**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to ensure an accurate assessment was completed for one of 13 residents reviewed in the sample (Resident (R) 13). R13's assessment inaccurately documented that she was not a wanderer. This had the potential for the lack of identification of current problems and resident needs, leading to an incomplete plan of care. Findings include: Review of the facility's policy titled Conducting an Accurate Resident Assessment dated 03/07/25 revealed, The purpose of this policy is to assure that all members [residents] receive an accurate assessment, reflective of the member's status at the time of the assessment, by associates qualified to assess relevant care areas. Review of R13's Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab revealed the resident was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease and muscle weakness. Review of R13's admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 04/15/25 revealed the resident had a Brief Interview for Mental Status (BIMS) score of four out of 15, indicating the resident was severely cognitively impaired. The resident was noted to be independent with ambulation and had no wandering noted. Review of R13's Progress Note dated 04/10/25 and located in the EMR under the Progress Note tab revealed the resident was not in her room and was found on the enclosed patio at 2:00 AM. She was also noted to have been wandering in and out of resident's rooms. She was redirected back to her room where a Certified Nurse Aide (CNA) remained with her to ensure her safety. Review of R13's Progress Note dated 04/13/25 and located in the EMR under the Progress Note tab revealed the resident continues to walk the hallways and says she is going to meet her husband (resident is widowed). During an interview on 04/24/25 at 11:00 AM the Assistant Director of Nursing (ADON) confirmed R13 had been noted to be wandering in and out of residents' rooms and was found on the enclosed patio off from the common area on 04/10/25. She confirmed the MDS with an ARD of 04/15/25 did not reflect that R13 had been wandering. During an interview on 04/24/25 at 12:15 PM conducted by the ADON, the MDS Coordinator (MDSC) confirmed she did not code R13 as a wanderer and she should have.

Based on record review, staff interviews, and policy review, the facility failed to ensure one of one resident reviewed for wandering (Resident (R) 13) out of a total of 13 sampled residents had a Care Plan developed to address the resident's wandering. This had the potential for the resident to have inadequate supervision related to wandering and unmet care needs. Findings include: Review of the facility's policy titled, Elopements and Wandering Members [Residents] revealed, The facility ensures that members who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Definitions: Wandering is random or repetitive locomotion that may be goal-directed (e.g., the person appears to be searching for something such as an exit) or non-goal directed or aimless . 4. Monitoring and Managing Members at Risk for Elopement or Unsafe Wandering . b. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. c. Interventions to increase associate awareness of the Member's risk, modify the Member's behavior, or to minimize risks associated with hazards will be added to the Member's care plan and communicated to appropriate associates. Review of R13's comprehensive Care Plan located in the EMR under the Care Plan tab revealed no evidence of a plan to address R13's wandering. Review of R13's Elopement Risk completed on 04/08/25 and located in the EMR under the Observation tab revealed the resident did not wander and was not an elopement risk. During an interview on 04/24/25 at 11:00 AM, the Assistant Director of Nursing (ADON) confirmed the resident did not have an updated Elopement Risk completed after the one completed on 04/08/25, or that a Care Plan had been developed to address the resident's wandering and should have. During an interview on 04/24/25 at 12:15 PM conducted by the ADON, the MDS Coordinator (MDSC) confirmed she did not code R13 as a wanderer on her admission MDS and she should have. She further revealed if she had correctly coded the resident as a wanderer it would have triggered that a care plan needed to be developed for the resident to address her wandering.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, review of the Centers for Disease Control and Prevention (CDC) guidelines, and facility policy review, the facility failed to ensure four of five residents (Resident (R) 2, R10, R11 and R20) reviewed for pneumococcal vaccines out of total sample of 13 residents were offered a pneumococcal vaccine per CDC guidelines. The failure of not offering/providing pneumococcal vaccines increased the risk for residents to contract pneumonia. Findings include: Review of the facility's policy titled, Pneumococcal Vaccine revised 04/25 revealed, It is our policy to offer members [residents] and associates immunization against pneumococcal disease in accordance with CDC guidelines and recommendations. Policy Explanation and Compliance Guidelines: 1. Each member will be assessed for pneumococcal immunization upon admission. Self-report of immunization shall be accepted. Any additional efforts to obtain information, such through the Georgia Registry of Immunizations [GRITS], shall be documented in the member's electronic medical record, including efforts to determine date of immunization of immunization or type of vaccine received. 2. Each member will be offered a pneumococcal immunization unless it is medically contraindicated or the member has already been immunized. Following assessment for any medical contraindications, the immunization may be administered in accordance with physician orders . Routine Vaccination: age [AGE] years or older who have: Not previously received a dose of PCV13, PCV15, PCV20, or PC21 or whose previous vaccinations history is unknown: 1 dose PCV15, or 1 dose PCV20, or 1 dose PCV21. If PCV15 is used, administer 1 dose of PPSV23 at least one year after the PCV15 dose . Previously received only PPSV23: 1 dose PCV15 or 1 dose PCV20, or 1 dose PCV21, at least one year after the last PPSV23 dose. Previously received both PCV13 and PPSV23, and the PPSV23 was received at age [AGE] years or older: Based on shared clinical decision making, 1 dose of PCV20 or 1 dose of PCV21 at least 5 years after the last pneumococcal vaccine dose. Review of CDC guidelines at cdc.gov/acip-recs/hcp/vaccine-specific/pneumococcal.htlm dated 01/08/25 revealed, Administer PCV15, PCV20, or PCV21 for all adults 50 years or older who have never received any pneumococcal conjugate vaccine, or whose previous vaccination history is unknown. Adults aged 50 years and older if a PPSV23 only was given, give a single dose of PCV21, PCV20, or PCF15 after one year after the last PPSV23 dose. If a PCV13 was only given, give a single dose of PCV21 or PCV20 one year after the PCV13 dose. If a PCV13 was given at any age and a PPSV23 at age [AGE] or older, it is recommended through shared clinical decision-making of either giving a single dose of PC21 or PCV20 for any adult aged 65 years or older who has completed the recommended vaccination series with both PCV13 and PPSV23. If a decision to administer PCV21 or PCV20 is made, a single dose is recommended after five years after the last pneumococcal vaccine dose. 1. Review of R2's Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab revealed R2 was admitted to the facility with a diagnosis of Parkinson's disease. R2's date of birth was 01/21/43 ([AGE] years old). Review of the GA Registry of Immunization Transactions & Services (GRITS) provided by the facility and undated, revealed R2 had received the Pneumococcal Polysaccharide (PPSV) 23 vaccine on 11/06/02, 05/26/10, and the Pneumo-Conjugate (PCV) 13 vaccine on 11/09/15. There was no evidence in the EMR that R2 was offered the PCV20 or PCV21 per recommendations of CDC. 2. Review of R10's Face Sheet located in the EMR under the Face Sheet tab revealed R10 was admitted to the facility with diagnoses including interstitial pulmonary disease and malignant neoplasm (cancer) of the prostate. R10's date of birth was 09/10/35 ([AGE] years old). Review of the GRITS provided by the facility and undated revealed R10 had received the PPSV 23 on 05/18/22. There was no evidence that R10 was offered the PCV15, PCV20, or PCV 21 per recommendations of CDC. 3. Review of R11's Face Sheet located in the EMR under the Face Sheet tab revealed R11 was admitted to the facility with diagnoses including Parkinson's disease and dementia. R11's date of birth was 06/18/51 ([AGE] years old). Review of the GRITS provided by the facility and undated revealed R11 received the PCV13 on 07/18/16, the PPSV23 on 09/24/18, and the PPSV23 on 10/19/19. There was no evidence that R11 was offered the PCV20 or PCV21 per recommendations of CDC. 4. Review of R20's Face Sheet located in the EMR under the Face Sheet tab revealed R20 was admitted to the facility with diagnoses including malignant neoplasm (cancer) of the anal canal and enlarged lymph nodes. R20's date of birth was 03/07/47 ([AGE] years old). There was no evidence in the EMR that R20 was offered a pneumococcal vaccine or if she had ever received any pneumococcal vaccines. During an interview on 04/24/25 at 12:30 PM, the Assistant Director of Nursing (ADON), who was also the Infection Preventionist (IP) confirmed R2, R10, R11, and R20 were not up to date with the CDC guidelines for offering and administering pneumococcal vaccinations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and facility policy review, the facility failed to ensure food was stored and prepared in a safe and sanitary manor. Specifically, the dietary staff failed to ensure food was stored, labeled, dated, and discarded when it expired. Additionally, the dietary staff failed to ensure proper hand hygiene and glove use to prevent cross contamination. The facility's failure placed all residents who receive an oral diet from the kitchen at risk for food borne illnesses. Findings include: Review of the facility's policy titled, Food Safety and Sanitation, dated 03/03/17 revealed ALL LEFTOVER FOODS MUST BE PROPERTY HANDLED: All leftover food items must be properly covered, labeled with the contents, and dated with a use-by date . Review of the facility's policy titled, Food Safety and Sanitation, dated 03/03/17 revealed .WASH HANDS FREQUENTLY: Hand washing is the single most important technique in preventing food borne illness. Wash hands frequently in a hand washing sink only and always after using the restroom, coughing, sneezing, or blowing your nose, after completing a specific job task, before putting on a pair of gloves and after removing the gloves, after you touch your hair or face, after picking up anything from the floor, after handling boxes or crates, after smoking, after serving or assisting members, after bussing soiled dishes, after removing trash, etc .Gloves are no substitute for proper handwashing. Always wash hands before putting on gloves and again after removing gloves. Change gloves often. Always change gloves before you start a new assignment Review of the facility's policy titled, Handwashing, dated 03/03/17 revealed Handwashing is the single most effective procedure in preventing the spread of harmful microorganisms. Employees must wash their hands frequently throughout their work shift . Proper hand washing steps included: .Dry hands using single service towels. Dry hands thoroughly with a new sanitary, single service towel. Turn the water faucet off with the towel you just used to dry your hands. Shutting the water off with your clean hands would re-contaminate them . Review of the facility's policy titled Storage of Food and Supply Products, dated 03/03/17 revealed .GLOVES ARE NO SUBSTITUTE FOR HANDWASHING: Gloves should be changed frequently. Change gloves after completing any specific job task, after coughing, sneezing, or blowing your nose, after picking up anything from the floor, or after handling boxes or crates, etc . Review of the facility's policy titled Storage of Food and Supply Products, dated 03/03/17 revealed All food and supply items will be stored in a safe and sanitary manner .All food products must be stored away as quickly as possible, especially items that require refrigeration or freezing .All food items must be properly covered or tightly wrapped when stored in a refrigerator or freezer. Leftover items should be labeled with the name of the food product, production date and the use-by date. Clear cling wrap is preferred over aluminum foil, so that food items can be seen more easily . Observation on 04/22/25 at 10:43 AM in the Farmhouse Kitchen refrigerator revealed food items without a label or had been labeled with a past due expiration date and was still available for use. Those items included: A half-full pint container of shredded cheddar cheese marked with an expiration date of 04/06/25 and another one-third full pint container not labeled, a small container of ranch dressing with no label, a small container of cocktail sauce with an expiration date of 04/12/25, a pint container of chocolate butter cream labeled with an expiration date of 04/14/25, and two bags of cheese, cheddar and parmesan with no labels. Observation and interview on 04/22/25 at 10:54 AM with the Certified Dietary Manager (CDM) of the Farmhouse Kitchen refrigerator contents listed above revealed she agreed those items had not been labeled or disposed of correctly. The expectation was whoever prepared the food would attach a label with the date open or made and the expiration date. The cook working should have been aware of outdated items in the refrigerator. During observations and interview on 04/23/25 from 12:00 PM until 12:45 PM of the Meadow House kitchen during lunch meal service, Cook3 was plating food to be served to the residents. Cook3 doffed (took off) her gloves, washed her hands in the sink, and then turned the sink off using her bare hand. Cook3 then donned (put on) a new pair of gloves, removed hard boiled eggs from a bag, and sliced the boiled eggs using the same pair of gloves she donned after she touched the sink knobs to turn off the water, which indicated possible cross contamination from the gloves to the sliced boiled eggs. Cook3 then proceeded to doff her gloves, washed her hands in the sink, and then turned the sink off touching the sink's knobs with her bare hands. Cook3 then donned a new pair of gloves to her contaminated hands and then sliced a tomato and cut up lettuce. During an interview at 12:40 PM, Cook3 stated she did not realize after washing her hands, shutting the water off with her bare hands, and then obtaining and donning gloves that her gloves could have been contaminated from not using a paper towel to [NAME] off the sink. During an interview on 04/23/25 at 12:55 PM, Cook1 stated he was the kitchen's lead cook and provided oversight to the other cooks. Cook1 also stated during the surveyor's observations, he observed Cook3 handling food with her contaminated gloves. During observations and interview on 04/23/25 from 12:00 PM until 12:45 PM of the Meadow House kitchen during lunch meal service, Cook3 was plating food to be served to the residents. Cook3 doffed (took off) her gloves, washed her hands in the sink, and then turned the sink off using her bare hand. Cook3 then donned (put on) a new pair of gloves, removed hard boiled eggs from a bag, and sliced the boiled eggs using the same pair of gloves she donned after she touched the sink knobs to turn off the water, which indicated possible cross contamination from the gloves to the sliced boiled eggs. Cook3 then proceeded to doff her gloves, washed her hands in the sink, and then turned the sink off touching the sink's knobs with her bare hands. Cook3 then donned a new pair of gloves to her contaminated hands and then sliced a tomato and cut up lettuce. During an interview at 12:40 PM, Cook3 stated she did not realize after washing her hands, shutting the water off with her bare hands, and then obtaining and donning gloves that her gloves could have been contaminated from not using a paper towel to [NAME] off the sink. During an interview on 04/23/25 at 12:55 PM, Cook1 stated he was the kitchen's lead cook and provided oversight to the other cooks. Cook1 also stated during the surveyor's observations, he observed Cook3 handling food with her contaminated gloves.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, Self-Administration of Medication Program, the facility failed to ensure two of 13 sampled residents (R) (R8 and R18) were assessed to determine if the practice of self-administration of medications would be safe, that physician's orders were obtained, and that medications were safely secured. The deficient practice had the potential to result in medication errors and to allow access to medications otherwise not prescribed by a physician to other residents. Findings include: Review of the facility's policy titled, Self-Administration of Medication Program, dated June 15, 2020, indicated It is the policy of the facility to allow the member or legal representative of the member the right to self-administer medication when it has been deemed by the interdisciplinary team that it is clinically appropriate. 6. When determining if self-administration is clinically appropriate for a member, the IDT will at a minimum consider the following: h. the medications appropriate and safe for self-administration; i. The member's physical capacity to swallow without difficulty and to open medications bottles. 7. The admitting nurse or designee will complete the Self-Administration of Medication Evaluation and report the findings to the Unit Manager or designee. 8. The IDT must also determine who will be responsible for storage. If medications are stored at the member's bedside, a lockbox or locked drawer must be used to store the medication(s). 10. Appropriate documentation of the above determination will be documented in the member's care plan. 12. Weekly documentation will occur after the first week for the next two weeks by the shift nurses, followed periodic monitoring. 1.Review of R8's Face Sheet indicated the resident was admitted with a diagnosis of secondary parkinsonism due to other external agents. Review of R8's admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 10/30/2023 indicated that R8's Brief Interview for Mental Status (BIMS) score was 13 out of 15 which indicated the resident was cognitively intact. Review of R8's Physician Orders lacked orders for the eye medications or documented evidence of an order for self-administration of eye drops. Review of R8's progress notes and documents in the electronic record lacked documented evidence the resident was evaluated for safe self-administration of eye drops. Review of R8's Care Plan lacked documented evidence of interventions for self-administration of eye drops. Observations on 12/1/2023 at 8:30 am and 12/2/2023 at 8:20 am revealed three bottles of eye drops (Systane Complete propylene glycol 0.6%) were on the over the bed table in R8's room. There also was one bottle of Refresh eye lubricant on the counter near the sink in R8's bathroom. R8 explained she had a condition known as dry eye syndrome and she had used the eye drops for over 40 years. R8 confirmed that she administered the eye drops herself and no one had informed her that she could not have them in her room. 2. Review of R18's Face Sheet indicated resident was admitted with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and other lack of coordination and muscle weakness (generalized). Review of R18's Five Day MDS with ARD date of 11/6/2023 indicated that R18's BIMS score was 15 out of 15 which indicates the resident was cognitively intact and the resident had impairment on one side of her upper extremities. Review of R18's Physician Orders lacked orders for Advil, or the fish oil tablets, or documented evidence of an order for self-administration of medications. Review of R18's progress notes and documents in the electronic record lacked documented evidence the resident was evaluated for safe self-administration of medications. Review of R18's Care Plan lacked documented evidence of interventions for self-administration of medications. Observations on 12/1/2023 at 8:16 am and 12/2/2023 at 8:24 am revealed a container of hydrocortisone cream 1%on top of the bedside dresser and a bottle of fish oil 1200 mg tablets and a bottle of Advil in the partially opened top drawer of the bedside table. R18 stated that the fish oil had been in her drawer for a couple of weeks now and it belonged to her husband. She further stated that the hydrocortisone cream and the Advil belonged to her, and she had not been told she could not have it in her room. Interview on 12/2/2023 at 9:03 am with Licensed Practical Nurse (LPN) AA revealed that she worked the entire facility and there was not a resident in the facility who had been deemed safe to self-medicate. LPN AA further stated that all medications were administered by the nurse and locked in the cabinets in each resident's room. LPN AA stated that only nurses had the key to access the locked medication cabinets in each resident's bathroom, therefore there were not supposed to be any medications in resident's rooms not secured. Interview on 12/2/2023 at 9:28 am with LPN BB revealed that she had worked consistently at the facility for 3-4 months. LPN BB also stated that there is not a resident in the facility that self-medicate. LPN BB further stated that an assessment must be completed to determine if a resident was deemed safe to self-administer their own medications and those medications would not be just lying around but would also be locked up. Interview and walking rounds on 12/2/2023 at 9:33 am with the Administrator, she stated that all medications should be either locked in the medication storage room or in the locked cabinet in resident's rooms. The Administrator stated that there was not a resident in the facility who had been assessed to safely self-medicate, therefore there should not be any unsecured medications in resident rooms. During walking rounds the Administrator verified the eyedrops in R8's room and the medications in R18's room. The Administrator reviewed resident records and verified there were no orders or self-medication assessments for the medications. The Administrator further stated that she was not aware that there were medications in resident's rooms that were not locked up and that maybe family members brought the medications into the facility. The Administrator further stated that she expects the staff to remove unsecured medications and inform the administrative team of the findings.