**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, review of the clinical record, and review of facility policy titled, Oxygen Administration, the facility failed to obtain a physician's order with a specific rate/setting for liters per minute (LPM) for oxygen therapy for, one of 12 residents (R) R #15 and failed to ensure the water humidification bottle was adequately filled for R #15. Findings include: Review of the facility policy titled, Oxygen Administration with a revision date of 8/2/2023 revealed the following: 1. Procedure: Regulate liter flow to ordered flow rate. 2. Infection Control Policy of O2 Humidifier Bottles: (1) O2 humidifier bottles should be used on all patients/residents receiving higher than 2 liters/minute of oxygen flow. (3) Humidifier bottles should be filled when water level drops below fill line marking. Record review for R#15 revealed a Brief Interview for Mental Status (BIMS) score 10 indicating minimal cognitive decline, full code status. Primary diagnoses included but not limited to, acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), major depressive disorder, and generalized anxiety disorder. Review of physician's orders included but not limited to, oxygen (O2) at 2-5 liters per minute (LPM) via nasal cannula (N/C) continuous every (q) shift, change respiratory circuit/supplies weekly q Monday. Review of the most recent comprehensive minimum data set (MDS) annual assessment dated [DATE] revealed: Section C - Cognitive Patterns-BIMS 10. Section I - Active Diagnoses-Medically Complex Conditions. Section O - Special Treatments, Procedures, and Programs-Included oxygen therapy. Review of the care plan included but not limited to, risk for shortness of breath (SOB), respiratory difficulties/distress related to chronic obstructive pulmonary disease (COPD), and history of respiratory failure. Oxygen use. Interventions included provide oxygen therapy as ordered. Observation on 9/5/2023 at 10:12 a.m., of Resident # 15 sitting up in bed, head of bed elevated, with O2 running at 4 LPM via N/C from concentrator at bedside. Observation on 9/5/2023 at 4:08 p.m. of R#15 sitting up in bed sleeping, head of bed elevated, O2 running at 4 LPM via N/C, and the humidification water bottle had a low water level. Observation on 9/6/2023 at 8:35 a.m. of R#15 sitting up in bed eating breakfast. Oxygen running at 4 LPM via N/C from concentrator at bedside, humidification water bottle empty. Observation on 9/6/2023 at 12:30 p.m. of R#15 lying in bed sleeping. Oxygen running at 4LPM via N/C from concentrator at bedside, humidification water bottle empty. Interview on 9/6/2023 at 2:23 p.m. with Licensed Practical Nurse (LPN) JJ checked the order in the clinical record and confirmed R# 15's order for oxygen was a range of 2-5 liters per minute (LPM) via nasal cannula (N/C) continuously. She revealed R#15 recently readmitted from hospital, the doctor did not give a specific oxygen setting when R#15 returned, and they did not have a specific rate. Looking at R#15's history in the clinical record, LPN JJ revealed R#15's oxygen order before going in the hospital was for 2-4 liters, and since his return on August 31st the new oxygen order was for 2-5 LPM. She revealed R#15 was the only resident that you can go on back and to on the setting, and confirmed there were no instructions for determining whether it should be set at 2 LPM versus 5 LPM. Interview further revealed they change tubing once a week, and the humidification water bottle was changed as needed. Most all residents were on 2 liters and their humidification water bottle lasts about a week, but the water bottle on R#15 was changed more frequently because he's on such a high (LPM) rate and it runs out quicker. LPN JJ also revealed the nurses look at the water in the bottle, monitor the water level, change it whenever it gets low. LPN JJ revealed that being on such a high LPM setting R#15's water runs out every 2-3 days. LPN JJ confirmed the water humidification bottle was empty, it should not be empty, and confirmed the oxygen was currently on 5 LPM. LPN JJ revealed the nurse was responsible for monitoring oxygen settings, for monitoring the humidification bottle water level, and should change it before it runs out. Interview on 9/6/2023 at 3:05 p.m. with the Director of Nursing (DON) confirmed R#15's oxygen setting order was for a range of 2-5 LPM, and revealed there should not be a range. Her expectation was that there should be an order with a specific number for the oxygen LPM rate, the water humidification water bottle should not be empty, and staff should be monitoring the water level and change it when it gets low near the fill line.

Based on observations, staff interviews and review of the facility policy titled, Medication Administration: General Guidelines, the facility failed to properly secure medications for one of two medication carts. Specifically, the facility left an insulin pen and four individually wrapped medication packages on top of the medication cart unattended. Findings include: Review of the facility policy Medication Administration: General Guidelines last revised on 4/10/2019, revealed: 16. During routine administration of medications, the medication cart is kept in the doorway of the patient/resident's room, with open drawers facing inward and all other sides closed and locked. No medications are kept on top of the cart, and all outward slides must be inaccessible to patients/residents or others passing by. Observation on 9/5/2023 at 11:35 a.m. revealed Licensed Practical Nurse (LPN) KK administering medications on the B Hall. LPN KK locked the medication cart, entered resident room B14, and closed the resident's door behind her. The medication cart was subsequently found to be locked and unattended with an insulin pen and four individually wrapped medications packages (Jardiance, probiotic, multivitamin and sennosides-docusate sodium) left on top of the cart with the drawers facing the hallway. Interview on 9/5/2023 at 11:37 a.m. with LPN KK revealed that medications should always be secured and confirmed that she had mistakenly left medications on top of the medication cart unattended. Interview on 9/6/2023 at 8:15 a.m. with LPN LL revealed that all narcotics are double locked on the medication carts and are counted each shift by the off going and oncoming nurses. She also revealed that all medication carts were to be locked when not attended. Interview on 9/6/2023 at 8:55 am with LPN GG revealed that all medications should be secured if the nurse isn't with the medication cart. She reported that they should never leave the medication cart unlocked or medications unsecured. Interview on 9/7/2023 at 1:12 p.m. with the Unit Manager revealed there were currently 14 residents residing on B Hall, one resident was able to independently ambulate, and three residents were able to independently travel the facility while seated in their wheelchairs.

Based on observations, staff interviews, and a review of the facility's policies titled Labeling, Dating and Storing and Foodborne Illnesses the facility failed to ensure food items in the pantry, cooler, refrigerator, and freezer were properly labeled and dated, opened food items were securely wrapped and sealed and foods were discarded when expired. The facility failed to practice safe and sanitary methods when preparing foods to prevent cross contamination and the spread of bacteria. The deficient practice had the potential to affect 60 out of 60 residents receiving an oral diet. Findings include: Review of policy titled, Labeling, Dating and Storing, reviewed 8/6/2023, revealed under Purpose: Food and beverage items will have an identifying label as well as a received date and opened date, as applicable for items prepared onsite, a use by date will also be indicated. Review of the policy titled Foodborne Illnesses reviewed 8/6/2023, revealed under Purpose: It is the responsibility of the Dietary Manager (DM) to see that dietary employees practice safe and sanitary methods when preparing foods to prevent cross contamination and the spread of bacteria. It is the responsibility of the DM to see that food is properly stored to reduce the chance of temperature to prevent foodborne illnesses. Thaw meats under refrigeration at or below 41 degrees Fahrenheit in a drip proof container or submerged in a solid bottom pan under cold running water. Georgia Department of Public Health Food Facility Inspection Report has an 86 B score dated 7/18/2023. Observation on 9/5/2023 at 9:40 a.m. during initial tour of the kitchen revealed: In the refrigerator, a bowl of fruit cocktail/fruit salad was not labeled with content or dated with prep date or use by date. Raw chicken in a pot with ice and water covering it and plastic wrap covering the top was near the stove on a rolling cart. While in the kitchen the water was drained from the pot of raw chicken and replaced with more water, it was covered with plastic wrap and pushed into the cooler. It was dated 9/4/2023. In the pantry nine (9) green bowls with lids and cereal in them on a tray with no date were sitting on top of cereal bin. Interview on 9/5/2023 at 9:40 a.m. with the DM during the initial tour of the kitchen revealed the chicken in the pot of water and ice had been defrosting in the sink and it was being cooked for lunch. Observations of the kitchen on 9/6/2023 at 10:01 a.m. revealed: An opened bottle of barbecue sauce with a label that indicated refrigerate after opening was on a shelf in the pantry. An opened box of cranberry juice, wrapped in plastic wrap, was not labeled with an open or use by date in the cooler. An opened bag of cheese, wrapped in plastic wrap, was not labeled with an open or use by date in the freezer. A large plastic container with frozen chicken in red colored liquid was in the freezer. A large plastic zipper bag had several smaller bags of sandwich meat in it that was not labeled with an open or use by date. Interview on 9/6/2023 10:01 a.m. with the DM revealed the raw chicken in the freezer was left over defrosted chicken from yesterday and refrozen for future use. Interview on 9/7/2023 at 10:25 a.m. with the Assistant Dietary Manager BB revealed dates are placed on foods when delivered. We have certain sides of the freezer that we keep meat. To thaw the meat, we put it in a pan with ice and leave it in the cooler and prep and cook it.

Based on observations, record review, interviews, and review of facility policy 'Pressure Injury Prevention Program', the facility failed to enter wound care orders in the electronic medical record for one of one resident (R#47) reviewed for pressure ulcers. Findings include: Review of facility policy 'Pressure Injury Prevention Program' last revised 3/18/21 revealed: 'Procedure: B. Documentation 3. Documentation of the pressure injuries should be completed in the resident's EHR (electronic health record). Record review revealed R#47 was admitted to the facility with diagnoses including but not limited to hemiplegia affecting right dominant side, encephalopathy, seizures, and traumatic brain injury. Further review record review revealed R#47 had pressure ulcers to the left elbow, right foot, and sacrum. R#47 also has arterial ulcer to the left foot. During observation on 2/9/22 at 2:25 p.m. with Skin Integrity Coordinator (SIC) Registered Nurse (RN) revealed treatments performed to right and left feet. The SIC did not confirm orders prior to treatment and did not sign off that the treatments were completed afterward. Review of Medication Administration Record for February 2022 revealed there was no treatment orders in place for resident's wounds to right and left feet. During interview on 2/10/22 at 11:49 a.m. with RN SIC she confirmed that she did not verify resident's orders prior to performing treatments. States she is new to working at this facility and has not received training on how to add orders to the EHR system. During interview on 2/10/22 at 3:20 p.m. with the Assistant Director of Health Services confirmed R#47's treatment orders for his right and left foot were not in the EHR until she added them on 2/9/22.