Number of residents sampled: Number of residents cited: Based on observations, staff interviews, and review of the facility-provided document titled Position Description, Housekeeper, the facility failed to maintain seven of 24 resident bathrooms on the Memory First-A (MFA) unit in a clean, safe, and sanitary manner. Specifically, there were dusty bathroom air vent covers and a cracked toilet tank cover.Findings include:Review of the facility-provided document titled Position Description, Housekeeping, modified 10/2016, revealed the Job Purpose section stated, Provides cleaning services to provide a safe, sanitary, comfortable, and homelike environment for residents, staff, and the public. Housekeeping services provided are in accordance with facility policies and procedures and consistent with state and federal laws and regulations to maintain an environment that enhances the quality of life for residents. The Key Responsibilities section included, . 4. Cleans bathroom sinks, fixtures, and toilets, following center procedures. 11. Dust/damp cleans surfaces in patient/resident rooms (furniture, bed frames, windowsills, etc.) following center procedure.Observation of resident rooms on the MFA unit on 8/5/2025 revealed the following:8/5/2025 at 10:16 am, MFA 8-2: a dusty bathroom air vent cover.8/5/2025 at 11:07 am, MFA 17-2: a dusty bathroom air vent cover.8/5/2025 at 11:20 am, MFA 16: a dusty bathroom air vent cover.8/5/2025 at 3:49 pm, MFA 6: a dusty bathroom air vent cover.8/5/2025 at 3:58 pm, MFA 4: a dusty bathroom air vent cover. Observation of the same resident rooms beginning on 8/7/2025 at 10:30 am revealed that the aforementioned observations persisted.In an observation and interview with Housekeeping Aide JJ, on 8/7/2025 at 10:40 am, she stated her routine duties included dusting, sweeping, and mopping of resident rooms and bathrooms. She observed and confirmed the dust on the bathroom air vents in rooms MFA 8, 17, 16, 6, and 4, and stated it was the responsibility of the Maintenance Department to keep the bathroom air vent covers clean. In an observation and interview with the Housekeeping Supervisor, on 8/7/2025 at 3:40 pm, she observed and confirmed the presence of thick dust on the air vents in the identified bathrooms on the MFA unit. She stated it was the responsibility of the housekeeping staff to remove the surface dust from the air vents daily. She stated she had no actual policies, but scheduled duties were stored and accessed through the electronic housekeeping and maintenance tracker. She stated she would add the task of dusting the bathroom air vents to the list of daily duties for her staff. In an observation and interview with the Maintenance Director, on 8/7/2025, beginning at 4:00 pm, he stated he had only been working at the facility for a few months. He stated he performed annual cleaning of the insides of the bathroom air vents, but had no maintenance logs to speak of. He stated he cleaned approximately six to seven bathroom air vents per month. However, dusting the air vent covers was the responsibility of the housekeeping staff. He observed and confirmed the presence of a break in the toilet tank cover, which had been glued back together, but still had a large, sharp chip on the outer edge. He stated he would replace it as soon as possible. He stated staff usually reported maintenance concerns to him in person or by phone.

Based on observation, staff interviews, record review, and review of the facility's polices titled Infection Prevention and Control Plan and Medication Administration: Oral Medications, the facility failed to implement infection control practices for one of five residents (R) (R77) during medication administration observation. This deficient practice had the potential to place R77 at an increased risk of infection due to cross-contamination. Findings include:Review of the facility's policy titled Infection Prevention and Control Plan, reviewed 10/11/2022, revealed the Policy Statement section included, . The goals of the program are to decrease morbidity/mortality attributable to infections in residents; prevent and control outbreaks of infection in residents; prevent acquisition of infection by staff members .Review of the facility's policy titled Medication Administration: Oral Medications, reviewed 10/23/2024, revealed the Procedure and Key Points section included, . 6. Place medication into a souffle cup. Never touch any of the medication with fingers.Review of the Physician's Orders for R77, dated 5/25/2025, revealed medication orders including, but not limited to, adult low-dose aspirin over the counter (OTC) tablet, delayed release (DR); 81 milligrams (mg); amount (amt): 1 tablet; oral once a day, 9:00 am, potassium chloride capsule, extended release; 10 milliequivalent (mEq); amt: 2 capsules (caps); oral once a day 9:00 am, torsemide tablet; 5 mg; amt: 1 tablet; oral once a day 9:00 am.Observation on 8/6/2025 at 9:15 am, during medication administration with Licensed Practical Nurse (LPN) BB, revealed he was preparing medications for R77, and when he placed the aspirin 81 mg tablet, potassium chloride 10 mEq 2 tablets and torsemide 5 mg tablet in a medication cup, the cup tilted, and the medications fell on the medication cart. LPN BB used his bare hands, picked up the medications from the cart, and placed them back in the cup.In an interview on 8/6/2025 at 9:16 am, LPN BB confirmed he used his bare hands to pick up the medications from the medication cart. He stated he should not have used his bare hands to pick up the medications because it was an infection control issue, and the resident could get an infection.In an interview on 8/7/2025 at 10:34 am, the Director of Health Services (DHS) stated his expectations were for the nurses not to use bare hands to pick up tablets or medications. He stated the nurses were to use gloved hands when handling medications. The DHS further stated that there could be contamination of the medication, which the resident could receive.In an interview on 8/7/2025 at 10:37 am, the Infection Preventionist (IP) DD stated that during medication administration, the nurses were not to use bare hands to touch medications because it would be an infection control issue. She stated the nurse should use gloved hands to pick up medications if they spill. The IP further stated that the residents could be exposed to pathogens and could get infections.In an interview on 8/7/2025 at 10:45 am, LPN AA stated that if medications spill, the nurse should grab gloves and scoop them up with a spoon. She stated that bare hands should not be used to pick up or handle medications. LPN AA further stated that this would put the residents at risk of contracting infections.

Based on observations, staff interviews, record review, and review of the facility-provided document titled [Brand name] Blood Glucose Monitoring System Healthcare Professional Operator's Manual, the facility failed to place open dates on the vials of glucometer strips in two of four medication carts. This deficient practice had the potential to cause inaccurate blood sugar readings and worsening of medical conditions for the residents.Findings include:Review of the facility-provided document titled [Brand name] Blood Glucose Monitoring System Healthcare Professional Operator's Manual, revealed page 8 included, Important: . For vial test strips, record the date on the bottle when you open a new bottle of test strips.Observation on 8/6/2025 at 2:15 pm, during review of the B Hall medication cart, revealed one open vial of glucometer strips with no open date.In an interview on 8/6/2025 at 2:15 pm, Licensed Practical Nurse (LPN) BB confirmed there was one open vial of glucometer strips with no open date on the B Hall medication cart. He stated there should be an open date on it, and if it was used on the residents, there could be abnormal blood sugar readings.Observation on 8/6/2025 at 3:20 pm, during review of the medication cart on the Memory Care Unit, revealed one open container of glucometer strips with no open date.In an interview on 8/6/2025 at 3:20 pm, LPN CC confirmed there was one open vial of glucometer strips with no open date on the Memory Care Unit. She stated there should be an open date on glucometer strips when the vials were first opened, and if the strips were used on the residents, there could be skewed blood sugar readings.In an interview, the Director of Health Services (DHS) confirmed there was no open date on the vial of glucometer strips on the B hall medication cart. He stated his expectations were for the nurses to place open dates on the glucometer strip vials when they were opened. He stated it was the manufacturer's requirement for the strips' vials to have open dates when they were first opened. The DHS further stated that a negative outcome if the strips were used on the residents could be that they could have altered blood sugar readings.In an interview on 8/7/2025 at 10:45 am, LPN AA stated there should be open dates on the glucometer strips vials when they were first opened. She stated the nurses were responsible for placing open dates on the glucometer strip vials when they first opened them. She further stated that if the strips were used on residents, it could cause false blood sugar readings, and the resident could be given the wrong treatment.

Based on observations and staff interviews, the facility failed to maintain the kitchen in a clean and sanitary condition. This deficient practice had the potential to place residents receiving meals and hydration from the kitchen at risk of food-borne illness. The census was 85 residents. Findings include: The facility did not provide a policy for kitchen procedures.Observation of the kitchen on 8/6/2025, beginning at 10:00 am, revealed the following: 1. 26 of 26 storage crates in the kitchen were soiled with light and dark gray substances throughout the openings of the crates and the outside surfaces.2. The wall behind a storage rack for clean pots and pans was soiled. 3. A soiled return heating and air ventilation cover.In a concurrent observation of the kitchen and interview on 8/7/2025 beginning at 9:35 am, with the Certified Dietary Manager (CDM), she observed and confirmed that 26 of 26 storage crates were soiled with light and dark gray substances throughout the openings of the crates and the outside surfaces, the wall behind storage rack was stained, and the return heating and air ventilation was soiled. The CDM stated she started working at the facility in May 2025, and the storage crates had not been washed since she started. She further stated that the wall behind the clean pots and pans should be cleaned, and she had not addressed the other concerns related to maintenance. She stated she was not sure what duties the housekeeping and maintenance staff were responsible for in the kitchen. In a concurrent observation and interview with the Maintenance Director, on 8/7/2025 at 4:20 pm, he observed and confirmed the observations related to the soiled return heating and air ventilation cover. He stated he worked alone and, in addition to his routine duties, he expected staff to inform him of other needs throughout the facility, including the kitchen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and a review of the facility policy titled Cleaning Procedure-Kitchen area the facility failed to ensure a clean sanitary environment in the kitchen. The census was 66 of 67 residents will be affected. Findings include: A review of the facility policy titled It is policy of [NAME] Health to maintain a clean and sanitary environment to prepare patient/resident meals revealed that the policy applies to all dietary staff, housekeeping , and maintenance partners scheduled to assist in cleaning/sanitizing procedures, All soiled, dirty, dusty, surfaces and /or areas within the kitchen should be cleaned and /or sanitized (as needed ) immediately upon identification. During initial walk thru of the kitchen on 10/27/2023 at 08:00 am the surveyor observed the ceiling had dust mites hanging out from the ceiling. Observation of greasy burnt food debris inside the oven and the burner. During a follow up visit of the kitchen on 10/28/2023 at 8:35 am with the Dietary Manager (DM) , The surveyor observed confirmed the dust mites and greasy burnt food debris inside the oven and the burner with the DM. The DM stated that the Maintenance Director is responsible for keeping the kitchen ceiling free of dust mites. The DM further revealed that the staff has schedule for cleaning kitchen equipment. During a follow up visit of the kitchen on 10/29/2023 at 8:39 am observation of the dust mites were still hanging on the ceiling. During an interview on 10/29/2023 at 8:26 am with the facility Administrator regarding her expectation of dietary staff and she revealed that she expects the DM to make sure the dietary staff complete daily and monthly cleaning of the kitchen . During an interview on 10/29/2023 at 8:40 am with the DM regarding his expectation of the dietary staff he revealed that he expects the dietary staff to keep the kitchen clean . During an interview on 10/29/2023 at 10:17 am with the Administrator, she confirmed that she saw the dust mites in the kitchen ceiling and stated that after meal the diet staff will clean it During a follow up visit in the kitchen on 10/29/2023 at 11:42 am with facility consultant, Administrator and DM, confirmed that the oven and the burner were not clean.

Based on record review, staff interviews, and review of the policies titled Infection Prevention Control Plan and Infection Prevention and Control Program Surveillance Reporting the facility failed to provide evidence that infection control surveillance data was collected ten out of fifteen months reviewed (July 2022 through September 2023). Findings include: Review of the policy titled Infection Prevention and Control Program Surveillance Reporting review date 1/24/2023 indicated: Policy Statement-It is the policy of this facility to establish and maintain an Infection Control Program that includes detection, prevention, and control of the transmission of disease and infection among patients/residents and partners. The Administrator of the Healthcare Center is responsible for the Infection Control Program. All infection prevention and control practices reflect current Centers for Disease Control (CDC) guidelines. Procedure: 1. Patient/resident infection cases are monitored and documented by the IP. The IP reviews cases of infections, including tracking and analysis of the findings and develops an action plan to resolve identified concerns. 2. A report of resident infections, Epidemiology Report and monthly Tuberculosis (TB) reports are submitted monthly to the Administrator and Director of Health Services (DHS). Review of the policy titled Infection Prevention Control Plan review date 6/23/2023 indicated Policy Statement- This Infection Prevention and Control Plan outlines the framework by which all ___ facilities will assess, implement, and evaluate an active, effective, comprehensive facility-wide Infection Prevention and Control program. The Medical Director and Director of Health Services are responsible for the identification of appropriate resources and/or resource allocation that supports the Infection Prevention and Control Program. The goals of the program are to decrease morbidity/mortality attributable to infections in residents; prevent and control outbreaks of infection in residents; prevent acquisition of infection by staff members; maintain resident functional status; maintain optimal social environment for residents; and limit costs of care attributable to infections. The Infection Prevention and Control Program will incorporate risk assessments, surveillance activities, evidence-based prevention practices, communication to mitigate risks and decrease adverse outcomes related to Infection Prevention and Control. Review of the infection control binder provided by the Infection Preventionist (IP) on 10/28/2023 at 9:30 a.m. revealed no data was obtained for July 2022, August 2022, September 2022, October 2022, November 2022, December 2022, February 2023, March 2023, April 2023, and July2023. An interview on 10/28/2023 at 9:44 a.m. with the Director of Health Services (DHS) and the IP stated the infection control binder that contains the required information that includes the Monthly Healthcare Associated Infection Summary Report, line listing, mapping, Epidemiology Report Form, and Monthly Surveillance for Tuberculosis Form for 7/2022-12/2022 could not be located. An interview on 10/28/2023 at 12:10 p.m. with the Director of Health Services confirmed that there were no data collection February 2023, March 2023, April 2023, and July 2023. The DHS stated it is her responsibility to make sure that the data is collected to complete the Monthly Healthcare Associated Infection Summary Report, Line Listing, Mapping, Epidemiology Report Form, and Monthly Surveillance for Tuberculosis Form.

Based on record review, staff interviews, and review of the policy titled Antibiotic Stewardship Program, the facility failed to provide evidence of a monitoring system to track and trend antibiotic use for ten out of fifteen months of the infection control data reviewed (July 2022 through September 2023). Findings include: Review of the policy titled Antibiotic Stewardship Program review date 2/8/2023 indicated: Policy Statement-As part of the Infection Prevention and Control Program, ____ will implement and maintain an Antibiotic Stewardship Program (ASP). Under the direction of the Medical Director and Director of Health Services (DHS) the ASP is designed to promote appropriate use of antibiotics and improve patient health outcomes. The goal of ASP is to promote appropriate use of antibiotics to treat infections and reduce possible adverse events associated with antibiotic use. Each month the Antibiotic Stewardship Pharmacist will monitor, document, and provide each facility the following antibiotic use information on the Monthly Healthcare Associated Infection Summary Report: Percent of residents receiving antibiotics, Percent of new admissions receiving antibiotics, New Antibiotics Starts, Rate of Antibiotic Days of Therapy, New Antibiotics Starts, Rate of Antibiotic Days of Therapy (DOT), and Antibiotic Utilization Ratio. Review of the infection control binder provided by the Infection Preventionist (IP) on 10/28/2023 at 9:30 a.m. revealed no evidence of antibiotic surveillance data, analysis, documentation of follow up in response to the data or monthly antibiotic reporting for ten months. The ten months included July 2022, August 2022, September 2022, October 2022, November 2022, December 2022, February 2023, March 2023, April 2023, and July2023. An interview on 10/28/2023 at 12:10 p.m. the Director of Health Services (DHS) stated the facility has had problems with keeping an infection preventionist. She stated since May 2023 the facility has had three different people in the infection preventionist role. The facility hired a Registered Nurse on 10/2/2023 that will be fulfilling the IP role. An interview on 10/29/2023 at 10:15 a.m. with the Administrator and DHS. The Administrator stated the previous IP was not providing her with the monthly Healthcare Associated Infection Summary Report She stated her expectation is that the facility's policy and procedure are followed. She stated the infection control surveillance will be placed Performance Improvement Project and discuss in Quality Assurance and Performance Improvement (QAPI). The Administrator stated she will ensure all staff involved are doing their work. The DHS stated she has been reporting to the Physician based on the lab results and culture sensitivities and the physician will order the appropriate antibiotics based on the information given. She stated the pharmacy consultant has not provided the facility with the Antibiotic Stewardship Report. An interview on 10/29/2023 at 10:52 a.m. with the Senior Nurse Consultant stated the newly hired IP will be in-service on the infection control policy and procedure. She stated herself and the corporate IP will work closely with her to ensure that the HAI and ASP are completed monthly per policy and CMS guidelines. Post exit telephone interview on 10/30/2023 at 10:30 a.m. with the facility's Consultant Pharmacist BB stated he visits the facility monthly. During the visit to the facility, he will review the residents that have an order for antibiotics and look for a start date, stop date, and diagnosis. In the event he encounters a problem it is addressed with the Director of Health Services. The Pharmacy Consultant stated he is not responsible for generating the Antibiotic Stewardship Report for the facility. He is not part of the ASP but does participate in the quarterly QAPI meetings. Post exit telephone interview on 10/30/2023 at 1:59 p.m. with the facility's Pharmacist CC stated the Antibiotic Stewardship Report for the facility is auto generated every month between the third-sixth of the month. She uploads the report to Teams to each facility. The facility is responsible for accessing the folder and reviewing the antibiotics that are used for the month. She stated no one from the facility has ever communicated to her that the facility was unable to access the report. She stated her responsibility is to review the report before uploading it to Teams and the report is reviewed by herself. The Pharmacist stated she looks for anything that doesn't have a stop date, antibiotic that doesn't have a diagnosis, any antibiotic that stands out that is not normally used. She stated anything that is concerning she will reach out to the facility. She stated the pharmacy will also look to make sure the required information is in the order before sending the antibiotic to the facility. The pharmacist provided the surveyor with a copy of the facility's report from last month for review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to ensure that one of four exit doors was properly secured, resulting in one resident (R) (#27) eloping from the facility. The sample was 44 residents. Findings include: Review of facility's policy titled Elopement Prevention revised 06/02/17 reads, Residents of the center with cognitive deficits which place them at risk for elopement or engaging in unsafe wandering, will be referred for residency in the Memory Support Unit, where applicable, or for transfer/discharge to an environment secure enough to accommodate their needs. Review of record revealed that resident has a diagnosis of dementia with behavioral disturbances and has a history of wandering and exit seeking while in the facility. The care plan with a problem as behaviors lists a behavior of resident leaving out of the facility on 6/7/21. Review of record revealed that on 6/07/21 at 4:54 p.m. R#27 was observed outside the facility, in the front near the road, staff assisted him back in and resident was put on every 15-minute checks until ordered to stop, skin check revealed no skin issues, educated resident on safety and he stated understanding, R#27 was noted about 15 minutes prior to him being found outside. R#27 showed staff which door he went out of and stated that he wanted to go play in the woods like he use to do with his cousin. R#27 has history of wandering within the facility. Review of record revealed that on 3/18/21 at 1:50 p.m. R#27 was observed in the hallway of Memory Support Unit (MSU) appeared agitated, stating he's going home, and soon as he gets out those doors he's gone. R#27 has his bags packed. Redirection attempted, unsuccessful. Interview on 6/02/22 at 8:15 a.m. with Certified Nursing Assistant (CNA) AA revealed that she has worked at the facility for 8 years. CNA AA stated that she was the one who spotted R#27 outside the facility. (CNA) AA stated that the R#27 exited the building through the side exit door leading to the smoke porch and walked around the building and was up by the facility's driveway exit when he was retrieved. She stated that the door leading to the smoke porch did not close completely which allowed R#27 access out of the facility. She stated that the R#27 told her that he was headed to his house in [NAME] Ga. Interview on 6/02/22 at 8:57 a.m. with Maintenance Director revealed that he checks all the exit doors daily in the morning when he gets to the facility. He stated that the door checks are documented electronically in a Building Engines Program. He further stated that the front door is the only exit door that is equipped with the wander guard system. The other doors have the keypad to go in and out the facility. He also stated that he checked the smoke porch exit door the next day (6/08/21) after learning R #27 was found outside the facility the day before. The Maintenance Director stated that the facility has 4 exit doors, and each exit door is checked daily and loaded into the building engines program. Interview on 6/02/22 at 1:31 p.m. with the Maintenance Director revealed that he was on vacation on 6/5/21, 6/6/21 and 6/7/21. He stated that the Housekeeping Supervisor verbally told him that she checked the doors on those days and that the doors were working properly so he cleared the Door Checks Tasks the Building Engine program for those days when he returned from vacation on 6/08/21. The Maintenance Director further stated that the doors were working properly when he returned and checked them on 6/08/21. Interview on 6/02/22 at 1:52 p.m. with Housekeeping Supervisor revealed that she does check the doors when the Maintenance Director is not in the facility, but she did not check the doors on 6/05/21 or 6/06/21 because she did not work that weekend according to her work calendar. Housekeeping Supervisor: work schedule was verified with HR Director, and she did not work on the days in question. She further stated that she documents the door checks that she completes in a Manager Notebook, which was kept at the nurse's station. She further stated that the notebook is now missing.