Based on observations, staff interviews, record review, and review of facility's policy titled Tube Feeding Syringes, the facility failed to clean and store a tube feeding syringe after use for one of four residents (R) (R44) who received nutrition through a gastrotomy tube. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs, increased risk for infection, and a diminished quality of life. Findings include: Review of the facility's policy titled Tube Feeding Syringes dated 12/29/2023 under the section titled Intent revealed, It is the intent of this center to help prevent nosocomial infections (infection that develops during medical treatment) associated with enteral feeding equipment. Under the section titled Guidelines revealed, The following Procedural guidelines should be followed when storing a piston syringe: Tube Feeding and Medication Administration: wash the syringe; separate the piston from the barrel; Store the syringe separated on a clean surface to air dry, or place separated in a bag mounted to the feeding pump pole (the bag should not be airtight). Review of the Electronic Medical Record (EMR) revealed, R44 was admitted to the facility with diagnoses that included but was not limited to aphasia (inability to swallow), dysphasia (difficulty swallowing foods or liquids) following a cerebral infarction (stroke), and gastrostomy (surgical opening to the stomach for introduction of food) status. Review of R44's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 11/8/2024 revealed Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) of five, which indicated R44 had severe cognitive impairment; Section K (Swallowing/Nutritional status) revealed, R44 received 25% or less calories through parenteral or tube feeding and an average fluid intake per day by tube feeding of 1500 millimeters/day or less as a resident. Review of R44's EMR revealed physician's orders that included but was not limited to: Peg-tube flush, 150 milliliter every four hours per feeding tube dated 6/6/2024 and Peptamen 1.5 calories, one carton per feeding tube at bedtime; may be held for activities of daily living care, therapy, and medication administration dated 10/10/2024. Observations on 12/7/2024 at 7:48 am of R44's room revealed, a catheter tipped syringe on the nightstand uncovered with a white colored liquid in the tip of the syringe. There was a clear bag observed next to the uncovered syringe dated 12/6/2024. Observations and interview on 12/7/2024 at 2:55 pm with Licensed Practical Nurse (LPN) Wound Care Nurse AA revealed, a catheter tipped syringe with a white colored liquid in the tip of the syringe. LPN Wound Care Nure AA confirmed the observation and stated the catheter tipped syringe should not be stored on the nightstand. She stated the syringe should be cleaned after use, allowed to air dry, and then placed into a protective covering. Observation and interview on 12/7/2024 at 3:01 pm with the Assistant Director of Nursing/ Infection Preventionist revealed an observation of a catheter tipped syringe with a white colored liquid in the tip of the syringe lying on R44's nightstand uncovered. She confirmed the observation and revealed the syringe should not be left on the nightstand uncovered. She stated the nurse should clean and rinse the syringe thoroughly with water, allow to air dry, then place the syringe in a protective covering after each use. She stated the possible outcome of this practice would be the resident could develop a possible infection. Interview on 12/8/2024 at 12:19 pm with the Director of Nursing revealed that her expectation was that the nurse rinse the syringe out after use, allow the syringe to air dry, and then place the syringe in a protective covering. She stated the possible outcome of this practice would be the resident could possibly develop an infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and review of facility policies titled Storage Areas and Food Preparation and Distribution, the facility failed to discard milk by the use by date; failed to remove dented cans from the dry storage area; and failed to properly thaw ground beef to prevent bacteria growth and food borne illness. The facility had a census of 44 out of 48 residents that consumed an oral diet from the kitchen. Findings include: Review of the facility's policy titled Storage Areas dated 12/29/2023 under the section titled Guideline revealed, Dry Storage: Dented cans should be stored separately in a clearly labeled area. Review of the facility's policy titled Food Preparation and Distribution dated 12/29/2023 under the section titled Guideline revealed, Thawing methods: Submerged under running water at a temperature no greater than 70 F. 1. Observation on 12/6/2024 at 8:35 am of the two-door reach-in refrigerator near the steam table revealed an open case of 18, eight-ounce cartons of 2% (two percent) milk with a use by date [DATE]. During an interview on 12/6/2024 at 8:35 am, the Dietary Manager (DM) confirmed that the cartons of 2% milk had a use by date of [DATE]. The DM revealed that dietary staff should have discarded the milk. 2. Observation on 12/6/2024 at 8:45 am of the canned food storage rack revealed a can of black beans with a large dent towards the bottom. During an interview on 12/6/2024 at 8:45 am, the DM confirmed that the can of black beans was in the food storage rack and had a large dent. The DM revealed that dietary staff should have not placed the can in the rack and should have placed the dented can in her office which was the location for damaged cans. 3. Observation on 12/7/2024 at 8:50 am of the food preparation sink labeled Meat revealed a large tube of ground beef. The ground beef was on the bottom of the sink with cool water from the faucet running over the top. The ground beef was not covered or submerged in water. During an interview on 12/7/2024 at 8:50 am, the DM confirmed that the tube of ground beef was in the process of being thawed to use for lunch meal. The DM did not want to confirm if the ground beef was being properly thawed using the sink and running water. The DM did confirm that food items thawed in a sink should be submerged in water. The DM revealed that the ground beef should have been taken out of the freezer a few days earlier and placed in the refrigerator to be thawed.

Based on observations, staff interview, and review of the facility policy titled, Skilled Nursing Services - Storage Areas, the facility failed to ensure that opened food items were labeled and dated. The deficient practice had the potential to affect 41 residents receiving an oral diet. Findings include: Review of the facility policy titled, Skilled Nursing Services - Storage Areas, reviewed 12/30/2022 revealed food items should be covered, sealed, labeled, and dated appropriately. Observation on 7/28/2023 at 8:11 a.m. of the stand-alone refrigerator number four revealed a plastic bag containing mozzarella cheese slices that had not been labeled with an open date. Observation on 7/28/2023 at 8:18 a.m. of the stand-alone freezer number one revealed a large bag of frozen rolls that did not have a label with an open date. Further observation revealed an unknown meat wrapped in tin foil that did not have a label to identify the meat or an open date. Observation on 7/28/2023 at 8:16 a.m. of the stand-alone freezer number two revealed a large bag of chicken breasts that had been opened but did not have a label or an open date. Observation on 7/28/2023 at 8:20 a.m. of the stand-alone freezer number six revealed a bag of tater tots, cookies, French fries, and a 31-ounce bag of chopped green peppers, all unlabeled with no open date. Observation on 7/28/2023 at 8:23 a.m. of the stand-alone refrigerator in the kitchen (no number) revealed a 48-ounce jar of apple sauce and a 24-ounce plastic container of cottage cheese. Both items were unlabeled with no open date. Observation on 7/28/2023 at 8:25 a.m. of the stand-alone refrigerator located near the dry storage area (no number) revealed a bag with an unknown brown pudding type substance and a 16-ounce plastic container of frosting, which were unlabeled and did not have an open date. Further observation revealed a large stainless-steel bowl of chicken salad covered with tin foil, with an ice-cream scoop sitting on top of the chicken salad. The container was not labeled or dated. Observation on 7/28/2023 at 8:31 a.m. of the dry storage area revealed a 42-ounce container of quick oats, a 15-ounce box of sweetened corn cereal, a bag of devil's food cake mix (no weight), and a large bin of spiral pasta (no weight). All items were unlabeled with no open date. Observation on 7/28/2023 at 8:37 a.m. of the stand-alone freezer in the dining room revealed a large bag of frozen peas that were not labeled with the open date. Interview on 7/28/2023 at 8:42 a.m. with the Dietary Manager (DM) she acknowledged that the dry storage area, refrigerators, and freezers contained items that were not labeled and dated after they were opened. The DM explained she expected staff to label and date items after opening. She added that she also expected staff not to leave serving utensils inside any food containers.

Based on observations, staff interviews, record review, and review of the undated facility policy titled, Direct Supply TELS, the facility failed to maintain safe hot water temperatures for 17 rooms on two of three units, 100 Hall and 300 Hall, plus one Shower Room. Findings include: Review of the undated facility policy titled, Direct Supply TELS documented the following regarding the monitoring of water temperatures: 1. Ensure patient room water temperatures are between 105° and 115° Fahrenheit (or as specified by state requirements) .Georgia - shall not exceed 110 degrees Fahrenheit (F). Observation of resident rooms on 3/29/22 beginning at 10:00 a.m. on the 100 Hall and 300 Hall revealed hot water was extremely hot to touch in the following resident bathrooms: 101/103, 102/104, 105/107, 106/108, 109/111, 110/112, 301, 302, 303/304 and 305. On 3/29/22, beginning at 11:05 a.m., observation and testing of water temperatures in the resident's bathrooms with the Maintenance Director (MD) confirmed the following: 101-103=121.6 °F 102-104=130.6 °F 105-107=123.7 °F 106-108=129.1 °F 109-111=124.3 °F 110-112=127.5 °F 301-P=129.7 °F 302-P=125.0 °F 303-304=123.5 °F Bath=127.3 °F 305=122.5 °F During observation and interview with MD on 3/29/22 at 11:25 a.m., he observed the hot water heater on the 300 Hall which revealed the mixer was turned up to 130°F. He stated he sets the mixer at 110°F but staff have been known to adjust it when he's not in the building. He stated staff should notify him of needed repairs by entering a maintenance request into the electronic maintenance system called TELS. He stated that staff mostly just tell him what they need when they see him. Observation on 3/29/22 at 11:27 a.m. of the hot water heater located on the 200 Hall revealed it had a mixing valve but no gauge to set the temperature, so the MD measures the water temperature after making an adjustment. Interview with the Administrator on 3/29/22 at 11:30 a.m., surveyor informed him of the hot water readings on the 100 and 300 halls. He stated he was not aware of staff adjusting the mixing valves and had no resident complaints of burns to skin or water being too hot. He stated he would address the matter as soon as possible with the staff and contact a plumber for an assessment today. He stated he expected the staff to refrain from adjusting the hot water heaters and contact the MD with any problems. Observation Rounds on 3/29/22 5:10 p.m., with the MD after plumbing service revealed the following: 101-103=91.9°F 102-104=100.1°F 105-107=93.2°F 106-108=98.7°F 109-111=95.6°F 110-112=97.4°F 305=94.4°F 303-304=93.9°F 301-302=95.1°F Follow-up temperatures documented by the MD on 3/30/22 at 8:16 a.m. revealed the following: 102-104=103.4°F 101-103=98.6°F 106-108=103.2°F 110-112=99.3°F 111-109=101.6°F 107-105=103.7°F 305=102.8°F 304-303=103.6°F 302=99.4°F 301=102.8°F On 3/30/22 at 5:15 p.m., the MD documented the resident bathroom temperatures on the two resident units between 97.7°F and 101.6°F.

Based on observation, staff interview and review of the Georgia Food Code: US Food Code: Nation Restaurants Association/Serv Safe Guidelines and the undated facility policy titled, Food and Nutrition Services, the Dietary Manger (DM) failed to wash or sanitize her hands, or to wear gloves, prior to checking steam table temperatures during lunch service. This deficient practice had the potential to affect 40 residents receiving an oral diet. Findings Include: Review of the undated facility document titled Georgia food code: US Food Code: Nation Restaurants Association/Serv Safe Guidelines, revealed proper food safety handling practices should be implemented to minimize the risk of food borne illness. Guidelines of Cross Contamination revealed good hand washing techniques should be practiced, no bare hand contact with food items, and gloves should be changed between tasks. Review of the undated document titled Food and nutrition services: personal food items 4 (a) 1. revealed that that the proper hand washing protocol must be done as outlined in the procedure under DPH rule 511- 6-1-03 (5) to protect the cooked meal by contamination with bare hands. Observation and Interview on 3/29/22 at 12:34 p.m. with the DM, revealed that she performed the task of checking temperatures on the buffet during lunch and did not wash or sanitize her hands prior to task and she did not wear gloves during task. During this time an interview was conducted with the DM, and she revealed because she did not actually touch the food itself, she did not need to wear gloves for this task. An observation was made at this time of staff using utensils to place food onto plates and were wearing gloves. Observation on 3/29/22 at 12:34 p.m. with DM, revealed she did not wash her hands, use any hand sanitizer, or wear any gloves during obtaining steam table temperatures. Interview on 3/29/22 at 1:00 p.m. with the DM, confirmed she did not wear gloves when performing the task of checking food temperatures on the tray line and stated she doesn't recall if she washed or sanitized her hands prior to performing task. Interview on 3/29/22 at 3:00 p.m. with the Registered Dietitian (RD) for the facility, revealed she expects the kitchen staff to always follow kitchen food handling policies and procedures and proper infection control practices. Interview on 3/30/22 at 11:15 a.m. with Corporate Nurse Consultant, revealed that they don't have any infection control policy in the kitchen, but they do follow Food and Nutrition Guidelines from Georgia food code. Interview on 3/31/22 at 1:30 p.m. with [NAME] BB, confirmed that she has observed DM fail to follow the procedure for safe food handling before taking the temperature of the foods.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure the Administrator held a current license from the State of Georgia during the timeframe of [DATE] through [DATE]. Findings include: Upon request for employee records on [DATE], the Administrator was unable to provide a current copy his Administrator's license. Review of the Administrator's license at: http://verify.sos.ga.gov/verification/ revealed the license expired on [DATE]. During an interview with the Administrator on [DATE] at 5:54 p.m., he stated that he knew his license was due to expire on [DATE] and he renewed it timely but was unaware it had not processed until it was requested by the Survey Team. He stated he would not return on [DATE] and the corporate office would be sending the Regional [NAME] President (RVP) to replace him. He confirmed the facility was without a licensed Administrator from [DATE] through [DATE]. Interview with the RVP on [DATE] at 9:00 a.m., revealed that the Administrator was suspended on [DATE] pending the outcome of the investigation by the corporate office. He stated the Administrator was suspended until the license was renewed and an Interim Administrator was installed as of [DATE]. In addition, the RVP stated the corporate office performed an audit of all licensed personnel to confirm all licenses and certifications were current. On [DATE] at 9:00 a.m., The RVP brought in interim Administrator to run the facility until further notice.