Every finding on record at Tybee Island Trails of Journey LLC

Based on staff interviews, record review, and review of the facility policy titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, the facility failed to report injuries of unknown origin to the State Survey Agency (SSA) within the required time frame for one of three sampled residents (R) (R6) reviewed for abuse and neglect. The deficient practice had the potential for future unreported injuries of unknown origin, with the potential to affect residents' quality of life.Findings include:Review of the policy titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation last reviewed February 13, 2024, documented under Compliance Guidelines:. 8. Reporting/Response: The facility will report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required, and take all necessary corrective actions depending on the results of the investigation. The facility will analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences. Procedure for Response and Reporting Allegations of Abuse/Neglect/Exploitation:.2. The Administrator or designee will: a. Notify the appropriate agencies immediately: as soon as possible, but no later than 24 hours after discovery of the incident. In the case of serious bodily injury, no later than 2 hours after discovery or forming the suspicion. Review of the electronic medical record (EMR) revealed R6 was admitted to the facility with diagnoses including but not limited to schizoaffective disorder, unspecified, generalized anxiety disorder, type 1 diabetes mellitus with ketoacidosis without coma, chronic obstructive pulmonary disease, atherosclerotic heart disease of native coronary artery without angina pectorisRecord review of R6's admission Minimum Data Set (MDS) dated [DATE] assessed for Section C (Cognitive Patterns) a Brief Interview Mental Status Score (BIMS) of two, which indicated severe cognitive impairments. Section G (Functional Abilities) assessed non-ambulatory, no impairments for upper/lower extremities, dependent- maximum substantial assistance with most Activities of Daily Living Skills (ADL).Record review of R6's (nursing home facility) EMR Interdisciplinary Team (IDT) progress note (dated 05/28/2026 at 3:06 PM documented a fall incident. The note stated, Clearing Risk Management. IDT Meeting: Resident with unwitnessed fall in room while attempting self-transfer 05/07/2026. No injury. Action: NP (Nurse Practitioner) notified. Root Cause: Encephalopathy, anxiety, and chronic pain. Intervention: Place bed in the lowest position and add fall mat.Record review of R6's [name] nursing home facility EMR's progress note dated 05/21/2026 at 10:18 AM documented by the Primary Health Mental Health Nurse Practitioner (PMHNP) and noted by Nurse Practitioner NP (dated 05/28/2026 at 0:00 PM) stated They also report intermittent self-injury behaviors, including intentionally throwing herself from her wheelchair onto the floor, engaging in self-induced vomiting. This behavior appears impulsive and often triggered by internal distress, frustration, and a perceived lack of attention. The staff notes that the patient sometimes threatens to throw herself on the floor and has followed through on these threats without regard to her safety.Record review of R6's [name] hospital ER (Emergency Room) documented the chief complaint for ER visit as R6 was transferred from nursing home due to chief complaint of generalized weakness and pain.Record review of R6's [name] hospital ER physician's progress notes dated 05/30/2026 reported a fracture of ribs (3-6) (two-three) and pubic rami fracture (pelvic). Further review of the physician's progress note stated: Patient is the resident of [name] facility. Concern for neglect; multiple previous hospitalizations with DKA(Diabetic Ketoacidosis). Noted to have multiple new fractures during this hospitalization.Record review of [name] nursing home facility Licensed Practical Nurse (LPN) LPN EE EMR notes dated 06/08/2026 at 7:19 PM, documented resident returned via (by) ambulance on a stretcher. Arrived about 3:00 o' clock. VSS (vital signs) 117/65 82 18 98.2. pleasant. Treated at hospital for UTI (urinary tract infection); returned on ABX (antibiotic). 3 FX. (three fractures) Resident is able to make needs known. Record review of the [name] nursing home facility's Physician Assistant (PA) PA BB EMR progress note dated 06/09/2026 at 10:45 and 06/11/2026 at 4:36 PM documented R6 readmitted to the facility on [DATE] for rehabilitation following recent hospitalization at {named} Health was admitted with generalized weakness, pain, UTI (urinary tract infection), recurrent hypoglycemia, and multiple acute fractures (left lateral ribs 3-6 (three -six), right acetabular fracture, bilateral inferior pubic rami). R6 was also noted with a left frontal peritoneal hematoma.Record review of R6's care plan created 06/11/2026 listed a problem focus area of multiple fractures.Interview on 07/28/2026 at 2:00 PM with the Administrator revealed that she was unaware that R6 was noted to have injuries related to a fractured pelvis and ribs after her return from the hospital. She reported being aware that prior to hospitalization, the resident was exhibiting behaviors of throwing herself on the floor from her bed. She reported that if she had been made aware, she would have reported it to the State Office.Interview on 07/28/2026 at 2:45 PM with the Director of Nursing (DON) revealed being aware of the fractures once the R6 returned to the hospital on [DATE]. DON reported reading the hospital record and failing to discuss it with the Administrator and other staff. She reported being aware that prior to hospitalization, the resident was exhibiting behaviors of throwing herself on the floor from her bed. She confirmed not reporting R6 's injuries related to a fall to the State Office within the 24-hour time frame.Interview on 07/29/2026 at 2:01 PM, [name], Rehab Therapy Director, CC confirmed being knowledgeable of R6's fractured ribs and pelvis after R6 returned to the facility on [DATE]. This information was provided to her in R6's discharged hospital record. Therapy Director reported that her findings were discussed immediately with certified nursing assistant (CNA) AA and with an unknown nurse.Interview on 07/29/2026 at 10:10 AM with Certified Nursing Assistant (CNA) AA. CNA AA reported that R6 was known to be very confused, throw herself out of bed, and fall violently on the floor. She had a history of attempting to get out of bed without assistance and being found on the floor on several occasions. R6 was unable to ambulate without assistance and required supervision. CNA AA reported working on the day of 05/30/2026 (the day R6 fell out of bed). She reported entering R6's room, observing R6 on the floor by her bed. She recalled R6 moaning and groaning. She did not recall witnessing any bruises because she immediately summoned the nurse. The nurse on duty sent the resident to the hospital.

Based on observation, staff interviews, record review, and a review of facility's policy titled Pain Management and Wound Treatment Management, the facility failed to stop and address a resident pulling back during a dressing change and facial grimacing expressions of pain during wound care for one resident (R) (R33) of two residents observed for wound care. Actual harm occurred on 1/28/2026 when Licensed Practical Nurse (LPN) AA failed to assess and administer pain medication to R33 prior to providing wound care treatment, which resulted in pain during the treatment.Findings Include: Review of the facility policy titled Pain Management, date reviewed/revised 04/1/2025, revealed the Policy section included, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. The Policy Explanation and Compliance Guidelines section included, Recognition: . the facility will: a. Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated. 2. Faculty staff will observe for nonverbal indicators which may indicate the presence of pain. These indicators include but are not limited to: . facial expression (e.g., [such as] grimacing, frowning, .).Review of the facility's undated policy titled Wound Treatment Management revealed the Policy Explanation and Compliance Guidelines section included, .5. Treatment decisions will be based on . b. Characteristics of the wound: .iv. the presence of pain.Review of the quarterly Minimum Data Set (MDS) assessment for R33, dated 11/27/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 00 (indicating was unable to complete). Section GG (Functional Abilities and Goals) revealed the resident was dependent for all care. Section I (Active Diagnosis) revealed diagnosis of, but not all-inclusive, encephalopathy, dementia, schizophrenia, and cognitive communication deficit.A review of the care plan for R33 revealed the resident had severely impaired cognition related to dementia and schizophrenia, and staff would anticipate the resident's needs and provide care. Further review revealed the resident was unable to effectively communicate the presence of pain and was dependent on staff to monitor and identify signs and symptoms of pain and to provide the appropriate interventions. Interventions included monitoring for signs of non-verbal pain, including facial grimacing, and administering pain medication per the physician's orders.Review of the physician's orders for R33 revealed an order dated 8/16/2021 for Mapap (a pain reliever), give 2 tablets orally every 6 hours as needed for pain.Review of the Medication Administration Record (MAR) for R33, dated 01/01/2026 - 01/31/2026, revealed the pain medication was administered one time, on 1/28/2026 at 12:04 PM.During wound care observation on 01/28/2026 at 10:56 AM with Licensed Practical Nurse (LPN) AA, R33 was observed to exhibit facial grimacing and pulling away from the dressing change.In an interview on 01/28/2026 at 11:09 AM, LPN AA confirmed that the resident exhibited non-verbal signs of pain during the wound care. She stated that the resident was not medicated for pain before the procedure, and she did not assess the pain prior to the change of dressing. She confirmed the resident was grimacing and pulling back, and she continued to change the dressing. She stated that once the resident experienced pain, she should not have continued with the dressing change and should have notified the nurse.In an interview on 01/29/2026 at 05:14 PM, the Unit Manager stated the wound care nurse should assess pain prior to providing wound care and return to perform the wound care after treatment of pain.In an interview on 01/30/2026 at 06:45 AM, the Director of Nursing (DON) stated the wound care nurse should address pain prior to a dressing change. She stated that the nurse should ask the resident about pain and, if needed, have the nurse treat pain and move to another resident while the medication kicks in. She further stated that if a resident complained of pain during treatment, continue to provide care, being as gentle as possible, and treat pain once care is complete.

Based on observations, staff interviews, and review of the facility's policy titled Food Safety Requirements, the facility failed to label, store, prepare, and discard food under sanitary conditions. In addition, the facility failed to ensure the cleanliness of the kitchen floors and equipment used for residents. The deficient practices had the potential to place the 48 residents receiving nutrition and hydration at risk for foodborne illness.Findings include: Review of the facility's policy titled Food Safety Requirements, revised on 03/25/2025, documented under Policy Explanation and Compliance Guidelines number 1-e. Equipment used in the handling of food, including dishes, utensils, mixers, grinders, and other equipment that comes in contact with food; number 3- iv. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (when applicable)/ discarded; number 8-e. Cleaning and sanitizing the internal components of the ice machine according to the manufacturer's guidelines. Observation tour of the kitchen on 01/27/2026, beginning at 11:55 AM, with the Certified Dietary Manager (CDM), revealed the following concerns were identified and confirmed:Refrigerator one contained a bottle of red sauce labeled 12/31/2025.Refrigerator one contained a block of butter partially covered without a label or date.Refrigerator two contained a bottle of barbecue sauce without an expiration date.The dry pantry contained a bag of lettuce with wilted, brown leaves.A metal shelf on the side of the stand-up freezer contained a black plastic container that contained heads of cabbage that were wilted with patches of yellow leaves and black spots, without a label or date.The walk-in freezer contained one partially covered pie without an open or expiration date.The stand-up freezer contained five unidentified bags of meat without labels.The dry pantry contained one box of bananas on the floor, next to a plastic container of sanitizing wash and walk solution.A refrigerator contained three jars of apple sauce without an expiration date.The can opener had a greasy, black substance.Prep table had paper, dishcloth, and cup lids. The kitchen floor under the can opener had a sticky red substance covering that area.The vents and light fixtures over the stove had thick, grey particles on them. The hand sanitizer dispenser next to the hand-washing sink was covered with thick, grey particles.A rolling serving cart with boxes, empty cans, lettuce with brown leaves, and empty thickener containers to be disposed of. During the tour, the CDM confirmed all identified concerns and stated the staff needed a lot of education on labeling, dating, and discarding items. She stated that the kitchen was due for a deep cleaning and did not know when it had last been cleaned. She confirmed that vents, light fixtures, and a hand sanitizer dispenser next to the hand-washing sink were covered with thick, grey particles. CDM confirmed that empty boxes, empty cans, lettuce with brown leaves, and empty thickener containers were placed on top of the rolling serving cart. She confirmed that all items should be discarded in the trash bin. She confirmed that the ice machine had a dried mixture of white and rust residue on the front, along the inner lip of the bin opening, and on the inside of the lid.Observation and interview on 01/28/2026 at 1:15 PM with the CDM confirmed that the ice machine located in the dining hall and used for the residents contained a dried mixture of a white and rust colored residue on the front of the machine, along the inner lip of the bin opening, and on the inside of the lid. She confirmed that black specks were present around the dispenser inside the ice machine and that the ice scoop was in the ice bin, uncovered. She confirmed it needed cleaning and that it was the responsibility of the maintenance department. She also confirmed that an uncovered trash can should not be placed in front of the ice machine and that all trash cans must be kept covered. An interview with the Maintenance Director on 01/28/2026 at 2:18 PM revealed that the exterior and interior of the ice machine had dried water stains and rust-colored residue. He confirmed that black specks were present inside the ice and that the ice scoop was in the ice bin, uncovered. The Maintenance Director confirmed that housekeeping and maintenance are responsible for keeping the ice machines clean. The maintenance Director also confirmed that the air conditioning vents in the dining area ceiling were covered with thick, grey particles. He confirmed he was unsure when the ice machine or the vents were last cleaned. He confirmed that housekeeping and maintenance were responsible for keeping them both clean.

Based on observation, staff and resident interviews, and record review, the facility failed to ensure three of 32 sampled residents' (R) (R2, R1, and R45) were treated with dignity. This deficient practice had the potential to place R2, R1, and R45 at risk of a diminished quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life.Findings include: 1. Review of the significant change Minimum Data Set (MDS) for R2, dated 12/15/2025, revealed that Section C (Cognitive Patterns) documented that R2 had a Brief Interview for Mental Status (BIMS) score of 14 (indicating little to no cognitive impairment). Section GG (Functional Abilities and Goals) documented that R2 was moderate assistance with eating and maximal assistance with oral hygiene. Section I (Active Diagnoses) documented diagnoses of, but not all inclusive, encephalopathy, unsteadiness on feet, dysphagia, gastrostomy, end-stage renal disease, hypothyroidism, type two diabetes mellitus, and acute respiratory failure with hypoxia. Review of the care plan for R2, dated 12/19/2025, revealed that R2 had an activity of daily living (ADL) self-care performance deficit, and her ADL requirements may vary from day to day. She required supervision to substantial assistance with ADLs. She uses a wheelchair for mobility. Intervention includes providing assistance with ADLs as needed. Record review revealed that R2 had an order 12/8/2025 for a pureed texture, nectar consistency pleasure tray. Observation 01/27/2026 at 1:20 PM revealed Certified Nursing Assistant (CNA) FF feeding R2 while standing over her. In an interview on 1/27/2026 at 1:27 PM, CNA FF confirmed that she was standing while feeding R2. She stated that she should not stand to feed residents. 2. Review of the quarterly MDS for R1, dated 12/10/2025, revealed that Section C (Cognitive Patterns) documented that R1 had a Brief Interview for Mental Status (BIMS) score of 0 (indicating severe cognitive impairment). Section I (Active Diagnosis) documented diagnosis of, but not all inclusive, Down syndrome, bipolar disorder, cognitive communication deficit, obstructive and reflux uropathy, and muscle weakness. Review of the care plan for R1, dated 01/12/2026, revealed that R1 had a urinary catheter and is at risk for urinary tract infections and injury. The urinary catheter was related to obstructive uropathy and benign prostate hypertrophy. Interventions include providing urinary catheter care per facility practice. Observation on 01/30/2026 at 6:02 AM revealed that Licensed Practical Nurse (LPN) BB knocked on the resident's door, introduced herself, and explained the procedure to R1. Observed revealed R1 in bed A. Further observation revealed that LPN BB did not pull the privacy curtain during catheter care for R1. Observation revealed that R1's roommate was in bed B during the care provided to R1. In an interview, LPN BB confirmed that she did not pull the privacy curtain while providing care and that she should have. In an interview on 01/30/2026 at 9:09 AM, the Unit Manager stated that the staff should close the door and pull the privacy curtain while providing care if another resident was in the room. In an interview on 01/30/2026 at 8:46 AM, the Administrator stated that staff should provide privacy in the room by pulling the curtain and closing the door, and if the resident was by the window, the blind should be closed. 3. Review of the quarterly MDS assessment for R45, dated 12/18/2025, revealed that Section C (Cognitive Patterns) documented that R45 had a BIMS score of 2 (indicating cognitive impairment). GG Section GG (Functional Abilities and Goals) documented that R45 needed supervision and touching assistance with eating. Review of the clinical record for R45 revealed diagnoses of, but not all inclusive, dementia, unspecified severity, with other behavioral disturbance, and dysphagia, oropharyngeal phase. Review of the physician orders for R45 revealed an order dated 12/8/2025 for a regular diet, mechanical soft texture, and thin consistency. Observation 01/27/2026 at 1:28 PM revealed Registered Nurse (RN ) Unit Manager II standing while feeding R45 her meal. In an interview on 01/27/2026 at 1:45 PM, RN Unit Manager II confirmed that she was standing while feeding the resident her lunch and stated that she should not stand to feed residents. In an interview on 01/30/2026 at 6:45 AM, the Director of Nursing (DON) stated that staff should sit while feeding the residents. In an interview on 01/30/2026 at 8:46 AM, the Administrator stated that staff should sit while feeding residents.

Based on record review and staff interview, the facility failed to notify the resident and/or the resident's responsible party when their personal funds were within $200.00 of the Social Security Income (SSI) limit and when accounts exceeded the $200.00 limit for one of 48 resident (R) (R43) accounts reviewed.Findings include:Review of the electronic health records (EHR) for R43 revealed diagnoses including, but not limited to, paranoid schizophrenia, schizophrenia, and brief psychotic disorder. Review of the quarterly Minimum Data Set (MDS) assessment for R43, dated 12/9/2025, revealed a Brief Interview Mental Status Score (BIMS) score of 11, indicating moderate cognitive impairment.Review of the Trial Balance report dated 01/30/2066 revealed the trust fund account for R43 exceeded the SSI limit of $2000.00.Review of the account document titled Resident Statement Landscape revealed that R43 was awarded $13,115.98 (March 2025), and the remaining balance in her account was $4,856.73.There was no documented evidence that the resident, or the responsible party, was notified of the amounts exceeding the SSI limit.During an interview on 01/30/2026 at 4:10 PM, R43 reported being unaware of the exact amount in her account. She stated she was informed on 01/30/2026 by the office manager staff of having $6,000.00 in her account.During an interview on 01/30/2026 at 2:00 PM, the Business Office Manager (BOM)/Financial Coordinator stated the SSI limit for the State of Georgia was $2000.00. The BOM/Financial Coordinator confirmed the resident's account balance and confirmed the facility had not notified the resident and/or the resident's responsible party of the excess in her account. The BOM/Financial Coordinator reported that she was instructed to keep resident fund accounts under $2,000.00 to qualify for Medicaid. She confirmed that the patient's liability for R48's accounts had already been pulled out for the month of January 2026 and that the remaining balance left in the resident's account was $4,856.73.A policy was requested, but was not provided.

Based on staff interviews and record reviews, the facility failed to ensure submission to the state-designated authority for a Preadmission Screening and Resident Review (PASRR) Level II for two residents (R) (R1 and R19) reviewed for PASRR from a sample of 32 residents. This deficient practice increased the potential to place R1 and R19 at risk of not receiving services and/or care according to their needs.Findings include: 1. Review of the electronic health record (EHR) under the Diagnosis tab for R1 revealed the resident was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, bipolar disorder and Down syndrome. Review of the quarterly Minimum Data Set (MDS) assessment for R1, dated 12/10/2025, revealed that Section C (Cognitive Patterns) documented that R1 had a Brief Interview for Mental Status (BIMS) score of 0 (indicating severe cognitive impairment). Section I (Active Diagnosis) documented diagnosis of, but not all inclusive, Down syndrome and bipolar disorder. Review of the hospital record for R1 revealed documentation dated 09/02/2025 that R1's active problem list included, but was not all-inclusive, for bipolar affective disorder and intellectual developmental disorder, mild. Past medical history included Down syndrome. A review of R1's orders revealed there was no psychiatric order for R1. Review of the PASRR Level I Assessment and DMA 6 for R1, dated 11/15/2025, revealed that diagnoses of schizophrenia and bipolar disorder were not marked. Review of the clinical record for R1 revealed no submissions for a PASRR Level II after admission.Review of the facility-provided list of residents with Level II PASRR revealed that R1's name was not listed. In an interview on 01/30/2026 at 11:00 AM, the Business Development Specialist confirmed that R1 did not have a PASRR Level II. She stated she would initiate PASRR Level II and that she should have initiated one on R1's admission. In an interview on 01/30/2026 at 8:46 AM, the Interim Administrator revealed that PSARR Level II was completed by the admission Coordinator and should be initiated on admission, and if during admission, a PASRR Level II was not initiated, it should be completed at the onset of admission. 2. Review of the EHR, under the Diagnosis tab, revealed that R19 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, other schizophrenia and bipolar disorder, unspecified. Review of R19 's quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment; Section I (Active Diagnosis) documented schizophrenia and bipolar disorder. Section N (Medications) documented that the resident received antipsychotic and antidepressant medications during the look-back period of assessment. Review of R19's EHR under the Orders tab revealed physician orders dated 12/2/2025 for olanzapine oral tablet 15 milligrams (mg), give 15 mg by mouth at bedtime, related to other schizophrenia and an order dated 09/4/2025 for Depakote oral tablet delayed release 500 mg, give 1 tablet by mouth three times a day, related to other schizophrenia and bipolar disorder, unspecified. Review of the PASRR Level I Assessment for R19, dated 11/7/2024, revealed that the document did not indicate diagnoses of schizophrenia or bipolar disorder. Review of the clinical records for R19 revealed no submissions for a PASRR Level II after admission. Review of the facility-provided list of residents with Level II PASRR revealed that R19's name was not listed. In an interview on 01/29/2026 at 2:30 PM, the Business Development Specialist DD confirmed the resident did not have a PASRR Level II. She confirmed the resident had qualifying diagnoses and stated that since the resident has not had any increase in behaviors, she had not submitted a PASRR Level II. She stated that if the resident exhibited an increase in behaviors, she would submit for a PASRR Level II.

Based on observation and staff interviews, the facility failed to ensure that one of two medication rooms was free of expired medication. This deficient practice had the potential to place residents at risk of receiving expired medications. Findings include:Observation on 01/29/2026 at 9:08 AM, of the supply room and over-the-counter medication room on Hall One with the Unit Manager, revealed two bottles of calcium 600 milligrams (mg) plus vitamin D3 400 units expired on 12/2025, three bottles of aspirin 325 mg expired 10/2025, one bottle of aspirin 325 mg expired 12/2025, two bottles of calcium 600 plus D3 expired 11/2025, one milk of magnesium expired 10/2025. The Unit Manager confirmed the expired medications. She stated the nurse was responsible for confirming medications were not expired before removing them from the storage closet. In an interview on 1/29/2026 at 9:26 AM, the Central Supply Clerk confirmed that the medications had expired. She stated that she stocks the medication and supply room and places the medications on the shelves according to the medication. She further stated she checked for expired medication every other day and removed them from the shelves. In an interview on 1/30/2026 at 6:45 AM, the Director of Nursing (DON) stated that medication storage was completed by nurses and central supply staff. The DON stated that Central Supply stocks, rotates supplies, and removes expired medications.

Based on observations, staff interviews, record reviews, and a review of the facility's policy titled Enhanced Barrier Precautions, the facility failed to ensure infection control practices were followed for four of 32 sampled residents (R) (R33, R7, R30, and R40). This deficient practice had the potential to place R33, R7, R30, and R40 at risk of infection due to cross-contamination and exposure. Findings include: Review of the facility policy titled Enhanced Barrier Precautions, revised 4/1/2025, revealed the Policy section stated, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. The Policy Explanation and Compliance Guidelines section included, . 2. Initiation of Enhanced Barrier Precautions: . b. An order for enhanced barrier precautions will be obtained for residents with any of the following: Wounds, . indwelling medical devices (e.g. [such as] central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC [Peripherally Inserted Central Catheter] lines, midline catheters) even if the resident was not known to be infected or colonized with a MDRO (multidrug resistant organism). 1. Review of the quarterly Minimum Data Set (MDS) for R33, dated 11/27/2025, revealed that Section GG (Functional Abilities and Goals) documented that the resident was dependent for all care. Review of the care plan for R33, dated 01/7/2026, revealed the resident had a potential for pressure ulcer development related to bowel and bladder incontinence and impaired cognition from diagnoses of dementia and schizophrenia, and an abrasion to the top of the second toe on the right foot. Interventions included examining the resident's skin daily for open or reddened areas and reporting abnormal findings to the nurse, maintaining dignity and privacy, encouraging the resident to change soiled clothing and assist as needed, using a pressure reduction mattress, providing treatment as ordered, and a weekly skin audit by a licensed nurse. Review of the physician orders for R33 revealed an order dated 01/22/2026 to cleanse the right foot anterior with Dakin's solution, pat dry, apply alginate, and apply an island dressing, then apply a boot for protection every day shift. Observation on 01/28/2026 at 10:56 AM revealed that Licensed Practical Nurse (LPN) AA completed wound care to the right lateral anterior foot wound, wearing gloves and a mask. Observation revealed she changed gloves during the procedure, but did not sanitize her hands between glove changes or wear a gown. In an interview on 01/28/2026 at 11:09 AM, LPN AA confirmed that she did not wear a gown during the dressing change and did not sanitize her hands between glove changes. 2. Review of the quarterly MDS for R7, dated 12/15/2025, revealed that Section I (Active Diagnosis) revealed diagnosis of but not all-inclusive anemia, hypertension, renal insufficiency, diabetes mellitus, depression, bipolar disorder, schizophrenia, pressure ulcer of left heel, pressure ulcer of right lower back stage 4, pressure ulcer of left lower back stage 4. Review of the care plan for R7, dated 11/12/2025, revealed that R7 requires enhanced barrier precautions (EBP) due to a pressure ulcer on the right and left ischium. Interventions included wearing gowns and gloves during high-contact resident care activities, ensuring EBP signage is posted outside the resident's room and above the head of the resident's bed, educating the resident and family on the reason and procedure for enhanced barrier precautions, and notifying the physician of any signs or symptoms of active infection. Review of the physician orders for R7 revealed an order dated 7/23/2025 to place under enhanced barrier precaution due to an ulcer of the right buttock, ensuring appropriate (PPE) personal protective equipment is used during the resident care activities every shift. Observation on 01/28/2026 at 02:44 PM revealed Registered Nurse (RN) CC performed a PICC line dressing change. Observation revealed she did not wear a gown and did not perform hand hygiene between glove changes. In an interview on 01/28/2026 at 05:33 PM, RN CC confirmed that she did not wear a gown while changing the PICC line dressing for R7. She stated that she does not need to wear a gown during a PICC line change. In an interview on 01/29/2026 at 05:14 PM, the Unit Manager stated that when changing PICC line dressings, a gown, gloves, and a mask should be worn. In an interview on 01/30/2026 at 06:45 AM, the Director of Nursing (DON) stated that wound care should be provided with enhanced barrier precautions, including a gown, gloves, goggles, and a mask. She further stated residents with a PICC line, g-tube, catheters, and communicable disease are under EBP, which means to wear a gown, gloves, and a mask, and when changing a PICC line dressing, the nurse should wear a gown. 3. Review of the admission Record for R40 revealed that the resident resided in room [ROOM NUMBER]. Review of the quarterly MDS for R40, dated 12/15/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status Score (BIMS) of 15, which indicated little to no cognitive impairments. Review of the EHR revealed that vital signs for R40, dated 01/24/2026 to 01/30/2026, were within normal limits (temperature, pulse, respiration, and oxygen saturation). Continued review revealed no signs of respiratory infection. Observations on 01/27/2026 at 01:44 PM, 01/28/2026 at 02:30 AM, 01/29/2026 at 10:03 AM, and 01/30/2026 at 09:01 AM revealed R40 lying in bed in room [ROOM NUMBER]. In an interview on 01/28/2026 at 03:01 PM, R40 reported having concerns about residing in a room with a roommate with flu-like symptoms. R40 reported having no symptoms or signs of cough, fever, or respiratory problems. 4. Review of the admission Record for R30 revealed that the resident resided in room [ROOM NUMBER]. Review of the EHR for R30 revealed a hospital record documented Influenza positive on 01/24/2026. Review of the progress notes for R30 revealed an entry dated 01/27/2026 at 05:30 AM of Resident returned to facility via EMS (Emergency Medical Services) at 03:00 AM. Review of the physician's orders for R30 revealed an order dated 01/26/2026 for Tamiflu oral capsule 75 milligrams (mg), one capsule by mouth two times a day for influenza for three days. Observation on 01/27/2026 at 01:44 PM of resident room [ROOM NUMBER], R30's, door revealed no droplet precaution signage. In an interview on 01/28/2026 at 01:00 PM, the Medical Director (MD) confirmed that R30 was on transmission-based precautions because of the flu. The MD reported being unaware that resident R40 resided in the room with R30. He stated that R30 should have been placed in a different room upon return to the facility with the diagnosis of influenza. In an interview on 01/30/2026 at 02:00 PM, Register Nurse (RN) Supervisor stated R30 had not exhibited signs of influenza before being admitted to the hospital with kidney concerns. She stated R30 was diagnosed with influenza while in the hospital. She further stated that R40 had not exhibited signs of influenza. She stated R40 should have been placed in a different room upon return from the hospital, and further stated there was an empty room available when R40 returned on 01/27/2026. She confirmed R30's door did not have signage to inform staff and visitors of droplet precautions and stated the signage should be on the door. In an interview on 01/29/2026 at 10:01 AM, the admission Manager acknowledged that the facility census dated 01/26/2026 and 01/27/2026 revealed that a vacant room was available, and R30 could have been placed in the vacant room upon returning from the hospital. In an interview on 01/29/2026 at 10:14 AM, the Administrator and Director of Nursing (DON) confirmed that a room was available per the facility's census on 01/26/2026 and 01/27/2026. They reported being unaware that the staff had placed a resident with a diagnosis of influenza (R30) in a room with a resident without symptoms of or a diagnosis of influenza (R40). The Administrator reported that her expectations were for staff to place the resident in a vacant room and not compromise the other resident's health. The DON reported that staff should have placed R30 in the vacant room rather than in a room with another resident who was not diagnosed with influenza nor had influenza-like symptoms.

Based on observations and staff interviews, the facility failed to label and date items in the freezer, failed to ensure items in dry food storage were not expired, failed to prevent cross-contamination hazards by storing scoops in the container, failed to wear hairnets, and failed to ensure routine cleaning and sanitation of the kitchen. This deficient practice had the potential to place 49 of 49 residents who received an oral diet from the kitchen at risk of foodborne illness. Findings Include: During the initial kitchen tour on [DATE] at 7:47 am the following items were identified: 1. Dietary Aide AA and Dietary Aide BB were not wearing hairnets upon the surveyor's entry into the kitchen. 2. Items in the white standup freezer were not labeled or dated, including pancakes, cookies, biscuits, sausage, and fish nuggets. 3. In the dry storage pantry there were: a. Three bottles of expired thickened water with a use-by date of [DATE]. b. There were four plastic storage containers with sugar, rice, and flour with scoops on top and not in a bag. One scoop was in the container. During an interview on [DATE] at 7:59 am with [NAME] FF, she confirmed the items in the standup freezer were not labeled or dated and reported that items in the freezer should have had a label on them. During an interview on [DATE] at 8:07 am with Dietary Aide AA, he confirmed that scoops should be kept on top of the container and bagged. During an interview with the Dietary Manager (DM) on [DATE] at 10:51 am, the DM acknowledged that storage bins did not have use by date, and she also confirmed that the scoops should not be kept in the containers with the rice, sugar, and flour. It was reported that the kitchen is deep cleaned monthly, and it was last deep clean was three weeks ago. The DM was unable to provide documentation of the cleaning. During a secondary tour of the kitchen on [DATE] at 11:00 am, observation revealed there were four bags of unlabeled and dated meat in the walk-in freezer that were identified as beef stew by the DM. Observation on [DATE] at 11:06 am revealed [NAME] CC who was observed to lick her gloved finger when sampling pureed sweet peas. [NAME] CC was not observed washing hands or changing gloves. During an interview and observation on [DATE] at 12:00 pm, the DM reported an area on the floor with build-up was there because they were unable to move the table from the area to clean that area of the floor. The refrigerator was noted to have rusted, and the DM reported that it was due to the cleaning product that was used on the refrigerator. She reported that she has been out for a while, and the cleaning schedule may have gotten off track during her absence. An email from the Licensed Dietitian (LD) stated, The Nutritional Services Sanitation Inspection was completed by the LD on [DATE] and identified concerns with items not being labeled and dated. In an interview on [DATE] at 4:54 pm, the Administrator acknowledged that the items in the refrigerator and freezer should be labeled and dated. The Administrator stated she was not sure of the cleaning schedule but acknowledged that the kitchen should be cleaned daily. The Administrator further reported that hairnets should be worn by staff when in the kitchen. Lastly, the Administrator confirmed that [NAME] CC should not have sampled the sweet peas from her finger.

Based on observations, staff interviews, record review, and review of the facility policies titled, Hand Hygiene and Infection Surveillance, the facility failed to maintain an effective infection prevention control program to ensure proper sanitation between resident interactions, failed to ensure beverages were covered before delivering on the hallway, failed to ensure hand sanitation when delivery meal trays, and failed to demonstrate ongoing surveillance, recognition, investigation, and control of infection to prevent the onset and spread of infection. These deficient practices placed all 49 residents residing in the facility at risk of contracting avoidable infections. Findings include: 1. Review of the facility policy titled Hand Hygiene, dated 2023, indicated the following: Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Observation on 10/26/2024 at 12:36 pm, in the dining room, revealed Registered Nurse (RN) UU with gloves on going from table to table cleaning multiple resident's hands with wipes. RN UU did not change gloves between residents. Observation on 10/26/2024 at 12:51 pm of a lunch food tray cart leaving the dining room and pushed to a resident hallway revealed there were seven trays on the cart, each with an uncovered beverage cup, during the meal delivery. Observation on 10/27/2024 at 1:09 pm of lunch meal tray delivery on a resident hallway by Certified Nursing Aide (CNA) TT revealed CNA TT delivering 12 meal trays to resident rooms. She was observed moving items on bedside tables and sometimes touching the residents in the rooms when delivering the trays. CNA TT did not use hand sanitizer or wash her hands between each delivery. During an interview with CNA TT on 10/27/2024 at 3:02 pm, it was reported that hand sanitizer was not used due to eczema. She reported typically she would use gloves but was informed that gloves could not be worn in the hallways with the surveyors in the building. CNA TT reported that the beverage cups were never covered when being delivered down the hallway, and she had not been directed to cover the cups. During an interview with the Administrator on 10/28/2024 at 2:43 pm, she stated staff should cover all drinks with a lid before distributing them down the hallways. She added that she did not know why the staff had not been covering the drinks, and she said it was the nursing staff's responsibility to ensure drinks were covered during transport. During further interview, she stated she expected staff to wash their hands and/or use hand sanitizer between resident contact and before and after entering and exiting a resident's room. She stated if the staff member had a skin condition that contraindicated the use of a hand sanitizer, she would expect the staff member to wash their hands when entering and exiting a resident's room and when assisting a resident. The Administrator indicated she had no problem or issues with the staff utilizing gloves to provide care. During an interview with the Interim Director of Nursing (DON) on 10/28/2024 at 2:51 pm, she stated that she expected staff to cover all drinks with lids before transporting them outside the dining room. The Interim DON stated it was the nursing staff's responsibility to ensure the drinks were covered. 44960 2. Review of the facility's policy titled Infection Surveillance, revised 7/1/2024, revealed the Policy Statement was A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infections and to monitor adherence to recommended infection prevention practices in order to reduce infections and prevent the spread of infections. Review of the Infection Control Tracking Reports revealed the facility did not have documented evidence of infection control surveillance data for nine of ten months (January through September) for 2024. During an interview with the Interim Director of Nursing (DON)/ Infection Control Preventionist (ICP) on 10/27/2024 at 10:41 am, she stated she had taken the role of the facility's ICP in August of 2024 and was unable to locate any documentation for the monthly infection controls tracking system for 2024. Further interview revealed she did not know where the infection control tracking data for the past nine months (January through September) was and was only able to find infection control tracking data for 2021 and 2022. During an interview on 10/27/2024 at 2:40 pm, the Administrator stated she thought there was a more updated book with the 2024 monthly infection control surveillance data but could not locate it.

Based on observations and staff interviews, the facility failed to ensure the outdoor garbage and refuse area was maintained in a sanitary manner. This deficient practice had the potential to attract pests and rodents and transfer harmful microorganisms to food leading to food borne illness for the 49 residents residing in the facility. Findings include: During the initial observation of the dumpster area on 10/26/2024 at 8:30 am with Dietary Aide AA, there were two blue dumpsters observed with the door fully opened on one and partially opened on the other with a brief hanging out of the opening. During a second tour of the dumpster area on 10/27/2024 at 10:36 am with the Dietary Manager (DM), trash was on the ground to the right of one of the dumpsters and the door was opened on the other dumpster. The DM acknowledged the trash on the ground and that the dumpster doors should always be closed. During an interview with the Administrator on 10/27/2024 at 4:54 pm, it was acknowledged that the dumpsters should be kept closed on both the top and the sides. The Administrator went on to report that two dumpsters had been placed for nursing to put their items that would be separate from where dietary puts their trash.

Based on staff interviews, record review, and review of the facility policy titled Comprehensive Care Plans, the facility failed to develop or implement comprehensive person-centered care plans for eight of 38 sampled residents (R) (R39, R42, R8, R19, R3, R10, R13, and R22). This failure increased the potential for R39, R42, R8, R19, R3, R10, R13, and R22 to not receive treatment and/or care according to their needs. Findings include: A review of the facility's undated policy titled Comprehensive Care Plans, revealed the care planning process would include an assessment of the resident's strengths and needs. The comprehensive care plan would be developed within seven days after completion of the comprehensive Minimum Data Set (MDS) assessment, and all Care Assessment Areas (CAAs) triggered by the MDS would be considered in developing the plan of care. Other factors would be determined by the interdisciplinary team (IDT) or as evidenced by the resident's clinical record. 1. A review of R39's medical record revealed diagnoses including dementia, weakness and unsteadiness on his feet, cognitive communication deficit, sexual dysfunction, and hypertension. A review of R39's MDS OBRA Annual Assessment, dated 2/14/2024, Section V (Care Assessment Area [CAA] Summary), revealed the assessment triggered cognitive loss/dementia, communication, activities of daily living (ADL) functional/rehabilitation potential, urinary incontinence, psychosocial wellbeing, behavioral symptoms, and pressure ulcer. A review of R39's medical record revealed physician's orders dated 2/8/2024 for amlodipine besylate, 5 milligrams (mg) one tablet by mouth (PO) one time a day (QD) for hypertension, 9/27/2024 Abilify 2 mg PO QD for dementia with behavioral disturbances, and 2/22/2024 Provera 5 mg PO QD morning for hypersexuality. A review of R39's care plan revealed that it did not include a plan for dementia, communication, ADL functional/rehabilitation potential, urinary incontinence, psychosocial well-being, behavioral symptoms, risk for pressure ulcer, and hypertension. 2. A review of R42's medical record revealed diagnoses including dementia, cognitive communication deficit, hypertension, gastroesophageal reflux disease (GERD), hyperlipidemia, and major depressive disorder. A review of R42's MDS OBRA Admission Assessment, dated 2/26/2024, Section V (CAA Summary), revealed the assessment triggered cognitive loss/dementia, communication, urinary incontinence, behavioral symptoms, pressure ulcer, and psychotropic drug use. A review of R42's medical record revealed physician's orders dated 3/13/2024 for lorazepam 1 mg PO three times a day (TID) for anxiety, 3/8/2024 trazodone hydrochloride (HCL) tablet 25 mg PO at bedtime (HS) for insomnia, 2/15/2024 amlodipine besylate 10 mg PO QD for hypertension, 2/15/2024 rosuvastatin calcium 10 mg PO QD for lipid control (hyperlipidemia), 2/15/2024 pantoprazole sodium 40 mg PO QD for GERD, 2/15/2024 quetiapine fumarate oral 50 mg PO QD for manic disorder, 2/14/2024 olanzapine 5 mg PO two times (BID) a day for manic disorder, and 2/14/2024 losartan potassium 50 mg PO BID for hypertension. A review of R42's care plan revealed the care plan did not include a plan for cognitive loss/dementia, communication, urinary incontinence, behavioral symptoms, pressure ulcer risk, psychotropic drug use, hypertension, anxiety, antipsychotic drug use, insomnia, GERD, hyperlipidemia, and manic disorder. 3. A review of R8's medical record revealed diagnoses including atrial fibrillation, chronic obstructive pulmonary disease (COPD), seizures, cerebral infarction, insomnia, hyperlipidemia, GERD, hypertension, and mental disorder. A review of R8's MDS OBRA Admission Assessment, dated 9/9/2024, Section V (CAA) Summary, revealed the assessment triggered cognitive loss/dementia, communication, and dental care. A review of R8's medical record revealed physician's orders dated 10/17/2024 for olanzapine 5 mg PO TID for psychosis, 10/11/2024 Depakote 250 mg PO BID for dementia with behavioral disturbances, 8/30/2024 hydrocodone-acetaminophen 5-325 mg PO every 6 hours as needed for pain, 8/28/2024 Trelegy Ellipta inhalation aerosol 100-62.5-25 micrograms (MCG)/actuation (ACT) one puff via oral inhalation in the morning for COPD, 8/28/2024 donepezil HCl 5 mg PO at HS for dementia, 8/28/2024 atorvastatin calcium 20 mg at PO HS for hyperlipidemia, 8/28/2024 levetiracetam 1000 mg PO BID for seizures, 8/29/2024 diltiazem 120 mg PO in the morning for hypertension, 8/28/2024 metoprolol tartrate 25 mg give 0.5 tablet PO BID for hypertension, and 8/28/2024 pantoprazole sodium 40 mg, PO QD for GERD. A review of R8's care plan revealed the care plan did not include a plan for dementia, communication, dental care, antipsychotic drug use, pain, narcotic use, COPD, hyperlipidemia, seizures, hypertension, GERD, atrial fibrillation, cerebral infarction, mental disorder, and insomnia. 4. A review of R19's medical record revealed diagnoses of hyperlipidemia and GERD. A review of R19's medical record revealed physician's orders dated 8/16/2021 for omeprazole 40 mg PO QD for GERD and 8/16/2021 atorvastatin 20 mg PO QD for hyperlipidemia. A review of R19's care plan revealed that it did not include a plan for hyperlipidemia and GERD. During an interview with the MDS Coordinator on 10/27/2024 at 3:30 pm, the MDS Coordinator acknowledged that the MDS assessment triggered areas in R39, R42, and R8's CCA Summary that had not been care planned. She also acknowledged that R39, R42, R8, and R19's additional diagnoses and current medications had not been utilized in developing the residents' care plans. She stated the residents should have been care planned for areas related to clinical diagnoses, medications, and behavioral concerns. During an interview with the Interim Director of Nursing (DON) on 10/28/2024 at 7:47 am, she explained that all triggered CAAs identified during the MDS assessment should be included in a resident's current individualized care plan developed by the MDS Coordinator. She added that care plans should consist of clinical diagnoses and other areas of concern related to each resident's medical, emotional, behavioral, and psychosocial status. The DON acknowledged that R39, R42, R8, and R19 should have been care planned for the areas that were not in their care plans. During an interview with the Administrator on 10/28/2024 at 7:56 am, she stated her expectation was that the MDS Coordinator complete a thorough assessment for each resident, inclusive of the MDS CAAs, medical record, clinical diagnoses, medications, behavioral symptoms, psychosocial/mental status, and any other areas identified during the IDT meetings. The Administrator added that she expected the MDS Coordinator to include goals and interventions for each area identified in the resident's individualized comprehensive care plan. The Administrator acknowledged that the care plans for R39, R42, R8, and R19 did not reflect a comprehensive care plan. 37739 5. A review of R3's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Section E (Behavior) documented that rejection of care behaviors was not exhibited, and Section GG (Functional Abilities and Goals) documented R3 required partial/moderate assistance with personal hygiene. A review of the care plan, last updated 10/24/2024, revealed that R3 required set-up assistance from staff with personal hygiene. Observations of R3 on 10/26/2024 at 1:19 pm, 10/27/2024 at 8:36 am, 10/27/2024 at 12:00 pm, and 10/27/2024 at 4:51 pm revealed his face was not shaved. 6. A review of R10's Quarterly MDS assessment dated [DATE] revealed Section E (Behavior) documented that rejection of care behaviors was not exhibited, and Section GG (Functional Abilities and Goals) documented R10 required partial/moderate assistance with personal hygiene. A review of the care plan, last updated 7/17/2024, revealed that R10 required set-up, supervision, and limited assistance with ADL care related to a diagnosis of CVA (cerebrovascular accident) with left-side weakness. The Goal included assistance with ADLs will be provided. The Interventions included keeping the resident's nails clean and cut. Observations on 10/26/2024 at 9:44 am and 10/27/2024 at 12:00 pm revealed R10 had a full beard, and his nails were long and sharp and needed to be trimmed. An observation on 10/27/2024 at 2:09 pm revealed R10's face had been shaven, and he had a goatee, but his nails were still long and not trimmed. 7. A review of the Quarterly MDS assessment dated [DATE] revealed Section C (Cognitive Patterns) documented a BIMS score of 10 (indicating moderate cognitive impairment), and Section J (Health Conditions) documented R13 frequently experienced moderate pain. There was nothing checked in Section L (Oral/Dental Status). A review of the Annual MDS assessment dated [DATE] revealed Section L (Oral/Dental Status) documented obvious or likely cavity or broken natural teeth. A review of R13's care plan dated 10/18/2024 revealed that R13 had potential for oral/ dental health problems related to having broken teeth and dental caries. A Goal was that R13 would not develop any open area of the gums and would maintain adequate oral hygiene through the next review. Interventions included having dental consultants as needed, observing R13 for oral pain and ulceration, and observing/documenting/reporting to physicians any signs or symptoms of oral/dental problems needing attention. An observation of R13 on 10/26/2024 at 11:20 am revealed missing/broken/decayed teeth. In an interview, R13 stated that the dentist came three or four months ago and was going to do something for him, but they never came back. He stated he does have pain in his mouth and that he had told staff about his pain. During an interview on 10/28/2024 at 1:00 pm, the Administrator confirmed that R13 had not received dental care from a dental provider since 2/21/2024 8. A review of R22's Quarterly MDS assessment dated [DATE] revealed Section E (Behavior) documented that rejection of care behaviors was not exhibited, Section GG (Functional Abilities and Goals) documented R10 required supervision with personal hygiene, and Section L (Oral/Dental Status) documented R22 had obvious or living cavities or broken natural teeth. A review of the care plan, dated 10/24/2024, revealed R22 required supervision with ADL care related to impaired cognition from diagnoses of schizophrenia and bipolar disorder. Interventions included to keep resident's nails clean and cut. Further review of the care plan revealed that R22 had a potential for oral/dental health problems related to missing some natural teeth and had cavities. The Goal was the resident would not develop any open area of the gums and would maintain adequate oral hygiene. The Interventions included coordinating arrangements for dental care as needed/ordered and dental consults as needed. A review of R22's EMR revealed that there was no dental assessment in the clinical record. An observation of R22 on 10/26/2024 at 1:19 pm revealed he had decayed/broken missing teeth. Observations on 10/26/2024 at 1:19 pm and 10/27/2024 at 2:15 pm revealed R22's face was unshaven, and his nails were long and jagged with a dark substance under them. Cross-Reference F677 and F791

Based on observations and staff interviews, the facility failed to ensure a clean, comfortable, and homelike environment for nine of 26 resident rooms (Rooms 15, 10, 11, 18, 20, 7, 16, 17, and 9) and one of two shower rooms (Ladies' Shower Room). These deficient practices had the potential to place the residents residing in and using the rooms at risk of living in an unsanitary and unsafe living environment and a potential for diminished quality of life. Findings included: During a resident room observation in room [ROOM NUMBER] on 10/26/2024 at 8:04 am, the following was observed: unlabeled and unbagged personal care products (skin and hair cleanser), unbagged and unclean graduate sitting on the back of the toilet, the paper towel dispenser was empty, the toilet was dirty, and the hand sanitizer dispenser was not working. A resident room observation in room [ROOM NUMBER] on 10/26/2024 at 9:19 am revealed thin linen sheets with stains, stains on the privacy curtain by Bed A, and writing on the walls by Bed A. A resident room observation in room [ROOM NUMBER] on 10/26/2024 at 10:36 am revealed a small indenture behind the door, missing paint from the door, rust on the vent in the room, faded spots in the privacy curtain, and there was no pull string for the overbed light. A resident room observation in room [ROOM NUMBER] on 10/26/2024 at 10:36 am revealed the floor tile was dirty and stained, broken window blinds, rust, dirt, and chipped paint in the room near the air unit, and the air unit was not sealed (the outside light was visible from the unit). An observation of the shared bathroom for rooms [ROOM NUMBERS] revealed the following: an empty soap dispenser, the floor vinyl peeling up, and plastic molding detaching from the wall. A resident room observation in room [ROOM NUMBER] on 10/26/2024 at 11:20 am revealed a broken toilet with the toilet tank cover sitting on the floor behind the toilet. The toilet flushing mechanism was observed to stick and continue to run when flushed. The sink was caked with a white and green thick build-up. There were unlabeled and unbagged personal care products (skin and hair cleanser), the floor vinyl peeling up, and the plastic molding was detaching from the wall. A resident room observation in room [ROOM NUMBER] on 10/26/2024 at 2:11 pm revealed a short privacy curtain between Bed A and Bed B. An observation in the shared bathroom for room [ROOM NUMBER] and room [ROOM NUMBER] on 10/26/2024 at 9:45 am revealed the sink was dirty with hair, there were no paper towels in the dispenser, the toilet seat was observed with a dried brown substance on it, and hair was on the toilet. A resident room observation in room [ROOM NUMBER] on 10/27/2024 at 8:55 am revealed a strong urine smell in the room, missing paint from the wall, and short privacy curtains. A resident room observation in room [ROOM NUMBER] on 10/27/2024 at 8:58 am revealed a stained/bleached-out privacy curtain near Bed A. On 10/27/2024 at 4:30 pm, the Ladies' Shower Room was observed with a rusty chair and a black substance on the mesh shower chair. During an interview on 10/27/2024 at 4:26 pm, Housekeeper NN confirmed there was a strong urine smell in room [ROOM NUMBER] and stated it was a normal nursing home scent. She was unable to tell how often rooms were deep cleaned. During a comprehensive tour of the facility with the Administrator and the Regional Director of Environmental Services (RDES) on 10/28/2024 at 11:56 am, they confirmed all the areas of concern. The RDES stated that he visits the building twice a month.

Based on observations, resident and staff interviews, record review, and review of the facility policy titled Dental Services, the facility failed to provide routine and emergency dental services for three of 38 sampled residents (R) (R3, R13, and R22). This failure placed R3, R13, and R22 at risk for unmet needs and a diminished quality of life. Findings included: A review of the facility's undated policy titled Dental Services revealed the Policy was, It is the intent of this facility to assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care. The Policy Explanation and Compliance Guidelines section included . 9. All actions and information regarding dental services, including any delays related to obtaining dental services, will be documented in the resident's medical record. 1. A review of the electronic medical record (EMR) revealed R3 was admitted to the facility on [DATE]. A review of the EMR revealed R3's funding source was documented as Medicaid Georgia (GA). A review of R3's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Section L (Oral/Dental Status) documented R3 had no natural teeth or tooth fragments and was edentulous. A review of R3's EMR revealed that there was no dental assessment in the clinical record. Observations of R3 on 10/26/2024 at 1:19 pm, 10/27/2024 at 8:36 am, 10/27/2024 at 12:00 pm, and 10/27/2024 at 4:51 pm revealed he had no teeth or dentures. 2. A review of the EMR revealed that R13 was admitted to the facility on [DATE]. A review of the EMR revealed R13's funding source was documented as Medicaid GA. A review of the Quarterly MDS assessment dated [DATE] revealed Section C (Cognitive Patterns) documented a BIMS score of 10 (indicating moderate cognitive impairment), and Section J (Health Conditions) documented R13 frequently experienced moderate pain. There was nothing checked in Section L (Oral/Dental Status). A review of the Annual MDS assessment dated [DATE] revealed Section L (Oral/Dental Status) documented obvious or likely cavity or broken natural teeth. A review of the last dental exam documents dated 2/21/2024 revealed that R13 needed full mouth extractions under sedation due to R13 experiencing pain. He was ordered an antibiotic for an infection (clindamycin 150 milligrams (mg) every six hours until gone). The documentation further noted that there was a referral to an oral surgeon due to sedation and that the referral was sent to the facility. An observation of R13 on 10/26/2024 at 11:20 am revealed missing/broken/decayed teeth. In an interview, R13 stated that the dentist came three or four months ago and was going to do something for him, but they never came back. He stated he does have pain in his mouth and that he had told staff about his pain. 3. A review of the EMR revealed that R22 was admitted to the facility on [DATE]. A review of the EMR revealed R22's funding source was documented as Medicaid GA. A review of the Quarterly MDS assessment dated [DATE] revealed Section L (Oral/Dental Status) documented R22 had obvious or living cavities or broken natural teeth. A review of R22's EMR revealed that there was no dental assessment in the clinical record. An observation of R22 on 10/26/2024 at 1:19 pm revealed he had decayed/broken missing teeth. During an interview on 10/27/2024 at 12:12 pm, the Interim Director of Nursing (DON) stated that the Dental Provider last provided services in July 2024. She stated dental services were scheduled quarterly, by referral from staff, and on admission if they needed an assessment. She further stated R13 had stated that he had pain, but the location of the pain was not documented. She stated that the nurse should have documented the location of the pain. During an interview on 10/27/2024 at 12:26 pm, the Administrator confirmed that R13 went to the dental clinic twice due to pain and dental concerns. She stated, We have been working on his teeth for a while. Yes, he has mouth pain. She further stated the facility had changed dental providers in July 2024 and that she and the DON had been working to get residents on the list for the dental provider since then. During an interview on 10/28/2024 at 1:00 pm, the Administrator confirmed that R3 and R22 did not have any initial or routine dental assessment from a dental provider since admission to the facility. During an interview on 10/28/2024 at 1:00 pm, the Administrator confirmed that R13 had not received dental care from a dental provider since 2/21/2024 and that there was a referral to an oral surgeon due to sedation needs.

Based on observations, resident and staff interviews, record review, and review of the facility policy titled Activities of Daily Living (ADLs), the facility failed to provide ADL care to three of 38 sampled residents (R) (R3, R10, and R22) related to facial shaving and nail trimming/cleaning. This failure had the potential to cause R3, R10, and R22 to have unmet needs and to feel self-conscious of their appearance. Findings included: A review of the facility policy titled Activities of Daily Living (ADLs), dated 2/12/2022, revealed the Policy was, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming, and oral care. The Policy Explanation and Compliance Guidelines section included . 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 1. A review of R3's electronic medical record (EMR) revealed diagnoses of, but not limited to, dementia with behavioral disturbance, restlessness and agitation, delusional disorders, and hallucinations. A review of R3's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of three (indicating severe cognitive impairment), Section E (Behavior) documented that rejection of care behaviors was not exhibited, and Section GG (Functional Abilities and Goals) documented R3 required partial/moderate assistance with personal hygiene. Observations of R3 on 10/26/2024 at 1:19 pm, 10/27/2024 at 8:36 am, 10/27/2024 at 12:00 pm, and 10/27/2024 at 4:51 pm revealed his face was not shaved. During an interview on 10/28/2024 at 9:47 am, Certified Nursing Assistant (CNA) GG stated that she assisted R3 with a shower on 10/26/2024. She stated that she did not ask the resident if he wanted to be shaved because the men usually refused. She stated that they do not do shower sheets or document anywhere if the residents had their faces shaved. 2. A review of R10's EMR revealed diagnoses of, but not limited to, cerebral infarction (CVA), muscle weakness (generalized), unsteadiness on feet, and hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. A review of R10's Quarterly MDS assessment dated [DATE] revealed Section C (Cognitive Patterns) documented a BIMS score of 12 (indicating moderate cognitive impairment), Section E (Behavior) documented that rejection of care behaviors was not exhibited, and Section GG (Functional Abilities and Goals) documented R10 required partial/moderate assistance with personal hygiene. An observation on 10/26/2024 at 9:44 am revealed R10 had a full beard, and his nails were long and sharp and needed to be trimmed. When asked about cutting his nails, R10 stated, No one does that. He stated no one had asked him if he wanted his nails cut. An observation on 10/27/2024 at 12:00 pm revealed R10's face was not shaved, and his nails had not been trimmed. An observation on 10/27/2024 at 2:09 pm revealed R10's face had been shaven, and he had a goatee, but his nails were still long and not trimmed. During an interview on 10/27/2024 at 12:07 pm, CNA JJ stated that she does assist the residents with shaving and nail care on their shower days. 3. A review of R22's EMR revealed diagnoses included, but not limited to, schizophrenia, bipolar disorder, and muscle weakness. A review of R22's Quarterly MDS assessment dated [DATE] revealed Section C (Cognitive Patterns) documented a BIMS score of 10 (indicating moderate cognitive impairment), Section E (Behavior) documented that rejection of care behaviors was not exhibited, and Section GG (Functional Abilities and Goals) documented R10 required supervision with personal hygiene. An observation on 10/26/2024 at 1:19 pm revealed R22's face was unshaven and his nails were long and jagged with a dark substance under them. An observation on 10/27/2024 at 2:15 pm revealed R22's face was unshaven and his nails were long and with a dark substance under them. In an interview with R22, he stated, All I need is a good shave. During an interview on 10/27/2024 at 2:15 pm, the Wound Care Nurse stated that she helped with shaving, haircuts, and trimming nails, but the residents refused care at times. She confirmed there was no documentation of ADL care being offered or refusals of ADL care. During an interview on 10/27/2024 at 12:02 pm, CNA JJ stated that she showered R22 recently but didn't clip or clean his nails and did not shave him. She stated she did not have a reason why those tasks were not completed.

Based on observations, staff interviews, and review of the facility policy titled Promoting/Maintaining Resident Dignity During Mealtimes, the facility failed to promote dignity during dining for four of 36 sampled residents (R) (R16, R45, R42, and R250) related to staff referring to residents as feeders and not serving resident meals at the same time for residents who were dining together. These failures had the potential to diminish the resident's quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life. Findings included: A review of the facility's undated policy titled Promoting/Maintaining Resident Dignity During Mealtimes, revealed the Policy of It is the practice of the facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality of life, recognizing each resident's individuality and protecting the rights of each resident. The Policy Explanation and Compliance Guidelines section included 1. All staff members involved in providing feeding assistance to residents promote and maintain resident dignity during mealtimes. During a breakfast dining observation on 10/28/2024 at 8:00 am, the staff was observed passing out meal trays in the main dining room to approximately 32 residents. Certified Nursing Assistant (CNA) EE came into the dining room and was told by CNA GG that all the trays had not arrived. CNA EE confirmed that 11 residents did not have meal trays, including the dependent residents. CNA GG stated loudly, The feeder's trays ain't [sic] here? She was observed to reference the dependent residents as feeders multiple times during the meal observation in the direct area of the dependent residents (R16, R45, and R42). During a breakfast dining observation on 10/28/2024 at 8:00 am, four residents (R250, R8, R41, and R17) were observed sitting at the table together awaiting their meals. Three of the four residents (R8, R41, and R17) were served at 8:00 am. R250 was not served a tray and was observed watching the other three residents eat. During an interview with R250 at 8:10 am, he was asked if he was ready for breakfast, and he stated he wanted coffee and breakfast. During this observation, R17 finished breakfast and left the dining room at 8:15 am, and R8 finished his meal at 8:19 am and left the table. R41 stayed at the table with R250. She motioned for the Director of Nursing (DON) to come to the table at 8:26 am and stated that R250 had not received a breakfast tray. The DON asked Licensed Practical Nurse (LPN) HH if there was a tray for R250. LPN HH stated, What? He didn't eat? The DON said to R250, We got you a tray coming. Thank you (R41) for letting me know. R250's received a meal tray at 8:28 am. During an interview with LPN HH on 10/28/2024 at 8:31 am, she stated R250 was new to her, and she did not know he had not eaten until the DON informed her. She stated she would fill out a diet slip just in case they didn't have one. During an interview on 10/28/2024 at 10:49 am, CNA EE stated that she had received in-services related to dining, and stated All residents at the same table should be served at the same time. She explained that the situation with R250 not getting a tray was because he was new and must have come in over the weekend, so LPN HH had to go to the kitchen to get his tray. She was asked about the dependent residents and stated, Feeders come in last. We like to get the feeders out of bed. The feeders sit at the round table. She was asked if any of the dependent residents were alert, and she confirmed that R45 and R42 were alert. She was asked if she had received education related to labeling residents as feeders being a dignity concern, and she stated that she had always called them feeders. During an interview on 10/28/2024 at 11:00 am, LPN HH stated that she had not noticed if the staff referred to dependent residents as feeders, but if they had, that would be a dignity concern, especially if they were doing so in front of the residents. She stated if she was made aware of this or observed this behavior, she would pull the staff to the side and correct them. She confirmed that R45 and R42 were alert, dependent on staff for dining assistance, and sat in the dining room at the round table with R16.

Based on staff interviews, record review, and a review of the facility policy titled Residents' Rights and Treatment Regarding Advance Directives, the facility failed to ensure there were no discrepancies related to Advanced Directives for one of 38 sampled residents (R) (R3). The deficient practice had the potential to result in R3's Advance Directives not being followed. Findings included: A review of the facility policy titled Residents' Rights and Treatment Regarding Advance Directives, dated [DATE], revealed that it is the policy of this facility to support and facilitate a resident's right to request, refuse, and/or discontinue medical or surgical treatment and to formulate an advance directive. Decisions regarding advanced directives and treatment will be periodically reviewed as part of the comprehensive care planning process, the existing care instructions, and whether the resident wishes to change these instructions. Any decision-making regarding the resident's choice will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care. A review of the Electronic Medical Record (EMR) for R3 revealed an admitted [DATE]. A review of the care plan, last updated on [DATE], revealed that R3 had an advanced directive for Do Not Resuscitate (DNR) and that the resident DNR wishes wound be followed by staff through the next review. In the event that R3's heart stops beating, the facility staff were instructed not to perform Cardiopulmonary Resuscitation (CPR). It was noted that the facility would maintain the DNR form under Advance Directives in the resident's medical record. A review of the EMR revealed that R3 was documented as being a Full Code. However, a review of the physical medical chart revealed that R3 had a Physician Orders for Life-Sustaining Treatment (POLST) Georgia form dated [DATE] noting an order for DNR and a POLST Georgia form dated [DATE] noting an order for full code. During an interview on [DATE] at 9:40 am, Registered Nurse (RN) KK confirmed that the facility used a hybrid system of the EMR and the physical medical record. RN KK stated that she would use the EMR to identify the code status of a resident who was found unresponsive. She confirmed that the EMR noted that R3 was full code and that she would provide resuscitation efforts if R3 was found unresponsive. She was asked about the POLST Georgia form dated [DATE] noting an order for DNR in the physical record and she acknowledged that this was a discrepancy and needed to be reviewed. During an interview on [DATE] at 9:48 am, the Minimum Data Set (MDS) Coordinator stated that the POLST Georgia form dated [DATE], noting that R3 had an active order for full code, should have been removed due to the date. She stated that the nurse should have put the order in the EMR when the new POLST Form was signed by the physician. During an interview on [DATE] at 10:09 am, the Director of Nursing (DON) stated that the nurses are supposed to look at the EMR to determine resident code status. She was asked to verify R3's status. She stated that he was full code and that they would start CPR if he was found unresponsive. During an interview on [DATE] at 10:12 am, the Administrator stated there was a discrepancy in the EMR and the physical medical record for R3. She confirmed that she was the acting Social Worker and that it was between her and the DON to ensure that the EMR was updated. She confirmed that R3's current code status was DNR.

Based on observations and staff interviews, the facility failed to ensure that the Nursing Call System was functioning and operational for four of 26 resident rooms/bathrooms (Rooms 16, 17, 18, and 7). This failure placed the residents residing in the rooms at risk of accident, injury, or unmet needs related to an inability to call for staff assistance. Findings included: During an observation on 10/26/2024 at 9:44 am, the call light cord in room [ROOM NUMBER] was observed on the floor and not plugged into the Nursing Call Light Panel on the wall behind the resident bed. Certified Nursing Assistant (CNA) GG entered the room and verified the cord was on the floor and unplugged from the wall. When she tried to plug it back up, it was observed that the Nursing Call Light Panel only had one hole to accommodate one cord. There were two residents assigned to room [ROOM NUMBER]. CNA GG stated she would notify the nurse and the maintenance department. During an observation on 10/26/2024 at 9:48 am of the shared bathroom for room [ROOM NUMBER] and room [ROOM NUMBER], observation revealed no Nursing Call Light Panel was accessible in the bathroom. There was a gray panel with no accommodation for a call light cord. CNA GG confirmed this observation. During an observation on 10/26/2024 at 10:36 am in room [ROOM NUMBER], the call light cord was not functioning for the resident in Bed B. During observations and interview on 10/26/2024 at 10:53 am, the Interim Director of Nursing (DON) confirmed the Nursing Call Light Panel in room [ROOM NUMBER] only had one hole to accommodate one resident call light, even though two residents were assigned to that room. She further confirmed the resident's call light cord was not functioning to activate the Nursing Call System for the resident in room [ROOM NUMBER] Bed B. During an observation on 10/26/2024 at 10:57 am in room [ROOM NUMBER], the call light was pressed multiple times but wouldn't come on when the resident pressed the button to alert staff that they needed assistance. Registered Nurse (RN) KK was called into the room and confirmed that the Nursing Call System was not functioning. She stated that a new call light cord may be needed. During a second observation on 10/28/2024 at 11:47 am in room [ROOM NUMBER], the Nursing Call System had not been repaired and was not functional to accommodate both residents in the room. At this time, the Administrator and Regional Director of Environmental Services (RDES) stated staff had not informed the Administrator that the call lights were not functional in Rooms 16, 17,18, and 7 and in the shared bathroom of rooms [ROOM NUMBERS]. The RDES stated that he visited the facility twice a month and did rounds but was not aware of the Nursing Call System not functioning for all residents.

Based on observations, staff interviews, record review, facility document review, and review of the facility policies titled Fall Risk Assessment and Elopements and Wandering Residents, the facility failed to ensure a complete post-fall assessment was performed for one of 13 residents (R) (R23) who sustained a fall. The facility also failed to complete an elopement assessment for one of 38 sampled R (R6). This deficient practice created a potential risk to the safety and well-being of R23 and R6. Findings include: 1. Review of the facility policy titled Fall Risk Assessment, dated 2023, revealed the Policy was It is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. Review of the blank facility-provided document titled Fall/Incident Documentation & Reporting indicated When a resident has a fall/incident do the following: 1. Complete the fall/incident packet. 2. Then go to the electronic medical record (EMR). 3. Trigger UDA (User Defined Assessment). Record review revealed R23's diagnoses included, but not limited to, generalized muscle weakness, difficulty walking, insomnia, and unspecified dementia. Review of R23's EMR Progress Notes revealed a fall documented on 10/11/2024. The note documented that R23 was transferred to the hospital after the fall and returned with a cast to the left lower arm due to a fractured wrist. Observation on 10/26/2024 at 9:00 am revealed R23 with a cast on her left arm. During an interview and review of the EMR on 10/27/2024 at 2:25 pm, the Interim Director of Nursing (DON) confirmed a post-fall assessment dated [DATE] was triggered but not fully completed and further confirmed the UDA section was not completed. The Interim DON reported that she was unsure why this portion of the assessment was not completed. In an interview on 10/27/2024 at 4:28 pm, Licensed Practical Nurse (LPN) VV reported if a resident had an unwitnessed fall, the resident should be assessed for injury and neurological status. She further reported that an incident report should be completed after every fall. LPN VV was unsure if the triggered UDA should be completed after every fall event. In an interview on 10/27/2024 at 4:54 pm, the Administrator reported after a fall, an incident report and assessment of the resident should be completed, and all components of the incident report/assessment should be completed including the UDA. She stated she was unsure why the UDA was not triggered and completed for R23's fall on 10/11/2024. 44960 2. A review of the facility's undated policy titled Elopements and Wandering Residents revealed the Policy Statement was This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. A review of R6's clinical record revealed diagnoses including, but not limited to, dementia with behaviors, paranoia with schizophrenia, cognitive communication deficit, intellectual disability, and extrapyramidal movement disorders. A review of R6's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 8 (indicating moderate cognitive impairment), Section E (Behaviors) documented no behaviors exhibited, Section GG (Functional Abilities and Goals) documented R6 was independent with mobility, and Section P (Restraints) documented a wander/elopement alarm was not used. A review of the clinical record revealed no assessment for elopement was completed before R6 eloped from the facility on 9/11/2024. During an interview on 10/26/24 at 11:32 am, R6 stated he recalled leaving the facility a few weeks ago. R6 stated he left the facility because he was tired of living there. During an interview on 10/27/2024 at 10:05 am, the Administrator revealed she recalled getting a telephone call that R6 was found outside the facility ambulating about a block from the facility. She further stated she directed Staff Member MM to escort the resident back to the facility. She stated R6 was escorted back to the facility, was assessed, and responsible parties were notified.

Based on observation, staff interviews, and review of the facility policy titled, Food Receiving and Storage, the facility failed to ensure that items were labeled/dated and used before the expiration date in the main kitchen. The facility also, failed to ensure that items in the dry storage area in the main kitchen were dated when received and were labeled and dated with a use by date. The deficient practice had the potential to affect 40 of 40 residents receiving an oral diet. Findings include: Review of the Policy titled, Food Receiving and Storage, with a revised date [DATE] revealed under policy statement : Foods shall be received and stored in a manner that complies with safe food handling practices. Under, Dry food and Storage: number 2. Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use. Further review of the Policy indicated under,Refrigerated /Frozen Storage number 1. foods are covered, labeled and dated (use by date). number 7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded. During the initial tour of the kitchen on [DATE] at 11:40 a.m. with the Dietary manager (DM) revealed the following: 1. The reach in refrigerator on the right side of the kitchen at the entrance had four one-quart Grade-A Ultra-Pasteurized 40% Milkfat Heavy Cream cartons with an expiration date of [DATE]. 2. Two 15 oz. cans ultra pasteurized-sweetened whipped non-dairy topping with a best by date of [DATE]. 3. The second reach in refrigerator towards the rear of the kitchen had a 5 five-pound (2.26 kg) bucket of Chicken salad with a handwritten date it was opened on [DATE], and a use by date of [DATE]. (Review of the weekly menu reported chicken salad sandwiches were served frequently) 4. Inside the white reach in freezer there was one large pan covered with foil with no label or use-by date on it. 5. The white freezer also had two bags of previously cooked stuffed baked potatoes without a label or use by date written on the bags. 6. The walk-in freezer had a very large piece of ice frozen on top of food boxes that contained food that was not identifiable. During a tour of the dry storage area 0n [DATE] at 12:00 p.m. the following was revealed: 1. There were two large bags of opened spaghetti noodles wrapped in plastic wrap and there was no label or use-by date. 2. There were eight one1-liter bottles of Pedialyte Electrolyte Solution with no date and a black substance was on the top of the bottles, and as well as, on the bottles. Interview on [DATE] from 11:40 a.m. until 12:24 p.m. with the DM revealed that when the freezer defrosts, the water drips onto the food boxes causing it to freeze on top of the food boxes making it difficult to tell what is in the boxes and to separate the boxes. The DM confirmed the expired dairy products in the refrigerator, and that the chicken salad was past the use-by date. The DM reported the large pan in the white freezer was a pan of cornbread dressing that was placed in there a month ago, and it was not labeled or dated along with the stuffed seafood baked potatoes; she reported that the spaghetti noodles were recently opened but were not labeled and dated. The DM reported the Pedialyte was purchased when the COVID stay-in-place was first initiated, and they kept the Pedialyte in case a resident needed extra electrolytes.

Based on observation, record review, review of the facility policy titled Restorative Nursing Services, and staff interviews, the facility failed to provide restorative nursing services for one of two residents with contractures (R) (#12). Actual harm occurred when the contracture to R#12's left hand worsened and became painful to touch and/or movement after the resident was discharged from therapy and the facility failed to provide restorative services for the resident. Findings include: Review of the clinical record revealed R#12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Significant Change Minimum Data Set (MDS) dated [DATE] revealed R#12 had a Brief Interview of Mental Status (BIMS) score of one indicating severe cognitive impairment. The resident required two person extensive to total assistance of staff for activities of daily living (ADLs) and had limitations in range of motion (ROM) of upper and lower extremities. Review of the Physical Therapy (PT) Discharge Summary dated 12/14/2021 revealed that the resident had received PT services from 10/25/2021 to 12/14/2021 for therapeutic exercises, strengthening and training. Continued review revealed that the resident was discharged on [DATE] to the Restorative Nursing Program for Active Range of Motion (AROM) and Passive Range of Motion (PROM) to bilateral upper and lower extremities six days per week. Review of a Nursing Restorative Care Program referral from Therapy to Nursing dated 12/15/2021 revealed: Goals: 1. Patient will maintain Bilateral U/LE (upper/lower extremity) ROM and strength. Approaches: 1. Perform Bilateral U/LE therapeutic exercises and slow stretching 6 days per week. A Physician's Interim/Telephone Order for the above restorative program was written on 12/17/2021. However, there was no indication in the medical record that R#12 received restorative services for ROM after discharge from PT on 12/14/2021. Observations on 1/18/2022 at 1:17 p.m., 1/19/2022 at 9:50 a.m., and 1/20/2022 at 11:42 a.m. revealed R#12 with both hands clenched closed. Resident was able to partially open right hand when instructed to do so. Indentations were observed in the palm of right hand. Resident's left hand remained closed with all four fingers pointed into the palm. The resident was unable to open left hand when asked. Interview with Therapy Manger (TM) BB on 1/19/2022 at 10:51 am. revealed that she worked with R#12 for contractures of hands and legs. PT was addressing the contractures and discharged the resident to restorative services. She stated that she did not write a restorative plan to place anything in the resident hands because at the time of discharge, the resident was able to open both hands and did not require anything in her hands. She stated during further interview that the therapy department had not received further notification or communication from the nursing department since the resident was discharged from services on 12/14/2021. Interview with the Director of Nursing (DON) on 1/19/2022 at 11:08 a.m. revealed the facility currently does not have a restorative nurse and she is currently overseeing the restorative program. DON stated she has not had the opportunity to look over the restorative plan of care for residents on the restorative program to determine if the current restorative plans needed to be revised or if any residents on the restorative program needed to be referred to therapy. DON confirmed that the facility currently has only one restorative aide. The restorative aide is currently on vacation, and no one does the restorative plan of care when she's not working. DON further stated she does not know where the restorative book containing the restorative care plans is located. Interview with Certified Nursing Assistant (CNA) CC on 1/19/2022 at 11:56 a.m. revealed that R#12's left hand has gotten worse. She yells in pain when her left hand is touched. CNA CC stated she has reported this issue to the nurses. Interview and observation on 1/19/2022 at 12:39 p.m. with Licensed Practical Nurse (LPN) DD (treatment nurse) revealed fingers on R#12's left hand were difficult to open. Resident complained of pain when LPN DD attempted to move fingers on the left hand. LPN DD was able to open the first finger on he left hand. There was an indentation in the palm of the resident's hand from the resident's first finger. LPN DD stated there are no treatment orders, but she looks at and washes R#12's hands with soap and water every two days and applies a gauze in her hand. She stated that R#12 does complain of pain when she washes her hand. She stated that R#12 holds her hands closed very tightly. LPN DD stated that R#12 has had hand contractures for the past year. Interview and observation on 1/19/2022 at 2:25 p.m., TM BB came into R#12's room to observe the resident's left hand contracture. She stated R#12's left hand was not contracted closed as it is now when she was discharged from therapy on 12/14/21. She further stated R#12 was able to open both hands at that time. TM BB replied, this (contracture of the left hand) is worse. TM BB was able to open the first finger on the resident's left hand to verify the indentations on the left palm from first finger and the indentations on the right hand. R#12 complained of pain when fingers on left hand were moved. TM BB further stated that R#12 needs to be evaluated by Occupational Therapy for hand contractures. Interview and observation with Registered Nurse (RN)/Unit Manager (UM) AA on 1/20/2022 at 8:50 a.m. revealed she was not aware that R#12 could not open her left hand. She confirmed that R#12's left hand was contracted closed, and she (R#12) complained of pain when fingers on left hand were moved. Phone interview with Restorative Aide (RA) GG on 1/20/2022 at 3:03 p.m. revealed that she usually works five to six days per week, and she is not sure who does restorative when she's not at work. She stated she had given the restorative book with the restorative plan of care sheets to the DON in December 2021. RA GG stated that she did not receive notification of R#12 needing restorative services until sometime in January 2022. She stated that TM BB gave her the notification at that time. She confirmed that restorative care was not being documented. Review of facility policy titled Restorative Nursing Services revised February 2021 revealed: 3. Restorative goals and objectives are individualized and resident-centered and are outlined in the resident's plan of care. 8. The nurse will record in the resident's medical record information relative to changes in resident's medical/mental condition or status.

Based on observation, record review, review of facility policy titled Change in a Resident's Condition or Status, and staff interviews, the facility failed to notify the physician of pain and worsening contracture to the left hand for one resident (R) (#12) of two residents with contractures. Actual harm occurred when the contracture to R#12's left hand worsened and became painful to touch and/or movement after the resident was discharged from therapy and the facility failed to provide restorative services for the resident. Findings include: Review of facility's policy titled Change in a Resident's Condition or Status revised February 2021 revealed: 1. The Nurse will notify the resident's attending physician or on-call physician when there has been: d. A significant change in the resident's physical/emotional/mental condition. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Review of the Significant Change Minimum Data Set (MDS) dated [DATE] revealed R#12 was admitted to the facility on [DATE] and had a Brief Interview of Mental Status (BIMS) score of one indicating severe cognitive impairment. The resident required two person extensive to total assistance of staff for activities of daily living (ADLs) and had limitations in range of motion (ROM) of upper and lower extremities. Review of the Physical Therapy (PT) Discharge Summary dated 12/14/2021 revealed that the resident had received PT services from 10/25/2021 to 12/14/2021 for therapeutic exercises, strengthening and training. Continued review revealed that the resident was discharged on [DATE] to the Restorative Nursing Program for Active Range of Motion (AROM) and Passive Range of Motion (PROM) to bilateral upper and lower extremities six days per week. The Physician's was notified on 12/17/2021 and gave a telephone order for the restorative program. However, there was no indication in the medical record that R#12 received restorative services for ROM after discharge from PT on 12/14/2021. Observations on 1/18/2022 at 1:17 p.m., 1/19/2022 at 9:50 a.m., and 1/20/2022 at 11:42 a.m. revealed R#12 with both hands clenched closed. Resident was able to partially open right hand when instructed to do so. Indentations were observed in the palm of right hand. Resident's left hand remained closed with all four fingers pointed into the palm. The resident was unable to open left hand when asked. Interview with Therapy Manger (TM) BB on 1/19/2022 at 10:51 am. revealed that she worked with R#12 for contractures of hands and legs. The resident was able to open both hands when discharged from therapy. Interview with Certified Nursing Assistant (CNA) CC on 1/19/2022 at 11:56 a.m. revealed that R#12's left hand has gotten worse. She yells in pain when her left hand is touched. CNA CC stated she has reported this issue to the nurses and the nurses medicate her for pain but sometimes she refuses medications. Interview and observation on 1/19/2022 at 12:39 p.m. with Licensed Practical Nurse (LPN) DD (treatment nurse) revealed fingers on R#12's left hand were difficult to open. Resident complained of pain when LPN DD attempted to move fingers on the left hand. LPN DD stated there are no treatment orders, but she looks at and washes R#12's hands with soap and water every two days and applies a gauze in her hands. She stated that R#12 does complain of pain when she washes her hands. LPN DD stated that she has not called the physician regarding the pain or worsening left hand contracture. During an interview on 1/20/2022 at 9:50 a.m., the Registered Nurse (RN)/Unit Manager (UM) AA stated that the facility's protocol is that when a resident has a new onset or worsening pain, or change in condition, the expectation is that the nurse communicates this to the physician. RN/Unit Manager AA further stated that she was not aware that R#12 was complaining of pain to the left hand. Interview on 1/20/2022 at 9:42 a.m. with the Director of Nursing (DON) revealed that her expectation for the staff is that they communicate all change in conditions of residents to the DON and Administrator. The DON stated that she has not been made aware of any changes in condition for R#12. DON further stated that the treatment nurse is responsible for documenting any care that she renders to a resident. The treatment nurse should have notified the physician of any abnormal findings.

Based on observations, record review, staff interviews, and review of the facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program the facility failed to protect two of four residents (R#140 and R#14) from physical abuse. Actual Harm occurred on 12/14/2021, when R#6 physically abused R#140 causing bruising to R#140's jaw and two lacerations to the residents ear. Findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program revised April 2021 revealed Policy Statement: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Policy Interpretation and Implementation: The residents abuse, neglect, exploitation, and misappropriation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect resident from abuse, neglect, exploitation, and misappropriation of property by anyone but not necessarily limited to: b. other residents . 1. Record review revealed R#6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed R#6 had a Brief Interview of Mental Status (BIMS) of 6 indicating severe cognitive impairment. The resident exhibited no behaviors during the assessment period. Record review revealed R#140 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Quarterly MDS dated [DATE] Section C (Cognitive Pattern) documented R#140 was never/rarely understood, indicating resident had significant cognitive impairment. Section E (Behavior) documented the following: A. Physical behavioral symptoms directed toward others = 1 (Behavior of this type occurred 1 to 3 days) B. Verbal behavioral symptoms directed towards others = 1 (Behavior of this type occurred 1 to 3 days) during the assessment period. Review of the care plan for R#140 dated 11/16/2021 revealed Focus: Resident is exhibiting behaviors related to dx (diagnosis) of dementia with behaviors. He is resisting care, verbally abusive to other residents, verbally abusive to staff, wandering. Goal: Resident will have no complications related to behaviors through the next review. Interventions: Administer medications as ordered, encourage resident to not resist care, if refuses care, leave and come back and try again after a few minutes. Monitor behaviors, and document on the MAR (medication administration record), psych services as needed, Re-direct when wandering into other resident's rooms, remove resident from conflict, redirect, and reassure resident as needed. Review of facility Heath Status Note dated 12/14/2021 at 7:35 a.m. revealed writer heard the CNA (certified nursing assistant) yelling stop, stop. Writer noted R#140 on floor outside of room [ROOM NUMBER] with the resident in room [ROOM NUMBER]-1 (R#6) standing up out of his wheelchair bent over R#140 holding him by the legs. Resident noted with blood on right ear with two small lacerations noted on earlobe and bruising noted to right side of face. Resident right ear cleaned with soap and water and dressing applied that the resident took off. Residents separated with R#140 monitored at nursing station. Review of Facility Incident Report form dated 12/17/2021 documented the type of incident which was resident to resident abuse. Details of incident were as follows; R#6 physically abused R#140 for entering his personal space. Interview on 1/20/2022 at 3:04 p.m. with Administrator in reference to altercation between R#6 and R#140 revealed the incident did occur, the residents were separated and R#140 was monitored at the nurse's station. Further interview also revealed R#140 did sustain injuries that were treated in house and behavioral health services, physician, and family members were notified of the incident for both residents. 2. Record review of the facility's Face Sheet revealed that R#11 was admitted to the facility 3/6/2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS for R#11 dated 11/2/2021 revealed a BIMS score was 10 indicating moderate cognitive impairment. The resident required supervision and/or oversight from staff for walking in room or corridor but did not require staff assistance. Review of the resident's behaviors revealed the resident had other behavioral symptoms not directed toward others one to three days during the assessment period. Review of the Quarterly MDS for R#14 dated 11/17/2021 revealed that the residents BIMs score was six indicating severe cognitive impairment. The resident required supervision and/or oversight from staff for walking in room or corridor but did not require staff assistance. Review of the resident's behaviors revealed the resident did not have any behaviors during the assessment period. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Health Status Note dated 10/4/2021 documented that the CNA (Certified Nursing Assistant), who was present and witnessed the incident, told the nurse that R#11 walked up to R#14 who was sitting in a chair on the smoke porch and told him to move. When R#14 didn't move, R#11 raised her hand to hit the resident on the head and scratched him in the face. Review of the Facility Incident Report Form dated 10/3/2021 documented the type of incident was resident-to-resident abuse. Details of the incident included R#11 physically hit R#14 when he sat in her chair on the patio. Injury was documented to have occurred and included scratches to the right side of R#14's cheek. Documentation included the residents were separated, assessed for injuries, first aid was rendered to injuries, and the physician and family were notified. Nursing Description documented R#14 noted with blood dripping on the right side of face. Attempted interview on 1/21/2022 at 2:00 p.m. with R#11 revealed that the resident was unresponsive to questions. Interview on 1/20/2022 at 3:17 p.m. with Registered Nurse (RN) AA revealed that R#11 and R#14 did have an altercation when they were in the smoking area. RN AA stated that the residents were separated; the physician, responsible party, and Administrator were notified. RN AA stated that when a resident hits another resident that it is abuse.

Based on record review, review of the facility policy titled Comprehensive Person-Centered Care Plans, and staff interview, the facility failed to develop and implement a comprehensive person-centered care plan that included interventions to address hand contractures for one resident (R) (#12) of two residents with contractures. Actual harm occurred when the contracture to R#12's left hand worsened and became painful to touch and/or movement after the resident was discharged from therapy and the facility failed to provide restorative services for the resident. Findings include: A review of the facility policy titled, Comprehensive Person-Centered Policy dated December 2016 revealed that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the physical, psychosocial, and functional needs is developed and implemented for each resident. Review of the clinical record revealed R#12 was admitted to the facility on [DATE]. On 10/25/2021, the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Significant Change Minimum Data Set (MDS) dated [DATE] revealed R#12 had a Brief Interview of Mental Status (BIMS) score of one indicating severe cognitive impairment. The resident required two person extensive to total assistance of staff for activities of daily living (ADLs) and had limitations in range of motion (ROM) of upper and lower extremities. Review of the Physical Therapy (PT) Discharge Summary dated 12/14/2021 revealed that the resident had received PT services from 10/25/2021 to 12/14/2021 for therapeutic exercises, strengthening and training. Interview with Therapy Manger (TM) BB on 1/19/2022 at 10:51 am. revealed that she worked with R#12 for contractures of hands and legs. PT was addressing contractures and discharged the resident to restorative services. A review of R#12's comprehensive care plan dated 11/8/2021 revealed no documentation of interventions regarding the care necessary to maintain current level of function or to address specific care for the resident's hand contractures. Interview on 1/19/2022 at 10:35 a.m. with MDS Coordinator KK revealed she is responsible for completing residents' comprehensive care plans on admission. She verified she had revised the comprehensive care plan for R#12 on 11/8/2021. At this time MDS Coordinator KK reviewed R#12's comprehensive care plan and confirmed that there was not a resident centered care plan specifically regarding hand contractures or any interventions in place to prevent further decline in range of motion. During an interview on 1/19/2022 at 11:44 a.m., the Administrator was made aware that there was not a care plan for R#12's hand contracture. The Administrator verified that this was something that should have been care planned. Cross refer to F688.