**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews and record reviews, the facility failed to provide showers/baths for two residents (R) (R268 and RA) who were dependent on staff for activities of daily living (ADLs). The sample size was 31 residents. The deficient practice placed R268 and RA at risk for unmet needs and a diminished quality of life. Findings include: 1. A review of R268's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed section C (Cognition) documented a Brief Interview of Mental Status (BIMS) score of 10 (indicating moderate cognitive impairment), section GG (Functional Abilities and Goals) documented R268 required extensive assistance with baths/showers, section I (Active Diagnoses) documented R268 had diagnoses including but not limited to Parkinson's disease, dementia, and sickle-cell disease. A review of the ADL plan of care revealed that R268 was scheduled for a bath/shower on Mondays, Wednesdays, and Fridays on the day shift. A review of ADL documentation for April 2024 revealed that R268 received a bath/shower on 4/1/2024 and 4/3/2024. The facility could not provide documentation that R268 received a bath/shower at any other time in April 2024. In an interview on 5/5/2024 at 9:33 am, the Assistant Director of Nursing (ADON) and Senior Nurse Consultant confirmed there was no documentation that the resident had more than two baths in April 2024. The Senior Nurse consultant stated there were issues with the electronic documentation system that caused documentation not to be captured, and they were aware of the issue. However, there was no backup system in place for documentation of ADL care. 2. A review of RA's MDS admission assessment dated [DATE] revealed section C (Cognition) documented a BIMS score of 14 (indicating intact cognition), section GG (Functional Abilities and Goals) documented R A was dependent with setup or clean up assistance with a bath/shower, section I (Active Diagnoses) documented morbid obesity, difficulty in walking and muscle weakness. In an interview on 5/3/2024 at 9:32 am, RA revealed she received a bath yesterday. However, it had been a while since she had a bath. She was unaware of the bath schedule. She stated she was sometimes offered a bath, but normally she must request one. RA stated she would request a bath, and they would pass her by if she was asleep. She stated she must sometimes wait until days later to get a bath. A review of ADL documentation dated 5/5/2024 revealed RA was scheduled to receive a bath/shower on Mondays, Wednesdays, and Fridays on the night shift and required substantial/maximal assistance. However, a review of the Bath Schedule Wing 1, updated 5/2/2024, revealed RA was scheduled for a bath/shower on Tuesdays, Thursdays, and Fridays on the day shift. A review of bathing data from the electronic medical record revealed the resident did not receive a scheduled bath/shower on 2/28/2024, 3/1/2024, 3/8/2024, 3/15/2024, 3/18/2024, 4/5/2024, 4/10/2024, 4/12/2024, 4/15/2024, 4/19/2024, 4/24/2024, and 4/26/2024. Upon request, the facility could not provide further documentation for baths/showers for RA. In an interview on 5/5/2024 at 10:06 am, Registered Nurse (RN) BB revealed RA's schedule just changed, but she believed the resident requested a bath based on what was best for her schedule. She was unaware of any issues with the resident not receiving a bath as scheduled. In an interview on 5/5/2024 at 10:20 am, the ADON revealed they do not have a policy related to baths/showers. She stated that they find out the residents' preferences and schedule them. In an interview on 5/5/2024 at 10:58 am, Certified Nursing Assistant (CNA) CC revealed RA's bath/shower schedule just changed to Tuesday, Thursday, and Saturday on the day shift on 5/2/2024. She reviewed the bath/shower sheet dated 5/1/2024, and it was documented that the resident was asleep, and a bath/shower would be provided later if needed. She was unaware of who documented that information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and a review of the facility policy titled 3.1 HR Conditions of Employment: Standard of Conduct Smoking Guidelines, the facility failed to implement their smoking policy and procedures regarding designated smoking areas for staff. The census was 67 residents (R). Findings include: A review of the facility policy titled 3.1 HR Conditions of Employment: Standard of Conduct Smoking Guidelines, dated 2019, revealed the intent of the guidelines was to promote safety for associates, patients, customers, and visitors. The guidelines revealed that smoking was only permitted in a designated smoking area. A review of R34's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed section C (Cognition) documented a Brief Interview for Mental Status (BIMS) score of 14 (indicating little to no cognitive impairment.) During an interview on 5/3/2024 at 9:50 am, R34 stated the night staff, especially on weekends, were not answering the call lights. He added that when they answer it, they turn it off and do not address the issues. He stated he had reported it to the Administrator, who said he would try to fix the problem, but nothing had been resolved. He further stated that from 1:00 am to 5:00 am, he hears the facility's front door slamming shut constantly. He stated he did not know why staff was going in and out of the door so many times as no residents were on the porch. He further stated that cigarette butts were on the porch every morning. An observation of the facility's front patio on 5/4/2024 at 4:05 am revealed that Licensed Practical Nurse (LPN) AA exited the facility's front door and lit a cigarette. LPN AA sat on the patio chairs and smoked until 4:12 am. She extinguished her cigarette on the ground, threw the cigarette butt into the trashcan next to the fire extinguisher, and reentered the facility. An observation of the facility's front patio on 5/4/2024 at 5:00 am revealed that LPN AA exited the facility's front door and lit a cigarette. At 5:07 am, the facility's Administrator arrived in the parking lot. Observation revealed LPN AA put her cigarette out on the ground, threw the cigarette butt into the trash can next to the fire extinguisher, and reentered the facility. During an interview with the Administrator on 5/4/2024 at 5:09 am, he stated the facility was smoke-free for the residents, but the staff was permitted to smoke on the back patio. The Administrator noted the back patio was equipped with a fire extinguisher, ashtrays, and a fire-retardant container for cigarette butts. He stated the staff was not permitted to smoke anywhere else on facility grounds. The Administrator acknowledged an employee was smoking on the front porch when he arrived, but he could not identify the employee as it was dark outside. During an interview with LPN AA on 5/4/2024 at 5:20 am, she stated staff was permitted to smoke on the back porch of the facility. She stated that she heard coyotes and was uncomfortable smoking on the back porch. She further stated she did not know if she was allowed to smoke in her car and added that she was not familiar with all the facility rules related to smoking. LPN AA stated she knew she was not supposed to smoke on the front porch and did not know if the trash can on the front porch was rated for fire or a safe place to dispose of cigarette butts. An observation of the trash can on the facility's front porch on 5/4/2024 at 7:34 am revealed that it contained paper products, cups, and other paper materials. An observation of the facility's back patio on 5/4/2024 at 8:13 am revealed fire-retardant canisters for the disposal of cigarette butts only and a fire extinguisher attached to the wall, which was within the inspection date.

Based on observation, staff interview, record review, and a review of the facility's policy titled, Medication Storage in the Care Center, the facility failed to ensure that one of four medication carts were locked when the carts were out of view or unattended by the nurse or CMA. This failure had the potential to affect nine Residents who wander. Findings include: During a review of policy, Medication Storage in the Care Center, it was revealed medications and biologicals are stored safely, securely, and properly. Only licensed nurses, consultant pharmacists, and those lawfully authorized to administer medications are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended to by persons with authorized access. Observation of Hall B on 4/15/2023 at 8:57 a.m. a medication cart was found unlocked from 8:57 a.m. to 9:13 a.m.; Licensed Practical Nurse (LPN) BB noticed the surveyor monitoring the unlocked cart and went down the hall and locked the cart. Interview on 4/15/2023 at 9:13 a.m. with LPN BB she verified the medication cart was unlocked and that it should be locked whenever the cart is unattended. Interview on 4/15/2023 at 11:00 a.m. with Registered Nurse (RN) CC revealed she was responsible for the medication cart on Hall B, and she would make sure it was locked. Interview on 4/15/2023 12:20 p.m. with Director of Nursing (DON) revealed the medication cart on Hall B was unlocked; the DON states medication carts and treatment carts are locked if not in use or if someone is not standing by the cart. Today, the DON provided education on locking medication carts today to staff that were in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and review of the facility's policy titled, Test Water Temperature, the facility failed to ensure that hot water temperatures in resident bathrooms remained below 110 degrees Fahrenheit (F). This deficient practice affected two of four halls (Hall 2A and Hall 2B - in rooms 48, 53, 57, 59, and 61). Findings include: Review of policy titled Test Water temperature (undated) revealed the following: 1. Ensure patient room water temperatures are between 105 degrees F and 115 degrees Fahrenheit (or as specified state requirements). Georgia - shall not exceed 110 degrees. 2. Test temperature in shower areas 3. Text temperature at mixing valve. Observations on 4/14/2023 from 9:13 a.m. until 10:15 a.m. revealed the following: In room [ROOM NUMBER] the hot water in the bathroom stings hands. In room [ROOM NUMBER] the hot water in the bathroom stings hands. In room [ROOM NUMBER] the hot water in the bathroom stings hands. In room [ROOM NUMBER] the hot water in the bathroom stings hands. In room [ROOM NUMBER] the hot water in the bathroom stings hands. On 4/14/2023 a hot water temperature tour was conducted from 3:35 p.m. through 3:49 p.m. with Maintenance DD and the Interim Administrator and the following was revealed: 1. In room [ROOM NUMBER] the hot water temperature was 124.4 degrees F. 2. In room [ROOM NUMBER] the hot water temperature was 121 degrees F. 3. In room [ROOM NUMBER] the hot water temperature was 120.5 degrees F. 4. In room [ROOM NUMBER] the hot water temperature was 120.3 degrees F. 5. In room [ROOM NUMBER] the hot water temperature was 121.6 degrees F. A follow up tour of the hot water temperatures in the identified rooms was conducted on 4/14/2023 from 4:54 p.m. through 5:03 p.m. with the Plumbing Representative and Corporate Consultant DD revealed: 1. In room [ROOM NUMBER] the hot water temperature was 98 degrees F. 2. In room [ROOM NUMBER] the hot water temperature was 99 degrees F. 3. In room [ROOM NUMBER] the hot water temperature was 100 degrees F. 4. In room [ROOM NUMBER] the hot water temperature was 100 degrees F. 5. In room [ROOM NUMBER] the hot water temperature was 98 degrees F. At the end of the tour Corporate Consultant DD agreed to provide monitoring through the night for all halls to ensure that the hot water temperatures do not exceed 110 degrees F. Review of Quality Improvement Data Collection Grid revealed the following: 1.On 4/14/2023 from 7 p.m.-8 p.m. and 10 p.m.-11 p.m. no hot water temperatures over 110 degrees F. 2.On 4/15/2023 from 1 a.m.-2 a.m., 3 a.m.-4 a.m., 6 a.m.-7 a.m. - no hot water temperatures over 110 degrees F. Observation and interview on 4/16/2023 at 10:47a.m. with the Interim Administrator the online waterlog report titled Logbook Documentation was reviewed. The log did not specify which rooms were being checked nor did it identify follow up if the hot water temperature was over 110 degrees F. The Interim Administrator confirmed that on 3/13/2023 and 3/13/2023 the hot water temperatures were identified on Hall 2B and C with temperatures of 115.3- and 113.1-degrees F and on 3/15/2023 at 117.3 degrees F. The temperatures were then reported that the Maintenance Assistant HH checked rooms randomly and if the water temperature is over 110 degrees F, he rechecks the hot water heater and rechecks. The Interim Administrator confirmed that the waterlogs do not reflect which rooms Maintenance HH is checking nor that he is rechecking if temperatures are over 110 degrees F. Interim Administrator reported that when checking the hot water temperatures rooms should be identified on the water temperature log and if hot water temperatures were readjusted. She further revealed that hot water temperatures should continue to be checked to see if they are out of range to determine the root of the problem. The Interim Administrator reported that if hot water was out of range maintenance personnel should have notified the Maintenance Supervisor and if continued issues the Administrator should have been notified as well. Interview on 4/16/2023 11:27 a.m. with Maintenance Assistant FF revealed that she was responsible for checking the hot water temperatures in the past. She continued to report if the hot water temperature were over 109 degrees F the supervisor notified, other rooms were checked, the mixing valve lowered, and then the temperatures would be rechecked. At the time of exit on 4/16/2023 there were no hot water temperatures over 110 degrees F.

2. During a review of policy, Infection Prevention Plan, The Infection Prevention Plan provides an overview of the infection prevention practices of the center that is charged with the promotion of a healthy and safe environment to reduce the risk of infections in patients, staff, and visitors and others in the healthcare environment. The goals of the infection prevention program include to prevent and control the transmission of infectious and communicable diseases and to maintain a sanitary environment for personnel and patients. A review of policy, Disposal of Sharps it was revealed; The facility shall discard contaminated sharps into the sharps container marked biohazard. Contaminated sharps shall be discarded immediately or as soon as feasible into designated containers. Contaminated sharps will be discarded into containers that are closable, puncture resistant, leak proof on sides and bottom, and color-coded red. Observation on 4/15/2023 at 11:35 a.m. CMA AA completed a finger stick blood sugar procedure; during the procedure it was revealed CMA AA put on gloves, cleaned the finger, put a barrier on the table, and cleaned the meter before and after use; at the end of the procedure CMA AA took the used lancet and wrapped it in a napkin and put it in a plastic cup and then she put the plastic cup in the regular trash container on the medication cart; when asked about disposal of the lancet stated she wrapped it in the cup and put it in the trash; RN CC was standing nearby and informed CMA AA the lancet goes in the biohazard sharp container. RN CC put on gloves and took the plastic cup out of the trash container and put it in the sharps container. Interview with Registered Nurse (RN) CC on 4/15/2023 at 11:40 a.m. revealed lancets are discarded in the biohazard sharps container. Interview on 4/15/2023 at 12:20 p.m. with Director of Nursing (DON) revealed lancets should go in the sharps container and not the regular trash. She indicated she would take the CMA through a finger stick competency check today. Based on observations, staff interviews, and a review of the facility's policy titled, Laundry Services, Disposal of Sharps, and Infection Prevention Plan, the facility failed to ensure dust buildup in the laundry room to prevent cross contamination. The facility also failed to dispose of items containing blood in an appropriate manner. Findings include: 1. Review of policy titled Laundry Services (dated 2020) revealed: Guidance - Separating Clean from Dirty in the laundry - Areas should be cleaned on a regular schedule. The tour of the laundry room was on 4/15/2023 beginning at 8:31 a.m. revealed the following: 1.There was dust build up noted on the wall behind the washing machines. 2.There was dust build up on the emergency shower device. 3. There was dust build up on the fan that was located on the wall near the dryers. Interview on 4/15/2023 at 8:51 a.m. with Laundry Aide GG revealed the dust buildup on the walls, fans, and shower device were confirmed. At the time of the observation clean laundry was in the dryer. Laundry Aide GG reported that she dusts whenever she has time to do so. The Housekeeping Supervisor and Maintenance Assistant FF were also present during the tour. Maintenance Assistant FF reported that dusting of the laundry room is done monthly and it is a part of the monthly report of duties that has to be performed. Maintenance Assistant FF could not recall the last time she dusted but agreed to provide documentation of this monthly task. Observation and interview on 4/16/2023 at 11:47 a.m. with Interim Administrator provided a copy of the online maintenance report for the laundry room and confirmed that dusting was not indicated as a task. The Interim Administrator reported that her expectation was for all areas in the laundry room to be dust free.