Every finding on record at Clinton-Hickman County Nursing Facility

Based on observation, interview, facility document and policy review, the facility failed to ensure sanitary conditions were maintained in the kitchen related to cleanliness and food storage. These deficient practices had the potential to affect all residents who received food from the facility kitchen. The findings included: A facility policy titled, Food Receiving and Storage, revised 07/2024, revealed, Foods shall be received and stored in a manner that complies with safe food handling practices. The policy also indicated, 6. Food in designated dry storage areas shall be kept off the floor (at least 18 inches) and clear of sprinkler heads, sewage / waste disposal pipes and vents. A facility policy titled, Sanitization, revised 10/2008, revealed, The food service area shall be maintained in a clean and sanitary manner. The policy indicated, 2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use or proper cleaning. The policy also indicated, 3. All equipment, food contact surfaces, and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and / or chemical sanitizing solutions. The policy indicated, 17. The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout the work areas during all tasks, and to clean after each task before proceeding to the next assignment. An observation of the kitchen with the Dietary Manager (DM) on 05/11/2026 at 8:50 AM revealed excessive buildup of old dried food debris underneath the steam table. Additional observations revealed excessive food spillage and debris inside drawers of the food preparation table, soiled parchment paper inside drawers, and food storage concerns including two 35-pound boxes of soybean salad oil stored directly on the floor in the dry storage room. Two black fans mounted above the dish machine were observed with excessive dust accumulation and blowing toward clean dishes stored underneath. Further observations revealed excessive dust accumulation on walls, ceiling vents, and ventilation systems located above food preparation areas, utensil storage areas, crates of dishes, and the food preparation table. During a concurrent interview, the DM described the observation of the food buildup on the steam table as crud from when staff had dropped food. The DM stated the area should be cleaned daily but acknowledged she did not know the last time it had been cleaned and estimated it had been a couple of months. The DM stated maintenance staff were responsible for cleaning the vents and confirmed it had been several months since they had been cleaned. The DM stated the fans were used to air dry the dishes. She stated she could see the dust on the fans. The DM stated that maintenance staff usually took the fans down and cleaned them. She stated it had been a couple of months since the fans had been taken down. During an interview on 05/14/2026 at 1:40 PM, Dietary Aid (DA) 2 stated she was not assigned items on the cleaning schedule. She stated she cleaned the bottom of the steam table but not as often as she should. During an interview on 05/14/2026 at 10:03 AM, the DM stated the kitchen cleaning checklist was not task-specific, and staff were not assigned routine cleaning duties. She stated that the drawers on the food preparation table were not on the cleaning schedule. The DM stated that the soybean salad oil should not be stored on the floor. She stated she did not check behind staff to ensure things on the cleaning checklist were completed. During an interview on 05/14/2026 at 11:27 AM, the Maintenance Director stated he removed the fans and dietary staff cleaned them. He acknowledged the fans were dusty and estimated they had last been cleaned approximately two months prior. During an interview on 05/14/2026 at 1:31 PM, the Registered Dietitian (RD) stated that dust accumulation had previously been noted on return air vents and stated those concerns had been communicated to the Dietary Manager and maintenance staff.During an interview on 05/14/2026 at 11:34 AM, the Director of Nursing (DON) stated that all food items should be stored off the floor. During an interview on 05/14/2026 at 10:39 AM, the Administrator stated that the DM was responsible for ensuring the cleaning schedule was followed and expectations were met. She stated she went into the kitchen for audits and did not notice the dust. The Administrator stated that the fans and vents should have been cleaned, and boxes should not have been stored on the floor.

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. Food items were not dated at the time of storage. Food that had been opened were not covered and/or sealed to prevent contamination. The deficiency had the potential to affect 32 of the facility's 32 residents who consumed food from the kitchen. The findings include: Review of the facility's revised policy titled, Food Safety Requirements, dated 04/01/2025, revealed food would be stored according to professional standards for food service safety. Continued review revealed food would be stored in a manner that helps to prevent deterioration and contamination, including from growth of microorganisms. Additonally, labeling, dating, and monitoring refrigerated food, including but not limited to, leftovers, so it would be used by the use-by date, and keeping foods covered or in tight containers was required. a. Observation of Freezer1, on 06/17/2025 at 10:45 AM, revealed cheddar cheese omelets, okra, corn, bread sticks, all in their original box/containers with unsealed flaps were undated, and the internal plastic bag was not covering the food items exposing them to potential contamination. Continued observation revealed one plastic bag of broccoli opened, uncovered and was not dated. b. Further observation of the dry pantry storage revealed a large bag of cereal that was opened, removed from the original container, and placed into a storage bag but was undated. Continued observation revealed a large bag of macaroni opened, and undated. c. Additional observation of the bread cart, revealed one opened and undated loaf of gluten-free bread not covered to prevent potential contamination. In an interview with Cook1, on 06/17/2025 at 11:15 AM, she stated she had worked there for 6 months. She stated she was aware that food items should be stored properly which included dating, labeling, and ensuring the foods were covered. She stated she had been trained and was aware that all dietary staff were responsible to ensure residents were not served contaminated foods. She further stated that the facility's policy and procedures should be followed regarding food safety. She stated if staff had not followed those guidelines there was always the potential for residents to become sick. In an interview with Dietary Aide1, on 06/18/2025 at 12:18 PM, she stated when food items were received from the delivery truck, she had verified the order and ensured the old supply was rotated and the new was dated when it had been received and stored. She stated if anything was opened for use it was to be labeled and dated, and covered before storing on pantry shelves, refrigerator and/or freezer. She stated all staff were responsible to securely cover and store the remaining food items in the freezer or refrigerator after opening the food boxes/containers which included labeling and dating the items to ensure they were not used after the expiration date. Additionally, she stated she had taken care of this herself, but all staff were supposed to check to make sure it had been done. In an interview with the Dietary Manager (DM), on 06/17/2025 at 11:15 AM, she stated she had a good team in the kitchen but understood that some food items had not been covered, labeled, and dated. She stated there would be a reeducation of the importance of food safety. She stated her expectations were that all dietary staff would use their knowledge and training and follow the facility's food safety policy to ensure residents were being served good food. During an interview with the Administrator, on 06/18/25 at 2:45 PM, she stated her expectations for the dietary staff was to follow food safety guidelines when storing food products ensuring they were dated, labeled, and covered. She further stated those policies were in place to ensure resident safety from foodborne illnesses, but also to provide the residents with foods that the wanted to eat.

AMENDED Based on observation, interview, record review, and review of the facility's documents and policy, it was determined the facility failed to ensure the residents' environment remained as free of accident hazards as possible for thirty-five (35) of thirty-five (35) sampled residents (Residents [R] 30, 18, 31, 2, 11, 1, 3, 10, 139, 32, 8, 15, 35, 36, 34 19, 26, 27, 25, 14, 33, 12, 5, 20, 9, 29, 4, 23, 28, 21, 6, 7, 13, 22, and 17. Review of the facility's policy revealed water heaters servicing residents' rooms, and bathrooms were to be set to temperatures (temps) of no more than 110 Fahrenheit (F) or the maximum allowable temp per state regulation. However, observation of water temp checks on 04/23/2024, in twenty-three (23) rooms, where residents resided, revealed the water temps ranged between 118 degrees F and 123 degrees F, which was not within the acceptable parameters for ensuring resident safety. The findings include: Review of the facility policy titled, Water Temperatures, Safety of, dated 12/2009, revealed tap water in the facility was to be kept within a temperature range to prevent scalding of residents. Per policy review, water heaters that serviced residents' rooms, bathrooms, common areas, and tub/shower areas were to be set to temperatures of no more than 110 F or the maximum allowable temperature per state regulation. Continued review revealed maintenance staff were responsible for conducting periodic tap water temperature checks and recording the water temperatures on a safety log. Review of the Admission Record revealed the facility admitted R1 on 12/14/2022, with diagnoses to include: unspecified atrial fibrillation, unspecified heart failure and left lower extremity cellulitis. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed R1 to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. In an interview with R1 on 04/23/2024 at 12:38 PM, while the State Survey Agency (SSA) Surveyor was checking water temps, she stated, the water is burning hot. It will burn you if you let it run a few minutes. Observation of the temperature of hot water in R1's sink revealed the temp was 121.5 degrees F. Observation of water temperature checks on 04/23/2024, beginning at 12:00 PM, revealed the water temps in resident Rooms 201, 202, 203, 204, 205, 206, 207, 208, 209, 210, 211, 212, 213, 214, 215, 216, 217, 218, 219, 220, 221, 222, and 223 ranged between 118 degrees F and 123 degrees F, which was not within the facility's acceptable parameters of 110 degrees F. Review of the facility's water temp logs, provided by the Maintenance Director, revealed the log was a notebook with two (2) random room water temp checks completed per month. Further review revealed the recorded temp readings were recorded at 107 degrees F, for all checks noted. In an interview on 04/24/2023 at 9:10 AM, the Maintenance Director stated water temps were checked monthly in two (2) random resident rooms, and he stated he normally used a digital thermometer. He stated however, the digital thermometer needed a battery and he had started using a hand-held thermometer with a dial gauge. The Maintenance Director stated no calibration was needed for the digital thermometer. He stated last week the water heater needed repairing as it was not working, and a plumber came to the facility and released a valve and the heater worked fine after that. The Maintenance Director stated he had a call out to the plumbing agency and was waiting for a return call related to the high water temps. He stated he had checked the water heater that morning and the water temperature was good. The Maintenance Director further stated the contract plumbing company the facility used was located in another town approximately 30 minutes away. During an interview on 04/25/2024 at 4:12 PM, the Administrator stated she was not aware of any further issues with hot water heater since it had been repaired the previous week. She stated someone would be at the facility next week to inspect the hot water heater. The Administrator stated a potential outcome of hot water temps being too high would be a resident could get burned. She further stated the water temps were checked periodically and she agreed that checking two (2) rooms a month was not enough to ensure the water temps were in a safe range.

Based on observation, interview, record review and review of the facility policy, it was determined the facility failed to develop and implement a baseline care plan for residents that included instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care. Per the facility's policy, the baseline care plan was to be developed within 48 hours of a resident's admission. However, during review of Resident (R) 32's medical record, it was determined the facility failed to develop a baseline care plan for the residents, and reactivated his/her comprehensive care plan from a previous admission without updating or revising the care plan. The findings include: Review of the facility policy titled, Care Plans, Baseline, dated 12/ 2016, revealed a baseline plan of care to meet a resident's immediate needs was to be developed for each resident within 48 hours of admission to the facility. Review further revealed the baseline care plan was to be used until staff could conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan. Review of the Admission Record for R32 revealed the facility admitted the resident on 04/08/2024, with the following diagnoses; acute respiratory failure with hypoxia, chronic obstructive pulmonary disease with acute exacerbation and personal history of urinary tract infection (UTI). Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed R32 to have a Brief Interview for Mental Status (BIMS) score of 14 out of 14, indicating she was cognitively intact. Continued review of R32's record revealed the resident had a previous admission to the facility on [DATE] and had been discharged home on 05/01/2023. During an interview on 04/22/2024 at 11:22 AM, R32 stated she had been at the facility for a couple of weeks. She stated she lived alone at home and had sustained a fall during which she broke her wrist. She stated she got UTIs frequently, and at the time of the fall at home she had a UTI and had been dizzy. Further review of R32's record revealed no documented evidence of a Baseline Care Plan developed upon his/her admission on 04/08/2024. Record review revealed a Baseline Care Plan dated 03/17/2023, which noted R32 was at risk for elopement and wandering, with an intervention in place for the resident to have a wander alert bracelet to her left ankle. Observation on 04/23/2024 at 09:18 AM revealed R32 had no wander alert bracelet on her left ankle. Continued review of the Baseline Care Plan dated 03/17/2023, revealed the facility had not assessed R32 as at risk for elopement. Per review of the 03/17/2023 Baseline Care Plan, the facility noted R32 had the potential for pain related to a stage three (3) pressure injury; however, record review revealed that was not a current problem for the resident. Further review of R32's record revealed the facility documented R32 had a fractured wrist and a history of recurrent urinary tract infections (UTIs); however, review of the resident's care plan revealed the facility failed to include those problems on the care plan with interventions necessary. During an interview with State Registered Nurse Aide (SRNA) 5 on 04/25/2024 at 1:30 PM, she stated changes occurring in residents were on the Kardex (nurse aide care plan) in the facility's Point Click Care (PCC) electronic health record. She stated she received report from the previous shift SRNAs and the nurse on shift. SRNA5 stated she provided care for R32 and the resident was not at risk for elopement, nor did she currently have a pressure injury. She further stated however, she could not recall if those things were documented on the Kardex or not. In an interview with SRNA4 on 04/25/2024 at 1:36 PM, she stated she reviewed the Kardex for her assigned residents' information and for any changes. She stated the nurses also gave the SRNAs report. The SRNA further stated R32 was not on the board as being at risk for elopement. In an interview with Registered Nurse (RN)1 on 04/26/2024 at 1:44 PM, she stated the Baseline Care Plan was initiated on admission, and new interventions were posted at the nurses' station and provided to the aides as education. She stated she saw updates on residents on the dashboard in PCC. RN1 stated if a resident had a chronic UTI or a current UTI the resident should have a care plan for infection to address that problem. She further stated a new care plan should have been initiated for R32, as the resident had been discharged almost a year. During an interview with RN2 on 04/26/2024 at 1:55 PM, she stated Baseline Care Plans were initiated on admission by the admitting nurse. She stated a resident's care plan should be revised when changes occurred or when the resident was readmitted from the hospital if changes were needed. RN2 stated R32 should have had a new care plan initiated when she was admitted currently. During an interview with the Director of Nursing (DON)/MDS Nurse on 04/26/2024 at 3:26 PM, she stated she had been completing residents' MDS Assessments since August 2023. She stated she was still learning the MDS and care plans. The DON/MDS Nurse stated she had been really struggling trying to review new admissions to get them an accurate Baseline and Comprehensive Care Plan in place. She stated new admits were discussed in the Medicare meeting however, which occurred daily. The DON/MDS Nurse stated she reactivated R32's care plan from her previous admission even though the resident had been discharged for almost a year. She stated she did not know she was not aware she could not do that. The DON/MDS Nurse stated she also failed to update R32's care plan when the resident was admitted to the facility again on 04/08/2024. She stated R32 did have a care plan for UTI/Infection as she had a history of chronic UTIs and received an antibiotic prophylactically. (However, review of R32's care plan revealed a care plan for potential for pain related to UTIs dated 01/27/2023, with no other documentation of UTIs or infections). The DON/MDS Nurse stated she did not believe there would be any negative outcomes for not revising a resident's plan of care. During an interview with the Administrator on 04/25/2024 at 4:12 PM, she stated R32's care plan should not have been reactivated from 03/13/2023, as the resident was not the same as she was when she had been a resident at the facility previously. She stated R32 had been discharged for almost a year, and a new Baseline Care Plan should have been initiated on her current admission. The Administrator stated R32 had not had any negative outcomes related to the care plan not having been developed for the resident's current admission diagnoses.

Based on observation, interview, record review, and review of the Centers for Medicare and Medicaid (CDC) practices and facility's policy, it was determined the facility failed to implement the use of appropriate Personnel Protective Equipment (PPE) for three (3) of eight (8) sampled residents (Resident #3, Residents #6, and Resident #8), who were newly admitted or readmitted residents to the facility. The findings include: Review of the 11/04/2020 Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic; from CDC home website revealed the recommended infection prevention and control (IPC) practices, for a patient that was admitted with suspected or confirmed COVID included; place the patient in a single room with door closed. Personnel entering the room should use PPE. PPE recommended when caring for a patient with suspected or confirmed COVID-19 includes the following: Respirator or Facemask (N95 respirator, Disposable respirators and facemasks), goggles or a face shield. Protective eyewear (e.g., safety glasses, trauma glasses), gloves, and gowns. Review of the facility's policy titled, Cohorting Residents and Isolation for COVID 19,, last revised 10/05/2020 revealed residents who were a new admission, who were asymptomatic and COVID 19 negative, and readmissions would be admitted to the yellow zone if there were positive cases in the facility, The yellow zone was for new admissions who were asymptomatic and COVID 19 negative. However, further review revealed the policy did not address when there was no positive cases in the facility, when there was no longer a yellow zone, what isolation precautions the resident would be placed on, and what PPE needed to be worn by staff. Interview with the Regional State Infection Control Nurse (RIFCN) for Region 10 (Western Kentucky{KY}) of the Commonwealth, on 11/16/2020 at 9:28 AM, revealed the following guidance (cohorting of residents dated 08/26/2020) from the Department of Public Health (DPH) was sent via e-mail to the facility's IFCN on 10/13/2020 related to admissions and readmissions. Review of YELLOW ZONE guidance for admission and readmission of residents: provided via email by RIFCN, on 11/16/2020 at 9:28 AM, revealed if asymptomatic, COVID-19 negative residents with known or potential exposure (new admissions, Residents returning from the hospital, Residents who frequently travel outside of the facility {(i.e. [MEDICAL TREATMENT] appointments}, and roommates of COVID-19 positive residents, should be located in a unit near an entrance/exit with clearly defined unit borders (i.e. fire doors or plastic barriers) and be an area with dedicated equipment. The staffing should be dedicated nursing and environmental staff and have no resident or staff contact with the Red or Green zones. The Personal Protective Equipment (PPE) required in providing care of the above resident would be full PPE (eye protection {face shield or goggles}, gown, gloves, and mask {surgical mask for aerosol-generating procedures, N95 should be used if available and staff are fit tested }. Residents should be moved to a green zone when at the end of (14) fourteen days, if asymptomatic. Green zone was defined as asymptomatic residents/COVID-19 negative residents with no known or potential exposure and care provided under normal operations consistent with current long-term care guidelines. Observation on 11/10/20 at 11:10 AM, revealed documentation at the entrance of the facility stated AS OF 11/02/2020, 2 POSITIVE EMPLOYEES. Review of the admission of residents' list provided by the facility revealed, Resident #3 was admitted on [DATE], Resident #8 was admitted on [DATE] and Resident #6 was readmitted to the facility on [DATE]. However, observation on 11/10/2020 at approximately 11:50 AM during tour of the facility, revealed Resident #3 in the doorway of the room. There was no PPE storage (gown, gloves, mask, face-shields) outside Resident #3's room or on the door. Further observation revealed there were no resident rooms, including Resident #6 or Resident #8 in the facility with signage on the door that indicated the residents were on any precautions, or of any storage of PPE at the entrance to the residents' rooms or on the doors. In addition, the facility did not have a COVID unit or an identified yellow zone. Interviews on 11/11/2020, with Licensed Practical Nurse (LPN) #3, at 1:07 AM; 11/13/2020 with Certified Medication Aide (CMA) #1, at 7:57 AM; CMA #2 at 8:18 AM; and, Licensed Practical Nurse #1 at 8:34 AM, revealed there were no residents on isolation precautions at this time. Interview with LPN #2, on 11/14/2020 at 8:57 AM, revealed there were no residents on isolation precautions at that time. She stated the last time any residents were on isolation was when they had the COVID unit. LPN #2 stated new admissions were required to be placed in isolation for 14 days and staff were to wear gloves, mask, and N95 with a mask face shield. She stated all new admits were supposed to be cared for as if they have COVID. She stated she cared for Resident #3 (who was a new admission) and he/she was not on isolation. Interview with Registered Nurse (RN) #2, on 11/15/2020 at 10:40 AM, revealed there were no residents on isolation precautions at that time. She stated the facility was not screening (testing the residents at the facility) at this time because they did not have a COVID unit. Further interview revealed when the facility had the COVID Unit, residents were placed on isolation for fourteen (14) days when they came out of the hospital. RN #2 stated if the resident had no signs or symptoms of COVID, they would no longer be on isolation precautions. Interview with RN #3, on 11/12/2020 at 2:30 PM, revealed that new admission were on droplet isolation for 14 days, but there were no new admissions. She stated she had worn only a facemask, N95 mask, and gloves when assessing Resident #3. Interview with RN #1, on 11/13/2020 at 8:39 AM, revealed when they had new admissions, the residents were placed on droplet precautions for fourteen (14) days. She stated there were no residents on isolation and it had been two to three (2-3) weeks since anyone on isolation. RN #1 stated staff wore gowns, gloves, N95 with facemasks and shields. However, she stated there were no new admissions at this time. She stated she had obtained Resident #3's vital signs and assessed his/her incision with gloves, facemask and N95 in place, but she had not worn a face shield, gown or booties while assessing the resident. Interview with facility's Infection Control Nurse (IFCN), on 11/12/2020 at 3:34 PM, revealed new admissions were isolated in their room, for seven (7) days and staff had to wear a N95 and paper mask, but they did not need to wear a gown. She stated they were not testing new admits or readmits unless symptomatic. She stated it was in the facility's admission and readmission policy for COVID; however, review of the policy revealed it did not contain this information. The IFCN stated that residents were not placed on isolation precautions, but they placed an isolation bag on the door so there were gowns and gloves on the door. When interviewed related to the reason the isolation bag was placed on the door since the IFCN stated residents were not on isolation precautions, the IFCN did not answer. She stated that when residents were first admitted or readmitted , they were put in a room by themselves for seven to fourteen (7-14) days. Interview with facility's IFCN and Director of Nursing (DON), on 11/16/2020 at 11:16 AM, revealed the COVID unit was broken down 11/02/2020 and the facility did not have zones anymore. Review of email dated 11/11/2020 from facility IFCN to RIFCN revealed the following information: that the facility had no new cases in the facility at this time Further interview with DON on 11/16/2020 at 11:40 AM and 3:19 PM, revealed when asked about isolation precautions for newly admitted and readmitted residents, she stated that she could not say exactly, but if the residents were asymptomatic they were isolated for ten (10) days. If they were symptomatic, they were isolated for fourteen (14) days, and if someone was severely immunosuppressed, that would be a different time. She stated staff do not have to be in full PPE when providing care to these residents, but staff use masks and gloves. The DON stated the facility did not have any residents with signs and symptoms of COVID or in isolation. Interview with Administrator on 11/12/2020 at 11:25 AM, and on 11/16/2020 at 3:19 PM, revealed the facility no longer had a dedicated COVID unit, She stated the facility worked with the local health department, and they did not do anything without public health and Medical Director, stating that was their guidance. Interview on 11/16/2020 at 8:39 AM, with Regional Epidemiologist (RE) revealed she assumed the facility followed CMS guidance. The RE stated she did not think that the facility really knew what they were supposed to be doing. Her understanding was the county was red and the facility was supposed to test residents weekly, if in the critical incidence rate. She stated she had not been asked by facility for guidance related to testing of residents/or of frequency, and she had spoken with the facility IFCN. When asked about admissions or readmissions RE stated she had not given any guidance for new admissions to them specifically, and to her knowledge they have not asked. RE stated quarantine meant if employees provided care to a resident in quarantine, staff were to wear full PPE which was mask, gown and gloves and signage should be placed on the resident's door. In addition, eye protection which was either goggles or a shield if they have available. RE stated she did not recall a time when the facility has asked her about this and if they had she usually referred facilities to the CDC for guidance.

Based on observation, interview, record review, and facility policy review and the Kentucky Department of Public Health (KDPH) site map , it was determined the facility failed to ensure testing of residents in a timely manner related to COVID-19 pandemic positivity rates within the region. The findings include: Observation on 11/10/20 at 11:10 AM, revealed documentation at the entrance of the facility stated AS OF 11/02/2020, 2 POSITIVE EMPLOYEES. Review of the Kentucky Department of Public Health (KDPH) site Kentucky Map, dated 11/09/2020 revealed Hickman County was shaded red which indicated all staff and residents in Long Term Care facilities needed to be tested for COVID 19 twice a week. Interview with the Administrator, on 11/16/2020 at 3:19 PM, revealed the county was shaded orange prior to that. Further review of the map revealed orange indicated all residents and staff should be tested weekly. Review of email written documentation provided by the Administrator on 11/13/2020, revealed the last COVID testing of residents was on 10/30/2020. However, prior to 11/09/2020, staff and residents were supposed to be tested weekly, after 11/09/2020, resident were supposed to be tested two (2) times weekly; per the Kentucky Map at the KDPH site. Further review of the email documentation revealed resident testing information, dated 11/02/2020, stated residents would be screened daily for signs/symptoms of COVID, and would be rapid tested if there were signs/symptoms (s/sxs), then followed by a lab test for confirmation. After a positive rapid test, the resident would be placed on droplet precautions until confirmed, and if confirmed, the protocol would be followed, per policy. Interview on 11/12/2020 at 3:34 PM, with the facility's Infection Control Nurse (IFCN), revealed the facility was not testing residents and was advised by the Medical Director that unless the resident was having s/sx, they were not supposed to test residents. She stated the facility was following the Centers for Disease Control (CDC) guidelines. She further stated she did not remember the last day a resident was tested . Interview with the Regional IFCN (Infection Control Nurse) for Region 10 (Western Kentucky (KY)) of the Commonwealth, on 11/16/2020 at 9:28 AM, revealed she had been in contact with the facility's IFCN and Director of Nursing (DON) via email offering guidance. She stated she had recommended a teleconference with the Department of Public Health to provide information because the facility seemed to be struggling. The Regional IFCN stated she had informed the facility that the meeting was non-regulatory and was a way to help facilities fight COVID. Further interview revealed that she had reached out several times and informed the facility of her available schedule for a conference-call with the HAI-AR (Healthcare Associated Infection/Antimicrobial Resistance Prevention Program) team since the facility's numbers of positivity were going up. She stated the teleconference would have included information on testing frequency. She further stated the facility's IFCN responded on 11/11/2020 that they appreciated the offer, but they were working with the LHD (locate health department). Further interview with facility IFCN and DON, on 11/16/2020 at 11:16 AM, revealed the last testing of residents was in October 2020. Interview with Local Health Department (LHD) Epidemiologist, on 11/16/2020 at 8:29 AM, revealed she had been in contact with the facility and that she assumed they were looking at CMS guidance for testing as the LHD was only in a guiding advisory role. She stated it was her understanding that residents were supposed to be tested weekly if in the critical incidence rate. Further interview revealed the facility called weekly and she spoke with the IFCN related to testing, but not on the frequency of testing. She stated the facility had not asked her about frequency for testing of the residents or staff. She revealed she spoke with the facility on 11/13/2020; and was told they were not going to test the whole facility, but they did not say why. Interview with Medical Director, on 11/16/2020 at 10:16 AM, revealed the facility had routine meetings to ensure the facility was following the guidelines from the LHD and CMS. He stated it was the responsibility of the DON, IFCN, Administrator and himself to follow the guidelines. The Medical Director further stated that due to the recent increase in local numbers he did think testing needed to be more frequent at this point. He further stated he was not aware of any conference call offered by the Department of Public Health to provide guidance and he would have been more than happy to participate. Interview with Administrator, on 11/12/2020 at 3:05 PM; and, on 11/16/2020 at 2:00 PM and 3:19 PM, revealed she did not think the facility had tested any resident in the last two (2) weeks. The Administrator stated she utilized CDC/CMS/ LHD/KYDPH/ and Medical Director as references. She stated she had just heard of the regional IFCN emails that morning (11/16/2020); and, of the offer for the meeting but it was not regulatory, and she had not known of it until that morning. Further interview with the Administrator revealed that testing of the residents made them anxious. She revealed she discussed this with the Medical Director; and he stated if residents tested negative for COVID, there was no need to test any further unless they were symptomatic. She stated that everything was done with the guidance from LHD and Medical Director. The Administrator stated the county was orange and the LHD confirmed it was orange. She revealed the dynamics had changed and all residents were tested today and would be tested twice weekly. She stated she had seen the rate at 10:30 PM, on Friday night (11/13/2020) on the COVID 19 site, but the county had been orange since 11/02/2020. She revealed the facility made the decision this morning (11/16/2020) with the Medical Director to start testing the residents.

Based on interview, record review, facility investigation review, and facility policy review, it was determined the facility failed to take action to prevent further abuse while the investigation process was completed for one (1) of three (3) sampled residents (Resident #1) . On 05/07/2020, Resident #1 reported to two (2) staff members that he/she was abused by Certified Nurse Aide (CNA) #1. The two staff members failed to protect the residents when they left the alleged perpetrator providing care to residents while they each reported the allegation. The findings include: Review of facility policy titled, Abuse Prevention Program, dated March 2017 revealed residents have the right to be free from abuse-this includes but is not limited to, freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical abuse. As part of the abuse prevention program the administration will protect the resident from anyone, facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individuals. Review of facility policy titled, Abuse Reporting and Prevention. last revised March 2017, revealed the Administrator will ensure that any further potential abuse is prevented. Record review revealed the facility admitted Resident #1 on 01/29/2020 with [DIAGNOSES REDACTED]. Review of abuse allegation investigation for Resident #1 dated 05/07/2020 revealed Resident #1 alleged Certified Nursing Assistant (CNA) #1 hit his/her arm and pushed him/her on to bed. Statements were obtained from the Physical Therapy Assistant/Regional Manager (PTA/RM), Social Services Director (SSD), Unit Manager (UM), and Licensed Practical Nurse (LPN) #1. The facility determined the allegation was unsubstantiated. Further review of the investigation revealed there was no documented evidence the facility identified PTA/RM and LPN #1 failed to protect residents when they left CNA #1 providing care to residents while each of them reported the allegation. Resident #1 was unavailable for interview due to being transferred to a geriatric behavioral health facility on 05/11/2020. Interview with CNA #1 on 05/14/2020 at 12:01 PM revealed she went into Resident #1's room and the resident stated that roommate (sibling) was dying and needed to call family. CNA #1 stated Resident #1 then became irate, and yelled and threatened her. CNA #1 revealed she informed Resident #1 that she was just changing roommate, and it would not take long. CNA #1 said Resident #1 then went in the hall and shortly after that LPN #1 came into room stating that Resident #1 had told PTA/RM that CNA #1 had hit the resident and pushed resident down. The CNA stated LPN #1 then talked with Resident #1 and kept resident at bay while CNA #1 was changing the roommate. Resident #1 told the nurse that she had pushed her down. CNA #1 revealed she then left the room and went and changed another resident and was trying to finish rounds when LPN #1 came to her a few minutes later and told her, she had to clock out and leave. CNA #1 stated she clocked out at 2:22 PM, but did not know what time she had went into Resident #1's room. CNA #1 revealed she was educated by the facility that when an abuse allegation is made, then staff should immediately remove the resident out of harms way. Interview with PTA/RM on 05/14/2020 at 1:02 PM revealed she was obtaining a wheelchair from the storage unit across from Resident #1's room when she heard a loud conversation from behind the closed door of Resident #1's room. PTA/RM stated Resident #1 opened the door, walked out into hallway, and told her to get CNA #1 out of room or wanted the CNA out of the room. PTA/RM revealed she asked the resident what was wrong and explained to the resident that CNA #1 was providing care. Resident #1 stated he/she did not care, that CNA #1 had pushed him/her down on bed and hit him/her. PTA/RM stated she told the resident to let her go see what she could do and the resident stated okay and went back into room. PTA/ RM revealed she went to LPN #1 and told her about the resident's allegation. PTA/RM said she told LPN #1 that she may want to check in the room because CNA #1 was still in the room with the resident. PTA/RM further revealed she had been educated to remove a resident from the alleged abuse situation immediately. Interview with LPN #1, on 05/14/2020 at 12:30 PM and 4:05 PM, revealed she was told by PTA/RM that there were loud voices coming from Resident #1's room and she needed to go see what was going on. LPN #1 stated that PTA/RM told her that Resident#1 had stated he/she had been hit on the arm and pushed on the bed, by CNA #1. LPN #1 revealed she entered the room and Resident #1 was to the right of CNA #1, and the resident stated he/she was going to slap CNA #1 if she did not get out of the room. LPN #1 stated she had the resident step to the side of the room and CNA #1 continued providing care to Resident #1's roommate and then stepped from the room. Resident #1 then told LPN #1 that CNA #1 hit and pushed him/her on to the bed. LPN #1 revealed she looked at Resident #1's skin and found no abrasions, marks and no signs of scuffle or anything. LPN #1 stated she then went to report the allegation to DON and then sent CNA #1 home immediately. LPN #1 stated she went to find CNA #1; and CNA #1 was coming out of the kitchen pushing a linen cart down the hallway. LPN #1 revealed she did not know where CNA #1 was before being found coming out of the kitchen. LPN #1 stated there was a few minutes before she got the DON out of a meeting to tell of the allegation. LPN #1 revealed she had been educated if an allegation of abuse occurred they are to automatically remove the resident from harm, and report to abuse coordinator (Administrator), and if she was not there, report to DON. LPN #1 stated she felt she had ensured the safety of Resident #1 immediately. Interview with the SSD on 05/14/2020 at 10:13 AM, revealed when an allegation of abuse is reported, the staff is to tell the immediate supervisor, and if alleged perpetrator is a staff member, he/she should be removed from care and sent home immediately to ensure the safety of all residents. Interview with the Director of Nursing (DON) on 05/14/2020 at 1:53 PM and 3:44 PM, revealed when an allegation is received it is to be reported immediately. The DON stated if the alleged perpetrator is a staff member, then he/she should be sent home immediately. She revealed when staff are educated on abuse, they are told to make resident safe and notify the administrator immediately. The DON stated she felt that the residents were protected as the allegation was reported and CNA #1 was sent home. Interview with the Administrator on 05/14/2020 at 4:51 PM revealed she did not realize the resident or CNA #1 was not with LPN #1 when she reported the allegation. The Administrator stated she agreed that CNA #1 should have been with the nurse when she reported the allegation; and the PTA/RM should not have left CNA #1 with the residents.

Based on observation, interview, and facility policy review, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Observation and interview revealed most staff enter the building through the facility's lower level patio entrance at the back of the building to clock in for work, then go up to the second level of the facility to the Nurses Station to be screened for signs/symptoms of COVID-19. Further observation revealed the Nurse's Station where staff were screened was in the middle of the hallway where resident rooms were located and not at an entrance to facility. The findings include: Review of the facility policy titled, Infection Control Measures during Pandemic Influenza/[MEDICAL CONDITION], last revised April 2011, revealed to screen all employees for influenza-like illness before coming on duty. Train staff to verbally and visually screen visitors at facility entry points for pandemic illness. Observation and interview with the Administrator on 05/06/2020 at 4:30 PM, revealed there were two (2) entrances to the facility during the COVID-19 pandemic: one (1) at the upper level front entrance, and one (1) at the lower level patio entrance. Observation of the upper level of the facility's front entrance revealed, once a person was in the lobby of the facility, where he or she was screened, there was a locked door with a coded keypad, and only facility staff knew the code. Further observation and interview with the Administrator on 05/06/2020 at 4:30 PM revealed the facility's lower level patio entrance at the back of the building was used by most of the staff to clock in for work. Once clocked in, the staff would go by stairway or elevator to the facility's second level to the Nurses Station, in order to be screened for signs/symptoms of COVID-19. If staff went up by elevator, the elevator door opened to an area where residents normally used to watch television or have activities, etc., and staff have to walk by resident rooms to get to the Nurses Station. If staff go up the stairs, the door opened directly at the Nurse Station, but they were still in a resident care area before being screened. All residents' rooms were on the second level of the facility, and the Nurses Station was in the middle of the hallway in the resident care area, where employee screening took place. Phone interviews on 05/07/2020 with Certified Nurse Aide (CNA) #1 at 3:31 PM, Licensed Practical Nurse (LPN) #1 at 3:48 PM, and Medication Technician (MT) #1 at 5:18 PM, revealed they entered the facility on the lower level at the patio door, wearing their masks; however, they were not screened until they were in the resident care area, near the Nurses Station. Phone interview with the Social Services Director (SSD), on 05/07/2020 at 3:12 PM, revealed she had used both entrances to the facility at different times. She revealed if she entered at the front entrance of the facility, she was screened in the front lobby; if she entered at the patio entrance on the lower level, she was screened at the Nurses Station on the upper level, in the resident care area. Phone interview with the Infection Control (IC) Nurse, on 05/07/2020 at 4:42 PM, revealed she voiced understanding that staff were not being screened upon entrance at the patio door downstairs, before coming to the upper level at the Nurses Station, in the middle of the resident care area. She stated we should probably have someone at the patio door to screen. Phone interviews on 05/07/2020 with Maintenance at 2:47 PM, and the Dietary Manager (DM) at 2:59 PM, revealed no visitors were allowed in the building at this time, except vendors, who were screened downstairs before coming through the door, and they never went upstairs. Further interview with the Dietary Manager revealed Dietary staff never went in the resident care area, and she screened her staff downstairs in the kitchen area. Phone interview with the Director of Nursing (DON), on 05/07/2020 at 2:30 PM, revealed staff hand sanitize at the time clock on the lower level, use Windex on the time clock, and clock in, sanitize again, and come up the stairs or elevator to the Nurses Station for screening. Sometimes they can get screened by Dietary, who's on the lower level of the facility. Interview with the Administrator, on 05/06/2020 at 3:50 PM, revealed the upper level front entrance was used for screening people working in the front office, for the most part. She stated contract therapists and probably half of us working the front, used the front door. The front door was opened 9:00 AM through 4:00 PM, Sunday through Saturday, and someone was there to screen, but locked otherwise. Further interview revealed the majority of the staff used the lower level back patio entrance to the facility, which has a keypad on both sides of the door. She stated there was no one at this entrance to monitor or screen the employees. She added the lower level was where the staff clocked in, and then go to the upper level by way of stairs or elevator, to the Nurses Station for screening. She further stated, once the staff come up the stairs or the elevator, they stand in line six (6) feet apart on X markers, social distancing with their masks on, and lined up for screening at the Nurses Station.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure food was stored, in accordance with professional standards for food service safety. Observation of the kitchen, on 07/30/19, revealed food items stored in walk-in refrigerator and reach-in refrigerator were not dated. Review of the facility Census and Condition, dated 07/30/19, revealed forty-two of forty-three residents received their meals from the kitchen. The findings include: Review of the facility policy titled, Food Receiving and Storage, last revised (MONTH) 2014, revealed all foods stored in the refrigerator will be covered, labeled, and dated. Observation of the walk-in refrigerator during initial tour, on 07/30/19 at 6:11 PM, revealed one (1) bag of American cheese, one (1) package of bologna, and a container of diced tomatoes; not dated. Observation of the reach-in refrigerator revealed a container of apple juice with approximately twenty-five percent (25%) remaining, not dated. Interview with Dietary Aide #1, on 07/30/19 at 6:35 PM, revealed all items stored in the refrigerators should be dated. Interview with the Dietary Manager, on 08/01/19 at 11:30 AM, revealed she expected all food items in the freezer to be dated.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure the residents environment remains as free of accident hazards as possible. Observation on 07/31/19, revealed cleaning chemicals left on top of a cart in the hallway, unattended. The findings include: Review of the facility policy titled, Housekeeping Equipment/Carts, not dated, revealed chemicals for cleaning should be stored in the closed compartment when carts are unattended. Observation on 08/01/19 from 9:23 AM through 9:31 AM, revealed a bottle of Antibacterial Foaming Bath and Surface Cleaner, and Comet Cleaner with Bleach, were left unattended on top of a housekeeping cart on the two-hundred (200) hall, with seven (7) residents observed nearby. Interview with Housekeeper #1 on 08/01/19 at 9:43 AM, revealed she was mopping the floor in a nearby resident's room. She stated she should have placed the cleaner bottles in the compartment on the cart and not on top of the cart. Interview with the Housekeeping Supervisor on 08/02/19 at 9:15 AM, revealed he expected housekeeping staff to keep cleaning chemicals in the compartments on their carts, out of reach of residents. Interview with the Administrator on 08/02/19 at 10:05 AM, revealed she expected housekeeping staff to keep cleaning chemicals locked up while the cart was unattended.

Based on interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to ensure one (1) of three (3) sampled residents, received care consistent with professional standards of practice, to promote healing, and to prevent pressure ulcers unless the individuals clinical condition demonstrated that they were unavoidable (Resident #1). Resident #1 returned to the facility from the hospital on [DATE] with a Skin Deep Tissue Injury (SDTI) to the left heel; however, there was no documented evidence a full assessment of the SDTI was completed to include the length, width, depth, and presence of exudates or necrotic tissue per facility policy. In addition, facility staff failed to float the resident's heels per physician's orders [REDACTED]. The findings include: Review of the facility's titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, last revised April 2018, revealed the nursing staff will assess and document an individual's significant risk factors for developing pressure ulcers. The nurse shall describe and document/report the following: full assessment of pressure sore including location, stage, length, width, and depth, presence of exudates or necrotic tissue, and current treatment including support surfaces. The staff will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. The Physician will assist staff to identify the type and characteristics of an ulcer. The physician will help identify and define any complications R/t pressure ulcer. Record review revealed the facility readmitted Resident #1 on 01/31/19 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1's cognition was severely impaired with a Brief Inventory of Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. Further review of the MDS assessment revealed the facility assessed the resident required extensive assistance of two (2) plus persons for bed mobility, was at risk for developing pressure ulcers/injuries, and occasionally incontinent of bladder. Review of Resident #1's Hospital Consultation Report, dated 01/30/19, revealed Resident #1 had a SDTI to left heel that had light purple discoloration and measured 2.5 centimeters (cm) in length by 1.5 cm in width with skin intact. Review of Readmission Nursing Assessment revealed the facility assessed Resident #1 had a SDTI to the left heel upon readmission from the hospital on [DATE]; however, further review of the assessment and the resident's medical record revealed there was no documented evidence licensed staff assessed the SDTI to include the length, width, depth, and presence of exudates or necrotic tissue per facility policy. Interview with Licensed Practical Nurse (LPN) #1, on 04/03/19 at 2:35 PM, revealed she readmitted Resident #1 from the hospital on [DATE]. LPN #1 stated the resident had a SDTI to his/her left heel which had a protective heel dressing that she removed to assess the left heel; however, she failed to document the wound characteristics. LPN #1 revealed resident's left heel was black however, she failed to further assess the size and integrity of the wound, document in Resident #1's medical record, and failed to implement any treatment. Review of Resident #1's admission orders [REDACTED]. Review of Resident #1's Comprehensive Care Plan, At Risk for Skin Breakdown, dated 12/17/18, revealed the facility identified a SDTI to the resident's left heel on 01/31/19 with interventions to have an air mattress to bed, heel boots to offload heels when in bed or up in chair, and apply [MEDICATION NAME] (an absorbent foam dressing), change every three (3) days and whenever necessary. Review of the Bi-Weekly SDTI/Wound Status log (form the Director of Nursing (DON) utilized to monitor pressure wounds/injuries in the facility and not part of the resident's record), dated 02/04/19 (five {5}days after admission), revealed an assessment of Resident #1's left heel as SDTI, not open, unstageable, 3.2 cm in length by 4.7 cm in width. Interview with the DON, on 04/05/19 at 3:25 PM, revealed the Bi-Weekly SDTI/Wound Status log is not a part of Resident #1's medical record; however, a tool she used to monitor pressure wounds/injuries. The DON stated she assessed Resident #1's SDTI on left heel on 02/04/19 and documented it on the Bi-Weekly Status log but did not document assessment findings in the resident's Electronic Health Record (EHR) (or the weekly wound observation tool). Review of Resident #1's Physician Order, dated 02/04/19, revealed to verify heel boots are on every shift for protection and review of Resident #1's February 2019 Treatment Administration Record (TAR), revealed documentation the heelboots were applied as ordered. Further review of Resident #1's Medical Record revealed there was no documented evidence a weekly Wound Assessment was completed per facility protocol. until 02/14/19. Review of a Wound Weekly Observation Tool, dated 02/14/19 (fourteen {14} days after admission and ten (10) days after DON assessment on 02/04/19) revealed Resident #1 had a SDTI on left heel which measured 5.5 cm in length by 6.0 cm in width with a small opening at edge of wound allowing scant amount of sanguineous drainage, no odor, or signs/symptoms of infection, wound bed 100 % necrotic. Further review revealed the resident acquired an additional pressure wound to the left foot measuring 0.2 cm in length and 0.5 cm in width with no other description of wound documented. Review of the a Physician Order, dated 02/28/18, revealed to float heels on pillows when in bed. Interview with State Registered Nursing Assistant (SRNA) #2, on 04/04/19 at 9:45 AM, revealed Resident #1 had a pressure area to the left heel. SRNA #2 stated the resident had heel boots to both feet at all times; however, he/she did not ensure Resident #1's heels were elevated off the bed to relieve pressure. Interview with SRNA #3, on 04/04/19 at 10:05 AM, revealed Resident #1 had to wear heel boots because of pressure wound to his/her left foot. SRNA #3 stated the resident wore heel boots at all times; however, the he/she did not keep the heels elevated to relieve pressure off the heel boots. Interview with Registered Nurse (RN) #1, on 04/03/19 at 4:05 PM, revealed the facility had a wound care team which consisted of the Unit Nurse, Nurse Navigator, MDS Coordinator, and the DON. RN #1 stated the wound care team was responsible to track pressure wounds, obtain measurements, and document assessment findings. RN #1 further revealed the wound care team assessed residents with pressure wounds on Monday and Thursday and the assessments were documented on the Weekly Wound Observation in the resident's EHR. Further interview revealed the nurse on the unit was responsible to perform weekly skin audits and any residents identified with pressure wounds/injuries or skin impairment should be documented in the resident's EHR. Further interview with the DON, on 04/05/19 at 3:25 PM, revealed she expected the staff to document the descriptive characteristics of the SDTI, to identify changes in the wound, and to evaluate the need to alter treatment to promote healing. The DON stated she expected the nurses on the unit to document assessment findings in the resident's EHR.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure a resident's medical record reflected the resident's condition in accordance with accepted professional standards, practices, and maintained medical records on each resident that were complete and accurately documented for one (1) of three (3) sampled residents (Resident #1). Resident #1 was readmitted to the facility on [DATE] with a Skin Deep Tissue Injury (SDTI) to the left heel; however, there was no documented description and/or characteristics of the SDTI in the resident's medical record until 02/14/19 after the facility assessed the pressure wound/injury as an unstageable pressure ulcer. The findings Include: Review of the facility policy titled, Charting and Documentation, no date, revealed all services provided to the resident, progress toward the care plan goals, or any changes in resident's medical, physical, functional, or psychological condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation in the medical record may be electronic, manual, or a combination. Review of the facility's titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, revised April 2018, revealed the nursing staff will describe and document assessment of pressure sore including location, stage, length, width, and depth, presence of exudates or necrotic tissue, and current treatment including support surfaces. Record review revealed the facility readmitted Resident #1 on 01/31/19 with [DIAGNOSES REDACTED]. Review of Resident #1's Hospital Consultation Report, dated 01/30/19, revealed Resident #1 had a SDTI to left heel that had light purple discoloration and measured 2.5 centimeters (cm) in length by 1.5 cm in width with skin intact. However, review of Resident #1's Medical Record revealed the facility failed to document the resident's condition of SDTI to the left heel and maintain medical records to include assessments from 01/31/9 through 02/14/19. Interview with Licensed Practical Nurse (LPN) #1, on 04/03/19 at 2:35 PM, revealed she readmitted Resident #1 from the hospital on [DATE]. LPN #1 stated the resident had a SDTI to his/her left heel and she failed to document an assessment of the wound in the resident's medical record. Interview with Registered Nurse (RN) #1, on 04/03/19 at 4:05 PM, revealed pressure ulcer/injury assessments should be documented on the Weekly Wound Observation in a resident's Electronic Health Record (EHR). Interview with Director of Nursing (DON), on 04/04/19 at 3:25 PM, revealed she expected staff to document assessment findings in the resident's EHR. Interview with the Nurse Navigator and Administrator, on 04/04/19 at 11:00 AM, revealed she expected staff to maintain a resident's medical record with accurate documentation of the resident's condition.

Based on observation, interview, record review and a review of facility policy, it was determined the facility failed to complete a thorough investigation of an allegation of abuse for one (1) of two (2) sampled residents. On 09/19/18, it was alleged a nurse pulled on Resident #1's nose, after giving the resident an injection due to being combative; however, the Administrator failed to interview the two (2) Emergency Medical personal who reportedly observed the incident. The findings include: Review of the facility's Abuse Investigation and Reporting policy, not dated, revealed all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Further review of the policy revealed revealed the role of the investigator is to interview the person(s) reporting the incident. Review of the facility investigation documentation, 09/19/18, revealed the Emergency Medical Service Dispatcher alleged two EMS workers who were there to transfer the resident to the hospital witnessed the facility nurse to pull Resident #1's nose after administering a shot to the resident due to combativeness. The allegation was unsubstantiated based on employee and staff interviews. However, further review of the investigation revealed there was no documented evidence the Administrator interviewed the two (2) EMS employees which allegedly witnessed the allegation. Interview with the first (1st) Responder, on 10/11/18 at 12:45 PM, revealed he saw the male nurse give the shot and walk by and grab the resident by the nose. He stated he felt it was uncalled for as the resident was already agitated and combative and swinging at the staff. He revealed he reported the incident the next day to the EMS Director and also to the 11-7 nurse that received the resident back from the hospital. Upon return to the facility, the resident was resting calmly. Interview with the Emergency Medical Technician, (EMT) on 10/11/18 at 1:29 PM, revealed after the nurse gave the resident the [MEDICATION NAME] (anti-psychotic) injection, he pinched the resident's nose. He stated the male nurse had a smug look on his face. Interview with the Administrator, on 10/11/18 at 12:27 PM, revealed she had initiated and completed her investigation of the allegation on 09/19/18 and the alleged perpetrator was allowed to return to work on the 3-11 shift and was not suspended. She stated she interviewed the EMS Supervisor and the EMS Supervisor said, she had nothing to report.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure they revised the care plan for one (1) of fourteen (14) sampled Residents (Resident #18). Resident #18 sustained falls on 01/29/18, 04/04/18, and 04/14/18, however, the facility failed to implement interventions to address the root cause of the falls. On 04/22/18, the resident attempted to self transfer resulting in another fall with complaints of low back and right hip pain and was sent to the emergency room for evaluation. Resident #18 was admitted to the hospital with [REDACTED]. Although surgical intervention was not required, the fractures caused a decline in the residents activities of daily living. The findings included: Review of the facility's policy titled, Accident/Incidents Policy, last revised 06/13/16, revealed to document what you did for the resident and any new interventions that were put in place to prevent another occurrence. Record review revealed the facility admitted Resident #18 on 09/21/17, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3) indicating the resident was not interviewable. Review of the facility provided fall investigations, revealed on 01/29/18 Resident #18 had fall when attempting to get out of bed unassisted, on 04/04/18 while attempting to get out of bed unassisted, on 04/14/18 when his/her knees buckled while walking in the hall; and on 04/22/18 when attempting to get out of bed unassisted. Two of the incidents revealed the resident did not have on non-skid socks per the comprehensive care plan. However, review of the Comprehensive Care Plan revealed there was no documented evidence of new interventions put in place after each fall. Review of the Discharge Summary from the hospital revealed Resident #18 was hospitalized from [DATE] through 04/24/18. The Discharge Summary stated the resident presented to the ER after a fall with complaints of low back and right hip pain. The computer tomography (CT) Scan showed minimally displaced fractures of the right ilium and right superior pubic ramus. There was also a mildly displaced [MEDICAL CONDITION] inferior pubic ramus. Resident #18 did not require surgical intervention. Review of the facility's Look Back Report for 04/26/18 through 05/02/18 revealed the resident had a decline in bed mobility, transfers, toileting; locomotion on and off the unit, dressing, personal hygiene, bathing; and ambulation. Interviews on 05/10/18 with Licensed Practical Nurse (LPN) #1/Charge Nurse, at 5:43 PM, and LPN/Nurse Navigator at 5:47 AM revealed the facility's policy was to initiate a new intervention with each fall. Interview with the Director of Nursing on 05/10/18 at 5:04 PM revealed prior to the resident's (MONTH) (YEAR) falls the resident was up ad lib. The DON stated she expected staff to follow the care plan for the resident . Further interview with the DON revealed a bed alarm was not initiated due to the resident's history of anxiety and agitation, a low bed was not initiated because it would have been difficult for the resident to get out of bed, and a bedside floor mat was not initiated because she thought the mat would increase the resident's fall risk. However, the DON stated she did not document her thought process in the clinical record. She stated she stood by her decision not to implement new interventions related to the falls.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (1) of fourteen (14) residents (Resident #18). Resident #18 was assessed and care planned at risk for falls. Resident #18 sustained falls while attempting to transfer from his/her bed on 01/29/18 and 04/04/18, however, the facility failed to put interventions in place to address the root cause of the falls. On 04/22/18, Resident #18 attempted to transfer from the bed again sustaining another fall that resulted in fractures of the right ilium, right superior pubic ramus, and the right inferior pubic ramus with hospitalized from [DATE] through 04/24/18. There were still no interventions put in place to address the falls. Although surgical intervention was not required, the fractures caused a decline in bed mobility, transfers, toileting; locomotion on and off the unit, dressing, personal hygiene, bathing; and ambulation. The findings included: Review of the facility's policy titled, Accident/Incidents Policy, last revised 06/13/16, revealed the facility is to ensure it provides an environment that is free from accident hazards as possible and residents receive adequate supervision and assistance devices to prevent accidents. Document in the medical records and complete the falls follow up communication flow sheet. In addition, obtain necessary order for any new intervention to make sure new interventions are placed on the care plan and the nursing aide Kardex care plan. Document what you did for the resident and any new interventions that were put in place to prevent another occurrence. Record review revealed the facility admitted Resident #18 on 09/21/17 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #18's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3) indicating the resident was not interviewable. Further review of the Quarterly MDS dated [DATE], revealed Resident #18 required total care with assistance of one (1) person for bathing; supervision with assistance of one (1) person for dressing; and was independent with supervision for eating. For all other activities of daily living (ADLs), bed mobility, transfers, ambulation, locomotion on and off the unit, toileting and hygiene, the resident required set up assistance with supervision. The MDS indicated Resident #18's balance on transition and walking was steady at all times with no functional limitations. Review of the Admission and Quarterly Fall assessment dated [DATE] revealed Resident #18 scored seventy (70) on the assessment indicating he/she was at high risk for fall. A score of forty-five (45) or higher indicates high risk. Review of the Comprehensive Care Plan for risk for falls, dated 09/22/17, revealed I walk with a cane because my balance is a little unsteady and I take a lot of medications that can increase my risk for falls. The goal was I will have no falls through review date. Further review revealed interventions/tasks which included I am to wear non-skid socks if I am in bed or up without shoes; Remind me to use my cane and ask for help with walking; The nurse will need to monitor me for side effects of [MEDICATION NAME] and [MEDICATION NAME] every shift. Hand written in on the care plan was 04/04 fall and 04/22 actual fall-to ER. 04/22 diagnosis-fractures pelvis-admitted . Review of the facility provided fall investigations for Resident #18 revealed the resident had falls when attempting unassisted transfers from the bed on 01/29/18 and 04/04/18. The facility determined the resident fell on [DATE] because he/she was not wearing non-skid socks; and the facility failed to identify a cause for the 04/04/18 fall. However, further review of the Comprehensive Care Plan revealed there was no documented evidence new interventions were put in place to address the resident not having on non-skid socks and the resident falling attempting to transfer from the bed. Further review of the Fall Investigation Reports revealed Resident #18 sustained another fall on 04/22/18 at 6:33 AM due to an unassisted transfer, and it was determined the resident was not wearing non-skid socks. The resident complained of low back and right hip pain. He/she was transferred to the emergency room (ER) for evaluation. Review of the Discharge Summary from the hospital revealed Resident #18 was hospitalized from [DATE] through 04/24/18. The Discharge Summary stated the resident presented to the ER after a fall with complaints of low back and right hip pain. The computer tomography (CT) Scan showed minimally displaced fractures of the right ilium and right superior pubic ramus. There was also a mildly displaced [MEDICAL CONDITION] inferior pubic ramus. Resident #18 did not require surgical intervention. Review of the facility's Look Back Report for 04/26/18 through 05/02/18 revealed the resident had a decline in performance of Activities of Daily Living (ADL's). The resident required extensive care with the assistance of two (2) people for bed mobility, transfers, and toileting; extensive care with assistance of one (1) person for locomotion on and off the unit, dressing, personal hygiene, and bathing; and ambulation did not occur during the look back period. Further review of the Comprehensive Care Plan revealed there was still no documented evidence new interventions were put in place to address the resident not having on non-skid socks and the resident falling attempting to transfer from the bed again on 04/22/18. Interview with Licensed Practical Nurse (LPN) #1, Charge Nurse, on 05/10/18 at 5:43 PM revealed the facility policy was to initiate a new intervention with each fall. Sometimes an intervention is as simple as more frequent rounds. Interview with LPN #3, Nurse Navigator, on 05/10/18 at 5:47 PM revealed some kind of intervention was always initiated with each new fall. LPN #3 stated I can't think of any reason why we wouldn't do something for each fall. Interview with the Director of Nursing on 05/10/18 at 5:04 PM revealed prior to Resident #18's falls in (MONTH) (YEAR), the resident was up ad lib. The DON stated the resident removed the non-skid socks him/herself, and the resident believed he/she was capable of much more than he/she actually was. The DON revealed a bed alarm was not initiated due to the resident's history of anxiety and agitation and she thought the resident would become agitated with the sound. The DON further stated a low bed was not initiated because it would have been difficult for the resident to get out of bed, nor did she initiate a bedside floor mat because she thought the mat would increase Resident #18's fall risk. The DON stated she expected staff to follow the care plan for the resident. She further stated she stood by her decision to not implement new interventions. The DON stated she did not document her thought process in the clinical record. Interview with the Administrator on 05/10/18 at 5:55 PM revealed I understand where we failed. We should have at least tried with an intervention. I expect the staff of this facility to follow policy and procedure and adherence to federal and state guidelines.

Based on observation, interview, record review, review of the Physician's Desk Reference (PDR) Nursing Drug Handbook, and facility policy review it was determined the facility failed to ensure one (1) of fourteen (14) sampled residents was not administered a [MEDICAL CONDITION] medication without an appropriate diagnosis (Resident #1). Resident #1 was being administered [MEDICATION NAME] (anti-psychotic) with a [DIAGNOSES REDACTED]. The findings included: Review of the facility's policy titled, Medication Monitoring and Management, not dated, revealed In order to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, facility staff, the attending physician/prescribe and the consultant pharmacist perform ongoing monitoring for appropriate, effective and safe medication use. When selecting medications and non-pharmacological interventions, members of the interdisciplinary team participate in the care process to identify, assess, address, advocate for, monitor, and communicate the resident's needs and changes in condition. The resident's medication regimen is evaluated when an admission or re-admission occur. Review of the PDR Nursing Drug Handbook, 2012 edition, revealed [MEDICATION NAME] is used for treatment of [REDACTED]. Review of the Black Box Warning revealed elderly patients with dementia-related [MEDICAL CONDITION] treated with antipsychotic drugs are at an increased risk of death, most are cardiovascular or infectious in nature. [MEDICATION NAME] ([MEDICATION NAME]) is not approved for the treatment of [REDACTED]. Record review revealed the facility admitted Resident #1 on 02/06/15, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had disorganized thinking with difficulty focusing and a [DIAGNOSES REDACTED].#1's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of ninety-nine (99) indicating the resident was not interviewable. Additionally, Resident #1 was hospitalized [DATE] to 01/31/18 with Acute Pneumonia. Observation of Resident #1 on 05/08/18 at 11:57 AM revealed the resident was in bed, sleeping. Further observation on 05/08/18 at 12:54 PM revealed Resident #1 up in a wheel chair at the dining room table, feeding self with cues. Additional observation on 05/09/18 at 2:37 PM revealed the resident was up in the wheel chair self-propelling in the hall. Review of the physician's orders [REDACTED]. Interview on 05/10/18 at 4:40 PM, with Licensed Practical Nurse (LPN) #1, revealed Resident #1 had been taking [MEDICATION NAME] since 01/31/18 since his/her admission. LPN #1 stated the resident had psychotic episodes where he/she lashed out, yelled, and hit walls and doors, but he/she had not made deliberate attempts to hit anyone. LPN #1 stated the resident definitely exhibited psychotic behaviors but he would have expected the resident to have a [MEDICAL CONDITION] [DIAGNOSES REDACTED]. Interview on 05/10/18 at 4:20 PM with the LPN #3, Nurse Navigator, revealed she was not aware Resident #1 needed a certain [DIAGNOSES REDACTED]. Interview on 05/10/18 at 4:39 PM with Registered Nurse (RN) #1 revealed she had no idea why the resident was taking [MEDICATION NAME]. RN #1 stated the resident was taking the medication prior to her employment with the facility. She further stated Resident #1 had exhibited psychotic behaviors, but she was unaware that the resident did not have a [DIAGNOSES REDACTED]. Interview on 05/10/18 at 5:56 PM, with the Director of Nursing (DON) revealed she and the MDS Coordinator reviewed residents' charts when they return from a hospitalization and the Nurse Navigator reviewed the charts for newly admitted residents. The DON stated no one had been reviewing the residents that had been at the facility for any length of time to ensure appropriate [DIAGNOSES REDACTED]. Telephone interview on 05/10/18 at 4:26 PM with the Advance Practice Registered Nurse (APRN) revealed she could not answer why the resident did not have an appropriate [DIAGNOSES REDACTED]. The APRN stated the resident continues to have behaviors and [MEDICAL CONDITION] would be an appropriate [DIAGNOSES REDACTED].

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure food was distributed in accordance with professional standards for food service safety related to staff failing to use proper hand hygiene between passing trays to individual residents and handling resident drinking straws with their bare hands. Observation on 05/08/18 at 12:30 PM revealed Certified Nurse Aide (CNA) #1 was passing lunch food trays without cleansing her hands between the set up of trays for residents; and, touching a straw with her bare hands and placing the straw in a glass of tea without using gloves. The findings include: Review of the facility's Infection Control Policy, last revised 06/2012 and reviewed 06/2017, revealed the facility was to provide a safe, sanitary and comfortable environment and prevent the development and transmission of disease and infection for the residents and staff. Further review revealed to provide proper hand hygiene and to look for trends in groups, room mate, dining room partners, etc. for potential breaks in infection control. Observation during the lunch meal on 05/08/18 at 12:30 PM, revealed CNA #1 removed a tray from the lunch cart without using hand sanitizer or her washing hands; placed the tray in front of a resident, removed the lid, and placed a straw in the tea glass with her bare hands. The CNA then placed the trash removed from opening the tray and the food cover on another counter. She then picked up another tray without sanitizing her hands. She did this two more times without sanitizing her hands or washing with soap and water. Interview with Certified Nurse Aide #1 on 05/10/18 2:49 PM, revealed she was supposed to sanitize her hands between residents and not supposed to touch any food, utensils or straws with her bare hands. She stated she was supposed to follow the facility's policy and use sanitizer between residents. Interview with the Director of Nursing (DON), on 05/10/18 at 2:00 PM revealed she expected the staff to not touch any food or utensils with their bare hands and to use hand sanitizer in between each tray passed before passing another tray.

Based on observation, interview, and facility policy review, it was determined the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Observation of the kitchen revealed there was food stored in the walk-in in refrigerator opened and/or not dated; a large open cornmeal bag had the scoop laying in the cornmeal; the bin storing the open cornmeal, flour and sugar bags was dirty with caked white/yellow material all over it; there were two (2) sanitizer buckets present in the kitchen - one was empty and the other had visibly soiled water in it and when tested it read zero (0) sanitizer; and, the utility room had brooms and dirty clothes laying in the floor. Review of the facility Census and Condition, dated 02/14/17, revealed thirty-nine (39) of thirty-nine (39) residents received their meals from the kitchen. The findings include: 1. Review of the facility's policy titled, Proper Food Handling, not dated, revealed all perishable leftovers must be covered, dated and labeled. Observation of the walk-in refrigerator, on 05/14/17 at 10:20 AM, revealed a container of gravy open to air, a container of broccoli with cheese open to air, a container of mashed potatoes open to air, a container of barbeque chicken open to air and not dated, and a container of coleslaw open to air and not dated. 2. Review of the facility's policy titled, Sanitation, last revised December 2008, revealed the cleaning sanitization solution be maintained at 50-100 parts per million (PPM). Further review revealed the sanitizing solution should be changed at least once per shift or if solution becomes cloudy or visibly dirty. Observation of the cleaning cloth buckets, on 05/14/17 at 10:38 AM, revealed there were two (2) sanitizer buckets present in the kitchen - one was empty with nothing in it and the other had visibly brownish soiled water in it and when tested the sanitizer test strip was not showing any sanitizer agent in the bucket. 3. Review of the facility's policy titled, General Dietary Rules and Procedures, not dated, revealed the Dietary Manager will be responsible for the overall cleanliness and sanitation of the kitchen and storage areas. Observation of the cornmeal, flour and sugar bin, on 05/14/17 at 10:40 AM, revealed the cornmeal scoop and handle of the scoop was laying down in the cornmeal. Further observation of the bin storing the open cornmeal, flour and sugar bags revealed it was very dirty with caked white/yellow material all over it. Observation of the utility room, on 05/14/17 at 10:44 AM, revealed the utility room was very cluttered with two (2) brooms laying in the floor and dirty clothes laying in the floor. Interview with the Director of Food Services, on 05/15/17 at 12:40 PM, revealed the food being open to air and the scoop laying in the cornmeal was not acceptable. She stated the bin the cornmeal, flour and sugar was stored in should be kept clean. She revealed she did not have a specific policy for the utility room; however, the brooms and dirty clothes laying in the floor in the utility room was not acceptable. She stated she expected staff to be sure the sanitizer buckets have the proper sanitizer levels and to replace the solution when it becomes visibly soiled. She further stated she expected staff to follow the facility policies. Interview with the Administrator, on 05/16/17 at 5:40 PM, revealed he expected the facility staff and the kitchen staff to follow facility policies.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to ensure infection control procedures were used by staff while providing care for four (4) of ten (10) residents sampled residents (Residents #1, #2, #3, and #5). Observations revealed staff failed to handle linen to prevent spread of possible infection while providing care for Resident #1 and #3; to change gloves and use proper hand hygiene while caring for Resident #1 and #2; and failed to handle a medication bottle lid to prevent infection for Resident #5. The findings include: Review of facility policy titled, Standard Precautions and Hand Hygiene, dated July 2013, revealed during the delivery of healthcare, avoid unnecessary touching of surfaces in close proximity to the resident to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surfaces. Staff should wear gloves when providing care which involves any personal contact. Further review revealed in the course of resident care, gloves should be changed before further contact with clean surfaces, the resident, or staff if they have become soiled with potentially infectious material (e.g., stool, urine). After such care, staff should remove gloves and wash hands. In addition, hand hygiene should be performed after contact with blood, body fluids or excretions, mucous membranes, non-intact or intact skin, wound dressings, or if hands will be moving from a contaminated-body site to a clean-body site during resident care. Review of facility policy titled, Incontinence Care, Bowel, dated 02/10/04, revealed soiled linen must be handled so as to prevent contamination of the environment with feces. 1. Record review revealed the facility admitted Resident #1 on 09/03/15 with [DIAGNOSES REDACTED]. Observation of perineal care on Resident #1 with Certified Nurse Aide (CNA) #1, on 05/16/17 at 9:05 AM, revealed CNA #1 placed the soiled plastic linen bag at the right of the resident's head and then after the care was completed transported the bag with the dirty linen over the resident's head and placed it on the left side of the resident's head. Further observation revealed after the care was completed the CNA did not remove gloves and wash her hands before turning the resident in the bed and touching the resident's sheets. Interview with CNA #1, on 05/16/17 at 10:08 AM, revealed the dirty plastic bag should have been at the foot of the bed not at the head of the bed due to germs and contamination. She stated there would be an infection control issue by transporting the dirty bag over the resident's head and face. She revealed she should have changed her gloves after cleaning the resident's buttocks, and before touching the resident's sheets and turning the resident. Observation of a skin assessment on Resident #1 with Licensed Practical Nurse (LPN) #1, on 05/16/17 at 9:15 AM, revealed LPN #1 inspected the resident's feet and proceeded to scrape a piece of dirt from between the resident's toes. Further observation revealed after inspection of the feet, LPN #1 did not change gloves and proceeded to inspect the perineal area and apply barrier cream. Interview with LPN #1, on 05/16/17 at 10:16 AM, revealed she should have changed gloves after assessing the resident's feet and removing dirt from toes and before assessing the perineal area and applying barrier cream. She stated assessing from the feet to the perineal area would put the resident at risk for contamination and infection. 2. Record review revealed the facility admitted Resident #2 on 09/08/08 with [DIAGNOSES REDACTED]. Observation of CNA #2 providing catheter care to Resident #2, on 05/16/17 at 9:30 AM, revealed after the CNA completed catheter care, she emptied the catheter bag, and then cleaned the bag drainage spout with an alcohol pad. The CNA proceeded to pick up six (6) other alcohol pads in the package and placed in her pocket and then picked up her walkie talkie with the dirty gloved hand. Interview CNA #2, on 05/16/17 at 10:30 AM, revealed she should have changed gloves after providing catheter care and before touching any other objects. She stated she should not have touched the alcohol pads and placed them in her pocket as they would have been contaminated. She revealed she should not have picked up the walkie talkie with her contaminated gloves as it could spread germs. 3. Record review revealed the facility admitted Resident #3 on 03/03/11 with [DIAGNOSES REDACTED]. Observation of CNA #3 providing perineal care to Resident #3, on 05/15/17 at 10:30 AM, revealed the CNA placed the dirty wash clothes on the bed side table with no barrier while providing perineal care and did not place them in the dirty linen bag until care was completed. Interview (Post Survey) with CNA #3 on 05/17/16 at 10:35 AM revealed the soiled linen should be placed in a plastic bag and not on the bedside table. She stated she had plastic bags in her pocket and she should have used them, however it had become a habit. She revealed placing the soiled cloths on the bedside table is a risk for contamination. 4. Record review revealed the facility admitted Resident #5 on 06/28/10 with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Observation of medication pass on 05/15/17 at 11:21 AM revealed Certified Medication Aide (CMA) #1 administered Fluorometholone Suspension 0.1% to Resident #5, however, when the CMA removed the lid from the eye drop container the top was placed down on the medication box. Interview with CMA #1, on 05/15/17 at 11:25 AM, revealed she normally lays the top on the box, however it would be an infection control issue to lay the lid down on the box. She stated she was taught in school to keep the top in a clean gloved hand or top up to prevent contamination. Interview with the facility Pharmacy Consultant, on 05/15/16 at 1:37 PM, revealed the eye drop lid should have been laid on a barrier, glove or in a medication cup to prevent contamination. Interview (Post Survey) with Registered Nurse (RN) #1, on 05/17/17 at 10:39 AM, revealed she expected soiled linen from Resident #1 and #3 to be placed in a plastic bag, not on the bedside table and not at the foot of the bed, but in a plastic bag at the foot of the bed to prevent contamination. She revealed the resident should not have dirty linen come across their face as a dirty item could fall out and onto the resident's head. She further stated when providing a skin assessment, the nurse should change gloves after assessing a dirty area such as the feet and before going to the perineal area as this could be an infection control issue. She also stated when administering eye drops to a resident the nurse or Certified Medication Aide (CMA) should hold the lid of the eye drops in a gloved hand and not place it on the table or a box as it could become contaminated. Interview with the Director of Nursing on 05/16/17 at 10:20 AM revealed the policy does not state for an eye drop lid to be placed in a glove or on a clean surface; however, it was a nursing standard of practice and is what she expects to decrease risk for infection. She stated dirty linen should be placed in a bag at the foot of the bed and not passed over the resident. She revealed when a nurse performs a skin assessment she expects the nurse to change his/her gloves when going from a dirty area to a clean area as she would have expected going from the feet to the perineal area. She further stated when a staff member is providing care for a resident only the supplies required should go into the room, therefore only one (1) alcohol pad should have been taken into Resident #2's room. She revealed the other alcohol pads would have been contaminated as well as the walkie talkie and the CNA should have washed his/her hands after providing care for the residents and before touching other objects as this would be considered an infection control issue.

Based on observation, interview, and review of the facility's policy and procedure, it was determined the facility failed to ensure food was stored, prepared, distributed, and served under sanitary conditions. Review of the Census and Condition, dated 06/01/16, revealed forty-one (41) of forty-one (41) resident received their meals from the kitchen. Observations on 05/31/16 revealed Dietary Cook/Aide #1 dropped the thermometer into one of the dishes and did not change out the dish. In addition, she touched her face with gloved hands to push her eyeglasses and used the same gloves to serve turkey slices. Further observation revealed Dietary Aide # 2 dropped a loaf of bread on the floor and proceeded to pick the bread up from the floor and made sandwiches with the bread. Additionally, a gallon of milk was noted in the reach in refrigerator not dated when opened. The findings include: Review of the facility's policy and procedure, titled Proper Food Handling, dated 02/27/12, revealed all food/liquids opened should be labeled and dated, and any items or food that is dropped on the floor must be discarded if it cannot be properly sanitized. In addition, staff should wear gloves when handling ready-to-eat foods such as fruits, sandwiches or breads; wash hands and change gloves often; and change gloves before beginning a different task or entering a new work station, after sneezing, coughing or touching your hair or face with a glove hand, and as soon as the gloves become soiled or torn. Observations of the lunch meal tray line, on 05/31/16 at 11:25 AM, revealed the Dietary Cook/Aide #1 was taking food temperatures and allowed the entire thermometer to fall into one of the dishes. She did not change out the dish, as well as she touched her face with gloved hands to push her eye glasses and used the same gloves to serve turkey slices without the use of tongs. Additionally, Dietary Aide #1 left the tray line to place the turkey in the oven to reheat and returned to the tray line without changing her gloves and washing her hands. Further observation, on 05/31/16 at 11:30 AM, revealed Dietary Aide #2 dropped a loaf of bread on the floor and proceeded to pick the bread up from the floor and place it on a clean counter and made sandwiches with the bread. In addition, a gallon of milk was noted in the reach in refrigerator not dated when opened. Interview with Dietary Cook/Aide #1, on 05/31/16 at 11:50 AM, revealed she was aware of the need to wash her hands and change her gloves after leaving the tray line for any reason or after contaminating her gloves for any reason. Additionally, she stated the pans of food she dropped the thermometer into should have been discarded and replaced with new. Interview with Dietary Cook # 2, on 05/31/16 at 11:45 AM, revealed she should have discarded the loaf of bread she dropped on the floor because the outside of the bread bag was contaminated after being on the floor. She revealed she was not thinking and used the bread to make sandwiches, which she should not have. Interview with the Dietary Manager, on 05/31/16 at 12:10 PM, revealed she expected the Dietary Staff to abide by the facility's policy and procedures related to proper hand hygiene and glove use as well as dating any items when they were opened.