Every finding on record at Barren County Nursing and Rehabilitation

Based on observation, interview, and review of the facility's policy, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, which had the potential to affect 89 of the facility's 89 residents who consumed food from the kitchen. Observation of the kitchen area revealed food items were exposed to the air and/or potential contamination. Both the refrigerator and dishwasher area had strong odors, and several areas of the kitchen were soiled. One of the facility's ice machines, which was used to serve ice to the residents, was not clean. The findings include: Review of the facility policy titled, Food Receiving and Storage, revised 07/2014, revealed food shall be received and stored in a manner that complies with safe food handling practices. Per this policy, all foods stored in the refrigerator or freezer would be covered. Continued review of the policy revealed food services or other designated staff would maintain clean food storage areas at all times. 1. Observation during initial tour of the kitchen on 08/05/2025 revealed the following:a. Observation of Refrigerator 1, on 08/05/2025 at 11:45 AM, revealed multiple food items were exposed to the air and/or potential contamination. Three bowls of mandarin oranges were not covered. Foods that had covers but were not sealed and were at least partially exposed included broccoli, chicken noodle soup, tomato soup, bologna, shredded cheese, cheese dip, and sour cream. In addition, observation of the dry storage area revealed a bucket of flour with the top uncovered and exposed to the air and/or contaminants. b. Observation of Refrigerator 2, on 08/05/2025 at 11:50 AM, revealed one box of bacon in its original container with the flaps opened and the plastic wrapping on the inside opened, exposing it to the air and/or contaminants. c. Observation of Freezer 1, on 08/05/2025 at 11:55 AM, revealed one box of hamburger patties in its original box. The flaps to the box and its inner plastic package were opened, exposing the food to the air and/or potential contamination. 2. During initial tour of the kitchen on 08/05/2025 at 11:50 AM, observation of Refrigerator 2 revealed a very strong sour odor. A stream of milk puddled on the floor. Additional observation of the kitchen, on 08/07/2025 at 3:00 PM, revealed the floor in Refrigerator 2 had been cleaned; however, there was still a foul odor. Observation at this time revealed at least four potatoes in a box stored in the refrigerator had black mushy spots and appeared to be rotten. 3. During initial tour of the kitchen, observation of the dishwasher area on 08/05/2025 of 11:55 AM revealed a strong pungent odor. The floor had an opening in the tile where a pipe ran into it and was surrounded by a black substance and particles of trash. A brownish grimy substance was covering the bottom of the dishwasher where the water was discarded. In addition, observation in the general kitchen area revealed the sink and upper wall around it was soiled with particles of grime and a brown substance as well as the baseboards and floors. 4. On 08/06/2025 at 10:40 AM, observation of the dining room revealed two ice machines, both filled with ice. The first ice machine had grime on the side of the machine where the scoop was located. Further observation revealed the inner part of the first ice machine's door hinge had a black substance in the crease and streaks of discoloration on the metal top above where the ice was stored. The first ice machine also had a brownish-orange colored substance on the inside wall where the ice was stored. Additional observation while going into the kitchen revealed the wooden door with a metal panel was covered with grime. In an interview with Cook1, on 08/06/2025 at 10:55 AM, he stated he was responsible to store food items when needed. He further stated was aware that all food items were to be covered, dated and labeled. He stated if those food items were not covered there was potential to contaminate those foods but also, food could be spoiled. In an interview with Cook2, on 08/06/2025 at 11:20 AM, she stated she was a cook but also had responsibilities to store food items when retrieving items for meals. She stated food that were not covered securely could cause cross-contamination and/or bacterial growth which could potentially cause resident's harm. She further stated all staff should ensure that all foods stored were covered securely to prevent potential contamination or sickness to residents. In an interview with Cook3, on 08/07/2025 at 3:20 PM, she stated she was new to the facility within 90 days. She stated she was educated that all staff were responsible for cleaning the kitchen and had depended on where you were working for daily task assignments. She stated all staff were assigned deep cleaning tasks as well and they were to be logged. She stated all dietary staff were responsible for food storage including ensuring food items were securely covered to prevent food from spoiling and potentially making residents sick from contamination. In an interview with [NAME] 4, on 08/07/2025 at 3:30 PM, she stated she had worked in the facility for three years. She stated she was a cook, and she had many responsibilities in the kitchen including preparing meals and food storage. She stated all staff were provided tasks for daily and weekly deep cleanings and it was all staff's responsibility to ensure these tasks were completed. She further stated regarding the food storage process that all dietary staff were responsible to follow food safety guidelines to prevent potential food contamination of any stored food items. She also noted that if staff did not follow policy and food safety guidelines to ensure foods were stored and covered properly, residents could become ill if served contaminated or spoiled foods. In an interview with the Dietary Manager, on 08/07/2025 at 3:15 PM, she stated she had not observed an odor in Refrigerator2; however, she was not aware of the rotten potatoes in the box. Additional interview with the Dietary Manager, on 08/08/2025 at 12:05 PM, revealed her expectations for the dietary staff were to follow policy regarding food safety and ensure that all stored food items were covered and dated. She stated if staff were not following those guidelines residents could potentially be affected by foodborne illnesses. The Dietary Manager stated staff working in a specific area in the kitchen were responsible to complete daily tasks in that area. She also noted her expectations for staff regarding kitchen cleanliness was to complete weekly assigned cleaning tasks and sign off after completion. Interview with the Administrator, on 08/08/2025 at 8:20 AM, revealed the first ice machine, which was old, was discarded, with the Administrator indicating the need for a new one. Additional interview with the Administrator, on 08/08/2025 at 2:40 PM, revealed her expectations for the dietary department and food safety service regarding food storage was that staff had followed the facility's policy which stated food items were to be covered not sealed. She further stated expectations were that staff would follow their cleaning tasks to ensure cleanliness in the dietary department.

Based on observation, interview, record review, and review of facility policy it was determined the facility failed to ensure that one (Resident (R) 60) of 19 sampled residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Staff failed to provide treatment in accordance with the care plan and physician orders for R60, who had non-pressure related skin impairment. The findings include:Review of the facility policy titled Skin Integrity - Skin Tears, dated 01/02/2020 and revised on 03/24/2022, revealed it was the policy of the facility to provide proper treatment and care to maintain skin integrity. This policy pertains to the prevention and management of skin tears. The facility would utilize a systematic approach for the prevention and management of skin tears, including assessment, care planning, monitoring, and modification of interventions as appropriate.Review of the Resident Face Sheet revealed the facility admitted R60 to the facility on [DATE] with diagnoses including unspecified fall, rhabdomyolysis (a breakdown of muscle tissue), and chronic kidney disease. Review of the Observation Detail List Report, admission Observation, dated 07/23/2025, revealed R60 had skin alteration, as the upper right and left extremities had bruising and skin tears.Review of the admission Minimum Data Set (MDS), with an assessment reference date (ARD) of 07/24/2025, revealed a Brief Interview for Mental Status (BIMS) score of 10/15, indicating R60 had moderate cognitive impairment. Continued review of the MDS revealed that R60 was admitted to the facility with skin tears, application for non-surgical dressing, and application of ointments.Review of the Comprehensive Care Plan dated 07/23/2025, revealed that R60's skin tears, which were present on admission, were not included in the plan of care. The care plan did, however, note that R60 was at risk for skin impairment related to impaired mobility. Interventions dated 07/23/2025 included weekly and as needed (PRN) skin inspection as directed, keep clean and dry as possible, minimize exposure to moisture, provide incontinent care after each incontinent episode, avoid hot water, use mild cleansing agent that minimized irritation, reduce friction and injuries by using lubricants, protective films, protective dressings or protective padding as ordered, and treatment as ordered. Review of admission Orders, dated 07/23/2025, revealed an order for mupirocin (antibiotic) ointment. Special instructions were to clean skin tears left upper extremity near the elbow with normal saline, pat dry, apply a thin application of mupirocin covered with telfa, secure with kerlix (gauze dressing), and change daily and PRN. Review of physician's orders dated 07/26/2025 also revealed an order to cleanse skin tears to the right forearm gently with normal saline, pat dry, apply petroleum gauze, wrap with kerlix daily, and to monitor skin tears to the right and left forearms every shift for signs and symptoms of infection. Review of physician's order dated 08/06/2025 revealed staff were to cleanse skin tears to right lower forearm gently with normal saline, pat dry, apply petroleum gauze and wrap with kerlix daily, twice a day. Review of all physician orders since admission revealed no evidence of orders for band-aids to be applied to skin tears/wounds.Observation on 08/05/2025 at 1:18 PM revealed R60 had two large band-aids on his left forearm that were visibly soiled. The band-aid near the left elbow was dated 08/03/2025. A band-aid at the left wrist area was not dated. Continued observation revealed R60 also had one band-aid to the right wrist area dated 08/03/2025, as well as a large island-type dressing to the right elbow area dated 08/03/2025. Observation revealed no Vaseline gauze, telfa, or kerlix in use for any of these areas. Interview with R60 at the time of this observation revealed that he got a couple of the sores from trying to get himself off the floor after a fall at home, and another one after a fall in the facility. He stated he was unsure of how often the band-aids were to be changed.Observation on 08/06/2025 at 10:34 AM revealed R60's band-aids and dressing on his right arms continued to show a change date of 08/03/2025. During interview with R60 at the time of this observation, he stated no one had come and changed the band-aids. He stated he disliked the band-aids because the plastic ones pulled his arm hair when they came off. He stated they (the soiled band-aids) were looking bad.Observation on 08/07/2025 at 9:18 AM revealed R60 now had a kerlix (gauze dressing) on each arm. The kerlix was not secured and was hanging off both of his arms. Further observation revealed there was no Vaseline gauze to the skin tears on the right arm (in accordance with the 07/26/2025 orders.) R60's skin tears on the left arm were not covered with a dressing. During interview at the time of the observation, R60 stated, They changed my dressings last night. Review of the Treatments Administration History, dated 07/23/2025 to 08/07/2025, revealed Registered Nurse (RN) 1 signed the electronic health record (EHR) on 08/04/2025, 08/05/2025, and 08/06/2025, indicating she had completed R60's treatments as ordered. Interview with RN1, on 08/08/2025 at 11:39 AM, revealed that although the Treatment History documented that the treatments were completed, she had not changed R60's dressings on 08/04/2025 through 08/06/2025. She stated, It gets hectic at times, and that's no excuse, but I did not get to it. RN1 stated she accidentally signed the treatment record, indicating the treatment had been completed, adding, I guess I hit the wrong button. RN 1 stated it was important to follow the orders that the physician had given to ensure residents received the best care.Interview with the Unit Manager/Treatment Nurse, on 08/08/2025 at 10:36 AM, revealed she was not aware that R60's dressings were not changed for three days or that the specific treatment orders were not followed. She stated that not following the physician's order was not appropriate. She stated she expected the nurses to follow the physician's order and do the treatments as they are ordered. During interview with the Director of Nursing (DON) on 08/08/2025 at 12:51 PM, she stated she expected staff to practice within the scope of their practice, and if there was a problem, she expected them to let her know. The DON stated she was not made aware that R60's skin tear treatments were not completed for three days or that the wrong treatment was used. She stated she would expect the correct treatment to be in place.Interview with the Administrator, on 08/08/2025 at 2:18 PM, revealed she was not clinical, but she expected staff to work within their scope of practice and to notify the physician if needed.Interview with the Medical Director, on 08/08/2025 at 2:49 PM, revealed she expected the facility to follow orders, and if there was a concern, she expected them to let her know. The Medical Director stated she was also the wound provider for the facility, and she expected treatments to be completed as ordered. She stated if R60 had an order for petroleum gauze then that was what should have been applied and not a band-aid, and daily treatments should be done every day.

Based on observation, interview, record review, and policy review, the facility failed to develop and implement a comprehensive person-centered care plan for one (Resident (R) 60) of 19 sampled residents. The resident was assessed with skin tears on admission and through the Minimum Data Set (MDS) assessment process. However, the facility failed to care plan this specific, active care need. In addition, staff failed to implement care plan interventions by providing care as ordered for R60. The findings include:Review of the facility policy titled Comprehensive Care Plans, revised on 03/03/2025, revealed it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident to meet a resident's medical, physical, mental, and psychosocial needs. The comprehensive care plan would describe services to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being, and specific interventions that reflect the resident's needs and preferences.Review of the Resident Face Sheet revealed the facility admitted R60 to the facility on [DATE] with diagnoses including unspecified fall, rhabdomyolysis (a breakdown of muscle tissue), and chronic kidney disease. Review of the Observation Detail List Report, admission Observation, dated 07/23/2025, revealed R60 had skin alteration, as the upper right and left extremities had bruising and skin tears.Review of the admission Minimum Data Set (MDS), with an assessment reference date (ARD) of 07/24/2025, revealed that R60 was admitted to the facility with skin tears, application for non-surgical dressing, and application of ointments. a. Development of Care Plan:Review of the Comprehensive Care Plan dated 07/23/2025, revealed that R60's skin tears, which were present on admission and assessed through the MDS process, were not included in the plan of care. During an interview with the MDS Assistant on 08/08/2025 at 12:12 PM, she stated she had been doing MDS assessments for one year and was still learning. She stated the purpose of the care plan was to help establish a baseline for resident care and to set goals for them to achieve. Interview with the MDS Assistant revealed R17 had an at-risk (for skin impairment) problem in place. However, she stated, R60 was admitted to the facility with actual skin tears/current skin impairment (rather than being at risk for a future problem) and should have had a care plan on admission. b. Implementation of Care Plan:Further review of the Comprehensive Care Plan, revealed that although it did not address R60's tears, it did note that R60 was at risk for skin impairment related to impaired mobility. Interventions dated 07/23/2025 included weekly and as needed (PRN) skin inspection as directed, keep clean and dry as possible, minimize exposure to moisture, provide incontinent care after each incontinent episode, avoid hot water, use mild cleansing agent that minimized irritation. The care plan also called for staff to reduce friction and injuries by using lubricants, protective films, protective dressings or protective padding as ordered, and treatment as ordered.Review of admission Orders, dated 07/23/2025, staff were to clean skin tears left upper extremity near the elbow with normal saline, pat dry, apply a thin application of mupirocin covered with telfa, secure with kerlix (gauze dressing), and change daily and PRN. Review of physician's orders dated 07/26/2025 also revealed an order to cleanse skin tears to the right forearm gently with normal saline, pat dry, apply petroleum gauze, wrap with kerlix daily, and to monitor skin tears to the right and left forearms every shift for signs and symptoms of infection. Review of physician's order dated 08/06/2025 revealed staff were to cleanse skin tears to right lower forearm gently with normal saline, pat dry, apply petroleum gauze and wrap with kerlix daily, twice a day. Review of all physician orders since admission revealed no evidence of orders for band-aids to be applied to skin tears/wounds.Observation on 08/05/2025 at 1:18 PM and 08/06/2025 at 10:34 AM revealed R60 had revealed no Vaseline gauze, telfa, or kerlix in use for any of the skin tears for which treatment was ordered. The resident had two large band-aids on his left forearm that were visibly soiled. The band-aid near the left elbow was dated 08/03/2025. A band-aid at the left wrist area was not dated. Continued observation revealed R60 also had one band-aid to the right wrist area dated 08/03/2025, as well as a large island-type dressing to the right elbow area dated 08/03/2025. Additional observation on 08/07/2025 at 9:18 AM revealed R60 now had a kerlix (gauze dressing) on each arm. The kerlix was not secured and was hanging off both of his arms. Further observation revealed there was no Vaseline gauze to the skin tears on the right arm (in accordance with the 07/26/2025 orders.) R60's skin tears on the left arm were not covered with a dressing. (Refer to F684.)Review of the Treatments Administration History, dated 07/23/2025 to 08/07/2025, revealed Registered Nurse (RN) 1 signed the electronic health record (EHR) on 08/04/2025, 08/05/2025, and 08/06/2025, indicating she had completed R60's treatments as ordered.Interview with RN1, on 08/08/2025 at 11:39 AM, revealed that although the Treatment History documented that the treatments were completed, she had not implemented the care plan by changing R60's dressings as ordered on 08/04/2025 through 08/06/2025. She stated, It gets hectic at times, and that's no excuse, but I did not get to it. Interview with the Director of Nursing (DON) on 08/08/2025 at 12:51 PM revealed that the facility had two MDS nurses and one had been on vacation when the facility admitted R60. The DON stated she was not informed R60's skin tear treatments were not completed for three days or that the wrong treatment was used. The DON stated she expected the MDS nurses to review the care plans and ensure it was accurate. Further interview with the DON revealed she expected the plan of care to be followed.

Based on observation, interview, record review, and review of facility policy, the facility failed to provide respiratory care as care planned and ordered for one (Resident (R) 91) of 19 sampled residents. Staff failed to ensure that oxygen therapy was delivered in accordance with physician orders. The findings include: Review of the facility policy titled Oxygen Administration, dated 01/02/2021, revealed oxygen therapy would be administered only under the order of the physician. Per this policy, the care plan shall identify interventions to include the type of oxygen delivery system and equipment setting for prescribed flow rates.Review of the Resident Face Sheet revealed the facility admitted R91 to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease (COPD).Review of the Comprehensive Care Plan, reviewed 06/10/2025, revealed R91 had a problem for respiratory/pulmonary. Per the care plan, R91 had a respiratory problem with impaired gas exchange related to COPD. Interventions included administering oxygen as ordered.Review of a Physician Order, dated 11/11/2022, revealed that oxygen was to be delivered at 2 liters per minute (2L/M) via nasal canula. Review of the Treatment Administration Record (TAR) for 08/01/2025 - 08/08/2025, revealed that the oxygen flow rate was ordered for 2L/M via nasal canula, with a frequency of every shift. The record was signed off by Licensed Practical Nurse (LPN) 3.Observation on 08/06/2025 at 9:52 AM, revealed that R91's oxygen flow rate was 4L/M, (not 2L/M as ordered). Interview with the resident at this time confirmed that her oxygen flow rate should be 2L/M. Additional observations on 08/06/2025 at 10:51 AM, 12:03 PM, and 3:15 PM, as well as on 08/07/2025 at 8:51 AM revealed that R91's oxygen flow rate was 4L/M.During interview with LPN3 on 08/07/2025 at 1:10 PM, she stated that the resident's flow rate should be checked at the start of the shift. LPN3 stated R91's oxygen was to be provided at 2L/M liters per minute. The nurse then checked and confirmed R91's flow rate was 4L/M, rather than the ordered rate of 2L/M. At this time, LPN3 adjusted the flow rate back to 2L/M and identified that complications associated with the overuse of oxygen included hyperventilation and/or decreased respiratory rate.Interview with the Administrator on 08/08/2025 at 2:18 PM revealed that she expected staff to work within their scope of practice.

Based on interviews, record review, facility document review, and facility policy review, it was determined the facility failed to ensure a consistent process was in place for addressing resident grievances and maintaining evidence of efforts to resolve grievances for one (1) of one (1) sampled residents reviewed for grievance concerns (Resident #42) of a total sample of twenty-nine (29) residents. Interview with Resident #42 on 03/06/2023 at 10:46 AM, revealed the resident had expressed concerns about his/her roommate, and missing items. Further interviews revealed the facility failed to complete a grievance and make efforts to resolve the grievance. The findings include: Review of the facility's policy, Resident and Family Grievances, dated 01/04/2020, revealed the facility would support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. The policy also revealed grievances may be voiced in the following forms: a verbal complaint to a staff member or Grievance Official, written complaint to a staff member or Grievance Official or a written complaint to an outside party, a verbal complaint during resident or family council meetings, and/or via the company's toll free Customer Service Line (if applicable). Additionally, the policy revealed in accordance with the resident's right to obtain a written decision regarding his or her grievance, the Grievance Official would issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. The written decision would include at a minimum: the date the grievance was received, the steps taken to investigate the grievance, and a summary of pertinent findings or conclusions regarding the resident's concern(s), a statement as to whether the grievance was confirmed or not confirmed and any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued. Record review revealed the facility admitted Resident #42 with diagnoses which included Chronic Obstructive Pulmonary Disease, Diabetes Mellitus, and Alzheimer's Disease. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 12/14/2022, revealed Resident #42 had a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact. Further review of the MDS indicated the resident exhibited no behavioral symptoms. According to the MDS interview for daily and activity preferences, Section F, the resident felt it was very important to take care of their personal belongings and very important to have a place to lock up their things to keep them safe. Review of Resident #42's Care Plan, dated as reviewed 03/06/2023, revealed no focus areas or interventions for behaviors. Interview with Resident #42, on 03/06/2023 at 10:46 AM, revealed he/she went to the Social Services Director (SSD) on 05/09/2022 about a resident in the next room who hit them. Resident #42 indicated the SSD said she would handle the problem. Resident #42 stated he/she had missing clothes and had a roommate that had gone through the resident's personal belongings while Resident #42 was in the hospital. Resident #42 indicated he/she told the SSD about those issues. The resident stated a person could not file a grievance at the facility. Interview with the Administrator, on 03/06/2023 at 12:27 PM, revealed he the facility had received only one grievance in the past year, and it was related to meal delivery. Additional interview with the Administrator, on 03/06/2023 at 2:05 PM, revealed he tried to separate out concerns versus grievances. He indicated social services staff had a log, and the resolutions were documented on the log sheet. Review of Resident #42's Progress Notes, dated 05/02/2022 through 06/27/2022, revealed no entries related to the resident's grievance of 05/09/2022. Review of the Customer Concern Logs, revealed no entries in May 2022 related to Resident #42 being hit by another resident or that the resident had missing clothes. Further review revealed there was no documentation of Resident #42's concerns on the social services' untitled concern log. Additional interview with Resident #42, on 03/07/2023 at 8:50 AM, revealed the resident stated he/she kept a log with the date he/she attempted to file a grievance with the SSD. The resident stated he/she went to see the SSD on 05/09/2022 about an incident with another resident, and the SSD stated it was not a grievance. Resident #42 stated they then went to a nurse to get a grievance form, and the nurse went to see the SSD. The resident stated he/she could not recall the nurse's name. Resident #42 stated the SSD then came to the resident and took the resident to her office. Resident #42 explained to the SSD that a resident had assaulted Resident him/her on 05/09/2022. Resident #42 stated they were at the other resident's door and saw the other resident out of the corner of their eye, and then the resident came toward Resident #42. Resident #42 stated they had to put their arm up to block a hit to the face and received a bruise on their forearm. Resident #42 stated the SSD denied the resident's request to file a grievance but indicated she would handle the resident's concerns. Resident #42 stated the resident who hit them was no longer in the facility. Additional interview with the Administrator, on 03/07/2023 at 9:30 AM, revealed he was informed of Resident #42's concerns. He stated he would report the resident's allegation and begin an investigation. Interview with the Social Services Director (SSD), on 03/07/2023 at 9:43 AM, with the Administrator present, the SSD stated she did not recall Resident #42 ever coming to her about an allegation of assault or another resident hitting Resident him/her. She stated she did remember the facility putting a stop strip on Resident #42's door. The SSD indicated concerns were generally brought up in the morning meetings, and the team decided what needed to be done. She further revealed the facility had only had one grievance in the past year. Additional interview with the SSD, on 03/07/2023 at 4:30 PM, revealed that in January 2023, the facility had a mock survey, and she received instructions, training, and new forms to use for the grievance process. During a telephone interview on 03/08/2023 at 4:50 PM, Registered Nursing (RN) #8 stated she vaguely remembered Resident #42 coming to the SSD with concerns. RN #8 stated she happened to be present when the resident came to the SSD because the Director of Nursing (DON) was out that day. RN #8 stated Resident #42 knew the other resident was confrontational at times and did not want the resident coming around them. She stated she did not recall Resident #42 being hit but did recall that the resident put their arm up to block a hit. RN #8 indicated she and the SSD did not think the situation was abuse; however, she could not recall everything Resident #42 reported. She revealed grievances were handled by social services and stated they did not file a grievance for Resident #42's concerns. RN #8 stated usually, if there was any concern from a resident or family, the concern would be sent to the appropriate department, such as nursing concerns were given to nursing and food concerns were given to the kitchen. She stated if she had thought the incident was abuse, she would have reported it. During a follow-up interview on 03/09/2023 at 6:45 AM, the SSD again stated she did not recall Resident #42 ever coming to her to report that another resident attacked or hit the resident. She stated if that had happened, she would have reported the incident as abuse. Interview with the Administrator, on 03/07/2023 at 9:56 AM, revealed residents could file a grievance. He stated some concerns were addressed with a work order or calling the family, and they did not log every concern but did route it to the appropriate person to address the concern. He further stated not all of the issues on the untitled concern log had a grievance form associated with them because those were only concerns. The Administrator stated he considered a grievance to be when the facility staff tried to get everything resolved and could not, then a formal grievance would be filed. He stated he did not consider concerns the same level as a grievance. The Administrator stated when a family had a concern, the facility did not do a formal grievance, but just tried to fix the concern. The Administrator stated the facility asked the resident and/or responsible party if their issue was a grievance or just a concern. The Administrator the facility took care of residents' and families' needs when they arose. Interview with the Activities Director, on 03/09/2023 at 8:39 AM, revealed resident rights were discussed in the Resident Council meetings, and she had spoken with the residents in the meeting about how to file a grievance. She stated she asked the residents if they understood what the difference was between a grievance and a concern. She stated a grievance was an issue that was a really major issue, and a concern would be a small issue. She stated a concern, to her, might be a bed that was not made, and a grievance would be that clothes were missing. She then stated that, following Resident Council meetings, if there was a concern, she would verbally communicate it to either nursing, the kitchen, social services, or maintenance. Stated she did ask the residents if they would like to file a grievance, and most chose to not file one. The Activities Director stated it had been a while since anyone had completed a grievance form. She stated she always asked the resident if the concern was happening all the time or only once, as that could be the difference between a concern and a grievance. She stated once she informed the appropriate department, they would take care of the concern. Interview with the Director of Nursing (DON), on 03/09/2023 at 9:37 AM, revealed grievances were handled by the SSD; however, if it was a concern, the team usually took care of those before they became a grievance. The DON stated the team usually discussed concerns from the residents or families in the morning meetings. She stated a grievance was a concern that was not taken care of. The DON stated when the Resident Council met and had concerns, those were grievances and were brought to the DON if they were nursing-related, and other concerns went to the SSD. She stated all concerns should be on the concern log (untitled facility form). She stated she did not recall any concern regarding Resident #42 and the other resident, who was no longer in the facility, but she was off work on 05/09/2022. She further stated she did not realize a grievance and concern would be the same thing. Additional interview with the Administrator, on 03/08/2023 at 9:48 AM, revealed the corporate office recently came to the facility and did a mock survey and identified that the facility's grievance process needed to be shored up. The Administrator indicated it was determined they needed to have one log with all the concerns listed. During a follow-up interview on 03/09/2023 at 10:48 AM, the Administrator stated his expectation regarding the grievance process was to ensure the facility identified areas where they could improve and to provide opportunities for residents, families, staff, and visitors to inform the facility of areas that needed to be investigated so they could be corrected. He further stated the facility's grievance and concern policy needed to be modified. The Administrator indicated the facility did have a process for taking grievances and concerns, which was functioning, but they would be switching to a different form and, going forward, would document on one form.

Based on observations, interviews, and facility policy review, it was determined the facility failed to ensure food was covered during transport to two (2) (Gold and [NAME] Hall) of five (5) resident hallways to prevent potential contamination of residents' food. This deficient practice had the potential to affect forty-six (46) residents who resided on the Gold and [NAME] Halls. Observations on 03/07/2023 and 03/08/2023, revealed staff parked a covered meal tray cart between Room nine (9) and Room ten (10) on the Gold Hall. Continued observation revealed staff carried residents' meal trays to Rooms #1 (one), #10 (10), and #12 (twelve). The meal trays contained sugar cookies, salads, and beverages that were uncovered and exposed to air. The findings include: Review of the facility's policy, Assistance with Meals, not dated, revealed the policy did not address covering food items during meal delivery. Observation on 03/07/2023 at 11:32 AM, revealed staff parked a covered meal tray cart between room [ROOM NUMBER] and room [ROOM NUMBER] on the Gold Hall. Continued observation revealed staff then carried residents' meal trays to room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]. The meal trays contained sugar cookies, salads, and beverages that were uncovered and exposed to air. Observation on 03/07/2023 from 11:50 AM to 12:03 PM, revealed staff delivered meal trays to Rooms 15, 16, 17, 18, 20, 22, and 24 on the [NAME] Hall. The meal trays contained salads which were uncovered and exposed to air. Observation and interview, on 03/08/2023 at 11:33 AM, revealed Certified Nurse Aide (CNA) #14 removed a meal tray from a covered meal tray cart parked near resident room [ROOM NUMBER] on the Gold Hall. The tray contained bowls of food that were uncovered. The CNA delivered the meal tray to the resident who resided in room [ROOM NUMBER]. CNA #14 stated the covered tray delivery cart was used to protect the food from other residents, germs, and contamination. CNA #14 revealed that due to the food on the tray being served in bowls, the food was not covered. Observation on 03/08/2023 at 11:39 AM, revealed Licensed Practical Nurse (LPN) #15 remove a resident's meal tray from the covered meal tray cart parked near resident room [ROOM NUMBER] on the Gold Hall. The tray contained apple juice and a dessert which were uncovered and exposed to air. LPN #15 delivered the meal tray to the resident who resided in room [ROOM NUMBER]. Interview on 03/08/2023 at 11:43 AM, with LPN #15, revealed the covered meal tray delivery cart was used to keep the food warm and protected from germs. LPN #15 stated it was a concern to have uncovered food on the trays when they were removed from the cart and transported down the hall. She revealed she had noticed the resident's drink and dessert were uncovered. LPN #15 stated dietary should cover all food items before the meal tray was placed on the cart. Interview on 03/08/2023 at 11:49 AM, with CNA #13, revealed the purpose of the covered cart was to keep the food warm and covered so the food was not exposed to germs. CNA #13 stated all food items on the meal tray should be covered to protect the food from contamination. Interview on 03/08/2023 at 1:08 PM, with the Certified Dietary Manager (CDM), revealed staff should try to get the closed cart as close to the resident's room as possible and then remove the tray and take it directly into the resident's room. The CDM stated the staff should not walk down the hallway with uncovered food items. Interview on 03/09/2023 at 9:10 AM, with the Registered Dietitian, revealed she expected the covered carts to get to the hall promptly and be as close to the resident's room as possible before the food was removed from the cart. Interview on 03/09/2023 at 9:31 AM, with the Administrator, revealed staff should take the covered cart either directly to the resident room or one to two rooms away before removing the tray from the cart. The Administrator stated that because the food items were covered until the meal tray arrived on the resident hallway, it was not a significant risk to walk the food uncovered a few feet to the residents' rooms. Interview on 03/09/2023 at 9:48 AM, with the Director of Nursing (DON), revealed residents should receive their food hot and in a sanitary manner. The DON stated staff should push the cart down the hall to the resident rooms as the staff delivered the meal trays.

Based on interviews, record review, facility document review, and facility policy review, it was determined the facility failed to protect a resident's right to be free from physical abuse by another resident for one (1) of two (2) sampled residents reviewed for abuse (Resident #125) of a total sample size of twenty-nine (29) residents. Review of a Long Term Care Facility-Self-Reported Incident Form, dated 04/04/2022, revealed Resident #31 slapped Resident #125 while the residents were in the lobby. The findings include: Review of the facility's policy, Abuse Policy, not dated, revealed, Purpose Reporting and Investigation of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of resident/patient's property. Definitions 'Abuse' means the willful (the individual must have acted deliberately, not that they must have intent to injury or harm) infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. 1. Record review revealed the facility admitted Resident #125 11/06/2021 with diagnoses which included Alzheimer's Disease, Anxiety Disorder, and Psychotic Disorder. Review of a Quarterly Minimum Data Set (MDS) assessment, dated 07/27/2022, revealed Resident #125 had a Brief Interview for Mental Status (BIMS) score of one (1), indicating the resident had severe cognitive impairment. The MDS indicated the resident had no behavioral symptoms. According to the MDS, the resident required extensive assistance with transfer and required supervision with locomotion on or off the unit. Review of Resident #125's Care Plan, dated as initiated 11/08/2021, revealed a focus area of behavioral symptoms and indicated the resident had a behavior problem at times related to Alzheimer's type Dementia, Psychotic Disorder with hallucinations at times, anxiety, and depression. Further review revealed the resident was unaware of safety and health needs and would put his/her hands in feces and rub them on themselves and would wander into other residents' rooms and take their belongings. Interventions directed staff to observe the resident for behavioral episodes and to attempt to determine the underlying cause. 2. Record review revealed the facility readmitted Resident #31 01/09/2023 with diagnoses which included Bipolar Disorder, Psychosis, and Schizoaffective Disorder. Review of a Significant Change Minimum Data Set (MDS) assessment, dated 01/13/2023, revealed Resident #31 had a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicating the resident was cognitively intact. Further review of the MDS, indicated the resident had no behavioral symptoms. According to the MDS, the resident required extensive assistance with transfer and required supervision with locomotion on and off the unit. Review of Resident #31's Care Plan, dated 08/16/2022, revealed a focus area of behavioral symptoms and indicated the resident had behavior problems of offering other residents food and drinks, requesting items from dietary and giving them away to other residents, seeing things that were not there, physically aggressive behaviors toward others and negative statements/cursing others. Further review of the care plan included interventions directing staff to intervene when necessary to protect the rights and safety of others. Review of a Long Term Care Facility-Self-Reported Incident Form, dated 04/04/2022, revealed the facility notified the state survey agency of an abuse allegation on 04/04/2022. The description of the incident indicated Resident #31 slapped Resident #125 while the residents were in the lobby. The residents were immediately separated. Review of a Resident Investigation Tool for Allegation of Abuse Neglect, Misappropriation of Resident Property, dated 04/04/2022, revealed Resident #125 was yelling for a male resident to stop yelling. Resident #31 approached Resident #125 and told them not to yell at the male resident and smacked Resident #125. The form indicated Resident #125 was not injured during the incident. Review of Resident #125's Progress Notes, dated 04/04/2022, revealed Resident #125 was sitting in the lobby yelling at another resident when an alert and oriented resident (Resident #31) approached Resident #125 and made contact with the resident. Resident #125 was assisted back to his/her room. Review of Resident #31's Progress Notes, dated 04/04/2022, revealed staff reported to the Social Services Director (SSD) that Resident #31 approached another resident and made contact with a disoriented and confused resident (Resident #125). Resident #31 stated the other resident (Resident #125) was laughing and yelling and they were tired of hearing it. Resident #31 was educated on the importance of not hitting other residents. Resident #31 was also notified they were being sent to a medical center for a psychiatric/behavioral evaluation. Review of Resident #125's One Time Skin Review, dated 04/04/2022, revealed Resident #125 did not have any new skin issues. Review of Resident #31's Patient Health Summary, dated 04/04/2022, revealed Resident #31 was evaluated for agitation and hitting. Review of Resident #31's Med [Medication] Management Note, dated 04/05/2022, revealed the provider recommended medication changes, including increasing the resident's dose of Abilify (an antipsychotic medication) to fifteen (15) milligrams (mg) daily, due to Resident #31's worsening fluctuations of mood, paranoia, and behaviors. The note indicated Resident #31 had been verbally aggressive, cursing at staff, and hit another resident in the face on 04/04/2022. Review of Progress Notes, dated 04/01/2022 through 05/01/2022, revealed no other resident-to-resident altercations involving Resident #31. Interview with Resident #31, on 03/07/2023 at 3:14 PM, revealed he/she couldn't remember the incident with Resident #125. Interview on 03/08/2023 at 11:06 AM, with Certified Nurse Aide (CNA) #16, revealed she saw Resident #125 yelling, which upset Resident #31. Resident #31 then hit Resident #125. CNA #16 did not remember where Resident #125 was hit. The CNA stated Resident #125 did not report any pain. CNA #16 stated she did not work with Resident #31 a lot, so she did not know what behaviors the resident had prior to the incident. Interview on 03/08/2023 at 1:05 PM, with the Social Services Director (SSD), revealed she did not remember the incident between Resident #125 and Resident #31. She stated Resident #31 was sent out in the past for a behavioral health stay. The SSD could not remember if the incident with Resident #125 had triggered Resident #31's behavioral health stay. Interview on 03/09/2022 at 9:56 AM, with the Director of Nursing (DON), revealed she did not really remember the incident between Resident #31 and Resident #125. She did not recall if or where Resident #31 hit Resident #125. The DON stated Resident #31 had never gotten physically angry prior to this and it had not happened again since. The DON stated Resident #31 had a tele-health appointment with their doctor and was sent for an evaluation. Interview with the Administrator, on 03/09/2022 at 10:19 AM, revealed he was on vacation when the incident in question occurred. He stated for a resident-to-resident altercation, he would expect staff to intervene, separate the residents, report to the nurse, and contact the SSD, the DON, and/or the Administrator.

Based on interview, record review, and review of facility protocol, it was determined the facility failed to provide pharmaceutical services related to acquiring and administering drugs to meet the needs of its residents for one (1) of ten (10) sampled residents (Resident #8). Resident #8 was admitted to the facility on [DATE] at 7:40 PM and was discharged from the facility on 07/07/2021 at 4:45 PM. During the resident's stay at the facility the resident did not receive medications as ordered and missed two (2) doses of oral [MEDICATION(S)] antibiotic HCL Solution (50 milligrams (mg)/milliliter (ml), give 5 ml which was ordered to treat [CONDITION(S)]. Additionally, the resident missed one (1) dose of the following medications: [MEDICATION(S)] HCL ER (SR) 150 mg tablet (antidepressant medication); [MEDICATION(S)] 1000 mg (to treat low levels of Vitamin B); [MEDICATION(S)] HCL 30 mg (antidepressant medication); [MEDICATION(S)] 2.5 mg (medication used to treat hypertension); [MEDICATION(S)] Packet 4 Grams (GM) (medication to reduce cholesterol); Famotidine 20 mg (gastric acid secretion reducer); [MEDICATION(S)] 650 mg (antacid); and Saccharomyces boulardii 250 mg (probiotic). Interview with Resident #8's son revealed he took the resident home due to the facility failing to administer the resident's medications. The findings include: Review of the Facility Process for Admission orders, undated, revealed: (1) Transcribe orders into Point, Click, Care (PCC) (computerized system); (2) Once orders are transcribed into PCC, the pharmacy will fill orders and send out on next delivery as there are two (2) deliveries daily; (3) If there is a medication needed prior to delivery, the nurse is to check the Cubex (automated medication dispensing system). If the needed medication is not in the Cubex, the Pharmacy is to be called and medication is to be requested to be sent from the back up pharmacy. Closed record review revealed the facility admitted Resident #8 on 07/06/2021 at 7:40 PM, with diagnoses including Enterocolitis due to [CONDITION(S)] (infection of the large intestine caused by [CONDITION(S)] bacteria); [CONDITION(S)] and [CONDITION(S)] following Cerebral Infarction affecting Left Non-Dominant side; and [CONDITION(S)], Unspecified. Review of the Admission Minimum Data Set (MDS) Assessment, dated 07/07/2021, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating intact cognition. Further record review revealed Resident #8 was discharged from the facility on 07/07/2021 at 4:45 PM. Resident #8's Physician's orders, dated 07/06/2021, revealed orders for [MEDICATION(S)] HCL Solution 50 mg/ml, give 5 milliliters orally every six (6) hours until 07/19/2021, then give 2.5 ml every six (6) hours until 07/26/2021, then give 2.5 ml every twelve (12) hours until 08/02/2021 for [CONDITION(S)]. Further review revealed orders dated 07/06/2021 for [MEDICATION(S)] HCL ER (SR) 150 milligrams (mg) tablet two (2) times a day; [MEDICATION(S)] 1000 mg daily; [MEDICATION(S)] HCL 30 mg daily; [MEDICATION(S)] 2.5 mg daily; [MEDICATION(S)] Packet 4 Grams (GM) daily; Famotidine 20 mg daily; [MEDICATION(S)] 650 mg, one tablet by mouth two (2) times daily; and Saccharomyces boulardii 250 mg, one tablet two (2) times daily. Review of Resident #8's Medication Administration Record (MAR), dated July 2021, revealed the resident did not receive any medications during his/her stay at the facility from admission on 07/06/2021 at 7:40 PM through discharge on 07/07/2021 at 4:45 PM. Per the MAR, the resident missed two (2) doses of [MEDICATION(S)] medication HCL Solution 50 milligrams (mg)/milliliter (ml), give 5 milliliters (ml) which was to be administered on 07/07/2021 at midnight and 07/07/2021 at 10:00 AM. Further review of the MAR revealed the resident missed one (1) dose of the following medications: [MEDICATION(S)] HCL ER (SR) 150 milligrams (mg) tablet; [MEDICATION(S)] 1000 mg; [MEDICATION(S)] HCL 30 mg; [MEDICATION(S)] 2.5 mg; [MEDICATION(S)] Packet 4 Grams (GM); Famotidine 20 mg; [MEDICATION(S)] 650 mg and Saccharomyces boulardii 250 mg which were all to be administered on 07/07/2021 at 10:00 AM. Telephone interview with Resident #8's son, on 03/15/2022 at 1:40 PM, revealed the facility admitted the resident on 07/06/2021 in the evening hours, although he could not remember the time of admission. Per interview, he called Resident #8 the morning of 07/07/2021 and the resident complained he/she had not received any of his/her medications. Continued interview revealed the resident's son spoke with the Director of Nursing (DON) on the morning of 07/07/2021 after talking with Resident #8. He stated he informed the DON the resident had not received any of his/her medications. Per interview, he was under the impression the DON was going to administer the resident's medications after the phone call. Additional interview revealed Resident #8's son called the resident on 07/07/2021 at 3:30 PM and the resident stated he/she still had not received his/her medications. Further, the resident's son then came to the facility to bring Resident #8 home due to the resident not receiving ordered medications. Additional interview revealed he went to the pharmacy and was able to obtain Resident #8's medications within ten (10) minutes. The resident's son stated he was very concerned that Resident #8 did not receive his/her [MEDICATION(S)] antibiotic for [CONDITION(S)]. Telephone interview with Registered Nurse (RN) #1, on 03/17/2022 at 9:40 AM, revealed Resident #8 was admitted to the facility on the evening of 07/06/2021 and she was unsure why the resident did not receive his/her dose of [MEDICATION(S)] due at midnight on 07/07/2021 by the nurse assigned. Per interview, RN #1 came on duty on 07/07/2021 at 6:00 AM. She stated Resident #8's 10:00 AM medications were not administered on 07/07/2021 by the Certified Medication Technician (CMT) as the medications had not arrived from pharmacy and she (RN #1) was not notified timely by the CMT that the medications had not arrived in order to obtain them from the Cubex. Further, she was responsible to administer the resident's 10:00 AM dose of [MEDICATION(S)] on 07/07/2021; however, she was also waiting on this medication to come from pharmacy in a pre-mixed suspension. RN #1 stated she called pharmacy the morning of 07/07/2021 and was instructed to mix the IV [MEDICATION(S)] medication which came in a vial in a powdered form with sterile water to administer orally. RN #1 further stated she obtained the IV [MEDICATION(S)] from the Cubex and then had to go to the pharmacy to pick up the sterile water to mix the [MEDICATION(S)] medication as the sterile water was not in the Cubex. RN #1 stated by the time she had received all of Resident #8's oral medications from pharmacy and had prepared the [MEDICATION(S)] for administration, it was 4:30 PM. Per interview, Resident #8's son was in the facility to take him/her home at that time and refused to allow the nurse to administer the medication. RN #2 stated the resident was discharged on [DATE] at 4:45 PM. Continued interview revealed Resident #8 did not receive any of his/her ordered medications on 07/07/2021. Telephone interview with Consultant Pharmacist #1, on 03/17/2022 at 1:06 PM, and 03/17/2022 at 3:00 PM, revealed when a resident was admitted to the facility after 7:00 PM, the resident was to have medication administered as ordered. Per interview, if the resident's medication did not arrive at the facility on time for administration, the nurse should let the Pharmacist know in order for the Pharmacist to call the back- up pharmacy to deliver the medication. Consultant Pharmacist #1 stated there were also medications available in the Cubex at the facility. Further interview revealed [MEDICATION(S)] could be reconstituted and administered orally by an RN or Licensed Practical Nurse (LPN) and if the nurse had questions as to how to reconstitute the medication, the nurse could consult with the Pharmacist. Interview with the Director of Nursing (DON), on 03/16/2022 at 9:30 AM, revealed a resident should never miss their medications. Per interview, pharmacy was to be notified immediately of all new admissions, and nurses were to ensure all medications were available within four (4) hours of a resident's admission. The DON stated Stat medications were to be called to the facility pharmacy who would notify the back-up pharmacy. Further, a lot of medications were in the facility's Cubex Medication box to be obtained in the instance in which a medication was not immediately available from pharmacy. Continued interview revealed the nurses thought the [MEDICATION(S)] antibiotic should be mixed at the pharmacy and be sent in oral suspension and were not familiar with mixing the [MEDICATION(S)] for oral suspension. The DON stated after the incident involving Resident #8, the facility identified the need for staff education. Per interview, the nurses and Certified Medication Technician (CMT) were educated on 07/09/2021 on which medications were kept in the Cubex and the need for the CMTs to notify the nurse timely if medications were not available for administration. Interview with the Administrator on 03/17/2022 at 12:50 PM, revealed it was his expectation medication be made available for new admissions in a timely manner. He stated he would expect the nurses to follow protocol and call the facility pharmacy to have the back-up pharmacy acquire the medication when needed. Further interview revealed after this incident involving Resident #8, he identified the need for auditing through Quality Assurance related to new admissions receiving medications. He stated audits had been performed on new admissions over the last three (3) months to review medication administration. Further, the facility also identified the need for nursing education related to new admissions and obtaining resident medication and this education was completed on 07/08/2021 with nurses and CMTs.

Based on interview, Employee Files review, and review of the Certified Medication Technicians (CMTs) Job Description Summary, it was determined the facility failed to have an effective system to validate the credentials for two (2) of six (6) sampled employees hired as Certified Medication Technicians (Employee #7 and #8). Interview and record review revealed the facility did not validate Employee #7 and Employee #8's credentials related to ability to administer medications, and allowed the employees to administer medications to residents. Employee #7 was hired on 04/16/2019 and administered medications through 03/16/2022 until Surveyor intervention; and Employee #8 was hired on 05/25/2021 and administered medications through November 2021. However, there was no documented evidence Employee #7 and Employee #8 were certified as CMTs. The findings include: Review of the Certified Medication Technicians (CMTs) Job Description Summary, dated 12/2018, revealed the Certified Medication Technicians (CMTs) administer medications to residents as ordered by the attending physician, under the direction of the charge nurse and the Director of Nursing. The administration of medication shall be in accordance with established nursing standards, the policies, procedures and practices of this facility and the requirements of this state. Further review of Job Requirements revealed current Medication Aide Certification was required. 1. Review of Employee #7's Employee File, revealed she was hired in the position of Certified Nursing Assistant/Certified Medication Technician (CNA/CMT) with a hire date of 04/16/2019. Although Employee #7's credentials for CNA were verified, there was no documented evidence the employee had completed the Kentucky Medication Aide (KMA) classes and no documented evidence the facility validated the employees CMT credentials prior to hire. There was a photocopy of a letter with Employee #7's name, congratulating her on passing the Kentucky Medication Aide State Exam written test from the Kentucky Community & Technical College, but the letter was not dated, and the letterhead was missing. Continued review of the Employee File, revealed Employee #7 was still employed and was working as a CMT at the facility. Interview with Employee #7, on 03/15/2022 at 2:55 PM, revealed she administered medications from April 2021 through March 2022 at the facility. She stated she had attended the Kentucky Medication Aide (KMA) class in 2008 or 2009 and completed clinicals at a local nursing facility. She further stated she sent a copy of her letter showing completion of the KMA class to the facility a few months ago. The State Survey Agency (SSA) Representative asked for a copy of her letter as the copy in her file was not dated, and could not be accepted. Employee #7 stated she would look for the letter; however, it was not provided. 2. Review of Employee #8's Employee File, revealed the employee was hired on 05/25/2021 in the position of CNA/CMT. Although the employees credentials for CNA were verified, there was no documented evidence the employee had completed the Kentucky Medication Aide (KMA) classes and no documented evidence the facility validated the employees CMT credentials prior to hire. Continued review revealed CNA #8 resigned on 12/31/2021. Interview with Employee #8, on 03/15/2022 at 1:55 PM, revealed she had applied for a CMT position and was hired at the facility in May 2021. She stated she had worked as a CMT June 2021 through November 2021, often working twelve to sixteen (12-16) hour days on the medication cart. Further, she had completed an online class through a Medical Academy, but had not attended KMA/medication administration classes and had not had clinical experience related to medication administration prior to hire at the facility. Per interview, she was unaware her Med Tech Training Certificate for the six (6) hour credit course was not meant for a long-term care setting until the Director of Nursing (DON) and Administrator removed her from the CMT position in November 2021. Review of an email, dated 03/16/2022, from the Program Coordinator at the local Kentucky Community & Technical College, revealed she had verified with the Registrar's Office that neither Employee #7 or Employee #8 was ever enrolled in Kentucky Medication Aide (KMA) courses at the Kentucky Community & Technical Colleges. Interview with the Staff Development Coordinator (SDC), on 03/16/2022 at 2:23 PM, revealed she had been the SDC for approximately eight (8) months and was responsible for validating the credentials for new employees. She further stated she checked the Board of Nursing website to validate credentials of licensed staff and CNAs. She further stated a request for KMA validation had to be completed via fax or email through the KMA data base. Further, a CNA was required to take the Kentucky Medication Aide (KMA) classes and pass a state test before working as a CMT. She stated she was unaware that Employee #7 and #8 were not certified to administer medications. Per interview, she was not in the SDC position at the time these employees were hired, and therefore did not validate their credentials. Interview with the Director of Nursing (DON), on 03/17/2022 at 11:16 AM, revealed only licensed nurses and Certified Medication Technicians could administer medications. The DON stated Employee #7 was hired as a CMT to pass medications and she (DON) was not aware this employee was not certified to pass medications until the State Survey Agency (SSA) Representative informed her on 03/16/2022. Further interview revealed she requested CMT credentials from Employee #7 in November 2021. Per interview, after this request, Employee #7 sent a photo of her KMA letter stating she had passed the state test and this was put in her employee file. However, the DON admitted the letter was not dated and the letterhead was not attached. Continued interview with the DON, on 03/17/2022 at 11:16 AM, revealed Employee #8 brought in a certificate for Med Tech Training from the Medical Academy. The DON stated she called the local Community College in November 2021 in regards to the Medical Academy online class and was told it could not be used in the long-term care setting. She stated she also received an email from the Community College verifying this. Per interview, Employee #8 was removed from the medication cart upon the DON gaining this information, and then resigned on 12/31/2021. Further interview revealed Employee #7 and Employee #8's credentials as a CMT should have been validated when they were hired. Per interview, Employee #7 and Employee #8 did not have valid letters of completion in their employee files nor did they have validation of CMT credentials. Interview with the Administrator, on 03/17/2022 at 11:35 AM, revealed the DON made him aware that Employee #8 was not certified to pass medications in November 2021 and this employee was removed from the CMT position. He further stated Employee #7 had worked as a CMT since May of 2019 and he was unaware until this survey that this employee's credentials were not validated prior to hire. Per interview, Employee #7 was removed from the medication cart upon the SSA Representative identifying Employee #7 was not certified as a KMA. He stated the previous SDC should have validated the credentials of Employee #7 and Employee #8 prior to hire for the CMT position.

Based on observation, interview, record review, review of CDC guidelines, and facility policy and information handout review, it was determined the facility failed to ensure infection control practices to prevent the spread of COVID-19 were implemented per facility policy. Observations revealed one (1) staff failed to don personal protective equipment (gloves, gown, and face shield) when entering a resident's room (Resident #3) who was on droplet precautions; and two (2) staff failed to ensure masks covered nose and mouth when worn in facility. Review of a list of Residents in isolation provided by facility on 10/06/2020 revealed nine (9) residents were on droplet precautions. The findings include: Review of facility policy titled. Identification of Possible COVID-19 Protocol, last revised 04/09/2020 revealed the facility should provide the right supplies to ensure easy and correct use of PPE. Make PPE, including facemasks, eye protection, gown, and gloves available immediately outside of the resident room. Review of a facility information handout titled, Dos and Don'ts of COVID-19, revealed COVID-19 is currently a droplet [MEDICAL CONDITION]. If a resident is on precautions make sure you know the correct type and wear these correctly each time you enter the room. For example, for a resident on droplet precautions you would need to don gloves, gown, mask, and eye protection. Review of CDC guidelines dated July 15, 2020 revealed Health Care Professionals (HCP) should wear a facemask at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers. When available, facemasks are preferred over cloth face coverings for HCP as facemasks offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others. Cloth face coverings should NOT be worn instead of a respirator or facemask if more than source control is needed. To reduce the number of times HCP must touch their face and potential risk for self-contamination, HCP should consider continuing to wear the same respirator or facemask (extended use) throughout their entire work shift, instead of intermittently switching back to their cloth face covering. 1. Record review revealed the facility admitted Resident #3 on 09/28/2020 with diagnoses, which included Heart Failure, Aftercare following Joint Replacement Surgery, Type 2 Diabetes Mellitus, and Acute [MEDICAL CONDITION]. Review of Resident #3's baseline care plan revealed Resident #3 to be on transmission-based precautions, with COVID testing initiated by facility. Observation on 10/06/2020 at 1:03 PM revealed Certified Medication Assistant (CMA) #1 entered Resident #3's room to provide coffee to the resident without donning a gown, gloves or face shield. Further observation revealed the coffee cup was placed on over bed table directly in front of resident. There was a sign on the door that read, Stop, please check with nurse before entering. Interview with CMA #1 on 10/06/2020 at 1:05 PM revealed she was supposed to wear personal protective equipment (PPE) in room to include (gown/gloves/mask). CMA #1 stated the resident is on droplet precautions for COVID 19 due to being a new admit. She revealed the distance from resident to the coffee cup placed on the table was less than six (6) feet and she should have worn the PPE (gown/gloves/mask) when going into the room. 2. Observation on 10/06/2020 at 1:50 PM revealed Certified Nursing Assistant (CNA) #1 was wearing a mask below nose while on residential hallway--providing care. In addition, observation on 10/07/2020 at 3:50 PM revealed CNA #2 standing at kiosk, putting in information with mask pulled down to chin exposing nose and mouth. Interviews on 10/06/2020 at 1:50 PM with CNA #1 and on 10/07/2020 at 3:50 PM with CNA #2 revealed masks should be worn at all times and should cover the nose and mouth. Interview with Staff Development Coordinator/Infection Control Nurse (SDC/IFCN) on 10/07/2020 at 8:40 AM revealed staff should wear gown, mask and gloves when entering residents' rooms who are on isolation precautions to protect staff from the resident (if they come from hospital) and to protect the resident from staff as well. Additionally, SDC/IFCN stated any new admits are put on isolation and if we send anyone out they are put on isolation for fourteen (14) days when they return. She further revealed she expected all staff to wear masks when in facility and to ensure the mask is covering their nose and mouth when worn. Interview with the Director of Nursing (DON) on 10/06/2020 at 3:42 PM and 10/07/2020 at 3:38 PM and 4:45 PM, revealed she expected masks to be worn above ears an over nose and mouth when in facility. The DON stated PPE is in the bins outside the door of isolation rooms to make it easier for the staff to access and should be used anytime they go into the room to provide direct care. The DON further revealed staff should wear the PPE all the time (gown, gloves, mask, face shield) if close enough to cough or sneeze on them. Interview with Administrator on 10/07/2020 at 4:55 PM revealed masks and PPE should be worn according to Center for Disease Control (CDC) guidelines.

Based on observation, interview, and review of facility policy, it was determined the facility failed to serve food in accordance with professional standards for food service safety related to lack of hand sanitation during meal pass. The findings include: Review of facility policy,Assisting the Resident with In-Room Meals, not dated, revealed if there is contact with soiled dishes, clothing or the resident's personal effects, the employee must wash his/her hands before serving food to the next resident. Observation during a meal pass on 12/02/19 at 12:06 PM, on the one-hundred West Hall (100) hall, revealed a staff member failed to sanitize her hands while distributing and setting up trays for three residents. Further observation revealed she pulled soiled privacy curtains twice during the tray pass and failed to sanitize her hands. Interview with Certified Nurse Aide (CNA) #1 on 12/02/19 at 12:19 PM, revealed she should have sanitized her hands after touching contaminated items and in between residents while passing trays. Interview with the Director of Nursing (DON) on 12/04/19 at 2:32 PM, revealed she would expect the aides to sanitize their hands after touching any contaminated item and after each resident, to prevent the spread of infections.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure drugs and biological's used in the facility must be labeled in accordance with currently accepted professional principles, and include the the expiration date when applicable related to four (4) insulin pens not being dated when opened; and a bottle of Tums not being stored appropriately. The findings include: Review of the facility's policy, titled, Storage of Medication, not dated, revealed if a medication was not dated the facility was to use the pharmacy dispense date as the date opened. Further review of the policy revealed Review of the facility's policy revealed the facility shall store all drugs and biological's in a safe, secure, and orderly manner. Observation of two (2) of four (4) medication carts, on 12/02/19 at 2:06 PM, revealed one (1) medication cart with four (4) insulin pens not dated when opened. Interviews on 12/02/19 with Licensed Practical Nurse (LPN) #1 at 2:15 PM and LPN #2 at 2:20 PM revealed any multi-dose vial of medication should be dated when opened. Interview with Assistant Chief Nursing Executive (CNE), on 12/02/19 at 2:24 PM, revealed multi-dose vials of medications should be dated when opened and when an insulin is noted to not be dated when opened, it should be discarded and a new one ordered. Interview with the CNE, on 12/04/19 10:17 AM, revealed the facility policy was a backup in case a multi dose was found not dated so they would not have to discard the medication. She stated her expectation was for nursing to follow the regulation. Interview with the Administrator, on 12/04/19 at 10:01 AM, revealed his expectations were for staff to follow the facility policy, however the facility policy stated to follow the delivery date and if they were within the thirty (30) days of delivery, the insulin would still be used regardless of whether or not it was dated when opened. He revealed if the facility policy was in conflict with the regulation, then he would rely on his clinical staff to make the determination as to whether or not to use the undated vial. 2. Record review revealed the facility readmitted Resident #69 on 07/27/15, with [DIAGNOSES REDACTED]. Observation of Resident #69's room on 12/02/19 at 11:34 AM and 12/03/19 at 8:55 AM, revealed a bottle of Tums on a bedside table. Interview with Registered Nurse (RN) #1 on 12/04/19 at 2:29 PM, revealed no medication should be left unattended at the bedside. She stated if the staff noticed the bottle of Tums, they should have been removed. Interview with the Director of Nursing (DON) on 12/04/19 at 2:34 PM, revealed the Tums should not be at the bedside and if noticed by staff, they should have been removed. The DON stated the resident's son may have brought them in.

Based on observation, interview, and record review, it was determined the facility failed to ensure two (2) of three (3) sampled residents reviewed for respiratory care in the selcted sample of eighteen (18) received necessary respiratory care and services that is in accordance with professional standards (Residents #69 and #72). Observations on 12/02/19, 12/03/19, and 12/04/19, revealed Resident #69's nebulizer was not being stored properly when not in use. Further observation revealed Resident #72 did not have a No Smoking/Oxygen in use sign posted outside the door. The findings include: Review of the facility policy, Oxygen Administration, not dated, revealed in order to ensure safe oxygen administration a No Smoking/Oxygen in Use sign should be placed outside of the room entrance door. Review of the facility policy, Administering Medications through a Small Volume Nebulizer, not dated, revealed equipment should be stored in a plastic bag when not in use. Record review revealed the facility admitted Resident #69 on 07/27/15, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 11/12/19, revealed the facility assessed Resident #69's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated the resident was interviewable. Review of Resident #69's Physician's Order Summary for (MONTH) 2019, revealed an order for [REDACTED]. Observations on 12/02/19 at 11:34 AM, 12/03/19 at 8:54 AM, and 12/04/19 at 8:55 AM, revealed Resident #69 in his/her room. Further observation revealed his/her nebulizer laying on a beside table, located near the resident, not stored in a plastic bag. 2. Record review revealed the facility admitted Resident #72 on 10/25/14, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 11/14/19, revealed the facility assessed Resident #72's cognition as impaired with a Brief Interview for Mental Status (BIMS) score of four (4), which indicated the resident was not interviewable. Review of Resident #72's Physician's Order Summary for (MONTH) 2019, revealed an order for [REDACTED]. Interview with Registered Nurse (RN) #1 on 12/04/19 at 2:29 PM, revealed nebulizer equipment should be bagged when not in use to prevent contamination. She further stated an oxygen in use sign should be posted outside the residents room to alert family and staff of oxygen use. Interview with the Director of Nursing (DON) on 12/04/19 at 2:34 PM, revealed she would expect nursing to place the nebulizer and equipment in a plastic bag to keep the items clean. The DON further stated an oxygen sign should be posted outside the residents door when oxygen is in use to let staff and visitors know oxygen is being used.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure the care plan was reviewed and revised for one (1) of eighteen (18) sampled residents (Resident #40). Resident #40 was on anti-coagulant therapy and required diabetic care for insulin dependent diabetes; however, there were no interventions documented on the Certified Nurse Aide (CNA) care plans so the CNA's would know what care/precautions to provide the resident. The findings included: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, dated (MONTH) (YEAR) revealed a Comprehensive, person-center care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan will include measurable objectives and timeframe's and will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The Interdisciplinary Team must review and update the care plan when there has been a significant change in the resident's condition, when the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly Minimum Data Set (MDS) assessment. Record review revealed the facility admitted Resident #40 on 07/11/19 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 10/15/19 revealed the facility assessed Resident #40's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fourteen (14) which indicated the resident was interviewable. Further review of the MDS found the resident's functional status of personal hygiene required extensive assist of two staff. and the resident received anticoagulant therapy five days and insulin seven days. Review of Resident #40's Physician orders for (MONTH) 2019 revealed an order for [REDACTED]. The resident also received Humalog insulin sliding scale. Review of the Comprehensive Care Plan for Risk for Abnormal Bleed related to Multi Med use including anticoagulant and blood thinner revealed interventions to observe for signs/symptoms of bleeding such as hematuria, petechiae, easy excessive bruising, bleeding gums, positive hemoccult, hemoptysis, abnormal labs, change in vital signs and to notify medical doctor or nurse practioner for abnormal's. These interventions were for the CNA, Registered Nurse, Licensed Practical Nurse, Physical Therapy, and Occupational Therapy. However, review of Resident 40's CNA Care Plan, not dated revealed there were no precautions/interventions to address the resident being on anticoagulant therapy. Review of the Comprehensive Care Plan for Risk for abnormal blood sugars related to Diabetes Mellitus dated 07/18/19 with interventions/task of accu checks, meds, labs, supplements, diagnostic test as order, vital signs as indicated, encourage adequate nutritional intake, observe for [MEDICAL CONDITION] such as thirst, headache, blurred vision, increased urination, weight loss, abnormal accu checks, abnormal labs, observe for symptoms of [DIAGNOSES REDACTED] such as shakiness, hunger, light headed, headache blurred vision, excessive sweating, confusion, and provide interventions accordingly. Further review revealed there were no interventions to address the resident's skin care due to the Diabetes Mellitis. Interview with CNA #3 on 12/14/19 at 1:48 PM revealed she provided care for Resident #40 but she has had no training on anti-coagulant therapy regarding care of skin and what to watch for. She stated she guessed they may have increased bleeding. She further revealed, as she took out her care guide, this is what I go by to care for my residents. Her CNA care plan revealed no special instructions for Resident #40 related to his/her anti-coagulant therapy or diabetic care. She revealed she was aware the resident was a diabetic and noted the resident would eat an increased amount of snacks brought in from family. She was not aware of signs and symptoms of a resident with high or low blood sugar and stated she had received no training on diabetic care. She did reveal she knew she could not cut the resident's toe nails. Interview with CNA #4 on 12/14/19 at 2:14 PM revealed she provided care for Resident #40 on a regular basis and she did not know the resident was on an anti-coagulant/blood thinner; however she was aware the resident was a diabetic and on insulin. She stated she has had no training on that. She further revealed she goes by what is on the CNA Care Plan for all residents care. She was also aware she was unable to clip toe nails on diabetic residents. Interview on 12/14/19 at 2:30 PM with the MDS Coordinator revealed she had been adding bleeding risks if a resident is on anticoagulants; however, she had not placed those on Resident #40's CNA care plan yet. She also revealed diabetic care should be on the CNA care plans. Interview on 12/04/19 at 3:16 PM with the Director of Nursing (DON) revealed there was no special training for residents on anti-coagulant therapy for CNA's. She stated, the CNA knows how to report things. She stated she would revise the CNA care plans/Kardex to reflect special care for residents on anti-coagulant therapy and diabetic care. She also revealed she thought word of mouth was good enough for CNA's to learn about residents needs. Interview with MDS Coordinator and Administrator on 12/04/19 at 3:47 PM after review of the CNA Kardex and Care Guide revealed there was no documented evidence of care for a resident with anti coagulant therapy and diabetic care and agreed the information was important and should be on the CNA care guide.

Based on observation and interview it was determined the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Observations of the kitchen revealed dirty kitchen equipment and foods left out and uncovered. Review of the facility Census and Condition, dated 09/05/18, revealed eighty-six (86) of eighty-nine (89) residents received their meals from the kitchen. The findings include: Interview with the Dietary Manager on 09/07/18 at 1:08 PM, revealed the facility does not have any specific policies on any kitchen area and they follow the state and federal regulations. 1. Observation of the reach in refrigerator on 09/04/18 at 3:18 PM, revealed the inside area had food particles and remnants of food all over the bottom area and a visible build up of brown and white material on the inside of both doors. Interview with Dietary Aide #1 on 09/04/18 at 3:34 PM, revealed the refrigerator was supposed to be cleaned out the day before, but she had got behind and had not done it. 2. Observation of the kitchen on 09/04/18 at 3:30 PM, revealed two (2) pans of cinnamon rolls laying out on the counter uncovered with several observations of flies landing all on them. Interview with the Dietary Manager on 09/04/18 at 3:30 PM, revealed the cinnamon rolls had been laying out uncovered for about a hour. 3. Observation of the kitchen on 09/04/18 at 3:11 PM, revealed the kitchen's can opener had a build-up of a yellowish dry material on the cutting edge area and area surrounding the cutting edge. 4. Observation of the oven on 09/04/18 at 3:34 PM, revealed the left oven was visibly soiled/dirty with several areas of black crusty build up present. Interview with the Dietary Manager on 09/07/18 at 1:08 PM, revealed she expected the can opener to be cleaned after each use, any spill or dropping of foods to be cleaned up immediately, the refrigerator to be cleaned out on night shift, and the oven to be cleaned as they go if they spill something along with weekly as scheduled. She stated she expected foods to not be left out uncovered as it is a potential infection control issue.

Based on interview, record review, and review of the facility policy, it was determined the facility failed to ensure a written notice of transfer/discharge, which included the reason for the resident's transfer, was sent to a representative of the Office of the State Long-Term Care Ombudsman for three (3) of twenty (20) sampled residents (Residents #7, #52, and #78). Record review for Residents #7, #52, and #78 revealed no documented evidence a representative of the Office of the State Long-Term Care Ombudsman was notified of resident transfers. The finding include: Review of the facility policy titled, Transfer & Discharge, dated 11/01/16, revealed the facility shall permit each resident to remain at the center, and not transfer or discharge the resident from the center except in accordance with Federal and State laws. Notice requirements included, before the facility transfers or discharges the resident, it shall notify the resident and the resident's representative of the basis for the transfer or discharge in a language and manner they understand; and will also notify the State Long-Term Care Ombudsman. 1. Record review revealed the facility admitted Resident #52 on 09/08/17 with [DIAGNOSES REDACTED]. Review of the Physician Order dated 06/26/18, revealed to transfer to behavioral health. However, further review of the medical record revealed there was no documented evidence a representative of the Office of the State Long-Term Care Ombudsman was notified of the resident's transfer. 2. Record review revealed the facility admitted Resident #7 to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Nurse's Note, dated 07/18/18, revealed Resident #7, left the facility per wheelchair and was transferred to the local hospital for surgery this morning. However, further review of the clinical record revealed there was no documented evidence a representative of the State Long-Term care Ombudsman was notified of the transfer. 3. Record review revealed the facility admitted Resident #78 to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Nurse's Note, dated 07/31/18, revealed Resident #78 was transferred to a local hospital on [DATE] for Urinary Tract Infection [MEDICAL CONDITIONS] and Pneumonia. Review of Resident #78's hospital discharge summary, revealed Resident #78 was admitted to the hospital on [DATE] and discharged back to the facility on [DATE], with a discharge [DIAGNOSES REDACTED]. However; further review of the clinical record revealed there was no documented evidence a representative of the State Long-Term Care Ombudsman was notified of the transfer. Interview with the Social Services Director (SSD) on 09/06/18 at 4:19 PM revealed the facility had not been notifying the Ombudsman when residents were transferred or discharged . She stated there was not a facility policy for the notification. She further stated the facility referred to the federal regulations. Interview with the Administrator on 09/06/18 at 4:19 PM revealed the facility had not been notifying the Ombudsman of transfers and discharges; however, he stated we emailed the (MONTH) discharges to the Ombudsman today.

Based on interview, record review, and review of the facility Resident Assessment Instrument (RAI) 3.0 Manual, it was determined the facility failed to review and revise the care plan for one (1) of twenty (20) sampled residents (Resident #51). Resident #51 fell on [DATE] and the facility failed to revise the care plan to include interventions which addressed the root cause of the fall instead of adding a duplicate intervention. The findings include: Review of the RAI 3.0 Manual, Section 4.7 revealed the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written care plan. Record review revealed the facility admitted Resident #51 on 09/14/15 with [DIAGNOSES REDACTED]. Review of the facility's fall investigation for Resident #51 revealed the resident had a fall from bed on 09/04/18 when attempting to reach down to get something off the floor. Causative factors included history of falls and impaired safety awareness/judgment. However, review of the Comprehensive Care Plan dated 06/07/18 and last revised 09/07/18 revealed the care plan was revised on 09/05/18 with a duplicate intervention of non-skid strips on floor added to the care plan on 09/04/18. In addition, there was no documented evidence the care plan was revised to include an intervention to address the root cause of the fall, which was the resident reaching for something on the floor while in the bed. Interview with Licensed Practical Nurse #1 (LPN) on 09/07/18 at 1:05 PM revealed she completed the fall investigation on 09/04/18. She stated she put non-skid strips on the floor because there was non-skid strips to only the right side of the bed, even though the comprehensive care plan stated non-skid strips to both sides of the bed. She stated the resident fell on the left side of the bed. LPN #1 further stated she placed the fall investigation in the MDS Assistant's mailbox as she was responsible for placing new interventions on the care plans. She also revealed she considered a reacher, but the resident wouldn't remember to use it. Interview with the MDS Assistant on 09/07/18 at 1:19 PM revealed she added the intervention of non-skid strips to both sides of the bed to the care plan on 09/04/18 even though the intervention had already been put into place previously. She further stated she did not check the care plan to see if the intervention was already in place. Interview with the Director of Nursing (DON) on 09/07/18 at 4:17 PM revealed the staff needed to look at the entire situation of the fall, establish a root cause and initiate an intervention that was pertinent to the root cause. She stated she expected a new intervention with each fall and the care plans needed to be reviewed to assure there was not a duplication of interventions. On 09/07/18 at 11:27 AM the DON stated non-skid strips to both sides of the bed was not an appropriate intervention for a fall as a result of reaching for something in the floor. The DON further revealed the fall investigation was passed on to the MDS Assistant who updated the care plans and the MDS Assistant was supposed to ensure the intervention was appropriate and add it to the care plan.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure an appropriate intervention was initiated to prevent further accidents for one (1) of twenty (20) residents (Resident #51). Resident #51 was assessed and care planned at risk for falls. On 09/04/18, the resident was reaching for an object on the floor and fell from bed. The intervention initiated was a duplicate intervention and inappropriate to prevent another fall with the same root cause. The findings include: Review of the facility policy titled, Falls dated (MONTH) (YEAR), revealed the purpose of the policy was to establish a process that identified risk and establishes interventions to mitigate the occurrence of falls. Tools: If the fall occurred from chair/wheelchair, evaluate the reason for the fall in order to choose appropriate interventions. If the fall occurred and resident is cognitively impaired, interventions would include toileting programs/schedule, ask families to assist in ideas for an activity basket, memory book, photo albums; Restorative programs - exercise/ambulation; appropriate footwear. Record review revealed the facility admitted Resident #51 on 09/14/15 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #51's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of nine (9) indicating the resident was interviewable. However, interview with the resident on 09/04/18 at 9:22 AM revealed he/she did not provide reliable information. Further review revealed the facility also assessed the resident required extensive assistance of two (2) staff for transfers, was non-ambulatory, had functional limitations with impaired range of motion to bilateral lower extremities, and required human assistance for balance with surface to surface transfers and seated to standing transfers. Review of the Comprehensive Plan for at risk for falls related to muscle weakness and decreased mobility, dated 06/07/18 and last revised 09/07/18 revealed Resident #51 was at risk for falls. Interventions included non-skid strips to the floor by both sides of the bed. Review of the facility's Fall Investigation for Resident #51 revealed the resident had a fall from bed on 09/04/18 when attempting to reach down to get something off the floor. Causative factors included history of falls and impaired safety awareness/judgment. The intervention listed on the fall investigation was non-skid strips to both sides of the bed which did not address the root cause of the fall, which was the resident reaching to pick something off the floor from bed. Interview with Licensed Practical Nurse (LPN) #1 on 09/07/18 at 1:05 PM revealed she completed the fall investigation on 09/04/18. She stated she put non-skid strips on the floor because there was non-skid strips to only the right side of the bed, even though the comprehensive care plan stated non-skid strips to both sides of the bed. She stated the resident fell on the left side of the bed. She stated she considered a reacher but the resident would forget to use it and there was nothing in the floor, so the nurse added non-skid strips. The resident's medications were reviewed and adjustments were made to the anti-anxiety medication. Interview with the Director of Nursing (DON) on 09/07/18 at 4:17 PM revealed the staff needed to look at the entire situation of the fall, establish a root cause and initiate an intervention that was pertinent to the root cause. She stated she expected a new intervention with each fall and the care plans needed to be reviewed to assure there was not a duplication of interventions. On 09/07/18 at 11:27 AM the DON stated non-skid strips to both sides of the bed was not an appropriate intervention for a fall as a result of reaching for something in the floor. The DON further revealed the fall investigation was passed on to the MDS Assistant who updated the care plans and the MDS Assistant was supposed to ensure the intervention was appropriate and add it to the care plan.

Based on interview, record review, and facility policy review, it was determined the facility failed to coordinate residents' care with an interdisciplinary group to provide the needs of a terminally ill resident as delineated in a specific plan of care and coordinated between the facility and hospice agency for one (1) of twenty (20) sampled residents (Resident #59). Resident #59 was receiving Hospice care; however, there was no documented evidence of a coordinated plan of care between the hospice agency and the facility. The findings include: Review of the facility provided Hospice-Nursing Facility Services Agreement, version (MONTH) 2014 revealed the facility shall participate in any meetings for coordination of services provided to Hospice residents. Hospice and Facility shall communicate with one another regularly and as needed for each particular Hospice resident. Each party is responsible for documenting such communications in its respective clinical records to ensure that the needs of Hospice residents are met twenty-four (24) hours per day. Record review revealed the facility admitted Resident #59 on 08/30/18 with [DIAGNOSES REDACTED]. Further review revealed the resident was admitted to Hospice services on 08/30/18 with a terminal [DIAGNOSES REDACTED]. Review of Resident #59's Hospice Care Plans dated 08/30/18 revealed specific care the Hospice nurse provided during weekly visits along with parameters and guidelines for vital signs, pain control and symptom management. However, review of the Resident #59's facility's Comprehensive Care Plan dated 08/30/18 revealed the problem/need was Family has chosen for resident to receive Hospice care. Approaches included coordinate with Hospice team to assure experiences as little pain as possible. However, the care plan was not specific as to how the pain would be controlled nor was the care plan person-centered. Further, the comprehensive care plan did not reflect Hospice interventions for a coordination of care for the resident. The Hospice care plan nor the comprehensive care plan mirrored the other. Interview with the Minimum Data Set (MDS) Assistant on 09/07/18 at 9:11 AM revealed the facility had completed coordinated care plans in the past for some residents. She stated there was no hospice schedule available, for reference, as far as she was aware. She revealed she did not know why there was not a coordinated care plan for Resident #59. She further stated she would be responsible for completing the coordinated care plan for the facility. In addition, the MDS Assistant stated there was not one (1) person designated to coordinate hospice care. Interview with the MDS Coordinator (MDSC) on 09/07/18 at 9:38 AM revealed the MDS Assistant would have been responsible for coordinating the Hospice care plan with the facility care plan. The MDSC stated she did not know why Resident #59 did not have a coordinated care plan. Interview with the Director of Nursing (DON) on 09/07/18 at 4:14 PM revealed she expected communication with Hospice to coordinate care plans and get the communication out to the staff.

Based on observation, interview, record review, and review of the facility's Clinical Nursing Skills and Techniques by Perry and Potter, it was determined the facility failed to ensure the resident's right to privacy was honored for one (1) of twenty (20) sampled residents (Resident #62). Observation on 09/05/18 revealed staff failed to close the window blinds to ensure the resident's privacy prior to providing urinary catheter care. The resident's room was at ground level, and there was a person walking outside the window. The findings include: Review of Clinical Nursing Skills & Techniques by Perry & Potter, 9th Edition, Chapter 18, Personal Hygiene revealed to avoid embarrassment, always act in a professional and sensitive manner and provide patient privacy at all times. Procedural steps include, provide privacy. Record review revealed the facility admitted Resident #62 on 04/07/17 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #62's cognition as intact with a Brief Interview for Mental Status (BIMS) score of thirteen (13) which indicated the resident was interviewable. Observation of Certified Nurse Assistant (CNA) #6 on 09/05/18 at 2:40 PM revealed Resident #62 was in the bed by the window. CNA #6 pulled the curtain and proceeded to provide catheter care. The window blinds were open while care was provided. The surveyor noted a person walking outside the window and the surveyor stepped between the resident and the window. Interview with Resident #62 on 09/05/18 at 2:50 PM revealed he/she did not like the blinds left open during care. He/she stated staff usually closed the blinds when care was provided. Interview with CNA #6 on 09/05/18 at 2:55 PM revealed she did not think anyone could see inside unless they were right up on the window. The CNA stated she normally leaves the blinds open because you can't see in. The CNA further stated I did not think about closing the blinds, really. Interview with CNA #4 on 09/05/18 at 3:00 PM revealed she leaves the blinds open when providing care. She stated she never really thought about it. Interview with the Director of Nursing (DON) on 09/07/18 at 4:20 PM revealed she expected the window blinds to be closed during care for privacy.