Azalealand Nursing Home

Based on observation, resident and staff interviews, and record review, the facility failed to ensure resident privacy during incontinent care and transfer for two of 29 sampled residents (R) (R22) (R59). This deficient practice had the potential to place both residents at risk of a diminished quality of life and cause emotional distress and lack of trust.Findings include:Record review of the electronic health record (EHR) for R22 revealed diagnoses including, but not limited to, dementia and fracture of an unspecified part of the neck of the right femur, subsequent encounter for closed fracture with routine healing.Record review of the Quarterly Minimum Data Set (MDS) for R22, dated 01/16/2026, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of nine (indicating mild cognitive impairment). Section GG (Functional Abilities and Goals) documented that the resident was dependent for Activities of Daily Living (ADLs), with transfers requiring the use of a mechanical device.Observation on 02/27/2026 at 9:48 AM revealed Certified Nursing Assistants (CNA) DD and CNA BB providing a transfer to a shower bed using a Hoyer lift for R22 with the room door wide open. R22's body was observed extended in the air, allowing public view exposure from the waist down, exposing her brief and the disfigurement of her legs from the contracture.Interview on 02/27/2026 at 10:30 AM with CNA DD and CNA BB, both staff confirmed they forgot to close the room door. Both CNAs reported that the Hoyer lift and the shower bed could fit in the room with the door closed. They confirmed that this was a dignity issue.Interview on 02/29/2026 at 10:01 AM with the Director of Nursing (DON) revealed the DON reviewed the photographs with the surveyor. She confirmed that the transfer was a deficient practice and was a dignity issue. She reported that certified nursing assistants had enough space in the resident's room to position the shower bed in R22's room and close the door to ensure privacy.Interview on 02/29/2026 at 5:30 PM with the Administrator revealed the Administrator reviewed the photographic evidence. He reported being unaware of the incident until it was brought to his attention by the surveyor. He reported that he planned to address the issues.Record review of the electronic health record (EHR) for R59 revealed diagnoses including, but not limited to, paroxysmal atrial fibrillation, type 2 diabetes mellitus with diabetic neuropathy, cognitive communication deficit, and presence of a cardiac pacemaker.2. Record review of the Quarterly Minimum Data Set (MDS) for R59, dated 01/2/2026, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 15 (indicating little to no cognitive impairment). Section GG (Functional Abilities and Goals) documented that the resident required substantial/maximal assistance for toileting and was essentially dependent for most Activities of Daily Living (ADLs).Observation on 02/29/2026 at 9:48 AM revealed CNA CC providing incontinent care to R59. Continued observation revealed that the window blinds were open and the privacy curtain did not completely encircle the bed for R59, and R59 was observed with no covering on her bare body below the waist. This allowed exposure of R59 to other people entering her room and open view to the public outside. The resident's window faced the public street and the front lawn walkway.Interview on 02/28/2026 at 12:11 PM with R59 revealed and confirmed the curtain was open and reported that CNAs never closed the window blinds. R59 reported that her preference was for CNAs to ensure her privacy by closing the window.Interview on 02/28/2026 at 12:14 PM with CNA CC confirmed forgetting to ensure the privacy curtains encircled the bed and to close the window blinds. CNA CC confirmed receiving training on closing the blinds.Interview on 02/28/2026 at 12:31 PM with the DON revealed that her expectations were for staff to pull privacy curtains during patient care. She reported that this incident with R59 would be classified as a dignity issue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record review, and review of the facility's policy titled Medication Storage in the Facility, the facility failed to ensure four of 29 sampled residents (R) (R53, R37, R38, and R59) did not have unauthorized and unsecured medications at the bedside. This failure had the potential to result in medication errors, improper use, and adverse drug events for the residents.Findings include:
Review of the facility's policy titled, Medication Storage in the Facility with effective date of May 1, 2020, under the Policy section revealed, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supple is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Under the Procedures section revealed, .B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications permitted to access. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access.
1. Review of R53's Electronic Health Records (EHR) revealed diagnoses that included, but were not limited to, hemiplegia and hemiparesis following other cerebrovascular disease affecting right dominant side, ophthalmoplegic migraine, not intractable, hemiplegia and hemiparesis following other cerebrovascular disease affecting left non-dominant side.
Review of R53's Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Section C (Cognitive Patterns) revealed, a Brief Interview of Mental Status (BIMS) score of six which indicated severe cognitive impairment, and Section GG (Functional Abilities and Goals) revealed, impairment on one side to the upper and lower extremities, required substantial/maximal assistance with activities of daily living (ADL).
Review of R53's Physician's Orders revealed there were no active orders for eye drops or nasal sprays. Further review of the physician orders revealed that there were no physicians' orders authorizing the resident to self-administer medications.
Review of R53's EHR revealed there was no evidence that a self-administration of medications assessment had been completed to determine if the resident could not self-administer medications.
Observation on 02/27/2026 at 9:05 AM revealed, R53 lying in bed with [Name] lubricant eye drops and ipratropium bromide nasal spray was sitting on the bedside table.
During a concurrent observation and interview on 02/27/2026 at 2:24 PM, the Director of Nursing (DON) and Certified Medication Aide (CMA) AA both confirmed that the [Name] lubricant eye drops and ipratropium bromide nasal spray was sitting on top of the bedside table inside R53's room. Interview with the Director of Nursing (DON) revealed that she was unsure if R53 had been assessed to self-administer medications or if an order was in place for R53 to self-administer medications but would check and ask CMA AA to remove the medications from the room. She revealed her expectation was for the nurses to remove medications and not to leave them in the room unattended.
Interview on 02/27/2026 at 2:35 PM with the ADON and DON, R53, R37, R38, and R59 records were reviewed. The Assistant Director of Nursing (ADON) confirmed the residents did not have a physician's order to self-administer medications nor had an assessment been completed for R53, R37, R38, and R59. Further review of the records revealed that R53 did not have an order for eye drops or nasal spray. ADON revealed that R53's had to have brought the medications from home because they do not carry that brand of eyedrops and there were no orders for either of them. The DON revealed she would plan to provide education to the residents' family not to bring medication from home and leave them in the resident's room and for staff to remove medications not authorized from the room. The DON confirmed that the residents (R53, R37, R38, and R59) could not self-administer their own medications.
Findings include
2. Review of R37's Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) score of twelve, which indicated cognitive awareness with little to no cognitive impairment. Section GG (Functional Abilities and Goals) revealed impairment on one side of the upper and lower extremities and that the resident required substantial/maximal assistance with Activities of Daily Living (ADLs).
Review of R37's Physician's Orders revealed an active order for eye drops dated 04/25/2024. The order stated: Refresh Tears Ophthalmic Solution 0.5% (Carboxymethylcellulose Sodium Ophth) instill 1 drop in both eyes three times a day for dry eyes. Further review revealed no physician orders authorizing the resident to self administer medications.
Review of R37's EHR revealed no evidence that a self administration of medications assessment had been completed to determine whether the resident could self administer medications.
Observation on 02/27/2026 at 9:05 AM revealed R37 lying in bed with [Name] lubricant eye drops sitting on the bedside table.
3. Review of R38's Electronic Health Record (EHR) revealed diagnoses that included, but were not limited to, Parkinson's disease without dyskinesia and without mention of fluctuations, unspecified dementia (moderate) without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, hypertension, squamous blepharitis of the right upper eyelid, squamous blepharitis of the left upper eyelid, and prediabetes.
Review of R38's admission Minimum Data Set (MDS) assessment dated [DATE] for Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated little to no cognitive impairment. Section GG (Functional Abilities and Goals) revealed no impairment of the upper or lower extremities and that the resident required partial/moderate assistance with Activities of Daily Living (ADLs).
Review of R38's Physician's Orders revealed no active orders for eye drops. Further review revealed no physician orders authorizing the resident to self administer medications.
Review of R38's EHR revealed no evidence that a self administration of medications assessment had been completed to determine whether the resident could self administer medications.
Observation on 02/27/2026 at 9:05 AM revealed R38 lying in bed with [Name] lubricant eye drops sitting on the bedside table.
4. Review of R59's Electronic Health Record (EHR) revealed diagnoses that included, but were not limited to, type 2 diabetes mellitus with diabetic neuropathy (unspecified), paroxysmal atrial fibrillation, cognitive communication deficit, and presence of a cardiac pacemaker.
Review of R59's Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated little to no cognitive impairment. Section GG (Functional Abilities and Goals) revealed no impairment of the upper or lower extremities and that the resident required partial/moderate assistance with Activities of Daily Living (ADLs).
Review of R59's Physician's Orders revealed an active order for eye drops (start date 11/12/2024). The order stated: Artificial Tears Ophthalmic Solution (Artificial Tear Solution) instill 1 drop in both eyes three times a day for dry eyes. Further review revealed no physician orders authorizing the resident to self administer medications.
Review of R59's EHR revealed no evidence that a self administration of medications assessment had been completed to determine whether the resident could self administer medications.
Observation on 02/27/2026 at 10:01 AM revealed R59 lying in bed with [Name] lubricant eye drops sitting on the bedside table.
Interview on 02/27/2025 at 4:35 PM with the Director of Nursing revealed she confirmed the medications at the bedside for R37, R38, and R59. She reported that none of the above mentioned residents were authorized to self administer medications. She stated that if any of the residents had prescription medications, the medications should remain on the medication cart. She confirmed that the medications appeared to be over the counter products brought in by family. She reported that her expectation was for nursing staff to monitor medications at the resident's bedside.

Based on observations, staff interviews and review of the facility's policy titled Food and Storage, the facility failed to ensure food items were properly stored, sealed, and labeled. In addition, the facility failed to maintain sanitary conditions for one of three ice machines. The facility had 66 residents who received oral nutrition and were therefore affected by these deficient practices.Findings include:A record review of the facility policy Food Storage stated: Sufficient storage facilities are provided to keep food safe, wholesome, and appetizing. Food is stored, prepared, and transported at an appropriate temperature and by methods designed to prevent contamination.A brief observation of the kitchen dated 02/27/2026 at 8:00 AM revealed the following:The following open food items were not dated or labeled: two packs of fish sticks, chicken breast, diced ham, hush puppies, hamburger patties, onion rings, pound cake, a slice of cake, sliced tomatoes, grits, cream of wheat, unidentifiable frost bitten meat, and shredded cheese.The following food items were found in the dry pantry closet with no expiration date: two packs of spaghetti noodles wrapped in saran wrap, two open bags of macaroni noodles, an open bag of wide noodles, and an opened bag of rice. In addition, the ice machine in the kitchen was observed to have a dirty substance on both the outside and the inside.Observation/interview on 02/27/2026 at 8:00 AM with the Certified Dietary Manager (CDM) revealed and confirmed that the items listed above were not dated or labeled, and that the ice machine was dirty on the inside and outside.Interview on 02/27/2026 at 9:30 AM with the Dietary Supervisor (DS) confirmed that the above items should have been labeled and dated with open and expiration dates.DS also confirmed he would have the ice machine serviced by the professional company that maintained it. He further confirmed that all unlabeled and undated food would be discarded.

Based on staff interviews, review of facility documents, review of the document titled Rules and Regulations for Criminal Background Checks: 111-8-12-.03(h), and review of the facility policy titled, Abuse Neglect and Exploitation, the facility failed to ensure the screening component of their abuse policy was consistently implemented. Specifically, the facility failed to provide evidence of background checks for three Licensed Practical Nurses (LPNs) (LPN 7, LPN 9, and LPN 10) of five licensed staff whose employee files were reviewed. This deficient practice had the potential to place residents residing in the facility at risk of abuse, neglect, and exploitation from staff. The census was 70 residents.
Findings included:
A review of the facility policy titled, Abuse Neglect and Exploitation, reviewed/revised in 2/2023, revealed, The components of the facility abuse prohibition plan are discussed herein: I. Screening A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials' [sic] checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. 2. Screenings may be conducted by the facility itself, third-party agency or academic institution. 3. The facility will maintain documentation of proof that screening occurred.
A Georgia Department of Community Health document titled, Rules and Regulations for Criminal Background Checks: 111-8-12-.03(h) revealed, Licensed Healthcare Providers* who are EXEMPT from state fingerprint background check requirements as long as the employer checks with the applicable licensing board to verify that the license is in good standing: included, -Nurses- includes advanced practice registered nurse, nurse practitioner, certified registered nurse anesthetist, certified nurse midwife, clinical nurse specialist, registered nurse professional, and licensed practical nurse. The document further indicated, *This is a listing of common professionals that may work in the long-term care setting.
LPN 7's personnel file revealed her hire date was 9/17/2024. LPN 7's employee file indicated she was exempt from the GCIC [Georgia Crime Information Center, an official criminal record report for Georgia]/Criminal Background Check. The facility had no evidence a background check was completed for LPN 7 prior to employment.
LPN 9's personnel file revealed her hire date was 10/8/2024. LPN 9's employee file indicated she was exempt from the GCIC/Criminal Background Check. The facility had no evidence a background check was completed for LPN 9 prior to employment.
LPN 10's personnel file revealed her hire date was 2/20/2024. LPN 10's employee file indicated she was exempt from the GCIC/Criminal Background Check. The facility had no evidence a background check was completed for LPN 10 prior to employment.
During an interview on 11/7/2024 at 1:38 pm, the Human Resources (HR) Director stated she conducted license checks yearly for the licensed staff, and any marks against their license would be reflected. She stated licensed nurses had their fingerprints run before they got their license. The HR Director further stated the facility used to do background checks for licensed nurses until GCHEXS (Georgia Criminal History Check System, a state and federal fingerprint-based criminal history background check utilized to make employment eligibility determinations) was initiated in 2020 and the rules changed. She stated no background checks had been done for licensed staff since the rule changed if the license check came back in good standing. According to the HR Director, the Georgia Board of Nursing completed the background checks for licensed nurses.
During an interview on 11/7/2024 at 8:26 am, the Administrator stated the facility was under the impression that if an LPN's license check came back without issues, then no additional criminal background check was needed. He stated license checks had been completed, and all licenses of staff working in the facility were in good standing. He stated the facility had not done criminal background checks on LPNs 7, LPN 9, or LPN 10.

Based on observation and staff interviews, the facility failed to evaluate the Wound Care Registered Nurse's competencies associated with the provision of wound care and infection control. Infection control concerns were noted during the provision of wound care for one of three residents (R) (R4) observed during wound care. This deficient practice had the potential to have a negative impact on residents receiving wound care at the facility.
Findings included:
During an interview on 11/7/2024 at 1:21 pm, the Director of Nursing (DON) stated the facility did not have a policy that addressed nurse competencies.
An observation of wound care on 11/4/2024 beginning at 10:46 am revealed he Wound Care Registered Nurse (RN) entered the resident's room with clean dressings and medication and placed them directly on the resident's bed without using a barrier. Prior to initiating wound care, the Wound Care RN did not wash her hands are put on a gown, but she applied gloves. The Wound Care RN proceeded to remove three wound dressings, including one from the resident's right knee, one from the resident's right lateral thigh, and one from the resident's left lower leg. The Wound Care RN did not wash hands or change gloves during the removal of each of these dressings. The Wound Care RN then cleaned and applied treatment to the resident's right lateral leg wound without changing gloves or washing her hands. She then returned to the treatment cart to obtain supplies for the remaining treatments and left the resident's right knee wound and left lower leg wound open to air. Upon returning to the treatment cart, the Wound Care RN used hand sanitizer and gathered the remaining supplies for treatment. At 10:56 am, she applied gloves, returned to the resident's room, and placed the treatment items directly on the resident's bed without using a barrier. At 10:57 am, the Wound Care RN cleaned the resident's right knee wound and immediately cleaned the resident's left lower leg wound without washing hands or changing gloves between wounds. The Wound Care RN then applied the treatment on the right knee wound and covered it with a dry dressing, then immediately applied the treatment on the left lower leg wound and covered it with a dry dressing, without cleaning hands or changing gloves between wounds. After completing the treatments, the Wound Care RN asked if the resident wanted a snack. She then obtained a snack bag from the resident's window ledge, removed her gloves, and without washing her hands, opened the snack and provided it to the resident. After exiting the resident's room, The Wound Care RN returned to the treatment cart and placed the treatment supplies inside the cart, without first washing or sanitizing her hands.
During an interview on 11/4/2024 at 11:04 am, the Wound Care RN stated she did not know she needed to clean her hands and change gloves between cleaning a wound and dressing a wound. She further stated she did not know she should treat each wound separately. The Wound Care RN stated she had not been trained to use a barrier for placing clean supplies used to treat wounds. The Wound Care RN stated she received training on wound care from an online wound care company. She stated there was a portion of the program that addressed infection control during wound care. She further stated neither the Infection Control Preventionist nor the Director of Nursing (DON) had watched her perform wound care.
During an interview on 11/7/2024 at 3:38 pm, the DON stated that during wound care, the Wound Care RN should have used a barrier for treatment supplies, so they did not contact the surface of the resident's bed. The DON stated the Wound Care RN should have cleaned her hands and changed gloves during wound care, going from dirty (cleaning the wound) to clean (application of medications and dressings), and should have treated one wound at a time to prevent cross contamination of the wounds.
During an interview on 11/7/2024 at 1:54 pm, the DON stated the Wound Care RN took an online wound care certification course in August 2024. According to the DON, the Wound Care RN paid for the course and brought a copy of her certificate to the facility; however, the DON indicated the facility was unable to find the completion certificate and said the online company's system was down, so they were unable to access a copy of the Wound Care RN's course completion certificate.
During a follow-up interview on 11/7/2024 at 3:37 pm, the DON stated she expected nurses to be competent in infection control during wound care. The DON confirmed she had no documentation of competency evaluations for the Wound Care RN.
During an interview on 11/7/2024 at 3:52 pm, the Administrator stated he expected nurses to be competent in infection control during wound care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** An observation on 11/5/2024 at 8:00 am revealed an unlocked medication cart was located outside of the nurses' station on the Skidaway Hall. No staff were observed in the area.
A concurrent observation and interview on 11/5/2024 at 8:04 am revealed Licensed Practical Nurse (LPN) 11 approached the medication cart and stated he was trained not to leave the medication cart unlocked. He stated he usually locked it to make sure nobody could access the medications inside the cart. LPN 11 stated if the cart was left unlocked and unattended, someone could access the medications and take something they should not.
During an interview on 11/6/2024 at 2:19 pm, LPN 8 stated medication carts must be secured so nobody could get into the medications or take something out of it, which would be risky if someone took something they should not.
During an interview on 11/6/2024 at 4:09 pm, LPN 10 stated the medication cart should be locked when not in a nurse's line of sight to ensure residents' safety. LPN 10 said it could cause serious consequences if a resident took a medication from a cart that they should not have.
During an interview on 11/7/2024 at 3:38 pm, the DON stated medication carts should be locked when not attended by staff to ensure residents' safety and to keep residents from getting medications they should not have.
During an interview on 11/7/2024 at 3:52 pm, the Administrator stated he expected medication carts to be locked because somebody could get into the carts and take medications they should not have.
Based on observations, staff interviews, and review of the facility policy titled, Medication Storage in The Facility, the facility failed to ensure two of five treatment and medication carts were locked and secured when unattended by staff. This deficient practice created the potential for residents, unauthorized staff, and visitors to have access to medications and biologicals stored in the carts.
Findings included:
A review of the facility policy titled, Medication Storage in The Facility, effective 5/1/2020, indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.
An observation on 11/4/2024 at 9:39 am revealed a treatment cart was unlocked on the [NAME] Hall. The treatment cart contained Biofreeze, lactate lotion, betamethasone cream, clindamycin cream, diclofenac gel, antifungal powder, one bottle of alcohol, and one bottle of peroxide.
During an interview on 11/4/2024 at 9:45 am, Registered Nurse (RN) 1 stated treatment carts should be locked if they were not attended by staff or out of staff's line of sight. RN 1 confirmed the treatment cart was unlocked, but then walked away to talk to another staff member without first locking the treatment cart.
During an interview on 11/4/2024 at 9:52 am, Licensed Practical Nurse (LPN) 2 stated the treatment cart should not be left unlocked.
During an interview on 11/4/2024 at 11:44 am, the Director of Nursing (DON) stated if staff left the treatment cart unattended, they should lock it to ensure only those authorized to do so accessed the cart.
During an interview on 11/5/2024 at 8:42 am, the Administrator stated treatment carts should be locked unless they were in use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, a review of the facility policy titled, Personal Hygiene, and review of the Food and Drug Administration (FDA) Food Code 2022, the facility failed to ensure staff wore beard restraints when serving food and failed to ensure resident food items stored in a nourishment refrigerator were labeled and dated. These failures had the potential to affect all residents receiving meals from the dietary department.
Findings included:
1. A review of the facility's undated facility policy titled, Personal Hygiene indicated, If hair is long and not covered properly with a cap, a hair net must be worn.
The FDA Food Code 2022, dated 01/18/2023, revealed Chapter 2. Management and Personnel, 2-4 Hygienic Practices, 2-402 Hair Restraints, specified, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed to be worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.
On 11/5/2024 at 11:35 am, the Food Service Director (FSD) was observed with facial hair on his chin and a full mustache. The FSD was observed serving trays for the lunch meal, including chicken, potatoes, vegetables, and bread, while not wearing a beard or mustache restraint.
During an interview on 11/5/2024 at 1:56 am, the FSD stated he did not require his staff to wear beard restraints or facial hair coverings.
During a follow-up interview on 11/5/2024 at 4:09 pm, the FSD stated beard nets were required if a beard was full and long.
During an interview on 11/6/2024 at 2:09 pm, the FSD stated if someone had the same amount of hair that was on his face on their head, he would require them to wear a hair net. The FSD said the facility did not have a policy that specifically addressed the use of beard restraints.
During an interview on 11/06/2024 at 2:54 pm, the Administrator stated the facility had beard restraints available for use. The Administrator said he had never been concerned about a trimmed goatee. The Administrator further stated the facility's policy did not specify beard restraints were required, but he knew regulations required them.
2. A review of the facility policy titled, Use and Storage of Food Brought in by Family or Visitors, revised in 1/2017, indicated, 2. Food items must be labeled with content and dated. a) The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator. b) The prepared food must be consumed by the resident within 3 days. c) If not consumed within 3 days, food will be thrown away by facility staff.
An observation on 11/07/24 at 8:15 am revealed the nourishment refrigerator located on [NAME] Hall had a sign posted that indicated the refrigerator would be cleaned out every Friday and expiration dates would be checked.
During a concurrent interview and observation of the nourishment refrigerator on [NAME] Hall on 11/7/2024 at 8:16 am, Certified Nursing Assistant (CNA) 6 stated kitchen staff restocked the nourishment refrigerator with resident supplements every two days. The following items were observed inside the refrigerator, not labeled or dated: a bowl of an unidentified food item labeled for a resident that was not dated and a bowl of an unidentified food item that was not dated or labeled. The freezer compartment contained a cup and a smoothie, but neither was labeled or dated.
During an interview on 11/7/2024 at 8:25 am, Licensed Practical Nurse (LPN) 7 stated the nourishment refrigerator was used for the residents, and everything should be dated and labeled.
During an interview on 11/7/2024 at 8:39 am, the Dietary Manager (DM) stated the nourishment refrigerators were checked each morning and filled with supplies. The DM said all food items in the nourishment refrigerator should be labeled and dated.
During an interview on 11/7/2024 at 8:56 am, the Administrator stated he expected any resident food items to be labeled and dated.
During an interview on 11/7/2024 at 12:21 pm, the Director of Nursing (DON) stated the nourishment refrigerators on the units should be used for residents, and all food items should be labeled and dated.

Based on observations, staff interviews, record review, review of the facility-provided document titled, Wound Care Procedure, and review of the facility policy titled, Enhanced Barrier Precautions, the facility failed to implement enhanced barrier precautions (EBP) and failed to ensure licensed staff followed proper infection control practices during and after the provision of wound care for one of three residents (R) (R4) reviewed for wound care. This deficient practice had the potential to increase R4's risk of infection due to cross-contamination and increased the potential for staff to spread infection to other residents residing in the facility.
Findings included:
A review of a facility-provided undated document titled Wound Care Procedure included . 3. Each wound will be treated individually. 4. When multiple wounds are being dressed, the dressings will be changed in order of least contaminated to most contaminated (i.e. [id est, that is] change extremity wounds before wounds contaminated with stool). Dressings of infected wounds should be changed last. 5. Set up clean field on the overbed table with needed supplies for wound cleansing and dressing application: a. If the table is soiled, wipe clean. b. Place a disposable cloth or linen saver on the overbed table. c. Place only the supplies to be used per wound on the clean field at one time (include wound cleanser, gauze for cleaning, disposable measuring guide, and pen/pencil, skin protectant products as indicated, dressings, tape). 6. Establish area for soiled products to be placed (Chux [disposable absorbent pad] or plastic bag). 7. Wash hands and put on clean gloves. The policy further indicated that after removing the dressing, staff should, 9. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. 10. Wash hands and put on clean gloves. 11. Cleanse the wound as ordered, taking care not to contaminate other skin surfaces or other surfaces of the wound (i.e., clean outward from the center of the wound). Pat dry with gauze. 12. Wash hands and put on clean gloves. 13. Apply topical ointments or creams and dress the wound as ordered. Protect surrounding skin as indicated with skin protectant. 14. Secure dressing. [NAME] with initials and date. 15. Discard disposable items and gloves into appropriate trash receptacle and wash hands.
A review of the facility policy titled, Enhanced Barrier Precautions, effective 3/2024, revealed, Definitions: Enhanced barrier precautions EBP refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. The policy further revealed, . 4. High-contact resident care activities include:
a. Dressing
b. Bathing
c. Transferring
d. Providing hygiene
e. Changing linens
f. Changing briefs or assisting with toileting
g. Device care or use: central lines, urinary catheters, feeding tubes, PICC [peripherally inserted central catheter] lines, midline catheters
h. Wound care: any skin opening requiring a dressing.
An admission Record revealed the facility admitted R4 on 6/27/2024. According to the admission Record, the resident had a diagnosis of sequela of an infection and inflammation due to an internal fixation device of the right femur.
A Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/13/2024, revealed R4 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. According to the MDS, R4 had open lesions other than ulcers, rashes, or cuts, had surgical wounds, received surgical wound care, and had nonsurgical dressings applied.
R4's Order Summary Report, listing active orders as of 11/6/2024, contained an order started on 8/22/2024 for EBP due to right thigh/right knee wounds. The Order Summary report also reflected the following wound treatment orders:
- an order dated 8/18/2024 for a wound vacuum to the resident's right lateral leg wound. The order indicated that if the wound vacuum became dislodged, staff should cleanse the wound with wound cleanser, apply a silver strip to the site, cover with an island dressing twice daily and as needed, and notify the nurse practitioner and wound care nurse;
- an order dated 8/21/2024 for a negative pressure dressing to the resident's right knee wound. The order indicated that if the negative pressure dressing became dislodged, staff should cleanse the wound with wound cleanser, pat dry, coat the wound bed with Xeroform (a yellow, petroleum-impregnated gauze dressing used to cover wounds) or medicated honey, and cover with a dry dressing every shift; and
- an order started on 9/27/2024 to clean a wound to the resident's left lower extremity, pat dry, and to apply silver sulfadiazine and a dry dressing one time a day on Mondays, Wednesdays, and Fridays.
An observation of wound care on 11/4/2024 beginning at 10:46 am revealed there was no EBP sign on R4's door or door frame. The Wound Care Registered Nurse (RN) entered the resident's room with clean dressings and medication and placed them directly on the resident's bed without using a barrier. Prior to initiating wound care, the Wound Care RN did not wash her hands or put on a gown, but she applied gloves. The Wound Care RN proceeded to remove three wound dressings, including one from the resident's right knee, one from the resident's right lateral thigh, and one from the resident's left lower leg. The Wound Care RN did not wash hands or change gloves during the removal of each of these dressings. The Wound Care RN then cleaned and applied treatment to the resident's right lateral leg wound without changing gloves or washing her hands. She then returned to the treatment cart to obtain supplies for the remaining treatments and left the resident's right knee wound and left lower leg wound open to air. Upon returning to the treatment cart, the Wound Care RN used hand sanitizer and gathered the remaining supplies for treatment. At 10:56 am, she applied gloves, returned to the resident's room, and placed the treatment items directly on the resident's bed without using a barrier. At 10:57 am, the Wound Care RN cleaned the resident's right knee wound and immediately cleaned the resident's left lower leg wound, without washing hands or changing gloves between wounds. The Wound Care RN then applied the treatment on the right knee wound and covered it with a dry dressing, then immediately applied the treatment on the left lower leg wound and covered it with a dry dressing without cleaning hands or changing gloves between wounds. After completing the treatments, the Wound Care RN asked if the resident wanted a snack. She then obtained a snack bag from the resident's window ledge, removed her gloves, and, without washing her hands, opened the snack and provided it to the resident. After exiting the resident's room, The Wound Care RN returned to the treatment cart and placed the treatment supplies inside the cart without first washing or sanitizing her hands.
During an interview on 11/4/2024 at 11:04 am, the Wound Care RN stated she did not know she needed to clean her hands and change gloves between cleaning a wound and dressing a wound. She further stated she did not know she should treat each wound separately. The Wound Care RN stated she had not been trained to use a barrier for placing clean supplies used to treat wounds.
During a follow-up interview on 11/6/2024 at 2:12 pm, the Wound Care RN stated she had asked the Director of Nursing (DON) about the concerns identified during R4's wound care and was told she should use a barrier for treatment supplies to ensure she had a clean field to work from for treatments and dressing changes. The Wound Care RN further stated she knew whether residents required EBP because a sign was generally posted to let staff know they required EBP. According to the Wound Care RN, R4 did have open wounds, but they had minimal drainage, so the Wound Care RN did not think the resident needed to be on EBP.
During an interview on 11/6/2024 at 4:09 pm, Licensed Practical Nurse (LPN) 10 stated that if a resident had open wounds, a mask, gloves, and a gown should be worn to provide care to them. She further stated residents on EBP should have a sign on their door.
During an interview on 11/7/2024 at 3:38 pm, the DON stated she expected a resident with draining wounds to be on EBP and to have an EBP sign posted on the door. The DON stated that during wound care, the Wound Care RN should have used a barrier for treatment supplies so they did not contact the surface of the resident's bed. The DON stated the Wound Care RN should have cleaned her hands and changed gloves during wound care going from dirty (cleaning the wound) to clean (application of medications and dressings) and should have treated one wound at a time to prevent cross contamination of the wounds.