Every finding on record at Baptist Health Hardin

The facility failed to implement its abuse/neglect policies for two of 11 records reviewed. This failure resulted in the potential for residents to be exposed to an individual with a history of abuse or misconduct.The findings include:Review of the facility's policy, Employment Policy (External and Internal), revised 09/05/2024 revealed, All new offers of employment will be contingent upon successfully completing a required background check and various employee health screenings.Review of the facility's policy, Identification and Reporting of Suspected Abuse/Neglect and Exploitation Situations, revised 05/08/2025 revealed, All potential employees are screened during pre-employment through a criminal background check and reference check. Additionally, all potential nursing personnel (RNs, LPNs, and certified nursing aides) are screened through the Kentucky Board of Nursing abuse registry for any history of abuse, neglect, or mistreating residents.Review of personnel files revealed the following: the facility hired Patient Care Assistant (PCA)1 on 12/30/2024 but documentation revealed the Kentucky Adult Caregiver Misconduct Registry completed on 01/06/2025, seven days after the hire date. Additionally, continued review revealed the facility hired PCA2 on 11/07/2022 but documentation revealed their Kentucky Adult Caregiver Misconduct Registry and OIG Exclusion List check was completed on 11/10/2022, three days after employment. Interview with Executive Director of Human Resources (EDHR) on 09/26/2025 at 9:10 AM revealed the process for vetting potential new employees included verification of any licensure and completion of background checks and drug screening. The EDHR stated all the facility checked all new hires against the Office of Inspector General exclusion database, National Sex Offender Registry, and the Kentucky Vulnerable Adult Mistreatment check. He reported no one was allowed to start work until results were received from the background checks. The EDHR reported the risks of not completing these background checks prior to a new employee starting work would be putting someone in access to patients who could cause harm to those patients. He stated, our number one risk is harm to the patients. We would not want to put residents in physical harm or cause them any harm in the way of someone who would steal medications or property from them.In an interview on 09/26/2025 at 4:35 PM, the Unit Manager of the Skilled Nursing Facility stated that Human Resources played a big role in verifying a person was physically safe to work here. She reported no new employees were permitted to begin work until all background checks were completed. In an interview on 09/26/2025 at 4:56 PM, the acting Director of Nursing stated that potential new employees absolutely should be vetted by Human Resources. She stated she felt that if a candidate made it to her, they were vetted by Human Resources. She stated new employees should absolutely not be allowed to being work before all background checks were completed because risk is high; you don't know people sometimes even when they have had a proper background check.In an interview on 09/26/2025 at 5:33 PM, the Administrator stated he expected potential new employees to be vetted prior to beginning employment in the facility by going through the Human Resources process and that, they [Human Resources] follow all of the required background checks before hire. He reported he was not aware of any new employees being permitted to begin work prior to all background checks being completed and that the risk of that happening was, risk of getting a criminal on your staff.

Based on interview, record review, and facility policy review, it was determined the facility did not provide the Ombudsman with resident discharge notifications, or hospital transfer notifications for two (2) of two (2) residents, Resident #9 and #10. Resident #9 was discharged to the community without ombudsman's notification, and Resident #10 was hospitalized without the ombudsman's notification. The findings include: Attempted review of the facility policy related to Transfers, Discharges, and Notifications to Residents, Representatives, and the Ombudsman, revealed the facility did not have a policy pertaining to notifications. Review of Resident #9's clinical record revealed the facility admitted the resident, on 04/01/19 with a [DIAGNOSES REDACTED]. However, the facility transferred the resident to the hospital for admission, on 04/12/19 with [DIAGNOSES REDACTED]. Review of Resident #10's clinical record revealed the facility admitted the resident, on 04/05/19 with a [DIAGNOSES REDACTED]. Continued review revealed the facility discharged Resident #10 to the community on 04/19/19. Interview with the Social Services Director, on 07/02/19 at 7:46 PM, revealed she did not provide written notification to the ombudsman, the resident's representative, or the resident regarding the reasons for transfer/discharge. She stated she did not provide any information related to the transfer, therefore, she had no reason to document the discharge in the medical record. She stated the facility did not have a policy related to the resident discharge that directed staff to provide notifcation to the resident, the resident's representative, or the ombudsman. Interview with Unit Manager, on 07/02/19 at 7:50 PM, revealed the facility did not have a policy related to notification of the Ombudsman of transfers and discharges of residents in the facility. She stated the notification responsibility would belonog to the social services staff. The Unit Manager stated notification was not provided to the Ombudsman. Interview with the Administrator, on 07/02/19 at 8:22 PM, revealed he also carried the role of the Medical Director for the facility. He stated he was not aware if the facility reported the discharges and transfers to the Ombudsman.

Based on observation, interview, personnel record review, and the facility policy review, it was determined the facility failed to complete reference checks for three (3) of three (3) newly hired staff, State Registered Nurse Aides (SRNA) #2, #3, and #4. The findings include: Review of the facility's policy, Identification and Reporting of Suspected Abuse/Neglect, and Exploitation Situations, review date 05/10/19, revealed the purpose identified potential victims of abuse or neglect and complied with state and federal regulations. Each resident had the right to be free from mistreatment, abuse, neglect, and exploitation. The facility planned for the screening and training of employees, the protection of residents, and for the prevention, identification, investigation, and reporting of mistreatment, abuse, neglect, and exploitation. All potential employees were screened during pre-employment through a criminal background check and a reference check. Review of SRNA #2's personnel file revealed her date of hire (DOH) was 05/06/19, and no reference check was documented as completed prior to SRNA #2 beginning employment. Review of SRNA #3's personnel file revealed her DOH was 05/20/19, and the facility did not provide evidence in the file or documentation of a completed reference check prior to hire. Review of SRNA #4's personnel file revealed her DOH was 03/25/19, and the facility did not provide evidence in the file or document a completed reference check. Interview with the Human Resource Manager (HRM), on 07/02/19 at 12:28 PM, revealed there were no reference checks on any of the staff. He stated there was a time period when the facility completed reference checks; however, the facility no longer completed the reference checks for the new hires. Continued interview with the HRM, and the Coordinator of Recruitment and Retention, on 07/02/19 at 3:47 PM, revealed the facility policy selection process was to verify current and past employment, and verify employer dates of services. The HRM stated there were some staff changes and the reference checks were not obtained on some of the new hires. Interview with the Unit Manager, and the Director of Nursing (DON), on 07/02/19 at 7:50 PM, revealed the nursing facility staff did not complete any of the hiring process for the new hires. They stated the Human Resource Department completed all components of the hiring process.

Based on observation, interview and facility policy review the facility failed to implement an effective infection control program with medication pass. Staff brought one (1) of two (2) medication carts into multiple resident rooms without sanitation in between residents. Staff were observed to handle medication with contaminated gloves while the medications were returned to a cup and re-administered the same medications to a resident and touched the medication when they handed the medication to the resident for consumption. In addition, staff failed to sanitize hands or don new gloves after they touched a multitude of surfaces and provided an injection a resident. The findings are: The facility did not provide a policy on infection control or medication administration in regards to medication carts at resident bed side. Review of the facility policy, Hand Hygiene (HH) revised (MONTH) 2019, revealed hand hygiene was the most effective pressure to prevent transmission of infection. Staff were to complete HH after staff touched contaminated devices, patients' environments or handled bodily substances. Observation, on [DATE] 08:53 AM of medication Pass with Registered Nurse (RN) #1 revealed the medication cart was brought into the a resident's room and stationed at the residents bedside. The resident was observed to have placed all the medication tablets onto the over the bed table and proceeded to count the tablets. The resident was observed to have swallow difficulty with a large tablet, regurgitated, and RN #1 was observed to have assisted with a held napkin under the resident's chin and manipulated the napkin with her gloved hands full of stomach matter. RN #1 was observed to have scooped up the resident pills into the medication cup with the same gloved hands used to assist to clean and wipe the resident's mouth, chin and manipulation of the cloth with stomach contents. The resident's medication were placed into the medication cart. RN #1 was observed after completion of assist with a clothing change of the resident to have wash hands, put clean gloves onto hands, and pulled the cup out of the drawer and physically removed the medications with her fingers from the cup one by one and gave them physically to the resident. The resident was observed to have self-administered the medications which were in the cup which were handled with contaminated gloves. RN #1 continued with the same gloved hands to proceed to inject a medication into the resident abdomen without washed or replaced the gloves to her hands. Continued observation of RN #1 with observation of medication pass, on [DATE] at 9:17 AM, revealed RN #1 completed the medication pass with the first resident and proceeded to the next residents' room and took the medication cart into the residents room and parked the cart besides the resident's bed. The cart was not sanitized before the RN entered the next room. Interview with RN #1, on [DATE] at 9:30 AM, revealed RN #1 stated she pulled the medication carts into the room with medication pass so she was able to pass resident medications timely. RN restated on, [DATE] at 9:51 AM, she normally brought the medication cart into each resident room. Continued observation of medication pass, on [DATE] at 9:30 AM, revealed RN #1 washed her hands and donned clean gloves. RN #1 was observed to have handled the computer mouse, typed in information on the keyboard, pulled the curtain, moved resident table, call bell and handled bedding. RN #1 continued and prepared an injection for the resident and continued with the same gloved hands to clean the resident's skin, pinch the resident's skin and complete the injection with the same gloves. RN #1 continued medication pass observation, on [DATE] at 10:04 AM, revealed RN #1 removed the cart from a resident's room and proceeded into the next resident's room and brought the medication cart to the bedside and parked the cart. The medication cart was not sanitized before she entered the room with the cart. After completion of the medication pass, RN #1 brought the medication cart to the nurses station and parked the cart to the wall and left the cart. RN #1 was not observed to sanitize to sanitize the cart after contact with multiple resident rooms with medication pass. Interview with RN #1, on [DATE] at 3:11 PM, revealed staff were to properly wash their hands and don gloves when medication pass was ongoing to prevent cross contamination. She stated staff were not to take medication carts into resident rooms who were under isolation, and she did not routinely take the cart into resident rooms after 12:00 PM. However, in the AM she stated residents required a lot of medications at one time and to save time she brought the carts into each resident room. RN #1 stated she did not wipe down the medication carts after leaving each room because each resident were given single dose medication packets. In addition, she stated Certified Nursing Assistants (CNA) were to wipe the vital sign machine after every use and room. She continued and stated she touched a resident's medication with her gloved hands after she scooped up the medication previously with dirty gloves. She stated it was not typical for her to handle medications but the resident was very difficult at the time. RN #1 further stated she should not have handled the medication and was to pass medications to the resident with a spoon. She stated this was to prevent transfer of germs to the resident. RN #1 stated staff were to follow infection control practice to prevent the spread of germs at all times. She further stated she completed education for infection control, hand hygiene and medication pass for the facility; however, she used poor practices with hand hygiene, when she touched the medications. She stated poor infection control practices would cause residents to become ill. Interview with the Unit Manager (UM), on [DATE] at 11: 56 AM, revealed staff were to use a hand foam when entering or leaving resident rooms during medication pass. She stated staff were to wear gloves if medication was to be handled. She stated medication carts were not to be brought into resident rooms that was in isolation. However, it was common practice for staff to have medication carts into resident rooms and work from the bedside. However, she stated the aides were required to wipe down the vital machine cart so she thought this would be the same practice with medication carts to prevent cross contamination from one room to another. She further stated staff were not to touch multiple surfaces with medication pass. The UM stated the medications were to be readied , then hands re-cleaned and gloves donned to complete the medication pass or injection to prevent issues. The UM stated all staff were to maintain proper hand hygiene and use good infection control practices. She stated this was to prevent infections; and residents could become ill if not followed. Interview with the Director of Nursing, on [DATE] at 11:56 AM, revealed she was unsure if medication carts were brought into resident rooms. She stated the unit had not identified infection control issues with medication pass. She further stated she did not audit staff's medication pass techniques. She further stated staff were not to handle medications at any time and were to ensure hand hygiene practices were followed at all times to prevent infection. Furthermore, the Director stated the facility did not have a policy on carts at the bedside and infection control practices. Interview with the Unit Based Educator, [DATE] at 12:49 PM, revealed medications which were not prescribed to a resident were not to enter another resident's room. She stated medications were not to be handled by the staff; and if they were handled the medications were to be disposed and the nurse was to restart, because it was an infection control issue. She stated she did not conduct audits or observe medication pass for the unit or facility. She further stated all staff had monthly in-service books to review and they were to review the material printed and sign to signify the material was read and understood. However, an audit of staff's knowledge was not completed routinely or randomly. Interview with the Chief Medical Officer/Administrator, on [DATE] at 8:22 PM, revealed the facility did not identify issues or concerns related to infection control practices. He stated the Quality Assurance meeting routinely discussed infection control and no identified issues were brought to the meeting. He stated as Administrator he did not have an issue with medication carts being brought into resident rooms unless the resident was in isolation. He stated all residents came from an acute unit in the hospital so the unit knew what the resident had so this was not an issue in regard to infection control. He further stated infection control with medication pass was not a focus of his; however, the facility practiced infection control techniques as a whole and was committed to be a shepherd of good practice. He stated once a month staff were sent out for shopper audits where management observe ten (10) opportunities to foam in and foam out and if it was observed a reward was given. He stated with medication pass staff were to do the best they could and perfection was not obtainable.

Based on observation, interview and facility policy review it was determined the facility failed to ensure one (1) of one (1) medication refrigerators was secured and one (1) of two (2) medication carts was secured and supervised. Observations revealed the medication refrigerator key hung from the outer door lock and the refrigerator contained ten (10) vials of injectable [MEDICATION NAME] (Tetrahydrocannabinol (THC) a man-made form of the active substance in marijuana) in a locked inner box. Interview with staff revealed the key was left in the door of the medication refrigerator at all times and numerous staff were able to access the medication room. In addition, staff left a medication cart unlocked and unsupervised in a resident's room at the resident's bedside. The findings include: Review of facility policy, Storage of Medications, reviewed 04/23/18, revealed staff ensured medications were secure at all times. The facility policy defined secured as a locked area, room or cabinet where access was restricted to authorized personnel and under constant visual surveillance and control. Review of Resident #60's clinical record revealed the facility admitted the resident on 07/01/19 with [DIAGNOSES REDACTED]. Review of Resident #61's clinical record revealed the facility admitted the resident on 06/25/19 with [DIAGNOSES REDACTED]. Observation, on 06/02/19 at 9:32 AM, revealed Registered Nurse (RN) #1 brought a medication cart into the room of Resident #60 and Resident #61. The RN then left the room with the medication cart in the residents' room unsupervised, and unlocked wth a drawer opened and medications visible. RN #1 returned to the room at 9:36 AM and shut the drawer while she stood at the medication cart. Interview with RN #1, on 07/02/19 at 9: 40 AM, revealed she left the medication cart in the residents' room unattended by staff when she left to obtain a pill splitter. She stated staff were not to leave medication carts in a resident's room whether locked or unlocked. RN #1 stated staff were to supervise medication carts at all times and the medication cart was not supervised when she left the room. She further stated in a perfect world staff would never leave medication carts unlocked. She further stated residents were at risk for safety issues because the medications were accessible while she was out of the room. She stated she was to ensure medications were safe, secure and her responsibility at all times was to ensure residents were safe. Observation, on 07/01/19 at 4:02 PM, revealed RN #3 walked up to the medication room refrigerator and was observed to open the door with a key protruding from the lock. RN #3 identified the key as the key to the unit refrigerator. RN #3 counted ten (10) vials of injectable [MEDICATION NAME] in the locked compartment in the refrigerator. Interview with RN #3, on 07/01/19 at 4:02 PM, revealed the facility kept the key to the refrigerator in the door and was in the door the entire time the refrigerator was in the medication room. She stated the door to the room and inner lock was considered the double lock for scheduled medications. However, she stated numerous staff were able to access the room. Interview with the Unit Secretary, on 07/01/19 at 4:17 PM, revealed she was able to access the medication room at any time. She further stated the facility kept the key in the refrigerator door for the many years she worked at the facility and staff were not instructed to do otherwise. Interview with the Hospital Based Pharmacy Tech, on 07/01/19 at 4:17 PM, revealed the facility considered the door to the medication room one lock and the medication compartment in the refrigerator as the second lock therefore the door to the refrigerator did not need to be locked. He further stated if the door to the refrigerator was locked it would be a triple lock. Further observation, on 07/01/19 at 4:17 PM, revealed Certified Nursing Assistant (CNA) #1 entered the medication room after she accessed the door. The CNA obtained a product for resident care and left the room. Interview with CNA #1, on 07/01/19 at 4:17 PM, revealed the CNA was able to access the door to the medication room at any time. She stated the supplies for the resident were held in the medication room and most staff had access to the room for resident care needs. Continued interview with RN #3, on 07/01/19 at 4:30 PM, revealed when she opened the refrigerator in the medication room the key hung from the lock. She stated the medication refrigerator was unlocked so therefore the mediations in the secured inner compartment were not double locked. She stated the facility was responsible to ensure schedule medications were double locked to prevent diversion. She stated the facility educated staff on proper medication securement and double locks for schedule medications. Interview with the Facility Unit Based Educator, on 07/02/19 at 12:49 PM, revealed staff were educated on proper medication safety, supervision and securement. She stated staff were to keep medication carts locked and supervised at all times unless stored at the nurses station. However, the facility did not teach staff not to take medication carts into the resident room. She further stated staff put resident's safety at risk when medication carts were unlocked and left unsupervised in resident's room. She further stated as the Unit Based Educator she did not audit the facility for medication pass or medication safety. Interview with the Unit Manager, on 07/02/19 at 12:14 PM, revealed medication carts were not to be left in resident rooms when the nurse was not in the room. She stated the staff was to supervise the cart at all times to ensure the residents were safe, and this included locking the cart when they were not in eyesight. However, she stated staff commonly took medication carts into resident rooms with medication pass. She stated staff were educated by the unit educator on medication safety as well as yearly in the education program. She further stated she did not identify issues with unsupervised or unlocked carts. She continued and stated the facility counted the medication room door as the first lock which was why the key was left in the refrigerator side. She stated staff were to ensure the double lock system was present at all times in regard to scheduled medications. She stated the facility recognized the issue of the key left in the door at all times with the survey Interview with the Director of Nursing, on 07/02/19 at 12:14 PM, revealed carts were to be locked and supervised at all times. She stated she did not audit medication pass. She further stated the Unit Manager did not identify issues to her with unsupervised or unlocked medication carts. She stated the facility expected nurses to keep medications and residents safe. Interview with the Administrator, 07/02/19 at 8:33 PM, revealed as Administrator he did not have an issue with medication carts being brought into resident rooms. He stated facility placed two locks to the refrigerator scheduled medication area with the door as one lock and the compartment as the second. He further stated he was unaware of what items were held in the medication room and who would need access to the room. He further stated the facility knew changes were required after the survey process identified the medication refrigerator was unlocked.

Based on interview and facility policy it was determined the facility failed to reconcile controlled medications for one (1) of one (1) Automated Dispensing Cabinet (ADC) to ensure all controlled medications were accounted for as per facility policy. The findings include: Review of facility policy, Management of Controlled Substances and Medications at High Risk of Diversion, revised 09/08/18, revealed an ADC unit inventory count was to be conducted weekly by the Unit Manager and a witness. Observation, on 07/01/19 at 11:00 AM, revealed the facility utilized an ADC to store scheduled medications to be administered to residents. Registered Nurse #1 was observed removing a scheduled medication for a resident with no other staff to witness if the count of medication was correct. Interview with Registered Nurse (RN) #1, on 7/02/19 at 9:49 AM, revealed staff did not count controlled medications in the ADC. She stated the unit was told what the count was in the ADC unit. She stated the nurses counted the medications in the cart and placed the count into the ADC system when the unit requested a count. She stated the ADC unit received the information from all the nurses. She stated the facility did not routinely count the schedule medications because pharmacy staff counted monthly or when they came to refill stock, and a witness was not required with the removal of a schedule medication to ensure the count was correct upon access into the drawer. Interview with the Pharmacy Tech, on 7/02/19 at 4:17 PM, revealed Pharmacy staff counted the controlled medication drawer in the ADC unit monthly and when new stock was added. He stated only the drawer to which the added stock was counted at that time and not all the drawers that contained controlled medications. Interview with the Unit Manager (UM), on 07/02/19 at 12:22 PM, revealed scheduled medications were reconciled monthly. She stated the ADC unit ensured the scheduled medication count was correct at all times. She stated staff signed into the computer, the ADC unit asked what the count was for the scheduled medication and the input into the computer was provided by staff. She stated two staff were not required to be present for removal of a scheduled medication and the ADC unit relied on what the staff input was to the unit. She stated staff were not required to count between shifts. She further stated she completed scheduled reconciliation monthly on the ADC unit. She stated the facility relied on the honesty of the staff. The UM stated the reason for scheduled medication reconciliation was to ensure the count was correct and identify diversion quickly. Interview with the Director of Nursing, on 07/02/19 at 11:56 AM, revealed the UM counted the scheduled medications once a month. However, she stated the facility may change this to a weekly schedule. She stated the ADC unit relied on staff for the input of the count of scheduled medications each time the drawer's were accessed. She stated medication reconciliation was to ensure diversion was identified quickly. She further stated the facility relied on the nurses for accurate input. Interview with the Administrator, on 07/02/19 at 8:22 PM, revealed the pharmacy in the facility was to complete scheduled medication reconciliation. However, he claimed ignorance to the process, requirements and further stated he probably should.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to serve food under sanitary conditions. Housekeeping staff were observed cleaning on two (2) of two (2) hallways during meal service, including delivery and set-up. The findings include: Review of the contracted Environmental Agency's New Hire Training Associate Record, dated August, 2012, revealed Housekeeping Staff were not trained to discontinue cleaning during mealtimes. Review of the contracted Environmental Agency's Residential Room Cleaning Procedure, dated 10/01/16, revealed no directive concerning guidelines related to mealtime. Review of the facility's Nursing Facility Patient Tray policy, updated 09/18/17, revealed the procedures for assembling, passing and retrieving resident food trays. The policy did not address housekeeping during mealtimes. Review of the facility's Material Safety Data Sheet (MSDS), dated 09/15/15, revealed Stride Floral Neutral Cleaner (mop solution) was classified as a Category 2A hazard and if ingested could cause irritation to mouth, throat and stomach. Other symptoms included stomach pain and nausea. Observation, on 06/12/18 at 12:00 PM, revealed Housekeeper #2 using a stand-up motorized floor scrubber on Hallways A and B. He maneuvered the floor scrubber around the Catering Associates as they delivered trays. Observation, on 06/12/18 at 12:05 PM, revealed Catering Associate #1 walked around a housekeeping cart in room [ROOM NUMBER], on Hallway B, and delivered a lunch tray. Further observation revealed Housekeeper #1 mopped room [ROOM NUMBER] while Patient Care Associate (PCA) #1 situated the lunch tray for Resident #116. Observation, on 06/12/18 at 12:08 PM, revealed Housekeeper #2 maneuvered the motorized stand-up floor scrubber around the open lunch tray cart on Hallway A. Observation, on 06/12/18 at 12:09 PM, revealed PCA #2 interrupted Housekeeper #2 telling him, you can't clean while patients are eating. Interview with Housekeeper #1, on 06/12/18 at 12:13 PM, revealed she was called by the unit to mop the floor in room [ROOM NUMBER]. Housekeeper #1 stated the cleaning chemicals, dust and dust mites could end up in resident food when she cleaned an area during meal times, which could potentially hurt residents. Interview, on 06/12/18 at 12:16 PM, with Housekeeper #2 revealed he always scrubbed the floors of halls A and B during mealtimes and did not see a problem. Interview with PCA #2, on 06/13/18 at 1:33 PM, revealed she asked Housekeeper #2, to stop using the motorized floor scrubber around the open food cart. She stated chemicals, dust and trash could contaminate the resident's food and make them sicker. She further stated a previous employer educated her regarding this matter. Interview, on 06/13/18 at 10:40 AM, with the Director of Environmental Services revealed he worked for the facility on a contractual basis. He stated the Housekeepers received training when hired and annually regarding infection control and cleaning chemical usage. Housekeepers were instructed to follow a cleaning schedule and to discontinue cleaning only if a patient complained. Interview, on 06/13/18 at 3:05 PM, with the Nurse Manager revealed she supervised the care of the patients in the absence of the Director of Nursing. She stated she was not educated regarding discontinuing housekeeping services during meal times. However, she stated cleaning during meals could release chemical smells which could be bothersome to residents. She further stated dust could contaminate the food and if chemicals got in the food that could cause harm to the patient. Interview with the Chief Medical Officer, on 06/13/18 at 3:33 PM, revealed he was unaware of regulations regarding the performance of housekeeping duties during meal service but stated doing so potentially led to cross contamination and harm to residents.

Based on observation, interview, and record review, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Observation revealed staff failed to change gloves and wash their hands after touching potentially contaminated objects/items and returning to the food service line to prepare meal trays for residents. The facility also failed to ensure the solution used to clean food preparation countertop surfaces contained the required amount of sanitizing agent. The findings include: 1. A review of the facility's policy regarding sanitizing solution for contact surfaces revealed the facility's sanitizing agent should reach two to four hundred (200-400) parts per million (ppm) to ensure surfaces were sanitized. A review of the Food Establishment Inspection Report conducted by the Health Department, dated 02/06/16, revealed the facility was cited because the facility failed to use sanitizer in water used to clean contact surfaces. Observations on 05/02/17 at 9:25 AM revealed solution used to wipe countertop surfaces where raw meats and vegetables were prepared was less than two hundred (200) ppm. Staff tested the sanitation solution source four (4) additional times and the solution was less than two hundred (200) ppm each time. On 05/02/17 at 9:35 PM an interview with the cook in the Midline Area revealed meats and vegetables were prepared in that area. He stated he had changed the solution used to clean the area earlier that morning but did not test the solution to ensure there was enough sanitizing agent in the solution. An interview on 05/02/17 at 3:41 PM with the Chef revealed a diluted sanitation solution in any area of the kitchen could lead to a spread of infection and cross-contamination. 2. A review of the facility's policy titled Sanitation and Infection Prevention/Control; Hand Hygiene, dated January 2016, revealed all associates were required to wash their hands before, during, and after food preparation. In addition, the policy stated hands were required to be washed after contact with potentially contaminated areas. Observation of preparation of food trays for residents on 05/02/17 at 3:39 PM, revealed a Food/Nutrition Team Leader was serving food for residents from the steam table. The team leader left the steam table, moved a serving cart, and touched the kitchen door of the kitchen to call for additional needed items. The team leader returned to the steam table and continued to serve food with the same gloved hands. The team leader did not wash her hands or change her gloves after touching the potentially contaminated surfaces. On 05/02/17 at 12:12 PM an interview with the Food/Nutrition Team Leader revealed she should have never left the food service line and returned without washing her hands. She stated this could cause cross-contamination. An interview with the Food/Nutrition Manager on 05/03/17 at 2:35 PM revealed she expected residents' food to be prepared, distributed, and served under sanitary conditions.

Based on observation, interview, and review of the facility's policy for infection control, it was determined the facility failed to have effective transmission-based precautions to prevent the possible spread of infections for two (2) of seven (7) sampled residents (Residents #2 and #4) and two (2) unsampled residents (Residents B and C). Observations on 05/02/17 revealed staff failed to clean/disinfect the blood glucose (blood sugar) monitor after each use while checking Resident #2, Resident #4, and Resident C's blood glucose. In addition, staff dropped a package containing an aspirin tablet on the floor during medication administration for Resident B, and then attempted to administer the medication to the resident. The findings include: 1. A review of the facility's policy titled Blood Glucose Monitoring/Quality Control, with a revision date of 02/16/17, revealed the blood glucose meter must be cleaned/disinfected after each patient use utilizing Clorox Healthcare Germicidal Bleach wipes. According to the policy, the meter should remain wet for one (1) minute while using the wipes, and then allow for one (1) minute of drying time for the meter. Observations of blood glucose monitoring conducted by Registered Nurse (RN) #1 on 05/02/17 at 11:50 AM revealed the nurse retrieved the blood glucose meter from a charging station and conducted blood glucose testing for Resident #2. RN #1 did not clean/disinfect the meter and proceeded to Resident C's room and checked the resident's blood glucose without cleaning/disinfecting the meter prior to the test. After completing the testing for Resident C, RN #1 proceeded to conduct blood glucose testing on Resident #4 without cleaning/disinfecting the meter. After completing testing for Resident #4, RN #1 returned the meter to the charging station at the nurses' station and did not clean/disinfect the meter. Interview with RN #1 on 05/02/17 at 12:00 PM revealed the RN was aware the blood glucose meter was required to be cleaned/disinfected after each patient use, but she forgot to clean/disinfect the meter as required when conducting blood glucose testing for Resident #2, Resident #4, and Resident C. An interview with the Unit Manager on 05/02/17 at 3:05 PM revealed the blood glucose meter was required to be cleaned/disinfected after each resident use. The Unit Manager stated the facility checked all employees' competency related to blood glucose meter cleaning/disinfecting when hired and annually. The Unit Manager also stated she monitored staff performance daily by observing resident care and had not identified any concerns with RN #1 failing to clean/disinfect the blood glucose meter. 2. An interview with the Facility Director of Inpatient Services on 05/03/17 at 9:20 AM revealed the facility did not have a policy for the use of items/medications that were dropped on the floor. The Director of Inpatient Services stated it was facility practice to discard medications or medication packages that had been dropped on the floor and not to administer the medication to a resident. Observations of medication administration conducted on 05/03/17 at 8:20 AM revealed Licensed Practical Nurse (LPN) #1 dropped a medication package containing an aspirin tablet on the floor while preparing medications for Resident B. LPN #1 retrieved the package from the floor with a gloved hand and asked RN #2 what she should do with the medication. RN #2 told LPN #1 that since the package had not been opened, LPN #1 could administer the medication to Resident B. Additional observation revealed LPN #1 opened the package and dropped the medication into a cup without changing her gloves, washing/sanitizing her hands, or cleaning/sanitizing the pill package and was going to administer the medication to the resident. Interview with LPN #1 conducted on 05/03/17 at 8:30 AM revealed she did not know if the medication could be administered and asked RN #2 for guidance. Interview on 05/03/17 at 8:35 AM with RN #2 revealed the RN thought the medication could be utilized if the medication had not been opened.

Based on interview, review of employee files, and review of the facility's abuse/neglect policy, it was determined the facility failed to conduct pre-employment reference checks for five (5) of five (5) sampled newly hired employees as required by the facility's policy. The findings include: A review of the facility's policy titled Identification and Reporting of Suspected Abuse/Neglect and Exploitation Situations, with a revision date of 01/04/17, revealed a reference check was required for all potential employees during pre-employment to screen for potential abuse. A review of employee personnel files for five (5) employees, Registered Nurse (RN) #1, RN #3, and State Registered Nurse Aides (SRNAs) #1, #2 and #3 who were hired from 01/30/17 to 04/10/17 revealed no evidence the facility had conducted reference checks for these employees prior to the employees being hired. An interview with the Human Resources (HR) Representative on 05/03/17 at 10:20 AM, who was responsible for conducting the required screenings of potential new hires revealed that criminal record, nurse aide abuse registry, adult misconduct registry, and licensure checks were completed on potential new hires. However, the HR Representative stated she stopped checking previous employment references three years ago because previous employers gave no information regarding the employee. The HR Representative stated she was not aware reference checks were required to be completed. An interview with the Director of Medical Inpatient Services on 05/03/17 at 10:20 AM revealed the facility HR Department handled all pre-employment screenings for new employees and the Director was not aware the HR Department was not following the facility's policy regarding screening employees.

Based on interview, review of the facility's policy, and review of the facility's investigations, it was determined the facility failed to report two (2) allegations of abuse to the appropriate state agency, Office of Inspector General (OIG). Unsampled Resident A alleged a physician at the facility spoke to him/her in abusive way. In addition, Unsampled Resident B's family member alleged a Patient Care Assistant (PCA) handled Unsampled Resident B's legs roughly during a transfer to the bed. Both allegations were investigated by the facility but not reported to OIG. The findings include: Review of the facility's policy titled, Identification and Reporting of Suspected Abuse/Neglect & Exploitation Situations, revised 04/01/16, revealed the facility shall report both alleged violations and the results of investigations in accordance with State Law. The policy also referenced Kentucky Regulatory Statute (KRS) 209.030 for the reporting requirements for suspected abuse, neglect, or exploitation of residents. The policy's contents revealed any person, including but not limited to a physician, nurse, social worker, or care taker, having reasonable cause to suspect a resident had suffered abuse, neglect, or exploitation, shall report or cause reports to be made. An oral or written report shall be made immediately to the Department of Protection and Permanency, OIG, and the local/state Ombudsman upon identification of suspected abuse, neglect, or exploitation of a resident. Further review of the facility's policy revealed, in addition to KRS 209.020, the State Operations Manual Appendix PP--Guidance to Surveyors for Long Term Care Facilities, F224, F225, and F226, was referenced in development of the policy. Review of the facility's clinical record for Unsampled Resident A, revealed the facility admitted the resident on 07/19/16 with [DIAGNOSES REDACTED]. Review of facility's report of an alleged incident of verbal abuse, dated 07/21/16, revealed Unsampled Resident A told a licensed nurse that on the evening of 07/21/16, one of the facility's physicians had been verbally abusive when speaking to him/her. The licensed nurse reported Unsampled Resident A's allegation to the Unit Manager, who in turn reported the allegation to the Director of In-Patient Services. The Chief Medical Officer (CMO) for the Nursing Facility was involved in the interviews conducted with the perpetrator (physician) and the physician was suspended from duty. The facility's Director of Quality Management conducted the investigation and the allegation was substantiated. Unsampled Resident A's care was immediately assigned to another physician and corrective action was taken against the perpetrator by the Medical Executive Committee, which included suspension of the physician and implementation of a Corrective Action Agreement, dated 08/09/16, signed by the physician, the hospital's Chief Medical Officer, and the hospital's Chief Executive Officer. Review of the completed investigation did not reveal documentation that the allegation of verbal abuse toward Unsampled Resident A was reported to OIG or to the patient advocate (Ombudsman) assigned to represent the facility's residents. Interview, on 09/01/16 at 12:25 PM, with the Director of Quality (DQ), revealed he completed the investigation related to Unsampled Resident A and the alleged verbal abuse by a physician, and the allegation was substantiated. The DQ stated the incident was reported to Adult Protective Services (APS) via the State Department of Social Services and this report was made by the Hospital's Department of Risk Management, which was responsible for ensuring incident reporting occurred, but the incident was not reported to OIG. He stated he thought there needed to be more clarification about the formal reporting process so the appropriate agencies were notified of allegations of abuse. The DQ stated he had access to the federal regulations related to protecting residents from abuse and was aware such incidents were to be reported to the state agency (OIG) within five (5) working days of the incident. The DQ stated he thought the abuse allegation was reported to the Ombudsman that represented residents at the facility, but he would have to do more research to discover when the Ombudsman was notified of the allegation of abuse associated with Unsampled Resident A. Review of the facility's clinical record for Unsampled Resident B, revealed the facility admitted the resident on 08/04/16 with [DIAGNOSES REDACTED]. Review of the facility's investigation of the alleged incident of rough handling of Unsampled Resident B's legs during a transfer to his/her bed, by a PCA, revealed the allegation was unsubstantiated. However, further review of the investigation revealed the facility did not report the incident to OIG or to the patient advocate (Ombudsman) assigned to represent the facility's residents. Interview, on 09/01/16 at 12:31 PM, with Director of In-Patient Services, revealed she conducted the investigation related to the allegation, made by the family member of Unsampled Resident B, that a PCA handled the resident's legs roughly when the PCA transferred the resident into bed. The Director of In-Patient Services stated the allegation was unsubstantiated and was reported to the Unit Nurse Manager, the Chief Medical Officer for the Skilled Nursing Unit, and to APS. The Director of In-Patient Services stated the facility's policy for abuse prevention required staff to report allegations of abuse to OIG within five (5) working days of the incident, but she did not report the incident that involved Unsampled Resident B to OIG. The Director of In-Patient Services stated she had access to the federal regulations and was aware the federal regulation for abuse prevention required the facility to report allegations of abuse to the appropriate state agencies. Interview, on 09/01/16 at 1:26 PM, with the facility's Chief Medical Officer (CMO) revealed staff informed him of the allegations of abuse involving Unsampled Resident A and Unsampled Resident B. The CMO stated he was involved in the interviews and the corrective action process related to the physician's alleged verbally abusive comments made to Unsampled Resident A. The CMO stated in both cases, Unsampled Residents A and B were protected from contact with the perpetrators during the investigations. However, the CMO stated the facility messed up because the incidents were not reported to OIG. The CMO stated the Hospital's Department of Risk Management, which also managed reporting for the Acute Care Units of the Hospital, the Nursing Facility, and Outpatient Care Services, was to ensure all components of the Nursing Facility's Abuse Prevention Policy were followed. However, the CMO stated since he was in charge of the Nursing Facility, he was ultimately responsible for ensuring the facility's policies were followed. The CMO stated he thought the breakdown in the required reporting process occurred because he, and perhaps other staff members, were under the impression that when one state agency, such as APS, was notified then all necessary reporting had occurred. The CMO stated the only explanation he could offer for the failure to report to OIG was the staff members' general lack of knowledge of the reporting process.

Based on interview, review of the facility's policy, and review of the facility's investigations, it was determined the facility failed to follow the components for required formal reporting as outlined in the abuse prevention policy. Two (2) allegations of abuse were not reported to the appropriate state agency, Office of Inspector General (OIG). Unsampled Resident A alleged a physician at the facility spoke to him/her in abusive way. In addition, Unsampled Resident B's family member alleged a Patient Care Assistant (PCA) handled Unsampled Resident B's legs roughly during a transfer to a bed. The facility completed investigations for the allegations, but the allegations and findings were not reported to OIG. The findings include: Review of the facility policy titled, Identification and Reporting of Suspected Abuse/Neglect & Exploitation Situations, revised 04/01/16, revealed the facility shall report both alleged violations and the results of investigations in accordance with State Law. The policy also referenced Kentucky Regulatory Statute (KRS) 209.030 for the reporting requirements for suspected abuse, neglect, or exploitation of residents. The policy's contents also revealed any person, including but not limited to a physician, nurse, social worker, or care taker, having reasonable cause to suspect a resident had suffered abuse, neglect, or exploitation, shall report or cause reports to be made. An oral or written report shall be made immediately to the Department of Protection and Permanency, OIG, and the local/state Ombudsman upon identification of suspected abuse, neglect, or exploitation of a resident. In addition, the results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State Law (including the state survey and certification agency) within five (5) working days of the incident. Further review of the facility's policy revealed, in addition to KRS 209.020, the State Operations Manual Appendix PP--Guidance to Surveyors for Long Term Care Facilities, F224, F225, and F226, was referenced in development of the policy. Review of the facility's clinical record for Unsampled Resident A, revealed the facility admitted the resident on 07/19/16 with [DIAGNOSES REDACTED]. Review of facility's report of an alleged incident of verbal abuse, dated 07/21/16, revealed Unsampled Resident A reported to a facility's licensed nurse that on the evening of 07/21/16, one of the facility's physicians had been verbally abusive when speaking to the resident. The licensed nurse reported Unsampled Resident A's allegation to the Unit Manager, who in turn reported the allegation to the Director of In-Patient Services. The Chief Medical Officer (CMO) for the Nursing Facility was involved in the interviews conducted with the perpetrator (physician) and the physician was suspended from duty. The facility's Director of Quality Management conducted the investigation and the allegation was substantiated. Unsampled Resident A's care was immediately assigned to another physician and corrective action was taken against the perpetrator by the Medical Executive Committee, which included suspension of the physician and implementation of a Corrective Action Agreement, dated 08/09/16, signed by the physician, the hospital's Chief Medical Officer, and the hospital's Chief Executive Officer. Review of the completed investigation did not reveal documentation that the allegation of verbal abuse toward Unsampled Resident A was reported to OIG or to the patient advocate (Ombudsman) assigned to represent the facility's residents. Interview, on 09/01/16 at 12:25 PM, with the facility's Director of Quality (DQ) revealed he completed the investigation related to Unsampled Resident A and the alleged verbal abuse by a physician, and the allegation was substantiated. The DQ stated the incident was reported Adult Protective Services (APS) via the State Department of Social Services (DSS) and this report was made by the Hospital's Department of Risk Management, which was responsible for ensuring incident reporting occurred, but the incident was not reported to OIG. He stated he thought there needed to be more clarification about the formal reporting process so the appropriate agencies would be notified of abuse allegations. The DQ stated he had access to the federal regulations related to protecting residents from abuse and was aware the allegations were to be reported to OIG within five (5) working days of the incident. The DQ stated he thought both allegations of abuse (referring to the separate allegations related to Residents A and B) were also reported to the Ombudsman that represented residents at the facility, but that he would have to do more research to discover when the Ombudsman was notified. Review of the facility's clinical record for Unsampled Resident B, revealed the facility admitted the resident on 08/04/16 with [DIAGNOSES REDACTED]. Review of the facility's investigation of the alleged incident of rough handling of Unsampled Resident B's legs during a transfer to his/her bed, by a PCA, revealed the allegation was unsubstantiated. However, further review of the investigation revealed the facility did not report the incident to OIG or to the patient advocate (Ombudsman) assigned to represent the facility's residents. Interview, on 09/01/16 at 12:31 PM, with Director of In-Patient Services revealed she conducted the investigation related to the allegation, made by the family member of Unsampled Resident B, that the resident's legs were handled roughly when a PCA transferred the resident into bed. The Director of In-Patient Services stated the allegation was reported to the Unit Nurse Manager, the Chief Medical Officer (CMO) for the Skilled Nursing Unit, and to APS. She said the allegation was unsubstantiated. The Director of In-Patient Services stated the facility's policy for abuse prevention required staff to report incidents of alleged abuse to OIG within five (5) working days of the incident, but she did not report the incident that involved Unsampled Resident B to OIG. She stated since OIG was not notified, the facility did not follow its abuse prevention policy. The Director of In-Patient Services stated that all staff responsible for reporting allegations of abuse should receive clarification on who was responsible for the formal reporting of allegations of abuse. The Director of In-Patient Services stated she had access to the federal regulations and was aware the federal regulation required the facility to report allegations of abuse to the appropriate state agencies. Interview, on 09/01/16 at 1:26 PM, with the facility's Chief Medical Officer (CMO) revealed staff informed him of the allegations of abuse involving Unsampled Resident A and Unsampled Resident B. The CMO stated he was involved in the interviews and the corrective action process related to the physician's alleged verbally abusive comments toward Unsampled Resident A. The CMO stated in both cases, the residents were protected from further contact with the perpetrators during the investigations. However, the CMO stated the facility messed up because the incidents were not reported to OIG, therefore the facility did not follow the reporting component of its policy. The CMO stated the Hospital's Department of Risk Management, which also managed reporting for the Acute Care Units of the Hospital, the Nursing Facility, and Outpatient Care Services, was to ensure all components of the Nursing Facility's Abuse Prevention Policy were followed. However, since he was in charge of the Nursing Facility Unit within the hospital, he was ultimately responsible for ensuring the Long Term Care policies/procedures were followed. The CMO stated he thought the breakdown in the required reporting process occurred because he, and perhaps other staff, were under the impression that when one state agency, such as APS, was notified then all necessary reporting had occurred. The CMO stated the only explanation he could offer for the failure to report to OIG was the staff members' general lack of knowledge of the reporting process.

Based on observation, interview and policy review, it was determined the facility failed to store food in a sanitary manner with opened food items not dated in the freezer (four (4) bags), raw meat opened and not labeled, dessert trays in the refrigerator with no date, sugar and flour bins-tops dirty and not dated when food product was placed in the bins. The findings include: Review of the Infection Control Policy (as it related to the dating system of food items), revised February 2012, revealed left overs would be disposed of within seven (7) days. The staff may write date prepared on aluminum foil or use special stickers that say Made Tues, Use by Mon (date of use to be written in). 1. Observation of the Early Cook Freezer door, on 11/12/15 at 8:30 AM, revealed there was a sign on the outside of the door that asked are all opened foods covered and dated? Observations made during the Kitchen Tour, on 11/12/15 at 8:30 AM, revealed the Early Cook Freezer had two (2) bags of corn opened, not dated, one (1) bag of peas open and not dated, one (1) bag of mixed vegetables opened and not dated. 2. Observation of the self rising flour bin, sugar bin and plain flour bin, on 11/12/15 at 8:32 AM, revealed all three (3) bins had a yellow and white film on the lid and rim of the bin. There was no date or label for how long the product had been in the bin. 3. Observation of the dessert and salad refrigerator, on 11/12/15 at 8:35 AM, revealed a large cart, ten (10) shelves long, with different desserts and salads covered with no label or date. 4. Observation of the walk in refrigerator, on 11/12/15 at 8:40 AM, revealed raw (bloody) pork tenderloin opened with no label or date. No food was under the meat. 5. Observation of the Dry Storage Area, on 11/12/15 at 8:44 AM, revealed six (6) bins holding items such as northern beans, pinto beans, macaroni noodles, and other types of noodles, rice and brown rice, not labeled or dated to show how long the product had been in the bins. Interview with the Food Specialist, on 11/13/15 at 12:41 PM, revealed food was to be dated when opened. She stated the food items needed to be labeled so that the staff would know when to use the food and not cause any food bourne illness. Interview with the Cook, on 11/13/15 at 12:35 PM, revealed when food was opened it needed to be labeled and dated. The Cook stated the food needed to be labeled and dated to ensure the food was being used by the right time frame. The Cook stated the meat should have been placed in a separate pan, labeled and dated. The opened meat could contaminate other food if placed under the meat. Interview with the Supply Tech, on 11/13/15 at 12:50 PM, revealed he stored the beans, pinto beans, noodles etc and no one had informed him to label and date the bins. He stated the supply of beans and noodles would be consumed between a month and six (6) months. The Supply Tech stated he had not received any training on storage and labeling since he had been working at the facility. Interview with the Supervisor of Food and Nutrition, on 11/13/15 at 12:30 PM, revealed the facility had seven days to utilize a food product when it was opened. The Supervisor of Food and Nutrition stated he could not guarantee the food if not dated because he would not know how long it had been opened. The Supervisor of Food and Nutrition stated meat should not be stored opened. The meat should have been taken out, washed, placed into a pan, wrapped and dated. He stated he was trying to prevent any food bourne illness. He stated the residents are compromised and do not want them to become sick. The Supervisor of Food and Nutrition stated the staff had not been educated within the last year on safe food storage and labeling. The Supervisor of Food and Nutrition stated that the bins of food were cleaned weekly and could have been cleaned better.

Based on interviews, record review, and review of the facility's policy, it was determined the facility failed to provide notice before a room change for two (2) of five (5) sampled residents. Residents #2 and 4. Registered Nurse (RN) #1 moved Resident #2 against the resident's will and without notice to the resident or responsible party. The facility also moved Resident #4 without notice for isolation purposes. The findings include: Review of the facility's policy regarding Notification of Changes, reviewed June 2013, revealed the facility would notify the resident, family and/or legal representative when there was a room change. 1. During the initial tour of the facility, on 11/12/15 at 8:15 AM, Resident #2 stated he/she had recently been moved to the present room without notice and the resident was upset about the move. The resident stated a nurse was giving medication to the resident's roommate when Resident #2 had requested assistance to the bathroom. The resident stated the nurse assisted the resident to the bathroom and when they came out of the bathroom, the nurse put her hands on the resident's shoulders and told the resident he/she was being moved to another room. Resident #2 stated he/she was very upset and started fussing with the nurse. The resident told the nurse he/she did not want to move. However, the resident stated the nurse did not listen to him/her and moved the resident anyway. The resident stated he/she had informed the Unit Manager on Monday, 11/10/15, of the incident and was told the Unit Manager would get back with him/her. However, the resident had not been told anything about the Unit Manager's findings and the resident still wanted to move back to the former room. Review of the electronic clinical record for Resident #2 revealed an Activity of Daily Living (ADL) assessment note for 11/08/15 that stated the resident had been moved to room [ROOM NUMBER] so the resident could be closer to the bathroom. The writer documented the resident was angry and would rather have the police called to give him/her a ride home. Another note (no date or time) revealed the House Supervisor was notified of the resident's unhappiness with being moved for safety and the resident told the writer he/she should be able to go wherever and whenever they wished without a babysitter. Continued review of the clinical record revealed the facility admitted the resident to the Skilled Nursing Facility (SNF) on 10/31/15 to room [ROOM NUMBER]. The resident was receiving rehabilitation (rehab) services to improve mobility. The facility performed a Brief Interview for Mental Status where the resident scored a thirteen (13) out of possible fifteen (15), which meant the resident's cognition was intact and could be interviewed. Interview with the Unit Manager, on 11/12/15 at 11:29 AM, revealed the Charge Nurse (Registered Nurse #1) reported to her that on Sunday (11/08/15) Resident #2 had asked to go to the bathroom. The nurse was administering medications to the resident's roommate and she told the resident if he/she waited she would assist. The nurse told the Unit Manager Resident #2 became angry-cursing and yelling. She spoke with the resident on Monday and the resident was still upset. The resident told her when the resident came out the bathroom, the nurse grabbed his/her shoulder and walked him/her to another room. She stated the resident had moved before because of a roommate problem. The Unit Manager had not asked the nurse if she had given notice to the resident before the move. She validated the resident was moved that day and the resident was unhappy about the move. The Unit Manager stated the resident did not want to move; however, the nurse had moved the resident because of safety reasons. A telephone interview with Registered Nurse (RN #1), on 11/12/15 at 11:41 AM, revealed she was the Charge Nurse for the unit on Sunday (11/08/15) and was Resident #2's nurse for that day. She stated normally the resident's roommate would put on the call light whenever Resident #2 was attempting to get up without assistance. When she went into room [ROOM NUMBER] that day, Resident #2 was observed walking half-way across the room, going to the bathroom, unassisted. The safety alarm had not activated because the resident had removed the box and placed it in the top drawer of the night stand. This was around 10-10:30 AM. The nurse stated she was worried about the resident so I asked him/her to go to room [ROOM NUMBER] with me, so he/she would be closer to the bathroom. She stated the resident became very angry and called the nurse a stupid [***] . When she attempted to put a gait belt around the resident's waist, the resident demanded the device be removed and it was. The resident told the nurse to call the law. RN #1 stated she walked the resident to room [ROOM NUMBER]. She stated the resident's daughter was out of town and she attempted to call the contact person. She stated the resident was very upset about the move and had became upset as soon as she talked to the resident about the room change. She stated the resident had gone to the bathroom two times that morning and the resident's roommate voiced frustration. The nurse stated she had asked the roommate if he/she wanted to move and the roommate told her he/he should not have to move, the roommate preferred to have Resident #2 moved and that was what the nurse did. RN #1 stated she called the Unit Manager and reported the incident. She had not asked Resident #2 if he/she wanted to move to another room, she just thought it would be safer for the resident. Interview with RN #2, on 11/12/15 at 3:55 PM, revealed when she returned to work on Monday, 11/09/15, she received report from RN #1 and was informed about the resident being upset. She stated RN #1 had requested a change of teams so she would not have to take care of Resident #2. During the medication pass that morning, the resident told this nurse he/she had been moved to another room and didn't like it. The resident told the nurse he/she should not have been treated like that. The resident told RN #2 he/she had to go to the bathroom very quickly. When the resident left the bathroom, RN #1 whisked the resident to another room because the resident had gotten up without asking for assistance. The resident told RN #2, he/she felt like they were being punished. The resident told the nurse he/she had been mistreated, and that was the resident's perception. 2. Interview with Resident #4, on 11/13/15 at 11:45 AM, revealed he/she had been moved to another room in the middle of the night without notice. The resident stated it was because of his/[MEDICAL CONDITION]. The resident stated nobody had asked him/her if they wanted to move. Record review revealed the facility admitted the resident on 11/05/15 with [DIAGNOSES REDACTED]. Interview with the RN #3, on 11/13/15 at 10:40 AM, revealed the resident was moved because they needed to place the resident in isolation. Interview with the Infection Preventionist, on 11/13/15 at 10:48 AM. revealed infection control practices are hospital wide including the SNF. She stated it was the hospital's policy to look back up to a year for any patient that had a history of [REDACTED]. This included the SNF.

Based on interview and review of the Quality Assurance (QA) meeting signature sheets, it was determined the facility failed to have the designated members in attendance and failed to conduct the QA meetings at least quarterly to identify quality deficiencies and implement appropriate plans of action. The findings include: The facility did not provide a policy for the Quality Assurance Committee. Interview with the Vice President/Chief Medical Officer, on 11/13/15 at 10:16 AM, revealed the Nursing Facility's QA was incorporated into the hospital's QA and had no specific policy for the Skilled Nursing Facility (SNF). Review of the QA signature sheets revealed the Skilled Nursing Facility held a QA meeting on 12/29/14, August 2015, and 11/10/15. However, the 11/10/15 QA meeting only consisted of two (2) members and no physician representative. Interview with the Vice President/Chief Medical Officer and Director of Medical Inpatient Services (new Director of Nursing over the Skilled Nursing Facility), on 11/13/15 at 10:16 AM, revealed there had been no QA meetings from December 2014 to August 2015 because they were new in their positions and were unaware of the requirements. The Vice President stated it was his responsibility to conduct the QA meetings because he was responsible for the oversight of the SNF. He stated there had been many leadership changes and it had fallin through the cracks. He stated he recently had a discussion regarding the QA process with the Director of Nursing and the Unit Manager. The Director of Nursing stated she had just recently became aware the QA committee had to be separate from the hospital's QA and must meet at least quarterly. She stated she then set up a schedule to ensure the QA meetings were being held, but failed to identify certain members had to be present. She stated the Unit Manager and herself were the only QA members present at the 11/10/15 QA meeting. The Vice President stated the SNF had a Medical Director but had not been asked to attend the QA meetings.

Based on interviews and review of the facility's policy, it was determined the facility failed to develop and implement procedures to prevent abuse/neglect of residents. The facility's Abuse Policy was integrated with the acute hospital's policies and did not include procedures on how to investigate an allegation of abuse, and the protection of the resident. In addition, the facility failed to develop policy and procedures for identification of abuse that involved staff to resident. The facility's Abuse Policy only addressed outside sources of abuse such as Child and Spouse Abuse. The facility received an allegation of abuse on 11/08/15; however, failed to investigate or report to the State Agencies. In addition, the facility failed to protect the resident and allowed the nurse to continue to work with other residents after the allegation. Refer to F225 The findings include: Review of the facility's Abuse Policy regarding Reporting Suspected Abuse/Neglect, reviewed March 2014, revealed the staff was to report suspected abuse or neglect to the Administrator/designee immediately. The Administrator/designee reported the suspected abuse immediately to the State Agencies, Ombudsman Office, Facility Medical Director, the resident's physician, and Law Enforcement Officials. However, closer review of the Abuse Policy revealed the identification and reporting of suspected abuse referred to outside persons (child abuse and spousal abuse) and did not include staff to resident abuse. The policy did not include protection of the resident during the investigation. Interview with Resident #2 during the initial tour, on 11/12/15 at 8:15 AM, revealed the resident voiced a concern regarding a room change. However, as the resident detailed the story, he/she stated a nurse grabbed him/her by the shoulder and moved the resident to another room. The resident voiced they were upset. The resident told the surveyor he/she had informed the Unit Manager of the incident. The resident remained upset regarding what had happened to him/her. Review of Resident #2's clinical record revealed the facility admitted the resident to the Skilled Nursing Facility (SNF) on 10/31/15 with [DIAGNOSES REDACTED]. The facility performed a Brief Interview for Mental Status where the resident scored a thirteen (13) out of possible fifteen (15), which meant the resident's cognition was intact and could be interviewed. Interview with the Unit Manager revealed the Charge Nurse (RN#1) reported to her that on Sunday (11/08/15) Resident #2 had asked to go to the bathroom. The nurse was administering medications to the roommate and told the resident if he/she could wait, she would assist. The nurse told her the resident became angry-cursing and yelling. She spoke with the resident on Monday (11/09/15) and the resident told her when he/she came out of the bathroom, the nurse grabbed his/her shoulder and walked him/her to another room. She then stated the resident had told her the nurse had man-handled him/her. The Unit Manager stated she had not asked the resident what he/she meant by those statements and did not investigate further to determine if it was an allegation of abuse. She stated she had not reported because she had not realized it could have been an allegation of abuse. A telephone interview with RN #1, on 11/12/15 at 11:41 AM, revealed there was an incident on Sunday (11/08/15) where Resident #2 was upset about being moved to another room. She stated she was worried about the resident falling so she asked the resident to go to another room (room [ROOM NUMBER]) to be closer to the bathroom. The resident became very angry and called the nurse a [***] . When the nurse attempted to put a gait belt around the resident's waist, he/she demanded the belt be removed. The resident told RN #1 to call the law. The RN stated she walked the resident to room [ROOM NUMBER] and tried to hold the resident's hand, but he/she refused. The nurse stated the only time she touched the resident was when she applied the gait belt. She denied touching the resident's shoulder. The resident told the nurse she was going to go to prison for what she did. She stated the Unit Manager had told her the resident alleged she had touched his/her shoulder. Interview with RN #2, on 11/12/15 at 3:55 PM, revealed she had worked the following Monday after the incident. During the morning medication pass, Resident #2 told this nurse she didn't like being moved and should not have been treated like that. The resident stated he/she had to go to the bathroom in a hurry, when she left the bathroom, the nurse whisked him/her off to another room because the resident had gotten up without assistance. The resident stated he/she felt they were being punished. The resident told the nurse he/she had been mistreated. Interview with the Director of Medical Inpatient Services (Director of Nursing for the SNF), on 11/13/15 at 11:30 AM, revealed she was unaware of the incident. She stated the Unit Manager had not investigated the incident as an allegation of abuse. There was no documentation of the incident except what was documented in the clinical record. She stated she now realized the facility's Abuse Policy was the same used for the acute hospital and did not have the components required in Long Term Care setting. She stated the incident was not investigated nor reported. She validated RN #1 was allowed to work after the resident's allegation. She stated she was new in this position and did not realize the SNF needed a different Abuse Policy from the hospital.

Based on interviews, record review, and review of the facility's policy, it was determined the facility failed to investigate and report an allegation of abuse and failed to protect one (1) of five (5) sampled residents, (Resident #2). The Unit Manager received an allegation of abuse on 11/08/15 from Resident #2 that Registered Nurse (RN) #1 had grabbed his/her shoulder and man-handled the resident. However, there was no investigation and RN #1 did not report the allegation to the State Agencies. In addition, RN #1 was allowed to work and continued to care for other residents. The findings include: Review of the facility's Abuse Policy regarding Reporting Suspected Abuse/Neglect, reviewed March 2014, revealed the staff was to report suspected abuse or neglect to the Administrator/designee immediately. The Administrator/designee was to report the suspected abuse immediately to the State Agencies, Ombudsman Office, Facility Medical Director, the resident's physician, and Law Enforcement Officials. However, closer review of the Abuse Policy revealed the identification and reporting of suspected abuse refered to outside persons (child abuse and spousal abuse) and did not include staff to resident abuse. The policy did not include protection of the resident during the investigation. Refer to F226. Interview with Resident #2 during the initial tour, on 11/12/15 at 8:15 AM, revealed the resident voiced a concern regarding a room change. However, as the resident detailed the story, he/she stated a nurse grabbed him/her by the shoulder and moved the resident to another room. The resident voiced they were upset. The resident told the surveyor he/she had informed the Unit Manager of the incident. The resident remained upset regarding what had happened to him/her. Review of Resident #2's clinical record revealed the facility admitted the resident to the Skilled Nursing Facility (SNF) on 10/31/15 with [DIAGNOSES REDACTED]. The facility performed a Brief Interview for Mental Status where the resident scored a thirteen (13) out of possible fifteen (15), which meant the resident's cognition was intact and could be interviewed. Interview with the Unit Manager revealed the Charge Nurse (RN#1) reported to her that on Sunday (11/08/15) Resident #2 had asked to go to the bathroom. RN #1 was administering medications to the roommate and told the resident if he/she could wait, she would assist. RN#1 told the UM the resident became angry-cursing and yelling. She spoke with the resident on Monday and the resident told her when he/she came out of the bathroom, the RN grabbed his/her shoulder and walked him/her to another room. She stated the resident had been moved to another room that day and was unhappy about the move. She then stated the resident had told her the nurse had man-handled him/her. The Unit Manager stated she had not asked the resident what he/she meant by those statements and did not investigate further to determine if it was an allegation of abuse. She stated she had not reported because she had not realized it could have been an allegation of abuse. The Unit Manager could not provide any written documentation that she investigated the incident. A telephone interview with RN #1, on 11/12/15 at 11:41 AM, revealed there was an incident on Sunday (11/08/15) where Resident #2 was upset about being moved to another room. She stated she was worried about the resident falling so she asked the resident to go to another room (room [ROOM NUMBER]) to be closer to the bathroom. The resident became very angry and called the nurse a [***] . When the nurse attempted to put a gait belt around the resident's waist, he/she demanded the belt be remove. She told me to call the law. She stated she walked the resident to room [ROOM NUMBER] and tried to hold the resident's hand but he/she refused. The nurse stated the only time she touched the resident was when she applied the gait belt. She denied touching the resident's shoulder. The resident told the nurse she was going to go to prison for what she did. Interview with RN #2, on 11/12/15 at 3:55 PM, revealed she had worked the following Monday after the incident. She stated RN #1 requested to change teams so Resident #2 would not be assigned to her. RN #1 informed her of the incident and she stated that was out of character for the resident. During the morning medication pass, Resident #2 told RN #2 she didn't like being moved and should not have been treated like that. The resident explained the story as the resident had to go to the bathroom very quickly. When she left the bathroom, the nurse (RN #1) had whisked the resident off to another room because he/she got up without asking for assistance. The resident felt he/she was being punished. The resident told the nurse he/she had been mistreated. Interview with the Director of Medical Inpatient Services (Director of Nursing for the SNF), on 11/13/15 at 11:30 AM, revealed she was unaware of the incident. She stated the Unit Manager had not investigated the incident as an allegation of abuse. There were no documentation of the incident except what was documented in the clinical record. She stated she now realized the facility's Abuse Policy was the same used for the acute hospital and did not have the components required in Long Term Care setting. She stated the incident was not investigated nor reported. She validated RN #1 was allowed to work after the resident allegation. In addition, review of the abuse training provided to the facility's staff revealed the staff were educated with other hospital staff using the same online modules. The training included the information in the facility's Abuse Policy regarding outside sources of abuse and not staff to resident abuse.

Based on observation, interview, and review of the facility's policy for enteral feeding it was determined the facility failed check placement of a Gastrostomy tube prior to administration of a bolus tube feeding for one resident (Resident #1) with a Gastrostomy tube out of a total sample of eight (8). The findings include: Review of the facility's Enteral Feeding Policy, revised July 2012, revealed to prevent aspiration confirm tube placement by aspiration of gastric contents and use a syringe with 10-30 ml of air pushed through the tube while auscultating the patient's stomach to confirm tube placement. The policy further stated never give feeding until placement has been checked. Observation, on 01/13/15 at 11:38 AM, of a bolus tube feeding for Resident #1 revealed the License Practical Nurse (LPN) #1 checked residual of the resident's stomach contents. There was no residual. The nurse then flushed the Gastrostomy tube with sixty (60) ml of water. She then administered the bolus tube feeding and flushed the tube with water after all the tube feeding had been administered. She did not auscultate with air to confirm tube placement. The nurse did not have a stethoscope. Interview with LPN #1, on 01/13/15 at 11:42 AM, revealed she had checked the tube for placement earlier that morning when given medications and did not think to check again prior to giving the bolus tube feeding. She stated she should check placement of the Gastrostomy tube each time a medication or feeding was given via the tube. Interview with the Skilled Unit Director, on 01/14/105 at 2:40 PM, revealed Gastrostomy tube placement are to be checked prior to administering a medication or feeding. She said all nurses are supposed to check placement with air auscultation and stomach residual. She stated if a resident was on a continuous feeding via pump, placement should be checked prior to medication administration. She revealed all nurses are trained during skills check-off and competency tested . Nurses do actual demonstration of the skills, including tube feeding. She stated the competency of the nurses are monitored by the Unit Based Educators and they document problems and conduct on the spot training to correct the problem. She stated she had not had any reports of any nurse who did not perform placement of a Gastrostomy tube prior to administering medication or tube feeding. She again stated all nurses must pass competency test that included checking for placement of a Gastrostomy tube. She continued to state that day to day monitoring is conducted by the Charge Nurse and the Unit Based Educators. Oversight was provided by the Unit Manager.

Based on observation, interview and policy review, it was determined the facility failed to store food under sanitary conditions. Observation during tour of the kitchen revealed two (2) bags of french fries, one (1) bag of shredded cheese and one (1) bag of shredded carrots were opened and not labeled or dated. The findings include: Review of the Food and Nutrition Infection Control Policy, revised 02/12, revealed expiration dates were checked daily on foods served by Food and Nutrition. All leftovers must be discarded within seven (7) days. Observation during tour of the kitchen, on 11/05/13 at 8:30 AM, revealed two (2) bags of frozen french fries were stored in the freezer not labeled or dated. In addition one (1) bag of shredded cheese and one (1) bag of shredded carrots, were in the walk-in cooler, not labeled or dated. Interview with Food Specialist #1, on 11/06/13 at 1:40 PM, revealed when retrieving items from the refrigerator, Food Specialist #1 would look at the date on the package before using. If the package date was older than six (6) days from the day when the item was opened, Food Specialist #1 would then dispose of the food. Food Specialist #1 stated when a food item was opened, the item needed to be dated and labeled to prevent residents from getting sick. Interview with Food Specialist #2, on 11/06/13 at 1:47 PM, revealed he utilized carrots at times and when he was finished he would role up the carrot bag and put a date on it before storage. Food Specialist #2 stated they labeled and dated food items so that they would know how old a food item was and to prevent individuals from getting sick. Interview with the Director of Food and Nutrition, on 11/06/13 at 3:00 PM, revealed foods should be labeled and dated when opened and stored in the refrigerator. The Director of Food and Nutrition stated when items were older that seven (7) days, the food items would be disposed of, because it was no longer fresh. The Director of Food and Nutrition stated they disposed the food item to prevent food bourne illness.

Based on observation, interview, and record review, it was determined the facility failed to provide an ongoing activity program to meet the interest of two (2) out of nine (9) sampled residents. The facility assessed Resident #2 and #9's preferences for customary routine and activities to include music that were identified to be somewhat important to very important to the residents. The staff failed to offer either resident music through a radio or CD player and were not informed the television had music channels. The findings include: The facility did not provide a policy for activities. However, review of the admission packet contained a social history/interest form and the preferences for customary routine and activities interview form. 1. Observation of Resident #2, on 11/05/13 at 8:20 AM, revealed the resident was sitting in a recliner chair be side the bed. At 10:03 AM, the resident was observed again in the recliner. Continued observation on 11/05/13 at 10:30 AM, 11:09 AM, 12:00 Noon, 1:02 PM, 1:52 PM, and 3:55 PM, revealed the resident was sitting in the recliner chair. The television was on; however, observation revealed the resident was not watching. During the Quality of Life assessment interview, on 11/06/13 at 11:00 AM, revealed the resident loved Southern Gospel music. The resident had a specific group called the Signature Sound that the resident loved to listen to and when at home the resident played the many CD's that had been purchased. The resident revealed he/she had went to many concerts to see the group and even traveled on a cruise with the group. The lead singer had even sent the resident flowers when the resident was in the hospital. The resident talked extensively about the love of the group's music and he/she had missed listening to their music. The resident stated they had not been offered a radio or CD player for music. The resident told the surveyor he/she would love to be able to listen to the many CDs the resident had purchased. The resident indicated he/she would love to have the music. Review of the clinical record revealed the facility admitted Resident #2 on 10/31/13 status [REDACTED]. Review of the Prospective Payment System (PPS) assessment completed on 11/05/13 revealed the resident had no cognition loss and was assessed to be calm and cooperative. Review of the interim care plan revealed the care plan only addressed the resident's clinical status. 2. Observation of Resident #9, on 11/06/13 at 1:34 PM, revealed the resident was sitting up in the recliner chair, angry and talking loudly. The resident verbalized he/she was tired of the hospital, tired of the bed, chair, therapy and everything about the nursing facility. RN #1 came into the room to calm the resident. She informed the resident that whenever the resident's physician came in to visit, a discharge to home order would be obtained. She stated that the Therapy Department had met and determined the resident was ready for discharge. Interview with Resident #9, during the above observation, revealed the resident liked music, country music and would like to listen to music. The resident told the surveyor he/she was used to being active and he/she was bored. The resident stated he/she was tired of watching television. Interview with RN #1, on 11/06/13 at 1:40 PM, revealed there was a radio/CD player in the activity room. She went and obtained the radio/CD player and placed in the resident's room. She stated the resident was upset and wanted to go home. Continued observation at 2:45 PM, revealed Resident #9 was sitting in the recliner, quiet and calm, listening to country music on the radio/CD player. The resident stated he/she enjoyed the music. Review of the resident's clinical electronic record revealed the facility admitted the resident on 10/26/13. Review of the preference for customary routine and activities form (completed on 13/30/13) revealed music was identified as a patient activity preference and it was very important to the resident. Interview with Recreational Therapist, on 11/06/13 at 12:45 PM and 2:05 PM, revealed he was responsible for completion of the preferences for customary routine and activities for each resident admitted to the Skilled Unit. When he reviewed the forms he stated Residents #2 and #9 were assessed to like music and the form indicated it was important to the residents. The Recreational Therapist stated there was no specific staff assigned to do activities, all staff was responsible. He indicated he worked with the Unit Manager to develop an activity program for the residents. He stated it was a challenge because most residents were there for a short term stay for therapy and then return to home. He revealed there was no activity calender. He said they had tried a calender before and found no residents wanted to attend any of the scheduled activities. Residents were busy with therapy during the week and on weekends with family visits. There was no outside groups that came to the nursing facility and no volunteers. They used to provide church services; however, they stopped coming because of low attendance. They had holiday and special events in the activity room and residents would attend them. Each resident was invited to eat in the unit's dining room, but most refused. Each resident was offered books, magazines, puzzles, and movies each day. When asked about music, the Recreational Therapist stated there were music channels on the televisions. However, he could not find the channels. The Unit Manager searched and found the music channels. The music channels were located in the higher numbers (eighty-80) and it was not listed on the television channel guide given to the residents. Continued interview with the Recreational Therapist revealed when he had interviewed Residents #2 and #9 regarding music preference he had not asked the residents what specific type of music they liked. He did not know Resident #2 loved Southern Gospel music and wanted to listen to the music. He stated a radio/CD player was available for use and he was sure the staff had offered the residents that option. Interview with the Unit Manager, on 11/06/13 at 12:45 PM (she was present during the interview with the Recreational Therapist) and 2:50 PM, revealed the Personal Care Attendant (PCA) would ask each resident at the beginning of each shift what they wanted to do and asked them if they wanted to eat in the dining/activity room. She stated it was everyone's job to assist the resident with activities. Residents were offered books, puzzles, magazines, and movies. Weekends were the same. She stated the PCA would document what the resident was doing. The Unit Manager stated she made daily rounds and asked residents what they liked to do. She did not know if the radio/CD player had been offered to Residents #2 and #9. Review of the electronic documentation for Resident #2 revealed, on 11/04/13 at 8:06 AM, the PCA documented TV/movies/music. The same thing was documented on 11/05/13 and 11/06/13. The staff stated the combination appeared in the computer and did not state what specific choice was being offered. Interview with PCA #1, on 11/06/13 at 3:05 PM, revealed she worked day shift and each morning during rounds she would ask the residents what they wanted to do that day. She stated there usually was not enough time to conduct planned activities because of therapy schedules and bathing (daily). Most residents liked to watch television; however, she offered books, magazines, and puzzles also. She stated Resident #2 usually watched television and worked with therapy. She stated the daughter visited frequently. There was a CD player in the activity room for use; however, she had not offered music. None of the residents had requested a radio/CD player. Residents #2 and #9 was interviewed again, on 11/06/13 at 3:20 PM, that revealed they had not been offered a radio/CD player before today.