Every finding on record at Cedar Ridge Health Campus

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the resident's right to privacy by allowing a video camera to be installed, which actively monitored a resident's room without documented consent or adherence to facility policy for 1 of 2 residents reviewed for dignity, Resident (R) 3. The findings include: Review of the facility's policy titled, Resident Electronic Monitoring SOP [Standard Operating Procedure], undated, revealed, The resident, attorney-in-fact, or guardian must authorize the installation and use of the device for remote monitoring on our standard authorization form. The campus must prior approve any electronic monitoring devices to make sure that they are the type allowable by law, and only facility personnel may install the devices after they have been approved. We may post notices in and outside the resident's room that electronic monitoring is in use.Review of the facility's policy titled, Resident Rights Guidelines, revised 05/11/2017, revealed, Our residents have a right to: a. Be treated with dignity and respect and d. Privacy.Review of R3's admission Record revealed the facility admitted the resident on 01/04/2025 with diagnoses of heart disease, acute kidney failure, atrial fibrillation, malnutrition, diabetes mellitus, and dementia.Review of R3's annual Minimum Data Assessment [MDS], with an Assessment Reference Date (ARD) of 11/14/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 11 of 15, indicating R3 had moderate cognitive impairment.Review of R3's Care Plan included a problem statement initiated on 01/04/2025 that indicated the resident was at risk for falls related to weakness and impaired balance. Interventions directed staff to monitor with a non-recording portable video camera (initiated 12/10/2025).During an observation on 01/19/2026 at 10:28 AM, a camera was observed mounted inside R3's room, positioned high on the wall to the left of the door, pointing directly at the bed. The monitor for the camera was located behind the nurses' station.During an observation on 01/20/2026 at 8:55 AM, the camera in R3's room was on, and the monitor was visible on the desk behind the nurses' station.During an observation on 01/21/2026 at 11:34 AM, the camera in R3's room remained in place, pointed toward the bed, with the unattended monitor active at the nurses' station.Review of R3's Physician Order Report, for the timeframe of 12/20/2025 through 01/20/2026, revealed no orders for the use of the electronic monitoring device. Review of R3's medical record revealed no written consent was found for the use of the monitor/camera. The facility obtained verbal consent from R3's Power of Attorney (POA) during the survey on 01/21/2026.Attempts were made to contact R3's POA during the survey on 01/20/2026 at 6:21 PM, 01/21/2026 at 10:45 AM, and 01/22/2026 at 8:46 AM and 10:28 AM, to confirm that the use of the video monitor had been discussed and consent obtained. There was no response from the POA by the end of the survey on 01/22/2026. During an interview on 01/21/2026 at 1:27 PM, the Ombudsman stated she researched state law and found that cameras in resident rooms were not allowed, although there was conflicting information about audio consent. She stated that at a minimum, a policy and consent should be in place.During an interview on 01/22/2026 at 8:40 AM, the Director of Environmental Services stated at first, she had not obtained consent for anything for any resident, then she was the witness during a phone call to R3's POA the previous day (during the survey) for the camera. She stated she heard the POA say it was okay.During an interview on 01/22/2026 at 8:45 AM, the Director of Health Services (DHS) stated the facility obtained verbal consent the previous day because they did not realize they needed to obtain consent. During an interview on 01/22/2026 at 9:35 AM, Clinical Support Staff 5 stated it was a state law that the Executive Director (ED) had the right to request a camera in the facility. She stated it was a fixed monitoring device and not recording, and the ED gave verbal approval for it. During an interview on 01/22/2026 at 10:45 AM, Activities Staff 4 stated when the facility installed the camera, the staff was told to make sure it was turned off during personal care and whenever the resident was not in the room.During an interview on 01/22/2026 at 10:46 AM, Licensed Practical Nurse (LPN) 1 stated staff was told when the camera was installed, they needed to turn it off whenever personal care was being provided. LPN1 stated the monitor was on and sitting at the desk next to her. During a concurrent observation, LPN1 turned the monitor face down. She stated there was a button on the monitor to turn it off, or the staff could just unplug it when they were in the room.During an interview on 01/22/2026 at 11:35 AM, the Interim ED stated the facility had verbal consent from the POA prior to the use of the camera, but they were not sure it was documented. She stated they thought the consent to photograph included in the admission record covered it, and they had tried to contact the POA twice to confirm the consent, with no response.

Based on observation, interview, record review, review of the manufacturer's instructions for use, and facility policy review, the facility failed to ensure a medication error rate of 5 percent (%) or less. Observation on 01/22/2026 revealed 2 errors administering insulin (given to lower blood sugar) out of 27 opportunities observed for correct medication administration, which yielded a medication error rate of 7.41%. The errors affected 2 of 5 residents observed for medication administration, Resident (R) 11 and R23.The findings include: Review of the facility's policy titled, Medication Administration - General Guidelines, revised 11/2018, revealed, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Further review of the policy revealed, 4) FIVE RIGHTS - Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away.On 01/22/2026 at 1:25 PM, the Director of Health Services (DHS) stated the facility did not have a policy on insulin use. Review of the manufacturer's instructions for use in a document titled, NovoLog(R) (insulin aspart) Injection Flex Pen Instructions for Use, revised 02/2023, revealed the section titled, Giving the airshot before each injection, included, Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: E. Turn the dose selector to 2 units and F. Hold your Novolog FlexPen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge, then G. Keep the needle pointing upwards press the push-button all the way in. Further review revealed, The dose selector returns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times.Review of R23's Physician Order Report revealed the facility admitted the resident on 12/28/2020 with diagnoses to include type 2 diabetes mellitus with hyperglycemia. Further review of active orders as of 01/22/2026 revealed an order dated 07/06/2025 for insulin aspart U-100 (rapid acting insulin with a concentration of 100 units per milliliter [ml]) insulin pen, with instructions to give per sliding scale (dose of insulin based upon the blood glucose level). 1. During an observation of medication administration on the 100 Hall on 01/22/2026 at 11:43 AM, Licensed Practical Nurse (LPN) 3 attached a needle to R23's insulin aspart pen, turned the dose selector to ten units, and began to walk toward the resident. The State Survey Agency (SSA) Surveyor stopped LPN3 to confirm if she was ready to administer the insulin and asked about priming the pen. LPN3 stated she was not aware the needle needed to be primed prior to dialing the dose. Review of the manufacturer's instructions for use in a document titled, Instructions for Use Humalog ([NAME]-ma-log) KwikPen (insulin lispro) injection, revised 07/2023, specified, Prime before each injection. - Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. - If you do not prime before each injection, you may get too much or too little insulin. Further review revealed, Step 6: - To prime your Pen, turn the Dose Knob to select 2 units. Step 7: - Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 8: Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and [0] is seen in the Dose Window.Review of R11's Physician Order Report revealed the facility admitted the resident on 12/24/2025 with diagnoses to include type 2 diabetes mellitus with ketoacidosis without coma and type 2 diabetes mellitus with diabetic neuropathy, unspecified. Further review of active orders as of 01/22/2026 revealed an order dated 12/30/2025 for Humalog KwikPen Insulin (insulin lispro) insulin pen, with instructions to give five units three times a day with meals for diabetes.2. During an observation of medication administration on the 200 Hall on 01/22/2026 at 11:55 AM, Registered Nurse (RN) 2 attached a needle to R11's Humalog KwikPen, turned the dose selector to 5 units, and began to walk toward the resident. The SSA Surveyor stopped RN2 to confirm if she was ready to administer the insulin and asked about priming the pen. RN2 stated, Oh yeah, I am supposed to prime it with two units.During an interview on 01/22/2026 at 10:46 AM, LPN1 stated nurses should prime the insulin pen needle with two units prior to dialing in the dose to be administered to ensure the resident was getting the full amount ordered.During an interview on 01/22/2026 at 11:20 AM, the DHS stated nurses should follow the manufacturer's recommendations to prime the needle prior to use to ensure the full amount of insulin ordered was administered. During an interview on 01/22/2026 at 11:35 AM, the Interim Executive Director (ED) stated she expected the nurses to follow manufacturer guidelines with the use of insulin pens, and the medication error rate should be less than 5%.

Based on observation, interview, record review, and facility policy review, the facility failed to develop a comprehensive person-centered care plan for each resident to meet his or her preferences and goals for 1 of 14 sampled residents (Resident (R) 6). Observation of R6 on 01/22/2025 at 9:02 AM and again on 01/23/2025 at 9:00 AM revealed an Occupational Therapist (OT) assisting the resident with application of a left arm splint. During interviews with staff and R6, it was determined the splint was a resident preference worn at her discretion and not a recommendation of the facility. However, the resident's preference was not included in her comprehensive care plan. The findings include: Review of the facility's policy titled, Comprehensive Care Plan Guideline, dated 05/22/2018, revealed the purpose was to ensure appropriateness of services and communication that would meet the resident's needs, severity/stability of conditions, impairment, disability, or disease in accordance with state and federal guidelines. Further review revealed care plan interventions should be reflective of risk area(s) or disease processes that impacted the individual resident. Review of R6's Face Sheet revealed the facility admitted the resident on 10/18/2024 with diagnoses including chronic kidney disease (CKD), urinary tract infection (UTI), left-sided weakness following a stroke, and multiple myeloma. Review of R6's Minimum Data Set [MDS] with an Assessment Reference Date (ARD) of 10/21/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 out of 15, which indicated the resident was cognitively intact. Further review revealed R6 had an upper extremity impairment on one side. Review of R6's Comprehensive Care Plan, dated 10/21/2024, revealed the care plan contained no interventions that addressed R6's preferences related to use of a left-hand splint. Review of R6's outside hospital records revealed an inpatient OT note, dated 10/15/2024, that stated R6 would benefit from a left resting hand splint. Further review revealed OT provided a prefabricated left upper extremity (LUE) resting hand orthotic. However, it was not the appropriate size, and the resident was educated on steps to acquire an orthotic after discharge from the hospital. Review of R6's facility's OT Evaluation, dated 10/19/2024, revealed R6 needed partial to moderate assistance for upper body dressing. Further review revealed a musculoskeletal assessment of the left upper extremity (LUE) impairment with a notation that the resident had worn a left resting hand splint. Observation on 01/22/2025 at 9:02 AM revealed OT1 returned R6 to her room via a wheelchair and applied a splint to R6's left hand before he exited the room. In an immediate interview with OT1, he stated the resident's splint was worn for comfort purposes only and was not part of her therapy services. Additional observation of R6 in her room on 01/23/2025 at 9:00 AM revealed OT1 applied a splint to the resident's left hand. In an interview with R6 on 01/24/2025 at 9:38 AM, she stated she was given a hand splint when she was hospitalized and brought it with her to the facility, but it was too big for her hand. R6 stated someone at the facility brought her a smaller one, and it fit better. She further stated she wore it most days during the day but took it off at night. In an interview with Registered Nurse (RN) 2 on 01/24/2025 at 9:42 AM, she stated she had observed R6 with the splint in place but had neither applied nor removed it. RN2 further stated the resident wore the splint for comfort and therapy applied/removed the splint as needed per R6's preference. In an interview with OT1 on 01/24/2025 at 9:53 AM, he stated R6 had a LUE splint when she was admitted to the facility. He stated he noticed it one day in her room, and when asked, she stated it was too big, so he offered to find a smaller one and ordered it online. OT1 stated the splint served no purpose other than comfort and was used at the resident's request. He further stated if the splint was used per the resident's preference, it should be included on her care plan. In an interview on 01/24/2025 at 9:46 AM with the Therapy Director, she stated R6 used the splint on her left hand for comfort only, and it was not something recommended by therapy or ordered by the physician at the facility. The Therapy Director stated the resident had a splint when she was admitted , but it was too big, so one of the therapists ordered a smaller one that was a more appropriate size. She further stated neither the physician at the facility nor therapy ordered the splint. However, the Therapy Director stated if R6 wore the splint per her preference, it should be included on her care plan. In an interview with the MDS Coordinator on 01/24/2025 at 9:17 AM, she stated information from a resident's hospital discharge summary as well as their history and physical was used for their initial MDS. She further stated nursing completed baseline care plans and information from all sources was used for compilation of the Comprehensive Care Plan (CCP). The MDS Coordinator stated therapy put in their own orders, and R6 had no orders for a splint from either therapy or the physician. She further stated for ongoing assessments, in addition to medical record information, she assessed residents and made observations. The MDS Coordinator stated she had not observed R6 with a brace to her LUE. In an interview with the Director of Nursing (DON) and the Regional Nurse Consultant (RNC) on 01/24/2025 at 10:23 AM, both stated a note should have been placed in R6's electronic health record (EHR) that stated the resident wore the splint for comfort. The DON stated she was torn because there was not a physician order, so she was not sure it had to be on her care plan. When asked about resident preferences and actions performed by the facility, the RNC stated if staff was helping the resident with the splint as need or requested, information related to her preferences should have been included on her plan of care. In an interview with the Administrator on 01/24/2024 at 1:57 PM, she stated it was not necessary to include the splint on R6's care plan because it was not required for her care, not ordered by the physician, and not recommended by therapy. When asked about resident preferences in relation to care plans, the Administrator stated all resident preferences could not be included on a care plan because it would never end, and she was not sure how a plan of correction would be completed that addressed that. Additionally, the Administrator stated R6 probably could have applied the splint by herself (however, both observations revealed it was applied by OT1). The Administrator stated she could somewhat understand what the State Survey Agency (SSA) Surveyor said, but it was still only a preference and not an order. The Administrator further stated she was unaware R6 even had a splint.

Based on observation, interview, and review of the facility's policy, the facility failed to store food in accordance with professional standards for food service safety. Observation on [DATE] of the shared nourishment refrigerator and freezer for the 100, 200, and 300 Units revealed multiple food items that were not labeled or dated. The findings include: Review of the facility's policy titled, Food Brought Into Facility, dated [DATE], revealed food brought in by family members, friends, or guests must be properly labeled and dated after being inspected by a staff member that had been properly trained to receive and inspect food. Observation on [DATE] at 8:53 AM of the shared nourishment refrigerator for the 100, 200, and 300 Units contained a 20 ounce bottle of Mountain Dew, not labeled or dated to indicate who it belonged to and when it was stored. Observation of the freezer revealed a partially consumed frozen Mountain Dew 20 ounce bottle, a frozen small chocolate Frosty, and a small bowl of what appeared to be strawberry ice cream with chocolate syrup that was covered with clear wrap. None of these items were labeled or dated indicating who they belonged to or when they had been brought in. In an interview on [DATE] at 8:59 AM with the Dietary Manager (DM), she stated she checked everything yesterday, so non-resident items or non-labeled items had been added either yesterday evening or this morning. In an additional interview with the DM on [DATE] at 11:05 AM, she stated she had determined the Mountain Dew in the freezer and refrigerator both belonged to a resident in room [ROOM NUMBER], and staff had failed to label and date them when placed in the refrigerator and freezer. In an additional interview on [DATE] at 10:11 AM with the DM, she stated the resident in room [ROOM NUMBER] asked staff to make his Mountain Dew cold, so they placed the opened one in the freezer and the unopened one in the refrigerator. However, staff failed to mark his name on them. The DM stated she did not know who the small Frosty belonged to, and the ice cream had been taken off a tray for another resident and saved for later. However, again they were not labeled and dated. The DM stated she did not know why staff had not labeled and dated the items and was not sure if staff had been educated on labeling and dating items placed in the refrigerator, as there was some newer staff in the building that had not been present during the previous survey. The DM stated food items not labeled or dated could potentially spoil and if consumed lead to illness for residents. In an interview on [DATE] at 2:09 PM with the Administrator, she stated she knew dietary staff checked nourishment refrigerators every evening for items not labeled, dated, or expired when stocking snacks, so she knew these unlabeled/undated items had not been in there long. She stated staff had been educated on the facility's policy on labeling and dating items placed in nourishment refrigerators. She stated her expectation was for staff to label and date everything placed in the nourishment refrigerator and freezer, even if staff anticipated the food item would only be there for a short time.

Based on observation, interview, and review of the facility's policies, it was determined the facility failed to prepare and store food under sanitary conditions. Observation of the kitchen on [DATE] revealed staff did not perform hand hygiene between glove changing and tasks. Observation of the Skilled nourishment room on [DATE] revealed non-food items stored with food items and undated food items. The findings include: Review of the facility's policy titled Guideline for Handwashing/Hand Hygiene, dated [DATE], revealed all health care workers shall utilize hand hygiene frequently and appropriately. Per the policy, hand hygiene should be performed after removing gloves, with gloves worn as directed with Standard Precautions; before and after eating; and after toileting. Review of the facility's policy titled, Food Safety and Handling, dated ,d+[DATE], revealed date marking must be done when food was Time and Temperature Foods (TTF), Ready to Eat (RTE) foods, which was refrigerated and held more than twenty-four (24) hours. Per the policy, the RTE potentially hazardous foods must be marked with the date of preparation and must be consumed or discarded within seven (7) days, including the day of preparation. Review of the facility's policy titled, Storage Procedures, dated ,d+[DATE], revealed food storage areas were used for food and paper supplies. Per the policy, chemical/poisonous items were not stored in the food storage area. Open packages were labeled, dated, and stored in closed containers. Dry bulk foods were stored in plastic containers with tight covers or bins which were easily sanitized. Stock was dated and rotated so that the oldest items were used first. Observation on [DATE] at 10:00 AM on the initial tour of the kitchen revealed an ingredient bin with no label or date which contained a white powder looking product. Observation of the walk-in refrigerator revealed five (5) bags, each containing five (5) pounds of shredded cheddar cheese. These cheddar cheese bags were not dated. Also, on the top shelf, there was a small piece of white cheese covered in clear wrap with no label or date. Continued observation of the dry storage area revealed a number 303 (volume approximately two (2) cups and weight approximately fifteen (15) to seventeen (17) ounces) size can of cream of chicken soup, which had a dent the size of the palm of a hand. In addition the following cans were not dated: five (5) number 303 cans of clam juice; three (3) cans of light red kidney beans; one (1) can of sliced peaches; two (2) cans of peach filling; three (3) cans of lemon pudding; one (1) can of applesauce; three (3) cans of hot fudge sauce; two (2) cans of diced tomatoes; nine (9) cans of fancy tomato sauce; three (3) cans of pizza sauce; and two (2) cans of diced tomatoes. Further observation revealed cake mix on a shelf in a clear zip lock bag not sealed and not dated; opened brownies mix and cake mix on a shelf not dated or closed; and an opened bag of long grain rice on a shelf not dated. Observation on [DATE] at 11:50 AM and 11:55 AM revealed Dietary staff changed gloves between tasks, with no hand hygiene/washing between the change. Observation on [DATE] at 10:00 AM of the Skilled Unit revealed the nourishment room freezer with ice packs in the freezer door. Further observation revealed the refrigerator contained an undated Golden Kens Italian 1.5 ounce packet, in a foam Mr. Snappy Cup. Also, observation revealed one (1) staff member's personal cup with a black lid and one (1) wrapped pumpkin cookie not dated on the nourishment room counter. During interview with Dining Services Assistant #1 on [DATE] at 10:01 AM, she stated, to prevent cross contamination, hand washing was required between changing gloves, after using the bathroom, and when changing tasks. She stated opened foods should be covered and a date label attached to show when the food would expire. She stated if an expiration date was not on the food item it must be thrown out because expired food could make the resident sick because the food could have soured. She stated cans were placed on the rack so that the cans received first would be used first. She explained the method to rotate food was first in/first out (FIFO) or to first use the food item which had been in stock the longest. During interview with Cook #1 on [DATE] at 10:10 AM, she stated washing hands, to prevent cross contamination, was required when entering the kitchen, between changing gloves, when touching anything, and when changing tasks. She stated staff used the print genie to label food in the walk-in refrigerator and to rotate food on the shelf. She stated the ingredient bin must be labeled and dated with the food product's information to prevent the wrong food ingredient being used to prepare food. She stated rotating and dating food would prevent food from being used that might be spoiled. She stated food not dated or labeled was thrown out, and a dented can would be sent back to the food supplier. During interview with the Director of Dining Services on [DATE] at 10:24 AM, she stated she expected staff members to wash hands after every task and/or between changing gloves. She stated her expectation was for staff members to use the print genie to produce a date sticker and place it on the food product and rotate cans first in and first out (FIFO) to prevent outdated food product from being used. She stated for food items left opened, a potential was created for cross contamination and bug infestation. During an interview with the Director of Health Services on [DATE] at 1:46 PM, she stated her expectation was for staff to wash hands any time they were soiled or between glove changes. She stated hand hygiene was important to protect the residents from cross contamination. She stated staff must date food when opened and when received into the kitchen. She stated if food was stored with non-food items, the potential existed for physical and chemical cross contamination. During an interview with the Executive Director (ED) on [DATE] at 2:22 PM, she stated her expectations were for Dietary staff to wash hands with soap and water when indicated; to date food and use the First in and First Out (FIFO) method for storage; and to keep food items and non-food items in separate locations and stored safely.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to protect residents from abuse for Resident #1, one (1) of six (6) sampled residents. While providing care, Resident #1 struck SRNA #1, who cursed and held Resident #1's arm while continuing to provide care. The findings include: Review of the facility's policy titled, Abuse and Neglect Procedural Guidelines, dated 08/29/2019, revealed the facility defined abuse to include the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. The policy further defined verbal abuse to include oral communication to residents within hearing distance. Review of a Long Term Care Facility Self-Reported Incident Form, Final Report, dated 05/17/2021, revealed, on 05/09/2021 at approximately 4:00 PM, State Registered Nurse Aide (SRNA) #1 and Personal Care Assistant (PCA) #1 were in Resident #1's room to provide incontinence care. SRNA #1 reported she was struck in the back of the head by Resident #1, exclaimed God Damn under her breath and held Resident #1's arm initially above his/her head; then, she held Resident #1's arm between her legs so Resident #1 could not swing at her while she and PCA #1 completed Resident #1's care. Per the report, SRNA #1's statement and PCA #1 statement varied on what occurred, with PCA #1's statement alleging further abusive action by SRNA #1, to include pulling Resident #1's shirt over his/her head and threatening Resident #1. Review of a skin assessment, conducted on 05/12/2021, following the incident on 05/09/2021, revealed no new areas or evidence of injury to Resident #1. Review of a Radiology Report, dated 05/13/2021, revealed an X-ray was completed of Resident #1's right shoulder to rule out right shoulder injury; it revealed no acute fracture or dislocation. Review of a draft of a KYIBRS (Kentucky Incident Based Reporting System) Report, dated 05/12/2021, revealed the local police department was informed and investigated the incident, which was classified as an Assault, 4th Degree (no visible injury). In addition, statements provided by SRNA #1 and PCA #1 to police were consistent with statements provided to the facility by SRNA #1 and PCA #1. Review of Resident #1's medical record revealed Resident #1 was readmitted to the facility, on 01/04/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility assessed Resident #1, in a Quarterly Minimum Data Set (MDS) Assessment, dated 04/16/2021, as having a Brief Interview for Mental Status (BIMS) score of nine (9) of fifteen (15), indicating moderate cognitive impairment. The facility further assessed Resident #1 as having unclear speech, sometimes understanding others, and sometimes being understood. Resident #1 was assessed as requiring extensive assistance of two (2) persons for toileting. Review of Resident #1's Comprehensive Care Plan revealed a problem area, dated 12/09/2020, in which Resident #1 exhibited physically abusive and resistive behaviors towards staff during hands on care. Interventions included approaching the resident in a calm and unhurried manner; explaining the process prior to delivery of care; when feasible, keeping personal space between the resident and staff; and explaining all care in a step-by-step manner. Interview with SRNA #1, on 06/02/2021 at 9:14 AM, revealed on 05/09/2021 sometime in the afternoon, she went to change Resident #1 with PCA #1's assistance. She revealed when she went in the room, Resident #1 was his/her regular self, able to answer simple yes or no questions, with some understanding of what she was saying. SRNA #1 stated while getting things ready to change Resident #1, the resident struck her in the back of the head behind her ear, and she exclaimed God damn! under her breath, as it hurt. She stated she said that really hurt and we don't hit and held his/her arm down so that she could finish her care. The she stated she and PCA #1 pulled Resident #1 up in bed. SRNA #1 denied pulling Resident #1's shirt over his/her head, being rough with him/her, or threatening Resident #1. She revealed Resident #1 seemed his/her normal self following care, was smiling, and did not seem upset. In addition, SRNA #1 stated, on 05/12/2021, she received a call from management staff that she was being investigated for abuse and was suspended; two (2) days later, on 05/14/2021, she was terminated from employment as a result of their investigation. Further, SRNA #1 revealed 05/09/2021 was a very busy day, and they were running short of supplies that fit residents. She emphasized, by holding Resident #1's arm, she was not trying to hurt anyone, but was trying to protect herself from getting hit again. Interview with PCA #1, on 06/02/2021 at 1:37 PM, revealed on 05/09/2021 between 4:00 PM and 4:30 PM, she and SRNA #1 went to change Resident #1. She revealed SRNA #1 stated, I'm going to change you, but her tone of voice was guarded and not friendly. She stated when she got supplies together and put them on the bed, Resident #1 struck SRNA #1 in the back of the head. PCA #1 stated SRNA #1 grabbed the resident, and while the resident was yelling, pushed his/her arm down over his/her head into the mattress. In addition, PCA #1 stated she could not understand what Resident #1 was trying to say, but by the tone of the resident's voice, it sounded like he/she was hurting. Per interview, she stated SRNA #1 then pulled Resident #1's shirt up over his/her head and said, Shut up!, and You make me so [OBSCENITY] ing mad I want to punch you in the face. Furthermore, PCA #1 stated SRNA #1 then brought Resident #1's arm down below the mattress and between her legs and held it in place so she could change the resident. She said SRNA #1 asked her, Has he ever made you that mad?, and she stated no resident had ever made her that mad. PCA #1 stated after Resident #1 was changed, SRNA #1 released the resident's arm, and PCA #1 stayed with him/her for a few minutes, talking with the resident and making sure he/she was comfortable. In addition, PCA #1 stated Resident #1 seemed his/her normal self after the incident and was not complaining of pain or anything. Per interview, she stated Resident #1 did not have a good short-term memory, and although she had worked with the resident since October 2020, he/she was just now starting to remember PCA #1's name. Interview with SRNA #4, on 06/01/2021 at 1:04 PM, revealed she had worked with Resident #1, and he/she had behaviors of hitting people, although she was not sure whether it was due to pain or due to his/her brain injury. She revealed when the resident was trying to hit, she asked him/her to hold his/her left arm with his/her right hand, and the resident was pretty good about doing that, although it was not always effective. SRNA #4 stated when Resident #1 attempted to hit, staff tell the resident that he/she should not do that. In addition, she stated when Resident #1 did hit, he/she would be just kidding, and the resident did not mean to hit, but just did not know what to do with himself/herself. Per interview, SRNA #4 stated she had not heard about any incident involving Resident #1. Interview with SRNA #7, on 06/01/2021 at 3:09 PM, revealed recently there had been a change to ensure two (2) people were present in Resident #1's room whenever entering the room for any task. She stated sometimes he/she hit staff, usually when being changed. She stated the resident was less likely to hit when staff was talking to him/her, especially about basketball. Further, SRNA #7 stated if Resident #1 continued to try to hit, staff encouraged the resident to hold his/her left arm, which worked sometimes, although not every time. Per interview, she revealed she had not heard about any incident involving Resident #1. Interview with SRNA #8, on 06/02/2021 at 10:33 AM, revealed she had worked with Resident #1 since she first started at the facility over three (3) years ago. She described Resident #1 in positive terms, but stated Resident #1 did like to try to hit at times, which could sometimes be prevented by asking the resident to hold his/her left hand. She revealed Resident #1 constantly asked what your name was and laughed a lot. She stated she had not heard of any incident; however, she had been questioned by management staff regarding abuse, and there had been a change to two (2) staff required at all times when entering Resident #1's room. In addition, SRNA #8 stated she had assisted staff in changing Resident #1 today, and the resident's mood and behavior was unchanged from her previous times working with him/her. Per interview, SRNA #8 stated she had heard no complaints about SRNA #1, and she seemed like a good aide in her limited experience working with her. Interview with SRNA #9, on 06/02/2021 at 11:15 AM, revealed she had observed no changes in Resident #1's behaviors. She stated she worked with SRNA #1 and PCA #1 on 05/09/2021, up until shift change at 2:00 PM that day, and described both in positive terms. She stated she had never observed SRNA #1 to be physically or verbally abusive to anyone and described PCA #1 as very good with residents. Interview with the Assistant Director of Health Services (ADHS), on 06/01/2021 at 2:36 PM, revealed she was working, on 05/12/2021, and took PCA #1's statement when she initially reported the incident that occurred on 05/09/2021. PCA #1 told the ADHS she felt another aide was more aggressive with Resident #1 than she felt the aide should have been. The ADHS stated PCA #1 shared it had been bothering her and weighing on her, and she needed to tell somebody. Per interview, the ADHS stated she then initiated an investigation, assisted staff with skin assessments and interviews, and performed staff education. She revealed there was no physical evidence of abuse regarding Resident #1, and due to difficulty communicating with Resident #1 and him/her having chronic pain, an x-ray was done, which revealed no injury. Interview with the Interim Executive Director, on 06/02/2021 at 2:13 PM, revealed she was contacted, on 05/12/2021, by the ADHS, who explained PCA #1 reported an incident that had occurred on 05/09/2021. She revealed she interviewed SRNA #1 and PCA #1 and suspended them both pending results of the investigation. She stated, during the investigation, the decision was made to terminate SRNA #1 due to abuse. Further, she revealed there were some discrepancies between the statements of SRNA #1 and PCA #1, but SRNA #1 did not deny holding Resident #1's arm down and cursing after she was struck. The Interim Executive Director stated she expected residents to be free from any type of abuse.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to report allegations of abuse within two (2) hours for Resident #1, one (1) of six (6) sampled residents. Resident #1 struck a staff member who was providing care, on 05/09/2021, with the staff member cursing and holding the resident's arm to prevent being struck again; however, the incident was not reported to facility management staff or the State Survey Agency (SSA), until 05/12/2021, three (3) days later. The findings include: Review of the facility's policy titled, Abuse and Neglect Procedural Guidelines, dated 08/29/2019, revealed any staff member should report known or suspected abuse to local or state agencies. The policy further stated staff was responsible for reporting all alleged violations immediately, but not later than two (2) hours after an allegation was made, if the allegation involved abuse, to the administrator of the facility and to other officials, including the SSA. Review of the facility's Long Term Care Facility Self-Reported Incident Form, Final Report, dated 05/17/2021, revealed, on 05/09/2021 at approximately 4:00 PM, State Registered Nurse Aide (SRNA) #1 and Personal Care Assistant (PCA) #1 were in Resident #1's room to provide incontinence care. Per the report, SRNA #1 reported she was struck in the back of the head by Resident #1, exclaimed God Damn under her breath, and held Resident #1's arm initially above his/her head, and after, held Resident #1's arm between her legs so Resident #1 could not swing at her while she and PCA #1 completed Resident #1's care. Per the report, PCA #1 did not tell administration about the event until 05/12/2021, three (3) days after the event occurred. Review of the facility's nursing schedule, for 05/09/2021 through 05/12/2021, revealed SRNA #1 worked from 2:00 PM until 10:00 PM on 05/09/2021, and from 6:00 AM until 9:30 PM on 05/11/2021. Review of Resident #1's skin assessment, conducted on 05/12/2021 following report of the incident on 05/09/2021, revealed no new areas or evidence of injury to Resident #1. Review of Resident #1's Radiology Report, dated 05/13/2021, revealed an X-ray was completed of Resident #1's right shoulder to rule out right shoulder injury. The report revealed no acute fracture or dislocation to Resident #1's right shoulder. Review of Resident #1's medical record revealed the resident was readmitted to the facility, on 01/04/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility assessed Resident #1, in a Quarterly Minimum Data Set (MDS), dated [DATE], on the Brief Interview for Mental Status (BIMS) with a score of nine (9) of fifteen (15), indicating moderate cognitive impairment. The facility further assessed Resident #1 as having unclear speech, sometimes understanding others and sometimes being understood. Resident #1 was assessed as requiring extensive assistance of two (2) persons for toileting. Review of Resident #1's Comprehensive Care Plan revealed a problem area, dated 12/09/2020, in which Resident #1 exhibited physically abusive and resistive behaviors toward staff during hands on care. Interventions included approaching the resident in a calm and unhurried manner; explaining the process, in a step-by-step manner, prior to delivery of care; and when feasible, keeping personal space between the resident and staff. Interview with SRNA #1, on 06/02/2021 at 9:14 AM, revealed, on 05/09/2021 sometime in the afternoon, she went to change Resident #1 with PCA #1. She revealed while getting things ready, the resident struck her in the back of the head behind her ear, and she exclaimed God damn! under her breath, as it hurt. She stated she said to Resident #1, That really hurt, and, We don't hit, and held his/her arm down so that she could finish her care; then, she and PCA #1 pulled Resident #1 up in bed. She denied pulling Resident #1's shirt over his/her head, being rough with him/her, or threatening Resident #1. In addition, SRNA #1 stated, on 05/12/2021, she received a call from management staff that she was being investigated for abuse and was suspended, and two (2) days later, on 05/14/2021, she was terminated from employment as a result of the investigation. Interview with PCA #1, on 06/02/2021 at 1:37 PM, revealed on 05/09/2021 some time between 4:00 PM and 4:30 PM, she and SRNA #1 went to change Resident #1. She revealed SRNA #1 stated, I'm going to change you, but her tone of voice was guarded and not friendly. She stated when she got supplies together, Resident #1 struck SRNA #1 in the back of the head. She stated SRNA #1 grabbed Resident #1, pushed the resident's arm down over his/her head into the mattress, with Resident #1 yelling. In addition, she stated she could not understand what Resident #1 was trying to say, but by the tone of his/her voice, it sounded like the resident was hurting. She revealed SRNA #1 then pulled Resident #1's shirt up over his/her head and said Shut up!, then said You make me so [OBSCENITY] ing mad I want to punch you in the face. She revealed SRNA #1 then brought Resident #1's arm down below the mattress and between her legs and held it so she could change him/her. She revealed after changing, SRNA #1 released Resident #1's arm, and PCA #1 stayed with the resident for a few minutes, talking with him/her and making sure he/she was comfortable. Continued interview with PCA #1 revealed she did not know there was a short time period to report the incident, and wasn't sure who to report to. She went on to reveal the event had been eating her up so much knowing SRNA #1 was working there, and she finally went and said something to the Assistant Director of Health Services (ADHS), even though it was a couple of days later. PCA #1 stated she was educated by the ADHS on the need to report immediately any suspected abuse. Interview with SRNA #8, on 06/02/2021 at 10:33 AM, revealed she had worked with Resident #1 since she first started at the facility over three (3) years ago. She described Resident #1 in positive terms, but stated Resident #1 did like to try to hit sometimes, which could sometimes be prevented by asking him/her to hold his/her left hand. She stated she had been questioned by management staff regarding abuse, and there had been a change to two (2) staff required at all times when entering Resident #1's room. Interview with the ADHS, on 06/01/2021 at 2:36 PM, revealed she was working, on 05/12/2021, and took PCA #1's statement when she initially reported the incident that occurred on 05/09/2021. PCA #1 said she felt another aide was more aggressive with Resident #1 than she felt the other aide should be. She stated PCA #1 shared it had been bothering and weighing on her, and she needed to tell somebody. The ADHS stated she initiated an investigation at that time, assisted with skin assessments and interviews, and performed staff education. She stated there were no physical findings, even from the X-ray, which revealed no injury. The ADHS stated she educated PCA #1 on the importance of reporting any suspected abuse immediately. Interview with the Interim Executive Director, on 06/02/2021 at 2:13 PM, revealed she was contacted, on 05/12/2021, by the ADHS, who explained PCA #1 reported an incident that had occurred on 05/09/2021. She stated she interviewed SRNA #1 and PCA #1 and suspended them both pending results of the investigation. Further, she stated the decision was made to terminate SRNA #1 due to abuse. She stated SRNA #1 did not deny holding Resident #1's arm down and cursing after she was struck by the resident. The Director stated her expectation was if staff even suspected abuse, it be reported immediately.

Based on interview, record review, review of facility Policy, and review of the Kentucky Board of Nursing Advisory Opinion Statements, it was determined the facility failed to ensure services were provided according to accepted standards of practice for one (1) of thirteen (13) sampled residents, Resident 200. The facility admitted Resident 200 on 11/28/18 for rehabilitation following surgery for [REDACTED]. Resident #200 requested the ordered [MEDICATION NAME] (narcotic pain medication) on 11/28/18 at approximately 8:30 PM; however, there was no documented evidence the resident received the ordered pain medication until 11/29/18 at 8:06 AM, over eleven and a half (11.50) hours later. The findings include: Review of the facility's IA1: Provider Pharmacy Requirements Policy, revised 01/2017, revealed new medication orders were to be faxed to the pharmacy and would be available for administration as soon as possible on the next routine delivery or may be available from the emergency medication kit (1st dose cart). Review of the Kentucky Board of Nursing Advisory Opinion Statement (KBN AOS), Roles of Nurses in the Administration of Medications via Various Routes; Accountability and Responsibility of Nurses, revised 2012, revealed, in accordance with KRS 314.02(2), nurses were responsible and accountable for making decisions that were based upon the individual's educational preparation and current clinical competence in nursing, and required licenses to practice nursing with reasonable skill and safety. Nursing practice should be consistent with the Kentucky Nursing Laws, established standards of practice, and evidence based. Review of KBN AOS #14 Patient Care Orders, revised 10/14/15, revealed licensed staff should administer medication prescribed by the physician/Advanced Practice Registered Nurse and prepare and give the medication in the prescribed dosage, route, and frequency. Review of Resident #200's medical record revealed the facility admitted the resident on 11/28/18 with [DIAGNOSES REDACTED]. Review of Resident #200's Hospital Discharge Information, dated 11/28/18 at 2:38 PM, revealed the resident was being discharged after a Total Hip Replacement and the final medication list included [MEDICATION NAME] 5/325 milligrams oral tablet four (4) times per day for ten (10) days. Review of admission physician's orders [REDACTED].; 7:00 AM-7:00 PM, 7:00 PM-7:00 AM. Further review revealed [MEDICATION NAME] was the only pain medication listed per physician's orders [REDACTED]. Review of the Observation Detail List Report, completed 11/28/18 at 7:17 PM, revealed Resident #200 was admitted at 4:12 PM, and the resident's pain level was a five (5) on a scale of one (1) to ten (10) with ten (10) being the highest pain level. Further review revealed the Physician was notified of the admission at 5:13 PM and at 5:30 PM the pharmacy was notified to have the resident's medications sent to the facility Stat (urgent). Interview with Resident #200's spouse and daughter, on 11/29/18 at 12:30 PM, revealed the resident had spent the night crying with pain. Additional interview revealed when pain medication was requested, Resident 200 was informed the pain medication had not arrived and the pharmacy was closed. Continued interview revealed there was no offer of non-pharmacological pain interventions such as ice to the affected area, and the ice pack brought with the resident on admission had not been re-frozen for use. Interview on 11/29/18 at 4:22 PM, with Resident #200, revealed he/she had received pain medication at approximately 8:00 AM and Noon today, and his/her current pain level was two (2) out of ten (10) on the pain scale. Per interview, the resident requested pain medication at approximately 8:30 PM, after admission on 11/28/18, for a pain level of nine (9) out of ten (10), and was told medications were not available, the Pharmacy was closed and pharmacy would not open to send the medication. Further interview revealed there was no non-pharmacological pain interventions offered, such as the ice wrap he/she had brought with him/her from the hospital or cold compression wrap. Review of Resident #200's Medication Administration Record [REDACTED]. Review of Resident #200's Treatment Administration Record (TAR), dated (MONTH) (YEAR), revealed on 11/28/18, the resident had a pain level of five (5) on the 7:00 AM-7:00 PM, shift and a pain level of five (5) on the 7:00 PM-7:00 AM shift. Additional review revealed there was no documented evidence of non-pharmalogical interventions for pain implemented including cold compress to the left hip during the timeframe of 11/28/18 7:00 PM through 11/29/18 at 8:00 AM. Review of the content list for the Emergency Medication Kit, revised 10/01/18 revealed [MEDICATION NAME] 5-325 mg was included in the Kit. Interview with Registered Nurse (RN) #3, on 11/29/18 at 3:05 PM, revealed she was assigned to Resident 200 the evening and night of his/her admission from 7:00 PM on 11/28/18 until 11/29/18 at 7:00 AM. She further stated she had not been employed at the facility very long and was fairly new to long term care, and was therefore unaware of all the facility processes. Continued interview revealed on the evening of 11/28/18, Resident #200 requested pain medication and was assessed as having a pain level of five (5) on a pain level scale of one (1) to ten (10). Further interview revealed she called pharmacy on 11/28/19 at 8:00 PM, and 11/29/18 at Midnight about the need for Stat [MEDICATION NAME] and was told each time the medication would arrive at the facility. RN #3 revealed the pharmacy staff did not inform her she could obtain the [MEDICATION NAME] from the emergency medication kit (1st dose cart). She further stated Resident #200's [MEDICATION NAME] pain medication did not arrive at the facility until the morning of 11/29/18 after she had left the building. Additional interview revealed orientation after hire was very short and she was not familiar with the facility emergency medication kit 1st dose cart. RN #3 revealed she had not requested assistance or questioned other nurses about what to do if pain medication was unavailable, nor did she offer non-pharmalogical interventions for Resident #200's pain. Review of the Nurse New Hire Checklist, undated, revealed during orientation, nurses received education on retrieving medications from the firstdose cart; Pharmacy cutoff and delivery times; PRN medication administration and Trilogy Service Standards that included pain medication. Interview with the Assistant Director of Nursing (ADON), on 11/29/18 3:58 PM, revealed Pharmacy would not send medications STAT if the medication was available in the firstdose cart, such as the [MEDICATION NAME] 5-325 mg for Resident #200. Further interview revealed RN #3 should have called the Pharmacy for an access code for the firstdose cart, then retrieved and administered the PRN pain medication. Interview with the Director of Health Services (DHS), on 11/29/18 3:23 PM, revealed she had met with Resident 200 and the resident's spouse this morning (11/29/18) about concerns voiced earlier related to the lack of pain medication availability on the previous shift and how uncomfortable Resident 200 had been. Continued interview revealed Resident 200 had been medicated immediately at 8:06 AM when concerns were voiced. Further interview revealed she had spoken with RN #3 about the failure to utilize the firstdose cart for the pain medication for Resident 200. The DHS stated, RN #3 told her had been afraid that the Pharmacy would not issue a firstdose cart code in order to implement the system because the medication had been ordered STAT. The DHS further stated she reminded RN #3 of being trained by other nurses and of the multiple resources available to her if she was unsure of a process, including the other nurse in the building, the on call manager and the twenty four (24) hour Pharmacy number. Continued interview revealed the DHS had worked a shift with RN #3 prior to this and had run into this same situation of accessing medications from the firstdose box for a late admission; therefore, the nurse should have been knowledgeable of this process. Additional interview revealed pain medication should be administered as per physician's orders [REDACTED]. Interview with the Administrator on 11/29/18 at 5:19 PM, revealed it was her expectation staff provide pain medication as prescribed, per professional standards. Per interview, RN #3 should have ensured Resident #200 received the ordered [MEDICATION NAME] for pain management. Continued interview revealed there was administrative staff on call after normal business hours in case the nursing staff had a question related to the facility's processes.

Based on interview, record review, and review of facility Policy, it was determined the facility failed to provide pain management for one (1) of thirteen (13) sampled residents, Resident 200. The facility admitted Resident 200 on 11/28/18 for rehabilitation following surgery for [REDACTED]. Although the resident requested the ordered [MEDICATION NAME] (narcotic pain medication) on 11/28/18 at approximately 8:30 PM, there was no documented evidence the resident received the ordered pain medication until 11/29/18 at 8:06 AM, over eleven and a half (11.50) hours later. The findings include: Review of the facility's IA1: Provider Pharmacy Requirements Policy, revised 01/2017, revealed new medication orders were to be faxed to the pharmacy and would be available for administration as soon as possible on the next routine delivery or may be available from the emergency medication kit (1st dose cart). Review of Resident #200's medical record revealed the facility admitted the resident on 11/28/18 with [DIAGNOSES REDACTED]. Review of the Hospital Discharge Information, dated 11/28/18 at 2:38 PM, revealed the resident was being discharged after a Total Hip Replacement and the final medication list included [MEDICATION NAME] 5/325 milligrams oral tablet four (4) times per day for ten (10) days. Review of Resident 200's admission physician's orders [REDACTED].; 7:00 AM-7:00 PM, 7:00 PM-7:00 AM. [MEDICATION NAME] was the only pain medication listed per physician's orders [REDACTED]. Review of the Observation Detail List Report, completed 11/28/18 at 7:17 PM, revealed Resident #200 was admitted at 4:12 PM, and the resident's pain level was assessed as a five (5) on a scale of one (1) to ten (10) with ten (10) being the highest pain level. Further review revealed the Physician was notified of the admission at 5:13 PM and at 5:30 PM the pharmacy was notified to have the resident's medications sent to the facility Stat. Interview with Resident #200's spouse and daughter, on 11/29/18 at 12:30 PM, revealed Resident #200 had spent the night crying with pain. Continued interview revealed when pain medication was requested, Resident 200 was informed the pain medication had not arrived and the pharmacy was closed. Further interview revealed there was no offer of non-pharmacological pain interventions such as ice to the affected area, and the ice pack brought with the resident on admission had not been re-frozen for use. Interview on 11/29/18 at 4:22 PM, with Resident #200, revealed he/she had received pain medication at about 8:00 AM and Noon today, his/her current pain level was two (2) out of ten (10) on the pain scale, and he/she was feeling much better. Further interview revealed the resident requested pain medication at approximately 8:30 PM, after admission on 11/28/18, for a pain level of nine (9) out of ten (10), and was told medications were not available, the Pharmacy was closed and pharmacy would not open to send the medication. Continued interview revealed there was no non-pharmacological pain interventions offered, such as the ice wrap he/she had brought with him/her from the hospital or cold compression wrap. Review of the Medication Administration Record [REDACTED]. Review of the Treatment Administration Record (TAR), dated (MONTH) (YEAR), revealed on 11/28/18, the resident had a pain level of five (5) on the 7:00 AM-7:00 PM, shift and a pain level of five (5) on the 7:00 PM-7:00 AM shift. Further review revealed there was no documented evidence of non-pharmalogical interventions for pain implemented including cold compress to the left hip during the timeframe of 11/28/18 7:00 PM through 11/29/18 at 8:00 AM. Review of the content list for the Emergency Medication Kit, revised 10/01/18 revealed [MEDICATION NAME] 5-325 mg was included in the Kit. Interview with Registered Nurse (RN) #3, on 11/29/18 at 3:05 PM, revealed she was assigned to Resident 200 the evening and night of his/her admission from 7:00 PM until 11/29/18 at 7:00 AM. She stated she had not been employed at the facility very long and was fairly new to long term care, and was therefore unaware of all the facility processes. Further interview revealed on the evening of 11/28/18 Resident #200 requested pain medication and was assessed as having a pain level of five (5) on a pain level scale of one (1) to ten (10). Continued interview revealed she called pharmacy on 11/28/19 at 8:00 PM, and 11/29/18 at Midnight about the need for Stat [MEDICATION NAME] and was told each time the medication would arrive at the facility. RN #3 stated the pharmacy staff did not inform her she could obtain the [MEDICATION NAME] from the emergency medication kit (1st dose cart). She stated Resident #200's [MEDICATION NAME] pain medication did not arrive at the facility until the morning of 11/29/18 after she had left the building. Further interview revealed orientation after hire was very short and she was not familiar with the facility emergency medication kit 1st dose cart. Further, she stated she had not requested assistance or questioned other nurses about what to do if pain medication was unavailable, nor did she offer non-pharmalogical interventions for Resident #200's pain. Interview with RN #2, on 11/29/18 1:44 PM, revealed she had been RN #3's mentor at the facility during the nurse's orientation. Per interview, the PRN [MEDICATION NAME] pain medication for Resident 200 could have been retrieved from the emergency medication kit 1st dose cart until the resident's pain medication arrived from pharmacy. Continued interview revealed, although Resident 200's medications were ordered Stat; if medications were available from the emergency medication kit 1st dose cart, those medications were to be utilized until the next pharmacy delivery. Review of the Nurse New Hire Checklist, no date, revealed during orientation, nurses received education on retrieving medications from the firstdose cart; Pharmacy cutoff and delivery times; PRN medication administration and Trilogy Service Standards that included pain medication. Interview with the Assistant Director of Nursing (ADON), on 11/29/18 3:58 PM, revealed Pharmacy would not send medications STAT if the medication was available in the firstdose cart, such as the [MEDICATION NAME] 5-325 mg for Resident #200. Per interview, RN #3 should have called the Pharmacy for an access code for the firstdose cart, then retrieved and administered the PRN pain medication. Interview with the Director of Health Services (DHS), on 11/29/18 3:23 PM, revealed she had met with Resident 200 and his/her spouse this morning (11/29/18) about concerns voiced earlier related to the lack of pain medication availability on the previous shift and how uncomfortable Resident 200 had been. Further interview revealed Resident 200 had been medicated immediately at 8:06 AM when concerns were voiced. Continued interview revealed she had spoken with RN #3 about the failure to utilize the firstdose cart for the pain medication for Resident 200. She stated RN #3 said she had been afraid that the Pharmacy would not issue a firstdose cart code in order to implement the system because the medication had been ordered STAT. She further stated she reminded RN #3 of being trained by other nurses and of the multiple resources available to her if she was unsure of a process, including the other nurse in the building, the on call manager and the twenty four (24) hour Pharmacy number. The DHS also stated she had worked a shift with RN #3 prior to this and had run into this same situation of accessing medications from the firstdose box for a late admission; therefore the nurse should have been knowledgeable of this process. Interview with the Administrator on 11/29/18 at 5:19 PM, revealed it was her expectation pain medication was provided as per physician's orders [REDACTED].#3 should have ensured Resident #200 received the ordered [MEDICATION NAME] to manage the resident's pain. Further, there was administrative staff on call after normal business hours in case the nursing staff had a question related to the facility's processes.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure services were provided in accordance with each resident's written Comprehensive Care Plan for one (1) of twelve (12) sampled residents (Resident #3). Resident #3's Comprehensive Care Plan revealed the resident had updated interventions which included: fortified foods; [MEDICATION NAME] (an appetite stimulant medication); and fortified shakes three (3) times a day. However, interview and record review revealed Resident #3 was no longer receiving the care plan interventions of fortified foods or fortified shakes three (3) times a day or [MEDICATION NAME] (medication used for appetite stimulation). Observation, on 06/04/15, of Resident #3's weight being obtained revealed the resident's weight was 151.8 pounds (lbs) with a re-weight obtained of 152.0 lbs, which was a significant weight loss from his/her weights obtained previously. The findings include: Review of the facility's policy titled, Interdisciplinary Team Care Plan Guideline, revised January 2008, revealed the purpose of the care plan was to ensure the appropriateness of services and communication which met a resident's needs, severity/stability of conditions, impairment, disability, or disease. Policy review revealed problem areas were identified with interventions reflective of the individuals needs and risk. Interview, on 06/04/15 at 8:09 PM, with the Executive Director revealed her expectation was for staff to follow residents' Comprehensive Care Plans. Review of Resident #3's medical record revealed the facility admitted the resident on 02/16/06, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 04/12/15, revealed the facility assessed Resident #3 as moderately cognitively impaired, but interviewable, with a Brief Interview for Mental Status (BIMS) score of eight (8) out of fifteen (15). Review of Resident#3's Comprehensive Care Plan, undated, revealed the facility had care planned the resident for Heights/Weights with the resident's weight to remain at a healthy range and without unwarranted significant weight change. Continued review of the care plan revealed interventions which included to review Resident #3's overall weight trends at least once monthly and make necessary recommendations to the Physician for approval should the resident experienced any undesired weight change. Continued review of Resident #3's Comprehensive Care Plan revealed the facility also care planned the resident for Meals/Snacks/Fluids with updated interventions which included: on 01/22/15, add fortified foods to diet, fortified shake daily; on 02/25/15, add [MEDICATION NAME] for the resident's appetite, monitor; on 03/04/15, increased fortified shakes to TID (three times per day) related to weight loss; on 03/24/15, Med Pass 2.0 (a nutritional supplement given at medication pass times) 120 cc (cubic centimeter) bid (two times per day) for thirty (30) days related to weight loss, monitor; and on 04/15/15, Medpass increased to TID, monitor. Further review of the Meals/Snacks/Fluids care plan revealed to coordinate care efforts with the resident, family and caregivers and Interdisciplinary Team (IDT). Review of monthly physician's orders [REDACTED]. Continued review of the June 2015 monthly physician's orders [REDACTED]. Review of prior physician's orders [REDACTED]. However, review of Resident #3's 04/03/15, re-admission physician's orders [REDACTED]. Further review of Resident #3's medical record of the resident's weight records revealed the documented weights for him/her for 2015 were as follows: on 01/13/15 the weight was 178.5 lbs, on 02/17/15 the weight was 168.5 lbs, on 03/03/15 the weight was 168 lbs, on 04/04/15 the weight was 165.5 lbs, and on 05/05/15 the weight was 160.2 lbs. Observation, on 06/04/15 at 4:40 PM, of Resident #3's weight being obtained by Licensed Practical Nurse (LPN) #1 revealed the resident's weight initially was 151.8 pounds (lbs), LPN #1 re-weighed him/her with a re-weight of 152.0 lbs, which was a significant weight loss from the previously documented weights. Interview, on 06/04/15 at 2:59 PM, with the Dietician revealed she developed Resident #3's nutrition care plans with interventions and the resident had a history of [REDACTED]. The Dietician revealed she had recommended: the [MEDICATION NAME] 15 mg to improve the resident's appetite; the fortified foods for extra protein and calories; and increased the fortified shakes to three (3) times a day because the resident's intake was not sufficient to meet his/her dietary needs. Continued interview revealed she had increased the Med Pass 2.0 supplement to three (3) times per day to help with wound healing. The Dietician stated she expected the interventions she had recommended which included the [MEDICATION NAME] and fortified shakes, to be implemented as the resident continued to need them. Per interview, the Dietician was unaware Resident #3's [MEDICATION NAME] and fortified shakes had been discontinued in April when the resident was readmitted after hospitalization . Further interview with the Dietician revealed Resident #3's meal ticket was supposed to include the order for the fortified foods. The Dietician revealed she was unaware Resident #3 was no longer receiving the fortified foods; however, she stated the resident should be receiving the fortified foods, as per the care plan. Interview, on 06/04/15 at 6:21 PM, with the Dietary Manager revealed the last order sent by nursing to dietary, on 04/15/15, had a Mechanical Soft Diet documented and had not included the Physician ordered and care planned fortified foods. Interview, on 06/04/15 at 7:43 PM, with the Director of Health Services (DHS) revealed care plan interventions were to be followed to maintain a resident's safety and provide adequate care. The DHS revealed Resident #3's nutrition care plan interventions included fortified foods, [MEDICATION NAME], fortified shakes and Med Pass 2.0, and the resident's care plan was only being implemented at that time for the Med Pass intervention. She revealed the [MEDICATION NAME] and fortified shakes were not included on Resident #3's re-admission orders [REDACTED]. Per interview, no one had questioned why the interventions for the [MEDICATION NAME] and fortified shakes and food were not in place. Per interview, the fortified foods were on Resident #3's re-admission orders [REDACTED]. The DHS revealed there had been a breakdown in the facility's system because the failure to implement Resident #3's nutrition interventions was not identified. Further interview revealed the goal of the care plan was for Resident #3 not to lose weight and to be comfortable, but by not following the resident's care plan interventions this had possibly contributed to his/her weight loss. Interview, on 06/04/15 at 8:09 PM, with the Executive Director (ED) revealed care plans were based on assessments and directed the team on how to best care for residents. Per interview, she hoped all interventions ordered by the Physician were followed, and as the fortified foods were on the resident's current physician's orders [REDACTED].

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure the Dietician's recommended nutritional supplements and therapeutic diet were followed for one (1) of twelve (12) sampled residents (Resident #3). Resident #3 had a history of [REDACTED]. The Dietician's recommendations were ordered by the Physician and care planned. However, the facility failed to ensure the Dietician's recommendations were reordered after Resident #3 was readmitted to the facility following a hospitalization . In addition, the facility failed to notify the Dietician when the [MEDICATION NAME] and fortified shake orders were not continued after Resident #3's re-admission to the facility. Also, Resident #3 had a physician's orders [REDACTED]. The findings include: Review of the facility's policy titled, Guidelines for Weight Tracking, revised date of May 2014, revealed the purpose of the policy was to ensure residents' weights were monitored for weight gain and/or loss to prevent complications arising from compromised nutrition. The Policy revealed the Dietician or representative reviewed the resident's nutritional status, usual body weight and current weight to implement a nutritional program as warranted. Record review revealed the facility admitted Resident #3 on 02/16/06, with [DIAGNOSES REDACTED]. Review of the 04/12/15, Quarterly Minimum Data Set (MDS) Assessment revealed the facility assessed Resident #3 as moderately cognitively impaired through the Brief Interview for Mental Status (BIMS) assessment. Review of the March 2015 monthly physician's orders [REDACTED]. Review of other physician's orders [REDACTED].#3's fortified shakes to three (3) times per day (TID) per dietary recommendations. Continued record review revealed Resident #3 was re-admitted to the facility on [DATE], after a hospitalization . Review of Resident #3's June 2015 monthly physician's orders [REDACTED]. Review of Resident#3's Comprehensive Care Plan, undated, revealed the facility had care planned the resident for Heights/Weights and Meals/Snacks/Fluids. Continued review of the Heights/Weights care plan revealed a goal of no unwarranted significant weight change and interventions which included reviewing the resident's overall weight trends at least once monthly and make any recommendations to the Physician for approval if the resident experienced any undesired weight change. Continued review of the Meals/Snacks/Fluids care plan revealed the resident was on a mechanical soft diet with fortified foods per orders. Further review revealed the interventions were updated to include: on 1/22/15, fortified foods were added with a fortified shake daily; on 02/25/15, [MEDICATION NAME] medication was added related to appetite, and monitor; on 03/04/15, the fortified shakes were increased to three (3) times daily (TID) related to weight loss; on 03/24/15, Med Pass 2.0 (a nutritional supplement given during medication pass) 120 cubic centimeter (cc) two (2) times daily (BID) for thirty (30) days related to weight loss and monitor; and on 04/15/15, the Med Pass supplement was increased to TID and monitor. However, review of the June 2015 monthly physician's orders [REDACTED]. Review of Resident #3's weight records revealed the resident's weights were documented as follows for 2015: on 01/13/15, 178.5 pounds (lbs); on 02/17/15, 168.5 lbs; on 03/03/15, 168 lbs; on 04/04/15, 165.5 lbs; and weekly weights obtained on 05/05/15, 05/12/15, 05/19/15, 05/26/15 revealed the resident's weight was documented as 160.2 lbs for all four (4) dates. However, observation and interview, on 06/04/15 at 4:40 PM, of Resident #3 being weighed by Licensed Practical Nurse (LPN) #2 revealed an initial weight of 151.8 lbs was obtained, and when the resident was re-weighed a weight of 152 lbs was obtained. Interview with LPN #2 revealed she had previously weighed Resident #3 before using the sit down weigh machine which was calibrated to 0.0 prior to obtaining a resident's weight. Continued review of Resident #3's previously documented weights for 2015, compared to the weight of 152 lbs obtained on 06/04/15, revealed the resident had experienced a one (1) month weight loss of 5% from the 05/05/15 weight of 160.2 lbs; a three (3) month weight loss of 8% from the 04/04/15 weight of 165.5 lbs; and a six (6) month weight loss of 14% from the 01/13/15 weight of 178.5 lbs. Continued record review of the Nutrition Progress Notes revealed a Note, dated 04/06/15, which documented Resident #3's meal intake of the mechanical soft fortified foods diet was 41.7% times (x) seven (7) days, and the resident's supplements included fortified shakes TID with meals, Med Pass 2.0 120 ml BID related to weight decrease. The Note revealed Resident #3 also received [MEDICATION NAME] 15 mgs daily related to appetite. Review of the Nutrition Progress Note, dated 05/05/15, revealed Resident #3's Med Pass supplement was increased to 120 ml three (3) times a day related to not meeting needs. Even though review of Resident #3's Comprehensive Care Plan revealed it had been updated on 04/15/15, for the Med Pass supplement to have been increased to TID then. Interview, on 06/04/15 at 2:59 PM, 4:00 PM, and 5:32 PM, with the Dietician revealed when assessed Resident #3 had triggered for Dementia, History of Pneumonia, Chronic Urinary Tract Infections and she had written nutrition care plans with interventions for the resident. Per interview, Resident #3 was above his/her ideal body weight of 115 lbs, was overweight and was assessed on 04/14/15, to consume approximately 56.5% of meals, over a seven (7) day period and 100% of his/her snacks. The Dietician revealed her nutrition assessment on 05/05/15, was related to Resident #3's wound needs, as the resident had experienced skin breakdown. Per interview, the Med Pass supplement was increased to three (3) times daily at that time to help with wound healing and provided extra calories and protein for healing. The Dietician stated Resident #3 had experienced a 3% weight loss between the April and May weights. Continued interview revealed however, she was unaware the resident had experienced a significant weight loss of greater than 10%, over a six (6) month period, based on the May 2015 weight of 162 lbs and the November 2014 weight of 179 lbs. She stated this was because on her 05/05/15 nutrition assessment she had been focused on Resident #3's wound needs and had not reviewed the resident's prior weights at that time. Per the Dietician, if she had been aware of the significant weight loss she would have reviewed Resident #3's interventions and physician's orders [REDACTED]. Observation, on 06/02/15 at 05:41 PM and 5:49 PM, revealed Resident #3 was in the dining room eating being assisted with his/her meal with no fortified shake (Mighty Shake) observed and no meal ticket present with the meal. Review of Resident #3's meal ticket, kept in a notebook on the Legacy Unit, where the resident resided, revealed the meal ticket was blank with no documented evidence of the diet orders for him/her. Interview, on 06/04/15 at 1:11 PM, with Certified Nursing Assistant (CNA) #1 revealed the meal ticket was a part of the facility's checks to ensure a resident had the right diet and Resident #3 was on a mechanical soft diet. Continued interview with CNA #1 revealed a resident's meal ticket was supposed to include if the resident needed a fortified shake with their meals. Continued interview, on 06/04/15 at 12:47 PM, with LPN #1 revealed Resident #3 was receiving a mechanical soft diet and the meal ticket was supposed to ensure the correct diet was served. LPN #1 revealed Resident #3 had not been getting the fortified shakes because they were not on the resident's meal ticket. Interview, on 06/04/15 at 1:50 PM, with the Dietary Manager (DM) revealed she did not assess residents for weight loss, and on the Legacy Unit, where Resident #3 resided, meals were served family style for lunch and dinner so meal tickets were not provided. Per interview, a meal ticket was provided with the breakfast meal and the nurse was given a copy of the most current meal ticket to review for accuracy. The Dietary Manager revealed someone should have identified Resident #3's meal ticket was blank with no diet order documented. Further interview revealed nursing communicated to the dietary department when and if a resident was supposed to get a fortified shake with meals. Further record review revealed Resident #3's 04/03/15 re-admission physician's orders [REDACTED]. Review of the Nutrition Recommendation, dated 04/14/15, revealed the Dietician's recommendation which clarified Resident #3's diet was regular mechanical soft, and not the NAS mechanical soft diet ordered on his/her re-admission. However, further review of the 04/14/15, Nutrition Recommendation revealed no documented evidence of continuation of the fortified foods recommendation. Therefore, review of a Diet Order Communication sent to dietary by a nurse, dated 04/15/15, revealed it only included the recommendation to change Resident #3's diet to mechanical soft. Interview, on 06/04/15 at 7:04 PM, with LPN #3 revealed he had transcribed the Dietician's recommendation on 04/15/15, and wrote the diet order as mechanical soft, as per the Dietician's recommendation which had not included fortified foods. The Dietician revealed she had previously recommended for Resident #3 to receive: [MEDICATION NAME] 15 mg to improve the resident's appetite; fortified foods; and had increased the resident's fortified shakes to three (3) times a day. She stated this was because Resident #3's meal intake was not sufficient and she thought those interventions were still in place, as per her recommendations, when she wrote the 04/06/15 and 05/05/15 Nutrition Progress Notes and performed the 04/14/15 dietary assessment. Continued interview, on 06/04/15 at 6:21 PM, with the Dietary Manager revealed as far as she knew Resident #3 was only on a Mechanical Soft Diet, as the last order sent by nursing to the dietary department, on 04/15/15, had been for a Mechanical Soft Diet. Per interview, the order sent by nursing had not included the Physicians Orders for Resident #3 to receive fortified foods. Even though review of the May 2015 and June 2015 monthly physician's orders [REDACTED].>Interview, on 06/04/15 at 7:14 PM with the Assistant Director of Health Services (ADHS) revealed the Dietician had submitted a copy of her dietary recommendations for Resident #3 when she had clarified the resident's re-admission diet order. Per interview, on re-admission on 04/03/15, Resident #3 had an order for [REDACTED].#3's diet order, and therefore, had not included the fortified food order. Continued interview revealed when nursing communicated the Dietician's recommendation to dietary, the nurse changed Resident #3's diet to just a mechanical soft diet, as the fortified foods order was not included. The ADHS revealed a breakdown had occurred in the communication process, and the nurse should have looked to see what Resident #3's whole diet order was and included the fortified foods. Further interview with the Dietician, on 06/04/15 at 6:39 PM, revealed Resident #3's meal ticket was supposed to include the fortified foods and she was not aware the resident was no longer receiving fortified foods. The Dietician revealed the physician's orders [REDACTED]. Per interview, there was a system breakdown because she was not notified when Resident #3's weight declined between the April 2015 re-admission weight of 168 lbs, and the May 2015 weight of 162.2 lbs. The Dietician revealed Resident #3 was not getting the diet the Physician had ordered, but the resident had not experienced a significant one (1) month weight loss, as the weight loss was 4.7%. In addition, the Dietician stated even if Resident #3 was only getting the regular mechanical soft diet and the Med Pass supplement three (3) times a day, the resident was getting thirty-one (31) calories per kilogram (kg) which was sufficient to promote weight gain. Further interview revealed the Dietician based this on Resident #3's current meal consumption average which was calculated at 57% times seven (7) days. Interview, on 06/04/15 at 7:43 PM, with the Director of Health Services (DHS) revealed Resident #3's meal ticket had no dietary information or food allergies [REDACTED]. Per interview, nursing staff should have caught this omission. The DHS revealed the Dietician's recommendations for [MEDICATION NAME] and fortified shakes were not included on the resident's re-admission orders [REDACTED]. Continued interview revealed Resident #3's February and March monthly weights, the April re-admission weight which was 168 lbs, and the May weekly weights which were stable at 160.2 lbs had not flagged the resident for significant weight loss. The DHS stated had not had a June weekly weight performed yet, prior to the 06/04/15 weight obtained for the Surveyor. In addition, the DHS reported Resident #3 body mass index (BMI) was still higher than normal, and therefore, the level of care changes did not flag the resident for further interventions. Interview, on 06/05/15 at 6:07 PM, with Resident #3's Physician revealed the resident was at risk for weight loss due to Dementia which caused fluctuations in eating and was a leading cause of weight loss. The Physician revealed when Resident #3 was hospitalized , the hospital staff did not think [MEDICATION NAME] was appropriate for the resident and had discontinued the medication. Per interview, it was really a toss of the coin to know if it had benefited Resident #3. The Physician revealed someone had dropped the ball by not adding the fortified Mighty Shakes upon Resident #3's re-admission in April. Continued interview revealed he was not concerned Resident #3 had experienced a six (6) month weight loss of 10%, based on the May weights. Per the Physician, this was because Resident #3 remained above his/her ideal body weight, was eating well now and getting more than needed, looked good and was not malnourished. However, the Physician reported if Resident #3 had continued to experience weight loss it would have been a concern. Interview, on 06/04/15 at 8:09 PM, with the Executive Director (ED) revealed she hoped all interventions ordered by the Physician were always followed. Per the ED, however, if fortified foods were not being provided for Resident #3, the facility was not following the physician's orders [REDACTED].

Based on observation, interview and review of the facility policy, it was determined the facility failed to store and prepare food under sanitary conditions as evidenced by the ice cream freezer temperatures were not recorded, the deep fryer was not cleaned according to schedule, and all food products were not labeled and dated in the reach-in refrigerator. The findings include: Review of the facility's policy titled "Food Production Guidelines-Sanitation and Safety" (dated 2009) revealed cold food was to be held at forty-one (41) degrees Fahrenheit or below; however, the policy did not address required temperatures for frozen foods. In addition, the policy did not indicate how often temperatures were to be checked in order to ensure food was adequately cooled and/or frozen. Continued review revealed food prepared in advance was to be covered, labeled, dated, refrigerated, and used within seventy-two (72) hours. Observation during the initial kitchen tour, on 07/22/14 at 1:40 PM, revealed no thermometer was found in the ice cream freezer, and no temperatures had been recorded. Continued observation revealed oil in the deep fryer was dark black in color, and splatter from the deep fryer was noted on the surface of the stove. In addition, the reach-in refrigerator held a clear plastic pitcher containing a purple liquid which was not labeled or dated. Observation during the follow-up kitchen tour, on 07/23/14 at 12:20 PM, revealed a clear container of a tan liquid, and a pitcher containing an opaque liquid, were stored in the reach-in refrigerator without labels or dates. Review of the Refrigerator/Freezer Temp Log, dated July 2014, revealed no temperatures were recorded for the ice cream freezer prior to 07/22/14, the date of the initial kitchen tour. Continued review of the Log revealed the reference point for freezer temperatures was zero (0) degrees Fahrenheit. Review of the Deep Fryer Cleaning Log revealed the deep fryer was cleaned once in March, on 03/18/14, and was cleaned twice each month from 04/15/14 through 07/21/14. Continued review revealed comments on the condition of the oil included "very dirty", "very, very dirty", and "really dirty". Review of the daily, weekly and monthly cleaning lists revealed the deep fryer was not listed for regularly scheduled cleaning. Interview with Dietary Aide #1, on 07/23/14 at 3:15 PM, revealed food containers were to be covered with plastic wrap, labeled and dated. She stated if the food was not dated, it should be thrown out. Continued interview revealed she was not assigned to clean the deep fryer, and the cook checked the equipment temperatures. Interview with Cook #1, on 07/23/14 at 3:20 PM, revealed all foods should be labeled and dated, and thrown out after three (3) days. She stated she checked the refrigerator and freezer temperatures; however, she stated the ice cream chest temperatures had never been checked. Continued interview revealed the deep fryer was supposed to be cleaned twice weekly, but she was not sure who was responsible. Interview with the Director of Food Service, on 07/23/14 at 3:30 PM, revealed open food containers were to be labeled and dated for seven (7) days and then discarded. She stated if food was not labeled and became outdated, bacteria could grow and make the residents sick. She further stated there was no temperature log for the ice cream freezer, and no temperatures had been checked or recorded prior to 07/22/14. Continued interview revealed the deep fryer was to be cleaned twice weekly, every Monday and Friday. She explained if the oil in the deep fryer was not changed regularly, bacteria could grow, food would not cook properly, and the taste of the food would be affected, with the result of a poor food product.

Based on observation, interview and review of the Daily Nurse Staffing form, it was determined the facility failed to post the Daily Nurse Staffing data at the beginning of each shift on the skilled living units. In addition, staffing information was not displayed in a prominent place readily accessible to residents and visitors on the Memory Care Unit. The findings include: Interview with the Administrator, on 07/24/14 at 4:40 PM, revealed the facility did not have a policy related to the posting of the nurse staffing hours. She stated the facility followed the regulation for posting of staffing information. 1. Observation of the posted Daily Nurse Staffing on the skilled living units, on 07/22/14 at 4:20 PM, revealed the posting covered all three (3) shifts for the 24-hour period. Subsequent observation, on 07/23/14 at 9:30 AM, revealed new staffing information for the skilled units was posted, again for all three (3) shifts. 2. Observation on the Memory Care Unit, on 07/23/14 at 12:27 PM, revealed the staffing list was laying between the wall and the hand rail, behind the nurses' desk. The staffing list was dated 07/23/14 and included staffing for the first, second and third shifts. Continued observation revealed the staffing information was not easily visible to staff, residents and visitors outside the nurses' station. Subsequent observation on the Memory Care Unit, on 07/24/14 at 9:50 PM, revealed the staffing information was not posted and was not visible. Interview with Licensed Practical Nurse #2/Unit Manager, on 07/24/14 at 9:50 AM, revealed the staffing list had not been posted. She stated the information should be posted on the wall, but was located in a notebook on the desk. Continued interview with the Administrator, on 07/24/14 at 4:50 PM, revealed the staffing list should be posted on the wall in a clear plastic frame, in a location that could readily be seen by visitors. She stated the facility posted the nurse staffing hours daily in the morning, and she was not aware of the requirement for staffing to be posted at the beginning of each shift.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure nasal cannula oxygen (O2) tubing was dated and/or covered when not in use, for one (1) of thirteen (13) sampled residents (Resident #10), and one unsampled resident (Resident A). In addition, the facility failed to ensure staff changed gloves and performed hand washing during the serving and distribution of food. The findings include: A review of the facility's policy "Guidelines for Administration of Oxygen (undated), revealed oxygen tubing was to be changed weekly and PRN (as needed). Further review revealed the tubing was to be labeled and dated when changed. Continued review revealed the policy did not address how tubing was to be stored when not in use. Interview with the Director of Nursing (DON), on 05/24/14 at 5:30 PM, revealed it was her expectation for O2 tubing to be changed immediately when or if it was found on the floor, or if were not properly dated and bagged. 1. Medical record review revealed the facility admitted the Resident #10 on 12/27/10 with [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED].#10 at two (2) liters per minute, as needed to keep the resident's oxygen saturation above ninety (90) percent. Review of the Care Plan revealed Resident #10 was at risk for altered breathing patterns relative to COPD. Medical record review revealed Resident A was admitted by the facility on 12/06/13 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 06/23/14, revealed the facility assessed the resident to be cognitively intact and interviewable. Review of the Physician order [REDACTED]. Review of the Care Plan revealed Resident A had altered breathing patterns related to CHF and became short of air at times. Observation during the initial tour of the facility, on 07/22/14 at 2:03 PM, revealed Resident #10's 02 tubing was lying across the resident's bed without being covered. Continued observation of the roommate, Resident A, revealed the 02 tubing was on the floor under the resident's wheelchair, was uncovered, and was not dated. Subsequent observation, on 07/22/14 at 5:35 PM, revealed Resident #10's O2 tubing remained across his/her bed and Resident A's O2 tubing remained on the floor under the wheelchair. Interview with Resident A, on 07/22/14 at 5:38 PM, revealed he/she used the oxygen at night. Continued interview revealed the resident could not say how long the 02 tubing had been on the floor. Interview with State Registered Nursing Assistant (SRNA) #1, on 07/22/14 at 5:40 PM, revealed she had not seen Resident A's 02 tubing on the floor. She stated she did not know tubing lying over the bed was a problem. She further stated she had been in-serviced on infection control practices. Continued interview revealed it would be a problem for the resident to use O2 tubing which was contaminated with germs. Interview with License Practical Nurse (LPN) #4, on 07/22/14 at 5:45 PM, reveled all SRNAs were in-serviced on infection control practices. He stated the SRNAs had been informed to change the tubing weekly, or report to the charge nurse. He further stated the Desk Nurse was responsible for making rounds and checking the residents' 02 settings and ensure the tubing was functional and dated. He stated the resident would be exposed to a potential problem with infection if the 02 tubing were not changed regularly. Interview with LPN #3, on 07/23/14 at 3:25 PM, reveled It was all of the nurses' responsibility to change, label and date 02 tubing. She stated O2 tubing should be bagged when not in use. She further stated a resident's system could already be weak, making it easier to contract an infection. Interview with The Director of Nursing (DON), on 07/23/14 at 3:35 PM, reveled it was her expectation for all staff to follow the facility's protocol for preventing infections. She stated in-services were provided on infection control for all staff, including the SRNAs. Interview with LPN #5, on 07/24/14 at 2:25 PM, revealed it was her responsibility to make rounds as part of her assignment. She stated as the desk nurse, she should have caught the oxygen tubing on the floor and across the resident's bed. Continued interview revealed if the potentially contaminated nasal cannula were placed back on the resident, it could increase the resident's risk of becoming infected. Subsequent interview with The DON, on 07/24/14 at 5:30 PM, revealed it was her expectation to reduce the risk for transmitting infections. She stated the tubing should have been changed and dated immediately once discovered on the floor. She further stated failure to do so placed the resident at risk for an infection. 2. Observation on the 300 Hall, on 07/23/14 at 12:39 PM, revealed Dietary Aide #2 arrived with an ice cream cart and proceeded to serve residents in their rooms. Further observation revealed the Dietary Aide work gloves while serving the ice cream; however, she was observed to rub her eye and push her glasses up with her gloved hand, and continued to the next resident's room without changing her gloves and washing her hands. Interview with Dietary Aide #2, on 07/23/14 at 12:45 PM, revealed she had received Infection Control training. She stated she should have removed her gloves, washed her hands and applied new gloves after she rubbed her eye and pushed her glasses up. Continued interview revealed the process should be repeated during the serving of food, every time a resident or surface was touched, or if the gloves became soiled. Further observation, on 07/23/14 at 12:55 PM, revealed Dietary Aide #2 washed her hands, applied new gloves and proceeded to the 200 Hall to serve ice cream. The Dietary Aide knocked on a resident's door, turned the doorknob and entered the room. When the Dietary Aide returned to the hall, she changed her gloves but did not wash or sanitize her hands. Interview with the Director of Food Service, on 07/24/14 at 5:20 PM, revealed all dietary staff were trained on hand sanitation upon hire, and quarterly via computer training. Review of in-service records with the Director of Food Service revealed Dietary Aide #2 had completed infection control in-services as they were offered, since being hired in 2007.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by failure to ensure the sanitizer level was at the appropriate level in the sanitizer buckets at food preparation (prep) areas. The findings include: Review of the facility's policy titled, "Dining Services", undated, revealed the first sanitizer bucket was to be prepared at 5:30 AM, then checked at 7:00 AM and 9:00 AM and every two (2) hours thereafter to ensure it met the appropriate disinfectant level of two hundred (200) parts per million. Observation during the tour of the kitchen, on 11/06/12 at 4:07 PM, revealed Dietary Aide #1 checked the sanitizer level in the sanitation bucket and the test strip did not change to the appropriate color to indicate the sanitizer was at an appropriate level. Interview with Dietary Aide #1 at the time of the check, revealed the acceptable level was two hundred (200) parts per million (ppm) or greater. Observation of the test strip revealed the sanitizer level was not within two hundred (200) parts per million (ppm) range. Interview, on 11/06/12 at 4:07 PM, with Dietary Aide #2 revealed he had changed the sanitizer bucket when he came in after lunch. Interview, on 11/06/12 at 5:12 PM, with the Dietary Manager revealed the sanitizer level in the sanitizer buckets was checked when filled at approximately 5:30 AM, then at 7:30 AM and 9:00 AM. She stated if the sanitizer level was not at the acceptable level of two hundred (200) parts per million then it was changed and checked again to ensure it was acceptable. Then the sanitizer buckets were checked again at 11:00 AM, 1:00 PM, 3:00 PM, and after dinner. She stated Dietary Aide #1 should have checked the sanitizer level in the sanitizer bucket at 3:00 PM and obviously had not done so as the sanitizer did not register on the test strip. She stated this could harm a resident in that it could cause a food borne illness.

Based on observation, interview, and review of facility's policy, it was determined the facility failed to store all drugs and biological in locked compartments and in accordance with current accepted professional principles. The findings include: Review of facility's policy, "Medication Storage in the Facility", revised 02/01/10, revealed medications and biological should be stored safely, securely, and properly. The procedure for storing potentially harmful substances, such as cleaning supplies, should be to stored in a locked area separately from medication. Observation on Legacy Lane (Memory Care Unit) of the facility, on 11/05/12 at 10:00 AM, revealed a container of Sani-Cloth Plus Germicidal Disposable Cloths sitting on top of the medication cart, next to a container of Sani Hands Gel Hand Wipes and bottle of hand sanitizer. Warning on top of Sani-Cloth Plus Germicidal Disposable Cloths stated not a skin wipe, to be used on hard surfaces. Staff was not present at the medication cart at that time. Interview with Registered Nurse (RN) #1, on 11/05/12 at 10:10 AM, revealed it was not necessary to have a container on top of the medication cart due to residents could come into contact with the germicidal cloths. Interview with Licensed Practicsal Nurse (LPN) #3, on 11/06/12 at 2:15 PM, on Legacy Lane revealed Sani-Cloth Plus Germicidal Disposable Cloths were used to sanitize the Glucometer to decrease possible spread of infection. When asked where the container of germicidal cloths was stored, LPN #3 unlocked the medication cart and opened the 3rd (third) drawer, revealing a container sitting directly next to liquid medications. Oral medications were also stored in this drawer. Interview with RN #2, Assistant Director of Nursing (ADON), on 11/06/12 at 2:55 PM, revealed Sani-Cloth Plus Germicidal Disposable Cloths were used to sanitize the Glucometer to decrease the possible spread of infection. When asked where the container of germicidal cloths was stored, the ADON unlocked and opened the drawer of the treatment cart, revealing a container with other medical supplies. The ADON stated the container of germicidal cloths should not be stored with medications. Interview with Director of Nursing (DON), on 11/06/12 at 3:00 PM, revealed Sani-Cloth Plus Germicidal Cloths were not to be stored on top of the medication cart. The DON stated germicidal cloths should be stored in the supply room, behind a locked door, or in the treatment cart with other medical supplies. The DON stated germicidal cloths should be stored away from consumables such as medications. When asked specifically aboutthe Legacy Lane medication cart, the DON stated the container of germicidal cloths should be stored in the bottom drawer of medication cart, away from medications.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to maintain an infection control program designed to provide a sanitary environment and to help prevent the development and transmission of disease and infection. Observation on 11/04/12 around 10:00 AM, revealed the Activity Director (AD) passing ice to the residents and leaving the ice scoop in the ice chest. Observation on 11/05/12, during the lunch meal on hall (200), revealed the domed plate cover lids fell out of the bottom of the tray delivery cart, onto the carpet, and staff pick the lids off the floor and put them back on the bottom of the cart with undelivered resident food trays still in the cart. The findings include: Review of the facility policy entitled "Infection Control- General Policy Statement", no date, revealed all employees were in serviced on the prevention and control of infections before being assigned to resident care, annually and as deemed necessary by the Infection Control Practitioner (ICP). Observation, on 11/04/12 at 10:00 AM, revealed the AD passing ice on the (200) hall to the residents and leaving the ice scoop in the ice chest. The Director of Nursing Services (DNS) was observing this writer observe the ice pass and stated that she (AD) didn't know to "not leave it in there". Interview with the AD, on 11/05/12 at 9:45 AM, revealed she was aware the ice scoop should not have been left in the ice chest. Further interview revealed she had infection control training but it had been awhile and she "just got distracted sometimes". Interviews with State Registered Nurse Aide (SRNA) #4 and #5, on 11/06/12 at 2:25 PM and 2:30 PM, revealed the ice scoop should be stored in the holder because it was an infection control issue to leave it in the ice. Both SRNAs stated they had infection control training on the computer and in-services yearly and as needed. Observation, on 11/05/12 at 12:20 PM, during the lunch meal on hall (200), revealed the domed plate cover lids fell out of the bottom of the tray delivery cart, onto the carpet, and staff pick the lids off the floor and put back on the bottom of the cart with undelivered resident food trays still in the cart. Interviews with SRNA #6, on 11/04/12 at 12:50 PM, and Licensed Practical Nurse (LPN) #2 at 12:55 PM, revealed the lids should not have been put back in the food cart with undelivered resident trays because it was an infection control issue. Interview with Kentucky Medication Aide (KMA) #5, on 11/04/12 at 1:00 PM, revealed it was an infection control issue for her to have put the contaminated lids back in the food cart with undelivered resident trays on it. Interview with the Staff Educator, on 11/06/12 at 2:35 PM, revealed all staff was given infection control training during orientation, yearly and as needed. The Staff Educator further stated both issues with the ice pass and the tray pass created infection control issues.

Based on observation, interview and review of the facility's policy it was determined the facility failed to prepare and distribute food in a sanitary manner. The facility failed to ensure staff changed gloves and washed hands between tasks and failed to ensure food was held at the proper temperature. The facility's failure had the potential to effect fifty-one (51) of fifty-one (51) residents in the facility. The findings include: Interview, on 11/03/11 at 11:39 AM, with the facility's Nurse Consultant revealed the facility did not have a policy on handwashing specific to the dietary department. 1. Observation of the tray line, during the noon meal on 11/01/11, revealed Cook #6 did not test the holding temperature of the gravy, beef patties, chipped turkey, chicken wings, french fries or hash browns. Interview, on 11/03/2011 at 11:29 AM, with Cook #6 revealed she did not test all the food on the steam table. She explained she had done that when the foods were taken from the cooker and did not retest them when she did the main meal items. Interview, on 11/03/11 at 11:14 AM, with the Dietary Manager revealed the facility tested holding temperatures for the regular foods, pureed foods and mechanically altered foods on the steam table. She stated the alternate foods were tested when they were removed from the cookers, and not after they were placed on the steam table. 2. Observation of Dietary Aide (DA) # 5, on 11/01/11 at 12:05 PM, revealed she plugged in the microwave with her gloved hands. Further observation revealed she proceeded to heat some bacon and finished cooking a grilled cheese sandwich. Continued observation revealed she prepared a bacon, lettuce and tomato sandwich and sliced the sandwich in half. Observation revealed DA #5 touched the bread with the gloved hand used to plug in the microwave. Continued observation revealed DA #5 passed the grilled cheese sandwich and bacon sandwich to the cook on the serving line. Further observation revealed DA #5 took the skillet, used to cook to the grilled cheese sandwich, to the dirty dish line. DA #5 was observed to proceed to the food preparation counter and begin cleaning the counter. Observation of DA #5 revealed while cleaning the food preparation table she received a bowl of soup from a staff member working in the dining room. Continued observation revealed she obtained blinder parts from the clean sink area, touched the inside of the blinder with gloved hands then pureed the bowl of potato soup and delivered it to the staff in the dining room. Continued observation revealed DA #5 did not change her gloves or wash her hands until all the above task were completed. During interview, on 11/01/11 at 12:18 PM, with DA #5 she stated "you got me, I didn't changes my glove on Tuesday (11/01/11) after plugging in the microwave". The DA explained gloves should be changed and hands washed between each task. 3. Observation, on 11/01/2011 between 12:15 PM and 12:21 PM, revealed Cook #6 transferred food from the kitchen steam table onto a cart and then onto the steam table in dining room. Observation revealed during the process of transferring the food to the dining room the cook touched the door with her gloved hand twice. Upon completion of the transfer of food, Cook #6 began serving food without changing her gloves or washing her hands. Interview, on 11/03/11 at 10:59 AM, with Cook #6 revealed she had touched the door when transferring food to the dining room on 11/01/11. In further interview Cook #6 stated gloves should be changed and hands washed anytime she left the kitchen and went back in. 4. Observation, 11/02/11 between 6:25 AM and 6:44 AM, revealed Cook #7 took a pan of sausage from the steamer using oven mitts. Continued observation revealed the cook removed the oven mitts and her hands were gloved. In further observation, Cook #7 placed sausage in the meat grinder and ground the sausage. The cook left sausage setting on the food preparation table uncovered and swept the floor by the preparation table. Observation revealed Cook #7 failed to change her gloves or wash her hands. Interview, on 11/03/11 at 10:59 AM, with Cook #7 revealed cooks should change gloves and wash hands after using oven mitts because they "get groddy" inside. 5. Observation of DA #5, on 11/03/2011 from 12:02 PM until 12:17 PM, revealed she took a container to the walk-in refrigerator and returned to the food preparation table. Further observation revealed DA #5 entered the walk-in refrigerator and returned with a tray of salads. The DA was observed to then obtain a tray of fruit cups from the walk-in refrigerator without changing gloves or washing her hands. Further observations during this time revealed DA #5 took coffee cups and serving trays to the dining room staff and took clean saucers to the cook on the serving line. DA #5 did not change gloves or wash her hands during this observation period. In interview, on 11/03/11 at 12:18 PM, with DA #5 revealed she did not touch food during the observation period on 11/03/11 and therefore did not change her gloves or wash her hands. Interview, on 11/03/2011 at 11:11 AM, with DA #9 revealed staff should wash hands and change gloves when they start work, when changing from one job to another, when going in and out of the kitchen, when going in and out of the walk-in refrigerator, and after using the oven mitts. Interview, on 11/03/2011 at 11:14 AM, with the Dietary Manager revealed staff was to wear gloves and wash hands when working with food, when they go outside of the kitchen and come back in, when they use the oven mitts and when they go from dirty to clean in non food tasks.

Based on interview and record review, it was determined the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being for one (1) of five (5) sampled residents, (Resident #1). The facility failed to assess Resident #1 after an episode of emesis and congestion was reported. The findings include: Review of Resident #1's medical record revealed the facility admitted Resident #1 the facility on 11/18/07 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 05/14/11, revealed the facility assessed Resident #1 as severely cognitively impaired. Interview with the Assistant Director of Nursing (ADON), on 08/08/11 at 2:00 PM, revealed Resident #1 would experience emesis sporadically as a result of his/her [DIAGNOSES REDACTED] of Esophagus. The ADON went on to reveal that when Resident #1's episodes of emesis began occurring more often, it was a strong indicator that Resident #1 needed a [MEDICATION NAME] injection to open up his/her esophogeal sphincter. An interview with Licensed Practical Nurse (LPN) #1, on 08/08/11 at 2:54 PM, revealed Resident #1 would have episodes of emesis on average 2 days a week, more frequently if needing a [MEDICATION NAME] treatment. Follow up interview, on 08/10/11 at 2:23 PM, revealed Resident #1's vomiting could be a one-time episode, and that vomiting twice in a day was not out of the ordinary. Review of nursing notes, dated 07/25/11, reveal at 1:00 PM staff reported to LPN #1 that Resident #1 had vomited during lunch. Review of the nursing notes revealed no evidence that Resident #1 was assessed at that time. An interview with LPN #1, on 08/08/11 at 2:54 PM, revealed she assessed Resident #1 on 07/25/11 after lunch, at which time Resident #1 was breathing fine and talking while at the nurses station. LPN #1 stated Resident #1 exhibited no signs or symptoms of distress at that time. An interview with Certified Nursing Assistant (CNA) #4, on 08/09/11 at 2:47 PM, who cared for Resident #1, revealed she told LPN #1 on 07/25/11 between 2:30 PM and 3:00 PM that Resident #1 had vomited again and was congested, while CNA #1 stayed with Resident #1 and cleaned him/her up. CNA #4 revealed the Advanced Registered Nurse Practitioner (ARNP) was at the nurses station as well. Further, CNA #1 revealed she spoke with the Assistant Director of Nursing (ADON) on the way back to Resident #1's room, informing her that Resident #1 had another episode of vomiting and was congested. CNA #4 went on to reveal the ADON instructed her to ensure Resident #1's head of bed was elevated. Further review of 07/25/11 nursing notes reveal at 2:45 PM staff reported to LPN #1 that Resident #1 had increasing emesis and possible congestion. Review of the notes revealed no evidence LPN #1 assessed Resident #1 following the report by staff. The nursing note went on to reveal Resident #1 was discovered by staff entering his/her room to prepare him/her to go to the dining room, at 3:35 PM, as having no signs of life. Staff informed LPN #1, who found Resident #1 to have no signs of life with cyanotic changes beginning to take place. Record review and interview revealed Resident #1 was a DNR. Interview with LPN #1, on 08/10/11 at 2:23 PM, revealed CNA #4 did not report Resident #1 as being in acute distress when she reported the emesis and congestion at 2:45 PM on 07/25/11. LPN #1 went on to state she had informed the ARNP of the situation, and the ARNP intended to see Resident #1 later that day. Continued interview with LPN #1 revealed Resident #1 had a history of [REDACTED]. In an interview with the Assistant Director of Nursing (ADON), on 08/08/11 at 2:00 PM, it was revealed that Resident #1 had a history of [REDACTED].#1's condition. Interview with the ADON, on 08/10/11 at 1:59 PM, revealed CNA #4 had also informed her that Resident #1 had an episode of emesis, but it was not presented in such a way to indicate Resident #1 was in any distress. The ADON stated she informed CNA #4 to make sure Resident #1' head of the bed was elevated. Interview with ARNP, on 08/10/11 at 1:03 PM, ARNP confirmed she was planning on seeing Resident #1 that evening before leaving the facility. The ARNP went on to reveal if she were in a nursing capacity, and was informed a resident experienced vomiting and congestion, she would check on the resident. Further interview revealed she was in the building and went to Resident #1 immediately upon a report of no signs of life. Further interview revealed the ARNP felt the cause of death was related to a heart condition because there were no signs of aspiration. Interview with LPN #2, on 08/10/11 at 10:00 AM, revealed she would assess a resident if staff informed her a resident had vomited again after vomiting previously. Review of Resident #1's Comprehensive Care Plan revealed no evidence the facility had developed a care plan for the assessment and interventions related to Resident #1's emesis, although this was mentioned by staff several times during the course of the investigation as normal behavior for Resident #1. Further interview with staff went on to consistently reveal Resident #1 had periodic [MEDICATION NAME] injections to act as a paralytic to keep his/her esophogeal sphincter functioning properly. Review of the Comprehensive Care Plan revealed no evidence these problems were addressed. Interview with CNA #7, on 08/10/11 at 12:56 PM, revealed she last saw Resident #1 just after 3:00 PM when she arrived for work, revealing that Resident #1's appearance and breathing appeared normal at that time. Interview with the Funeral Home Director, on 08/10/11 at 10:04 AM, revealed no evidence of aspiration during post-mortem care.