Every finding on record at Waycross Health and Rehabilitation

Based on observation, staff interviews, and review of the facility's policy titled Wound Care, the facility failed to ensure staff followed infection control processes during wound care for one of 10 residents (R) (R38) reviewed for wound care. This deficient practice had the potential to place R38 at risk of infection due to cross-contamination. Findings include: Review of the facility's policy titled Wound Care, reviewed 12/27/2024 revealed the Intent section stated, It is the intent of this center to provide guidelines for clean technique in providing wound care. The Guideline section included, . Perform hand hygiene. Put on appropriate Personal Protective Equipment (PPE) and first pair of clean gloves. Remove the soiled dressing and place into a bag at the bedside . Remove gloves and perform hand hygiene. Put on second clean gloves. Cleanse the wound using Normal Saline . Remove gloves, perform hand hygiene and apply third pair of gloves. Apply peri-wound protectant and apply clean dressing as ordered. Remove gloves and perform hand hygiene and repeat the process if performing another dressing change. Review of R38's electronic medical record (EMR) revealed diagnoses including, but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of R38's Physician Orders revealed an orders including, but not limited to, 12/23/2024: Cleanse left upper arm abscess area with N/S (normal saline), pat dry, apply skin barrier wipe to surrounding peri wound, apply honey alginate and cover with composite dressing every Monday, Wednesday, and Friday, Dx (diagnosis): cutaneous abscess of left upper limb. 3/8/2025: Cleanse skin graft to left thigh with NS, pat dry, apply skin barrier wipe to peri-wound, apply petroleum gauze and cover with composite dressing every Monday, Wednesday, and Friday-Dx: skin donor, autologous, 12/23/2024: Cleanse wound on right side of neck with NS, pat dry, apply skin barrier wipe to surrounding peri-wound, apply wet-to-dry gauze and cover with composite dressing daily, Dx: pressure ulcer stage 2. Review of R38's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Section M (Skin Conditions) documented one stage 2 pressure ulcer, open lesion(s), pressure ulcer care, application of nonsurgical dressings, and application of ointments/medications. Review of R38's care plan, with an onset date of 12/24/2022, revealed a Care Area/Problem of Skin breakdown: at risk for/actual breakdown. Interventions included Treatments/dressings as ordered per physician, applications of ointments/medication to skin, observe for and report signs/symptoms of infection, and enhanced barrier precautions. Observation of wound care for R38 on 3/19/2025 starting at 11:15 am and concluding at 11:40 am revealed the Wound Care Nurse (WCN)/Registered Nurse (RN) gathered and set up supplies, donned PPE and entered R38's room. The wound nurse performed wound care and dressing change(s) as follows: 1. Left arm abscess: The WCN/RN placed a clear plastic trash bag at the foot of R38's bed, removed dressing from R38's left upper arm/below the shoulder and discarded in the plastic trash bag. Wound nurse changed gloves but did not wash or sanitize hands, cleaned site with normal saline, changed gloves but did not wash or sanitize hands, applied skin prep to surrounding skin, covered wound bed with a small medi-honey dressing, and covered/secured with a bordered composite dressing. 2. Left thigh skin graft: The WCN/RN pulled back the bedding and exposed R38's left leg with a dressing on the upper thigh, asked R38 if he was alright and positioned his leg for comfort. She then removed the dressing, changed gloves but did not wash or sanitize hands, applied skin prep to surrounding skin, covered wound bed with petroleum gauze, covered/secured with bordered composite dressing. 3. Right outer neck: The WCN/RN removed R38's oxygen nasal cannula from his nose, removed the right side neck dressing, changed gloves but did not wash or sanitize hands, cleaned site with normal saline, changed gloves but did not wash or sanitize hands, applied skin prep to surrounding skin, changed gloves but did not wash or sanitize hands, applied wet to dry gauze to wound bed, covered with 4x4 gauze folded in half, secured with bordered composite dressing, and reapplied R38's oxygen. In an interview on 3/19/2025 at 11:42 am, outside of R38's room, the WCN/RN acknowledged she did not sanitize her hands when changing gloves during the wound care. She stated she thought it was acceptable to only change the gloves. In an interview on 3/19/2025 at 12:53 pm, the Director of Nursing (DON) confirmed the WCN/RN should sanitize her hands during wound care when changing gloves, after removing the dirty/soiled dressing and after cleaning the wound. The DON revealed her expectation was for all nurses to sanitize their hands when they change gloves during wound care, or during any care when going from dirty or soiled to clean.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled Pharmacy Services: Bedside Storage of Medication, the facility failed to assess one of 29 sampled residents (R) (R48) for the ability to self-administer medications prior to leaving medications at the bedside. This deficient practice had the potential to place R48 at risk of unsafe medication use. Findings include: Review of the facility's undated policy titled Pharmacy Services: Bedside Storage of Medication revealed the Guideline section included, The Pharmacy supports bedside medication storage for patients who are able to self-administer medications upon the written order of the prescriber and when it is deemed appropriate in the judgment of the nursing center's interdisciplinary patient assessment team. Review of R48's clinical record revealed diagnoses including, but not limited to, dementia, chronic kidney disease, anxiety, and hypertension. Review of R48's Admission Minimum Data Set (MDS) dated [DATE] revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 3 (indicating severe cognitive impairment). Review of R48's care plan revealed no care plan for self-administration of medication. Review of R48's Physicians Orders revealed no order for medication self-administration. Review of the clinical record revealed there was no assessment for medication self-administration. During concurrent observation and interview on 3/18/2025 at 10:30 am, R48 stated he had pain medication in a bottle in his room. Observation revealed that the bottle contained white pills with red writing on them. In an interview on 3/18/2025 at 11:23 am, Certified Medication Aide (CMA) AA stated she was unaware that R48 had medication at his bedside. In an interview on 3/18/2025 at 11:29 am, the Director of Nurses (DON) stated that she was unaware that R48 had medications at the bedside. She further stated that residents should not have any medications at the bedside. In an observation on 3/18/2025 at 11:32 am, CMA AA and the DON verified that R48 had a bottle of pills on his over-bed table. The DON removed the pills from R48's room and discussed not having medications at the bedside with the resident.

Based on record review, interviews, and review of the facility policies, the facility failed to ensure soup was served at a safe temperature for one resident (R) (R#45) of 26 sampled residents. Actual harm occurred when R#45 sustained second degree burns to the left forearm and left side on 11/26/22. Findings include: Review of the facility policy titled Skilled Inpatient Services Personal Food Items, review date 12/4/21, revealed it is the intent of the center to provide education on safe and sanitary storage, handling, and consumption of food brought to patients by families and visitors. Guideline: The center should be responsible for assisting patients with reheating items as needed, assisting with feeding as needed. A calibrated thermometer is available for checking temperature, as needed. Calibrating a thermometer signage is available in the designated areas: Heating commercial items: 135 degrees F (Fahrenheit). Review of the facility's document titled Best Practice: Serving of Hot Beverages and Hot Food - Prevention of Burns dated 7/14/21 revealed: Recommended serving temperature for the prevention of burns from hot beverage items - 130 - 145 degrees F, or per patient preference. Serving tips: Staff should always alert patients when hot beverages or hot food is being served and always offer assistance. Staff should never leave hot items unattended unless the situation is deemed safe. Place hot beverages and hot foods away from the edge of the table and near the patient's dominant hand; ensure the food is in the patient's direct line of vision. When heating/re-heating food for immediate service, associates should utilize a calibrated thermometer to monitor temperatures. Temperatures should be recorded on the nurse pantry heating/re-heating log for documentation. When food is heated/re-heated for immediate service: If opening up a commercially packaged food item 135 degrees F must be reached for food safety, or per package directions. It is recommended to allow hot beverages to cool down for 5-10 minutes prior to serving. This will allow the beverage to reach the recommended range of 130-145 degrees F for service. In general, 2 minutes allows for a reduction of 5 degrees F. Review of the clinical record revealed R#45 was admitted to the facility on [DATE] with diagnoses that included unspecified intellectual disabilities and generalized muscle weakness. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed R#45 with a Brief Interview for Mental Status (BIMS) score of 15 which indicated resident is cognitively intact. R#45 required extensive assistance with two-person physical assistance with bed mobility and dressing, and one-person extensive assistance with personal hygiene. Supervision- oversight, encouragement or cueing with one-person physical assistance was required for eating. Review of a Progress Note for R#45 dated 11/26/22 revealed the following, Patient was eating soup in bed and spilled it on her left arm and side. Patient's elbow is scalded and open and draining. Patient also has a large, scalded area to her left side with two blisters that have formed. Patient does complain of area stinging but denies any real pain. A fax to (name) concerning the injury; new orders received for wound care nurse to assess for care per facility protocol, recommendation of pressure offloading as tolerated. Cleanse with wound cleanser, pat dry, prep blisters and intact burned skin with skin preps, apply Medihoney to the open area and apply non-adhesive bandage to the area and tape securely. Patient tolerated well. No signs/symptoms of distress on departure. Will continue to monitor. Review of Nurses Note dated 11/28/22 revealed spoke with R#45 and daughter at bedside related to burn incident. Resident Care Coordinator (RCC) also present. R#45 stated that she asked (CNA CC) to warm up her ramen noodles for her. The daughter showed a container like the one used, for reference. It was a commercially packed product made of paper. CNA CC returned with the product and opened it for R#45. Resident stated that she (resident) wrapped a paper napkin around it and when she picked it up, she spilled it on herself. Review of a Physician Progress Note dated 11/28/22 revealed R#45 was evaluated. Resident with second degree burns to the left forearm and left side. Second degree burns: positive for blisters to the left forearm and left side. Some blisters to the forearm have burst. Review of the Physician Orders for R#45 revealed an order with a start date of 11/28/22 that documented: 1. Xeroform Petrolatum Overwrap 1 x 8 Bandage. 1 bandage topically every 3 days on day shift. Cleanse burn to left arm with normal saline, pat dry, apply xeroform gauze, apply 4x4 gauze, then wrap with rolled gauze and tape secure. Pain Scale Check. Site Check. Diagnosis (Dx): Burn. Order discontinued 12/3/22. 2. Skin Barrier Protective Wipe. Day Shift. Apply to blisters on left side. Dx: Burn. Order discontinued 12/3/22. 3. Xeroform Petrolatum Overwrap 1 x 8 Bandage. 1 bandage topically every 3 days on day shift. Cleanse burn to left arm with normal saline, pat dry, apply xeroform gauze, apply 4x4 gauze, then wrap with rolled gauze and tape secure. Pain Scale Check. Site Check. Dx: Burn. Order discontinued 12/3/22. Current Physician Orders with a start date of 12/3/22 revealed: 1. Honey - alginate Monday, Wednesday, and Friday Day Shift (and as needed for accidental removal) - Cleanse burn # 1 (closest to ribs) to left lateral side with wound cleanser, pat dry, apply honey alginate dressing, and cover with an adhesive foam dressing. 2. Honey - alginate Monday, Wednesday, and Friday Day Shift (and as needed for accidental removal) - Cleanse burn # 2 (below #1) to left lateral side with wound cleanser, pat dry, apply honey alginate dressing, and cover with an adhesive foam dressing. 3. Honey - alginate Monday, Wednesday, and Friday Day Shift (and as needed for accidental removal) - Cleanse burn to left lower arm near elbow with wound cleanser, pat dry, apply honey alginate dressing, and cover with an adhesive foam dressing. During an interview on 12/17/22 at 8:52 a.m., R#45 stated she wanted a cup of soup, and the little girl went to heat it up. When she brought it back, it was scalding hot. The soup was brought back to the resident in the paper cup, the cup was flimsy, and she could not hold it in her hands. R#45 stated that she dropped the soup, and she began to holler out for help, but no one came right away. Resident stated the nurse came in and left out stating she was going to send someone back to help her. Resident stated the same nurse later said to her, I thought you only wanted to be changed and she responded Yes, I need to be change out of this gown, I burnt myself with some soup. R#45 stated it took the staff 45 minutes to come to see what she wanted and probably would not have come then if she would not have called her daughter to call the nursing home to get her some help. Resident stated that after this incident occurred, she asked her daughter to take her Ramen noodle soups home, she didn't want any more. Resident stated that she did not go out to see a doctor for the burns, the burns were treated in the facility and the areas are healing well now. Resident stated that burns are on her left arm near the elbow and along her left side. Observation revealed a white bandage to residents left arm dated 12/16/22. During an interview with Social Services Director (SSD) on 12/17/22 at 9:12 a.m. She stated that there was a cup of soup that someone warmed up, and another staff member picked it from the pantry, reheated, and took to the resident. The SSD stated that she was told that the soup was not cool. SSD further stated that this incident occurred while she was out of the facility sick, but she followed up with R#45 post incident. During an interview with Licensed Practical Nurse (LPN) AA on 12/17/22 at 9:17 a.m. revealed there is a microwave and a food thermometer in the pantry. LPN AA further informed surveyor that all foods and liquids heated/reheated for residents must be logged onto the Food Temperature Log in the pantry before being served to residents. LPN AA stated that this has always been the process staff are supposed to follow when reheating foods for residents. LPN AA informed surveyor that staff had received education on this process prior to and after R#45 got burned with the soup. During an interview on 12/17/22 at 9:49 a.m. the Director of Nursing (DON) stated the Ramen noodle soup was prepared and served to resident in the paper cup which it is packaged. DON further stated that she was informed that the soup was placed on the bed side table and the resident wrapped a napkin around the paper cup and dropped it on herself as the napkin slipped off the cup. DON stated that Certified Nursing Assistant (CNA) CC served resident the soup after a different CNA (CNA DD) heated it in the microwave. According to the Food Temperature Log, CNA DD heated the soup up to a temperature of 160 degrees and it was supposed to be between 135 to 140 degrees. DON further stated that CNA DD did not view the noodle soup as a liquid, and she was confused about that. During an interview with Certified Dietary Manager (CDM) on 12/17/22 at 11:13 a.m., she stated that no food is brought back into the kitchen to be reheated. It is all done in the pantry in front of the nurse's station. CDM stated that there is a thermometer and the reheating guidelines in the pantry for the staff use. CMD informed surveyor that she conducted an inservice for the staff on 10/20/22 and covered the importance of taking and documenting temperatures of reheated foods. She stated that the temperature guidelines were also discussed in this training. During a telephone interview with CNA CC on 12/18/22 at 9:26 a.m. she stated that R#45 wanted her soup warmed so she got it out the closet and gave it to CNA DD, who heated the soup and handed it back to her. CNA CC stated that she then took the soup back to resident and placed it on her bedside table. CNA CC stated that the soup was in a Styrofoam cup and the cup was covered so, she had no idea as to how hot the soup was. CNA CC stated that later R#45 was on the call light twice. The nurse answered the light first and she answered the light the second time and resident informed her that she was wet and needed to be changed. CNA CC stated that she informed resident that her assigned aide would be with her in a minute. CNA CC further stated that resident did not inform her that she had spilled the soup or was burning, and she did not observe soup spilled on resident at this time. CNA CC further stated that resident's daughter phoned the facility and informed a nurse that resident had spilled the soup and was burning or stinging. CNA CC revealed she had received training on the process for heating foods and liquids prior to the incident. During a telephone interview with CNA DD on 12/18/22 at 10:40 a.m. revealed that she remembers the incident with the soup. She stated that she was in the pantry reheating food for another resident when CNA CC brought the Ramen noodles to her and informed her, she did not know how to do it. CNA DD stated, after she finished reheating another resident's food, she read the directions on the Ramen noodles, heated up water in the microwave, and poured the water onto the Ramen noodles and handed it back to CNA CC. CNA DD stated she did not check the temperature of the water that she heated up nor did she check the temperature of the soup once she combined the noodles and the water. CNA DD stated that she was in-serviced prior to the incident and after the incident on heating foods and liquids. CNA DD reiterated that she did not serve R#45 the soup. CNA DD clarified that the 160-degree temperature she recorded on the Food Temperature Log was for the food she reheated for another resident, and she had no idea as to what the temperature of the soup was because she did not know she had to take the temperature of the hot water she heated in the microwave. During an interview with the Administrator on 12/18/22 at 11:27 a.m. revealed staff check the temperatures of food items to make sure it is not too hot prior to serving the residents. She also stated that the CDM noticed that the documentation on heating and reheating foods was lacking so she conducted an inservice prior to R#45 getting burned with the soup. Administrator stated that it is her expectation that the temperature of all foods is checked prior to being served to the residents. Administrator stated that she was not aware of the time it took the staff to remove the spilled soup and assess R#45. She further stated that the way she understood it was that it was removed as soon as it happened. She also stated that she was not made aware that the temperature of the soup was not checked and recorded prior to being served to R#45. During a telephone interview with Licensed Practical Nurse (LPN) EE on 12/18/22 at 11:36 a.m., she revealed she was working the night of the incident. LPN EE stated she was in the hall passing medications and she answered R#45's call light. She stated R#45 informed her that she had spilled something on herself and was wet and needed to be changed. LPN EE stated that she informed R#45 that her CNA would get her changed in a few minutes. LPN EE stated that resident did not appear to be in any distress and resident did not inform her that she had spilled hot soup. LPN EE further stated that later, CNA CC entered R#45's room and informed resident also that her CNA will be in to assist her shortly. LPN EE stated that she was not aware that R#45 had spilled soup and was burned it until resident's family phoned the facility. LPN EE stated that upon assessment R#45 sustained two blisters and a burned area with scalding and skin peeling on the left side of her body. During a post survey telephone interview with Registered Nurse (RN) OO on 12/18/22 at 3:55 p.m. revealed that she was sitting at the nurse's station when R#45's daughter called and was informed at this time that resident had spilled soup on herself and had burns. She stated that up until this point that the staff was not aware that resident had been burned. She further stated that while sitting at the desk she does recall R#45's call light being on at least once.

Based on observations and interviews the facility failed to maintain sanitary and clean conditions related to cross contamination on one of three hallways (B Hall) and in the laundry room. The facility census was 54 residents. Findings include: 1. An observation on 12/17/22 at 10:58 a.m. of Laundry Aide II sweeping the lint from under the dryer. After sweeping Laundry Aide II began folding clean linens without washing or sanitizing her hands. At 11:02 a.m. Laundry Aide II sat down and placed clean folded linens in the path of a fan with dust buildup. During an interview with Laundry Aide II on 12/17/22 at 11:06 a.m. she revealed that she washes hands when she first comes in and starts her loads. She acknowledged that she should have washed or sanitized her hands after using the broom before folding the linens. She reported that the fan in the laundry room is believed to belong to one of the other laundry aides and she acknowledged the dust buildup on the fan. Laundry aide reported that typically if something has been compromised due to cross contamination the items are rewashed. 2. A. On 12/17/22 at 11:16 a.m. Housekeeper JJ was observed cleaning room B8. She is noted to have mopped the bathroom and used the same mop to continue mopping the bedroom. Housekeeper JJ was not observed cleaning the call light cord or cleaning the bed rails when cleaning the room. B. On 12/17/22 at 11:45 a.m. Housekeeper JJ observed mopping bathroom in room B7 and using the same mop to then mop the resident's room. Housekeeper was also observed to clean the toilet with the toilet bowl brush and then used the brush to clean the floor around the toilet. Housekeeper JJ was not observed cleaning the call light cord or cleaning the bed rails when cleaning the room. C. On 12/17/22 at 12:42 p.m. Housekeeper Supervisor observed and confirmed Housekeeper JJ cleaning room and bathroom of B10. Housekeeper JJ was observed spraying chemicals on the toilet then using a towel to remove the chemicals from the toilet. The same towel was then used to clean the sink. Housekeeper was then observed to mop the bathroom and then began mopping half of the room with the same mop. Housekeeper JJ was not observed cleaning the call light cord or cleaning the bed rails when cleaning the room. During an interview on 12/17/22 at 12:02 p.m. with the Housekeeping Supervisor she reported that laundry staff should sanitize their hands prior to touching clean linens or before getting anything in or out of the washer and the dryer. In regard to mopping, she reported that the room should be mopped first and then the bathroom and the housekeeper should exit through the adjoining room. During an interview with the Infection Preventionist on 12/17/22 at 12:22 p.m. it was revealed that the best practice is to mop the bathroom last because it is the dirtiest. During interview with Housekeeper JJ and Housekeeper Supervisor on 12/17/22 at 1:25 p.m. Housekeeper JJ reported that another Housekeeper trained her to mop the bathroom first and then to mop the room. She also confirmed that she used the toilet bowl brush in the toilet and then on the floor. Housekeeper acknowledged that the bed rails and call light cords were not cleaned but expressed she was the only Housekeeper at this time. Laundry policy requested related to cross contamination, but the Housekeeping Supervisor reported there was no policy.

Based on record review, staff interviews, and review of policy Advanced Directives, the facility failed to obtain a Physician's signature for a Physician Orders for Life Sustaining Treatment (POLST) for Allow Natural Death (AND)/Do Not Resuscitate (DNR) consents for one of 26 residents reviewed, Resident (R) (R#44). Findings include: Review of policy titled, Advance Directives, with a review date of 12/4/2021, revealed the following: POLST - Physician's Order for Life Sustaining Treatment Procedure for periodically reviewing patient choices and preferences related to health care decisions after admission: A POLST that has been appropriately completed will be accepted and followed by the center. Review of POLST form Guidance for completing the POLST form - Additional Guidance for Care Professionals revealed: I. When a POLST form is signed by the Patient and Attending Physician all orders may be executed without restriction. Review of medical record for R#44 revealed no Physician's signature on POLST that was signed by R#44 on 10/25/22. Interview on 12/6/22 at 4:03 p.m. with Social Services confirmed that when a resident signs the POLST only one Physician signature is needed for Allow Natural Death/DNR. POLST for R#44 is still at the doctor's office. Social Services reported that ultimately it is her responsibility to get the signed form back from the doctor and she did not have a reason for why the POLST had not been signed by the Physician for R#44. Interview on 12/16/22 at 4:20 p.m. with Licensed Practical Nurse (LPN) FF revealed that she looks for resident's code status by looking at the electronic medical record (EMR) or in the POLST book. Upon looking at the EMR and the POLST book LPN FF reported that R#44 had a code status of DNR. Review of the POLST for R#44 confirmed that there was no Physician's signature. Interview on 12/17/22 at 9:26 a.m. with the Administrator revealed the POLST for R#44 was signed by the Physician last night. She reported that she is unsure why it was not signed prior to last night and Social Services was responsible for following up related to getting it signed. It was further reported that the form is typically returned from the Physician within one week.

Based on record review and interviews, the facility failed to follow the care plan for one of five residents ((R) R#44) reviewed related to administering medications as ordered. Findings include: Review of the medical record revealed R# 44 admitted to facility on 10/25/22 and had an admitting diagnosis that included unspecified, essential (primary) hypertension (HTN). Review of care plan dated 10/25/22 revealed a care plan for antihypertensive related to HTN which included an intervention of administer medication as ordered. R#44 had a Physician's Order for carvedilol 25 milligram (mg) tablet 1 tablet by mouth 2 times per day, hold if Systolic BP (blood pressure) Less than 140, hold if Diastolic BP Less than 90 with a start date of 11/25/22. Review of the electronic medication administration record (EMAR) for November 2022 revealed medication administered for blood pressure at 9 a.m. on 11/25 - 138/72; 11/26 - 138/74; 11/27 -120/70; and 11/30 - 132/62. Review of the EMAR for December 2022 revealed medication administered for blood pressure at 9 a.m. on 12/1 -138/70; 12/5 - 144/68; 12/6 - 140/68; 12/9 -140/68; 12/10 - 138/72; 12/11 - 138/78; 12/12 - 159/75; 12/14 - 140/68; and 12/15 -128/70. Review of the EMAR for November 2022 and December 2022 revealed medication administered for blood pressure at 8 p.m. on 12/1 - 157/77; 12/2 - 166/88; 12/3 -136/69; 12/4 - 145/77; 12/5 - 148/84; 12/6 - 148/75; 12/7 - 134/65; 12/8 - 149/67; 12/9 -122/76; 12/10 - 146/86; 12/11 - 148/80; 12/12 - 156/76; 12/13 - 136/72; 12/14 - 142/86; 12/15 - 146/82; 11/25 - 96/56; 11/26 - 128/86; 11/27 - 148/78; and 11/29 - 133/72. During an interview on 12/18/22 at 10:55 a.m. with Licensed Practical Nurse (LPN) AA confirmed dates in which carvedilol should have been held but was administered outside of the parameters of the order. Cross refer to F684.

Based on record review, interviews, and review of the facility policy titled Pharmacy Services Medication Administration General, the facility failed to follow Physician's Orders related to a blood pressure medication for one of five residents ((R) R#44) reviewed for unnecessary medication. Findings include: Review of policy titled Pharmacy Services Medication Administration General (dated 2019) revealed medications are to be administered as prescribed, in accordance with good nursing principles. Review of the medical record revealed R#44 admitted to facility on 10/25/22 and had an admitting diagnosis that included unspecified, essential (primary) hypertension. R#44 also had a Physician Order for carvedilol 25 milligrams (mg) tablet (CARVEDILOL) 1 tablet by mouth 2 times per day, hold if Systolic BP (blood pressure) Less than 140, hold if Diastolic BP Less than 90 with a start date of 11/25/22. Review of the electronic medication administration record (EMAR) for November 2022 revealed the medication carvedilol was administered with the following blood pressure at 9 a.m. on 11/25 - 138/72; 11/26 - 138/74; 11/27 -120/70; and 11/30 - 132/62. Review of the EMAR for December 2022 revealed the medication carvedilol was administered with the following blood pressure at 9 a.m. on 12/1 -138/70; 12/5 - 144/68; 12/6 - 140/68; 12/9 -140/68; 12/10 - 138/72; 12/11 - 138/78; 12/12 - 159/75; 12/14 - 140/68; and 12/15 -128/70. Review of the EMAR for November 2022 and December 2022 revealed the medication carvedilol was administered with the following blood pressure at 8 p.m. on 12/1 - 157/77; 12/2 - 166/88; 12/3 -136/69; 12/4 - 145/77; 12/5 - 148/84; 12/6 - 148/75; 12/7 - 134/65; 12/8 - 149/67; 12/9 -122/76; 12/10 - 146/86; 12/11 - 148/80; 12/12 - 156/76; 12/13 - 136/72; 12/14 - 142/86; 12/15 - 146/82; 11/25 - 96/56; 11/26 - 128/86; 11/27 - 148/78; and 11/29 - 133/72. Consultant Pharmacist's Medication Regiment Review Recommendations Pending a Final Response dated 12/16/22 revealed Pharmacy recommended Carvedilol should be given with food to minimize the risk of orthostatic hypotension. Please consider changing administration times to coincide with meals 9 am and 6pm. During an interview on 12/18/22 at 10:55 a.m. with Licensed Practical Nurse (LPN) AA confirmed that there have been trainings provided to staff related to monitoring the parameters of blood pressure for residents. LPN AA reviewed the EMAR for December 2022 and confirmed dates in which carvedilol should have been held but was administered outside of the parameters of the order. During an interview with on 12/18/22 at 11:16 a.m. with the Director of Nursing (DON) and Resident Care Coordinator (RCC) HH, the DON reported that she was not aware of the medication being administered outside of the parameters of the order until she received info from the pharmacist on 12/16/22. DON confirmed that medication for R#44 was not being administered as ordered. The pharmacist was called, and a message was left but there was no response. A post survey interview with R#44's Physician was conducted on 12/18/22 at 3:16 p.m. The Physician expressed that the expectation is that medications are administered as ordered and after review of what was entered on the EMAR, he confirmed that the medication should have been held if it was outside of the parameters listed on the order.

Based on record review, staff interview, and review of facility policy titled Baseline Care Plan, the facility failed to develop a baseline care plan within 48 hours of admission for two residents (R) R#45 and R#295). The facility census was 44. Findings include: Review of Policy titled Baseline Care Plan (2020) revealed Intent: Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan of delivery of care and services by receiving a written summary of the baseline care plan. Guide: 1. Admitting nurse begins the development of the patient's baseline plan of care, which is formed from the admission nursing assessment. 2. Admitting nurses, review the care plan for each patient, after completing the admission assessment to individualize patient care needs. 3. Baseline care plans will address at a minimum, the patient's initial goals based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Interdisciplinary team will collaborate with nursing to address all specific patient needs. 1. Review of the clinical record revealed R#45 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#45's care plans done on admission do not address the presence of a cardiac pacemaker, hypertension, [CONDITION(S)], and heart failure. 2. Review of the clinical record revealed R#295 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R#295's records also revealed allergies to shellfish, peanuts, milk, and iodine. Review of R#295's care plan done on admission does address diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Care plans also do not address allergies to shellfish, peanuts, milk, and iodine. Interview on 8/05/2021 at 12:56 p.m. with Minimum Data Set (MDS) Coordinator who stated a completed baseline care plan was not completed on R#45 and R#295 on admission. MDS Coordinator further revealed that she was responsible completion of these baseline care plans. Interview with the Director of Health Services on 8/5/2021 at 1:01 p.m. revealed she is not familiar with the baseline care plan process and is not sure about the policy regarding them.

Based on record review, staff interview, and policy review the facility failed to develop a comprehensive person-centered care plan to address the resident's physician order [REDACTED]. Findings include: Record review revealed that R#23 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Record review revealed that R#23 has a physician order [REDACTED]. Review of Medication Administration Record [REDACTED]. R#23 has a physician order [REDACTED].>Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] for R#23 revealed received an anticoagulant five days in the reference period. Review of the care plans for R#23 revealed no care plans, set goals or interventions for the use of an anticoagulant (Xarelto) and a heart medication ([MEDICATION NAME]). Interview on 9/06/2018 at 12:00 p.m. with LPN DD revealed if a resident is on [MEDICATION NAME] she checks the residents pulse prior to administration of medication. She stated the order is to hold pulse if less than 60. If it remains low she notifies the physician. She stated for a resident on a blood thinner she looks for unusual bleeding, nose bleed, vaginal bleed, rectal bleeding or bruising. She would expect the care plan to include R#23's order for Xarelto and [MEDICATION NAME]. Interview on 9/06/2018 at 12:44 p.m. with the DON revealed R#23 is on both Xarelto and [MEDICATION NAME] and the care plan should reflect the use of both medications. She agreed the R#23 did not have a care plan for Xarelto or [MEDICATION NAME]. Interview on 9/06/2018 at 12:59 p.m. with the MDS Coordinator revealed she creates a care plan for areas triggered by the MDS, medications, and current conditions. She agreed there was not a care plan, goal or interventions in place for the use of R#23's prescribed [MEDICATION NAME] or Xarelto. Review of the policy titled Patient's Plan of Care copyrighted (YEAR) Ethica Health and Retirement Communities, revealed an intent to develop and maintain an individualized plan of care for each patient.

Based on observations, record review, resident, and staff interviews, the facility failed to ensure that Activities of Daily Living (ADL) care was provided related to nail care for one resident (R#36). The sample size was 28 residents. Finding include: Record review for R#36 revealed that she was admitted to facility with the [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for R#36 revealed a BIMS (Brief Interview Mental Status) score of 7 which indicates a cognitive impairment. It also showed the need for extensive assistance with person hygiene. Observation of shower/bath documentation revealed that R# 36 received a shower and or bath on 9/4/17, 8/30/18, 8/25/18, 8/23/18, 8/21/18. Observations on 9/4/18 at 3:04 p.m., 9/5/18 at 8:43 a.m., and 9/5/18 at 4:52 p.m. revealed the resident's fingernails were 1/2' long with dark brown debris under the nails. Several of the fingernails were broken with jagged edges and had chipped nail polish on the bottom half of the nails. During an interview on 9/4/18 at 3:04 p.m. with R#36 revealed that stated that her nails were too long and that she would like for them to be cut. During an interview on 9/6/18 at 8:15 a.m. with CNA AA revealed that nail care is given during showers or baths. CNA AA stated that if a resident refuses care, she would then report it to the nurse so that the nurse could document the refusal of care. During an interview on 9/6/18 at 8:25 a.m. with CNA BB revealed that when she gives personal grooming care to a resident, she cleans the resident's face, brushes their teeth, and cleans and cut fingernails. During an observation and interview on 9/6/18 at 8:40 a.m. with LPN CC revealed that R#36's nails were 1/2 long with dark brown substance underneath the nails, some with jagged edges and chipping nail polish. Continued interview revealed that CNA's can clean and cut fingernails that R #36 did need nail care.

Based on observation, interview and policy review, the facility failed to follow infection control procedures for one resident receiving a blood sugar and two residents who received a pulse oximeter reading. The census was 68 residents. Findings include: 1. An observation made on 9/4/2018 at 3:50 p.m. revealed LPN EE putting on gloves in the hallway, gathered his supplies, and walk into resident (R) room, checked the residents blood sugar, and departed the residents room without removing his gloves or sanitizing his hands. Interview on 9/4/2018 at 4:25 p.m. with LPN EE revealed he agreed he should have sanitized his hands and put on gloves in the residents room, check the resident's blood sugar, then remove his gloves and sanitize his hands before leaving the resident's room. Interview with the DON on 9/6/2018 at 9:32 a.m. revealed that her expectation that all nurses would not put on a pair of gloves in the hallway at the med cart, gather blood sugar supplies, walk into the resident's room and perform a blood sugar, wearing the same gloves, and then walking out of the room wearing the same gloves to clean glucometer. Review of the document titled Glucometer Disinfection effective (YEAR) revealed: 1. Wear gloves during finger stick glucose monitoring. 2. Change gloves that have touched potentially blood-contaminated objects or fingerstick wounds before touching clean surfaces. 3. Remove and discard gloves in appropriate recepticals. 4. Perform hand hygiene immediatly after removal of gloves and before touching other medical supplies intended to use on other residents. 2. Observation on 09/05/18at 8:04 at a.m. during medication administration with Licensed Practical Nurse (LPN) GG on C hall medication cart, obtained resident #68's pulse with facilty equipment, pulse oximeter, then placed the pulse oximeter into her uniform pocket however, and was not observed to clean the equipment prior to or after it was used for R#68. Observation on 09/05/18 at 8:40 a.m. revealed that LPN GG entered another resident's room on the C hall, reached into her uniform pocket and pulled out facilty equpiment, pulse oximeter, and obtained R#64's pulse with the pulse oximeter, then placed the equpiment back into the uniform pocket. LPN GG came back to the medication cart and took the pulse oximeter out of the uniform pocket and placed the pulse oximeter on top of the medication cart. LPN GG reported that R#64's pulse was 70 however, LPN GG did not clean the pulse oximeter prior to or after it was used on R#64. Interview on 09/06/18 at 9:32 a.m. with the DON revealed that it is not appropriate for nurses to use pulse oximeters between residents and the equipement should be cleaned with sani wipes prior to and after use and espiecially cleaned between use on residents. Also reported that the nurse shoul not put the pulse oximeter into their uniform pocket after it has been used on a resident.

Based on observation, record review and staff interview, the facility failed to ensure that foods in one of three reach-in freezers was labeled with the open date and contents, and sealed to avoid exposure; failed to discard one container of a dessert syrup past the manufacturer's expiration date in one of one dry storage rooms; and failed to ensure that two items (chopped pork and pureed sweet potatoes) on the steam table were held at or above 135 degrees to help prevent the potential for foodborne illness at one meal observed. Review of the facility's Form CMS-672, Resident Census and Conditions of Residents form, revealed that the facility's census on 10/16/17 was 68 residents with six residents that received tube feedings, which indicated 62 residents received an oral diet. Findings include: 1. During initial tour of the kitchen on 10/16/17 at 10:42 a.m., a clear unlabeled plastic bag of meat was observed on the floor on the left side of reach-in freezer #2, and the meat was soft to touch. This was verified by the Food Service Manager (FSM) at this time, who stated the meat was chicken livers that was being served for lunch that day, and that all foods should be labeled when removed from the original packaging, and either used immediately or discarded if soft. Further observation on the right side of the reach-in freezer #2 at this time revealed a clear plastic bag that contained two chicken drumsticks that was open to air, and not labeled with the contents or open date. 2. On 10/18/17 at 11:42 a.m., Cook AA was observed preparing pureed sweet potatoes, and after the preparation she placed the sweet potatoes from the food processor into a pan, covered it and reheated it on the stovetop for a few minutes, then placed it on the steam table to hold until lunch was served. Further observations revealed that the first tray for lunch was plated at 12:12 p.m., and the steam table temps were taken by the FSM using the facility's calibrated thermometer beginning at 12:21 p.m. Observation of the temperature of the pureed sweet potatoes revealed that it was 126 degrees Fahrenheit (F), and the FSM removed the pan the sweet potatoes were in, which had been nested inside a second metal pan on the steam table, to reheat them. Further observation during this meal service revealed that the cook removed several pork chops off the steam table, and after deboning them placed them in the food processor to obtain a chopped consistency, and then placed them directly onto the steam table. The temperature of this chopped pork revealed that it was 112 degrees F., and after reheating it on the stovetop the FSM was unable to get the temperature above this and so discarded the meat. The staff was observed to make two more attempts to prepare chopped pork in the food processor, but the temps of the pork was 108 degrees and 120 degrees, so the FSM used the alternate of chicken patties for the residents on a chopped meats diet. During interview with the FSM on 10/19/17 at 9:01 a.m., she verified that the chopped pork never got over 120 degrees after three attempts, and stated that the staff did not take into account that the temperature of the meat would drop after preparing it in the food processor. During further interview, the FSM verified that the pureed sweet potatoes were only 126 degrees, and that she did not know why the staff had placed the pan inside a second pan on the steam table. The FSM stated that at the time the steam table temperatures were taken at lunch yesterday, that approximately one or two residents had already been served the chopped pork, and that two residents had been served the pureed sweet potatoes before they were reheated. During interview with the FSM on 10/19/17 at 12:01 p.m., she stated that in general she liked to keep the steam table holding temperatures between 140 and 145 degrees, and no lower than 136 degrees. Review of the facility's Food Preparation, Storage and Serving policy with a release date of May 2017 revealed that food holding will be monitored for basic safe temperature controls and serviced under sanitary temperatures and conditions. Review of a list provided by the FSM revealed that nine residents received a pureed diet, and four residents received a diet with chopped meats. 3. During observation in the dry storage room on 10/19/17 at 8:56 a.m., a near-empty 17-ounce squeeze bottle of Caramel Dessert Sauce labeled with an open date of 12/1/14, and a manufacturer's expiration date of 3/21/16, was seen on a shelf with other condiments. Further review of the manufacturer's labeling included to refrigerate the item if it was going to be stored for an extended period. This was verified by the FSM at this time, who stated she had recently thrown out several of these dessert sauce bottles, and did not know where this bottle had come from and that it should be disposed of.

Based on observation, record review and staff interview, the facility failed to ensure that one of three reach-in freezers (freezer #2) was maintained in a manner to ensure foods were frozen solidly. There were 62 residents that received an oral diet. Findings include: During the initial tour of the kitchen on 10/16/17 at 10:42 a.m., condensation was noted to be clinging to the top interior of reach-in freezer #2 on the right-hand side. Further observation revealed that this condensation could be wiped away easily, as it was not frozen. Further observation revealed that there was a puddle of a dark red material with the appearance of blood on the flooring at the front right side. Observation on the floor of the left side of this freezer revealed a clear unlabeled bag of meat with the appearance of raw chicken livers, and the meat was soft when touched. This was verified by the Food Service Manager (FSM) at this time. Observation of the inner aspect of the right-side freezer door revealed that the gasket seal was not secured in place, and was loosely hanging down at the top and medial aspects of the door. This was confirmed by the FSM, who stated the gasket was loose but not that bad back in July, and that a new door gasket had been ordered. During interview with the FSM on 10/19/17 at 9:25 a.m., she stated that she had noticed that all of the foods stored toward the front right side of reach-in freezer #2 (where the gasket seal was off) were soft, and she threw the food out. She further stated that the blood noticed on the floor of the freezer on 10/16/17 was from a bag of chicken livers, which were on the right side of the freezer before moving them to the left side of the freezer. Review of a distributing company Sales Order provided by the FSM revealed that the freezer door gasket was ordered on [DATE] at 11:14 a.m.

Based on observation, staff and resident interviews, and record review, the facility failed to follow the plan of care for transfers for one of four residents (R#19) who required assistance with transfers. The sample size was 4 residents. Findings include: Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was also given the [DIAGNOSES REDACTED]. The interdisciplinary plan of care for the resident, dated 8/26/16 and most recently dated as reviewed 8/5/17, states R#19 is totally dependent for transfers, with interventions including requires two person assist w/ transfers, may use lift. The CNA Care Plan Worksheet, which is available for CNA's to find resident specific information regarding resident care, includes, in the Mobility Status area, a check mark beside 2 person in the Transfers section, and a check mark beside Mechanical Lift, and sling or 2 people pick-up is hand-written on the form in this area. The DON explained during an interview on 10/18/17 at 2:00 PM that the CNA Care Plan Worksheet is updated upon any changes and during care planning meeting, but they are not routinely dated at any time. Review of a Facility Incident Report Form dated 7/22/17, which was used by the facility to report the incident to the Health Care Facility Regulations Division of DCH, and Interdisciplinary Progress Notes from the Resident's medical record dated 7/22/17 and 7/23/17, revealed that Resident (R) #19 received a fracture on 7/21/17, when a staff member, using a Sabina II (stand up) lift, without assistance of an additional staff member transferred her from her chair to her bed. During this transfer, R #19 experienced a fracture to her right wrist.

Based on observation, record review, staff and resident interviews, the facility failed to prevent an injury for one of four residents (R#19) who required assistance with transfers. The sample size was 4 residents. Findings include: Resident #19 was admitted with diagnoses, that included but not limited to, [DIAGNOSES REDACTED], [DIAGNOSES REDACTED], dysarthria, and anarthria. She was also diagnosed with [REDACTED]. Review of a Facility Incident Report Form dated 7/22/17, and Interdisciplinary Progress Notes from the Resident's medical record dated 7/22/17 and 7/23/17, revealed that R#19 received a fracture to her right wrist on 7/21/17, when a staff member, used a Sabina II (stand up) lift, without the assistance of an additional staff member, transferred R#19 from her chair to her bed. During an interview with R #19 in her room on 10/18/17 at 12:10 PM, she stated that on the night of 7/21/17, a male CNA that she was not familiar with came to her room with a stand-up lift to put her to bed. She stated she told him that the staff usually lifts her physically using two people and that she did not routinely use the lift. She further stated that she told him she was not able to use the stand-up lift at all because she could not bear weight on her legs. R#19 further stated that the CNA told her that he had asked the charge nurse and she told him that he must use this lift for her. R#19 stated that while she was being placed in the lift by the the CNA, another CNA entered the room and did something for her room-mate, but then immediately left the room, leaving only the one CNA to use the lift to transfer her to bed. R#19 further revealed that her arms were dangling over the edge of the lift and that when she was lowered onto the bed, her right arm was under her and it became twisted at the wrist, causing pain, which she reported to the CNA, at that time. She also stated that a strap on the lift rubbed against her neck and caused redness and pain to the area. Record Review of a Radiology report for R#19, dated 7/23/17, revealed that the X-ray was for the residents right wrist and the documented findings revealed the following: there is a fracture of the distal radius with angulation. The soft tissues are swollen. Impression: Acute fracture of the distal radius. The interdisciplinary plan of care for the resident, dated 8/26/16 and most recently dated as reveiwed 8/5/17, states R#19 is totally dependent for tranfers, with interventions including requires two person assist w/ transfers, may use lift. The CNA Care Plan Worksheet, which is available for CNA's to determine the resident specific information regarding resident care, revealed that in the are are marked Mobility Status, a check mark was documetned beside 2 person. in the area of the form titled Transfers section a check mark was documented beside the Mechanical Lift and sling or 2 people pick-up is hand-written on the form. The DON explained during an interview on 10/18/17 at 2:00 p.m. that the CNA Care Plan Worksheet is updated with any changes and during the care plan meeting, but that they (CNA Care Plan Worksheets) are not routinely dated when changes are made. Interview with the Director of Nursing on 10/18/17, at 2:00 p.m., revealed that she was contacted by the RN Supervisor on 7/22/17 at approximately 5:00 p.m., immediately after R#19 reported the incident to staff. The DON revealed that she immediately suspended the staff members involved in the incident and began the investigation. The incident was self-reported to the Department of Community Health on the same day, and the final investigation was sent in on 7/28/17. Upon completion of the investigation by the facility, the CNA who was involved and the Charge Nurse, who was the supervisor for the CNA were terminated from employment for failure to follow the care plan for the resident.

Based on observation and staff interviews, the facility failed to provide a sanitary environment free from urine odor for two shared bathrooms on Hall A (Room A-1 and Room A-10). This had the potential to effect four residents. The sample size was 33 residents. Findings include: Several observations were made on 10/16/17 at 11:21 a.m, 1:38 p.m, 10/17/17 at 9:27 a.m, 10:35 a.m , 10/18/17 at 11:00 a.m, 2:35 p.m, 5:15 p.m, 10/19/17 at 10:00 a.m, 11:20 a.m, and 2:00 p.m revealed strong urine odor in resident's bathrooms for Room A-1 and Room A-10. Interview and observation of Rooms A-1 and A-10 with Administrator on 10/19/17 at 2:09 p.m revealed that she was unaware of an urine odor in the bathrooms. She verified the strong odor in both bathrooms. She further stated that she can have the problem addressed within 20 minutes and have staff use vinegar to eliminate the odors. She stated that her expectations are that all facility staff address any urine odor and refer to housekeeping staff. Interview and observation of Room A-1 and A-10 with Director of Nursing on 10/19/17 at 2:11 p.m revealed that she identified the urine odor in Room A-1 earlier on 10/16/17 and had addressed the issue with the Housekeeping Supervisor. She was unaware that an urine odor was present on today in bathroom A-1. She felt that at least one of the residents per each room who shared the bathroom was having urine spills. She reported that her expectations are that the facility is free of urine odors caused by urine spills. She also stated that she felt the urine odors are embedded in the bathroom tiles. She stated the facility protocol is for staff to log all work orders in the Housekeeping/Maintenance Log. The log is kept at the nursing stations. Late interview with the Administrator on 10/19/17 at 2:31 p.m revealed that her investigations of the situation revealed that one of the residents is care plan for urinating on the bathroom floor. She stated that her expectations are that staff follow the facility policy and procedure with monitoring, reporting, and cleaning urine spills. She reported no specific policy that pertains to facility odors. She further stated that she only been in her new position in the facility as a interim Administrator for a few weeks. She was not familiar with all the policies and not able to locate any specific policies at this time. She did have a policy on Housekeeping and Maintenance but nothing specific to sanitation in reference to urine odors. Interview with Housekeeping Supervisor on 10/19/17 at 2:45 p.m revealed that he was aware of the urine odor in the bathrooms prior to taking on his new position. He stated that he had put in orders for cleaning products to address the problem. He was unaware that his housekeeping staffs were not addressing the urine odors this week in the bathrooms. He reported that his expectations are that housekeeping staff monitor and clean the bathrooms for urine odors and urine spills.

Based on observation, record review, resident and staff interview, the facility failed to ensure that the Minimum Data Set (MDS) assessment was accurate related to dental status for one resident (R) (#31), and for Level II PASRR (Preadmission Screening and Resident Review) status for one resident (#56). The sample size was 33 residents. Findings include: 1. Review of R #31's Annual MDS dated [DATE] revealed that she was coded as having no oral or dental issues, and review of the Care Area Assessment Summary (CAAS) for this MDS revealed that Dental Care did not trigger as an area of concern. Review of a risk for mouth pain due to teeth in poor condition care plan revealed an effective date of 7/2/12. Review of an Admission assessment dated [DATE] noted that R #31 had missing natural teeth and decayed areas. Observation of R #31's teeth on 10/17/17 at 1:53 p.m. revealed that there were several missing teeth on the top, and there one was broken tooth near the front and the remaining teeth were discolored and appeared to be in poor condition. Interview with R #31 at this time revealed that she denied tooth pain or difficulty chewing her food. Interview with the Social Services Director on 10/18/17 at 5:11 p.m. revealed that R #31 had not elected to sign up for the facility's contracted dentistry service. Interview with the Resident Assessment Instrument (RAI) Director on 10/19/17 at 8:40 a.m. revealed that she was the one that coded the dental section of the MDS, and that when she had done R #31's assessment the previous week she did not see any missing or broken teeth. She further stated that since the resident denied mouth pain, she didn't go any further to assess when the resident said she was having no oral problems. During interview with the RAI Director on 10/19/17 at 9:31 a.m., she stated that she had just made another observation of R #31's teeth, and saw a black area on a tooth on the top right side toward the back, and a broken tooth on the top in the front. She stated during further interview that the resident should have been coded as having likely cavity or broken natural teeth on the Annual MDS. 2. Review of R #56's clinical record revealed that he had [DIAGNOSES REDACTED]. Review of a State of Georgia Level II PASRR Review Outcome Notification dated 1/22/14 revealed that R #56 was eligible to receive additional specialized services and/or supports according to an individualized plan of care to treat the serious mental illness. Review of a Behavioral Health progress note dated 8/31/17 revealed R #56 had anger problems, manifested in aggressive but non-violent ways; continues to need outpatient treatment; continues to exhibit symptoms of an emotional disorder that interferes with day to day functions. Review of his Annual MDS dated [DATE] revealed that he was not coded as evaluated by Level II PASRR for a serious mental illness. Review of his [MEDICAL CONDITION] drug use care plan revealed that he refused care and had depression. Further review of this care plan revealed an intervention for a psychiatric consult as indicated, but no notation of the Level II services. During interview with the RAI Director on 10/19/17 at 8:50 a.m., she stated that she coded Section A of the MDS, which included PASRR. She further stated that the Social Services Director gave her a list of which residents were Level II, and verified the most recent list dated 10/12/17 included R #56. During interview with the RAI Director on 10/19/17 at 9:31 a.m., she stated that R #56 was approved for Level II services in January of 2014, and so the December 2016 Annual MDS was incorrect and should be modified to reflect that he was on Level II at that time. DONE

Based on observation and staff interview, the facility failed to hold food at the proper temperature during lunch service. This had the potential to effect a census of 70 residents. Findings include: On 05/21/2015 at 12:20 p.m., observation of the steam table temperatures with the Dietary Manager, using a facility thermometer that was calibrated between food items, revealed the following food items were not being held at the proper temperature: chopped chicken - 110 degrees Farenheit pureed squash - 100 degrees Farenheit candied yams - 110 degrees Farenheit pureed chicken, individually pre-packaged - 132 degrees Farenheit On 05/21/2015 at 1:00 p.m. the Dietary Manager (DM) questioned the cook, AA who revealed that there was no warmer, so after being cooked food sat on the top of the stove, with no burners on, until being transferred to the steam table. The cook further revealed that the timing of taking the steam table temperatures for meal services varied. The DM revealed that she had had a problem with the right side of the steam table about two months ago but had not had any problems since. A review of the facility Safe Food Handling Practices: Food Temperatures Section I. D. revealed The danger zone for the growth of bacteria is 41 degrees Farenheit (F.) to 140 degrees F. and that foods should be kept at temperatures either above or below the danger zone. Section I.G. revealed Keep hot foods hot. Hot foods should be kept at 140 degrees F. or higher. #1. Place foods on the steam table no more than 20 minutes before serving. Heat food to at least 140 degrees F. before putting it on steam table. Section I.H. revealed .Never allow foods to stay at room temperature or place on a warm range or griddle Section I.I. revealed Heat leftovers to an internal temperature of at least 165 degrees F. before placing on the serving line. Interview with the Dietary Manager on 05/21/2015 at 12:40 p.m. revealed that the holding table temperatures should have been at least 135 degrees Farenheit.

Based on record review and staff interviews the facility failed to ensure that a recommendation for Range of Motion (ROM), to the left shoulder, by Physical Therapy to prevent further contractures was put into place for one (1) resident (#23) in a sample of twenty-two (22) residents. Findings include: Review of the clinical record of resident #23 revealed a recommendation by physical therapy, dated 5/6/14, for nursing to provide restorative nursing for resident #23 to maintain ROM and prevent further contractures to left shoulder six (6)times per week. An interview with Minimum Date System, (MDS) nurse on 5/22/14 at 8:35 a.m. stated that there was no copy of the Functional Maintenance Program (FMP) dated 5/6/14 in the restorative notebook. MDS nurse stated when the restorative aide applies splint to the left hand she also does the FMP dated for 5/6/14. MDS nurse confirmed there is no documentation in the restorative notebook for the FMP dated 5/6/14. An interview with the restorative aide on 5/22/14 at 12:05 p.m. revealed that she provided care to the left shoulder after the splint was applied but confirmed this is not documented and could not provide evidence that the ROM exercises to the left shoulder was provided.

Based on record review and staff interview, it was determined that the facility failed to ensure that laboratory work was obtained as ordered by the physician for one (#28) of twenty two (22) sampled residents. Findings include: Record review of the clinical record for resident #28 revealed the following Diagnoses: [REDACTED]. gastro-ephogeal reflux disease (gerd) and dyspepsia. Resident #28 had a Basic Metbolic Panel (BMP) completed and reported to the facility on [DATE]. The laboratory results showed a low sodium level. The physician had ordered on [DATE] to give the resident sodium tablets twice a day and to repeat the Basic Metabolic Panel on 5/8/14. There was no evidence in the resident's medical record to confirm this was done as ordered. An interview with the Director of Nursing on 5/21/14 at 9:00 a.m. revealed that the laboratory test was not done as ordered. The Director of Nursing stated at that time that a laboratory notebook was kept with all the lab requisitions and were supposed to be checked by the charge nurse to ensure the laboratory tests were done. She stated that somehow this one fell through the cracks. Review of the facility Laboratory And Diagnostic Services Policy and Procedure revealed that physicians orders for laboratory and diagnostic services should be carried out as instructed by the physician's orders [REDACTED].