Every finding on record at Sparta Health and Rehabilitation

Based on observation, staff interviews, record reviews, and review of the facility's policy titled Helping Avoid Nosocomial Developed Skin Breakdown, the facility failed to provide activities of daily living (ADL) care to one of 25 sampled residents (R) (R13). Specifically, the facility failed to ensure that thorough incontinence care was provided to R13. This deficient practice had the potential to place R13 at risk of developing infections, foul odor, and skin breakdown. Findings include: Review of the facility's policy titled Helping Avoid Nosocomial Developed Skin Breakdown, reviewed 4/2024, included Incontinence cleansing and skin barriers may be used for incontinence patients. Review of R13's electronic medical records (EMR) revealed diagnoses including, but not limited to, debility, cardiorespiratory condition, and fracture. Review of the Significant Change Minimum Data Set (MDS) dated [DATE] revealed Section GG (Functional Abilities and Goals) documented R13 was dependent on staff for toileting, bathing, upper and lower body dressing, personal hygiene, and mobility. Section H (Bowel and Bladder) documented the resident was always incontinent of bowel and bladder. Section M (Skin Conditions) documented that R13 had a risk of pressure ulcers and had one stage 4 pressure ulcer. Observation on 3/12/2025 at 4:50 pm revealed Certified Nursing Assistant (CNA) AA performed incontinence care on R13 but did not lift the scrotum to clean around it or clean the surrounding areas. In an interview on 3/12/2025 at 5:10 pm, CNA AA confirmed she did not lift R13's scrotum to clean around it or clean the surrounding areas during incontinent care. She stated she should have cleaned the scrotum, but she did not. She stated when she did not clean the scrotal area properly, it could cause moisture in the area. In an interview on 3/13/2025 at 10:27 am, Licensed Practical Nurse (LPN) DD stated during incontinence care of the male resident, the resident's scrotum was to be lifted and the surrounding surface cleaned properly. LPN DD stated there might be residual urine or moisture in the perineal area, and if it was not cleaned and dried properly, the resident's skin condition could be affected. In an interview on 3/13/2025 at 10:50 am, the Director of Nursing (DON) stated during incontinence care, the scrotum was to be lifted and cleaned around the area. She further stated that if this was not done, it could cause moisture buildup and skin breakdown in the residents.

Based on observations, record reviews, staff interviews, and a review of the facility's policies titled Hand Hygiene, and Standard Precaution/Use of PPE [Personal Protective Equipment], the facility failed to ensure infection control processes were followed during resident care for one of 25 sampled residents (R) (R13). The deficient practice had the potential to increase the potential for cross-contamination and spread of infection. Findings include: Review of the facility's policy titled Hand Hygiene, reviewed 12/27/2024, revealed the Purpose section stated, Hand Hygiene is the single most important means of preventing the spread of infection. The use of gloves does not replace hand washing. The Guidelines section included, .Glove use: Change gloves and perform hand hygiene during patient care, if: Moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs. Review of the facility's policy titled Standard Precautions/Use of PPE, reviewed 12/27/2024, revealed the Intent section stated, It is the policy of this facility that: 1) all patient blood and body fluids will be considered potentially infectious. 2) standard precautions are indicated for all patients. The Guidelines section included, . Change gloves during patient care if the hands will move from a contaminated body site (e.g.[such as] perineal area) to a clean body site (e.g., face). Observation on 3/12/2025 at 4:50 pm revealed Certified Nursing Assistant (CNA) AA did not change her gloves while providing incontinence and activities of daily living (ADL) care to R13. Observation revealed CNA AA used one pair of gloves while providing incontinence and ADL care to R13. Further observation revealed that CNA AA removed her gloves before removing the gown she wore during the incontinence and ADL care. Observations revealed that she removed the gloves, then removed the gown with her bare hands by grasping the front of the gown, pulling it forward to remove it, and gathering it with both bare hands before placing it in the garbage bin. In an interview on 3/12/2025 at 5:10 pm, CNA AA confirmed she did not change her gloves while providing incontinence and ADL care to R13. She stated she should have changed her gloves because the resident could get an infection when the same gloves were used from dirty areas to clean areas. She further stated she should not have used the same gloves to put on the resident's clothes and touch the bed remote that she wore during incontinence care. CNA AA further stated that bacteria could spread from the dirty gloves to the resident and surrounding areas. CNA AA confirmed she did not remove her gown per infection control protocol after completing incontinence care. She confirmed she removed the gloves first, used her bare hands to grasp the front of her gown, removed it with her bare hands, and placed it in the garbage bin. She stated she should not have touched the outside of the gown with her bare hands because the germs or bacteria on the dirty gown could cause the spread of infection. In an interview on 3/13/2025 at 10:27 am, Licensed Practical Nurse (LPN) DD stated when removing gowns, the gown should be pulled away from the body with the gloves on, from inwards to outwards from the neck downwards to ensure germs from the outside of the gown do not get transferred to others or the resident. LPN DD further stated gloves should be changed if soiled or when going from a clean surface to a dirty surface. He stated one pair of gloves should not be used to provide incontinence care and ADL care since this could cause cross-contamination, and the resident could get an infection and get sick. In an interview on 3/13/2025 at 10:50 am, the Director of Nursing (DON) stated that gloves should be changed between incontinence care and other ADL care. She stated that it was not appropriate for the same gloves to be used throughout the procedure and that glove change was necessary when moving from dirty to clean. The DON stated that not changing gloves could cause the spread of infection. She further stated that gowns were to be removed before removing gloves to prevent the spread of germs.

Based on observation, interview, and facility policy review, the facility failed to ensure all hot food items were held above 135 degrees on the steam table to prevent food borne illness. This deficient practice had the potential to effect 36 of 42 resident that receive regular or mechanical soft textured diet. Findings include: Observation on 10/8/22 at 12:45 p.m. revealed the Dietary Manager (DM) assisting with obtaining hot food temperatures on the steam table using the facility's calibrated thermometer. Steam table temperatures were obtained halfway through lunch meal service. Continued observation revealed a deep square steam table pan containing tater tots had a temperature of 130 degrees. During an interview on 10/8/22 at 12:45 p.m. the DM confirmed that the tater tots were 130 degrees. The DM stated that hot foods should be at least 135 degrees on the steam table. Review of facility policy titled Food Preparation and Distribution revealed that hot foods should be held at or above 135 degrees Fahrenheit.

Based on observation, record review, interview, patient rights documents and facility policy review, the facility failed to implement care plan interventions to prevent falls for one (Resident (R) 41). Staff failed to provide care as required per R41's care plan, including the number of staff necessary to prevent accidents during the provision of care. As a result, the resident fell from his bed to the floor on two occasions. The facility failed to ensure R41 and R22's preferences for bathing were integrated into the care plan. The facility failed to develop a comprehensive care plan for R9 regarding nutritional risk, out of a survey sample of 13 reviewed for care plans. Findings include: Review of the facility's policy titled, Skilled Inpatient Services Patient's Plan of Care, dated 2020, was provided by the Administrator on 04/28/2021 at 11:31 AM, and revealed, .Each patient will have a person-centered comprehensive care plan developed and implemented to meet his other preferences.The patient's care plan should be reviewed after each MDS assessment and revised based on changing goal, preferences and needs. Review of a document titled, Patients Plan of Care, dated 2020 as copyrighted, revealed . Each patient will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the patient's medical, physical, mental and psychosocial needs. A comprehensive care plan should be developed within 7 days after completion of the comprehensive MDS assessment. When developing the comprehensive care plan, facility staff should use the MDS to assess the patient's clinical condition, cognitive and functional status, and use of services.The patient's care plan should be reviewed after each MDS assessment and revised based on changing goals, preferences and needs of the patient and in response to current interventions. The comprehensive care plan should also be updated as ongoing clinical assessments identify changes. 1.Review of a Face Sheet, found in R41's electronic medical record (EMR) under the Resident file, indicated the resident was admitted on [DATE]. Review of a Care Plan, found in R41's EMR under the Care Plan tab, dated 03/12/20, indicated the resident required assistance with hygiene. The care plan specifically informed staff the resident was non-weight baring, had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . An intervention initiated on 08/14/20 noted the resident required two staff members during the provision of care for support. Review of the Event Initial Note, found in R41's EMR under Nurses Notes, dated 08/14/20 and 01/23/21, revealed the resident fell out of bed on each date, while only one staff member provided personal care to the resident when he was in bed. During an interview on 04/27/21 at 10:29 AM, R41 stated he fell from his bed twice, and both incidents involved one staff member providing him care while he was in bed instead of two staff members. 2. Review of a Care Plan, found in R41's EMR under the Care Plan, tab dated as initiated 10/12/20, indicted the resident was to be provided bed baths per schedule. There was no evidence, in the resident's care plan, which showed the resident's preference in making the decision to take a shower or a bed bath. During an interview with R41 on 04/26/21 at 12:54 PM, the resident said he would prefer to take a shower instead of a bed bath. 3. Review of a Face Sheet, found in R9's electronic medical record (EMR) under the Resident file, indicated the resident was admitted on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R9s Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/08/20, revealed the resident had a Brief Interview for Mental Status (BIMS) which could not be determined. Under the Care Area Assessment (CAA), the resident triggered under nutritional status and directed staff to develop a care plan. Review of a Care Plan, found in R9's EMR under the Care Plan tab, failed to identify nutrition under a care area. During an interview on 04/28/21 at 3:54 p.m., the MDS Coordinator stated she was hired recently and was in the process of reviewing care plans for each resident and individualizing them. The MDS Coordinator stated the comprehensive assessment guides the development of the care plan and if an area triggered under the CAA this would be carried through to the care plan. A subsequent interview was conducted on 04/29/21 at 9:31 AM, the MDS Coordinator confirmed R9 triggered under nutrition and it was not carried through to the care plan. During an interview on 04/29/21 at 11:33 AM, the Director of Nursing (DON) stated it was her understanding that an issue that was triggered under the CAA staff were required to proceed to the development of the care plan with the associated triggered area. 4. Review of R22's undated Face Sheet, located in the resident's EMR, revealed R22 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R22's most current annual MDS, with an ARD of 05/03/20, revealed the resident had a BIMS of 15, which indicated the resident was cognitively intact. R22 had no behaviors, was totally dependent on staff for bathing, and was always incontinent of bowel and bladder. The resident's Preferences for Customary Routine and Activities, indicated that it was Somewhat important, to choose between a tub bath, shower, bed bath, or sponge bath. Review of R22's Care Plan, located in the resident's EMR under the care plan tab, revealed a care plan titled, Self care deficit, which was initiated 10/22/18, and reviewed 02/15/21. The self-care deficit care plan indicated, Bed bath daily, encourage patient to assist with care. Observation and interview on 04/26/21 at 9:49 a.m., R22 was noted to have facial hair on her chin. R22 indicated she would like to have a shower but only gets bed baths. The resident revealed she had not been showered since she was admitted to the facility. The resident revealed she was told she could not have showers because she was not able to stand. Observation and interview on 04/27/21 at 9:10 a.m. with R22, revealed she had a bed bath earlier in the morning, and the CNA cleaned off the resident's facial hair. The resident indicated she would like to have the facial hair removed more often, and still would like to shower. Interview on 04/28/21 at 9:55 a.m. with the DON revealed R22's MDS from 05/13/20 recorded the resident felt it was somewhat important to choose between bath, shower, bed bath, and sponge bath, which means the Certified Nursing Assistants should ask what R22's preference is each time the resident is bathed. Interview on 04/28/21 at 10:37 a.m. with the Activities Specialist, revealed she assesses all newly admitted residents upon admission regarding bathing preferences and R22 felt it was somewhat important to choose between bath, shower, bed bath, and sponge bath, and CNAs should ask the resident her preference each time the resident is bathed. The Activities Specialist indicated resident's bathing preferences should be in the resident's EMR under the Data Collection tab, but there were no bathing preferences listed for R22.

Based on interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer one of five residents (Resident (R) 29), and/or their representative, reviewed for pneumonia vaccinations, the opportunity for the resident to be vaccinated in accordance with CDC guidelines. The resident and/or their representatives were unable to share in clinical decision making with the medical provider as they were not given information or offered PCV13. The failed practice had the potential to increase the risk for pneumonia. Findings include: Review of the Centers for Disease Control and Prevention (CDC) website titled, Pneumococcal Vaccine Recommendations revealed, For adults [AGE] years or older who do not have an immunocompromising condition, [CONDITION(S)], or cochlear implant and want to receive PCV13(Prevnar 13), AND PVC13ND PPSV23 (Pneumovax23).Administer 1 dose of PCV13 first then give 1 dose of PPSV23 at least 1 year later. If the patient already received PPSV23, give the doe of PCV13 at least one year after they received the most recent dose of PPSV23. Anyone who received any doses of PPSV23 before age 65 should receive 1 final does of the vaccine at age 65 or older. Retrieved online 04/29/21 at http://www.cdc.gov/vaccines/vpd/pneumo/hcp/recommendations.html. Review of the facility policy titled, Skilled Inpatient Services Immunization of Patients, dated 2020, was provided by the Administrator on 04/28/21 at 11:00 AM. The policy revealed, .The patient/family representative will receive education and be informed about the benefits and risks of immunizations before being offered the vaccine.The facility will assure documentation in the patient's medical record of the information/education provided regarding the benefits and risks of immunization and the administration or refusal of or medical contraindications to the vaccine.Assess patients on admission for the need of vaccination against Streptococcus pneumoniae infection according to the following criteria:XXX[AGE] years or older, History of Prior Vaccination.None or unknown.Administer PCV13 followed in 1 year by PPSV23. Review of the Electronic Medical Record (EMR) of the undated Face Sheet, under the face sheet icon, revealed R29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was [AGE] years or older upon admission. Review of the EMR Immunization record under the Immunization tab, indicated R29 was administered .unknown PPV. on 03/01/01. Review of the EMR immunization record failed to reveal the resident was offered the PCV13. During an interview on 04/28/21 at 3:21 p.m., the Director of Nursing confirmed R29 was not offered or administered the PCV13. The DON indicated the vaccine should have been offered to the resident upon admission per CDC guidelines and facility policy.

Based on observation, interview, record review, Pharmacy document review, review of the [MEDICATION(S)] package insert review, and facility policy review, the facility failed to ensure adequate indications, specifically proper diagnoses, for the use of antipsychotic medications for three of five sampled residents reviewed for unnecessary medications (Resident (R) 15, R16, and R29). Finding include: Review of the facility's policy titled, Pharmacy Services Monitoring [CONDITION(S)] Medication, dated 2019, revealed it did not address the use of [CONDITION(S)] medications on residents who did not have diagnoses of [CONDITION(S)]. Review of a document titled Pharmacy Services, dated 2019 as copyrighted, revealed . The pharmacist, in conjunction with the nurse, physician, and other disciplines involved in the patient's care, closely monitors [CONDITION(S)] medication prescribed for the patient. failed to address indications for use of an antipsychotic medication. Review of the medication insert for [MEDICATION(S)] revealed, .Elderly patients with dementia-related [CONDITION(S)] treated with antipsychotic drugs are at an increased risk of death. [MEDICATION(S)] is not approved for elderly patients with dementia-related [CONDITION(S)]. Retrieved on 04/29/21. file:///C:/Users/tgriffith/Desktop/Sparta%20Health/ 9s064lbl.pdf 1. Review of R15's undated Face Sheet, located in the resident's electronic medical record (EMR), under the face sheet icon, revealed the resident was admitted to the facility on [DATE], with diagnoses that included but were not limited to, personal history of [CONDITION(S)], calcified tendinitis, and age-related [CONDITION(S)]. R15's most recent Minimum Data Set (MDS), with and assessment reference date (ARD) of 02/13/21, was provided by the Regional Nurse on 04/29/21 at 9:00 AM and reviewed at that time. The MDS revealed R15 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The MDS also revealed the resident had verbal behavioral symptoms directed toward others for 1 to 3 days in the 7 days prior to the assessment. The MDS revealed R15 had received antipsychotic medication 7 of 7 days prior to the assessment. Review of R15's Physician's Order, dated 11/17/2020, located under the orders tab in the resident's EMR, revealed the resident was ordered [MEDICATION(S)] (an anticonvulsant medication, sometime used in the treatment of [CONDITION(S)] disorder) 100 mg tablet by mouth one time per day for [CONDITION(S)]. Review of R15's Medication Administration Record (MAR), dated 04/01/2021 to 04/30/2021, located under the Med & Treat tab, revealed the resident received the physician ordered [MEDICATION(S)] 100 mg tablet by mouth at every morning from 04/01/21 to 04/29/21. Review of R15's Care Plan for [CONDITION(S)] drug use, dated 12/15/20 and reviewed 02/23/21, indicated the resident was to be monitored for behaviors and side effects for [CONDITION(S)] drug use. Observation on 04/26/21 at 9:08 a.m., in hall in wheelchair returning to room per self. Resident was pleasant, no behaviors noted. Observation on 04/26/21 at 2:13 p.m., R15 was in the Dining Room playing Family Feud with other residents during Activities. Resident was joining in the game with appropriate behaviors. Observation on 4/27/21 at R15 up to bathroom, getting dressed for the day per self. Pleasant and talkative. No behaviors observed. 2. Review of R16's undated Face Sheet, located in the resident's EMR, under the face sheet icon, revealed the resident was admitted to the facility on [DATE], with diagnoses that included but were not limited to, Alzheimer's disease, major depressive disorder, restlessness, and agitation. R16's most recent MDS, with and ARD of 02/07/21, was provided by the Regional Nurse on 04/29/21 at 9:00 AM and reviewed at that time. The MDS revealed R16 had a Brief Interview for Mental Status (BIMS) score which had not been assessed because the resident was rarely or never understood. The MDS also revealed the resident had no behaviors for potential indicators of [CONDITION(S)]. The MDS indicated R16 had received antipsychotic medication seven of seven days prior to the assessment. Review of R16's Physician's Order, dated 11/01/2019, located under the orders tab in the resident's EMR, revealed the resident was ordered [MEDICATION(S)] (an antipsychotic medication) 25 mg tablet by mouth at bedtime, to treat bpsd (behavioral and psychological symptoms of dementia). Review of R16's Medication Administration Record (MAR), dated 04/01/21 to 04/30/21, located under the Med & Treat tab, revealed the resident received the physician ordered [MEDICATION(S)] every night at bedtime from 04/01/21 to 04/29/21. Review of R15's Care Plans indicated a plane for anti-psychotic drug use, dated 02/20/19 and reviewed 02/15/21. Observation on 04/26/21 at 8:52 a.m., in room sitting in chair by with breakfast on over-the-bed table before her. Resident was not actively eating, eyes closed, did not respond when spoken to. No behaviors observed. Observation on 04/26/21 at 11:51 a.m., R16 was sitting up in chair in room in front of television, dressed, well [NAME]. No behaviors observed. Observation on 4/28/21 at 4:35 p.m., resident sitting in the facility entry area. Alert and responded to greeting but did not reply. No behaviors observed. Interview on 04/29/21 at 12:37 p.m., the facility's Medical Director revealed that the use of antipsychotics for Alzheimer's disease and dementia was an issue he and the facility needed to talk about as antipsychotics continued to be used. The Medical Director indicated residents who take antipsychotic medications should have a diagnosis of some type of [CONDITION(S)]. The medical director indicated bpsd was not an appropriate diagnosis for the use of antipsychotics, and a diagnosis of [CONDITION(S)] should have been added when R16 was admitted . 3. Review of a Face Sheet, found in R29's EMR under the Resident file, indicated the resident was admitted on [DATE] with diagnosis of altered mental status and Alzheimer's disease. Review of a Physician's Telephone .Order, found in R29's EMR under the Orders tab, dated 02/27/20, revealed the physician prescribed [MEDICATION(S)] 25 mg one tablet to be administered to the resident for [CONDITION(S)]. Review of a Care Plan, found in R29's EMR under the Care Plan tab, dated 03/04/20 as initiated, indicated the resident was on a [CONDITION(S)] medication and was easily agitated and the goal was to reduce the number of episodes of striking out at others. Interventions included to not argue with the resident when he had fearful delusions, to document the episodes of refusing care, and to monitor behavior as indicated. There was no indication(s) for use noted in the care plan to address the use of the [MEDICATION(S)]. Review of a paper document titled, Psychoactive Medication Consent Form, signed as dated 06/15/20, indicated, [MEDICATION(S)] 25 mg was to be administered one time a day for [CONDITION(S)] disorder. Review of Behavior Monitoring, found in R29's EMR under the Other tab, dated 09/01/20 through 04/29/21, revealed for the months of 09/2020 and 10/2020 the behavior monitored was for depressed mood and the diagnosis to support the use of [MEDICATION(S)] was [CONDITION(S)]. There was no evidence the resident experienced psychotic behavior for the months of 09/2020 and 10/2020. For the months of 11/2020, 12/2020, 01/2021, 02/2021, 03/2021, and 04/2021 the behavior monitored was for depressed mood and the diagnosis to support the use of [MEDICATION(S)] was Alzheimer's disease. There was no evidence the resident experienced psychotic behavior for the months 11/2020 through 04/29/21. Review of Nurses Note, found in R29's EMR under Nurses Note tab from 01/29/21 through 04/28/21 revealed the resident would refuse medications that were offered to him. There was no evidence the resident had psychotic behaviors. Review of eMAR (electronic medication administration record) found under R29's EMR (Med (Medication) & Treat (Treatment), tab for the months of 02/01/21 through 03/21/21, revealed the resident received 25 mg of [MEDICATION(S)] each night at bedtime for a diagnosis of [CONDITION(S)]. From 03/21/21 through 03/24/21 the resident was in the hospital being treated for pneumonia. Beginning 03/24/21 through 04/28/21, the eMAR indicated the resident received 25 mg of [MEDICATION(S)] each night at bedtime for a diagnosis of Alzheimer's disease. Review of R29's MDS with an ARD of 03/28/21, revealed the resident had a BIMS which could not be determined, and the facility indicated the resident had poor short- and long-term memory problems. The assessment noted the resident had no mood problems. The assessment noted the resident had behavioral symptoms such as hitting, kicking, or grabbing others within the past one to three days. The assessment also noted the resident had verbal behavioral symptoms such as yelling or threatening others within the past one to three days. During an interview on 04/28/21 at 8:16 AM, Certified Nursing Assistant (CNA) 9 stated R29 stated it takes two staff members to provide the resident with personal care and if there was just one person present, the resident will refuse care. CNA9 stated the resident was easy to work with and if the resident had behaviors, she would alert nursing about it and then reapproach the resident again to see if he would allow her to provide him care. An attempt was made to interview R29 on 04/28/21 at 8:22 AM and the resident did not respond to questions. During an interview on 04/8/21 at 9:00 AM, Licensed Practical Nurse (LPN) 13 stated R29 had no behavioral issues such as verbal or physical aggression. LPN13 then demonstrated on the EMR how behavior monitoring happens and stated the behaviors were associated with the medications the resident was prescribed and he was monitoring for depression. During an interview on 04/28/21 at 10:06 AM, CNA10 stated she was not afraid of R29 and he has never tried to hit her. CNA10 said there were times the resident wants to be left alone. During an interview on 04/28/21 at 6:39 PM, CNA8 stated R29 could get riled up a bit. CNA8 said when the resident gets riled up he would just walk away from him and then reapproach the resident later. CNA8 said the resident will scream and yell when he does not want a staff member to touch him and when this happens, he reports it to nursing. During an interview on 04/29/21 at 12:00 PM, the Regional Nurse stated the [MEDICATION(S)] was used for R29's behaviors toward others such as acting out towards staff and when he does not want assistance from the staff. The Director of Nursing (DON) was also present during this interview. The DON stated the resident could be very aggressive with staff and would not speak with staff. During an interview on 04/29/21 at 12:35 PM, the Medical Director stated the resident had a gradual dose reduction on other [CONDITION(S)] medication late last year and did not like to decrease two [CONDITION(S)] medications at the same time. The Medical Director stated [MEDICATION(S)] was a fantastic medication for dementia with behaviors and given the resident's history of [CONDITION(S)] the use of [MEDICATION(S)] has helped the resident. The Medical Director stated we were learning from the survey process and we need to discuss the use of [CONDITION(S)] medications more often. The Medical Director stated there needs to be an appropriate diagnosis when an antipsychotic medication was used and to further evaluate the reasons why a person was on a medication. The Medical Director stated if a resident does not need a medication the goal was to get rid of the medication. During an interview on 04/29/21 at 1:41 PM, the Consultant Pharmacist stated he has been coming out to the facility to do monthly medication reviews for the past five years. The Consultant Pharmacist stated the goal was to have a resident on the lowest possible dose of an antipsychotic medication. The Consultant Pharmacist stated R29 had two gradual dose reductions in 2020 and used to be prescribed [MEDICATION(S)] 100 mg twice a day. He went onto state the resident was currently on 25 mg of [MEDICATION(S)] one time a day. The Consultant Pharmacist stated the diagnosis of Alzheimer's disease and the use of [MEDICATION(S)] was considered off label use.

Based on interview, record review, and facility policy review, the facility failed to ensure that one (Resident (R) 41), out of a survey sample of three reviewed for accident hazards, received adequate supervision and assistance devices to prevent two separate falls from bed during the provision of care, thus placing the resident at potential harm. Findings include: Review of a facility document titled, Fall Management, dated 03/16, revealed . Each patient is assisted in attaining/maintaining his or her highest practicable level of function by providing the patient adequate supervision, assistive devices and/or functional programs as appropriate to minimize the risk for falls. Each patient's risk for falls is evaluated by the interdisciplinary team (IDT). If a fall occurs, the interdisciplinary team conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls. The Director of Nursing/Designee is responsible for coordination of an interdisciplinary approach to managing the processes for prediction, risk assessment, treatment, evaluation, monitoring, and calculation of resident falls Review of a Face Sheet, found in R41's electronic medical record (EMR) under the Resident file, indicated the resident was admitted on [DATE] with diagnoses that included spinal stenosis and cervical radiculopathy (when a nerve has been damaged and may cause weakness in upper extremities). Per review a Care Plan, found in R41's EMR under Care Plan, tab indicated R41 had a history of falls. Review of R41's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/11/20, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. The assessment noted the resident was extensive assistance in bed and required the assistance of two staff members. Review of an Event Initial Note, found in R41's EMR under Nurses Notes, dated 08/14/20 indicated R41 rolled out of bed. The Certified Nursing Assistant (CNA) 7 alerted the clinical staff immediately after the incident and the resident was assessed and had no injuries. The resident representative and the medical provider were both notified. Review of a document titled, Event QAPI (Quality Assurance Performance Improvement) Tool, dated 08/14/20, reported R41 rolled out of bed and the resident landed on a floor mat next to his bed. There was no evidence identified the resident required the assistance of two staff members during bed mobility during the provision of care. Review of R41's MDS with an ARD of 11/16/20 still indicated R41 required the assistance of two staff members with bed mobility. Review of an Event Initial Note, found in R41's EMR under Nurses Notes, dated 01/23/21 indicated R41 rolled out of bed during the provision of care. CNA8 alerted the clinical staff immediately after the incident and the resident was assessed and had no injuries. The resident representative and the medical provider were both notified. Review of a document titled Event QAPI Tool, dated 01/23/21, revealed R41 rolled out of bed when CNA8 changed his adult brief. During an interview on 04/27/21 at 10:29 AM, R41 stated he fell from his bed twice. The resident explained that one staff member pulled a sheet up from underneath him. The resident stated he was unable to grip his grab bar and rolled over and landed on his hands and his knees. The resident went onto state the second fall happened by another staff member. The second fall occurred when the staff member provided care to the resident and per the resident, his feet slipped off the bed. This time, according to the resident he was able to grab onto his grab bars and guide himself to the ground. The resident confirmed he was not injured after these two falls. The resident confirmed each staff member provided him assistance, while he was in bed, without a second staff member present. During an interview on 04/28/21 at 8:30 AM, CNA7 confirmed she was the staff member who provided care to R41 while he was in bed. CNA7 said she was the only one who provided him care at this time. CNA7 said she receives information on how to provide care to a resident from a handheld device called a Point of Care (POC). CNA7 stated the resident asked to be changed. CNA7 said the resident can assist in changing his position while in bed. CNA7 said the resident just rolled out of bed. She went onto state currently there are two staff members assigned to the resident during the provision of care. During an interview on 04/28/21 at 3:54 PM, the MDS Coordinator stated it was her understanding the handheld POC devices had information on the resident's activities of daily living (ADL) so the CNAs could see what they needed to do for each resident. A request was made to see this device and it was not provided. During an interview on 04/28/21 at 6:39 PM, CNA8 confirmed he was the only staff member present when he was fixing the sheet under the resident. CNA8 stated he asked R41 to roll over and then the resident landed on the floor. CNA8 said he typically receives direction on how to provide care to the residents with a POC device. CNA8 said there was no information identified on the POC device that would inform him the resident required the assistance of two staff members while he was in bed. CNA8 stated there was new guidance to have two staff members present during the provision of care for the resident. During an interview on 04/29/21 at 8:48 AM, the MDS Coordinator and the Regional Nurse were present. The Regional Nurse stated the POC device would have given CNAs direction on what care was needed for a resident. The Regional Nurse stated they cannot print up this section on the POC device. During an interview on 04/29/21 at 11:35 AM, the Director of Nursing (DON) confirmed she was the staff member who investigated the falls. The DON said every fall was discussed in the morning meeting to identify how each fall could be prevented. The DON was asked about the 08/14/20 and what preventative measures were implemented after this fall since R41 sustained a second fall on 01/23/21. The DON stated the resident more than likely did not want to wait for a second staff member to assist in the provision of care.

Based on observation, interviews, record review, and facility policy review, the facility failed to allow two of 13 residents (Residents (R) 41 and R22) the right for self-determination by failing to honor their bathing preference. Findings include: Review of the facility's policy titled, Skilled Inpatient Services a Comprehensive Patients' Rights Program, was provided by the Administrator on 04/28/21 at 11:31 AM, and revealed, . We believe that all staff should understand the importance of treating patients with care and respect, and honoring patients' right to make personal choices. 1. Review of a Face Sheet, found in R41's electronic medical record (EMR) under the Resident file, indicated the resident was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R41's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/16/20, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. The assessment noted the resident indicated a bathing choice was important to him. Review of paper documents, untitled, for R41, were dated 01/25/21 through 04/14/21, indicated the resident had nail care performed, mouth care was performed, his hair was combed, and lotion was applied on his skin. The forms failed to identify if the resident was asked if he wanted a tub bath, bed bath, or a sponge bath. During an interview with R41 on 04/26/21 at 12:54 PM, the resident said that he has not been offered a shower since his admission and only received a bed bath. The resident stated staff told him he could not be given a shower since he was a large man. The resident said he would like to take a shower instead of getting a bed bath all the time. During an interview on 04/28/21 at 8:16 AM, Certified Nursing Assistant (CNA) 9 stated she was aware the resident received bed bathes only. During an interview on 04/28/21 at 9:54 AM, the Director of Nursing (DON) stated the staff address preferences and R41 did not like to get up due to his weight. The DON said the shower bed was bariatric and all that the resident needs to do was to ask staff if he could be showered. During an interview on 04/28/21 at 10:10 AM, CNA10 said R41 only received bed baths. During an interview on 04/29/21 at 11:56 AM, the DON stated when a resident was admitted preferences were identified in the MDS assessment. The DON confirmed that the records that identified if nail care was provided, if oral care was provided, if R41's hair was combed was an activities of daily living record and not bathing records that would indicate if the resident was offered a preference in bathing. 2. Review of R22's undated Face Sheet, located in the resident's EMR, revealed R22 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R22's most current annual MDS with an ARD of 05/03/20, which was provided by the facility's Regional Nurse, on 04/29/21 at 9:00 AM, in the Activities Room, revealed the resident had a BIMS of 15, which indicated the resident was cognitively intact. R22 had no behaviors, was totally dependent on staff for bathing, and was always incontinent of bowel and bladder. The resident's Preferences for Customary Routine and Activities, indicated that it was Somewhat important, to choose between a tub bath, shower, bed bath, or sponge bath. Review of R22's Care Plan, located in the resident's EMR under the care plan tab, revealed a care plan titled, Self-care deficit, which was initiated 10/22/18, and reviewed 02/15/2021. The self-care deficit care plan indicated, Bed bath daily, encourage patient to assist with care. Observation and interview on 04/26/21 at 9:49 a.m., R22 was noted to have facial hair on her chin. R22 stated she would like to have a shower but only gets bed baths. The resident revealed she had not been showered since she was admitted to the facility. Observation and interview on 04/27/21 at 9:10 AM with R22, revealed she had a bed bath earlier in the morning, and the CNA cleaned off the resident's facial hair. The resident indicated she would like to have the facial hair removed more often, and still would like to shower. Interview on 04/28/21 at 9:55 AM with the DON revealed R22's MDS from 05/13/20 recorded the resident felt it was somewhat important to choose between bath, shower, bed bath, and sponge bath, which means the Certified Nursing Assistants should ask what R22's preference is each time the resident is bathed. Interview on 04/28/21 at 10:37 a.m. with the Activities Specialist, revealed she assesses all newly admitted residents upon admission regarding bathing preferences and R22 felt it was somewhat important to choose between bath, shower, bed bath, and sponge bath, and CNAs should ask the resident her preference each time the resident is bathed. The Activities Specialist indicated resident's bathing preferences should be in the resident's EMR under the Data Collection tab, but there were no bathing preferences listed for R22.

Based on observations, interviews, review of facility policy, and record review, the facility failed to ensure residents negative for COVID-19 were not housed with residents positive for COVID-19 for two out of 12 sampled residents (R#4 and R#6). Additionally, the facility failed to ensure staff were able to identify which residents were positive for COVID-19 and failed to ensure all personal protective equipment (PPE) was used while caring for residents positive for COVID-19. The facility documented 37 residents as positive for COVID-19 and six residents as negative for the COVID-19 virus. The census was 43. On June 17, 2020 at 6:15 p.m. a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing (DON), Infection Preventionist (IP), and the Regional Nurse were informed of the immediate jeopardy on June 17, 2020 at 6:15 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on May 30, 2020 and continued through June 17, 2020. An acceptable Immediate Jeopardy Removal Plan was validated on June 18, 2020. The immediate jeopardy was outlined as follows: The immediate jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. §483.80(a) Infection Prevention and Control Program (F880, Scope/Severity: K). The facility's failure to ensure residents testing negative for COVID-19 were housed in rooms separate from residents testing positive for COVID-19, staff were able to identify which residents tested positive and which tested negative for COVID-19, and staff followed infection control guidelines for Transmission Based Precautions (TBP) constituted an immediate jeopardy at F880. An Immediate Jeopardy Removal Plan was received on June 18, 2020. Based on observations, record reviews, interviews, and review of the facility's policies as outlined in the Immediate Jeopardy Removal Plan, it was validated that the corrective plans and the immediacy of the deficient practice was removed on June 18, 2020. The facility remained out of compliance at a lower scope and severity of E while the facility continued management level staff oversight of resident placement and infection control. This oversight process included the analysis of facility staff's conformance with the facility's Policies and Procedures for Infection Control Transmission Based Precautions. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures governing Admission Policies and Procedures for cohorting residents and Infection Control Practices. The immediate jeopardy Removal Plan was validated through observation, interview of staff, and review of in-service records. The immediate jeopardy Removal Plan included placing R#4, who tested negative, in a room with a resident negative for COVID-19 and placing R#6, who refused testing, in a private room. Additionally, isolation precaution signs were removed from rooms where residents had tested negative (two tests in a row) and staff were educated about identification of and proper PPE usage for residents positive for COVID-19. Observations included room assignments of residents testing negative for COVID-19, verification of signage for rooms of residents testing positive for COVID-19, and observations of staff wearing gowns when entering rooms of residents testing positive for COVID-19. Interviews with staff validated knowledge to follow both droplet and contact precautions whenever entering resident rooms who tested positive for the COVID-19 virus. Findings include: During the entrance interview on 6/17/20, the IP provided documentation of facility wide COVID-19 testing. The first testing was done between 4/23/20 and 5/11/20 and the second round of testing was done between 5/21/20 and 5/30/20. The IP confirmed the process for deciding when a resident comes off of Transmission Based Precautions (TBP) was determined by two negative COVID-19 tests in a row. A third facility wide testing was conducted on 6/16/20 and the results were available later in the day on 6/17/20. During the tour of the facility on 6/17/20 at 2:00 p.m., equipment slings with PPE were observed on all of the resident room doors. Signage for TBP included Droplet Isolation and Barrier (Contact) Isolation. The facility provided a list of dates and results of COVID-19 tests for all the residents in the facility. Review of the COVID-19 results revealed R#4 tested negative for the COVID-19 virus on 5/06/20 and 5/30/20. Review of the COVID-19 results revealed R#4 was roommates with a resident who tested positive for the COVID-19 virus on 5/30/20. Further review of the list of COVID-19 results revealed R#6 had refused to be tested and therefore had an unknown COVID-19 status. Review of the list of COVID-19 results revealed R#6 was roommates with a resident who had tested positive for COVID-19 on 5/6/20 and on 6/11/20. On 6/17/20 at 1:40 p.m., Licensed Practical Nurse (LPN) AA verbalized that if a negative COVID-19 tested resident was roomed with a positive test, to pull the curtain between the residents and provide care to the negative tested resident first. Barrier precautions (use of the gown) was limited to direct patient contact. On 6/17/20 at 1:42 p.m., the LPN BB verbalized that in resident room [ROOM NUMBER] of the three residents one tested negative for the COVID-19 virus and the other two tested positive. LPN BB stated, The residents do not have much interaction with each other, so it was okay to have them in the same room. On 6/17/20 at 1:45 p.m., Certified Nursing Assistant (CNA) CC entered room [ROOM NUMBER] without donning a gown to pick up used lunch dishes. CNA CC verbalized there were two negative COVID-19 residents and one positive housed in the room. CNA CC stated, A gown is used only if there is close contact with the resident. These interviews revealed that LPN BB and CNA CC were instructed to follow the signs on the rooms for what type of TBP and PPE were required for the residents but were not able to correctly identify the residents' COVID-19 status. On 6/17/20 at 1:50 p.m., the Environmental Services Aide DD entered room [ROOM NUMBER] and came out with a bag of trash, then performed hand hygiene, and entered room [ROOM NUMBER] (across the hallway from 101) and brought out the trash. room [ROOM NUMBER] and 114 had TBP signage and PPE on the doors indicating positive COVID-19 status of the residents. The Environmental Services Aide verbalized she was supposed to put on a gown when entering the room but had been instructed that the gowns were only for use during direct resident care. On 6/17/20 at 1:55 p.m., the Laundry Aide EE went into room [ROOM NUMBER] to deliver personal laundry. She went into the room without donning a gown. The Laundry Aide verbalized she should have put on a gown but did not. room [ROOM NUMBER] housed residents positive with COVID-19. On 6/17/20 at 3:15 p.m., the IP confirmed droplet precautions meant to use a mask and goggles and contact precautions included donning gown and gloves. The IP verified the signs outside each room included the specific instructions and the staff were expected to wear mask, goggles, gloves, and gowns when entering rooms. Review of in-service records dated 2/18/20, revealed staff read a copy of an untitled memo, dated 2/14/20, that instructed staff to place residents suspected of COVID-19 on contact and droplet isolation. Review of in-service records dated 5/6/20, revealed nurses were to keep a list of positive COVID-19 residents and staff were to treat all residents with droplet and universal precautions. Review of in-service records dated 5/20/20, revealed staff were to review the signs posted as they indicate the PPE to be used for entering the resident rooms. On 6/18/20 at 11:30 a.m., the Regional Infection Preventionist (RIP) verbalized, in a telephone interview, the staff were instructed to use droplet precautions at all times (wear a face mask) and gowns only for direct resident care, to save on gown usage. Review of policy Transmission Based Precautions dated November 2019, indicated, . place together in the same room (cohort) residents who are infected with the same pathogen. Avoid placing residents on Droplet Precautions in the same room with residents who have conditions that may increase the risk of adverse outcome from infection or that may facilitate transmission . Review of policy Transmission Based Precautions dated November 2019, indicated Droplet precautions included face mask covering and eye protection. Barrier or contact precautions included wearing gown and gloves.

Based on observation, staff interview and policy titled Food and Nutrition Services: Storage areas the facility failed to assure that food items were labeled and dated and used before expiration date. This effected 64 of 67 residents. Findings include: Observation on 8/20/18 at 10:22 a.m. during initial kitchen tour with the Dietary Manager, the following was identified: 1. There was a container of fudge rounds with an in date of 7/25/18 but there was no expiration date. 2. In the dry storage area there was a box containing kitchen bouquet browning sauce with 7/6/16 on lid and a date of 7/15/18 on the bottle but was unable to ascertain the use by date written on the label. 3. There were three-16ounce (oz) containers of beef base with date of 1/3/18 on label but no open or use by date; one container of ham base with 8/15/18 on the label; one container of chicken base with 8/1/18 on the label; and two vegetable base containers with 8/1/18 on the label. All of the containers were opened and none had an open or use by date. 4. There were five half gallon buttermilk cartons with an expiration date of 8/7/18 in the milk cooler. 5. There was a plastic container with cheese spread dated 8/10/18 and use by date of 8/15/18. 6. There was one bag with five hotdog buns, 12 pack hot dog buns, and two loaves bread none with expiration date. 7. There was one 16 count Captain John Derst's hot dog buns with a use by date of 7/20/18. 8. There was one 46 oz Sysco thickened sweet tea with a label date of 8/5/18 and a use by date of 8/10/18. The directions on the container revealed once opened store at ambient temperature up to 8 hours or refrigerate for up to seven days. Interview on 8/20/18 at 11:04 a.m. with the Dietary Manager who reported that labels on products are when items are received. He went on to report that bases are good for 30 days once opened. Dietary Manager further reported that the policy is to write use by and open dates on items once they have been opened. He reported that the box with browning sauce was to be thrown away. Interview on 8/20/18 at 11:19 a.m. with the Dietary Manager who reported he is responsible for assuring labeling and dating of items in the kitchen. Interview on 8/23/18 at 2:39 p.m. with the Dietary Manager who reported that he checks items weekly for labeling and dating. He further reported that he typically checks items on Tuesdays and Fridays. Dietary Manager reported that a worker was getting ready to throw the thickener away when it was place on the shelf. He further reported that he has seven days to use his bread and acknowledged no dates on bread to identify timeline for usage. Food and Nutrition Services: Storage areas Intent: It is the intent of this center to store food that maintains quality and safety. 1. All items will be inspected for quality and temperature control upon receipt. a. Items will be covered, sealed, labeled, and dated appropriately. 7. Refrigerator d. FDA refrigerator and freezer storage chart may be used as a reference for proper dating.

Based on observation, policy review and staff interview, the facility failed to provide privacy for two of two residents (R) R#41 and R#64 during point of care testing for blood glucose level. The sample size was 41. Findings include: Review of Facilities statement of rights, undated, revealed under section B Personal and Privacy Rights bullet four revealed that you have the right to privacy in medical treatment. 1. Review of R #41 clinical record revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 0, which indicated severe cognitive impairment. Observation on 08/22/18 at 11:09 a.m., Licensed Practical Nurse (LPN) AA entered R #41 room to obtain finger stick blood sugar (FSBS). She explained procedure to resident, who was lying in her bed, bed A closest to door. LPN AA proceeded to perform FSBS for R #41 without providing privacy by closing the door to the room or pulling privacy curtain, to ensure privacy from her roommate. 2. Review of R #64 clinical record revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicated no cognitive impairment. Observation on 08/22/18 at 11:15 a.m., Licensed Practical Nurse (LPN) AA entered R #64 room to obtain finger stick blood sugar (FSBS). She explained procedure to resident, who was lying in her bed, bed B beside window. LPN AA proceeded to perform FSBS for R #64 without providing privacy by closing the door to the room or pulling privacy curtain, to ensure privacy from her roommate. During interview on 8/22/18 at 11:20 a.m., with LPN AA, she stated she should have pulled the privacy curtain before checking the residents blood sugar. Interview on 8/22/18 at 2:02 p.m with Director Of Nursing (DON) stated her expectation is for residents privacy be maintained for all care provided, including obtaining blood sugar.

Based on observation and interviews, the facility failed to ensure that it was maintained in a safe, clean and comfortable home-like environment including use of residents room closet for storage space; repairing a hole in sheet rock, dirt buildup and cob webs and slow draining sink in bathroom; inoperable overbed light and ripped privacy curtain. The sample size was 41. 1. Observation on 8/20/18 at 2:50 p.m., 8/22/18 at 10:50 a.m. and 8/23/18 at 12:51 p.m. revealed semi-private room [ROOM NUMBER] bed-1 and bed-2 closet was being used for storage of facility supplies and medical equipment. During a walk through with Maintenance Director on 8/23/18 at 2:28 p.m., he confirmed the identified environmental concerns. He stated that he does not have a routine schedule of maintenance duties, but he gets work orders from the staff to items that require repair or maintenance. He stated he was not aware of any of the concerns that were identified. He further stated that he did not think it was ok to use a residents room closets for facility storage. Interview with Administrator on 8/23/18 at 2:46 p.m., stated the facility is short on storage space, and they had an extra closet from a room that went from three beds down to two beds, so they started using it for storage of therapy chair cushions, pillows, wheel chair foot rests, floor mats, and some clothing items. She further stated that she did not think it was acceptable to store facility supplies in a residents bedroom. Observation on 8/20/18 at 1:58 p.m. in room [ROOM NUMBER] the over bed light for bed A does not work. Observation on 8/21/18 at 9:22 a.m. in room [ROOM NUMBER] there is a hole in the wall near the bathroom door, there is dirt buildup under sink in the bathroom, slow draining sink, and cob web in lower corner leading into the bathroom. Observation on 8/21/18 at 09:07 a.m. in room [ROOM NUMBER] there is a large rip at top of the privacy curtain, hole in wall near window, and missing paint from walls. Interview on 8/23/18 at 4:17 p.m. with Housekeeping Supervisor revealed that daily tasks include dusting, mop and clean behind night stands, sweep and dust mop floors, clean toilet last. Housekeeping Supervisor reported that she tries to observe every room daily to assure it has been cleaned. Further reporting that as issues are identified staff are in-serviced and corrections are made. She reported that staff have been in-serviced on how to clean resident's rooms and dusting for cobwebs should be done. Interview on 8/23/18 at 4:44 p.m. with the Housekeeping Supervisor who reported that she is currently awaiting a shipment of new privacy curtains. She reported that the last privacy curtain order received the curtains were too large for the room. Review of documentation from HSK supervisor revealed that rip in privacy curtain was identified on 8/7/18 but had not been replaced yet due to the reorder.with the Housekeeping Supervisor reported that if staff identify holes in walls they should be notifying maintenance.

Based on observation, record review and staff interview the facility failed to develop a person centered care plan for one dependent resident (R) #60 related to grooming: nail care. The sample size was 41. Findings include: A review of the clinical record for R #60 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 12, which indicated mild cognitive impairment. Section G revealed that the resident was assessed for extensive assist by two plus person for bed mobility, locomotion on/off the unit, dressing and toilet use. The resident was assessed as total dependence with transfers. Observation on 8/22/18 at 10:50 a.m., 8/23/18 at 10:30 a.m. and 8/23/18 at 4:26 p.m., revealed that fingernails on both hands have dark brown material underneath and are untrimmed. Review of updated care plan for R #60, dated 5/22/18, did not have evidence that R #60 had a care plan problem to include assistance needed with Activities of Daily Living (ADL) care. Interview on 8/23/18 at 2:30 p.m., with Certified Nursing Assistant (CNA) CC stated that does nail care when she recognizes residents need them done. She further stated that nail care is done on the residents bath day. She was not certain when R #60 bath days were. Interview on 8/23/18 at 3:52 p.m., with Minimum Data Set (MDS) Coordinator, stated she does the majority of the assessment herself, and she reviews medical record and interviews staff, observe residents to get information for the assessment. She further stated that extensive assistance with toilet use would entail that the resident would need assistance with perineal care and hygiene, and therefore should have been care planned for activities of daily living (ADL) care. She further stated that she did not look at it from the perspective that resident peri-care after toileting would be considered ADL care. Interview on 8/23/18 at 4:26 p.m., with Licensed Practical Nurse (LPN) BB verified that R #60 fingernails are dirty with brown material underneath nails on both hands and that nails are untrimmed. She further stated that the CNA's are supposed to do nail care whenever they recognize that they need it. She stated that anyone can and should do nail care for the residents.

Based on observation, policy review, and staff interview, the facility failed to practice acceptable infection control practices to prevent possible cross-contamination, by one of two licensed nurses observed, as evidenced by not disposing of blood glucose sharps materials in appropriate containers. The sample size was 41. Findings include: Review of the facility policy titled Glucometer Disinfection with effective date of (YEAR), indicated the facility policy is that all glucometers shall be thoroughly cleaned and disinfected between resident uses if individual glucometers are not available. Under Diabetes Care Procedures & Techniques, bullet number four (4): Dispose of used fingerstick devices and lancets at the point of use in an approved sharps container. 1. Observation on 8/22/18 at 11:09 a.m., on the 100 Hall, with Licensed Practical Nurse (LPN) AA, perform finger stick blood sugar (FSBS) check. She removed the glucometer from the top drawer of the medication cart. She placed it on top of the cart while she gathered the supplies needed for the FSBS. She entered the residents room after permission was granted from resident. She placed tissue on residents over-bed table as a barrier. Plastic cup was placed on Kleenex barrier. LPN AA washed her hands and donned gloves after drying them. She explained the procedure to resident and cleaned resident finger with alcohol swab. She lanced finger and wiped blood away with another tissue. Blood sample was obtained without complications. Nurse removed her gloves and secured all supplies used during procedure inside glove, including the lancet, and disposed of them in the trash receptacle on the side of medication cart. She cleansed the glucometer after use with a germicidal wipe for approximately 2 minutes and dried it with a Kleenex. 2. Observation on 8/22/18 at 11:15 a.m., on the 100 Hall, with Licensed Practical Nurse (LPN) AA, perform finger stick blood sugar (FSBS) check. She removed the glucometer from the top drawer of the medication cart. She placed it on top of the cart while she gathered the supplies needed for the FSBS. She entered the residents room after permission was granted from resident. She placed tissue on residents over-bed table as a barrier. Plastic cup was placed on Kleenex barrier. Nurse washed her hands and donned gloves after drying them. She explained the procedure to resident and cleaned resident finger with alcohol swab. She lanced finger and wiped blood away with another tissue. Blood sample was obtained without complications. Nurse removed her gloves and secured all supplies used during procedure inside glove, including the lancet, and disposed of in the trash receptacle on the side of medication cart. She cleansed the glucometer after use with a germicidal wipe for approximately 2 minutes and dried it with a Kleenex. Interview on 8/22/18 at 11:20 a.m., with LPN AA, stated she was told that if she secured the supplies used, including the lancet inside the glove, then she could dispose of it in the regular trash. When asked if this was the facility policy, she replied yes. Interview on 8/23/18 at 2:02 p.m., with Director of Nursing (DON), stated that LPN AA has been trained on the policy and procedure for checking blood sugars and that sharps are to be disposed of in the sharps container. She further stated that her expectation is for residents privacy be maintained for all care provided, including obtaining blood sugar. 3. Observation on 8/20/18 at 9:35 a.m., revealed room [ROOM NUMBER]-2 with unlabeled bath bedpan and three (3) unlabeled bath basins. Bathroom is shared by four (4) female residents. 4. Observation on 8/20/18 at 11:51 a.m., revealed room [ROOM NUMBER]-2 with unlabeled bath basin on toilet tank top and unlabeled and unbagged bedpan on the floor in the bathroom. Bathroom was shared by four (4) female residents. On 8/23/18 at 2:02 p.m., walking rounds with DON verified the identified concerns with the storage and labeling resident personal care equipment such as bath basins and bed pans. She stated that all the clinical staff are responsible for checking daily to make sure that they are bagged and labeled appropriately. She stated her expectation is that all resident personal care equipment be labeled with their name and bagged. Interview on 8/23/18 at 3:31 p.m., DON and Nurse Consultant stated the facility did not have a policy on storage of resident personal care equipment.

Based on observation, record review, and staff interview, the facility failed to maintain the holding temperature of two hot foods on the steam table above 135 degrees, and failed to ensure that the temperature of one of one walk-in coolers was maintained at or below 41 degrees to prevent the potential for foodborne illness. There were 72 residents who received an oral diet, and the sample size was 35 residents. Findings include: 1. On 8/15/17 at 12:27 p.m., Dietary Aide CC was observed taking steam table temperatures at lunch with the facility's calibrated thermometer. Further observations revealed that the temperature she obtained for a pre-packaged pureed chicken pouch was 128 degrees Fahrenheit (F), and the temperature of a pureed corn pouch was 122 degrees F. This was verified during interview with Dietary Aide CC. Interview with the facility's Registered Dietician (RD) on 8/15/17 at 12:49 p.m., she verified the temperature of the pureed chicken was 128 degrees and the pureed corn was 120 degrees. During observation at this time, the RD had the pureed chicken and pureed corn removed from the tray line and reheated to temperature of 140 degrees F. Interview with the Dietary Manager on 8/16/17 at 11:00 a.m. revealed that there were 72 residents who consumed an oral diet. During further interview, she stated that 15 residents were receiving pureed diets, and five of those 15 residents were receiving double portion sizes. The Dietary Manager further stated that when the tray line temperatures were taken on 8/15/17 at 12:27 p.m., 25 trays had already been sent to the floor for the residents, including six pureed diets, with four of the six receiving large portions. Review of the Hot/Cold Temperature Log dated 8/15/17 at tray line start time of 12:00 p.m., revealed that the temperature for the pureed chicken pouch was 170 degrees F, and the pureed corn was 182 degrees F. 2. During observation of the walk-in cooler temperature on 8/14/17 at 9:22 a.m. revealed that it was 42 degrees F. This was verified during interview with the Dietary Manager at this time. Further observations made on 8/14/17 at 2:12 p.m. and 2:36 p.m. revealed the walk-in cooler temperature was 44 degrees F each time. Observation on 8/14/17 at 4:06 p.m. revealed that the walk-in cooler temperature was 46 degrees F, and the Dietary Manager asked the kitchen staff members at this time not to enter the walk-in cooler for 30 minutes. During observation on 8/14/17 at 4:36 p.m., the temperature in the walk-in cooler was 45 degrees F, and the cooler had not been entered by staff between 4:06 p.m. and 4:36 p.m. During further observation on 8/15/17 at 12:34 p.m., the temperature in the walk-in cooler was 44 degrees F. Review of the facility Refrigerator/Freezer/Dry Storage Temperature Log revealed on 8/13/17 the walk-in cooler temperature was 44 degrees F for the p.m. time slot. Interview with the Registered Dietician on 8/16/17 at 11:59 a.m. revealed that if cooler temps were above 41 degrees, staff were to call the maintenance company. She verified during further interview that the walk-in cooler temperature on 8/13/17 was 44 degrees as recorded on the Refrigerator/ Freezer/Dry Storage Temperature Log, and stated that the maintenance company had been called to service the unit. She further stated that there was not a policy addressing temperatures for the cooler or steam table, but that they referred to the Food Preparation, Storage and Serving policy. Review of the facility policy titled Food Preparation, Storage and Serving dated May 2017 revealed: It is the intent of this center to serve safe food and practice basic safe food handling principles. Food service associates will follow best practice standards from ServSafe, Georgia Department of Health, FDA (Food and Drug Administration), and CMS (Centers for Medicare and Medicaid Services) Regulations. Food storage standards will be in place to ensure food is stored under correct conditions and used timely for best quality value of products. Food holding will be monitored for basic safe temperature controls and serviced under sanitary temperatures and conditions. Review of the Georgia Department of Public Health Rules and Regulations Food Service revealed the following: Time/Temperature Control for Safety Food, Hot and Cold Holding. Except during preparation, cooking, or cooling, or when time is used as the public health control, time/temperature control for safety food shall be maintained at 41 degrees F or below, or 135 degrees F or above.

Based on observations, interviews, and review of the Housekeeping policy, the facility failed to ensure a consistent home-like odor-free environment for 3 of 3 (100, 200 and 300) halls in which odors were periodically present where residents resided. Findings include: On 8/14/17 at 10:47 a.m., observation of the bathroom in room 204 revealed that it had a strong urine odor. Further observation revealed that there were no visible signs of soilage in the restroom. On 8/14/17 at 11:33 a.m., a strong urine odor was noted in the bathroom of room 208, which was shared by four male residents. Further observation revealed that the toilet appeared clean, and no urinals or other urine collection devices were seen in the bathroom. On 8/15/17 at 9:15 a.m., observation of the restroom in room 204 revealed that it continued to have a strong urine odor present. Observation during a tour on 8/16/17 at 10:20 a.m. -11:00 a.m. of the halls reveals a strong unpleasent odor indicative of urine in rooms 103, 107, 108, 208, 214 307 and 308. Interview with the Housekeeping Supervisor verified that the facility has problems containing odors in these rooms. The Housekeeping Supervisor further revealed that the facility had just changed chemicals and cleaning products to help control odors.

Based on observations and staff interview, the facility failed to maintain a functioning call light system for two (2) of sixty nine(69) residents in the facility. 1. On 8/14/17 at 1:52 p.m., the bathroom call light for rooms 205 and 206 on the locked unit was pulled, and observed to not light up outside the doorway in the hall, to visually alert staff that assistance may be needed. Further observation revealed that a nursing staff member from outside the locked unit responded to the call light, and stated during interview that a light illuminated on the nurse call system located at the nurse's station (which was located outside of the locked unit). On 8/15/17 at 10:20 a.m., the bathroom call light for rooms 205 and 206 was checked again, and this time it did not light up in the hallway outside the room, nor light up or alarm at the console at the nurse's station. This was verified during interview with Certified Nursing Assistant (CNA) AA, who stated that all four residents in rooms 205 and 206 would be able to use the call light. On 8/15/17 at 10:36 a.m., all of the bathroom call lights on the 200-hall were checked with CNA AA and CNA BB, and all of them were fully functional except for rooms 205 and 206 which did not illuminate in the hallway, but this time alarmed at the console at the nurse's station when activated. 2. On 8/14/17 at 10:47 a.m., observation of the call light for room 204-B revealed that there was no push button mechanism at the end of the call light cord, and the call light was not functional. During interview with the Maintenance Supervisor on 8/15/17 at 10:08 a.m., he stated that he found out about needed maintenance repairs by word of mouth from the nursing staff. He further stated there was also a log book to record needed repair work in, but staff was not good about using it. He stated during further interview that he checked the call lights at least monthly.

Based on observations and staff interview, it was determined that the facility failed to ensure clean personal care resident equipment for one resident (#15) in a sample of 35 residents. Findings include: During observations on 3/25/13 at 2:18 p.m., 3/26/13 at 9:45 a.m. and 12:40 p.m., 3/27/13 at 8:15 a.m., 9:20 a.m., and 12:51 p.m., and on 3/28/13 at 8:15 a.m., there were multiple dried stains on the cushions and arm rests of the Broda chair used by resident #15. During observation and an interview on 3/28/13 at 8:50 a.m., the Director of Nurses (DON) observed the stained Broda chair in use for resident #15. She stated that anyone could have wiped down the cushions when they observed them dirty and stained.

Based on observation, record review and staff interview, the facility failed to implment care plan interventions and restorative plans to provide range of motion (ROM) exercises during bathing for one resident ("Q"), and to apply a knee brace and palm guard device for one resident (#48) in a sample of three residents with contractures and reviewed for potential ROM concerns in a total sample of 35 residents. Findings include: 1. During an interview on 3/25/13 at 1:38 p.m., Licensed Practical Nurse (LPN) "AA" stated that resident "Q" had contractures of his/her hands and knees. On 03/25/13 at 3:19 p.m., resident "Q" was observed to have contractures of his/her fingers, wrists, and knees. Licensed staff had coded the resident on the 2/26/13 annual Minimum Data Set (MDS) assessment as having functional limitations in range of motion of the upper and lower extremities on both sides, and with no cognitive impairment. There was a care plan to address the resident's needs in the area of activities-of daily living because of [MEDICAL CONDITION] and contractures with an intervention for nursing staff to provide passive ROM (PROM) exercises to the resident's extremities with the bath. However, on 03/27/13 at 10:00 a.m., Certified Nursing Assistants (CNA) "BB" and "CC" were observed giving resident "Q" a bedbath. The only time the resident's limbs were observed to be manipulated was to bend them just enough to remove or put on the resident's clothing. After the bath was completed, CNA "BB" applied splints to the resident's hands and lower arms but, did not provide PROM exercises. During an interview at 12:35 p.m., resident "Q" stated that there was a staff member who would do ROM for a few minutes but, it was not done every day. During an interview on 3/28/13 at 12:00 p.m., the LPN MDS Coordinator/Restorative Coordinator verified the care plan intervention was for nursing staff to provide PROM exercises to the resident's extremities with the bath. See F318 for additional information regarding resident "Q". 2. Resident # 48 had [DIAGNOSES REDACTED]. Licensed staff coded him/her on the 1/10/13 Minimum Data Set (MDS) assessment as having limitations in his/her upper and lower extremities. There was a care plan since 10/29/12 to address the resident's need for total care with activities-of-daily living because of [MEDICAL CONDITION] and contractures. There were interventions for gentle passive range of motion (PROM) with bathing and to refer to the restorative intervention plan. There was a 12/17/11 Functional Program form with a documented plan for staff to apply a palm guard on the resident's right hand following gentle PROM to the hand. There was a 11/21/11 Functional Program form with a documented plan for PROM to both of the resident's legs. There was a 2/13/13 Functional Program form with a documented plan for staff to apply bilateral knee extension braces and a hip abduction brace. However, observations revealed that staff did not apply the palm guard and knee extension braces as planned. See F318 for additional informtation regarding resident #48.

Based on observations, it was determined that the facility failed to ensure the dignity of one resident (#15) during dining and while in bed in a sample of 35 residents. Findings include: Resident #15 had [DIAGNOSES REDACTED]. Licensed staff coded the resident as totally dependent for eating and bed mobility on the 12/27/12 Minimum Data Set (MDS) assessment. There was a care plan since 7/27/12 to address the resident's need for total assistance with activities of daily living because of his/her muscle contractures, [MEDICAL CONDITION], and cognitive and communication deficits. There was an intervention for restorative services when eating for swallowing when eating. However, staff failed to promote the resident's dignity when he/she was in bed and failed to assist the resident with eating in a timely manner. 1. During an observation on 3/16/13 at 9 a.m., resident #15 was in bed and the lower half of his/her body was visible from the entrance of his/her room. Although the privacy curtain had been partially pulled, the resident's lower body and incontinence brief were visible from the hall. At 10:10 a.m., there were two certified nursing assistants (CNAs) in the resident's room next to his/her bed. The lower half of the resident's body and brief were still visible from the hall. After the CNAs left the resident's room, he/she was in bed with a shirt and brief on but, remained exposed to the hall. 2. Observation of the lunch meal in the main dining room on 3/25/13 at 12:47 p.m. revealed that resident #15 was seated in a Broda chair at a table with two other residents. Although staff had served his/her meal, there was no assistance provided until 1:05 p.m.. The other residents ate and completed their lunch prior to the resident having received assistance from staff to eat.