The Enclave at Barnesville

Inspectors wroteBased on observation, medical record review, review of facility policies, and interview, the facility failed to develop and implement comprehensive, individualized and adequate pressure ulcer interventions to prevent the development of a pressure injury/ulcer for Resident #55. This affected one resident (#55) of one resident reviewed for facility acquired pressure injuries. The facility census was 52. [...]

Inspectors wroteBased on review of facility records, observation of kitchen and meal service, and interview with staff, the facility failed to store food in a sanitary manner and the drainpipes were maintained to prevent sewage odor in the kitchen. This had potential to affect 52 residents who receive meals from the kitchen. The facility census was 52. Findings Include: 1. Observations on 05/04/26 between 8:10 A.M. and 8:34 A.M. during the initial kitchen tour revealed the dry storage pantry had a strong sewage smell coming from an open drainpipe in the floor. Dietary Manager (DM) #209 verified the odor and reported it had been that way for several months and both administration and maintenance were aware of the concern. Observation and interview on 05/05/26 at 4:20 P.M. with DM #209 revealed the odor in the dry storage area was no longer present. [...]

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure resident assessment data accurately reflected the residents' status. This affected four residents (Resident #8, #29, #30 and #55) of 46 resident records reviewed for accuracy of assessments. The census was 52.

Inspectors wroteBased on review of the facility dietary manual, observation, tasting of the pureed dinner items, and interview, the facility failed to ensure foods were prepared to an appropriate puree consistency. The had the potential to affect nine residents (Residents #3, #12, #17, #22, #27, #32, #56, #57, and #58) the facility identified as receiving a puree diet. The facility census was 52.

Inspectors wroteBased on observation, resident interview, staff interview, and review of the facility policy, the facility failed to accommodate Resident #26 personal preferences of having a nightstand and personal toiletries in her bathroom. This affected one (Resident #26) out of two reviewed for accommodation of need. Facility census was 52.

Inspectors wroteBased on record review, observation, and staff interview, the facility failed to ensure a resident's care plan was revised to reflect the preference of the resident's family for the resident to not wear any splints, braces, or other orthotics as part of the resident's contracture management. This affected one (Resident #17) of 24 residents reviewed for care plans.

Inspectors wroteBased on medical record review, physical therapy records review, and interviews the facility failed to provide a timely implement a functional management program for Resident #29. This affected one (Resident #29) of one resident reviewed for restorative therapy services. The census was 52. Findings Include:Review of the medical record for Resident #29 revealed admission to the facility on [DATE] for diagnoses including acute respiratory failure, depression, hyponatremia (low salt level in blood), gastrointestinal bleed, anemia, high blood pressure, and hepatic encephalopathy (water on the brain leading to confusion). Review of the Resident #29 medical record revealed a physician's order on 04/10/26 for physical therapy treatments dated 04/10/26 through 04/25/26. [...]

Inspectors wroteBased on observation, record review, interview and policy review the facility failed to ensure residents identified at risk for elopement and resided on a secured memory care unit did not exit the facility without staff knowledge, failed to ensure interventions for residents identified at risk for elopement were timely implemented and failed to ensure fall prevention interventions were in place. This affected three residents (Resident #39, #54 and #17) of six residents reviewed for accidents.

Inspectors wroteBased on review of medical records, review of facility investigation, observations, interviews, facility assessment review and policy review the facility failed to provide comprehensive, resident centered dementia care to prevent resident to resident physical abuse. This affected two residents (Resident #14 and #32) of two residents reviewed for abuse. The facility census was 52.

Inspectors wroteBased on staff interview, record review, and review of facility policy, the facility failed to ensure physician-ordered medication parameters were followed for use of a narcotic pain medication and a heart rate was monitored as ordered prior to administration of medication. This affected two (#30 and #33) of five residents reviewed for unnecessary medications and medication review. The facility census was 52.

Inspectors wroteBased on observation, record review, staff interview, and policy review, the facility failed to ensure their medication error rate did not exceed 5%. The facility had three errors out of 33 opportunities for a medication error rate of 9%. This affected two (Resident #25 and #31) of four residents reviewed during medication administration observations.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure a nurse followed appropriate hand hygiene practices after administering eye drops to one resident (Resident #31) and before preparing medications for another resident (Resident #11). The facility's census was 52.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure residents were provided appropriate notices when transferred to the hospital and the State's local Ombudsman was notified of all transfers/ discharges from the facility as required. This affected three (Resident #45, #51, and #53) of three residents reviewed for hospitalizations and/ or planned discharges.

Inspectors wroteBased on record review and interview, the facility failed to submit the required staffing information for the fourth quarter of July 1st 2024 through September 20th 2024 to the payroll based journal (PBJ) data. This had the potential to affect all residents. The census was 46.

Inspectors wroteBased on observation and interview, the facility failed to maintain infection control practices. This had the potential to affect 26 residents (#1, #2, #3, #4, #5, #6, #7, #9, #10, #11, #12, #15, #17, #18, #19, #21, #23, #25, #26, #28, #32, #35, #36, #44, #47, and #152) of 46 residents residing in the facility.

Inspectors wroteBased on medical record review, interview, and policy review the facility failed to ensure Preadmission Screening and Resident Review (PASARR) were accurately completed. This affected three residents ( #3, #40, and #43) of three reviewed for PASARR.

Inspectors wroteBased on record review and interview, the facility failed to revise a comprehensive, person-centered care plan with interventions for oxygen therapy and antipsychotic medication treatment. This affected two residents (#7, #46) of seven residents reviewed for respiratory care and unnecessary medications. The facility census was 46.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure Resident #33's blood glucose level reading was obtained prior to administering insulin and failed to timely identify Resident #26's edema. This affected two residents (#33, #26) of three residents reviewed for change in condition and edema.

Inspectors wroteBased on record review, observations, and interview, the facility failed to ensure an order for an alternating air mattress was followed for a resident at risk for developing pressure ulcers. This affected one resident (#32) of four residents reviewed for pressure ulcers. The facility census was 46.

Inspectors wroteBased on record review, observations, and interview, the facility failed to ensure an order for non-skid strips was followed. This affected one resident (#32) of one resident reviewed for falls. The facility census was 46.

Inspectors wroteBased on record review and interview, the facility failed to implement interventions for weight loss after a significant weight loss in one month of 5.45%. This affected one resident (#19) of two residents reviewed for nutrition. The facility census was 46.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident's oxygen humidifier bottle was changed timely. This affected one resident (#7) of one resident reviewed for respiratory care. The facility identified six residents who received oxygen therapy.

Inspectors wroteBased on medical record review, interview, and policy review the facility failed to ensure a resident had a comprehensive assessment and plan of care for Post Traumatic Stress Disorder (PTSD). This affected one resident (#40) of one reviewed for behavioral/emotional.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident did not receive an unnecessary antibiotic. This affected one resident (#44) of one resident reviewed for unnecessary antibiotic. The facility census was 46.

Inspectors wroteBased on medical record review, review of pharmacy recommendation, interview, and policy review the facility failed to ensure appropriate diagnoses for psychotropic medication and failed to have supporting evidence for declining gradual dose reduction recommendations and increasing dose of psychotropic medication. This affected two residents (#43 and #46) of six resident reviewed for unnecessary medication review.

Inspectors wroteBased on record review including review of facility payroll records and facility billing/financial information, review of the facility assessment, review of the employee handbook, review of the facility Resident [NAME] of Rights, review of the facility Abuse/Neglect policy and procedure and interviews, the facility neglected to meet financial obligations for the delivery of care and maintenance and to operate in a manner to ensure all bills were being paid timely to prevent the potential interruption in services and to meet the total care needs of all residents admitted to and/or retained in the facility and failed to have adequate and effective systems in place to ensure staff were compensated via payroll benefits based on their hired agreement and payroll schedule. [...]

Inspectors wroteBased on record review, facility policy review, facility assessment review, and interviews, the facility failed to establish an effective governing body, legally responsible to establish and implement policies regarding the management and operation of the facility, including but not limited to compliance with all financial obligations for the delivery of care. This had the potential to affect all 42 residents in the facility.

Inspectors wroteBased on record review, staff interview and policy review, the facility failed to ensure continuous evaluations were in place to verify financial obligations were met as planned to prevent a potential disruption in resident care and services through the Quality Assurance Performance Improvement (QAPI) program committee. This had the potential to affect all facility residents. The facility census was 42.

Inspectors wroteBased on record review, including review of the facility payroll records, review of facility billing/financial information, review of email communication, review of the employee handbook, review of the facility Abuse/Neglect policy and procedure and interviews, the facility neglected to meet financial obligations for the delivery of care and maintenance and to operate in a manner to ensure all bills were being paid timely to prevent potential interruption in services and to meet the total care needs of all residents admitted to and/or retained in the facility. The facility also failed to have an effective system in place to ensure staff were compensated via payroll benefits based on their hired agreement and payroll schedule. [...]

Inspectors wroteBased on record review, facility policy review, facility assessment review, and interviews, the facility failed to establish an effective governing body, legally responsible to establish and implement policies regarding the management and operation of the facility, including but not limited to compliance with all financial obligations for the delivery of care. This had the potential to affect all 41 residents in the facility.

Inspectors wroteBased on record review, staff interview and policy review, the facility failed to ensure continuous evaluations were in place to verify financial obligations were met as planned to prevent a potential disruption in resident care and services through the Quality Assurance Performance Improvement (QAPI) program committee. This had the potential to affect all facility residents. The facility census was 41.

Inspectors wroteBased on record review, facility policy review, facility assessment review, and interviews, the facility failed to establish an effective governing body, legally responsible to establish and implement policies regarding the management and operation of the facility, including but not limited to compliance with all financial obligations for the delivery of care. This had the potential to affect all 30 residents in the facility.

Inspectors wroteBased on record review, staff interview and policy review, the facility failed to ensure continuous evaluations were in place to verify financial obligations were met as planned to prevent a potential disruption in resident care and services through the Quality Assurance Performance Improvement (QAPI) program committee. This had the potential to affect all facility residents. The facility census was 30.

Inspectors wroteBased on observation, record review including review of facility payroll records, review of facility billing/financial information, review of the [NAME] County Treasurer report, review of the facility assessment, review of the employee handbook, review of the facility admission agreement, review of the facility Abuse/Neglect policy and procedure and interviews, the facility neglected to meet financial obligations for the delivery of care and maintenance and to operate in a manner to ensure all bills were being paid timely to prevent potential interruption in services and to meet the total care needs of all residents admitted to and/or retained in the facility and failed to have adequate and effective systems in place to ensure staff were compensated via payroll benefits based on their hired agreement and payroll schedule. [...]

Inspectors wroteBased on record review, facility policy review and interview, the facility failed to establish an effective governing board, legally responsible to establish and implement policies regarding the management and operation of the facility, including but not limited to compliance with all financial obligations for the delivery of care and maintenance. This had the potential to affect all 42 residents in the facility.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure food was stored properly, kitchen equipment was clean, the kitchen environment was clean, kitchen staff's hair was properly restrained, kitchen staff washed hands after touching trash can lids and prior to donning (putting on) gloves, and the Robot Coup was sanitized and dried between uses. This had the potential to affect all 44 residents receiving food from the kitchen. The facility census was 44.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure garbage and refuse was disposed of properly. This had the potential to affect all 44 residents residing in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure the ice machine drain had an air gap to prevent potential backflow of drain contents into the ice machine. This had the potential to affect all 44 residents residing in the facility.

Inspectors wroteBased on medical record review, observation, MedScape online drug reference app review and staff interview, the facility failed to ensure resident assessments were completed accurately. This affected five (Resident #4, #5, #13, #26 and #27) of 15 residents reviewed for assessments. The facility census was 44.

Inspectors wroteBased on interview, resident record review, and facility policy review, the facility failed to ensure residents received a written summary of their baseline care plan. This affected four Resident (#4, #11, #38 and #42) of four residents reviewed for baseline care plans. The facility census was 44.

Inspectors wroteBased on observation, interview, spread sheet review, and facility policy review, the facility failed to ensure the spread sheet was followed and residents received the correct portion of food. This affected the 23 residents receiving the regular line meal (#1, #2, #5, #6, #7, #8, #9, #10, #15, #19, #23, #24, #25, #29, #31, #32, #35, #37, #39, #41, #43, #44, and #301) and the 11 residents receiving the mechanical soft meal (#4, #12, #17, #20, #26, #27, #28, #33, #34, #42, and #45) for the lunch meal observation. The facility census was 44.

Inspectors wroteBased on observation and interview, the facility failed to prepare pureed food in the proper form. This had the potential to affect all seven residents (#3, #13, #16, #21 #22, #36, and #38) who were receiving pureed meals. The facility census was 44.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure a resident's representative was notified of orders for laboratory tests. This affected one (Resident #101) of two residents reviewed for notification of change in condition. The census was 44.

Inspectors wroteBased on medical record review, review of a facility investigation, and interview, the facility failed to ensure allegations of abuse were reported to the State Survey Agency. This affected one (Resident #101) of three residents reviewed for abuse.

Inspectors wroteBased on medical record review, review of a facility investigation, and interview, the facility failed to ensure allegations of abuse were thoroughly investigated. This affected one (Resident #101) of three residents reviewed for abuse. The census was 44.

Inspectors wroteBased on medical record review and staff interview the facility failed to provide written transfer notification to the resident and/or representative when a resident was transferred to the hospital. This affected two (Resident #49 and #4) of three residents reviewed for hospitalization. The facility census was 44.

Inspectors wroteBased on medical record review, policy review and staff interview the facility failed to ensure residents and/or resident representatives admitted to the hospital were provided bed hold notification. This affected one (Resident #49) of three residents reviewed for hospitalization. The facility census was 44.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure a Preadmission Screening/Resident Review (PAS/RR) assessment was accurate upon admission and failed to ensure an updated PAS/RR was submitted to determine if a resident would benefit from specialized services. This affected one (Resident #3) of one resident reviewed for PAS/RR. 16 residents were screened for need for PAS/RR reviews. The census was 44.

Inspectors wroteBased on record review, observation, staff interview, and policy review, the facility failed to ensure fall prevention interventions were implemented as per the resident's plan of care. This affected one (Resident #27) of two residents reviewed for accidents. The census was 44.

Inspectors wroteBased on medical record review, inter-department email communication review and staff interview, the facility failed to ensure dietary recommendations were communicated effectively. This affected one (Resident #31) of four residents reviewed for nutrition. The facility census was 44.

Inspectors wroteBased on observation, interview, and resident record review, the facility failed to ensure a resident was assessed prior to the use of bed side rails and she was properly care planned for bed side rails. This affected one Resident (#38) of one resident reviewed for accidents. The facility census was 44.

Inspectors wroteBased on record review, review of hospital records, and staff interview, the facility failed to ensure medications were only used when there was an adequate indication for use and a resident did not receive antibiotics administered via an intramuscular (IM) injection unless warranted for the treatment of an infection. This affected one (Resident #4) of five residents reviewed for unnecessary medications. The census was 44.

Inspectors wroteBased on medical record review, policy review, and interview, the facility failed to ensure anti-psychotic medications were utilized only when medically necessary. This affected one (Resident #3) of five residents reviewed for medication use. The census was 44.

Inspectors wroteBased on observation, interview, tray card review, menu review and facility policy review, the facility failed to ensure preferences were honored when providing beverages. This affected three Residents (#2, #15, and #23) of three residents reviewed for beverage of choice. The facility census was 44.

Inspectors wroteBased on record review, observation, staff interview, and policy review, the facility failed to follow appropriate infection control practices by not ensuring a resident's indwelling urinary catheter bag was kept off the floor. This affected one (Resident #13) of one residents reviewed for catheters.

Inspectors wroteBased on record review, review of the facility's infection control log, review of infection reports, staff interview, and policy review, the facility failed to maintain an effective antibiotic stewardship program to ensure antibiotics were not used unnecessarily. This affected two (Resident #4 and #42) of five residents reviewed for antibiotic use.