Every finding on record at Savannah Crossing of Journey LLC

Based on observations, staff interviews and review of the facility's policy titled Food and Storage, the facility failed to ensure food items were properly stored, sealed, and labeled. In addition, the facility failed to maintain sanitary conditions for one of three ice machines. The facility had 66 residents who received oral nutrition and were therefore affected by these deficient practices.Findings include:A record review of the facility policy Food Storage stated: Sufficient storage facilities are provided to keep food safe, wholesome, and appetizing. Food is stored, prepared, and transported at an appropriate temperature and by methods designed to prevent contamination.A brief observation of the kitchen dated 02/27/2026 at 8:00 AM revealed the following:The following open food items were not dated or labeled: two packs of fish sticks, chicken breast, diced ham, hush puppies, hamburger patties, onion rings, pound cake, a slice of cake, sliced tomatoes, grits, cream of wheat, unidentifiable frost bitten meat, and shredded cheese.The following food items were found in the dry pantry closet with no expiration date: two packs of spaghetti noodles wrapped in saran wrap, two open bags of macaroni noodles, an open bag of wide noodles, and an opened bag of rice. In addition, the ice machine in the kitchen was observed to have a dirty substance on both the outside and the inside.Observation/interview on 02/27/2026 at 8:00 AM with the Certified Dietary Manager (CDM) revealed and confirmed that the items listed above were not dated or labeled, and that the ice machine was dirty on the inside and outside.Interview on 02/27/2026 at 9:30 AM with the Dietary Supervisor (DS) confirmed that the above items should have been labeled and dated with open and expiration dates.DS also confirmed he would have the ice machine serviced by the professional company that maintained it. He further confirmed that all unlabeled and undated food would be discarded.

Based on observation, resident and staff interviews, and record review, the facility failed to ensure resident privacy during incontinent care and transfer for two of 29 sampled residents (R) (R22) (R59). This deficient practice had the potential to place both residents at risk of a diminished quality of life and cause emotional distress and lack of trust.Findings include:Record review of the electronic health record (EHR) for R22 revealed diagnoses including, but not limited to, dementia and fracture of an unspecified part of the neck of the right femur, subsequent encounter for closed fracture with routine healing.Record review of the Quarterly Minimum Data Set (MDS) for R22, dated 01/16/2026, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of nine (indicating mild cognitive impairment). Section GG (Functional Abilities and Goals) documented that the resident was dependent for Activities of Daily Living (ADLs), with transfers requiring the use of a mechanical device.Observation on 02/27/2026 at 9:48 AM revealed Certified Nursing Assistants (CNA) DD and CNA BB providing a transfer to a shower bed using a Hoyer lift for R22 with the room door wide open. R22's body was observed extended in the air, allowing public view exposure from the waist down, exposing her brief and the disfigurement of her legs from the contracture.Interview on 02/27/2026 at 10:30 AM with CNA DD and CNA BB, both staff confirmed they forgot to close the room door. Both CNAs reported that the Hoyer lift and the shower bed could fit in the room with the door closed. They confirmed that this was a dignity issue.Interview on 02/29/2026 at 10:01 AM with the Director of Nursing (DON) revealed the DON reviewed the photographs with the surveyor. She confirmed that the transfer was a deficient practice and was a dignity issue. She reported that certified nursing assistants had enough space in the resident's room to position the shower bed in R22's room and close the door to ensure privacy.Interview on 02/29/2026 at 5:30 PM with the Administrator revealed the Administrator reviewed the photographic evidence. He reported being unaware of the incident until it was brought to his attention by the surveyor. He reported that he planned to address the issues.Record review of the electronic health record (EHR) for R59 revealed diagnoses including, but not limited to, paroxysmal atrial fibrillation, type 2 diabetes mellitus with diabetic neuropathy, cognitive communication deficit, and presence of a cardiac pacemaker.2. Record review of the Quarterly Minimum Data Set (MDS) for R59, dated 01/2/2026, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 15 (indicating little to no cognitive impairment). Section GG (Functional Abilities and Goals) documented that the resident required substantial/maximal assistance for toileting and was essentially dependent for most Activities of Daily Living (ADLs).Observation on 02/29/2026 at 9:48 AM revealed CNA CC providing incontinent care to R59. Continued observation revealed that the window blinds were open and the privacy curtain did not completely encircle the bed for R59, and R59 was observed with no covering on her bare body below the waist. This allowed exposure of R59 to other people entering her room and open view to the public outside. The resident's window faced the public street and the front lawn walkway.Interview on 02/28/2026 at 12:11 PM with R59 revealed and confirmed the curtain was open and reported that CNAs never closed the window blinds. R59 reported that her preference was for CNAs to ensure her privacy by closing the window.Interview on 02/28/2026 at 12:14 PM with CNA CC confirmed forgetting to ensure the privacy curtains encircled the bed and to close the window blinds. CNA CC confirmed receiving training on closing the blinds.Interview on 02/28/2026 at 12:31 PM with the DON revealed that her expectations were for staff to pull privacy curtains during patient care. She reported that this incident with R59 would be classified as a dignity issue.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled Medication Storage in the Facility, the facility failed to ensure four of 29 sampled residents (R) (R53, R37, R38, and R59) did not have unauthorized and unsecured medications at the bedside. This failure had the potential to result in medication errors, improper use, and adverse drug events for the residents.Findings include: Review of the facility's policy titled, Medication Storage in the Facility with effective date of May 1, 2020, under the Policy section revealed, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supple is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Under the Procedures section revealed, .B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications permitted to access. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. 1. Review of R53's Electronic Health Records (EHR) revealed diagnoses that included, but were not limited to, hemiplegia and hemiparesis following other cerebrovascular disease affecting right dominant side, ophthalmoplegic migraine, not intractable, hemiplegia and hemiparesis following other cerebrovascular disease affecting left non-dominant side. Review of R53's Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Section C (Cognitive Patterns) revealed, a Brief Interview of Mental Status (BIMS) score of six which indicated severe cognitive impairment, and Section GG (Functional Abilities and Goals) revealed, impairment on one side to the upper and lower extremities, required substantial/maximal assistance with activities of daily living (ADL). Review of R53's Physician's Orders revealed there were no active orders for eye drops or nasal sprays. Further review of the physician orders revealed that there were no physicians' orders authorizing the resident to self-administer medications. Review of R53's EHR revealed there was no evidence that a self-administration of medications assessment had been completed to determine if the resident could not self-administer medications. Observation on 02/27/2026 at 9:05 AM revealed, R53 lying in bed with [Name] lubricant eye drops and ipratropium bromide nasal spray was sitting on the bedside table. During a concurrent observation and interview on 02/27/2026 at 2:24 PM, the Director of Nursing (DON) and Certified Medication Aide (CMA) AA both confirmed that the [Name] lubricant eye drops and ipratropium bromide nasal spray was sitting on top of the bedside table inside R53's room. Interview with the Director of Nursing (DON) revealed that she was unsure if R53 had been assessed to self-administer medications or if an order was in place for R53 to self-administer medications but would check and ask CMA AA to remove the medications from the room. She revealed her expectation was for the nurses to remove medications and not to leave them in the room unattended. Interview on 02/27/2026 at 2:35 PM with the ADON and DON, R53, R37, R38, and R59 records were reviewed. The Assistant Director of Nursing (ADON) confirmed the residents did not have a physician's order to self-administer medications nor had an assessment been completed for R53, R37, R38, and R59. Further review of the records revealed that R53 did not have an order for eye drops or nasal spray. ADON revealed that R53's had to have brought the medications from home because they do not carry that brand of eyedrops and there were no orders for either of them. The DON revealed she would plan to provide education to the residents' family not to bring medication from home and leave them in the resident's room and for staff to remove medications not authorized from the room. The DON confirmed that the residents (R53, R37, R38, and R59) could not self-administer their own medications. Findings include 2. Review of R37's Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) score of twelve, which indicated cognitive awareness with little to no cognitive impairment. Section GG (Functional Abilities and Goals) revealed impairment on one side of the upper and lower extremities and that the resident required substantial/maximal assistance with Activities of Daily Living (ADLs). Review of R37's Physician's Orders revealed an active order for eye drops dated 04/25/2024. The order stated: Refresh Tears Ophthalmic Solution 0.5% (Carboxymethylcellulose Sodium Ophth) instill 1 drop in both eyes three times a day for dry eyes. Further review revealed no physician orders authorizing the resident to self administer medications. Review of R37's EHR revealed no evidence that a self administration of medications assessment had been completed to determine whether the resident could self administer medications. Observation on 02/27/2026 at 9:05 AM revealed R37 lying in bed with [Name] lubricant eye drops sitting on the bedside table. 3. Review of R38's Electronic Health Record (EHR) revealed diagnoses that included, but were not limited to, Parkinson's disease without dyskinesia and without mention of fluctuations, unspecified dementia (moderate) without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, hypertension, squamous blepharitis of the right upper eyelid, squamous blepharitis of the left upper eyelid, and prediabetes. Review of R38's admission Minimum Data Set (MDS) assessment dated [DATE] for Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated little to no cognitive impairment. Section GG (Functional Abilities and Goals) revealed no impairment of the upper or lower extremities and that the resident required partial/moderate assistance with Activities of Daily Living (ADLs). Review of R38's Physician's Orders revealed no active orders for eye drops. Further review revealed no physician orders authorizing the resident to self administer medications. Review of R38's EHR revealed no evidence that a self administration of medications assessment had been completed to determine whether the resident could self administer medications. Observation on 02/27/2026 at 9:05 AM revealed R38 lying in bed with [Name] lubricant eye drops sitting on the bedside table. 4. Review of R59's Electronic Health Record (EHR) revealed diagnoses that included, but were not limited to, type 2 diabetes mellitus with diabetic neuropathy (unspecified), paroxysmal atrial fibrillation, cognitive communication deficit, and presence of a cardiac pacemaker. Review of R59's Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated little to no cognitive impairment. Section GG (Functional Abilities and Goals) revealed no impairment of the upper or lower extremities and that the resident required partial/moderate assistance with Activities of Daily Living (ADLs). Review of R59's Physician's Orders revealed an active order for eye drops (start date 11/12/2024). The order stated: Artificial Tears Ophthalmic Solution (Artificial Tear Solution) instill 1 drop in both eyes three times a day for dry eyes. Further review revealed no physician orders authorizing the resident to self administer medications. Review of R59's EHR revealed no evidence that a self administration of medications assessment had been completed to determine whether the resident could self administer medications. Observation on 02/27/2026 at 10:01 AM revealed R59 lying in bed with [Name] lubricant eye drops sitting on the bedside table. Interview on 02/27/2025 at 4:35 PM with the Director of Nursing revealed she confirmed the medications at the bedside for R37, R38, and R59. She reported that none of the above mentioned residents were authorized to self administer medications. She stated that if any of the residents had prescription medications, the medications should remain on the medication cart. She confirmed that the medications appeared to be over the counter products brought in by family. She reported that her expectation was for nursing staff to monitor medications at the resident's bedside.

Based on observations, staff interviews, a review of the facility policy titled, Personal Hygiene, and review of the Food and Drug Administration (FDA) Food Code 2022, the facility failed to ensure staff wore beard restraints when serving food and failed to ensure resident food items stored in a nourishment refrigerator were labeled and dated. These failures had the potential to affect all residents receiving meals from the dietary department. Findings included: 1. A review of the facility's undated facility policy titled, Personal Hygiene indicated, If hair is long and not covered properly with a cap, a hair net must be worn. The FDA Food Code 2022, dated 01/18/2023, revealed Chapter 2. Management and Personnel, 2-4 Hygienic Practices, 2-402 Hair Restraints, specified, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed to be worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. On 11/5/2024 at 11:35 am, the Food Service Director (FSD) was observed with facial hair on his chin and a full mustache. The FSD was observed serving trays for the lunch meal, including chicken, potatoes, vegetables, and bread, while not wearing a beard or mustache restraint. During an interview on 11/5/2024 at 1:56 am, the FSD stated he did not require his staff to wear beard restraints or facial hair coverings. During a follow-up interview on 11/5/2024 at 4:09 pm, the FSD stated beard nets were required if a beard was full and long. During an interview on 11/6/2024 at 2:09 pm, the FSD stated if someone had the same amount of hair that was on his face on their head, he would require them to wear a hair net. The FSD said the facility did not have a policy that specifically addressed the use of beard restraints. During an interview on 11/06/2024 at 2:54 pm, the Administrator stated the facility had beard restraints available for use. The Administrator said he had never been concerned about a trimmed goatee. The Administrator further stated the facility's policy did not specify beard restraints were required, but he knew regulations required them. 2. A review of the facility policy titled, Use and Storage of Food Brought in by Family or Visitors, revised in 1/2017, indicated, 2. Food items must be labeled with content and dated. a) The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator. b) The prepared food must be consumed by the resident within 3 days. c) If not consumed within 3 days, food will be thrown away by facility staff. An observation on 11/07/24 at 8:15 am revealed the nourishment refrigerator located on [NAME] Hall had a sign posted that indicated the refrigerator would be cleaned out every Friday and expiration dates would be checked. During a concurrent interview and observation of the nourishment refrigerator on [NAME] Hall on 11/7/2024 at 8:16 am, Certified Nursing Assistant (CNA) 6 stated kitchen staff restocked the nourishment refrigerator with resident supplements every two days. The following items were observed inside the refrigerator, not labeled or dated: a bowl of an unidentified food item labeled for a resident that was not dated and a bowl of an unidentified food item that was not dated or labeled. The freezer compartment contained a cup and a smoothie, but neither was labeled or dated. During an interview on 11/7/2024 at 8:25 am, Licensed Practical Nurse (LPN) 7 stated the nourishment refrigerator was used for the residents, and everything should be dated and labeled. During an interview on 11/7/2024 at 8:39 am, the Dietary Manager (DM) stated the nourishment refrigerators were checked each morning and filled with supplies. The DM said all food items in the nourishment refrigerator should be labeled and dated. During an interview on 11/7/2024 at 8:56 am, the Administrator stated he expected any resident food items to be labeled and dated. During an interview on 11/7/2024 at 12:21 pm, the Director of Nursing (DON) stated the nourishment refrigerators on the units should be used for residents, and all food items should be labeled and dated.

Based on staff interviews, review of facility documents, review of the document titled Rules and Regulations for Criminal Background Checks: 111-8-12-.03(h), and review of the facility policy titled, Abuse Neglect and Exploitation, the facility failed to ensure the screening component of their abuse policy was consistently implemented. Specifically, the facility failed to provide evidence of background checks for three Licensed Practical Nurses (LPNs) (LPN 7, LPN 9, and LPN 10) of five licensed staff whose employee files were reviewed. This deficient practice had the potential to place residents residing in the facility at risk of abuse, neglect, and exploitation from staff. The census was 70 residents. Findings included: A review of the facility policy titled, Abuse Neglect and Exploitation, reviewed/revised in 2/2023, revealed, The components of the facility abuse prohibition plan are discussed herein: I. Screening A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials' [sic] checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. 2. Screenings may be conducted by the facility itself, third-party agency or academic institution. 3. The facility will maintain documentation of proof that screening occurred. A Georgia Department of Community Health document titled, Rules and Regulations for Criminal Background Checks: 111-8-12-.03(h) revealed, Licensed Healthcare Providers* who are EXEMPT from state fingerprint background check requirements as long as the employer checks with the applicable licensing board to verify that the license is in good standing: included, -Nurses- includes advanced practice registered nurse, nurse practitioner, certified registered nurse anesthetist, certified nurse midwife, clinical nurse specialist, registered nurse professional, and licensed practical nurse. The document further indicated, *This is a listing of common professionals that may work in the long-term care setting. LPN 7's personnel file revealed her hire date was 9/17/2024. LPN 7's employee file indicated she was exempt from the GCIC [Georgia Crime Information Center, an official criminal record report for Georgia]/Criminal Background Check. The facility had no evidence a background check was completed for LPN 7 prior to employment. LPN 9's personnel file revealed her hire date was 10/8/2024. LPN 9's employee file indicated she was exempt from the GCIC/Criminal Background Check. The facility had no evidence a background check was completed for LPN 9 prior to employment. LPN 10's personnel file revealed her hire date was 2/20/2024. LPN 10's employee file indicated she was exempt from the GCIC/Criminal Background Check. The facility had no evidence a background check was completed for LPN 10 prior to employment. During an interview on 11/7/2024 at 1:38 pm, the Human Resources (HR) Director stated she conducted license checks yearly for the licensed staff, and any marks against their license would be reflected. She stated licensed nurses had their fingerprints run before they got their license. The HR Director further stated the facility used to do background checks for licensed nurses until GCHEXS (Georgia Criminal History Check System, a state and federal fingerprint-based criminal history background check utilized to make employment eligibility determinations) was initiated in 2020 and the rules changed. She stated no background checks had been done for licensed staff since the rule changed if the license check came back in good standing. According to the HR Director, the Georgia Board of Nursing completed the background checks for licensed nurses. During an interview on 11/7/2024 at 8:26 am, the Administrator stated the facility was under the impression that if an LPN's license check came back without issues, then no additional criminal background check was needed. He stated license checks had been completed, and all licenses of staff working in the facility were in good standing. He stated the facility had not done criminal background checks on LPNs 7, LPN 9, or LPN 10.

Based on observation and staff interviews, the facility failed to evaluate the Wound Care Registered Nurse's competencies associated with the provision of wound care and infection control. Infection control concerns were noted during the provision of wound care for one of three residents (R) (R4) observed during wound care. This deficient practice had the potential to have a negative impact on residents receiving wound care at the facility. Findings included: During an interview on 11/7/2024 at 1:21 pm, the Director of Nursing (DON) stated the facility did not have a policy that addressed nurse competencies. An observation of wound care on 11/4/2024 beginning at 10:46 am revealed he Wound Care Registered Nurse (RN) entered the resident's room with clean dressings and medication and placed them directly on the resident's bed without using a barrier. Prior to initiating wound care, the Wound Care RN did not wash her hands are put on a gown, but she applied gloves. The Wound Care RN proceeded to remove three wound dressings, including one from the resident's right knee, one from the resident's right lateral thigh, and one from the resident's left lower leg. The Wound Care RN did not wash hands or change gloves during the removal of each of these dressings. The Wound Care RN then cleaned and applied treatment to the resident's right lateral leg wound without changing gloves or washing her hands. She then returned to the treatment cart to obtain supplies for the remaining treatments and left the resident's right knee wound and left lower leg wound open to air. Upon returning to the treatment cart, the Wound Care RN used hand sanitizer and gathered the remaining supplies for treatment. At 10:56 am, she applied gloves, returned to the resident's room, and placed the treatment items directly on the resident's bed without using a barrier. At 10:57 am, the Wound Care RN cleaned the resident's right knee wound and immediately cleaned the resident's left lower leg wound without washing hands or changing gloves between wounds. The Wound Care RN then applied the treatment on the right knee wound and covered it with a dry dressing, then immediately applied the treatment on the left lower leg wound and covered it with a dry dressing, without cleaning hands or changing gloves between wounds. After completing the treatments, the Wound Care RN asked if the resident wanted a snack. She then obtained a snack bag from the resident's window ledge, removed her gloves, and without washing her hands, opened the snack and provided it to the resident. After exiting the resident's room, The Wound Care RN returned to the treatment cart and placed the treatment supplies inside the cart, without first washing or sanitizing her hands. During an interview on 11/4/2024 at 11:04 am, the Wound Care RN stated she did not know she needed to clean her hands and change gloves between cleaning a wound and dressing a wound. She further stated she did not know she should treat each wound separately. The Wound Care RN stated she had not been trained to use a barrier for placing clean supplies used to treat wounds. The Wound Care RN stated she received training on wound care from an online wound care company. She stated there was a portion of the program that addressed infection control during wound care. She further stated neither the Infection Control Preventionist nor the Director of Nursing (DON) had watched her perform wound care. During an interview on 11/7/2024 at 3:38 pm, the DON stated that during wound care, the Wound Care RN should have used a barrier for treatment supplies, so they did not contact the surface of the resident's bed. The DON stated the Wound Care RN should have cleaned her hands and changed gloves during wound care, going from dirty (cleaning the wound) to clean (application of medications and dressings), and should have treated one wound at a time to prevent cross contamination of the wounds. During an interview on 11/7/2024 at 1:54 pm, the DON stated the Wound Care RN took an online wound care certification course in August 2024. According to the DON, the Wound Care RN paid for the course and brought a copy of her certificate to the facility; however, the DON indicated the facility was unable to find the completion certificate and said the online company's system was down, so they were unable to access a copy of the Wound Care RN's course completion certificate. During a follow-up interview on 11/7/2024 at 3:37 pm, the DON stated she expected nurses to be competent in infection control during wound care. The DON confirmed she had no documentation of competency evaluations for the Wound Care RN. During an interview on 11/7/2024 at 3:52 pm, the Administrator stated he expected nurses to be competent in infection control during wound care.

Based on observations, staff interviews, and review of the facility policy titled, Medication Storage in The Facility, the facility failed to ensure two of five treatment and medication carts were locked and secured when unattended by staff. This deficient practice created the potential for residents, unauthorized staff, and visitors to have access to medications and biologicals stored in the carts. Findings included: A review of the facility policy titled, Medication Storage in The Facility, effective 5/1/2020, indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. An observation on 11/4/2024 at 9:39 am revealed a treatment cart was unlocked on the [NAME] Hall. The treatment cart contained Biofreeze, lactate lotion, betamethasone cream, clindamycin cream, diclofenac gel, antifungal powder, one bottle of alcohol, and one bottle of peroxide. During an interview on 11/4/2024 at 9:45 am, Registered Nurse (RN) 1 stated treatment carts should be locked if they were not attended by staff or out of staff's line of sight. RN 1 confirmed the treatment cart was unlocked, but then walked away to talk to another staff member without first locking the treatment cart. During an interview on 11/4/2024 at 9:52 am, Licensed Practical Nurse (LPN) 2 stated the treatment cart should not be left unlocked. During an interview on 11/4/2024 at 11:44 am, the Director of Nursing (DON) stated if staff left the treatment cart unattended, they should lock it to ensure only those authorized to do so accessed the cart. During an interview on 11/5/2024 at 8:42 am, the Administrator stated treatment carts should be locked unless they were in use. 36105 An observation on 11/5/2024 at 8:00 am revealed an unlocked medication cart was located outside of the nurses' station on the Skidaway Hall. No staff were observed in the area. A concurrent observation and interview on 11/5/2024 at 8:04 am revealed Licensed Practical Nurse (LPN) 11 approached the medication cart and stated he was trained not to leave the medication cart unlocked. He stated he usually locked it to make sure nobody could access the medications inside the cart. LPN 11 stated if the cart was left unlocked and unattended, someone could access the medications and take something they should not. During an interview on 11/6/2024 at 2:19 pm, LPN 8 stated medication carts must be secured so nobody could get into the medications or take something out of it, which would be risky if someone took something they should not. During an interview on 11/6/2024 at 4:09 pm, LPN 10 stated the medication cart should be locked when not in a nurse's line of sight to ensure residents' safety. LPN 10 said it could cause serious consequences if a resident took a medication from a cart that they should not have. During an interview on 11/7/2024 at 3:38 pm, the DON stated medication carts should be locked when not attended by staff to ensure residents' safety and to keep residents from getting medications they should not have. During an interview on 11/7/2024 at 3:52 pm, the Administrator stated he expected medication carts to be locked because somebody could get into the carts and take medications they should not have.

Based on observations, staff interviews, record review, review of the facility-provided document titled, Wound Care Procedure, and review of the facility policy titled, Enhanced Barrier Precautions, the facility failed to implement enhanced barrier precautions (EBP) and failed to ensure licensed staff followed proper infection control practices during and after the provision of wound care for one of three residents (R) (R4) reviewed for wound care. This deficient practice had the potential to increase R4's risk of infection due to cross-contamination and increased the potential for staff to spread infection to other residents residing in the facility. Findings included: A review of a facility-provided undated document titled Wound Care Procedure included . 3. Each wound will be treated individually. 4. When multiple wounds are being dressed, the dressings will be changed in order of least contaminated to most contaminated (i.e. [id est, that is] change extremity wounds before wounds contaminated with stool). Dressings of infected wounds should be changed last. 5. Set up clean field on the overbed table with needed supplies for wound cleansing and dressing application: a. If the table is soiled, wipe clean. b. Place a disposable cloth or linen saver on the overbed table. c. Place only the supplies to be used per wound on the clean field at one time (include wound cleanser, gauze for cleaning, disposable measuring guide, and pen/pencil, skin protectant products as indicated, dressings, tape). 6. Establish area for soiled products to be placed (Chux [disposable absorbent pad] or plastic bag). 7. Wash hands and put on clean gloves. The policy further indicated that after removing the dressing, staff should, 9. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. 10. Wash hands and put on clean gloves. 11. Cleanse the wound as ordered, taking care not to contaminate other skin surfaces or other surfaces of the wound (i.e., clean outward from the center of the wound). Pat dry with gauze. 12. Wash hands and put on clean gloves. 13. Apply topical ointments or creams and dress the wound as ordered. Protect surrounding skin as indicated with skin protectant. 14. Secure dressing. [NAME] with initials and date. 15. Discard disposable items and gloves into appropriate trash receptacle and wash hands. A review of the facility policy titled, Enhanced Barrier Precautions, effective 3/2024, revealed, Definitions: Enhanced barrier precautions EBP refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. The policy further revealed, . 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 toileting g. Device care or use: central lines, urinary catheters, feeding tubes, PICC [peripherally inserted central catheter] lines, midline catheters h. Wound care: any skin opening requiring a dressing. An Admission Record revealed the facility admitted R4 on 6/27/2024. According to the Admission Record, the resident had a diagnosis of sequela of an infection and inflammation due to an internal fixation device of the right femur. A Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/13/2024, revealed R4 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. According to the MDS, R4 had open lesions other than ulcers, rashes, or cuts, had surgical wounds, received surgical wound care, and had nonsurgical dressings applied. R4's Order Summary Report, listing active orders as of 11/6/2024, contained an order started on 8/22/2024 for EBP due to right thigh/right knee wounds. The Order Summary report also reflected the following wound treatment orders: - an order dated 8/18/2024 for a wound vacuum to the resident's right lateral leg wound. The order indicated that if the wound vacuum became dislodged, staff should cleanse the wound with wound cleanser, apply a silver strip to the site, cover with an island dressing twice daily and as needed, and notify the nurse practitioner and wound care nurse; - an order dated 8/21/2024 for a negative pressure dressing to the resident's right knee wound. The order indicated that if the negative pressure dressing became dislodged, staff should cleanse the wound with wound cleanser, pat dry, coat the wound bed with Xeroform (a yellow, petroleum-impregnated gauze dressing used to cover wounds) or medicated honey, and cover with a dry dressing every shift; and - an order started on 9/27/2024 to clean a wound to the resident's left lower extremity, pat dry, and to apply silver sulfadiazine and a dry dressing one time a day on Mondays, Wednesdays, and Fridays. An observation of wound care on 11/4/2024 beginning at 10:46 am revealed there was no EBP sign on R4's door or door frame. The Wound Care Registered Nurse (RN) entered the resident's room with clean dressings and medication and placed them directly on the resident's bed without using a barrier. Prior to initiating wound care, the Wound Care RN did not wash her hands or put on a gown, but she applied gloves. The Wound Care RN proceeded to remove three wound dressings, including one from the resident's right knee, one from the resident's right lateral thigh, and one from the resident's left lower leg. The Wound Care RN did not wash hands or change gloves during the removal of each of these dressings. The Wound Care RN then cleaned and applied treatment to the resident's right lateral leg wound without changing gloves or washing her hands. She then returned to the treatment cart to obtain supplies for the remaining treatments and left the resident's right knee wound and left lower leg wound open to air. Upon returning to the treatment cart, the Wound Care RN used hand sanitizer and gathered the remaining supplies for treatment. At 10:56 am, she applied gloves, returned to the resident's room, and placed the treatment items directly on the resident's bed without using a barrier. At 10:57 am, the Wound Care RN cleaned the resident's right knee wound and immediately cleaned the resident's left lower leg wound, without washing hands or changing gloves between wounds. The Wound Care RN then applied the treatment on the right knee wound and covered it with a dry dressing, then immediately applied the treatment on the left lower leg wound and covered it with a dry dressing without cleaning hands or changing gloves between wounds. After completing the treatments, the Wound Care RN asked if the resident wanted a snack. She then obtained a snack bag from the resident's window ledge, removed her gloves, and, without washing her hands, opened the snack and provided it to the resident. After exiting the resident's room, The Wound Care RN returned to the treatment cart and placed the treatment supplies inside the cart without first washing or sanitizing her hands. During an interview on 11/4/2024 at 11:04 am, the Wound Care RN stated she did not know she needed to clean her hands and change gloves between cleaning a wound and dressing a wound. She further stated she did not know she should treat each wound separately. The Wound Care RN stated she had not been trained to use a barrier for placing clean supplies used to treat wounds. During a follow-up interview on 11/6/2024 at 2:12 pm, the Wound Care RN stated she had asked the Director of Nursing (DON) about the concerns identified during R4's wound care and was told she should use a barrier for treatment supplies to ensure she had a clean field to work from for treatments and dressing changes. The Wound Care RN further stated she knew whether residents required EBP because a sign was generally posted to let staff know they required EBP. According to the Wound Care RN, R4 did have open wounds, but they had minimal drainage, so the Wound Care RN did not think the resident needed to be on EBP. During an interview on 11/6/2024 at 4:09 pm, Licensed Practical Nurse (LPN) 10 stated that if a resident had open wounds, a mask, gloves, and a gown should be worn to provide care to them. She further stated residents on EBP should have a sign on their door. During an interview on 11/7/2024 at 3:38 pm, the DON stated she expected a resident with draining wounds to be on EBP and to have an EBP sign posted on the door. The DON stated that during wound care, the Wound Care RN should have used a barrier for treatment supplies so they did not contact the surface of the resident's bed. The DON stated the Wound Care RN should have cleaned her hands and changed gloves during wound care going from dirty (cleaning the wound) to clean (application of medications and dressings) and should have treated one wound at a time to prevent cross contamination of the wounds.

Based on observation, interviews, record review, and policy review, the facility failed to ensure staff followed infection control policies related to transmission-based precautions for one of five residents (R) (#1) observed for infection control practices. Certified Nurse Aide (CNA) AA cared for a resident positive for COVID-19 and removed the resident's contaminated drinking cup without ensuring proper disposal and handling. Findings include: Review of the facility's Covid 19 Operational Guideline, revised on 7/19/20, directed lf any resident is considered suspicious for COVID-19 as determined by RN or MD, that resident will be placed in isolation . airborne/ contact precautions will be implemented immediately. Confirmed positive residents will be isolated in the COVID care area with airborne + contact precautions with the fire doors closed. The resident will have face mask during close personal care if coughing. Review of a Nurse's Note dated 7/29/20 at 1:17 p.m. in the Charting Notes tab in R#1's electronic health record (EHR) documented the resident was positive for Covid 19 and placed in isolation. Review of a COVID-19 Test Result Summary obtained from the medical record dated 7/29/20 documented that a nasopharyngeal (nose and throat) swab obtained on 7/27/20 was positive for [DIAGNOSES REDACTED]-CoV-2/2019-nCoV (COVID-19). Observation on 8/4/20 at 11:30 a.m. revealed the facility had a dedicated COVID Unit. Posted on the closed fire doors to the COVID Unit, were signs titled AIRBORNE/CONTACT PRECAUTIONS and CONTACT/DROPLET PRECAUTIONS directed that EVERYONE MUST . USE DEDICATED OR DISPOSABLE EQUIPMENT. During an observation on 8/4/20 at 2:33 p.m. on the COVID Unit, CNA AA entered R#1's room to perform incontinence care. CNA AA was already wearing an N95 mask, long sleeved gown, and face shield and donned gloves upon entering the room. While providing incontinence care the resident had several episodes of non-productive coughing with positional changes and was not wearing; nor offered a mask. At the completion of the incontinence care the resident asked CNA AA for water. CNA AA removed the soiled gloves, used alcohol-based hand rub (ABHR), re-gloved, entered the resident's room, and obtained a white 12 oz Styrofoam cup from the resident's bedside table. The CNA exited the room with the Styrofoam cup and placed it on a nightstand table in the hall (clean area). CNA AA removed gloves, used ABHR, got the Styrofoam cup from the nightstand, went to the nurse's station, and got ice from a small cooler with a scoop, and water from the sink. CNA AA re-gloved and entered the resident's room to give her the water. During an interview on 8/4/20 at 2:40 p.m., CNA AA stated she did not know why she got the used disposable cup from the resident's room and stated she should have used a clean cup. During an interview on 8/4/20 at 3:10 p.m., the Infection Control Nurse stated that all residents on the COVID Unit are on transmission-based precautions and the contact and droplet precautions signs are utilized by the facility to denote that. The Infection Control Nurse stated that since R#1 was on transmission-based precautions, the CNA should not take the cup that was in the resident's room outside of the room; she should have used a clean cup. In addition, the Infection Control Nurse stated that action contaminated the clean surface and she would make sure it was cleaned right away.

Based on record review and staff interviews, the facility failed to ensure the medication, [MEDICATION NAME] (a [MEDICAL CONDITION] medication) was ordered upon admission for one resident (R) (#70) of 34 sampled residents. Findings include: Review of R#70's medical record revealed she was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the hospital record titled Sound Physicians Hospitalist History and Physical dated 12/2/19 revealed the resident has past medical history of [REDACTED]. Her [MEDICAL CONDITION] stimulating hormone (TSH) blood level completed on 12/2/19 was within normal range at 1.31 with a reference range of 0.47-4.68. Review of R#70's hospital record titled Sound Physicians Hospitalist Nursing Home Orders dated 12/6/19 revealed the resident was ordered [MEDICATION NAME] 100mcg one tablet PO daily. Review of R#70's Physicians Orders dated 12/7/19 did not have an order for [REDACTED]. Review of the routine laboratory results dated [DATE] conducting by the facility revealed an elevated TSH level of 9.380 with a range of 0.270-4.200. A note written on the laboratory record indicated to recheck on 12/11/19. Review of the laboratory results dated [DATE] revealed an elevated TSH level of 12.240 with a reference range of 0.270-4.200. A note written on the laboratory record indicated no [MEDICATION NAME] therapy start 50 mcg and recheck TSH level in eight weeks. An interview held on 1/09/2020 at 9:49 a.m. with the Registered Nurse (RN) Assistant Director of Nursing (ADON) revealed when a resident is admitted to the facility either she or the Director of Nursing (DON) review the orders and input them into the system. She looked at R#70's discharge orders from the hospital and verified the resident had an order for [REDACTED]. She indicated all orders are double checked after orders are transcribed. They check the orders against the actual orders from the hospital. She stated the order for the [MEDICATION NAME] was overlooked. An interview held on 1/09/2020 at 10:41 a.m. with the DON revealed new admission orders [REDACTED]. She indicated she completed R#70's admission orders [REDACTED]. She indicated the orders are transcribed according to the hospital orders and if the facility Physician wants something different, she completes a Post Admission Order and another nurse will double check for correctness/errors. She stated the orders were originally put in by her and verified by RN EE. The DON reported no other problems with transcription of orders.

Based on observations, staff and resident interviews, the facility failed to ensure rooms had privacy curtains that provided full visual privacy for the residents in 22 rooms out of a total of 49 rooms on three (3) of three (3) halls. This deficiency affected 41 residents out of a facility census of 72. Findings include The environmental tour began on 8/7/18 at 9:32 a.m. with the Director of Nursing (DON), and at 11:39 a.m. with the Contract Maintenance Director. Observation revealed resident privacy curtains that had a space/gap of 54 inches or less that did not provide full visual privacy coverage during patient care in the following rooms: #1, #3, #4, #7, #8, #9, #10, #11, #16, #18, #24, #26, #27, #28, #29, #30, #31, #34, #36, #37, #39 and #44. During an interview with the Director of Nursing (DON) on 8/7/18 at 9:32 a.m. while on a walk through of random rooms (room [ROOM NUMBER]-#13) she agreed that the privacy curtains did not provide the full visual privacy for those residents required to meet Federal Regulations. During an interview on 8/7/18 at 11:39 a.m., with the Contract Maintenance Supervisor, AA, (housekeeping), revealed that no training had been provided to her regarding the privacy curtains. During an interview with BB at which time he revealed that facility maintenance is responsible for putting up and removing the privacy curtains. He stated that his expectations are that if the Account Manager, CC, has any problems with the curtains it should be reported at once to the facility. During an interview with CNA, DD, on 8/7/18 at 11:44 a.m. she stated that she was not aware that the curtains should provide privacy from one end of the rod to the other end. She felt that as long as the curtain hid the person from the opening of the door there wasn't a problem. She reported that she understood if another resident or staff member were to come into the room it would be a privacy issue for the resident. She also stated that she has received in-services on the privacy curtains. During another interview with the DON on 8/7/18 at 1:56 p.m. revealed that her expectations are for her staff to ensure the privacy curtains are pulled during patient care and that the curtains provide full visual privacy. She stated that she was not aware that the curtains did not provid full visual privacy until it was identified during the survey. She further stated that the facility did not have a policy pertaining specifically to privacy curtains. During an interview on 8/7/18 at 2:17pm with Resident #64 (R#64), she stated that the gap in the privacy curtain does not give her privacy and that it bothers her because people would be able to see her when she was receiving care.

Based on record review and staff interview the facility failed to complete a discharge Minimum Data Set (MDS) assessment for one (1) resident (R#1). The facility census was 72 residents and the sample size was 18 residents. Findings include: Record review for R#1 revealed he was admitted to the facility on [DATE] and was discharged from the facility on [DATE]. Review of the completed MDS's for R#1 revealed a discharge MDS was not completed in a timely manner. Review of the document titled Daily Stand-Up dated [DATE] revealed R#1was to be discharged on [DATE]. All department employees receive a copy of this report daily. Interview with the MDS Coordinator on [DATE] at 11:03 a.m. revealed she received a message from the State Agency MDS Coordinator on [DATE] stating a discharge MDS was not completed or transmitted to them. She agreed a discharge MDS was not completed for R#1. She revealed when a resident is discharged or expired from the facility she receives a notice of discharge. Interview with the Director of Nursing (DON) on [DATE] at 3:33 p.m. revealed admissions and discharges are discussed in the morning meetings. All department head employees receive a copy of the report daily. She stated the MDS Coordinator is responsible for completing all the MDS's in a timely manner. The MDS Coordinator is expected to attend the morning meeting held Monday through Friday.

Based on record review and interviews the facility failed to provide the resident and or the resident's representative a copy of the Base Line Care Plan to ensure the resident and or the resident's representatives were aware of the instructions needed to provide effective and person-centered care to meet the professional standards of quality of care for two Residents (R) (R#10, R#51). The sample size was 29 residents. Findings Include: Review of the care plan reveals that the Base Line Care Plan was not provided to R#10 or her representative. R#10 was re-admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. During an interview with the Director of Nursing (DON) on 8/7/18 at 9:58 a.m. she revealed that this resident does not have a signature on the page of the Base Line Care Plan that would indicate that the resident or her representative received a copy of the Base Line Care Plan. She stated that she makes a note in the nursing notes that this was given but confirmed that there was no documentation in the nursing notes to indicate that the Base Line Care Plan was provided to R#10 or her representative. 2. R#51 was admitted to the facility on [DATE] under the services of Hospice Care. Review of the care plan for R#51 revealed that the document titled Base Line Care Plan dated 6/29/2018 was not signed by the resident or her representative. Review of the residents medical record revealed no documentation that the resident or representative received a copy of the Base Line Care Plan. During an interview with the Director of Nursing (DON) on 8/7/2018 at 9:58 a.m. she revealed that this resident did not have a signature on the page of the Base Line Care Plan that would indicate that the resident or her representative received a copy of the Base Line Care Plan.

Based on observation and staff interview, the facility failed to serve beverages and desserts that were covered until delivery for seventy-one (71) residents receiving meals and failed to dispose of expired and outdated foods in a timely manner from two of two (2 of 2) refrigerators used for residents. Findings include: 1. Observation on 6/24/13 at 12:15 p.m. revealed food trays were delivered from the kitchen to the dining room on an open cart. The iced tea, water and the dessert of pineapple upside down cake were not covered. Continued observation of meals delivered to the halls for distribution to residents revealed the beverages and desserts to be covered when leaving the kitchen, but were uncovered when placed on the tray before being carried down the hall for presentation. Observation of the noon meal on 6/25/13 and 6/26/13 revealed the same process. Interview on 6/26/13 at 12:20 p.m. with the Dietary Manager revealed she was not aware of the delivery system after the meals left the kitchen and that it needed to be remedied . 2. Observation on 06/26/2013 at 11:00 a.m. of the Skidaway/Colonial hall resident's refrigerator revealed: two (2) cans of expired Glucerna supplement dated June 1, 2013 , one (1) 14 ounce (oz) container of expired Danimals vanilla yogurt dated June 17, 2013, one (1) expired container of 4 oz Dannon light and fit yogurt dated May 30, 2013, one (1) container of expired SmartGels strawberry fraise labeled best if used by September 7, 2012 and one (1) container of Breakfast Blend Yogurt dated March 10, 2013. Continued observation revealed one (1) jar of preserves with the seal popped, not dated or labeled, one (1) opened container of 46 oz orange juice not dated, one (1) 64 oz Healthy Balance apple juice with splenda not dated, one (1) 48 oz container of Thick and Easy thickened ice tea open and not dated and one (1) 48 oz container of thick and easy apple juice opened and not dated. Observation on 06/26/2013, at 10:45 a.m. of the Brogden Hall resident's refrigerator revealed: one (1) 64 oz V8 splash opened and not dated, one (1) 46 oz Lyons ready care thickened water opened and not dated, one (1) 46 oz Thirsty orange juice opened and not dated, two (2) 48 oz Thick and Easy iced tea opened and not dated and two (2) 48 oz Thick and Easy [MEDICATION NAME] drink opened and not dated. Interview with the Housekeeping Supervisor and housekeeping staff member "HH" on 06/26/2013 at 11:42 a.m. revealed that expired food should not be present in the resident's refrigerators and that it is housekeeping's responsibility to check the refrigerator daily for outdated and/or expired food and remove from the refrigerator. Interview with the Director of Nursing (DON) on 06/26/2013 revealed all containers should be dated when they are opened. Interview with Licensed Practical Nurse (LPN) "EE" on 06/26/2013 revealed that nursing staff is responsible for checking the dates on nutritional supplements such as Glucerna 1.0 as they are stocked in the refrigerator and as they are removed prior to giving to the resident to assure no outdated supplements are given. Interview with LPN "FF" on 06/27/2013 revealed that one (1) resident on Skidaway hall was receiving one (1) Glucerna 1.0 can daily as a nutritional supplement. Record review of the Medication Administration Record (MAR) for the resident receiving Glucerna 1.0 revealed he was receiving the Glucerna one (1) can daily at six-thirty 6:30 p.m. Review on 06/27/2013 of the Policy and Procedure for Pantry refrigerator maintenance revealed that in order to store, distribute and serve nourishment under sanitary conditions: the refrigerators would be cleaned daily by the housekeeping staff with cleaning recorded on the refrigerator maintenance record, opened and unused food items would be labeled and dated, and outdated perishable foods would be removed and recorded on the refrigerator maintenance record. Perishable food older than three ( 3) days would be considered outdated.

Based on observations and staff interview the facility failed to assure that three (3) of thirty (30) resident bathroom facilities and three (3) of twenty-one (21) resident over-the-toilet assist seats were in good repair, and that one (1) of thirty (30) resident toilets were clean. Findings include: Observations made on 06/24/2013 beginning at 9:37 a.m revealed that the bathrooms in rooms eight (8), shared with room six (6,) and room ten (10), shared with room twelve (12), had white over-the-toilet seats with areas of rust and white paint chipping off the legs. The toilet for rooms 10/12 also had brown matter behind the toilet seat and at the bottom of the connecting pipe on the back of the toilet. Observations made on 06/25/2013 at 9:30 a.m. and 2:30 p.m., 06/26/2013 at 9:10 a.m. and 06/27/2013 at 8:45 a.m. continued to reveal brown matter behind the toilet seat and at the bottom of the pipe in the bathroom for rooms 10/12. Observations on 06/25/2013 at 1:00 p.m. revealed bathrooms for room twenty-nine (29), shared with room twenty-eight (28), room forty-four (44), shared with room forty-three (43), and room forty-six (46), shared with room forty-five (45) had paint cracked and peeling off the walls. Interviews and tour with the maintenance director on 06/25/2013 at 12:35 p.m. and 06/27/2013 at 10:25 a.m. revealed he is in charge of inspecting resident equipment used for toileting and transfers and for the bathrooms being painted and that he was not aware of the rusty, peeling over-the-toilet seats or paint peeling off the walls in the indicated bathrooms. Interviews on 6/27/2013 at 11:05 a.m with Certified Nursing Assistant (CNA) "DD" and at 11:09 a.m. with housekeeping staff "GG" revealed that both housekeeping and CNA's are responsible for assuring resident toilets are clean.

Based on observation, record review and staff interview, the facility failed to follow interventions listed on the Comprehensive Care Plan related to the monitoring of three (3) residents (# 76,#77 and #83) taking antipsychotic medications for behaviors and potential side effects from a sample of thirty-five (35) residents. Findings include: 1. Review of the Clinical Record for Resident # 77 indicated the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the Nurses Notes indicated the resident developed behaviors including scratching and grabbing at staff, making inappropriate sexual advances toward staff and resisting care. Review of the physician's orders [REDACTED]. The medication was increased to 50 mg twice a day on 3/23/13. Review of the Care Plan that was developed 3/26/13 to address the use of the [MEDICATION NAME] revealed an intervention to monitor the resident for side effects of the medication which was listed on the Medication Administration Record. (MAR). Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Interview on 6/26/13 at 2:15 p.m. with the Director of Nursing confirmed the side effects had not been monitored for the resident after the medication was started in March 2013 and in April 2013. Continued interview revealed that there were no blank forms available to initiate the monitoring of behaviors and side effects. 2. Resident #83 was admitted to the facility on [DATE] from home with a [DIAGNOSES REDACTED]. Upon admission, [MEDICATION NAME] was her only medication. Review of the physician orders [REDACTED]. Review of the the resident's Care Plan, updated 4/10/13 revealed that the resident exhibited increased behaviors that included, hallucinations and [MEDICAL CONDITION], request to die or be killed and physical and verbally aggressive behaviors Review of a physician's orders [REDACTED]. Review of a Care Plan developed 4/16/13 for the use of the [MEDICATION NAME] and [MEDICATION NAME] revealed interventions that included to visually observe for changes in the resident's functional status, visually observe for side effects of the medications which were listed on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the MAR indicated [REDACTED]. Interview on 6/26/13 at 3:00 p.m. with the Director of Nursing (DON) confirmed there was no monitoring of the side effects of the medications or consult with the physician about the possibility the [MEDICATION NAME] could be causing the increased agitation and yelling. 3. Review of the clinical record for resident #76 revealed that the resident was admitted to the facility 09/30/11 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Quarterly Assessment completed 05/09/13 revealed that the resident was assessed as alert with confusion, behaviors of yelling out, resisting care and receiving antianxiety medications daily. Review of the Nurses Notes dated 05/13/13 at 9:00 p.m., revealed the resident hollered, pushed medications away, talked about things that did not make any sense, and thought she was in New York. Continued review revealed that the resident was resistant to care and kicked at staff. Review of the Nurses Notes dated 05/15/13 at 11:00 p.m., revealed the resident was hollering, tearing the diaper and throwing it on the floor, refused to eat and spitting out some medication. Review of the physician's orders [REDACTED]. by mouth every evening secondary to residents behaviors especially in the p.m. - Yelling, refusing care - verbally abusive to staff. Review of the care plan for [MEDICAL CONDITION] medication dated 09/25/13 and updated 05/29/13 revealed the following interventions: Monitor for changes in functional status, Inform physician of any adverse reactions to medication, Monitor for changes in mood/behavior, and Visually observe for side effects listed on MAR Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Interview with Registered Nurse (RN) "AA" on 06/27/13 at 11:25 a.m., revealed that per the care plan the nurses are expected to write the type of behaviors observed on the Behavior Monitoring sheet for each shift. Continued interview revealed that when a resident is started on [MEDICAL CONDITION] medication the pharmacy should be notified to send a preprinted Behaviors Monitoring Sheet for the new [MEDICAL CONDITION] medication ordered. The nurse confirmed that behavior monitoring was not documented for June 2013.

Based on observation, record review and staff interview, the facility failed to monitor three residents (# 76, 77 and 83) taking antipsychotic medications for behaviors and potential side effects on a sample of thirty-five residents. Findings include: 1. Review of the Clinical Record for Resident # 77 indicated the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the Nurses Notes indicated the resident developed behaviors including scratching and grabbing at staff, making inappropriate sexual advances toward staff and resisting care. Review of the physician's orders [REDACTED]. The medication was increased to 50 mg twice a day on 3/23/13. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Interview on 6/26/13 at 2:15 p.m. with the Director of Nursing confirmed the side effects had not been monitored for the resident after the medication was started in March 2013 and in April 2013. Continued interview revealed that there were no blank forms available to initiate the monitoring of behaviors and side effects. 2. Review of the closed medical record indicated resident #83 was admitted to the facility on [DATE] from home with a [DIAGNOSES REDACTED]. Upon admission [MEDICATION NAME] was her only medication. Review of the Nurses Notes for February and March 2013 indicated no evidence of behaviors or anxiety. Review of the Physician order [REDACTED]. Review of the resident's clinical record revealed there was no [DIAGNOSES REDACTED]. Review of the Nurses Notes dated 4/10/13, revealed the resident was confused, angry at the staff, was hitting and yelling. On 4/11/13 the resident continued to exhibit verbal and physically aggressive behaviors. Review of a Physician order [REDACTED]. The medication was increased to 50 mg twice a day on 4/24/13 related again to escalation of behaviors. Review of the MAR for March and April 2013 indicated no evidence the resident was monitored for behaviors or for potential side effects of the medications. Review of the facility's procedure for behavior monitoring indicated the resident would be monitored for behaviors and potential side effects of the medication every shift. Interview on 6/26/13 at 3:00 p.m. with the Director of Nursing (DON) confirmed there was no monitoring of the side effects of the medications and the physician was not consulted about the possibility that the [MEDICATION NAME] could be causing the increased agitation and yelling. Continued interview confirmed there was no [DIAGNOSES REDACTED]. Review of the Manufacturer's Physician Prescribing Information Document indicated adverse reactions such as stimulation, sleep disturbances, hallucinations and other adverse behavioral effects such as agitation, rage, irritability, and aggressive or hostile behavior had been reported. 3. Review of the clinical record for resident #76 revealed that the resident was admitted to the facility 09/30/11 with diagnoses that included [MEDICAL CONDITION](CAD), status [REDACTED]. Review of the Minimum Data Set (MDS) Quarterly Assessment completed 05/09/13 revealed that the resident was assessed as receiving antianxiety medications daily and exhibiting verbal behaviors one (1) to three (3) days during the assessment period. Review of the Nurses Notes dated 05/13/13 at 9:00 p.m., revealed the resident hollered, pushed meds away, talked about things that did not make any sense, and thought she was in New York. Continued review revealed that the resident was resistant to care and kicked at staff. Review of the Nurses Notes dated 05/15/13 at 11:00 p.m., revealed the resident was hollering, tearing diaper and throwing it on the floor, refused to eat and spit out some medication. Review of the physician's orders [REDACTED]. by mouth every evening secondary to residents behaviors especially in the pm - Yelling, refusing care - verbally abusive to staff. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Interview with Registered Nurse (RN) "AA" on 06/27/13 at 11:25 a.m., revealed that per the care plan the nurses are expected to write the type of behaviors observed on the Behavior Monitoring sheet for each shift. Continued interview revealed that when a resident is started on [MEDICAL CONDITION] medication the pharmacy should be notified to send a preprinted Behaviors Monitoring Sheet for the new [MEDICAL CONDITION] medication ordered. The nurse confirmed that behavior monitoring was not documented for June 2013.

Based on observation and staff interview, the facility failed to store personal care items in a sanitary manner for one (1) resident # 78 in one (1) shared bathroom during three (3) of four (4) days of the survey from a sample of thirty five (35) residents. Findings include: Observations of the shared bathroom for resident # 78 on 06/24/13 at 9:50 a.m., on 6/25/13 at 1:45 p.m. and on 6/26/13 at 11:00 a.m. revealed a bath basin with the resident's name on it on the floor under the sink uncovered. Interview with the DON on 06/27/13 at 10:05 a.m. revealed that it was her expectation that the staff would secure all personal equipment covered, and not left on the floor.

Based on observation, record review and staff interview, the facility failed to keep water temperatures below 120 degrees Fahrenheit (F) for four (4) resident rooms on two (2) of three (3) halls, and in one (1) of three (3) common shower rooms. The facility also failed to ensure that chemicals were kept in a locked area in two (2) of three (3) common shower rooms, and one (1) Storage Room on one (1) of three (3) halls. There were seven (7) residents in the facility identified as being independently mobile and cognitively impaired. The facility census was eighty-seven (87) residents. . Findings include: 1. On 12/05/11 starting at 1:35 p.m., the following water temps were taken using the surveyors' thermometers: Room 18 on the Skidaway Hall: 120.4 degrees F Common Bathroom 1 on Colonial Hall: 121.6 F Room 13 on the Colonial Hall: 123 degrees F At 2:10 p.m., the Maintenance Director checked water temps with the facility's thermometer and obtained the following readings: Colonial Bathroom 1: 120.1 degrees Room 18 on Skidaway Hall: 126 degrees; the faucet was hot to touch Room 24/25 on Skidaway Hall: 124.7 degrees The Maintenance Director stated he tried to keep the water temps between 110 and 116 degrees. 2. On 12/06/11 at 7:40 a.m., observations in the unlocked Bathroom 1 on the Colonial Hall revealed a cabinet on the wall that had a lock on it with the key inserted in the lock. However, the key did not have to be turned to open the cabinet. Contents of the cabinet included one full bottle with a screw-on cap, and one 1/3-full spray bottle of Comet Cleaner with Bleach. Labeling included that it was an eye and skin irritant, and that a physician should be called immediately if swallowed. This was verified by the Director of Nurses (DON), who said the cabinet should be kept locked. At 7: 56 a.m., observations in the unlocked Bathroom 2 on the Skidaway Hall revealed an unlocked wall cabinet that contained a full can of Betco Glybet Disinfectant spray. Label precautions included that it caused eye and skin irritation. This was verified by the DON, who removed the chemical. On 12/06/11 at 3:36 p.m., observations in the unlocked Storage Room across from the Brogden Nurses Station revealed an unlocked lower cabinet that contained a full gallon bottle of Betco Fiber Pro Foam Control Liquid Defoamer Concentrate. Label Safety Instructions included that it may cause eye irritation, and to contact a physician if swallowed. Also in this cabinet was a full gallon bottle of Betco SuperKemite Heavy Duty Cleaner and Degreaser. Label warnings included that it was toxic, corrosive, and caused burns. This was confirmed by the DON, who removed the containers. On 12/07/11 at 9:00 a.m., the DON stated the chemicals in the Storage Room on Brogden were left by a contractor. She provided a listing of residents in the facility who were independently mobile and cognitively impaired. This included two residents on Colonial Hall; two on Skidaway Hall; and three on Brogden Hall.

Based on observation, record review and staff interview, the facility failed to ensure that their medication error rate was less than 5%. Four (4) errors out of fifty-three (53) opportunities for two (2) of ten (10) residents were noted by two (2) nurses on one (1) of three (3) halls for a med error rate of 7.54%. Findings include: On 12/06/11 at 9:55 a.m., Licensed Practical Nurse (LPN) 'AA' was noted to give resident # 115 his/her morning medications, including [MEDICATION NAME], and [MEDICATION NAME]. Later review of the physician's orders [REDACTED].#115 at 8:00 a.m. This was verified by LPN 'AA' at 2:20 p.m. On 12/06/11 at 4:05 p.m., LPN 'BB' was noted to give resident # 31 the medications Carvedilol and [MEDICATION NAME]. Later review of the physician's orders [REDACTED]. This was verified by LPN 'BB,' who stated she usually gave the Carvedilol at the same time as the [MEDICATION NAME]. On 12/07/11 at 3:15 p.m., the Director of Nurses (DON) stated the staff had one hour before, and one hour after the scheduled time to give a med.