Every finding on record at Woods at Sparta of Journey LLC, The

Based on observation, staff interviews, and review of the facility's policy titled Food Safety Requirements, the facility failed to ensure sanitary conditions in the kitchen. This deficient practice had the potential to place the 37 residents who received food or nutrition from the kitchen at increased risk of foodborne illness. Findings include:Review of the facility's policy titled Food Safety Requirements, reviewed 7/2025, revealed the Definition section included, Contamination means the unintended presence of potentially harmful substances, including, but not limited to, microorganisms, chemicals, or physical objects.Observation on 12/9/2025 at 9:30 am with the Dietary Manager (DM) in the kitchen revealed one window-unit air conditioner (AC) located above a countertop with a dish rack containing silverware and another containing cups. Observation revealed the AC unit had a buildup of grey, fuzzy substance and black, flaky substance on the vents. The AC unit was turned on and blowing across the racks of dishes. The DM confirmed the findings. Observation on 12/9/2025 at 12:50 pm with the DM in the kitchen revealed the AC above the racks of dishware continued to have a black, flaky substance in the vents. The DM confirmed the findings.Observation on 12/11/2025 at 11:05 am with the DM in the kitchen revealed that the AC unit located above the racks of dishes had been cleaned. The DM stated that maintenance had cleaned the unit and would make cleaning the unit part of the routine maintenance.

Based on staff interview and record review, the facility failed to ensure that one resident (R) (R35) with a qualifying diagnosis, from a sample of 28 residents, was referred to the appropriate state-designated authority for Level II PASRR (Preadmission Screening and Resident Review). This deficient practice had the potential to place R35 at risk of not having her mental and psychological care needs met. Findings include:Review of the admission Record for R35 revealed diagnoses including, but not limited to, major depressive disorder, dated 10/15/2018, anxiety disorder, dated 10/15/2018, and Post Traumatic Stress Disorder (PTSD), dated 8/22/2024. Further review revealed no diagnosis of dementia or Alzheimer's disease. Review of the Annual Minimum Data Set (MDS) assessment for R35, dated 8/7/2025, revealed that Section A (Identification Information) documented that the resident was not currently considered by the state-level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 13 (indicating little to no cognitive impairment). Section I (Active Diagnoses) documented that the resident had diagnoses, including, but not limited to, anxiety, depression, and PTSD. Review of the Quarterly MDS assessment for R35, dated 11/13/2025, revealed that Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 15 (indicating little to no cognitive impairment). Section I (Active Diagnoses) documented that the resident had diagnoses, including, but not limited to, anxiety, depression, and PTSD. Review of the physician's orders for R35 revealed an order dated 1/10/2025 for Zoloft oral tablet 50 milligrams (mg) 0.5 tablet by mouth one time a day related to PTSD. Review of the clinical record for R35 revealed no PASRR Level II. In an interview on 12/10/2025 at 2:45 pm, the Social Services Director (SSD) confirmed that R35 had diagnoses including PTSD, depression, and anxiety, and did not have a submission for a PASRR Level II. The SSD stated that R35 had qualifying diagnoses for a PASRR Level II submission and should have had one.

Based on record review, staff and resident interviews, review of the facility policy titled, Incidents and Accidents, facility's tool titled Electrical Stimulation Prep, Precautions, and Contraindications, and Operational Manual, the facility failed to ensure three of 19 sampled residents (R) (R14, R15, R30) were free of accidents and hazards. Actual harm occurred on 6/5/2024, when physical therapy staff failed to oversee an electrical stimulation (e-stim) treatment (a device that sends electrical impulses through electrodes attached to the skin to help with physical therapy and fitness) treatment for R14, resulting in a burn to the right leg with 100% slough in the wound bed. Additionally, the facility failed to ensure resident's (R) (R14), (R15), and (R30) safety by having power strips maintained on the floor and bedside table while being utilized with medical equipment. Findings include: A review of the facility's undated policy titled Incidents and Accidents, revealed it is the policy of the facility for staff to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. Compliance guidelines: 6. In the event of an incident or accident, immediate assistance will be provided, or securement of the area will be initiated unless it places one at risks or harm. Any injuries will be assessed by the licensed nurse or practitioner and the affected individual will not be moved until safe to do so. First aid will be given for minor injuries such as cuts or abrasions. 8. The supervisor or other designee will be notified of the incident/accident. 9. The nurse will contact the resident's practitioner to inform them of the incident/accident, report any injuries or other findings, and obtain orders, if indicated. 12. The nurse will enter the incident/accident information into the appropriate form/system within 24 hours of occurrence and will document all pertinent information. 13. Documentation should include the date, time, nature of the incident, location, initial findings, immediate interventions, notifications and orders obtained or follow-interventions. A review of the facility's tool titled Electrical Stimulation Prep, Precautions, and Contraindications, indicated electrical stimulation can be used in an adjunctive treatment in managing many disorders. Contraindications and Precautions: Over areas with diagnosed pathology (e.g., diabetic neuropathy). A review of the facility's tool titled _____ Operational Manual, Warning: Do not use this device under these conditions - On open wounds or rashes, or over swollen, red, infected, or inflamed areas or skin eruptions, or on top of, or in proximity to cancerous lesions; over areas of skin that lack normal sensation. Never apply the electrodes to - If the patient experiences any skin irritation or redness after a session, do not continue stimulation in that area of the skin. General Warnings - Before administering any treatment to a patient you should become acquainted with the operating procedures for each mode of treatment available, as well as the indications, contraindications, warnings, and precautions. Consult other resources for additional information regarding the application of electrotherapy and ultrasound. General precautions - If a patient is injured during treatment discontinue use immediately and contact your dealer about the injury. 1. Review of the Electronic Medical Record (EMR) for R14 revealed a diagnosis that included Type 2 diabetes mellitus with diabetic neuropathy and generalized muscle weakness. Review of the Quarterly Minimum Data Set (MDS) assessment for R14 dated 6/12/2024 revealed a Brief Interview for Mental Status Score (BIMS) of 14, indicating little or no cognitive impairment. Review of the EMR for R14 revealed a physician order dated 5/10/2024 for physical therapy to address the therex, theract, neuro re-ed and electrical stimulation (e-stim) and or ultrasound (U.S.) for right knee pain 1-5 times per week for 30 days. Further review of physician orders revealed an order to wash right lower extremity with soap and water, pat dry, apply Silvadene cream/non-stick dressing daily and as needed with a start date of 6/26/2024. Review of the Physical therapy Evaluation and Plan of Treatment for R14 dated 5/10/2024 revealed a plan of treatment that included Modality application, electric stimulation, manual and modality application, ultrasound, and constant attendance. Goal -Patient will exhibit a decrease in pain at rest to 4/10 in the right knee to increase patient's ability to perform functional transfers with supervision. Record review of the Physical Therapy Treatment Encounter Note for R14 revealed that on 6/5/2024, upon therapist entering R14's room, resident presented with sores around right lower leg appearing to be from e-stim machine. Resident denying two sores origin being e-stim, stating sore on the right inner knee from e-stim the previous day and he has been treating it with antibiotic ointment. E-stim held this day, will follow up. Further review of therapy notes revealed there were not any follow -up notes related to the burns. Record review of the EMR for R14 revealed there was no evidence that the physician or nurse practitioner had been notified related to his burn until 6/16/2024 (11 days later). Review of the therapy progress notes revealed R14 received an e-stim treatment on 6/13/2024 for 20 minutes after the therapy staff were aware of the burn sustained and identified on 6/5/2024. Record review revealed a progress note dated 6/16/2024 that indicated R14's right lower leg was observed to be red and warm to touch, resident verbalized some tenderness to the area. R14 was also observed with an open area below his right knee which he reported occurred with the therapy treatment. Nurse Practitioner (NP) was called, and new orders were received for Bactrim DS, one tablet by mouth twice a day for ten days. Record review revealed a progress note dated 6/18/2024 which indicated a treatment order for the burn sustained for e-stim on 6/5/2024 was not received until 6/16/2024. An order was received for Bactroban and Santyl to the area. Further review revealed the burn was covered and an order was received for Bactroban and Santyl to site. Further review of R14's record revealed a weekly wound observation tool dated 6/18/2024, which indicated the resident had a burn; this was the first observation, and the burn had 100% slough in the wound bed. The burn measured 05 x 05 x 01 millimeters(mm). Record review revealed a progress note dated 6/18/2024 which indicated the e-stim has been discontinued at this time. During an observation and interview on 8/9/2024 at 8:40 am with R14, he stated that he sustained a burn on his right leg at the facility. He further revealed the therapy department had received a new machine that was supposed to stimulate his muscles and nerves in his leg. R14 further stated the girl from therapy entered his room, applied the device to three different areas on his leg, and left the room. R14 was observed to still have brown marks on his leg and a white bandage. R14 further stated that after about 15 or 20 minutes, the areas where the device was applied began to burn him like crazy, so he removed the pads from his leg. The resident stated after removing the device, he noticed, he had three burn marks on his leg. He stated two of the areas on the outer aspect of his right leg were really superficial and eventually left two brown marks, but the area on the inner aspect just below the knee was really bad, deep, and very tender. R14 further revealed that he informed the therapist when she returned to the room, but she just took the machine and left the room. Observations of the room revealed an electrical surge protector on the resident's bedside table with the red indicator light illuminated. There were three cords plugged into the surge protector with a container of clear liquid alongside the surge protector. During an interview on 8/9/2024 at 3:06 pm with the Physical Therapy Assistant (PTA) DD stated that she noticed the two brown areas and an open area on the right lower leg of R14. She further stated that R14 informed her that the e-stim had gotten too hot, and he removed the device from his leg, and the resident informed her not to worry about it. PTA DD stated she documented her observations in the progress notes and informed the Therapy Manager on the day of her observations. She revealed that she always remained with the resident during treatment, which lasted between 15 and 20 minutes. PTA DD further revealed whenever she implemented the e-stim treatment, she monitored the resident for complications, and he never voiced any concerns to her during or after the treatment. PTA DD further stated she failed to communicate her observations to the nursing staff or Administrator. During an interview on 8/9/2024 at 3:49 pm with the Assistant Director of Nursing (ADON) revealed no one from physical therapy alerted the staff about the burn that R14 received during treatment. The ADON reviewed the EMR and verified there was not any documentation in the record to include an event report or change in condition report related to the burn until 8/16/2024. The ADON further stated the nurses should have completed a Situation Background Assessment Recommendation (SBAR) and contacted the physician or NP after learning of the areas. During an interview on 8/9/2024 at 3:54 pm with Licensed Practical Nurse (LPN) BB, who stated that she learned of R14 having a burn when he informed her and notified the Registered Nurse (RN) Supervisor on 6/16/2024. LPN BB stated no one from the physical therapy department informed her of the incident with the e-stim device. During an interview on 8/9/2024 at 4:05 pm with the Administrator revealed she was aware R14 was receiving treatment for a burn, but she was not aware the burn was sustained during an e-stim treatment with physical therapy. The Administrator further stated she was under the impression that the burn was discovered shortly after his admission to the facility, and he had prior to coming to the facility. During a telephone interview on 8/9/2024 at 4:10 pm with the Regional Rehabilitation Manager revealed she was made aware of the resident sustaining a burn during e-stim treatment, a performance improvement plan (PIP) was put in place, education for e-stim training with the physical therapy staff was provided. The Regional Rehab Manager stated she couldn't change what happened, but she reinforced the education and the training after learning of the incident. Observation on 8/10/2024 at 8:51 am revealed R14 lying in bed with his head covered. The surge protector remains on the bedside table, unsecured, with a red indicator light on and two cords plugged into the device. A follow-up interview on 8/10/2024 at 9:23 am with the Physical Therapy Manager stated she did not document when she was informed of the burn on R14, nor did PTA DD complete an incident report. The Physical Therapy Manager further stated she assumed the PTA DD reported the burn to nursing. The Physical Therapy Manager verified that R14 received e-stim treatment on 6/13/2024 after the therapy staff was aware of the burn and that the e-stim treatments were not discontinued until 6/18/2024. A telephone interview on 8/10/2024 at 9:45 am with PTA EE revealed she administered e-stim treatment for R14. PTA EE further stated the treatments were supervised; she stated someone would always be in there throughout the treatment, most likely. PTA EE stated that R14 never gave her indications that the treatment was hurting. She further stated the Physical Therapy Manager informed her of the burn, and she went and looked at it and observed a hole burned in his leg. She stated she was not sure when the e-stim treatment burn occurred. PTA EE further revealed if she had documented the treatment on the 13th, then she was not aware of the burn, and e-stim therapy is contraindicated to continue treatment on a resident who had sustained a burn. During a follow-up interview on 8/10/2024 at 10:30 am with R14 he stated that he was never informed that the machine could potentially cause a burn. R14 stated that the nurses told him that he needed to go to the doctor due to a deep hole burned in his leg, but they did not do anything for a long while. R14 revealed when he went to the wound doctor for his left amputation, he had the doctor look at the burn, and he gave him some Silvadene cream to put on it. On 8/10/2024 at 11:25 am, the Administrator and Physical Therapy Manager entered R14's room with the surveyor and stated the education with the physical therapy department began on 6/19/2024. She did not give a reason why the education was delayed. A follow-up interview on 8/10/2024 at 2:34 pm with the Infection Control Preventionist (ICP)/Wound nurse, stated R14 had already received antibiotics for treatment, and he went to the wound doctor for his stump. She revealed the wound doctor gave her an order on 6/26/2024 for the Silvadene cream. She stated that R14 reported the burn was very tender. 2. A review of the EMR for R30 revealed a diagnosis that included but not limited to chronic pulmonary disease, generalized anxiety disorder, and major depressive disorder. Review of the quarterly MDS for R30 dated 6/4/2024 revealed a BIMS of 14, indicating little or no cognitive impairment. Observation on 8/09/2024 at 8:33 am and 3:12 pm revealed an unsecured surge protector on the floor with the red light on, indicating it was in use. The surge protector was on the floor at the foot of R30's bed and had the oxygen concentrator, nebulizer, and electrical bed plugged in at the time of this observation. Observation on 8/10/2024 at 8:46 am revealed R30 sitting up in bed eating breakfast. The surge protector continues to be on the floor, unsecured, with medical equipment plugged into the device. During an interview on 8/10/2024 at 10:12 am with R30 revealed the surge protector has been on the floor for over a week. He further stated the Maintenance Director (MD) placed it there when he was repairing their bathroom and never placed it back on the wall. 3. Record review of EMR for R15 revealed a diagnosis that included but not limited to chronic pulmonary disease, heart failure, shortness of breath, and obstructive sleep apnea. Record review of the quarterly MDS for R15 dated 6/14/2024 revealed a BIMS of 5, indicating severe cognitive impairment. Observation on 8/9/2024 at 8:24 am and 3:19 pm in R15's room revealed an unsecured surge protector on the floor at the head of the bed with the oxygen concentrator and electrical bed plugged into the surge protector. Observation on 8/10/2024 at 8:48 am in R15's room revealed the surge protector remained on the floor unsecured with the oxygen concentrator plugged in and the bed. During an interview on 8/10/2024 at 10:18 am with Certified Nursing Assistant (CNA) AA, revealed she was aware that surge protectors were supposed to be mounted on the wall and off the floor for safety reasons. She further stated all staff were responsible for notifying the maintenance supervisor when they were not properly mounted. During an interview on 8/10/2024 at 10:24 am with LPN AA revealed she was never informed that surge protectors should not be on the floor and were required to be mounted if being utilized by medical equipment. LPN AA further stated she could see that unmounted electrical devices could potentially be a hazard. During an interview on 8/10/2024 at 10:31 am with Housekeeping Aide CC revealed she had visualized surge protectors in resident's rooms on the floor and tables but was not aware that was an issue and it needed to be reported. Interview and walking rounds on 8/10/2024 at 10:41 am with the Director of Nursing (DON) and Maintenance Director (MD) verified the unsecured surge protectors on the floor and resident bedside table being utilized with medical equipment plugged into them. The DON stated the MD was responsible for mounting surge protectors on the wall and that surge protectors should never be on the floor. The MD stated he thought surge protectors should be mounted on the wall because it was a trip hazard. The MD further stated he walks around and checks surge protectors weekly, and they were last checked last Friday. The MD revealed further staff informed him yesterday morning (8/9/2024) that there were some surge protectors on the floor, but he didn't have time to mount the surge protectors.

Based on observation, staff and resident interviews, record review, and a review of the facility's Facility Assessment, the facility failed to ensure the physical therapy staff were informed or educated prior to applying an electronic medical device for electrical stimulation treatment (also known as e-stim, which is a treatment method often used in physical therapy and pain management to deliver mild electrical currents through the patient's skin to either target the muscles to stimulate quicker recovery or the nerves to reduce pain) for one of one resident (R) (R 14). Actual harm occurred on 6/5/2024, when physical therapy staff failed to oversee an e-stim treatment for R14, resulting in a burn to the right leg with 100% slough in the wound bed. Findings include: A review of the Facility Assessment, dated 8/8/2024, revealed Purpose Statement: The purpose of this assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Information About Our Staff Training/Education and Competencies: Our facility's training program includes an orientation process and ongoing training for all new and existing staff, including managers, nursing, and other direct care staff, and other individuals consistent with their expected roles. The training content at a minimum includes Effective communication, special needs of residents, and identification of resident changes in condition. Record review of the quarterly Minimum Data Set (MDS) for R14 dated 6/12/2024 revealed a Brief Interview of Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. During an observation and interview on 8/09/2024 at 8:40 am with R14, he stated that he sustained a burn on his right leg at the facility after a girl from physical therapy applied the device in three different areas and left the room. R14 stated the device started burning him like crazy and he removed the device. Once he removed the device R14 stated he saw three burn marks on his leg. R14 revealed that staff should not be allowed to use them as [NAME] pigs to try out new equipment without the proper training. R14 stated the staff did not have any training on the machine and that the Physical Therapy Assistant (PTA) DD informed him she had to go home and look up the operation of the device online. During an interview on 8/9/2024 at 3:01 pm with the Physical Therapy Manager, she revealed that R14 was the only resident with a treatment plan to include e-stim treatment in the last couple of years. The Therapy Manager stated she was not credentialed to administer the treatment, but it was her understanding that once the e-stim treatment started, the staff member applying the device was required to remain with the resident throughout the entire treatment. The Therapy Manager further stated that the therapy staff were not trained nor received education in the facility to ensure they were competent before initiating the e-stim treatment because it is a part of their schooling. During an interview on 8/9/2024 at 3:06 pm with the Physical Therapy Assistant (PTA) DD stated the facility did not provide her with any training on the e-stim device before initiating treatments for R14. PTA DD stated she received modality training while in school, and she can apply the e-stim, but we don't get a certification for it. During an interview on 8/9/2024 at 4:05 pm with the Administrator revealed she believes the therapy staff should have some type of skill checkoff to ensure that they are competent. The Administrator revealed that she was aware R14 was receiving treatment for a burn, but she was not aware the burn was sustained during an e-stim treatment with physical therapy. During a telephone interview on 8/9/2024 at 4:10 pm with the Regional Rehabilitation Manager revealed that there was no training provided to the therapy staff related to the e-stim device before the burn occurred. She stated the therapy staff are trained through their certification on e-stim. She further stated the therapy department has made it a practice from that point forward that the staff will be trained to ensure they are appropriately applying the treatment. During a follow-up interview on 8/10/2024 at 9:23 am with the Physical Therapy Manager, she stated she assumed the Physical Therapy Assistants (PTA)s had more experience as clinicians. During a telephone interview on 8/10/2024 at 9:45 am with the Physical Therapy Assistant (PTA) EE revealed the facility did not provide any formal training on e-stim. PTA EE stated she applied the device on herself to figure it out before she used it on the R14. On 8/10/2024 at 11:25 am the Administrator and Physical Therapy Manager entered R14's room with the surveyor and stated the education with the physical therapy department began on 6/19/2024. She did not give a reason why the education was delayed. Cross Reference F689

Based on observations, staff interviews, and review of the facility policies titled Manual Warewashing-3 Compartment Sink and Food Receiving and Storage, the dietary staff failed to prevent wet nesting with stacks of steam table pans to prevent bacteria growth, failed to store food items off the floor in the dry storage area, and failed to demonstrate the proper usage of the three compartment sink to prevent cross-contamination. The deficient practices had the potential to place 40 residents who received an oral diet from the kitchen at risk of contracting a foodborne illness. Findings include: 1. A review of the facility's undated policy titled Manual Warewashing-3 Compartment Sink revealed the sanitizing procedures for three-compartment sink included to allow pots/utensils to air dry and store pots upside down or covered. Observation on 8/9/2024 at 8:50 am revealed four stacks of steam table pan on a shelf under the steam team. A stack with four square pans were pulled apart which revealed the inside of the top pan was wet with water. Continued observation revealed a stack with five large rectangle pans, and when the top pan was pulled from the stack, the inside was wet with water. In an interview on 8/9/2024 at 8:50 am, the Dietary Manager (DM) confirmed that the inside of the top stacked square steam table pan and the top of the large rectangle steam table pan were wet with water. The DM revealed that dietary staff were to completely air-dry pans before stacking. 2. A review of the facility's undated policy titled Food Receiving and Storage revealed food in designated dry storage areas shall be kept off the floor (at least 18 inches) and clear of sprinkler heads, sewage/waste disposal pipes, and vents. Observation on 8/9/2024 at 8:55 am of the dry storage area revealed two stacks of cases of food on the floor in the dry storage area. One stack had four cases of food items stacked on top of each other. The second stack had six cases of food items stacked on top of each other. During an interview on 8/9/2024 at 8:55 am, the DM confirmed that the two stacks of food items were directly on the floor. The DM stated that they had a grocery delivery yesterday (8/8/2024), and no one had an opportunity to put the groceries away. The DM stated that when her shift ended, she had to punch out and was not able to continue to work, which left the food items in the dry storage area on the floor. 3. A review of the facility policy titled Manual Warewashing-3 Compartment Sink included A 3-step process used to manually wash, rinse, and sanitize dishware correctly. Chemical sanitizing solution used according to manufacturer's instruction. Immerse rinsed pots/utensils in sanitizer per manufacturer instructions. A review of the Multi-Quat Sanitizer Product Specification Document revealed: Expose all surfaces to the sanitizing solution for a period of not less than 1 minute. Observation on 8/10/2024 at 10:35 am of the three-compartment sink revealed the facility was utilizing a quaternary chemical solution to sanitize dishware. Continued observation revealed Dietary [NAME] II washed the food processor bowl and blade by washing in soapy water, rinsing with clean water, and then swished the dish items in the sanitizing solution for a second. Dietary [NAME] II did not place the dishware items in an area to air dry, he placed the food processor bowl and blade on the main unit to continue food preparation. In an interview on 8/10/2024 at 10:35 am, Dietary [NAME] II confirmed that he only had the food processor bowl and blade in the chemical sanitizing solution for a second. The dietary cook revealed that dishware should be submerged in the solution for at least 60 seconds. He further revealed that he was nervous, which was why he did not keep the dish items in the sanitizing solution for the recommended period of time. In an interview on 8/10/24 at 10:35 am, the DM revealed that she expected dietary staff to submerge dishware in the sanitizing solution for at least 60 seconds.

Based on observations and staff interviews, the facility failed to properly maintain one of two dumpsters to prevent leakage onto the ground. The facility census was 40 residents. Findings include: Observation on 8/9/2024 at 9:00 am of the dumpster area revealed that the facility had two medium-sized dumpsters located on asphalt behind the building. The dumpster closest to the building was missing the plug located towards the bottom of the dumpster. Continued observation of this dumpster revealed a liquid substance actively dripping from the unplugged hole. During an interview on 8/9/2024 at 9:00 am, the Dietary Manager (DM) confirmed that no plug was in place at the bottom of the dumpster. The DM also confirmed that the unplugged hole was actively dripping a liquid substance onto the asphalt ground. Observation on 8/10/2024 at 9:00 am of the dumpster closest to the building revealed that the plug at the bottom was still not in place. In an interview on 8/10/ 2024 at 9:00 am, the DM confirmed that the dumpster continued to have no bottom plug in place. Observation on 8/11/2024 at 9:30 am of the dumpster closest to the building revealed that it continued to have no plug in place at the bottom side. Continued observation revealed that it was actively dripping a liquid substance onto the asphalt ground. In an interview on 8/11/2024 at 9:30 am, the DM confirmed that there still was no plug in place on the dumpster and that the unplugged hole was actively leaking liquid a substance The DM stated that she notified the maintenance director and was told that he contacted the waste management company to have them bring a plug for the dumpster. In an interview on 8/11/2024 at 12:05 pm, the Administrator revealed that the dumpsters were city-owned and the city maintains them. The Administrator revealed that she had just been made aware that there was no plug in place in one of two dumpsters. The Administrator revealed that the facility does not have a policy regarding dumpsters or waste disposal. In an interview on 8/11/2024 at 1:45 pm, the Interim Maintenance Director (IMD) confirmed that the dumpster closest to the building had no bottom plug in place and was actively leaking a liquid substance. The IMD stated that the dumpsters were owned by the city, and he had contacted the company indicated on the dumpsters and asked if someone was available to bring a plug for the dumpster. The IMD confirmed he was notified on 8/9/2024 by the DM that the plug on the one dumpster was missing. He further stated that the plug likely dislodged during the last garbage pick-up. The IMD revealed that he did contact the waste management company and asked if someone could come this weekend and replace the missing plug. He revealed that he had gone to the hardware store and purchased a plug for the dumpster due to not knowing when the waste management company would come and replace it.

Based on observations, staff interviews, and review of the facility's policies titled Infection Prevention and Control Program and Laundry Services, the facility failed to maintain an effective infection control program by failing to ensure infection control policies were followed during the handling, storage, and processing of linens. In addition, the laundry staff failed to ensure the washing machine was clean and free from chemical deposits, dust, and lint. These failures had the potential to spread infection due to cross-contamination to 40 residents residing in the facility. Findings include: A review of the facility's policy titled Infection Prevention and Control Program, reviewed and revised 1/9/2024, revealed the facility had 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. The Policy Explanation and Compliance Guidelines section included: 12. Linens: a. Laundry and direct care staff shall handle, store, process, and transport linens to prevent spread of infection. b. Clean linen shall be separated from soiled linen at all times. c. Clean linen shall be delivered to resident care units on covered linen carts with covers down. A review of the facility's undated policy titled Laundry Services revealed the Purpose was To assure a clean supply of linens and to protect employees who handle and process the laundry. The policy included: II. Transportation of Linen - A. Clean linen is not to come in contact with dirty linen. IV. Protecting Personnel Who Sort Laundry - A. In the laundry, hand hygiene facilities, and protective barriers (e.g., fluid-resident gowns or aprons, gloves, and masks/face protection) shall be made available to personnel who sort laundry. During a tour of the laundry on 8/9/2024 at 9:05 am, the Laundry Supervisor revealed the facility had one operable industrial washer. The washer was fed washing chemicals by Echo-Lab and observed to have accumulations of chemical residue and dust on the surfaces. Laundry Aide/Floor Tech GG was observed handling dirty and clean laundry without wearing personal protective equipment (PPE). Further observations on the clean side of the laundry revealed an uncovered clothing rack with resident clothing hanging for distribution. In an interview on 8/9/2024 at 9:12 am, Laundry Aide GG stated he was not aware he needed to wear PPE when handling linen in the laundry. He further stated he had observed all the chemical spills and dust on the washer, but he was not sure who was responsible for keeping it clean. Laundry Aide GG also verified the clothing on the rack was clean and ready to be distributed to residents. He further stated he was not aware that the rack needed to be covered and stated he had never witnessed the rack being covered in the laundry or when taken on the hall. In an interview on 8/9/2024 at 9:19 am, the Laundry Manager revealed he had only been in the position for a short while and did not receive any training. He verified the chemical spillage and further stated that the laundry aides were responsible for wiping the washer down and keeping it clean. The Laundry Manager also stated he was unaware the clean clothing rack should be covered or that the laundry staff was required to wear PPE when handling soiled linen and clothes. Observations on 8/9/2024 at 10:34 am revealed Laundry Aide GG leaving the laundry with an uncovered metal laundry basket containing clean linen. Laundry Aide GG went to the 100 Hall, parked the uncovered linen basket directly in front of the dirty linen cart, and began to place linen on the clean linen cart. In an interview, Laundry Aide GG stated he had never been told or witnessed laundry coming from the laundry room to the floor to be covered. He verified the clean linen cart was next to the dirty linen cart and stated it should not be. Laundry Aide GG proceeded to place the linen on the clean linen cart, transported the remaining linen uncovered to the 200 Hall, and loaded the remainder of the linen on that clean linen cart. In an interview on 8/9/2024 at 10:39 am, the Director of Nursing (DON) stated she would ensure the linen on the 100 and 200 Halls was rewashed before being used. The DON confirmed all linen and processed resident clothing should always be covered prior to leaving the laundry. She further stated laundry staff should wear gloves and gowns when handling soiled linen and dirty clothes in the laundry. In an interview on 8/9/2034 at 10:41 am, the Laundry Manager stated he had not witnessed the laundry basket being covered when linen was transported, and he was unsure if it should be covered or not. He further stated no one had informed him, but he was aware that the clean and dirty linen carts should never be together. In an interview on 8/9/2024 at 10:47 am, the Infection Prevention Nurse revealed clean linen should always be covered during transport and clean and dirty linen should never be together. She further stated the laundry aides were required to wear PPE when handling soiled items in the laundry. In an interview on 8/9/2024 at 10:54 am, the Administrator revealed clean and dirty linen should be separated at all times and not stored together. In an interview on 8/10/2024 at 8:57 am, Laundry Aide HH revealed she transported laundry to the floor in the laundry baskets and had never covered it during transport. Laundry Aide HH also stated she had never covered the clothes rack of personal clothing when transporting it to the halls to distribute to residents and had never worn PPE when handling contaminated or clean linen. She stated she had cleaned the chemicals on the washer, but she was not aware of a schedule or who was responsible for cleaning the washer.

Based on staff interviews, record review, and review of the facility policy titled Resident Assessment-Coordination with PASARR (preadmission screening and resident review) Program, the facility failed to ensure two of four residents (R) (R34 and R35) reviewed with a serious mental disorder (MD) were referred for a Level II PASARR assessment on admission or within 30 days of a new diagnosis. This deficient practice had the potential to affect the appropriate level of care and services provided for R34 and R35. Findings include: A review of the facility policy titled Resident Assessment-Coordination with PASARR Program, dated 1/9/2024, revealed the Policy was This facility coordinates assessments with the PASARR program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receive care and services in the most integrated setting appropriate to their needs. 1. A review of the electronic medical record (EMR) revealed that R34 was admitted to the facility on [DATE] with a diagnosis including, but not limited to, Post-Traumatic Stress Disorder (PTSD). A review of the Face Sheet revealed no diagnoses of dementia or Alzheimer's disease. A review of the annual Minimum Data Set (MDS) dated [DATE] revealed section A (Identification Information) documented the resident was not currently considered by the State Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Section I (Active Diagnoses) documented PTSD. A review of the quarterly MDS dated [DATE] revealed Section I (Active Diagnoses) documented PTSD. A review of the EMR revealed a PASARR Level I request dated 2/15/2022 without bipolar disorder marked on the form. A further review revealed no re-submission for a PASARR Level I after R34 was admitted to the facility, and there was no PASARR Level II. In an interview on 8/10/2024 at 3:00 pm, the Director of Nursing (DON) verified there was no PASARR Level II in R34's clinical record. She stated that the PASARR Level I should have documented R34's diagnosis of PTSD. She stated when a resident was admitted to the facility, the Social Service Director (SSD) reviewed the PASARR Level I and the resident's diagnoses to determine if the PASARR Level I, which was submitted before admission, was accurate and should submit an accurate PASARR Level I if the resident had a qualifying diagnosis. She stated if the PASARR submission did not contain accurate diagnoses, the resident could be at risk of not receiving needed services. The SSD was not available for interview. 33548 2. A review of the medical record revealed that R35 was admitted to the facility on [DATE] and had diagnoses including, but not limited to, dementia without behaviors, depression, anxiety disorder, and delusional disorder. A review of the annual MDS assessment dated [DATE] and the quarterly MDS assessment dated [DATE] revealed no PASARR Level II assessment completed. Continued review of the quarterly MDS assessment dated [DATE] revealed R35 had a BIMS (Brief Interview for Mental Status) score of 15 indicating cognition is intact. A review of the medical record revealed a PASARR Level I assessment was completed on 3/16/2024 and indicated that R35's primary diagnosis was not dementia. The section of the PASARR Level 1 that indicates if R35 had a primary diagnosis of serious mental illness was blank as well, as the remaining sections of the assessment sections were blank, revealing no information. An interview on 8/10/2024 at 3:45 pm with the Business Office Manager (BOM) and the DON revealed that a PASARR Level II assessment had not been completed for R35. The BOM revealed that residents admitted to the facility come with a PASARR Level I assessment completed. A continued interview with the BOM revealed that when residents are admitted to the facility from the hospital, such as R35, she assumed that a PASARR Level II assessment was initiated by the hospital and was in progress. The DON revealed that it is the responsibility of the social worker to review the resident's diagnosis and check to ensure that a PASARR Level II assessment has been completed or needs to be completed. The DON revealed that with R35's diagnosis of anxiety disorder, the resident should have been assessed for a PASARR Level II. The DON revealed that the social worker was not available for an interview.

Based on staff interviews, record review, and review of the facility policy titled Abuse, Neglect, and Exploitation, the facility failed to ensure pre-employment screenings, specifically reference checks, were conducted prior to employment for eight of 60 employees. This deficient practice had the potential to place residents residing in the facility at risk of abuse, neglect, and exploitation from staff. The census was 40 residents. Findings include: A review of the facility policy titled Abuse, Neglect, and Exploitation, dated 8/1/2024, revealed the Policy was It is the policy of this facility to provide protection 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. The section titled Screening documented A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. 2. Screening may be conducted by the facility staff itself, third-party agency, or academic institution. 3. The facility will maintain documentation of proof that the screening occurred. A review of employee files on 8/10/2024 with the Business Office Manager (BOM) revealed the following: 1. The Administrator was hired on 2/5/2024 with no reference checks completed. 2. The Director of Nursing (DON) was hired on 6/24/2024 with no reference checks completed. 3. The Dietary Manager was hired on 2/21/2022 with no reference checks completed. 4. The Infection Preventionist was hired on 4/1/2024 with no reference checks completed. 5. The Minimum Data Set (MDS) Coordinator/Registered Nurse (RN) was hired on 7/22/2024 with no reference checks completed. 6. Licensed Practical Nurse (LPN) BB was hired on 4/15/2024 with no reference checks completed. 7. Dietary [NAME] KK was hired on 4/6/2024 with no reference checks completed. 8. RN LL was hired on 4/13/2024 with no reference checks completed. The DON had an active, unencumbered RN license. The Infection Preventionist had an active, unencumbered LPN license. The MDS Coordinator/RN had an active, unencumbered RN license. LPN BB had an active, unencumbered LPN license. There were no concerns identified related to abuse or neglect within the facility. In an interview on 8/10/2024 at 1:00 pm, the BOM stated the Human Resource Director was on leave, and she was filling in for her. She stated she was unable to locate the employee pre-employment reference checks. In an interview on 8/11/2024 at 2:30 pm, the Administrator stated the Human Resource Director was responsible for ensuring the new hire packet of documents was completed and maintained in the employee file. She stated the required documents included a pre-employment reference check. She stated employee reference checks were used to obtain information about the potential employee's character. She confirmed the facility was unable to provide documentation of reference checks or physicals for eight of the employee files reviewed.

Based on staff interviews, record review, and review of the facility policy titled Resident Assessment-Coordination with PASARR (preadmission screening and resident review) Program, the facility failed to ensure one of four residents (R) (R19) reviewed with a serious mental disorder (MD) was referred for a Level II PASRR assessment on admission or within 30 days of a new diagnosis. This deficient practice had the potential to affect the appropriate level of care and services provided for R19. Findings include: A review of the facility policy titled Resident Assessment-Coordination with PASARR Program, dated 1/9/2024, revealed the Policy was This facility coordinates assessments with the PASARR program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receive care and services in the most integrated setting appropriate to their needs. The Policy Explanation and Compliance Guidelines section included .6. The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority. A review of the electronic medical record (EMR) revealed R19 was initially admitted to the facility on [DATE] with diagnoses including, but not limited to, schizophrenia. A review of the Face Sheet revealed no diagnoses of dementia or Alzheimer's disease. A review of the annual Minimum Data Set (MDS) dated [DATE] revealed section A (Identification Information) documented the resident was not currently considered by the State Level II PASARR process to have serious mental illness and/or intellectual disability or a related condition. Section I (Active Diagnoses) documented schizophrenia. A review of the quarterly MDS dated [DATE] revealed Section I (Active Diagnoses) documented schizophrenia. A review of the EMR revealed a PASARR Level I request dated 5/5/2017 revealed schizoaffective was marked as a diagnosis, and dementia was not marked as a diagnosis. A review of a facility-provided document titled PASARR (Level I) Look Up, printed 8/9/2024, revealed the Status documented Pending. A review of the EMR revealed there was no PASARR Level II. In an interview on 8/10/2024 at 3:00 pm, the Director of Nursing (DON) verified no PASARR Level II in R19's clinical record. She stated she was unsure why the PASAR Level II could not be located. She verified that R19's PASARR Level I, dated 5/15/2017, was marked with a diagnosis of schizoaffective disorder, and the status on the PASARR (Level I) Look Up was documented as Pending. She stated the Social Service Director (SSD) typically reviewed potential new admissions and referred for a PASARR Level II if the resident had a qualifying diagnosis. She stated not having a complete and accurate PASARR determination could put the resident at risk of not receiving needed services. In an interview on 8/10/2024 at 3:05 pm, the Business Office Manager stated she received new admission information and reviewed the documentation to ensure a submission for a PASARR Level I had been submitted prior to admission. She confirmed the PASARR Level I, dated 5/15/2017, contained the diagnosis of schizoaffective disorder and the status documented as Pending. She stated that the Pending status indicated that the resident did qualify for a PASARR Level II, and she was unsure why R19 did not have a PASARR Level II. The SSD was not available for interview.

Based on staff interviews, record review, and review of the facility's policy titled Comprehensive Care Plans, the facility failed to develop or implement a comprehensive, person-centered care plan for two of 19 sampled residents (R) (R14 and R15). Specifically, the facility failed to develop a care plan for pain management for R14 and implement a care plan for oxygen therapy for R15. The deficient practice had the potential to place R14 and R15 at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: A review of the facility's undated policy titled Comprehensive Care Plans revealed the Policy stated, It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with residents rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS [Minimum Data Set] assessment. 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 1. A review of R14's electronic medical record (EMR) revealed the Face Sheet documented diagnoses including, but not limited to, type 2 diabetes mellitus with diabetic neuropathy and generalized muscle weakness. A review of R14's quarterly MDS with an Assessment Reference Date (ARD) of 6/12/2024 revealed section GG (Functional Abilities and Goals) documented no functional range of motion of the upper extremities and impairment on one side of the lower extremities. Section J (Health Conditions) documented that R14 had the presence of pain. A review of the Physical Therapy Evaluation and Plan of Treatment dated 5/10/2024 revealed a plan of treatment which included modality application, electric stimulation, manual and modality application, ultrasound constant attendance. The goal included the patient will exhibit a decrease in pain at rest to 4/10 in the right knee to increase patient's ability to perform Functional transfers with supervision. A review of R14's care plan dated 11/30/2023 revealed there was no care plan area for pain management or diagnosis of type 2 diabetes with neuropathy. 2. A review of R15's EMR revealed diagnoses included but were not limited to, acute and chronic respiratory failure with hypercapnia, heart failure, shortness of breath, chronic obstructive pulmonary disease (COPD), morbid (severe) obesity due to excess calories, and obstructive sleep apnea. A review of R15's quarterly MDS with an ARD of 6/14/2024 revealed section O (Special Treatments, Procedures and Programs) documented that R15 received oxygen therapy. A review of R15's care plan, dated 1/5/2024, revealed R15 was at risk for a decline in respiratory function related to a history of oxygen dependence, respiratory failure, shortness of breath/wheezing, pneumonia, and diagnoses of COPD and obstructive sleep apnea. Interventions included administering respiratory treatments per current orders and referring to physician orders for details. During an interview on 8/10/2024 at 2:46 pm, the MDS/Care Plan Coordinator verified a care plans related to pain management and diabetes with neuropathy were not developed for R14. She stated there should have been a care plan area for pain management that included interventions prescribed for pain management, including e-stim treatments. She verified that R15's care plan included administering respiratory treatments per current orders and stated if the resident was not receiving the oxygen as ordered by the physician, then the care plan was not being followed. During an interview on 8/10/2024 at 4:01 pm, the Director of Nursing (DON) verified R14 did not have a care plan developed for pain management or e-stim treatments. She stated she was unaware that the care plans were not developed. The DON further stated all care areas, including medications, diagnosis, and treatments, should be care planned. The DON verified R15's care plan for oxygen and stated the care plan was not being followed. Cross-Reference F695

Based on observation, staff interviews, review of the posted menu, review of the recipe for puree fried chicken, and review of the facility policy titled Food Preparation Guidelines, the dietary staff failed to follow the recipe for fried chicken as printed, compromising the nutrient value. This deficient practice affected six residents who received puree consistency and three residents who received mechanical soft ground consistency from 40 residents receiving an oral diet. Findings include: A review of the resident menu revealed lunch meal to be served included fried chicken, blackeye peas, collard greens, cornbread, and cake. A review of the recipe for Chicken Fried Pureed Thick revealed the ingredients listed were fried chicken, low sodium chicken base, hot water, and food thickener. A review of the facility policy titled Food Preparation Guidelines revealed the cook or designee shall prepare menu items following the facility's written menus and standardized recipes. Foods shall be prepared by methods that conserve nutritive value, flavor and appearance. This includes but is not limited to preparing foods as directed. Observation on 8/10/2024 at 10:40 am of Dietary [NAME] II puree fried chicken revealed he placed three eight-ounce spoons of steamed diced chicken from a stock that was on the stovetop into the food processor bowl and pureed. Dietary [NAME] II stopped the food processor twice to scrape the sides of the bowl and added an unmeasured amount of water. Once the chicken achieved the desired pureed consistency, Dietary [NAME] II placed it in a steam table pan for service. Continued observation revealed Dietary [NAME] II had ground some of the steamed plain chicken in a pan and placed it in the steam table. During an interview on 8/10/2024 at 10:45 am, Dietary [NAME] II confirmed the posted menu and stated the residents were to receive fried chicken for lunch. Dietary [NAME] II revealed he had always used plain diced chicken for fried chicken and stated he steams it in a stock pot with chicken broth. Dietary [NAME] II was unsure if there was a recipe to follow for fried chicken. During an interview on 8/10/2024 at 10:45 am, the Dietary Manager (DM) confirmed that plain steamed chicken was used for preparing the fried chicken indicated on the menu. The DM revealed that they have always used plain diced chicken and not actual fried chicken. The DM revealed that the facility's Registered Dietitian (RD) had not been made aware that dietary staff were using plain steamed chicken instead of fried chicken for puree. The DM stated that she thought as long as it was chicken, it would be fine to use. In a telephone interview on 8/11/2024 at 10:05 am, the facility's RD revealed she had not been made aware that dietary staff was using steamed plain diced chicken instead of actual fried chicken for puree and mechanical soft ground. The RD revealed that she expects dietary staff to follow recipes, and when fried chicken is indicated, it is to be served to all diet consistencies, including puree and ground. The RD stated that actual fried chicken should have been prepared to provide the proper nutrient value as well as for taste/flavor. The RD revealed that the DM should notify her when making any adjustments to recipes.

Based on observation, staff interviews, review of facility menus, and review of the facility policy titled Therapeutic Diet Orders, the facility failed to follow established menus posted to ensure the appropriate nutrition was provided to residents. In addition, the facility also failed to notify the Registered Dietitian (RD) of meal/menu substitutions. This deficient practice affected three residents receiving a mechanical soft ground diet and six residents receiving a puree diet, from 40 residents consuming an oral diet. Findings include: A review of the facility policy titled Therapeutic Diet Orders revealed that the facility provided all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences. A review of the main resident menu and the Diet Spread Sheet revealed the posted lunch meal for all diet consistencies was fried chicken, black eye peas, collard greens, cornbread, and cake. Observation on 8/10/2024 at 12:30 pm of Dietary [NAME] JJ, while plating the lunch meal for residents receiving a mechanical soft ground meat diet, revealed the cook placed ground plain chicken topped with brown gravy, boiled cabbage, blackeye peas, and a slice of cornbread on the plate. Continued observation of Dietary [NAME] JJ plating the lunch meal revealed for residents receiving a puree diet, the cook placed plain puree chicken topped with brown gravy, puree blackeye peas, and mashed potatoes. In an interview on 8/10/2024 at 12:30 pm, Dietary [NAME] JJ revealed that gravy in a pan on the stovetop was brown gravy to use for the ground and pureed chicken. Dietary [NAME] JJ stated they use the brown gravy because that is how they have always served that meal. In an interview on 8/10/2024 at 12:30 pm, the Dietary Manager (DM) confirmed that the posted menu to be served was fried chicken, blackeye peas, collard greens, and cornbread. The DM stated that she did notify the RD they were going to substitute cabbage for collard greens. The DM stated that brown gravy was added to the ground pureed chicken because she thought the residents would like it that way. The DM stated that she does not have the option, when ordering, to purchase chicken gravy which is why they use brown gravy on chicken. Continued interview with the DM revealed that the residents receiving puree consistency were served mashed potatoes for a substitute for puree cabbage and stated they did not have time to puree the cabbage for that meal. The DM also confirmed that the residents receiving puree consistency meals were not served pureed cornbread as listed on the menu and stated that it just was not prepared. The DM revealed that the RD was not notified of the brown gravy being added to the ground and pureed chicken, the substitution of mashed potatoes for pureed cabbage, and not serving pureed cornbread. In a telephone interview on 8/11/2024 at 10:05 am, the facility's RD revealed that she was notified and approved the substitution of cabbage for collard greens for the lunch meal. The RD revealed that she was not notified that dietary staff were adding gravy to ground and pureed chicken. The RD revealed that she was not notified that dietary staff substituted mashed potatoes for pureed cabbage, and she was not notified that dietary staff eliminated serving puree cornbread. The RD stated that dietary staff should serve the menu as posted and should notify her of any modifications to the menu. The RD stated the DM should either call her or send a text message with the food substitution as well as complete the food substitute log sheet which she reviews and signs after review when in the facility.

Based on record review, staff interview, and review of the facility policy titled Use of Psychotropic Medication, the facility failed to ensure a stop date was implemented, not to exceed 14 days for psychotropic medications for one of six residents (R) reviewed for unnecessary medications (R3). Findings include: A review of the facility's undated policy titled Use of Psychotropic Medication revealed as needed (PRN) psychotropic drugs should be used only when necessary and for a limited duration. If the attending physician or prescribing practitioner believed that it was appropriate for the PRN order to be extended beyond 14 days, they would document the rationale in the resident's medical record and indicate the duration of the PRN order. A review of R3's physician orders dated 5/30/2024 revealed an order for 0.5 milligrams (mg) of Ativan (a psychotropic medication used to treat anxiety) by mouth every four hours as needed for anxiety. The order had an indefinite end date. A review of the Medication Administration Record (MAR) revealed R3 was administered Ativan 0.5 mg by mouth on 7/4/2024 at 4:30 pm, 7/10/2024 at 9:00 am, 7/13/2024 at 8:15 am and 9:09 pm, 7/21/2024 at 4:00 am, 8/6/2024 at 9:00 am, and 8/9/2024 at 7:45 am. During an interview with the Director of Nursing (DON) on 8/10/2024 at 12:27 pm, she stated that she and the Assistant Director of Nursing (ADON) had audited resident charts to ensure psychotropic medications had a 14-day stop date. The DON stated that R3's Ativan order should have had a 14-day stop date, but it was overlooked.

Based on observations, staff interviews, record review, and a review of the facility policies titled, Oxygen Administration and Nebulizer Therapy, the facility failed to provide respiratory care consistent with professional standards of practice for two of five residents (R) reviewed for respiratory services (R15 and R30). Specifically, the facility failed to ensure oxygen (O2) was administered as ordered for R15 and failed to properly store the nebulizer mouthpiece, when not in use, for R30. The deficient practices had the potential to cause respiratory distress for R15 and respiratory infection for R30. Findings include: A review of the facility's undated policy titled Oxygen Administration revealed the Policy Explanation and Compliance Guidelines section included: 1. Oxygen is administered under orders of a physician, except in the case of an emergency. 5. Other infection control measures include: e. Keep delivery devices covered in a plastic bag when not in use. A review of the facility's undated policy titled Nebulizer Therapy revealed the Policy Explanation and Compliance Guidelines section included: Care of the Resident: . 15. When medication delivery is complete, turn the machine off. 16. Disassemble and rinse the nebulizer with sterile or distilled water and allow to air dry. Care of Equipment: 7. Once completely dry, store the nebulizer cup and mouthpiece in a [sealed] bag. 1. A review of the electronic medical record (EMR) revealed R15's diagnoses included, but were not limited to, acute and chronic respiratory failure with hypercapnia, heart failure, shortness of breath, chronic obstructive pulmonary disease (COPD), and obstructive sleep apnea. A review of the active physician orders for R15 included an order dated 8/23/2023 for O2 at 2 liters per minute (LPM) continuous. A review of R15's electronic medication record (eMAR) dated July 2024, August 2024, and July 2024, revealed the O2 was not documented as administered. Further review of the EMR revealed there was no documentation of R15 refusing or removing the O2. Observations on 8/9/2024 at 8:24 am and 3:19 pm revealed R15 lying in bed with the O2 tubing and nasal cannula (NC) lying across the bed rail of the bed exposed to the environment, and R15 was not receiving the O2. Observation on 8/10/2024 at 8:48 am, in R15's room, revealed the O2 tubing and NC lying across the bed rail exposed to the environment, and R15 was not receiving the O2. The O2 concentrator (a machine that dispenses O2) was turned on. 2. A review of the EMR revealed R30's diagnoses included, but not limited to, dyspnea and COPD with acute exacerbation. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status Score (BIMS) of 14 (indicating little or no cognitive impairment). A review of R30's care plan, dated 2/9/2022, revealed that R30 was at risk for a decline in respiratory function and/or respiratory distress due to his smoking and disease process (COPD). He uses oxygen per physician's order, as well as jet neb treatment/other respiratory medications. A review of the active physician orders for R30 included ipratropium-albuterol solution (a medication used to control the symptoms of lung disease) 0.5-2.5 (3) milligrams (mg)/3 milliliter (ml) 1 applicator inhale orally via nebulizer four times a day for shortness of breath and wheezing. Observations on 8/9/2024 at 8:33 am and 3:12 pm in R30's room revealed the nebulizer cup and mouthpiece were lying on the resident's bed, unbagged and exposed to the environment. Observation on 8/10/2024 at 8:46 am in R30's room revealed the nebulizer cup and mouthpiece were lying on the bed, unbagged and exposed to the environment. In an interview on 8/10/204 at 10:12 am, R30 revealed he used the nebulizer frequently and had been told to keep it in a plastic bag. He stated the bag had been thrown away and had been missing for a few days. In an interview on 8/10/2024 at 10:18 am, Certified Nursing Assistant (CNA) AA stated she was aware that respiratory tubing should be stored in a clear plastic bag if the resident was not using it. She further stated storing respiratory supplies cuts down on infections and germs and all staff were responsible for ensuring the tubing and mouthpieces were stored while not in use. In an interview on 8/10/2024 at 10:24 am, Licensed Practical Nurse (LPN) BB stated R30's nebulizer should be stored in a plastic bag when not in use. LPN BB confirmed R15's physician's order was for continuous O2 and stated the resident does not like to wear it. LPN BB stated the Nurse Practitioner was aware that R15 did not like to wear the O2, but she had not changed the order because of R15's respiratory history. During walking rounds on 8/10/2024 at 10:41 am, the Director of Nursing (DON) verified that R30's nebulizer mouthpiece was unbagged and exposed to the environment. The DON also verified that R15's nasal cannula was across the bedrail and exposed to the environment. She stated the nursing staff was responsible for ensuring all respiratory circuits were clean and placed in a plastic bag when they were not being used to reduce respiratory infections due to environmental exposure. In an interview on 8/10/2024 at 11:21 am, the DON verified that R15's order for O2 was continuous and that she was aware that the resident does not always have O2 on. The DON further stated the O2 order had been addressed with the Nurse Practitioner, but no changes were made. The DON verified there was no documentation of R15 being noncompliant with the respiratory treatment. The DON further stated the nurse should document noncompliance with physician orders.

Based on record review, staff interviews, and review of the facility policy titled Comprehensive Care Plans, the facility failed to revise the care plan for one resident (R) (R3) who had a change in code status. The sample size was 19. Findings include: A review of the facility's undated policy titled Comprehensive Care Plans, revealed the comprehensive care plan would be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS) assessment. A review of R3's MDS assessments revealed the quarterly MDS assessment was completed on [DATE]. A review of the physician orders dated [DATE] revealed that R3's code status was Do Not Resuscitate (DNR). A review of the Physician Orders for Life-Sustaining Treatment (POLST) document dated [DATE] revealed that R3 had a change in code status from DNR to Allow for Natural Death. A review of R3's care plan revealed the resident was care planned for Full Code status, which indicated the staff was to honor the resident's wish and perform Cardiopulmonary Resuscitation (CPR) in the event of a medical emergency. During an interview with the MDS Coordinator on [DATE] at 3:15 pm, she acknowledged that R3 was care planned for Full Code status. She indicated the care plan should have been revised to reflect a DNR. The MDS coordinator stated the failure to revise the care plan was an oversight. During an interview with the Director of Nursing (DON) on [DATE] at 3:15 pm, she explained that the Social Service Director (SSD) was the person who handled code status changes and reported them to the MDS Coordinator. The DON stated it was her expectation for the MDS Coordinator to revise the care plan when a resident had a change in code status.

Based on observations, staff interviews, and a review of the facility policies titled Maintenance Inspection and Preventative Maintenance Program, the facility failed to ensure a safe, clean, comfortable home-like environment in four of 29 resident rooms (Rooms 111, 113, 102, and 302) and one common area (the Resident Dining Room). The deficient practices placed residents at risk of living in an unsanitary and unsafe living environment and the potential for diminished quality of life. Findings include: A review of the facility's undated policy titled Maintenance Inspection, revealed the Policy of The facility would be maintained to assure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. A review of the facility's undated policy titled Preventative Maintenance Program revealed the Policy of A Preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Observations on 8/9/2024 at 9:10 am and 8/10/2024 at 3:50 pm of room [ROOM NUMBER] revealed five missing tiles on the floor next to the bed next to the hallway door. Observations on 8/9/2024 at 9:10 am and 8/10/2024 at 3:50 pm of the shared restroom of room [ROOM NUMBER] and room [ROOM NUMBER] revealed the light over the sink did not have a cover, only a bare lightbulb. Observations on 8/9/2024 at 9:15 am and 8/10/2024 at 3:55 pm in room [ROOM NUMBER] revealed the baseboards on all four walls had scattered areas of chipped paint. Observations on 8/9/2024 at 9:15 am and 8/10/2024 at 3:55 pm of the restroom for room [ROOM NUMBER] revealed an area of peeling paint on the wall next to the sink, measuring approximately 3 inches wide by 8 inches long, exposing the drywall. An observation on 8/11/2024 at 8:45 am of the Resident Dining Room revealed five ceiling tiles with brown and black discolorations. 35180 Observations of room [ROOM NUMBER] on 8/10/2024 at 9:51 am and 8/11/2024 at 7:51 am and 10:54 am revealed four floor tiles were loose and not fixed in place next to bed 102-1. During an interview with the Administrator on 8/11/2024 at 10:56 am, she confirmed the floor tiles beside bed 102-1 were broken and not fixed in place. The Administrator acknowledged the loose tiles should have been repaired or replaced. 33548 Observation on 8/9/2024 at 9:15 am of room [ROOM NUMBER] revealed a square tile on the left side of the window sill was missing. Observation on 8/11/2024 at 8:35 am of room [ROOM NUMBER] revealed the tile on the window sill remained missing. During observation rounds on 8/11/2024 at 9:50 am, the Administrator and Interim Maintenance Director verified the environmental findings in rooms 111, 113, 102, 302, the restrooms of 109/111 and 113, and the Resident Dining Room. He stated he was unaware of the concerns in rooms [ROOM NUMBERS]. He confirmed he was aware of the missing floor tiles in room [ROOM NUMBER] and stated the Corporate Maintenance Director was aware of the missing floor tiles and was trying to find replacement tiles. He stated he had noticed the discolored ceiling tiles in the Resident Dining Room on 8/10/2024 and would get them replaced as soon as possible. During a continued interview, he stated he conducted observational rounds throughout the facility daily to observe for needed repairs but had no documentation of the rounds or repairs. He stated the Corporate Maintenance Supervisor was in the facility a few times per month to observe for needed repairs and to provide guidance. In an interview on 8/11/2024 at 10:20 am, the Administrator stated her expectations were for maintenance concerns to be repaired and corrected as soon as possible. She stated she would like repairs to be made and for the facility to be maintained in a home-like environment. She further stated the facility was recruiting for a permanent Maintenance Director. In an interview on 8/11/2024 at 10:54 am, the Corporate Director of Procurement, Information Technology, and Maintenance stated she was in the facility at least monthly to conduct observational rounds and provide guidance to the Interim Maintenance Director. She stated she was unaware of the concerns in Rooms 102, 113, 302, or the Resident Dining Room. She confirmed she was aware of the missing floor tiles in room [ROOM NUMBER] and stated she was in the process of finding matching tiles. She stated she and/or the Interim Maintenance Director should have been aware of the observations, and repairs should be made in a timely manner. She further stated the maintenance concerns could cause the residents to feel like their home was less home-like than it should be.

Based on staff interview, record review, and a review of the facility policy titled Notification of Changes, the facility failed to timely notify the health agent of a significant change related to a burn for one of 18 sampled Residents (R) (R14). This deficient practice places the resident at risk for complications such as infection and further deterioration of the burn wound. Findings Include: A review of the facility's undated policy titled Notification of Changes, revealed the facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: 1. Accidents a. Resulting in injury. b. Potential to require physician interventions. Additional considerations: 1. Competent individuals: a. The facility must still contact the resident's physician and notify resident's representative if known. Record review of the quarterly Minimum Data Set (MDS) for R14 dated 6/12/2024 revealed a Brief Interview of Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. Record review of the Physical Therapy Treatment Encounter Note for R14 revealed that on 6/5/2024, upon therapist entering residents' room, R14 presented with sores around right lower leg appearing to be from e-stim machine (a device that sends electrical impulses through electrodes attached to the skin to help with physical therapy and fitness). Resident denying two sores origin being e-stim, stating sore on the right inner knee from e-stim the previous day and he has been treating it with antibiotic ointment. E-stim held this day, will follow up. Further review of therapy notes revealed there were not any follow-up notes related to the burns. Record review of the Electronic Medical Record (EMR) for R14 revealed there was no evidence that the physician or Nurse Practitioner (NP) had been notified related to R14's burn until 6/16/2024 (11 days later). Record review of a progress note for R14 dated 6/16/2024 that indicated R14's right lower leg was observed to be red and warm to touch, resident verbalized some tenderness to the area. R14 was also observed with an open area below his right knee which reported occurred with the therapy treatment. NP was called, and new orders received for Bactrim DS one tablet by mouth twice a day for ten days. During an interview on 8/9/2024 at 3:06 pm with the Physical Therapy Assistant (PTA) DD stated that she noticed the two brown areas and an open area on the resident's right lower leg and documented her observations in the progress notes. The PTA DD further stated that she did notify the Physical Therapy Manager on the day of her observations but did not communicate her observations to the nursing staff or Administrator. During an interview on 8/9/2024 at 3:49 pm with Assistant Director of Nursing (ADON) revealed no one from therapy alerted the staff about the burn that R14 received during treatment. The ADON reviewed the electronic record and verified there was no documentation in the record to include an event report or change in condition report related to the burn. The ADON further stated the nurses should have completed an SBAR and contacted the physician or NP after learning of the areas. Interview on 8/10/2024 at 9:23 am with Physical Therapy Manager stated she did not document when she was informed of the burn, nor did she or PTA DD complete an incident report. The Physical Therapy Manager further stated that she assumed the PTA DD reported the burn to nursing. She further stated it was her mistake by not asking PTA DD if she had reported the incident and for not following up on the incident. A telephone interview on 8/11/2024 at 10:25 am with the Medical Director (MD) revealed he was aware of the burn but was unsure of the timeliness of the notification. He stated he knew the NP was involved and ordered some antibiotics. The MD further stated any burns sustained in the facility should be reported to the provider immediately and the burns should be monitored frequently by staff. Cross Reference F689

Based on observations, staff interviews, record review, and review of the facility policy titled Labeling and Dating Guidelines, the facility failed to discard expired foods in the dry goods storage room and refrigerator. In addition, the facility failed to clean and secure overhead vents in the kitchen. These failures had the potential to promote foodborne illnesses associated with bacterial growth and cross contamination for 45 of 46 residents consuming an oral diet. Findings include: Review of the facility policy titled Labeling and Dating Guidelines not dated revealed: Upon receipt, all items must have a received date and an expiration date. Upon opening, all items must have an open date and a use by date. Observation on [DATE] at 8:50 a.m. of the kitchen refrigerator revealed: An open box of cubed potatoes that was not labeled with content, no expiration date, no open date or use by date on bag. A bottle of ranch dressing with an open sticker of [DATE] that indicated to use within 30 days after opening. A jar of [NAME] sauce with an open sticker dated [DATE] without a lid and covered with plastic wrap on the top; no expiration date or use by date was located on the jar. A bottle of salad dressing with an open sticker dated [DATE], with no neck label or label with content; no expiration date or use by date was located on the bottle. A box of 11 five (5)-ounce containers of honey cream cheese spread with an expiration date of [DATE]. A bottle of extra creamy whip cream with an open sticker of [DATE] and expiration date of [DATE]. A jar of salsa with an open sticker date of [DATE] is not labeled with an expiration date or use by date on the jar. Observation on [DATE] at 8:50 a.m. of the dry food storage room revealed: An open bag of grits that was not labeled with an expiration date, open date or use by date on bag. An open bag of rice with an open date of [DATE] without an expiration date or use by date. Three (3) unlabeled plastic sleeves of saltine crackers in a box of smaller packs of saltine crackers were found with no open date, no expiration date, or no used by date. Four (4) 32-ounce bags of shredded coconut bags with an expiration date of [DATE]. Interview on [DATE] at 8:50 a.m. during the time of the observations with Dietary Manager/Cook revealed she was removing all expired foods as observed. Observation on [DATE] at 8:50 a.m. of the six overhead vents in the kitchen revealed rust and dust on them. One of the vents was not totally secured to the ceiling, and one part was hanging freely. Interview on [DATE] at 9:01 a.m. with the Administrator revealed she was not sure if they have a policy for food storage, and if they didn't have one, she knew they used safe practices. Interview on [DATE] at 9:21 a.m. with the Dietary Manager/Cook and Administrator revealed they label food as they come in and mark them off for so many days to determine the expiration date. They reported that the Dietician comes to the facility on Mondays to check for expired food.

Based on observation, staff interview, and record review, the facility failed to complete an oxygen (O2) therapy care plan for one of 21 Residents (R) (R#2) receiving O2 therapy. This failure had the potential for residents to not receive treatment and/or care according to their needs. Findings include: Observation on 07/25/2023 at 10:30 a.m. of R#2 wearing a nasal cannula for oxygen therapy. His oxygen concentrator was properly dated 7/24/2023 by his bedside at an O2 level of 2.5 liters per minute (LPM). A review of the physician orders dated 7/5/2023 revealed an order for O2 at two-four LPM as needed for low 02 Saturation 89% below every 24 hours. A review of the care plan revised on 7/17/2023 did not include a focus area or interventions for oxygen therapy. Interview on 7/27/2023 at 10:15 a.m. with Registered Nurse (RN) CC verified the physician's orders for O2 at two-four LPM to be administered to the resident. RN CC confirmed that the O2 therapy should be on the care plan. She verified that there was no O2 therapy care plan in place and added it while being interviewed.

Based on observations, resident record review that included hospital records, staff interviews, and review of the Georgia Practical Nurses Practice Act, the facility failed to ensure that for two (2) residents (#1 and #8), on a survey sample of thirteen (13) residents, of which six (6) were fed via gastrostomy tube, gastric feeding orders were followed and to ensure that a resident who was fed by gastrostomy tube received the appropriate treatment and services to prevent complications in tube feeding, in accordance with professional standards of quality. This failure resulted in harm for Resident #1, and resulted in the likelihood of serious harm to other residents with gastrostomy tubes. It was therefore determined that an immediate and serious threat to resident health and safety existed as of July 5, 2010 and was removed on August 26, 2010, at which time the facility implemented a plan to remove the immediate jeopardy. The Georgia Practical Nurses Practice Act, 43-26-30, Article 2, Chapter 2, Standards of Nursing Practice, Section 3F, specifies that the licensed practice nurse maintains safe and effective nursing care rendered directly or indirectly. Chapter 2.3.2 (J) 2 Standards Related to Licensed Practical Nurse Professional Accountability indicates that the licensed practical nurse implements treatments and procedures of client care, and Chapter 2.3.2 (K) indicates the nurse documents care provided. Findings include: Cross refer to F322. 1. Review of the Interdisciplinary Progress Notes for Resident #1 revealed Nurse "AA" found the resident's gastrostomy tube ([DEVICE]) not intact on 7/05/2010 at 5:00 a.m., and replaced the [DEVICE] with a size 20 French (Fr.) catheter. However, the July 2010 Physician's Orders signed on July 2, 2010 documented the resident was to have a size #24 Fr. [DEVICE], and there was no physician's order to change the [DEVICE]. There was no documentation on 7/05/2010 that placement of the tube was checked after replacement prior to administering medications, flushes and feedings, or that the tube was checked for residual and placement every four hours, per the physician's orders. Additionally, there was no documented evidence that the physician was notified of the problems with the [DEVICE]/PEG tube and that it had been changed in the facility. A 7/13/2010 addendum to the 7/5/10 Interdisciplinary Progress Notes( eight (8) days after the [DEVICE] had been re-inserted) documented that [DEVICE] placement was re-checked by the 7-3 nurse, and noted to be intact. During a telephone interview on 8/24/10 at 5:50 p.m., staff member "AA" acknowledged that that on 7/5/2010, he/she had replaced the tube without physician notification and had inserted a #20 Fr. catheter because it was the closest available to the size needed. This staff member said he/she had checked placement by pushing air, then resumed feeding and flushes. During an interview on 8/25/2010 at 1:40 p.m., staff member "BB" acknowledged that on the morning of 7/5/2010 at the beginning of the day shift, he/she verified placement of the [DEVICE] by pushing in air and heard the gurgling sound, but then pulled back and did not receive any residual stomach contents. An Interdisciplinary Progress Note written by nurse "GG" at 10:00 a.m. on 7/5/10 documented the nurse was informed that the resident's respirations were irregular, with short somewhat shallow breaths. The skin was cool and clammy to touch, and an order was obtained to send the resident to the hospital. The hospital Imaging Service report dated 7/05/2010 documented in the History section the impressions of a small pneumoperitoneum, likely related to repositioning, and that the tip of the gastric tube and balloon lay within the intra-abdominal cavity, needing to be repositioned. An Operative Report dated 7/05/2010 documented the Preoperative [DIAGNOSES REDACTED]. The Indications section documented the attempt to reposition the tube by nursing home staff, but that apparently, the [DEVICE] did not re-enter the stomach and was within the peritoneal cavity. The Report further documented that the old [DEVICE] could be seen along the stomach wall, obviously not within the stomach itself. A nursing facility Interdisciplinary Progress Note documented the resident was returned from the hospital on [DATE] at 7:00 p.m., but the next Progress Note, at 11:15 p.m., documented the resident to be vomiting through the trachea, nose, and mouth. The resident was again transferred to the hospital. The hospital Physician's Orders dated 7/11/2010 at 8:40 a.m. documented [DIAGNOSES REDACTED]. A hospital Imaging Services report documented a CT Pelvis with Contrast was performed on July 11, 2010. Findings revealed a large abscess above the bladder, and a second fluid collection in the left hemipelvis adjacent to the sigmoid colon. The Impression documented multiseptated abscess collection within the pelvis, and a smaller abscess collection in the left adnexa. A hospital Progress Note dated 7/12/2010 documented a thick, purulent fluid with solid components were aspirated from the abscess. A review of the laboratory report from the culture and sensitivity of the pelvic abscess fluid revealed it grew out as Lactobacillus Species. 2. Record review for Resident #8 revealed a Physician's Order for August 2010 indicating that a size #20 French gastrostomy tube was to be inserted in the gastrostomy tube site. However, during observation of the gastrostomy tube and site of Resident #8 on 8/25/2010 at 12:10 p.m. with the Director of Nursing, a size #24 French gastrostomy tube was observed in the gastrostomy site. During this same observation, the Director of Nursing agreed that the wrong size tube had been inserted. The above findings were confirmed during interview with Administrative Staff Member "EE" on 8/25/2010 at 3:04 p.m. It was determined that the immediate jeopardy was removed as of August 26, 2010, by which time the facility had completed the following actions: 1. All nurses have been re-educated on the proper method of insertion of gastrostomy tubes. Each one has been observed and checked off via returned demonstration. We have 14 nurses employed and all were trained by the Education Coordinator. Newly employed nurses will be educated on the proper method of insertion of gastrostomy tubes prior to performing this task. This was completed on 8/25/2010. 2. A chart review of those patients with feeding tubes was conducted by Nurse Consultants ( 2 [DEVICE]s and 4 PEG tubes) to assure that the orders were complete, transcribed correctly and are being followed by the nurses. This was completed on 8/25/2010. 3. The DON, Nurse Consultant or designee will conduct random weekly observations of nurses performing tube feedings and/or flushes for the next six weeks. Results will be reported to the Performance Improvement Committee with follow-up action as indicated by the team. This will be ongoing for the next six weeks and then will be reevaluated. 4. Individual supply bins were obtained for the two patients with gastrostomy tubes. This was completed on 8/25/2010. 5. The training kit with reference manual for nurses on this topic was placed by the nurse consultant in the chart room and the nurses have been instructed on the location. This was completed on 8/25/2010. 6. The Performance Review Committee was convened this morning, August 26, 2010 to review the above stated actions. In attendance was the Medical director, Director of Nursing, Nurse Consultant, Regional Vice-President. and Administrator. This plan will be reviewed monthly during the regularly scheduled meeting for three months. The next meeting will be held on September 22, 2010. Based on these corrective plans/actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice had been removed on August 26, 2010. However, the effectiveness of these corrective plans/actions could not be fully assessed to ensure ongoing application and completion. The weekly random observations of nurses performing tube feeding and/or flushes will be ongoing over the next six weeks. This will need to be evaluated for effectiveness and to ensure that the results were forwarded onto the Performance Improvement Committee. Additionally, the results of the Performance Improvement Committee will be reviewed and assessed by the Quality Assurance Committee on a monthly basis for the next three months. The next meeting is scheduled for September 22, 2010. Therefore, the noncompliance continues, with a scope and severity level of the deficiency is decreased to the "E" level.

Based on observations, record reviews, review of hospital records, family interview and staff interviews, the facility failed to ensure that five (5) residents (#1, 5, 6, 8,and 9), on a total survey sample of thirteen (13), six (6) of which were fed via gastrostomy tube, received appropriate treatment and services in accordance with Standards of Care and Physicians' orders. This resulted in serious harm for one (1) resident, (Resident #1), and the likelihood for serious harm to five (5) resident (#5, #6, #8 , #9 and #11). It was therefore determined that an immediate and serious threat to resident health and safety existed as of July, 5, 2010 and was removed on August 26, 2010, at which time the facility implemented a plan to remove the immediate jeopardy. Findings include: 1. Review of Resident #1's Interdisciplinary Progress Notes dated 7/5/2010 at 5:00 a.m., revealed Nurse "AA" found the resident's [DEVICE] not intact at this time. A [DEVICE] was inserted with a size #20 French (Fr) in one attempt. The note further recorded the [DEVICE] was intact, and feeding and flushes were tolerated well. An addendum to the 7/5/10 Interdisciplinary Progress Notes was dated as written on 7/13/2010 at 11:00 p.m., eight (8) days after the [DEVICE] had been re-inserted and three (3) days after the resident returned from the first hospital visit. The Note documented at 5:00 a.m. on 7/5/2010, the resident was resting quietly in bed. The head of the bed was elevated. A report was given to oncoming nurse "BB". [DEVICE] placement was re-checked again by the 7-3 nurse, and was noted to be intact. An Interdisciplinary Progress Note documented as written by nurse "GG" at 10:00 a.m. on 7/5/10 documented the nurse was informed by a staff member that the resident's respirations were irregular. Upon entering the room, the resident was observed taking short somewhat shallow breaths, and the skin was cool and clammy to touch. The physician extender was notified of symptoms and ordered to send the resident to the hospital for evaluation. July 2010 Physician's Orders signed on July 2, 2010 documented the resident had a #24 Fr [DEVICE], and specified to check placement before administering medications, flushes and feedings, and to check for residual and placement every four hours. Additionally, on the second page of these orders, it was documented with a order origination date of 1/06/2010, to clean the PEG tube site with soap and water daily (7-3) and to apply dry dressing to the PEG tube site as needed for drainage. (Thus, raising the question if this tube was a [DEVICE] or a PEG tube.) According to review of the documentation in the Interdisciplinary Progress Notes by nurse "BB", the Physician's orders were not followed related to the [DEVICE]/PEG tube as follows: 1) There was no physician's order to change the [DEVICE]/PEG tube. Yet Nurse "BB" documented in the the tube was replaced on 7/05/2010. 2) Nurse "BB" documented changing the [DEVICE]/PEG tube and re-inserting a size #20 Fr [DEVICE], instead of using the same size tube that had just came out, which was a size #24 Fr [DEVICE]. 3) There was no documentation by the nurses, "AA" or "BB" on 7/05/2010 that placement of the tube was checked prior to administering medications, flushes and feedings, or that the tube was checked for residual and placement every four hours. 4) There was no documentation by nurse "BB" on 7/05/2010 that placement was checked, how placement was checked after re-insertion of the tube, or that residual was checked. 5) There was no documentation the physician was notified that the tube had come out and been replaced by facility staff. A review of the hospital Imaging Service report dated 7/05/2010 documented in the History: Check for PEG tube placement. Repositioned at nursing home. The Impression: 1) Small pneumoperitoneum, likely related to repositioning. 2) Tip of the gastric tube and balloon lies within the intra-abdominal cavity and needs to be repositioned. A review of the hospital Discharge Summary dated 7/10/2010 documented further history obtained from the nursing home revealed the night before the resident was transferred to the ER the PEG tube was changed. A review of the Operative Report dated 7/05/2010 documented the Preoperative [DIAGNOSES REDACTED]. The Procedure was a Esophagogastroduodenoscopy with PEG tube placement. The Indications documented the tube had attempted to be repositioned by the nursing home. Apparently the [DEVICE] did not re-enter the stomach and was within the peritoneal cavity. Because of this the resident is scheduled for EGD and PEG tube replacement. The technique documented the old gastrostomy tube could be seen along the stomach wall; however, it was obviously not within the stomach itself. The gastrostomy tube was then removed and a PEG tube was placed and checked for placement by the Gastroscope which confirmed placement of the [DEVICE] and a flange was passed over the tube and sutured into place. The hospital Progress Notes dated 7/09/2010 at 11:15 a.m. documented surgery was done and it was all right to begin tube feeding at 10 cubic centimeters (ccs) an hour. On 7/10 2010 at 3:00 p.m., the Progress Notes documented to plan to transfer to the nursing home. The facility's Interdisciplinary Progress Notes documented the resident was returned from the hospital on [DATE] at 7:00 p.m. via Emergency Medical Services (EMS) with [DEVICE] intact. The next Progress Note was at 11:15 p.m. and documented the resident was noted to be vomiting through the trachea, nose, and mouth. The physician was called and a request was made to send resident out. The EMS was called for transfer of the resident to hospital. The hospital's Physician's Orders dated 7/11/2010 at 8:40 a.m. documented Diagnosis: [REDACTED]. The notes further documented a plan for a surgical consult for a CT guided percutaneous drainage of pelvic abscess. A report from the hospital Imaging Services of a CT Pelvis with Contrast was performed on July 11, 2010 and the findings revealed there was a large abscess collection with peripheral enhancement located above the bladder situated along the anterior pelvis measuring 16.8 cms in width by 8.6 cms in length and 8.6 cms in thickness. A few fluid-filled collections are seen adjacent to the left uterus. This could represent a 2nd abscess collection and measures 4.5 cms. by 4.3 cms., a second additional fluid collection seen in the left hemipelvis adjacent to the proximal sigmoid colon measures 4.6 cms. by 4.0 cms. by 2.3 cms. The Impression documented Multiseptated abscess collection within the pelvis, the largest measuring 16 cms. x 10 cms. located in the anterior pelvis just above the bladder and posterior to the uterus. Smaller loculated abscess collection in the left adnexa as described. The percutaneous gastric tube was in good position with residual and a smaller amount of pneumoperitoneum compared to the precious exam. A hospital Progress Note dated 7/12/2010 documented patient is scheduled for drainage of pelvic abscess at 10:00 a.m. Additionally, on 7/12/2010, an Invasive Diagnostic Procedure note and Imaging Service report documented a CT guided percutaneous placement of drainage catheter, using a 14-French pigtail drainage catheter which was advanced into the abscess collection. Thick, purulent fluid with solid components aspirated and sent to the lab for culture and sensitivity. Will reassess in the morning or Monday for possible removal. An Imaging Service report dated 7/13/2010 of a CT of Abdomen without Contrast, and a Physician's Progress Note, revealed the pelvic abscess drainage with the Jackson Pratt catheter has been removed with significantly smaller abscess collection. An Imaging Service report dated 7/14/2010 revealed another CT of Abdomen without Contrast was conducted and revealed a reaccumulation of the pelvic abscess, bilateral pleural effusions are appreciated and larger on the left that have progressed since the previous exam, which correlates to the resident's elevated white blood cell count. A Physician's Order dated 7/15/2010 revealed another CT Guided drainage of Pelvic abscess was scheduled, and was done at 7:00 a.m. on 7/15/2010, according to the Invasive Diagnostic Procedure report. A laboratory report from the culture and sensitivity of the pelvic abscess fluid revealed it grew out as Lactobacillus Species. An Imaging Service report dated 7/19/2010 revealed a CT of Pelvis without Contrast was conducted to reassess the pelvic abscess and after removal of the drainage catheter. This report revealed the fluid collection compared to the previous exam was smaller. A hospital Physician's Order dated 7/21/2010 documented to discharge the resident back to the nursing home on that date. A nursing home Interdisciplinary Progress Note dated 7/21/2010 at 12:45 p.m. documented the resident returned to the facility from the hospital. Another note at 2:30 p.m. revealed a family member of the resident summoned the nurse to the resident's room and said the resident had thrown up out of the nose and trach. Further, the family member said the resident had been vomiting that morning before they discharged the resident from the hospital. The family member said he/she wanted the hospital to keep the resident because they knew the resident was sick but was released. While the nurse was assessing the resident the resident vomited a large amount of pink stomach contents. The nurse called the physician and informed him of the resident's symptoms and the physician ordered the resident to be sent back to the hospital. EMS arrived at 2:25 p.m. to transport the resident. The hospital later called at 10:45 p.m. and reported that the resident was transferred to a Medical Center in another city. On 8/06/2010 at 5:00 p.m., it was documented the resident returned to facility. During an interview conducted with family member "B", on 8/23/2010 at 7:30 p.m., this family member stated that the surgeon had told the family that he was 100% sure the abscess came from the tube in the pelvis. The family member also said he/she had approached the Director of Nursing (DON) about the surgeon telling him/her the tube had been put in wrong and the DON became belligerent and argumentative. During a telephone interview on 8/24/10 at 5:50 p.m., staff member "AA" said on 7/5/2010 the resident's [DEVICE] was not intact so he/she replaced the tube and inserted a #20 Fr catheter. This staff member further said he/she had chosen the 20 fr because it was the closest to the size needed that was available. Additionally, the staff person said he/she had checked placement by pushing air and was confident that the tube was in place. She resumed feeding and flushes per gravity and flushed after it infused. This staff member said there was no problem with the tube when the shift was over at 7 :00 a.m. Also, this staff member said he/she did not call the doctor because it was the type of tube that could be replaced at the nursing home. During an interview on 8/25/2010 at 1:40 p.m., staff member "BB" said on the morning of 7/5/2010 at the beginning of the day shift he/she verified placement of the [DEVICE] by pushing in air and heard the gurgling sound then pulled back and did not receive any residual stomach contents. During observation of [DEVICE] care and staff interview with licensed staff member "II"on 8/24/2010 at 1:40 p.m., this staff member said he/she had changed many old type [DEVICE]s but the current tubes have to be changed at the hospital. Record review revealed physician's orders for August 2010 to clean the site with soap and water daily and apply a dry dressing as needed for drainage. The August treatment record from August 6-31, 2010 revealed the treatment had not been documented as done for six (6) times, August 12, 16, 18, 19, 20, and 24th, 2010. 2. On 08/24/2010 at 5:15 p.m., observation of the [DEVICE] site for resident #5 revealed a moderate amount of brownish drainage. During observation of [DEVICE] care for resident #5 on 08/25/2010 at 12:36 p.m., there was a moderate amount of brown exudate noted around the stoma. There was a current Physician's order for the stoma to be cleansed with soap and water daily. However, during observation of the [DEVICE] care with staff nurse "GG", the nurse cleaned the site with normal saline instead of soap and water as ordered, and the site started dark red bleeding after manipulation of tube. Staff nurse "GG" said there was a 1 cm area of irritation. Additionally, he/she said it was not there on 8/23/2010 when he/she had done the treatment. There was no treatment initiated for the irritation. Record review of the Treatment Records for June, July and August 2010 revealed the daily [DEVICE] care/treatment had not been documented as done for (7) seven days in June, 6/3/2010, 6/20/2010, 6/23/2010, 6/24/2010, 6/25/2010, 6/27/2010, and 6/28/2010; eight (8) days in July, 7/02/2010, 7/04/2010, 7/08/2010, 7/13/2010, 7/14/2010, 7/18/2010, 7/19/2010, and 7/20/2010; and three (3) days in August, 8/14/2010, 8/22/2010, and 8/24/2010. 3. Observation of the [DEVICE] on 8/24/10 at 5:30 p.m., revealed resident # 6 had a PEG tube with a moderate amount of dried brown drainage around the stoma. There were no physician's orders to clean or dress the site. 4. Record review for Resident #8 revealed a Physician's Order for August 2010 indicating that a size #20 French gastrostomy tube was to be inserted in the gastrostomy tube site. During observation of the gastrostomy tube and site of Resident #8 on 8/25/2010 at 12:10 p.m. with the Director of Nursing, a size #24 French gastrostomy tube was observed in the gastrostomy site. During this same observation, the Director of Nursing agreed that the wrong size tube had been inserted. 5. Record review for Resident #9 revealed a current Physician's order to clean the gastrostomy tube site with soap and water daily and dry well. Review of the August 2010 Treatment Record revealed no documented evidence that the treatment had been done as ordered on [DATE], 8/10/2010 and 8/16/2010. The above findings were confirmed during interview with Administrative Staff member "EE" on 8/25/2010 at 3:04 p.m. On 8/24/2010 at 3:30 p.m. upon inquiring to conduct a review of the facility's Policy and/or Procedure regarding the insertion of gastrostomy tubes, the Director of Nursing presented numerous one-page documents, which she indicated had been printed from a computer, none of which referenced the insertion of gastrostomy tubes, nor which would have been accessible to staff. One of these documents indicated that staff were to use a Declogger to declog/unstop a feeding tube. When Licensed Nursing Staff Members "AA", "GG" and "HH" were interviewed on 8/25/2010 at 11:25 a.m.. regarding the use of this device, they all stated that they had not used this device in years and further indicated that one of their Nurse Practitioners had told them not to use this device. When these same Licensed Staff Members were interviewed regarding a Policy and/or Procedure addressing gastrostomy tube insertion and how to check for placement, they were unaware of where a policy might be. Nurse Staff Member "GG" stated that there might be a manual in the chart room about gastrostomy tube insertion, but was unable to find one. Upon interview on 8/25/2010 at 12:00 p.m. with the Director of Nursing, Nurse Consultants "EE" and "FF", explaining that the documents that had been submitted to the surveyors did not address gastrostomy tube insertion and/or checking for placement, they found a manual entitled Nursing Service Policies and Procedural Guidelines. This manual was reviewed and did not include a procedure that addressed gastrostomy tube insertion and/or how to check for placement of a gastrostomy tube. Upon interview with Corporate Staff Member "CC" on 8/25/2010 at 4:10 p.m., he/she stated that he/she was sure there must be a policy and/or procedure addressing gastrostomy tube insertion and checking for placement. He/she then telephoned Corporate Staff Member "DD" at this time. Corporate Staff Member "CC" then stated that Corporate Staff Member "DD" informed him/her that there should be a Ross Kit in the facility with a manual and this was their policy. During additional interview with Corporate Staff Members "CC" and "DD" on 8/25/2010 at 5:00 p.m., both agreed that the Policy and Procedure should be available and/or accessible to staff, and furthermore agreed that staff should be aware where this information was located in the facility. Review of the Ross Kit Manual revealed that their Policy and Procedure indicated that there should be a written order when a nurse removes or replaces a gastrostomy tube and that the replacement of an existing tube should be replaced with the same size tube unless otherwise indicated. It was determined that the immediate jeopardy was removed as of August 26, 2010, by which time the facility had completed the following actions: 1. All nurses have been re-educated on the proper method of insertion of gastrostomy tubes. Each one has been observed and checked off via returned demonstration. We have 14 nurses employed and all were trained by the Education Coordinator. Newly employed nurses will be educated on the proper method of insertion of gastrostomy tubes prior to performing this task. This was completed on 8/25/2010. 2. A chart review of those patients with feeding tubes was conducted by Nurse Consultants ( 2 [DEVICE]s and 4 PEG tubes) to assure that the orders were complete, transcribed correctly and are being followed by the nurses. This was completed on 8/25/2010. 3. The DON, Nurse Consultant or designee will conduct random weekly observations of nurses performing tube feedings and/or flushes for the next six weeks. Results will be reported to the Performance Improvement Committee with follow-up action as indicated by the team. This will be ongoing for the next six weeks and then will be reevaluated. 4. Individual supply bins were obtained for the two patients with gastrostomy tubes. This was completed on 8/25/2010. 5. The training kit with reference manual for nurses on this topic was placed by the nurse consultant in the chart room and the nurses have been instructed on the location. This was completed on 8/25/2010. 6. The Performance Review Committee was convened this morning, August 26, 2010 to review the above stated actions. In attendance was the Medical director, Director of Nursing, Nurse Consultant, Regional Vice-President. and Administrator. This plan will be reviewed monthly during the regularly scheduled meeting for three months. The next meeting will be held on September 22, 2010. Based on these corrective plans/actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice had been removed on August 26, 2010. However, the effectiveness of these corrective plans/actions could not be fully assessed to ensure ongoing application and completion. The weekly random observations of nurses performing tube feeding and/or flushes will be ongoing over the next six weeks, and will need to be evaluated for effectiveness and that the results were forwarded onto the Performance Improvement Committee. Additionally, the results of the Performance Improvement Committee will be reviewed and assessed by the Quality Assurance Committee on a monthly basis for the next three months, with the next meeting being scheduled for September 22, 2010. Therefore, the noncompliance continues, with a scope and severity level of the deficiency decreased to the "E" level.