Every finding on record at Woods at Lumber City of Journey LLC, The

Based on observation, resident and staff interviews, record review, and review of the facility's policy titled Accidents and Supervision, the facility failed to ensure supervision of resident (R) (R1) .related to elopement attempt. Specifically, the facility failed to provide watchful oversight of R1 to prevent an exit from the building unassisted from a total of three residents who wander and exit-seek. This deficient practice placed R1 at potential risk for avoidable accidents or injury, and a diminished quality of life. Findings Include:A record review of Comprehensive Care Plan Policy revealed It is the policy of the facility to develop and implement a comprehensive person- centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the residents' comprehensive assessments. Policy explanation and Compliance Guidelines: 8. Qualified staff responsible for carrying out interventions specified in care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.A Record Review of R1 electronic health record (EHR) revealed the following diagnoses that included but not limited to Alzheimer's disease, dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance.Review of R1's Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of five for severe cognitive impairment. The resident Elopement/ Wandering Risk Evaluation for R1 was implemented on 08/08/2026 after elopement as a result R1 score was a 4.0. A note on evaluation states that he should be supervised when outside.A Review of care plans revealed R1 is at risk for elopement, posing safety concerns date Initiated: 06/20/2025. The goal for R1 revealed that he will not leave the facility without a responsible person accompanying him and his safety will be maintained through date initiated 06/20/2025.A record review of late progress notes revealed residents were noted to be in front of the parking lot with staff. saying he was going to go to [NAME]. Writer encouraged residents to come inside for safety reasons. Residents ambulated into the facility without difficulty. Nurses noted B/P 128/68, Respirations 18, Temp 98.8, pulse 88 and 02 Sat 99%(per cent). Resident received water to drink.Observation on 08/19/2026 at 5:15 PM of R1's revealed R1 was standing at front entrance and exit door. R1 had to be redirected by Director of Nursing (DON) and Administrator. A phone interview on 08/18/2026 at 1:18 PM with Licensed Practical Nurse (LPN), LPN AA revealed resident R1was seen in the rocking chair outside. He was outside for about 15 minutes with other residents. It was daylight between 6PM - 7PM. LPN AA looked outside from nursing station and saw residents heading toward the street walking on grass in parking lot. During this time LPN AA noticed other residents sitting on porch with no staff was seen. This happened on a Friday two weeks ago. LPN AA admitted that R1 should not have been outside by himself because he has a low BIMS and he is not cognitively intact.Interview on 08/20/2026 at 8:58 AM with the Director of Nursing (DON) and Administrator confirmed that residents care plan was not followed. R1 should have been supervised by staff. To ensure this does not happen again they had an elopement drill and re-educated staff for Elopement. Interview on 08/20/2026 at 11:45 PM with MDS Coordinator confirmed a Certified Nursing Assisted (CNA) should have escorted him outside and accompanied for duration of him being outside. R1 has a care plan that explains that the goal is that residents should always be accompanied by a CNA or staff and was created on 06/20/2025. Many negative outcomes could have happened. MDS also confirmed that R1's care plan should have been updated once residents wandered outside on 08/07/2026.

Based on interviews, record review, and policy titled, Accidents and Supervision the facility failed to ensure one of six sample residents (R) (R1) received adequate supervision outside to prevent potential accidents. s. This deficient practice had the potential to result in negative safety outcomes, such as falls, accidents and elopements.Findings Includes:A review of Policy titled, Accidents and Supervision revealed, the resident environment will remain as free of accident hazards as possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes. 3. Implementing interventions to reduce hazard(s) and risk(s).4. Monitoring for effectiveness and modifying interventions when necessary.Policy Explanation and Compliance Guidelines. 5. Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision. b. Based on the individual resident's assessed needs and identified hazards in the resident environment.A Record Review of R1 electronic health record (EHR) revealed the following diagnoses that included but not limited to Alzheimer's disease, dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbances.Review of R1's Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) with a score of 4.0 indicating severe cognitive impairment. The resident Elopement/ Wandering Risk Evaluation for R1 was implemented on 08/08/2026 after elopement. A note on evaluation states that he should be supervised when outside.A Review of care plans revealed R1 is at risk for elopement, posing safety concerns date Initiated: 06/20/2025. The goal for R1 revealed that he will not leave the facility without a responsible person accompanying him and his safety will be maintained through date initiated 06/20/2025.A phone interview with Licensed Practical Nurse (LPN) on 08/18/2026 at 1:18 PM, LPN AA revealed R1was seen in the rocking chair outside. He was outside for about 15 minutes with other residents. It was between 6PM - 7PM. LPN AA looked outside from nursing station and saw residents heading toward the street walking on grass in parking lot. During this time LPN AA noticed other residents were seen outside with no staff visible. This happened on a Friday two weeks ago. LPN AA admitted that R1 should not have been outside by himself because he has a low BIMS and he is not cognitively intact.Interview on 08/18/2026 at 2:55 PM with Charge Nurse (CN). CN BB stated he was working on 08/07/2026. The incident happened after six. Unit Manager heard staff say R1 was outside in parking lot. CN BB confirmed that he saw LPN AA walking to R1, then walking towards building bring him back to the building. Unit manager revealed that R1 normally goes outside with staff. He confirmed that this incident had the potential of an accident he should never have been outside without staff.Interview on 08/20/2026 at 8:58 AM with the Director of Nursing (DON) and Administrator confirmed R! had an Elopement and wandering care plan and interventions were not followed. R1 should have been supervised by staff. They both confirmed that this incident had potential for accidents.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Ice Machines and Portable Ice Carts, the facility failed to ensure that one of one ice machines was clean and sanitized. This had the potential to affect 54 out of 59 residents receiving an oral diet from the kitchen.Findings include:Review of the facility's policy titled, Ice Machines and Portable Ice Carts, with revised date of 4/25/2025, Under the Policy statement revealed, It is the policy of this facility to ensure that ice machines/carts are working in proper order, cleaned, and maintained as per Federal, State, local, or facility guidance, according to manufacturer's instructions and current standards of practice. Under Policy Explanation: revealed, 1. Ice machines can be prone to microbial contamination due to improper handling or storage of ice, poor cleaning or maintenance of equipment, or through ice handling equipment. Proper cleaning, maintenance, and infection control in relation to ice machines is important to decrease the risk of illness to residents, staff and visitors. Under Compliance Guidelines revealed, 1. Ice machines will be cleaned at a frequency specified by the manufacturer or, if manufacturer specifications absent, at a frequency necessary to preclude accumulation of soil or mold.Observation on 8/12/2025 at 10:18 am revealed, a black substance on the inside of the ice machine where the door opens, in the corners/crevices, on both the left and right side.Observation and interview on 8/12/2025 at 10:18 am with the Dietary Kitchen Manager (DKM), confirmed that the ice machine had a black substance when wiped with a white paper towel. She revealed that the ice machine had been cleaned, and she didn't know why that black substance was in the ice machine. The DKM stated that the Maintenance Director was responsible for cleaning the ice machine.Interview on 8/13/2025 at 1:41 pm with the Maintenance Director revealed that he had a schedule that he followed to clean the ice machine and provided the surveyor a copy of the Work History Report schedule.Review of the Work History Report schedule revealed that the Ice Machines/Ice Bins was marked as done on-time on 5/30/2025, 2/27/2025, 11/1/2024 and 8/6/2024. There was no further indication that the Ice Machines/Ice Bins had been serviced since 5/30/2025.

Based on resident and staff interviews, record review, and review of the facility's policy titled Advance Directive, the facility failed to provide residents and/or representatives written information regarding the right to accept or refuse medical or surgical treatment for two out of three Residents (R) (R9 and R33). The deficient practice had the potential to affect the resident's highest practical physical, mental, and psychosocial well-being.Finding include: Review of the facility's policy titled Advanced Directive Policy dated 3/5/2025 under the Policy statement revealed, 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 formulate advanced directives. Under Policy Explanation and Compliance Guidelines revealed, .2. The facility will provide the resident or resident representative information, in a manner that is easy to understand, about the right to refuse medical or surgical treatment and formulate an advance directive.1. Review of the clinical records revealed that R33 was admitted with diagnoses that included but not limited to dementia and acute kidney failure.Review of clinical records for R33 revealed, there was no documentation that the facility provided the resident and/or representative with written information regarding the right to accept or refuse medical or surgical treatment.2. Review of the clinical records revealed that R9 was admitted with a diagnoses that included but not limited to type 2 diabetes and sequelae of cerebral infarction.Review of clinical records for R9 revealed, there was no documentation that the facility provided the resident and/or representative with written information regarding the right to accept or refuse medical or surgical treatment.Interview on 8/12/2025 at 1:30 pm with the Social Worker (SW) revealed that she was not aware of any language in the admission packet where a resident accepts or denies medical or surgical treatment. During the interview, the SW printed the admission packet for R33 and R9. During a review of the admission packets for R33 and R9 with the SW, she confirmed that the paperwork did not include a consent for the residents and/or representatives to accept or deny medical or surgical treatment. Interview on 8/13/2025 at 2:00 pm with the Corporate Nurse confirmed that they did not have an advanced directive with verbiage of a consent for the resident and/or representative to accept or deny medical or surgical treatment in R33's or R9's clinical records.

Based on observation, staff interviews, and review of the facility's policy titled Safe and Homelike Environment, the facility failed to ensure that it maintained a safe, comfortable, and homelike environment for two out of 15 rooms located on the 100 hall. Specifically, the toilet lid was the wrong size in the bathroom of room [ROOM NUMBER]-1 and the paint was peeling from the wall in room [ROOM NUMBER]-2.Findings include: Review of the facility's policy titled Safe and home-like environment dated 4/23/2025 under the Policy statement revealed, In accordance with resident rights, the facility will provide a safe, clean, comfortable home-like environment, allowing the residents to use his or her personal belongings to the extent possible. This includes. Be sure that the resident can receive care and services safely and that the physical layout of the facility maximizes residence independence and does not pose a safety risk. Under Policy Explanation and Compliance Guidelines revealed, 3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment.Observation on 8/12/2025 of rooms [ROOM NUMBERS]-2 revealed that room [ROOM NUMBER]-1's toilet lid did not fit and was wrong size. Further observation revealed that in room [ROOM NUMBER]-2, the paint was peeling from the wall.A walk-through observation on 8/14/2025 at 2:30 pm with the Maintenance director confirmed that the toilet in the bathroom of room [ROOM NUMBER] had the wrong size toilet lid, which did not fit. The Maintenance Director acknowledged that this could lead to possible harm. The Maintenance Director confirmed that the paint was peeling from the wall in room [ROOM NUMBER]-2 needed to be repainted. He explained that he would order a new toilet lid and repaint the resident's wall.

Based on record review, staff interviews, and review of the facility's policy titled Abuse, Neglect and Exploitation, the facility failed to report resident-to-staff abuse immediately, but no later than 2- hours of the allegation to the State Agency for one out of 32 sampled Residents (R) (R68).Finding include:Review of the facility's policy titled Abuse, Neglect and Exploitation, dated 3/25/2025 Under the Policy statement revealed, It is the policy of the facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Under the Reporting/Response section revealed, A. The facility will have written procedures that include: Reporting of all alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies within specified timeframes: a. Immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the event that causes the allegation does not involve abuse and does not result in serious bodily injury. 5. Taking all necessary actions as a result of the investigation, which may include, but are not limited to the following: a. Analyzing the occurrence (s) to determine why abuse, neglect, misappropriation of resident property, or exploitation occurred, and what changes are needed to prevent further occurrences: b. Defining how care provision will be changed and /or improved to protect residents receiving services; Defining how care provision will be changed and /or improved to protect residents receiving services; C. Training staff on changes and administering staff competency after implementation; d. Identification of staff responsible for the implementation of corrective actions: e. The expected date for implementation, and identification of staff responsible for the implementation of corrective actions. The expected date for implementation is to be confirmed, along with the identification of staff responsible for monitoring the plan's implementation. Review of R68's clinical record revealed an admission date of diagnosis, including, but not limited to, schizoaffective disorder, bipolar disorder, and dementia.Review of the Quarterly Minimum Data Set (MDS) for R68, dated 9/24/2024 revealed, for Section C (Cognitive Patterns) revealed, a Brief Interview for Mental Status (BIMS) score of 00 which indicated cognitive impairment.Review of a social worker (SW) progress note dated 9/24/2024 revealed that the SW had been actively looking for an alternate placement for R68, a resident with aggressive behaviors. All of the many facilities that I have contacted deny her. Today, 9/24/2024, the resident snatched the housekeeper's broom from her and threatened to hit her and many other staff members. The resident stated that she wanted the phone to call her guardian, but when I attempted to give her the phone, she threatened to hit me with the broom. The Nurse Practitioner signed a 1013 to have the resident sent to the emergency room Service for an evaluation. The resident has become increasingly aggressive toward staff and other residents. Review of the Incident Summary revealed that on 9/24/2024, at approximately 8:15 am, R68 suddenly got agitated. She threw her breakfast at her (Certified Nursing Assistant) CNA. She pulled off her colostomy bag and smeared feces on the floor. She grabbed a wheelchair and started hitting the door with it. She snatched the broom from the housekeeper and started swaying it at the staff. She threatened to hurt someone. She threatened to kill someone. The social worker attempted to calm her down and get the broom from her. The resident refused to return the broom. The resident would not give staff the broom. The staff notified me. I attempted to talk to R68. She almost hit the Administrator with the broom. I instructed staff to call the police, and the police arrived. The staff got the broom from R68. A 1013 was issued. Police stayed and helped calm R68 down as he waited for transport. R68 was discharged to the hospital. Review of the Facility Reported Incident Report Form dated 9/25/2024 revealed that the verbal and physical abuse towards staff happened on 9/24/2024 however it was not reported to the state until 9/25/2024 which resulted in the facility's failure to follow the required 2-hour reporting regulation for abuse.Interview on 8/13/2025 at 10:25 am with the Administrator revealed that the reason she submitted the facility incident report to the state the next day about the abuse was because it was witnessed. However, she confirmed that it should have been reported immediately or no later than two hours.

Based on staff interviews, record review, and review of the facility's policy titled Discharge Planning Process, the facility failed to ensure one out of four Residents (R) (R68) reviewed for discharges was not inappropriately transferred and discharged against the resident and/or representative wishes. As a result, R68 stayed at the hospital longer than expected until placement could be found at another facility.Findings include:Review of the facility's policy titled Discharge Planning Process dated 4/1/2025 under the Policy statement revealed, It is the policy of the facility to develop and implement an effective discharge planning process that focuses on the residence. Discharge goals, the preparation of residence. To be active partners and effectively transition them to post-discharge care and the reduction of factors leading to preventable readmissions. Under the Procedure section revealed, 10. The facility will assist residents and their resident representatives to choosing an appropriate post-acute care provider (another SNF, HHR, IRF, or LTCH) that will meet the resident's needs, goals, and preferences. (a.) This Social Services Director, or designee, shall compile available data on other post-acute care options to present to the resident, including, but not limited to: i. Data on providers within the residence desire geographic. Area, where available. ii. All the measure data, based on standardized. Patient assessments data, publicly available on CMS Care Compare website. iii. Data on resource use. To the extent the data is available, such as number of residents/patients. Are discharged to the community, and rates of potential preventable hospital rating readmissions. (b.) The facility will ensure that the data used to relevant in applicable to the resident's goal of care and treatment preferences. (c.) The Facility will present provider information to the resident and resident representatives, if applicable, in an accessible and understanding. Format and will answer any questions to assist in the resident/representative's understanding.12. The results of the evaluation in the final discharge plan will be discussed with the resident or resident representative. All relevant information will be provided in the discharge summary to avoid unnecessary delays and the residents discharge or transfer, and to assist the residents in adjustment to his or her new living environment.Review of R68's clinical record revealed diagnoses, that included but not limited to, schizoaffective disorder, bipolar disorder, and dementia.Review of the Quarterly Minimum Data Set (MDS) for R68, dated 9/24/2024 revealed, for Section C (Cognitive Patterns) revealed, a Brief Interview for Mental Status (BIMS) score of 00 which indicated cognitive impairment.Review of the Incident Summary revealed that on 9/24/2024, at approximately 8:15 am, R68 suddenly got agitated. She threw her breakfast at her (Certified Nursing Assistant) CNA. She pulled off her colostomy bag and smeared feces on the floor. She grabbed a wheelchair and started hitting the door with it. She snatched the broom from the housekeeper and started swaying it at the staff. She threatened to hurt someone. She threatened to kill someone. The social worker attempted to calm her down and get the broom from her. The resident refused to return the broom. The resident would not give staff the broom. The staff notified me. I attempted to talk to R68. She almost hit the Administrator with the broom. I instructed staff to call the police, and the police arrived. The staff got the broom from R68. A 1013 was issued. Police stayed and helped calm R68 down as he waited for transport. Review of the FORM 1013-Certificate Authorizing Transport to Emergency Receiving Facility & Report of Transportation (Mental Health) dated 9/24/2024 revealed, it was incomplete and missing the location, referring staff, receiving staff, and telephone number.Review of a progress note dated 9/24/2024 revealed that R68 was discharged to the Behavioral Health Unit on 9/24/2024. There was no documentation of prior arrangements found in the medical records nor was there notification that R68's guardian was made aware of the transfer. Further review of records revealed that no 30-day notice was given to R68 and/or a representative. The facility never received approval for admittance to the Behavioral Health Unit.Interview on 8/12/2025 at 10:30 am with the Social Worker (SW) revealed that R68 had shown many behavior issues in the past, but on 9/24/2024, she was chasing staff and residents with a broom, and she threw her tray at staff and she would not give the broom back to the staff then 911 was called. Further interview revealed that the police took her to the Behavioral Health Unit. The SW admitted that she did not have approval, nor had prior arrangements been made, and she was not sure who gave the verbal instruction to take her there. The SW further revealed the police ended up taking her to the hospital after denial. She confirmed that the 1013 form was incomplete and stated that the interim Administrator gave verbal instructions on where to take R68. The SW also confirmed that she should not have been discharged to the Behavioral Health Facility and that no discharge planning was conducted to ensure a successful discharge. The SW began to explain that after she was taken to the hospital, the resident was denied coming back and was never given a bed hold or a 30-day notice. In a further interview the SW revealed, R68 was a ward of the state, and that she had spoken with a representative, who was distraught because she wanted her to return to the facility until they found a behavioral health unit that would approve R68.Interview on 8/12/2025 at 11:00 am with the Administrator, revealed that she was at the building when R68 was chasing staff with a broom, and she threw her tray at staff and hit them. R68 was also smearing feces on the floor and yelling and cursing at the staff. The Administrator called 911, and the police came to assist and transported her to the Behavioral Health Facility, where she was admitted . However, R68 was not accepted there because she did not have approval to be admitted . The Administrator explained that the police took the residents there without instruction from the facility. After the Administrator was shown the incomplete form for 1013, she admitted that the form did not give instructions on where to take the resident. No prior documentation was found of arrangements being made for transfer. The Administrator stated that she could not have done anything different and that R68's behavior was a danger to herself, residents, and other staff. The Administrator confirmed that R68 was not allowed to return to the facility, even after receiving 1013 services from the hospital.An interview on 8/12/2025 at 11:15 am with the Corporate Nurse revealed that the facility could have done several things differently for R68 such as providing R68 with a bed hold and allowing the resident to return after receiving services from the hospital. The clinical team could have implemented behavioral interventions until they found a behavioral health unit and conducted a proper discharge.A phone interview on 8/13/2025 at 11:34 am with the Director of Behavioral Health of Georgia (DBHG) revealed that R68 was a ward of the State of Georgia. The (DBHG) revealed that the resident was not allowed to come back to the facility and was in the hospital longer than expected due to the facility's decision not to accept her back.

Based on staff interviews, record review, and review of the facility's policy titled Discharge Planning Process, the facility failed to develop and implement an effective discharge plan to ensure a successful discharge for one out of four Residents (R) (R68) reviewed for discharges. Specifically, R68 was not accepted back to the facility after hospital discharge and did not have a discharge transfer to another facility in place.Findings include: Review of the facility's policy titled Discharge Planning Process dated 4/1/2025 under the Policy statement revealed, It is the policy of the facility to develop and implement an effective discharge planning process that focuses on the residence. Discharge goals, the preparation of residence. To be active partners and effectively transition them to post-discharge care and the reduction of factors leading to preventable readmissions. Under the Procedure section revealed, 10. The facility will assist residents and their resident representatives to choosing an appropriate post-acute care provider (another SNF, HHR, IRF, or LTCH) that will meet the resident's needs, goals, and preferences. (a.) This Social Services Director, or designee, shall compile available data on other post-acute care options to present to the resident, including, but not limited to: i. Data on providers within the residence desire geographic. Area, where available. ii. All the measure data, based on standardized. Patient assessments data, publicly available on CMS Care Compare website. iii. Data on resource use. To the extent the data is available, such as number of residents/patients. Are discharged to the community, and rates of potential preventable hospital rating readmissions. (b.) The facility will ensure that the data used to relevant in applicable to the resident's goal of care and treatment preferences. (c.) The Facility will present provider information to the resident and resident representatives, if applicable, in an accessible and understanding. Format and will answer any questions to assist in the resident/representative's understanding.12. The results of the evaluation in the final discharge plan will be discussed with the resident or resident representative. All relevant information will be provided in the discharge summary to avoid unnecessary delays and the residents discharge or transfer, and to assist the residents in adjustment to his or her new living environment.Review of R68's clinical record revealed diagnoses, including, but not limited to, schizoaffective disorder, bipolar disorder, and dementia.Review of the Quarterly Minimum Data Set (MDS) for R68, dated 9/24/2024 revealed, for Section C (Cognitive Patterns) revealed, a Brief Interview for Mental Status (BIMS) score of 00 which indicated cognitive impairment.Review of a progress note dated 9/24/2024 revealed that R68 was discharged to the Behavioral Health Unit on 9/24/2024. There was no documentation of prior arrangements found in the medical records nor was there notification that R68's guardian was made aware of the transfer. Review of the FORM 1013-Certificate Authorizing Transport to Emergency Receiving Facility & Report of Transportation (Mental Health) dated 9/24/2024 revealed, on 9/24/2024 at 0900 R68 appeared to be a mentally ill person requiring involuntary treatment in that he/she appears to be mentally ill. The form was missing the location, referring staff, receiving staff, and telephone number. Further review of medical records revealed that no bed hold notice was given to R68 nor a representative and that the facility never received approval for admittance to [Name of Facility] Behavioral Health Unit.Interview on 8/12/2025 at 10:30 am with the Social Worker (SW) revealed that R68 had shown many behavior issues in the past, but on 9/24/2024, she was chasing staff and residents with a broom, and she threw her tray at staff and she would not give the broom back to the staff then 911 was called. Further interview revealed that the police took her to the Behavioral Health Unit. The SW admitted that she did not have approval, nor had prior arrangements been made, and she was not sure who gave the verbal instruction to take her there. The SW further revealed the police ended up taking her to the hospital after denial. She confirmed that the 1013 form was incomplete and stated that the interim Administrator gave verbal instructions on where to take R68. The SW also confirmed that she should not have been discharged to the Behavioral Health Facility and that no discharge planning was conducted to ensure a successful discharge. The SW began to explain that after she was taken to the hospital, the resident was denied coming back and was never given a bed hold or a 30-day notice. In a further interview the SW revealed, R68 was a ward of the state, and that she had spoken with a representative, who was distraught because she wanted her to return to the facility until they found a behavioral health unit that would approve R68. Interview on 8/12/2025 at 11:00 am with the Administrator verified she was in the building when R68 chased staff with a broom and threw her tray at them. R68 was also seen smearing feces on the floor, yelling, and cursing at the staff. The Administrator stated she called 911, and the police came to assist and transported her to the Behavioral Health Facility however, R68 was not accepted there because she did not have approval to be admitted . The Administrator explained that the police took the residents there without instruction from the facility. After the Administrator was shown the incomplete 1013 form, she admitted that the form did not give instructions on where to take the resident. There were no prior documentation was found of arrangements being made for transfer. The Administrator stated that she could not have done anything different because R68's behavior was a danger to herself, residents, and other staff.An interview on 8/12/2025 at 11:15 am with the Corporate Nurse revealed that the facility could have done several things differently for R68 such as providing R68 with a bed hold and allowing the resident to return after receiving services from the hospital. The clinical team could have implemented behavioral interventions until they found a behavioral health unit and conducted a proper discharge.A phone interview on 8/13/2025 at 11:34 am with the Director of Behavioral Health of Georgia (DBHG) revealed that R68 was a ward of the State of Georgia. The (DBHG) revealed that the resident was not allowed to come back to the facility and was in the hospital longer than expected due to the facility's decision not to accept her back.A bed hold policy was requested but was not provided.

Based on observations, staff interviews, and record review, the facility failed to ensure that the menu was followed to assure the appropriate nutrition was received for residents on a puree diet. This had the potential to affect five out of five residents who received a puree diet at the facility.Findings include: Observation and interview on 8/13/2025 at 10:30 am revealed, Dietary [NAME] (DC) II preparing a meal for the five residents who received a pureed diet. The Dietary Kitchen Manager (DKM) was present and provided a copy of menu and the recipe for Philly steak filet, dinner roll, mashed potatoes, and vegetable juice. Further observation revealed the preparation of the puree meal that included the Philly Steak Filet which consisted of seven scoops of Philly Steak, and four scoops of gravy placed in the food processor, pureed and then checked for consistency. Once the consistency was reached, the processor was emptied, cleaned, and air dried; the station was sanitized; and the processor was prepared for the next item. The Philly Steak was then placed in a 6 serving pan, covered, and placed in the oven for warmth. During the observation, an interview was conducted with DC II that revealed, although the facility had five pureed residents, the kitchen prepares for seven, so that a resident could get an extra serving if they wanted more. DC II then washed her hands and changed gloves, then she added seven rolls and one cup of water and placed them in the food processor, pureed, and checked for consistency. Another 1/3 cup of water was added, then pureed again. Once the consistency had been reached, the rolls were placed in a 5 serving pan and placed in the refrigerator. Once completed the processor was cleaned, air dried, and the station was sanitized. Review of the facility provided Steak Filet 2-ounce (OZ) conv (PHILLY) PU recipe menu revealed, the preparations of ingredients for serving sizes in the amount of 10, 50, 75, 100, and 150; For the serving size of 10 revealed, 10- 3oz steak fillet, 2 Tablespoons-1 1/2 teaspoon of food thickener bulk and 1 1/4 cup of stock bee/soup base conv. The recipe menu did not provide the preparation of ingredients to be used to prepare a puree diet for seven residents and it also specified for thickener to be added to the recipe. Review of the facility provided Dinner Roll (DOUGH) PU recipe menu revealed, the preparations of ingredients for serving sizes in the amount of 10, 50, 75, 100, and 150; For the serving size of 10 revealed, one each, 2 Tablespoons-1 1/2 teaspoon of food thickener bulk, and 1 1/4 cup of water or juice. The recipe menu did not provide the preparation of ingredients to be used to prepare a puree diet for seven residents and it also specified for thickener to be added to the recipe. An interview on 8/13/2025 at 10:50 am with DKM confirmed that the kitchen staff did not follow the menus during the puree process. The menus call for a serving size of 10; however, they only make enough for seven residents. She stated that they reduce the number of servings to have the serving size to equal seven residents.

Based on observations, staff interviews and review of the facility's policies titled, Infection Prevention and Control Program and Medication Administration, the facility failed to ensure infection control practices was maintained during one of two wound care observations and one of one perineal care observations conducted with staff Registered Nurse (RN) RN BB, Licensed Practical Nurse (LPN) LPN CC, Certified Nursing Assistant (CNA) CNA GG, and CNA HH ). The deficient practice had the potential to spread infection to other residents and staff.Findings include:Review of the facility's policy titled, Infection Prevention and Control Program, last date revised 5/19/2025, under the Policy statement revealed, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Under Policy Explanation and Compliance Guidelines revealed, .4. Standard Precautions, a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. B. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. C. All staff shall use personal protective equipment (PPE) according to established facility policy governing use of PPE. Review of facility's policy titled, Medication Administration dated 4/1/2025 under the Policy statement revealed, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Under Policy Explanation and Compliance Guidelines revealed,. 14. Remove medication from source, taking care not to touch medication with bare hand.1. Observation on 8/13/2025 at 9:40 am of wound care conducted with RN BB and LPN CC revealed, they both entered R4's room with a plastic container filled with wound care supplies in hand. RN BB removed personal items on the bedside table belonging to R4 and placed the wound supply container on the bedside table without sanitizing the surface. LPN CC assisted with the removal of the soiled wound dressing. LPN CC used the soiled gloved hands to assist in opening sterile pack of abdominal (ABD) pad dressing on the bedside table, picking up the tube of Medihoney and squeezing the gel onto the ABD sponge. RN BB applied the ABD sponge with Medihoney gel on to the wound bed and held it in place while LPN CC prepared a second and third ABD sponge with Medihoney and handed it to RN BB to apply to the wound. LPN opened a silicone foam dressing with the same soiled gloved hands and passed it to RN BB to apply over the wound site.2. Observation on 8/14/2025 at 10:45 am of perineal care for R3 was conducted with CNA GG, CNA EE, CNA FF and Staff Coordinator/CNA HH revealed, all staff entered the room, sanitized hands, and donned gown and gloves. CNA GG provided the perineal care using wipes, while the other staff held R3 in position. CNA GG she did not stop to wash her hands or use hand sanitizer and apply clean gloves during the perineal care or with transferring the resident to the mobile chair with use of the Hoyer lift. Staff coordinator/CNA HH was observed removing an outer layer of gloves after the perineal care for R3 was complete and prior to transferring her to the mobile chair.Interview on 8/14/2025 at 11:00 am with Staff Coordinator/CNA HH revealed that she received training on infection prevention and control which included proper us of Personal Protective Equipment (PPE), proper hand hygiene and utilizing disinfecting products. CNA HH acknowledged that she wore double gloves during the perineal care procedure as that would keep her from having to walk away to change gloves. CNA HH confirmed that double gloving was not an acceptable practice. During an interview on 8/14/2025 at 11:15 am with CNA GG, the procedure she followed during the perineal care was reviewed. CNA GG confirmed that she did not stop to wash her hands or use hand sanitizer and apply clean gloves during the perineal care or with transferring the resident to the mobile chair with use of the Hoyer lift.Interview on 8/14/2025 at 12:30 pm with the Director of Nursing (DON) confirmed that her expectations when the nurse performs a procedure that they are to wash their hands with soap and water before, between and after each treatments. The DON revealed that during perineal care, her expectations are for staff to adhere to enhanced barrier precaution standards which include use of gowns and gloves when giving direct patient care explaining that when in the room, they are to wash hands, don gown and gloves to complete perineal care. After perineal care is complete, they are to remove soiled gloves, sanitize hands and don clean gloves to proceed with assisting the resident with transferring. The DON confirmed that double gloving was not an acceptable practice when rendering resident care.

Based on record review, staff and family interviews, and review of the facility policy the facility failed to provide supervision and failed to ensure that coffee was served at a safe temperature for one of one residents (R#10) reviewed for [CONDITION(S)]. Actual harm occurred on 8/10/2021, when R#10 sustained [CONDITION(S)] to his right thigh after spilling coffee on himself when he was allowed to self-transport hot coffee via wheelchair without staff assistance. Findings include: Review of the facility policy titled, Hot Beverages Brought in from the Outside (2021) purpose identified to ensure safety when dealing with hot temperature fluids and beverages . Liquids at 135 degrees Fahrenheit or higher can cause severe burning and even blistering. Record review revealed R#10 was admitted to the facility 11/7/2007 with diagnoses that included anxiety disorder, [CONDITION(S)], dysphagia, [CONDITION(S)], type 2 diabetes mellitus with diabetic [CONDITION(S)], and [CONDITION(S)]. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed R#10 was assessed to have a Brief Interview for Mental Status score of 99 which indicated severely impaired cognition. The resident was never/rarely made decisions regarding tasks of daily life with short and long-term memory deficits. R#10 required extensive assistance with one-person physical assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Supervision- oversight, encouragement or cueing with setup help was needed for locomotion on unit, locomotion off unit, and for eating. Record review of a progress note for R#10, dated 8/10/2021 at 10:05 a.m. revealed the following, The resident is being assisted with personal care and dressing this morning by the CNA (certified nursing assistant). Upon removing his pants an inflamed area noted to his right thigh. The areas skin looks like a deflated blister to the right thigh approx. 5.0 centimeters (cm) x 2.5 cm in size. No drainage noted to the area and the skin is approximated. The resident does not show any non- verbal cues of pain, nor does he voice any pains. (sic) The MD was notified with new orders given. In addition, the family was notified. Record review of the Physician orders for R#10 revealed an order dated 8/10/2021 that documented, Monitor the inflamed area to the right upper thigh daily and apply [MEDICATION(S)] cream topically every day until the area is resolved. Every day shift for inflamed area to right thigh. The order had a start date of 8/11/2021. Further Record review revealed an order dated 8/11/2021 that documented the following: monitor right top of inner thigh for signs and symptoms of infections Q (every) shift. Every shift for burn to right top of inner thigh for 14 days. The order had a start date of 8/11/2021 and an end date of 8/25/2021. Review of a Facility Incident Report dated 8/11/2021 documented the type of injury as a skin burn with the details of the incident being documented to be: Resident (R#10) had coffee, holding it on his wheelchair seat and spilled the coffee on his right inner upper thigh. Injury was documented to be a coffee burn to the area described. Treatment was required and included cleaning the area, applying [MEDICATION(S)] (a topical antimicrobial medication used to treat [CONDITION(S)]), and the area was covered. The incident report documents that the Physician and the Responsible party were both notified. During an interview on 3/30/2022 at 11:45 a.m., with the Family of R#10 revealed the resident had a burn to his right thigh in August of 2021. Stated she phoned the police because she felt as if he had been burned. During an interview on 3/30/2022 at 2:00 p.m. with Licensed Practical Nurse (LPN) AA, she revealed she was working the day of the incident, which occurred in the morning time. LPN AA stated she was in the hall passing medications and Certified Nurse Assistant (CNA) BB, called her to R#10's room and showed her the area to R#10's right upper leg. She further revealed she observed R#10 had what appeared to be a burn about 3 ½ inches by 2 ½ inches in size. LPN AA stated the area appeared to be a pink to red blister. LPN AA stated she phoned the primary care physician and received new orders to treat the area. During an interview on 3/30/2022 at 2:20 p.m. with CNA BB revealed that he was preparing to provide ADL care (activities of daily living care) for R#10 and when he removed R#10's pants, he noticed an area on the residents right leg that was watery and puffy. CNA BB reported that he called the nurse to look at the area. During an interview on 3/30/2022 at 3:09 p.m. with the Wound Care Nurse (WCN) revealed she was not employed at the facility at the time the incident occurred with R#10, however, she did treat the area when she started working at the facility. WCN revealed the area was treated for approximately 2 weeks after she started before it was healed and that during her initial observation of the area she assessed the area to be approximately 1 centimeter (cm) by 1 cm in size. During an interview on 3/30/2022 at 3:17 p.m. with Dietary Cook CC revealed the coffee in the kitchen gets very hot and, in her opinion, it was hot enough to burn a resident. It was further revealed that R#10 had a two-handled plastic cup with a lid that is used when he gets coffee. Dietary Cook CC also confirmed that R#10 likes to place the cup between his legs. A post survey interview on 4/14/2022 at 12:38 p.m. with the Administrator revealed that he became the Administrator at the facility in September 2021. He reported that since being at the facility staff have used ice cubes in the coffee to bring the temperature down. He explained that staff hold the cup until the ice cubes have melted and then the cup is given to the resident. The Administrator stated there are no other monitoring systems in place other than the ice cubes in the coffee.

Based on record review, staff interviews the facility failed to ensure that the staff designated as Dietary Manager was a Certified Dietary or Food Service Manager or had a similar food service management certification or degree. This had the potential to affect 68 residents receiving an oral diet. Findings include: Review of the job description for Dietary Manager (DM) (revised 4/11) revealed entry qualifications that included but not limited to graduate of dietary manager certification course as applicable and long-term care or acute care facility experience preferred. Further review revealed DM signed the job description on 10/25/19. During an interview with the DM on 3/2/2020 at 10:30 a.m. revealed that she began working at the facility on October 2019. The DM revealed that she is Serve Safe certified but denies that she was a Certified Dietary Manager (CDM). The DM explained that she was supposed to be signed up for the classes this week. During an interview with the Administrator on 3/6/2020 at 10:40 a.m. revealed that the Dietitian is at the facility at least once per month but is not at the facility at least 30 hours or more per week. The Administrator revealed that a visiting CDM assists the current DM but was not in this facility daily. The Administrator revealed that she was not aware of the regulations related to requirements for the DM.

Based on observation, staff interviews, and review of the facility policy titled, Storage, Food storage and family members, Nutritional Services Manual the facility failed to ensure that items were labeled/dated and used before the expiration date in the kitchen, emergency food storage, and in one food pantry. Failed to ensure that the ice machine was maintained in a sanitary manner. The facility failed to ensure that the dry storage area and microwave in the kitchen were clean and items in the kitchen were labeled and dated. Failed to log refrigerator and freezer temperatures. This deficient practice had the potential to affect 68 residents receiving an oral diet. Findings include: Review of the policy titled Food storage and family members dated [DATE] all food is stored in the unit refrigerators. All food should be labeled, dated, and covered with a use by date. All unit refrigerators will have a thermometer on the inside and this will be recorded. Review of policy titled Storage with a revision date of [DATE] indicated all food items stored after opening or preparation will be covered, labeled, and dated. It further indicated that dry food items are placed in a clean, ventilated storeroom according to the inventory sheets. Lastly, all items are placed on shelving units, at least 6 off the floor. Review or policy titled Nutritional Services Manual dated ,[DATE] revealed the following: Procedure 4. utilize the First in, First out (FIFO) method when stocking and rotating product. 5. Ensure all food and chemical containers are labeled with name and dated received. Review of the Preventive Maintenance documented: Schedule: At some sites the water supply to the ice machine will contain significant quantities of minerals, and that will result in a water system becoming coated with these minerals, requiring more frequent maintenance than twice per year. Bin Liner Cleaning and Sanitizing: At the same time of scale removal and ice machine sanitation. Review of the maintenance system preventative maintenance the ice machine should be have filters checked, coils cleaned, and inside sanitized every three months. During the initial kitchen tour on [DATE] at 10:30 a.m. with the Dietary Manager (DM) the following was revealed: 1. In the walk-in cooler there was an open bag of sausage with seven sausage patties with no open dated noted. 2. There was a 15-pound box of bacon that did not have an open date or expiration date. 3. There were multiple boxes of juice cups (orange, cranberry, and apple) that did not have a thaw date. The instructions on the box suggested that the juices be used within 14 days of thawing. 4. There were two white containers with flour and cornmeal in each but neither had an open date or a use by date. 5. There were two bags of strawberry yogurt with a use by date of [DATE]. 6. There was a box of cucumbers with one cut cumber being in a clear storage back with no date. 7. There was food splatter in the microwave. 8.11:10 am observation of the ice machine revealed black buildup on the lip of ice machine. During a second kitchen tour on [DATE] at 3:05 p.m. with the Dietary Manager the following was revealed: 1. In the dry storage area there were four bags of vanilla wafers dated with an in date of [DATE] but no expiration dated noted. 2. There was a container with saltines that did not have an in date or an expiration date. 3. There were four 9-ounce (oz) packages of taco seasoning with no expiration date. 4. There was a rice container half full with the lid opened. 5. There was a sugar container that did not have an in date or an expiration date. 6. The containers with Frosted Flakes, Rice Krispies, and Raisin Bran had a use by date of [DATE]. 7. There was a container with Cheerios that did not have a use by date. 8. In the emergency food area there were six Tropicana Grapefruit juices with an in date of [DATE] and an expiration date of [DATE], Frosted Mini Wheats with an in date of [DATE] and an expiration date of [DATE], and eight 1.77-liter containers of cranberry juice with an expiration date of [DATE]. Observation of the Resident Pantry on [DATE] at 4:03 p.m. with the Dietary and the CDM revealed the following: 1. In the freezer there was one party pizza with a best by date of [DATE] and enchiladas with a best by date of [DATE]. It is noted that none of the items in the freezer had a name on them. 2. In the refrigerator there was a container of mayonnaise with an open date of [DATE] and a best by date of [DATE]. During an ongoing interview with the DM on [DATE] from 10:30 a.m. until 11:15 a.m. revealed that the Dietary Manager reported that the sausage was opened this morning. It was then reported that the flour and cornmeal were placed in the plastic containers a week ago. It was also reported that the items normally don't stay in the containers longer than a week. The Dietary Manager reported that the microwave is wiped down after each use and confirmed the splatter in the microwave. The Dietary Manager then reported that she cleans the filters for the ice machine weekly, but she is not aware of who is responsible for cleaning the ice machine. She reported that she had not cleaned the inside of the ice machine since she had been employed at the facility. During an interview and observation on [DATE] at 9:18 a.m. with the Maintenance Director he confirmed that there was a black buildup on the ice machine liner. During an observation on [DATE] at 11:35 a.m. with Cook LL in the prep area Cook LL was observed pouring a partially used bag of cereal into a container that was already filled with cereal. There was a total of four cereal containers on the shelf that did not have in dates or use by dates. During an ongoing interview and observation with the Dietary Manager and CDM on [DATE] from 3:05 p.m. until 3:45 p.m. In the dry storage area, the Dietary Manager confirmed the buildup on the floors in the dry storage area and revealed that housekeeping had stripped the floor before, but the storage room should be cleaned daily. The CDM reported that she visits the facility once a month and reported that items in containers (sugar, flour, and cornmeal) should have an open date and expiration date. The CDM revealed that the sugar was placed in the container today and should have a date on it. In the prep area in the kitchen the containers with cereal were observed and both the DM and CDM reported that new cereal should never be placed in a container that already had cereal in it. It was reported that cereal containers should be emptied and cleaned prior to new cereal being placed in it. Interview on [DATE] at 4:03 p.m. with Dietary Manager who reported that the pantry refrigerator was to be checked daily and she was responsible for doing so. The Director of Nursing (DON) reported that the resident and staff share the pantry refrigerator. During an interview with the Administrator on [DATE] at 8:17 a.m. revealed that it was her expectation that the ice machine be cleaned once a problem area has been identified. She revealed that Maintenance will now put ice machine cleaning on the monthly schedule. Upon review of the picture of the ice machine with the black build up she stated that the machine will have to be cleaned now. During the emergency water tour with the Housekeeping Supervisor on [DATE] at 2:45 p.m. there were six 5-gallon containers of water observed sitting on the floor with another 25 5-gallon containers sitting on a pallet. The Housekeeping Supervisor confirmed that the water should not be sitting on the floor. During an interview with the Administrator on [DATE] at 10:40 a.m. revealed that the dietary staff are responsible for checking for expired items in the pantry refrigerator as well as for cleaning of the pantry, and dietary is responsible for logging refrigerator and freezer temperatures in the pantry area. During a review of refrigerator and freezer temperature logs for the pantry on [DATE] the logs revealed missing temperatures for [DATE] included the 14th, 15th, 22nd-26th, and 29th. Review of log for February 2020 revealed missing temperatures from the 10th thru 18th and 20th thru 29th.

Based on observation, staff and resident interviews, record review and review of facility policy titled, Resident/ Patient Grievance Process the facility failed to make information on how to file a grievance or complaint available for five of 33 residents. Findings include: Review of an undated policy titled, Resident/ Patient Grievance Process revealed the facility will provide written Concern/ Complaint Procedure for Residents/ Patients to the resident/ patient and/per family/ responsible party on admission. This includes, but is not limited to Information and explanation of the Concern/Complaint Process How to communicate when you have a concern or complaint Staff assistance in preparing concern/complaint reports Resolving concerns and complaints During a group Resident Council meeting on 3/4/2020 at 10:25 a.m. R#23, R#24, R#25, R#50, and R#53, who were able to respond to interview questions appropriately, stated that they did not know how to file a grievance. Record review of Resident Council Minutes dated 3/5/19 through 3/4/2020 revealed only two grievances had been filed by residents since the last survey in 2019, and neither of those two grievances were filed from residents in this meeting. Review of the Resident Council meeting minutes revealed that there was not any evidence of documentation that education on how to file a grievance had been discussed with the Resident Council. In addition, review of the facility's grievance book revealed that that there was not any evidence that R#23, R#24, R#25, R#50, and R#53 had ever filed a grievance. An interview on 3/4/2020 at 5:15 p.m. with the Social Service Director (SSD) revealed the residents can go to any staff member to file a grievance if she isn't available. The SSD stated that there are also extra grievance forms in the copy room. Once the form is completed, it is taken to the appropriate department. During admissions, residents are educated on how to file a grievance. If the resident is incoherent, their family members are educated on how to file a grievance.

Based on record review and staff interview, and review of the facility's policy titled, Basic Life Support/CPR the facility failed to obtain two Physician signatures and a Guardian signature for a DNR (Do Not Resuscitate) Provider Orders for Life-Sustaining Treatment (POLST) order form for one of 16 residents (R#16) reviewed for Advance Directives. Findings include: Review of the facility's policy titled, Basic Life Support/CPR with no revision date revealed: The purpose is to ensure that the facility is able to and does provide emergency basic life support immediately when needed, including cardiopulmonary resuscitation (CPR), to any resident requiring such care to the arrival of emergency medical personnel in accordance with related physician's orders [REDACTED]. Review of the Quarterly Minimum Data Set (MDS) for R#16 dated [DATE] in section C for cognitive patterns revealed a Brief Interview in Mental Status (BIMS) of 12 indicating the resident was moderate cognitive impairment. Review of the [DIAGNOSES REDACTED]. Review of the Statutory Form Power of Attorney revealed the R# 16 sister was is the Power of Attorney (POA) for finance and not healthcare. Review of POLST dated [DATE] for R#16 revealed a section was checked for: Do Not Resuscitate (DNR) There were not any Physician's signatures on the document. Review of the Front sheet labeled stop revealed R#16 was a DNR. Review of the MAR indicated [REDACTED] Review of the care plan updated date [DATE] revealed R#16 was FULL CODE Review of the Social Service progress notes dated [DATE] revealed Upon reviewing POLST status residents' sister signed a new POLST on [DATE] to change status from FULL code to DNR. The POLST required two Physician's signatures due to sister signing. An interview on [DATE] at 2:57 p.m. with Staff AA stated that she goes over the POLST and advanced directives with the resident or the resident's responsible party (RP) via the admission packet and if she isn't present then the nurses complete the admission packet with the resident / resident's RP. Staff AA said the POLST/advanced directives must be completed before the resident gets to the building. An interview on [DATE] at 3:01 p.m. with Staff AA (Admission/Marketing Director) and Social Service Director (SSD) BB R#16 was a FULL CODE and when the resident was hospitalized , his sister made the decision to change R#16 to DNR on [DATE]. SSD BB indicated the doctor was not in facility at the time of change and a copy is placed on the chart and the original document was taken to the doctor's office for a signature. SSD BB agreed that R# 16 would remain a FULL CODE until the DNR POLST dated [DATE] was signed. An interview on [DATE] at 3:09 p.m. with LPN CC revealed that she identifies a resident as being a FULL CODE or DNR from the Medication Administration Record [REDACTED]. LPN CC revealed via the MAR indicated [REDACTED]. An interview on [DATE] at 5:16 p.m. with SSD BB verified that R#16 was not provided on the code status list indicating a code status of DNR or FULL CODE. She said that the resident doesn't have an advanced directive which list the sister as the POA. She said the sister is the POA of finance and confirms the resident has decision making capacity. She also confirms R# 16 returned to the facility from the hospital on [DATE] and states the resident should have been on the code status list printed by the pharmacy. She confirms R# 16 doesn't have any documentation which would give his sister permission to make decisions regarding his healthcare.

Based on observations, record review, staff interviews and review of the facility policy titled, Condition Change of the Resident the facility failed to promptly notify the responsible party for a change in condition for one of 33 residents (R) (R# 218) reviewed for change in condition. Findings include: Review of the policy titled, Condition Change of the Resident Documentation Guidelines revealed: Notification of the resident's responsible party, including date and time of changes in the resident's medical/mental condition and/or Status. Policy Interpretation: The Licensed Nurse or other, will notify the resident's Attending Physician or on-call Physician when there has been a significant change in the resident's physical/emotional/mental condition. Record review revealed that R#218 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident has a Brief Interview for Mental Status (BIMS) of12 indicating that the resident had moderate impaired cognition. A review of the nurses notes for R# 218 dated 10/11/19 revealed the resident complained of shortness of breath. Further review revealed that R# 218's Physician was notified, but there was not any documentation that the resident's representative or family member was notified of the resident's change in status. An interview on 3/6/2020 at 1:26 p.m. with the Director of Nursing (DON) revealed that the DON's expectation was that the Physician and family be notified whenever there was a change in the resident's condition.

Based on record review, staff interviews, and review of the facility's policy titled, Baseline Care Plan/Summary the facility failed to ensure that the baseline care plans were completed and reviewed with residents and/or family within 48 hours for three of 20 Residents (R's) (R#14, R#37 and R#118) of 20 residents reviewed. Findings include: Review of the policy titled, Baseline Care Plan/Summary documented that a baseline care plan for each resident will be developed within 48 hours of the resident's admission to this facility. It further documented that a written summary of the baseline care plan will be provided in a language that the resident/representative can understand. Documentation in the resident's medical record will reflect that the summary or a copy of the baseline care plan was given to the resident/representative. There was no date indicated when this policy was initiated. 1. Review of medical record for R#14 revealed [DIAGNOSES REDACTED]. Review of baseline care plan revealed the resident was admitted on [DATE] however, review of the form did not indicate that form was completed. There was no completion date and there was no evidence that the baseline care plan was reviewed with the resident or family. 2. Review of medical record for R#37 revealed [DIAGNOSES REDACTED]. Review of baseline care plan for R#37 revealed an admitted [DATE] and a completion date of 7/11/19. There was no evidence that resident/representative were involved as evidenced by no signatures or documentation that the baseline was reviewed with the resident/family. 3. Review of medical record for R#118 revealed [DIAGNOSES REDACTED]. During review of the baseline care plan for R# 118 there was an admission date of [DATE], but further review did not reveal a completion date. There was also not any evidence that the baseline care plan was reviewed with the resident or representative or completed within 48 hours. During an interview on 3/5/2020 at 12:34 p.m. with the Minimum Data Set (MDS) Coordinator revealed that nursing staff was to complete the baseline care plan and she updates it until the comprehensive care plan is completed. During an interview with the Social Services Director (SSD) on 3/6/2020 at 8:55 a.m. revealed that upon admission a 72-hour meeting is set up with residents and family members but denies that the baseline care plan is reviewed at that time. During an interview on 3/6/2020 at 12:28 p.m. with Licensed Practical Nurse (LPN) KK revealed that baseline care plans are completed typically the day that residents are admitted to the facility. LPN KK reviewed care plans for R#14 and R#37 and acknowledged that a completion date and date reviewed with resident/family should be documented. An interview on 3/6/2020 at 12:40 p.m. with the Director of Nursing (DON) revealed that the baseline care plan was to be completed immediately upon admission by the charge nurse and that the baseline care plan is then discussed during the 72-hour care plan meeting. The DON acknowledged that the date of completion date should be documented on the baseline care plan as well as the date it was discussed with the resident and/or family.

Based on observation, record review, and staff interviews the facility failed to follow the care plan related to potential alterations in cardiac function for one of 33 (R#218) residents reviewed for care plans. Findings include: Review of the medical record for R #218 revealed a [DIAGNOSES REDACTED]. Review of the the care plan for R#218 dated 10/15/19 revealed an intervention to assess for shortness of breath. Nursed notes dated 10/12/2019 at 5:40 p.m. documented the following: Resident comes rolling up the in his wheelchair asking for his O2 (oxygen) Sat (saturation) to be checked. He (R#218) was informed he needs to return to his room and get back on his O2. Further review revealed there was not any evidence of documentation that R#218 was assessed for shortness of breath. During an interview with the Director of Nursing (DON) on 3/6/2020 at 1:26 p.m. The DON revealed that it was her expectation that the care plans are followed and that R#218 should have been assessed for shortness of breath.

Based on observation, record review and staff interviews, the facility failed to follow Physician's order for a 1500 milliter (ml) fluid restricted diet for one of 33 residents reviewed for diet. Findings include: A closed record review of the medical record for R#218 revealed a Physician's dietary order for a 1500ml fluid restricted diet but further record review revealed R#218 received a regular diet. During an interview with the Director of Nursing (DON) on 3/6/2020 at 1:26 p.m. revealed that the nurse should have checked the orders for R#218 and the DON revealed that R#218 should have received the 1500ml fluid restricted diet.

Based on observation and staff interview, the facility failed to ensure that infection control practices were followed during wound care for one resident (R#5) of three residents reviewed for wound care. Findings include: Observation on 3/4/2020 at 10:16 a.m. of wound care with Licensed Practical Nurse (LPN) JJ for R#5 revealed LPN JJ picked up the 4x4 gauze squares with her bare hand. Observation revealed that she scratched her lip, she then placed the trash bag in the trashcan and moved the trash can within reach. The LPN then washed her hands and turned off the faucet and closed the bathroom door with a paper towel. Further observation revealed that LPN JJ moved R#5's urinary catheter and with the same gloves on removed the resident's dirty dressing without washing her hands or sanitizing and changing her gloves prior to removing the dressing. An interview on 3/4/2020 at 10:54 a.m. with the LPN Wound Care Nurse JJ revealed that she had been to a wound care class but was not certified in wound care. She confirmed that she handled the 4 x 4 gauze squares with her bare hands when she was setting up the supplies for the wound care, and she also confirmed that she didn't sanitize her hands, remove her gloves and don clean gloves after moving the resident's urinary catheter. LPN JJ stated that she should have asked the other staff to move the urinary catheter or she should have removed the contaminated gloves, washed her hands and donned clean gloves. An interview on 3/5/2020 at 9:00 a.m. with the Director of Nursing revealed that her expectation was that the nurses would follow infection control practice and should not have touched the 4x4 gauze squares with her bare hand and that she should not have touched the urinary catheter and then removed the resident's dressing with the same gloves.