Evergreen Health And Rehabilitation Center

Review of R3's Care Plan tab in the EMR revealed a care plan dated 7/3/2024 identifying R3's refusal for care.

Nursing interventions include: Encourage resident to accept care. If refusal occurs, wait and approach at a later time.

Review of the documentation in the electronic software utilized by the facility for documenting care, the task for Personal Hygiene from 5/8/2025 through 9/4/2025 was reviewed.

During this time frame, documentation revealed that R3 received care and was either independent, received limited assistance, or received total assistance in the receipt of personal hygiene.

The staff did not document during the 9/3/2025 to 9/4/2025 timeframe that R3 refused care for personal hygiene but did have care provided on both days.On 9/3/2025 at 9:35 AM, R3 was observed in his room in bed lying on his right side. R3's fingernails were observed to be long and jagged with a brown substance observed underneath the nails. On 9/3/2025 at 12:21 PM, R3 was asked if this surveyor could see his nails. R3 showed the surveyor his nails and the nails were in the same condition as the previous observation. On 9/4/2025 at 8:28 AM, R3 was observed coming back from breakfast.

When asking about R3's clothing, R3 stated he got a bath the previous day (Tuesday) and changed his clothing.

During an interview on 9/4/2025 at 3:40 PM, the Assistant Director of Nursing (ADON) provided the care plan regarding refusals for R3.

While the care plan addressed refusals, it was not specific to personal hygiene or nail care.

The ADON was notified that on 9/3/2025 and up to the time of this conversation, that R3's nails had been observed to be long and jagged, with brown matter underneath.

The Administrator walked up to this conversation and was notified as well about R3's nails and stated staff would take care of R3's nails.

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Evergreen Health and Rehabilitation Center 139 Moran Lake Road, NE Rome, GA 30161

exiting the facility.

The video did not contain a date stamp or a time stamp, but it did show the sun

stated that during the medication pass around 8:00 PM that day, another staff member alerted the

facility, and R1 could not be located. LPN4 then notified the Administrator, the Social Services Director, the police department, and the family member.Interview on 9/4/2025 at 12:45 PM by telephone, RT1 stated that around 6:30 PM or 7:00 PM he arrived at the facility and LPN4 opened the door and walked away. As LPN4 was walking away, RT1 held the door as R1 exited the facility. RT1 thought R1 was a family member that had been visiting. RT1 verified that no staff alerted him that R1 was a resident and not to let him exit.Interview on 9/3/2025 at 10:00 AM, the Social Services Director (SSD) stated that she was notified on 4/30/2025 of R1's elopement. SSD was told by the South LPN2 that R1 was found at a gasoline station by Preacher, a person known to the family of R1, near R1's nephew's apartment. R1 was taken to the nephew's apartment, but the nephew was not home.

The family member of R1 was called and was told by Preacher they were taking R1 back to the facility.

Around 10:00 PM on 4/30/2025, a car pulled up to the side door. R1 exited the car and was admitted to the facility.

The car drove away while the police were inside the facility, along with the Administrator, the Director of Nursing, and the SSD.

The SSD called the family member that evening and asked who Preacher was and how could the SSD contact him.

The Family member stated that was Preacher but did not have a phone number. SSD asked again who Preacher was and the family member stated, That's Preacher.Interview with LPN2, who was the charge nurse on the South unit, on 9/3/2025 at 4:00 PM, she stated that she received a phone call on 4/30/2025 at 9:45 PM from R1's family member who stated that Preacher found R1 at a gas station near the propane tanks. R1's Family member stated that Preacher took R1 to his nephew's apartment, but no one was there. R1's Family member stated that Preacher was bringing R1 back to the facility.

The Police, Administrator, SSD all see the car pull up to the side of the facility, R1 exits the car and enters the facility.

The car drives away.Review of EMR under the Progress Notes dated 4/30/2025 indicate that R1 was given a thorough examination when R1 returned.

There was no evidence of physical trauma or physical injury.Four attempts were made to contact the family member. No response was received.

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Evergreen Health and Rehabilitation Center 139 Moran Lake Road, NE Rome, GA 30161

Based on observations, staff interviews, record review, and facility policy review, the facility failed to

Hall long and South Hall short) reviewed. In addition, the facility failed to ensure two of two medication room refrigerators (North Hall and South Hall) were locked and the schedule II lock box (containing narcotics that have a high incidence of abuse) were affixed to shelving, as required.

This failure had the potential of medication diversion to residents, staff or visitors, and residents receiving ineffective medications.

Findings include:

Review of the facility policy titled, Medication Storage in the Facility, Expiration Dating of Medications, dated February 17, 2020, revealed, .Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier.Injectable medication dispensed by pharmacy will be discarded thirty (30) days after initial dose or according to the manufacturer recommended discard date.

The medication will be noted with the date the medication was initially opened.

Review of the facility policy titled, Medication Storage in the Facility, Storage of Medications, dated June1, 2018 revealed,.Schedule II, III, IV, and V controlled medications are stored separately from other medications in a locked drawer or compartment designated for that purpose.All medications dispensed by the pharmacy are stored in the container with the pharmacy label.The nurse will check the expiration date of each medication before administering it.No expired medications will be administered to a resident.1.

During an observation of the South Hall Medication Room on 9/3/2025 at 3:10 PM with Licensed Practical Nurse (LPN) 7 revealed the medication room refrigerator was unlocked and the narcotic lock box was inside the refrigerator and not affixed to the shelving.

The locked narcotic box revealed five vials of lorazepam (a medication used to treat anxiety and agitation-a scheduled IV (four) medication) was inside. In addition, the refrigerator shelves on the door and the floor of the refrigerator were noted with debris and a yellowish sticky substance. LPN7 confirmed that the locked box was not affixed, and the refrigerator was dirty.During an observation of the North Hall Medication Room on 9/3/2025 at 3:25 PM with LPN5 revealed the medication room refrigerator was unlocked and the narcotic lock box was locked but was not affixed to the shelf in the refrigerator.

The narcotic locked box contained 12 vials of lorazepam. LPN5 confirmed that the locked box inside the refrigerator was not affixed to the shelving.2.

Review/observation of the South Hall Short Medication Cart on 9/4/2025 at 8:19 AM with LPN 6, who administered medications from the Short Hall cart, revealed one Lantus (long-acting insulin) kwik pen without a name, date when opened, and/or expiration date on the pen.

The kwik pen showed a full vial was 260 units however, the vial showed 80 units. LPN 6 confirmed that the kwik pen did not have a resident's name on it and had been used but did not know which staff was using the unlabeled pen. LPN6 stated she did not know for certain which resident was receiving the insulin from the kwik pen but R17 was the only resident receiving Lantus from that medication cart.Review/observation of the South Hall Long Medication Cart on 9/4/2025 at 9:08 AM with LPN 8 revealed the following:1. A Tresiba insulin (long-acting insulin) kwik pen with an expiration date of 8/21/2025.2. A vial of Lantus insulin with an open date of 7/18/2025 and expiration date of 8/18/2025.3. A vial of Lispro insulin (short-acting insulin) which was not dated when opened or had an expiration date listed on the vial but had been used.4. A vial of Lispro insulin which was opened which had an open date of 7/30/2025 and an expiration date of 8/27/2025.5.

There was one vial of Lantus insulin and one vial of Lispro insulin that were unopened and unused, however, the label stated that it was to be refrigerated until opened.LPN 8 stated during the observation that the insulins were expired and should not have been used. LPN 8 further stated that insulin should be refrigerated until opened.

During an interview on 9/5/2025 at 9:35 AM, the Assistant Director of Nursing (ADON) stated that insulins should not be used after the expiration date and the medication room refrigerators were to be locked.

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Evergreen Health and Rehabilitation Center 139 Moran Lake Road, NE Rome, GA 30161

During an interview on 9/4/2025 at 10:30 AM, the Housekeeping Director (HKD1), when asked