Every finding on record at Essex Rehabilitation and Healthcare Center

Based on observation, interview, record review, and facility policy review, the facility failed to provide an assistive device in a manner designed to prevent accidents for 1 of 4 sampled residents (Resident (R) 28). Staff failed to follow instructions for the use of a mechanical lift while providing care for R28. The findings include: Review of the facility document Active Stand Up Lifting, of the policy titled, Mechanical Lift, dated 04/2013, revealed, active stand-up lifting with [NAME] and Liko Safety Vest, (product designed to help with patient support and stability) revealed instructions for use of the stand-up lift, including directions to, Position [NAME] and adjust the width of the base, so that the patient's feet can be centered on the footrest. Further review revealed, Attach and tighten the strap around the lower legs. Review of the admission Record for R28 revealed the facility admitted the resident on 06/19/2023, with diagnoses that included hemiplegia and hemiparesis (partial weakness on one side of the body) following a cerebral infarction (stroke) affecting the left non-dominant side. Review of the Annual Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 03/02/2025, revealed R28 had a Brief Interview of Mental Status (BIMS) of nine out of 15, which indicated the resident had moderate cognitive impairment. Continued review of the MDS revealed R28 had impairment of an arm and a leg on one side of their body and used a wheelchair for mobility. Further review revealed the facility assessed R28's ability to move from a sitting to a standing position to require substantial staff assistance. Review of R28's Care Plan revealed the facility identified a focus area, initiated 06/19/2023, that indicated the resident required assistance for potential to restore or maintain maximum function of self-sufficiency for transferring from one position to another. Per review, the focus area noted R28's need for assistance was related to cognitive deficit, deconditioning, generalized muscle weakness, physical limitations, poor judgement, and a cerebral vascular accident with left sided weakness. Further review revealed the interventions included: staff to monitor safety awareness (initiated 06/19/2023); provide substantial/maximal assistance for chair to bed to chair transfers (initiated 01/17/2024); and use the [NAME] lift L-Sling (initiated 12/11/2024). Observation on 03/31/2025 at 2:21 PM, revealed State Registered Nursing Assistant (SRNA) 6 was observed moving R28 to his/her wheelchair from the hall to the shower room. Observation revealed R28's pants were wet in the rear of the pants, down to their knees. During a concurrent interview, SRNA 6 stated it was easier to change the resident with the mechanical lift. Per observation, at 2:26 the stand lift (a [NAME] II EE Liko brand) was placed in position, and SRNA 6 placed the stand up lift leg strap around the leg rest and did not place the strap around the back of the resident's legs. Continued observation revealed R28 was wearing slide-on slippers, and his/her left foot, which was on the footrest, was part of the way out of the slipper. Observation revealed R28's right foot was halfway on the footrest, with the resident's heel hanging off the back of the footrest. Further observation revealed SRNA 6 was unable to assist R28 as his/her left hand was holding on to the lift bar, so SRNA 6 then requested assistance from SRNA 7. In addition, observation revealed at 2:31 PM, SRNA 6 attempted to lift R28's left foot to remove his/her pants; however, was unable to complete that maneuver, and the SRNA's then placed the resident back into the wheelchair. During interview on 03/31/2025 at 2:40 PM, SRNA 6 stated staff always used the stand lift because R28 was not able to stand independently. SRNA 6 further stated R28's left hand was weaker, but the resident could manage using the standing lift. During interview on 04/02/2025 at 2:43 PM, SRNA 9 stated the leg strap should always be fastened around the back of the resident's legs, and the resident's feet should be flat on the footrest for safety. During interview on 04/03/2025 at 1:01 PM, Certified Medication Technician (CMT)/SRNA 2 stated for a standing lift, the resident should have the leg strap around the legs to prevent falls. During interview on 04/03/2025 at 1:21 PM, SRNA 6 stated R28's feet should have been flat on the footrest, but the resident had a foot problem. She said she fastened the leg strap around the leg rest to protect the front of the resident's legs, adding that she did it the correct way it should be done. Review of the [NAME] Lift Skills Checklist, for SRNA 6, with an observation date of 01/06/2025, revealed the skills checklist was signed by the Director of Staff Development (DSD). Per review, the Sabrina Lift Skills Checklist noted SRNA 6 met the requirements of the skills checklist. Continued review of the Checklist revealed the section titled, Lifting with Vest, included to center a resident's feet/foot on the foot support placed flat enough to bear 25-305 of body weight. Further review revealed to adjust the lower-leg support touching and parallel to shins, just below kneecap, for comfortable resistance and support, with calf straps being used for safety when necessary. Additional review revealed to secure the calf strap behind a resident's calves to remind the resident to avoid stepping off the lift while in motion. During interview on 04/03/2025 at 2:19 PM, the Physical Therapist (PT) stated therapy did the initial evaluation for a resident's ability to use a standing lift and then informed the nursing department of the recommendations. The PT said use of the standing lift required the resident's feet to be flat on the footrest, and the leg strap should go behind the resident's legs. The PT further stated if the resident's feet were not flat and their legs were not secured with the strap, it could contribute to a fall because it decreased the resident's stability. During interview on 04/03/2025 at 2:25 PM, the Director of Rehabilitation (DOR) stated they received referrals from the nursing department or for a new admission and evaluated the residents for the use of a standing lift. She reported the resident's feet should be flat on the footrest, not half off the footrest, and the strap should be around the back of the resident's legs. The DOR stated that was preventative if the resident's legs buckled. She further stated the risk was a probable fall if the resident's feet fell off the footrest or if his/her legs buckled with no strap around them. During interview on 04/03/2025 at 2:30 PM, Licensed Practical Nurse (LPN) 3 stated for the standing lift, a resident's feet should be flat on the footrest, and the strap should go around the back of the resident's legs. She further stated staff should follow the directions for use of the lift. LPN 3 additionally stated she monitored staff using the standing lift randomly. During interview on 04/03/2025 at 2:40 PM, Unit Manager (UM) 4 stated for use of the standing lift, it was not safe to have a resident's foot half off the footrest. UM 4 said the leg strap should go around the back of the resident's legs for safety. She further stated staff should follow the directions for use of the lift. During interview on 04/03/2025 at 3:35 PM, the Director of Nursing (DON) stated the expectation was for the resident's feet to be flat on the footrest, but if the resident could bear weight, it would not matter. She said if the resident's legs buckled, the leg rest was the main protection, and the fact that they had a leg strap was sort of extra. The DON further stated generally she expected staff to follow directions for use for the standing lift, but it was not a cut and dry situation. During interview on 04/04/2025 at 10:53 AM, the Director of Staff Development (DSD) stated when she taught staff on using the standing lifts, she prioritized safety and following the instructions for the lifts. She reported all residents should use the leg strap, because the resident's feet could slide, and the leg strap would help to stabilize them. The DSD said staff should have the resident's feet positioned correctly on the footrest, with their whole foot on the footrest, and the strap should be around the resident's legs. She further stated if the leg strap was not on and the feet were not fully on the footrests, a resident could fall. During interview on 04/04/2025 at 4:09 PM, the Administrator stated the leg strap was optional for the standing lift but was not required. He stated it should be used if it was care planned to be used. The Administrator said both of a resident's feet should be flat on the footrest unless the resident decided to move them. He further stated he expected staff to focus on safety during the transfer and make sure the resident was supported.

Based on record review, interview, and facility document and policy review, the facility failed to ensure the residents' right to be free from misappropriation of property was maintained for 3 of 3 residents reviewed for misappropriation of resident property (Resident (R)45, R10, and R158). The findings include: Review of the facility policy titled, Abuse, Neglect, or Misappropriation of Resident Property, revised 10/15/2022, from the Administrative Policies manual, revealed the facility believed its residents had the right to be free from .or misappropriation of resident property. Per review, the facility would do whatever was in its control to prevent .or misappropriation of their property. Review of the facility policy titled, Abuse, Neglect, Misappropriation, and Exploitation, dated 08/2019, from the Social Services Manual revealed misappropriation of resident property was defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Continued review revealed examples of misappropriation of resident property included, but were not limited to: identity theft; theft of money from bank accounts; unauthorized or coerced purchases on a resident's credit card; and unauthorized or coerced purchases from resident's funds. Review of the admission Record for R45 revealed the facility admitted the resident on 07/19/2024, from another skilled nursing facility. Further review revealed R45 had a medical history that included diagnoses of: generalized anxiety disorder, mild cognitive impairment, major depressive disorder and bipolar disorder. Review of the admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 07/25/2024 for R45, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating he/she was intact cognitively. Additionally, review of the admission MDS Assessment revealed the facility assessed R45 as considering having a place to lock his/her belongings in order to keep them safe somewhat important. Review of the Significant Change in Status MDS Assessment, with an ARD of 01/31/2025, revealed the facility assessed R45 as having a BIMS score of five, indicating he/she was severely cognitively impaired. Further MDS review revealed the facility again assessed R45 as considering having a place to lock his/her belongings to keep them safe while in the facility as very important. Review of the facility's Inventory of Personal Effects, dated 07/19/2024, for R45 revealed the resident was admitted to the facility with one wallet. Review of the Progress Notes for R45 revealed facility's former SW noted on 09/30/2024, speaking to the resident regarding his/her missing debit card being found in the laundry and documented R45 informed the SW his/her credit card was also missing. Per review of the Note, the former SW told R45 to contact his/her bank to let them know so the credit card could be canceled, but noted it might also be found in the laundry. Continued review revealed the former SW asked R45 if he/she was locking his/her valuables up, and the resident responded saying he/she was no longer leaving his/her wallet or checkbook on the bed tray when not in his/her room. Review of the Progress Notes dated 10/08/2024 revealed Social Services (SS) and the Activity Director (AD) had spoken to R45 and educated the resident on staff not being able to use his/her debit or credit cards or checks to purchase cigarettes for him/her. Review of an untitled log entry dated 11/25/2024 of missing resident items revealed R45 had lost a wallet and $40.00. Per review, the column titled, Found, (which listed where each item on the log was located) revealed a report of R45's missing wallet and $40.00 was turned over the Administrator. Further review revealed no documented evidence R45's missing wallet or $40.00 was ever located. Review of the Missing Resident Item form dated 11/25/2024, revealed R45 alleged missing his/her wallet and $40.00, which the resident reported on 11/24/2024. Per review, R45 had last seen the wallet on 11/23/2024, and thought he/she might have lost it when out on a facility shopping trip. Continued review of the form revealed the AD reported R45 made his/her own purchase while on the shopping outing, and the AD was not aware if the resident had the wallet during that outing. Review of the form revealed the store where R45 went for the outing was to be contacted. Further review revealed the form had been signed by the Administrator on 11/25/2024; however, had not been signed and completed by the Administrator until 01/10/2025. In addition, review of the form revealed the Administrator's handwritten notes documented R45 said the wallet was lost on outing. Review further revealed the Administrator also noted speaking to R45's previous facility on 01/09/2025, and that facility confirmed having the wallet and would send the wallet to the current facility. Review of the form also revealed the Administrator documented local police and Adult Protective Services (APS) were notified on 01/09/2025, of potential fraudulent activity related to R45's reported missing items. Review of the facility's initial report of an Allegation of Theft or Misappropriation of Property, dated 01/09/2025, revealed the report had been submitted to APS, and noted it served as both an initial and final report. Per review of the report, fraudulent activity began on R45's account in 11/2024, with the alleged perpetrator noted as being unknown. Continued review of the report revealed the facility suspected R45's debit card or other financial information might have been used fraudulently by someone outside of the facility. Further review of the report revealed the facility notified APS that they needed assistance with handling the fraudulent use of R45's debit card, and might need to pursue guardianship for the resident. In addition, review of the report revealed the fraudulent transactions had been made in a variety of cities throughout Kentucky and Indiana. In interview on 04/30/2025 at 2:30 PM, the facility's former SW stated R45 came to her in 11/2024 to report having lost his/her wallet, and the former SW helped the resident look for it. The former SW stated R45 had lost his/her wallet so many times, and facility staff, just helped the resident look for it and usually it was found. She denied having any knowledge of R45 having lost credit or debit cards in 11/2024, and had not been aware of any fraudulent purchases using the resident's accounts until well after the fact. The former SW stated the Business Office Manager (BOM) discovered the fraudulent purchases, after receiving a copy of R45's bank statements. She said in 11/2024, facility staff discussed R45's lost wallet during a morning meeting, and there had been discussion of the facility bus having been searched with the wallet not being located. The former SW reported the morning meeting discussion had not been documented though. During interview on 05/01/2025 at 12:23 PM, the Business Office Manager (BOM) stated in her role, she was not routinely involved in reports of missing items. The BOM said she had not been informed of R45's report of the lost wallet and money in 11/2024. She explained she was not informed until 01/2025, when she became involved. The BOM stated R45 received her own bank statements, and on 01/09/2025, the resident came to her with a copy of the bank statement. She reported R45 wanted her to review the bank statement due to charges that the resident thought looked suspicious. According to the BOM in interview, R45 told her she needed to go to the bank, so the BOM made the resident an appointment with the bank the following Monday, on 01/13/2025. She said the Assistant Administrator (AA) transported R45 to the appointment at the bank that Monday. The BOM stated, I had no idea what was going on. She reported there were some charges R45 said were suspicious; but the resident said they were none of my business. The BOM said at one point, it came up that R45 was paying expenses for a friend in an apartment, but when she asked the resident if the friend had been given the bank cards or permission to pay their bills with them, the resident stated. no. She stated she notified the Administrator of the suspicious charges on R45's account so the Administrator could get Adult Protective Services (APS) involved and maybe consider getting a court-appointed guardianship for the resident. During interview on 05/01/2025 at 12:59 PM, the AA stated he was not normally involved in reports of lost or missing items and did not recall being involved in R45's report of a missing wallet. He said he had taken R45 to the bank on one occasion; however, did not recall exactly when that was. The AA further stated he also did not know the specifics as to what happened when the resident was at the bank. During interview on 05/01/2025 at 1:30 PM, R45 stated when she came to the facility, she had a wallet in her possession. R45 confirmed that was the wallet she reported as missing to facility management in 11/2024. The resident stated the facility helped her contact the bank and credit card company to get her accounts suspended or closed, but the resident could not recall at what point that occurred. R45 said she not recall who State Registered Nurse Aide (SRNA) 36 was; however, she had never given the SRNA permission to use her financial accounts. R45 further stated the facility's Administrator identified what happened, and the SRNA was currently being prosecuted. In interview on 05/01/2025 at 3:15 PM, the Administrator stated that if a resident reported a lost or missing item, facility staff initiated an in-house search. He said the lost or missing item information was posted in order for staff to know to be on the lookout for the item(s). The Administrator stated when R45 reported the missing wallet all he could think to do was call the store where the resident thought he/she might have lost it. He reported therefore, it (the investigation) was just left open until January (2025) when he became aware of extra information. He stated he had not reached out to the resident's listed contact in 11/2024, as the resident thought the wallet had been lost in a store while he/she was on a shopping trip. Per the Administrator in interview, R45 had not cooperated with him after reporting the missing items, so he left the report open until he had more information to go on. The Administrator said R45 went to the BOM on 01/09/2025, with a bank statement and questioned some of the transactions. He said he offered to help R45 contact the financial institutions; however, the resident would not let him. In continued interview on 05/01/2025 at 3:15 PM, the Administrator stated after R45 came to staff on 01/09/2025 with his/her concerns, he remembered the resident's report of a missing wallet from 11/2024, so he pulled that information. The Administrator said after discussing with R45 his/her missing items, it was discovered the resident might have been paying for utilities at an apartment, and staff felt something was going on. He stated all they could do at the time (01/09/2025) was talk to APS as it was felt R45 was mismanaging his/her money, and it was thought the resident probably needed a guardian. The Administrator reported he contacted the local police department on 01/09/2025 as well, but did not contacted the State Survey Agency (SSA). In additional interview on 05/01/2025 at 3:15 PM, the Administrator said he thought he had not started interviewing staff or other residents about potential fraud or misappropriation until 01/20/2025, when a second resident's family (R158's) reported some charges they had not approved. He stated the second resident's family sent him a screenshot of an alert they received about a transaction. The Administrator said he recognized one of the places listed on the screenshot as also where a transaction occurred on R45's statements. He reported R158 had only been living at the facility for about a week at that time, so he pulled the staffing sheets for that time period, and that narrowed things down quickly. The Administrator stated R45 and R158 resided on the same unit, so he started looking at staff who had worked there. He said he also pulled the criminal background checks for all of the staff assigned to the residents' unit during the timeframe in question to ensure all of them had been completed. 2. Review of the admission Record for R158 revealed the facility admitted the resident on 01/09/2025, with diagnoses that included major depressive disorder and generalized anxiety disorder. Further review of the admission Record revealed Family Member (FM) 35 was listed as the resident's emergency contact. Review of the admission MDS Assessment, with an ARD of 01/16/2025, revealed the facility assessed R158 to have a BIMS score of 15, which indicated the resident had intact cognition. Further MDS review revealed R158 considered having a place to lock his/her belongings to keep them safe while in the facility as, not very important. During interview on 05/01/2025 at 2:05 PM, FM 35 stated the person who used R158's financial information made three or four transactions with the resident's debit card and also took some cash. FM 35 said as FM 36 handled R158's finances, that FM should also be included in the conversation. FM 35 placed the State Survey Agency (SSA) Surveyor on a brief hold and added FM 36 to the call. Once on the call, FM 36 stated the transactions on Resident 158's debit card and resulting fees were reimbursed by the bank; however, the resident also had $27.00 in cash missing. FM 35 and FM 36 said all they knew was that a facility staff member had made the transactions on R158's account, but they did not know who that staff person was. FM 35 and FM 36 stated when they identified the fraudulent charges on R158's account they contacted the facility. Per the family members in interview, when they contacted the facility, they were informed the facility was very thankful they caught the charges because it helped the facility narrow down which staff might have done it. FM 35 and FM 36 stated they identified the fraudulent charges on their own and had not been alerted by the facility to be on the lookout for potential fraudulent activity. 3. Review of the admission Record for R10 revealed the facility admitted the resident on 07/22/2022, with diagnoses of dementia and major depressive disorder. Review of the Quarterly MDS Assessment, with an ARD of 03/13/2025, revealed the facility assessed R10 to have a BIMS score of 12, which indicated the resident was moderately cognitively impaired. During interview on 05/01/2025 at 2:20 PM, R10 stated he/she lost his/her credit card approximately three months prior, but it had since been found. R10 initially stated he/she was not aware of anyone using their card without permission. However, when the SSA Surveyor asked R10 if he/she remembered the bank reimbursing him/her for purchases he/she had not made, the resident recalled there had been a few charges on his/her card while it was lost and the bank reimbursed them. R10 stated it had all been taken care of, and the resident did not wish to discuss further. card while it was lost and the bank reimbursed them. Review of an electronic mail (email) correspondence, dated 01/20/2025, revealed the facility submitted an initial report to the SSA by way of email on 01/20/2025 at 12:44 PM. Review of the facility's, Self-Reported Incident Form- Initial Report, dated 01/20/2025, revealed the facility notified the SSA of Misappropriation of Property and a Suspected Crime involving R45 and R158. Continued review revealed the Report identified SRNA 36 as the potential suspect and noted she had been suspended as of 01/20/2025. Review of the facility's, Self-Reported Incident Form- Final Report/5 Day Follow-up, signed by the Administrator on 01/23/2025, revealed the facility initiated interviews with interviewable residents and no other potential victims were identified. Per review of the Report, revealed the facility had been unable to interview SRNA 36, the suspected perpetrator, as she had not returned to the facility to meet with the Administrator. Continued review revealed R45 and R158 resided on the same unit where SRNA 36 had been usually assigned to work. Review of the Report revealed on 01/20/2025, another resident, who resided on the same unit with R45, and had been cared for by SRNA 36, was also notified of potential fraudulent activity on his/her account by his/her bank. Further review revealed after completion of their investigation, the facility concluded, Based on similarities in the suspected fraudulent charges on both resident financial statements received, the location being southern Indiana, the home address of the suspected perpetrator, and the verification that her name is associated with a personal account of one of the businesses of suspected fraudulent charges, the facility is verifying that the event did occur and that the identified person [SRNA 36] is the perpetrator. Review of the facility's, Self-Reported Incident Form- Initial Report, dated 01/30/2025, revealed the facility notified the SSA of Misappropriation of Property and a Suspected Crime involving R10. Per review, SRNA 36 was identified as the suspected perpetrator. Continued review revealed on 01/30/2025, R10 provided a bank statement to the BOM with potential fraudulent charges on his/her account during the timeframe from 01/07/2025 through 01/21/2025. Further review revealed the Report noted it was highly probable the case was related to the initial report involving R45 and R158 from 01//2025. In addition, review revealed the Administrator was to update the local police department with the additional information following submission of the initial report. Review of SRNA 36's personnel record SRNA 36's personnel record revealed her date of hire at the facility was 09/13/2024. Per review of SRNA 36's Application for Employment, signed by her on 09/04/2024, revealed the SRNA reported her address was in Kentucky, and her Work History had been limited to Kentucky. Continued review revealed SRNA 36 answered No to questions regarding whether she had ever been convicted of abuse or neglect to another person, convicted of misappropriation of property, convicted of a crime, or had any criminal charges pending. Further review of SRNA 36's personnel record of the criminal background check results, dated 09/04/2024, revealed multiple charges that had been either dismissed, amended down, or no true bill handed down by grand jury. However, further review revealed it was noted that Charge 1, filed on 06/14/2024 for Theft-Receipt of Stolen Credit/Debit Card- 1 Card was disposed on 08/16/2024 as GUILTY. Unsuccessful telephone call attempts were made on 04/01/2025 at 4:08 PM, and 04/02/2025 at 9:52 AM, to reach SRNA 36 and voice mail messages were left requesting a call back. On 04/03/2025 at 10:33 AM, a third telephone call attempt was made and the individual who answered stated it was the wrong number. During interview on 04/03/2025 at 3:19 PM, a Police Department Detective (PDD) from the local police department stated a warrant had been issued for SRNA 36's arrest; however, she had not been detained as of yet. The PDD stated he had been able to compile enough evidence for a felony charge in his jurisdiction. The PDD reported SRNA 36 had been charged in relation to the purchases made using R45's, R158's and R10's funds. He further stated the amounts of fraudulent purchases made or attempted by SRNA 36 were into the thousands of dollars range. Review of the fraudulent transaction logs for R45, R158, and R10 revealed the facility identified the following amounts of misappropriated funds for each resident: R45-a total of $2087.03 on the resident's credit card account and a total of $479.07 on the resident's checking account, for a total of $2566.10; R158-a total of $253.49 on the resident's checking account; and R10-a total of $212.96 on the resident's checking account. During the interview on 05/01/2025 at 3:15 PM, the Administrator stated when he saw State Registered Nurse Aide (SRNA) 36's criminal background check, he thought, hmmmmm, because he saw the history of charges against her. He said SRNA 36, when originally hired, resided in Kentucky; however, he noticed her address had changed to somewhere in Indiana, where some of the fraudulent charges occurred. The Administrator reported on 01/20/2025, he suspected an employee of the facility made the fraudulent charges, and had narrowed it down to that specific individual. He said he sent an initial report to the SSA on 01/20/2025, and listed both R45 and R158 as the victims. The Administrator stated on 01/30/2025, a third resident (R10) received his/her bank statement for 01/2025 and questioned some of the charges. He further stated at that point he submitted a second initial report to the SSA for the charges affecting R10. He additionally stated the case was in the police departments' hands.

Based on observation, interview, record review, facility document and policy review, the facility failed to provide care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice for 1 of 2 residents sampled for skin conditions out of the total sample of 32, (Resident (R)95). R95 sustained a skin tear; however, staff failed to notify the physician and obtain an order for treatment and failed to complete an incident report and/or skin assessment. Staff then provided treatment to the skin tear without an order. The findings include: Review of the facility's Wound Care Manual of the policy titled, Skin Tear Dressing Procedure, version dated 05/22/2018, revealed to obtain a Physician's order and May Follow Facility Skin and Wound Protocol'. Per review, the Wound Protocol noted to cleanse a wound with normal saline or appropriate wound cleanser; if a skin flap remained to gently approximate skin edges and apply steri strips; apply a transparent dressing; and change the transparent dressing prn [as needed] or when wound has healed. Review of R95's admission Record revealed the facility admitted the resident on 10/29/2024, with diagnoses that included dementia and acute kidney failure. Review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 02/01/2025, revealed the facility assessed R95 to have a Brief Interview for Mental Status (BIMS) score of seven out of 15, which indicated the resident was severely cognitively impaired. Further MDS review revealed the assessed R95 as having no skin concerns, including ulcers, skin tears, or surgical wounds. Review of R95's, Skin Check assessments for 03/05/2025, 03/12/2025, 03/19/2024, 03/26/2025, 03/29/2025, and 04/02/2025 revealed no documentation of skin integrity concerns noted. Review of R95's current Care Plan Report, initiated on 10/30/2024, revealed it included a focus area that indicated the resident had the potential for skin integrity impairment such as skin tears related to fragile skin, decreased safety awareness, poor coordination/balance, weakness, syncope, and medication use. Further review revealed the interventions included: staff to observe R95's skin per the facility protocol; provide skin care per the protocol; and provide treatment as ordered by the physician. Review of R95's Order Summary Report, with active orders documented as of 04/04/2025, revealed no orders for treatment of a skin tear or any wound prior to 04/03/2025, when the State Survey Agency (SSA) Surveyor intervened. During observation of R95's skin on 03/31/2025 at 11:37 AM, a wound was noted on the resident's right leg, with a transparent bandage in place to the wound. In interview, at the time of observation, R95 was unable to state how he/she had gotten the wound, but facility staff were aware of its presence. Observation on 04/03/2025 at 3:44 PM, with the Unit Manager (UM) 4 revealed she completed an observation of R95's right leg. In interview, at the time of the observation, she stated there appeared to be a small skin tear on the leg, which she described as smaller than quarter size, with a skin flap present. UM 4 said skin checks were done on the third shift on Tuesdays by the nurses. She reported the skin tear on R95's leg was something that needed to be documented on a skin check and she needed to notify the Administrator of it. During a concurrent interview, R95 stated the nurse who put on the dressing on said she would be back to take it off when it was ready; however, that had been days ago, and the nurse never returned. During interview on 04/03/2025 at 4:04 PM, Registered Nurse (RN) 21 stated the facility protocol for a new wound was to do an incident report (so they knew where the wound came from), then let the physician know, put in an order, complete a pain assessment, and complete a skin check. She said documentation was done in the chart and was to include a non-ulcer skin assessment and an order for treatment. RN 21 explained if someone found a wound first, they were to report it to her as she was the treatment nurse. She further stated she had been unaware of the skin tear on R95's leg and she did not know who applied the transparent dressing over the wound. During interview on 04/03/2025 at 4:20 PM, State Registered Nursing Assistant (SRNA) 34 stated a skin assessment was done at admission, but he also checked residents' skin during incontinence brief changes or shower. SRNA 34 reported residents could easily get injured by bumping into a table, bed, or wheelchair. He said if he noticed any skin concerns, he would immediately report it to the charge nurse. SRNA 34 further stated he noticed a skin tear on R95's right leg the previous week and reported it to a nurse immediately. During interview on 04/04/2025 at 02:02 PM, SRNA 31 stated the previous week, she noticed a skin tear on R95's right leg while she was assisting the resident into bed, using a gait belt transfer. She further stated she reported it to the nurse, Licensed Practical Nurse (LPN) 32, immediately after observing it. During interview on 04/04/2025 at 9:53 AM, LPN 32 stated she had been aware of R95's skin tear. She said on 03/31/2025, an SRNA had reported to her that the resident had an injury from a gait belt. The LPN reported she gave first aid to the resident, applied a transparent bandage, and called the provider to get treatment orders. She stated however, she did not document that information in the resident's chart. LPN 32 further stated nor had she notified the resident's family; put in orders; reported the wound to any other staff; or completed an incident report due to becoming too busy on her shift. During interview on 04/04/2025 at 9:31 AM, Nurse Practitioner (NP) 33 stated skin tears were expected to be reported to the provider. The NP said staff could call her or the on-call provider, and she would provide treatment orders. She further stated if staff did not report the skin tear, there would be the possibility of the skin tear progressing and causing infection. During interview on 04/04/2025 at 9:38 AM, the Director of Nursing (DON) stated for skin checks, she expected staff to look at the resident's skin every time they provided care, and if they saw anything they were expected to report it. The DON stated a SRNA was expected to report any issues to the nurse, who would contact the provider to get an order, and staff were then expected to follow the physician's order. During interview on 04/04/2025 at 9:42 AM, the Administrator stated skin checks were to be performed weekly, and if anyone noticed any concerns, they were to act on it. He stated he expected staff to apply first aid to stop any bleeding and cleanse a wound and follow the facility's wound care protocol. The Administrator reported he also expected staff to then follow through with an incident report so they knew what happened to the resident. He further stated staff were expected to document skin checks in the electronic medical record (EMR) in full and communicate with the nurse and the provider for obtaining treatment.

Based on interview, record review, and facility document and policy review, the facility failed to ensure it did not employ staff having been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law, which affected 3 of 3 residents reviewed for misappropriation of resident property (Residents (Rs)45, R158, and R10), and had the potential to affect all residents that resided in the facility. The facility employed State Registered Nurse Aide (SRNA) 36, whose preemployment background check reflected a guilty finding for theft-receipt of stolen credit/debit card. In 01/2025, the facility, in conjunction with the local police department, identified SRNA 36 as the suspect in the misappropriation of Residents (Rs) 45's, 158's, and 10's resident funds. Subsequently charges were filed in Kentucky and Indiana, and a warrant issued for SRNA 36's arrest. The findings include: Review of the facility policy, Abuse, Neglect, or Misappropriation of Resident Property, revised 10/15/2022, from the facility's, Administrative Policies manual, revealed, The facility will do whatever is in its control to prevent mistreatment, neglect, exploitation, and abuse of our residents or misappropriation of their property. Per policy review, the facility would not employ individuals that had been found guilty of abusing, neglecting, exploiting, or mistreating residents by a court of law or who had a finding entered into the state's Nurse Aide Registry concerning abuse, neglect, or misappropriation of their (resident) property. Continued review the facility was to report any knowledge it had of actions by a court of law against an employee, which indicated unfitness for service as a nurse aide or other facility staff to the state's Nurse Aide Registry or licensing boards and/or registries. Policy review revealed screening of potential employees (including contracted, temporary agency and volunteers) would be performed by the facility for abuse, neglect, exploitation, or misappropriation of property. Continued review revealed the policy did not specify the means by which the facility would review to determine if tentative employees had been found guilty of abuse, neglect, mistreatment, exploitation or misappropriation by a court of law, such as criminal background checks. In addition, further review revealed the policy also did not specify crimes which were to prohibit employment at the facility. Review of the, Employee Handbook, dated 10/2021, revealed Criminal & [and] Other Background Checks were required for all employees of the company (facility). Per review, if an employee had been charged, arrested, indicted, or convicted of any crime while employed at the company, the employee was required to notify the Administrator of such action within 24 hours. Continued review revealed the company had the discretion to administer disciplinary action up to and including termination or not hiring an applicant with a felony or misdemeanor charge, arrest, indictment, or conviction, including pending charges. Further review revealed the company also had the option to request a criminal record check at any time during an individual's employment, and continued employment was contingent upon the outcome of the criminal record check. In addition, failure to disclose all requested criminal history, required background information, or failure to comply with the policy by any applicant or employee might be grounds for termination. Record review revealed the facility admitted R45 in 07/2024, and noted the resident lost a debit card in 09/2024, which was later found in laundry on 09/30/2024. Per review of R45's progress notes, when the former Social Worker (SW) notified the resident his/her debit card had been found, the resident then also reported a lost credit card. Continued review revealed in 11/2024, R45 reported losing his/her wallet. Review of the facility's, Missing Resident Item form, dated 11/25/2024, revealed R45 alleged his/her wallet and $40.00 in cash was missing. Per review of the form, revealed R45 reported last seeing his/her wallet on 11/23/2024, when he/she was out on a facility shopping trip. Review of the facility's documentation revealed R45's report of the missing wallet and cash was left open until 01/09/2025, when the resident reported suspicious charges on his/her bank statements. Continued review of the facility's documentation revealed on 01/20/2025, a second resident's family (R158's) contacted the Administrator about what appeared to be fraudulent transactions on the resident's financial account. Further review revealed on 01/30/2025, a third resident (R10) reported to the Administrator also identifying fraudulent charges on his/her bank statement. Additional review of facility documentation revealed the facility, in conjunction with the local police department, identified SRNA 36 as the suspect in the three residents' fraudulent charges on their financial accounts. Review further revealed charges were filed in Kentucky and Indiana, and a warrant was issued for SRNA 36's arrest. Review of SRNA 36's personnel record revealed her date of hire at the facility was 09/13/2024. Review of the, Application for Employment, signed by the SRNA on 09/04/2024, revealed the SRNA reported an address in Kentucky, and the Work History provided was limited to Kentucky. Continued review of the Application revealed SRNA 36 answered No to questions regarding whether she had ever been convicted of abuse or neglect to another person, convicted of misappropriation of property, convicted of a crime, or had any criminal charges pending. Further review of SRNA 36's personnel record revealed the criminal background check results, dated 09/04/2024, noted multiple charges that had been either dismissed, amended down, or no true bill handed down by grand jury. In addition, review revealed, Charge 1, filed on 06/14/2024 for Theft-Receipt of Stolen Credit/Debit Card- 1 Card was disposed of on 08/16/2024 as GUILTY. Review of an electronic mail (email) correspondence, dated 09/09/2024, between the Assistant Administrator (AA), Chief Human Resources (HR) Officer of the facility's management company, and part-time attorney/General Counsel (PTGC) with the facility's management company revealed the AA had provided a copy of SRNA 36's criminal background check results to the Chief HR Officer. Per review of the email communications, the AA advised the Chief HR Officer that it appeared to him all of SRNA 36's charges had been dismissed and/or amended down; however, the AA asked the Chief HR Officer to double check. Continued review revealed the AA also advised the Chief HR Officer there was nothing noted on SRNA 36's application regarding pending charges or convictions. Further review of the email communications revealed the Chief HR Officer agreed with the AA; however, he copied the PTGC on the email to have her review and confirm. In addition, review of the email correspondence revealed the PTGC responded that per the report, all charges drop against SRNA 36 had been dropped; thus, the facility was advised they were good on this one. Telephonic (Phone) attempts were made to interview SRNA 36 on 04/01/2025 at 4:08 PM and 04/02/2025 at 9:52 AM, with voicemail messages left requesting a call back. A third phone attempt was made on 04/03/2025 at 10:33 AM, to reach SRNA 36; however, the individual that answered said it was the wrong number. In interview on 04/30/2025 at 3:46 PM, the PTGC stated she had been employed part time by the facility's management company as an attorney/general counsel. She stated the normal process for pre-employment screening in Kentucky was that an outside service ran background checks and Office of Inspector General (OIG) checks. The PTGC said they also reviewed for barrier crimes, which she stated was an old term for a list of specific crimes considered unacceptable findings. She reported now, the list was not so clearcut, and they had to review to see how long ago the charges were and consider other details, such as did it happen thirty years ago and the person had nothing since. The PTGC stated they would not allow someone to work for the company that was guilty of theft or fraud against an individual. She said abuse, theft, or assault against a child or senior would be a no go for hire. In continued interview on 04/30/2025 at 3:46 PM, the PTGC confirmed she had access to the email correspondence regarding SRNA 36's criminal background check results. She reviewed the email information and stated the guilty finding on the report would have required the circumstances of the credit card theft be determined. The PTGC said they should have asked for more details about who the victim of the credit card theft had been; however, did not see evidence in her emails that they had ever asked for more details. She stated it was, obviously a misinterpretation of the report (on her part). The PTGC reported initially she believed the Charge 1 against SRNA 36 had ultimately been dismissed, but said it was listed on the report as guilty. She said in reviewing the document now, it was very difficult to read, and the Charge 1 disposition was concerning. The PTGC stated if she was reviewing the background check results now, she would ask for all the details of the credit card theft SRNA 36 had been ultimately found guilty of, and then determine whether it was something that should stop the facility from hiring her. She further stated the results of SRNA 36's criminal background check would have warranted gathering more information before proceeding with hire of her. During a follow-up interview on 04/30/2025 at 5:00 PM, the PTGC stated she wished to correct some of what she stated in her previous interview. The PTGC stated after talking with the State Survey Agency (SSA) Surveyor, she reviewed SRNA 36's criminal background check results further, and she felt the Charge 1, with the guilty disposition, was later amended down, then ultimately dismissed. She referenced code numbers associated with Charge 1 and Charge 3 (code 0712630) against SRNA 36, and said she took the Charge 1 and Charge 3 to be the same charge. She stated the code numbers were not associated with the actual crime of theft-receipt of stolen credit/debit card. The PTGC further stated those numbers were associated with SRNA 36's charges, so she interpreted the report to mean all of the charges against her had ultimately been dismissed. Review of the undated document from the Administrative Office of the Courts (AOC) titled, Research and Statistics UOR Code [Uniform Crime Reporting Code] Disclaimer revealed the state police assigned the codes to criminal offenses occurring in the state. Continued review revealed the state official list of UOR Codes by KRS [Kentucky Revised Statutes] number and descriptor could be obtained at the state police website at www.kentuckystatepolice.org. Review of a document titled, UOR Code Descriptions, dated 07/16/2018, revealed there were 338 pages of UOR Codes associated with various criminal offenses. Continued review revealed the, UOR Code 0712630 (listed for SRNA 36) was associated with a Class A misdemeanor for, THEFT-RECEIPT OF STOLEN CREDIT/DEBIT CARD-1 CARD. In interview on 05/01/2025 at 8:33 AM, the [NAME] County Deputy Clerk reviewed SRNA 36's case history and stated the SRNA pled guilty to Charge 1. She stated Charge 3 was amended down to a lower charge and then dismissed. The [NAME] County Deputy Clerk stated the UOR Code, 0712630, was a code used in the state that coincided with the crime SRNA 36 had been charged with. She explained that in the state, the codes were assigned to a variety of charges people could be charged with. She stated the Charge 1 and Charge 3 for SRNA 36, having the same code listed did not indicate both of the charges had been dismissed; it just meant the SRNA had been charged with two counts of theft/receipt of stolen credit/debit card. The [NAME] County Deputy Clerk reiterated for Charge 1, SRNA 36 pled guilty, and stated the SRNA's Charge 3 was amended down to a lower charge and then dismissed. In an additional interview on 05/01/2025 at 11:48 AM, the PTGC stated they believed everything had been dismissed on SRNA 36's criminal background check report. She stated the facility needed to talk about their system for reviewing background check results for potential employees. The PTGC said they perhaps should implement reaching back out to the third-party company that obtained the background check results to have them [NAME] more information when the results were not clearcut. She reported she had known SRNA 36 had been found guilty of Charge 1, but the guilty charge alone was not a reason not to hire her. The PTGC stated they should have asked for more details, such as whose credit card it was, in order to determine if they should proceed with hire or not. She again said they believed the charges had been dismissed, so they did not ask for additional details. The PTGC explained it was important to accurately review potential employees' background check reports so they could filter out people who might be a danger to residents or someone else. She further stated this was the first time she had ever misinterpreted an employee's background report. The PTGC additionally stated more than one person came to the wrong conclusion when reviewing SRNA 36's background check results before her hiring. In interview on 05/01/2025 at 11:00 AM, the Chief HR Officer stated if something came up during preemployment screening for potential employees, such as their background check or something was questionable, the facility sent it to him and he got legal (the PTGC) involved if they needed to be. He said he and the PTGC then reviewed the potential employee's preemployment screening and advised the facility as per the regulations. The Chief HR Officer explained there was not an all-inclusive list of crimes prohibiting the hiring of someone. He stated however, if there was anything on a criminal background report that might be a felony or findings that were not clear, such as amended, dismissed, or changed charges, then the Chief HR Officer and the PTGC got involved. The Chief HR Officer stated he and the PTGC got involved so they could look and make sure the facility was meeting the regulatory requirements. In continued interview on 05/01/2025 at 11:00 AM, the Chief HR Officer confirmed he had access to the email correspondence regarding SRNA 36's criminal background check results. He reviewed the email information and stated the AA sent a copy of the background check results to him to double check to ensure they were in line with the facility's guidelines and hiring requirements. The Chief HR Officer reported there had been several lines of charges and some appeared to have been amended down or dismissed. He said that, to him, it appeared all the charges had been dismissed. The Chief HR Officer stated he forwarded a copy of the background check results for R36 to the PTGC to have her review the results as well to be sure. He said the PTGC reviewed the information and agreed all charges had been ultimately dismissed, so they let the facility know they were okay to proceed with hire of SRNA 36. In further interview on 05/01/2025 at 11:00 AM, the SSA Surveyor requested the Chief HR Officer review SRNA 36's criminal background check results and provide his interpretation of the results. He stated SRNA 36's results were tricky. He stated they noticed the Charge 1 and Charge 3 for theft-receipt of stolen credit/debit card both had a number of 0712630, so they determined the charges had been dismissed on 08/16/2024. The Chief HR Officer said he was not aware the number 0712630 was a UOR Code that was assigned to that particular offense. He reported he was not in law enforcement, but because it had the same number and charge description, they thought the charges matched, and the report meant the charges had all been dismissed. The Chief HR Officer stated they identified SRNA 36 as not to have been found guilty of theft-receipt of stolen credit/debit card, and would have reviewed her application to see if it included any explanations. He reported if it had been a felony, SRNA 36 probably would not have been approved for hire, and if it had been a misdemeanor, the SRNA might or might not have been approved for hire. The Chief HR Officer said per the email correspondence from the AA, there had been nothing noted on SRNA 36's application about pending or old convictions. In additional interview on on 05/01/2025 at 11:00 AM, the Chief HR Officer stated they needed to have analyzed SRNA 36's guilty finding to see if it was a misdemeanor or felony or if there had been anything that fell under abuse, neglect, or misappropriation per state regulations. He said had they realized SRNA 36 had a guilty finding, they would have sought more information. The Chief HR Officer reported they would also have asked the applicant why she had not disclosed that information on their application, determined who the victim had been, and then, depending on circumstances, they might or might not have hired her. In interview on 05/01/2025 12:59 PM, the AA stated he occasionally reviewed potential employees' preemployment background checks, typically if the Administrator was off or was not in the building for some reason. He said the facility normally conducted what they called a 'triple check for preemployment screening. The AA reported the triple check consisted of criminal background checks, abuse registry checks, and a check to make sure any necessary certifications were active. He stated he recalled being involved in that process for SRNA 36. The AA said he recalled SRNA 36's criminal background check came back with at least one charge that looked to be initially a felony charge that had been amended down or dismissed or both. He explained that anytime there were concerns noted on a potential employee's background check results, they forwarded the results to the Chief HR Officer for review. The AA stated the Chief HR Officer then advised the facility as to whether they could proceed with hiring that employee. He further stated for SRNA 36, the facility had been advised that everything was dismissed or amended down, so the facility proceeded with hiring her. In interview on 05/01/2025 at 2:49 PM, the Administrator stated the facility's preemployment screening process consisted of an interview with the applicant. He said if there was interest in the applicant, they checked the abuse registry, any applicable certifications, the state adult caregiver misconduct list, the Office of Inspector General's (OIG's) exclusion list, and performed a criminal background check. The Administrator stated per his understanding, a felony offense, abuse, neglect, exploitation, or a sexual crime would prohibit employment of that individual. He reported he had been out at the time SRNA 36's criminal background check results were reviewed. The Administrator said however, the AA reviewed SRNA 36's results and forwarded them to the Chief HR Officer to ensure the SRNA was not classified under categories where the facility could not employ her. He reported to his understanding, one of SRNA 36's charges had been dropped to a misdemeanor, which would not prohibit the facility from hiring her. The Administrator further stated a guilty finding for theft, specifically receipt/use of stolen credit/debit card, would not necessarily exclude the SRNA from being eligible for hire.

Based on interview, record review, and facility document and policy review, the facility failed to report suspected misappropriation of resident property to the State Survey Agency (SSA) within 24 hours of forming suspicion of misappropriation for 1 of 3 residents reviewed for misappropriation of resident property (Resident (R)45). The findings include: Review of the facility's, Administrative Policies manual area titled, Abuse, Neglect, or Misappropriation of Resident Property Policy, revised 10/15/2022, revealed the Administrator was to ensure the Division of Licensure and Regulation (Office of Inspector General (OIG) and Adult Protective Services [APS] were notified immediately but no later than two hours after an allegation was received for all complaints of abuse .or misappropriation of resident property. Continued review revealed for all allegations that did not involve abuse or had not resulted in serious bodily injury, the Administrator was to ensure the Division of Licensure and Regulation and APS and other appropriate agencies were notified no later than 24 hours after the allegation was received. Review of the admission Record, for R45 revealed the facility admitted the resident on 07/19/2024, from another skilled nursing facility. Per continued review of the admission Record, R45 had a medical history that included diagnoses of generalized anxiety disorder, mild cognitive impairment, bipolar disorder, and major depressive disorder. Review of the facility's admission Minimum Data Set (MDS) Assessment for R45, with an Assessment Reference Date (ARD) of 07/25/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Further review MDS review revealed the facility assessed R45 as considering having a place to lock his/her belongings to keep them safe while in the facility as somewhat important. Review of the Significant Change in Status MDS Assessment with an ARD of 01/31/2025, revealed the facility assessed R45 to have a BIMS score of five out of 15, indicating severe cognitive impairment. Review further revealed the facility assessed R45 to consider having a place to lock his/her belongings to keep them safe while in the facility as very important. Review of the facility's initial report of an Allegation of Theft or Misappropriation of Property, dated 01/09/2025, revealed the report was submitted to APS, and noted it served as both an initial and final report. Continued review revealed fraudulent activity began on R45's account in 11/2024, and the alleged perpetrator was unknown. Per review, the report indicated the facility suspected R45's debit card or other financial information might have been used fraudulently by someone outside of the facility. Further review revealed the facility notified APS they needed assistance with handling the fraudulent use of R45's debit card, and guardianship might need to be pursued for the resident. In addition, review of the report further revealed fraudulent transactions had been made in a variety of cities throughout Kentucky and Indiana. However, review revealed no documented evidence a report of misappropriation of resident property was submitted to the SSA on behalf of R45, when they formed a suspicion of potential misappropriation of resident property on 01/09/2025. During an interview on 05/01/2025 at 12:23 PM, the Business Office Manager (BOM) stated R45 received his/her own bank statements, and on 01/09/2025, the resident came to her with a copy of the bank statement. The BOM said R45 wanted her to review the statement due to charges that the resident thought looked suspicious. She reported, I had no idea what was going on. There were some charges [the resident] said were suspicious but others [the resident] said were none of my business. The BOM stated at one point, it came up that R45 was paying expenses for a friend in an apartment. She said she asked R45 if he/she had given a friend his/her bank cards or permission to pay their bills, to which the resident said no. The BOM further stated she notified the Administrator of the suspicious charges, so the Administrator could get APS involved and maybe consider getting a court-appointed guardianship for R45. During an interview on 05/01/2025 at 3:15 PM, the Administrator stated on 01/09/2025, R45 went to the BOM with a bank statement with questions about some transactions. He said through discussions with R45 information was discovered that suggested the resident had been paying for utilities at an apartment, so facility staff felt something was going on. The Administrator stated R45 was not very forthcoming when asked about the charges at that time, and all they could do at the time (01/09/2025) was talk to APS because they felt the resident was mismanaging his/her money. He said APS was contacted as it was felt R45 needed a state guardian, and he also contacted the local police department on 01/09/2025; however, had not contacted the SSA. The Administrator reported he had not made a report to the SSA on 01/09/2025, because there was no reason to suspect anything fraudulent, and the facility just needed APS' assistance in getting the resident a guardian. He stated he could not verify the charges on R45's bank statement were fraudulent on 01/09/2025, but he had to say that to get APS to accept the case. During an interview on 04/30/2025 at 3:46 PM, the facility's Part-Time General Counsel (PTGC), with the facility's management company, stated if the facility identified concerns with potential fraudulent activity with resident funds, regardless of whether the facility thought it occurred within their building, the facility needed to report to the SSA within 24 hours. During an interview on 05/02/2025 at 12:14 PM, the [NAME] President of Health Services (VPHS), also with the facility's management company, stated when an Administrator suspected fraudulent activities or a resident reported suspicious charges on their account, the expectation would be consistent with the regulatory requirement and what the facility' policy specified. The VPHS further stated the regulatory requirement and facility policy was to report to the SSA within 24 hours.

Based on interview, record review, and facility document and policy review, the facility failed to ensure a thorough investigation was completed and submitted to the State Survey Agency (SSA) within five days of forming the suspicion a resident's financial information was being used fraudulently for 3 of 3 residents sampled for misappropriation of resident property (Residents (R)45, 158, and 10). On 01/09/2025, R45 reported suspicious charges on his/her financial statement to facility staff. However, the facility failed to submit an initial report of suspected misappropriation of resident property to the SSA or conduct interviews with residents to determine if other residents were potentially impacted, or interview staff to determine what knowledge they might have had until 01/20/2025. On that date a second resident's family (R158's) contacted the Administrator about what appeared to be fraudulent transactions on their family member's financial account. Additionally, on 01/30/2025, a third resident (R10) reported to the Administrator he/she identified fraudulent charges on his/her bank statement. The facility, in conjunction with local police, eventually identified State Registered Nurse Aide (SRNA) 36 as the suspect with charges filed in Kentucky and Indiana, and a warrant issued for the SRNA's arrest. The findings include: Review of the facility's, Administrative Policies manual policy titled, Abuse, Neglect, or Misappropriation of Resident Property, revised 10/15/2022, revealed the facility would do whatever was in its control to prevent mistreatment, neglect, exploitation, and abuse of our residents or misappropriation of their property. Per review of the policy, Investigation allegations of abuse, neglect, exploitation, or misappropriation of resident property and injuries of unknown origin will be investigated by the facility. Continued review revealed the Administrator was responsible to direct the investigation process and ensure all appropriate agencies were notified, as indicated. Review of the policy further revealed it did not provide specific instructions as to what a thorough investigation should consist of, or when certain investigatory actions should be taken. Record review and review of facility documentation revealed the facility admitted the resident in 07/2024, and the resident reported losing a debit card in 09/2024, which was noted as found in the laundry on 09/30/2024. Review of the Progress Notes for R45 dated 09/30/2024, revealed the facility's former SW documented talking to the resident about his/her missing debit card being found in the laundry and noted the resident told her he/she had a credit card that was also missing. Review of an untitled facility log notation dated 11/25/2024, for missing resident items revealed documentation of R45 losing a wallet and $40.00 in cash. Continued review of the untitled log, under the column titled, Found, (which listed where each item on the log was located) revealed a report of R45's missing wallet and $40.00 was turned over the Administrator. Further review revealed no documented evidence R45's missing wallet or $40.00 was ever located. Review of the Missing Resident Item form dated 11/25/2024, revealed R45 reported on 11/24/2024, missing a wallet and $40.00 in cash. Review revealed the form had been signed by the Administrator on 11/25/2024; however, had not been signed and noted as completed by the Administrator until 01/10/2025. Further review of the form revealed the Administrator documented notifying the local police and Adult Protective Services (APS) on 01/09/2025, of potential fraudulent activity related to R45's reported missing items (from 09/2024 and 11/2024). Review of the facility's Allegation of Theft or Misappropriation of Property, initial report dated 01/09/2025, revealed the report had been submitted to APS, and was noted to have served as both an initial and final report. Review of the report revealed in 11/2024, fraudulent activity had began on R45's account and the alleged perpetrator noted as being unknown. Per review, the facility suspected R45's debit card or other financial information might have been used fraudulently by someone outside of the facility. Continued review revealed the facility notified APS regarding needing assistance with handling the fraudulent use of R45's debit card, and might need guardianship pursued for the resident. Further review of the report revealed the fraudulent transactions had been made on R45's accout in several cities throughout Kentucky and Indiana. However, the facility failed to conduct interviews, at that time, with staff to determine if they might have had knowledge of SRNA 36's misappropriation of residents funds. Nor, did the facility interview other residents to determined whether other residents had also been impacted until 01/20/2025, when another resident reported suspicious charges on his/her account. The facility failed to provide documented evidence of a report of misappropriation of resident property having been submitted to the SSA on 01/09/2025, when suspicion of potential misappropriation of resident property was formed. Review of an electronic mail (email) correspondence dated 01/20/2025, revealed the facility submitted an initial report of R45's misappropriated funds to the SSA by way of email on 01/20/2025 at 12:44 PM. Review of the facility's, Self-Reported Incident Form- Initial Report, dated 01/20/2025, revealed another resident's (R158's) family notified the facility of fraudulent transactions they had not approved on the resident's account. Per review, the State Survey Agency (SSA) was notified on that date of Misappropriation of Property and a Suspected Crime involving R45 and R158. Further review revealed the report identified State Registered Nurse Aide (SRNA 36) as the potential suspect and noted she had been suspended as of 01/20/2025. Review of the facility's, Self-Reported Incident Form- Final Report/5 Day Follow-up, signed by the Administrator on 01/23/2025, revealed the facility initiated interviews with interviewable residents with no other potential victims identified. Review revealed the facility had been unable to interview SRNA 36, the suspected perpetrator, as she had not returned to the facility to meet with the Administrator and was unable to be reached. Per review, R45 and R158 were identified to have resided on the same unit where SRNA 36 had usually worked. and on 01/20/2025, another resident (R10), who also resided on that same unit was notified of potential fraudulent activity on his/her account by his/her bank. Continued review revealed after completing the investigation, the facility concluded based on similarities in the suspected fraudulent charges on the residents' financial statements occurring in the same area of southern Indiana, where the suspected perpetrator resided, the facility verified the events occurred and the identified person (SRNA 36) was the perpetrator. Review of the facility's, Self-Reported Incident Form- Initial Report, dated 01/30/2025, revealed another resident (R10) provided the facility's Business Office Manager (BOM) with his/her bank statement with potential fraudulent charges occurring during the timeframe of 01/07/2025 through 01/21/2025. Per review, the facility notified the SSA of Misappropriation of Property and a Suspected Crime involving R10 on that date. Continued review revealed SRNA 36 was again identified as the suspected perpetrator. Review further revealed it was noted as highly probable the case was related to the initial report involving R45 and R158 from 01//2025. In interview on 05/01/2025 at 12:23 PM, the BOM stated R45 received his/her own bank statements. She said on 01/09/2025, R45 came to her with a copy of his/her bank statement, wanting her to review the statement due to charges the resident thought looked suspicious. The BOM reported R45 also told he/she needed to go to the bank, she made the resident an appointment with the bank the following Monday, 01/13/2025. She stated the Assistant Administrator (AA) transported R45 to the appointment at the bank. The BOM said she had no idea what was going on. The BOM further stated she notified the Administrator of the suspicious charges on R45's account in order for the Administrator to get APS involved and maybe consider getting court-appointed guardianship for the resident. During interview on 05/01/2025 at 3:15 PM, the Administrator stated when R45 reported his/her wallet missing, the resident would not give him much information. He said, so he told R45 all he could do was call the store the resident thought they lost the wallet at to see if someone turned it in. The Administrator reported as a result of that the investigation was just left open until January [2025] when he found out the extra information. He explained on 01/09/2025, R45 had gone to the BOM with his/her bank statement and questioned some of the transactions. The Administrator stated R45 did not come to facility staff with concerns about his/her finances until 01/09/2025, and that was when he remembered the resident's report of a missing wallet from 11/2024, so he pulled that information. He said all the facility could do at the time (01/09/2025) was talk to Adult Protective Services (APS) as it was felt R45 was mismanaging his/her money and probably needed a guardian. The Administrator stated he contacted APS and the local police department on 01/09/2025; however, had not contacted the SSA then. He reported he had not made a report to the SSA on 01/09/2025, as there had been no reason to suspect anything fraudulent, and the facility just needed APS' assistance in getting the resident a guardian. In continued interview on 05/01/2025 at 3:15 PM, the Administrator stated he initiated an investigation on 01/09/2025, which included calling R45's contact, the local police, and scheduling an appointment at the bank for the resident. He said however, he had not started doing any sort of interviews with staff or other residents to determine if others might have been affected on 01/09/2025. The Administrator reported he did not think he started any sort of resident or staff interviews regarding potential fraud or misappropriation until 01/20/2025. He stated on that date R158's family called to report some charges the resident and/or family had not approveed. The Administrator explained he thought he acted appropriately, and further said, I do not see what a few days difference makes, and I did not suspect fraud at first. I did not think an employee did this. He said R158's family sent him a screenshot of an alert they received about a transaction, and he recognized the transaction occurred at similiar place and area as was on R45's statements. The Administrator stated after he started comparing he realized it was the exact same place as one of the transactions on R45's account. He explained as R158 had only been in the facility for about a week, he was able to pull the staffing sheets for that time period and that narrowed things down quickly. The Administrator reported R45 and R158 resided on the same unit, so he looked at the staff who had worked on it and started there. In further interview on 05/01/2025 at 3:15 PM, the Administrator stated he pulled the criminal background checks for all of staff assigned to R45's and R158's unit during the timeframe in question to make sure all of the checks had been completed. He said as he looked at SRNA 36's checks he thought, hmmmmm, when he saw a history of charges against her. The Administrator stated it was at that point, on 01/20/2025, that he suspected it was an employee of the facility and narrowed it down to a specific individual. He said it was at that point he proceeded with an initial report to the SSA. The Administrator stated in his initial report to the SSA on 01/20/2025, he listed both R45 and R158 as the victims. He stated R10 received his/her bank statement for 01/2025 and the resident reported questioning some of the charges on the statement. The Administrator further stated he submitted a second initial report to the SSA for the charges affecting R10, and the case was in the police departments' hands. During interview with the Senior [NAME] President of Health Services (SVPHS) and the [NAME] President of Health Services (VPHS) on 05/02/2025 at 12:14 PM, they both reported working for the facility's management company. The VPHS stated when an Administrator suspected fraudulent activities or a residents reported suspicious charges on their account, the expectation would be consistent with the regulatory requirements (for conducting investigations). The VPHS reported an initial report was to be made within 24 hours (to the appropriate agencies) and an investigation began as soon as possible. The VPHS said an investigation should consist of interviewing staff and other residents to determine what knowledge they might have or whether other residents were potentially also impacted. She further stated those interviews should be initiated as soon as an allegation was made.

Based on observation, interview, record review, facility document review, and facility policy review, the facility failed to take action to ensure nutritional parameters were maintained for one (Resident (R) 48) of two residents reviewed for nutrition. R48, who was clinically underweight, based on a low Body Mass Index (BMI), had orders for a nutritional supplement. The Registered Dietitian (RD) and medical provider were not promptly informed when the resident was not offered and/or did not consume the full amount of ordered supplement. The findings include: Review of the facility policy titled, Weight Policy, dated 08/2013, revealed, The weight committee/care plan team will review and take appropriate measures to resolve weight loss or gain. Review of the admission Record for R48 revealed the facility admitted the resident on 07/30/2021, with diagnoses of adult failure to thrive and other symptoms and signs concerning food and fluid intake. Review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 03/21/2025, revealed R48 had a Brief Interview for Mental Status (BIMS) score of 9/15, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required setup or clean-up assistance with eating, was 60 inches (5 feet, 0 inches) tall, and weighed 78 pounds. Review of R48's Care Plan Report included a focus area revised on 03/21/2025 that indicated the resident was far below the ideal body weight and required a therapeutic diet, therapeutic approach, and supplemental approaches. Interventions included for staff to provide the diet as ordered by the physician, refer to the dietitian for evaluation/recommendations (initiated 01/10/2023), and weigh/review weights per facility protocol with weekly weights times for four weeks (revised on 03/21/2025). Review of R48's weight record revealed the resident was weighed monthly for the last six months. Weights included 83.0 pounds on 09/24/2024 and 77.6 pounds on 03/25/2025. This constituted a 5.4-pound (6.5%) weight loss in a six-month period. Review of the Progress Note, dated 03/07/2025 for R48, uploaded at 12:00 AM, and written by the Nurse Practitioner (NP), revealed the resident reported they were doing well, and staff reported the resident was eating some of the meals and supplements. The resident's weight was noted and had been stable over the past year. The note indicated the resident was underweight, and the NP would continue to monitor this closely, along with the treatment team. The note indicated that the resident's BMI was below normal parameters, and that the resident had been referred to the RD for dietary consultation and recommendations/strategies for achieving a healthy BMI. Review of R48's, Progress Note, dated 03/20/2025 at 8:43 PM and written by the RD, 11 days after the NP referral, revealed R48 had fluctuations in weight with no significant weight loss in the last 30/90/180 days. The resident's current weight was 78 pounds with a body mass index of 15.3, indicating the resident was underweight. The resident's meal intake was less than 50% of most meals on average. The resident was offered many supplements daily due to less-than-optimal intake, and these included Med Pass 2.0 120 milliliters (ml) by mouth twice a day with medication delivery. The note indicated the resident's preferences were being honored by dietary. The RD's recommendation was to continue to encourage intakes and monitor for changes with needs and treatment plans. Review of R48's current Physician Orders confirmed an order, dated 11/10/2023, for Med Pass 2.0 (a dietary supplement) 120 ml three times a day with medication pass. Observation of a medication pass on the 200 Hall on 04/02/2025 at 7:25 AM, Certified Medication Technician/State Registered Nursing Assistant (CMT/SRNA) 2 was observed to administer 60 ml of Med Pass 2.0 to 48 (Not the ordered amount of 120 mls). In interview on 04/02/2025 at 7:25 AM, CMT/SRNA 2 said R48 had a physician order to receive 120 ml of Med Pass 2.0; however, 60 ml was all that was poured because the resident would not drink more than that. CMT/SRNA 2 further stated when a resident took only 60 ml of Med Pass 2.0, the amount was be entered into the system (electronic medical record) and the hall nurse was notified. Review of the 02/20/2025 Medication Administration Record (MAR) for R48 revealed the resident only received a partial amount of the ordered volume of Med Pass 2.0 supplement on 50 out of 84 occasions. Review of the 03/2025 MAR revealed R48 only received a partial amount of Med Pass 2.0 on 63 out of 93 times. Further review revealed as of 04/02/2025, the 04/2025 MAR noted R48 only received a partial amount of Med Pass 2.0 supplement for three out of four doses. During interview on 04/02/2025 at 9:22 AM, Licensed Practical Nurse (LPN) 3 stated if a resident refused a medication/supplement, the CMT was expected to report that information to one of the three nurses that covered the unit. She said she was the desk nurse for the 200 Hall on 04/02/2025, and had not received a report on 04/02/2025 that a resident had refused anything. LPN 3 reported once a nurse was informed of a refused medication or supplement, they should attempt to get the resident to take the medication or supplement. She further stated if a resident continued to refuse, the physician should be called if it was life threatening or the Nurse Practitioner (NP) notified if it was not life threatening. In interview on 04/02/2025 at 9:37 AM, LPN 1 stated if a medication was refused by a resident, a CMT was expected to complete a form that would be provided to the nurse. LPN 1 said he would try to determine why the resident was not taking the medication and would encourage them to take it. He reported if the resident continued to refuse, he would then chart the refusal and include the effort to readminister the medication, along with the resident's preference. LPN 1 explained he had not been informed on 04/02/2025 that the Med Pass 2.0 was not delivered in the full amount to R48. He said R48 did not care for the supplements and sometimes thought they were baby food. He stated when a situation like that occurred, he would report it to LPN 3, and if he had a good reason, he would be in touch with (update) the NP, within nursing judgement. He clarified it was discretionary on what items he would report to a physician or NP. In interview on 04/02/2025 at 9:59 AM, Unit Manager (UM) 4 stated when a resident refused a medication or supplement, the CMT was expected to notify the nursing team (desk nurse, cart nurse, or UM) of the refusal. UM 4 said if the CMT reported that information to her, she would make a note in her notebook. She explained she would review with the resident, assess if needed, and chart what she discovered in a progress note, along with the education she provided to the resident. UM 4 stated If a resident did not have the cognition to be educated, she then contacted the family and provided education. She said it was expected the other two nurses on the unit would complete the same process. She stated if a resident took only a portion of the medication or supplement, she would notify the physician and the department that ordered/recommended the medication or supplement. The UM reported if the resident desired a partial dose of a supplement, the nurse should try to discover the root cause of the refusal of the whole amount as it could be something they could adjust. She said the partial refusal would be documented, and the information reported in the morning meeting. UM 4 explained that in the morning, prior to the meeting, a UM would review the 24-hour report in the electronic medical record (EMR), but a partially administered supplement would not show up on that report. She stated that information would have to be verbally reported to the IDT, based on the report received by staff. The UM reported that information would then be discussed in the morning Interdisciplinary Team (IDT) meeting, and they would watch the resident for trends. She stated she had been made aware of R48's partial refusal of Med Pass 2.0 on 04/02/2025 (after SSA Surveyor intervention). UM 4 said she would document R48's partial refusal later in the shift. She further stated if it was a chronic refusal, there might not be a note every time; however, the previous refusals should be documented and then care planned by another department. In interview on 04/02/2025 at 11:47 AM, the RD stated she worked onsite at the facility two days per week. She said upon her arrival at the facility, she evaluated residents based on various factors, including but not limited to assessment dates, weight changes, and the use of supplements. The RD reviewed the previous Progress Note, dated 03/20/2025, and explained that the phrase, less than optimal intake, referred to the meal intake and not the supplement intake. She reported if a resident was consuming a partial dose of Med Pass 2.0, she would investigate for a trend and if the trend continued, she would decrease the supplement to the desired amount. The RD said she should be made aware by word of mouth (verbally) of a resident consuming less than the ordered amount of their supplement. She stated it had not been reported to her that R48 was being provided and/or consumed less than the ordered amount of Med Pass 2.0. The RD further stated her expectation was for staff to report to her if a resident did not desire the ordered amounts, and, in response, she would change the order/recommendation. She additionally stated because R48 had a low meal intake, she was pushing as much supplement as possible to keep the resident's calorie intake up. In interview on 04/03/2025 at 11:44 AM, the NP stated her expectation for someone refusing medication, including a supplement, was for the CMT to notify a nurse and then the nurse to notify her. She reported R48 had been underweight the entire time while a resident of the facility, and had multiple interventions, including dietary supplements. The NP said she was aware R48 had consumed smaller amounts of the supplement the last few days (prior to this interview). She stated it was her expectation staff notify the RD of the amount of supplement consumed. The NP further stated R48's weight loss was of concern, and she continued to review the resident frequently and adjust as necessary. In interview on 04/04/2025 at 11:25 AM, the Infection Preventionist/Quality Assurance (IP/QA) Nurse stated during morning meeting, departmental staff, which included dietary, nursing, and other departments, reviewed progress notes from the previous 24 hours. The IP/QA Nurse said the Administrator documented notes on the concerns on the Cardinal IDT team meeting minutes. The IP/QA Nurse further stated the team had discussed R48's weight in the past, but did not recall discussing the resident in 02/2025 or 03/2025. In interview on 04/04/2025 at 10:43 AM, the Director of Nursing (DON) revealed when a supplement was recommended by the RD, the nursing team was to receive the order and enter it into the EMR. She said for Med Pass 2.0 supplements, the clinical staff member passing the medication was expected to document the amount the resident consumed. The DON reported for a partial dose, the amount consumed was to be documented on the resident's MAR, and the refused amount reported to the nurse, who would then provide notification to the NP and the RD, depending on the situation. She stated the refusal or partially missed dose should also be reported by the UM to the IDT team during the morning meeting to discuss weight loss. The DON said she did not recall anything being brought up in the morning meeting regarding R48. The SSA Surveyor reviewed the partial administrations of Med Pass 2.0 with the DON, and she stated R48 had not lost significant weight and asked why it mattered. In interview with the Administrator, on 04/04/2025 at 12:33 PM, he stated when a resident refused a medication/supplement or consumed only a portion, he expected staff to honor the resident's desires. He said when there was a partial refusal, the CMT should report that information to the nurse. The Administrator stated the clinical staff should then try to give the refused medication/supplement. He reported once the refusal became a trend, the UM was to report that information to the IDT team, and if the IDT team observed a pattern, they would intervene before it impacted the health of the resident. The Administrator said the nursing team was responsible to communicate any information documented on the MAR to the RD. He stated he was aware R48 was taking partial amounts of the Med Pass 2.0 supplement and had a Quality Assurance (QA) document that was evidence of the resident being reviewed and discussed by the IDT team. However, review of the referenced document revealed it did not indicate a date, nor did it include the Med Pass 2.0 supplement under the supplement section.

Based on observation, interview and review of facility policy it was determined the facility failed to store food under sanitary conditions. Observations on initial kitchen tour revealed opened containers of spices not dated; a box of cornstarch box missing the top and not dated; and a white powdery substance in a clear container with a scoop and not labeled or dated. In addition, observations of resident nursing unit nourishment refrigerator revealed resident food products not labeled or dated. The findings include: 1. Review of the facility policy Food Storage, dated 11/15/12, revealed staff labeled all incoming foods with a delivery date and/or open date or use by date. Review of the facility policy Food Safety Policy, dated 06/23/17, revealed the goal of the nursing facility ensured the safety of all residents and included the prevention of food borne illnesses. Residents had the right to receive foods brought in by family and visitors, and staff placed all foods in sealed storage containers and dated for the date the food arrived at the facility. Additionally, foods brought into the facility were discarded after forty-eight (48) hours. Observation, on 02/11/2020 at 8:45 AM, during the initial kitchen tour revealed on the shelves above a kitchen prep table the following: ground ginger and ground nutmeg dated 06/18/16, two (2) containers of lemon juice dated 01/18/18, with manufacturer's use by dates of 09/14/18, and 11/14/19. A container of fennel seeds dated 04/24 with no year or use by date noted. The lids to the spices and fennel seeds lids remained opened to air. A box of cornstarch was dated 10/31/19 and had no top, exposing the contents to air. A container of Worcestershire sauce had a manufacturer's use by date of 01/05/2020. Continued observation of kitchen, on 02/11/2020 at 11:00 AM, revealed on the shelf above the kitchen prep table, a white powdery substance in a clear-lidded container. The container was not labeled or dated and contained a scoop. Interview, on 0[DATE]20 at 10:27 AM, with the Assistant Dietary Manager/Cook (ADM), revealed rotation of spices was the cook's responsibility. The ADM stated spices lasted for two (2) years or until the manufacturer's use by date. Staff closed container lids/covers to prevent dust or other particles from falling into the container and preventing a potential for cross contamination, and staff closed the lids to containers after every use. The white powdery substance was thickener in the clear container and needed a label and date. Without a label, staff may mistake the thickener for sugar, flour or detergent. Staff did not leave scoops in containers due to the potential of cross contamination, and staff closed the cornstarch lid, dated and bagged the box after opening. Interview, on 0[DATE]20 at 10:44 AM, with the Dietary Manager (DM), revealed staff closed the spice lids after use. In addition, the DM stated the facility expected staff to label the spices, cornstarch and lemon juice with an opened date, and follow the manufacturer's date of expiration. The DM stated the open containers of spices and cornstarch can allow pests and dust particles to enter, a potential for cross contamination. Staff labeled and dated the thickener and removed the scoop. The unlabeled thickener may be confused with sugar, salt or a chemical powder, and the scoop left in the thickener was a potential for cross contamination. 2. Review of the facility policy Food Safety Policy, dated 06/23/17, revealed the goal of the nursing facility ensured the safety of all residents and included the prevention of food borne illnesses. Residents had the right to receive foods brought in by family and visitors, and staff placed all foods in sealed storage containers and dated for the date the food arrived at the facility. Additionally, foods brought into the facility were discarded after forty-eight (48) hours. Observation, on 02/12/2020 at 10:36 AM, revealed the nourishment refrigerator on the North unit contained an unlabeled item in the freezer and refrigerator. Observation, on 02/12/2020 at 10:45 AM, revealed on the South unit a nourishment refrigerator with a container of French onion dip with no date and no resident identification. Interview, on 0[DATE]20 at 1:05 PM, with Licensed Practical Nurse (LPN) #2, revealed staff from Medical Records checked the nourishment refrigerator daily, every morning during the week and insured the food brought in by family was dated and labeled. She stated food not labeled or dated was thrown out. Interview, on 0[DATE]20 at 2:10 PM, with LPN #4, revealed staff refused to accept food containers not dated with a residents' name brought by the family. LPN #4 stated food not dated or identified with residents' name was discarded. LPN #4 checked the nourishment refrigerators every morning and afternoon prior to leaving for the day. Interview, on [DATE]20 at 9:37 AM, with the Director of Nursing (DON), revealed the Dietary Manager ensured all food items were labeled and dated. The DON stated spices and other food items were to be closed when not used to prevent the potential of foreign particles and cross contamination of the food products. Interview, on [DATE]20 at 10:49 AM, with the Administrator, revealed her expectations for food items to be dated, and labeled according to the facility policy. She stated food containers were to be labeled and dated and closed to prevent cross contamination. Food brought in by family was labeled, with date and resident name and if the food protect was not labeled or identified, then thrown out.

Based on observation, interview, and facility policy review, it was determined the facility failed to provide a separately locked, permanently affixed compartment for the storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1[AGE]6 for one (1) of two (2) medication storage refrigerators. The South Unit medication refrigerator contained four (4) vials of [MEDICATION NAME], (a Schedule IV medication classification, and a benzodiazepine with antianxiety, sedative, and anticonvulsant effects), which were not stored or secured properly. The findings include: Review of the facility policy Controlled Substances, dated 10/01/15 revealed under General Provisions 1 that controlled substances were classified by the Controlled Substances Act of 1[AGE]0 as follows D. Schedule IV drugs with less potential for abuse and included benzodiazepines, and all controlled substances were to be stored separately from other medications and under double lock at all times. The policy did not reveal Schedule IV drugs, which required refrigeration, be stored and maintained in a separately locked, and permanently affixed refrigerator compartment. Observation, on 02/12/2020 at 8:30 AM, of the South Nursing Unit's medication refrigerator revealed four (4) one (1) milliliter (ml) vials of medication labeled [MEDICATION NAME] two (2) milligrams (mg) per ML. The vials were not secured in a separately locked and permanently affixed storage compartment. Interview with the RN Supervisor, on 02/12/2020 at 8:30 AM, and 0[DATE]20 at 11:00 AM, revealed [MEDICATION NAME] was a narcotic, and was part of the Emergency Drug Kit (EDK) and needed to be refrigerated. She revealed the [MEDICATION NAME] was always stored in the side door of the medication refrigerator, isolated from the other medications. She stated she believed the medication to be secure because the refrigerator was locked, and well as the medication room door. She was not aware a Scheduled IV drug such as [MEDICATION NAME] should be secured in separately locked, and permanently affixed storage compartment. Interview with the South Nursing Unit Charge Nurse, on 0[DATE]20 at 11:05 AM, revealed the [MEDICATION NAME] was part of the EDK, and was reconciled by the nursing staff each shift. She stated she felt the [MEDICATION NAME] was secure in the refrigerator because it was behind a locked door, in a locked medication refrigerator, and under camera surveillance. She was not aware a Scheduled IV drug such as [MEDICATION NAME] should be secured in separately locked, and permanently affixed storage compartment. Telephonic interview, on [DATE]20 at 9:19 AM, with the Consultant Pharmacist revealed she was aware the facility did not store the [MEDICATION NAME] for the EDK in a separately locked, and permanently affixed storage compartment. She stated she was aware [MEDICATION NAME] was a Scheduled IV narcotic and needed to be stored with a double lock. She revealed a separately locked, and permanently affixed storage compartment would make it more difficult to misappropriate the drug.

Based on record review, interview, and facility policy review it was determined the facility failed to develop an baseline care plan for anticoagulation therapy within forty-eight (48) hours for one (1) of twenty-six (26) sampled residents, Resident #62. The findings include: Review of the facility's policy Resident Care Plan, page revision dated 11/13/17, revealed the initiation of the baseline care plan began with the designated registered nurse (RN) upon admission of a resident. The baseline care plan included the instructions needed to provide effective and patient-centered care for the resident to meet professional standards of quality care. The baseline care plans included, but were not limited to the initial goals of a resident, physician orders, dietary orders, therapy services, social services, and PASRR recommendations, if applicable. Staff completed the baseline care plan within forty-eight (48) hours of the residents' admission to the facility. Review of the clinical record for Resident #62 revealed the facility admitted the resident on 10/11/18 with [DIAGNOSES REDACTED]. Continued review of the clinical record for Resident #62 revealed physician orders, dated 10/11/18, written for [MEDICATION NAME] (anticoagulation medication) 40 milligram (mg) subcutaneous every day. Upon further review, an order, dated 10/25/18, was for the [MEDICATION NAME] to continue an additional two (2) weeks. Review of the Medication Administration Record [REDACTED]. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the Admission Minimum Data Set (MDS) for Resident #62, with an Assessment Reference Date (ARD) of 10/18/18, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of five (5) out of fifteen (15), and determined his/her cognition was severely impaired. In addition, Section N0410, Medications, revealed anticoagulation days administered were zero (0). Review of the Baseline Care Plan, dated 10/11/18, for Resident #62 revealed an Anticoagulation care plan was not developed within the forty-eight (48) hour timeframe, nor added to the comprehensive care plan. Observations of Resident #62, on 12/12/18 at 08:58 AM, revealed the resident lying in the bed with the head of bed elevated with staff at the bedside assisting the resident with his/her meal. Interview with the Minimum Data Set (MDS) Nurse, on 12/13/18 at 11:10 AM, revealed she picked up the initial orders after the facility admitted Resident #62 and she developed the base line care plan. She stated the physician order [REDACTED]. She stated the anticoagulation therapy should have been included in the baseline care plan, as it was an admission order. Interview with Licensed Practical Nurse (LPN) #4, on 12/13/18 at 11:16 AM, revealed the baseline care plan was not inclusive of an anticoagulation therapy care plan; nor, elsewhere in the care plan. Interview with the Director of Nursing (DON), on 12/13/18 at 11:20 AM, revealed the baseline care plan initiated within the forty-eight (48) hour timeframe did not include anticoagulation therapy. Review of the baseline care plan, and the comprehensive care plan in place for (MONTH) (YEAR), revealed the facility did not update the baseline care plan with the anticoagulation therapy order for the [MEDICATION NAME]. She stated the admission orders [REDACTED]. Interview with the Administrator, on 12/13/18 at 11:30 AM, revealed staff began the baseline care plan for Resident #62 on the day of admission. He also stated the MDS Coordinator picked up the initial orders for Resident #62, before staff received the clarification order for [MEDICATION NAME]; therefore, the baseline care plan did not address the anticoagulation therapy. He stated the baseline care plan defined the initial goals of the resident and included physician orders, dietary orders, therapy services, and social services.

Based on observation, interviews, and review of the facility's policy, it was determined that the facility failed to serve food in a sanitary manner. Observations revealed two (2) Dietary Aides on the tray line with no beard guards and the Cook in the kitchen walking around the prepared food without a beard guard. In addition, staff touched Unsampled Resident C's food with contaminated bare hands. The findings include: 1. Review of the facility's Dietary Policy Manual, page 19, revised 02/09/16, revealed beard restraints should be worn to cover facial hair. Observation of meal preparation in the kitchen, on 10/26/17 at 11:25 AM, revealed Dietary Aide (DA) #1, DA #2, and the Cook were in the kitchen preparing food and their beards were not covered. Interview with DA #1, on 10/26/17 at 4:16 PM, revealed he never wore a beard guard nor had ever been provided with a beard guard. Interview with DA #2, on 10/26/17 at 4:23 PM, revealed he never wore a beard guard nor had ever been provided with a beard guard. He stated not wearing a beard guard could cause his facial hair to get into a resident's meal. Interview with the Dietary Manager, on 10/26/17 at 11:25 AM and 4:00 PM, revealed the facility had a policy for wearing hairnets and beard guards, and it was an oversight on her part for not ensuring staff followed the policy. The Manager stated the facility would buy some beard guards. Interview with the Administrator, on 10/27/17 at 3:53 PM, revealed it had not come to his attention that beard restraints were not used in the kitchen and there had been no complaints related to hair found in resident food. He stated all male staff received in-service training on the importance of wearing a beard restraint. 2. Review of the facility's Resident Meal Service policy, revised August 2013, revealed the distribution of trays to the residents was the responsibility of the nursing service under the supervision of Nursing and monitored by Dietary. The supervising nurse and the food service manager would arrange the routine for the operation. Observation, on 10/25/17 at 11:45 AM, during the lunch meal, revealed a tray was taken to Unsampled Resident C who was in his/her room. Unsampled Resident C was sitting in a wheelchair wearing house slippers. Certified Nursing Assistant (CNA) #4 placed the lunch tray on the table and set it up for Unsampled Resident C. CNA #4 proceeded to lift Unsampled Resident C's feet up and tried to get the table closer to the resident. CNA #4 was unable to get the tray closer, proceeded to lift the feet again with ungloved hands, and was successful with getting the table closer. CNA #4 wiped her face, nose, and hair a couple of times while assisting Unsampled Resident C. CNA #4 then lifted the bread roll, sliced it, and buttered it with the ungloved hand used to lift the resident's feet. CNA #4 left the room with a juice carton in her hand and took it back to the refrigerator at the nurses' station without washing her hands before she left the room. CNA #4 got a cup of coffee and a glass and took it back to Unsampled Resident C. CNA #4 left the room and went down the hall to the spa without washing her hands prior to leaving the room. Interview with CNA #4, on 10/26/17 at 2:15 PM, revealed she had slipped up yesterday (10/25/17) and should have washed her hands after lifting Unsampled Resident C's feet, which had bandages on them. She stated she should have used gloves to pick the roll up instead of her ungloved hands. CNA #4 stated she had contaminated Unsampled Resident C's food and silverware when she touched them with her hands. According to CNA #4, she was not aware she was supposed to use gloves when touching residents' food. Observation during the interview revealed she had a pair of gloves in her pocket during the interview. Interview with the Director of Nursing (DON), on 10/27/17 at 3:40 PM, revealed if staff touched a resident, they should not touch the food with their hands, they should use dietary gloves to set up the food for the resident. She stated it was not a good practice to touch a resident's foot and then touch their food. The DON revealed she did rounds to monitor how staff passed trays.

Based on observation, interview, record review, and review of facility policies, it was determined the facility failed to consistently implement their infection control program to prevent transmission of infection for five (5) of twenty-four (24) sampled and unsampled residents, Residents #2, #10, #14, and Unsampled Residents A and B. Staff failed to perform proper hand hygiene prior to performing a glucose check for Resident #2. Staff failed to wear appropriate Personal Protection Equipment (PPE) and/or perform proper hand hygiene for Resident #10 who was in isolation. Staff failed to change gloves following peri care for Resident #14 and staff failed to clean the glucometer between Unsampled Resident A and B. The finding includes: 1. Review of the facility's policy, Isolation Precautions, dated September 2014, revealed it was the facility's policy to prevent the transmission of infection through the use of isolation precautions. Standard Precautions were to be utilized by staff for all residents. Transmission-Based Precautions was utilized for known or suspected infections for which the route of transmission and/or prevention is known. Staff was to be informed of the initiation of isolation precautions. Signage was to be posted for precautions on the residents' door. Contact precaution included utilizing clean gloves when entering resident's room, during care, changing gloves, and after contact with infectious materials such as fecal material or wound drainage. In addition, staff was to remove gloves and perform hand hygiene with soap and water before leaving a resident area. Staff was to wear a gown when they entered the room and remove and dispose of the gown before leaving the resident's room. Review of the clinical record for Resident #10 revealed the facility admitted Resident #10 on 10/04/17, with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) for Resident #10, dated 10/11/17, revealed the resident was occasionally incontinent of bowel with use of an adult incontinent brief. The facility assessed the resident with a Brief Interview of Mental Status score of nine (9) out of fifteen (15) and determined the resident interviewable. Review of Resident #10's Care Plan, dated 10/11/17, revealed the resident was at risk for transmitting communicable diseases and was on contact isolation precautions. Observation of Resident #10's room, on 10/25/17 at 09:10 AM, revealed there was no signage on the resident's door to inform staff of the Contact Precautions. Observation of Resident #10, on 10/25/17 at 12:20 PM, revealed Certified Nursing Assistant (CNA) #7 entered Resident #10's room with a gown on but did not don gloves and did not wash her hands before leaving the room. Observation of Resident #10, on 10/25/17 at 12:25 PM, revealed the Housekeeper entered and exited Resident #10's room without putting on gown or gloves. The Housekeeper walked out of the room, took hand sanitizer back into the room, and placed it on the wall. The housekeeper used the hand sanitizer and left the room. The Housekeeper did not wash hands after leaving Resident #10's room. Observation, on 10/25/17 at 12:53 PM, revealed LPN #6 entered Resident #10's room and did not put on gloves before she entered the room. Observation, on 10/25/17 at 1:00 PM, revealed Dietary Aide #3 entered and exited Resident #10's room without putting on gown and gloves. Interview with Resident #10, on 10/26/17 at 10:00 AM, revealed that he/she had diarrhea and needed to stay in his/her room because other residents could be infected. Interview with the Housekeeper, on 10/27/17 at 1:19 PM, revealed staff used gowns, gloves, and masks for contact isolation. She stated gowns and gloves should be discarded in the trashcan in the room. She stated classes were provided monthly on infection control and if staff did not use proper precautions, residents could be harmed. Interview with the Director of Nursing, on 10/27/17 at 11:30 AM, revealed staff met each morning to review daily care for residents. She stated staff should wear gowns and gloves when entering a contact isolation room and she was not aware that staff from different departments were entering Resident #10's room without wearing gowns and gloves. She further stated not following the proper Isolation Precautions could cause harm to other residents. 2. Review of the facility's Handwashing Policy, dated September 2014, revealed personnel were required to wash their hands after each direct or indirect resident contact for which handwashing was indicated by acceptable standards of practice. Personnel should wash their hands after contact with blood, body fluids, secretions, excretions, and equipment or articles contaminated by them. The hands should be washed with soap and water after exposure to blood or body fluids. Review of the facility's Perineal Care Policy, from the Nursing Procedure Manual, revised April 2013, revealed the objective to perineal care was to prevent infection and odors. The facility did not provide a policy for removal of gloves. Observation of Resident #14, on 10/26/17 at 4:10 PM, revealed him/her lying in bed on his/her back with eyes open. CNA #2 and CNA #3 put on gloves and brought the mechanical lift in to assist with transfer. CNA #2 checked Resident #14's brief and found it wet. CNA #2 provided peri care. CNA#2 did not change his gloves after finishing peri care and placed a new brief on the resident. The mechanical lift did not have a battery and CNA #2, wearing gloves he had on during peri care, pulled the curtain back, opened the door, and went to get the battery. CNA #2 reentered the room, pulled the curtain, and transferred Resident #14 to the modified wheelchair. CNA #2 took a brush off the sink, brushed Resident #14's hair, and laid the brush down on the roommate's bed, then picked it back up and continued to brush the resident's hair. He then removed his gloves and washed his hands. Interview with CNA #2, on 10/26/17 at 4:25 PM, revealed staff should change gloves after peri care was completed, as it was an infection control issue issue. CNA #2 further revealed staff should wash hands after peri care because whatever the Resident might have could be spread to others. CNA #2 stated he did not wash his hands after peri care because he was in a hurry. Interview with the DON, on 10/27/17 at 1:25 PM, revealed staff should remove gloves after peri care. She stated it posed a risk of infection control as germs could be spread to other residents and staff. The DON stated the facility did rounds to monitor compliance with peri care procedures. 3. Observation of Registered Nurse (RN) #1, on 10/26/17 at 11:35 AM, revealed she performed an accu-check on a resident while wearing gloves. She then removed the gloves, applied new gloves, and sanitized the glucometer. RN #1 did not perform hand hygiene before she applied the new gloves, and proceeded to complete an accu-check on a different resident, Resident #2. Interview with RN #1, on 10/26/17 at 12:15 PM, revealed staff should perform hand hygiene between resident contact and after removing gloves. She stated failure to do so could spread germs between residents. She further stated she was unaware of her failure to perform hand hygiene when completed the accu-checks. Interview with the Director of Nursing, on 10/27/2017 at 3:00 PM, revealed staff was expected to perform hand hygiene between removing and donning gloves and always between residents. It was expected staff would perform hand hygiene per policy. 4. Review of the facility's policy, Glucometer - Cleaning and Disinfection, dated 4/2013, revealed the glucometer was to be cleaned with a germicidal disposable cloth/wipe. When the glucometer was completely dry, it may be used for the next resident. Observation during medication administration, on 10/26/17 at 8:20 AM, revealed Registered Nurse (RN) #1 used a glucometer to check the blood glucose of Unsampled Resident D. RN #1 proceeded with the same glucometer to check blood glucose of Unsampled Resident A without cleaning the machine. Continued observation of the medication pass revealed RN #1 checked Unsampled Resident B's blood glucose using the same glucometer that had not been cleaned between residents. Interview with RN #1, on 10/26/17 at 8:39 AM, revealed there were two (2) glucometers available for use on the medication cart and she thought she had cleaned the machines after each resident's use. She stated she was supposed to clean the glucometer with a sani-wipe (bleach) between each use. Interview with the Director of Nursing, on 10/27/17 at 3:00 PM, revealed the glucometer should be cleaned between resident use. She stated there was a risk of spreading infection if glucometers were not cleaned between residents. Interview with the Administrator, on 10/27/17 at 3:53 PM, revealed staff should sanitize glucometers in between use with a disinfectant wipe to prevent the spread of infection. He stated his expectation was for staff to have washed their hands in between residents and that going from wearing one pair of gloves to another would lower the chance of the spread of infection, but his expectation was hand washing between residents. The Administrator revealed he was responsible for educating staff on isolation precautions. He stated audits were performed periodically to ensure isolation precautions were followed.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to develop a care plan for one (1) of twenty-one (21) sampled residents, Resident #11. The facility failed to develop a care plan regarding restorative services for Resident #11. The findings include: Review of the facility policy Resident Care Plan, dated August 2012, revealed the facility should develop and implement an interdisciplinary written care plan based on physicians' orders and assessment of resident needs. Review of the clinical record for Resident #11 revealed the facility admitted Resident #11 on 12/27/16 with a [DIAGNOSES REDACTED]. Review of Resident #11's Minimum Data Set (MDS) assessment, dated 09/12/17, revealed the facility assessed Resident #11 with a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) and determined Resident #11 was interviewable. The facility assessed Resident #11 with impairment of Range of Motion (ROM) in both lower extremities. Review of the physician's telephone order, dated 09/07/17, revealed Resident #11 was to be evaluated for physical therapy and it was permissible to include ROM exercises. Review of the facility's electronic record Rehab Communications to Nursing revealed the facility referred Resident #11 to the restorative program, on 10/03/17, with restorative services to begin 10/04/17. The communication listed exercises and splinting to increase ROM, prevent strength loss, or worsening of contractures. Review of the paper Rehab Communications to Nursing form, dated 10/02/17, also revealed restorative services would begin 10/04/17 with exercises and splinting to increase ROM, prevent strength loss, or worsening of contractures. On 10/26/17 at 9:40 AM, review of the Restorative Nurse's binder of communications from Rehab to Nursing revealed there was not a restorative care plan for Resident #11. Observation of Resident #11, on 10/25/17 at 8:55 AM and 10:05 AM and on 10/26/17 at 8:20 AM and 9:35 AM, revealed Resident #11 was not wearing his/her bilateral leg splints. Interview with Resident #11, on 10/26/17 at 9:35 AM, revealed restorative staff usually worked with him/her to prevent worsening of bilateral leg contractures. Resident #11 stated restorative staff would move his/her legs in range-of-motion exercises. The restorative program was to place bilateral leg splints for as long as Resident #11 could tolerate, which was usually up to five (5) hours. Resident #11 revealed he/she had not been assisted by restorative staff since he/she had completed physical therapy. Interview with the Restorative Nurse, on 10/26/17 at 10:10 AM, revealed Rehab would refer residents to Restorative. The Restorative Nurse stated she developed a care plan at the time a resident was referred to Restorative. The Restorative Nurse was unsure the reason Resident #11 did not have a care plan and was therefore not receiving services. Additional interview with the Restorative Nurse, on 10/26/17 at 1:35 PM, revealed she failed to develop a restorative care plan and thus provide restorative services for Resident #11. She stated she was not aware of the referral. The Restorative Nurse stated she had not received the paper referral and had not known that she needed to check the electronic record. Interview with the nurse, on 10/27/17 at 10:20 AM, revealed she recognized the risk of worsening of contractures without development of a care plan providing for treatment by Restorative services. Interview with the Nurse Practitioner, on 10/27/17 at 1:50 PM, revealed he was not aware there was not a restorative care plan for Resident #11 and thus did not receive Restorative treatment as ordered. On 10/27/17 at 2:20 PM, interview with the Occupational Therapy Program Director revealed Resident #11 was referred to the restorative program for ROM exercises and splinting. She stated lack of developing a care plan with appropriate restorative interventions could lead to worsening of contractures. Interview with the Director of Nursing (DON), on 10/27/17 at 3:40 PM, revealed she had oversight over the Restorative Nurse. The DON stated she was supposed to receive a hardcopy of all referrals, however this did not always occur. The DON stated she believed contractures could worsen without development of a care plan and interventions in the form of restorative services. Interview with the Administrator, on 10/27/17 at 3:53 PM, revealed that the restorative team initiates their own care plans for residents who have been assessed by physical therapy for the need of restorative care. The administrator revealed that Resident #11 had not had a restorative care plan developed but that the oversight would have been caught through the facility's quality assurance team. He revealed that if care needs were not relayed appropriately on the residents care plan that a delay or decline could occur to the resident. The Administrator revealed he tracked referrals to the rehab department, but not to Restorative services. He stated he recognized the need for tracking of Restorative referrals, in addition those from Rehab.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide treatment and services to prevent further contractures for one (1) of twenty-one (21) sampled residents, Resident #11. The facility failed to provide restorative services for Resident #11, as ordered, for range-of-motion (ROM) exercises and bilateral leg splinting. The findings include: Review of the facility's Restorative Nursing policy, dated September 2012, revealed the purposes of the restorative nursing program included helping residents obtain or maintain independence and establishing life patterns within existing limitations to enhance quality of life. The policy stated that restorative sought to maximize the residents' abilities, foster independence, improve self-image and self-esteem, minimize conditions, which decrease abilities, and improve overall quality of life. Review of the clinical record for Resident #11 revealed the facility admitted the resident on 12/27/16, with a [DIAGNOSES REDACTED]. Review of Resident #11's quarterly Minimum Data Set (MDS) assessment, dated 09/12/17, revealed the facility assessed Resident #11 with a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) and determined Resident #11 was interviewable. The facility assessed Resident #11 with impairment of ROM to both lower extremities. Review of a physician's telephone order, dated 09/07/17, revealed Resident #11 was to be evaluated for physical therapy and it was permissible to include ROM exercises. Review of a Physical Therapy discharge summary, dated 10/04/17, revealed Resident #11 was discharged to the facility's Restorative Nursing Program for splinting (knee extension and ankle dorsiflexion) and lower extremity ROM and assist from staff for mobility. Review of a paper Rehab Communication to Nursing form, from Physical Therapy, dated 10/02/17, revealed Resident #11 was to begin restorative services on 10/04/17. Staff was to provide Active ROM in a chair, all planes, and Passive ROM to bilateral lower extremities. Bilateral knee extension and ankle dorsiflexion boots were to be donned four (4) to seven (7) hours as tolerated. The short-term goal listed was to increase ROM, and prevent strength loss or worsening contracture. Review of an electronic Rehab Communications to Nursing form, dated 10/03/17, revealed Physical Therapy referred Resident #11 to the restorative program, to begin 10/04/17. Staff was to provide Active ROM in a chair, all planes, and Passive ROM to bilateral lower extremities. Bilateral knee extension and ankle dorsiflexion boots were to be donned four (4) to seven (7) hours as tolerated. The short-term goal was to increase ROM, and prevent strength loss or worsening contracture. Review of the Restorative Nurse's binder of communications from Rehab to Nursing revealed no restorative plan of care for Resident #11 since the referral to begin restorative services on 10/04/17. Review of electronic Restorative Nursing documentation for Active ROM, Passive ROM, and Splint/Brace application revealed no documentation of completion for 10/04/17 to 10/27/17. Observation of Resident #11, on 10/25/17 at 8:55 AM and 10:05 AM and on 10/26/17 at 8:20 AM and 9:35 AM, revealed Resident #11 was not wearing his/her bilateral leg splints. Interview with Resident #11, on 10/26/17 at 9:35 AM, revealed restorative staff usually worked with him/her to prevent worsening of bilateral leg contractures. Resident #11 stated restorative staff would move his/her legs in range-of-motion exercises. The restorative program was to place bilateral leg splints for as long as Resident #11 could tolerate, which was usually up to five (5) hours. However, Resident #11 revealed restorative staff had not assisted him/her since discharge from Physical Therapy. Interview with the Restorative Nurse, on 10/26/17 at 10:10 AM and 11:40 AM, on 10/26/17 at 1:35 PM, and on 10/27/17 at 10:20 AM, revealed the facility process was for Physical Therapy to refer residents to Restorative and Physical Therapy taught the restorative aides how to perform the treatments. She stated she developed a care plan at the time the resident was referred to Restorative. The Restorative Nurse was unsure the reason Resident #11 was not receiving treatment from Restorative. She stated she did not develop a care plan or provide restorative services for Resident #11. She stated that she was not aware of the referral and did not receive the paper referral and did not know she needed to check the electronic record. She stated she recognized the risk of worsening of contractures without treatment by Restorative. Interview with the Nurse Practitioner, on 10/27/17 at 1:50 PM, revealed he was not aware Resident #11 had not received restorative care, as ordered. Interview with the Occupational Therapy Program Director, on 10/27/17 at 2:20 PM, revealed Resident #11 was referred to the restorative program for ROM exercises and splinting. She stated lack of restorative care could lead to worsening of contractures. Interview with the Director of Nursing (DON), on 10/27/17 at 3:40 PM, revealed she had oversight of the Restorative Nurse. The DON stated she was supposed to receive a hardcopy of all referrals, but that did not always happen. The DON stated contractures could worsen without the intervention of restorative services. Interview with the Administrator, on 10/27/17 at 3:53 PM, revealed Resident #11 not receiving restorative therapy had been an oversight on their part. He stated the facility would have discovered the oversight in Resident #11's care plan meeting. He revealed failure to perform splinting range of motion for a resident with contractures would have been concerning because it could have caused the contractures to get worse. The Administrator revealed he tracked referrals to the rehabilitation department, but not to Restorative.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure the residents' environment remained free from hazards. The facility stored chemicals in three (3) unlocked areas accessible to residents including one (1) of two (2) Soiled Utility Rooms, one (1) of one (1) Employee Lounges, and one (1) of two (2) Activity/Dining Rooms. The findings include: Review of the facility's policy titled Hazard Communication Program, revised 06/15/16, revealed all hazardous chemicals used in the workplace had the original manufacturer's label including a product identifier, hazard statement, and precautionary statement. The facility administrator or their designee ensured that all containers had appropriate labels. Review of the Material Data Safety sheets (MDS) for Heparin Lock Flush Solution, undated, revealed the product caused eye and respiratory tract irritation. Review of the MDS for Acetone Nail Polish Remover, dated December 2001, revealed the product caused skin irritation, eye discomfort, vomiting, headache, nausea, and/or narcotic effect. Review of the MDS for Goo-Gone, dated 10/18/10, revealed the product caused eye irritation, skin irritation, headache, nausea, drowsiness, pneumonitis, pulmonary edema, central nervous system depression, convulsions, loss of consciousness, and could be harmful or fatal if aspirated into the lungs. Review of the MDS for Airlift Tropical Scent Air Freshener, dated 10/31/01, revealed the product caused eye and skin irritation, respiratory irritation, and had harmful effects if swallowed including loss of consciousness and death. Review of the MDS for Rapidry Spray Nail Polish Dryer, dated 08/01/08, revealed the product caused nausea, vomiting, diarrhea, and central nervous system depression. This product caused temporary impairment of vision. This product caused skin irritation, and inhalation caused central nervous system depression and difficulty breathing. Review of the MDS for Clorox Disinfecting Aerosol Spray, dated February 1999, revealed the product caused eye irritation, ethanol intoxication, and respiratory tract irritation. Review of the MDS for Clorox Germicidal Wipes, dated May 2005, revealed the product caused eye irritation. Review of the MDS for Envy Liquid Disinfectant Spray, undated, revealed the product caused eye irritation and stomach discomfort if ingested. Review of the MDS for Virex II 128 Germicidal Cleaner, dated 06/23/94, revealed the product caused permanent eye damage, permanent skin injury, respiratory tract irritation, and severe damage to the digestive tract. Observation, on 09/06/16 at 03:45 PM, revealed an unlocked cabinet in an unlocked common area, Corner Café, contained five (5) sixteen ounce (16oz) bottles of acetone nail polish remover, one (1) spray bottle of Virex II 126 germicidal cleaner, and four (4) aerosol cans of Rapidry Spray Nail Polish dryer. Observation, on 09/06/16 at 05:05 PM, revealed an unlocked cabinet inside an unlocked soiled utility room on the two hundred (200) hallway contained one (1) spray bottle of Goo-Gone and one (1) Heparin lock flush. Observation, on 09/07/16 at 03:20 PM, revealed a cabinet underneath the sink in the unlocked employee lounge contained the following: one (1) one quart (1qt) bottle of Envy liquid disinfectant spray; one (1) nineteen ounce (19oz) Clorox disinfectant aerosol spray; one (1) one quart (1qt) Airlift Tropical Air Freshener; one (1) container of Clorox germicidal wipes; and one (1) unmarked one quart (1qt) spray bottle containing a clear liquid. Interview with Certified Nursing Assistant #1, on 09/07/16 at 01:30 PM, revealed residents could access the soiled utility room on the two hundred (200) hallway because the door did not have a lock. He stated there was a risk of residents drinking the chemicals and the chemicals should have been stored in the housekeeping supply closet. Interview with the Activities Director, on 09/07/16 at 03:30 PM, revealed the facility stored the cart containing the nail polish remover, nail dryer, and Virex in the beauty parlor. She stated the chemicals found in the cart posed a hazard to residents. She stated she was unaware that the cart had been stored in the activities room. She revealed she used the cart twice per month for activities. Interview with the Housekeeper, on 09/08/16 at 09:47 AM, revealed residents could access the employee lounge and the chemicals found underneath the sink posed a risk of residents getting chemicals into their eyes or ingesting the chemicals. She stated the facility labeled all bottles and she was unable to identify the contents of the unmarked spray bottle. She stated she was unaware there were chemicals under the sink. Interview with Housekeeping/Laundry Supervisor, on 09/09/16 at 09:12 AM, revealed residents could access the employee lounge and staff leaving chemicals under the sink put residents at risk. She stated she was unsure what was in the unlabeled spray bottle and that it was unsafe to have unlabeled spray bottles. Interview with the House Supervisor, on 09/09/16 at 09:25 AM, revealed he was unaware staff had stored chemicals under the employee lounge sink and staff should have stored the chemicals in a lockable closet. He stated it was a concern because residents could have accessed the chemicals and harmed themselves. He stated the cart stored in the soiled utility closet was not normally stored there and normally did not contain any harmful items. He further stated he had completed morning rounds but had not identified chemicals stored where residents had access. Interview with Director of Nursing, on 09/09/16 at 10:38 AM, revealed she was unaware chemicals were stored under the sink in the employee lounge and they could have had a potential poison control issue. She stated the cart discovered in the soiled utility room was a storage cart, but staff was not to store hazardous items on the cart. She stated staff should have stored the cart containing nail polish remover in the Beauty Parlor.

Based on observation, interview, record review and review of the facility's Handwashing Policy, it was determined the facility failed to follow an infection control program for two (2) of three (3) residents requiring dressing changes, of the four (4) total sampled residents (Residents #2 and #3). The Wound Nurse failed to wash her hands and change gloves when moving from a dirty area to a clean area during dressing changes. The findings include: Review of the facility's Handwashing Policy, dated August 2005, revealed personnel were required to wash their hands after each direct or indirect resident contact for which handwashing was indicated by acceptable standards of practice. Personnel would wash their hands: after contact with blood, body fluids, secretions, excretions, and equipment or articles contaminated by them; and when indicated between tasks and procedures to prevent cross contamination of different body sites. 1. Review of Resident #2's medical record, revealed the facility admitted the resident on 06/03/13, with [DIAGNOSES REDACTED]. Observation of a dressing change by the Licensed Practical Nurse (LPN) Wound Nurse for Resident #2's left heel, on 09/10/14 at 9:44 AM, revealed the Wound Nurse washed her hands and donned gloves. The Wound Nurse then removed the ace wrap and dirty dressing from Resident #2's left leg and heel. The Wound Nurse then removed her gloves and washed her hands. The Wound Nurse then donned clean gloves and cleaned the resident's wound to his/her left heel and removed a scab with her right gloved hand. The Wound Nurse then applied a clean dressing to Resident #2's heel with both her left and right gloved hands. She did not remove her gloves or wash her hands before moving to a clean area from a dirty one. 2. Review of Resident #3's medical record, revealed the facility admitted the resident on 09/29/13, with [DIAGNOSES REDACTED]. Observation of a dressing change by the LPN Wound Nurse for Resident #3's coccyx area, on 09/10/14 at 9:00 AM, revealed the Wound Nurse washed her hands, donned clean gloves and removed the old dressing from the right hip wound. She removed her soiled gloves and washed her hands. The Wound Nurse donned clean gloves then cleaned the sacral wound with a Q-tip and a 4 x 4. Without removing the soiled gloves or washing her hands, the Wound Nurse then packed the right hip wound with Dakins and taped a 4 x 4 to the wound. The Wound Nurse then removed her gloves, washed her hands and donned on new gloves before going to the second left hip wound and removed the old dressing from the left hip wound. She removed her gloves, washed her hands, and donned clean gloves and cleaned Resident #3's left hip wound with 4 x 4 and used a different 4 x 4 each time. The 4 x 4' s' were visibly soiled with a red and brown substance as she wiped the wound clean. The Wound Nurse did not remove her soiled gloves or wash her hands before applying the clean Dakins fluffs to the left hip wound layer by layer with the same contaminated gloved hand. The Wound Nurse then applied a clean abdominal Pad to the wound and taped it in place. Interview with the Wound Nurse, on 09/11/14 at 10:59 AM, revealed she was provided two (2) weeks of training from the previous Wound Nurse. The Wound Nurse stated she did not realize she had not removed her gloves or washed her hands when moving from dirty to clean during the dressing changes. The Wound Nurse stated she was supposed to remove her soiled gloves and wash her hands to prevent infecting the resident's wound with germs. The Wound Nurse stated she was nervous and should have washed her hands. Interview with the Director of Nursing (DON), on 09/11/14 at 2:58 PM, revealed the Wound Nurse should have washed her hands and changed her gloves when moving from a dirty area to a clean area during a wound dressing. The DON stated the Wound Nurse was trained by Corporate on wound care and also checked off with return demonstration of wound care. The DON stated staff were to wash their hands to prevent the spread of infection. Review of the Wound Nurse's Annual Skills Checklist, dated 03/04/14, revealed the Wound Nurse had been checked off on clean dressing changes, sterile dressing changes and pressure ulcer prevention and care. Interview with the Administrator, on 09/11/14 at 3:33 PM, revealed he monitored wounds in the Quality Assurance (QA) meetings. The Administrator stated if a wound was not progressively healing it would zone him to see if the resident needed a wound specialist and therapy.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the care plan described all aspects of the care needs for one (1) of twenty-two (22) sampled residents. The facility did not include in the care plan for [MEDICAL CONDITION], the physician ordered, knee high [MEDICAL CONDITION] Embolic Deterrent (TED) hose for Resident #3. The findings include: Review of the facility's policy regarding Resident Care Plan, Version 8/2012, revealed it was the policy of the facility to provide an interdisciplinary written care plan based on the physician's orders [REDACTED]. Review of a [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Quarterly Assessment, dated 03/05/13, for Resident #3 revealed the facility assessed the resident at a score of ten (10) on the Brief Interview for Mental Status (BIMS) which indicated the resident was interviewable. Review of a Physician Order, dated 09/13/10, revealed knee-high TED hose were ordered for Resident #3 for [MEDICAL CONDITION] and were to be put on in the AM and taken off at the hour of sleep. Review of the Physician order [REDACTED]. Review of the Treatment Administration Record (TAR) for Resident #3, dated 05/01/13 through 05/31/13, revealed the nurse had initialed the TAR that the TED hose were put on the resident at 6:00 AM on 05/31/13. Review of the most recent Certified Nursing Assistant (CNA) Resident Care Guide and the Comprehensive Nursing Care Plan, created on 09/24/10 and revised on 03/05/13, for Resident #3 revealed the MD ordered TED hose was not listed as a care need for Resident #3. Observation, on 05/31/13 at 9:00 AM and at 11:10 AM, revealed Resident #3 sitting up in a wheelchair with no TED hose in place. Interview with Resident #3, on 05/31/13 at 9:00 AM, revealed the TED hose were in a drawer in the bedside chest. The resident stated sometimes he/she thought the staff would forget to put them on. Interview, on 05/31/13 at 10:00 AM, with Register Nurse (RN) #1 the Minimum Data Set (MDS) Coordinator revealed the facility did not usually care plan TED hose. RN #1 stated TED hose probably should be on the CNA Resident Care Guide. Interview with CNA #1, on 05/31/13 at 10:15 AM, revealed he did not know what TED hose were and did not put them on the resident, because it was not on the Resident Care Guide for Resident #3. Interview, on 05/31/13 at 11:05 AM, with the Director of Nursing (DON) revealed it was the nurse's responsibility to see that the TED hose are put on a resident as ordered by their physician. The DON was uncertain why Resident #3 did not have the TED hose on and was uncertain of the reason for the TED hose. She stated she supposed the resident could get [MEDICAL CONDITION]. Interview, on 05/31/13 at 11:25 AM, with RN #2 revealed the CNA's put the TED hose on the residents, but the nurse was responsible to check that the TED hose were in place. RN #2 stated she did not check to see if the TED hose were in place for Resident #3 and should not have initialed the TAR that it had been done. Interview with the Administrator, on 05/31/13 at 11:50 AM, revealed the purpose of the care plan was to identify what the interdisciplinary team had identified as a need for a resident's care. The care plan drives the resident's care. The Administrator stated the CNA's know the TED hose as socks that is why the CNA did not know what TED hose were.

Based on observation, interview and review of the facility's policy Medication Administration, it was determined the facility failed to have the medication cart under the direct observation of the person administering medication or have the medication cart locked for one (1) of six (6) medication carts. The medication cart on the Canterberry Cove Hall was found unlocked and not being observed by nursing personnel during the medication pass. The findings include: Record review of the facility's policy regarding Medication Administration, undated, revealed the policy did not address the security of the medication cart during the medication pass. Observation, on 06/01/12 at 10:15 AM, on the Canterberry Cove Hall revealed the medication cart outside of the room of a resident, the drawers facing outward into the hall and unlocked. Two nursing personnel were facing a resident in the room during the medication administration, both of their backs to the cart. The personnel were identified as Certified Medication Technician (CMT) #1 and Licensed Practical Nurse (LPN) #1. Observation, on 06/01/12 during the tour of the facility which began at 10:00 AM, revealed Resident "B" wandering into the rooms of three(3) different residents. Twice Resident "B" was redirected out of the rooms which were not his/hers by Housekeeper #1 when Housekeeper #1 had observed the resident in the rooms. Resident "B" was assessed by the facility with cognitive impairment. Observation, on 06/01/12 during the tour of the facility which began at 10:00 AM, revealed Resident "D" in a wheelchair going up and down the halls inside the facility, to include the Canterberry Cove Hall where the unlocked medication cart was observed. Resident "D" was assessed by the facility with cognitive impairment. Observation, on 06/01/12 at 10:10 AM, revealed Resident "A" in a wheelchair moving up and down the Canterberry Cove Hall. The resident had stopped and pulled on this surveyors shirt, spoke unintelligible, patted this surveyor and continued up the hall in his/her wheelchair in the direction of the medication cart. The facility assessed Resident "A" with cognitive impairment. Interview, on 06/01/11 at 10:15 AM, with CMT #1 revealed the policy related to the medication cart was to have only the side open that you were using and have the cart in front of the door of the resident receiving the medication. She stated the cart was to be locked when not in view. She stated if she had been in-serviced on the medication cart it had been a while. CMT #1 offered no answer to the consequences to the resident if a resident accessed the medication cart. Interview, on 06/01/12 at 10:20 AM, with LPN #1 revealed she was unaware the medication cart was unlocked. She stated the cart should always be locked or within eyesight and she had been trained to keep the cart locked. She indicated residents do wander in the facility and if it was noted that a resident got into the medication cart, she would check the medications to make sure none were missing. She offered no consequences to the resident if a resident accessed the medication cart other than she would hope and pray a resident would not get into an unlocked cart. Interview, on 06/01/12 at 10:25 AM, with the South Charge Nurse revealed the medication carts are monitored all the time by spot checks. She stated staff were in-serviced on the medication carts and it was an ongoing process within the facility. The facility did have residents that wander and she stated she assumed harm could come to the residents from an unlocked cart. The policy for the medication cart was if you were working off the cart, you could pull it in the doorway of the resident's room and the medication cart must be in visual site. Interview, on 06/01/12 at 10:30 AM, with the North Charge Nurse revealed the policy regarding medication carts was for the carts to remain locked. The cart may be unlocked to pull meds, then locked back, she stated. She stated the carts were monitored during the walk through of the halls. She indicated there were residents that wander in the facility and they could get into an unlocked medication cart. She further stated if the resident did not know any better and took a medication from an unlocked cart, they could be injured or die. She stated there are some dangerous meds kept in the medication carts. Interview, on 06/01/12 at 10:40 AM, with the Director of Nursing (DON) revealed the facility did not have a policy on the medication carts. The facility adheres to standard nursing, what they are taught with respect to the security of the medication carts. She stated the staff had been in-serviced on the medication carts, including that the medication carts were to remain locked unless the cart was in view. In addition, it was revealed medication carts were monitored by checking the cart (that it was locked) as the staff passed by. She did not speculate the consequences to the resident if an unlocked cart was accessed by a resident. Interview, on 06/01/12 at 2:30 PM, with Registered Nurse (RN MDS) #1 revealed there was a medication pass policy. She stated the medication cart was to be locked at all times when you were not standing by the cart. It was revealed the staff had been in-serviced on the medication carts. Additionally, seh stated there was a risk to the residents if the cart was not locked or observed.