Reserve at Fort Gaines of Journey LLC, the

Inspectors wroteBased on observations, resident and staff interviews, record review, and facility policy review, the facility failed to serve food that was palatable and hot to three of 23 sampled residents (Resident (R) 8, R11, and R13) reviewed for food palatability. This failure had the potential to affect all 51 residents who consumed food prepared from the facility's kitchen.

Inspectors wroteBased on observations, staff interviews, and facility policy review, the facility failed to discard food with expired use by dates and cover and date food stored in kitchen refrigeration units. The facility failed to ensure the kitchen's electric slicer and knives were clean prior to being stored for use. These failures had the potential to create an environment for food-borne illnesses which could affect 51 residents who consumed food prepared from the facility's kitchen. Findings Include: Review of the facility's policy titled, Food Safety Requirements, revised on 10/2022, specified, . Food shall be received and stored in a manner that complies with safe food handling practices . 8. All food stored in the refrigerator or freezer will be covered, labeled, and dated . Review of the facility's policy titled, Sanitation, revised on 10/2022, specified, . [...]

Inspectors wroteBased on staff interviews and record review, the facility failed to provide the residents and/or their representatives with written information of the right to accept or refuse medical or surgical treatment and/or formulate an advance directive for five of 23 sampled residents (Resident (R) 48, R26, R41, R14, and R15) reviewed for Advanced Directives. This failure created the potential the resident wishes to not be followed if the residents were unable to speak for themselves.

Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to provide written transfer/discharge notices that stated the reason for transfer, the place of transfer, and other information regarding the transfer to three of 23 sampled residents (Resident (R) 48, R29, and R26) reviewed for discharge to the hospital. This failure had the potential to affect the residents by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired.

Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for one of 23 sampled residents (Resident (R)11) reviewed for Preadmission Screening and Resident Review (PASARR) and one of 23 sampled residents (R11) reviewed for unnecessary medications. This failure placed the resident at risk of having unmet care needs and services.

Inspectors wroteBased on record review, resident and staff interviews, and facility policy review, the facility failed to follow professional standards of practice when they did not clarify medication orders for two of 23 sampled residents (Resident (R) 11 and R25). Staff did not clarify a physician's order for discontinuing an antidepressant abruptly for R11 and did not clarify R25's physician order for an antipsychotic medication that contained two different frequencies for administration. This had the potential to cause the residents to suffer adverse consequences.

Inspectors wroteBased on observations, record review, resident and staff interviews, and facility policy review, the facility failed to ensure nail care and/or showers were provided for three of 23 sampled residents (Resident (R) 49, R24 and R37) reviewed for activities of daily living (ADLs). This failure had the potential to cause R49, R24, and R37 to have unmet care needs.

Inspectors wroteBased on observations, staff interviews, record review, and policy review, the facility failed to store a Trilogy (a noninvasive ventilator device used to assist breathing for patients with respiratory issues) mask in a manner to prevent contamination for one of 23 sampled residents (Resident (R)156) reviewed for respiratory services. This failure increased the risk of respiratory infection.

Inspectors wrote2. Review of R25's Face Sheet, located under the Profile tab in the EMR, revealed R25 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease. Review of R25's quarterly MDS, located under the MDS tab in the EMR and with an ARD of 9/07/2024, revealed R25 had a BIMS score of 10 out of 15, which indicated R25 was moderately cognitively impaired. R25 was coded as receiving antipsychotic medications while a resident at the facility. Review of R25's Care Plan, located under the Care Plan tab in the EMR and dated 09/20/23, revealed a focus of, [R25] is easily angered\annoyed [sic] by others, uses profanity, demanding, inpatient, behaviors not always altered. Has dx [diagnosis] of brief psychotic disorder, vascular dementia with behavioral problems, drug seeking behaviors [sic]. Non compliant [sic] with care/tx [treatment]. [...]

Inspectors wroteBased on record review, staff interviews, and facility document review, the facility failed to have a complete and accurate medical record regarding documentation of a change in condition for one of 23 sample residents (Resident (R)15). This failure had the potential for the following shifts not to be completely informed of the resident's status.

Inspectors wroteBased on record review, staff interviews, policy review, and review of McGeer criteria (a tool designed to support facility healthcare-associated infection surveillance), the facility failed to have an Antibiotic Stewardship Program that followed current standards of practice for prescribing an antibiotic for three of 23 sampled residents (Resident (R) 33, R42, and R8) reviewed for antibiotic stewardship. This failure had the potential to cause residents to be prescribed antibiotics that were potentially unnecessary.

Inspectors wroteBased on record review, staff interviews, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to provide a pneumococcal vaccine once the resident's responsible (RP) had signed the consent form for one of 23 sampled residents (Resident (R) 24) reviewed for immunizations. This failure had the potential to increase the resident's risk of developing pneumonia.

Inspectors wroteBased on observation, staff interview, and Review of the facility policies titled, Refrigerator and Freezers, Food Safety Requirement, Sanitation, and Food Preparation and Service. The facility failed to ensure that expired foods were removed from the cooler; all food items in the coolers, refrigerator or freezers were labeled and included the date the item was placed in the cooler, refrigerator or freezer; failed to label and date chicken that was thawing in the cooler; failed to ensure that shelves used to store clean pots and pans was free from white powder and failed to ensure that the inside of the freezer was free of frost build-up. This deficient practice had the potential to affect 52 of 55 residents receiving an oral diet.

Inspectors wroteBased on documentation review, Staff interview, and review of the facility policy titled, Surveillance for Healthcare-Associated Infections, the facility failed to develop an effective Antibiotic Stewardship Program (ASP) to reduce the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use which has the potential to affect all residents. Specifically, three (Residents (R) 9, R37, and R4) were prescribed an antibiotic (s) without diagnostic testing that identified an organism and documented symptomology to support the continued use of an antibiotic.

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled, Resident/Family Participation-Assessment/Care Plans. The facility failed to ensure three residents (Resident's (R) 31, R9 and R37) were receiving timely care plan conferences. Findings Include: Review of the facility's policy titled, Resident/Family Participation-Assessment/Care Plans dated 11/2018 revealed, Policy Interpretation and Implementation, 1. The resident and /or representative are invited to attend and participate in the care plan conference. Notice shall be made by mail, electronic mail and/or telephone . 1. Review of R31's admission Record found in the EMR under the Profile tab, revealed R31 was admitted on [DATE] with a primary diagnosis of cardiac arrhythmias. [...]

Inspectors wroteBased on staff interviews, resident interview, and review of the facility policy titled, Hospice Program F684, F849, F552, the facility failed to ensure the plan of care was comprehensive for residents receiving hospice services for three of five residents (Resident (R) 31, R37, and R10).

Inspectors wroteBased on record review, staff interview, and review of the facility policy titled, Transfer and/or Discharge, Including Against Medical Advice (AMA). The facility failed to ensure two of two residents and/or their representatives (Residents (R) 35 and R54) were provided with written transfer/discharge notice that stated the reason for transfer, the place of transfer, and other information regarding the transfer or appeal information. In addition, the facility failed to send the transfer/discharge notices to the State Long Term Care Ombudsman's office. This failure has the potential to affect any resident or Resident Representative (RR) in having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer if the resident or RR desired. In addition, the Long-Term Care Ombudsman's office was not aware of facility-initiated transfers from this facility.

Inspectors wroteBased on record review, staff interview, and review of facility policies titled, Transfer and/or Discharge, Including Against Medical Advice (AMA) and Bed Hold. The facility failed to ensure two of two residents (Resident (R) 35 and R54) reviewed for facility initiated emergent transfer to the hospital and/or their Resident Representative (RR) received a written bed hold notice that included all required information from a sample of 21 residents. This failure had the potential to contribute to possible denial of re-admission and loss of the resident's home following a hospitalization for residents transferred to the hospital.

Inspectors wroteBased on interview, record review, document review, and review of the facility policy titled, Pre-admission Screening and Resident Review (PASRR) the facility failed to ensure one of three residents (Resident (R) 1) reviewed for the PASRR process, who was admitted with a mental health diagnosis, was referred for a Level II screening. This failure increases the risk for a resident with a mental illness diagnosis from not receiving specialized services.

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled, Care Plans-Baseline. The facility failed to develop a baseline care plan within 48 hours of the resident's admission that included resident-specific health concerns, intervention, services, and treatment to be administered by facility personnel to properly care for the resident immediately upon their admission. In addition, the facility failed to provide the residents and their representative with a summary of the baseline care plan for three of three residents (R) 107, R106 and R34) reviewed for new admission to the facility.

Inspectors wroteBased on observation, staff interview, record review, and review of the facility policy titled, Quality of Life-Activities of Daily Living . The facility failed to assist with activities of daily living (ADL), specifically bathing and shaving for one (Resident (R) 35) for ADL care out of a total sample of 21 residents This failure had the potential to affect the residents' comfort, body image and increases the risk for infections.

Inspectors wroteBased on Staff interview, record review, and review of the facility bowel protocol, the facility failed to implement the facility's bowel protocol for one of one resident (Resident (R) 35). Specifically, the facility failed to ensure that R35 received medication for constipation as outlined in the facility's Criteria for Bowel Movement Protocol.

Inspectors wroteBased on staff interviews, record reviews, and review of the facility policy titled, Weight Assessment and Intervention. The facility failed to assess nutritional status for weight loss and tube feeding for two of four residents (Resident (R) 50, and R10). Specifically, the facility failed to ensure that R50 and R10 were evaluated by the Registered Dietician (RD) monthly for weight loss.

Inspectors wroteBased on observation, staff interviews, record review and review of the facility policy titled, Gastric Tube Feeding Via Continuous Pump. The facility failed to accurately implement one of three resident's (R )10 physician order regarding the amount of tube feeding to receive and failed to accurately document the time the tube feeding was started and ended and the amount the resident received of tube feeding formula per day.

Inspectors wroteBased on staff interviews, record reviews, and review of the facility policies titled, Medication Administration Schedule and Physician Medication Orders,. The facility failed to administer medication per physician's orders for one of eight residents (Resident (R) 34). Specifically, the facility failed to ensure that R34 received nicotine patches as ordered by physician for smoking cessation.

Inspectors wroteBased on observation, document review, staff interviews, and review of the facility policy titled, Posting Direct Care Daily Staffing Numbers. The facility failed to ensure the nurse staffing information was accurate and posted in a prominent place readily accessible to residents and visitors. The facility also failed to ensure the facility retained the daily nurse staff posting documents for a minimum of 18 months. This failure had the potential to affect all residents and visitors to the facility.

Inspectors wroteBased on observations and staff interviews the facility failed to maintain an environment that was free from peeling and chipped paint on two of four halls with 23 of 50 rooms affected.

Inspectors wroteBased on record review and staff interviews the facility failed to develop a care plan to address hypoxemia for one of five residents (R#13) receiving oxygen therapy.