Every finding on record at Campbellsville Nursing and Rehabilitation Center

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure staff adhered to infection prevention and control practices, including hand hygiene and cleaning and disinfection of resident care equipment, to prevent the transmission of infections. The failure had the potential to affect all residents. The findings include: Review of the facility's policy titled, Infection Control Program Standard of Practice, revised 11/2017, revealed the purpose of the facility's infection control program was to prevent the spread of infection. In addition, review revealed the purpose also included providing appropriate education for staff and residents concerning infection control and to monitor infections and facility areas of infection. Continued review revealed hand washing, clinical equipment disinfecting, and isolation guidelines were included and intended to meet the Centers for Disease Control and Prevention (CDC) guidelines for long-term care and regulatory requirements. Further review revealed all isolation precautions and hand washing techniques for staff and residents were to follow the CDC long-term care guidelines. Additionally, the facility's infection control program was to be guided by recommendations via the CDC website. 1). Review of the facility's policy titled, Enhanced Barrier Precautions Standard of Practice, revised 04/2024, revealed enhanced barrier precautions (EBP) were additional infection control measures that might be implemented as needed as part of the facility's infection control practices to help prevent and manage the transmission of diseases and infections. Continued review revealed EBP might be implemented during high-contact care activities for residents with chronic wounds, indwelling medical devices, and/or residents with identified targeted multidrug-resistant organisms when contact precautions did not apply. Further review revealed when a resident was placed on EBP the facility was to determine the process for resident identification to alert staff when high-contact activities might require additional infection control measures, including the use of gown and gloves. Review of the facility's enhanced barrier tracking log, undated, revealed facility documentation identified 13 residents had been placed on EBP for conditions requiring additional infection control measures such as, wounds, indwelling medical devices, dialysis shunts, Foley catheters, and surgical incisions. Observation on 01/04/2026 at 10:20 AM, at the time of the State Survey Agency (SSA) entry, revealed EBP signage posted outside of some residents' room doors. Review of the EBP signage revealed instructions for everyone to clean their hands before entering and when leaving those rooms. Continued observation revealed the signage instructed providers and staff to wear gloves and a gown for high-contact resident care activities, including dressing, bathing or showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use, and wound care. Further observation revealed the signage instructed staff not to wear the same gown and gloves for the care of more than one resident. 1a). Observation on 01/04/2026 at 10:40 AM, revealed signage indicating the need for EBP precautions posted above and below the room number placard for resident room [ROOM NUMBER] (where Resident(R)9 and R55 resided) on the East Wing. Per observation, the signage instructed staff to clean their hands before entering and when leaving the room. Continued review of the EBP signage indicated both residents in resident room [ROOM NUMBER] were on EBP. Observation revealed State Registered Nurse Aide (SRNA) 1 entered without performing the required hand hygiene prior to entry and exited the room without performing necessary hand hygiene. Review of R9's medical record revealed the resident had been on EBP since 11/27/2025, due to the presence of a dialysis shunt. Review of R55's medical record revealed the resident had been on EBP since 12/01/2025, due to a neck dressing. In interview with SRNA 1, on 01/04/2026 at 10:40 AM, she said she entered resident room [ROOM NUMBER], which had residents on EBP, and failed to perform hand hygiene after exiting the room. She stated she did not believe hand hygiene was required because she had only provided the resident with water. SRNA 1 reported she had not performed hand hygiene because she had forgotten. She further stated not practicing proper hand hygiene as required could spread illness to other residents allowing them to get sick. 1b). Observation on 01/04/2026 at 10:44 AM, revealed Kentucky Medication Aide (KMA) 1 entered R9's and R55's room without performing hand hygiene prior to entering the room. Per observation, KMA 1, while in R9's and R55's room, removed oxygen tubing from an oxygen machine and discarded the tubing in the garbage. Continued observation revealed KMA 1 then exited R9's and R55's room without performing hand hygiene and proceeded to resident room [ROOM NUMBER] (where R5 resided) on the East Wing without performing hand hygiene. Observation revealed R5 was on EBP due to the presence of a Foley catheter. Review of R5's medical record revealed the resident had been on EBP since 11/16/2024.A telephone (phone) interview was attempted with KMA 1 on 01/04/2026 at 10:44 AM; however, the KMA stated she was not working at the time and declined to speak with the State Survey Agency (SSA) Surveyor. In interview on 01/04/2026 at 11:00 AM, R55 stated KMA 1 came in her room, and did something with her oxygen tubing. The resident further stated KMA 1 then threw the oxygen tubing in the garbage beside her bed. 1c). Observation on 01/04/2026 at 11:20 AM, revealed SRNA 2 entered resident room [ROOM NUMBER] (R9's and R55's room) without performing hand hygiene. Per observation, SRNA 2 exited resident room [ROOM NUMBER] without performing hand hygiene, proceeded to an office area to obtain personal scissors, and returned to resident room [ROOM NUMBER] to cut oxygen tubing. Continued observation revealed SRNA 2 discarded oxygen tubing in the garbage. Further observation revealed however, SRNA 2 failed to perform hand hygiene before or after handling the oxygen equipment or when exiting resident room [ROOM NUMBER]. In interview with SRNA 2 on 01/04/2026 at 11:20 AM, she stated when she entered and exited resident room [ROOM NUMBER] on the East Wing, she had not thought about performing hand hygiene. She said she had not looked to see if the residents were on any type of precautions before entering the room. SRNA 2 reported she had been asked to change the resident's oxygen tubing and had been in a hurry at the time. She further stated she should have washed her hands for the safety of the residents and to prevent the spread of germs. 1d). Observation on 01/04/2026 at 3:53 PM, revealed SRNA 6 exited resident room [ROOM NUMBER] (where R24 resided) on the [NAME] Wing without performing hand hygiene. Per observation, while in the room, SRNA 6 changed the resident bed linens without wearing a gown or gloves. Review of R24's medical record revealed the resident had been on EBP since 01/02/2026 due to a wound dressing. In interview with SRNA 6 on 01/04/2026 at 3:53 PM, she stated she entered resident room [ROOM NUMBER] on the [NAME] Wing and had not paid attention to the posted EBP signage. She reported she should have performed hand hygiene and worn the appropriate PPE. She acknowledged her failure to do perform hand hygiene could result in contamination to herself or the spread of germs that could make residents sick. In interview with Registered Nurse (RN) 1, on 01/04/2026 at 10:51 AM, she stated she was responsible for resident room [ROOM NUMBER] on the East Wing; however, said she was not aware if the residents assigned to that room were on EBP. She reported her expectations for staff entering resident room [ROOM NUMBER], were for the staff to follow Personal Protective Equipment (PPE) 1 requirements regardless of whether they were on the clock or not. RN 1 further stated failure to follow PPE protocols could result in the spread of germs and illness to other residents. In interview with the Infection Preventionist (IP) on 01/06/2026 at 10:02 AM, she stated it was important for staff to follow the posted EBP signage for residents' safety. She said proper hand hygiene was the first line of defense to prevent the spread of germs. The IP reported it was her expectation for all staff to follow proper infection prevention protocols for the safety of residents and to prevent the spread of germs. In interview with the Administrator on 01/06/2026 at 1:11 PM, she stated it was her expectation for staff, regardless of whether they were clocked in for work or not, to follow the EBP signage for the safety of residents. 2). Review of the facility's policy titled, Homelike Environment Standard of Practice, reviewed 04/2025, revealed residents were to be provided a safe, clean, comfortable, and homelike environment. Continued review revealed the facility was to maintain cleanliness and order throughout the environment. Further review revealed overall cleanliness was maintained to promote resident comfort and safety. Review of the facility's, Night Shift CNA Chore Sheet document revealed it outlined the routine cleaning and handling of resident care equipment and supplies. Per review, the Chore Sheet did not include instructions or expectations for the cleaning or disinfection of shower chairs used for resident bathing. Observation on 01/04/2026 at 12:24 PM, in the East Wing shower room revealed a shower chair used for resident showers with a dark, mold-like substance present on multiple surfaces. Per observation, the substance was on the fabric seat sling, along the seams of the sling material, and on the white plastic frame of the shower chair, including areas near joints, bolts, and tubing connections. Further observation revealed the dark residue was also on the lower portions of the chair frame and around the wheels. In interview with SRNA 4 on 10/05/2026 at 9:17 AM, she stated the shower chair located on the East Wing was not clean presently. She reported the shower chair had not been cleaned in at least seven months. SRNA 4 said she would not want residents' skin to come into contact with the mold-like substance present on the chair due to health concerns. She stated such contact could cause infections to residents. SRNA 4 further stated she would not sit in the shower chair herself and would not want her loved ones to have to sit on it. In interview with SRNA 5 on 01/05/2026 at 9:22 AM, she stated residents could get sick from sitting on the shower chair in its present condition. She reported she would not sit on the chair herself, nor would she want her loved ones to have to sit on it. SRNA 5 further stated the shower chair should be cleaned before being used for residents. In interview with the Director of Nursing (DON) on 01/05/2026 at 10:06 AM, she stated the SRNAs were responsible for cleaning the shower chairs. She said that task was included on a nightly chore list completed by the SRNAs. The DON stated licensed nurses reviewed and checked off on the chore list and she or the Assistant Director of Nursing (ADON) provided oversight to ensure the tasks were completed as required. She further stated however, she did not know the last time she or the ADON had checked the shower room chairs to verify they were being cleaned. In interview with the ADON on 01/05/2026 at 10:25 AM, she stated she and the DON had oversight responsibility to ensure shower chairs were being cleaned and were safe for resident use. She reported the mold-like substance observed on the shower chair appeared to have been present for a long time. The ADON said she could not identify the last time the shower chairs had been cleaned or inspected. She stated residents could experience skin issues or other complications if the mold-like substance contacted their skin, or if they had an open wound. The ADON further stated exposure to the mold-like substance could also result in respiratory issues for residents. In interview with Licensed Practical Nurse (LPN) 2 on 01/05/2026 at 10:34 AM, she stated the shower chair located in the East Wing shower room was filthy. LPN 2 stated the black matter present on the chair appeared to be mold-like and said she would not sit in that chair herself nor want a loved one to sit on it. She further stated she was concerned about cross-contamination and potential respiratory issues for residents. LPN 2 additionally stated she was concerned that steam from the showers could allow the mold-like substance to spread throughout the shower room. In interview with the DON on 01/05/2026 at 11:50 AM, she stated she reviewed the night shift chore sheet and determined cleaning of the shower chairs was not included on the chore list. She said that had been an oversight on her part. The DON further stated she could not identify when the shower chairs had last been cleaned. In continued interview with the Administrator on 01/06/2026 at 1:11 PM, she stated it was her expectation for staff to ensure all equipment used for residents to be clean and maintained in a clean condition to ensure resident safety.

Based on observation, interview, and review of facility policies, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety.The findings include: 1). Review of the facility policy titled, Staff Attire HCSG Policy 024, revised 01/2025, revealed all staff members were to have their hair off their shoulders and confined in a hair net or cap, with facial hair properly restrained. Further review revealed all staff members were to store all personal belongings, including cell phones, in designated areas away from food preparation or food and supply areas. Observation, on 01/04/2026 at 10:35 AM, revealed [NAME] 1 and Dietary Aide (DA) 1 preparing residents' lunches without hair nets in place as per the policy. Per observation, [NAME] 1 was wearing a headband that covered her ears; however, which was completely open on top with her ponytail on top of her head. Further observation revealed DA 1 had no a hair net or hair covering on. Observation, on 01/04/2026 at 11:33 AM, revealed [NAME] 1 took a phone out of her back pocket to answer a call during the lunch tray line. Continued observation revealed [NAME] 1 placed the phone back in her pocket and continued plating residents' food without performing hand hygiene and donning new gloves. Observation, on 01/05/2026 at 11:56 AM, revealed [NAME] 1 left the steam table with her gloves on to go to the microwave to heat up cheese on a burger. Continued observation revealed [NAME] 1 then returned to the steam table without removing the gloves, performing hand hygiene and donning new gloves. Observation, on 01/05/2026 at 12:06 PM, revealed [NAME] 1 leaned her gloved hands on the top of the steam stable sneeze guard for several minutes. Continued observation revealed [NAME] 1 then continued scooping chicken pot pie from its tin container onto a resident's plate and putting a hamburger from one plate to another with her gloved hands. Per observation, additional observation the Regional Dietary Manager (RDM) came into the kitchen with no beard cover in place, and without performing hand hygiene, to go to the dishwasher side of the kitchen. Further observation revealed the RDM then left the kitchen area. During interview, on 01/05/2026 at 3:03 PM, Cook1 stated she thought she could wear a cap instead of a hair net. [NAME] 1 stated she could see how, by not wearing a hair net, hair could fall into the residents' food. She reported by not performing hand hygiene and changing gloves that could contaminate the food and cause a resident to get sick. [NAME] 1 further stated she had received some training related to dietary sanitation; however, could not recall when she received that training. During interview, on 01/05/2026 at 3:00 PM, the Dietary Account Manager stated [NAME] 1 usually wore a hair net under her other head coverings. She said she was aware anyone entering or being in the kitchen was to wear a hair net per the facility policy. The Dietary Account Manger reported proper hand hygiene was expected of staff serving food on the tray line and in the kitchen in general. Additionally, she further stated the kitchen was short staffed and was not sure how to correct that. During interview, on 01/05/2026 at 2:30 PM, the RDM stated all dietary staff needed to wear a hair net or a hat, and if they had a beard, they were to wear a beard net. He said hand hygiene was expected to be performed whenever hands became soiled. The RDM reported it was his expectation for residents' food to be prepared and served in a sanitary manner to prevent cross contamination. He further stated he would be ensuring dietary staff were trained on kitchen expectations, hand hygiene and sanitation. During an interview, on 01/06/2026 at 9:55 AM, the Administrator stated it was her expectation dietary staff wore hair nets or hats and wore beard guards when necessary. Further, she stated when dietary staff were working behind the steam table, and moved to another part of the kitchen, they were to wash their hands and don new gloves prior to working at the steam table again. The Administrator stated dietary staff were to follow facility dietary policies and regulations related to storing, preparing, and serving food. The Administrator continued to state that it was ultimately her responsibility for the kitchen staff and how it was run. 2). Observation, on 01/05/2026 at 3:05 PM, of the facility's emergency food supply revealed it included expired food items that included four bags of rice cereal with an expiration of 12/05/2025; two cases of apple juice with an expiration of 06/11/2025; and one case of chocolate chip cookies that expired on 07/01/2025. During continued interview, on 01/05/2026 at 2:30 PM, the RDM stated it was his expectation for food to be stored in a safe and sanitary manner, to include no expired food, to prevent cross contamination. He said it was his expectation that staff followed the dietary policies. He further stated he was aware that more kitchen staff were needed and will be working on that in the future.

Based on observation and interview, the facility failed to ensure kitchen surfaces and equipment were free of an excessive amount of rust, black build up, and dust. These deficient practices had the potential to affect all residents who received food from the kitchen. The findings included: On 08/19/2024 at 8:59 AM, the initial tour of the kitchen, was conducted with the Certified Dietary Manager (CDM). At 9:04 AM, the ceiling vent above the two-door reach-in cooler was observed with an excessive amount of rust and black buildup. At 9:05 AM, a black substance was observed on the gasket inside of the two-door reach-in cooler. At 9:17 AM, a ceiling tile above the exhaust fan for the dish machine was missing, and the area where the ceiling tile was missing had a black buildup. At 9:20 AM, the ceiling vent in the dry storage room was observed with an excessive amount of dust. On 08/19/2024 at 9:08 AM, the CDM stated maintenance staff were responsible for cleaning the ceiling vents. The CDM stated that she would have the gasket inside of the two-door reach-in cooler cleaned that day and stated, It needs to be replaced. She stated it was not a part of the cleaning schedule, but she could add it. The CDM stated all staff were responsible for cleaning. On 08/22/2024 at 11:54 AM, the CDM stated that once a month, maintenance staff changed the filters for the ceiling vents. She stated she was not sure who was responsible for checking ceiling vents or ceilings. On 08/22/2024 at 11:55 AM, the District Manager stated he came in two times a month to complete unit inspections. He stated that maintenance staff were responsible for anything in the ceiling. He stated that he had not completed an inspection that month. Per the District Manager, the facility staff utilized an electronic system to add work orders as their way of communicating to maintenance staff. On 08/22/2024 at 11:59 AM, the CDM stated she had not submitted a work order for the ceiling vents. On 08/22/2024 at 12:14 PM, the Maintenance Director stated he changed the filters for the ceiling vents monthly. He stated that the kitchen staff should clean the vents. The Maintenance Director stated that he changed the filters sometime the previous week but could not recall the exact date of the deep cleaning for the ceiling vents. On 08/22/2024 at 4:22 PM, the CDM stated the ceiling had been in the current condition since September 2023. On 08/22/2024 at 4:37 PM, the Director of Nursing stated she did not go in the kitchen and would defer anything related to the ceiling to the maintenance department. On 08/21/2024 at 2:40 PM, the Administrator stated that there was no policy related to maintenance in the kitchen or cleanliness in the kitchen. On 08/22/2024 at 4:42 PM, the Administrator stated the building was in the process of a remodel.

Based on interview, record review, and facility policy review, the facility failed to develop a care plan addressing the use of an anticoagulant for 1 (Resident #24) of 6 sampled residents reviewed for unnecessary medications. The facility also failed to develop a care plan addressing hospice services for 1 (Resident #37) of 1 resident reviewed for hospice and end of life. The findings include: Review of the facility's policy titled, Comprehensive Care Plans Standard of Practice, dated 10/2020, specified, An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs is developed for each resident. The policy further specified, 3. Each resident's comprehensive care plan is designed to: a. Identify problem areas; b. Incorporate risk factors associated with identified problems; and e. Reflect treatment goals, timetables, and objectives in measurable outcomes; f. Identify the professional services that are responsible for each element of care. 1. Review of Resident #24's (R24) Admission Face Sheet revealed the facility admitted R24 on 06/24/2024. Further review revealed the resident had diagnoses that included history of pulmonary embolism and hypertension. An Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/12/2024, revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident was prescribed an anticoagulant. Review of R24's Physician's Order Form As of 08/21/2024, contained an order, dated 07/06/2024, for rivaroxaban (an anticoagulant), 20 milligrams (mg) every evening with supper. Resident #24's Careplan Report revealed no goals or interventions related to the resident's use of an anticoagulant medication. During an interview on 08/22/2024 at 12:58 PM with MDS Coordinator #1 and MDS Coordinator #2, MDS Coordinator #2 stated that if a resident received an anticoagulant, there should be a care plan that addressed it. MDS Coordinator #1 confirmed R24 did not have a care plan for anticoagulants; however, they should have had one. During an interview on 08/22/2024 at 2:25 PM, the Director of Nursing (DON) stated care plans were in place to let everyone know what care the residents needed. The DON stated R24 should have had a care plan addressing the use of an anticoagulant. 2. Review of R37's Admission Face Sheet revealed the facility admitted the resident on 01/02/2024. According to the Admission Face Sheet, the resident had a history that included diagnoses of Alzheimer's disease, malnutrition, and dementia. Review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/10/2024, revealed R#37 had short- and long term- memory problems and severely impaired cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS). The MDS also indicated R#37 received hospice services. Review of R#37's Physician's Order Form As of 08/21/2024, contained an order, dated 01/02/2024, for hospice services. Review of R#37's Careplan Report revealed the facility did not develop a care plan addressing Hospice/Comfort Care until 08/20/2024, during the survey. During an interview on 08/22/2024 at 12:58 PM, MDS Coordinator #2 stated R#37 was admitted to the facility on hospice and confirmed a care plan specifically for hospice should have been developed. During an interview on 08/22/2024 at 2:25 PM, the Director of Nursing (DON) stated care plans were in place to let everyone know what care the residents needed.

Based on observation, interview, record review, and facility policy review, the facility failed to maintain an effective infection prevention and control program to prevent the transmission of communicable diseases. The facility reported an outbreak of [MEDICAL CONDITION] on 11/19/19 with sixteen (16) residents affected. Observations revealed nine (9) of the sixteen (16) residents' rooms did not have Personal Protective Equipment readily available outside of the room and thirteen (13) of the residents' rooms did not have signage in a conspicuous place outside the resident's room identifying the category of precautions and/or instructions to see the nurse before entering. The findings include: Review of the facility's policy entitled Infection Control Program Standard of Practice, dated (MONTH) (YEAR) revealed the standard of practice is to prevent the spread of infection and provide appropriate education for staff and residents concerning infection control. According to the policy, hand washing and isolation guidelines are included and intended to meet standards of Centers for Disease Control and Prevention (CDC) guidelines for long-term care. Further review revealed the infection control program would be guided by recommendations via the CDC website. Review of the CDC Guideline for the Prevention and Control of Norovirus Gastroenteritis Outbreaks in Healthcare Settings, dated 2011, revealed that during outbreaks patients with norovirus gastroenteritis should be placed on Contact Precautions for a minimum of 48 hours after the resolution of symptoms to prevent further exposure of susceptible patients. Interview with the DON on 11/19/19 at 2:37 PM revealed Resident #32, who resides on the East Unit, had an episode of vomiting on 11/18/19; however, the resident has a [DIAGNOSES REDACTED]. Further interview revealed Resident #49, who resides on the West Unit, had an episode of vomiting later on 11/18/19. According to the interview, on 11/19/19 more residents began to develop vomiting and diarrhea, so the facility began tracking and mapping the residents. Further interview revealed the DON contacted the local health department and was informed that unless the outbreak consisted of a bacterial infection or influenza the health department did not need to be notified. Review of the Nursing Home Antimicrobial Stewardship Guide/Infection Tracking form revealed sixteen (16) residents developed vomiting and/or diarrhea by 11/19/19. Observations on 11/19/19 at 4:45 PM revealed nine (9) residents (Residents #8, #10, #30, #35, #39, #42, #49, #54, and #114) that were listed on the infection tracking form as having vomiting and/or diarrhea had no Personal Protective Equipment (PPE) readily available outside of the room and no signage posted in a conspicuous place outside the residents' rooms to identify the category of the precautions and/or instructions to see the nurse before entering. Further observations revealed four (4) residents (Residents #3, #20, #34, and #50) had PPE readily available outside of the room; however, there was no signage posted in a conspicuous place outside the residents' rooms to identify the category of the precautions and/or instructions to see the nurse before entering. Interview with the DON on 11/19/19 at 5:16 PM revealed the Medical Director was contacted with instructions to maintain the residents in isolation for 48 hours and to use the CDC guideline to post precautions and utilize PPE. Further interview with the DON on 11/21/19 at 2:29 PM revealed the facility's Medical Director gave instructions on 11/19/19 to keep the residents in the room, shut down the dining room, and follow standard precautions. Further interview revealed as more residents started presenting with symptoms the precautions were changed from standard precautions to contact precautions and the CDC guidelines were followed to keep the residents in isolation for 48 hours after the last symptom.

Based on observation, interview, and record review, it was determined the facility failed to provide appropriate respiratory services related to oxygen therapy for one (1) of twenty-two (22) sampled residents (Resident #6). Resident #6 was observed on 11/19/19 receiving oxygen via nasal cannula at two (2) liters per minute (LPM); however, the order for Resident #6's oxygen was discontinued in (MONTH) 2019. The findings include: Upon request of the policy on 11/20/19 for administration of oxygen therapy, the Director of Nursing stated the facility did not have a policy related to oxygen therapy. Upon request of the policy/procedure on 11/21/19, for transcribing physician orders [REDACTED]. Observation of Resident #6 on 11/19/19 at 3:17 PM, revealed the resident in the room seated in a wheelchair. The resident was wearing oxygen via nasal cannula at two (2) LPM. Further observation of the resident on this date at 4:15 PM revealed the resident up in a wheelchair outside the room without oxygen tubing on. The wheelchair had a portable oxygen concentrator but it was set at zero (0) LPM. Observation of Resident #6 on 11/20/19 at 2:11 PM, revealed the resident was in the room seated in a wheelchair. The resident was not wearing oxygen and there was not an oxygen concentrator in the room. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) quarterly assessment, dated 08/11/19, revealed a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident had severe cognitive impairment. The MDS also revealed the resident was on oxygen therapy at the time of the assessment. Review of a physician order [REDACTED].#6 had an order, dated 04/27/18, for Oxygen at two (2) LPM via nasal cannula, continuously. Review of the comprehensive care plan for Resident #6 did not reveal an identified risk related to respiratory status or ineffective gas exchange. Interview with the Director of Nursing (DON) on 11/20/19 at 5:10 PM, revealed Resident #6 did not have a current physician's orders [REDACTED]. She further stated she would complete a medication error as she is the one who received the order to discontinue the oxygen. Review of the Medication Error Report, dated 11/20/19, revealed failure to discontinue the oxygen as ordered. Documentation revealed the physician and the family were notified. Interview with the DON on 11/21/19 at 9:16 AM, revealed the management team reviews all new orders in the EMR every morning, Monday through Friday. The DON stated they did not require the nurses to write out the physician orders [REDACTED]. Further interview with the DON at 10:00 AM on this date revealed she had received the phone order to discontinue the oxygen on Resident #6 sometime in September, but had failed to enter the order into the EMR.

Based on observation, record review, and interview, it was determined the facility failed to maintain the kitchen equipment in a sanitary manner. Observation revealed two (2) ovens underneath the range and five (5) steam table wells were in need of cleaning. The findings include: Interview with the Corporate Dietary Manager (CDM) at 2:50 PM on 11/01/18 revealed there were no policies or procedures in place for cleaning the range ovens or the steam table wells. Observation during the initial tour of the kitchen at 10:20 AM on 10/30/18 revealed two (2) ovens located underneath the range top had a heavy accumulation of burned food debris and burned fluid spills inside both ovens. Review of the weekly cleaning schedule revealed the stove and ovens were scheduled to be cleaned every week on Sunday and Monday. However, there was no documented evidence that the stove and ovens had been cleaned. Further review of the weekly cleaning schedule revealed the steam table was scheduled to be cleaned every week on Monday and Friday. However, there was no documented evidence that the steam table had been cleaned. Interview at 1:45 PM on 11/01/18 with the Corporate Dietary Manager and the Dietary Manager in training revealed they agreed that the two (2) ovens and the five (5) steam table wells were in need of cleaning. The Dietary Manager in training stated she did not know when the equipment had last been cleaned.

Based on interview, record review, and review of the facility's medication administration policy, it was determined the facility failed to provide medications in accordance with professional standards of practice for one (1) of three (3) sampled residents (Resident #1). The findings include: Review of the facility's Medication Administration policy (undated) revealed the facility would provide safe administration of all medications to residents. The procedure stated that all licensed personnel administering medications would check to ensure that the correct resident was being administered the ordered medication prior to each medication administered. Review of Resident #1's medical record revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's physician orders [REDACTED]. Review of a facility medication error report dated 03/24/18 at 11:10 PM revealed on 03/24/18, Resident #1 was administered [MEDICATION NAME] medication by mistake. Interview with Licensed Practical Nurse (LPN) #1 on 04/09/18 at 11:40 AM revealed on 03/24/18, she mistakenly gave Resident #1 an antibiotic that had been ordered for another resident. LPN #1 stated she had failed to utilize the facility's procedure for ensuring the medication was administered to the right resident. LPN #1 stated she immediately realized that she had administered the medication to the wrong resident, and left the resident's room to check the resident's medication record to ensure the resident was not allergic to the medication. LPN #1 stated the resident did not have an allergy listed to the medication, and therefore she did not report the medication error to anyone, including facility administrative staff. Interview with the Director of Nursing (DON) on 04/09/18 at 12:35 PM revealed the facility became aware of the medication error when the family of Resident #1 reported it to another nurse at the facility, who then informed the DON. The DON stated that an investigation was initiated and LPN #1 verified that she had administered Resident #1 a medication which had not been ordered on [DATE]. The DON stated he then notified the resident's family and physician immediately. The DON stated that each licensed personnel administering medications to residents was required to observe the medication rights contained in the facility's policy including ensuring the correct identity of the resident prior to medication administration.

Based on interview, record review, and review of the facility's medication administration policy, it was determined the facility failed to provide pharmaceutical services to ensure adequate acquiring of medication to meet the needs of one (1) of three (3) residents (Resident #2). The facility failed to ensure the medication ordered by Resident #2's physician was available for administration to the resident on 04/08/18. The findings include: Review of the facility's policy, Ordering and Receiving Controlled Medications, dated (MONTH) 2010, revealed resident medications requiring refill would be submitted to the pharmacy a minimum of three (3) days prior to the date the medication will be required for administration, to ensure an adequate supply of the medication is available. Review of Resident #2's medical record revealed the facility admitted the resident on 03/23/18 with [DIAGNOSES REDACTED]. Review of a Brief Interview for Mental Status (BIMS) assessment and a list of interviewable residents provided by the facility on 04/09/18, revealed Resident #2 had a BIMS score of twelve (12), which indicated Resident #2 was cognitively intact. Review of Resident #2's physician orders [REDACTED]. Interview with Resident #2 on 04/09/18 at 10:35 AM revealed staff did not administer his/her [MEDICATION NAME] (a medication used to treat anxiety and panic disorders) on 04/08/18 when the resident requested the medication. Further interview with the resident revealed when he/she requested the medication, the nurse told the resident that he/she was out of the medication and none was available in the facility for administration to the resident. Interview with Licensed Practical Nurse (LPN) #2 on 04/09/18 at 12:36 PM revealed that Resident #2 had requested [MEDICATION NAME] on 04/08/18; however, the resident did not have any of the medication available for administration. LPN #2 stated that to ensure residents had as needed medications available for administration, staff were required to contact the pharmacy and reorder the medication when approximately three doses remained. However, according to LPN #2, Resident #2's [MEDICATION NAME] had not been reordered timely, and the resident did not have the medication available for administration on 04/08/18. Interview with the Director of Nursing (DON) on 04/09/18 at 2:30 PM revealed he had not been aware that Resident #2 had run out of [MEDICATION NAME] and did not have the medication available for administration on 04/08/18.

Based on interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to ensure an injury of unknown source was immediately reported and investigated for one (1) of three (3) residents (Resident #15). On 08/08/17, staff identified that Resident #15 had dark red/purple-colored bruising across his/her breast, under the right arm, and on each side of the upper rib area that staff or the resident could not explain and the source of the injury was not observed. The staff failed to report the injury to administrative staff until 08/09/17, the next day. However, even after administrative staff were notified of Resident #15's injuries, the facility failed to report the unknown injury to the State Survey Agency and to Adult Protective Services. The findings include: Review of the facility's policy and procedure titled Abuse Prohibition Standards of Practice, revised September 2016, revealed all incidents of alleged abuse would be reported to the administrator or the administrator's designee. In addition, all incidents of alleged abuse, including injuries of unknown origin, would be reported to the state survey agency within two hours and an investigation would begin immediately. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #15's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of 0, indicating Resident #15 was not interviewable. Record review revealed the facility readmitted Resident #15 on 08/01/17 with [DIAGNOSES REDACTED]. Review of a Resident Incident Report dated 08/09/17 at 11:00 PM revealed Resident #15 had dark red/purple bruising under his/her right arm, across the bottom of his/her breast in the diaphragmatic area, and on each side of the upper rib area. Interview with State Registered Nurse Aide (SRNA) #1 on 08/17/17 at 3:04 PM, and SRNA #2 on 08/18/17 at 5:05 PM, revealed the SRNAs provided care for Resident #15 on 08/08/17. SRNA #1 and SRNA #2 stated they identified dark red/purple bruising under Resident #15's right arm, across the bottom of his/her breast, and on each side of the upper rib area at approximately 8:00 PM when they assisted Resident #15 to bed. SRNA #1 and SRNA #2 stated they immediately reported the bruising to Resident #15's nurse, Licensed Practical Nurse (LPN) #1. Interview with LPN #1 on 08/18/17 at 7:04 PM, revealed SRNA #1 and SRNA #2 notified her that Resident #15 had dark red/purple bruising under his/her right arm, across the bottom of his/her breast in the diaphragmatic area, and on each side of the upper rib area. Further interview with LPN #1 revealed she did not report the injury of unknown origin until the next day. LPN #1 stated she had been trained to report all injuries of unknown origin to the Administrator as soon as they were discovered, but stated she did not report the incident that night because it was late in the evening. Interview with the Director of Nursing (DON) on 08/18/17 at 2:27 PM, revealed she was not notified of Resident #15's injury of unknown origin until approximately 10:00 or 11:00 AM on 08/09/17. Further interview with the DON revealed she did not report the incident to the state survey agency (OIG) because her investigation determined it was plausible that the bruising was caused by the use of a gait belt.

Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure the physician acted upon pharmacy recommendations for (1) one of (15) sampled residents (Resident #8). The pharmacist recommended a gradual dose reduction (GDR) in Risperidone (an antipsychotic medication used to treat schizophrenia or bipolar disorder) for Resident #8 on 03/03/17 and 07/13/17; however, there was no evidence the resident's physician reviewed or documented what action was needed to address the pharmacist's recommendations. The findings include: Review of the facility's Medication Regimen Review and Reporting policy, dated September 2008, revealed findings and recommendations from pharmacy reviews would be communicated to those with authority and/or responsibility to implement the recommendations, and they would respond in an appropriate and timely fashion. Review of Resident #8's medical record revealed the facility admitted the resident on 08/04/16, with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 1, indicating severe cognitive impairment. Review of the pharmacy recommendations for Resident #8 dated 03/09/17 revealed the resident had been on Risperidone 0.5 milligrams (mg) every morning and Risperidone 0.25 mg every evening since August 2016. The pharmacist recommended that the resident's physician evaluate the dose and consider a gradual dose reduction of Risperidone to ensure the resident was receiving the lowest possible effective dose. However, further review revealed there was no response from resident's physician and no evidence the facility followed up with the physician regarding the pharmacist's recommendation. Review of the pharmacy recommendations for Resident #8 dated 07/13/17 revealed the pharmacist again documented that the resident had been on Risperidone 0.5 mg every morning and Risperidone 0.25 mg every evening since August 2016. The pharmacist again recommended that the resident's physician evaluate the resident's Risperidone dosage and consider a gradual dose reduction of Risperidone. However, there was no evidence the resident's physician had reviewed or taken any action to address the pharmacist's recommendation. Interview with the Director of Nursing (DON) on 08/18/17 at 5:50 PM, revealed she was responsible to ensure pharmacy recommendations were sent to the physician and acted upon. She stated when she received pharmacy recommendations, she reviewed them and sent them to the physician. However, interview with the DON revealed she did not have a system in place to ensure the residents' physicians responded to pharmacy recommendations. Further interview with the DON revealed she was not aware Resident #8's physician did not address/act on the pharmacy recommendations on 03/03/17 and 07/13/17.

Based on interview, closed record review, and review of facility policy, it was determined the facility failed to ensure the physician documented the need for a discharge for one (1) of three (3) sampled residents (Resident #1). On 06/12/17 Resident #1 was witnessed hitting a television in the lobby with a remote control and having aggressive behaviors. On 06/13/17 the resident threw two (2) drinks in the dining room and attempted to throw a breakfast tray; however, staff intervened and removed the tray. After the resident was taken out of the dining room the resident picked up a mouse from a computer on a medication cart and threw it down the hallway. The facility contacted the resident's physician and a telephone order was received to obtain laboratory work and, if the resident refused the blood tests, to send to the emergency room for evaluation for increased agitation. The facility attempted to obtain a laboratory specimen from the resident and he/she refused. The facility sent the resident to the Emergency Department for evaluation on 06/13/17. There was no evidence in the medical record that the physician documented the need for transfer as required. The findings include: Interview with the Administrator on 06/21/17 at 3:15 PM revealed the facility did not have a policy on transferring and discharging residents. She stated that any time a resident is sent out of the facility the resident's medical information is sent with them. She stated she was not aware of the requirement for the physician to document the need to transfer or discharge a resident. Review of Resident #1's closed record revealed the facility admitted the resident on 06/05/17 with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of ninety-nine (99) indicating the resident was not interviewable. Further review of the MDS revealed the resident exhibited rejection of care daily during the lookback period. Furthermore, the facility assessed the resident to have a plan of discharge back to the community. Review of the nursing departmental notes dated 06/12/17 revealed Resident #1 was witnessed hitting a television in the lobby with a remote control and having aggressive behaviors. Review of the nursing departmental notes dated 06/13/17 revealed the resident was demonstrating behaviors with increased agitation. The resident was observed to throw his/her breakfast drinks on the floor and attempted to throw his/her food tray. The resident then threw the mouse from the medication cart computer down the hallway. Review of telephone physician orders [REDACTED]. The order further stated if the resident refused the tests to send the resident to the emergency room for evaluation for increased agitation. Review of the nursing departmental notes dated 06/13/17 revealed the resident refused the bloodwork and Emergency Medical Services arrived at 9:40 AM to transfer the resident to the emergency room . Review of Resident #1's hospital record revealed the resident was brought into the emergency roiagnom on [DATE] due to increased behaviors. A review of the emergency room Physician Documentation from Resident #1's hospital admitted d 06/13/17 revealed the facility sent Resident #1 to the hospital for a psychiatric evaluation due to increased behaviors. Upon arrival at the hospital, the resident was evaluated and it was determined the resident did not meet criteria to be admitted to the hospital. Further review revealed the hospital's plan was to send the resident back to the facility; however, the facility refused to take the resident back. Documentation revealed the hospital notified the facility on 06/13/17 that the resident did not meet requirements to be admitted ; however, the Assistant Director of Nursing (ADON) and Administrator stated they would not accept the resident back at the facility unless the resident's behaviors were under control. According to the hospital History and Physical, the resident was admitted for observation because the facility refused to readmit Resident #1 and Social Services was consulted to assist with finding placement for the resident in another facility. The hospital discharged Resident #1 home with family on 06/15/17. Interview with the ADON on 06/21/17 at 11:19 AM revealed he received a phone call from the hospital on [DATE] to inform him that Resident #1 did not meet the requirements to be admitted . He stated that he informed staff at the hospital that the facility would not admit the resident back to the nursing facility until the resident's behaviors had been addressed. The ADON stated he then transferred the phone call to the Administrator. Further interview with the ADON revealed he was not aware that the resident's physician needed to document about the resident's discharge in the resident's medical record. Interview with the Administrator on 06/21/17 at 12:28 PM revealed Resident #1 started having increased behaviors on 06/12/17. She stated the resident's physician was notified and orders were received to obtain bloodwork and if the resident refused to send him/her to the emergency room for psychiatric evaluation. Further interview revealed the resident refused to let staff obtain the bloodwork, therefore, the facility sent the resident to the emergency room as ordered by the physician. The Administrator stated that the hospital called and informed the ADON that the resident did not meet criteria for admission and that they would be sending the resident back to the facility; however, the ADON said the resident would not be admitted back to the nursing facility until his/her behaviors were under control. She stated the call was transferred to her and she told the hospital staff that the resident was a danger to himself/herself and other residents and that she would not admit the resident back to the nursing facility until the resident had been evaluated and treated by a psychiatric center. According to the Administrator, she was not aware a physician was required to document the basis for the resident's discharge and why the resident's needs could not be met at the facility.

Based on interview and record review it was determined the facility failed to provide a discharge notice to one (1) of three (3) sampled residents (Resident #1) who was discharged from the facility. On 06/12/17 Resident #1 was witnessed hitting a television in the lobby with a remote control and having aggressive behaviors. On 06/13/17 the resident threw two (2) drinks in the dining room and attempted to throw a breakfast tray; however, staff intervened and removed the tray. After the resident was taken out of the dining room the resident picked up a mouse from a computer on a medication cart and threw it down the hallway. The facility contacted the resident's physician and a telephone order was received to obtain laboratory work and, if the resident refused the blood tests, to send to the emergency room for evaluation for increased agitation. The facility attempted to obtain a laboratory specimen from the resident and he/she refused. The facility sent the resident to the Emergency Department for evaluation on 06/13/17. The findings include: Interview with the Administrator on 06/21/17 at 3:15 PM revealed the facility did not have a policy on transferring and discharging residents from the facility. Review of the facility's policy titled Resident Rights Standard of Practice, dated November 2016, revealed it did not address the resident's rights related to being transferred or discharged from the facility. Review of Resident #1's closed record revealed the facility admitted the resident on 06/05/17 with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of ninety-nine (99) indicating the resident was not interviewable. Further review of the MDS revealed the resident exhibited rejection of care daily during the lookback period. Furthermore, the facility assessed the resident to have a plan to be discharged back to the community. Review of the nursing departmental notes dated 06/13/17 revealed the resident was demonstrating behaviors with increased agitation. The resident was observed to throw his/her breakfast drinks on the floor and attempted to throw his/her food tray. The resident then threw the mouse from the medication cart computer down the hallway. Review of telephone physician orders [REDACTED]. Review of the nursing departmental notes dated 06/13/17 revealed the Emergency Medical Services arrived at 9:40 AM to transfer the resident to the emergency room . Review of Resident #1's hospital record revealed the resident was brought into the emergency roiagnom on [DATE] for increased behaviors. A review of the emergency room Physician Documentation from Resident #1's hospital admitted d 06/13/17 revealed the facility sent Resident #1 to the hospital for a psychiatric evaluation due to increased behaviors. Upon arrival at the hospital, the resident was evaluated and it was determined the resident did not meet criteria to be admitted to the hospital. Further review revealed the hospital's plan was to send the resident back to the facility; however, the facility refused to take the resident back. Documentation revealed the hospital notified the facility on 06/13/17 that the resident did not meet requirements to be admitted ; however, the ADON and Administrator stated they would not accept the resident back at the facility unless the resident's behaviors were under control. According to the hospital History and Physical, the resident was admitted for observation because the facility refused to readmit Resident #1 and Social Services was consulted to assist with finding placement for the resident in another facility. The hospital discharged Resident #1 home with family on 06/15/17. Interview with the facility's Business Office Manager on 06/21/17 at 12:15 PM revealed she had not given the resident a discharge notice. She stated she spoke with the resident's family and informed them of doing a bed hold; however, the family stated they could not afford to pay for a bed hold. Further interview revealed she was not aware that a discharge notice should have been given. Interview with the ADON on 06/21/17 at 11:19 AM revealed he received a phone call from the hospital on [DATE] to inform him that Resident #1 did not meet the requirements to be admitted to the hospital. He stated that he informed staff at the hospital that the facility would not admit the resident back to the nursing facility until the resident's behaviors had been addressed. The ADON stated he then transferred the phone call to the Administrator. Further interview with the ADON revealed he was not aware that the resident needed to be given a discharge notice. Interview with the Administrator on 06/21/17 sat 12:28 PM revealed Resident #1 started having increased behaviors on 06/12/17. She stated the resident's physician was notified and orders were received to obtain bloodwork and if the resident refused the bloodwork, to send him/her to the emergency room for psychiatric evaluation. Further interview revealed the resident refused to let staff obtain the bloodwork, therefore, the facility sent the resident to the emergency room as ordered by the physician. The Administrator stated that the hospital called and informed the ADON that the resident did not meet criteria for admission and that they would be sending the resident back to the facility; however, the ADON said the resident would not be admitted back to the nursing facility until his/her behaviors were under control. She stated the call was transferred to her and she told the hospital staff that the resident was a danger to himself/herself and other residents and that she would not admit the resident back to the nursing facility until the resident had been evaluated and treated by a psychiatric center. Further interview revealed the facility did not issue the resident a discharge notice. The Administrator stated she was not aware that a discharge notice was required because the resident was transferred to the hospital with intent to be admitted for psychiatric evaluation. Interview with the District Ombudsman on 06/21/17 at 1:16 PM revealed she had not received a copy of Resident #1's discharge notice. She further stated that she was not aware that Resident #1 had be sent to the emergency room and that the facility had refused to allow the hospital to transfer the resident back to the facility.

Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure a bruise was appropriately assessed and monitored for one (1) of three (3) sampled residents (Resident #1). Review of the facility's skin documentation revealed an area (a bruise) to the left heel was observed on 07/09/16; however, there was no documented evidence the facility continued to assess the area to determine if the area was worsening until 07/22/16. The findings include: Review of the facility policy, Skin/Wound Procedures, revision date May 2014, revealed the intent of the policy was the prevention of pressure ulcer development and the promotion of healing of pressure areas/ulcers that were present. Interview on 08/17/16 at 1:24 PM with the facility's wound care nurse, Licensed Practical Nurse (LPN) #1, revealed the facility did not have a policy related to the assessment and monitoring of bruises observed on a resident; however, bruises should be assessed and measured when first identified. The interview further revealed the physician should be notified when a bruise was identified and an order obtained to monitor the area. LPN #1 stated the order was to be placed on the Treatment Sheet to alert the staff of the area and the facility staff should complete an incident report and attempt to identify the cause of the bruise. Review of the medical record for Resident #1 revealed the facility admitted the resident on 03/25/16 with [DIAGNOSES REDACTED]. Further review of the medical record revealed Resident #1 was transferred on 08/07/16 to an outside facility for an evaluation of a left lower extremity wound. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 07/02/16, revealed the resident required extensive assistance of two (2) staff members for bed mobility. Review of Resident #1's Incident Report, dated 07/01/16, revealed the resident was assessed to have bruising to the left heel which was determined to be caused by movement of the resident's legs and the resident hitting his/her heel on the bed. Further review of the report revealed the area was measured as 5 centimeters (cm) by 6 cm and described as blue/purple looking. Review of Resident #1's Wound Healing Progress Report revealed on 07/01/16 the resident was assessed to have a bruise to the left heel. The document did not include measurements or a description of the area. Continued review of the report revealed the bruise was assessed on 07/09/16 and 07/23/16 with no measurements and no description of the area. Further review of the report revealed on 07/30/16 the area was measured and documented to measure 13.5 cm by 13.0 cm. Review of Resident #1's Wound Assessment Report, dated 07/01/16, revealed the resident was assessed to have a bruise on the left heel that was dark purple/blue and no measurement of the bruise noted. Review of Resident #1's Wound Assessment Report, dated 07/09/16, revealed the resident was assessed to have a bruise on the left heel that was fading purple/blue in appearance and no measurement of the bruise noted. Further review of the report revealed the resident had a treatment in place which was a ROHO cushioning device (a protective boot) with two (2) socks in place on the left lower extremity at all times. Review of Resident #1's Wound Assessment Report, dated 07/16/16, revealed the bruise on the resident's left heel was not assessed. Review of Resident #1's Wound Assessment Report, dated 07/23/16, revealed the resident was assessed to have a bruise on the left heel that was dark purple/blue in appearance and no measurement of the bruise was noted. Further review of the report revealed Resident #1 had a treatment in place which was a Zero-G brace (a protective boot) to bilateral feet at all times as the resident allows and continue to wear ROHO boot on the left foot underneath the Zero-G boot. Review of Resident #1's Wound Assessment Report, dated 07/30/16, revealed the resident was assessed to have a bruise to the left heel that was dark purple/blue in appearance and with measurements of 13.5 cm in length and 13.0 cm in width. Review of Resident #1's Departmental Notes for the Weekly Skin Meeting, dated 07/22/16, revealed the resident's self-inflicted bruising to the left heel was discussed and the area was dry and hardened. Further review of the note revealed the resident had a treatment in place of ROHO boots and Zero-G boots in place with resident noncompliance. Review of Resident #1's Departmental Notes for the Weekly Skin Meeting, dated 07/27/16, revealed the area to the resident's left heel was discussed and the physician and family were aware the areas were secondary to the end of life process. Further review of the note revealed the current treatments were continued and the resident continued to have noncompliance. Review of Resident #1's Physician Progress assessment/note, dated 07/29/16, revealed the resident was assessed to have a post-traumatic left heel bruise and bilateral malleolus bruising. Further review of the document revealed the resident's pulses were absent in the left foot and behind the left knee. Review of Resident #1's Physician Progress assessment/note, dated 08/03/16, revealed the resident was assessed to have a vascular wound to the left lower extremity. Continued review of the note revealed the Physician had a discussion with Resident #1's family and explained that due to the resident's poor nutritional status and poor circulation the wound would continue to decline without surgical intervention; however, the resident's family declined a surgical consultation at that time. Review of Resident #1's Treatment Sheets, dated July 2016 and August 2016, revealed no documented evidence the resident's bruise was monitored daily according to facility practice. Interview on 08/17/16 at 1:49 PM with State Registered Nurse Aide (SRNA) #1 revealed the SRNA observed the bruise on Resident #1's heel and reported the bruise to the nurse around the beginning of July. The interview further revealed Resident #1's bruise continued to get bigger and worse even though the staff protected the area with heel protectors and padded the area. Interview on 08/17/16 at 1:56 PM with Registered Nurse (RN) #1 revealed the bruise on Resident #1's left heel was reported to the RN and the RN immediately went and assessed the area. The interview further revealed the RN measured the area and completed an incident report and determined the area occurred because of the resident's continuous movement of the lower extremity against the bed, and heel protectors were implemented at that time. Continued interview revealed the RN reported she had measured the area at the time the area was reported to her; however, she thought she forgot to enter the measurement on the wound monitoring sheet. RN #1 revealed she did notify the physician of the area and she should have placed an order to monitor the area on the treatment sheet to alert staff to monitor the area for decline or healing. The RN stated that it would be difficult to monitor an area to determine if the area was healing or declining without a description and measurements of the area. Interview on 08/17/16 at 1:24 PM with LPN #1 (Skin Nurse) revealed the she was not in the facility on the day the area was found on Resident #1's left heel but was made aware of the area the next day. The interview revealed the area on Resident #1's heel appeared to be a light colored bruise. LPN #1 denied she measured the area because she did not initially discover the area, and a bruise was usually measured only when identified and just monitored after that. Continued interview with the LPN revealed without knowledge of what an area initially looked like, and measurements, it would be difficult to accurately assess if an area was improving or declining but she typically looked at the wounds each week. Further interview with LPN #1 revealed she was unsure of when the resident's wound declined because she was off work for vacation for over a week and when she returned to work the area had gotten bigger and other areas had developed on the left lower extremity. Interview on 08/17/16 at 3:08 PM with the Director of Nursing (DON) revealed the DON was unaware exactly when the area on Resident #1's left heel declined but thought it was toward the end of July when the area started being discussed in the weekly skin meeting. The interview further revealed the area started as a bruise and heel protectors were put into place. Continued interview revealed Resident #1 also developed some ischemic areas on the left lower extremity and treatments were initiated for the areas. The DON revealed the facility and the resident's physician spoke with the resident's family a couple of times to inform the family that due to the resident's decreased circulation the area would probably decline without surgical intervention and the family initially refused for the resident to have a surgical evaluation. Further interview revealed the family eventually requested a surgical consultation because the area continued to decline. The DON revealed Resident #1's bruise should have initially been assessed and measured, the physician should have been notified, and an order obtained to monitor the bruise daily for decline. The interview further revealed she was unaware the measurements of the bruise had not been placed on the wound monitoring sheet and it would have been difficult to adequately assess and monitor the bruise without the knowledge of what the bruise initially looked like and the size of the bruise. Interview on 08/18/16 at 4:15 PM with the Administrator revealed the area on Resident #1's left heel initially started as a bruise and declined. The interview further revealed the physician assessed the resident and the area a couple of times and spoke with the family about the probability that the area would not improve and would decline without surgical intervention due to the resident's poor circulation. Continued interview revealed the resident's family initially declined to have a surgical consultation and then agreed when the wound got progressively worse. The Administrator revealed she felt like the staff adequately monitored the area on the resident's left heel, even though there was no documentation of the monitoring because the resident had some type of heel protectors in place during the time the resident had the bruise and the staff was supposed to assess the area when the heel protectors were applied and removed each day. The Administrator revealed the facility staff was not required to measure a bruise after the initial assessment and the skin nurse looked at the wounds/areas each week and would know if the area had declined.

Based on observation, interview, and review of facility policy it was determined the facility failed to store drugs and biologicals in a controlled temperature environment for two (2) of two (2) medication rooms. Multiple medications were found stored in both the East and West medication rooms with temperature labels directing temperatures not to exceed seventy-seven (77) degrees Fahrenheit. However, observations on 06/02/16 revealed the temperature in the East medication room was eighty-one (81) degrees Fahrenheit and the temperature in the West medication room was eighty-five (85) degrees Fahrenheit. In addition there was no thermometer or temperature log in either medication room. The findings include: Review of the facility's policy titled Storage of Medication, dated September 2010, revealed medications requiring a controlled room temperature was defined as 68 degrees Fahrenheit to 77 degrees Fahrenheit. Observations on 06/02/16 at 5:00 PM of the East medication room revealed the temperature to be 81 degrees Fahrenheit. In the East medication room the facility stored the Emergency Drug Kit (EDK) which contained medications including Coumadin (anticoagulant), Depakote (anticonvulsant), Digoxin (anti-dysrhythmic), Theophylline (bronchodilator), Remeron (antidepressant), Glucophage (antidiabetic), and Zoloft (antidepressant) which all indicate the storage temperature to be 68 to 77 degrees Fahrenheit. Additionally, in the East medication room an overstock of medication for residents was kept in the medication room. Residents #2, #12, and #13, and unsampled Residents A, B, C, D, E, F, G, H, I, and J had medications including Vancomycin (anti-infective), Gabapentin (anticonvulsant), Metoprolol (antihypertensive), Zofran (antiemetic), and Sinemet (anti-Parkinson), which all indicated the storage temperature to be 68 to 77 degrees Fahrenheit. Observation on 06/02/16 at 5:30 PM of the West medication room revealed the temperature to be 85 degrees Fahrenheit. In the West medication room the facility stored the EDK which contained the same medications as the East medication room. Also, in the West medication room an overstock of medication for residents was kept in the medication room. Resident #2 and unsampled Resident K had medications including Vancomycin (anti-infective), Piperacillin-Tazo (anti-infective), and Meropenem (anti-infective), which all indicated the storage temperature to be 68 to 77 degrees Fahrenheit. Interview with Pharmacist #2 at 06/02/16 at 6:00 PM revealed effectiveness of a medication could change if the medications were stored in an area where the temperature was outside of the range of 68 to 77 degrees Fahrenheit. She further revealed none of the medications on the list from the facility that were stored above 77 degrees Fahrenheit would pose a danger but might not be as effective. She also added the EDK boxes were changed out every two weeks. Interview with the Director of Nursing on 06/02/16 at 7:08 PM revealed a thermometer was usually kept in both medication rooms and checked by the third shift staff daily. She further revealed no one had ever complained about the medication room temperatures being increasingly warm.

Based on interview, record review, and review of the facility abuse policy, it was determined the facility failed to conduct required Kentucky Adult Caregiver Misconduct Registry checks for five (5) of five (5) employee files reviewed prior to employment. The findings include: Review of the facility policy, Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown Source, and Misappropriation of Resident Property, (not dated) revealed that the facility will screen all potential employees for a history of abuse, neglect, or mistreatment of [REDACTED]. Review of the employee file for Employee #1 revealed the employee was hired on 02/09/16. The Kentucky Adult Caregiver Misconduct Registry check was conducted on 02/14/16, after employment. Review of the employee file for Employee #2 revealed the employee was hired on 02/22/16. The Kentucky Adult Caregiver Misconduct Registry check was conducted on 03/14/16, after employment. Review of the employee file for Employee #3 revealed the employee was hired on 03/08/16. The Kentucky Adult Caregiver Misconduct Registry check was conducted on 03/14/16, after employment. Review of the employee file for Employee #4 revealed the employee was hired on 04/19/16. The Kentucky Adult Caregiver Misconduct Registry check was conducted on 04/22/16, after employment. Review of the employee file for Employee #5 revealed the employee was hired on 05/23/16. The Kentucky Adult Caregiver Misconduct Registry check was conducted on 06/01/16, after employment. Interview with the Human Resources Director on 06/02/16 at 6:04 PM revealed that she was responsible for conducting the required background checks on employees prior to hire. She stated some have been checked a little late. She further stated that she used a check-off sheet to ensure everything was accurate in the employee files. Furthermore, she stated that she does self-audits to ensure all mandatory employee background checks have been performed.

Based on observation, interview, and facility policy review, the facility failed to ensure foods were palatable for residents on the East Hall during the noon meal on 06/01/16. A test tray conducted for a regular tray on 06/01/16 revealed the rice was not palatable and tasted bland. The findings include: Review of the Food Quality and Palatability policy (dated May 2014) revealed foods would be prepared by methods to conserve nutritive value, flavor, and appearance and foods would be palatable and attractive. The policy noted the menu items would be prepared according to the menu, production guidelines, and standardized recipes. In addition, the policy stated the dietary cook would be responsible to season foods appropriately in accordance with the recipe and region and/or ethnic preferences, and use cooking techniques to ensure color and flavor retention. Interviews conducted during the initial facility tour revealed on 05/31/16 at 1:35 PM Resident J stated the only complaint he/she had about the facility was regarding the food. Resident J stated the food was awful and had no taste. Interview conducted with Resident #2 on 06/01/16 at 11:21 AM revealed he/she was also satisfied with the care provided by the facility staff. However, Resident #2 complained the food was not very good and did not have much taste. A group meeting conducted with six (6) alert/oriented residents on 06/01/16 at 9:30 AM, revealed five (5) of the residents (Residents F, L, M, N, and O) verbalized complaints about the food at the facility. These residents stated foods were not always cooked properly, sometimes under/overcooked, and foods frequently did not have enough seasoning and tasted bland. The residents stated the problems started approximately three (3) months ago when the facility started losing dietary staff. In addition, the residents stated they had verbalized these concerns to facility staff during resident council meetings. However, review of the March 2016, April 2016, and May 2016 Resident Council Meeting minutes revealed the residents were offered a meal of the month choice and no complaints related to food were identified. A test tray was conducted during the noon meal from the East Hall food cart on 06/01/16 at 12:22 PM with the Registered Dietitian. The beef liver with onions was 104.8 degrees Fahrenheit and tasted warm and seasoned, the corn was 115.8 degrees Fahrenheit and tasted warm and seasoned, and the rice was 116.3 degrees Fahrenheit and tasted warm but was very bland with little seasoning. The Registered Dietitian validated these findings from the test tray. Interview conducted with the Dietary Cook on 06/02/16, at 1:35 PM, revealed the Cook stated she followed the recipe (which suggested 7/8 tablespoon salt be added) when preparing the rice on 06/01/16. The Cook stated she added both salt and pepper to the rice during cooking. Interview conducted with the Dietary District Manager (DDM) on 06/02/16 at 4:00 PM, revealed he was temporarily acting as the Dietary Manager (DM) since the DM had quit without notice on 06/01/16. The DDM stated he and the Registered Dietitian were not aware of any complaints of foods not being seasoned. In addition, the DDM stated he and the Registered Dietitian were in the process of reviewing the menus and recipes to ensure food quality and to eliminate any problems with possible repetitive food items. The DDM stated he had tasted the food items including the rice from the noon meal on 06/01/16 and agreed the rice tasted bland even though the menu had been followed.

Based on observation, interview, and review of facility policy it was determined the facility failed to maintain an effective infection control program to prevent the transmission of disease and infection for one (1) unsampled resident (Resident A). During medication pass on 06/01/16, facility staff was observed to dispense the resident's fourteen (14) oral medications into her bare hands before putting them into a medication cup and giving them to the resident. The findings include: Interview with the Director of Nursing (DON) on 06/02/16 at 5:50 PM revealed the facility did not have a policy specifically related to infection control and dispensing medications. The DON stated on 06/02/16 at 6:20 PM that the facility used standard precautions for dispensing medications. Observation of the medication administration on 06/01/16 at 9:04 AM revealed Registered Nurse (RN) #1 dispensed the medication [MEDICATION NAME] 0.5 milligram (mg) tablet, [MEDICATION NAME] 100 mg tablet, Magnesium Oxide 400 mg tablet,[MEDICATION NAME] mg tablet, [MEDICATION NAME] 325 mg tablet, Folic Acid 1 mg tablet, Losartan 100 mg tablet, Therapeutic Vitamin/Mineral Tablet, Vitamin B-12 1,000 mg tablet, [MEDICATION NAME] 25 mg tablet, Arthritis Pain Relief 650 mg tablet, [MEDICATION NAME] 2.5 mg tablet, Potassium Chloride 10 milliequivalents (meq) tablet, and a [MEDICATION NAME] 80 mg tablet, in her bare hands before putting them into the medication cup and giving the medication to Resident A. Interview with RN #1 on 06/01/16 at 9:20 AM revealed the facility just recently changed the packaging of the medications and she was not use to popping the pill out into the medication cup. She further revealed she had been trained to wear gloves if she was going to dispense the medication into her hands before putting the medications into the medication cup. Interview with the Infection Control Nurse on 06/02/16 at 5:50 PM revealed the nurses were trained to pop the pill from the package into the medication cup. She further revealed the nurses could pop the pill into a gloved hand before dispensing the pill into the medication cup. She added she does rounds and observations of the nurses administering medications and had not identified any concerns with infection control. Interview with the DON on 06/02/16 at 6:20 PM revealed the nurses are supposed to pop the medication into the medication cup. The DON further revealed the facility used standard infection control practices when administering medications. She also added she does random observations, along with staff from pharmacy, and had not identified any concerns with staff administering medications.

Based on observation, interview, record review, and review of facility policy it was determined the facility failed to ensure an incident of alleged abuse was immediately reported to the Director of Nursing (DON) and/or Administrator for one (1) of three (3) sampled residents (Resident #1). On 04/28/16 or 04/29/16 (exact date unknown), the Dietary Manager was told of an alleged occurrence of abuse and failed to report the allegation immediately. The findings include: Review of the facility's policy titled Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown Source, and Misappropriate of Resident Property, (undated) revealed all allegations/alleged violations must be reported to the Administrator and Director of Nursing (DON)/designee immediately. The policy stated Immediately means as soon as possible, but not to exceed 24 hours after discovery of an incident. Interview with the Dietary Manager on 05/03/16 at 12:41 PM and at 2:19 PM revealed a cook told her on 04/28/16 or 04/29/16 (unsure of the exact date) that another staff member had told her that Certified Nurse Aide (CNA) #5 and CNA #6 had been cursing, and CNA #6 had thrown something at CNA #5, almost hitting Resident #1. Further interview with the Dietary Manager revealed she did not report the allegation of abuse to the DON/Administrator because I don't believe what people say, unless I see it with my own eyes. Record review revealed Resident #1 was admitted to the facility on [DATE] with Hypertension, [MEDICAL CONDITION], Muscle Weakness, and Allergic Rhinitis. Review of the Quarterly Minimum Data Set (MDS) assessment completed on 01/23/16 revealed the facility assessed the resident's Brief Interview for Mental Status (BIMS) score to be 15, determining the resident was interviewable and his/her cognition to be intact. Observation of Resident #1 on 05/04/16 at 11:24 AM revealed the resident was sitting in a wheelchair in his/her room. There were no bruising or reddened areas identified. Resident #1 was interviewed during the observation and denied anyone at the facility being mean or abusive to him/her. The resident further denied any incident where he/she was almost hit or hit by an object thrown by a CNA. Interview with CNA #5 on 05/03/16 at 2:30 PM revealed CNA #5 was unaware of an incident between himself and CNA #6. Interview with CNA #6 on 05/03/16 at 4:07 PM revealed CNA #6 denied throwing anything at CNA #5 that almost hit a resident. Interview with the Administrator on 05/03/16 at 12:29 PM revealed there was no investigation of the alleged incident because she was not aware of the incident. A review of in-service education for the Dietary Manager revealed she was trained on Preventing, Recognizing, and Reporting Resident Abuse on 02/20/15. Interview with the Administrator on 05/03/16 at 5:06 PM revealed she was not made aware of the allegation until 05/03/16. The Administrator stated the Dietary Manager should have reported the incident according to the facility policy.

Based on observation, interviews, and review of facility policies, it was determined the facility failed to store, prepare, distribute, and serve food under sanitary conditions for fifty-seven (57) of fifty-eight (58) residents of the facility who received nutrition from the kitchen. Observations in the kitchen on 05/19/15 revealed food in the walk-in cooler was not dated or labeled, food was stored on the floor, and pans were being stored wet. Observations in the kitchen on 05/20/15 revealed staff was using thermometers that had not been calibrated, utensils were stored inappropriately, potentially hazardous foods were being stored incorrectly, the cook was touching food with bare hands, the cook placed dirty pans on a clean grill, the meat slicer had brown particles around the blade, cleaning rags were stored on top of the flour and sugar bins, a dietary aide was not taking temperatures of cold foods, and the sanitizer in the three-compartment sink was being tested incorrectly. The findings include: Review of the facility's policy for the Three Compartment Sink (no date) revealed Sink 3 should have at least 200ppm-400ppm of sanitizer. Review of the facility's policy, Suggested Steps to Running /Organizing Tray Line, (no date) revealed temperatures of all items (including beverages) were to be taken for palatability. Review of the facility's policy, Cold-Holding Guidelines, (no date) revealed staff was to use a food thermometer to measure the food's internal temperature and record the temperature on the tray line food temperature record prior to the start of meal service at breakfast, lunch, and dinner. Staff was to ensure that all cold food was at least 41 degrees Fahrenheit or colder. Review of the facility's policy, Sanitation and Infection Control, (no date) revealed staff was to allow dishes to drain thoroughly and air dry after washing. Review of the facility's policy, Safe Refrigerator Storage, (no date) revealed raw eggs were not to be stored on the top shelf of the refrigerator. The policy further revealed all food was to be stored above the floor on racks, shelves, or other surfaces that could be cleaned thoroughly. Review of the facility's policy, Good Sanitation to Serve Food Safely, (no date) revealed staff was to always wear gloves or use tongs when handling food that is cooked or ready-to-eat. 1. Observations on 05/19/15 at 3:13 PM during the initial tour of the kitchen revealed the following: eight squeeze bottles of sauce in the walk-in cooler sitting on a shelf to the left of the door that were not dated, a tray that had sixteen bowls of assorted desserts sitting on top of milk crates that were not labeled or dated, and a five-gallon bucket of pickles stored on the floor of the walk-in-cooler. Interview with the Dietary Manager on 05/21/15 at 9:10 AM revealed that the bottles of sauce and desserts should have had a date on them, and the bucket of pickles should not have been on the floor. 2. Observation on 05/19/15 at 3:15 PM during the initial tour revealed five clear full-size pans in a stack stored on a wire rack beside the three-compartment sink with standing water on all the pans. Interview with the Dietary Manager on 05/21/15 at 9:10 AM revealed that the pans should have been dried on the wire rack and not stored wet. 3. Observation on 05/19/15 at 3:22 PM during the initial tour revealed a flour bin under the end of the serving line with no date on it. Interview with the Dietary Manager on 05/21/15 at 9:10 AM revealed that the flour bin should have a date on it. 4. Observation on 05/20/15 at 9:45 AM revealed Cook #1 testing the sanitizer in the three-compartment sink. The cook was observed to use a testing strip and dip it into the sanitizer compartment. The strip read zero (0) parts per million (ppm) of sanitizer. Cook #1 repeated the process and the strip continued to show zero (0) ppm. Cook #1 stated it had been that way a couple of weeks. Review of the sink sanitizer log revealed the log had been filled out every day and had readings from 200 to 400 ppm for the past week. Interview with Cook #1 on 05/21/15 at 3:45 PM revealed she had not been recording the sanitizer readings because she did not want to lie about it not being correct. Cook #1 further stated she had been getting readings of zero (0) for a week or two. She stated, Sometimes it wouldn't show anything (0 ppm) and sometimes it would be dark blue (400+ ppm), but that she would let the DM know immediately if she took a bad reading. Interview with the Dietary Manager on 05/21/15 at 9:10 AM revealed that she had received an e-mail from someone higher up about the sanitizer for the three-compartment sink and that they were supposed to send someone to look at it. She stated she thought the sanitizer mixed in automatically. 5. Observation on 05/20/15 at 11:11 AM revealed a spatula stored in a drawer that had work gloves with black stains on them lying against the spatula; the drawer also had two screwdrivers, tape, and ink pens lying against the spatula. Interview with the Dietary Manager on 05/21/15 at 9:10AM revealed that the spatula should not have been in the drawer. 6. Observation on 05/20/15 at 11:15 AM revealed liquid eggs stored in a clear pitcher on the top of a wire rack in the walk-in cooler. The pitcher had liquid eggs spilled on the outside of it, and the pitcher was stored directly above three bags of fresh spinach and an open bag of fresh parsley. Interview with Cook #1 on 05/21/15 at 3:45 PM revealed that she had put the eggs on the top shelf. Cook #1 stated she knew the eggs were supposed to be stored on the bottom. Interview with the Dietary Manager on 05/21/15 at 9:10 AM revealed that the liquid eggs should be stored on the bottom shelf; she did not know why they were on the top shelf. 7. Observation on 05/20/15 at 11:25 AM revealed Cook #1 was taking temperatures of the food on the steam table. Cook #1 was not wearing gloves and was placing the entire thermometer all the way into the food she was checking, occasionally touching the food with her bare hands. Cook #1 was not observed calibrating the thermometer before taking temperatures. Interview with Cook #1 on 05/21/15 at 3:45 PM revealed that she thought the thermometer was to be calibrated once a week, but had been informed by the DM it should be done at least once a day. Cook #1 also stated she should have been wearing gloves when taking food temperatures. Interview with the Dietary Manager on 05/21/15 at 9:10 AM revealed that thermometers should be calibrated daily, and staff was always supposed to have gloves on when checking food temperatures. 8. Observation on 05/20/15 at 10:40 AM revealed Dietary Aide #1 did not take temperatures of the milk or cold foods before serving the food items. Interview with Dietary Aide #1 on 05/21/15 at 3:10 PM revealed she should have taken the temperatures of the cold food items. Interview with the Dietary Manager on 05/21/15 at 9:10 AM revealed Dietary Aide #1 should have taken the cold food temperatures. 9. Observation on 05/20/15 at 11:48 AM revealed Dietary Aide #1covered all of the drinks and cold items to be served completely with ice allowing melted water to collect on the items. Interview with Dietary Aide #1 on 05/21/15 at 3:10 PM revealed she should have put the ice in the bottom and not covered the items completely. She stated that she got in a hurry while preparing the drinks. Interview with the Dietary Manager on 05/21/15 at 9:10 AM revealed that cold food items that are being served on the tray line should not be completely covered in ice. 10. Observation on 05/20/15 at 11:51 AM revealed Cook #1 placed a used/soiled dish on top of the clean grill. There was also a used/soiled pan on top of the grill. Interview with Cook #1 on 05/21/15 at 3:45 PM revealed she should not have put the dirty dishes on the clean grill. Interview with the Dietary Manager on 05/21/15 at 9:10 AM revealed that Cook #1 should not have put the dirty dishes on the grill. 11. Observation on 05/20/15 at 12:09 PM revealed a meat slicer that had brown particles around the blade. Interview with the Dietary Manager on 05/21/15 at 9:10 AM revealed that the brown particles should not have been on the meat slicer and she did not know the last time it had been used. 12. Observation on 05/20/15 at 9:45 AM revealed used/soiled cleaning rags and used gloves lying on the top of a flour bin and a sugar bin underneath the end of the serving line. Interview with the Dietary Manager on 05/21/15 at 9:10 AM revealed that the used cleaning rags and used gloves should not have been on top of the flour bin and sugar bin.