Based on observations, staff interviews, record review, and review of the facility's policy titled Medication Labeling and Storage, the facility failed to ensure that expired medications were removed from active medication storage in one medication storage room and one of two medication carts. This deficient practices had the potential to place the residents at risk of receiving expired medications and had the potential to allow unauthorized access to controlled medications. Findings include:Review of the facility's policy titled Medication Labeling and Storage, revised February 2023, included, . If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.During an observation on 7/1/2025 at 4:55 pm of the medication storage room, medication cart, and medication refrigerator, with the Assistant Director of Nursing (ADON), the following were observed:In the medication storage room: One bottle of magnesium oxide 400milligram (mg), with an expiration date of 6/2025.One bottle of vitamin D 10mcg with an expiration date of 5/2025. Two bottles of milk of magnesium 16 fluid (F) ounce (oz) with an expiration date of 5/2025.One bottle of Geri Lanta 12oz, with an expiration date of 6/2025. One bottle of iron tablets, 325mg, with an expiration date of 6/2025. Three bottles of docusate sodium liquid 50mg/5 milliliter (ml), with expiration dates of 6/2025. One bottle of aspirin 81mg, with an expiration date of 7/2024.One bottle of folic acid 1000 micrograms (mcg) tablets, with an expiration date of 6/2025, was observed in one of two medication carts. During the observations, the ADON revealed that she had checked the storage room herself only a few days prior to the survey. She stated that she had removed all the expired medications and was very surprised at what was found. She added that a thorough reassessment would be done and all drugs checked and restocked.During an interview on July 2, 2025, at 12:46 p.m., the Director of Nursing (DON) revealed that a pharmacy consultant audits the medication carts and completes medication passes monthly. The DON stated that during the audits, all expired medications were removed and discarded. She stated that the supply clerk was responsible for auditing and stocking the medication supply room. She further stated that the nurses and managers were responsible for discarding expired medications.

Based on observations, staff interviews, and review of the facility's policies titled Handwashing/ Hand Hygiene, Infection Prevention and Control Program, and Laundry Policy, the facility failed to ensure staff follow proper hand hygiene techniques when performing blood glucose testing on one resident (R) (R5). In addition, the facility failed to ensure the infection control process was followed when transporting clean linen to residents' rooms and for clean clothing in the laundry room. These deficient practices had the potential to place the residents at risk of infections due to cross-contamination. Findings include:Review of the facility's policy titled Hand Washing/ Hand Hygiene, revised August 2019, included, .Use an alcohol based hand rub containing at least 62% [percent] alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: after removing gloves. Hand hygiene is the final step after removing and disposing of personal protective equipment. The use of gloves does not replace hand washing/ hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.Review of the facility's policy titled Infection Prevention and Control Program, reviewed November 2022, included . Standard Precautions, Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. All staff shall use personal protective equipment (PPE) according to established facilities policy governing the use of PPE. The Linens section included .Clean linen shall be delivered to resident care units on covered linen carts with covers down.Review of the facility's policy titled Laundry Policy, included . Staff shall consider all previously worn clothing and use linens as potentially contaminated. The facilities laundry area will provide hand washing, PPE. Laundry staff will be in service on handling linens and laundry on a regular basis.1. Review of R5 clinical record revealed diagnoses including, but not limited to, type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene.Observation on 7/2/2025 at 11:40 am revealed Licensed Practical Nurse (LPN) JJ performed a finger stick blood glucose test on R5. Observation revealed LPN JJ changed gloves without performing hand hygiene during the procedure.During an interview on 7/2/2025 at 12:04 pm, LPN JJ revealed that she should have performed hand hygiene between glove changes and stated that she was overwhelmed. 2. During an observation of the laundry area on 7/2/2025 at 12:12 pm, with the Maintenance and Housekeeping Manager, observation revealed a laundry attendant transporting clean linen in a covered laundry cart with resident clothing on hangers and hanging from the outside of the cart's handlebars. The clothing was uncovered and was observed brushing against the walls and handrails of the hallway. The Maintenance and Housekeeping Manager confirmed that the resident's clothing was uncovered and that they were brushing the walls and handrails in the hallways. He stated the clothing would have to be rewashed. Further observation of the laundry room revealed a basket containing clean clothing sitting by the folding table. The leg of a pair of pants was observed hanging from the basket and resting on the floor. The Maintenance and Housekeeping Manager stated the pants would have to be rewashed. During an interview on 7/2/2025 at 12:30 pm, the Laundry Attendant revealed that she did not return the soiled resident clothing to the laundry room. She stated that she was unaware that the resident's clothing on the cart needed to be covered, and did not realize the clothing had brushed against the walls in the hallway. The Laundry Attendant confirmed that they had transported the resident's laundry uncovered several times before.

Based on observation, policy review, and staff interviews, the facility failed to ensure that open food items in the dry storage area were securely wrapped, labeled, and dated, and also failed to discard food items by their expiration dates. This deficient practice had the potential to place residents who received an oral diet from the kitchen at risk of foodborne illness. The census was 78.Findings include:Review of facility policy titled Food Safety Handling Policy, included, . Notes labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date or discarded. Foods covered and in air-tight containers.1. Observation on 6/30/2025 at 10:23 am revealed a white plastic container of chicken bouillon concentrate in the walk-in freezer, with a use-by date of 12/11/2024. Further observation in the walk-in freezer revealed a bag of opened and undated breaded chicken tenderloin strips.2. Observation on 6/30/2025 at 10:45 am in the kitchen revealed two floor dry storage bins, unmarked and undated. The Dietary Manager (DM) stated the bins contained sugar and flour.3. Observation on 7/1/2025 at 11:15 am in the walk-in freezer revealed an opened and undated bag of sliced squash, an opened and undated bag of tater tots, and an opened and undated bag of chopped broccoli. In an interview on 6/30/2025 at 10:45 am, the DM verified that the bouillon was expired, and the frozen chopped broccoli was left over from the previous lunch meal, and had not been labeled. He stated that all staff were responsible for discarding expired food items and rotating stock.

Based on staff interview, record review, and review of the facility policy The Place Facilities Resident Personal Funds-Surety Bond Policy, the facility failed to maintain a surety bond sufficient to cover the current total funds in the resident trust account. The deficient practice had the potential to affect 29 residents with funds managed by the facility. Findings include: Review of the facility policy titled, The Place Facilities Resident Personal Funds-Surety Bond Policy, revised 11/2022, revealed the following: Assurance of Financial Security: 1. The facility will purchase a surety bond, or otherwise provide assurance satisfactory to the Secretary, to assure the security of all personal funds of residents deposited with the facility. Review of the resident trust account monthly statements dated January 2023 through June 2023 revealed the following beginning monthly balances: January 2023 ($88,529.30), February 2023 ($89, 963.16), March 2023 ($93,150.06), April 2023 ($88,396.63), May 2023 ($83,136.07), and June 2023 ($84,358.70). Review of the Bond Transaction Summary with a Transaction Effective Date of 12/15/2022 and a Term of Bond dated 12/15/2022 through 12/14/2023 documented a bond amount of $70,000. Interview on 8/2/2023 at 2:22 p.m. with the Administrator revealed he was unaware that the surety bond did not cover the monthly beginning/ending balances of the facility's resident trust account. He stated he would increase the amount of the surety bond to $100,000 as soon as possible.

Based on observations, resident and staff interviews, and review of facility policies titled, Homelike Environment and The Place Facilities Environmental Services Cleaning and Repair, the facility failed to maintain a safe, functional, and sanitary environment in 10 of 50 resident rooms (N 3, N 4, N 5, N 6, N 7, N 10, S 11, S 17, S 18, and S 23). Specifically, resident rooms were observed to contain debris in packaged terminal air conditioner (PTAC) units, eroded/broken dressers/nightstands, dirty air vents in bathrooms, holes/cracks in drywall, and rusted/peeling toilet commode frames. Findings include: Review of the facility policy titled, Homelike Environment, revised February 2021 revealed the following: Policy Statement: Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. Review of the facility policy titled, The Place Facilities Environmental Services Cleaning and Repair, revised November 2022 documented its policy as follows: It is the policy of this facility to regularly monitor environmental services to ensure the facility is maintained in a safe and sanitary manner and assessed on a regular basis. Observations of resident rooms beginning on 8/1/2023 at 10:00 a.m. revealed the following: N 3: PTAC unit with debris in the vent. N 3-B: Nightstand with front panel missing from the top drawer; second night stand missing knobs from two drawers. N 4: Bathroom with dirty air vent, loose baseboards, rusted toilet commode frame, large brown stain in the toilet, loose baseboards and holes in the walls surrounding the sink, and television cable wires hanging approximately three to four feet from the floor N 5-A: Nightstand rotting away at the base, PTAC units with black substance on the vent grill. N 5-B: Gashes in the drywall behind the bed, nightstand missing two of four knobs from the top two of three drawers. N 6: Bathroom with a hole in the wall behind the toilet, rusted/peeling toilet commode frame, loose baseboards around the room. N 7: Bathroom: dirty air vent, soap and hand sanitizer dispensers not working, no paper towels in dispenser, toilet with left bolt exposed, and right bolt missing or broken. N 10: Baseboards loose from the wall under the sink, baseboards dirty around the room, windowsill with breaks in the inlet surrounding the window, and bathroom with dirty air vent. S 17: One metal object measuring approximately 1 inch x 4 inches on the floor behind the toilet. Resident (R) (R#64) confirmed he uses the restroom. Observations of resident rooms on 8/2/2023 beginning at 9:15 a.m. revealed the following: S 11: The over bed table located close to bed A was observed to have peeling surface areas on the table edge and scattered brown, crusty areas on the metal frame. S 18: There were two open areas approximately two centimeters in diameter and approximately five feet from the floor on the wall located to the left of the doorway and between the restroom and bed A area. There was peeling paint and missing wall material located on the wall to the left of the doorway and next to bed A. S 23: The paper towel dispenser was observed to have scattered brown areas on the front and both sides of the dispenser. Observations of resident rooms on 8/3/2023 at 3:45 p.m. with the Maintenance Director revealed the conditions of the resident rooms mentioned above were still present and confirmed with the Maintenance Director. He stated the staff were familiar with the process for reporting maintenance concerns and he checked the Maintenance Log frequently throughout the day.

Based on record review and staff interviews, the facility failed to obtain a concurring Physician's signature for a Physician Orders for Life Sustaining Treatment (POLST) for Do Not Resuscitate (DNR) consents for Residents (R) (R#19 and R#66). The sample size was 31 residents. Findings include: 1. Review of medical record for R#19 revealed a POLST with a choice to allow natural death/DNR that was signed by one Physician on 10/13/21 and resident's son, that was not the residents Power of Attorney, on 10/13/21 there was no concurring Physician's signature. Further review of the Medical Record for R#19 also revealed that there was not a Health Care Agent for R#19 on file at facility. Interview with Social Services Director (SSD) On 1/11/22 at 12:19 p.m. revealed that when a resident is admitted to the facility Advanced directives are discussed at that time with the resident and the family member. If the resident is cognitive, they are given the POLST form to complete which is then signed by the resident, physician, and the social services director. If the resident is not cognitive and unable to speak for themselves the residents responsible party is given the POLST document, and they will sign or them. Continued interview revealed that staff member was not aware that at any time there should be a concurring physician signature for residents that are not cognitive and who do not have a health care agent or court appointed guardian. Further interview did confirm that R#19 should have had a second physicians' signature on the POLST document due to residents' cognitive status and lack of legal guardianship. Interview with R#19 family member on 1/11/22 at 12:56 p.m. revealed that he did file for guardianship on October 29, 2021 and will not be finalized until 1/18/2022. Further interview also confirmed that family member did not have guardianship over resident at the time the POLST document was signed on 10/13/2021. Interview with Direct of Nursing (DON) revealed that the POLST form for residents with a cognitive deficit should have two physician signatures if they do not have health care agent on file. Further interview also confirmed that R#19 should have had a concurring physician signature on the POLST document. 2. Review of the clinical record for R #66 revealed a POLST signed by the daughter of R#66 on 11/30/21 but there was no evidence that the daughter was the residents Health Care Agent. Review of the POLST revealed that it only had one Physician's signature with no concurring Physician signature. Review of document titled Guidance for completing POLST form revealed under additional guidance for health care professionals Section III. When a POLST form is signed by an authorized person (other than the health care agent) and attending Physician; I. If section A indicates allow natural death -Do Not Attempt Resuscitation, this order may be implemented when the patient is a candidate for non-resuscitation as defined by Georgia Code 31-39-2 (4). A concurring physician signature is required per Georgia code 31-39-4 (c)

Based on observations and interviews the facility failed to ensure that privacy curtains for three of sixteen rooms on the South Hall were clean and provided complete privacy for one resident (R) R#66. The facility also failed to repair a hole in the wall in room five on the South Hall. Findings include: Observation of resident's privacy curtain on south hall for R#66 on 1/09/22 at 3:47 p.m. revealed brown stains noted by the hem of the curtain and does not provide full privacy. Observation on 1/10/22 at 8:37 a.m. revealed there was a whole in the wall behind the door south hall room S5. Observation resident privacy curtain room South 12a on 1/10/22 at 8:43 a.m. revealed dark brown stains noted on the outside and inside of the curtain near the outer aspects of the curtain. Observation on 1/10/22 at 9:27 a.m. revealed privacy curtain has dark brown stain at the base of the curtain by the hem on both sides of the curtain room South 11. An interview with License Practical Nurse (LPN) FF revealed that there is a maintenance book at the nursing station for staff use. If there are any maintenance issues, they are put in the book which is checked daily by the Maintenance Director. Further interview also revealed that she did not notice that the privacy curtain for R#66 did not provide full privacy. Environmental rounds conducted with Administrator and Maintenance/Housekeeping supervisor on 1/12/22 at 8:16 a.m. confirmed all environmental observations that were observed during facility initial tour. An interview with Maintenance Director on 1/12/22 at 8:26 a.m. revealed that when there is an issue that needs to be addressed, the staff will fill out a form in the maintenance book that is at each nursing station. The Maintenance Director further revealed that if there are any emergency repairs that need to be attended to the staff will let him know verbally and he would address those issues immediately. The maintenance book is checked every morning for any needed repairs. Further interview also revealed that he was not aware of the repairs nor the condition of the privacy curtains that were revealed during environmental rounds. Continued interview also revealed that deep cleanings are conducted which entails disinfecting the entire room including the bed and bed rails, changing the privacy curtains, and fogging the room with disinfectant as well. An interview with Housekeeper EE on 1/12/22 at 1:09 p.m. revealed that the deep cleaning process consist of cleaning the entire room and disinfecting it with Clorox. Housekeeper EE further revealed that the deep cleaning also includes the bed rails, floors, any stains that are on the walls and the privacy curtains are inspected as well. If the privacy curtains are stained it is reported to the laundry department and they would remove the curtain and replace them with a clean curtain. Further interview also revealed that deep cleans for the residents' rooms are completed as needed. An interview with the Administrator on 1/12/22 at 1:15 p.m. revealed that the observations that were revealed during environmental rounds were not known to him.