River Towne Center

F-F697

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 14 115566 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115566 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River Towne Center 5131 Warm Springs Rd Columbus, GA 31909

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or 49138 potential for actual harm Based on observations, resident interviews, staff interviews, record review, and review of the facility policy Residents Affected - Few titled Activities of Daily Living (ADL), Supporting, the facility failed to ensure that two of 49 sampled residents (R) (Resident R12 and Resident R43) received activities of daily living (ADL) care related to receiving scheduled showers to maintain good personal hygiene. This deficient practice had the potential to place Resident R12 and Resident R43 at risk of being unclean and feeling insecure about their appearance.

Findings include:

Review of the facility policy titled Activities of Daily Living (ADL), Supporting, revised 3/2018, revealed the Policy Statement stated, Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. The Policy Interpretation and Implementation section included, . 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the residents and in accordance with the care plan, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care).

1. Review of Resident R12's Admission Record revealed diagnoses including, but not limited to, type 2 diabetes mellitus with diabetic neuropathy, end-stage renal disease, muscle weakness, morbid obesity, depression, and anxiety.

Review of Resident R12's Quarterly Minimum Data Set (MDS) assessment, dated 4/11/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 15 (indicating little to no cognitive impairment). Section GG (Functional Abilities and Goals) documented upper extremity impairment

on both sides, lower impairment on one side, and required substantial to maximum assistance with showering or bathing. Section O (Special Treatments, Procedures, and Programs) documented that Resident R12 received dialysis.

Review of Resident R12's Care Plan Report, dated 11/29/2022, revealed a Focus area, dated 11/29/2022, of ADL self-care performance deficit related to decreased mobility. Interventions included assisting the resident with hygiene and grooming.

Review of Resident R12's Bath Skin Assessment Forms for April 2025 revealed forms dated 4/1/2025, 4/8/2025, 4/15/2025, and 4/23/2025. Documentation revealed Resident R12 refused on 4/1/2025 and 4/15/2025. There was no documentation of baths or showers for any other dates in April 2025.

In an interview on 4/22/2025 at 11:47 am, Resident R12 revealed she was in and out of the facility for dialysis and was not offered showers. Resident R12 stated she has not received a bed bath or shower for about a month. She stated

she had asked staff for a shower and was informed her scheduled shower days were on Monday, Wednesday, and Friday. Resident R12 stated she was out of the facility for dialysis on her scheduled shower days.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 14 115566 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115566 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River Towne Center 5131 Warm Springs Rd Columbus, GA 31909

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 In an interview on 4/23/2025 at 11:03 am, Certified Nursing Assistant (CNA) UU stated Resident R12 received a shower on Monday and Friday and a bed bath on other days and the showers or baths were documented on Level of Harm - Minimal harm or the shower sheets. potential for actual harm 2. Review of Resident R43's Admission Record revealed diagnoses including, but not limited to, legal blindness, Residents Affected - Few muscle weakness, glaucoma, and schizophrenia.

Review of Resident R43's Quarterly MDS assessment, dated 3/6/2025, revealed Section C (Cognitive Patterns) documented a BIMS of 14 (indicating little to no cognitive impairment). Section GG (Functional Abilities and Goals) documented Resident R43 required partial to moderate assistance with showering or bathing.

Review of Resident R43's Care Plan Report revealed a Focus area, initiated 11/6/2018, of ADL self-care performance deficit related to confusion, impaired balance, visual impairment of being legally blind, and glaucoma. Interventions include requiring the assistance of one person with ADLs and providing a sponge bath when a full bath or shower cannot be tolerated.

Review of Resident R43's Bath Skin Assessment Forms for one month revealed forms dated 3/31/2025, 4/4/2025, 4/7/2025, and 4/11/2025. There was no documentation of baths or showers for any other dates in April 2025.

In an interview on 4/22/2025 at 11:47 am, Resident R43 stated she did not receive showers as scheduled.

In an interview on 4/23/2025 at 10:36 am, Resident R43 stated her shower days were Monday and Friday, and she did not receive showers as scheduled. Observation revealed Resident R43 wearing the same pants as on 4/22/2025.

In an interview on 4/23/2025 at 11:03 am, CNA UU stated Resident R43 was provided a shower on Monday and Friday and a bed bath on the other days. CNA UU stated Resident R43 did not refuse showers and the showers or baths were documented on the shower sheets.

In an interview on 4/23/2025 at 11:12 am, Licensed Practical Nurse (LPN) LL stated that residents should receive showers as scheduled.

In an interview on 4/24/2025 at 6:13 pm, the Director of Nursing (DON) stated that showers should be provided as scheduled. She further stated that if a resident refused, staff should inform the nurse and reattempt.

In an interview on 4/24/2025 at 6:30 pm, the Administrator stated residents should receive showers as scheduled.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 14 115566 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115566 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River Towne Center 5131 Warm Springs Rd Columbus, GA 31909

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm 44757

Residents Affected - Few Based on observations, resident interviews, and staff interviews, the facility failed to ensure an environment free from accident hazards on one of seven medication carts and in three of 49 sampled residents' (R) (Resident R12, Resident R87, and Resident R36) rooms. This deficient practice had the potential to place the residents at risk of accident hazards.

Findings include:

1. Observation 4/22/2025 9:37 am of the medication cart located on the 200 Hall revealed an unpackaged three cubic centimeter (cc) syringe, with an uncapped needle attached, lying on top of a biohazard container attached to the medication cart.

In a concurrent observation and interview on 4/22/2025 at 9:46 am, Registered Nurse (RN) MM verified the syringe location. She stated the syringe should have been placed completely in the biohazard container. She further stated there was a potential for a resident to pick up the syringe with the attached needle and have an adverse outcome.

In an interview on 4/22/2025 at 9:50 am, Unit Manager (UM) CC revealed that syringes and needles should be disposed of by placing them completely inside the biohazard containers. UM CC stated he expected all syringes and needles to be disposed of properly.

In an interview on 4/22/2025 at 9:53 am, the Director of Nursing (DON) revealed that opened syringes and needles should not be sticking out of the biohazard container. The DON revealed that the syringe should be

in the biohazard container and the top should be closed.

In an interview on 4/22/2025 at 9:55 am, the Administrator stated that syringes and needles should be disposed of by ensuring they were completely in the biohazard container to avoid injuries.

49138

2. a. Observation on 4/22/2025 at 11:47 am revealed a container of an aerosol disinfecting spray sitting on Resident R12's bedside table, within easy reach of a resident.

During an observation and interview on 4/22/2025 at 12:25 pm, RN TT confirmed that aerosol disinfecting spray should not be left at the resident's bedside.

In an interview on 4/23/2025 at 6:13 pm, the DON confirmed that hazardous chemicals, including aerosol disinfecting spray, should not be accessible to residents.

In an interview on 4/24/2025 at 6:30 pm, the Administrator stated that cleaning products or aerosol items, such as household cleaners, should not be in resident rooms.

50941

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 14 115566 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115566 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River Towne Center 5131 Warm Springs Rd Columbus, GA 31909

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 b. Observation on 4/22/2025 at 9:52 am in Resident R87's room revealed a multi-purpose cleanser sitting on top of the toilet tissue dispenser in the bathroom. Level of Harm - Minimal harm or potential for actual harm In an interview on 4/22/2025 at 12:49 pm, Certified Nursing Assistant (CNA) HH verified that the multi-purpose cleanser was sitting on the toilet tissue dispenser. She stated that Resident R87's family member brings Residents Affected - Few in cleaner to clean Resident R87's bedroom.

In an interview on 4/22/2025 at 12:59 pm, RN ZZ stated she knew that the chemical was not supposed to be there, but the family member brought it in.

During a concurrent observation and interview on 4/22/2025 at 1:07 pm, LPN JJ stated that staff were supposed to remove the chemicals from resident rooms, and she was unaware of any chemicals in Resident R87's room.

In an interview on 4/22/2025 at 1:15 pm, the DON stated she was unaware that the family member was bringing the chemical in.

c. Observation on 4/22/2025 at 10:20 am, in Resident R36's room, revealed a container of disinfecting cleaner under

the sink in the bathroom.

In an observation and interview on 4/22/2025, the DON verified that the container of disinfecting cleaner was under the sink and that it should not be there. She stated Resident R36's family had brought it in.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 14 115566 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115566 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River Towne Center 5131 Warm Springs Rd Columbus, GA 31909

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51557 potential for actual harm Based on staff interviews, resident family interviews, record review, and review of the facility policy titled Pain Residents Affected - Few Assessment and Management, the facility failed to provide pain management for one of 49 sampled residents (R) (Resident R385).

Findings include:

Review of the facility's policy titled Pain Assessment and Management, revised 10/2022, revealed the General Guidelines section included, 1. The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice,

the comprehensive care plan, and the resident's choices related to pain management. 5. Acute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained. The Steps in the Procedure section included, Assessing Pain 1. Assess the resident at admission and during ongoing assessments to help identify the resident who is experiencing pain or for whom pain may be anticipated during specific procedures, care, or treatment. and Monitoring and Modifying Approaches . 5. Contact the prescriber immediately if the resident's pain or medication side effects are not adequately controlled.

Review of Resident R385's Admission Minimum Data Set (MDS), dated [DATE REDACTED], revealed Section J (Health Conditions) documented Resident R385 received PRN (as-needed) pain medication, pain frequency was occasional, pain interfered with sleep occasionally, and the pain intensity score was three (indicating severe pain).

Review of Resident R385's Admission Record revealed the resident was admitted to the facility on [DATE REDACTED] from an acute care hospital with diagnoses including, but not limited to, encounter for other orthopedic aftercare, muscle weakness, and spinal stenosis, cervical region.

Review of Resident R385's Nursing Admission Screening/History assessment, dated 12/11/2024, revealed the reason for admission was neck surgery, the resident had pain, and pain was assessed at a level of five on a scale of one to ten.

Review of Resident R385's Physician's Orders revealed an order dated 12/11/2024 at 1:57 pm for oxycodone-acetaminophen tablet (a medication used to treat moderate to severe pain) 7.5-325 milligrams (mg) one tablet every six hours as needed for pain.

Review of Resident R385's Medication Administration Record (MARS) dated 12/2024 revealed a physician's order dated 12/11/2024 at 1:57 pm for oxycodone-acetaminophen tablet 7.5-325 mg one tablet every six hours as needed for pain. Review revealed Resident R385 did not receive the medication on 12/11/2025. Further review revealed Resident R385 did not receive the medication on 12/12/2024 at 2:22 pm.

In a telephone interview on 4/24/2025 at 7:59 am, Resident R385's family member stated Resident R385 had complained of pain all night after her admission to the facility and did not receive any pain medication. Resident R385's family member stated the nurse had informed her that the order for the pain medication was not sent to the facility from the hospital, and the physician was not notified.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 14 115566 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115566 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River Towne Center 5131 Warm Springs Rd Columbus, GA 31909

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 In an interview at 4/24/2025 5:45 pm, Admissions Director RR and Registered Nurse (RN)/Hospital Liaison SS stated that the process for opiod pain medication was for the hospital to send a hard copy of the Level of Harm - Minimal harm or prescription with the resident, the nurse receiving the resident should fax the hard copy of the prescription to potential for actual harm the pharmacy, and the pharmacy should send the nurse a code to access the emergency medication supply and obtain the ordered medication. Residents Affected - Few

In an interview on 4/24/2025 at 6:00 pm, the Director of Nursing (DON) reviewed Resident R385's electronic medical

record (EMR) and stated she was unable to locate the hard copy of the prescription for Resident R358's pain medication in the scanned documents. She stated the hard copy of the prescription was not received upon

the resident's admission, and the receiving nurse did not call the physician to obtain an order for overnight pain relief. The DON confirmed that the facility's normal process for narcotic pain medication was for the hospital to send over a hard copy of the prescription so the receiving nurse could fax it to the pharmacy and then receive a code from the pharmacy to be able to pull the narcotic out of the emergency stock until the pharmacy delivered the residents medication.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 14 115566 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115566 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River Towne Center 5131 Warm Springs Rd Columbus, GA 31909

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 51557 Residents Affected - Few Based on observations, staff interviews, and review of the facility policy titled Medication Labeling and Storage, the facility failed to ensure expired medications were discarded after the expiration date in one of two medication rooms. This deficient practice had the potential to place residents at risk of receiving medications with altered effectiveness.

Findings include:

Review of the facility policy titled Medication Labeling and Storage, revised February 2023, revealed the Policy Interpretation and Implementation Medication Storage section included, . 3. If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.

Observations on 4/23/2025 at 4:53 pm in the [NAME] Side Medication Storage Room revealed three boxes of bisacodyl suppositories expired 1/2025, one opened container of Tylenol 325 milligrams (mg) expired 11/25/2024, and three containers of Renavite expired 10/2023 were stored with other unexpired medications

on the storage shelves.

In an interview on 4/23/2025 at 5:20 pm, Registered Nurse (RN) CC verified the findings and stated that discontinued medications should be placed in a box in the medication room and picked up by the pharmacy to be destroyed monthly.

In an interview on 4/24/2025 at 10:14 am, the Director of Nursing (DON) stated that expired and discontinued medications should be removed from the shelves and placed in a box in the medication storage room for the pharmacy to destroy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 14 115566 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115566 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River Towne Center 5131 Warm Springs Rd Columbus, GA 31909

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50943

Residents Affected - Many Based on observations, staff interviews, and review of the facility policy titled Food Receiving and Storage,

the facility failed to ensure food items were discarded upon expiration. This deficient practice had the potential to promote foodborne illnesses in the 110 residents receiving an oral diet from the kitchen.

Findings include:

Review of the facility's policy titled Food Receiving and Storage, dated [DATE REDACTED], revealed that the Policy Statement stated, Foods shall be received and stored in a manner that complies with safe food handling practices.

During a tour of the kitchen on [DATE REDACTED], beginning at 9:50 am with the Dietary Manager (DM), observations revealed:

One container of ground allspice seasoning with an expiration date of [DATE REDACTED].

One container of ground ginger seasoning with an expiration date of [DATE REDACTED].

One box of French-style dressing packets with an expiration date of [DATE REDACTED].

One box of gelatin expired [DATE REDACTED].

Observations of the walk-in cooler with the DM revealed:

Two boxes of cabbage with expiration dates of [DATE REDACTED] and [DATE REDACTED].

One container of cream cheese with an expiration date of [DATE REDACTED].

One container of cottage cheese with an expiration date of [DATE REDACTED].

One container of ricotta cheese with an expiration date of [DATE REDACTED].

In an interview on [DATE REDACTED] at 10:15 am, the DM confirmed the findings in the kitchen. The DM stated that inventory checks were conducted, and expired food items should be discarded.

In an interview on [DATE REDACTED] at 12:30 pm, the Administrator stated that his expectation for the kitchen staff was to ensure all expired food items were discarded.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 14 115566 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115566 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River Towne Center 5131 Warm Springs Rd Columbus, GA 31909

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46691 potential for actual harm Based on record review, observations, staff interviews, and review of the facility's policy titled Departmental Residents Affected - Few (Respiratory Therapy) -Prevention of Infection Level I the facility failed to ensure the safe handling, labeling, and storage of nebulizer equipment to prevent contamination for one Resident(R)(Resident R1) of 23 sampled residents. This deficient practice had the potential to contribute to the spread of infection and respiratory illness.

Findings include:

A review of the facility's policy titled Departmental (Respiratory Therapy) -Prevention of Infection Level I

Purpose-The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol:

2.Take care not to contaminate internal nebulizer tubes.

3.Wipe the mouthpiece with damp paper towel or gauze sponge.

4.Store the circuit in plastic bag, marked with date and residents.

Review of Resident R1's medical record revealed she was admission on 8/6/2021 with diagnoses including chronic obstructive pulmonary disease (COPD), HIV disease, dementia, schizophrenia, and muscle weakness.

Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE REDACTED] revealed a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. Section J documented shortness of breath when lying flat and with exertion.

Review of physician orders dated 1/16/2025 revealed an active order for Ipratropium-Albuterol inhalation solution, 3ml inhaled orally every 6 hours as needed for shortness of breath.

Observation on 4/22/2025 at 2:04 pm revealed Resident R1's nebulizer mask sitting on the nightstand unbagged and unlabeled.

Observation on 4/23/2025 at 10:15 am revealed Resident R1's nebulizer mask again sitting on the nightstand unbagged and unlabeled.

Observation /interview on 4/23/2025 at 11:03 am with Certified Nursing Assistant (CNA), CNA UU, confirmed that Resident R1's nebulizer mask was not bagged or labeled. CNA UU stated she was unsure if it was required.

Interview and observation on 4/23/2025 at 3:25 pm with Licensed Practical Nurse, ( LPN) LL, LPN LL confirmed that the nebulizer mask was not bagged or labeled. LPN LL stated that, according to infection control procedures, the mask should have been properly bagged and labeled.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 14 115566 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115566 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River Towne Center 5131 Warm Springs Rd Columbus, GA 31909

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Interview on 4/23/2025 at 6:13 pm with the Director of Nursing (DON) confirmed that nebulizer masks should be bagged after use to prevent contamination and comply with infection control standards. Level of Harm - Minimal harm or potential for actual harm XXXXXXXXXXX

Residents Affected - Few 49138

Based on observations, resident interviews, staff interviews, record review, and review of the facility policies titled Departmental (Respiratory Therapy) Prevention of Infection and Gastrostomy/Jejunostomy Site Care,

the facility failed to ensure that respiratory masks were stored in a sanitary manner for two of five residents (R) (Resident R1 and Resident R70) reviewed for respiratory care. In addition, the facility failed to ensure dressing changes were performed as ordered for one of 31 R (Resident R23) with a feeding tube. These deficient practices had the potential to place Resident R1, Resident R70, and Resident R23 at risk of avoidable infections due to cross-contamination.

Findings include:

Review of the facility policy titled Departmental (Respiratory Therapy)Prevention of Infection, revised 11/2011, revealed the Purpose section stated, The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. The Steps in the Procedure section included, Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: . 7. Store the circuit in a plastic bag, marked with date and resident's name, between uses.

Review of the facility policy titled Gastrostomy/Jejunostomy Site Care, revised 10/2011, revealed the Purpose section stated, The purposes of this procedure are to promote cleanliness and to protect the gastrostomy or jejunostomy site from irritation, breakdown and infection.

1. Review of Resident R1's Admission Record revealed diagnoses, including but not limited to pneumonia and chronic obstructive pulmonary disease (COPD).

Review of Resident R1's Quarterly Minimum Data Set (MDS), dated [DATE REDACTED], revealed that Section J documented that Resident R1 had shortness of breath when lying flat and with exertion.

Review of Resident R1's Order Summary Report revealed an order dated 1/16/2025 for ipratropium-albuterol inhalation solution (a medication used to treat wheezing, shortness of breath, and coughing), 3 milliliters (ml) inhaled orally every six hours as needed for shortness of breath.

Observation on 4/22/2025 at 2:04 pm and 4/23/2025 at 10:15 am revealed Resident R1's nebulizer mask lying on the nightstand, unbagged and exposed to the environment.

In a concurrent observation and interview on 4/23/2025 at 11:03 am, Certified Nursing Assistant (CNA) UU confirmed that Resident R1's nebulizer mask was not stored in a protective bag. CNA UU stated she was unsure if the mask was required to be stored in a protective bag.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 14 115566 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115566 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River Towne Center 5131 Warm Springs Rd Columbus, GA 31909

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 In a concurrent observation and interview on 4/23/2025 at 3:25 pm, Licensed Practical Nurse (LPN) LL confirmed that the nebulizer mask was exposed to the environment and not in a protective bag. LPN LL Level of Harm - Minimal harm or stated that, according to infection control procedures, the mask should have been properly stored in a potential for actual harm protective bag.

Residents Affected - Few In an interview on 4/23/2025 at 6:13 pm, the Director of Nursing (DON) stated that nebulizer masks should be placed in a protective bag after use to prevent contamination and comply with infection control standards.

51557

2. Review of Resident R70's Admission Record revealed diagnoses including, but not limited to, pneumonia, chronic pulmonary edema, cardiomegaly, chronic respiratory failure, tracheostomy status, COPD, and acute pulmonary edema.

Review of Resident R70's Annual MDS assessment dated [DATE REDACTED] revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 15 (indicating little to no cognitive impairment). Section O (Special Treatments, Procedures, and Programs) documented Resident R70 received oxygen therapy, suctioning, tracheostomy care, and non-invasive mechanical ventilator while a resident.

Review of Resident R70's Physicians' Orders revealed an order dated 2/16/2025 to clean BiPAP (Bilevel Positive Airway Pressure [a medical device that assists with breathing]) wash, tubing, and reservoir with soap and water, rinse with sterile water, and allow to dry.

Observations on 4/22/2025 at 10:03 am and 4/23/2025 at 7:47 am and 10:29 am, in Resident R70's room, revealed a BiPAP mask lying on the bedside table, unbagged and exposed to the environment.

In an interview on 4/22/2025 at 10:00 am, Resident R70 stated the BiPAP equipment was washed two days prior.

In an interview on 4/23/2025 at 10:44 am, Resident R70 stated that staff often allowed the BiPAP mask to fall on the floor and that staff do not place the mask in a protective bag.

In an interview on 4/23/2025 at 10:52 am, LPN AA confirmed that the BiPAP mask was not in a protective bag and was exposed to the environment.

In an interview on 4/24/2025 at 9:57 am, the DON stated that BiPAP tubing and masks should be stored in a protective bag when not in use.

3. Review of Resident R23's Admission Record revealed diagnoses including, but not limited to, gastrostomy status.

Review of Resident R23's Physicians' Orders revealed an order dated 4/14/2025 for PEG Tube (percutaneous endoscopic gastrostomy [a feeding tube placed into the stomach through the abdominal wall]) site care and dressing change every shift.

Observation on 4/22/2025 at 9:42 am revealed Resident R23's PEG tube site dressing was discolored with dark brown drainage and was dated 4/16/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 14 115566 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115566 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River Towne Center 5131 Warm Springs Rd Columbus, GA 31909

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 In a concurrent observation and interview on 4/22/2025 at 10:07 am, LPN AA confirmed Resident R23's PEG tube site dressing was soiled and dated 4/16/2025. Level of Harm - Minimal harm or potential for actual harm In an interview on 4/24/2025 at 9:52 am, the DON stated that her expectation was for PEG tube site dressings to be changed daily. She stated nursing staff was responsible for PEG site dressing changes. Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 14 115566