Every finding on record at Breckinridge Place

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure residents were free of significant medication errors for one (1) of three (3) residents sampled for medication administration in a total sample of twenty-four (24) residents (Resident #16). Observation of medication administration on 07/19/2023 at 9:18 AM, revealed Certified Medication Aide (CMA) #1 dropped a white tablet onto Resident #16's left leg. He proceeded to obtain another tablet from the medication cart and he placed a pink tablet in the medicine cup. When the Surveyor questioned CMA #1 regarding the medication he confirmed he had pulled the wrong medication and proceeded to remove the correct medication (Docusate Sodium) from the medication cart for administration. The findings include: Review of the facility's policy, Medication Administration, dated 08/01/2015, revealed medications were administered accurately and on time according to Physician Orders. Any time medications were dropped on a contaminated surface they should be disposed of according to facility protocol and procedure. Further review of the policy revealed any errors or incidents were to be reported to the Charge Nurse immediately. Review of Resident #16's medical record revealed the facility admitted the resident on 09/22/2022, with diagnoses which included Heart Failure, Unspecified, and Chronic Atrial Fibrillation, Unspecified. Review of Resident #16's Quarterly Minimum Data Set (MDS) Assessment, dated 06/06/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of six (6) out of fifteen (15) indicating severe cognitive impairment. Review of Resident #16's Physician Orders and Medication Administration Record (MAR), dated July 2023, revealed Resident #16 was scheduled to receive a Docusate Sodium (stool softner) tablet 100 milligrams (mg), and Hydralazine (blood pressure) 100 mg daily at 9:00 AM. Review of Certified Medication Aide (CMA) #1's Personnel Record revealed the facility hired him on 11/16/2021. Further review revealed CMA #1 had received Medication Competency Training at the facility on 03/30/2023. Observation of medication administration on 07/19/2023 at 9:18 AM, revealed Certified Medication Aide (CMA) #1 was observed administering Resident #16's medications with a spoon. CMA #1 dropped a white tablet onto Resident #16's left leg. He retrieved the tablet and discarded it in the trash receptacle on the medication cart. The Surveyor asked what the medication was and CMA #1 stated it was Hydralazine (used for high blood pressure) and obtained another tablet from the medication cart. Further observation revealed CMA #1 had placed a pink tablet in the medicine cup. The Surveyor asked CMA #1 about the color of the discarded pill and he stated it was pink. However, when CMA #1 retrieved the tablet from the trash receptacle it was a white tablet. CMA #1 confirmed the tablet was white and proceeded to remove the correct medication (Docusate Sodium) from the medication cart to be administered to Resident #16. During an observation and interview on 07/19/2023 at 9:18 AM, Certified Medication Aide (CMA) #1 stated Resident #16' blood pressure may have dropped if he had administered an additional dose of the Hydralazine. In an interview with the Director of Nursing (DON) on 07/20/2023 at 11:20 AM, she stated CMA #1 told her about the mistakes he had made during medication administration. The DON stated he had received education regarding medication administration upon hire. She stated she expected staff to ensure the correct medications were administered. Further she stated Resident #16's blood pressure could have plummeted had he/she been given the extra dose of the Hydralazine.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the Comprehensive Care Plan was implemented for one (1) of four (4) sampled residents (Resident #17). The facility care planned Resident #17 to require extensive assistance of two (2) staff for turning, repositioning, and bed mobility. However, on 02/21/2022, Certified Nursing Assistant (CNA) #1 provided incontinent care for Resident #17 alone, and without the care planned assistance of two (2) staff members. During the provision of incontinent care by only CNA #1, Resident #17 rolled off the bed and was observed as bleeding from his/her face. Resident #17 was transferred to the hospital emergency room and subsequently admitted to the hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Review of the facility policy titled, Care Plan dated August 2015, revealed a Comprehensive Plan of Care was to be developed and implemented for each resident that included measurable objectives and timetables for meeting a resident's identified medical, nursing and mental/psychosocial needs. Per review, the Interdisciplinary Team (IDT) along with the resident, family members, or legal representative, were to develop and implement the comprehensive, person-centered care plan for each resident. Residents' Comprehensive Plan of Cares were to be developed within seven (7) days of their admission, then quarterly and with a significant change of condition thereafter. Further review revealed residents' care plan interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Review of the medical record for Resident #17 revealed the facility admitted the resident on 12/23/2019, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Significant Change of Status Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #17 as severely cognitively impaired as evidenced by the Brief Interview for Mental Status (BIMS) score of three (3). Review of the Comprehensive Care Plan for Resident #17 revealed the facility had care planned the residents for falls dated 01/10/2022, related to a history of falls prior to admission, his/her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed Resident #17's care plan contained an bed mobility intervention, with an initiated date of 01/10/2022, which noted the resident required assistance of two (2) staff to turn and reposition in bed every two (2) hours. Continued review revealed a previous intervention noting Resident #17 required assist of two (2) staff for toileting initiated on 01/10/2022 which had been documented as resolved. Review revealed an intervention initiated 03/09/2022 (after the incident on 02/21/2022), which stated due to Resident #17's poor safety awareness he/she was to have a low bed at all times. Further revealed an intervention initiated 03/23/2022, noting Resident #17 was not toileted and required total assist with check and change every two (2) hours. Review of the facility's Kardex (a document used by CNA's which noted a resident's care plan interventions) for Resident #17 dated 02/20/2022 and 02/21/2022, revealed the resident required extensive assistance of two (2) staff for turning and repositioning regarding his/her bed mobility. Further review of the Kardex revealed Resident #17 required extensive assistance of two (2) staff also for toileting. Interview with Licensed Practical Nurse (LPN) #1 on 04/13/2022 at 9:30 PM, revealed she was a contracted agency nurse and 02/20/2022 had been her first night working at the facility. Per interview, LPN #1 had received a fast track orientation. She stated on 02/21/2022 at 5:30 AM, CNA #1 was yelling for help from a resident's room and she went to that room to assist. LPN #1 revealed upon walking into the room she observed the resident lying on the floor bleeding from the left side of his/her forehead. According to LPN #1, she obtained the resident's vital signs, initiated neurological (neuro) checks of the resident, and obtained an order to send Resident #17 to the emergency room (ER). Continued interview revealed Emergency Medical Services (EMS) staff arrived and placed Resident #17 stretcher left facility at 5:49 AM to transport the resident to the ER. LPN #1 stated CNA #1 told her she had been changing Resident #17 and the resident placed his/her left leg over the right leg, then rolled out of bed. Further interview revealed LPN #1 knew Resident #17 required two (2) staff persons assistance for his/her incontinent care. LPN #1 revealed she had been under the impression CNA #1 was also aware the resident required two (2) person assist for incontinent care. Review of the hospital Emergency Department (ED) Provider's Notes dated 02/21/2022, revealed Resident #17 had complex left facial fractures with depression of the left orbital floor, extensive facial swelling, and depressed nasal bone fractures. In addition, continued review revealed Resident #17's x-ray results of the left lower extremity revealed a comminuted (where a bone is broken, splintered, or crushed into a number of pieces) and somewhat impacted (when a bone is driven into another bone from the force of an injury) fracture involving the distal femoral diametaphysis. Interview with Registered Nurse (RN) #2 on 04/14/2022 at 1:10 PM, revealed she had been working the night shift on 02/21/2022 with CNA #1. According to RN #2, she and CNA #1 had been performing the last rounds of residents and she was by herself in another resident's room when the incident of Resident #17 falling out bed occurred. RN #2 stated she assumed CNA #1 had decided to go ahead and start Resident #17's on her own without assistance. She further revealed the Kardex in Point Click Care was the care plan used by staff for knowing residents's care needs. Interview with CNA #3 on 04/14/2022 at 1:58 PM, revealed he had been working at the facility for almost three (3) years, and knew Resident #17 was an assist of two (2) staff before the incident and currently still was. According to CNA #3, the Kardex was available on the computer at the nurse's station for staff to review, and was staff could find out what kind of care to provide for their residents. Further interview revealed the Assistant Director of Nursing (ADON), who was also the MDS Nurse, updated residents' care plans and Kardexes. Interview with CNA #8 on 04/14/2022 at 2:05 PM, revealed she had worked for the facility for three (3) years. According to CNA #8, newly admitted residents Kardexes were kept on the inside of their closet doors for approximately two (2) weeks after admission for staff to review; however, the Kardex was also always on the computer for them to review. Further interview revealed Resident #17 had previously and still was an assist of two (2) staff for incontinent care. CNA #8 stated most of the facility residents were an assist of two (2) staff. Interview with CNA #6 on 04/15/2022 at 9:30 AM, revealed the Kardex was located on the computer at the nurse's staff. Per CNA #6, staff were supposed to look at their assigned residents Kardexes at the beginning of their shift. Further interview revealed if staff did not follow the residents' care plans/Kardexes the resident or staff could get hurt. Interview with CNA #7 on 04/15/2022 at 9:45 AM, revealed that she had worked at the facility for seven (7) years. Continued interview revealed the facility's Kardex was where staff looked to see what kind of care a resident needed. Per CNA #7, Resident #17 was an assist of two (2) staff for everything except eating and doing small Activities of Daily Living (ADLs) like brushing his/her own hair. Further interview revealed the facility staff received training at monthly meetings, through inservices, and on modules on the computer. Interview with CNA #1 on 04/19/2022 at 7:30 AM, revealed she had been certified as a CNA for a little over a year and worked for a contract agency. CNA #1 revealed the first assignment she had been given by the contract agency was working at the facility. She stated she had been oriented for approximately a week when first starting work at the facility. Per interview, while being oriented she had written down the amount of assistance each resident needed that she observed being cared for. Continued interview revealed CNA #1 had cared for Resident #17 while working at the facility, and had reviewed the resident's Kardex during that time. CNA #1 stated the night of the incident, 02/21/2022 she felt she was familiar with Resident #17's care needs, and had not reviewed his/her Kardex prior to providing care of the resident. According to CNA #1, on the night of the incident when entering Resident #17's room she noticed his/her bedrails were no longer on the bed. CNA #1 stated she had gone into Resident #17's to provide incontinence care by herself, and turned the resident onto his/her sides with the bed in position that was about waist high to her. She revealed she noticed only the Chux pad and drawsheet needed changing, so she assisted Resident #17 to lie flat on his/her back while she obtained her supplies from the end of the bed. Per CNA #1, while she was obtaining her supplies Resident #17 crossed his/her left leg over the right leg and then rolled out of his/her bed onto the floor. She stated she called for the nurse to come to Resident #17's room, and the nurse came, looked at the resident, took his/her vital signs, and started neuro (neurological) checks of the resident. Further interview revealed Resident #17 was sent out to the hospital by the nurse. CNA #1 further stated she had been charting Resident #17 as an extensive assist, as that was what she had thought the resident was. The CNA stated she had observed other CNA's providing care for Resident #17 by themselves. She additionally stated the contract agency she worked for notified her approximately two (2) hours before she was to work again at the facility after the incident, to let her know her contract had been canceled by the facility. Interview with the Administrator on 04/15/2022 at 10:15 AM, revealed her expectations were for all staff, including CNA #1, to have provided the assist of two (2) staff to change Resident #17 as per the resident's care plan/Kardex. The Administrator revealed all staff were expected to receive shift report from the staff leaving, and to read their assigned residents' Kardex before providing the residents' care. Further interview revealed when a resident required a two (2) person assist the assigned staff person was expected to wait for assistance from another staff member, and not provided care alone. The Administrator revealed staff education had been provided and was still ongoing.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of four (4) sampled residents received adequate supervision and assistive devices to prevent accidents (Resident #17). The facility assessed and care planned Resident #17 to be at risk for falls and to require the assistance of two (2) staff for bed mobility and incontinent care. However, on 02/21/2022 Certified Nursing Assistant (CNA) #1 provided incontinent care to the resident without the assistance of another staff member as per the care plan. As a result, Resident #17 rolled off the side of the bed during the incontinent care provided by CNA #1. The resident sustained left facial fractures and left [CONDITION(S)] as a result of rolling off the bed which required surgical intervention. The findings include: Review of the facility's policy titled, Incidents and Accidents, dated August 2015, revealed an incident report was to be completed for any occurrence including, but not limited to falls or suspected falls, including fractures and head injuries which were to be reported immediately. Review revealed the resident was not to be moved unnecessarily until his/her condition had been assessed. Per review of the policy, a full body assessment was to be completed and documented on the post fall skin assessment form, and the resident's neurological signs were to be assessed as appropriate. Continued review revealed the Physician was to be notified and orders obtained for care, and the resident's family notified of the accident, resident's status and orders obtained for care. Review revealed the resident was to be transferred to the emergency room as needed, and his/her Plan of Care updated as necessary with implemented interventions. According to review of the policy, a fall screening was to be performed on any resident's falls or suspected falls. The policy review revealed the Director of Nursing and Administrator, or designee were to be immediately notified and would notify the Vice President of Clinical Operations when incidents were reported to the State Agency and as necessary. Further review revealed interventions were to be documented in the facility's incident reporting system as well as in the Nurse's Notes, and resident's plan of care (acute). Review further revealed an internal incident/accident report was to be completed for quality assurance purposes, and witness statements completed with signatures. Review of the facility policy titled, Resident Safe Environment, dated August 2015, revealed the facility promoted and maintained each resident's dignity and independence in a safe environment. Per review, the standard of the policy was to evaluate all residents for fall risk by using the fall evaluation form initially, quarterly, and as indicated by the interdisciplinary review of incident evaluations. Further review of the policy revealed staff were to report any unsafe acts promptly and initiate team evaluations. Review of Resident #17's medical record revealed the resident was admitted to the facility on [DATE], with the following diagnoses: Dementia, Type 2 Diabetes Mellitus, and [CONDITION(S)] [CONDITION(S)]. Review of the Significant Change of Status Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #17 to have a Brief Interview for Mental Status (BIMS) score of three (3) which indicated severe cognitive impairment. Review of Resident #17's Comprehensive Care Plan, revealed a Focus for falls related to his/her Dementia diagnosis, a history of falls prior to admission and his/her decreased mobility from a recent hospitalization dated 01/10/2020. Review of the Care Plan revealed an intervention for Resident #17's bed mobility which noted the resident required assistance of two (2) staff to turn and reposition in bed every two (2) hours, with an initiation date of 01/10/2020. Continued review revealed an intervention for the resident to have a low bed at all times due to poor safety awareness with an initiation date of 03/09/2022. Further revealed under toilet use an intervention documented stating Resident #17 was not toileted and required total assistance for a check and change every two (2) hours initiated on 03/23/2022. In addition, a previous resolved intervention was noted Resident #17 required assistance of two (2) staff for toileting which had been initiated on 01/10/2020. Review of Resident #17's Kardex (a facility document utilized by CNAs noting each residents' care needs), dated 02/20/2022, and 02/21/2022, revealed for bed mobility Resident #17 required extensive of two (2) staff to turn and reposition in bed, and for toileting. Review of the Morse Fall Scale document dated 12/13/2021, revealed a score of fifty-five (55) for Resident #17, a score of forty five (45) or higher, indicated the resident was at a high risk for falls. Further review of the facility's Morse Fall Scale documents for Resident #17 revealed a Fall Scale dated 02/21/2022, which noted the resident had a score of fifteen (15), a score of zero (0) to twenty four (24), indicated the resident was at a low risk for falls. Observation on 04/12/2022 at 9:10 AM, of Resident #17 revealed the resident lying on his/her bed with eyes open. Interview with Resident #17 at the time of observation revealed the resident stated his/her name and stated he/she liked to stay in bed. No facial deformities noted. Review of the facility's investigation's summary dated 02/21/2022, revealed the Interdisciplinary Review Committee (IRC) had reviewed an incident which had occurred on 02/21/2022. Review revealed Resident #17 had not had any falls in the last two (2) years; however, on last rounds on 02/21/2022 at 5:30 AM, CNA #1 had been changing Resident #17 without assistance of another staff. Review revealed during CNA #1 changing Resident #17, the resident kicked his/her leg over and rolled off the bed. Per review, an Acute Care Plan had been initiated, the facility's Physician and Power of Attorney (POA) had been notified of the incident. Continued review revealed Resident #17 was sent out to the emergency room (ER) for evaluation and treatment after the fall, and admitted to the hospital with facial fractures and a left [CONDITION(S)]. Further review revealed the agency CNA's contract was terminated for failure to follow Resident #17's care plan. Review further revealed the the facility identified the cause of the incident as CNA #1 performing Resident #17's care without the care planned assistance of two (2) staff. In addition, a Quality Assurance (QA) meeting was conducted and an inservice for staff implemented regarding reviewing residents' Kardexes. Review of CNA #1's statement, from the facility's investigation dated 02/21/2022, revealed she had been on the right side of Resident #17's bed and had the resident turn over towards her to roll up the Chux (a disposable protective pad) and draw sheet (a sheet utilized to assist with moving people in bed) during incontinence care. Continued review revealed CNA #1 had documented she had moved to the left side of Resident #17's bed and had the resident roll towards her again, as she had seen she needed to remove the Chux pad and drawsheet completely from under the resident. Review revealed CNA #1 had Resident #17 lay flat and pulled the draw sheet up halfway, telling the resident to hold on, we're about to roll. Further review revealed Resident #17 placed his/her left leg over his/her right leg and was rolling off the bed before she realized it. Review further revealed CNA #1 ran to the other side of Resident #17's bed as soon as possible and observed the resident lying on the floor in a cradle position. Review of the Emergency Department (ED) Provider's Note dated 02/21/2022, revealed a Computerized Tomography (CT) scan had been performed of Resident #17's face, and x-rays performed of the resident's lower extremity. Continued review revealed the CT scan results of Resident #17's facial bones without contrast showed complex left facial fractures with depression of the left orbital floor (bones surrounding the eyeball), depressed nasal bone fractures and extensive left facial swelling. Further review revealed the results of the left knee x-ray noted a comminuted (where the broken ends of a bone are shattered into many pieces) and somewhat impacted fracture (when broken ends of a bone are jammed together by the force of an injury) involving the distal femoral diametaphysis. Interview on 04/13/2022 at 9:30 PM, with Licensed Practical Nurse (LPN) #1 revealed she was an agency(contracted) nurse, and had worked her first night at the facility on 02/20/2022. Per interview, LPN #1 had received a fast track orientation for working at the facility prior to her shift on 02/20/2022. She stated on the morning of 02/21/2022 at 5:30 AM she was passing residents' medications when she heard CNA #1 yelling for help from a resident's room (Resident #17's room) and she went to the room to assist. Continued interview revealed when she walked into the resident's room she observed the resident lying on the floor, and bleeding on the left side of his/her forehead. According to LPN #1, she obtained the resident's vitals (vital signs), started performing neuro checks(neurological checks), and obtained an order to send the resident to the emergency room . LPN #1 stated Emergency Medical Service (EMS) staff arrived, placed the resident on a stretcher, and left facility at 5:49 AM to transport him/her to the emergency room . Further interview revealed CNA #1 stated she had been changing the resident when the resident crossed his/her left leg over the right one and then rolled out of bed. Licensed Practical Nurse (LPN) #1 further stated she had known the resident was a two (2) person assist for incontinent care, and had been under the impression CNA #1 had also been aware of that information as the CNA had been working at the facility for a while. In addition, LPN #1 stated she had notified the resident's POA, the DON and Administrator, and filled out the necessary paperwork regarding the incident. Interview further revealed Resident #17's fall and injuries could have been prevented had CNA #1 waited for assistance from another staff member. Interview on 04/14/2022 at 1:10 PM, with Registered Nurse (RN) #2 revealed she had been working on the facility's night shift with CNA #1 on 02/21/2022. Per interview, she had been a CNA herself at the time of the incident and had been performing last rounds with CNA #1. She revealed she had been in another resident's room providing care when CNA #1 was assisting Resident #17 with incontinence care and experienced the fall from the bed. RN #2 stated she was aware at the time of the incident that Resident #17 was a two (2) person assist for turning, changing, and toileting. Further interview revealed she assumed CNA #1 decided to start caring for Resident #17 on her own, as she had not waited for assistance. RN #2 stated the Kardex in the facility's Point Click Care computerized system was the residents' care plan staff referred to know the residents' care needs. In addition, RN #2 revealed CNAs and nurses received report from the staff going off shift before starting their work, and she always looked at the Kardex each shift too to see whether any changes had occurred. Interview on 04/14/2022 at 1:58 PM, with CNA #3 revealed he had been a CNA working at the facility for almost three (3) years. He stated the Kardex was available on the computer at the nurse's station and was where you find out what kind of care residents needed. Further interview revealed the MDS Nurse updated residents' care plans and Kardexes. CNA #3 further stated Resident #17 was an assist of two (2) staff for care before 02/20/2022, and still was currently. Per interview, CNA #3 revealed if Resident #17 had the assistance of the required two (2) person assist, then he/she would try to help roll himself/herself. Further interview revealed when a resident was a two (2) person assist, he always let the residents know to wait and someone would be right with them to assist them. Interview on 04/14/2022 at 2:05 PM, with CNA #8 revealed she had been working at the facility for three (3) years. She stated for new admits the Kardex was kept on the inside of their closet doors for approximately two (2) weeks for staff to refer to; however, was always on the computer also for review. Further interview revealed she had known Resident #17 was an assist of two (2) staff for incontinent care, and most of the facility's residents were assist of two (2) staff. CNA #8 further stated if a resident was a two (2) person assist she went and got someone to help her. In addition, she revealed she the MDS Nurse made necessary changes to residents' care plans and Kardexes. Interview on 04/15/2022 at 9:30 AM, with CNA #6 revealed she had been a CNA for three (3) years. Continued interview revealed the Kardex for residents was located on the computer and staff were supposed to look at it at the beginning of their shift to know what care residents needed. CNA #6 stated if a resident's care plan/Kardex was not followed a resident or staff could get hurt; however, was not aware of any staff not following residents' Kardexes. Interview with CNA #7 on 04/15/2022 at 9:45 AM, revealed that she had been with the facility for seven (7) years. Continued interview revealed the Kardex was where you go to see what kind of care a resident needed. CNA #7 stated Resident #17 was an assist of two (2) staff for everything except eating or small Activities of Daily Living (ADLs such as brushing his/her hair. Further interview revealed staff received training at monthly meetings, during inservice education, and on modules on the computer. Interview on 04/19/2022 at 7:30 AM, with CNA #1 revealed she worked through a contract agency, and had been a CNA for a little over a year. She stated her first assignment as an agency CNA had been at the facility, and she had worked at the facility for a little over a year. The CNA stated she had reviewed Resident #17's Kardex previously when working at the facility and provided care for the resident. However, had not reviewed the Kardex the night of the incident as she felt she was familiar with the resident's care. CNA #1 revealed when she walked into Resident #17's room that night she had noticed there were no longer any bedrails on his/her bed. Per interview, Resident #17 had bilateral siderails on his/her bed. CNA #1 stated Resident #17's bed had been in the low position when she went in to provide his/her incontinent care; however, she moved it higher to provide the resident's care. Continued interview revealed CNA #1 turned Resident #17 over onto his/her right side towards her in order to roll up the Chux pad and draw sheet. Continued interview revealed CNA #1 then moved to the other side of Resident #17's bed, rolled the resident onto his/her left side, and observed she just needed to change the Chux pad and draw sheet. She stated she assisted Resident #17 to lie flat on the bed, pulled the sheet halfway up and went to get her supplies which were lying at the end of the bed. CNA #1, while she was at the end of the bed Resident #17 placed his/her left leg over the right leg and in doing so, rolled out of the bed onto the floor. She revealed Resident #17 was curled in a somewhat fetal position on the floor after rolling out of the bed, and was bleeding from his/her head and elbow. The CNA stated she went to the resident's side to look at him/her and make sure he/she was okay. She stated she called for the nurse to come, and the nurse looked at the resident, took his/her vitals, started neuro checks and sent the resident out to the hospital. CNA #1 revealed she had been oriented for approximately one (1) week when she first started working at the facility, and during that time had written down how much assist each resident needed according to what she observed during her orientation. Further interview revealed she had thought Resident #17 was an extensive assist and had been charting the resident as such since she started working at the facility. CNA #1 further revealed she had seen other CNA's going into Resident #17's room to change him/her by themselves. In addition, she stated the contract agency she was employed through called her approximately two (2) hours before she was to work her next shift at the facility, and told her the facility had canceled her contract. Interview on 04/15/2022 at 10:15 AM, with the Administrator revealed she expected all staff, including CNA #1, to provide assist of two (2) staff to change Resident #17 as per his/her care plan/Kardex. Continued interview revealed staff were expected to obtain shift report from the off going staff, and to read the Kardex for all their assigned residents before providing care for their assigned residents. Interview revealed when a resident was a two (2) person assist, staff members were expected to provide the care residents required. The Administrator stated education had been provided after the incident and was ongoing. Per interview, the facility identified the CNA's failure to follow Resident #17's care plan as the root cause of the incident. Further interview revealed for the agency staff the facility utilized a fast track orientation was provided by facility staff. In addition, the Administrator revealed spot checks were being performed visually and verbally by administrative staff after the incident.

Based on observation, interview, and facility policy review, it was determined the facility failed to store food in accordance with professional standards for food service safety. Observation revealed opened food items in the facility's reach in refrigerator and dry storage area which were not dated. The findings include: Review of the facility policy titled, Dietary Services Food Handling and Preparation, Dry Storage, dated 08/01/2015, revealed all foods were to be labeled as to content and dated. Observation on 04/12/2022 at 9:03 AM, of the facility's kitchen area revealed the reach in refrigerator had an opened container of beef base flavoring that was approximately half full; however, was not labeled or dated. Continued observation revealed an employee's unopened coffee beverage present in the reach in refrigerator. Observation of the dry storage area revealed an opened container of chocolate fudge frosting which was not dated. Interview on 04/12/2022 at 9:03 AM, with the Cook revealed all food items should be dated when opened. She revealed employees should not be placing their personal drinks in the facility refrigerator. Observation during the interview revealed the Cook removed the employee's coffee beverage as well as the opened, undated Beef Base Flavoring from the reach in refrigerator, and the opened container of chocolate fudge frosting from the dry storage area. Interview on 04/15/2022 at 9:27 AM, with the Dietary Manager revealed all opened food items located in the reach in refrigerator were to always be labeled and dated. He revealed staff were not to put their personal drinks in the kitchen refrigerator. Further interview revealed food items not dated or labeled should have been removed and discarded as they created a potential for foodborne illness if used and served to residents.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Observation of the kitchen, on 04/09/19, revealed food stored in the walk-in refrigerator was not dated. Review of the facility Census and Condition, dated 04/09/19, revealed twenty-three (23) residents received their meals from the kitchen. The findings include: Review of the facility policy titled, Refrigerated Storage, dated (MONTH) 1. (YEAR), revealed all foods will be properly wrapped and/or stored in sealed containers and dated and labeled. Observation of the walk-in refrigerator during initial tour, on 04/09/19 at 10:52 AM, revealed a bag of parmesan cheese not dated. Interview with Dietary Aide #1, on 04/11/19 at 8:31 AM, revealed all items stored in the refrigerator should be dated and labeled. She further stated if staff observed an item not dated, the item should be discarded. Interview with the Dietary Manager, on 04/09/19 at 11:00 AM, revealed she expected all food items in the refrigerator be dated by the staff member who placed the item in the refrigerator. She further stated she would discard the bag of parmesan cheese.

Based on observation, interview, record review, and review of the Resident Assessment Instrument (RAI) 3.0 User's Manual, it was determined the facility failed to complete a Significant Change in Condition Minimum Data Set (MDS) assessment, for two (2) of thirteen (13) sampled residents (Resident #1 and Resident #8). Review and comparison of the Quarterly MDS assessment, dated 03/27/19, with the Admission MDS assessment, dated 12/28/18, revealed Resident #1 had a significant improvement in Activities of Daily Living (ADLs) and bowel/bladder. However, a Significant Change in Condition, Improvement MDS was not identified or initiated. Resident #8 had a decline in ADLs and bowel/bladder continence. However, further review of the resident's MDS assessment revealed a Significant Change in Condition was not identified and a Significant Change MDS assessment was not completed, per the RAI 3.0 User's Manual. The findings include: Interview with the MDS Coordinator, on 04/11/19 at 1:42 PM, revealed the facility does not have a policy for completion of MDS assessments; however, the RAI 3.0 User's Manual was used as a reference when completing MDS assessments. Review of the RAI 3.0 User's Manual, Version 1.16, October, (YEAR), revealed a significant change is a major decline or improvement in a resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions; the decline is not considered self-limiting; impacts more than one (1) area of the resident's health status; and requires interdisciplinary review and/or revision of the care plan. MDS assessments are not required for minor or temporary variations in resident status - in these cases, the resident's condition is expected to return to baseline within two (2) weeks. However, staff must note these transient changes in the resident's status in the resident's record and implement necessary assessment, care planning, and clinical interventions, even though an MDS assessment is not required. 1. Record review revealed the facility admitted Resident #8 on 10/30/17, with [DIAGNOSES REDACTED]. Review of the Annual MDS Assessment, dated 10/24/18, Section G, Functional Status, Item G0110 B, revealed the resident required supervision with set-up help only (Coded 1/1) for bed mobility. Review of Section H, Bladder and Bowel, Item H0300, revealed the resident was always continent of urine; and Item H0400 revealed he/she was always continent of bowel. Review of the Quarterly MDS Assessment, dated 02/05/19, Section C, Cognitive Pattern, Item C0500, revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of three (3), indicating severely impaired cognition. Review of Section G, Functional Status, Item G0110 B, revealed the resident required extensive assistance of one (1) staff (coded 3/2) with transfers, a decline from the previous code of 1/1. Review of Section H, Bladder and Bowel, Item H0300, revealed the resident was frequently incontinent of bowel and bladder, a decline in continence. However, further review of Resident #8's MDS assessments revealed there was no Significant Change MDS assessment completed per the RAI manual. 2. Record review revealed the facility admitted Resident #1 on 12/21/18, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 03/27/19, revealed the facility assessed Resident #1's cognition as severely impaired with a BIMS score of eight (8), which indicated the resident was not interviewable. Review of the Admission MDS, dated [DATE], Section G, revealed Resident #1 required extensive assistance of one (1) staff for bed mobility (Coded 3/2); required extensive assistance of two (2) staff for transfers (Coded 3/3); required extensive assistance of two (2) staff for toileting (Coded 3/3); and required extensive assistance of two (2) staff for ambulation (Coded 3/3). Additional review of the Quarterly MDS, dated [DATE], Section G, revealed Resident #1 required limited assistance of one (1) staff (Coded 2/2) for bed mobility; required limited assistance of one (1) staff with transfers (Coded 2/2); required extensive assistance of one (1) staff with toileting (Coded 3/2); and required extensive assistance of one (1) staff for ambulation (Coded 3/2). All areas had improved from the prior MDS assessment dated [DATE]; however, a significant change in condition MDS was not identified and initiated related to his/her improvement in Activities of Daily Living (ADLs) and bladder. Observation, on 04/09/19 at 11:30 AM, and on 04/10/19 at 11:42 AM, revealed Resident #1 ambulated in the hall way with a walker and stand-by assistance of one (1) staff. Interview with the MDS Coordinator, on 04/11/19 at 1:17 PM, revealed Resident #1's ability to participate in ADLs fluctuated, and sometimes was able to participate more than other times. However, the MDS Coordinator was unable to provide documentation to reflect the fluctuation in the resident's ADL abilities. The MDS Coordinator further stated she should have initiated a Significant Change in Condition, Improvement MDS for Residents #1 and #8. Interview with the Director of Nursing (DON), on 04/11/19 at 2:10 PM, revealed the MDS Coordinator should have initiated a Significant Change in Condition, Improvement MDS for Residents #1 and #8, based on the improvement in ADLs.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.16, October, (YEAR), it was determined the facility failed to ensure one (1) of thirteen (13) sampled residents received an accurate assessment, reflective of the resident's status (Resident #19). Resident #19 was taking an anti-coagulant medication; however, the resident's Minimum Data Set (MDS) assessment indicated the resident was not on an anti-coagulant. The findings include: Interview with the MDS Coordinator, on 04/11/19 at 1:42 PM, revealed the RAI User's Manual was used for reference when completing MDS assessments. Review of the RAI 3.0 User's Manual, Version 1.16, October, (YEAR), Section N0401, Medications Received, revealed the intent of the items in this section is to record the number of days, during the last seven (7) days that any type of injection, insulin, and/or select medications are received by the resident. Medications are an integral part of the care provided to residents of nursing homes. They are administered to try to achieve various outcomes, such as curing an illness, diagnosing a disease or condition, arresting or slowing a disease's progress, reducing or eliminating symptoms, or preventing a disease or symptom. Residents taking medications in these medication categories and pharmacologic classes are at risk of side effects that can adversely affect health, safety, and quality of life. Review the resident's medical record for documentation that any of these medications were received by the resident during the seven (7)-day look-back period. Section N0410E, Anticoagulant (e.g., [MEDICATION NAME], or low- molecular weight [MEDICATION NAME]): Record the number of days an anticoagulant medication was received by the resident at any time during the seven (7)-day look-back period. Include any of these medications given to the resident by any route (e.g., PO, IM, or IV) in any setting (e.g., at the nursing home, in a hospital emergency room ) while a resident of the nursing home. Code a medication even if it was given only once during the look-back period. Record review revealed the facility admitted Resident #19 on 01/04/19, with [DIAGNOSES REDACTED]. Review of Resident #19's Physician order [REDACTED]. However, review of the Significant Change MDS assessment, dated 03/20/19, Section N0410E, revealed the MDS was coded zero (0), indicating Resident #19 had not taken anti-coagulant medication during the seven (7)-day look-back period. Interview with the MDS Coordinator, on 04/11/19 at 1:42 PM, revealed Resident #19 took the anti-coagulant, [MEDICATION NAME], during the seven (7)-day look-back period for the MDS assessment and the medication should have been coded on the MDS. She stated the medication was overlooked when completing the MDS assessment. Interview with the Director of Nursing (DON), on 04/11/19 at 2:43 PM, revealed she expected the MDS to be coded accurately and to reflect any care the residents received.

Based on record review, interview and review of the facility's policy, it was determined the facility failed to develop and/or implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment, for two (2) of thirteen (13) sampled residents (Resident #14 and Resident #16). Review of the comprehensive care plan revealed Resident #14 had Stage II pressure ulcers to the left and right buttocks. However, review of a previous care plan revealed the wounds were healed on 04/04/18. Additionally, Resident #14 had excoriation to the scrotum with treatment ordered. However, the current care plan did not reflect the altered skin. Further record review revealed Resident #16 was being treated with intravenous (IV) fluids for dehydration. However, an acute care plan for dehydration was not initiated. The findings include: Review of the facility policy titled Care Plans, dated August, (YEAR), revealed plans of care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals for the resident. The facility develops a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing and mental/psychosocial needs that are identified in the comprehensive assessment. When a new approach / intervention or goal is identified, the care plan will be updated accordingly. 1. Record review revealed the facility admitted Resident #14 on 03/13/17 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment, dated 03/07/19, revealed the facility assessed Resident #14 to have moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of nine (9), which indicated the resident was interviewable. However, after speaking with the resident, it was determined he/she provided unreliable information. Review of the Physician's Phone Order, revealed Resident #14 had open areas to his/her buttocks, apply [MEDICATION NAME] cream to buttocks twice daily with a start date of 03/13/18 and a discontinued date of 04/04/18. Additional review of the Physician's Order, dated 03/05/19, revealed [MEDICATION NAME] Cream to the excoriated area of the scrotum two (2) times a day. Review of the Comprehensive Care plan, dated 03/15/19, revealed the resident had actual impairment to skin integrity related to fragile skin, noncompliance with turning with one (1) Stage II to the right buttock and one (1) Stage II to the left buttock. Additionally, the care plans did not reflect the impaired skin/excoriation of the scrotum or the ordered treatment. Interview with the MDS Coordinator, on 04/11/19 at 1:38 PM, revealed the previous comprehensive care plans were placed in the care plan book when the annual MDS assessment was completed. An updated, working copy of the care plans was printed. However, the MDS Coordinator stated the latest care plan should have been updated to reflect that the Stage II pressure ulcers were healed on 04/04/18, but was not until 04/10/19. She further stated the care plan should have been updated, but it was an oversight on her part. Additionally, the MDS Coordinator stated the resident's scrotal excoriation and treatment should have been reflected on the care plan, but was also an oversight on her part. Interview with the Director of Nursing (DON), on 04/11/19 at 2:28 PM, revealed there should have been a Potential care plan once the skin impairment care plan was discontinued on 04/04/18. However, a care plan was not initiated until 04/10/19 for potential skin impairment Additionally, the scrotal excoriation was not care planned from the time [MEDICATION NAME] was ordered. The DON stated she expected the scrotal excoriation to be on the care plan as well as care plans to be updated and/or discontinued when skin impairments were healed. 2. Record review revealed the facility admitted Resident #16 on 12/10/18 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed Resident #16's cognition as intact with a BIMS score of fourteen (14), which indicated the resident was interviewable. Observation and interview with Resident #16, on 04/09/19 at 11:03 AM, revealed he/she was receiving intravenous (IV) fluids. The resident stated he/she was dehydrated and had a bladder infection. Additionally, the resident stated I guess I don't drink enough. Review of the Physician's Order, dated 04/08/19, revealed an order for [REDACTED]. Review of the Comprehensive Care plans revealed there was no care plan implemented to reflect acute dehydration and/or the care of Resident #16 related to dehydration. Interview with the Unit Coordinator, on 04/11/19 at 2:05 PM, revealed the DON was responsible for initiating acute care plans and updating care plans for immediate changes. She stated, in the absence of the DON, it was the Unit Coordinator's responsibility. Interview with the DON, on 04/11/19 at 2:31 PM, revealed she should have created an acute care plan for the nurse to initiate when there was an acute problem. The DON stated she does not go into the computer to add a care plan, the MDS Coordinator does that. She stated there should have been a Dehydration Care Plan related to the IV fluid lab orders and care of the resident.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, for two (2) of thirteen (13) sampled residents (Resident #13 and Resident #6). The findings include: Review of the facility policy titled Care Plans, dated August, (YEAR), revealed plans of care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals for the resident. The facility develops a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing and mental/psychosocial needs that are identified in the comprehensive assessment. When a new approach/intervention or goal is identified, the care plan will be updated accordingly. 1. Record review revealed the facility admitted Resident #13 on 03/29/17, with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment, dated 02/20/19, revealed the facility assessed Resident #13's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident was not interviewable. Review of the Comprehensive Care Plan, dated 11/27/18, revealed the resident was at risk for decline in visual function related to disease processes. However, further review of the care plan revealed it had not been updated to include the intervention, apply eye patch to right eye in the morning, on at all times while awake, and remove at bedtime. Review of the Physician's Order, dated 03/20/19, revealed an order to, apply eye patch to right eye in the morning, on at all times while awake, and remove at bedtime. Interview with the MDS Coordinator, on 04/11/19 at 1:42 PM, revealed she completed the initial Comprehensive Care Plans for residents, and new interventions were added by the Director of Nursing (DON). Interview with the DON, on 04/11/19 at 2:43 PM, revealed she was responsible for updating the care plans with new interventions. She further stated updated the nurse aide care plan; however, she failed to add information to the Comprehensive Care Plan. The DON stated the order should have been added to the resident's care plan timely to reflect the care being provided by staff. 2. Record review revealed the facility admitted Resident #6 on 08/03/18 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 01/25/19, revealed the facility assessed Resident #6's cognition to be moderately impaired with a BIMS score of eleven (11), which indicated the resident was interviewable. Review of the Physician's Order Sheet revealed an order for [REDACTED]. Review of the Comprehensive Care Plan, initiated on 02/03/19, revealed Resident #6 was on palliative/comfort care related to Dementia; however, interventions on the care plan did not include the specific instructions as listed in the Physician's Order: discontinue weights, routine labs with the exception of yearly TSH, no IV fluids and resident to remain in the facility. Additionally, review of the Comprehensive Care Plan revealed care of Resident #6's Mediport was not included on the care plan. Interview with the MDS Coordinator, on 04/11/19 at 1:22 PM, revealed she was responsible for initiating care plans. She stated the Mediport care would be included in the intervention Medicate and treat per Physician Orders, and stated that intervention was not individualized, or person centered. Additionally, the MDS Coordinator stated the specific directives related to palliative care also would go under the intervention Medicate and treat per Physician Orders. She stated the care plan generally addressed all the interventions specified in the Physician's Orders, but the care plans were not specific to Resident #6. Interview with the DON, on 04/11/19 at 2:21 PM, revealed the care plans were not person-centered/individualized care plans, and should be more specific to each resident.

Based on interview, record review, and review of the facility policy, it was determined the facility failed to ensure that a resident who is incontinent of bladder and/or bowel receives appropriate treatment and services to prevent urinary tract infections [MEDICAL CONDITION] and to restore as much continence as possible, for two (2) of thirteen (13) sampled residents (Resident #1 and Resident #8). Record review revealed the facility failed to complete a three (3) day continence management diary when a decline in bladder continence occurred for Residents #1 and #8. Additionally, a bladder program was not implemented to restore as much bladder and bowel function as possible for Residents #1 and #8 per facility policy. The findings include: Review of the facility policy titled Bowel and Bladder Program, dated August, (YEAR), revealed the objectives of a bowel and bladder program are to reduce incontinent episodes to enhance the resident's dignity. A voiding diary is initiated on admission. Comatose and semi-comatose residents - proceed directly to check and change program. In this case, no assessment is needed. Other incontinent residents - follow the Resident Assessment Instrument (RAI) guidelines to establish a pattern for the resident. Complete a Bowel and Bladder Assessment if bladder training is indicated. Review of the RAI 3.0 Users Manual, Version 1.16, October, (YEAR), revealed the procedure for bowel and bladder training includes: review the medical record for evidence of a trial of an individualized, resident-centered toileting program. A toileting trial should include observations of at least three (3) days of toileting patterns with prompting to toilet, and for recording results in a bladder record or voiding diary. Toileting programs may have different names, such as habit training/scheduled voiding, bladder rehabilitation/bladder retraining. Review records of voiding patterns (such as frequency, volume, duration, nighttime or daytime, quality of stream) over several days for those who are experiencing incontinence. Voiding records help detect urinary patterns or intervals between incontinence episodes and facilitate providing care to avoid or reduce the frequency of episodes. Simply tracking continence status using a bladder record or voiding diary should not be considered a trial of an individualized, resident-centered toileting program. Residents should be reevaluated whenever there is a change in cognition, physical ability, or urinary tract function. 1. Record review revealed the facility admitted Resident #1 on 12/21/18, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 03/27/19, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of eight (8), which indicated the resident was not interviewable. Further review of the Quarterly MDS assessment, dated 03/27/19, revealed Resident #1 was always incontinent of bladder with no bladder plan in place, which was a decline from the 12/28/18 Annual MDS assessment indicating the resident was frequently incontinent, with no bladder plan in place. Additional record review revealed a three (3) day bowel and bladder diary was completed on admission; however, there was no bladder program initiated. There was no documented evidence that a three (3) day bowel and bladder diary was completed for the 03/27/19 decline, nor was a bladder program initiated. Interview with the MDS Coordinator, on 04/11/19 at 1:20 PM, revealed when there was a decline in a resident's bowel or bladder functioning, she notified the Director of Nursing (DON). However, she stated Resident #1's decline was overlooked, and she did not notify the DON of this particular decline. Interview with the DON, on 04/11/19 at 2:13 PM, revealed a three (3) day bowel and bladder diary was completed upon admission and if there was a decline, then another three (3) day diary would be completed. The DON stated the MDS Coordinator should have notified her of the decline in urinary incontinence for Resident #1 and a new three (3) day assessment would have been initiated. The DON further further stated, based on the decline in the assessments, the resident should have been assessed with [REDACTED]. She stated it was her responsibility to complete the bowel and bladder assessments once the MDS Coordinator alerted her regarding a decline. 2. Record review revealed the facility admitted Resident #8 on 10/30/17, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 02/05/19, revealed the facility assessed Resident #8's cognition as severely impaired with a BIMS score of three (3), which indicated the resident was not interviewable. Review of the Annual MDS Assessment, dated 10/24/18, Section H, Bladder and Bowel, Item H0300, revealed the resident was always continent of urine; and Item H0400 revealed he/she was always continent of bowel. However, review of the Quarterly MDS assessment, dated 02/05/19, Section H, Bladder and Bowel, Item H0300, revealed the resident was frequently incontinent of bowel and bladder, with a decline in continence. Additional record review revealed there was no documented evidence a three (3) day bowel and bladder diary was completed for the 02/05/19 decline, nor was a bladder program initiated. Interview with Certified Nurse Aide (CNA) #1, on 04/11/19 at 1:12 PM, revealed Resident #8 was continent of bowel and bladder when she began working in the facility. She further stated the resident was more incontinent lately, requiring staff to toilet him/her every two (2) hours. CNA #1 stated the resident wore pull-ups during the day and incontinent briefs at night. Interview with CNA #2, on 04/11/19 at 1:18 PM, revealed Resident #8's Dementia has progressed and would forget to go to the bathroom, and had experienced more incontinence recently. She further stated the resident ambulated with a rolling walker, and still would take himself/herself to the bathroom at times; however, not consistently. CNA #2 stated that staff toilet the resident every two (2) hours during the day and he/she wore incontinence briefs while asleep. Interview with the MDS Coordinator, on 04/11/19 at 1:42 PM, revealed when there was a decline in a resident's bowel or bladder functioning, she notified the Director of Nursing (DON). However, she stated Resident #8's decline was overlooked, and she did not notify the DON of this particular decline. Interview with the DON, on 04/11/19 at 2:43 PM, revealed a three (3) day bowel and bladder diary was completed upon admission and if there was a decline, then another three (3) day diary would be completed. The DON stated the MDS Coordinator should have notified her of the decline in urinary incontinence for Resident #8 and a new three (3) day assessment would have been initiated. She stated it was her responsibility to complete the bowel and bladder assessments once the MDS Coordinator alerted her regarding a decline.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to maintain medical records on each resident that are complete and accurately documented, for two (2) of thirteen (13) sampled residents (Resident #25 and Resident #11). The facility failed to complete a discharge summary for Resident #25. Additionally, the Director of Nursing (DON) completed dental assessments on 08/22/18, 11/21/18, and 02/20/19 for Resident #11; however, the dental assessments were inaccurate. The findings Include: Review of the facility policy titled, Charting and Documentation Guidelines, dated August, (YEAR), revealed documentation in medical records of residents, by the interdisciplinary team, should provide: 1. Communication of the resident's care, treatment, response to the care, signs, symptoms, and programs of the resident to providers of care. 2. Assistance to the physician in prescribing medications and treatments. 3. Assistance to the interdisciplinary team in the development of a plan of care. 4. A legal record that protects the resident, physician, nurse, and facility. 5. A source to support charges to the resident for services rendered. Review of the facility policy titled, Discharge Summary and Plan of Care, dated August, (YEAR), revealed the discharge summary should include completion of a discharge summary by the nurse caring for the resident, for anticipated discharge home or to another facility. 1. Closed record review revealed the facility admitted Resident #25 on 12/13/18 and discharged the resident home on 01/24/19. Further review of the closed record revealed the Discharge Summary had not been completed. Interview with the DON, on 04/11/19 at 2:43 PM, revealed she expected all residents' medical records to be complete and accurate. 2. Record review revealed the facility admitted Resident #11 on 10/28/15 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 04/10/19, revealed the facility assessed Resident #11 to be moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score of thirteen (13), indicating the resident was interviewable. Further review of the MDS assessment revealed Section L0200 of the MDS Assessment, was not completed. Review of dental assessments, dated 08/22/18, 11/21/18, and 02/20/19, revealed the resident was edentulous. Review of the Comprehensive Care Plan, last revised on 02/27/19, revealed Resident #11 had oral/dental health problems related to a history of dental caries and broken teeth. Interventions included oral assessment quarterly and as needed (PRN). Observation and interview with Resident #11, on 04/09/19 at 11:26 AM, revealed his/her bottom teeth had many caries (decay), were broken, and several teeth were missing. The resident stated his/her teeth were not painful, nor did he/she have problems chewing food. Interview with the DON, on 04/10/19 at 4:40 PM, revealed Resident #11's Power of Attorney (POA) was in charge of the resident's private dental care, as the resident had declined dental care at the facility, up to 02/06/19, whenever he/she agreed to have dental care in the facility. She revealed the contract dentist comes to the facility every six (6) months, in (MONTH) and June. The DON stated the resident was suppose to see the dentist in (MONTH) this year. Additionally, the DON stated she completed the dental assessments on 08/22/18, 11/21/18, and 02/20/19; however, they were inaccurate. She stated she circled the word edentulous on the dental assessments by accident. She stated she understood edentulous meant lacking teeth, and she should have circled the word missing on the assessments.

Based on interview, closed record review, and review of the facility policy, it was determined the facility failed to complete a discharge summary and recapitulation of the resident's stay, for one (1) of two (2) residents' closed records reviewed for discharge planning (Resident #25). Resident #25 was discharged home on[DATE] ; however, there was no documented evidence a recapitulation of stay or discharge summary was completed per the facility policy. The findings include: Review of the facility policy titled, Discharge Summary and Plan of Care, dated August, (YEAR), revealed the discharge summary should include completion of a discharge summary by the nurse caring for the resident, for anticipated discharge home or to another facility. Closed record review revealed the facility admitted Resident #25 on 12/13/18 and discharged the resident home on 01/24/19. Further review of the closed record revealed no documented evidence the discharge summary had been completed. Interview with the Director of Nursing (DON), on 04/11/19 at 2:43 PM, revealed she was responsible for completing the nursing section of the discharge summary. The DON further stated she expected a discharge summary to be completed on each resident upon the resident's discharge and she had no explanation as to why she failed to complete Resident #25's discharge summary.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Observation of the kitchen, on [DATE] and on [DATE], revealed concerns with foods being stored in the refrigerator which had passed their used by dates, dirty kitchen equipment, sanitation concerns with the trayline counter area, open and unsealed foods being stored in the walk-in refrigerator and the walk-in freezer, and sanitation issues with Cook #1's apron and hands. Review of the Census and Condition, dated [DATE], revealed twenty-one (21) of twenty-one (21) residents received their food from the kitchen. The findings include: 1. Review of the facility's policy titled, Leftover Food Storage, dated [DATE], revealed all foods must be stored in approved, food safe containers made from non-porous materials, such as metal or plastic. It further stated all containers must be covered with a fitted lid, plastic wrap, foil wrap or freezer wrap and each tray or container should be dated and identified. It also revealed, all refrigerated leftover foods were used within 72 hours or discarded. 2. Review of the facility's policy titled, Refrigerated Storage, dated [DATE], revealed all foods will be wrapped and/or stored in sealed containers, dated and labeled. Observation of the kitchen, on [DATE] at 1:36 PM, revealed the walk-in refrigerator had a pan of uncooked carrots in the pan with the foil covering the carrots having a hole in it. Further observation of the walk-in refrigerator at that time, revealed a container of barbeque sauce with a used by date of [DATE]; ham in a plastic ziploc bag with a used by date of [DATE], and diced turkey in a pan with a used by date of [DATE]. 3. Review of the facility's policy titled, General Sanitation Guidelines, dated [DATE], revealed dietary department staff were required to follow recommended sanitation practices and sanitation practices were based on federal, state and local regulations. It further stated dietary staff will wear clean attire and aprons will be changed when dirty. Further review of the policy revealed all equipment and work units will be cleaned and sanitized after use. Observation of the oven, on [DATE] at 1:47 PM, revealed, on the right side, the stove had a massive build-up of black and brown material that was caked on and crusted in appearance. Observation of the kitchen's manual can opener, on [DATE] at 1:51 PM, revealed visible dirty with a build-up of brownish and black crusted material on the cutting edge and the area surrounding the cutting edge. Observation of the kitchen's meat slicer, on [DATE] at 1:54 PM, revealed a build-up of yellowish/brown crusted material all over the back of the cutting blade and scattered all over the slicer. Observation of the kitchen, on [DATE] at 12:05 PM, prior to the trayline starting, a visibly soiled wash rag with reddish, brown and black material on it was laying on the trayline counter against six (6) clean plate cover lids, along with the spatula to serve the meat loaf visibly soiled with remnants of meatloaf, and a red sauce all over the spatula, as the spatula was laying on the trayline counter. Further observation revealed Cook #1 placed clean gloves against her apron that had visible food particles and reddish brown material on it, and then proceeded to grab clean plates, plate warmers and plate covers with her gloved hands. Continued observation revealed Cook #1 was serving meat loaf and using her left hand to reposition meatloaf on the plates for the residents, and with Cook #1's visibly soiled left gloved hand, she continued to grab clean plates and handled clean plate warmers and lids/covers, which visibly soiled those items. 4. Review of the facility's policy titled, Frozen Storage, dated [DATE], revealed all frozen foods will be properly wrapped, dated and labeled. Observation of the walk-in freezer, on [DATE] at 1:39 PM, revealed veggie burgers in a plastic bag open to air and an open box of beef patties open to air. Interview with Cook #1, on [DATE] at 12:08 PM, revealed she was going to use the spatula that was laying out on the trayline counter to serve the meatloaf. She stated she forgot and left the dirty rag on the trayline area. She stated the trayline counter was not clean and she needed to wipe it down with a rag from the sanitizer bucket. Interview with the Dietary Manager, on [DATE] at 3:41 PM, revealed she expected the kitchen staff to ensure they followed facility policies and procedures, along with the state and federal guidelines pertaining to the kitchen. She stated she expected the staff to serve, distribute and store the food in a sanitary manner. She stated food should be sealed completely when stored, labeled and dated, discarded after the used by date and/or expired date and expected staff to clean equipment as they go. Interview with the Administrator, on [DATE] at 3:36 PM, revealed she expected the kitchen staff to follow facility policies and procedures, as well as the federal and state regulations, pertaining to the kitchen area.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure Physician notification for one (1) resident (Resident #3), in a sample size of twelve (12) residents. Resident #3 was transferred on 03/10/18 to the hospital with chest and back pain; however, the Physician was not notified. The findings include: Review of the facility policy entitled Physician/Legal Representative Notification, dated (MONTH) (YEAR), revealed the charge nurse will make two (2) attempts to notify the attending Physician in a ten (10) minute period; if unsuccessful, they will notify the Physician on call or the Medical Director. All notifications and/or attempted notifications are to be documented in the nurse's notes. Record review revealed the facility admitted Resident #3 on 03/13/17 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #3 was assessed as requiring extensive assistance with activities of daily living (ADLs) and to have a Brief Interview Mental Status (BIMS) score of (9) nine, signifying moderate cognitive impairment. Review of a Nursing Home To Hospital Transfer Form, dated 03/10/18, revealed Resident #3 was transferred to the hospital with complaints of chest and back pain. Review of progress notes, dated 03/11/18 at 8:19 AM, revealed a late entry from 03/10/18 at 5:30 PM stating the Power of Attorney (POA) was notified of the resident's transfer to the hospital at time of the transfer; however, no Physician notification. Interview with the Director of Nursing (DON), on 06/21/18 at 12:12 PM, revealed the nurse was new and had not documented notification of the Physician. She revealed there should have been an entry that the Physician was notified. She stated the nurse was not available for interview at this time, due to serving on jury duty. Interview with the Administrator, on 06/21/18 at 4:41 PM, revealed she expected staff to follow the facility policy, as well as Federal and State regulations, and she expected the Physician to be notified about residents being transferred out.

Based on observation, interview, and review of the facility's policy and procedures, it was determined the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions. Observation of the kitchen revealed undated and uncovered items in the refrigerator and observation of the lunch tray line service revealed the Dietary Cook left the tray line on several occasions to retrieve items and returned to the tray line pass without changing her gloves and washing her hands. Review of the facility's Census and Condition, dated 04/03/16, revealed twenty-four (24) of twenty-five residents received their meals from the kitchen. The findings include: 1. Review of the facility's policy and procedure, titled General Sanitation Guidelines, dated 08/01/15, revealed Dietary Department Staff and any other staff entering the food preparation and service area should wash hands before going on duty or any time when re-entering the kitchen. Dietary Department Staff should follow hand washing policy and procedure to prevent transmission of bacteria and frequently and thoroughly wash their hands. Observation of the lunch tray line service, on 04/04/16 at 12:05 PM, revealed the Dietary Cook left the tray line during tray preparation to retrieve utensils, dropped fish into the deep fryer and retrieved it, and retrieved a roll from the package with her hands. However, she did not change her gloves or wash her hands before returning to the tray line service. Interview with the Dietary Cook, on 04/04/16 at 12:32 PM, revealed she should have changed gloves and washed her hands after leaving the tray line. 2. Review of the facility's policy and procedure, titled Dietary Services Food Handling and Preparation, dated 08/01/15, revealed all foods should be labeled as to content and dated. Dietary Staff should ensure raw food supplies are correctly stored in the facility after delivery. Additional review revealed all frozen food should be properly wrapped, dated, and labeled. All containers must be covered with a fitted lid, plastic wrap, foil wrap or freezer wrap. Each tray or container should be dated and identified. Initial kitchen observation, on 04/03/16 at 9:07 AM, revealed there were salads in bowls uncovered with no date, mushrooms open and uncovered and with no date, lemonade with no date or lid on the pitcher, and Kool-Aid with no date of when it was made. Interview with the Dietary Manager, on 04/04/16 at 2:00 PM, revealed the cook should have changed her gloves and washed her hands after leaving the tray line for any reason and items in the refrigerator and freezer should be covered, dated, and labeled when opened or placed in the refrigerator.

Based on observation, interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to ensure the care plan intervention was followed related to medication administration for one (1) of eight (8) residents (Resident #8). Resident #8 was care planned for staff to administer medications as ordered. However, observation of a medication pass on 04/04/16 revealed Licensed Practical Nurse (LPN) #1 failed to administer the medication per physician's orders [REDACTED]. The findings include: Review of the facility's policy and procedure, titled Care Plans, dated August 2015, revealed plans of care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals for the resident. Record review revealed the facility admitted Resident #8, on 12/20/11, with diagnoses, which included [MEDICAL CONDITIONS], Joint Contractures, Intracranial Injury, Dysphagia, Gastro-[MEDICAL CONDITION] Reflux, and Vitamin B-12 Deficiency [MEDICAL CONDITION]. Review of the Comprehensive Care Plan for impaired cognition and impaired thought processes related to Neurological symptoms due to [MEDICAL CONDITION], dated 02/20/16, revealed an intervention to administer medications as ordered. Review of the physician's orders [REDACTED]. However, observation of a Medication Pass, on 04/04/16 at 8:40 AM, revealed LPN #1 dissolved the Ortho Novum 777 and [MEDICATION NAME] and administered both of them mixed with the other medications instead of separately; and failed to administer the [MEDICATION NAME] mixed in apple juice per the physician's orders [REDACTED]. Interview with Licensed Practical Nurse (LPN) # 1, on 04/04/16 at 9:00 AM, revealed the care plan interventions should have been followed related to medication administration. Interview with the Director of Nursing (DON), on 04/05/16 at 2:19 PM, revealed she expected the nursing staff would follow the care plan interventions related to medication administration.

Based on observation, interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to ensure a medication error rate of less than five percent (5%). Observation of a medication pass revealed there were thirty-one (31) opportunities with five (5) errors, which resulted in a medication error rate of sixteen percent (16%). The findings include: Review of the facility's policy and procedure titled, Enteral Tube Medication Administration, dated 02/01/10, revealed crushed medications should not be mixed together. The powder from each medication should be mixed with water, or other suitable [MEDICATION NAME] if water is unacceptable, before administration. Each medication should be administered separately to avoid interaction and clumping. The enteral tubing should be flushed with at least five (5) milliliters (ML) of water between each medication to avoid physical interaction of medication. Record review revealed the facility admitted Resident # 8, on 12/20/11, with diagnoses, which included [MEDICAL CONDITIONS], Joint Contractures, Intracranial Injury, Dysphagia, Gastro-[MEDICAL CONDITION] Reflux, and Vitamin B-12 Deficiency [MEDICAL CONDITION]. Review of the physician's orders [REDACTED]. Observation, on 04/04/16 at 8:40 AM, of a medication pass revealed Licensed Practical Nurse (LPN) #1, administering medications to Resident #8 via a feeding tube. The medications administered included Ortho Novum 777 (birth control pill) ordered one (1) pill every day (administer one (1) tablet per tube daily, do not crush, dissolve in warm water, give separately), however, LPN # 1 dissolved the pill and mixed it with the other medications being given. The other medication was [MEDICATION NAME] (antacid) ordered thirty (30) milligrams (mgs) every day via tube and mix with apple juice and give separately and this was given mixed with the other medications and not with apple juice and not given separately. The LPN failed to flush to flush three (three) times (before the Ortho Novum, after the Ortho Novum and after the [MEDICATION NAME], which resulted in the resident not receiving the accurate amount of flushes. This resulted in five (5) medication errors. Interview with LPN #1, on 04/04/16 at 9:00 AM, revealed she was unaware of the fact the medications should be given separately in a feeding tube and flushed in between unless otherwise indicated and she should have followed the physician's orders [REDACTED]. Interview with the Director of Nursing, on 04/05/16 at 2:19 PM, revealed she expected staff to administer the medications per the physician's orders [REDACTED]. Interview with the Administrator, on 04/05/16 at 12:30 PM, revealed she expected the nursing staff to follow physician's orders [REDACTED].

Based on observation, interview, record review, and review of the Kentucky Board of Nursing (KBN) Advisory Opinion Statement (AOS) #14 Patient Care Orders, it was determined the facility failed to ensure service provided by the facility met professional standards of quality for one (1) of eight (8) sampled residents (Resident #8). Licensed Practical Nurse (LPN) #1 failed to administered Resident #8's medication per the physician's orders [REDACTED]. The findings include: Review of the KBN AOS #14 Patient Care Orders, dated 10/2010, revealed licensed practical nurses should administer medication in accordance with the physician or advanced practice registered nurse. Record review revealed the facility admitted Resident # 8, on 12/20/11, with diagnoses, which included [MEDICAL CONDITIONS], Joint Contractures, Intracranial Injury, Dysphagia, Gastro-[MEDICAL CONDITION] Reflux, and Vitamin B-12 Deficiency [MEDICAL CONDITION]. Review of the physician's orders [REDACTED]. Further review revealed to administer Ortho Novum 7777, one (1) tablet per tube daily, do not crush, dissolve in warm water, and give separately; and, administer [MEDICATION NAME] thirty (30) milligrams (mg) every day via [DEVICE], mix in four (4) to six (6) ounces of apple juice, and give separately. However, observation of a Medication Pass, on 04/04/16 at 8:40 AM, revealed LPN #1 dissolved the Ortho Novum 777 one (1) pill and administered it and the [MEDICATION NAME] (antacid) 30 mg pill mixed with all the other medications. The Ortho Novum was not administered separately and the [MEDICATION NAME] was not administered separately mixed in apple juice per the physician's orders [REDACTED]. Interview with LPN #1, on 04/04/16 at 9:00 AM, revealed she should have followed the physician's orders [REDACTED]. Interview with the Director of Nursing, on 04/05/16 at 2:19 PM, revealed she expected medications would be administered per the physician's orders [REDACTED]. Interview with the Administrator, on 04/05/16 at 12:30 PM, revealed she expected the nursing staff to follow the physician's orders [REDACTED].

Based on observation, interview and facility policy review, it was determined the facility failed to store, prepare, distribute and serve food under sanitary conditions. Observations of the kitchen, revealed undated and outdated food items stored in the refrigerator and a sanitizer bucket with the improper level of sanitizer. Review of the facility's Census and Condition, dated 04/15/15, revealed there were twenty-two (22) residents in the facility and two (2) of those residents were tube feeders and did not eat food from the kitchen area. The findings include: 1. Review of the facility policy for "Storing Leftover Food", dated 03/01/10, revealed cooked food items, that were not served to residents, may be saved up to three (3) days, in the refrigerator. The facility policy for "Food Preparation and Handling," dated 02/01/10, revealed dairy products can be held for fourteen (14) days, after opening, up to the expiration date. Observation of the refrigerators, on 04/15/15 at 12: 15 PM, revealed undated and opened bags of cheese: two (2) five (5) pound bags of shredded mozzarella cheese, dated 03/21/15 and approximately forty (40) slices of American cheese, with no dates to state how long the packages had been opened. Interview with the Dietary Manager, on 04/15/15 at 12:30 PM and review of the policy, revealed the morning cook was to have ensured all food items were labeled and dated properly. The mozzarella cheese should have been discarded after fourteen (14) days, according to policy and the cheese had been opened twenty-two (22) days. There were no initialed task forms to indicate the work had been completed and the Dietary Manger stated she was recently hired and in the process of getting these completed and stated she should have been monitoring this closer. 2. Review of the facility policy "Morning Cook Timeline and Task Checklist", the "Afternoon Cook Timeline and Task Checklist" and the "Prep Timeline and Task Checklist," undated, revealed the cook and the prep worker were to have filled all three (3) sanitation buckets with sanitizing solution, from the three (3) compartment sink at 5:30 AM, 10:00 AM and 2:00 PM A check of the sanitizer bucket, used to wipe the counters, on 04/17/15 at 11:40 AM, revealed the sanitizer level did not register on the test strips. Interview with the Cook, on 04/17/15 at 11:45 AM, revealed the sanitizer buckets should have been emptied at 10:00 AM and refilled with a fresh solution. However, the cook stated it had been very busy that morning and this had not been completed. Interview with the Dietary Manager, 04/15/15 at 12:30 PM, revealed the recommended sanitizer level was 250 parts per million (PPM) and she should have monitored to ensure the sanitizer buckets were emptied and fresh solution acquired. Interview with the Administrator, on 04/17/15 at 2:25 PM, revealed she would have expected the Dietary Manager to have monitored these concerns and ensured the dietary staff were completing their tasks in a timely manner.

Based on observation, interview, and review of the facility's policy/procedure, it was determined the facility failed to serve food under sanitary conditions related to appropriate handwashing when handling food. Additionally, the facility failed to ensure appropriate maintenance of the ice machine. The total census in the facility was twenty-two (22) residents, who all receive meals from the facility. Findings include: 1. Review of the Hand-washing Guidelines policy, dated 02/01/02, revealed the purpose of the policy was to prevent the spread of bacteria that may cause food borne illnesses. Hands should be washed every time an employee entered the kitchen. Observation of the tray line, on 03/18/14 at 12:00 PM, revealed the Dietary Aide left the kitchen wearing gloves, holding a tray with three prepared lunch plates. She came back to the kitchen with the empty tray and did not remove her gloves or wash her hands. She obtained two slices of bread with her hands from an open bag, placing one piece of bread on two different plates. She took the tray to the dining room with the two plates, wearing the same gloves. The Dietary Aide returned to the kitchen with the empty tray and did not remove the gloves or wash her hands. She put three more plates on the tray, placing one piece of bread (using her gloved hands) on each plate. She took the plates to the dining room and came back to the kitchen without washing her hands. She put one piece of bread on three more plates, wearing the same gloves. The Dietary Aide returned to the kitchen again, without washing her hands. Interview with the Dietary Manager, on 03/18/14 at 12:20 PM, revealed she expected staff to use hand sanitizer when coming back into the kitchen. She revealed the Dietary Aide should have used tongs for the bread, instead of her hands. Interview with the Administrator, on 03/20/14 at 12:00 PM, revealed she expects staff to follow the policy related to handwashing in the kitchen. Staff should wash their hands when entering the kitchen. 2. Review of the Cleaning of Miscellaneous Equipment and Utensils policy, dated 05/01/03, revealed the ice machine should be cleaned at least quarterly. The procedure included to wash the machine, inside and out, including legs and handle. Rinse, sanitize, and dry. Observation of the ice machine, on 03/18/14 at 10:00 AM, revealed a thick collection of dark gray particles noted on the upper surface of the machine, visible when the cover was lifted. Interview with the Administrator, on 03/20/14 at 12:00 PM, revealed maintenance staff clean the ice machine quarterly; however, there is no documentation. She revealed dietary staff were expected to wipe down the machine, as part of their routine cleaning.