Every finding on record at Savannah Nursing and Rehabilitation

Based on facility policy review, observation, and interview, the facility failed to maintain a clean and sanitary environment when small brown particles were found on top of the deep fryer and fryer basket, an oil like substance was observed dripping from the fryer onto the floor, a dark brown, gummy liquid was observed on the floor beside the deep fryer, loose particles and dried substances were found on the lids and down the sides of sugar, flour and meal storage containers and on metal storage racks, a dried, black substance covered the stove's cooking surface, the tabletop mini grill was covered with a dried, brown substance and loose particles and when a black substance was observed between the attached clear plastic barrier and the handwashing sink. The facility had a census of 88 with 85 residents receiving a tray from the kitchen. The findings include: 1. Review of the facility policy titled, Dietary Food Safety Requirements, revised 1/1/2026, revealed .It is the policy of the community.Food will be stored, prepared, and served in accordance with professional standards of food service safety. 2. Review of the facility policy titled, Dietary Cleaning, revised 1/1/2026, revealed .Adequate cleaning and sanitizing shall minimize the risk of food borne illnesses.The CDM [Certified Dietary Manager]/Kitchen Supervisor is responsible for maintaining a cleaning schedule to indicate which equipment and areas are to be cleaned and at what frequency.The CDM/Kitchen Supervisor shall audit the cleaning schedule for completeness.CDM/Kitchen Supervisor.shall conduct sanitation/safety inspection/kitchen observations. 3. Observations in the kitchen on 5/17/2026 at 9:15 AM and 2:50 PM, and on 5/18/2026 at 8:15 AM and 10:45 AM, revealed the following: a. Small brown particles were found on top of and inside the deep fryer, and fryer baskets. b. An oil-like substance was observed dripping from the fryer onto the floor and a dark brown gummy substance was observed on the floor to each side of the fryer. c. Sugar, flour, meal, and brown sugar were stored in four large plastic storage containers with clear lids, on the far back wall on the right side of the kitchen, with dried white substances and loose brown and white particles on top of the lids and down the sides of the containers. d. Metal storage racks were found with dried, splattered brown substances and tan particles on their surfaces. e. The stove surfaces were covered in a dried, burnt black substance. f. The tabletop mini grill had a sticky brown residue and brown particles inside. g. A black substance was observed between the clear plastic barrier that is attached to the side of the small sink where staff wash their hands. During an interview on 5/19/2026 at 8:20 AM, the CDM was asked if there should be a black substance between the clear plastic barrier and the sink. The CDM stated, No . The CDM acknowledged there should not be an oil-like substance and food particles on surfaces around the fryer, and dried, black buildup on the stovetop. The CDM was asked if the metal storage racks should have dried, splattered substances and food particles on their surfaces. The CDM stated .NO . The CDM was asked if the tabletop mini grill should have sticky brown residue and brown particles on its surface. The CDM stated No. The CDM was asked if the four large plastic storage containers with clear lids that stored the sugar, flour, meal and brown sugar should have dried substances and loose particles on top of the lids, and down the sides of the containers. The CDM stated no.

Based on facility policy review, facility competency review, medical record review, observation, and interview, the facility failed to ensure a resident with a percutaneous endoscopic gastrostomy (peg) tube (a feeding tube inserted through the abdominal wall directly into the stomach to deliver nutrition, fluids, or medications) received appropriate care and services to prevent complications for 1 of 1 (Resident #13) sampled residents reviewed for peg tube. The findings include: 1. Review of Licensed Practical Nurse (LPN) A's Medication administration via feeding tube competency check off sheet dated 8/15/2025, revealed .Check placement and gastric residual volume by auscultation [instilling air into the feeding tube with a syringe while using a stethoscope placed over the stomach to listen for rushing air] and aspiration [attaching a syringe to the open port of the feeding tube and gently pulling back to see gastric residual(stomach contents)].Satisfactory Performance. Review of the facility policy titled, Medication Administration, dated 1/1/2026, revealed .Medications administered via [by way of] feeding tube.Check placement and gastric residual volume by aspiration and auscultation. 2. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE], with diagnoses including Diabetes, Traumatic Brain Injury, and Gastrostomy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #13 scored a 1 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was severely cognitively impaired. Resident #13 was assessed for the use of a Peg tube. Review of the Care Plan dated 4/22/2026, revealed .has nutritional problem or potential nutritional problem, has peg-has Regular diet with finger foods.Use Enhanced Barrier Precautions- peg. Review of the Physician's Orders dated 4/22/2026, revealed .Check placement of enteral tube per auscultation and aspiration .every shift related to GASTROSTOMY STATUS. Review of the Physician's Orders dated 4/22/2026, revealed .Baclofen TAB [tablet] 10mg [milligram] Give 1 tablet enterally one time a day for muscle spasms. Review of the Physician's Orders dated 4/22/2026, revealed .Gabapentin Oral Capsule 300 mg.Give 3 capsule enterally one time a day. Review of the Physician's Orders dated 4/22/2026, revealed .Flush enteral tube with 30 ml of water before and after medications. Review of the Physician's Orders dated 4/22/2026, revealed .May crush medications.and combine. Observation outside Resident #13's room during medication administration on 5/18/2026 at 12:50 PM, revealed LPN A checked the physician's orders, and gathered her supplies. LPN A performed hand hygiene, donned gloves, emptied the Gabapentin capsules into the medication cup, crushed the Baclofen and emptied into the medication cup, removed her gloves and performed hand hygiene. LPN A knocked on Resident #13's door and entered the room. LPN A placed a barrier on the over the bed table and placed her supplies on the barrier. LPN A washed her hands and donned a gown and gloves. LPN A stated that she was going to auscultate to check placement of the peg tube. LPN A connected the syringe without the plunger to the peg tube and placed the stethoscope onto the Resident's abdomen. LPN A then poured 30 milliliters (ml) of water into the syringe and let it flow per gravity. LPN A stated that the tube was patent. LPN A administered the medications and flushed with 30 cc of water. LPN A removed her gown and gloves, washed her hands and exited Resident #13's room. LPN A failed to follow facility policy and physician's orders for checking the placement of the peg tube before administering medications. During an interview on 5/18/2026 at 1:15 PM, LPN A was asked if Resident #13's peg tube should have been flushed with water to check placement. LPN A stated, We just did a competency check off on that. I may have gotten it mixed up. LPN A was asked if the peg tube was not in the correct placement, could a 30-cc flush of water potentially cause complications to the Resident. LPN A stated, Yes. During an interview on 5/18/2026 at 1:20 PM, the Director of Nursing (DON) was asked if she would expect the staff to check for peg placement by auscultating with a 30-cc water flush. The DON stated, No.I would expect them to follow physician's orders.

Based on facility policy review, medical record review, and interview, the facility failed to reimburse funds within 30 days to 1 of 1 (Resident #107) sampled residents reviewed for personal fund accounts. The findings include: 1. Review of the facility policy titled, Resident Personal Funds, dated [DATE], revealed .Upon the discharge, eviction, or death of a resident with a personal fund deposited with the facility, the facility shall convey within 30 days the resident's funds and a final account of those funds to the resident, or in the case of death, the individual or probate jurisdiction administering the resident's estate, in accordance with State law 2. Review of the medical record revealed Resident #107 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Dementia, Hypertension, Schizophrenia, and Acute Kidney Failure. Review of the Discharge summary dated [DATE], revealed .expired . Review of Resident #107's Resident Fund Account revealed, a returned check dated [DATE] was issued for the account balance of $4,394.97, 6 days past the allotted 30-day time period. The facility failed to refund the remaining balance to Resident #107's estate within 30 days of death. During an interview on [DATE] at 7:52 AM, the Assistant Business Office Manager was asked to explain the process of conveyance of Resident funds after a resident expires. The Assistant Business Office Manager stated, .We key it in the system [the refund request], then it takes 24-48 business hours for it to be submitted to [named Administrator] to approve, once he approves it the cash handler can go in and print it [the refund check].Once it is entered on our [Business Office] end it is out of our hands. During an interview on [DATE] at 8:17 AM, the Administrator was asked when a resident funds check should be sent. The Administrator stated, The check has to be sent back to the family within 30 days. The Administrator was asked if Resident #107's check sent within that time frame. The Administrator stated, It was not.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 1 of 1 staff Licensed Practical Nurse (LPN) C failed to perform hand hygiene after tracheostomy (trach) care and failed to clean reusable equipment after a treatment for 1 of 1 resident (Resident #6) reviewed for trach care. The findings include: 1. Review of the facility policy titled, Infection Prevention and Control Program, dated 10/24/2022, revealed .Hand Hygiene Protocol .staff shall perform hand hygiene . after handling contaminated objects .after PPE [Personal Protective Equipment] removal .before and after performing resident care procedures .all reusable items and equipment requiring .disinfection shall be cleaned in accordance with our current procedures governing the cleaning and disinfection of soiled or contaminated equipment .reusable equipment shall be decontaminated using a germicidal detergent prior to storing for reuse. 2. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses including Traumatic Brain Injury, Hemiplegia, Gastrostomy, and Tracheostomy. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 2, which indicated Resident #6 had severe cognitive impairment, and was dependent on staff for all ADLs (Activities of Daily Living) except for feeding self. Resident #6 required suctioning and Tracheostomy Care. Review of the Physician's Orders dated 7/29/2022, revealed .Tracheostomy Care .Clean with normal Saline .trach stoma .Post Trach Care Vitals .Pre Trach Vitals .Tracheostomy cannula care . Observation during trach care on 11/20/2024 beginning at 2:51 PM, revealed LPN C was at Resident #6's bedside, performed trach care, removed his gloves and gown, picked up the pulse oximeter, and exited the room without performing hand hygiene. During an observation and interview on 11/20/2024 at 3:05 PM, LPN C was observed standing behind the Nurse Station with the pulse oximeter in his hand. LPN C was asked what he should have done with the pulse oximeter after completing a treatment. LPN C stated, .Oh I should have wiped it down and put it away ., went to the medication cart and began wiping the pulse oximeter down before placing it into the medication cart. During an interview on 11/21/2024 at 1:39 PM, LPN C confirmed he should have washed his hands before exiting the room and should have immediately sanitized the pulse oximeter before putting it back in the medication cart. During an interview on 11/21/2024 at 1:44 PM, the Director of Nursing (DON) confirmed staff should wash hands after removing gloves and that reuseable medical equipment should be sanitized after use. 47835

Based on policy review, observation, and interview, the facility failed to ensure food was stored properly when unlabeled and expired items were found in 1 of 2 (,d+[DATE] Hall) nourishment refrigerators and opened and undated items were found in 1 of 2 (walk in refrigerator) kitchen refrigerators. The findings include: 1. The facility policy titled Dietary: Food Storage, dated [DATE], revealed .Food shall be stored in accordance with professional standards for food service safety .food items are stored .covered, labeled and dated .All stored foods should have an expiration date . 2. Observation and interview in the kitchen walk in refrigerator on [DATE] at 8:49 AM, revealed an open, unlabeled, and undated tray of leftover desserts. The Dietary Manager stated, .this should be labeled and dated . Observation in the ,d+[DATE] Hall Nutrition Refrigerator on [DATE] at 10:54 AM, revealed 2 nutritional supplements unlabeled and expired. 3. During an interview on [DATE] at 3:22 PM, Registered Nurse (RN) D confirmed expired and unlabeled items should not be in the nutritional refrigerators. During an interview on [DATE] at 2:08 PM, the DON confirmed expired and unlabeled items should not be in the nutritional refrigerators.

Based on policy review, medical record review, and interview, the facility failed to notify the responsible party of a change of condition and new physician orders for 1 of 4 (Resident # 109) sampled residents reviewed. The findings include: 1. Review of the facility policy titled, Notification of Change, dated 3/28/2024, revealed .ensure the facility promptly informs .resident's representative, consistent with his or her authority, when there is a change requiring notification .The facility must inform the .resident's family member or legal representative when there is a change requiring such notification .Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include .life-threatening conditions .clinical complications .Circumstances that require a need to alter treatment. This may include .new treatment .discontinuation of current treatment .adverse consequences .acute condition . 2. Review of the medical record revealed Resident #109 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Dementia, Psychotic Disturbance, Behavioral Disturbance, and Agitation. Review of the clinical notes dated 10/21/2023, revealed .CNA [certified nursing assistant] reported resident noted to be more difficult to awake .bp [blood pressure] noted to be 88/48 .Resident only aroused to .sternum rub .resident placed in Trendelenburg and bp increased .Will continue to follow plan of care . Review of the medical record revealed no documentation that Resident #109's Responsible Party (RP) was notified of the Resident's change of condition on 10/21/2023. Review of the clinical note dated 10/25/2023, revealed .CNA reported to nurse that resident has not voided this shift. In and out cathed [catheterized] .foley inserted using sterile technique . Review of the medical record revealed no documentation that Resident #109's RP was notified of physician order for an indwelling catheter placed on 10/25/2023. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #109 was assessed as moderately impaired for daily decision-making skills and rarely or never understood. Review of the quarterly MDS assessment dated [DATE], revealed Resident #109 was assessed as moderately impaired for daily decision-making skills and rarely or never understood. During an interview on 11/21/2024 at 2:08 PM, the Director of Nursing (DON) confirmed that the RP should have been notified of changes in condition and new orders on residents.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 1 of 1 staff Licensed Practical Nurse (LPN) C failed to perform hand hygiene after tracheostomy (trach) care and failed to clean reusable equipment after a treatment for 1 of 1 resident (Resident #6) reviewed for trach care. The findings include: 1. Review of the facility policy titled, Infection Prevention and Control Program, dated 10/24/2022, revealed .Hand Hygiene Protocol .staff shall perform hand hygiene . after handling contaminated objects .after PPE [Personal Protective Equipment] removal .before and after performing resident care procedures .all reusable items and equipment requiring .disinfection shall be cleaned in accordance with our current procedures governing the cleaning and disinfection of soiled or contaminated equipment .reusable equipment shall be decontaminated using a germicidal detergent prior to storing for reuse. 2. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses including Traumatic Brain Injury, Hemiplegia, Gastrostomy, and Tracheostomy. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 2, which indicated Resident #6 had severe cognitive impairment, and was dependent on staff for all ADLs (Activities of Daily Living) except for feeding self. Resident #6 required suctioning and Tracheostomy Care. Review of the Physician's Orders dated 7/29/2022, revealed .Tracheostomy Care .Clean with normal Saline .trach stoma .Post Trach Care Vitals .Pre Trach Vitals .Tracheostomy cannula care . Observation during trach care on 11/20/2024 beginning at 2:51 PM, revealed LPN C was at Resident #6's bedside, performed trach care, removed his gloves and gown, picked up the pulse oximeter, and exited the room without performing hand hygiene. During an observation and interview on 11/20/2024 at 3:05 PM, LPN C was observed standing behind the Nurse Station with the pulse oximeter in his hand. LPN C was asked what he should have done with the pulse oximeter after completing a treatment. LPN C stated, .Oh I should have wiped it down and put it away ., went to the medication cart and began wiping the pulse oximeter down before placing it into the medication cart. During an interview on 11/21/2024 at 1:39 PM, LPN C confirmed he should have washed his hands before exiting the room and should have immediately sanitized the pulse oximeter before putting it back in the medication cart. During an interview on 11/21/2024 at 1:44 PM, the Director of Nursing (DON) confirmed staff should wash hands after removing gloves and that reuseable medical equipment should be sanitized after use.

Based on policy review, observation, and interview, the facility failed to ensure food was stored properly when unlabeled and expired items were found in 1 of 2 (100/200 Hall) nourishment refrigerators and opened and undated items were found in 1 of 2 (walk in refrigerator) kitchen refrigerators. The findings include: 1. The facility policy titled Dietary: Food Storage, dated 7/25/2024, revealed .Food shall be stored in accordance with professional standards for food service safety .food items are stored .covered, labeled and dated .All stored foods should have an expiration date . 2. Observation and interview in the kitchen walk in refrigerator on 11/18/2024 at 8:49 AM, revealed an open, unlabeled, and undated tray of leftover desserts. The Dietary Manager stated, .this should be labeled and dated . Observation in the 100/200 Hall Nutrition Refrigerator on 11/20/2024 at 10:54 AM, revealed 2 nutritional supplements unlabeled and expired. 3. During an interview on 11/20/2024 at 3:22 PM, Registered Nurse (RN) D confirmed expired and unlabeled items should not be in the nutritional refrigerators. During an interview on 11/21/2024 at 2:08 PM, the DON confirmed expired and unlabeled items should not be in the nutritional refrigerators.

Based on policy review, medical record review, and interview, the facility failed to notify the responsible party of a change of condition and new physician orders for 1 of 4 (Resident # 109) sampled residents reviewed. The findings include: 1. Review of the facility policy titled, Notification of Change, dated 3/28/2024, revealed .ensure the facility promptly informs .resident's representative, consistent with his or her authority, when there is a change requiring notification .The facility must inform the .resident's family member or legal representative when there is a change requiring such notification .Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include .life-threatening conditions .clinical complications .Circumstances that require a need to alter treatment. This may include .new treatment .discontinuation of current treatment .adverse consequences .acute condition . 2. Review of the medical record revealed Resident #109 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Dementia, Psychotic Disturbance, Behavioral Disturbance, and Agitation. Review of the clinical notes dated 10/21/2023, revealed .CNA [certified nursing assistant] reported resident noted to be more difficult to awake .bp [blood pressure] noted to be 88/48 .Resident only aroused to .sternum rub .resident placed in Trendelenburg and bp increased .Will continue to follow plan of care . Review of the medical record revealed no documentation that Resident #109's Responsible Party (RP) was notified of the Resident's change of condition on 10/21/2023. Review of the clinical note dated 10/25/2023, revealed .CNA reported to nurse that resident has not voided this shift. In and out cathed [catheterized] .foley inserted using sterile technique . Review of the medical record revealed no documentation that Resident #109's RP was notified of physician order for an indwelling catheter placed on 10/25/2023. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #109 was assessed as moderately impaired for daily decision-making skills and rarely or never understood. Review of the quarterly MDS assessment dated [DATE], revealed Resident #109 was assessed as moderately impaired for daily decision-making skills and rarely or never understood. During an interview on 11/21/2024 at 2:08 PM, the Director of Nursing (DON) confirmed that the RP should have been notified of changes in condition and new orders on residents.

Based on policy review, medical record review, and interview, the facility failed to follow its policy for weighing residents for 1 of 7 sampled residents (Resident #74) reviewed for nutritional status. The findings include: Review of the facility's policy titled, Dietary Weight Monitoring revised 11/9/2021, revealed .A weight monitoring schedule will be developed upon admission for all residents .Newly admitted residents .monitor weight . Review of the medical record revealed Resident #74 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record dated 8/1/2022, revealed Resident #74 weighed 134 pounds. Review of the facility's FULL NUTRITIONAL assessment dated [DATE], revealed Resident #74 weight was 128 pounds and documented, .Resident is at risk for malnutrition . The facility failed to obtain Resident #74's weight upon admission to the facility. During an interview on 9/21/2022 at 4:45 PM, the Director of Nursing (DON) confirmed Resident #74 was not weighed on admission. The DON stated, .should have been weighed on the day of admission .

Based on policy review, medical record review, observation, and interview, the facility failed to ensure a resident's skin condition was accurately assessed, a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Review of the facility's policy titled, .Pressure Injury Prevention ., dated 10/15/2021, revealed .This facility is committed to the prevention .and the promotion of healing of existing pressure injuries. It is the policy of this facility to implement evidenced-based interventions for all residents .who have a pressure ulcer .injury present, and to promote wound healing of various types of wounds in accordance with current standards of practice and Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .The attending physician .will be notified for .Presence if a new pressure ulcer/injury . Review of the facility's policy titled, .Physicians Verbal Order Policy, dated 5/24/2022, revealed .Enter the order into the medical record manually or electronically .Write T.O. (telephone order) or V.O. (verbal order), including date, time, name of the resident, the complete order .and sign the name of the physician or health care provider and nurse or sign off the electronic order .Follow through with orders by making appropriate contact or notification . Review of the facility's policy titled, .Documentation of Wound Treatments, dated 9/21/2021, revealed .The purpose of this policy is to provide a consistent process for accurate and complete documentation of wound assessments and treatments .The facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are .Complete .Accurately documented .Complete the weekly .Wound Assessment which includes the .anatomical location .Treatments are documented after the treatment is performed . Review of the medical record, revealed Resident #87 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #87 had intact cognition, was at risk for pressure ulcers, and had one unstageable - deep tissue injury present upon admission/entry. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 8/2022 and 9/2022 Treatment Administration Record (TAR), revealed wound care treatments were not documented as administered. Review of the facility Wound assessment dated [DATE], revealed .Date Wound Identified 08/27/2022 .Great Toe Left Anterior .Wound Type Pressure .Date of Assessment 08/29/2022 .Deep tissue injury .Intact skin % [percent] 100.00 .Wound size Length (cm) [centimeters] 0.50 .Width (cm) 2.00 . Review of the facility Wound assessment dated [DATE], revealed .Date Wound Identified 08/27/2022 .Great Toe Right Anterior .Wound Type Pressure .Date of Assessment 09/13/2022 Deep tissue injury .Wound size Length (cm) 0.50 .Width (cm)0.50 . During an interview on 9/20/2022 at 1:39 PM, the Director of Nursing (DON) confirmed skin prep was being applied to Resident #87's left toe daily. The DON confirmed there was not an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation in the resident's room on 9/20/2022 at 1:47 PM, revealed the DON pulled off Resident #87's sock to reveal a purple area to top of Resident #87's left toe, purple in color, approximately 0.3 centimeters long and 0.4 centimeters wide. During an interview on 9/20/22 at 3:03 PM, the DON confirmed the documentation of the right great toe was an error. The DON stated, .I put in right and it is on her left . The DON confirmed the order for skin prep was missed. The DON stated, .I got an order, wrote it on a sticky note and the order never got put in .

Based on policy review, medical record review, and interview, the facility failed to provide Care Plan interventions for an anticoagulant medication and failed to develop a comprehensive Care Plan for nutrition for 2 of 22 sampled residents (Resident #53 and #74) reviewed. The findings include: The facility policy titled, Comprehensive Careplan, dated 3/25/2022, revealed .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made . Review of the medical record, revealed Resident #53 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan with an effective date of 5/9/2022 - Present, revealed interventions were not developed for Resident #53's anticoagulant medication use. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #53 had severe cognitive impairment and received anticoagulant medication. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/21/2022 at 4:10 PM, the MDS Coordinator #1 confirmed Resident #53 had no interventions on the Care Plan for anticoagulant medication. During an interview on 9/21/2022 at 5:02 PM, the Director of Nursing (DON) confirmed there were no interventions on the care plan for anticoagulant medication. Review of medical record revealed Resident #74 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of admission/readmission MDS dated [DATE], revealed Resident #74 had severe cognitive impairment and required extensive assistance from staff for all activities of daily living (ADLs). Review of the medical record dated 8/1/2022, revealed Resident #74 weighed 134 pounds. Review of the facility's FULL NUTRITIONAL assessment dated [DATE], revealed Resident #74 weighed 128 pounds, and documented .Resident is at risk for malnutrition . Review of a Patient Weight Report dated 9/14/2022, revealed Resident #74 weighed 119 pounds, indicating a 7% (percent) weight loss in 30 days. Review of the Care Plan, initiated 8/1/2022 through present, revealed there was not a comprehensive Care Plan for Resident #74's weight loss. During an interview on 9/21/2022 at 5:30 PM, the DON confirmed that Resident #74 did not have a care plan for weight loss. The DON stated, .he (Resident #74) should have a Care Plan for weight loss .

Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual v 1.17, October 2019, medical record review, and interview, the facility failed to accurately assess residents for nutrition and falls for 2 of 22 sampled residents (Resident #62 and #74) reviewed for accuracy of MDS assessments. The findings include: Review of the Minimum Data Set, 3.0 RAI Manual v 1.17, dated October 2019, page 1-7 revealed .Federal regulations at 42 CFR 483.20 (b)(1)(xviii ), (g), and (h) require that (1) the assessment accurately reflects the resident's status . Review of medical record revealed Resident #62 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record dated 3/10/2022, revealed Resident #62 weighed 148 pounds, and on 8/2/2022 weighed 118 pounds indicating a 20% weight loss in 6 months. Review of the quarterly MDS dated [DATE], revealed Resident #62 had severe cognitive impairment, required extensive assistance from staff for all Activities of Daily Living (ADLs), and was not coded for weight loss in the last 6 months of the review period. During an interview on 9/21/2022 at 4:15 PM, MDS Coordinator #1 confirmed Resident #62's quarterly MDS assessment was not coded for weight loss in the last 6 months. The MDS Coordinator stated, .the MDS [assessments] should reflect weight loss during the last 6 months . Review of medical record revealed Resident #74 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed Resident #74 had 1 fall with no injury on 8/3/2022, and 1 fall with major injury on 8/11/2022, and weighed 134 pounds on 8/1/2022. Review of a Nurses Event Note dated 8/3/2022, revealed Resident #74 had an unobserved fall in his room and documented, .Resident laying in floor on right side beside his bed, Resident stated he was trying to get up . Review of a Nurses Event Note dated 8/11/2022, revealed Resident #74 had an unobserved fall in his room and documented, .Resident laying off to the right side of his bed, sitting up with knees bent, with hands on head .injury to head .complaints of pain at neck and base of head . Review of the admission/readmission MDS dated [DATE], revealed Resident #74 had severe cognitive impairment, required extensive assistance from staff for all ADLs, had no falls since admission, and had no weight loss during the review period. Review of the facility's FULL NUTRITIONAL assessment dated [DATE], revealed Resident #74 weighed 128 pounds, and documented .Resident is at risk for malnutrition . Review of a Patient Weight Report dated 9/14/2022, revealed Resident #74's weight was 119 pounds, indicating 7% (percent) weight loss in 30 days. During an interview on 9/21/2022 at 4:55 PM, MDS Coordinator #1 confirmed Resident #74's admission MDS was not coded for falls. MDS Coordinator #1 stated, .should have been coded for 2 falls on the admission/readmission MDS .the falls on the MDS [assessments] are coded incorrectly . MDS Coordinator #1 confirmed that Resident #74 should have been coded for his weight loss.

Based on policy review, medical record review, observation, and interview, the facility failed to monitor physical restraints for 1 of 1 (Resident #8) sampled residents reviewed for physical restraints. The findings include: 1. The facility's Restraint Policy dated 4/2019 documented, .Medical symptoms warranting the use of restraints should be documented in the resident's medical record, ongoing assessments, and care plans . 2. Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 3. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] documented Resident #8 had severe cognitive deficits, required extensive assistance with activities of daily living, had functional limitations in range of motion with impairment on one side of the upper and lower extremity, had (2) falls with no injuries, (1) fall with injury, and had a restraint. The care plan dated 6/27/19 documented Resident #8 had interventions to check the restraint every 30 minutes and release it every 2 hours. A physician's orders [REDACTED].Monitor 2 times daily .May utilize roll belt when in wc (wheelchair). Must check every 30 minutes and release every 2 hours for 15 mins (minutes) while in restraint . A nursing note dated 9/25/19 documented, .New order for roll belt while in wc. Must check every 30 mins and release every 2 hours . The (MONTH) 2019 Treatments documented, .Monitor non-self-release belt q (every) shift for placement and proper function, must check every 30 mins and release every 2 hours . The facility was unable to provide documentation the restraint was monitored as ordered. Observations on 12/02/19 at 9:10 AM and 4:08 PM on the 200 hall revealed Resident #8 seated in his wheelchair with a restraint around his waist that fastened behind his wheelchair. Observations on 12/4/19 at 3:20 PM outside the Conference Room revealed Resident #8 seated in his wheelchair with a restraint around his waist that fastened behind his wheelchair. Interview with the Director of Nursing (DON) on 12/4/19 at 4:25 PM in the conference room, the DON confirmed there was no documentation on the August, September, and (MONTH) 2019 treatment record that Resident #8's belt was checked every 30 minutes and released every 2 hours.

Based on policy review, medical record review, and interview, the facility failed to ensure a fall was documented and an investigation initiated timely for 1 of 3 (Resident #1) sampled residents reviewed for falls. The findings included: 1. The facility's Occurrence Reporting policy documented, The facility will complete an occurrence report to document the details of an accident/incident/occurrence/unusual event effecting the resident. (Named Nursing Facility) requires completion of an occurrence report that triggers an immediate and on-going investigation .Occurrence reports should be completed regardless if the resident sustained [REDACTED]. 2. Medical record review revealed Resident #1 was originally admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of the facility's investigation revealed Resident #1 was found on the floor on 3/9/19 shortly after midnight on the 3/8/19 6:00 PM to 6:00 AM shift with no noted injuries and was assisted back to bed. The Nurse's Event Note dated 3/9/19 at 12:00 PM documented, Notified by residents (resident's) wife that resident stated he had fallen the previous night (03/08/19) (the fall on 3/9/19 early morning) and was assisted back into bed by staff . Medical record review revealed there was no documentation on the 3/8/19 6:00 PM to 6:00 AM shift of the fall that occurred on 3/9/19 shortly after midnight and the Event Note was not completed until 3/9/19 at 12:00 PM, which was when the investigation was initiated. Interview with the Director of Nursing (DON) on 5/22/19 at 2:39 PM, in the Conference Room, the DON was asked when should a fall be documented. The DON stated as soon as the nurse becomes aware, after assessing the resident.

Based on policy review, observation, and interview, the facility failed to ensure food was served under sanitary conditions when 2 of 14 (Certified Nursing Assistant (CNA#1) and Restorative Aide (RA) #1) staff members touched residents' food with their bare hands during dining observations and expired supplements in 1 of 8 (Nurses storage closet) medication storage areas. The findings included: 1. The facility's TECHNIQUES FOR PREVENTING CROSS-CONTAMINATION policy documented, .Use plastic gloves when in direct contact with food during preparation. Example: preparing sandwich, raw meat, raw vegetables, etc. Gloves need to be changed between handling separate food items . Observations in the dining room revealed the following: a. 2/21/17 at 11:20 AM, CNA #1 rubbed her chin, did not wash her hands or don gloves, removed a sandwich from a sandwich bag and handled the sandwich with her bare hands for Resident # 129. CNA #1 did not don gloves prior to touching the resident's food. b. 2/22/17 at 5:13 PM, RA #1 opened baked potatoes with her bare hands for Resident #69 and 77. RA #1 did not don gloves prior to touching the resident's food. Interview with the Assistant Director of Nursing (ADON) on 2/22/17 at 5:52 PM, in the Administrator's office, the ADON was asked if it was acceptable for staff to handle food with their bare hands when serving residents in the dining room. The ADON stated, No. 2. The facility's MEDICATION STORAGE policy documented, .Routine checks must be accomplished to ensure that expired medication are discarded . Observations in the Nurses' storage closet on 2/22/17 at 5:45 PM, revealed 11 (4) ounce cans of nutritional supplement drinks with an expiration date of August 1, 2016. Interview with the Director of Nursing (DON) on 2/11/17 at 5:45 PM, in the Nurses' storage closet, the DON was asked who checks the supplements. The DON stated, Me and the ADON .check it periodically about every two months .

Based on policy review, medical record review and interview, it was determined the facility failed to update and revise a care plan related to urinary incontinence for 2 of 15 (Residents #12 and 104) sampled residents of the 31 residents included in the stage 2 review. The findings include: 1. Review of the facility's "Care Plans" policy documented, "...Reviews should reflect continuation of already identified problems, newly developed problems, new approaches, and newly developed goals. New problems should be added with date of review reflected on the care plan..." 2. Medical record review for Resident #12 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 6/25/14 documented, a brief interview for mental status (BIMS) of 3 indicating the resident was cognitively impaired and was always continent of bladder. Review of MDS with an ARD date of 7/5/14 documented, the resident was always incontinent of bladder." During an interview in the MDS office on 10/22/14 at 7:25 AM, MDS Coordinator #2 was asked if she expected to see an incontinence care plan for Resident #12. MDS Coordinator #2 stated, "Yes, I would expect to see a care plan. I don't have an incontinence care plan for (named resident #12) but I will add one now." During an interview on the 400 Hall on 10/22/14 at 7:30 AM, Certified Nursing Assistant (CNA) #2 was asked if Resident #12 was cognitive enough to use a call light when he needed to go to the bathroom. CNA #2 stated, "Not really." 3. Medical record review for Resident #104 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the MDS with an ARD of 6/25/14 documented, a BIMS score of 15 indicating the resident is cognitively intacted. and always continent of bladder. Review of MDS with an ARD of 9/16/14 documented, occasionally incontinent of bladder. During an interview in the MDS office on 10/21/14 at 12:20 PM, MDS Coordinator #1 was asked if she expected to see a urinary incontinence care plan for Resident #104. MDS Coordinator #1 stated, "I should have something on there (care plan). I could have sworn I had something but as far as incontinence, I don't see it. I just don't see it." During an interview on the 200 hall on 10/21/14 at 12:45 PM, CNA #1 was asked to explain Resident #104's incontinent episodes. CNA #1 stated, "She's usually incontinent early in the morning. We'll find she's wet." During an interview in Resident #104's room on 10/21/14 at 2:13 PM, Resident #104 was asked if she could explain her incontinent episodes. Resident #104 stated, "Several weeks ago I was hospitalized because I was septic and I have always had a lot of urinary tract Infections. These incontinent episodes started then but they are not as frequent as they have been. I sleep through the episodes (of incontinence)."

Based on policy review, observation and interview, it was determined the facility failed to ensure that food was prepared and served under sanitary conditions when kitchen staff did not completely cover their hair, allowed food items to be stored opened in the freezer and allowed 34 residents' food and beverages to be delivered uncovered during 2 of 2 (7/22/13 and 7/23/13) dining observations. The findings included: 1. Review of the facility's personal hygiene policy documented, "...Hair covering must be worn at all times with all hair under (the) covering..." Observations in the kitchen on 7/22/13 beginning at 10:20 AM revealed the following: a. Dietary staff member #2's hair was sticking out in the back and on the sides of her hair net. b. Dietary staff member #1 her was hair hanging out on the right side of her hair net. Observations in the dining room on 7/22/13 beginning at 11:20 AM revealed the following: a. Dietary staff member #3 was serving plates for residents with her hair sticking out in the back and on the sides of her hair net. b. Dietary staff member #1's hair was hanging out the side of her hair net. Observations in the kitchen on 7/23/13 at 4:35 PM revealed the following: a. Dietary staff member #1's hair was hanging the back and side of her hair net. b. Dietary staff member #4's hair was not completely covered with a hair net while serving residents' plates. During an interview in the conference room on 7/24/13 at 8:10 AM, Dietary staff member #1 was asked what the facility's policy was for covering staff's hair while in the kitchen. Dietary staff member #1 confirmed all hair should be covered. 2. Observations in the kitchen walk in freezer on 7/22/13 at 10:30 AM, revealed a bag of pancakes, a bag of pizza squares, a bag of french toast sticks, a bag of corn and a bag of hamburger patties were all stored opened in the freezer. During an interview in the kitchen walk in freezer on 7/22/13 at 10:30 AM, Dietary staff member #1 was asked if it is acceptable for the bags to be stored open in the freezer. Dietary staff member #1 stated, "...well that just depends on you today..." 3. Observations of meal delivery on 7/22/13 revealed the following a. At 11:30 AM - the 400 hall meal trays were removed from the cart and carried in the hall to residents rooms with food and beverages not covered. b. At 11:45 AM - the 200 hall meal trays were removed from the cart revealed and carried in the hall to residents rooms with food and beverages not covered. c. At 11:53 AM - the 300 hall meal trays were removed from the cart revealed and carried in the hall to residents rooms with food and beverages not covered. d. At 12:00 PM - the 100 hall meal trays were removed from the cart revealed and carried in the hall to residents rooms with food and beverages not covered. Observations of meal delivery on 7/23/13 revealed the following: a. At 5:20 PM - the 100 hall meal trays were removed from the cart revealed and carried in the hall to residents rooms with food and beverages not covered. b. At 5:25 PM - the 400 hall meal trays were removed from the cart revealed and carried in the hall to residents rooms with food and beverages not covered. c. At 5:30 PM - the 200 hall meal trays were removed from the cart revealed and carried in the hall to residents rooms with food and beverages not covered. d. at 5:50 PM - the 300 hall meal trays were removed from the cart revealed and carried in the hall to residents rooms with food and beverages not covered. During an interview in the conference room on 7/24/13 at 10:30 AM, dietary staff member #1 was asked what was the facility's policy for transporting food. Dietary staff member #1 stated, "...our policy is to put it (resident trays) in carts to transport it and cover it... we don't cover those (beverages and desserts) they stay in the cart until they are delivered into the room..."

Based on policy review and observation, it was determined Certified Nursing Assistant (CNA #1) failed to maintain or enhance each resident's dignity and respect by calling residents feeders in 1 of 2 (lunch meal on 7/22/13) dining observations. The findings included: Review of the facility's policy for courtesy titles documented, "It is the policy of this facility that all patients will be addressed by courtesy titles unless it can be documented that they prefer being addressed otherwise." Observations of the lunch meal service on the 400 hall on 7/22/13 at 11:45 AM, revealed 3 meal trays were left on the meal cart. CNA #1 was asked about the trays left on the meal cart. CNA #1 stated, "The ones (trays) left are our feeders... and they (staff) will get to them."

Based on medical record review and interview, it was determined the facility failed to ensure each resident was free of unnecessary medication usage when 2 of 10 (Residents #18 and 102) residents failed to have a [DIAGNOSES REDACTED]. The findings included: 1. Medical record review for Resident #18 documented an admitted ,[DATE] 12 with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. During an interview in the conference room on 7/24/13 at 3:50 PM, the acting Director of Nursing (DON) was asked if there was a [DIAGNOSES REDACTED]. The DON stated, "No, we missed them and (named Doctor) will add the [DIAGNOSES REDACTED]. 2. Medical record review for Resident #102 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. During an interview in the conference room on 7/24/13 at 8:40 AM, Nurse #1 stated, "...we had to get a clarification for the [MEDICATION NAME] and the [MEDICATION NAME] we did not have a [DIAGNOSES REDACTED]. During an interview in the conference room on 7/24/13 at 8:40 AM, the acting Director of Nursing confirmed there was not a diagnose for these medications noted above.