further review revealed, R#30 requires extensive two-person assistance with ADLs. Review of the care plan revised 10/9/2021 revealed R#30 has ADL self-care deficit related to history of [CONDITION(S)] ([CONDITION(S)]) with [CONDITION(S)], decreased sitting balance, and functional limitations. Interventions to care include resident requires limited to extensive assistance with hygiene, toileting, and oral care. Interview on 11/7/2021 at 2:16 p.m. with R#30, she stated she is supposed to get a shower/bath three times a week but has not received a bath in approximately four weeks. Interview on 11/9/2021 at 12:20 p.m. with Certified Nursing Assistant (CNA) AA and Licensed Practical Nurse (LPN) BB, confirmed that there was no evidence that R#30 had received a shower or bath since 10/26/2021. 3. Review of the clinical record for R#43 revealed resident was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review for R#43's Quarterly MDS dated [DATE] revealed a BIMS score of 9, indicating moderate cognitive impairment and resident requires extensive assistance with ADLs. Review of the care plan dated 9/29/2021 revealed R#43 has an ADL self-care deficit related to dementia, [CONDITION(S)], impaired balance, limited mobility. Interventions to care include requires extensive dependence on staff for personal hygiene and oral care. Monitor/document/report any changes. Observation on 11/07/2021 at 1:45 p.m. R#43 was in his room sitting in his wheelchair watching TV. Resident's clothing was visibly soiled with what appeared to be red stains on pants and shirt. Resident had dried red substance on his face and his hair appeared greasy and disheveled. Interview on 11/10/2021 at 10:30 a.m. with the DON, stated residents should receive a shower/bath two or three times a week, depending on their bath schedule. DON further stated her expectations are that the baths should be completed as scheduled. Cross Refer F677

Based on observations, record review, interviews, and review of the policy Activities of Daily Living, the facility failed to provide showers/baths as scheduled for three dependent residents (R) R#14, R#43, and R#30. The sample size was 35. Findings include: Review of facility policy titled Activities of Daily Living dated 1/1/2019 revealed residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care), mobility (transfer and ambulation, walking), elimination (toileting), dining (meals and snacks), and communication (speech, language, and any functional communication systems). 1. Review of the clinical record for R#14 revealed resident was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#14's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment and resident requires extensive assistance with ADLs. Review of the Ridgewood Manor Documentation Survey Report for Activities of Daily Living (ADL) for R#14, revealed shower/bath days as Tuesday, Thursday, and Saturday, on the day shift (7:00 a.m. to 3:00 p.m.). For the month of September 2021, R#14 did not receive a shower/bath on her scheduled shower days for 11 of 13 days. For the month of October 2021, R#14 did not receive a shower/bath on her scheduled shower days 13 out of 13 days. For November 2021 revealed there was no documentation of R#14 receiving a bath during this timeframe. During further review, there is no documentation the resident refused showers or baths on the scheduled days. Interview on 11/8/2021 at 10:27 a.m. with R#14, she stated she is scheduled to receive showers on Tuesdays, Thursdays, and Saturdays. During further interview, she stated she had not received a shower in two weeks. Interview on 11/9/2021 at 1:26 p.m. with Certified Nursing Assistant (CNA) DD, stated that residents shower/bath days based on A bed or B bed. She stated that completed showers are documented in the shower book. She stated that if a resident refuses their shower/bath, staff will try again. If the resident continues to refuse, this is communicated to charge nurse. During further interview with CNA DD, she stated some days she feels she is rushed to complete resident showers/baths due to staff shortage. Interview on 11/10/2021 at 8:34 a.m. with R#14, she stated that she still had not received a shower. R#14 further stated the staff provided her with bath wipes to wipe herself off when a shower is not provided. 2. Review of the clinical record for R#43 revealed resident was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review for R#43's Quarterly MDS dated [DATE] revealed a BIMS score of 9, indicating moderate cognitive impairment and resident requires extensive assistance with ADLs. Review of the Ridgewood Manor Documentation Survey Report for Activities of Daily Living (ADL) for R#43, revealed shower/bath days as every other day, on the day shift (7:00 a.m. to 3:00 p.m.). For the month of September 2021, R#43 did not receive a shower/bath on his scheduled shower days for seven of 14 days. For the month of October 2021, revealed there was no documentation of R#43 receiving a bath during this timeframe. For November 2021, revealed there was no documentation of R#43 receiving a bath during this timeframe. During further review, there is no documentation the resident refused showers or baths on the scheduled days. Observation on 11/7/2021 at 1:45 p.m. R#43 was in his room sitting in his wheelchair watching TV. Resident's clothing was visibly soiled with red stains on pants and shirt. Resident had dried red substance on his face and his hair appeared greasy and disheveled. Interview on 11/9/2021 at 11:25 a.m. with CNA EE revealed that due to a shortage in staff, the shower team has not been able to provide showers on a consistent basis. CNA EE revealed they offer the residents the option of a bed bath when there is enough staff as an option. CNA EE stated when a shower is provided, this information is documented in the shower book and when a resident refuses a shower it is documented in the chart and reported to the charge nurse. 3. Review of the clinical record review for R#30 revealed resident was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#30's Annual MDS dated [DATE] revealed a BIMS score of 15, indicating intact cognition. Further review revealed, R#30 requires extensive two-person assistance with ADLs. Review of the Ridgewood Manor Documentation Survey Report for Activities of Daily Living (ADL) for R#30, revealed shower/bath days as Tuesday, Thursday, and Saturday, on the day shift (7:00 a.m. to 3:00 p.m.). For the month of September 2021, R#30 did not receive a shower/bath on her scheduled shower days four out of 13 days. For the month of October 2021, R#30 did not receive a shower/bath on her scheduled shower days two out of 11 days. For November 2021 to current survey date, R#30 did not receive a shower/bath on three out of four scheduled days. During further review, there is no documentation the resident refused showers or baths on the scheduled days. Interview on 11/7/2021 at 2:16 p.m. with R#30, she stated that she is supposed to get a shower/bath three times a week but has not received a bath in approximately four weeks. Interview on 11/9/2021 at 12:20 p.m. with CNA AA and LPN BB, confirmed R#30 had not received a shower/bath since 10/26/2021. Interview on 11/10/2021 at 10:30 a.m. with Director of Nursing (DON) revealed there was a shower team but due to staff shortage, CNAs are responsible for completing showers as indicated by the shower schedule. She stated the shower/bath process is A Bed on one day and then B bed on the next day: then alternating days the following week. During further interview, she stated the resident should receive a bath two or three times a week and as requested by resident and according to preference. The DON stated that her expectation is that staff complete showers for residents as scheduled and requested.

Based on staff interviews, staff written statements, facility venipuncture policy, and the nurse professional standards act, the facility failed to ensure that one (1) nurse follow guidelines of removing a tourniquet after a blood draw, from one (1) resident (R#1) from a sample of eight (8) residents. The Facility Census is currently 67. Findings include: Review of the Rule 410.10.03 Georgia Standard of Practice for Registered Professional Nurses, Definition of Un-professional Conduct, indicate; (1) Nursing conduct failing to meet the minimal standards of acceptable and prevailing nursing practice, which could jeopardize the health, safety, and welfare of the public, shall constitute unprofessional conduct. This conduct shall include, but not limited to the following: 2. Practice - (a) using inappropriate or unsafe judgement, technical skill or interpersonal behaviors in providing nursing care; (g) failing to take appropriate actions to safeguard a patient's welfare. Interview on 10/26/2020 at 12:58 p.m. with the Director of Nursing (DON) revealed that an agency Registered Nurse (RN) left a tourniquet on resident #1 (R#1's) arm after performing venipuncture. She revealed that the resident's arm was assessed with [REDACTED]. She revealed that during her investigation of the incident, it was found that the tourniquet was left on the residents' right arm for at least twelve (12) hours although no injuries were noted on the resident. She revealed that the resident was sent to the hospital for evaluation of the right arm. An interview with Certified Nursing Assistant (CNA) MM revealed that she worked 7:00 p.m. until 7:00 a.m. on 8/16/2020 and discovered during her last rounds at 5:30 a.m. that R#1 had a tourniquet around her right upper arm which she removed and took to the nurse. She revealed that the residents' arm was blue and swollen and that the resident denied hurting or having pain. She revealed that the resident had on a gown that had a sleeve that came down to her elbow area and that the tourniquet was located on the resident's upper arm above the elbow. She revealed that while providing care throughout the night, she had not noticed the tourniquet because the sleeves covered the arm. Review of written statement dated 08/16/2020 14:39 p.m. from Registered Nurse (RN) NN indicated on 8/15/2020 orders were received to draw blood on R#1. At 17:50 p.m. a tourniquet was placed to her right arm and blood was drawn from her right antecubital. I forgot to remove the tourniquet from her arm and was informed that it was found on her the next morning. Review of the facility Lippincott Procedures Hamilton Medical Center, (revised: May 15, 2020) - Venipuncture Policy indicated the nurse/staff drawing blood should immediately release the tourniquet when blood begins to flow into the collection container. Review of the Agency Nurse Professionals Critical Skills Check List dated 8/3/2020 indicated that the Registered Nurse (RN) NN was proficient in Phlebotomy/ IV Therapy/ Invasive Procedures- drawing venous blood. It further indicated that the (RN) NN would perform all nursing functions within the RN's scope of practice. Cross refer to F684

Based on staff interviews, nurses notes, and facility incident report, the facility failed to ensure that the tourniquet was removed by the nurse from one resident's (R#1) arm, after drawing blood, from a sample of eight (8) residents. Findings include: Review of the facility Lippincott Hamilton Medical Center Venipuncture Policy (revised: May 15, 2020), indicated Implementation: Immediately release the tourniquet when blood begins to flow into the collection container. Review of Nurses Note, dated 8/16/2020 at 5:50 a.m., revealed that the nurse went to resident's room accompanied by one CNA to assist with turning resident to administer [MEDICATION NAME] 1-gram (gm) intramuscular (IM) injection. The CNA (Certified Nursing Assistant) assisted with turning resident onto left side while this nurse administered IM injection into the right hip using proper landmarks. Upon repositioning resident this nurse noticed a tourniquet on right arm. The nurse immediately removed the tightened tourniquet and assessed. Right arm severely swollen, mildly cool to touch with positive radial pulses, red indented area where the tourniquet was placed. Elevated right arm on pillows and gently massaged arm for approximately 20 minutes. Resident c/o (complained of) discomfort. At approximately 6:30 a.m. notified weekend supervisor of situation. She stated she would handle it when she arrived as she was on her way in. Review of the Nurses notes dated 8/16/2020 indicated resident sent to Emergency Department for evaluation and treatment of [REDACTED]. Review on Nurses notes dated 8/16/2020 13:00:11 (1:11 p.m.) indicated at 9:35 a.m. an order was received to send resident to the Emergency Department to be evaluated and treated r/t (related to) tourniquet being left on right arm for approximately 12 hours. Resident left the facility at 10:00 a.m. Review of the Hospital Emergency Department (ED) records revealed that R#1 arrived at 10:17 a.m. on 8/16/2020, with the following Diagnoses: [REDACTED]. Review of the History and Physical, dated 8/16/2020, revealed Extremities: good pulses in all extremities. Easily palpable right radial pulse, Linear [DIAGNOSES REDACTED] just proximal to the AC (antecubital) fossa, swelling distally. Petechial subq (subcutaneous) hemorrhage around AC. Further review of the ED records revealed that an Ultrasound (US) extremity Doppler unilateral was performed with result of no [MEDICAL CONDITION] (deep vein thrombus) in arm. The resident was discharged back to the facility on [DATE] at 11:21 a.m. with Physician order [REDACTED]. Review of written statement dated, 08/16/2020 14:39 (2:39 p.m.)., from Registered Nurse (RN) NN revealed that on 8/15/2020 orders were received to draw blood on R#1. At 17:50 p.m. a tourniquet was placed to her right arm and blood was drawn from her right antecubital. I forgot to remove the tourniquet from her arm and was informed that it was found on her the next morning. Review of written statement, dated 8/16/2020, from Certified Nurse Assistant (CNA) OO revealed that she was helping CNA MM do rounds at 5:00 a.m. They went into room to change R#1 and the nurse came in there to give the resident a shot and mentioned the swelling and walked out. CNA OO went around to the other side of the bed to look at the resident's arm and seen (sic) the tourniquet, I immediately removed it and took it to the nurse, once the nurse came back into the room, I walked out. Review of laboratory (lab) orders indicated a verbal order was given by the Nurse Practitioner (NP) on 8/15/2020 to draw BNP (Brain Natriuretic Peptide), CMP (Complete Metabolic Panel) one time only for [MEDICAL CONDITIONS] for one day. Review of lab form. dated 8/16/2020 at 17:50 (5:50 p.m.) indicated BNP, Complete Metabolic Panel- were drawn by RN NN. Interview on 10/26/2020 at 12:58 p.m. with the Director of Nursing (DON) revealed that an Agency nurse left a tourniquet on R#1's arm. She revealed that the resident's arm was assessed, with [MEDICAL CONDITION] and redness was noted. She revealed that during her investigation of the incident, it was found that the tourniquet was left on the residents' right arm for at least 12 hours. She revealed that no injuries were noted on the resident although the resident was sent to the hospital for evaluation of the right arm. Interview on 10/29/2020 at 11:48 a.m. with the DON revealed that the facility usually use an outside lab services; but, due to COVID-19 outbreak in the facility, a decision was made for nurses to collect the lab specimens in house, to prevent the spread of COVID-19. She revealed that all agency nurses were trained to draw blood, passed competency tests for blood draw (tourniquet placement and removal). She revealed that the lab slip revealed that RN NN drew the labs at 17:50 (5:50 p.m.) on 8/15/2020. Interview on 10/29/2020 at 1:47 p.m. with Certified Nurse Assistant (CNA) MM revealed that she worked 7:00 p.m. to 7:00 a.m. She revealed that R#1 had a tourniquet around her right upper arm that she removed on her last rounds about 5:30 a.m. on 8/16/2020 then took it to the nurse. She revealed that the residents' arm was blue and swollen. She revealed that the resident denied hurting or having pain. She revealed that the resident had on a gown that had a sleeve that came down to her elbow area and that the tourniquet was located on the resident's upper arm above the elbow. She revealed that while providing care throughout the night, she had not noticed the tourniquet because the sleeves covered the arm.

Based on record review, observations, staff interviews and review of the facility's document entitled, Relias Learning Transmission-Based Precautions, the facility failed to ensure staff followed isolation precautions for one (1) of two (2) sampled residents (Resident #1) who was on contact precautions. The findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's urinalysis (UA) lab results dated 6/8/20, revealed the presence of ESBL (extended spectrum beta lactamase, which are chemicals produced by a certain bacteria.) Review of a June 2020 physician's orders [REDACTED]. On 6/10/20 at 10:00 a.m. during an observation on the 100 hall, Resident #1's room had an isolation cart outside the door. There was no signage on the door indicating isolation precautions should be followed, and the door was open. During an interview on 6/10/20 at 10:55 a.m., the Interim Director of Nursing (DON) stated there were currently two (2) residents who required contact isolation. Residents on contact isolation should have signage on the door, and staff are to wear personal protective equipment (PPE) including gown, gloves, and a mask. On 6/10/20 at 11:05 a.m., Certified Nurse's Aide (CNA) #1 was observed in Resident #1's room. She was wearing only a mask with no gown or gloves. She moved some items on the resident's over bed table, received a card from the resident, moved the resident's bed, placed the card on the resident's wall, and moved the bed back to the original position. The Interim DON arrived at the room and noted the CNA not wearing a gown and gloves. She asked the CNA to step out of the room and without removing the mask, the CNA exited the room. The Interim DON instructed the CNA on the use of PPE. The CNA stated, I didn't know I was supposed to put all that on. She was asked to change her mask by the Interim DON on exit to the room. During an interview on 6/10/20 at 12:00 p.m., the infection control nurse stated it was her expectation for staff to wear a gown, gloves, and a mask in rooms with residents who required contact precautions. She stated the Relias documents provided were the policy for transmission based precautions used by the facility. During an interview with CNA #1 on 6/10/20 at 2:25 p.m., she stated she had entered Resident #1's room to respond to the needs of the resident's roommate and, I know I should have gowned up. She stated she has had training on proper use of PPE. A review of the facility document entitled, Relias Learning Transmission-Based Precautions, dated 2017 Section 3: Strategies for Practice Contact Precautions, read, When a resident is on contact precautions, you will be required to put on gloves and a gown upon entering the room.

Based on record review and staff interview and review of facility policy, the facility failed to ensure that controlled medications were free from misappropriation for two (2) residents (R), (R#1 and R#2) from a sample of three (3) residents. The facility census was ninety-six (96) residents. Findings include: Review of facility policy titled Grievances, Abuse Prohibition, Intent, Reviewed and Updated for Release (MONTH) (YEAR), revealed the following: It is the intent of this center to actively preserve each patient's right to be free from mistreatment, neglect, abuse, or misappropriation of patient's property . Misappropriation of patient property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a patients belongings or money without the patient's consent. 1. Review of the clinical record for R#1 revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the latest Minimum Data Set (MDS) completed on 10/25/18, revealed R#1 had been unable to complete Brief Interview for Mental Status (BIMS) scoring. Continued review revealed R#1 received opioid pain medication, had mild pain and received scheduled and as needed (PRN) medications for pain. Review of physician's orders [REDACTED]. Review of Controlled Drug Records revealed R#1 had documentation of five (5) PRN [MEDICATION NAME] administrations from 10/1/18 through 10/31/18. Continued review of Controlled Drug Records revealed R#1 had administrations of PRN [MEDICATION NAME] documented thirty-three (33) times from 11/1/18 through 11/30/18. The Controlled Drug Record from 11/29/18 through 12/6/18 was missing and the facility provided a faxed copy, used to reorder [MEDICATION NAME] from the pharmacy. A review of the pharmacy manifest of dates [MEDICATION NAME] orders were filled for R#1 revealed this [MEDICATION NAME] order for thirty (30) tablets was filled on 11/26/18. The documentation was completed on the faxed copy from 11/29/18 through 12/4/18. The [MEDICATION NAME] was reordered according to the fax date stamp on 12/4/18 and there were fifteen (15) remaining [MEDICATION NAME] on 12/4/18. Five (5) lines were blank on the faxed copy. R#1 also had Physician orders [REDACTED]. There were four (4) PRN documentations on the MAR for R#1, from 12/4/18 through 12/6/18 and these were subtracted from the missing [MEDICATION NAME] documentations. Six (6) [MEDICATION NAME] tablets, prescribed for R#1, were not accounted for on Controlled Drug Records or Medication Administration Records from 12/4/18 through 12/6/18. The next available Controlled Drug Record for [MEDICATION NAME] for R#1 was also a copy of the record faxed to the pharmacy to reorder on 12/13/18. A review of the date of this reorder revealed this order for 30 [MEDICATION NAME] was filled on 12/4/18. Documentations were recorded from 12/7/18 at 12:00 a.m. through 12/14/18 at 12:00 a.m. and there were seven (7) [MEDICATION NAME] that could not be accounted for when compared with the MAR. [MEDICATION NAME] was documented as administered on this copy of the Controlled Drug Record with seven [MEDICATION NAME] remaining. The next Controlled Drug Record was also a faxed copy with documentations from 12/14/18 through 12/20/18. This order for 30 [MEDICATION NAME] was filled on 12/14/18. [MEDICATION NAME] was also documented administered on this Controlled Drug Record for the second time on 12/14/18 at 12:00 a.m. There were seven (7) [MEDICATION NAME] that could not be accounted for. No documentations of the MAR indicated [REDACTED]. The faxed date stamp revealed [MEDICATION NAME] was reordered with eleven (11) tablets remaining on 12/20/18 at 12:00 p.m. Between 12/20/18 at 12:00 p.m. and the next Controlled Drug Records first documentation on 12/21/18 at 12:00 a.m. a comparison with the MAR indicated [REDACTED] The next Controlled Drug Record was an original, with documentations of administration beginning 12/21/18 at 12:00 a.m. and ending on 1/1/19 at 12:00 a.m. was reviewed and did not reveal any [MEDICATION NAME] was not accounted for. The Controlled Drug Record for 1/1/19 through 1/9/19 was also reviewed and there were no [MEDICATION NAME] tablets not accounted for. A narcotic count for R#1 was conducted on 1/9/19 at 12:20 p.m. and the count of controlled drugs was correct. Packaging of the controlled medication was observed and intact without evidence of tampering. There were no PRN [MEDICATION NAME] administrations documented on the Controlled Drug Records or (MONTH) (YEAR) and (MONTH) 2019 MAR's from 12/26/18 through 1/9/19 at 12:00 a.m. Observations of R#1 were conducted on 1/9/19 at 11:50 a.m., 1/9/19 at 12:40 p.m., 1/15/19 at 10:50 a.m., and 5:15 p.m. revealed R#1 was comfortable and no signs of discomfort were observed. Record review of Nurse's Medication Notes dated 11/3/18 at 12:00 a.m. revealed R#1 had requested her scheduled [MEDICATION NAME] at 12:00 a.m. Continued review revealed R#1 had told the nurse she was supposed to get her pain pill on 11/4/18 at 12:00 a.m. Record review of Nurse's Progress notes from 10/1/18 through 1/8/19 did not reveal any notes regarding unrelieved or continued pain. References in summaries were reviewed revealing R#1 was administered scheduled and PRN pain medication but there were no specific notes regarding dates and times of administrations to account for the missing [MEDICATION NAME]. An interview conducted with R#1 regarding pain medications on 1/9/19 at 11:50 a.m. revealed she was aware she was administered pain medication and it was effective. R#1 was unsure and could not remember if she requested pain medication. R#1 revealed she was not currently experiencing pain or discomfort. 2. Review of the clinical record for R#2 revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS for R#2 completed on 10/24/18 revealed a BIMS of 12, indicating moderate cognitive impairment. Review of physician's orders [REDACTED]. Review of the Pharmacy manifest listing dates filled for 30 [MEDICATION NAME] 5-325 mg every 8 hours PRN order for R#2 revealed a missing Controlled Drug Record faxed to the Pharmacy for refill on 11/23/18. The next available Controlled Drug Record had been retrieved from copies of Controlled Drug Records that had been faxed to the pharmacy for refill. The copy of the reorder was reviewed and documentation of administrations started on 11/29/18 and stopped on 12/10/18 at 8:00 p.m. with twelve (12) [MEDICATION NAME] left. Review of the (MONTH) (YEAR) and (MONTH) (YEAR) MAR's for R#2 revealed from 12/10/18 at 8:00 p.m. when the faxed copy of the Controlled Drug report ended, and the first [MEDICATION NAME] administered from the next Controlled Drug Record started on 12/13/18 at 8:00 p.m., there were documentations of two (2) administrations. Ten (10) [MEDICATION NAME] 5-325 prescribed for R#2 were not accounted for. Observations of R#2 on 1/9/19 at 12:54 p.m., 1/15/19 at 4:30 p.m. and 1/15/19 at 5:20 p.m. revealed no indications of pain or discomfort. Record reviews of the Nurse's Progress Notes and Physician's Progress Notes from 10/1/18 through 1/8/19 did not include any complaints of unrelieved pain. An interview was conducted with R#2 regarding pain medication on 1/9/19 at 12:46 p.m R#2 revealed she experiences pain from arthritis in her back, neck, shoulders arms and legs. R#2 revealed she asks for pain medication usually once or twice a day and receives it when she asks. R#2 revealed the pain medication is effective. She is able to go to meals in the dining room and activities and visit with her spouse after being administered the pain medications. An interview was conducted with the Director of Nursing (DON) on 1/9/19 at 9:10 a.m. regarding missing controlled drugs. The DON revealed the Assistant Director of Nurses (ADON) had texted a message to her on 11/7/18, that LPN AA administered more narcotics than other nurses. The DON revealed she had compared administrations documented on the Controlled Drug Reports with the corresponding Physician orders [REDACTED]. The DON revealed she was called by Unit Manager DD on the morning of 11/30/18 and was informed that the 7:00 a.m. change of shift count was incorrect. The DON revealed when she arrived at the facility Unit Manager DD showed her a blister pack of [MEDICATION NAME] belonging to R#1 that had been tampered with. LPN AA had worked the day before and administered medication to R#1. The DON revealed the package was [MEDICATION NAME] 10-325 mg and the there were opened foil seals that had been taped in the middle of the blister pack. The pills looked the same to the DON. When she checked the numbers on the substituted pills on the internet they were [MEDICATION NAME] 5-325. The DON and Administrator then made the decision to conduct drug screening for the nurses that had access to the Station 2 short hall medication cart, where R#1 resided. LPN AA had no opiates reported on her drug screen. The Consultant Pharmacist had been called, and came to the facility and destroyed the [MEDICATION NAME] 5-325 that had been substituted for 10 mg [MEDICATION NAME]. The DON revealed she and Unit Manager DD had counted and looked at packaging for all the other narcotics on Station 2 and had not found anything else tampered with, including [MEDICATION NAME] 5-325. The DON revealed she and Unit Manager DD continued to watch LPN AA and in general the controlled drug administrations on Station 2. On 12/26/18 Unit Manager DD and Staff Development Coordinator (SDC) GG had counted narcotics after 9:00 a.m. medication pass on Station 2 short hall cart was completed because LPN AA had gone in and out of the bathroom [ROOM NUMBER] or 4 times carrying her purse. They found the narcotic count was incorrect. The DON revealed the time of this unscheduled count was approximately 10:30 a.m. The Charge Nurses with access to the Station 2 short hall cart, including LPN AA who was administering medications from this cart on 11/30/18, were drug screened. LPN AA was suspended pending investigation and called a few hours later and resigned. The DON acknowledged she had not audited for missing narcotics at any time while watching LPN AA or the administration of controlled drugs on Station 2, by comparing MAR's to Controlled Drug Reports and then comparing pharmacy shipment manifests to determine if medication was being misappropriated.

Based on record review, review of facility policy, Administrator interview, and an interview of Georgia Crime Information Center Help Desk staff, the facility failed to ensure a Georgia Crime Information Center background check was completed for one (1) of six (6) licensed nurses hired during (MONTH) (YEAR) and (MONTH) (YEAR). The facility census was ninety-six (96) residents. Findings include: During a record review of employees files for licensed nurses, a failure to provide a Georgia Crime Information Center ( GCIC) background check was identified, related to a Licensed Practical Nurse (LPN) (LPN AA), hired on 10/2/18. The employee file for LPN AA included federal and Tennessee background screening. A review of facility policy titled Abuse Prohibition- Screening and Hiring Practices reviewed and updated for release (MONTH) (YEAR), revealed prior to hiring an employment applicant, the center shall request a criminal record check from GCIC to determine whether the applicant has a criminal record. Review of background checks for the six licensed nurses hired by the facility from 10/1/18 through 1/8/19 revealed an incomplete background check, missing the GCIC screening, for LPN AA. A review of Grievances, Entity Reported Incidents and Resident Council Minutes for 10/1/18 through 1/9/19 revealed the name of LPN AA was not mentioned. Further review of the employee file for LPN AA revealed she was suspended on 12/26/18, when the narcotic count on her medication cart was incorrect. Review of the separation notice for LPN AA revealed she left the facility after suspension pending further investigation and called back and resigned without notice on 12/26/18. An interview with the Administrator regarding pre-employment screening on 1/9/19 at 3:25 p.m. revealed he had called the third-party provider of background checks for the former corporation and they had told him LPN AA did not have a GCIC because she did not have a Georgia drivers license or address. A review of an email, provided by the Administrator on 1/9/19 at 5:05 p.m., addressed to the Administrator and sent on 1/9/19 at 4:59 p.m., from the former corporations third party background check provider, revealed the facility entered the request for a background check for LPN AA on 9/19/18 and did not request a statewide criminal search for Georgia. On 1/15/19 at 12:13 p.m. the GCIC Help Desk was contacted. The employee who answered the call would not provide her last name but explained that GCIC background checks include accessing the data bases of smaller municipalities and county court records that sometimes have a delay in reporting to the main GCIC database. These reports would also be delayed in reaching the federal and out of state criminal information systems. The GCIC employee revealed a Georgia address and drivers license were not a requirement for an employer to receive a GCIC background check because people from other states do commit crimes in Georgia.

Based on record review, Administrator and staff interview, and review of facility policy, the facility failed to report a situation involving misappropriation of a controlled drug ([MEDICATION NAME]) to the State Complaint Investigation Intake and Referral Unit or the local Police Department, for one (1) resident (R) (R#1) from a sample of three (3) residents. The facility census was ninety-six (96) residents. Findings include: A review of facility policy titled Reporting and Investigating Abuse Reviewed and Updated for Release (MONTH) (YEAR), revealed once a complaint or situation is identified involving alleged mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of patient property the incident will be immediately reported .The Administrator or designee will immediately notify the Complaint Investigation Intake and Referral Unit .of the incident and the pending investigation . Contact the local Police Department if there is reasonable cause to believe abuse or suspicion of a crime has occurred, to begin and investigation . Even if the police are called, the center will call the Complaint Investigation Unit as soon as possible. An interview conducted on 1/9/19 at 9:05 a.m. with the Administrator regarding an allegation of controlled medication misappropriation, revealed the Director of Nurses (DON) had been notified by the Assistant Director of Nurses (ADON) that on Station 2, a bottle of liquid [MEDICATION NAME] looked like it had been punctured from the top. The DON then joined the interview at 9:10 a.m. and revealed she had immediately examined the bottle and there was no sign of a puncture. The DON revealed she was not sure of the date this occurred and did not document the incident. The DON revealed the liquid was all the same in appearance and counted correctly when compared with the Controlled Drug Record, and there was no action to be taken. The Administrator revealed he had been made aware by the DON of an allegation made by the ADON on 11/7/18 that a Licensed Practical Nurse (LPN), (LPN AA) was administering more controlled medications than the other charge nurses. The DON revealed she and the Station 2 Unit Manager RN DD immediately counted narcotics and checked the resident's orders and could not find any controlled drugs being administered outside of the time frame allowed by the physician's orders [REDACTED]. The Administrator then revealed he had called the corporation and spoke to a Regional Vice President regarding possible drug testing. The Administrator revealed he was told that without more evidence than giving more narcotics than other nurses that drug screens on the nurses could not be conducted. The DON revealed she was informed by Unit Manager DD that the count was incorrect on Station 2 on 11/30/18 at 7:00 a.m. The DON revealed the Unit Manager had told her that five (5) or six (6) [MEDICATION NAME] 5 milligram (mg) had been substituted for 10 mg [MEDICATION NAME] on one resident's blister pack. The blister pack had been opened from the back and the pills substituted and then the foil on the back of the package had been taped. The DON revealed she and the Administrator had then instructed the ADON to conduct drug screens on the nurses on Station 2, and LPN AA had not tested positive for [MEDICATION NAME]. The DON revealed the count was incorrect again on the medication cart used by LPN AA on 12/26/18 and LPN AA was then suspended and she called back to resign without notice about 2 hours later. The Administrator revealed he had called the Consultant Pharmacist and discussed the above events on 11/30/18 and discussed the issue at the Quality Assurance meeting with the former interim Medical Director on 12/20/18. The Administrator revealed no one could think of anything else to do than what had already been done. Review of Medication Discrepancy Reports for R#1 from 10/1/18 through 1/8/18 revealed a Medication Discrepancy Report was completed on 11/30/18 as follows: Resident had orders for 10 mg [MEDICATION NAME], Three tablets were punched out and replaced with 5 mg tablets. Reported to Pharmacist - (3) 5 mg [MEDICATION NAME] were destroyed by DON/Pharmacist. This report was signed by the DON and Pharmacist on 11/30/18. A second discrepancy report dated 12/26/18 was reviewed as follows: Medication not given or signed out with doses missing- Hydro(sic) 10/325 mg X 3 missing. No harm to resident(s). Signed by LPN GG and on 12/30/18 the Consultant Pharmacist.Physician response was noted. An interview was conducted on 1/15/18 at 6:15 p.m. with the Administrator, related to reporting abuse. The Administrator revealed he had not considered missing medication as misappropriation of resident property and had not considered the evidence concrete enough to report to the police or the State Complaint Investigation Intake and Referral Unit.

Based on record review, staff, Administrator and Consultant Pharmacist interviews, review of facility policy and review of Consultant Pharmacist Monthly reports, the Consultant Pharmacist failed to audit Medication Administration Records (MAR's) and Controlled Drug Records when conducting monthly medication regimen reviews to address documentation irregularities related to the administration of an opiate, [MEDICATION NAME], for two residents (R) (R#1 and R#2) from a sample of three (3) residents. The facility census was ninety-six (96) residents. Findings include: Review of facility policy titled Controlled Medication Administration reviewed and updated (MONTH) 20, 2009, revealed the following procedural guideline: When a PRN (as needed) controlled medication is administered, the order of documentation is : 1st MAR, 2nd Nurses Medication (Med) notes, 3rd Controlled Drug Record Sheet. Review of Monthly Consultant Pharmacist Report Indicators for Appropriate Use of Medication revealed the following: J. Medications are used in the presence of acurate(sic) documentation, transcription and policy adherence pertaining to the use of any prescribed medication or treatment. 1. Review of the clinical record for R#1 revealed a physician's orders [REDACTED]. Review of the (MONTH) (YEAR) MAR for R#1 revealed two (2) PRN administrations were documented on the front of the MAR as follows: on 10/22/18 and on 10/29/18. Review of the (MONTH) (YEAR) Nurse's Med Notes on the back of the MAR revealed four (4) PRN administrations were documented. The (MONTH) (YEAR) Controlled Drug Record for R#1, revealed PRN [MEDICATION NAME] 10/325 mg was documented to have been administered five (5) times. The (MONTH) (YEAR) MAR for R#1 was reviewed and PRN [MEDICATION NAME] administrations were documented on the front of the [DATE] times. The Nurse's Med Notes on the back of the (MONTH) (YEAR) MAR revealed PRN [MEDICATION NAME] administrations were documented thirteen (13) times. The (MONTH) (YEAR) Controlled Drug Record for R#1 was then reviewed and compared to the (MONTH) (YEAR) MAR documentation. PRN [MEDICATION NAME] was documented as administered thirty-three (33) times. A review of the (MONTH) (YEAR) MAR for R#1 revealed PRN [MEDICATION NAME] administrations were documented twenty-three (23) times. A review of the (MONTH) (YEAR) Nurse's Med Notes for R#1's PRN [MEDICATION NAME] revealed twenty-two (22) documentation's. The Controlled Drug Record for R#1's PRN [MEDICATION NAME] documented administrations for (MONTH) (YEAR) was compared to the documented administrations on the (MONTH) (YEAR) MAR. Three completed original Controlled Drug Records were missing as follows: from 11/29/18 through 12/7/128, from 12/7/18 through 12/14/18 and from 12/14/18 through 12/21/18. Unit Manager DD revealed on 1/9/19 at 5:10 p.m. had searched for the missing Controlled Drug Records and they could not be found. An interview with the Unit Manager DD was conducted on 1/15/19 at 9:15 a.m. regarding missing Controlled Drug Records. She revealed she had been able to retrieve the Controlled Drug Records that had been faxed to the pharmacy and had been used to reorder [MEDICATION NAME] for R#1. Unit Manager DD revealed she was aware missing Controlled Drug Records could indicate narcotics were being misappropriated. Review of the Controlled Drug Records for R#1 for (MONTH) (YEAR) continued using the copies of faxed records and revealed PRN [MEDICATION NAME]/APAP 10/325 was documented removed from R#1's medications twenty-three (23) times. Review of the (MONTH) 2019 MAR and corresponding Controlled Drug Record for R#1 for 1/1/19 through 1/8/19 revealed no PRN [MEDICATION NAME] had been documented as administered or removed from the blister pack. 2. Review of the clinical record for R#2 revealed a physician's orders [REDACTED]. Review of the front of the (MONTH) (YEAR) MAR for R#2 revealed [MEDICATION NAME] 5/325 mg PRN for pain was documented as administered thirty-six (36) times. Review of the Nurse's Med Notes on the back of the (MONTH) (YEAR) MAR revealed administrations of PRN [MEDICATION NAME] 5/325 mg were documented twenty-eight (28) times. Review of Controlled Drug Record Sheets from 10/1/18 through 10/31/18 revealed [MEDICATION NAME] 5/325 mg PRN had been documented as administered forty-two (42) times. The (MONTH) (YEAR) MAR for R#2 was reviewed and documentation indicated [MEDICATION NAME] 5/325 mg PRN was administered twenty-six (26) times. Review of the Nurse's Med Notes on the back of the MAR for (MONTH) (YEAR) revealed documentation for thirty-three (33) administrations of PRN [MEDICATION NAME]. A review of R#2's Controlled Drug Record for 11/1/19 through 11/30/19 revealed forty-nine (49) documented administrations of PRN [MEDICATION NAME] 5/325. Review of the (MONTH) (YEAR) MAR for R#2 revealed documentation for the administration of PRN [MEDICATION NAME] twenty-eight (28) times. The Nurse's Med Notes on the back of the (MONTH) (YEAR) MAR for [MEDICATION NAME] PRN documented administrations twenty-two (22) times. From 12/1/18 through 12/10/18 the original Controlled Drug record was missing and a copy of the faxed Controlled Drug record, used to reorder from the Pharmacy on 12/10/18 with twelve (12) remaining, was the only document available. Review of the available (MONTH) (YEAR) Controlled Drug Record documentation revealed there were forty-four (44) documented administrations of [MEDICATION NAME] PRN for R#2. The (MONTH) 2019 MAR was reviewed and from 1/1/19 through 1/8/19 PRN [MEDICATION NAME] was documented administered five (5) times. The corresponding Nurse's Med Notes were reviewed and six (6) PRN administrations were documented. The Controlled Drug Record for R#2 from 1/1/19 through 1/8/19 was reviewed and PRN [MEDICATION NAME] was documented administered eleven (11) times. Review of the Monthly Consultant Pharmacist Report of consultant pharmacist activities from 10/1/18 through 11/1/18, 11/1/18 through 12/1/18 and 12/1/18 through 1/1/19, revealed the medication regimen for R#1 and R#2 was reviewed and there were no recommendations related to [MEDICATION NAME] or lack of documentation. One hundred percent (100%) of the residents reviewed met the indicator related to accurate documentation, transcription and policy adherence pertaining to the use of any prescribed medication or treatment. An interview on 1/15/19 at 2:05 p.m. with the Consultant Pharmacist regarding missing documentation and missing controlled medication revealed he had been told by the Director of Nurses (DON) that [MEDICATION NAME] 10 mg had been removed from a package and someone had substituted 5 mg [MEDICATION NAME] in its place. He was unsure of the number of [MEDICATION NAME] that had been tampered with. He had advised the DON to watch the narcotics and the suspected nurse. The second time this was discussed with him by the facility he was told the suspected nurse had quit, and he advised the DON to audit all narcotics to find what was missing. The Consultant Pharmacist revealed he considered a complete audit the comparison of the pharmacy shipment records with the Controlled Drug Records, and then a comparison with the MAR for each individual resident. He revealed that in his experience the way nurses misappropriate narcotics is to take the Controlled Drug Record when they take the medication. The Consultant Pharmacist revealed he had not been aware of any missing Controlled Drug Records. The consultant pharmacist revealed he had been in the building on 11/30/18 to destroy the [MEDICATION NAME] 5 mg that had been substituted for the 10 mg, and had also been in the building on 12/26/18 for monthly reviews and had not done any of the auditing of Controlled Drug Records and MAR's to look for misappropriated controlled drugs himself, but had expected to hear from the DON the next time he came, which will be this week, the results of the facility audits and have the documentation available to do some audits himself if there were any problems. He had told the DON that she needed to have available the exact medications missing and numbers of medications with dates that were missing if there was going to be any report to the Secretary of State or police. The Consultant Pharmacist revealed he had not checked the narcotic MAR documentation against the Controlled Drug Records or delivery records, but would have planned on doing that if the nurse was still here, he just wanted to make sure the nursing home would have all the documents available before he did any audits. An interview was conducted with the Administrator on 1/15/19 at 5:05 p.m. regarding job descriptions and contracts and revealed he had called the former management corporation on 1/9/19 and requested a job description and contract for the Consultant Pharmacist and as yet he had not received them. Continued interview on 1/15/19 at 6:00 p.m. regarding his expectations of the Consultant Pharmacist revealed he was aware of the monthly indicators for appropriate use of medications specifies the resident clinical records are to be reviewed for accurate and complete documentation of the administration of all medications and would have expected him to audit the narcotic records to ensure there were no administration or documentation irregularities and notify the Administrator in the monthly report if there were any concerns. The Consultant Pharmacist had not notified him of any concerns for R#1 or R#2.