Based on observation, record review, interviews, and facility policy review, the facility failed to assess for self-administration of medication for one of one resident (Resident (R) 11) reviewed for self-administration of medication out of a total sample of 19 residents. This had the potential to affect resident medication safety at the facility. Findings include: Review of R11's admission Record in the Profile tab of the electronic medical record (EMR) revealed an admission date of 01/27/21. The admission Record revealed R11's diagnoses included centrilobular emphysema and malignant neoplasm of bronchus/lung. Review of R11's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/19/24 and located in the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident had intact cognition. Review of R11's physician order written 07/28/22 located in the Orders tab revealed, Creon [lipase/protease/amylase], 36,000 unit-114,000 unit-180,000-unit capsule delayed release take two capsules, by mouth with meals. During an observation in R11's room on 02/02/25 at 11:49 AM, two blue and clear capsules in a medicine cup were observed on R11's bedside table. R11 was next to the bedside table and sleeping in his wheelchair. R11 woke up when surveyor knocked on the door. Surveyor asked R11 if those were his pills. He answered, Yes. Surveyor asked him what medicine the pills were. R11 answered, I don't know. [Certified Medication Aide (CMA) 1] gave them to me. Then I fell asleep before taking them. I'll take them now. Surveyor picked up the medicine cup with the pills in it and stopped Licensed Practical Nurse (LPN) 1 in the hallway as she walked by R11's doorway. Surveyor asked her, Did you give medicine to this resident this morning? LPN1 responds, No and we're not supposed to leave medicine [meds] with residents. The policy is that we don't leave meds at the bedside. I did not leave those meds with him. During an interview on 02/02/25 at 6:14 PM, CMA1 stated, No, we're not supposed to leave meds at the bedside, and I wouldn't do that. I put the meds in his hand, and he kept the medicine cup. I saw him raising it up to his mouth as I was walking away. So, I thought he took his meds. Otherwise, I wouldn't have left. I never leave meds at the bedside. We don't even leave medicated creams at the bedside. During an interview on 02/02/25 at 6:20 PM, the Administrator stated, We do not have anyone at this facility that self-administers their own meds. If we do, we have to first do a self-administration of meds assessment, then go over the request with the interdisciplinary team (IDT) on whether they are capable of self-administering their own meds. It's not something our residents do in this facility though. During an interview on 02/02/25 at 6:35 PM, Registered Nurse (RN) 1 stated, We don't leave medicine at the bedside according to our policy. I would have to look at the actual policy to go over what requirements there are for allowing self-administration of meds. During an interview on 02/02/25 at 6:41 PM, the Director of Nursing (DON) stated, We don't have anyone that self-administers their own medication. It is our policy that nursing staff do not leave meds at the bedside. We have to do a self-administration of meds assessment with the resident, discuss it with the IDT and family. There must be a doctor's order for it as well. My staff know they are not allowed to leave any meds at the bedside. Review of a list compiled on 02/02/25 and provided by the DON, revealed there were two independent ambulatory residents and seven residents that were mobile by propelling themselves in a wheelchair residing on the hall with R11 that potentially could have access to R11's room while he was not in his room. Review of the facility's policy titled, Pharmacy Services: Self-Administration of Medication by Patients, undated, indicated under the section Intent: To facilitate a process for safe self-administration of medications by patients when appropriate. Indicated under the section Guideline: Each patient who desires to self-administer medication is permitted to do so if the nursing center's IDT has determined that the practice would be safe for the patient and other patients of the nursing center and that the patient is able to accurately self-administer. Ability to appropriately self-administer medications should be documented in the patient's care plan. Indicated under the section Guideline: Nurses and aides are required to report to the charge nurse on duty on duty any medications found at the beside not authorized for bedside storage and to give unauthorized medications to the charge nurse for return to the family or responsible party.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and policy review, the facility failed to ensure the accurate code status was documented in the medical record to ensure the resident/family's wishes would be honored for one of 24 residents (Resident (R)23) reviewed for code status in the initial pool. This failure could result in a resident receiving cardiopulmonary resuscitation in the event they coded when their wishes were to not receive cardiopulmonary resuscitation. Findings include: Review of R23's code status revealed there was a discrepancy in the documentation between the physician's order, electronic medical record (EMR), and the Physician Orders for Life-Sustaining Treatment (POLST). Review of R23's current physician's order located under the Orders tab of the EMR revealed she had an order for a full code. The order had a start date of [DATE]. The top section of the EMR stated R23 was a full code. Review of a document located in the Document tab of the EMR titled Georgia Department of Public Health Physician Orders for Life-Sustaining Treatment (POLST) signed by R23's daughter on [DATE] and the physician on [DATE] revealed Section A Code Status had a check mark on Allow Natural Death and Do Not Attempt Resuscitation [DNR]. During an interview on [DATE] at 2:54 PM, the Director of Nursing (DON) and Social Service Director (SSD) each verified that both the top portion of the resident's record in the EMR and the physician's order stated R23's code status was documented as a Full Code. The SSD stated R23 must be a DNR since the POLST was marked DNR and was signed by the physician and a Family Member (FM)1. Review of R23's quarterly Minimum Data Set (MDS) assessment located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99 indicating R23's was severely cognitively impaired. Her admission date was [DATE]. Review of her diagnosis located in the Diagnosis tab of the EMR revealed her diagnoses included but was not limited to Alzheimer's disease and dementia. On [DATE] at 3:50 PM, Licensed Practical Nurse (LPN) 2 was asked if R23 were to code or be found without vital signs what she would do. LPN2 she would check the EMR for R23's code status. After checking R23's EMR, LPN2 stated R23 was a full code so she would start CPR. On [DATE] at 4:10 PM the SSD stated she spoke to FM1 on the phone on [DATE] and explained to her that the code status was a full code in the EMR and orders but that the POLST signed when R23 was admitted was for a DNR. She stated FM1 responded by saying let's just leave her code status a DNR as signed on the POLST when R23 was admitted to the facility. On [DATE] at 4:23 PM Assistant Director of Nursing (ADON) was asked about the facility's process for code status, and she stated the EMR would be checked and if it stated full code she would initiate CPR. On [DATE] at 2:10 PM FM1 stated R23 was to remain a DNR. Review of the facility policy titled Skilled Nursing Services Cardiopulmonary Resuscitation with a review date of [DATE] stated cardiopulmonary resuscitation (CPR) would be performed on residents who do not have an order to allow for natural death. The policy for Advanced Directives was requested on [DATE] at 2:54 PM. The DON provided a copy of an undated form titled Advanced Directives which was a form the resident/responsible representative completes to document the if they have an advanced directive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, the facility failed to notify the physician for one of two residents (Resident (R) 29) reviewed for change of condition out of 19 sampled residents. R29 was ordered medication as an intervention for pain; however, the resident missed three doses of medication, and the physician was not notified. Additionally, R29 could not fully complete an x-ray due to pain and the nurse failed to notify the physician. This failure prevented the medical provider the opportunity to make changes to the plan of care. Findings include: Review of the facility's policy titled, Changes in a Patient's Condition, reviewed 12/27/24 revealed .It is the intent of this center to notify the patient, his/her attending physician, and responsible party/patient representative of changes in the patient's condition and/or status .Nursing services is responsible for notifying the patient's attending physician when: .There is a significant change in the patient's physical, mental, or emotional status; .Changes in the patient's medical condition should be promptly recorded in the patient's medical record . Review of R29's undated Face Sheet, provided by the facility revealed the resident was admitted to the facility on [DATE]. Review of R29's physician order Summary Report, provided by the facility revealed on 09/10/24 the resident was ordered tramadol [opioid pain medication] 50 mg tablet, 1 tablet by mouth 2 times per day 7 days .Dx [diagnosis]: Acute pain due to trauma . The Summary Report also revealed that R29 was ordered a thoracic spine x-ray for acute pain due to trauma (a fall on 09/08/24). Review of R29's Electronic Medication Administration Record [eMAR], dated September 2024 and located in the resident's EMR under the Medications tab revealed on 09/10/24 the resident's pain was assessed to be a 10 on a scale of 1-10, with 10 being the highest pain level possible. Continued review of the eMAR revealed R29 was administered physician ordered PRN (as needed) acetaminophen with a post pain level of 1. Review of R29's Nurses Note, dated 09/10/24 and located in the resident's EMR under the Nurses Notes tab revealed Tramadol did not come in tonight, will start when it arrives from pharmacy. During an interview on 02/06/25 at 9:43 AM, Licensed Practical Nurse (LPN) 4 verified that she did not notify the physician on 09/10/24 when R29 missed the dose of tramadol because the pharmacy had not delivered it to the facility. Review of R29's Nurses Note, dated 09/11/24 and located in the resident's EMR under the Nurses Notes tab revealed 8am medication Tramadol 50mg not administered[.] Medication not in from pharmacy. F/U [follow up] with pharmacy stated medication will be in tonight. Will pass to on-coming nurse. Review of R29's complete EMR revealed no documented evidence the physician was notified of the resident not receiving her ordered pain medication. Review of R29's Nurses Note, dated 09/11/24 and located in the resident's EMR under the Nurses Notes tab revealed Resident was scheduled for x-ray today due to pain. Writer assisted x-ray tech [technician] with the task, but was unable to complete all the test due to the resident being in too much discomfort. The note was completed by Registered Nurse (RN) 1. Review of an email provided by the facility, dated 02/06/25 and from the x-ray contractor revealed 9/11/24 exam: PAIN .Best obtainable, PT [patient] was in pain and could not hold position for long .Nurse decided to stop exam before finishing due to PT pain . During an interview on 02/06/25 at 9:27 AM, the Director of Nursing (DON) stated when R29's medication did not arrive to the facility from the pharmacy on 09/10/24, it was her expectation LPN4 would have notified the provider that the tramadol had not arrived and get an order to hold the medication, and request an alternate medication be given. The DON also stated it was her expectation when R29 did not complete the x-ray as ordered on 09/11/24 due to being in pain, RN1 would have notified the provider that the x-ray could not be fully completed due to the resident being in pain and get further instruction from the provider. During an interview on 02/06/25 at 8:40 AM, in regard to R29's Nurses Note, dated 09/11/24 completed by RN1, RN1 stated she did not notify the resident's physician or another provider that R29 was not able to complete the ordered x-ray due to being in pain. The RN stated she should have notified the resident's physician. During an interview on 02/06/25 at 11:58 AM, NP1 stated on 09/10/24 she was notified R29 was complaining of increased pain. NP1 stated she ordered tramadol and an x-ray for R29. Continued interview revealed when the x-ray was not able to be fully completed as ordered because the resident was in pain, NP1 stated it was her expectation RN1 would have notified her or the physician to get further direction on what to do for R29's pain. During an interview on 02/06/25 at 1:59 PM, the Medical Director, who was also R29's attending physician, stated when R29 could not complete all of the x-ray because of being in pain, it was his expectation that the nurse would have notified him to get an order to treat the resident's pain. The Medical Director also stated that when R29's ordered tramadol did not arrive on 09/11/24 and the resident was in pain, the nursing staff should have notified himself or another provider to get an order to use the E-Kit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure one of one resident (Resident) (R) 40) out of a total sample of 19 residents comprehensive social assessments were completed accurately to reflect diagnoses of mental illness and/or intellectual disability (ID). Failure to accurately identify diagnosis of mental illness or ID had the potential to result in the resident not receiving additional specialized services. Findings include: Review of R40's electronic medical record (EMR) revealed an admitting and current diagnosis located under the Diagnosis tab of Undifferentiated Schizophrenia and mild intellectual disabilities. Review of the Admission section of the EMR revealed R40 was admitted to the facility on [DATE]. Review of the Comprehensive Social Assessment V2.0 located in the Assessment tab of the EMR with completion dates of 02/3/25, 11/08/24, 07/31/24, 05/9/24, 02/5/24, and 11/13/23 revealed no diagnoses of Undifferentiated schizophrenia and/or Mild intellectual disability. Each of these assessments was signed by the Social Service Director (SSD). In the Mental Development section of each of these assessments the SSD wrote No history of Mental Illness. On 02/06/25 at 9:05 AM, the SSD was asked about the mental illness and mild intellectual disability diagnosis., The SSD stated she was not aware R40 had those diagnoses. On 02/06/25 at 10:15 AM, Registered Nurse Resident Assessment Instrument (RAI) Director stated the SSD was expected to review the comprehensive social assessments to ensure they were accurate. The RAI Director stated the facility did not have a policy but followed the instructions in the RAI manual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure an accurate Level I screening prior to admission for one of one resident (Resident (R)40) reviewed for Preadmission Screening and Resident Review (PASRR) out of a total sample of 19 residents. This failure resulted in R40 not receiving a Level II screen for specialized services for mental illness (MI) and/or intellectual disability (ID). Findings include: Review of R40's electronic medical record (EMR) revealed his admitting and current diagnosis located under the Diagnosis tab included Undifferentiated Schizophrenia and mild intellectual disabilities. Review of the Admission section of the EMR revealed he was admitted to the facility on [DATE]. Review of the Comprehensive Social Assessment V2.0 located in the Assessment tab of the EMR with completion dates of 02/3/25, 11/08/24, 07/31/24, 05/9/24, 02/5/24, and 11/13/23 revealed no diagnoses of Undifferentiated schizophrenia and/or Mild intellectual disability. Each of the assessments were signed by the Social Services Director (SSD). In the Mental Development section of each of these assessments the SSD wrote No history of Mental Illness. The resident's EMR was reviewed in its entirety and was silent for a Level I or Level II Preadmission Screening/Resident Review (PASRR). On 02/06/25 at 8:38 AM the SSD provided a Level I PASRR that the hospital completed. Review of the document titled Preadmission Screening/Resident Review (PASRR) Level I Assessment Form DMA-613,dated 10/23/23 revealed No was marked for the question Does the resident have a primary diagnosis of serious mental illness, developmental disability, or related condition? The SSD stated the hospital inaccurately completed the Level I PASRR and as a result a Level II was never completed. On 02/06/25 9:05 AM the SSD was asked about the Mild Intellectual Disability diagnosis, and she stated she was not aware R40 had that diagnosis. The SSD stated she would update the application and send in per the PASSR company's request. The SSD provided an undated document titled Best Practice for PASRR and stated the facility followed the document as they did not have a policy for PASRR. Review of the document revealed PASRR status should be reviewed for all new admissions; the SSD should maintain an active, ongoing, and a current list of PASRR patients; and the list should contain, at a minimum, the patient's name, DMI or ID/DD, if they require services or do not require services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, the facility failed to ensure a baseline care plan was developed within 48 hours of a resident's admission for one of one resident (Resident (R) 45) reviewed for baseline care plans out of 19 sampled residents. Findings include: Review of the facility's policy titled, Baseline Care Plan, reviewed 12/27/24 revealed .To promote person-centered continuity of care and communication with the resident and representative, if applicable, regarding the initial plan for delivery of care and services .The center will complete and implement a baseline care plan within 48 hours of a resident's admission in collaboration with the resident and the representative, if applicable . Review of R45's undated Face Sheet, provided by the facility revealed the resident was admitted to the facility on [DATE]. Review of R45's entire electronic medical record (EMR) revealed no documented evidence a baseline care plan was developed for R45. During an interview on 02/05/25 at 2:53 PM, the Resident Assessment Instrument Director (RAI) stated the facility did not develop a baseline care plan for R45. The RAI stated she was responsible for completing resident's baseline care plans. The RAI also stated during the time the baseline care plan was supposed to be developed for R45, she was on leave and someone in the facility's corporation was covering for her remotely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, the facility failed to ensure the care plan was revised to address pain for one of 19 sampled residents (Resident (R) 29). This deficient practice placed the resident at risk for her pain not to be effectively managed. Findings include: Review of the facility's policy titled, Patient's Plan of Care, reviewed 12/27/24 revealed Intent .To promote person-centered patient care through a comprehensive care plan. Guideline. Each patient will have a person-centered comprehensive care plan developed and implemented to address the patients' medical, physical, mental, and psychosocial needs .Procedure .The comprehensive care plan should also be updated as ongoing clinical assessments identify changes . Review of the facility's policy titled, Pain Assessment, reviewed 12/27/24 revealed .Each patient identified with pain should have a care plan addressing pain management . Review of R29's undated Face Sheet, provided by the facility revealed the resident was admitted to the facility on [DATE]. Review of R29's Nurses Note, dated 09/08/24, located in the resident's EMR under the Nurses Notes, tab revealed Summoned to resident's room by CNA [Certified Nursing Assistant] @ [at] 2:00 am. CNA stated, 'She said she is hurting.' Resident observed lying in bed C/O [complain of] lower back pain. Resident stated, 'It hurts a little bit.' CNA stated, 'Upon movement resident yelled and Hollard [sic] out. Notified [Nurse Practitioner's (NP) name] @ 2:06 am. Received TO [telephone order] : Give PRN [as needed] Tylenol and Get X-Ray of Lumbar and Spine. Notified Mobile Images @ 2:10 am. Mobile Image operator stated, We will have someone come out on tomorrow. Will pass on to oncoming nurse. Review of R29's Nurses Note, dated 09/11/24 and located in the resident's EMR under the Nurses Notes tab revealed Resident was scheduled for x-ray today due to pain. Writer assisted x-ray tech [technician] with the task but was unable to complete all the test due to the resident being in too much discomfort. Review of R29's Care Plan, located in the resident's electronic medical record (EMR) under the Care Plan tab revealed the care plan did not include any problems, goal, or interventions related to pain. During an interview and record review on 02/06/25 at 8:40 AM, RN1 verified R29's care plan did not include a problem area of pain, did not include a goal related to pain, nor any interventions to address the resident's pain. During an interview and record review on 02/06/25 at 10:06 AM, the RAI [Resident Assessment Instrument] Director verified R29 did not have a care plan that addressed her pain. The RAI Director stated R29's care plan should have been revised to include a problem area of pain with a goal and interventions on 09/08/24 when she complained of pain and received and pharmacological intervention for pain. During an interview on 02/06/25 at 11:58 AM, Nurse Practitioner (NP) 1 stated it was her expectation R29's care plan would have been revised to include the problem area of pain after the resident complained of pain on 09/08/24 and then complained of increased pain on 09/10/24. During an interview on 02/06/25 at 1:59 PM, the Medical Director who was also the resident's attending physician stated it was his expectation R29's care plan would have included pain as a problem area after the resident complained of pain.

Based on observations, record review, interviews, and policy review, the facility failed to consistently implement a low bed and fall mats for one of four residents (Resident (R) 48) reviewed for accidents out of a total sample of 19 residents. Failing to consistently implement measures when the resident transfers self out of bed and/or chair increased the risk of R48 sustaining an injury. Findings include: Review of R48's Care Plan located in the Care Plan tab of the electronic medical record (EMR) revealed a care plan area titled fall risk with a review date of 12/17/24. The Care Area/Problem section of the care plan stated the resident will get out of bed or chair unassisted related to always being incontinent, right below the knee amputation, fall in the past six months, highly impaired vision, unsteady gait, fall within last 2 to 6 months and fall with in past month. The interventions included frequent checks, frequent observations, low bed, mat at both sides of bed, and place the resident in open area for maximum observation opportunities as tolerated. His care plan for limited mobility with a review date of 12/17/24 stated he needed assistance with functional activities of daily living because he had a right below the knee amputation. The interventions included assistance with activities of daily living as needed; Hoyer lift sling for transfers, manual wheelchair, and two person assist with transfers. His care plan area for Behaviors with a revised date of 12/23/24 stated he had behaviors related to psychosocial factors and as evidenced by anxiety, verbal behavior issues, agitation, and crawling on the floor. The care plan problem area stated he got on floor from the bed and the chair at times. Review of Fall Event documents provided by the Administrator on 02/05/25 at 1:30 PM revealed R48 had documentation of falls/sliding out of the bed or chair on 08/31/24 at 7:00 AM, 09/26/24 at 4:50 AM, 11/12/24 at 8:00 AM, 11/16/24 at 3:00 PM, 11/25/24 at 6:50 AM, 12/03/24 at 10:23 AM, 12/04/24 at 8:06 AM, 12/11/24 at 7:35 PM, 02/02/25 at 9:36 AM and 02/02/25 at 10:50 PM. The Fall Event report dated 02/02/25 and timed 10:50 PM stated the resident got out of his chair and started crawling around on the floor and obtained a skin tear to his right stump and right elbow. On 02/02/25 at 9:00 AM, R48 was observed in his room on the floor crawling around. His bedside table was overturned on its side, water was observed on the floor, and the resident's geriatric chair with the footrest in the up position was positioned across the door to the room. No staff were in the area or observed in the corridor and the resident's room was the last room on the hall furthest from the nursing station. The staff at the nursing station were alerted to the resident being on the floor. The Social Service Director (SSD) and Certified Nursing Assistant (CNA)5 went to the resident's room and verified he was crawling on the floor. CNA1 stated he was up in his chair in his room prior to him being on the floor. The SSD and CNA5 stated he often gets out of his chair and/or bed and crawls around on the floor. They verified he was alone in his room at the time of him getting out of his reclined geriatric chair. On 02/04/25 at 3:08 PM, R48 was observed in his bed sleeping. The bed was not in the lowest position and there were no mats on the floor on the sides of the bed. On 02/04/25 at 3:15 PM the Director of Nursing (DON) was informed of the situation. She verified the resident was in the room alone and the bed was not in the lowest position and the mats were not on the floor. She stated the mats should have been on the floor and the bed should have been in a lower position before the staff left him in the room unsupervised. Review of the facility policy titled Skilled Nursing Services Fall Management with a review date of 12/27/24 revealed it was the facility policy to provide the resident with adequate supervision, assistive devices and or functional programs as appropriate to minimize risk for falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, the facility failed to ensure pain medication was procured from the pharmacy and administered as ordered by the physician for one of 19 sampled residents (Resident (R) 29). The facility's failure increased the potential for R29 to have untreated pain when three doses of the pain medication were not available from the pharmacy. Findings include: Review of the facility's undated policy titled, Pharmacy Services Medication Unavailable for Administration, revealed .DEA [drug enforcement agency] Schedule II through V controlled substance medications require a signed prescription from the physician. At times, medications may become unavailable due to no prescription on file. The administering nurse should contact the dispensing pharmacist for further instruction on the necessary steps needed to obtain the medication .At any time a medication is not available for a specified time of administration, the nurse notifies the prescriber that the medication is not available and obtains a 'hold until medication available from pharmacy . Review of the facility's undated policy titled, Pharmacy Services Emergency Medication Kits (portable), revealed Intent. To facilitate emergency needs for medication by special delivery from the pharmacy or by using the center's approved emergency medication supply. Emergency pharmacy is available on a 24-hour basis. A limited supply of medications used in emergencies and/or starter doses of antibiotics is maintained in the center by the provider pharmacy in portable, sealed containers. The Emergency Kit is the property of the pharmacy . Review of the facility's Controlled Substances Emergency Box, dated 05/01/20 and provided by the facility revealed a list of medications kept in the facility's E-Kit. Included in the inventory was Ultram [tramadol] tablets, 50mg, and the quantity of 5 tablets. Review of an email from the facility's pharmacy dated 02/06/25 and provided by the facility revealed .Below is a timeline from the pharmacy's perspective for [R29's Name] Tramadol, a CIV [controlled schedule IV] prescription drug. 9/10 358 pm-received order for Tramadol 50 [mg] bid [twice a day] x [times] 7 days; pharmacist processed that order by 445pm; he did not fax that order to MD [medical doctor] because there was another order (below) that would have included these tabs within it on the prescription from the MD. 9/10 358PM-received a second order for Tramadol 50 mg bid prn to start after the 50 mg routine is complete; pharmacist processed that order at 446pm; requested prescription for tramadol electronically from [Medical Director's Name] @ [at] 447pm. 9/11 828am-received signed prescription back from [Medical Director's Name] electronic prescribing software; pharmacist processed medication @ 1121am and sent to filling station to be filled. 9/11 1206pm-meidcation filled and checked by second pharmacist then prepared for delivery to center on regular courier. 9/11 956pm-medication accepted at center . Review of R29's undated Face Sheet, provided by the facility revealed the resident was admitted to the facility on [DATE]. Review of the electronic medical record (EMR) revealed a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/31/24. Review of this MDS revealed R29 was not interviewable due to her cognitive status. Review of R29's Nurses Note, dated 09/08/24, located in the EMR under the Nurses Notes, tab revealed Summoned to resident's room by CNA [Certified Nursing Assistant] @ [at] 2:00 am. CNA stated, 'She said she is hurting.' Resident observed lying in bed C/O [complain of] lower back pain. Resident stated, 'It hurts a little bit.' CNA stated, 'Upon movement resident yelled and Hollard [sic] out. Notified [Nurse Practitioner's (NP) name] @ 2:06 am. Received TO [telephone order] : Give PRN [as needed] Tylenol and Get X-Ray of Lumbar and Spine. Notified Mobile Images @ 2:10 am. Mobile Image operator stated, We will have someone come out on tomorrow. Will pass on to oncoming nurse. Review of R29's Electronic Medication Administration Record [eMAR], dated September 2024 and located in the resident's EMR under the Medications tab revealed on 09/08/24 the resident's pain was assessed to be a 10 on a scale of 1-10, with 10 being the highest pain level possible. Continued review of the eMAR revealed R29 was administered the ordered PRN acetaminophen on 09/08/24 at 2:13 AM with a post pain level documented as one. Review of R29's physician order Summary Report, provided by the facility revealed on 09/10/24 the resident was ordered tramadol [opioid pain medication] 50 mg tablet, 1 tablet by mouth 2 times per day 7 days .Dx [diagnosis]: Acute pain due to trauma [fall on 09/07/24] . Review of R29's Nurses Note, dated 09/10/24 and located in the resident's EMR under the Nurses Notes tab revealed Tramadol did not come in tonight, will start when it arrives from pharmacy. Review of R29's Nurses Note, dated 09/11/24 and located in the resident's EMR under the Nurses Notes tab revealed 8am medication Tramadol 50mg not administered[.] Medication not in from pharmacy. F/U [follow up] with pharmacy stated medication will be in tonight. Will pass to on-coming nurse. Review of an email provided by the facility, dated 02/06/25 and from the x-ray contractor revealed 9/11/24 exam: PAIN .Best obtainable, PT [patient] was in pain and could not hold position for long .Nurse decided to stop exam before finishing due to PT pain . Review of R29's Nurses Note, dated 09/11/24 and located in the resident's EMR under the Nurses Notes tab revealed Resident was scheduled for x-ray today due to pain. Writer assisted x-ray tech [technician] with the task but was unable to complete all the test due to the resident being in too much discomfort. Review of the eMAR for September 2024 revealed no acetaminophen was administered for pain other than on 09/08/24 at 2:13 AM. Review of R29's Nurses Note, dated 09/11/24 and located in the resident's EMR under the Nurses Notes tab revealed 6pm medication Tramadol 50 mg not administered[.] F/U with pharmacy[.] Stated medication will be in tonight. Will pass to on-coming nurse. Review of R29's Electronic Medication Administration Record [eMAR], dated September 2024 and located in the resident's EMR under the Medications tab revealed the eMAR for tramadol 50 mg tablet was scheduled to be administered starting on 09/10/24 and ending on 09/17/24 at 8:00 AM and 6:00 PM. Continued review of the eMAR revealed R29 was not administered the 6:00 PM dose on 09/10/24, the 8:00 AM dose, nor the 6:00 PM dose of the tramadol medication on 09/11/24, which indicated the resident missed three doses of the physician ordered medication. During an interview and record review on 02/06/25 at 11:16 AM, Licensed Practical Nurse (LPN) 1 stated on 09/10/24 R29 was complaining about being sore and when the CNA touched R29, she did not want to be touched. LPN1 stated R29 did not indicate a pain level; however, R29 never complained of pain so when she said she was in pain, she immediately notified NP1 who ordered tramadol for pain and an x-ray. The LPN stated she put in both orders around 3:30 PM and the medication should have been delivered by the pharmacy that night. During an interview on 02/06/25 at 9:27 AM, the Director of Nursing (DON) stated when R29's medication did not arrive at the facility for it to be administered to the resident, it was her expectation that the nurse would have notified the provider that the tramadol did not arrive for it to be administered. The DON stated she had reviewed the information provided by the pharmacy and learned the pharmacy was waiting for a signed prescription from the physician. The DON stated the nurse could have called the pharmacy to see if the tramadol could have been pulled from the E-Kit and then the physician would needed to be notified for an order. During an interview on 02/06/25 at 11:58 AM NP1 stated on 09/10/24 she was notified R29 was complaining of increased pain. NP1 stated she ordered tramadol and an x-ray for R29. NP1 stated when the tramadol did not arrive at the facility for the resident's 09/11/24 dose, it was her expectation nursing would have called the pharmacy to get permission for tramadol to be used from the E-Kit (emergency medicine kit) and to get the expected arrival time of the ordered tramadol. During an interview on 02/06/25 at 1:59 PM, the Medical Director, who was also R29's attending physician, stated when R29's ordered tramadol did not arrive on 09/11/24 and the resident was in pain, the nursing staff should have notified himself or another provider to get an order to use the E-Kit which included tramadol.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the facility policy titled, Bed Hold During Hospital Stays and Therapeutic Leaves, the facility failed to provide a written bed hold agreement for one of 11 Residents (R1) who was sent to a behavioral facility for medication stabilization. The facility census was 59. Findings include: Review of the policy titled, Bed Hold During Hospital Stays and Therapeutic Leaves review date [DATE], Under Intent: It is the intent of this nursing center to offer all residents and/or his / her designee the choice of either paying the appropriate amount to hold the bed when the resident goes to the hospital or on therapeutic leave or releasing the bed and being readmitted to their previous room if available or to the first available bed. Closed Record Review Review of the Face Sheet revealed Resident 1 was admitted to the facility with the following diagnoses that include but not limited to Schizophrenia, type 2 diabetes mellitus, hypertension, depression, and gastro-esophageal reflux disease. Continued review of R1 face sheet also revealed that the resident was listed as the primary contact indicating he was his own responsible party. Review of the Quarterly Minimum Data set (MDS) dated [DATE] section C (Cognitive Pattern) indicated a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. Review of the Notice of Transfer or Discharges dated [DATE] with reason for transfer or discharge was to a stabilization unit. During review of R1 medical record there was not a bed hold agreement that explained the room rates after the Medicaid bed hold had expired that was signed and acknowledged by R1. An interview on [DATE] at 5:49 pm, the Administrator revealed that to prevent this occurrence she will talk to all departments to make sure everyone is on the same page.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observation during initial tour on 7/19/2021 at 12:35 p.m., revealed in room [ROOM NUMBER], all the baseboards are missing all around the room. Observation during initial tour on 7/19/2021 at 12:26 p.m., revealed in room [ROOM NUMBER], all the baseboards are missing all around the room. Observation during initial tour on 7/19/2021 at 12:14 p.m., revealed in room [ROOM NUMBER] exhaust fan in bathroom making a loud screeching noise. Observation during initial tour on 7/19/2021 at 12:11 p.m., air conditioning unit does not have a top on it. Observation during initial tour on 7/19/2021 at 12:21 p.m. revealed the shower room sink with water and appears to be clogged. Observation on 7/20/2021 at 10:10 a.m. revealed sink in shower room remains clogged. Observation on 7/20/2021 at 12:50 p.m. revealed ceiling tile in hallway between room [ROOM NUMBER] and room [ROOM NUMBER], split with a gap noted. Observation on 7/20/2021 at 2:10 p.m. revealed in room [ROOM NUMBER], all the baseboards are missing all around the room. Observation on 7/20/2021 at 2:10 p.m. revealed ceiling tile in the hallway at the exit door with gap and off center from the support rod. Interview with Administrator on 7/22/2021 at 9:52 a.m. who reported being unaware of the condition of the gaps in the tiles and peeling tiles in the resident bedrooms. The Administrator reported that resident mattress needed to be replaced and had not been aware of the mattress being soiled and ruined. The Administrator stated that the facility participated in Zone Rounds every morning and this consisted of designated staff who have different areas to observe. He did not have a Zone Round form to show when concerns or problems were identified. He stated that this information is not logged daily, and he would not have a record of it. Based on observations and staff interviews, the facility failed to ensure that it was maintained in a clean and comfortable environment. Specifically, the facility failed to keep bathrooms free from urine odors, failed to maintain upkeep of baseboards in residents' rooms, failed to maintain clog free sinks in one shower room and residents' bathrooms, and failed to maintain ceiling tiles in residents' rooms. The facility also failed to ensure one resident's mattress was maintained in a clean sanitized condition free from soil and dark brown substances. This deficient practice affected two of three halls. Findings include: 1. Observations on 7/19/2021 at 12:59 p.m., 7/20/2021 at 9:15 a.m.,7/21/2021 at 8:39 a.m., and 7/22/2021 at 9:54 a.m. of room [ROOM NUMBER] Bed A and Bed B revealed large gaps in the ceiling tiles in addition to peeling and stained ceiling tiles above each resident bed directly over their head. Observations of room [ROOM NUMBER] Bed C on 7/19/2021 at 1:00 p.m.,7/20/2021 at 9:16 a.m. and 11:02 a.m., 7/21/21 at 8:40 a.m., and 7/22/2021 at 9:55 a.m. revealed one resident mattress thin, soiled, and covered with dark brown substances Observations of room [ROOM NUMBER] on 7/19/2021 at 1:05 p.m. revealed water leakage and water on the floor in the bathroom. Observations of room [ROOM NUMBER] on 7/19/2021 at 1:07 p.m. and 3:01 p.m., 7/20/2021 at 9:17 a.m. and 11:03 a.m., 7/21/2021 at 8:40 a.m. and 3:03 p.m., and 7/22/2021 at 9:58 a.m. revealed strong urine odor in bathroom. Observations of room [ROOM NUMBER] on 7/19/2021 at 1:08 p.m., 7/20/2021 at 9:18 a.m. and 11:04 a.m., 7/21/2021 at 8:41 a.m. and 3:06 p.m., and 7/22/2021 at 9:59 a.m. revealed strong urine odor in the bathroom with peeling ceiling tiles and large gaps in the ceiling in the resident's room. Observations of room [ROOM NUMBER] on 7/19/2021 at 1:05 p.m. revealed water leakage and water on the floor in the bathroom confirmed with the Administrator, Maintenance Supervisor (MS), and Director of Nursing (DON). The Administrator and DON confirmed being unaware of the leaking toilet. The MS reported being aware of the toilet leakage for the last three days. He stated that he was waiting on a part for the toilet. There was one resident in the three-bedroom unit who used the toilet. During a later observation on 7/19/2021 at 1:30 p.m., the Maintenance Supervisor (MS) provided a tour of the bathroom for room [ROOM NUMBER] to confirm that the leakage was fixed. An environmental tour began on 7/22/2021 at 9:46 a.m. with the Administrator, Director of Nursing (DON), Housekeeping Supervisor (HKS), and the MS of which identified environmental issues were confirmed. Interview on 7/22/2021 at 9:47 a.m. with the MS who reported that he had removed the baseboards approximately two weeks ago. The MS reported that the facility was in the process of repairing the whole building with new floors but because of the pandemic the contractors who were hired had to stop working. He reported that the stained ceiling tile in room13 above bed A was due to a leakage that had occurred. He stated that he had tried to paint over the ceiling tile, but the stain continues to come through. He stated that the ceiling gap in the hallway between room [ROOM NUMBER] and room [ROOM NUMBER] was the result of a request by Life Safety. He stated that he was in the process of repairing the tiles in all the rooms that had gaps or holes in the ceiling. MS reported that a company had cleaned the air conditioners (a/c) and the a/c worker forgot to put the covering back on after cleaning it. He stated that he was not aware that the a/c covering was missing until today. The MS was unable to provide a log of items that he had identified as needing repair. The MS stated that he had not logged any repairs for the concerns involving the base boards, privacy curtains, stained ceiling, and ceiling tiles in his logbook. He reported that he just works on problems and concerns as they are identified. He reported that he had been working on the identified concerns. Interview on 7/22/2021 at 9:48 a.m. with HKS who reported being aware of the strong urine odor in the bathrooms for room [ROOM NUMBER] and 30. She reported that the problem was a result of the tiles which should be replaced. She also stated maybe if she tried to clean the bathroom, herself the odor could be eliminated. Another observation was made after the HK supervisor cleaned the room with her products. The HK Supervisor confirmed that the odor remained and was coming from the tiles that needed to be replaced in the bathrooms for rooms [ROOM NUMBERS].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review and staff interview, the facility failed to implement the individualized care plan for behavior monitoring for two residents (R#10 and R#37) who were receiving psychotropic medications; the facility also failed to develop a care plan for urinary tract infection for R#30. The sample size was 31 Residents. Findings include: Review of the facility policy titled Skilled Patient Services: Patient's Plan of Care dated 2020, revealed the intent is for each resident to have a person-centered comprehensive care plan developed and implemented to meet their preferences and goals, and address the patient's medical, physical, mental and psychosocial needs. 1. Resident #10 was admitted to the facility on [DATE] with diagnosis of Bipolar disorder, diabetes, hypothyroidism, vascular dementia, paranoid schizophrenia, chronic obstructive pulmonary disease (COPD), hyperlipidemia. Review of the Annual assessment dated [DATE] revealed Brief Interview for Mental Status (BIMS) was coded as 5, which indicated severe cognitive impairment. Section N revealed that the resident received antipsychotic meds seven of seven days and antidepressant meds seven of seven days. Review of the care plan for R#10, dated 10/23/2018 and reviewed 5/13/2021 revealed R#10 uses psychotropic drugs related to paranoia, outbursts, delusions, tearfulness and dementia with psychosis. Interventions to care include document episodes of refusing care, monitor behaviors as indicated and observe for possible side effects. 2. Resident #37 was admitted to the facility on [DATE] with diagnosis of cerebral infarction, aphasia, diabetes, transient ischemic attack (TIA), hypertension (HTN), and dementia. Review of the Comprehensive admission assessment dated [DATE] revealed Brief Interview for Mental Status (BIMS) was coded as 3, which indicated severe cognitive impairment. Section N revealed that the resident received antipsychotic meds seven of seven days and antianxiety seven of seven days. Review of the Care plan for R#37, dated 6/29/2021 revealed R#37 uses psychotropic drugs related to anxiety, dementia with behaviors, wandering, agitation, resisting care and disrobing. Interventions to care include monitor behaviors as indicated, administer medications as ordered, observe for side effects of medications and conduct behavior assessments as needed. Interview on 7/22/2021 at 4:25 p.m. with the Director of Nursing (DON) who stated that it is her expectation that nurses follow the care plan for behavior monitoring. She stated that the nurses have a checklist of tasks to complete before the end of their shift, and behavior monitoring is on the checklist. During further interview, she stated that she herself, the Assistant DON or the Resident Care Coordinator (RCC) do random audits of the EMR and discovered some of the nurses are not completing the behavior monitoring. Cross refer F757 3. Record review of R#30 's medical record revealed a diagnosis of urinary tract infection with an onset of 7/9/2021. Record review of a plan of care dated 11/25/2020 (last updated 5/13/2021) to address risk for skin breakdown. However, the care plan did not address R#30's most recent UTI. During an interview on 7/22/2021 at 3:23 a.m., the Minimum Data Set (MDS) Coordinator confirmed that the skin care plan did not address the resident UTI. The MDS also confirmed that a previous plan of care labeled Potential for UTI was deleted from R#30's record a few months ago. She confirmed that this UTI care plan should have never been resolved and should had been a continuation plan of care which could have been easily updated for further UTI' s. She further stated that a care plan for a UTI should have been implemented to address the plan of treatment for R#30's current UTI. MDS Coordinator stated that any of the charge nurses can implement/revise a care plan for treatment services for any residents. She stated that in this situation she was waiting to create a plan of care on the next MDS assessment which was due on 8/9/2021. Interview on 7/22/21 at 4:24 p.m., Register Nurse Clinical Coordinator (RN/RCC) confirmed that there was no plan of care to address R#30's present UTI. She also verified that she was the one who contacted the Nurse Practitioner (NP) to request a new order for R#30's antibiotic stewardship. She acknowledged that a UTI care plan should have been in place for this R#30's treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of policy titled Psychotropic Medications, the facility failed to monitor and document behaviors and side effects for two of five residents (R) R#10 and R#37 reviewed that received psychotropic medications. Findings include: Review of the policy titled Psychotropic Medications dated 2019 revealed that psychotropic drugs include, but are not limited to, drugs in following categories: anti-psychotic, anti-depressant, anti-anxiety, and hypnotic. Monitoring of psychotropic medications before (when able and as appropriate) or as soon as psychotropic medication therapy is initiated, patient-specific and targeted behaviors should be identified and monitored quantitatively and quantitatively to determine the effectiveness of the medication and the presence of side effects. Behaviors should be documented per shift per day. Side effects if present, an explanation should be documented in the medical record and the prescriber notified with any required follow-up documented and carried out. 1. Resident #10 was admitted to the facility on [DATE] with diagnosis of bipolar disorder, diabetes, hypothyroidism, vascular dementia, paranoid schizophrenia, chronic obstructive pulmonary disease (COPD), hyperlipidemia. Review of the Annual assessment dated [DATE] revealed Brief Interview for Mental Status (BIMS) was coded as 5, which indicated severe cognitive impairment. Section N revealed that the resident received antipsychotic meds seven of seven days and antidepressant meds seven of seven days. Review of the Physician Orders (PO) for R#10 dated 6/1/2021 through 7/22/2021 revealed orders for Quetiapine (a medication used to treat schizophrenia and bipolar disorder) 200 milligrams (mg) daily and 400 mg at bedtime; Ziprasidone (a medication to treat schizophrenia) 140 mg daily and 60 mg at bedtime; fluoxetine (a medication used to treat depression) 10 mg at bedtime. Review of Monitoring Weekly Report for the months of May 2021, June 2021 and July 2021 revealed no evidence of behaviors and/or side effects being monitored for the following dates: May 2021: revealed for behavior (paranoia) on the day shift: 5/3, 5/4, 5/7, 5/8, 5/9, 5/11, 5/13, 5/18, 5/21, 5/22, 5/23, 5/26, 5/28, and 5/31. Continued review for behavior (verbal aggression) on the day shift: 5/3, 5/4, 5/7, 5/8, 5/9, 5/11, 5/12, 5/13, 5/14, 5/18, 5/21, 5/22, 5/23, 5/26, 5/28 and 5/31. Continued review for behavior (resists care) on the day shift: 5/3, 5/4, 5/7, 5/8, 5/9, 5/11, 5/13, 5/14, 5/18, 5/21, 5/22, 5/23, 5/26, 5/28, and 5/31. Continued review for behavior (delusions) on the day shift: 5/3, 5/4, 5/7, 5/8, 5/9, 5/11, 5/13, 5/14, 5/18, 5/21, 5/22, 5/23, 5/26, 5/28, and 5/21. June 2021: revealed for behavior (paranoia) on the day shift: 6/1, 6/4, 6/9, 6/10, 6/11, 6/12, 6/13, 6/14, 6/15, 6/18, 6/19, 6/20, 6/23/, 6/28, and 6/29. Continued review for behavior (verbal aggression) on the day shift: 6/1, 6/4, 6/9, 6/10, 6/11, 6/12, 6/13, 6/14, 6/15, 6/18, 6/19, 6/20, 6/25, 6/28, and 6/29. Continued review for behavior (resists care) on the day shift: 6/1, 6/4, 6/9, 6/10, 6/11, 6/12, 6/13, 6/14, 6/15, 6/18, 6/19, 6/20, 6/23, 6/25, 6/28, and 6/29; Night Shift: 6/11. Continued review for behavior (Delusions) on the day shift: 6/1, 6/4, 6/9, 6/10, 6/11, 6/12, 6/13, 6/14, 6/15, 6/18, 6/19, 6/20, 6/23, 6/25, 6/28, and 6/29. July 2021: revealed for behavior (paranoia) on the day shift: 7/19; night shift 7/2. Continued review for behavior (verbal aggression) on the day shift: 7/3, and 7/19; night shift 7/2. Continued review for behavior (resists care) on the day shift: 7/3 and 7/19; Night shift: 7/2. Continued review for behavior (Delusions) on the day shift: 7/19. 2. Resident #37 was admitted to the facility on [DATE] with diagnosis of cerebral infarction, aphasia, diabetes, transient ischemic attack (TIA), hypertension (HTN), and dementia. Review of the Comprehensive admission assessment dated [DATE] revealed BIMS was coded as 3, which indicated severe cognitive impairment. Section N revealed that the resident received antipsychotic meds seven of seven days and antianxiety seven of seven days. Review of the Physician Orders (PO) for R#37 dated 6/11/2021 through 7/22/2021 revealed orders for Quetiapine 25 mg (a medication used to treat schizophrenia) at bedtime; Ativan 0.5 mg three times daily (TID). Review of Monitoring Weekly Report for the months of June 2021 and July 2021 revealed no evidence of behaviors and/or side effects being monitored for the following dates: June 2021: revealed for behavior (agitation) on the day shift: 6/18, 6/19, and 6/20. Continued review for behavior (anxiety) on the day shift: 6/18, 6/19, 6/20. July 2021: revealed for behavior (agitation) on the day shift: 7/19; night shift: 7/2. Continued review for behavior (anxiety) on the day shift: 7/19; night shift: 7/2. Interview on 7/22/2021 at 11:36 a.m. with Registered Nurse (RN) AA, stated that there is no trigger on the computer that alerts them that the resident needs to have behavior monitoring. She stated that she just knows based on the medications. She further stated that she looks at the monitor drop down box to see if her residents are on there for behavior monitoring. She stated she always does her documentation, but she may forget some at times. Interview on 7/22/2021 at 4:25 p.m. with the Director of Nursing (DON) stated that it is her expectation that nurses complete the behavior monitoring. She stated that the nurses have a checklist of tasks to complete before the end of their shift, and behavior monitoring is on the checklist. During further interview, she stated that she herself, the Assistant DON or the Resident Care Coordinator (RCC) do random audits of the EMR and discovered some of the nurses are not completing the behavior monitoring.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During initial tour on 7/19/2021 at 12:18 p.m., revealed privacy curtain in room [ROOM NUMBER] Bed A not providing full visual privacy for resident. During initial tour on 7/19/2021 at 12:22 p.m., revealed privacy curtain in room [ROOM NUMBER] Bed A not providing full visual privacy for resident. During initial tour on 7/19/2021 at 12:49 p.m., revealed privacy curtain in room [ROOM NUMBER] Bed A not providing full visual privacy for resident. During initial tour on 7/19/2021 at 12:50 p.m., revealed privacy curtain in room [ROOM NUMBER] Bed B folded and clipped on hooks on track at the head of the bed. During an interview with 7/22/2021 at 11:44 a.m. with the HKS it was reported that the privacy curtains are folded because the facility does not have enough hooks to hang the privacy curtains. She stated that she was very much aware that the privacy curtains should encircle the bed to provide full visual privacy for the residents. She was aware of the gaps in the curtains. She confirmed that the facility did not have enough curtains and verified that even if the curtains were folded in one room, the two inches difference from the fold still failed to lengthen the curtain width and eliminated the curtain gap. Based on observations and staff interviews, the facility failed to ensure that privacy curtains provided full visual privacy for a total of seven of 14 resident shared bedrooms (rooms: 10, 11,13, 24, 25, 27, and 30). Finding include: 1.Observations on 7/19/2021 at 12:59 a.m., 7/20/2021 at 9:15 a.m., 7/21/2021 at 8:39 a.m., and 7/22/2021 at 9:54 a.m., revealed short privacy curtains for room [ROOM NUMBER] both Bed A and Bed B. Observations on 7/19/2021 at 1:00 p.m., 7/20/2021 at 9:16 a.m., 7/21/2021 at 8:40 a.m., and 7/22/2021 at 9:55 a.m. revealed short privacy curtains for room [ROOM NUMBER] Bed B. Observations on 7/19/2021 at 1:07 p.m., 7/20/2021 at 9:17 a.m., 7/21/2021 at 8:40 a.m., and 7/22/2021 at 9:58 a.m. revealed short privacy curtains for room [ROOM NUMBER] both Bed A and Bed B. Observations on 7/192021 at 1:08 p.m., 7/20/2021 at 9:18 a.m. and 11:04 a.m., 7/21/2021 at 8:41 a.m. and 3:06 p.m., and 7/22/2021 at 9:59 a.m. for room [ROOM NUMBER] Bed A revealed short privacy curtains. An environmental tour began on 7/22/2021 at 9:46 a.m. with the Administrator, Director of Nursing (DON), Housekeeping Supervisor (HKS), and the Maintenance Supervisor (MS). Observation revealed resident privacy curtains with a with space/gap of 40.5 inches or less which did not ensure full visual privacy coverage including rooms 10, 11, 13, 24, 25, 27, and 30. In room [ROOM NUMBER] there was a 40.5-inch space/gap from the wall for both Bed A and Bed B. During an interview at the time of the observation on 7/22/2021 at 9:47 a.m., the MS confirmed that the privacy curtains were too short due to the gap measurements. He reported that the facility had privacy curtains on back order, and they were unavailable due to the COVID 19 pandemic. MS further stated that the facility did not have any additional curtains to hang. He was unaware of the lack of coverage the curtains were providing and neither was he aware of regulations that privacy curtains should provide full visual privacy. He reported that Housekeeping Aide EE was responsible for hanging all privacy curtains in the residents' rooms. The MS reported that he is only responsible for the functioning of the curtains. However, he is willing to take sole responsibility for the curtains being too short due to the lack of curtains to hang in the residents' rooms. The MS reported that problem is something that the housekeeping staff should not be held responsible for. Interview at the time of the tour observation on 7/22/2021 at 9:48 a.m., with HKS who reported that Housekeeping Aide EE is responsible for hanging the curtains. The housekeeping staff are responsible for cleaning the curtains. Interview and observation during the environmental tour on 7/22/2021 at 9:50 a.m., with the DON who reported that her Certified Nursing Assistants (CNA) and licensed nursing staff hold accountability for ensuring privacy curtains provide full visual privacy for the residents. She reported that the nursing staff and CNAs have received training on privacy curtains and resident privacy. The DON reported that she expected her CNA and licensed nursing staff to report any issues with privacy curtains. She could not recall the last time she checked privacy curtains in the resident rooms to monitor the length and width of the curtains. During the environmental tour on 7/22/2021 at 9:52 a.m., the Administrator reported that he was aware of the shortage of privacy curtains. However, he was not aware of the large gaps in the privacy curtains which prevented the residents from having full visual privacy. The Administrator reported that he submitted purchase orders for privacy curtains a few months ago for a few curtains as a tester to determine size and width. Unfortunately, the privacy had to be returned due to the wrong color and size. Interview on 7/22/2021 at 11:43 a.m. with the Housekeeping Aide EE, who reported being unaware of the specifics about privacy curtains providing full visual privacy. He acknowledged that he always folded some of the curtains due to not having enough hooks in one of the resident rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, policy review titled, Skilled Inpatient Services: Covid-19 Visitation Guidelines, Resident Rights, and review of the Centers for Medicare and Medicaid Services (CMS) QSO-20-39-NH Nursing Home Visitation-COVID 19, the facility failed to ensure that residents were allowed to receive indoor visitation for two residents (R) (R A and R B). The census was 51 Residents. Findings include: Review of the facility policy titled, Skilled Inpatient Services: Covid-19 Visitation Guidelines revised July 2021, revealed the intent is to provide guidance on how to conduct visitation as outlined by guidance from Georgia Department of Public Health and Centers for Medicare and Medicaid Services. Guidelines 1. Center must have met local, state, and federal criteria for allowing indoor visitation. 4. Visitor movement within the facility should be limited to the designated visitation area. Review of Resident Rights dated 2020, revealed the intent is for all staff to understand the importance of treating patients with care and respect, and honoring patients' rights to make personal choices. Guidelines 9. Unrestricted visitation. Review of the CMS QSO-20-39-NH Nursing Home Visitation-COVID 19 (dated 9/17/20 and revised 4/27/21) revealed that Facilities should allow indoor visitation at all times and for all residents regardless of vaccination status except for the following: Unvaccinated residents, if the nursing home's COVID-19 county positivity rate is >10% and <70% of residents in the facility are fully vaccinated; residents with confirmed COVID-19 infection whether vaccinated or unvaccinated until they have met the criteria to discontinue Transmission-Based Precautions; and residents in quarantine, whether vaccinated or unvaccinated, until they have met criteria for release from quarantine .Compassionate care visits should be permitted at all times. Review of the Department of Public Health website (dph.georgia.gov) revealed that the indicator report for [NAME] County dated 7/19/21 showed a 3.4% COVID-19 positivity rate from 7/1/21 to 7/14/21. The 3.4% county positivity rate indicated that [NAME] County had a low level of community transmission. Review of the Center for Disease Control (CDC) Healthcare Safety Network (NHSN) Reporting site for the week ending 7/4/2021 the Resident vaccination rate was 83.3% and a 47.1% Healthcare Personnel vaccination rate. Review of document on facility letterhead dated July 19, 2021, revealed information mailed to resident family members informing them of a designated visitation room within the facility along with guidelines for use of the room. Observation on 7/20/2021 at 3:30 p.m. R 'A' sitting in his wheelchair in the dayroom, watching television. Observation on 7/21/2021 at 11:45 a.m. R 'B' visiting with her daughter on the front porch of the facility. Phone interview on 7/19/2021 at 12:57 with family of R 'A', stated he visits his father three to four days per week. He stated the visits have all been held on the front porch. He stated that when he calls the facility to schedule visitation, he has never been given the option to have an indoor visit. During further interview, he stated that he would like to visit his father inside, but also outside when the weather is not too hot. Interview on 7/19/2021 at 3:30 p.m. with Infection Control Preventionist (ICP), revealed that the facility did not have any residents who were positive for COVID-19. She stated the facility started porch visits in March 2021. During further interview, she revealed about two weeks ago family members started asking about being able to visit residents inside the facility. She stated discussions were held in the morning meeting about converting a four-room suite into a designated visitation room, but they had not yet started allowing indoor visitations yet, but they were planning to do so soon. During further interview, she stated the only indoor visitation allowed is for compassionate care but stated the facility currently does not have any residents on end-of-life care. Interview on 7/21/2021 at 2:37 p.m. with the Administrator, revealed that current visitation is via window visits and porch visits. He stated the Activity Coordinator schedules and supervises the visits. He stated they are discussing setting up one of the resident four room suites as a designated visitation area so that families could have indoor visitations. He stated the plan will be to have one family visitation at a time inside, and still maintain the porch visits as well. He stated he is not certain when that will take place. During further interview, he stated the Interdisciplinary Team (IDT) made the decision to do the designated room, but has not discussed in room visits, due to protecting the residents and the staff from the potential exposure to the COVID virus. Interview on 7/22/21 at 9:35 a.m. with Activity Coordinator confirmed she is responsible for scheduling and supervising resident/family visitation. She stated outdoor porch visitation started in March 2020. She stated that visits are limited to two families at a time for 30-45 minutes. She stated that they discuss in the daily morning meeting about the progression of allowing indoor visitation, and stated that this week, they allowed a family member to visit in a designated space set up to facilitate indoor visitation. She stated the facility mailed out a letter to the families this week to indicate the starting of supervised visitation in this designated space, inside the facility. She further stated that the residents/family members are not allowed to visit anywhere else inside the facility, other than the designated room. She stated that the visitation process is discussed in morning meeting, and they have discussed allowing visitation in resident rooms, but no plans at this time to allow that.

Based on record review and staff interviews the facility failed to ensure that staff designated as the Dietary Manager was a Certified Dietary/Food Service Manager or had a similar food service management certification or degree. There were 46 of 51 Residents receiving an oral diet. Findings include: Review of document titled JOB TITLE: FOOD SERVICE MANAGER (with a revision date of 4/12) revealed the start date of 12/3/2019 for the Dietary Manager (DM). Further review of the document revealed should become a Certified Dietary Manager through completion of both a Dietary Managers Training Course and Certification Exam within five (5) years of employment. During an interview with the Nursing Home Administrator on 7/22/2021 at 11:13 a.m., the Administrator revealed that he was aware the current DM was not in compliance with the current regulations related to the requirements for the position of DM. The Administrator revealed the current DM began working at the facility as DM in December of 2019. It was confirmed that the DM is neither Serve Safe certified nor was she a Certified Dietary Manager (CDM). The Administrator explained the employee began work on the certification classes in January 2020 but had to temporarily stop the classes due to illness. Although the certifying institution granted the current DM a six-month extension, the DM decided in June 2021, that she no longer wanted to pursue getting the DM certification. Since that time, the corporate office has been sending a CDM to this facility at least three times per month while also calling to this facility on a weekly basis. The facility has not had a CDM since the Minimum Licensure/Certification Requirements were implemented.